Semper Fi: EDs in the military

Of all the mental disorders associated with the military, post-traumatic stress disorder (PTSD) is at the top, followed by suicide/depression and addiction. But a number of studies have found that a surprisingly large number of people in the military have eating disorders, at rates that exceed current population estimates. Being a member of the military presents a number of difficulties and unique challenges to ED treatment.

First, let’s look at the prevalence of EDs in military servicemen and women, and see how they compare to national averages:

Lifetime Prevalence*(females/males) Males in the Military† Females in the Military(Navy Nurses)‡
Anorexia Nervosa 0.9%/0.3%  2.5%  1.1%
Bulimia Nervosa 1.5%/0.5%  6.8%  12.5%
Binge Eating Disorder 3.5%/2.0%  n/a  n/a

*Population data derived from Hudson et al., 2007, “The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication.” †Male military data from McNulty, 1997, “Prevalence and contributing factors of eating disorder behaviors in active duty Navy men.” ‡Navy nurse data from McNulty, 1997, “Prevalence and contributing factors of eating disorder behaviors in a population of female Navy nurses.”

These numbers are interesting because they suggest that, in the military at least, EDs are more prevalent in men than in women. McNulty notes that

Anorexia and bulimia nervosa existed without difference among all active duty men regardless of rank/rate, job assignment, or age. Use of laxatives, diuretics, diet pills, vomiting, and fasting for standards increased during the body measurement and fitness periods, but year-round use of these methods existed at disturbing rates.

It’s difficult to conclude too much from these data because many people did not respond to the researchers requests for information, these were relatively small surveys, and the data is rather dated. However, newer information on EDs really doesn’t exist. Information on women in the Marines indicates roughly equivalent levels of EDs compared to the Navy data. Still, the prevalence of EDs in military men is much higher than you would expect based on population data.

It’s important to note, too, that these data are likely underestimates. In a book by the National Academies Press titled “Assessing Readiness in Military Women,” the authors comment that

The low response rate for military surveys of dieting practices is likely to be the result of a recently rescinded policy that specified the diagnosis of an eating disorder as cause for separation from military service, according to several speakers at the 1996 workshop. As a result, any attempts to estimate the prevalence of eating disorders in the military are likely to underestimate the problem, and studies suggest that the prevalence of subclinical forms of chronic disordered eating is likely to be even greater that that of full-blown eating disorders. Thus, it is not possible to assess the impact of disordered eating on military readiness.

Perfect Storm of Factors

So why is the prevalence of EDs so much higher than in the general population?

For one, many of those serving in the military are young, between 18-35. These years are the prime age for both ED onset and ongoing struggles with the illness. Thus one might naturally expect that this population is more likely to have an ED than the average American population, which includes those at much lower risk.

The American military’s weight and fitness standards are also implicated in the prevalence of disordered eating and EDs. Weigh-ins are mandatory, and failure to make weight can potentially cause issues. Thus many in the military use very disordered practices to “make weight,” such as diuretics, fasting, dieting, purging, etc. For those vulnerable to developing an ED, these can serve as a potential trigger. More strictly enforced weight and body fat standards are also a factor. Although only one-fifth of the women enrolled in a military weight loss program said they were dieting to make weight, aesthetic and health factors also played a significant role, with 42.8% of women dieting to improve their appearance and 32.6% for health concerns. The military’s focus on weight seems to amplify the current cultural obsession with thinness, the authors concluded (Rose et al., 1993; excerpted in the “Assessing Readiness” book)

Lastly, the stresses of deployment and combat present their own risk factors. A 2009 study in the American Journal of Epidemiology found that deployment to combat zones led to a higher risk of significant body weight loss and disordered eating onset than deployment to non-combat areas (Jacobson et al., 2009). Women in combat areas had 1.78 times the risk of developing significant disordered eating, and 2.35 times the risk of losing 10% or more of their original body weight. Again, in people vulnerable to EDs, the stresses of combat can lead to weight loss that sets off a spiral of events that culminates in an ED.

Treatment options for military members

In the US, members of the military receive treatment through the government-run Veteran’s Administration. I searched the VA website for information on eating disorders. I found one (count ’em, one) page on eating disorders, which was a brief information summary adapted from the National Institute for Mental Health. That’s it. For the thousands of military men and women with EDs, that’s the only information provided by the VA.

One of my readers made a comment about how the VA (didn’t) treat her anorexia, which is what got me thinking about this in the first place. I am keeping her identity private, but she had a lot to say about the grim realities of ED treatment available for those who serve in the military. She entered the military with an emerging ED that got worse through the two years she served. When she was hospitalized for depression and diagnosed with AN, she was forced to leave the service.

She writes:

It’s tough to get anybody to talk about this because if you’re in still, you would feel in jeopardy—I certainly did. If you’re out and receive benefits you take the chance of VA ‘reviewing’ your benefits and ‘adjusting’ them. In other words, you take a huge chance of being retaliated against and believe me when I tell you it happens…Less than 1% of the country serves but we sure do get forgotten and manipulated because most of the 99% believe the govt. or VA has our backs. Not so.

When I was in there wasn’t a set weight you had to maintain in military. Now there is. If you fall out of the range (presumably over) you CAN NOT get promoted. When I was younger this could have been problematic for me because I tend to a muscular build when I’m working out and I’m shorter. I know when I read about this that I was immediately stricken with how this shouldn’t matter as long as you can pass the PT test and do your job. Now you are called out, dressed down and reprimanded both in writing and weight monitored (weekly or monthly–I’d have to check the regs) until you get within range again. Every single time you’re weighed there has to be a written report so it goes in your file. The potential for all kinds of damage is huge as the longer it takes for someone to get back in that range the worse the situation will be for them since it’s considered to be willful misconduct. You know the rules and you’re choosing to break them. But, what if you came into service not fully grown since some people grow into their early twenties? What if you decide you want to lift weights and gain strength? What if you just don’t fit the BMI standards?

The VA has a lot of tasks to manage, but if they can focus so much on weight loss and dieting, then they also need to focus on the spectrum of eating disorder behaviors that occur in those in the military. I mean, the government is asking these people to put their lives on the line, so we owe them better.

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7 Responses to “Semper Fi: EDs in the military”

  1. One of the presentations at the upcoming International Conference on Eating Disorders is titled “Working with the U.S. Military to Prevent Eating Disorders and Obesity in Adolescent Dependents”.
    I’m glad to see someone is thinking about how the intensive military focus on weight may be affecting the next generation.

  2. Wow- that’s great. Thanks for sharing.

  3. This is very interesting and I do believe the statistics for the military are greatly under reported. I am currently trying to recover from my eating disorder and my hubby is in the military, He is targeted for being over weight and he may loose his job if his weight doesn’t come down. He is very healthy, strong and great at his job but does not meet the proper aesthetic. I hate seeing him suffer, knowing that I can’t be a proper support because I am fighting my own demons.

  4. I’m pretty open about the fact that I was in the military and actually having an eating disorder (especially one that required treatment) resulted in me getting medically discharged. I think the fact that needing mental health help (it’s not exactly private when you do, since you have to leave work to go over there) can impact your work life… and obviously can jeopardize even having a job whatsoever results in people living with it. I did until it became too obvious to everyone.

    I also think that certain personality traits that leave people pre-disposed to eating disorders also drive them to join the military… and that people with eating disorders are also pulled to that way of life. It seems appealing. I believe a girl on the documentary Thin even mentions that.

    The medical director of Timberline Knolls is going to be doing a presentation about this in March btw.

  5. Thank you so much for sharing this with me.

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  7. There was a female marine in inpatient treatment with me. She was *very* sick, and talked a lot about the mandatory weigh-ins as being a contributing factor. For some reason, she was forced to do “family therapy” with her commanding officer, who gave her direct orders to, for example, put butter on her bread. Unsurprisingly, this approach (as far as I could tell) was not terribly helpful to her.