Military-related trauma is associated with eating disorder symptoms in male veterans

The Impact of Adversity on Body Mass Index as Veterans Transition to Civilian Life

INTRODUCTION

The impact of adverse childhood experiences (ACEs), warfare exposure, and mental health symptoms upon changes in body mass index (BMI) were examined in a large U.S. post-9/11 veteran sample to assess gender-specific changes in BMI within the first 2½ years after military service.

MATERIALS AND METHODS

Data were collected with institutional approval in 6 waves between 2016 and 2019 from veterans who (1) separated from active duty component service branches (i.e., Army, Navy, Air Force, and Marine Corps) or National Guard or Reserve or (2) deactivated from active duty status after serving in a National Guard or Reserve component. Veterans self-reported height and weight at separation/deactivation at wave 2, and weight was asked at each subsequent wave. Multilevel growth model analyses estimated the relationship between ACEs, warfare exposure, and mental health symptoms and BMI for males and females. Weighted wave 5 analyses were conducted to ensure the sample was calibrated for nonresponse based on wave 1 and the full sample (n = 48,965) for each cross-classification of the weighting variables of gender, rank, and branch.

RESULTS

Approximately one-third of the veterans reported a normal BMI at separation/deactivation in comparison to being overweight (51%) or obese (20%). Twenty-six percent of male veterans had a normal BMI in contrast to almost half of the female veterans. Male veterans who experienced 3-7 ACEs had a higher BMI (0.74) compared to male veterans without any ACEs, where a BMI increase of 0.08 per year was reported. Female veterans who experienced 1-2 ACEs had a higher BMI (0.89) compared to female veterans without ACEs. Male veterans who engaged in warfare (e.g., combat patrols and firing a weapon at enemy combatants) and experienced corollaries (i.e., consequences of combat) or who experienced corollaries alone (e.g., saw refugees who lost their homes/belongings) had higher BMIs (1.14 and 0.82, respectively) compared to male veterans without warfare exposure. Female veterans who experienced corollaries had a higher BMI (0.94) compared to female veterans with no warfare exposure. Female veterans who experienced warfare (i.e., corollaries and combat) had a higher BMI (0.71) compared to female veterans with no warfare exposure. Male veterans who screened positive for likely post-traumatic stress disorder (PTSD) or depressive symptoms had a higher BMI (1.01 and 0.52, respectively) compared to male veterans who did not screen positive. Male veterans who screened positive for likely PTSD increased their BMI by 0.10 per year. Male veterans who screened positive for both likely PTSD and depressive symptoms had a higher BMI (1.32) compared to male veterans who did not screen positive, and they increased their BMI by 0.21 per year. Female veterans who screened positive for likely PTSD and depressive symptoms had a higher BMI (0.78) and increased their BMI by 0.25 per year compared to female veterans who did not screen positive.

CONCLUSIONS

Boosting veterans' and service members' mental and emotional healing from childhood and warfare adversities through sound health promotion policies and increased access to evidence-informed interventions is imperative for optimal body weight and physical health.

Examining posttraumatic cognitions as a pathway linking trauma exposure and eating disorder symptoms in veteran men and women: A replication and extension study

Trauma is a risk factor for eating disorders (EDs). Enhanced understanding of the pathways from trauma to EDs could identify important treatment targets. Guided by theory, the present study sought to replicate previous findings identifying posttraumatic stress disorder (PTSD) symptoms and shape/weight overvaluation as important pathways between trauma and ED symptoms and extend this work by investigating the role of posttraumatic cognitions in these associations. The sample included 825 female and 565 male post-9/11 veterans who completed cross-sectional survey measures of trauma, posttraumatic cognitions, PTSD symptoms, shape/weight overvaluation, and ED symptoms. Gender-stratified structural equation models were used to examine direct and indirect pathways from trauma exposure to EDs via PTSD symptoms and shape/weight overvaluation (replication) and posttraumatic cognitions (extension). Results suggested that trauma exposure was indirectly associated with ED symptoms via shape/weight overvaluation and posttraumatic cognitions. There was no indirect association between trauma exposure and ED symptoms via PTSD symptoms. Overall, findings from this study highlight the potential role of posttraumatic cognitions in understanding the association between trauma and ED symptoms. However, future longitudinal research is needed to verify the directionality of these associations and investigate cognitions as a potentially targetable risk mechanism in co-occurring trauma and EDs.

Associations between avoidant/restrictive food intake disorder profiles and trauma exposure in veteran men and women

OBJECTIVE

Trauma exposure, particularly interpersonal trauma, is prevalent among individuals with eating disorders (EDs), and trauma exposure and the subsequent development of posttraumatic stress disorder have been associated with poorer outcomes for ED treatment. To our knowledge, there are no published investigations of trauma exposure among individuals with avoidant/restrictive food intake disorder (ARFID), a new diagnosis introduced by the Diagnostic and Statistical Manual of Mental Disorders-5. We investigated associations between trauma exposure and ARFID profiles in a sample of U.S. military veteran men and women.

METHOD

Participants in this cross-sectional study included 1494 veterans randomly selected from the population of post-9/11 veterans who had separated from military service within the previous 18 months. They completed a survey assessing EDs, including the Nine Item ARFID Screen and trauma exposure.

RESULTS

Results revealed that 9.8% of the sample exceeded cutoffs for any ARFID profile, with the picky eating profile being the most common. Trauma exposure was prevalent among participants who exceeded cutoffs for ARFID, particularly the picky eating profile.

DISCUSSION

Findings highlight the importance of addressing EDs, including ARFID, in veterans. It will be important to examine the extent to which trauma and trauma-related disorders impact treatment outcomes for individuals with ARFID.

Incidence and prevalence of eating disorders among U.S. military service members, 2016-2021

OBJECTIVE

Despite unique experiences that may increase eating disorder risk, U.S. military service members are an understudied population. The current study examined incidence and prevalence of eating disorder diagnoses in U.S. military personnel.

METHOD

This retrospective cohort study utilized Military Health System Data Repository (MDR) data on eating disorder diagnoses (2016-2021). Active duty, Reserve, and National Guard U.S. military service members who received care via TRICARE Prime insurance were identified by ICD-10 eating disorder diagnostic codes.

RESULTS

During the 6-year surveillance period, 5189 Service members received incident eating disorders diagnoses, with a crude overall incidence rate of 6.2 cases per 10,000 person-years. The most common diagnosis was other/unspecified specified eating disorders, followed by binge-eating disorder, bulimia nervosa, and anorexia nervosa. There was an 18.5% overall rise in total incident cases across the surveillance period, but this trend was not statistically significant (p = 0.09). Point prevalence significantly increased across the 6-year timeframe for total eating disorders (p < 0.001). Period prevalence for 6-year surveillance period was 0.244% for total eating disorders, 0.149% for other/unspecified eating disorder, 0.043% for bulimia nervosa, 0.038% for binge-eating disorder, and 0.013% for anorexia nervosa.

DISCUSSION

Overall crude incidence estimates for total eating disorders were higher than reported in prior research that included only active duty Service members and required an eating disorder diagnosis code in the first or second diagnostic position of the medical record. Comprehensive and confidential studies are needed to more thoroughly characterize the nature and scope of eating disorder symptomatology within U.S. military personnel.

PUBLIC SIGNIFICANCE

U.S. military service members are a vulnerable population with regard to eating disorder symptoms. Previously reported incidence and prevalence estimates using data from the Military Health System may have been underestimated due to overly stringent case definitions. Given personal and occupational barriers (e.g., career consequences), confidential studies of military personnel may provide more complete data on the scope of eating disorders to inform screening and clinical practice guidelines for military populations.

Pilot Study on Classification of Sensory Symptoms in PTSD

PTSD treatment that focused on a sensory symptoms is increasing. The study aimed to explore symptoms and abnormalities in the five senses exhibited by persons with PTSD and to examine whether there are any differences depending on type of traumatic experience. Questionnaire was followed by interviews to clinical psychologists involved in the treatment of PTSD. 249 PTSD symptoms exhibited in the sensory organs were collected. Sensory symptoms were classified into three categories according to the type of symptoms and the type of traumatic events. Cluster 1 is a group formed by child abuse and violence together with audition, tactile, and hyperarousal. Cluster 2 is made up of natural disaster, accident, and sexual assault together with vision, olfaction and intrusion. Cluster 3 is made up of multiple traumas together with gustation and dissociation. It is speculated that the survivors of Child abuse and violence are hypersensitive to sounds, the presence of others, and physical contact because they try to quickly sense when a perpetrator is approaching. Natural disasters, accidents, and sexual assault are events with strong smell and severe visual impact, it is possible that they may easily cause reliving of the event in the form of shocking visual images and smells in flashbacks. Dissociation symptoms were related with complex trauma and taste. The mouth is the site of first contact between mother and child, and it is possible that gustatory dissociation may occur mainly in cases of severe and repeated trauma since early childhood.

Military sexual trauma, combat trauma, and disordered eating among United States veterans: An exploration of underlying mechanisms

Military sexual trauma (MST) and combat trauma (CT) survivors experience disproportionate risk for disordered eating. A survey of MST, CT, disordered eating, trauma-related self-blame, emotion regulation challenges, body dissatisfaction, and dissociation among military personnel with a history of military-related trauma was conducted. These survey-based cross-sectional data were analyzed via parallel mediation analyses and Analyses of Covariance (ANCOVA). Six parallel mediation analyses were conducted examining trauma-related self-blame, emotion regulation challenges, body dissatisfaction, and dissociation as mediators linking MST and CT, separately, with purging, restricting, and bingeing. ANCOVAs were also performed to examine differences in levels of bingeing, restriction, and purging among people exposed to MST, CT, both MST and CT, and neither. MST and CT exposure was indirectly related to bingeing via emotion regulation challenges. MST and CT was also indirectly related to both restriction and purging via emotion regulation challenges and trauma-related self-blame. Dissociation and body dissatisfaction were not significant mediators in any model. Participants endorsed high levels of disordered eating. Individuals exposed to both MST and CT reported greater bingeing, restricting, and purging than individuals exposed to either CT, MST, or neither. Findings highlight the nuanced symptoms that may increase risk for disordered eating among MST and/or CT survivors. Future treatment research should explore how addressing emotion regulation and trauma-related self-blame among individuals with MST and/or CT may help address disordered eating. Implications and future directions for this area of research are discussed.

Gender similarities and differences in associations between weight discrimination, shape/weight concerns, and eating disorder symptoms among post-9/11 veterans

OBJECTIVE

Weight discrimination, defined as mistreatment of people based on body weight, is associated with body image concerns and eating disorder (ED) symptoms. Military veterans are particularly vulnerable to developing ED symptoms, which may be due to experiences of weight discrimination resulting from the military's strict weight and fitness requirements. However, no previous study has examined these associations among veterans. We investigated relationships between weight discrimination during and after military service and shape/weight concerns and ED symptoms in post-9/11 veterans. Based on evidence for gender differences in weight discrimination, body image, and ED symptoms, we also examined whether gender moderated these associations.

METHOD

Participants were randomly selected from the population of post-9/11 U.S. veterans who had been discharged from the military within the previous 18 months. A total of 1494 veterans completed the Everyday Discrimination Scale, Eating Disorders Examination-Questionnaire, and the Eating Disorder Diagnostic Scale-5.

RESULT

Women were more likely to report weight discrimination and had higher levels of ED symptoms and shape/weight concerns than men. Weight discrimination in and after leaving the military were positively associated with shape/weight concerns and ED symptoms in the full sample and among men and women. Gender moderated the association between weight discrimination after leaving the military and shape/weight concerns such that the association was stronger among men.

DISCUSSION

Both male and female veterans may be vulnerable to developing ED symptoms, in part due to weight discrimination experienced during and after military service. Our findings emphasize the need to address weight discrimination and its consequences in veterans.

Gender differences in direct and indirect associations of trauma types with disordered eating in a national U.S. veteran sample

OBJECTIVE

Disordered eating (DE) in military veterans has been linked to trauma exposure, but the mechanisms underlying this association remain unclear. The current study documented the direct associations of DE with multiple trauma types in a gender-balanced sample of veterans and examined indirect associations of trauma and DE via self-reported PTSD symptoms and concerns about shape and weight.

METHOD

Participants included 1,187 veterans (50% women, 46% men, 4% another) from multiple service eras. Sampling weights were applied to enhance representativeness to the national veteran population.

RESULTS

Gender-stratified, weighted models revealed associations of premilitary, warfare, and postseparation trauma with DE in men and associations of premilitary, military sexual (MST), and postseparation trauma with DE in women. Monte Carlo estimation of indirect effects showed support for indirect associations of premilitary, warfare, and postseparation-related trauma/stressor exposure with DE via PTSD symptoms among men; postseparation stressors were also indirectly associated with DE via shape and weight concerns. Among women, each trauma type was indirectly associated with DE via shape and weight concerns but not PTSD symptoms. When trauma exposures were examined concurrently, MST and postseparation trauma exposure were uniquely associated with DE via shape and weight concerns among women. Only the indirect association of postseparation trauma/stressor exposure with DE via shape and weight concerns was significant among men.

CONCLUSIONS

Findings support the need for gender-specific interventions that target different mechanisms contributing to DE symptoms among veterans. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Eating Disorders in U.S. Active Duty Military Members and Veterans: A Systematic Review

INTRODUCTION

Feeding and eating disorders can be difficult to treat and frequently co-occur with other mental health conditions. The last systematic review of eating disorders in a military and veteran population was published in 2015. An updated review is warranted to re-examine the current literature on eating disorders in the active duty and veteran populations.

MATERIALS AND METHODS

A systematic review that described the prevalence, co-occurrence of other disorders and/or events, and health care utilization of U.S. active duty members and veterans was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Databases and Medical Subject Headings (MeSH) terms used are listed in Appendix A. Each category of the literature was extracted and graded using the Oxford Centre for Evidence-Based Medicine Levels of Evidence.

RESULTS

Twenty-one studies revealed prevalence estimates with varying rates based on demographic information. Trauma exposure is consistently associated with eating disorder development. Individuals diagnosed with eating disorders had greater health care utilization.

CONCLUSIONS

Research on eating disorders in the military and veteran populations has expanded in recent years. Limitations of the evidence included in this review stem from the use of self-reported questionnaires, changes to medical record systems, and limited generalizability to the overall population of patients with eating disorders. Further research should investigate the impact of demographic factors and trauma exposure on the development of an eating disorder within the military and veteran populations.

Design and methods of the Longitudinal Eating Disorders Assessment Project research consortium for veterans

INTRODUCTION

Military service members must maintain a certain body mass index and body fat percentage. Due to weight-loss pressures, some service members may resort to unhealthy behaviors that place them at risk for the development of an eating disorder (ED).

OBJECTIVES

To understand the scope and impact of EDs in military service members and veterans, we formed the Longitudinal Eating Disorders Assessment Project (LEAP) Consortium. LEAP aims to develop novel screening, assessment, classification, and treatment tools for veterans and military members with a focus on EDs and internalizing psychopathology.

METHODS

We recruited two independent nationally representative samples of post-9/11 veterans who were separated from service within the past year. Study 1 was a four-wave longitudinal survey and Study 2 was a mixed-methods study that included surveys, structured-clinical interviews, and qualitative interviews.

RESULTS

Recruitment samples were representative of the full population of recently separated veterans. Sample weights were created to adjust for sources of non-response bias to the baseline survey. Attrition was low relative to past studies of this population, with only (younger) age predicting attrition at 1-week follow-up.

CONCLUSIONS

We expect that the LEAP Consortium data will contribute to improved information about EDs in veterans, a serious and understudied problem.

The Relationship Between Childhood Sexual Abuse and Eating Disorders Among African American Adolescents in the United States

BACKGROUND

Childhood sexual abuse (CSA) is one of the numerous adverse childhood experiences. CSA involves coercing a child to engage in sexual acts and is especially heinous as children are unable to consent or advocate for themselves. The formative years of a child are very crucial; therefore, the influence of sexual abuse could be irreversible. The development of an eating disorder is one of the identified consequences of sexual abuse. Using African American adolescents as the sample group, we explored the association between sexual abuse and eating disorders.

METHODS

A cross-sectional study was done with secondary data from the National Survey of American LifeAdolescent Supplement (NSAL-A), 2001-2004. Multivariable logistic regression was used to determine the association between CSA and eating disorders (anorexia nervosa, bulimia nervosa, and binge eating disorders) while adjusting for weight satisfaction.

RESULTS

In our sample of 824 African American adolescents, one of whom was also of Caribbean descent, 3.5% reported a history of CSA, while 2.2% reported having an eating disorder. Only about 5.6% of those with a history of CSA reported having an eating disorder. However, other psychiatric disorders were noted among those with a history of abuse, notably panic attacks, which were present in 44.8% of CSA survivors. Our study found no significant association between CSA and eating disorders (OR= 1.14, 95% CI (0.06, 6.20)).

CONCLUSION

While we sought to relate CSA with the development of eating disorders, we noted no direct association between the two but instead found an association between panic attacks and CSA. The mediating effect of other psychiatric disorders on the development of ED in CSA survivors should be further researched. It is imperative that survivors of CSA undergo immediate psychiatric evaluation. Primary care providers of survivors of CSA should maintain a high index of suspicion and screen for mental health disorders in these patients.

Prevalence and Factors Associated with Eating Disorders in Military First Line of Defense against COVID-19: A Cross-Sectional Study during the Second Epidemic Wave in Peru

Few studies have evaluated eating disorders in military personnel engaged in defense activities during the COVID-19 pandemic. We aimed to determine the prevalence and factors associated with eating disorders in military personnel from Lambayeque, Peru. A secondary data analysis was performed among 510 military personnel during the second epidemic wave of COVID-19 in Peru. We used the Eating Attitudes Test (EAT-26) to assess eating disorders. We explored associations with insomnia, food insecurity, physical activity, resilience, fear to COVID-19, burnout syndrome, anxiety, depression, post-traumatic stress and selected sociodemographic variables. Eating disorders were experienced by 10.2% of participants. A higher prevalence of eating disorders was associated with having 7 to 12 months (PR: 2.97; 95% CI: 1.24-7.11) and 19 months or more (PR: 2.62; 95% CI: 1.11-6.17) working in the first line of defense against COVID-19, fear of COVID-19 (PR: 2.20; 95% CI: 1.26-3.85), burnout syndrome (PR: 3.73; 95% CI: 1.90-7.33) and post-traumatic stress (PR: 2.97; 95% CI: 1.13-7.83). A low prevalence of eating disorders was found in the military personnel. However, prevention of this problem should be focused on at-risk groups that experience mental health burdens.

Eating disorders and disordered eating in servicemen and women: A narrative review

OBJECTIVE

Eating disorders (EDs) are mental illnesses impacting all aspects of an individual's life. Recent research has examined EDs and disordered-eating behaviors in the military, a population subject to body composition standards, fitness requirements, and extreme stress. The purpose of this narrative review was to investigate ED and disordered-eating prevalence and their risk factors in ROTC (reserve officers' training corps), active-duty, and veteran servicemembers. The secondary purpose was to provide policy recommendations to reduce the burden of these conditions in the military.

METHODS

PubMed and PsycINFO were reviewed for relevant articles. All studies including data on EDs or disordered eating in U.S. active-duty, ROTC, or veteran populations were considered.

RESULTS

Results revealed a high burden of EDs and disordered eating with bulimic- and binge-type behaviors being the most common. Servicemembers exposed to trauma, including military sexual assault, and those with comorbidities like PTSD showed a higher prevalence. Body composition and fitness testing were also associated with a higher risk. Qualitative studies suggest these conditions serve as coping mechanisms for aspects of military life.

CONCLUSIONS

The high prevalence of EDs and disordered eating in the military points toward the importance of identification, treatment, and prevention. Policy change is necessary to protect servicemembers.

Trauma exposure and eating disorders: Results from a United States nationally representative sample

OBJECTIVE

Sexual assault, child abuse, and combat have been linked to eating disorders (EDs). However, noninterpersonal trauma is relatively understudied, and therefore it is unknown whether noninterpersonal trauma is associated with EDs. Furthermore, most previous studies do not account for multiple trauma exposures, or the relative association of traumatic events with EDs in the same statistical model.

METHOD

Multinomial regression was used to examine the association of lifetime ED diagnosis (anorexia nervosa [AN], bulimia nervosa [BN], binge eating disorder [BED]) with trauma type (sexual interpersonal, other interpersonal, war/combat, and noninterpersonal) in a nationally representative dataset of US adults in bivariate and multivariable (i.e., with all trauma types) models.

RESULTS

Sexual interpersonal trauma was significantly positively associated with AN and BED in bivariate and multivariable models. In the multivariable model, only BED was found to be equally associated with sexual interpersonal, other interpersonal, and noninterpersonal trauma.

DISCUSSION

These results indicate a strong positive association between sexual trauma and EDs, even when controlling for experiences of other trauma events. Future research should examine longitudinal mediators between trauma and EDs, especially sexual trauma, to identify what factors may explain this relationship.

PUBLIC SIGNIFICANCE STATEMENT

Individuals with eating disorders often experience traumatic events but it is unclear whether specific trauma types are more or less common in this population. This study found that only events such as rape and sexual assault are associated with anorexia nervosa, but that most trauma types are associated with binge eating disorder. Therefore, the relationship between trauma and binge eating disorder may function differently than other eating disorders.

Eating disorder behaviors and treatment seeking in self-identified military personnel and veterans: Results of the National Eating Disorders Association online screening

OBJECTIVE

To characterize disordered eating behaviors, eating disorder (ED) risk and diagnosis, and treatment seeking behaviors in active-duty military personnel/veterans compared with civilians.

METHOD

Self-selecting participants (n = 113,388; 1744 were military personnel/veterans) 18+ years old completed the National Eating Disorders Association's online screen. Engagement in and frequencies of disordered eating behaviors were compared across military/veteran and civilian groups and were stratified by gender. ED risk and diagnosis and treatment seeking behaviors were also compared.

RESULTS

Individuals in the military/veteran group were more likely to engage in diuretic/laxative use and excessive exercise compared with civilians. Compared with civilians, the military/veteran group had a lower percentage who screened "at risk for an ED" and a higher percentage who screened for "no risk". Females in the military/veteran group were more likely to engage in diuretic/laxative use, excessive exercise, and fasting compared with female civilians; males in the military/veteran group were more likely to engage in excessive exercise and less likely to engage in vomiting than male civilians. Of the self-identified military personnel/veterans who screened positive for any ED, 86% had never received treatment, which did not differ significantly from civilians. Notably, 56.7% of those (54.1% of military/veteran group; 56.7% of civilians) who completed an optional item on intention to seek treatment (n = 5312) indicated they would not seek treatment.

CONCLUSIONS

Disordered eating and ED profiles, but not treatment seeking, may differ between military personnel/veterans and civilians who complete an online ED screen. Future work should emphasize treatment options and connecting respondents directly to tailored resources.

Prevalence of eating disorders and comorbid psychopathology in a US sample of treatment-seeking veterans

OBJECTIVE

Eating disorders (EDs) are a well-studied public health issue in the general population. Less is known, however, about the prevalence of such conditions and levels of comorbid psychopathology among military and veteran populations. The current study sought to describe the probable prevalence of EDs and levels of comorbid psychopathology using a racially diverse treatment-seeking sample of US veteran men and women.

METHOD

Veterans (N =254) presenting for routine clinical care completed self-report questionnaires assessing EDs, posttraumatic stress disorder, depression, and shame.

RESULTS

Thirty-one percent of the sample met probable criteria for either bulimia nervosa (BN), binge-eating disorder, or purging disorder. Although overall ED prevalence estimates were similar across men and women, estimates of BN were higher among Black veterans compared to White veterans or veterans who identified as a race other than Black or White. Further, mean levels of psychopathology were significantly higher in veterans with a probable ED compared to those without.

DISCUSSION

This study extends previous research and highlights the importance of establishing dedicated ED screening programs within the Veterans Health Administration.

Association between relational trauma and empathy among male offenders in China

BACKGROUND

Offenders are more likely than the general population to have experienced relationship trauma. They are also more likely to have lower empathy. To date, relationships between historical trauma and later empathic states have not been examined among offenders.

AIMS

To explore the association between history of trauma in close personal relationships and empathy among offenders. Our research question is: Is such relational trauma associated with self-rated impairments in empathy?

METHODS

All men with a primary school education and above at a single all-male prison in Jiangsu Province in China were invited to participate. The self-reported Interpersonal Reactivity Index was used to evaluate empathy, and the Brief Betrayal Trauma Survey was to explore interpersonal trauma and classify such experiences.

RESULTS

Interpersonal trauma was associated with higher personal distress and lower empathic concern among men reporting relational trauma in adulthood, but only higher personal distress when the trauma reported was in childhood. Non-relational trauma was associated with higher empathic concern. Cognitive aspects of empathy varied little between groups.

CONCLUSIONS

Our findings add to the existing literature by making distinctions between the types of trauma and the age of key experience in its relationship to self-reported empathy. The differences found suggest that it may be helpful to consider planning any trauma-related interventions differently according to the type and age of trauma experiences.

Post-traumatic stress disorder may set the neurobiological stage for eating disorders: A focus on glutamatergic dysfunction

Post-traumatic stress disorder (PTSD) is a trauma and stress-related disorder which has been shown to be highly comorbid with, and commonly a precedent of, the eating disorders anorexia nervosa, bulimia nervosa, and binge eating disorder. The objective of this review is to discuss a potential overlapping neurobiological mechanism for this comorbidity. Alterations in glutamatergic neurotransmission have been observed in all four of the aforementioned disorders. Excessive excitation via glutamate contributes to excitotoxicity, and over-activation of the hypothalamic-pituitary-adrenal axis, both of which have implications for the deterioration of various brain structures. Prominent structures impacted include the hippocampus, hypothalamus, and prefrontal cortex, all of which are integral to the regulation of stress and eating. The current review suggests that altered glutamate function by trauma or extreme stress may facilitate PTSD and subsequent eating disorder onset, and that glutamatergic modulation may be a key treatment for individuals suffering from these conditions. This overlapping mechanism may help inform future research on individuals with comorbid PTSD and eating disorders, and it could also help inform ways to potentially prevent the onset of these conditions.

DSM-5 eating disorder prevalence, gender differences, and mental health associations in United States military veterans

OBJECTIVE

Little is known about prevalence estimates of new and revised DSM-5 eating disorders diagnoses in general, and especially among high-risk, underserved and diverse eating disorder populations. The aim of the current study was to determine prevalence, gender differences and correlates of DSM-5 eating disorders in veterans.

METHOD

Iraq and Afghanistan war era veterans (N = 1,121, 51.2% women) completed the Eating Disorder Diagnostic Scale-5 and validated measures of eating pathology and mental health between July 2014 and September 2019.

RESULTS

Overall more women than men (32.8% vs. 18.8%, p < .001) reported symptoms consistent with a DSM-5 eating disorder. Prevalence estimates (women vs. men) for the specific diagnoses were: Anorexia Nervosa (AN; 0.0% vs. 0.0%), Bulimia Nervosa (BN; 6.1% vs. 3.5%), Binge-Eating Disorder (BED; 4.4% vs. 2.9%), Atypical AN (AAN; 13.6% vs. 4.9%), Subclinical BN (0.0% vs. 0.2%), Subclinical BED (1.4% vs. 0.6%), Purging Disorder (2.1% vs. 0.7%), and Night Eating Syndrome (NES; 5.2% vs. 6.0%). Women were more likely to have BN or AAN, and there was no difference for BED or NES among genders. The eating disorder group had a higher mean BMI, and significantly greater eating pathology and mental health symptoms than the non-eating disorder group.

DISCUSSION

Approximately one-third of women, and one-fifth of men, reported symptoms consistent with a DSM-5 eating disorder diagnosis. These high prevalence estimates across genders, and associated mental health concerns, suggest an urgent need to better understand and address eating disorders in military and veteran populations.

Atypical Anorexia Nervosa, not so atypical after all: Prevalence, correlates, and clinical severity among United States military Veterans

OBJECTIVE

DSM-5 Atypical Anorexia Nervosa (AAN), a new eating disorder diagnosis, presents similarly to Anorexia Nervosa (AN) in the absence of severe underweight. The prevalence of AAN and other DSM-5 eating disorders was estimated in a sample of Veterans. Sociodemographic, mental health, and eating behavior correlates were examined.

METHOD

Iraq and Afghanistan war era Veterans (N = 1137, 51.6% female) completed the Eating Disorder Diagnostic Scale-5 for probable AAN diagnosis, and validated measures of eating pathology and mental health, between February 2016 and October 2019. Multivariate analyses compared Veterans with AAN to those with and without any DSM-5 eating disorder.

RESULTS

Among completers, 13.6% of women and 4.9% of men in the sample met criteria for probable AAN and 19.2% of women and 13.9% of men for another eating disorder. Mean age was 41 years, and on average BMIs were classified as overweight (BMI = 28.8, SD = 5.6) despite being at least 10% lower than their lifetime highest weight. Two-thirds reported dietary restraint on more than half the days in the past month. On measures of mental health, the AAN group had worse functioning than the no eating disorder group, similar functioning to Veterans with Binge Eating Disorder (BED), and better functioning than Veterans with Bulimia Nervosa (BN).

DISCUSSION

Results support AAN as a highly prevalent and clinically significant diagnosis. Findings highlight the need to identify and address eating disorders, particularly other specified eating disorders not meeting criteria for AN, BN, or BED, in active military and Veteran, and other high-risk and underserved, populations.

Diagnosis of Eating Disorders Among College Students: A Comparison of Military and Civilian Students

INTRODUCTION

Eating disorders are often under-detected, which poses a serious threat to the health of individuals with eating disorder symptoms. There is evidence to suggest that the military represents a subpopulation that may be susceptible to high prevalence of eating disorders and vulnerable to their underdiagnosis. Underreporting of eating disorder symptoms in the military could lead to this underdiagnosis of individuals with eating disorder symptoms. The purpose of this study was to examine the association between military affiliation and eating disorder symptoms among college students and the likelihood of eating disorder diagnosis among those with eating disorder symptoms using a large, diverse college-aged sample of both military-involved and civilian students.

MATERIALS AND METHODS

Participants for this study were from the 2015-2016, 2016-2017, and 2017-2018 Healthy Minds Study (HMS). Healthy Minds Study is a large, cross-sectional cohort study of both undergraduate and graduate students from universities and colleges across the United States and Canada. The Healthy Minds Study survey questions include assessment of demographic information, military status, self-reported eating disorder symptoms using the SCOFF questionnaire, and self-reported eating disorder diagnosis. Univariate analysis, chi-square analysis, and logistic regression with an unadjusted and covariate adjusted model were used to examine the association between eating disorder symptoms and military affiliation. These analyses were also used to examine the association between eating disorder diagnosis among those with eating disorder symptoms and military affiliation. All analyses were conducted using SPSS.

RESULTS

The prevalence of eating disorder symptoms was high among both the civilian (20.4%) and military-involved (14.4%) students. Among females, there was a significantly higher (P value = .041) prevalence of eating disorder symptoms among civilian college students (24.7%) compared to military-involved students (21.3%). Among those with eating disorder symptoms, the prevalence of diagnosis was low in both military and civilian students. Specifically, the prevalence of diagnosis was significantly lower (P value = .032) among military-involved college students (10.8%) compared to civilian college students (16.4%). Differences in sociodemographic characteristics (e.g., gender, race/ethnicity, and age) among military-involved and civilian college students appear to explain this association.

CONCLUSIONS

The underdiagnosis of eating disorders is far too common, and this represents a threat to the health of military and civilian populations alike. Underdiagnosis of eating disorders within military environments may be due to underreporting, particularly among men and racial/ethnic minority groups.

Gender-specific approach in psychiatric diseases: Because sex matters

In both animals and human beings, males and females differ in their genetic background and hormonally driven behaviour and show sex-related differences in brain activity and response to internal and external stimuli. Gender-specific medicine has been a neglected dimension of medicine for long time, and only in the last three decades it is receiving the due scientific and clinical attention. Research has recently begun to identify factors that could provide a neurobiological basis for gender-based differences in health and disease and to point to gonadal hormones as important determinants of male-female differences. Animal studies have been of great help in understanding factors contributing to sex-dependent differences and sex hormones action. Here we review and discuss evidence provided by clinical and animal studies in the last two decades showing gender (in humans) and sex (in animals) differences in selected psychiatric disorders, namely eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder), schizophrenia, mood disorders (anxiety, depression, obsessive-compulsive disorder) and neurodevelopmental disorders (autism spectrum disorders, attention-deficit/hyperactivity disorder).

The Mediating Role of Alexithymia in the Association Between Adverse Childhood Experiences and Postdeployment Mental Health in Canadian Armed Forces Personnel

Recent studies showing an association between adverse childhood experiences and the development of alexithymia in military personnel have generated interest regarding the role of alexithymia in the pathway linking childhood trauma exposure to mental health disorders. Accordingly, the current study was conducted to (a) examine the associations among adverse childhood experiences, alexithymia, and symptoms of depression and posttraumatic stress disorder (PTSD) among recently deployed Canadian military personnel and (b) assess the mediating role of alexithymia in these associations. Data collected from 2,927 members of the Canadian Armed Forces at baseline and after their return from an overseas deployment were subjected to a prospective path analysis. The results of the path analysis, R² = .35, pointed to a significant direct effect of childhood adversity on postdeployment mental health symptoms. Contrary to our expectations, the results also pointed to a negative indirect effect of childhood neglect, suggesting that childhood neglect contributed to lower levels of postdeployment depression and PTSD symptoms through the dimension of alexithymia related to difficulty in describing feelings. These patterns of associations, for the most part, persisted even when accounting for combat exposure during recent deployments, R² = .42. The present results are discussed in light of study limitations and methodological considerations, and policy and clinical implications are noted.

Impact of trauma in childhood and adulthood on eating-disorder symptoms

Exposure to a traumatic event is concurrently and prospectively associated with disordered-eating behaviors such as binge eating, restricting, and purging. Specifically, purging has been found to be elevated in individuals with trauma histories, suggesting that purging may be a method for coping with trauma-related distress. However, there has been limited research investigating whether the time at which trauma occurs during development is differentially associated with disordered-eating behaviors and internalizing psychopathology. The purpose of this study was to examine the effect of trauma that occurred in childhood, adulthood, or childhood and adulthood on eating disorder (ED) and internalizing psychopathology. Participants were community-recruited adults with a current DSM-5 ED (N = 225) and were subsequently grouped into categories based on the time at which trauma occurred. Groups included: no trauma exposure ED controls (n = 54), child trauma group (n = 53), adult trauma group (n = 53), and child+adult trauma group (n = 65). We compared groups on their level of disordered-eating symptoms. Participants were administered the Structured Clinical Interview for DSM-IV, the Eating Pathology Symptoms Inventory (EPSI), and the Inventory of Depression and Anxiety Symptoms-II (IDAS-II). Univariate analyses revealed significantly higher levels of purging symptomatology in the child+adult trauma group compared to the no trauma, child trauma, and adult trauma groups. The current study highlights the importance of assessing the timing of trauma among individuals with EDs. In particular, our study indicates a need for further investigation to explain why individuals with ED and trauma histories engage in greater purging.

Body image and body change behaviors associated with orthorexia symptoms in males

In recent years, Orthorexia Nervosa has received increasing attention as a form of restrictive disordered eating driven by concerns related to "healthy eating" as opposed to weight and shape concerns. To date, however, data on the correlates of orthorexia in men are lacking, particularly pertaining to the relationship between orthorexia and muscularity-related dimensions. A sample of 103 (M_age = 19.84) male college students completed an online questionnaire reporting on orthorexia symptoms, eating pathology, drive for muscularity, exercise dependence, and internalization of the thin and athletic ideals. Correlational analyses and linear regression models were used to explore relationships between orthorexia and variables of interest. Findings revealed positive relationships between high levels of orthorexia symptoms and eating pathology, exercise dependence, thin and athletic internalization, and behavioral dimensions of drive for muscularity. The results of this study extend our understanding of the correlates of orthorexia symptoms among young men and highlight their association with other dimensions of eating pathology as well as dysfunctional exercise. In addition, concerns related to healthiness may overlap with muscularity-related concerns, perhaps due to the conflation between health and muscular appearance in social constructions of male body ideals.

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.

A bifactor analysis of the Weight Bias Internalization Scale: What are we really measuring?

Internalized weight stigma (IWS) has been linked with disordered eating behavior, both directly, and as a mediator of the relationship between experienced weight stigma and maladaptive coping. However, the construct of IWS is highly correlated with the related constructs of body image and global self-esteem, and the three constructs may better be represented by underlying trait self-judgment. This overlap is not generally accounted for in existing studies. The present study investigated the shared variance between self-esteem, body image, and IWS in an international sample of higher-weight individuals. Bifactor analysis confirmed that the intermediary role of IWS in the relationship between experienced stigma and self-reported eating behavior was largely accounted for by aspects of body image and global self-esteem. Greater conceptual clarity in the study of IWS is needed to understand the mechanisms via which societal weight stigma impacts on individuals' self-directed judgments and downstream health-related behaviors.

Acceptance and commitment therapy as an adjunct to the MOVE! programme: a randomized controlled trial

OBJECTIVE

The current study tested the efficacy of an acceptance and commitment therapy (ACT) group intervention for disinhibited eating behaviour as an adjunct to the Veterans Affairs MOVE!© weight management programme.

METHODS

Veterans (N = 88) with overweight or obesity who completed the MOVE! weight management programme and self-identified as having problems with 'stress-related eating' were randomized to four 2-h weekly ACT sessions or a continued behavioural weight-loss (BWL) intervention. Assessments were completed at baseline, post-treatment and 3- and 6-month follow-up on outcomes of interest including measures of disinhibited eating patterns, obesity-related quality of life, weight-related experiential avoidance and weight.

RESULTS

The BWL group exhibited significantly greater reductions in binge eating behaviour at post-treatment compared with the ACT group. Significant improvements in other outcomes were found with minimal differences between groups. In both groups, decreases in weight-related experiential avoidance were related to improvements in binge eating behaviour.

CONCLUSIONS

Taken together, the continued BWL intervention resulted in larger improvements in binge eating behaviour than the ACT intervention. The two groups showed similar improvements in other disinhibited eating outcomes. Future studies are encouraged to determine if more integrated or longer duration of ACT treatment may maximize eating outcomes in MOVE.Trial Registration Number: This trial was registered with ClinicalTrials.gov database (NCT01757847).

Gender-based differential item functioning in measures of eating pathology

OBJECTIVE

Eating disorder (ED) symptoms are common and impairing in males, despite their perception as "female" disorders. As existing self-report symptom measures were developed and primarily validated in women, there is a need to establish the utility of these measures in men. The present study used differential item functioning (DIF) analyses to explore whether item endorsement differed by gender for three commonly used ED symptom measures.

METHOD

Participants were undergraduate men (n = 1,083) and women (n = 2,424) from three universities in the United States. Global scores on the Eating Attitudes Test-26 (EAT-26), Eating Disorder Examination Questionnaire (EDEQ), and Eating Disorder Diagnostic Scale for DSM-IV (EDDS) were examined. Tests of DIF were conducted by regressing each item against its composite scale score, and then comparing fit and variance explained (R² ) to a model with the interaction of item*gender. The clinical significance threshold for DIF is ΔR² ≥ 0.13.

RESULTS

There was no evidence of clinically significant DIF within the EAT-26, EDEQ, or EDDS.

DISCUSSION

Findings suggest that the examined measures perform similarly for undergraduate men and women, supporting their use in nonclinical male samples. However, development and testing of items reflecting ED symptoms that more commonly occur in males (e.g., muscularity-oriented behaviors) is encouraged.

Internalised Weight Stigma Moderates the Impact of a Stigmatising Prime on Eating in the Absence of Hunger in Higher- but Not Lower-Weight Individuals

A considerable body of evidence links internalised weight stigma with higher levels of disordered eating behaviour and cognitions in both normative- and higher-weight populations. However, to date, the impact of internalised weight stigma on objectively measured food intake has not been explored. In the present study, a weight-diverse sample of 158 non-smoking adults (BMI ≥ 25 kg/m2 n = 72, BMI < 25 kg/m2 n = 86) were recruited to a study on "The effects of hunger and satiety on information processing." Participants first completed a series of online questionnaires, then attended a lab visit in a fed state. Participants were randomised to read a sham news article on the negative consequences of either weight (stigma condition) or smoking (control condition) and answer some questions about the article. Then, under the pretence of a non-study-relevant break, participants were exposed to a pre-weighed selection of sweet and savoury snacks for 15 min. Mood and hunger levels were assessed prior to and after reading the vignette, and after the break. In contrast to the relationship with self-report eating behaviour, internalised weight stigma was not a significant independent predictor of total energy intake and did not moderate the relationship between exposure to the stigma prime and calories consumed. However, differences emerged on the basis of participants' weight status. Higher-weight participants with high levels of internalised weight stigma consumed fewer snack calories following exposure to a weight-stigma prime compared with a neutral prime (B = -137, SE = 58, t = -2.35, p = 0.020, 95% CI -252, -22) whereas those with low levels of internalised weight stigma tended to eat more in the weight stigma condition (B = 118, SE = 62, t = 1.91, p = 0.059, 95% CI -4, 241). In normative-weight participants, no differences in energy intake by levels of internalised weight stigma were observed. These findings suggest differences in the relationships between internalised weight stigma and self-reported disordered eating behaviour versus eating in the absence of hunger (EAH) measured under laboratory conditions. Additionally, internalised weight stigma appears to have differential effects on response to stigma in higher-weight and normative-weight individuals.

The physical and mental health burden of obesity in U.S. veterans: Results from the National Health and Resilience in Veterans Study

In this study, we provide an updated estimate of the prevalence of obesity in U.S. military veterans, and evaluate a broad range of sociodemographic, military, physical and mental health, and lifestyle characteristics associated with obesity in this population. Data were analyzed from a nationally representative sample of 3122 U.S. veterans who participated in the National Health and Resilience in Veterans Study (NHRVS). Associations between obesity status, and physical and mental health, and lifestyle variables were evaluated using multivariate logistic regression and linear regression analyses. Results revealed that 32.7% of U.S. veterans are obese, which is higher than the previously reported estimates for U.S. military veterans nationally, and was particularly high among younger and non-white veterans and those using the Veterans Heath Administration (VHA) healthcare system. Obesity was associated with greater trauma burden; elevated rates of a broad range of health conditions such as diabetes, arthritis, and heart disease, PTSD, nicotine dependence; poor physical and mental functioning and quality of life, and decreased engagement in an active lifestyle. Taken together, these results suggest that the prevalence of obesity is high in U.S. veterans and associated with substantial health burden. Results have implications for informing obesity prevention and treatment programs in veterans, and underscore the importance of assessing, monitoring, and treating obesity in this population.