Posttraumatic stress disorder diagnosis and gender are associated with accelerated weight gain trajectories in veterans during the post-deployment period

Weight change in a national cohort of U.S. Military Veterans engaged in medication treatment for opioid use disorder

Medication treatments for opioid use disorder (MOUD) save lives and improve outcomes for countless individuals. However, data suggest the potential for significant weight gain during methadone treatment and little is known about weight change during buprenorphine treatment. Using Veteran Health Administration administrative data from fiscal year 2017 to fiscal year 2019, two cohorts were created: 1) Veterans diagnosed with opioid use disorder (OUD) taking methadone (N = 1425); and 2) Veterans diagnosed with OUD taking buprenorphine (N = 3756). Linear mixed models were used to analyze weight change during the first MOUD treatment episode in the observation period. Random slopes and intercepts were included in the model to estimate variation in BMI across individuals and time. The data revealed a slight upward trend in BMI over the course of treatment. Specifically, a daily increase of 0.004 for Veterans in methadone treatment and 0.002 for Veterans in buprenorphine treatment was observed. This translates to a gain of about 10 pounds over the course of 1 year of methadone treatment and 5 pounds for 1 year of buprenorphine treatment for a Veteran of average height and weight. The amount of weight gain in methadone treatment is significantly less than other published findings, but nonetheless indicates that assessment and discussions between patients and providers related to weight may be warranted.

Heart Rate During Sleep in PTSD Patients: Moderation by Contact with a Service Dog

There is growing interest in the potential health benefits of dog ownership in both the lay and scientific communities. Large reductions in risk for cardiovascular disease and all-cause mortality in dog owners relative to non-owners have been observed in epidemiological samples. Persons diagnosed with posttraumatic stress disorder exhibit elevated risk for cardiovascular disease. The current study tested a sample of 45 U.S. military veterans with deployment-related posttraumatic stress disorder employing an intensive, longitudinal, within-subjects design contrasting sleep heart rate on nights with and without a service dog. As participants were engaged in residential psychiatric treatment, sleep opportunities, waking activities, meals, and medications, were consistently scheduled. The primary recording methodology, mattress actigraphy, enabled passive quantification of heart rate over a total sample of 1097 nights. Service dog contact was associated with reduced sleep heart rate especially in participants with more severe PTSD. Longer-term longitudinal studies will be needed to assess the durability and asymptotic magnitude of this effect. An unexpected effect of nights in study was associated with increased heart rate consistent with hospitalization-associated deconditioning.

Sexually dimorphic role of the locus coeruleus PAC1 receptors in regulating acute stress-associated energy metabolism

Severe stress leads to alterations in energy metabolism with sexually dimorphic onset or severity. The locus coeruleus (LC) in the brainstem that mediates fight-or-flight-or-freeze response to stress is sexually dimorphic in morphology, plays a key role in interactions between diet and severe stressors, and has neuronal input to the brown adipose tissue (BAT)-a thermogenic organ important for energy balance. Yet, little is known on how LC coordinates stress-related metabolic adaptations. LC expresses receptors for the neuropeptide PACAP (pituitary adenylate cyclase activating peptide) and PACAP signaling through PAC1 (PACAP receptor) are critical regulators of various types of stressors and energy metabolism. We hypothesized that LC-PAC1 axis is a sex-specific central "gatekeeper" of severe acute stress-driven behavior and energy metabolism. Selective ablation of PAC1 receptors from the LC did not alter stress response in mice of either sex, but enhanced food intake in females and was associated with increased energy expenditure and BAT thermogenesis in male mice. These results show a sexually dimorphic role of the LC-PAC1 in regulating acute stress-related energy metabolism. Thus, by disrupting LC-PAC1 signaling, our studies show a unique and previously unexplored role of LC in adaptive energy metabolism in a sex-dependent manner.

Mapping the network biology of metabolic response to stress in posttraumatic stress disorder and obesity

The co-occurrence of stress-induced posttraumatic stress disorder (PTSD) and obesity is common, particularly among military personnel but the link between these conditions is unclear. Individuals with comorbid PTSD and obesity manifest other physical and psychological problems, which significantly diminish their quality of life. Current understanding of the pathways connecting stress to PTSD and obesity is focused largely on behavioral mediators alone with little consideration of the biological regulatory mechanisms that underlie their co-occurrence. In this work, we leverage prior knowledge to systematically highlight such bio-behavioral mechanisms and inform on the design of confirmatory pilot studies. We use natural language processing (NLP) to extract documented regulatory interactions involved in the metabolic response to stress and its impact on obesity and PTSD from over 8 million peer-reviewed papers. The resulting network describes the propagation of stress to PTSD and obesity through 34 metabolic mediators using 302 documented regulatory interactions supported by over 10,000 citations. Stress jointly affected both conditions through 21 distinct pathways involving only two intermediate metabolic mediators out of a total of 76 available paths through this network. Moreover, oxytocin (OXT), Neuropeptide-Y (NPY), and cortisol supported an almost direct propagation of stress to PTSD and obesity with different net effects. Although stress upregulated both NPY and cortisol, the downstream effects of both markers are reported to relieve PTSD severity but exacerbate obesity. The stress-mediated release of oxytocin, however, was found to concurrently downregulate the severity of both conditions. These findings highlight how a network-informed approach that leverages prior knowledge might be used effectively in identifying key mediators like OXT though experimental verification of signal transmission dynamics through each path will be needed to determine the actual likelihood and extent of each marker’s participation.

Disentangling sex differences in the shared genetic architecture of posttraumatic stress disorder, traumatic experiences, and social support with body size and composition

There is a well-known association of traumatic experiences and posttraumatic stress disorder (PTSD) with body size and composition, including consistent differences between sexes. However, the biology underlying these associations is unclear. To understand the genetic underpinnings of this complex relationship, we investigated genome-wide datasets informative of African and European ancestries from the Psychiatric Genomic Consortium, the UK Biobank, the GIANT Consortium, and the Million Veteran Program. We used genome-wide association statistics to estimate sex-specific genetic correlations (r g ) of traumatic experiences, social support, and PTSD with multiple anthropometric traits. After multiple testing corrections (false discovery rate, FDR q < 0.05), we observed 58 significant r g relationships in females (e.g., childhood physical abuse and body mass index, BMI r g  = 0.245, p = 3.88 × 10-10) and 21 significant r g relationships in males (e.g., been involved in combat or exposed to warzone and leg fat percentage; r g  = 0.405, p = 4.42 × 10-10). We performed causal inference analyses of these genetic overlaps using Mendelian randomization and latent causal variable approaches. Multiple female-specific putative causal relationships were observed linking body composition/size with PTSD (e.g., leg fat percentage→PTSD; beta = 0.319, p = 3.13 × 10-9), traumatic experiences (e.g., childhood physical abuse→waist circumference; beta = 0.055, p = 5.07 × 10-4), and childhood neglect (e.g., "someone to take you to doctor when needed as a child"→BMI; beta = -0.594, p = 1.09 × 10-5). In males, we observed putative causal effects linking anthropometric-trait genetic liabilities to traumatic experiences (e.g., BMI→childhood physical abuse; beta = 0.028, p = 8.19 × 10-3). Some of these findings were replicated in individuals of African descent although the limited sample size available did not permit us to conduct a sex-stratified analysis in this ancestry group. In conclusion, our findings provide insights regarding sex-specific causal networks linking anthropometric traits to PTSD, traumatic experiences, and social support.

Post-traumatic stress disorder and the association with overweight, obesity, and weight change among individuals exposed to the World Trade Center disaster, 2003-2016

BACKGROUND

Among Veterans, post-traumatic stress disorder (PTSD) has been shown to be associated with obesity and accelerated weight gain. Less is known among the general population. We sought to determine the impact of PTSD on body mass index (BMI) and weight change among individuals with exposure to the World Trade Center (WTC) disaster.

METHODS

We examined individuals from the WTC Health Registry. PTSD symptoms were assessed on multiple surveys (Waves 1-4) using the PTSD Checklist-Specific. Three categories of post-9/11 PTSD were derived: no, intermittent, and persistent. We examined two outcomes: (1) Wave 3 BMI (normal, overweight, and obese) and (2) weight change between Waves 3 and 4. We used multivariable logistic regression to assess the association between PTSD and BMI (N = 34 958) and generalized estimating equations to assess the impact of PTSD on weight change (N = 26 532). Sex- and age-stratified analyses were adjusted for a priori confounders.

RESULTS

At Wave 3, the observed prevalence of obesity was highest among the persistent (39.5%) and intermittent PTSD (36.6%) groups, compared to the no PTSD group (29.3%). In adjusted models, persistent and intermittent PTSD were consistently associated with a higher odds of obesity. Weight gain was similar across all groups, but those with persistent and intermittent PTSD had higher estimated group-specific mean weights across time.

CONCLUSIONS

Our findings that those with a history of PTSD post-9/11 were more likely to have obesity is consistent with existing literature. These findings reaffirm the need for an interdisciplinary focus on physical and mental health to improve health outcomes.

Deriving Weight from Big Data: A Comparison of Body Weight Measurement Cleaning Algorithms (Preprint)

Background

Patient body weight is a frequently used measure in biomedical studies, yet there are no standard methods for processing and cleaning weight data. Conflicting documentation on constructing body weight measurements presents challenges for research and program evaluation.

Objective

In this study, we aim to describe and compare methods for extracting and cleaning weight data from electronic health record databases to develop guidelines for standardized approaches that promote reproducibility.

Methods

We conducted a systematic review of studies published from 2008 to 2018 that used Veterans Health Administration electronic health record weight data and documented the algorithms for constructing patient weight. We applied these algorithms to a cohort of veterans with at least one primary care visit in 2016. The resulting weight measures were compared at the patient and site levels.

Results

We identified 496 studies and included 62 (12.5%) that used weight as an outcome. Approximately 48% (27/62) included a replicable algorithm. Algorithms varied from cutoffs of implausible weights to complex models using measures within patients over time. We found differences in the number of weight values after applying the algorithms (71,961/1,175,995, 6.12% to 1,175,177/1,175,995, 99.93% of raw data) but little difference in average weights across methods (93.3, SD 21.0 kg to 94.8, SD 21.8 kg). The percentage of patients with at least 5% weight loss over 1 year ranged from 9.37% (4933/52,642) to 13.99% (3355/23,987).

Conclusions

Contrasting algorithms provide similar results and, in some cases, the results are not different from using raw, unprocessed data despite algorithm complexity. Studies using point estimates of weight may benefit from a simple cleaning rule based on cutoffs of implausible values; however, research questions involving weight trajectories and other, more complex scenarios may benefit from a more nuanced algorithm that considers all available weight data.

Construction and Use of Body Weight Measures from Administrative Data in a Large National Health System: A Systematic Review

OBJECTIVE

Administrative data are increasingly used in research and evaluation yet lack standardized guidelines for constructing measures using these data. Body weight measures from administrative data serve critical functions of monitoring patient health, evaluating interventions, and informing research. This study aimed to describe the algorithms used by researchers to construct and use weight measures.

METHODS

A structured, systematic literature review of studies that constructed body weight measures from the Veterans Health Administration was conducted. Key information regarding time frames and time windows of data collection, measure calculations, data cleaning, treatment of missing and outlier weight values, and validation processes was collected.

RESULTS

We identified 39 studies out of 492 nonduplicated records for inclusion. Studies parameterized weight outcomes as change in weight from baseline to follow-up (62%), weight trajectory over time (21%), proportion of participants meeting weight threshold (46%), or multiple methods (28%). Most (90%) reported total time in follow-up and number of time points. Fewer reported time windows (54%), outlier values (51%), missing values (34%), or validation strategies (15%).

CONCLUSIONS

A high variability in the operationalization of weight measures was found. Improving methods to construct clinical measures will support transparency and replicability in approaches, guide interpretation of findings, and facilitate comparisons across studies.

Eating Disorders and Overweight/Obesity in Veterans: Prevalence, Risk Factors, and Treatment Considerations

PURPOSE OF REVIEW

Eating disorders (EDs) and overweight/obesity (OW/OB) have a significant impact on veterans. This review highlights current research on EDs and OW/OB in this population.

RECENT FINDINGS

Prevalence estimates for both EDs and OW/OB among veterans remain consistent with and possibly higher than those in the general population. Both diagnoses share multiple risk factors, including trauma history, and mental health comorbidities. Although weight loss treatments have been fairly well studied among veteran samples, there are no published investigations on psychotherapies for EDs in this population. The Veterans Healthcare Administration is working to train providers in ED treatments. VHA treatments for OW/OB show some benefits and areas for improvement. Areas for future research include structured assessments for EDs and disordered eating behaviors in veterans to clarify prevalence estimates. There is a need for interventions that consider common mechanisms for ED and OW/OB, and there is a need for more research on the associations between different types of trauma and ED/OW/OB in veterans.

Clinically meaningful posttraumatic stress disorder (PTSD) improvement and incident hypertension, hyperlipidemia, and weight loss

OBJECTIVE

Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiometabolic disease. Clinically meaningful PTSD improvement is associated with a lower risk for diabetes, but it is not known if similar associations exist for incident hypertension, hyperlipidemia, and clinically relevant weight loss (i.e., ≥5% loss).

METHOD

Medical record data from Veterans Health Affairs patients with clinic encounters between fiscal year (FY) 2008 to 2015 were used to identify patients with worsening or no PTSD improvement (i.e., PTSD checklist (PCL) score decrease <10), small (10-19 point PCL decrease), and large (≥20 point PCL decrease) PTSD improvement. To estimate the association between degree of PTSD improvement and incident hypertension (n = 979), incident hyperlipidemia (n = 1,139) and incident ≥5% weight loss (1,330), we computed Cox proportional hazard models, controlling for confounding using inverse probability of exposure weighting (IPEW).

RESULTS

Overall, patients were about 40 years of age, 80% male and 65% White. Worsening or no PCL change occurred in about 60%, small improvement in 20%, and large improvement in 20%. After weighting data, compared with worsening or no change, both small and large PTSD improvements were associated, albeit not significantly, with lower risks for hypertension (HR = 0.68; 95% confidence interval, CI [0.46, 1.01] and HR = 0.79; 95% CI [0.53, 1.18], respectively). In weighted data, PTSD improvement was not associated with incident hyperlipidemia or ≥5% weight loss.

CONCLUSIONS

We observed limited evidence for an association between PTSD improvement and decreased hypertension risk. PCL decreases were not associated with hyperlipidemia or ≥5% weight loss. Further studies that measure potential physical health benefits of change in specific PTSD symptoms are needed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Women Veterans Experience with the VA MOVE! Weight Management Program

Background: Obesity prevalence is higher in women veterans overall than their civilian counterparts considering 44% of women veterans are obese. Thus, there is a critical need to understand the facilitators and barriers to women veterans' participation in weight management programs. The objective of this study is to explore facilitators and barriers to weight loss for women veterans enrolled in the Veterans Health Administration Motivating Overweight/Obese Veterans Everywhere (VA MOVE!) weight management program and gather feedback on the design and delivery of the MOVE! program.

Materials and Methods: Primary qualitative data were collected from women veterans who completed at least one MOVE! visit via semistructured telephone interviews. Two authors independently reviewed transcripts for data-derived codes. A content analysis approach was used within the software to code the transcripts.

Results: The mean age of participants was 52 years. Sixty-eight percent (N = 17/25) were black, and 52% (N = 13/25) lived >64 kilometers from the location of the MOVE! program. Facilitators to participation included both intrinsic (e.g., drive to become healthy) and extrinsic (e.g., drive to improve laboratories) motivating factors. Women expressed difficulty with learning in a group setting and applying lessons to their everyday lives. Others reported the setup of group classes triggered their post-traumatic stress disorder and prevented them from fully participating in the program. Additional barriers included distance traveled to group sessions and lack of access to exercise space.

Conclusions: Our results illuminate barriers and facilitators to engagement in the MOVE! program. Many of the barriers highlighted by these women veterans mirror barriers civilian women face, highlighting the possibility that our results could be applied to other programs designed to target weight loss in women.

Effects of disrupted ghrelin receptor function on fear processing, anxiety and saccharin preference in mice

BACKGROUND

Obesity is a risk factor for stress-related mental disorders such as post-traumatic stress disorder. The underlying mechanism through which obesity affects mental health remains poorly understood but dysregulation of the ghrelin system may be involved. Stress increases plasma ghrelin levels, which stimulates food intake as a potential stress-coping mechanism. However, diet-induced obesity induces ghrelin resistance which in turn may have deleterious effects on stress-coping. In our study, we explored whether disruption of ghrelin receptor function though high-fat diet or genetic ablation affects fear processing, anxiety-like behavior and saccharin preference in mice.

METHODS

Adult male C57BL6/J mice were placed on a standard diet or high-fat diet for a total period of 8 weeks. We first established that high-fat diet exposure for 4 weeks elicits ghrelin resistance, evidenced by a blunted hyperphagic response following administration of a ghrelin receptor agonist. We then carried out an experiment in which we subjected mice to auditory fear conditioning after 4 weeks of diet exposure and evaluated effects on fear extinction, anxiety-like behavior and saccharin preference. To explore whether fear conditioning as such may influence the effect of diet exposure, we also subjected mice to auditory fear conditioning prior to diet onset and 4 weeks later we investigated auditory fear extinction, anxiety-like behavior and saccharin preference. In a final experiment, we further assessed lack of ghrelin receptor function by investigating auditory fear processing, anxiety-like behavior and saccharin preference in ghrelin receptor knockout mice and their wild-type littermates.

RESULTS

High-fat diet exposure had no significant effect on auditory fear conditioning and its subsequent extinction or on anxiety-like behavior but significantly lowered saccharin preference. Similarly, ghrelin receptor knockout mice did not differ significantly from their wild-type littermates for auditory fear processing or anxiety-like behavior but showed significantly lower saccharin preference compared to wild-type littermates.

CONCLUSION

Taken together, our data suggest that disruption of ghrelin receptor function per se does not affect fear or anxiety-like behavior but may decrease saccharin preference in mice.

Risk Factors of Obesity in Veterans of Recent Conflicts: Need for Diabetes Prevention

PURPOSE OF REVIEW

To identify factors associated with obesity in veterans of the recent, Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) war conflicts.

RECENT FINDINGS

Over 44% OEF/OIF/OND veterans are obese (BMI > 30 kg/m²), which exceeds the national obesity prevalence rate of 39% in people younger than 45. Obesity increases morbidity, risk for type 2 diabetes (T2D), and mortality as well as decreases quality of life. A scoping review method was used to identify factors associated with obesity in young veterans. Military exposures, such as multiple deployments and exposure to combat, contribute to challenges in re-integration to civilian life in all veterans. Factors that contribute to increased risk for obesity include changes in eating patterns/eating disorders, changes in physical activity, physical disability, and psychological comorbidity. These conditions can contribute to a rapid weight gain trajectory, changes in metabolism, and obesity. Young veterans face considerable challenges related to obesity risk. Further research is needed to better understand young veterans' experiences and health needs in order to adapt or expand existing programs and improve access, engagement, and metabolic outcomes in this vulnerable population.

The association between PTSD and cardiovascular disease and its risk factors in male veterans of the Iraq/Afghanistan conflicts: a systematic review

Military personnel with Post-Traumatic Stress Disorder (PTSD) can experience high levels of mental and physical health comorbidity, potentially indicating a high level of functional impairment that can impact on both military readiness and later ill-health. There is strong evidence to implicate PTSD as a contributory factor to Cardiovascular Disease (CVD) among serving personnel and veterans. This systematic review focusses on the association between PTSD and cardiovascular disease/risk factors in male, military serving and ex-serving personnel who served in the Iraq/Afghanistan conflicts. PUBMED, MEDLINE, PILOTS, EMBASE, PSYCINFO, and PSYCARTICLES were searched using PRISMA guidelines. Three hundred and forty-three records were identified, of which 20 articles were selected. PTSD was positively associated with the development of CVD, specifically circulatory diseases, including hypertension. PTSD was also positively associated with the following risk factors: elevated heart rate, tobacco use, dyslipidaemia, and obesity. Conflicting data is presented regarding heart rate variability and inflammatory markers. Future studies would benefit from a standardized methodological approach to investigating PTSD and physical health manifestations. It is suggested that clinicians offer health advice for CVD at an earlier age for ex-/serving personnel with PTSD.