Incidence, Prevalence, and Risk of Eating Disorder Behaviors in Military Academy Cadets

Transcription

1 MILITARY MEDICINE, 174, 6:637, 2009 Incidence, Prevalence, and Risk of Eating Disorder Behaviors in Military Academy Cadets Matthew D. Beekley, PhD ; LTC Robert Byrne, USA (Ret.) ; Trudy Yavorek, MD ; Kelli Kidd, MS ; Janet Wolff, MS ; LTC Michael Johnson, USA (Ret.) ABSTRACT Eating disorders are a particular problem for college students, as well as college athletes and military personnel. We examined the incidence, prevalence, and risk of eating disorders at the United States Military Academy (USMA) over a 7-year period (total population 12,731 cadets). The incidence per year for females was 0.02% for anorexia, 0.17% for bulimia, and 0.17% for eating disorders not otherwise specified (EDNOS) and for males was 0.0% for anorexia, 0.003% for bulimia, and 0.02% for eating disorders not otherwise specified. The total prevalence of diagnosed eating disorders for females was 5% and for males was 0.1%. For females over the 7-year period, we found a prevalence of 0.2% for anorexia, 1.2% for bulimia, 1.2% for eating disorders not otherwise specified, and for males we found a prevalence of 0.0% for anorexia, 0.02% for bulimia, and 0.03% for eating disorders not otherwise specified. Nineteen percent of females and 2% of males scored a 20 or higher on the Eating Attitudes Test (EAT)-26 survey indicating they were at risk for developing an eating disorder. We conclude that the prevalence of eating disorders at USMA is comparable to civilian colleges. United States Military Academy, Department of Physical Education, Center for Personal Development, Mologne Cadet Health Clinic, United States Corps of Cadets, Office of Public Affairs, West Point, NY This manuscript was received for review in June The revised manuscript was accepted for publication in January INTRODUCTION Eating disorders such as anorexia nervosa and bulimia nervosa are serious psychiatric disorders that can result in significant medical and psychological outcomes. 1,2 The college or university experience may exacerbate eating disorder conditions because of issues such as emancipation, individuation, intimacy, pressure to complete developmental tasks, etc. The prevalence of anorexia has been reported to range from 0.6 to 2% for collegiate females 3 6 and 0.2 to 1.1% for collegiate males. 4,6,7 The prevalence of bulimia has been reported to range from 3 to 14% for collegiate females 3,4,8 and 0.02 to 0.2% for collegiate males. 7,8 Current DSM-IV criteria also identify eating disorders not otherwise specified (EDNOS) as a diagnosable eating disorder. The Eating Attitudes Test (EAT-26) is a survey used to identify individuals at risk for eating disorders by providing a cutoff point (20 points, at or above, which indicates an increased risk for eating disorders) based on scoring the results of the survey. 9 The EAT-26 is considered highly reliable and valid as a screening tool Prevalence reports of collegiate females with a score at or above the EAT-26 cutoff point range from 10 to 26%, 4,6,12,13 and reports of collegiate males with a score at or above the EAT-26 cutoff point range from 4 to 10%. 6,7 Eating disorders also are present in collegiate athletes Some data indicate that female collegiate athletes may actually have a higher prevalence than the nonathlete population. 18 Disordered eating patterns have also been noted in military personnel Questionnaire data from several studies have indicated that females in the military service have a prevalence of anorexia of 1.1%, bulimia %, and EDNOS % Questionnaire data have indicated that males in the Navy have a prevalence of anorexia of 2.5%, bulimia 6.8%, and EDNOS 40.8%. 21 Additionally, questionnaire data have indicated that the risk of eating disorders is 20% in female reserve officer training corps (ROTC) cadets. 22 These data indicate that military personnel, like collegiate athletes, may have a higher risk of eating disorders compared to other males and females in their age group. The purpose of this article is to examine the incidence, prevalence, and risk of eating disorder behaviors in United States Military Academy (West Point, New York) cadets during a 7-year period, and briefly explain the eating disorders multidisciplinary team approach to care at the academy. When reporting data concerning eating disorders, typically prevalence is reported, as opposed to incidence. Prevalence of an eating disorder refers to the number of diagnosed eating disorders at any one time in a population and is typically calculated by adding all cases together and dividing by the population; incidence refers to the number of newly diagnosed eating disorders during a period of time (e.g., a year or several-year period) and is typically calculated by figuring the number of new cases per time period and dividing by the population. Here we report both prevalence and incidence, as well as risk as determined by responses to the EAT-26 survey. All cadets must participate in athletics of some sort and are expected to adhere to military regulations concerning body weight for height. Thus cadets are considered to be both athletes and in the military. As such, we considered that our population may be at higher risk for eating disorders or have greater prevalence compared to other populations reviewed above. METHODS Cadets at the United States Military Academy from 1999 to 2005 were used. This includes a population of 10,859 MILITARY MEDICINE, Vol. 174, June

2 TABLE I. Average Height and Weight at Entry (1st Year) to USMA Female Height (in) Weight (lbs) n Height (in) Weight (lbs) n ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Male individual males and 1,872 individual females (a total of 12,731 individual cadets enrolled during this time period). Racial makeup of this population was Asian 6.7%, African- American 6.7%, Hispanic 5.7%, Caucasian 77%, and other 3.9%. Age was not followed in the population; however, the military academy limits the age of entry to the academy to 23 years. Thus our population fell in the age range of years, with the vast majority (>95%) in the 18- to 22-year range. Unfortunately, only height and weight upon entry to the academy were available; thus, mean (± SD) entry height and weight by year for all cadets are indicated in Table I. The Eating Attitudes Test (EAT-26) survey was electronically distributed via during the fall of each year for the 7-year period examined. The survey was distributed to all females (~15% of the academy population in any 1 year) and randomly to 200 males. Anonymity and the voluntary nature of the survey were emphasized to the cadets and identifying variables were removed from data before analysis. A score on the EAT-26 at or above 20 indicates significant symptoms or concerns characteristic of eating disorders. 9 Thus, scores at 20 or above are considered at risk. Response rate to the EAT-26 averaged 82.5% for females and 73.1% for males during the total 7-year period studied. Several methods were used to obtain a clinical interview of a cadet at risk for eating disorders. Cadets who received a score of 20 or higher on the EAT-26 survey were highly encouraged via an message to follow up with a medical doctor at the health clinic on campus. Cadets who had a BMI <19 at biannual weigh-ins were required to attend a mandatory screening with a medical doctor. Cadets could also selfrefer or be referred by their peers or chain of command. DSM IV criteria were used to diagnosis cadets with disordered eating. The same physician and same three psychologists diagnosed all eating disorders during the period examined in this study. Cadets were diagnosed with anorexia, bulimia, or eating disorder not otherwise specified. Cadets were also diagnosed with maladaptive eating. Maladaptive eating is a category developed for cadets seen who manifested eating disorder symptoms (e.g., food restriction, bingeing, bingeing and purging, excessive exercise to control or reduce weight, negative body image, restricted food interests, food rituals, diet pills, laxatives, food supplements to control weight, etc.), which in combination or frequency or severity TABLE II fell short of the DSM IV diagnostic criteria for anorexia, bulimia, or EDNOS. This category contained the largest number of cadets. This category may be viewed as a subclinical eating disorder. Statistical significance was set at p < The prevalence of eating disorders was calculated by adding up all cases and dividing by the population. The incidence of eating disorders was calculated by figuring the average of new cases per year and dividing by the population. 23 Raw scores of EAT-26 (an ordinal measure) across years at the academy were analyzed by a Friedman s test. The percentage (proportion, a nominal measure) of females at risk (scoring 20 or higher on EAT-26) was analyzed by a Cochran test followed by a McNemar test. Means are presented with SD unless otherwise noted. RESULTS Incidence of Diagnosed Eating Disorders at USMA by Year and Sex Anorexia Bulimia EDNOS Maladaptive F M F M F M F M F M F M F M EDNOS, eating disorder not otherwise specified. Eating Disorder Incidence The incidence of the three eating disorders medically diagnosed by DSM IV criteria (anorexia, bulimia, and eating disorders not otherwise specified) and for maladaptive eating from 1999 to 2005 at the academy is shown in Table II. During the 7-year period studied, 3 females and 0 males were newly diagnosed with anorexia, 22 females and 2 males newly diagnosed 638 MILITARY MEDICINE, Vol. 174, June 2009

3 FIGURE 1. Mean (± SD) female EAT-26 score per year at the academy. N = 1,455, only includes data for females who completed all 4 years at the academy. * indicates significantly different from 1st and 4th years, p < with bulimia, 22 females and 3 males newly diagnosed with eating disorder not otherwise specified, and 51 females and 6 males newly diagnosed with maladaptive eating. The incidence per year for females was 0.02% for anorexia, 0.17% for bulimia, 0.17% for eating disorders not otherwise specified, and 0.39% for maladaptive eating. The incidence per year for males was 0.0% for anorexia, 0.003% for bulimia, 0.02% for eating disorders not otherwise specified, and 0.008% for maladaptive eating. Eating Disorder Prevalence Our data indicate a prevalence of diagnosed eating disorders for females of 5% (98/1,872) and for males of 0.1% (11/10,859) at the academy. For females over the 7-year period, this represents a prevalence of 0.2% for anorexia, 1.2% for bulimia, 1.2% for eating disorders not otherwise specified, and 2.7% for maladaptive eating. For males over the 7-year period, this represents a prevalence of 0.0% for anorexia, 0.02% for bulimia, 0.03% for eating disorders not otherwise specified, and 0.06% for maladaptive eating. EAT-26 Results Over the entire 7-year period analyzed, 522 out of 2,772 female respondents scored a 20 or higher on the EAT-26 survey (19%) and 135 out of 5,587 male respondents scored a 20 or higher on the EAT-26 survey (2%). Note that these numbers reflect some of the same cadets who took the EAT- 26 survey each year (especially females, because the entire female population received the survey each year). Thus, the above numbers may reflect cadets who received a score of 20 or higher during multiple years (scores of the same cadet counted in multiple years). The yearly mean scores of the EAT-26 survey were able to be followed from entrance year to the academy through graduation year (a 4-year period for each class of cadets). We only analyzed the 4 groups of females that completed all 4 years at the academy (total n = 1,455). Not all women completed FIGURE 2. Mean female percentage considered at risk by score on EAT-26 per year at the academy. N = 1,455, only includes data for females who completed all 4 years at the academy. * indicates significantly different from 1st and 4th years, p < the survey from year to year, but the majority did (>80%). The mean score for females of the EAT-26 results per year at the academy is shown in Figure 1. The mean EAT-26 scores for the second and third year at the academy are statistically higher than the first or last year at the academy ( p < 0.05). We also analyzed the percentage (proportion) of females who were at risk (scored 20 or greater on the EAT-26) by year at the academy. We only analyzed the 4 groups of females that completed all 4 years at the academy (total n = 1,455). Not all women completed the survey from year to year, but the majority did (>80%). The results are shown in Figure 2. The percentage of women at risk (scoring 20 or greater) is significantly lower ( p < 0.05) for the first year at the academy vs. all other years. DISCUSSION Although it is difficult to make comparisons of eating disorder prevalence to data found across all the literature because of methodological differences, we believe USMA s prevalence of diagnosed eating disorders is similar to the normal collegiate civilian population. 1 8 Thus, USMA s prevalence of diagnosed eating disorders may be below that found for collegiate athletes, whose prevalence has sometimes been reported as higher than the normal collegiate population. 1 8 The prevalence reported in this article also appears below that reported for military personnel (see Introduction). Additionally, we found the percentage of those considered at risk for an eating disorder (scored 20 points or above on the EAT-26) was also within the limits of the normal collegiate population (see Introduction). We also noted changes in the results of the EAT-26 data based on time at the academy. Both raw scores of the EAT-26 and the percentage of those at risk (scoring 20 or more points) increased after being at the academy for a year (see Figs. 1 and 2 ). This increase in the percentage of female cadets at risk after being at the academy may be cause for concern. MILITARY MEDICINE, Vol. 174, June

4 Although somewhat scarce, previous longitudinal data from civilian college females indicate that disordered eating may get worse during the college years (and especially during the initial to second year of college), and that a worsening body image corresponded well to the increasingly disordered eating Thus, our data seem to mirror what has previously been found in the college female civilian population. It is unknown if the same or different factors account for these similar findings. Because of the unique nature of the military academy, different factors may contribute to the risk of developing an eating disorder compared to other college students. For instance, factors that might increase the risk of eating disorders at the academy include biannual weigh-ins, which include height and weight standards, daily physically demanding requirements, required meal attendance, regular required physical fitness testing, a standardized uniform, required sport participation of all cadets, an age requirement to enter the academy, a predominately white racial makeup, a predominately higher socioeconomic class, and higher achievement expectations, which could lead to compulsiveness or perfectionism. On the other hand, some of these same factors present at the academy might possibly decrease the risk of eating disorders. For instance, the physically demanding requirements might eliminate cadets who cannot perform physically because of nutritional problems secondary to their eating disorder. Constant interaction with other cadets (at mandatory mealtime, for instance) might also make it very difficult to conceal an eating disorder. Biannual weigh-ins would also identify cadets who are below the Army s BMI and body weight standards thus setting a clear limit for weight loss. Clearly further research needs to be done to examine the factors that can contribute to increased risk of eating disorders, especially in this unique population. Eating Disorder Multidisciplinary Team The eating disorder multidisciplinary team (MDT) at USMA is the standard of care for treating eating disorders. It consists of three clinical psychologists, a physician, and a registered dietitian. The MDT meets twice a month to develop coordinated care plans, discuss cases, and monitor progress of cadets identified with eating issues. Each cadet case is reviewed by the team to determine the nature of the disorder and the most appropriate treatment plan as well as to review/revise ongoing treatment. Each cadet case is followed by one of the three psychologists, the physician, and the dietitian. Frequency of appointments with each member is determined on an individual basis depending on the severity of the eating issue. Treatment by the MDT is confidential with limitations. If a cadet poses a medical risk to him- or herself or others, the chain of command must be notified; otherwise, voluntary treatment is kept confidential. The academy has the ability to mandate referrals for resistant cadets. In many cases, this is necessary, as evidence shows that severely underweight individuals often do not seek treatment on their own. 27 A recent study suggests that involuntary treatment of eating disorders can result in a positive response to the treatment, at least in the short term. 27 Shortcomings of Present Study Several methodological problems bear addressing. This study only examined a random sample of 200 men each year. This typically represents only ~6% of the male population at the academy in any 1 year. We are thus missing the majority of the male population with our survey. 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