Background Insomnia affects almost one in four military service members and veterans. The first-line recommended treatment for insomnia is cognitive-behavioral therapy for insomnia (CBTI). CBTI is typically delivered in-person or online over one-to-four sessions (brief versions) or five-to-eight sessions (standard versions) by a licensed doctoral or masters-level clinician with extensive training in behavioral sleep medicine. Despite its effectiveness, CBTI has limited scalability. Three main factors inhibit access to and delivery of CBTI including restricted availability of clinical expertise; rigid, resource-intensive treatment formats; and limited capacities for just-in-time monitoring and treatment personalization. Digital technologies offer a unique opportunity to overcome these challenges by providing scalable, personalized, resource-sensitive, adaptive, and cost-effective approaches for evidence-based insomnia treatment. Methods This is a hybrid type 3 implementation-effectiveness randomized trial using a scalable evidence-based digital health software platform, NOCTEM™’s Clinician-Operated Assistive Sleep Technology (COAST™). COAST includes a clinician portal and a patient app, and it utilizes algorithms that facilitate detection of sleep disordered patterns, support clinical decision-making, and personalize sleep interventions. The first aim is to compare three clinician- and system-centered implementation strategies on the reach, adoption, and sustainability of the COAST digital platform by offering (1) COAST only, (2) COAST plus external facilitation (EF: assistance and consultation to providers by NOCTEM’s sleep experts), or (3) COAST plus EF and internal facilitation (EF/IF: assistance/consultation to providers by NOCTEM’s sleep experts and local champions). The second aim is to quantify improvements in insomnia among patients who receive behavioral sleep care via the COAST platform. We hypothesize that reach, adoption, and sustainability and the magnitude of improvements in insomnia will be superior in the EF and EF/IF groups relative to the COAST-only group. Discussion Digital health technologies and machine learning-assisted clinical decision support tools have substantial potential for scaling access to insomnia treatment. This can augment the scalability and cost-effectiveness of CBTI without compromising patient outcomes. Engaging providers, stakeholders, patients, and decision-makers is key in identifying strategies to support the deployment of digital health technologies that can promote quality care and result in clinically meaningful sleep improvements, positive systemic change, and enhanced readiness and health among service members. Trial registration ClinicalTrials.gov NCT04366284. Registered on 28 April 2020.
Overweight/obesity and inadequate fitness in active duty personnel impact the wellbeing of service members and have significant costs for military readiness and budget. ShipShape (SS), the Navy's weight management program, was designed to promote nutritional, behavioral, and exercise education to service members. Although SS is an evidence-based program, about half of those who complete the program pass the Body Composition Assessment (BCA), one part of the Navy's comprehensive Physical Fitness Assessment (PFA). SS may not fully address underlying behavioral, psychological, and emotional barriers that influence poor eating and exercise habits. A novel solution to improve outcomes is to incorporate acceptance and commitment therapy (ACT) to promote mindful awareness of present moment experiences, improve psychological flexibility, and support commitment to behavior change. This paper describes a cohort-randomized controlled trial of ACT-enhanced SS (ACT + SS) compared to the standard SS-only program. Active duty service members referred to the SS program are randomized to receive 8-weekly ACT + SS or SS-only group interventions. Our aims are to: 1) determine the effectiveness of ACT + SS compared to SS-only; 2) examine psychological flexibility as a mechanism underlying intervention response; and 3) explore potential moderators of intervention response. The primary outcome is weight, one of the key components of the BCA; secondary outcomes include Body Mass Index (BMI), body fat %, self-reported BCA results, physical activity, problematic eating, and quality of life. We have designed a cohort-randomized trial with interventions that are pragmatically implemented in a real-life military setting, and outcomes that are immediately relevant to service members and leadership.
Overweight and obesity are disabling problems for veterans and place a heavy toll on their physical and mental health. Acceptance and commitment therapy (ACT) is an empirically supported intervention that shows promise in improving binge eating, weight, and psychological functioning. This preliminary study evaluated the feasibility and acceptability of an 8-week ACT group intervention for binge eating in veterans (N = 85) who were overweight or obese and explored preliminary intervention effects on binge eating and physical and mental health functioning. Veterans were predominantly male (86.7%) with an average age of 58 years, and 65% endorsed clinically significant binge eating. Qualitative results indicated the majority of veterans found the intervention useful. Baseline to post-treatment comparisons found significant reductions in binge eating symptoms, depression, global psychological distress, and body mass index, as well as improvement in functioning. Findings suggest implementing ACT for binge eating in veterans is feasible and deserves further exploration, addressing binge eating and weight control. Future studies should examine ACT for this population in a randomized controlled trial.
Introduction Rates of overweight and obesity have increased in the military, particularly in the U.S. Navy. While the Navy has implemented weight-management programs like ShipShape, findings on the effectiveness of these programs are mixed. Further knowledge on the characteristics of service members (SMs) who participate in these programs may help inform course curricula and improve outcomes. This study aimed to (1) examine characteristics of SMs referred to the Navy’s ShipShape program at a large military treatment facility, (2) compare these characteristics among SMs who did and did not enroll in a randomized clinical trial of ShipShape (ShipShape study participants), and (3) compare demographic and health characteristics of ShipShape study participants to that of a random and similarly sized sample of Navy SMs who responded to the 2015 DoD Health-Related Behaviors Survey (HRBS). Materials and Methods Data from active duty Navy SMs referred to the ShipShape program at a large military treatment facility were evaluated (n = 225). A subset of these SMs enrolled in the ShipShape study (n = 187). Among enrolled SMs, data from 147 who completed all measures were compared to that of HRBS respondents. Univariate ANOVA and chi-square analyses were used to examine (1) demographic and motivational differences between SMs who did and did not enroll in the ShipShape study and (2) differences in demographics and medical and mental health conditions between ShipShape study participants and Navy HRBS respondents. Results The majority of SMs referred to ShipShape were female with an average age of 28.3 years. Compared to SMs who did not enroll in the ShipShape study (n = 38), ShipShape study participants were more likely to be female, less likely to be Hispanic, and had higher motivation and emotional eating scores. Compared to Navy HRBS respondents (n = 164), ShipShape study participants (n = 147) were younger, more likely to be female, non-Hispanic, enlisted, and obese. Further, ShipShape study participants reported significantly fewer medical health conditions but higher rates of probable depression, anxiety, and PTSD and were more likely to report receiving current mental health treatment than HRBS respondents. Conclusion Overweight or obese SMs seeking weight loss in the ShipShape study were relatively young, female, non-Hispanic, motivated, but with greater emotional eating. ShipShape study participants endorsed few medical health conditions but had higher rates of probable mental health conditions compared to the HRBS sample. These findings suggest that SMs referred to Navy weight-management programs are likely experiencing comorbid mental health conditions which may interfere with the effectiveness of their weight loss efforts. The descriptive nature of this study and the focus on Navy SMs in only one ShipShape program may decrease the generalizability of our findings to participants at other locations. Nonetheless, these findings demonstrate the potential need for Navy weight-management programs that incorporate mental health treatment and address the specific needs of female and diverse SMs. A more comprehensive curriculum could improve the results of weight-management efforts, increase SM quality of life and fitness and thereby operational readiness.
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