Nine-Month Update on CARE’s Military Mental Health Study
Eating Disorders in the Military
Eating disorders in military populations have long been underdiagnosed and misunderstood. A common stereotype is that eating disorders only affect women, however research shows that eating disorders impact individuals across genders, races, and ethnicities, including within servicemembers. Eating disorders have one of the highest mortality rates of all mental illnesses. Furthermore, servicemembers of all genders are shown to have higher rates of eating disorders compared to the general population.
Disordered eating refers to a range of eating behaviors that negatively impact a person's physical, emotional, or mental health. These behaviors often disrupt daily functioning, interfere with normal life activities, and may lead to unhealthy relationships with food. Disordered eating encompasses a variety of patterns, such as restrictive eating, bingeing, or compensatory behaviors (e.g., vomiting or overexercising), which can result in physical or psychological consequences.
Fact: Eating disorders affect people of all genders, races, ethnicities, and ages.
Fact: Servicemembers face unique risk factors, including strict bodyweight requirements, physical fitness standards, and exposure to combat, that can heighten their vulnerability to disordered eating behaviors.
Military-Specific Eating Disorder Risk Factors
Research shows that military life presents several risk factors that may increase susceptibility to eating disorders, including:
Stress and Trauma: High levels of stress, including trauma, may contribute to disordered eating as a coping mechanism.
Cultural Norms: The military’s emphasis on appearance in uniform can reinforce body image issues, contributing to the development and maintenance of eating disorders.
Weight and Fitness Standards: The requirement to meet body mass index (BMI) and body fat percentage guidelines can lead servicemembers to engage in weight control behaviors such as fasting, purging, etc.
Eating Disorders Defined
Characterized by an intense fear of gaining weight, a distorted body image, and restriction of food leading to a medically concerning low body weight.
Characterized by distress related to a recurrent cycle of eating more than is considered typical while feeling a loss of control. This can happen alongside any inappropriate compensatory behaviors such as purging, excessive exercise, fasting, etc.
Characterized as consuming more food than what is considered typical alongside significant distress and loss of control when binging. Binge Eating Disorder patients do not have inappropriate compensatory behaviors present.
Other specified feeding or eating disorder, or OSFED, is an eating disorder classification in which there are clinically significant signs and symptoms of EDs are present, but the symptoms do not fall into a specific category of the DSM-5. Compensatory Eating Disorder and Purging Disorder are common OSFEDs.
Purging disorder is characterized by recurrent purging behavior with a lack of binging related to body weight and shape concerns. Purging disorder is also associated with distress.
A compensatory eating disorder is characterized by behaviors that are meant to “make up” for the distress of consumed food. This can include fasting and excessive exercise.
Characterized by an intense fear of gaining weight, a distorted body image, and restriction of food leading to a medically concerning low body weight.
Characterized by distress related to a recurrent cycle of eating more than is considered typical while feeling a loss of control. This can happen alongside any inappropriate compensatory behaviors such as purging, excessive exercise, fasting, etc.
Characterized as consuming more food than what is considered typical alongside significant distress and loss of control when binging. Binge Eating Disorder patients do not have inappropriate compensatory behaviors present.
Other specified feeding or eating disorder, or OSFED, is an eating disorder classification in which there are clinically significant signs and symptoms of EDs are present, but the symptoms do not fall into a specific category of the DSM-5. Compensatory Eating Disorder and Purging Disorder are common OSFEDs.
Purging disorder is characterized by recurrent purging behavior with a lack of binging related to body weight and shape concerns. Purging disorder is also associated with distress.
A compensatory eating disorder is characterized by behaviors that are meant to “make up” for the distress of consumed food. This can include fasting and excessive exercise.
Our Purpose
Our study aims to improve the detection and treatment of eating disorders among military servicemembers. Despite the significant physical and mental health risks associated with eating disorders, these disorders are often overlooked in the military due to insufficient screening methods and outdated assumptions about who is at risk.
Our study focuses on identifying risk factors for the development of eating disorders in recently entered servicemembers and improving early identification methods. Thus, Dr. Kelsie Forbush and her team at CARE created a military-specific screening tool - the Brief Assessment of Stress and Eating (BASE).
What is the BASE?
The Brief Assessment of Stress and Eating (BASE) is a newly developed screening tool designed specifically to identify eating disorders eating disorders and related mental health concerns, such as anxiety, depression, and trauma, in military populations. Unlike traditional eating disorder screening tools that do not adequately screen for eating disorders, especially in men and minority servicemembers, the BASE is tailored to the unique challenges faced by service members. It addresses the full spectrum of eating behaviors that are more common in military environments but often missed by other screeners.
How the BASE Is Being Tested in Servicemembers
The current study aims to evaluate the effectiveness of the BASE in detecting eating disorders among newly entered servicemembers. Our researchers are conducting large-scale testing to compare the BASE’s performance against existing screening tools. The study includes participants completing a survey every six months over the course of three years.
Goals and Anticipated Impact of the Study
We have three primary aims in this research, with the ultimate goal of improving mental health for active military servicemembers.
Goal 1
Compare BASE's accuracy relative to previously used methods for identifying military members who have eating, mood, or anxiety disorders. This will allow us to improve the identification of eating disorders in overlooked populations.
Goal 2
Understand factors specific to the military that may promote the development of an eating disorder. This will allow us to better identify risk factors going forward.
Goal 3
Learn how the relationship between eating behaviors, inner distress, and military experiences change over the first three years of service. This will help us understand what cultural standards might promote eating disorders in servicemembers.
Where We Are Now
We send a survey every six months to test the BASE’s performance against other screening tools. We are currently in month 9 of the study and are currently recruiting for the baseline and six-month surveys.
Participants Demographics
We invited any servicemember who entered the military between February 2023 and January 2024 (about 157K individuals in total) to participate in the study. We returned a number of 2,161 responses so far.
The Army makes up most of the population at 47.8%, but the Airforce makes a strong showing at 30.4% despite having about a quarter of active members. The Navy, followed by the Marine Corps and Coast Guard, make up the final 21.8%.
While only making up 17.5% of military personnel, women make up 57% of our study participants. Men make up the rest of the majority with 41% followed by transgender-identifying persons at 1%.
The majority of the racial makeup consists of white and Black individuals, totaling 86%, with the next majority being Native American individuals at 4%.
Resources
Our team cares about the well-being of our participants, so please reach out to these resources if you or a loved one need assistance with concerns related to eating disorders, mental health, sexual assault, domestic violence, substance abuse, and more. You can contact these resources via phone calls, texts, online chats, and more.More on the Research
The Brief Assessment of Stress and Eating, or BASE, is a screening tool that includes items from the Inventory of Depression and Anxiety Symptoms-Ⅱ (IDAS-Ⅱ) and the Eating Pathology Symptoms Inventory (EPSI), as well as screener-unique items. While it is currently being tested in active duty servicemembers, it was initially tested on the veteran population. As mentioned above, it was developed because many eating disorder screening tools do not cover common issues with service members effectively. Other eating disorder screeners are not as applicable to cisgender men or people in racial/ethnic minority groups. The BASE still needs a complete analysis; however, there are preliminary published findings for those who are interested.
The goal of the study linked here was to test the BASE across male and female genders. College students completed surveys for the BASE and for the Sick, Control, One, Fat, Food, or SCOFF, which is the most common questionnaire for screening for eating disorders. Then, the Eating Disorder Diagnostic Survey was used to make probable eating disorder diagnoses. The BASE did as well as the SCOFF in identifying eating disorders in cisgender women. The BASE, however, outperformed the SCOFF significantly for identifying potential eating disorders in cisgender college-aged men.
The BASE was also equivalent to or more sensitive when diagnosing women than other common screening tools such as the Weight Concerns Scale, the Eating Disorder Examination Questionnaire, and the Stanford-Washington University Eating Disorder screen. It also had a higher specificity than the Eating Disorder Examination Questionnaire’s ability to screen men accurately, which was seen in a past study.
The focus of this article was to describe the structure of the original study that created the BASE. The first part of the study consisted of four waves of online and paper-based surveys. The second part used surveys, interviews to assess current and lifetime eating disorders and other mental health disorders, and interviews to identify barriers for seeking eating disorder and trauma-related care during active duty.
The results found large differences in demographics who were more likely to respond. Men were much less likely to respond to mailings and participate than women. Non-commissioned officers, commissioned officers, and warrant officers were all more likely to participate compared to enlisted individuals. Veterans who identified as White, multiracial, or unknown were significantly more likely to participate than those who identified as Black or African American. Lastly, age of discharge had an impact. Older aged adults were more likely to participate than those aged 18-25.
The goal of this study was to examine if eating disorder-related symptoms predict substance use in US veterans who recently separated and the gender differences in these symptoms. This study had four waves of online surveys in order to test whether different points in time after separation predicted substance use. The surveys tested three main components, such as bulimic symptoms, characterized by a recurrent cycle of eating with a loss of control and behaviors such as purging, fasting, diuretic usage, excessive exercise, ect. Weight and body-related concerns were also tested, along with symptoms of restricting, which are characterized as behaviors that limit food intake often through dieting. It also tested alcohol problems, drug problems, and marijuana problems.
The study found that women had higher bulimic symptoms and restricting symptoms than men. While men have higher weight and body-related concerns and a negative attitude toward obesity than women. It was also found that men had significantly higher drug, alcohol, and marijuana problems than women. Lastly, it was found that women with higher bulimic symptoms at the first wave predicted alcohol, drug, and marijuana abuse. In men, higher restricting symptoms at the first wave predicted marijuana, drug, and alcohol abuse.
Thank You for Reading
Thank you for reading our nine-month progress report on our military mental health study. This report was prepared and written by undergraduate research assistants Madalyn Peterson, Brianna Mallett, and Sebastian Meriano with the support and review of senior CARE researchers.
Madalyn Peterson
Brianna Mallett
Sebastian Meriano
Department of Defense Acknowledgements
The U.S. Army Medical Research Acquisition Activity, 808 Schreider Street, Fort Detrick MD 21702-5014 is the awarding and administering acquisition office.
This work was supported by The Assistant Secretary of Defense for Health Affairs endorsed by the Department of Defense, in the amount of $4,230,958 dollars through the Peer Reviewed Medical Research Program under Award Number HT9425-23-1-0310 and in the amount of $1,721,698 dollars through the Peer Reviewed Medical Research Program under Award Number W81XWH1910207. Opinions, interpretations, conclusions, and recommendations are those of the author(s) and are not necessarily endorsed by The Assistant Secretary of Defense for Health Affairs endorsed by the Department of Defense.
This material is the result of work supported with resources and the use of facilities at the Dwight D. Eisenhower VA Medical Center under the VA of Eastern Kansas Healthcare System.