Eating Disorders and Overweight/Obesity in Veterans: Prevalence, Risk Factors, and Treatment Considerations

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.

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.

Psychiatric Issues in Women Veterans

Women veterans have unique life experiences and mental health needs, perhaps in part related to their high rates of exposure to traumatic events including military sexual trauma, combat trauma, and intimate partner violence. We review mental health difficulties among women veterans and describe related functional impairment. Evidence-based treatments are available, but barriers to care remain, including providers' lack of awareness of the unique needs of women veterans. Efforts are needed to increase access to evidence-based interventions, remove barriers to care, and improve provider competency working with this population to maximize clinical outcomes.

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.

Depression, Insomnia, and Obesity Among Post-9/11 Veterans: Eating Pathology as a Distinct Health Risk Behavior

INTRODUCTION

Understanding the interrelationships between co-occurring chronic health conditions and health behaviors is critical to developing interventions to successfully change multiple health behaviors and related comorbidities. The objective of the present study was to examine the effects of depression, insomnia, and their co-occurrence on risk of obesity and to examine the role of health risk behaviors as potential confounders of these relationships with an emphasis on eating pathologies.

METHODS

Iraq and Afghanistan conflict era veterans (n = 1,094, 51.2% women) who participated in the Women Veterans Cohort Study between July 2014 and September 2019 were categorized as having depression, insomnia, both, or neither condition. Logistic regression models were used to examine group differences in the risk of obesity. Health risk behaviors (i.e., eating pathology, physical activity, smoking, and hazardous drinking) were then assessed as potential confounders of the effects of depression and insomnia on the likelihood of obesity.

RESULTS

Obesity was most prevalent in individuals with co-occurring insomnia and depression (53.2%), followed by depression only (44.6%), insomnia only (38.5%), and neither condition (30.1%). Importantly, maladaptive eating behaviors confounded the depression-obesity association but not the insomnia-obesity association. There was no evidence that insufficient physical activity, smoking, or hazardous drinking confounded the effects of insomnia or depression on obesity.

CONCLUSIONS

These findings exemplify the complex relationships between multiple health conditions and behaviors that contribute to obesity. Elucidating these associations can enhance the precision with which interventions are tailored to efficiently allocate resources and reduce the severe health impact of obesity among veterans.

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.

The impact of the COVID-19 pandemic on eating disorders in U.S. military veterans

PURPOSE

The COVID-19 pandemic has had a profound impact on mental health around the world. Although there have been reports that the incidence of eating disorders (EDs) has increased during the pandemic, few longitudinal studies have examined recent changes in EDs. Men and women with military histories may be particularly vulnerable to EDs, underscoring the importance of investigating the impact of the COVID-19 pandemic on EDs in this population.

METHOD

We examined whether early-pandemic (Time 1; T1) posttraumatic stress disorder, depression, anxiety, and stress symptoms were associated with change in probable ED diagnostic status 1 year later (T2). We also investigated relationships from early pandemic mental health symptoms to change in ED diagnostic status from T1 to T2 via pandemic-related life circumstance pathways (health, financial, social, etc.). Participants included a population-based sample of 372 U.S. veterans who completed the T1 and T2 surveys.

RESULTS

Early pandemic mental health was significantly and positively associated with probable ED diagnostic status. Social and health satisfaction as well as physical health pandemic impacts mediated the associations between mental health symptoms and ED diagnostic status.

DISCUSSION

Findings highlight the importance of bolstering social connection, health-promoting behaviors, and access to ED treatment among veteran men and women impacted by the COVID-19 pandemic.

PUBLIC SIGNIFICANCE

The COVID-19 pandemic has had a profound impact on mental health, including eating disorders (EDs). We found that early pandemic mental health symptoms were significantly associated with changes in U.S. veterans' ED diagnostic status 1 year later. Mental health symptoms increased ED diagnoses via their impact on social and health satisfaction, as well as physical health impacts of the pandemic. Findings highlight the importance of increasing social connection, health-promoting behaviors, and ED treatment access among veteran men and women, who may be particularly vulnerable to EDs, during the COVID pandemic.

Obesity in Latinx and White U.S. military veterans: prevalence, physical health, and functioning

OBJECTIVE

While Latinx Americans in the general population are more likely to have obesity than non-Hispanic Whites, limited research has examined ethnic differences in obesity and its correlates among military veterans. To address this gap, we examined the prevalence, physical health and functional correlates of obesity in a population-based sample of Latinx and White U.S. military veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of veterans. Bivariate and multivariate analyses were conducted to evaluate the relation between obesity, and health and functioning measures in Latinx and White veterans.

RESULTS

The prevalence of obesity was significantly higher among Latinx veterans (weighted 43.6% vs. 35.5%; odds ratio (OR) = 1.4, 95% confidence interval (CI) = 1.10-1.81). While obesity was associated with a greater number of medical conditions, reduced functioning, higher somatic symptoms, and insomnia severity in both Latinx and White veterans, these differences were more pronounced in Latinx relative to White veterans, with higher rates of arthritis, liver disease, diabetes, high blood pressure and cholesterol, heart attack, stroke, migraine, and physical disability, and greater physical, mental, and psychosocial dysfunction.

CONCLUSION

Obesity is more prevalent in Latinx than in White U.S. veterans, and the associated elevated health and functional impairments are more pronounced in Latinx veterans. Characterization of co-occurring physical and functioning problems among Latinx and White veterans with obesity may help inform ethnically-sensitive obesity prevention and treatment efforts in this population.

Associations between probable eating disorders and healthcare use among post-9/11 veteran men and women

OBJECTIVE

Healthcare use is elevated among individuals with eating disorders (EDs); however, most people with EDs do not receive ED-specific care, likely due to factors such as the cost and availability of treatment as well as stigma. U.S. military veterans historically have been understudied in ED research. We investigated healthcare use and barriers to care among recently separated veteran men and women.

METHOD

In this cross-sectional study, 1494 participants completed an online or paper survey assessing ED symptoms, healthcare use, and logistical and attitudinal barriers to care. We estimated logistic regression models to investigate the association of ED status with healthcare use variables and examined gender similarities and differences in barriers to care.

RESULTS

Men and women with probable EDs reported low rates of ED treatment but greater healthcare use, during military service and since separating from service, compared to veterans without probable EDs (odds ratios = 1.57-7.05). Large proportions of participants reported that they did not know where to get help for EDs and that treatment is too costly. There were few gender differences in barriers to care (Cramer's V = 0.02-0.32).

CONCLUSION

Veterans reported high healthcare use but low rates of ED treatment. Findings underscore the need to increase the reach and accessibility of ED treatment in potentially vulnerable groups.

Binge Eating Disorder Is a Social Justice Issue: A Cross-Sectional Mixed-Methods Study of Binge Eating Disorder Experts' Opinions

BACKGROUND

Binge eating disorder is an autonomous DSM-V diagnosis characterized by discrete rapid consumption of objectively large amounts of food without compensation, associated with loss of control and distress. Environmental factors that contribute to binge eating disorder continue to evolve. This mixed-methods cross-sectional study assessed whether there is consensus among experts in the field about environmental factors that influence adult binge eating disorder pathology.

METHODS

Fourteen expert binge eating disorder researchers, clinicians, and healthcare administrators were identified internationally based on federal funding, PubMed-indexed publications, active practice in the field, leadership in relevant societies, and/or clinical and popular press distinction. Semi-structured interviews were recorded anonymously and analyzed by ≥2 investigators using reflexive thematic analysis and quantification.

RESULTS

Identified themes included: (1) systemic issues and systems of oppression (100%); (2) marginalized and under-represented populations (100%); (3) economic precarity and food/nutrition insecurity/scarcity (93%); (4) stigmatization and its psychological impacts (93%); (5) trauma and adversity (79%); (6) interpersonal factors (64%); (7) social messaging and social media (50%); (8) predatory food industry practices (29%); and (9) research/clinical gaps and directives (100%).

CONCLUSIONS

Overall, experts call for policy changes around systemic factors that abet binge eating and for greater public education about who can have binge eating disorder. There is also a call to take and account for the narratives and life experiences of individuals with binge eating disorder to better inform our current understanding of the diagnosis and the environmental factors that impact it.

Disordered eating in sexual minority post-9/11 United States veterans

OBJECTIVE

It is well documented that sexual minority individuals are more likely to report disordered eating (DE) than those identifying as heterosexual. Although DE is prevalent in veterans, investigation of potential disparities in DE among sexual minority veterans is limited. This study examined rates of DE in post-9/11 United States (U.S.) veterans identifying as sexual minorities and explored their association with discrimination because of marginalized identities.

METHODS

A national sample of recently separated post-9/11 U.S. veterans were recruited. Women (N = 805; heterosexual [n = 656]; lesbian [n = 51]; bisexual [n = 98]) and men (N = 558; heterosexual [n = 540]; gay [n = 11]; bisexual [n = 7]) completed a survey assessing eating behaviors, mental health, and military experiences. Weighted correlational and regression analyses were conducted. Analyses in men were exploratory.

RESULTS

DE was prevalent across gender and sexual orientation identity groups. Women identifying as bisexual and men identifying as gay reported higher rates of DE and consequent impairment compared to veterans who identified as heterosexual. There were no differences in DE between heterosexual and lesbian female veterans, but lesbian women reported lower DE-related impairment. Experiencing any discrimination in the military was positively related to DE.

DISCUSSION

This study found evidence of disparities in DE among sexual minority U.S. military veterans. While the factors contributing to these differences, such as the role of discrimination, are not completely understood, DE is a health concern for sexual minority veterans and requires continued investigation.

PUBLIC SIGNIFICANCE

Sexual minority individuals experience disparities in disordered eating; yet, this has not been explored in military veterans. This study found that disordered eating is a significant health concerns for veteran women and men, especially among those identifying as sexual minorities. More research is needed to explore why these disparities exist, such as the role of minority stress, in order to address the unique healthcare needs of these veterans.

Ginsenoside Rb1 Facilitates Browning by Repressing Wnt/β-Catenin Signaling in 3T3-L1 Adipocytes

BACKGROUND The discovery of browning in white adipose tissue has provided new ideas for treating obesity. Many studies have reported that ginsenoside Rb1 (G-Rb1) has activity against diabetes, inflammation, and obesity, but further investigation is needed on the effect and mechanism of G-Rb1 on browning. MATERIAL AND METHODS We treated 3T3-L1 adipocytes with 0-200 μM G-Rb1, and 0.5 μM Compound 3f and 30 μM SKL2001 were used to activate Wnt/b-catenin signaling. Adipocyte activity was evaluated by Cell Counting Kit-8. Oil Red O staining was used to detect the lipid droplets. Quantitative real-time polymerase chain reaction was used to measure the expression of Cd-137, Cited-1, Txb-1, Prdm-16, and Ucp-1 mRNA. Western blotting was used to measure the expression of Ucp-1, pGSK-3ß (Ser 9), GSK- 3ß, and ß-catenin proteins. The expression of Ucp-1 was also detected with immunofluorescence. RESULTS Adipocyte activity was not affected by 0-100 μM G-Rb1. However, G-Rb1 dose-dependently reduced the accumulation of lipid droplets; increased the expression of Cd-137, Cited-1, Txb-1, Prdm-16, and Ucp-1 mRNA; and increased the expression of Ucp-1, pGSK-3ß (Ser 9), GSK-3ß, and ß-catenin proteins. The accumulation of lipid droplets and the expression of Ucp-1 protein decreased as b-catenin increased. CONCLUSIONS G-Rb1 at various concentrations (0-100 μM) promoted the browning of adipocytes in a dose-dependent manner. Further, we confirmed that activation of Wnt/ß-catenin signaling could inhibit browning. Therefore, the browning promoted by G-Rb1 may be associated with the inhibition of Wnt/ß-catenin signaling.

Separating the Signal from the Noise: How Psychiatric Diagnoses Can Help Discern Food Addiction from Dietary Restraint

Converging evidence from both animal and human studies have implicated hedonic eating as a driver of both binge eating and obesity. The construct of food addiction has been used to capture pathological eating across clinical and non-clinical populations. There is an ongoing debate regarding the value of a food addiction "diagnosis" among those with eating disorders such as anorexia nervosa binge/purge-type, bulimia nervosa, and binge eating disorder. Much of the food addiction research in eating disorder populations has failed to account for dietary restraint, which can increase addiction-like eating behaviors and may even lead to false positives. Some have argued that the concept of food addiction does more harm than good by encouraging restrictive approaches to eating. Others have shown that a better understanding of the food addiction model can reduce stigma associated with obesity. What is lacking in the literature is a description of a more comprehensive approach to the assessment of food addiction. This should include consideration of dietary restraint, and the presence of symptoms of other psychiatric disorders (substance use, posttraumatic stress, depressive, anxiety, attention deficit hyperactivity) to guide treatments including nutrition interventions. The purpose of this review is to help clinicians identify the symptoms of food addiction (true positives, or "the signal") from the more classic eating pathology (true negatives, or "restraint") that can potentially elevate food addiction scores (false positives, or "the noise"). Three clinical vignettes are presented, designed to aid with the assessment process, case conceptualization, and treatment strategies. The review summarizes logical steps that clinicians can take to contextualize elevated food addiction scores, even when the use of validated research instruments is not practical.