Yale, VA Researchers Investigate Eating Disorders in Iraq and Afghanistan War-Era Veterans

Researchers at Yale School of Medicine and the VA Connecticut Healthcare System, in a pair of complementary studies, investigated eating disorders in Iraq and Afghanistan war-era veterans, a group thought to be at high risk for eating disorders.

New eating disorders —atypical anorexia nervosa, night eating syndrome, and binge-eating disorder—were included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) when it was last updated. Experts thought those disorders might be relevant for older adults, men, a range of racial and ethnic groups, and people who are overweight.

The Yale and VA research team, led by Robin Masheb, PhD, professor of psychiatry, examined the prevalence, gender differences and correlates of new and revised DSM-5 eating disorders in the first study, published in the International Journal of Eating Disorders.

More than 1,110 veterans completed a survey of measures studying longitudinal gender differences in healthcare utilization and health outcomes. While the investigators found no cases of anorexia nervosa (AN) they were surprised to find that 14 percent of women and 5 percent of men met criteria for probable aytpical AN.

Bulimia nervosa was reported in 6 percent of women and 3.5 percent of men; at least three times more common than in civilians. In binge-eating disorder and night eating syndrome, prevalence estimates ranged from 3 to 6 percent.

All together one-third of women and one-fifth of men met criteria for a likely DSM-5 eating disorder, and the eating disorders were associated with mental health concerns such as trauma, depression, and insomnia, the researchers found.

In the second study, published in Eating Behaviors, the investigators wanted to gain a better understanding of atypical anorexia given the prevalence in the surveyed veterans was so unexpectedly high, and that few research studies had been published on the disorder.

Atypical anorexia is characterized by an intense fear of weight gain and restrictive eating minus the dangerously low weight found in AN. In place of the very low body weight criterion, for the diagnosis of aytpical anorexia, these individuals must be at a body weight that is at least 10 percent below their highest adult weight.

The investigators found that at their highest weight, those with atypical anorexia were in the obese range, had lost on average 18 percent of their body weight, and were currently in the overweight range (average BMI was 28.8). Those with atypical anorexia had body weights similar to those with no eating disorder, but less than those with Bulimia or Binge-Eating Disorder.

On measures of mental health, they functioned worse than those without an eating disorder, similar to those with binge-eating disorder, and only slightly better than those with bulimia.

Masheb said there may be physiologic factors involved in aging and military fitness at odds with holding unusually low weights. Thus, Atypical Anorexia may be a variant of Anorexia more appropriate for capturing eating disorders in a wide range of adult populations including men and people who are overweight or in middle age and beyond, she said.

“We need to better understand how eating disorders present in this and other diverse populations so that we can begin to dispel myths and misconceptions among providers and patients that eating disorders only occur in young, low weight girls and women,” said Masheb, director of the Veterans Initiative for Eating and Weight (the VIEW at VA Connecticut Healthcare System).

Recognizing the growing need for eating disorder care among male and female veterans, the VA is enhancing treatment and expanding provider training for eating disorders.

Masheb’s Yale School of Medicine co-investigators were Sally Haskell, MD; Cynthia Brandt, MD, MPH; Christine Ramsey, PhD; and Suzanne Decker, PhD.