Anxiety and Abnormal Eating Behaviors Associated with Cyclical Readiness Testing in a Naval Hospital Active Duty Population

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1 MILITARY MEDICINE, 170, 8:663, 2005 Anxiety and Abnormal Eating Behaviors Associated with Cyclical Readiness Testing in a Naval Hospital Active Duty Population Guarantor: LCDR Janis R. Carlton, MC USNR Contributors: LCDR Janis R. Carlton, MC USNR*; CDR Gail H. Manos, MC USN ; LT John A. Van Slyke, MC USN Studies of abnormal eating behaviors in active duty military personal have found rates similar to or higher than the general population. We have reviewed these studies and extended the research to examine abnormal eating behaviors in a heterogeneous population at a major military medical center. We found high rates of body dissatisfaction, abnormal eating behaviors, and worry about passing the semiannual personal fitness assessment in both men and women. Abnormal eating behaviors were associated with worrying about the personal fitness assessment, and these measures were associated with body mass index and gender. Our data extend previous research indicating that cyclic or external pressure to maintain body weight within specified standards can produce unsafe eating and dieting behaviors. We recommend changes to the current system to incorporate treatment programs aimed at recognizing and treating eating disorders with a goal of producing more fit and healthy service members. Introduction n the U.S. military it is necessary to maintain adherence to I standards of appearance, fitness, and body composition. Evaluation of service members physical fitness and readiness is performed semiannually. Weight and height are measured against service-specific tables of maximum weight for height. If a service member exceeds the maximum allowable weight, an estimate of body fat percentage is calculated. Service members who fail to meet standards are referred to a weight-management and/or mandatory exercise program. Failure adversely affects evaluations, fitness reports, and advancement or promotion. Repeated failures can result in separation from the military. Although personal fitness is crucial to military readiness, cyclical measurements may lead to chronic or repeated crash dieting to meet weight standards and thus abnormal eating behaviors and impaired health and fitness. Previous studies of eating disorders in the military have found variable results with rates either similar to or higher than rates in the general population. These studies are reviewed below. The objective of our study was to obtain additional data regarding the prevalence of abnormal eating behaviors in a heterogeneous military population; to gather further information on how cyclic weight measurements, *Department of Mental Health, Naval Hospital, Rota, Spain 09645; jrcarlton@rota.med.navy.mil.. Department of Psychiatry, Naval Medical Center, Portsmouth, VA Previously presented as a poster at the annual American Psychiatric Association Meeting, May 2003, San Francisco, CA. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government. This manuscript was received for review In July The revised manuscript was accepted for publication in April fitness testing, and the associated anxiety affect eating behaviors; and to assess motivation for healthy treatment alternatives. Background Eating disorders constitute a group of increasingly common psychiatric and medical conditions that may involve significant medical and psychiatric morbidity, including electrolyte imbalances, cardiac arrhythmias, gastrointestinal complications, osteoporosis, mood disorders, and even suicide 1. The etiology of eating disorders is multifactorial, including genetic, cultural, psychodynamic, and biological factors Cognitive-behavioral models propose that societal pressure for thinness leads to dietary restraint, rigid food rules, and hunger with resulting disinhibition and binge eating. 10,12 Repeated dieting, and negative comments regarding eating, appearance, and weight are risk factors in eating disorders. 7,10 In the general population, the incidence of eating disorders appears to be increasing with a current lifetime prevalence of 0.5 to 1% for anorexia nervosa (AN) and 1 to 3% for bulimia nervosa (BN) in women, with rates in men about one-tenth of those for women. 2,13 17 Eating Disorders Not Otherwise Specified (ED NOS), a residual category for those that do not meet full criteria for either disorder, has an estimated prevalence of 3 to 30%. 2,13 In addition to societal pressures, military personnel have the stress of semiannual body composition measurements to meet at the expense of retention and promotion. In a study of active duty female nurses, McNulty 18 found that 1.1% of those surveyed met the criteria for AN, 12.5% for BN, and 36% for ED NOS. In a wider study of females in all branches of the military, McNulty 18 found similar rates for AN (1.1%) and BN (8.1%), but a higher rate of ED NOS (62.8%). In that study she found dramatically higher rates in female Marines for all categories (AN 4.9%, BN 15.9%, and ED NOS 76.7%). 19 In a study of active duty males, McNulty 20 found a prevalence of 2.5% for AN, 6.8% for BN, and 40.8% for ED NOS. Although abnormal eating behaviors were found to exist year round, there was a significant increase in these behaviors associated with the physical fitness assessment (PFA) cycle In her study, 3.7% of males surveyed reported vomiting year round to meet weight standards. This increased to 15% around the weigh-in period. Active duty males reported use of diet pills and laxatives at rates of 3.5% and 3.4%, respectively, year round, and those rates increased to 14.9% and 14.45% around the time for weigh-in and measurements. Of those surveyed, 31.5% reported some degree of fasting to lose weight during the month preceding the PFA and 12.2% reported fasting during the 2 preceding months. 22 In a 1-year prospective study of Army active duty women, Lauder et al. 21 used the Eating Disorders Inventory as a screen- 663

2 664 Anxiety and Abnormal Eating Behaviors in Active Duty Personnel ing questionnaire and followed up with a clinical interview. Their population was subsequently divided into those who met the criteria for an eating disorder, those considered at risk for developing an eating disorder, and those negative for eating disorder symptoms. They defined at risk as those who exhibited abnormal eating and dieting or purging behaviors that did not meet the full criteria for AN or BN. They found 33.6% to be at risk for an eating disorder and 8% met the criteria for diagnosis. There was a correlation between eating disorder categories and body satisfaction scores, with those at risk and those diagnosed expressing progressively greater dissatisfaction. Those authors included a subcategory of situational eating disorder, defined as abnormal eating behaviors consistent with a diagnosis of ED NOS, practiced intermittently, and associated with military lifestyle and fitness assessments. They found that external pressures associated with the military were rated progressively higher in subjects at risk and those diagnosed with an eating disorder. In a descriptive study of bulimic behaviors associated with enrollment in a military weight-management program, Peterson et al. 22 found that service members in such a program engaged in purging or excessively restrictive weight-loss behaviors two to fives times more frequently than military members not in a weight-loss program and four times more often than civilians in a comparable weight-management program. The first Naval instruction on physical fitness was issued in 1976 (OPNAVINST ). 23 Since that time there have been six revisions. Beginning with OPNAVINST B in 1982, there has been a provision for continuing assessment of the program and research in physical fitness and obesity. 24 In 1998, the Department of Defense Committee on Body Composition, Nutrition, and Health of Military Women and the Committee on Military Nutrition Research issued a report stating that the existing body composition standards for women may be in conflict with task-specific requirements and may interfere with readiness by encouraging unhealthy eating habits. The committees issued specific recommendations for changing the current policy, including more frequent testing to maintain fitness, promote healthy lifestyle changes, and decrease the risk of potentially injurious behaviors such as crash dieting associated with cyclical testing. They also addressed equality of standards for men and women and consideration of body type with regard to racial differences and individual characteristics such as breast size. They recommended further research in this area. 25 Methods An anonymous survey was mailed to all active duty personnel with valid addresses assigned to the Naval Medical Center Portsmouth in May Surveys were returned by stamped preaddressed envelopes. The survey contained questions about basic demographics, eating, dieting, exercise, changes in eating and dieting behaviors relative to the time preceding and following the PFA, anxiety or worry about passing the PFA, and a question regarding the need/motivation for assistance dealing with abnormal eating behaviors and weight regulation. The survey was assessed for face validity by a group of enlisted personnel and officers at the Naval Hospital Guantanamo Bay, Cuba. Any questions judged to be ambiguous were reworded, and the instrument was reassessed until there was consensus that the questions were clearly understandable and answerable. Content validity was confirmed by review by a group of military psychiatrists at the Naval Medical Center Portsmouth, Virginia. Internal consistency was measured by comparing the answers on similar questions within the survey instrument. Body mass index (BMI) was calculated for each respondent (BMI weight in kilograms/height in square meters). We used BMI as a standard measurement that is widely used by international agencies, including the World Health Organization, and does not contain the potential variability or error in body fat percentage estimated by different methods, formulas, and raters. Total responses for each possible answer and percentages were calculated. Data are presented as responses to individual questions and, in some cases, type (e.g., purging behavior) or category of response. For statistical analysis, answers were assigned a point value. For yes/no questions, a no was assigned a value of 0; a yes was assigned a value of 1. For questions with more than two possible responses, each response was weighted and assigned a point value. Point-biserial correlations (correlations in which one variable is dichotomous and the other is nondichotomous) were performed on these data. Tree root regression was performed for more complex relationships of worry about the PFA, abnormal eating behaviors, BMI, body image, self-esteem, age, and gender. An abnormal eating behavior scale was formed by weighting questions associated with eating behaviors and summing the weights for a total score. The higher the score, the more serious the eating disorder behaviors. A second category formed from questions related to worry about failing the PFA, or worry scale, was calculated in a similar manner. The tree root regression is a nonparametric scalable model well suited for this type of complex relationships among worry, demographic, behavior, and BMI. Results Demographic Data Of 1,797 surveys mailed, 161 (9%) were returned as undeliverable and 489 (30%) were completed and returned. This was adequate for a power of 80%. Of the respondents, 57% were men and 74% were officers. The sample was 79% Caucasian, 11% African American, and 10% other. The average age was years, and the average time in service was years. This return rate was adequate to provide the power needed for our analysis. The demographics of the respondents were representative of the population at a major military medical facility reflecting a higher percentage of officers and higher age than a general military population. Body Satisfaction In our sample population, 53% of respondents reported feeling dissatisfied with the appearance of their bodies. Self-esteem was closely associated with body image in 47%. Fear of gaining weight was reported by 41%. Women had a significantly greater weighted score on body dissatisfaction compared to men ( vs , p 0.001). Women were more likely than men to report that they were not satisfied with their appearance (61% vs. 46%, p 0.001). Women also were more likely to report that their self-esteem depended on appearance (60% vs. 38%, p 0.001).

3 Anxiety and Abnormal Eating Behaviors in Active Duty Personnel 665 Satisfaction with body image was inversely correlated with abnormal eating behaviors (r 0.404, p 0.001) and with worry about the PFA (r 0.489, p 0.001). That is, abnormal eating and worry were associated with dissatisfaction with body image. The association of self-esteem with body image was directly correlated with abnormal eating behaviors (r 0.320, p 0.001) and with worry about the PFA (r 0.119, p 0.008). There was a moderately high correlation between abnormal eating behavior and worry about the PFA (r 0.619, p 0.001). Thus, respondents dissatisfied with their appearance and those who associated self-esteem with body image were more likely to engage in abnormal eating behaviors and to worry about passing the PFA. Increasing worry about the PFA was associated with more abnormal eating behaviors. Abnormal Eating and Dieting Behaviors In our sample, 10% reported bingeing at least twice weekly within the previous 3 months and 34% reporting bingeing at some time. Another 31% to 39% reported binge-type behaviors such as eating until uncomfortably full or eating large amounts when not hungry. Fear of losing control when eating was reported by 11%. With regard to purging behaviors, 5% reported self-induced vomiting and 18% reported laxative, diuretic, or diet pill use to lose weight. Fasting was reported by 25% and exercising more than one time per day to lose weight was reported by 15%. Physical Fitness Assessment About one-third of respondents worried about failing the PFA, 28% worried about failing because of body weight, and 29% because of physical conditioning. Actual failure rates were 13% for weight and 12% for physical condition, with 6% failing more than once for weight and 2% failing more than once for physical condition. Associations among Body Image, Eating Behavior, BMI, and Anxiety about the PFA In association with the PFA, 24% of respondents reported going on a strict diet within the 2 months before the test and 7% reported that they were more likely to lose control of their eating in the 2 months before the PFA. Of those who admitted to purging behaviors, 67% were more likely to engage in these behaviors in the 2 months preceding the PFA. More than a 10-pound weight change associated with the PFA cycle was reported by 18% of the sample. The mean BMI was for women and for men. Larger BMI was associated with increasing age (r 0.113, p 0.013) and years in service (r 0.279, p 0.001). There was an inverse correlation between body image and BMI (r 0.339, p 0.001). That is those with a higher BMI were more likely to be dissatisfied with their body image. Abnormal patterns of behavior and anxiety about the PFA increased significantly at a BMI of 27.7, which, for most, would result in a failure on the weight portion of the PFA. Respondents who admitted to purging behaviors had a significantly higher BMI than those who did not purge ( vs , p 0.001). Respondents who indicated a loss of control over eating had a significantly higher BMI than those who did not lose control ( vs , p 0.001). Those who ate abnormally before the PFA or both before and after had a significantly higher BMI than those who ate abnormally only just after the PFA ( and , respectively, vs , p 0.001). Tree regression was used to assess complex relationships among BMI, body satisfaction, gender, age, abnormal eating behaviors, and worry about passing the PFA (Fig. 1). Cronbach s was 0.79 for the abnormal eating behaviors scale and 0.83 for the worry scale. Both scales were right skewed. The average abnormal eating scale was and the average worry score was Larger BMI was associated with increased abnormal eating behaviors and increased worry about the PFA, with a positive correlation between BMI and abnormal eating behavior (r 0.323, p 0.001) and between BMI and worry (r 0.487, p 0.001). Worry about the PFA was analyzed as a function of the other variables. The average worry score for all respondents (n 489) was 3.9. There was a bimodal distribution with relation to abnormal eating behavior. Those with an abnormal eating behavior score of 8 had an average worry score of 2.5 (n 378). For those with an abnormal eating behavior score 8, the average worry score was 8.8 (n 111). For those with abnormal eating behavior scores 8, there were differences related to body image and BMI. Those who were satisfied with body image had a mean worry score of 1.1 (n 210), whereas those who were not satisfied had a score of 4.3 (n 168). Of this subset of 168, those with a BMI 27.7 had a mean worry score of 3.1 (n 123) compared to a score of 7.5 for those with a BMI 27.7 (n 45). For the 111 respondents with an abnormal eating behavior score 8, those with a BMI 27.7 had a mean worry score of 11.0 (n 53) compared to a score of 6.7 for those with a BMI 27.7 (n 58). There were also gender differences. Men with a BMI 27.7 and abnormal eating score 8 had an average worry score of 4.1 (n 19) compared to 8.1 for women (n 39). For these Fig. 1. Tree regression showing the correlation among BMI, gender, anxiety about passing the PFA, and abnormal eating behaviors. Data are presented as worry or abnormal eating behavior scores derived from weighting questions associated with eating behavior or worry and summing the weights for a total score. The higher the score, the more severe the behavior or anxiety.

4 666 Anxiety and Abnormal Eating Behaviors in Active Duty Personnel women, those with a BMI 23.0 had a mean worry score of 4.0 (n 13) and those with a BMI between 23 and 27.7 had an average score of 10.1 (n 26). Thus, those with a higher BMI worried more about passing the PFA and were more likely to engage in abnormal eating behaviors, although this was more prominent in women. Of the 210 female respondents, 12% reported substantial worry about the PFA and 19% had an abnormal eating behavior score 8. Of note, the point for heightened worry about the PFA was a BMI of 23, within standards for the Navy and normal for women according to standards of the World Health Organization. Although a third or more of our population sample exhibited abnormal eating and weight-loss behaviors, only 2% of this sample had been officially diagnosed as having an eating disorder at some time in their lives. When asked about interest in a program to help them control weight or eating and dieting patterns, 31% indicated an interest in such a program. Discussion Our survey was the first to examine eating disorders in a mixed military population. A relatively high percentage of our respondents were male and/or officers, which reflects the general makeup of our population. A high percentage of our population reported dissatisfaction with their body appearance and self-esteem was dependent upon body image. Abnormal eating behaviors and worry about passing the PFA were associated with these measures. Women scored higher on these measures; however, our data indicate a significant proportion of men in the Navy are dissatisfied with their bodies and engage in abnormal eating behaviors. To date, only one other study examined abnormal eating behaviors in military men and found similarly elevated rates compared to the general male population. 20 Overall, our findings are consistent with other studies on eating and dieting behavior in the military, with high rates of body image dissatisfaction, abnormal patterns of eating and dieting, and a high correlation between these behaviors and the PFA cycle. A high percentage of our population (31 39%) reported bingeing or binge-like behaviors, 18% or more reported some type of purging behavior, and 25% reported fasting. These behaviors were associated with worrying about the PFA and were more likely to occur in those with higher BMI and/or poor body image. The World Health Organization has defined overweight as a BMI of 25 to 29.9 and obesity as a BMI of 30 or greater. The average BMI reported by our respondents, both male and female, would put them in the overweight category. In fact, 50% of our respondents reported a BMI of 25 or greater. In the PFA, individuals who are not within weight standards are measured for body fat assessment (BFA) to distinguish service members who are overweight because of larger muscle mass. Although our sample was from a medical command, our respondents reported abnormal eating patterns and compensatory behaviors, dissatisfaction with body image, and anxiety about the PFA. Other studies in Navy personnel have found lower rates of abnormal eating behaviors in health care workers (30%) and medical doctors (6%) compared to shipboard service members (65%). 20 Although our data would indicate that a third or more of our population sample exhibited behaviors consistent with disorders of eating, only 2% had actually been clinically diagnosed. This indicates that eating disorders are underreported in the military even at a medical command. It is not surprising that service members are reluctant to come forward. In addition to the stigma, the diagnosis may be grounds for disqualification from many assignments or administrative separation. Military providers may be reluctant to diagnose eating disorders because they are traditionally considered difficult to treat and may end a service member s career. The current remedial system does not assess the presence of disordered eating behaviors. The standard of care for eating disorders, when available, involves individual or group psychotherapy and/or pharmacotherapy Comments from respondents in our survey included concerns about the PFA leading to destructive eating patterns, lack of healthy food choices on duty, lack of command encouragement, and support for exercise. Many (31%) requested more nutrition education and behavior management-type programs. Currently, service members who fail a part of the PFA are referred to the command fitness program for remedial fitness training. Often this remedial training is generalized without regard to gender or age factors that affect performance expectations. The performance standards are based on gender and age. A 49-year-old woman is not expected to do as many push-ups or run 1.5 miles as quickly as a 19-year-old man, yet these two may be placed in the same training group. Either the older female is going to have trouble keeping up or the younger male is not going to get the level of training that he needs to pass the next PFA test. Externally applied fitness and weight standards may promote unhealthy eating and dieting patterns. Abnormal eating behaviors increase the risks for serious physical and emotional disorders and adversely affect work performance. Cycles of weight gain and restrictive weight loss and purging can be particularly unhealthy and may compromise military readiness. This study is consistent with other reports on abnormal eating and weightloss behaviors in diverse military populations. Together these suggest that we need to design and implement a treatment program aimed at intervention, education, and treatment. This should include a focus on prevention of obesity and disordered eating behavior, promotion of long-term weight and fitness standards through healthy lifestyle changes rather than episodic crash dieting, and consideration of more frequent monitoring of weight and fitness to decrease unhealthy and injurious behaviors that result from semiannual testing. These data may also be used to suggest changes in the way fitness is measured and enforced in the military. Conclusions Our population differed from previous studies in being mixed gender, older, and with a high proportion of officers. In other published surveys of abnormal eating behaviors in the military, single gender populations were sampled. We found a high rate of body dissatisfaction, abnormal patterns of eating, and inappropriate compensatory mechanisms to manage weight gain. This was highly correlated with worry about the PFA, particularly among those with a relatively high BMI. This rate was surprisingly high, especially considering that our population was primarily health care providers associated with a medical training facility. The results of this study are consistent with other re-

5 Anxiety and Abnormal Eating Behaviors in Active Duty Personnel 667 ports showing abnormal eating and weight-loss behaviors associated with the cyclic PFA testing. This indicates the need for development of an intervention program to complement current Navy programs for weight control and to establish healthier dietary and weight-management patterns. The first author is currently involved in development of a multidisciplinary fitness program at the Naval Hospital Rota. This program includes representatives from the PFA program, mental health, nutrition, health promotions, and the executive administration. The focus is on healthy lifestyle changes, nutritional and behavioral education, individualized fitness training, and sustainment. It is hoped that this program will become a benchmark that will promote optimal health and fitness, both physical and mental, in active duty personnel. Acknowledgments We thank Drs. Paul Kolm and T.J. Norton for their assistance. References 1. Dixon-Works D, Nenstiel RO, Aliabadi Z: Common eating disorders. Clin Rev 2003; 13: Dorian BJ, Garfinkel PE: The contributions of epidemiologic studies to the etiology and treatment of the eating disorders. Psychiatr Ann 1999; 29: Fairburn CG, Doll HA, Welch SL, Hay PJ, et al: Risk factors for binge eating disorder: a community-based, case-control study. Arch Gen Psychiatry 1998; 55: Garfinkel PE, Lin E, Goering P, et al: Bulimia nervosa in a Canadian community sample: prevalence and comparison of subgroups. Am J Psychiatry 1995; 152: Hill K, Hill KS, Daniell B: The biological substrate of eating disorders. Curr Opin Psychiatry 1997; 10: Kaplan AS, Ciliska D: The relationship between eating disorders and obesity: psychopathologic and treatment considerations. Psychiatr Ann 1999; 29: Liu Y, Gold M: Human functional magnetic resonance imaging of eating and satiety in eating disorders and obesity. Psychiatr Ann 2003; 33: Neumark-Sztainer D, Wall MM, Story M, Perry CL: Correlates of unhealthy weight-control behaviors among adolescents: implications for prevention programs. Health Psychol 2003; 22: Rodin G: The etiology of eating disorders: lessons from high-risk groups. Psychiatr Ann 1999; 29: Stice E: Risk and maintenance factors for eating pathology: a meta-analytic review. Psychol Bull 2002; 128: Wonderlich S, Peterson C, Mictchell J: Body image, psychiatric comorbidity, and psychobiological factors in the eating disorders. Curr Opin Psychiatry 1997; 10: Agras W: Nonpharmacologic treatments of Bulimia nervosa. J Clin Psychiatry 1991; 52: Kaplan H, Sadock B: Synopsis of Psychiatry, Behavioral Sciences/Clinical Psychiatry, pp Baltimore, MD, Williams & Wilkins, Carlat DJ, Camargo CA, Herzog DB: Eating disorders in males: a report on 135 patients. Am J Psychiatry 1997; 154: Olivardia RB, Pope HB, Mangweth B, Hudson JI: Eating disorders in college men. Am J Psychiatry 1995; 152: Tylka TL, Subich LM: A preliminary investigation of the eating disorder continuum with men. J Counseling Psychol 2002; 49: Woodside DB, Garfinkel PE, Lin E, et al: Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community. Am J Psychiatry 2001; 158: McNulty PA: Prevalence and contributing factors of eating disorder behaviors in a population of female Navy nurses. Milit Med 1997; 162: McNulty PA: Prevalence and contributing factors of eating disorder behaviors in active duty service women in the Army, Navy, Air Force, and Marines. Milit Med 2001; 166: McNulty PA: Prevalence and contributing factors of eating disorder behaviors in active duty Navy men. Milit Med 1997; 162: Lauder TD, Williams MV, Campbell CS, Davis GD, Sherman RA: Abnormal eating behaviors in military women. Med Sci Sports Exerc 1999; 31: Peterson AL, Talcott GW, Kelleher WJ: Bulimic weight-loss behaviors in military versus civilian weight-management programs. Milit Med 1995; 160: Department of the Navy: OPNAVINST , Department of the Navy: OPNAVINST B, Committee on Body Composition, Nutrition, and Health of Military Women, Committee on Military Nutrition Research, Food and Nutrition Board, Institute of Medicine. Assessing Readiness in Military Women: The Relationship of Body Composition, Nutrition, and Health, Executive summary of the clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults. Expert Panel, American Medical Association. Arch Intern Med 1998; 158: Yager J: Practice guideline for the treatment of patients with eating disorders: work group on eating disorders. Am J Psychiatry 2000; 157(Suppl. 1): Marcus MD, Levine MD: Eating disorder treatment: an update. Curr Opin Psychiatry 1998; 11: Walsh BT, Wilson GT, Loeb KL, et al: Medication and psychotherapy in the treatment of bulimia nervosa. Am J Psychiatry 1997; 154: