Issue 48 | Eating Disorders in Military and Defence Personnel
About this resource
Military and civilian service professions, such as the Australian Defence Force (ADF) and emergency services, as well as elite sports professions, require a certain level of physical fitness, discipline and performance. The intensive training undertaken by those in high performance occupations may not always prepare them for the potential psychological impacts (VVCS, 2016; Bartlett & Mitchell, 2015).
This month we give an overview of the research on eating disorders in ex-serving military personnel, and take a closer look at appropriate self-care and support pathways for Veterans, Australian Defence personnel and other elite professionals. We also discuss the risks and warning signs associated with eating disorders, to better assist health care providers, coaches and others working alongside people currently or previously involved in high performance occupations to appropriately identify and respond to symptoms.
If you are interested in collaborating with the NEDC, we encourage you to join and become an NEDC member.
Eating Disorders in ex-serving Military Personnel
This article was contributed by a Mental Health Advisor from the Department of Veterans' Affairs.
Eating disorders comprise a group of psychological conditions characterised by disordered food and body related cognitions, difficulties with self-regulation, and disordered eating behaviours (American Psychiatric Association [APA], 2013; Hay et al., 2014). Eating disorders present serious psychological and physical disability and have high rates of mortality (Bartlett and Mitchell, 2015).
There is limited research, particularly in Australia, exploring eating disorders in military populations, perhaps due to the misconception that eating disorders only affect females, and such concerns are not relevant in a male dominated environment. However, international research suggests that both male and female veterans do experience eating disorders (Bartlett & Mitchell, 2015). The rate of eating disorders in veterans is comparable to prevalence estimates of eating disorders in the general population (Mitchell, Rasmusson, Bartlett & Gerber, 2014). Such rates may be aligned with an increase in younger service members and female service members (Bartlett & Mitchell, 2015; Mitchell et al., 2014).
The research to date indicates increased exposure to stress and trauma to be linked to the development of disordered eating and eating disorders in both civilian and military cohorts (Brewerton, 2007; Forman-Hoffman et al., 2012; Rayworth, Wise, & Harlow, 2004). Additional evidence suggests that disordered eating behaviour may be a coping strategy to manage psychiatric symptoms, including negative affect (Jacobson et al., 2009; Forman-Hoffman et al., 2012; Maguan et al., 2012; Heatherton et al., 1991), with those veterans experiencing symptoms of post-traumatic stress disorder (PTSD) and depression more likely to meet criteria for binge eating disorder (Hoerster et al., 2015).
Bartlett and Mitchell (2015) conducted a review of the literature on eating disorders across military and veteran populations and found having comorbid mental disorders was linked, in both male and female veterans, to a higher incidence of eating disorders (Maguen, et al., 2012). There is also evidence to suggest that comorbid mental health conditions associated with an eating disorder diagnosis differ between men and women, with men experiencing mood disorders and substance abuse or dependence disorders and women experiencing mood disorders and personality disorders (Striegel-Moore, et al., 1999: Striegel-Moore, et al., 1999).
The military presents an environment that prides itself of discipline and high standards of physical fitness. The comparable prevelance of eating disorders in veterans to the general population (Mitchell et al., 2014) and the high rate of US veterans who are overweight and obese (Vieweg et al., 2007), highlights the risk that disordered eating behaviours may persist or develop following discharge from service as veterans attempt to lose or control their weight and cope with changes in lifestyle and routine.
National research in Australia focusing on lifetime prevalence of eating disorders among members who have left the military is yet to be undertaken. This could be a future direction for research to help inform targeted interventions and effective management of eating disorders for both current and ex-serving military personnel.
If you, or someone in your care is experiencing difficulties with an eating disorder, or other mental health concern, there are a number of resources available to support veteran and military personnel. These are discussed in the next article, ‘Veterans, ADF Personnel and Family Support Pathways’.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author
Bartlett, B. A., & Mitchell, K. S. (2015). Eating disorders in military and veteran men and women. International Journal of Eating Disorders, 48, 1057–1069
Brewerton, T. D. (2007). Eating disorders, trauma, and comorbidity: Focus on PTSD. Eating Disorders, 15, 285–304
Forman-Hoffman, V. L., Mengeling, M., Booth, B. M., Torner, J., & Sadler, A. G. (2012). Eating disorders, posttraumatic stress, and sexual trauma in women veterans. Military Medicine, 177, 1161–1168
Hay, P., Chinn, D., Forbes, D., Madden, S., Newton, R., Sugenor, L., Touyz, S. & Ward, W. (2014). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. RANZCP.
Heatherton, T. F., & Baumeister, R. F. (1991). Binge eating as escape from self-awareness. Psychol Bull, 110, 86–108
Hoerster, K. D., Jakupcak, M., Hanson, R., McFall, M., Reiber, G., … Hall, K. S. (2015). PTSD and depression symptoms are associated with binge eating among US Iraq and Afghanistan veterans. Eat Behav, 17, 115–118
Jacobson, I.G., Smith, T.C., Smith, B., Keel, P.K., Amoroso, P.J., … Wells, T.S. (2009). Disordered eating and weight changes after deployment: Longitudinal assessment of a large US military cohort. Am J Epidemiol, 169, 415–27
Maguen, S., Cohen, B., Cohen, G., Madden, E., Bertenthal, D., & Seal, K. (2012). Eating disorders and psychiatric comorbidity among Iraq and Afghanistan veterans. Womens Health Issues, 22, e403–e406
Mitchell, K. S., Rasmusson, A., Bartlett, B., & Gerber, M. R. (2014). Eating disorders and associated mental health comorbidities in female veterans. Psychiatry Res, 219, 589-591
Rayworth, B. B., Wise, L. A., & Harlow, B. L. (2004). Childhood abuse and risk of eating disorders in women. Epidemiology, 15, 271–278
Striegel-Moore, R. H., Garvin, V., Dohm, F. A., & Rosenheck, R. A. (1999). Eating disorders in a national sample of hospitalized female and male veterans: Detection rates and psychiatric comorbidity. Int J Eat Disord, 25, 405–414
Striegel-Moore, R. H., Garvin, V., Dohm, F. A., & Rosenheck, R. A. (1999). Psychiatric comorbidity of eating disorders in men: A national study of hospitalized veterans. Int J Eat Disord, 25, 399–404
Vieweg, W. V., Julius, D. A., Bates, J., Quinn, J. F., Fernandez, A., Hasnain, M., & Pandurangi, A. K. (2007). Posttraumatic stress disorder as a risk factor for obesity among male military veterans. Acta Psychiatrica Scandinavica, 116, 483–7
Veterans, ADF Personnel and Family Support Pathways
Between 2015 - 2016, over 20,000 Australian veterans and their families sought mental health support (DVA, 2016). Australian Defence Force (ADF) personnel undertake intensive training for operational duties, however it is recognised that such training does not always prepare the mind for the psychological impact of events that may be experienced or witnessed during combat (VVCS, 2016). The significant number of veterans seeking support indicates the need for awareness of services available for serving, ex-serving personnel and their families.
You may be working alongside someone currently or previously involved in the military or a family member who requires support or information. Health professionals, particularly GPs, have been identified as playing an important role in the mental health of veterans, ADF personnel and their families. Having knowledge of support pathways can assist with providing appropriate information and referrals to those affected.
With the advice of the Department of Veterans’ Affairs, we have provided links to useful websites and services that support the mental health and wellbeing of those who have served and their families.
The Department of Veterans’ Affairs delivers government programs, support and information for war veterans, members of the Australian Defence Force, members of the Australian Federal Police and their dependants.
Counselling Service - 1800 011 046, 24/7 assistance
Veterans and Veterans Families Counselling Service (VVCS) provides free and confidential, nation-wide counselling and support for war and service-related mental health conditions, such as post-traumatic stress disorder (PTSD), anxiety, depression, sleep disturbance and anger.
All-hours Support Line (ASL) - 1800 628 036, 24/7 assistance
The Department of Defence provides a portal with information and links to online resources for ADF members and their families to learn more about mental health, resilience and wellbeing. DoD also provide a confidential phone service, All-hours Support Line (ASL), to help ADF members and their families access mental health services.
At Ease is DVA’s online mental health information portal for serving and ex-serving personnel, families and health professionals. At Ease provides self-help tools and information to support mental health and wellbeing and is a gateway to websites and free mobile apps about stress, PTSD, alcohol management, resilience and suicide awareness and prevention. At Ease also offers links to a range of resources for health professionals, including GPs, for effective assessment and evidence-based treatment of veterans. Below are some of the tools referred to in At Ease:
- High Res: an eToolbox designed to help serving and ex-serving Australian Defence Force personnel and their families manage stress and build resilience.
- The Right Mix: a website involving tips, tools and strategies to assist with reducing the impact of drinking on one’s lifestyle
- Operation Life: a website and mobile app that teaches the warning signs of suicide and provides resources to help keep yourself and others safe.
Helpline - 1800 334 673 (Monday – Friday 8am to 9pm AEST, excluding national holidays)
Butterfly’s National Helpline is a free and confidential service providing information, counselling and referral for eating disorders, disordered eating, body image concerns and related issues. This service is open to anyone, including sufferers, carers, family, friends, health professionals, educators and employers.
For additional information, organisations and services, visit http://www.dva.gov.au/contact/ex-service-organisations.
Department of Veterans’ Affairs. (2016). Department of Veterans’ Affairs Annual Report 2015 – 2016. (2016). Canberra. Retrieved from: http://www.dva.gov.au/about-dva/accountability-and-reporting/annual-reports/annual-reports-2015-16
Resource: Physical Fitness and High Level Performance
Elite professions requiring a high level of discipline, fitness and performance can impact on one’s physical and psychological wellbeing. Extensive International research has found that individuals with careers emphasising physical fitness and weight requirements are at an increased risk of engaging in disordered eating and compensatory behaviours (Carlton, Manos & Van Slyke, 2005; Smith, Klosterbuer & Levine, 2009; Bartlett & Mitchell, 2015; Martinsen & Sundgot-Borgen, 2013; Werner et al, 2013). Such behaviours are associated with a pressure to perform or meet requirements, and in some cases trauma exposure (Bartlett & Mitchell, 2015). Additional studies have found that psychological characteristics such as a competitive drive, perfectionism, and strong achievement orientations are often desired among elite athletes (Thompson & Sherman, 2010; Selby & Reed, 2011).
Health care providers and coaches are in a unique position to denounce unhealthy attitudes and behaviours that may trigger disordered eating (Bonci et al., 2008). Having an awareness of the risks and warning signs associated with eating disorders can help coaches and clinicians develop preventative measures and assist with identifying and responding to eating disorders.
The NEDC have developed a resource, Eating Disorders and Fitness: Prevention, Early Identification and Response, to assist with understanding eating disorders, promoting health and wellbeing within elite professions, recognising and responding to eating disorders and supporting athletes who are undergoing treatment for an eating disorder.
Who is this resource for?
This resource is relevant for a range of professional contexts, where a certain level of tactical or regular fitness and performance is required and encouraged. If you work in the following professions, or support people within these fields, this resource can assist you in recognising the warning signs of an eating disorder, responding to these signs and supporting recovery.
- Emergency services – e.g Police, Fire and Ambulance
- Lifeguards, swim teachers and facility managers
- Outdoor education & recreation
- Sports Medicine — medical practitioners, physiotherapists, physical therapists
- Personal Trainers, sports, gym and dance coaches
Bartlett, B. A., & Mitchell, K. S. (2015). Eating disorders in military and veteran men and women: A systematic review. International Journal of Eating Disorders, 48: 1057–1069
Bonci, C. M., Bond, L. J., Granger, L. R., Johnson, C. L., Malina, R. M., Milne, L. W., et al. (2008). National athletic trainers' association position statement: Preventing, detecting, and managing disordered eating in athletes. Journal of Athletic Training, 43(1), 80-108
Carlton JR, ManosGH, Van Slyke JA. (2005). Anxiety and abnormal eating behaviors associated with cyclical readiness testing in a naval hospital active duty population. Military Medicine, 170:663–667
Martinsen, M., & Sundgot-Borgen, J. (2013). Higher Prevalence of Eating Disorders Among Adolescent Elite Athletes than Controls. Medicine and Science in Sports and Exercise, 45(6), 1188-1197
Selby, C. L. B., & Reel, J. J. (2011). A Coach ’ s Guide to Identifying and Helping Athletes with Eating Disorders. Journal of Sport Psychology in Action, 2, 100–112
Smith C, Klosterbuer A, Levine AS. (2009). Military experience strongly influences post-service eating behavior and BMI status in American veterans. Appetite, 52:280–289
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