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Military Accession and Disordered Eating Among Women: Clinical and Policy Recommendations [Military Medicine](Military Medicine Via Acquire Media NewsEdge) Eating disorder prevalence has steadily increased in the U.S. population. Between 1996 and 2006, there was a signifi- cant increase in rates of both diagnosis and hospitalization for adolescents and young adults-primarily women-with eating disorders.1 Health care professionals in the military have long been aware that new active duty accessions are at risk for problems related to eating, including serious medical disor- ders such as anorexia nervosa and bulimia nervosa, and that eating disorders in the military are consistently higher than in the civilian population.2,3 This article summarizes the literature bearing on the prevalence, risk factors, and context-specific triggers for eating disordered behavior among female service members. We suggest that stressors specific to military accession-when coupled with existing risk factors related to age, gender, family, and life experience-often exacerbate disordered eating. In essence, military induction itself may create the conditions for situation-induced eating impairment. We are concerned that the military could be far more effective in screening for and responding to disordered eating among new military personnel. In this commentary, we endeavor to bring fresh attention to the problem of disordered eating among new service members and offer a way forward for health care professionals and policy-makers with responsibility for military accessions. We begin by reviewing the revised diagnostic categories for eating disorders in the Diagnostic and Statistical Manual of Mental Disorders (5th edition: DSM-V),4 and provide a selective review of literature relevant to eating disorder risk factors and eating disorder risk during the military accession and indoctrination process. We con- clude with numerous recommendations for military health care providers and policy-makers. Although men certainly struggle with eating disorders-particularly men engaged in certain sports associated with cutting weight-this article focuses exclusively on women. The new DSM-V-the definitive source for prevalence rates of mental disorders-states that for both anorexia nervosa and bulimia nervosa, women are diagnosed far more frequently than men-at a 10:1 female to male ratio.4 Because persons with eating disorders are far more likely to suffer comorbid mood and anxiety disorders, personality psychopathology, and higher risk for suicidal behavior, it is essential that military providers be vigilant for eating disorder symptoms among women in the accession phase of military service.4 DSM-V EATING DISORDERS Anorexia Nervosa There are three essential features of anorexia nervosa: (1) per- sistent energy (caloric) intake restriction, (2) intense fear of gaining weight or becoming fat, and (3) a disturbance in self- perceived weight or body shape.4 Accurate weight assessments may pose a challenge because normal weight varies among individuals and Body Mass Index (BMI) assessments-now integrated into DSM-V criteria-are often not reliable, espe- cially in the case of adolescents.4 According to the DSM-V, the 12-month prevalence rate for anorexia nervosa among young women is approximately 0.4% and the onset is often associated with a stressful life event, such as leaving home for college. Bulimia Nervosa There are three essential features of bulimia nervosa: (1) recur- rent episodes of binge eating, (2) recurrent inappropriate compensatory behaviors to prevent weight gain, and (3) self- evaluation that is unduly influenced by body shape and weight.4 Patients with bulimia nervosa are often ashamed of their eating problems and attempt to conceal their symptoms. The prevalence of this disorder among young women is from 1% to 1.5%. As with anorexia the female to male ratio is 10:1 and the disorder may be triggered by external/situational or interpersonal stressors or negative affect.4 Binge Eating Disorder New to the DSM-V, binge eating disorder is defined as recur- ring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances.4 Importantly, the episodes of binging are char- acterized by lack of control once the binge begins. This patient will often experience feelings of guilt, embarrassment, or dis- gust and may binge eat alone to hide the behavior. Prevalence in young women is 1.6% and the triggers for the disorder are similar to those found in patients with bulimia nervosa.4 Other Specified Feeding or Eating Disorder A persistent criticism of the DSM-IV eating disorder categories was the fact that the most frequently diagnosed eating disorder was Eating Disorder Not Otherwise Specified (ED-NOS). This category was used in the case of persons with clinically signif- icant eating disorders that did not meet diagnostic criteria for anorexia nervosa or bulimia nervosa. In fact, evidence indi- cates that at the time of publication of the DSM-V in spring of 2013, ED-NOS accounted for nearly 60% of cases in eating disorder specialty clinics and 90% of eating disorder diagnoses in other settings.5,6 The new category in DSM-V, Other Specified Feeding or Eating Disorder, attempts to remedy the lack of precision in earlier nomenclature by allowing clinicians to diagnose eating syndromes that cause significant distress or impairment socially or occupationally. Examples of some of the eating disorders nested within this "other" category include atypical anorexia nervosa (signifi- cant weight loss but still within normal weight range), low frequency bulimia nervosa, low frequency binge eating, and purging disorder (frequent purging without binge eating). These new subcategories offer greater specificity when com- pared to the broad DSM-IV ED-NOS category. GENERAL RISK FACTORS FOR EATING DISORDERS Age and gender are the single most reliable risk factors for eating disorders. Young women-from puberty through their 20s-constitute the primary risk group.4,7 The highest inci- dence of eating disorder diagnoses occurs among college-age women-including women entering the military through enlisted or commissioned sources. Between 25% and 40% of college-age women express body dissatisfaction, difficulty with weight control, and worry about body weight and shape.8 Familial antecedents also contribute. Parents or siblings with weight problems and eating impairment, family member- typically maternal-modeling of dieting behavior, and family issues related to interpersonal control increase the risk for eating disorders.9 Both bulimia and anorexia are more likely in cultures or contexts in which thinness or low weight are highly valued.4 In these contexts-including modeling, elite athletics, and military service-young women are at risk for internalizing a thin body ideal.1-3 It appears that reactivity to body type role models may even have a neurological substrate. A recent functional magnetic resonance imaging study revealed that women's limbic systems showed greater activation when viewing other women's-versus their own-bodies.10 In the military context, new recruits exposed to notably thin and fit female role models may experience neurological reactivity, setting the stage for eating problems. Additional risk factors include overly restrained emotional expression, a pattern-or culture/context-of excessive exercise, college roommates that model dieting or excessive thinness, and abuse in child- hood.4,7,11 Finally, there is a significant subset of women with eating disorders that are not motivated by thinness as a body ideal as much as they are utterly repelled by the idea of being overweight.12 Of course, violation of weight standards in a military milieu may be particularly repellent for female service members. EATING DISORDERS AMONG FEMALE SERVICE MEMBERS It is clear that many of the salient risk factors for eating disorders are not only present, but in some cases intensified in military settings. Several studies suggest that entry-level mili- tary personnel are at significant risk for the onset or exacerba- tion of disordered eating. Prevalence rates for anorexia nervosa (1.1%), bulimia nervosa (8.1%-12.5%), and ED-NOS (36%- 62.8%) among female service members are considerably higher than those found in the civilian population.2,13 One contributing factor is the increasing numbers of overweight or obese individuals enlisting in the military and an increase in the number of persons seeking enlistment with histories of abuse.3 In one recent sample, 25% reported a history of verbal abuse, 15% reported physical abuse, and 6% reported a history of sexual abuse in childhood or adolescence.3 There are also several elements of the military culture that may predispose service members to disordered eating. These contextual factors include (1) maximum weight or BMI requirements that force new service members to cut weight or remain continually anxious about weight gain; (2) weight and BMI standards that fail to account for variations in body type as well as imprecise techniques for measuring these vari- ables; (3) shame, anxiety, and stigma associated with failing to meet weight standards-often exacerbated by assignment to a remedial exercise or weight-control program; (4) public "weigh-ins" or BMI measurements; (5) required meal atten- dance coupled with few low caloric food alternatives; (6) stan- dard uniforms that make service members feel overweight or unattractive; and (7) a pervasive emphasis on extreme thin- ness and athleticism as the military body ideal.2,13,14 Military Accession and Situational Eating Impairment In a review of both the traditional and the military-distinctive environmental factors placing military women at greater-than- average risk for disordered eating, Lauder and colleagues coined the term situational eating disorder to describe the intermittent eating disorder behaviors common among women in the early phase of their military careers.15 Accord- ing to these authors, a full 33% of their sample of 423 female Army soldiers met criteria for ED-NOS, whereas another 39% showed intermittent behaviors consistent with ED-NOS. In a follow-up study with 310 female Reserve Officers' Train- ing Corps officers-in-training, the authors discovered that 85% expressed a strong wish to drop weight and a full 20% were at risk for an eating disorder based on the perceived pressure to be thin and anxiety associated with frequent weigh-ins and potential repercussions for being overweight.16 Women entering the service academies carry all of the risk factors for disordered eating noted above. In addition, they are exceptionally high-achieving, prone to perfectionism, and tend to come from families who have pushed them to achieve at a high level throughout their educational careers. In many regards, this is a population of women "primed" to react negatively to perceived failure or evidence that they are not meeting or exceeding expectations. Caloric intake restriction, excessive exercise, and purging behavior may be attractive strategies for service academy women who feel themselves to be out of control or falling behind in the crucible of military accession. The concept of situational or contextual risk for eating disordered behavior is supported by two studies of women at the U.S. service academies. The first study evaluated cadets at the U.S. Military Acad- emy at Westpoint between 1999 and 2005 using the EAT-26 assessment of eating disordered behavior, the most widely used measure of eating problems in college-age adults.2,17 Although only 0.1% of male cadets self-diagnosed with an eating disorder, 5% of female cadets did so. More telling, 19% of females scored in the "at-risk" range for disordered eating on the EAT-26 indicating they engaged in problematic restricting, binging or compensatory behaviors with some fre- quency, though not enough to merit an eating disorder diag- nosis. A subsequent study of midshipmen at the U.S. Naval Academy largely confirmed the Westpoint findings. A longitu- dinal study of the class of 2012, also employing the EAT-26 measure, showed that on average, 20% of female members of the class of 2012 scored in the "at-risk" range for an eating disorder. More important, the data revealed a clear curvilin- ear trend in "at-risk" percentages across the 4 years at the Naval Academy: * Freshman (plebe) summer 7.9% * Freshman (plebe) winter 13.3% * Sophomore 26.4% * Junior 24.3% * Senior 19.5% This data indicate that eating disorder risk escalates rapidly during the first 2 years of induction into the Navy and then diminishes only modestly thereafter. This trend mirrors the Westpoint findings, which reported elevated scores during the second and third year at the military academy.2 This pattern of findings at the service academies appear to bolster Lauder and colleagues' assertion of a situational eating dis- order phenomenon among women associated with military accession.15 Students at both service academies say that anxiety related to height and weight standards, public weigh- ins, required meal attendance, and daily physical exercise requirements heightened their concerns about eating.2 More- over, a full 30% of the sample of Naval Academy students indicated belief that they would be separated from service if they disclosed an eating disorder, raising concerns about the extent to which service academy students would be inclined to seek assistance for serious eating problems. Just as the onset of college or other significant life changes or stressors may trigger eating disordered behavior in civilian women,4,7 entrance into the military appears to serve as a triggering mechanism for eating disorder risk among service members. Evidence from service academy cadets and mid- shipmen suggests that serious risk for eating dysfunction esca- lates quickly during the first year and peaks during the second and third years of service before showing a pattern of slight remission thereafter. In addition to the culture of thinness, discipline, and athleticism prevalent in the military, there is evidence from Displacement Theory that women are more inclined to suppress thoughts and feelings, directing them inward and managing them through food restriction in epi- sodes of binging.18 Displacement involves switching the target of one's feelings or impulses (e.g., aggression) to something more acceptable (e.g., self-denial, restriction). Termed "sup- pression of voice," women entering the tightly controlled and hierarchical structure of military service might be particularly vulnerable to using food to express internal distress. RECOMMENDATIONS FOR MILITARY HEALTH CARE PROVIDERS In light of the evidence pointing toward a real problem with situation-induced disordered eating among female military accessions, we now offer several specific recommendations for military health care providers. Our recommendations are intended specifically for generalists who are most likely to interface with new military recruits and officer candidates- often in the context of routine screenings or other forms of medical triage. Remain Alert to Clinical Indicators of Disordered Eating Because many-if not most-eating disorder sufferers are unlikely to self-report disordered eating, particularly in the military where stigma and threat of expulsion run high, it is imperative that medical providers remain alert to physical and psychological indicators of serious eating problems. Physically, be on alert for evidence of substantial weight loss, BMI index measurements below published norms, menstrual irregularity or amenorrhea, vital sign abnormalities, abnormal laboratory findings (secondary to self-induced vomiting, mis- use of laxatives or diuretics, or severe intake restriction) esophageal tears, gastric rupture, and other gastrointestinal symptoms.4 Of course, military dental personnel should be alert to unusual patterns of tooth enamel decay and all pro- viders should look for telltale pale scars on the patient's fingers-both of which are indicative of frequent purging. In addition to physical red flags, look for co-occurring evidence of depressed mood, social withdrawal, irritability, insomnia, and prominent signs of obsessive compulsive behavior or perfectionism. Inflexible thinking and overly restrained emo- tional expression, when coupled with physical symptoms, are additional causes for concern. Remain Alert to Comorbid Psychiatric Problems Military personnel suffering from eating disorders have ele- vated rates of psychiatric comorbidity. Studies of eating disorder comorbidity suggest markedly elevated rates of depression, anxiety, alcohol abuse, adjustment disorder, and post-traumatic stress disorder among military personnel with disordered eating.19 In one study, only 5% of female military veterans suffering from an eating disorder had no comorbid psychiatric disorder.20 This evidence suggests that when mil- itary health care providers encounter a service member with a diagnosis of substance use disorder, anxiety disorder, mood disorder, or a personality disorder, there should be some attention to the possibility that the patient simultaneously suffers from disordered eating of some sort. This is particularly important in the case of clinical depression because suicide rates are elevated in persons diagnosed with eating disorders.4 Specifically, mortality rates double among women suffering from an eating disorder and other psychiatric disorder.9 Make Appropriate Treatment Referrals as Early as Possible In military medical settings, mental health treatment stigma generally and eating-disorder stigma specifically may work against self-disclosure and treatment seeking among female accessions struggling with eating problems. This is certainly true in among civilian women of college age21,22 and there is strong evidence that stigma is alive and well in military settings as well.2,3 Providing women with a safe and supportive environment that encourages expression of thoughts, teaches healthy communicative strategies, and promotes positive cognitive coping strategies is likely to serve a useful starting point.19,23 Military mental health specialists with training in Cognitive Behavior Therapy, Dialectical Behavior Therapy, and family therapy in addition to nutritionists and dieticians with expertise in promotion of healthy eating habits will make useful targets for referral; these interventions represent the best in evidence-based outpatient care for eating disor- ders. Among college-age women, brief (3-4 hour) intensive prevention programs have shown exceptional promise in preventing the onset of eating disorders during the stress associated with leaving home and beginning college.24 Effec- tive prevention programs for military personnel would focus on achieving a healthy body ideal versus a thin ideal, improving dietary intake, nutritional science, and appropriate levels of physical activity. Despite the good potential for prevention of disordered eating, among those women in uni- form who do develop an eating disorder, as many as a quarter will relapse even following prolonged and intensive treat- ment, and many women who recover from an eating disorder retain certain features of atypical eating, restriction, or com- pensatory behavior.9 RECOMMENDATIONS FOR POLICY-MAKERS AND LEADERS Experience and clinical evidence suggest that improved responsiveness on the part of military health care providers will not be enough to significantly reduce the problem of disordered eating among female accessions. Several changes to military policy and administrative practice are necessary to change elements of the culture that currently fuel or exacer- bate problems with weight and appropriate eating among military personnel. In the section that follows, we highlight four specific recommendations for military policy-makers and local unit commanders. Improve Screening for Disordered Eating Before and During Accession Although current medical screening procedures during recruiting and accession into the military focus on major medical problems, including a history of treatment for psy- chiatric disorders, there is often less nuanced attention to risk factors for future disordered eating. Risk factors for disor- dered eating include being overweight or underweight at the time of recruitment, expressed body dissatisfaction, difficulty with weight control, worry about body weight and shape, mood problems, and personality psychopathology.8,9 Policy-makers and accession program managers should give specific attention to widespread implementation of stan- dardized screening tools for eating disorders. There are several well-validated and reliable self-report screening measures for administration in group formats. Two of the most well estab- lished screeners are the Eating Disorders Examination Ques- tionnaire (EDE-Q) and the Eating Attitudes Test (EAT-26).25,26 The EDE-Q offers sound psychometric properties and samples the behavioral aspects of eating disorder psychopathology (e.g., dietary restraint, eating concerns, shape concerns, weight concerns). The EAT-26 offers the appeal of an excep- tionally well-validated and widely utilized screening tool featuring a modest 26 items.26 It has been demonstrated to be highly effective as a sole means of detecting eating disor- ders. It is also possible that much shorter screening devices such as the SCOFF-featuring only 5 items-might be useful as a broad gateway screener during military accession.27 Of course, identification of significant risk for an eating disorder should be followed up with a more structured individual assessment, perhaps featuring a semi-structured interview such as the Interview for Eating Disorders, which can be adminis- tered by a range of health care professionals and serves as an effective tool for achieving differential diagnosis of anorexia nervosa, bulimia nervosa, and binge eating disorder.28 Change Practices Bearing on Body Assessment At most military commands-particularly those that handle new accessions (boot camps, service academies)-military personnel have their weight and BMI measured in large groups (companies or squads) such that each member's weight or BMI is public knowledge and may quickly become fodder for peer scrutiny and sometimes, ridicule. When com- bined with the shock of military induction, intense exposure to a thin/fit body ideal, body shame, and loss of control, there is concern that such public practices may exacerbate food intake restriction or purging.14 In addition, practices such as forcing women who exceed initial body weight or BMI stan- dards into "programs" designated for "overweight" or "out of regulations" service members may merely serve to increase stigma, shame, and extreme efforts to control weight. Rather than supportive, collaborative, and encouraging, these programs are often experienced as punitive and ostracizing. Emphasize Prevention It is problematic that most of the focus during the military accession and indoctrination process is on "intervention" after weight or eating problems emerge. Of course, an inter- ventionist approach can heighten stigma and there is evidence that once eating disorders develop, there may be chronic problems with relapse. In contrast, programmatic efforts emphasizing appropriate dietary intake, nutrition, a healthy body ideal, and positive coping strategies are likely to signif- icantly reduce the incidence of disordered eating among women during the military onboarding process and therefore the need for medical intervention.24 Address Stigma Associated With Eating Problems and Mental Health Care Mental health stigma is a daunting threat to the overall health and well-being of both service members and veterans. Pervasive stereotypes linking emotional distress with violence, weakness or incompetence, and powerful motivations to avoid diagnos- tic labels among service members play a role in low levels of mental health service seeking among those in need.29-31 Factors contributing to mental health care avoidance include discomfort discussing mental health problems, beliefs pro- moted by the military culture (e.g., mental health problems/ care = weakness and incompetence), negative leader behav- iors, career concerns, and witnessing negative experiences on the part of other treatment seekers.30 The story appears no brighter when it comes to eating disorders. There is strong evidence that college-age persons tend to hold eating-disorder sufferers responsible for their conditions. In one study, more than a third of subjects reported that people with such disor- ders should "just pull themselves together."22 Such stigma- tizing attitudes may be exacerbated in a military milieu that tends to prize independence and strict self-discipline. We concur with several recent authors who recommend concerted attention to the behavior and attitudes of local commanding officers when it comes to weight and eating problems. Sup- portive leader behaviors (e.g., low tolerance for harassment, modeling of healthy eating and exercise, strong support for prevention and nutrition programs, public encouragement for mental health care seeking) are likely to go a long way in decreasing both eating-disordered behaviors and mental health care stigma.32 Department of Leadership, Ethics & Law, United States Naval Academy, Luce Hall, Stop 7B, Annapolis, MD 21402. doi: 10.7205/MILMED-D-14-00075 REFERENCES 1. 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Brad Johnson, PhD; ENS Kelcie Davis, USN; ENS Victoria Gonzalez, USN (c) 2014 Association of Military Surgeons of the United States |