Every year, thousands of people enlist in the United States Armed Forces—signing contracts that require at least four years of active duty. Enlistment is the first and only time they are screened for eating disorders, defined by the American Psychiatric Association as “behavioral conditions characterized by severe and persistent disturbance in eating behaviors and associated distressing thoughts and emotions.” Currently, commanders and military medical providers are not adequately trained to recognize disordered eating signs among service members. Many living with the condition do so in secret—hesitant to seek any available help.

There are more than 1.4 million active service personnel in the U.S. Armed Forces, but data on eating disorder prevalence isn’t robust. Still, the information that exists hints at a pervasive issue. A 2005 study published in Military Medicine, based on survey results from 489 military service members, suggests that eating disorder rates among military soldiers are likely higher than reported. While only 2 percent of the respondents received a clinical diagnosis, a third or more of the military population sample exhibited behaviors consistent with eating disorders, like binging, purging, and fasting. This suggests that most soldiers with an eating disorder likely do not receive an official diagnosis. Additionally, a 2018 Department Of Defense study analyzed eating disorder diagnoses data from 2013 through 2017 and found that 1,788 active duty service members were diagnosed with anorexia nervosa, bulimia nervosa, or “other/unspecified eating disorder” (which includes binge eating disorder). The researchers say this rate is comparable to the general population, but numbers are potentially rising among military personnel.

For those who have tried to seek medical interventions, insurance coverage is a major barrier to quality care. Tricare, the health care program for uniformed service members, retirees, and their families, covers some treatment for eating disorders, but eating disorder treatment advocates maintain it’s not expansive enough, and it’s difficult to find treatment centers and therapists that will accept Tricare insurance. Furthermore, advocates say the fear of being discharged leaves military personnel suffering in silence.

Next month, Congress will review H.R.2767, the Supporting Eating Disorders Recovery Through Vital Expansion (SERVE) Act. The SERVE Act advocates for broader eating disorder treatment coverage for service members and their families. The bill also proposes better screening measures so commanders and medical providers are more equipped to spot signs. While the proposed policy is encouraging, it’s one piece of a complex puzzle. There are substantial access issues, but cultural norms exacerbate eating disorder risks among military personnel, says Katrina Velasquez, Esq, the founder and managing principal of Center Road Solutions, a public policy firm that works with the Eating Disorders Coalition for Research to advance eating disorders as a public health priority on Capitol Hill. “Commanding officers have been trained really well in suicide prevention, but there is a real lack of education around what to look for in terms of signs someone may have an eating disorder,” she says. This is in spite of the fact that certain aspects of military life can serve as body image landmines, putting service members at increased risk.

Military life can lead to higher risks of disordered eating

The United States Army has body composition standards that mandate how much a soldier should weigh depending on their gender, height, and age. This means that active service members must maintain specific weight requirements to keep their jobs. While it’s understandable that soldiers must be physically able to carry out their duties, some experts say the body composition requirements as outdated and not scientifically backed. The stipulations rely on body mass index (BMI), a standard developed in the 1830s originally intended to track major weight loss changes, not a marker for overall health.

Further, the requirements were originally put in place in the 1940s, amended only slightly in 2002 to include a tiered approach to body fat percentages tied to service-specific fitness tests. But BMI is still a core rubric for determining who is fit to serve. Besides being an outdated way to determine someone’s overall health, Velasquez says that any job with detailed physical requirements can put someone at greater risk for disordered eating.

Still, there’s a stark difference between being conscious of weight requirements and becoming obsessive, Johanna Kandel, the founder of The Alliance for Eating Disorders Awareness, explains. According to Ray Baskerville, a therapist at Ai Pono Maui, which provides eating disorder treatment help to soldiers and veterans, if a service member’s thoughts about weight impact how they live their life, and they are no longer able to do what they want to do in a healthy way, it’s likely morphed into an unhealthy relationship.

Interrogating soldier mindsets and attitudes around weight is incredibly important because, despite stereotypes, physical appearance is not an eating disorder indicator. “There’s this belief that someone with an eating disorder must look frail and weak, but someone can appear perfectly fine on the outside but inwardly struggling,” Kandel says. In other words, a soldier may look strong and even meet the body composition requirements but still live with an active eating disorder.

This is why Velasquez and Kandel both say better screening practices—or any since there are currently none for active-duty personnel—are crucial. According to an article published in the journal American Family Physician, medical providers can screen patients for eating disorders through physical findings (such as low body mass index, digestive problems, changes in skin, absence of menstruation, and slow heart action) as well as psychological questioning. This can include asking the patient if they feel they should be dieting, if their eating habits have changed, and how they feel about their body. Kandel says military medical providers must be taught both these physical and psychological signs. “It’s important not just to rely on Body Mass Index to indicate if someone has an eating disorder because there’s no one size fits all [rubric],” she says. “A screening should also be taking into account muscle mass as well as including psychological questions, such as how someone is feeling about their body and if they experience depression or anxiety.”

“People who are very disciplined and good rule followers make great soldiers. But those are also personality traits that can be tied to perfectionism and the need for control.” —Johanna Kandel, The Alliance for Eating Disorders Awareness

Besides maintaining weight requirements, all three experts say many soldiers often endure trauma—such as during deployment—which can also put them at increased risk for 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.”

“The reason why there is such a huge occurrence in eating disorders among people who have endured trauma is that it’s a maladaptive coping mechanism,” Kandel says. “People who have experienced trauma will [sometimes] use disordered eating as a way to escape and gain control.”

This struggle for control extends beyond military personnel who experience trauma. 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.”

On the flip side, Baskerville points out that many service members may feel they lack control because part of military life involves adhering to strict rules. “Depending on the nature of the eating disorder, there is often a component of control,” he says. “The person with the eating disorder may not have control over external aspects of their life, so they turn to restrictive ways in which they can control this one aspect.”

Baskerville, Kandel, and Velasquez all say many factors can contribute to disordered eating—it’s not straightforward. Still, maintaining body composition requirements, exposure to trauma, and a lack of control are all factors that put soldiers at increased risk.

Soldiers face significant barriers when seeking help

If a soldier with an eating disorder does want to seek help, doing so isn’t easy. Unfortunately, eating disorders carry a heavy stigma. Many believe that the condition is a sign of weakness and helplessness—two characteristics at odds with the typical soldier mentality, Velasquez says. “Because of the shame that’s often a component of having an eating disorder, there is a lot of vulnerability required to approach your [commander] and ask for help,” Baskerville says. “There really would have to be a lot of trust there.”

There is another complicating factor: Under Department of Defense policy, service members who have an eating disorder may be referred to a medical evaluation board, which could result in being medically disqualified for 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.

Kandel adds that many soldiers call The Alliance for Eating Disorders Awareness to get advice about asking for help without losing their jobs. “It’s a tough question to navigate because it’s a very real consequence,” Kandel says. “We try to educate them about the tsunami of physical and psychological consequences of not seeking help which may still result in having to leave the military anyway.” For instance, Kandel says there’s a connection between eating disorders and suicide, so they advocate for service members to put their health above their careers. “It’s unfair that soldiers have to make a decision between their well-being and keeping their job,” she adds.

Sharon Silas, the director of health care for the U.S. Government Accountability Office, helped compile a report for Congress about eating disorders in the military. Silas says that Tricare does cover a range of eating disorder treatment options, including inpatient hospitalization (for people with life-threatening conditions), residential treatment, partial hospitalization treatment (six hours of treatment a day, five to seven days a week), and intensive outpatient program (three to five hours of therapy, two to six days a week). While these offerings seem extensive, they are not widely accessible. Silas and her team found that half of the 166 eating disorder treatment facilities that accept Tricare are concentrated in five states (and only 32 of the 50 states have facilities that accept Tricare). This leaves soldiers in many states out of options. Additionally, Velasquez says Tricare doesn’t cover access to dietitians specializing in disordered eating, a service she believes is crucial for overcoming an unhealthy relationship with food.

The Alliance for Eating Disorders Awareness regularly receives calls about the struggle to find treatment facilities and therapists who accept Tricare, Kandel says. “We’re located in South Florida, a place that is highly concentrated with access to eating disorder specialists. But of all of the therapists in the area, only one accepts Tricare.” The reason for this, she says, is that therapists and other eating disorder specialists find the insurance provider challenging to work with. “I’ve heard from therapists who waited two or three years to get reimbursed from Tricare for their services,” Kandel says. Because of this, many refuse to accept this type of insurance.

Military families face even greater access barriers. Currently, Tricare does not cover eating disorder treatment for military dependents older than 21 years of age, a pain point the SERVE Act hopes to alleviate by expanding coverage to beneficiaries without age limitations. “We had a call just the other day from a woman whose husband is deployed. She has an eating disorder, but since she’s over the age of 21, Tricare won’t cover any treatment for her,” Kandel says.

In addition to broader coverage, early identification training for doctors, therapists, and dietitians working with service members is essential, Velasquez says, speaking to another hurdle the SERVE Act is looking to address. “During the pandemic, we’ve had a surge in calls from dietitians in the Army asking for training resources for how to work with clients with eating disorders because it’s something they are seeing more of particularly in the past year, and they haven’t been trained to treat them,” she says.

Velasquez also says we need more interest and funding for research surrounding this topic. “There is a vast lack of data,” she says. This is important, she explains, because without adequate data identifying how many service members and their families are experiencing disordered eating, it’s hard to pass policies that would directly help them.

The United States Armed Forces makes it very clear that enlisting requires certain sacrifices. Soldiers know that these sacrifices can include deployment and combat. However, being at war with one’s own body should never be a sacrifice one has to make.

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