The United States Armed Forces enlists thousands of people every year, signing contracts that require them to serve for at least four years. Currently, commanders and military medical providers are not adequately trained to identify the signs of disordered eating among service members. Eating disorders are defined as “behavioral conditions characterized by severe and persistent disturbance in eating behaviors and their associated distressing thoughts and emotions.” A large number of people with this condition live in secret—hesitant to reach out for assistance.
Over 1.4 million active military personnel serve in the U.S. Data on the prevalence of eating disorders is lacking among the military. Despite its limited availability, information indicates a pervasive problem. Study results from a survey of 489 military service members published in Military Medicine in 2005 suggest that eating disorder rates are likely higher than previously thought. Even though only 2 percent of the respondents received a clinical diagnosis, about a third of the respondents displayed eating disorder behaviors, such as bingeing, purging, and fasting. According to the analysis, the majority of soldiers with an eating disorder are not officially diagnosed. The Department of Defense recently studied eating disorder diagnoses from 2013 to 2017 to find 1,788 active duty service members with anorexia nervosa, bulimia nervosa, or unspecified eating disorders (such as binge eating disorder). Among military personnel, the rate is likely to be rising, but it is comparable to that in general.
For those who have attempted to seek medical interventions, insurance coverage is a major obstacle to getting quality care. There are some eating disorder treatment options covered by Tricare, the health care plan for uniformed service members, retirees, and their families, but eating disorder treatment advocates maintain it’s not extensive enough, and it’s difficult to find treatment centers and therapists who accept Tricare. Moreover, advocates claim that military personnel suffer in silence due to the fear of being discharged.
A bill to support eating disorders recovery through expansion (SERVE) will be considered by Congress next month. In its SERVE Act, members of the military and their families are advocated for broader access to eating disorder treatment. As part of the bill, doctors and commanders would be given better screening means for spotting symptoms. It’s encouraging that a policy is proposed, but it’s only a piece in a complex puzzle. The military faces a significant access issue, but cultural norms exacerbate eating disorder risks, says Katrina Velasquez, Esq, the founder and managing principal of Center Road Solutions, a policy firm that advocates for eating disorders as a public health issue on Capitol Hill. There has been a focus on suicide prevention for commanding officers, but there is a lack of education as to what to look for in terms of signs someone may have an eating disorder, she says. Even though military life can serve as a body image landmine, service members are at greater risk.
An increase in disordered eating can occur as a result of military life
Depending on a soldier’s gender, height, and age, the US Army has body composition standards. Members of the military must meet specific weight requirements in order to keep their jobs. Some experts say it’s outdated and not scientifically supported to require soldiers to have certain body compositions. These stipulations rely on the standard of body mass index (BMI), which was developed in the 1830s to track significant weight loss changes, rather than an indicator of general health.
A tiered approach to body fat percentages was added in 2002 to tie it to service-specific fitness testing. Originally put in place in the 1940s, the requirements have been only slightly modified in 2002. Yet, BMI is still a critical factor in determining who should serve. The old method isn’t just outdated, but it can increase someone’s risk of disordered eating if their job requires detailed physical requirements.
Johanna Kandel, the founder of The Alliance for Eating Disorders Awareness, explains that there is a clear difference between being aware of weight requirements and becoming obsessive. In Ray Baskerville’s opinion, if a service member’s thoughts about weight have an impact on how they live their lives and they are no longer able to engage in their favorite activities in a healthy way, then it is likely that they have developed an unhealthy relationship.
In spite of stereotypes, physical appearance is not indicative of eating disorders. Therefore, understanding the mindsets and attitudes around weight of soldiers is imperative. According to Kandel, “there’s this belief that someone with an eating disorder must appear frail and weak, but someone can appear perfectly fine on the outside but be very distressed on the inside.” The soldier may look strong and even meet body composition requirements, yet continue to suffer from an eating disorder.
Both Velasquez and Kandel believe better screening practices for active-duty personnel are crucial, since there are no currently available. A recent article in the journal American Family Physician suggests that medical providers can screen patients for eating disorders based on physical findings (such as low body mass index, digestive problems, changes in skin, and slow heart rate) as well as psychological questions. Inquire about the patient’s eating habits, how they feel about their body, and whether they feel like they should diet. Military medical professionals must also learn about psychological and physical signs, according to Kandel. Using BMI alone to identify an eating disorder isn’t always accurate because there is no universally applicable [rating system],” she says. As part of a screening, muscle mass and psychological factors such as how an individual feels about their body should be considered, as well as whether they suffer from anxiety or depression.”
The Alliance for Eating Disorders Awareness’ Johanna Kandel says, “Good rule followers and disciplined people make great soldiers. But those are also personal traits closely tied to perfectionism.”
Along with maintaining weight requirements, all three experts say soldiers often experience trauma-such as during deployment-which can also increase the chances of them developing an eating disorder. This is especially pertinent because between 10 and 20 percent of service members experience post-traumatic stress disorder (PTSD), according to the U.S. Department of Veteran Affairs. “There is a definite connection between trauma and eating disorders,” Velasquez says. “This includes post-traumatic stress disorder as well as military sexual trauma.”
“Eating disorders are so common among people who have experienced trauma because they are an unhealthy coping mechanism,” Kandel says. People who have experienced trauma will [sometimes] use disordered eating as a way to escape and gain control over their life.”
Traumatized military personnel are not the only ones who struggle for control. A small study published in the International Journal of Eating Disorders found a connection between control and disordered eating, something a study published in The Journal of Treatment and Prevention also found. Kandel says military culture often attracts people who respond well to elements of regimentation. “People who are very disciplined and good rule-followers make great soldiers,” she says. “But those are also personality traits that can be tied to perfectionism and the need for control.”
Despite the rigors of military life, Baskerville notes many service members feel an absence of control. According to him, an eating disorder may involve control depending on its nature. People with eating disorders may have little control over external factors in their lives, so they turn to controlling this one aspect through restrictive means.”
It’s not clear what causes disordered eating, say Baskerville, Kandel, and Velasquez. Maintaining the body composition required, dealing with trauma, and not being in control all increase the risk of soldiers.
Seeking help is extremely difficult for soldiers
Soldiers with eating disorders may find it difficult to seek help. There is a heavy stigma attached to eating disorders. As Velasquez points out, many consider the condition to be a sign of weakness and helplessness, both contradictory characteristics of soldiers. Because having an eating disorder is often accompanied by shame, asking your [commander] for help requires a great deal of vulnerability, Baskerville says. “It would take a lot of trust to deal with that.”
A third complicating factor is that Under Defense Department policy, service members who have an eating disorder can be medically disqualified from service. According to DOD data from 2013 through 2017, 124 active-duty service members were discharged from the military as a result of their eating disorder diagnosis and unsuccessful treatment. Kandel says that the fear of losing employment—a job that is often intricately connected to one’s sense of self—is a massive barrier to seeking help. “We have definitely received calls from soldiers who have been discharged [from] service because of their eating disorder,” she says.
It is not uncommon for soldiers to seek help from the Alliance for Eating Disorders Awareness in order to avoid losing their jobs. There is a serious consequence to this question, says Kandel. “We try to educate soldiers about the tsunami of physical and psychological consequences of not seeking help, which may lead to them having to leave the military.” For instance, Kandel says there is a connection between eating disorders and suicide, so they advise them to put their health above their careers.
Sharon Silas is the director of health care for the United States. An audit for Congress was prepared by the Government Accountability Office concerning eating disorders among military personnel. Inpatient hospitalization (for people suffering from life-threatening conditions), residential treatment, partial hospitalization service (six hours of treatment a day, five to seven days a week), and intensive outpatient service (two to six hours of therapy per day) are all options available under Tricare. There is a limited availability of these offerings, even though they seem extensive. Among the 166 eating disorder treatment facilities accepting Tricare, Silas and her team discovered that half are concentrated in five states (only 32 states have facilities accepting Tricare). Many states have no other option for soldiers. A dietitian who specializes in disordered eating is not covered by Tricare, Velasquez adds, a service that she says is crucial for changing one’s unhealthy relationship with food.
A number of calls about finding treatment facilities and therapists who accept Tricare are received by AEDA every day, Kandel says. “We are located in South Florida, a place with a high concentration of eating disorder specialists. However, only one of those specialists will accept Tricare.” Her explanation is that the insurer is difficult to work with. Kandel says therapists waited between two and three years for Tricare reimbursement for their services. It is because of this that many will not accept this form of insurance.
Access to healthcare is even more difficult for military families. The SERVE Act seeks to alleviate this problem by lifting the age restriction on coverage of eating disorder treatment for Tricare beneficiaries. An eating disorder patient called just the other day, but since she is over the age of 21, Tricare would not cover their treatment,” Kandel says.
In addition to gaining broader coverage, early detection training for health professionals who work with service members is essential, Velasquez said, referring to yet another obstacle SERVE is looking to resolve. As a consequence of the pandemic, dietitians from the Army have requested resources for training on working with people with eating disorders, since they are seeing more and more of them, and they aren’t trained to help,” says White.
In addition, Velasquez says that research on this topic needs more funding and interest. She says, “There are a lot of gaps in data.”. As a result, she says, it’s very difficult to pass policies that would address disordered eating if there is no reliable data on how many service members and their families are suffering from it.
It is very clear to enlistment applicants that certain sacrifices are required. Deployments and combat are among the sacrifices soldiers make. Nevertheless, an individual should never have to sacrifice his or her own body in order to be at war with it.
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