By Karen S. Mitchell, PhD
Eating disorders were historically under-recognized in U.S. military service members and veterans. However, we now know that military service members and veteran women and men experience eating disorders at least as often as women and men in the general U.S. and possibly more often.1,2,3 We also know that veterans of all genders, races, ethnicities, and ages can experience eating disorders.1 In addition to risk factors that have previously been associated with the development of eating disorders in non-military populations, military service members and veterans experience military-unique stressors that may contribute to eating disorders in these groups.
Risk Factors for Eating Disorders in Military Populations
Military service members and veterans are susceptible to the same risk factors for eating disorders as the general population, including other mental health conditions, low self-esteem, family eating and weight concerns, childhood abuse, food insecurity, and trauma exposure. In particular, trauma exposure, and posttraumatic stress disorder, have been associated with eating disorders.4 Military service members experience high rates of trauma exposure, including pre- and post-military trauma, as well as trauma experienced during the military.5,6 Service members also experience combat trauma as well as military sexual trauma (MST). MST in particular has been associated with eating disorders in veterans.7,8,9
The military also has very strict weight and fitness requirements. Failing to make weight can result in lack of promotion, not being authorized to attend military schools, or discharge from service.10 Pressure to achieve these weight requirements may lead to eating disorders in service members, which may persist after discharge from military service.11,12
Barriers to Treatment and Treatment Options
As in the general U.S. population, only a small proportion of service members and veterans with eating disorders may receive treatment for them.2 A national sample of veterans recently released from active duty identified several barriers to seeking help for an eating disorder including; not knowing where to get help, that it was difficult to schedule an appointment, and that treatment was too costly.2
For military service members, TRICARE (the health insurance program offered to military personnel, veterans, and their dependents by the US Department of Defense Military Health System) covers inpatient and outpatient eating disorder treatment. For Veterans Health Administration (VHA) patients, there are now 89 teams of providers trained in eating disorder treatment at VA medical centers across the country. Teams include a mental health therapist, a dietician, and either a psychiatrist or primary care physician. The teams provide outpatient eating disorder care that includes psychotherapy, medication management, primary care, and dietitian services. These teams can also provide consultation to other VA clinicians who are caring for veterans with eating disorders/disordered eating symptoms. For example, if a veteran with disordered eating was receiving treatment in another clinic such as general mental health, their provider could consult with a member of an eating disorder team in order to best address the veteran’s needs. Only outpatient eating disorder services are available at VA medical centers right now. If the VA cannot address a veteran’s treatment needs (such as when a higher level of care is required to address severe eating disorders), the VA will contract for community-based services that are outside of the VA healthcare system. In such cases, the veteran’s VA provider will work with the local Community Care office to arrange for community treatment.
Research
- The rate of eating disorders almost doubled in the military health records from 1998 to 2006.13
- High proportions of veterans experience eating disorders. Up to 18.5% of women and 8.5% of men in a national sample of U.S. military veterans screened positive for an eating disorder.1
- In a national sample, proportions of eating disorders did not differ significantly between White and Black veterans or between Latinx and non-Latinx veterans. Eating disorders were prevalent across age groups, with the highest proportions among veterans aged 19-29 and 40-49.1
- Among veterans who had been discharged or retired from service in the prior 18 months, eating disorders were prevalent among both men and women, but very few individuals with eating disorders had received treatment for them.2
- Veterans with eating disorders tend to have high rates of healthcare use, despite low rates of eating disorder-specific treatment.2,14 This may be because they are getting treatment for the physical consequences of the eating disorder, whereas eating disorder treatment would be more beneficial.
- Gay and bisexual men in a national sample of male veterans had higher levels of eating disorder symptoms compared to heterosexual men.15
- Bisexual female veterans in a national sample of post-9/11 veterans had higher rates of disordered eating and related impairment compared to heterosexual female veterans.16
- Many people with eating disorders are a higher weight. In a national sample of veterans, individuals who with larger sized bodies had higher proportions of probable eating disorders compared to individuals considered “healthy” or “overweight” by the medical field.1
- Miliary-related trauma was associated with eating disorder symptoms among veteran men and women in two separate samples.9,17
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Sources
[1] Mitchell, K. S., Masheb, R., Smith, B. N., Kehle-Forbes, S., Hardin, S., & Vogt, D. (2021). Eating disorder measures in a sample of military veterans: A focus on gender, age, and race/ethnicity. Psychological Assessment, 33(12), 1226–1238. https://doi.org/10.1037/pas0001050.
[2] Mitchell, K. S., Sienkiewicz, M., Smith, B. N., Vogt, D., Kehle-Forbes, S., & Cooper, Z. (2022). Associations between probable eating disorders and healthcare use among post-9/11 veteran men and women. Journal of psychosomatic research, 157, 110811. https://doi.org/10.1016/j.jpsychores.2022.110811.
[3] Cuthbert, K., Hardin, S., Zelkowitz, R., & Mitchell, K. (2020). Eating Disorders and Overweight/Obesity in Veterans: Prevalence, Risk Factors, and Treatment Considerations. Current obesity reports, 9(2), 98–108. https://doi.org/10.1007/s13679-020-00374-1.
[4]Mitchell, K. S., Mazzeo, S. E., Schlesinger, M. R., Brewerton, T. D., & Smith, B. N. (2012). Comorbidity of partial and subthreshold ptsd among men and women with eating disorders in the national comorbidity survey-replication study. The International journal of eating disorders, 45(3), 307–315. https://doi.org/10.1002/eat.20965.
[5]Zinzow, H. M., Grubaugh, A. L., Monnier, J., Suffoletta-Maierle, S., & Frueh, B. C. (2007). Trauma among female veterans: a critical review. Trauma, violence & abuse, 8(4), 384–400. https://doi.org/10.1177/1524838007307295
[6] Clancy, C. P., Graybeal, A., Tompson, W. P., Badgett, K. S., Feldman, M. E., Calhoun, P. S., Erkanli, A., Hertzberg, M. A., & Beckham, J. C. (2006). Lifetime trauma exposure in veterans with military-related posttraumatic stress disorder: association with current symptomatology. The Journal of clinical psychiatry, 67(9), 1346–1353. https://doi.org/10.4088/jcp.v67n0904
[7]Blais, R. K., Brignone, E., Maguen, S., Carter, M. E., Fargo, J. D., & Gundlapalli, A. V. (2017). Military sexual trauma is associated with post-deployment eating disorders among Afghanistan and Iraq veterans. The International journal of eating disorders, 50(7), 808–816. https://doi.org/10.1002/eat.22705
[8] Breland, J. Y., Donalson, R., Li, Y., Hebenstreit, C. L., Goldstein, L. A., & Maguen, S. (2018). Military sexual trauma is associated with eating disorders, while combat exposure is not. Psychological trauma: theory, research, practice and policy, 10(3), 276–281. https://doi.org/10.1037/tra0000276
[9] Arditte Hall, K. A., Bartlett, B. A., Iverson, K. M., & Mitchell, K. S. (2018). Eating disorder symptoms in female veterans: The role of childhood, adult, and military trauma exposure. Psychological trauma: theory, research, practice and policy, 10(3), 345–351. https://doi.org/10.1037/tra0000301
[10] The Army Body Composition Program. (2019). Army regulation 600-9. Available at: https://www.armyresilience.army.mil/abcp/pdf/ARN7779_AR600-9_FINAL.pdf
[11] Jacobson, I. G., Smith, T. C., Smith, B., Keel, P. K., Amoroso, P. J., Wells, T. S., Bathalon, G. P., Boyko, E. J., Ryan, M. A., & Millennium Cohort Study Team (2009). Disordered eating and weight changes after deployment: longitudinal assessment of a large US military cohort. American journal of epidemiology, 169(4), 415–427. https://doi.org/10.1093/aje/kwn366
[12] Bodell, L., Forney, K. J., Keel, P., Gutierrez, P., & Joiner, T. E. (2014). Consequences of Making Weight: A Review of Eating Disorder Symptoms and Diagnoses in the United States Military. Clinical psychology: a publication of the Division of Clinical Psychology of the American Psychological Association, 21(4), 398–409. https://doi.org/10.1111/cpsp.12082
[13] Antczak, A. J., & Brininger, T. L. (2008). Diagnosed eating disorders in the U.S. Military: a nine year review. Eating disorders, 16(5), 363–377. https://doi.org/10.1080/10640260802370523
[14] Bellows, B. K., DuVall, S. L., Kamauu, A. W., Supina, D., Babcock, T., & LaFleur, J. (2015). Healthcare costs and resource utilization of patients with binge-eating disorder and eating disorder not otherwise specified in the Department of Veterans Affairs. The International journal of eating disorders, 48(8), 1082–1091. https://doi.org/10.1002/eat.22427
[15] Bankoff, S. M., Richards, L. K., Bartlett, B., Wolf, E. J., & Mitchell, K. S. (2016). Examining weight and eating behavior by sexual orientation in a sample of male veterans. Comprehensive psychiatry, 68, 134–139. https://doi.org/10.1016/j.comppsych.2016.03.007
[16] Serier, K. N., Smith, B. N., Cooper, Z., Vogt, D., & Mitchell, K. S. (2022). Disordered eating in sexual minority post-9/11 United States veterans. The International journal of eating disorders, 55(4), 470–480. https://doi.org/10.1002/eat.23680
[17] Arditte Hall, K. A., Bartlett, B. A., Iverson, K. M., & Mitchell, K. S. (2017). Military-related trauma is associated with eating disorder symptoms in male veterans. The International journal of eating disorders, 50(11), 1328–1331. https://doi.org/10.1002/eat.22782