DISORDERED EATING BEHAVIOR AMONG UNITED STATES MILITARY PERSONNEL
Emily Ferrell
A Thesis
Submitted to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of
MASTER OF ARTS
May 2019
Committee:
Abby Braden, Advisor
Joshua Grubbs
Dara Musher-Eizenmann
© 2019
Emily Ferrell
All Rights Reserved iii ABSTRACT
Abby Braden, Advisor
Disordered eating behaviors such as binge eating, restrained eating, and compensatory behaviors are becoming increasingly common among U.S. Military Personnel. Previous research suggests that there may be a number of variables related to eating disorder development in this population: symptoms of post-traumatic stress disorder (PTSD), symptoms of body dysmorphic disorder (BDD), gender, military branch, and pre-military food insecurity. Although previous research has identified factors related to disordered eating in military personnel, this study sought to better understand the associations between each of these variables and the moderators of these associations as they influence the development of disordered eating behaviors in this population. A diverse sample of the military population was recruited using Amazon’s
Mechanical Turk (MTurk) to participate in an online survey, which included demographic measures, measures of psychopathological symptomatology (i.e., the Post-Traumatic Stress
Disorder Checklist – Military and the Yale-Brown Obsessive Compulsive Scale modified for
Body Dysmorphic Disorder), food insecurity (U.S. Household Food Security Survey Module:
Six-Item Short Form), and disordered eating behavior (Eating Disorder Examination
Questionnaire and the Binge Eating Scale). Researchers hypothesized that each of these variables would be related to disordered eating behavior and exacerbated by the presence of
PTSD and BDD symptoms. In this sample, military personnel reported greater disordered eating symptoms than the civilian population. Findings indicated that symptoms of PTSD and BDD were significantly associated with disordered eating even when controlling for pre-military food insecurity and gender. Symptoms of PTSD moderated the associations between gender and iv disordered eating behavior, but BDD symptoms only moderated the association between gender and binge eating. v
To my Poppy, Your unwavering support and love has helped me navigate every aspect of my life You believed in me even when I didn't believe in myself You are the most kind and selfless person I know Thank you for the wisdom you have shared Love Always, Emily
vi TABLE OF CONTENTS
Page
CHAPTER I. INTRODUCTION ...... 1
Current Research ...... 1
Psychopathological Symptomatology ...... 2
PTSD Symptoms ...... 2
BDD Symptoms ...... 3
Military and Non-Military Related Trauma ...... 4
Pre-Military Socioeconomic Status ...... 4
Pre-Military Food Insecurity ...... 5
Gender ...... 5
Research Questions ...... 6
CHAPTER II. METHOD ...... 9
Participants ...... 9
Procedures ...... 10
Measures ...... 10
Demographics ...... 10
Eating Disorder Examination Questionnaire ...... 10
Binge Eating Scale ...... 11
Trauma History Questionnaire ...... 12
Post-Traumatic Stress Disorder Checklist (Military) ...... 13
Yale-Brown Obsessive-Compulsive Scale Modified For Body Dysmorphic
Disorder ...... 14
Socioeconomic Status ...... 14 vii U.S. Household Food Security Survey Module: Six-Item Short Form ...... 15
Analytic Plan...... 15
Preliminary Analyses ...... 16
Primary Analyses ...... 17
Hypothesis 1 ...... 17
Hypothesis 2 ...... 18
Hypothesis 3 ...... 18
Hypothesis 4 ...... 18
Hypothesis 5 ...... 18
CHAPTER III. RESULTS ...... 20
Preliminary Analyses ...... 20
Primary Analyses ...... 21
Confirmatory Factor Analyses ...... 21
Multiple Regression Analyses ...... 22
Hypothesis 1 ...... 22
Overall Disordered Eating ...... 22
Compensatory Behavior...... 22
Restrained Eating Behavior ...... 23
Binge Eating Behavior ...... 23
Hypothesis 2 ...... 24
Moderated Regression Analyses ...... 25
Hypothesis 5 ...... 25
Overall Disordered Eating ...... 25
Compensatory Behaviors ...... 25 viii Restrained Eating ...... 25
Binge Eating ...... 25
Summary ...... 26
CHAPTER IV. DISCUSSION ...... 27
Limitations ...... 31
Conclusions ...... 34
REFERENCES ...... 35
APPENDIX A. MEASURES ...... 48
Military Screening Questionnaire ...... 48
Demographic Questionnaire ...... 49
Eating Disorder Examination Questionnaire ...... 50
Binge Eating Scale ...... 52
Trauma History Questionnaire ...... 54
Post-Traumatic Stress Disorder Checklist (Military) ...... 56
Yale-Brown Obsessive Compulsive Scale Modified For Body Dysmorphic Disorder 58
U.S. Household Food Security Survey Module: Six-Item Short Form...... 61
APPENDIX B. HSRB FORM FOR ORIGINAL APPLICATION ...... 62
APPENDIX C. CONSENT FORM ...... 63
APPENDIX D. TABLES ...... 64
APPENDIX E. FIGURES ...... 76 1
CHAPTER I. INTRODUCTION
Disordered eating behaviors such as binge eating, restrained eating, and compensatory behaviors are becoming increasingly common among U.S. Military Personnel. Prevalence estimates for eating disorders within female military members are 1.1% for Anorexia Nervosa
(AN), 8.1 to 12.5% for Bulimia Nervosa (BN) and 36 to 62.8% for eating disorders not otherwise specified (EDNOS). For male military members, prevalence estimates are 2.5% for AN, 6.8% for
BN, and 40.8% for EDNOS (Bartlett, 2015). In a national sample of civilians, the lifetime prevalence of eating disorders within females are 0.9% for AN, 1.5% for BN, and 3.5% for
Binge Eating Disorder (BED). For male civilians, the lifetime prevalence of eating disorders are
0.3% for AN, 0.5% for BN, and 2.0% for BED (Hudson, 2012). Furthermore, the prevalence of eating disorders within the military population has increased since 1998 (Bartlett, 2015).
Individuals that engage in disordered eating behaviors are at risk for excessively reduced bone density, muscle loss, dehydration (at times resulting in kidney failure), electrolyte imbalance, increased risk for heart failure, high/low blood pressure, gastric and esophageal rupture, tooth decay, peptic ulcers and pancreatitis, diabetes, and poor cholesterol (NEDA, 2016). The disproportionate amount of eating disorders occurring in military personnel may be explained by unique risk factors within that population such as combat exposure and military sexual assault.
Clearly, there is a need to better understand and thus reduce disordered eating behaviors among the members of the military.
Current Research
Limited research on eating disorders has been conducted with geographically representative samples of military personnel and the majority of this research has included female samples (Bartlett, 2015). With the rising prevalence rates of eating disorders in the 2
military population (Bartlett, 2015), it is imperative to gain a better understanding of the unique
psychosocial risk factors associated with eating disorders in military personnel. The current
study was designed to reach a more diverse sample of the military population. While previous
studies have reviewed a variety of risk factors relating to disordered eating in the military, this
study aimed to examine each risk factor in relation to specific disordered eating behaviors
(compensatory behaviors, binge eating, and restrained eating) to allow for a more comprehensive
understanding of how certain factors may increase risk for specific types of disordered eating
behaviors in the military population. Further, given the large proportion of individuals in the military population meeting criteria for EDNOS, this study sought to better understand the types of disordered eating behaviors individuals in this population are engaging in.
Psychopathological Symptomatology
Some of the most common psychopathological symptoms experienced by military personnel include symptoms of post-traumatic stress (Mitchell et al., 2016) and body dysmorphic symptomatology (Campagna, 2016).
PTSD Symptoms. The estimated lifetime prevalence of PTSD among Vietnam Veterans is 30.9 and 26.9% for males and females, respectively (Kulka et al., 1990). Among veterans of the Gulf War, 12.1% were diagnosed with PTSD (Kang et al., 2003). More recently, in a sample of military members who were previously deployed to Iraq and Afghanistan, the prevalence of
PTSD was 13.8% (Tanielian & Jaycox, 2008). While an overarching prevalence rate of PTSD in the military population is unknown, it has been well established that symptoms of post-traumatic
stress are commonly experienced by this population.
Results from a longitudinal study showed that among military personnel, PTSD is
associated with the development of disordered eating behavior (i.e., compensatory behaviors and 3 loss of control over eating; Mitchell et al., 2016). One possible explanation for this relationship is that individuals who have experienced a traumatic event may fall victim to the “self-medication hypothesis” (Brewerton, 2011). The self-medication hypothesis suggests that individuals with
PTSD may choose to alleviate psychological pain by eating high concentrations of unhealthy foods such as sugar, fat, salt, and caffeine (Brewerton, 2011).
Another theory posed to explain why symptoms of post-traumatic stress are associated with disordered eating emphasizes the role of fear conditioning (Strober, 2004). According to this theory, core components of the eating disorder are influenced by extreme fear conditioning, thus making individuals with disordered eating patterns more resistant to fear extinction (Strober,
2004). Similarly, hyperactive amygdala activity is often observed in individuals with symptoms of post-traumatic stress, which plays a role in emotion dysregulation and abnormal responses to fear conditioning (Blechert, 2007). Evidence of atypical amygdala and other neural component activity among individuals with anorexia nervosa has been observed in previous research (Kaye et al., 2009; Strober, 2004). Post-traumatic stress symptoms may be indicative of disordered eating because individuals with PTSD often exhibit extreme fear conditioning and delayed extinction of fears, similar to individuals with disordered eating patterns (Strober, 2004).
BDD Symptoms. Another psychopathological factor that may contribute to eating disorder development in the military are symptoms of Body Dysmorphic Disorder (BDD).
Prevalence rates of BDD in male and female military members are 13% and 21.7%, respectively
(Campagna, 2016). In a national sample of civilians, it is estimated that only 0.7 to 2.4% suffer with BDD (Bjornsson, 2010). BDD is characterized by preoccupation with physical appearance, incessant worry, and obsession with slight bodily defects (American Psychiatric Association,
2013). In a sample of entry level military personnel, BDD symptoms were associated with the 4 usage of supplements to lose weight, a compensatory behavior often observed in eating disorders
(Campagna, 2016). In another study examining a clinical sample of civilians, 32.5% of subjects with BDD symptoms also had a lifetime diagnosis of an eating disorder (Ruffolo, 2006).
Considering these findings, symptoms of body dysmorphia may predict overall disordered eating behaviors in military members.
Military and Non-Military Related Trauma
Among female veterans, exposure to a traumatic event (i.e., combat exposure, sexual assault, childhood physical and sexual abuse, and other types of adult physical abuse) has been associated with increased eating disorder risk (Hall, 2017a). In this sample, military-related trauma was the strongest predictor of eating disorder development among females (Hall, 2017a).
More specifically, sexual assault during military service is highly associated with eating disorder development in the female veteran population (Forman-Hoffman, 2012). Research has also found that military related trauma is an important risk factor for eating disorder development among male military personnel (Hall, 2017a). In a recent study, non-combat related military trauma was a stronger predictor of eating disorder development than combat exposure (Hall,
2017b). Additionally, among both male and female military personnel, multiple traumatic experiences (military and non-military related) were associated with increased eating disorder symptoms (Hall, 2017b).
Pre-Military Socioeconomic Status
Individuals from lower socioeconomic (SES) backgrounds are more likely to join the military than those from higher SES backgrounds (Browning, 1973). Furthermore, disordered eating behaviors are more common among individuals from low SES groups than those from high SES groups (Gibbons, 2001). The disproportionate number of individuals in the military 5
that come from low SES backgrounds may help explain the prevalence of eating disorders within
this population. The stress vulnerability hypothesis provides a framework that may support why
individuals with pre-military demographic factors such as low SES and prior food insecurity that
are then exposed to future stressors such as serving in the military are at higher risk for
disordered eating behaviors (Das, 2001). Thus, military personnel from lower SES backgrounds
may be at higher risk for disordered eating behavior because of the stressors they encountered as
a result of their pre-military SES.
Pre-Military Food Insecurity
Another demographic factor that may be related to disordered eating behavior in military
personnel is food insecurity, a state in which an individual does not have reliable access to food
and adequate nutrition (Campbell, 1991). A well-established compilation of literature has indicated that previous socioeconomic disadvantages are related to food insecurity
(Lahteenkorva, 2001). It has also been suggested that food insecurity is related to disordered eating behaviors (Becker, 2017). If pre-military SES is associated with disordered eating
behaviors, it is within reason to consider that pre-military food insecurity may also be associated
with disordered eating behaviors. Perhaps, pre-military SES and pre-military food insecurity lead
to poorer eating behaviors among military personnel. Thus, the large proportion of military
members from lower socioeconomic backgrounds may help explain the increase in disordered
eating behaviors within the population.
Gender
Differences in the treatment, daily experiences, and socialization of female and male
military members may account for the differences in rates and types of disordered eating
behaviors between the sexes. For example, Maguen (2011) found that military sexual trauma was 6 far more common among female military personnel (31%) than male personnel (1%), and
Haskell et al. (2010) found that female veterans were at higher risk for PTSD (33%) than male veterans (21%). Another study showed that female military personnel are at higher risk for mental health problems because they experience more interpersonal stressors than male military personnel (Vogt et al., 2005). For example, compared to men, women in the military are at far higher risk of experiencing military sexual assault and other gender-specific trauma (Zinzow et al., 2007). Another study suggested that women in non-military samples have less access to conditions that foster health as well as greater stress associated with their gender roles (Ross &
Bird, 1994).
Differences in disordered eating behaviors between females and males may also be due to gender differences in socialization and treatment. One study sampling female veterans suggested that the socialization of women in the military during basic training supports a culture that encourages bulimia in women (Callahan, 2009). One theory that has been posed to the increase in disordered eating behavior among females in this population suggests that these eating behaviors are responses to powerlessness in females who lack an external locus of control and are seeking a means of controlling their behavior (Dalgleish et al., 2001). The differential vulnerability hypothesis states that while females may experience the same stressors as males, they may react in a different manner leading to poorer psychological and physical health
(McDonough & Walters, 2001; Turner & Avison, 1987).
Research Questions
The aim of the present study was to identify factors that increase risk for disordered eating behaviors in military personnel. Confirmation of the theorized relationships in addition to understanding behavioral outcomes will help to support future development of preventative 7
efforts to protect military personnel from developing eating disorders as well as aid in awareness
and future treatment of disordered eating in the population. This research is an important first step on the road to: 1) better understanding the risk factors that contribute to the disproportionate
amount of disordered eating behaviors seen in military personnel and 2) identifying how each
predictor variable is uniquely related to specific eating disorder symptomatology – binge eating,
restrained eating, and compensatory behaviors. Although previous evidence suggests that these
variables may be shared risk factors for disordered eating behaviors in military personnel, none
of these factors have been tested in the same model.
This study used a model that incorporated the previously mentioned risk factors for
disordered eating in military personnel. Each of the relationships were examined separately to
identify which factors best predict specific types of disordered eating behaviors in military
personnel as well as overall disordered eating behavior. Although there are a multitude of
possible relationships implied with the number of risk factors considered, the current study
focused on the following a priori hypotheses:
1. Psychopathological symptomatology such as symptoms of post-traumatic stress and body
dysmorphic disorder would be associated with an increased risk for disordered eating
behaviors in military personnel. More specifically, of the two indicators of
psychopathological symptomatology, symptoms of post-traumatic stress would be the
strongest predictor of disordered eating behavior.
2. Military personnel would exhibit higher rates of compensatory behaviors and binge
eating behaviors than restrained eating behaviors.
Given that results from the confirmatory factor analysis indicated poor fit, post-hoc
hypotheses were examined: 8
3. The association between psychopathological symptomatology and disordered eating
behavior was hypothesized to be stronger when military related trauma was experienced
rather than when non-military related trauma was experienced.
4. Low Pre-Military Socioeconomic Status was hypothesized to be significantly associated
with greater disordered eating behaviors. In addition, it was hypothesized that the
association between Pre-Military Socioeconomic Status and disordered eating behavior
would be stronger in the presence of greater psychopathological symptoms.
5. Females would exhibit higher rates of disordered eating than males when
psychopathological symptomatology is low. When psychopathological symptomatology
is high it is hypothesized that males and females would exhibit similar levels of
disordered eating behavior.
Furthermore, there were two exploratory aims of this study:
Aim 1. To examine sample differences in reports of key study variables (Overall Disordered
Eating Behavior, Restrained Eating, Binge Eating, Compensatory Behaviors, PTSD Symptoms,
BDD Symptoms, and Pre-Military Food Insecurity) among the five military branches and active duty and non-active duty, and
Aim 2. To examine prevalence rates of exposure to various types of traumatic events. 9
CHAPTER II. METHOD
Participants
The current study recruited members of the military population using Amazon
Mechanical Turk (MTurk). MTurk is a website that allows researchers, businesses, and
individuals to obtain high quality data in a quick manner. Obtaining a geographically
representative sample of military personnel from Amazon Mechanical Turk (MTurk) provided
an ethnically, socio-economically, and gender diverse sample (Casler, Bickel, & Hackett, 2013).
MTurk has been successfully used to recruit members of the military in many previous studies
(Seligowski & Orcutt, 2016; Morgan, Desmarais, Mitchell, & Simons-Rudolph, 2017; Lancaster
& Harris, 2018). Previous research has suggested that 4% of all mTurk users are members of the
armed forces (Levay, Freese, & Druckman, 2016). The branch distribution on mTurk is
comparable to that of national samples with the Army representing approximately half of the
population (Lynn & Morgan, 2016; Department of Defense & Office of the Deputy Assistant
Secretary of Defense for Military Community and Family Policy, 2016).
Based on the screening criteria recommended by Lynn and Morgan (2016), all individuals who were able to correctly answer five of the five pre-screening questions as well as answer half of the attention gauge items (i.e., 1 of 2) were included in the study. Participants who answered more than half of the attention gauge items incorrectly were excluded from the study.
Four thousand three hundred and thirty-one people attempted the screener questions required for study enrollment. Of those 4,331, 250 (5%) were enrolled in the study because they were able to correctly answer the items in the screener. Of the 250 participants who correctly answered the questions in the military screener, 247 (98%) met inclusion criteria by answering quality control items appropriately. Thus, the final sample included 247 participants. 10
Procedures
Participants read and signed a consent form to participate. After consenting to participate in the survey, the participants were asked to answer several questions to assess their eligibility for the study. Screening questions recommended by the Society for Military Psychology and the
American Psychological Association were used to assess whether the participant is a member of the military (See Appendix, Lynn and Morgan, 2016). Participants who were unable to correctly answer five out of five of the screening questions were notified that they were ineligible to participate in the study.
After completing the eligibility questions, participants completed the questionnaire. Two attention gauge questions such as, “Please answer ‘strongly agree’ for this question,” were dispersed throughout the survey. After completing the survey, participants were thanked for their participation, received monetary compensation ($1.25 per survey) for their time, were provided with resources for psychological care, and received the contact information of the Principal
Investigator and Human Subjects Review Board (HSRB) Chair to answer any questions they may have. Approval from Bowling Green State University’s HSRB was obtained prior to recruiting participants.
Measures
Demographics. Demographic information was gathered (see Appendix), including age, gender, race/ethnicity, education level, income, height/weight, employment status, relationship status, branch of military, and reason for joining the military.
Eating Disorder Examination Questionnaire. The Eating Disorder Examination
Questionnaire (EDE-Q; Fairburn, 1993) was used to measure three of the four dependent variable outcomes: overall disordered eating behavior, restrained eating behavior, and 11
compensatory behaviors (See Appendix). The EDE-Q is a self-report questionnaire developed from the “gold standard” Eating Disorder Examination interview designed to assess eating attitudes and behaviors over the previous four weeks (Aardoom, 2012). This measure is constructed of four subscales that assess dietary restraint, shape concern, weight concern, and eating concern as well as an overall disordered eating score comprised of the four indices.
To obtain an index of overall disordered eating behavior, responses to all questions were averaged. To obtain a restrained eating score the responses to all items for the restraint subscale were averaged. One example of a restraint subscale question is, “Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)?” Responses to questions such as these will be rated by the participant using the
Likert scale method from either 0 (No Days) to 6 (Every Day). Answers to each of these items will represent the frequency in which a participant has engaged in this behavior during the past twenty-eight days. In addition to the four main subscales, the EDE-Q assesses compensatory behaviors with six items. One example of a compensatory behavior questions is, “Over the past
28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape or weight?” Responses to this question required a number answer ranging from 0 to 28. To obtain a compensatory behavior score, the answers to each of these items were summed. High levels of internal consistency reliability and validity have been established for this measure
(Aardoom, 2012). In this sample, a high level of internal consistency reliability was achieved
(Cronbach’s alpha = 0.96).
Binge Eating Scale. The Binge Eating Scale (BES) was used to measure binge eating behavior (Gormally et al., 1982). The BES asks participants to report current thoughts and emotions regarding binge eating behaviors (See Appendix). One example of a question on this 12
survey is, “Choose one of the following: (1) I don’t feel any guilt or self-hate after I overeat. (2)
After I overeat, occasionally I feel guilt or self-hate. (3) Almost all the time I experience strong guilt or self-hate after I overeat.” Responses were averaged with higher scores indicating greater amounts of binge eating behaviors. The BES has shown adequate test-retest reliability as well as internal validity (Timmerman, 1999). A high level of internal consistency reliability was also found for the BES in this sample (Cronbach’s alpha = 0.94).
Trauma History Questionnaire. To assess both military and non-military related trauma, the Trauma History Questionnaire (THQ) was administered (Hooper, 2010). The THQ is a self-report questionnaire composed of 24 yes or no questions assessing traumatic experiences
(See Appendix). An example of a question on this section of the questionnaire is, “Have you ever experienced a natural disaster such as a tornado, hurricane, flood or major earthquake, etc., where you felt you or your loved ones were in danger of death or injury?” Response options to these questions are dichotomous including the choices: yes (indicating that this happened to them) and no (indicating that this did not happen to them). For the purposes of this study, this survey was adapted to inquire about the time in which this event occurred and indicate whether this event was related or unrelated to military involvement or if the event was experienced both as a part of military involvement as well as in a separate context. The survey indicated that the trauma should be categorized as military related if the experience occurred while at basic training, on active duty, or during another military related situation or environment that they were exposed to. The survey also indicated that military related trauma does not include veteran status unless being a member of the military was directly related to the traumatic event that was experienced. The answers to each of these items represented the frequency in which a participant has been exposed to trauma prior to their military service. To obtain scores for military and non- 13
military related trauma, the number of “yes” responses to each question were summed then
dummy coded with the first variable using 0 to represent that no military related trauma had
occurred and 1 to represent that military trauma had occurred and the second variable using 0 to
represent that non-military related trauma had not occurred and 1 to represent that non-military related trauma had occurred. The mean test-retest reliability score among all types of trauma among a sample of college aged women administered the THQ was adequate (Hooper, 2010).
The THQ has shown adequate internal validity (Hooper, 2010). In this sample, there was high internal consistency reliability for the THQ (Cronbach’s alpha = 0.90).
Post-Traumatic Stress Disorder Checklist (Military). The Post-Traumatic Stress
Disorder Checklist – Military (PCL-M, Wilkins et al., 2011) was used to measure symptoms of post-traumatic stress in military personnel. This measure is a self-report questionnaire adapted
from the original survey created to screen for PTSD symptomatology, specifically to address
military-related symptoms of post-traumatic stress (Weather, 1991). This measure is very similar to the civilian version of the PTSD Checklist (Wilkins, Lang, & Normal, 2011) . The only difference between the two measures is that the military version PTSD Checklist alters the wording of each question to ask about traumatic military experiences rather than generalized traumatic experiences. The measure asked that participants answer the questions based on the past month (See Appendix). An example of a question on this self-report questionnaire is,
“Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful military experience?” Responses to questions such as these were rated by the participants using the Likert scale method from either 1 (Not at all) to 5
(Extremely). Answers to each of these items was used to represent the frequency in which a participant has engaged in this behavior during the past month. To obtain a score for severity of 14
PTSD symptomatology, the response values were averaged. Test-retest reliability of the PCL-M was 0.70 among a sample of Vietnam Veterans. The PCL-M has shown strong convergent and discriminant validity (Wilkins et al., 2011). A high level of internal consistency reliability was also found for the PCL-M in this sample (Cronbach’s alpha = 0.97).
Yale-Brown Obsessive-Compulsive Scale Modified For Body Dysmorphic Disorder.
For the purposes of this study, the Yale-Brown Obsessive-Compulsive Scale modified for Body
Dysmorphic Disorder (BDD-YBOCS), a clinician administered structured interview, was adapted to assess rate of severity of symptoms of body dysmorphia through a self-report survey method (Phillips et al., 2001). The survey asks participants to answer the questions based on their feelings and behaviors in the past week (See Appendix). An example of a question on this measure is, “How much of your time is occupied by thoughts about a defect or flaw in your appearance?” Responses to questions such as these were rated by the participant using the Likert scale method from either 0 (None/Never/Or a Similar Variation) to 5 (Extreme/Completely/Or a
Similar Variation). Answers to each of these items represented the severity and frequency in which the participant has experienced symptoms of body dysmorphia during the previous week.
Response values were averaged to obtain a total score. Strong test-retest, convergent, and divergent reliability have been confirmed for this measure (Phillips et al., 2001). High internal consistency reliability was found in this sample for the BDD-YBOCS (Cronbach’s alpha = 0.95).
Socioeconomic Status. Previous research has indicated that income is one of the best
indicators of socioeconomic status (Duncan, Daily, McDonough, & Williams, 2002; Galobardes,
Shaw, Lawlor, Lynch, & Smith, 2006). Thus, to measure socioeconomic status, participants were
asked to report their current and pre-military income based on the most recently updated federal
income quintiles established by the US Census Bureau. This method of measuring 15
socioeconomic status has been utilized across many other studies examining the impact of SES
(Lynch, Kaplan, Cohen, Tuomilehto, & Solonen, 1996; Yost, Perkins, Cohen, Morris, & Wright,
2001; Alter, Naylor, Austin, & Tu, 1999). The income quintiles established are: (1) Very Low
SES, 12,457 per year or less; (2) Low SES, 12, 457 to 32,631 per year, (3) Medium SES, 32,631
to 56,832, (4) High SES, 56,832 to 92,031 per year (5) Very High SES 92,031 or more per year
(US Census Bureau, 2017). The question measuring reported pre-military household income was
administered incorrectly in the survey. Thus, usage of reported household income as organized
by federal income quintiles was not able to be used in analyses for this study.
U.S. Household Food Security Survey Module: Six-Item Short Form. The U.S.
Household Food Security Survey Module: Six-Item Short Form is a 6-item self-report measure
assessing household food security: the ability to have physical, social, and economic access to sufficient, safe, and nutritious food (Gulliford, 2004). The short form food security measure was
validated and shown to highly correlate with the full measure used to assess household food
security (Gulliford, 2004). For the purposes of this study, the items on the survey were adapted
to assess household food insecurity prior to military involvement (See Appendix). An example of
an item on the questionnaire is, “The food that (I/we) bought just didn’t last, and (I/we) didn’t
have money to get more.” The response options for these items range from (0) Often true to (3)
Never true. To obtain a score for pre-military food insecurity, all items were summed, and
reverse coded such that higher scores indicated great pre-military food insecurity in the
household. Internal consistency reliability of this survey is high. High criterion validity has been
established for this measure (Gulliford, 2004). In this sample, fairly high internal consistency
reliability was achieved for this measure (Cronbach’s Alpha = .79). 16
Analytic Plan
Preliminary Analyses. Prior to conducting analyses, all participants who did not meet
study criteria were excluded. Secondarily, score distributions were examined by calculating
standard deviations, means, and ranges of primary study variables. The assumptions of
multicollinearity, homescadiscity, linearity, and normality were then examined. To assess the
assumption of multicollinearity, Pearson correlations were calculated between all relevant
independent and dependent variables (overall disordered eating, compensatory behaviors, restrained and binge eating behaviors, gender, pre-military income, pre-military food insecurity,
PTSD symptoms, and BDD symptoms). Variables that were highly correlated (greater than .80)
were not included in the same analyses, so as to not violate the assumptions of multicollinearity
(Alin, 2010). To assess the assumptions of homescadiscity and normality, Predictive Probability
(P-P) and scatterplots of all dependent variables (overall disordered eating, compensatory
behaviors, restrained and binge eating behaviors) were examined for distribution of scores.
Further, to assess the assumption of linearity, the Variance Inflation Factor (VIF) for each
variable was examined. Outliers in the data were examined by conducting a visual inspection of box plots.
To examine the demographic variables in the sample the percentage of individuals in the sample groups (i.e., different military branches, genders, races, ages, and time since military)
was calculated. Next, percentages were compared to national samples (Department of Defense
& Office of the Deputy Assistant Secretary of Defense for Military Community and Family
Policy, 2016) to examine whether the sample was representative of the population of interest.
Frequencies of the prevalence of trauma history were also calculated. Lastly T-tests were
conducted to compare mean differences in key study variables (Overall Disordered Eating 17
Behavior, Restrained Eating, Binge Eating, Compensatory Behaviors, PTSD Symptoms, BDD
Symptoms, and Pre-Military Food Insecurity) between gender and military status (active and
non-active duty). An ANOVA was conducted to examine differences between military branches
in key study variables (overall disordered eating, compensatory behaviors, restrained and binge
eating behaviors, PTSD symptoms, BDD symptoms, and pre-military food insecurity). Lastly,
Tukey’s HSD test was conducted to further examine significant differences between military
branches in PTSD symptoms and overall disordered eating behaviors.
Primary Analyses.
Hypothesis 1. A confirmatory factor analysis (CFA) was initially conducted to examine the relationship between psychopathological symptoms and disordered eating. A factor loading of .40 between all indicator variables for each latent variable was desired for it to be effectively
used in the structural equation model (Stevens, 1992). Further, the recommended criteria for
indices of model fit are as follows: the normed fit and Tucker Lewis indices should be greater than or equal to .95; the comparative fit index should be greater than or equal to .90; the root mean square error of approximation should be less than 0.08 (Schreiber, Nora, Stage, Barlow, &
King, 2006). Given that CFA results showed that criteria for fit indices was not met, multiple regression analyses were then used to examine whether psychopathological symptoms (PTSD
and/or BDD) were associated with an increased risk for disordered eating behaviors (overall
disordered eating, binge eating behavior, compensatory behaviors, and restrained eating
behaviors). Since BDD Symptoms and PTSD Symptoms were highly correlated (r = 0.812, p
<0.05), violating the assumption of multicollinearity, eight separate multiple regression analyses
were conducted to examine BDD and PTSD symptoms (IVs) as risk factors for disordered eating behavior (DVs). Covariates included gender, pre-military income, and pre-military food
insecurity. 18
Hypothesis 2. To examine whether compensatory and binge eating were reported more frequently than restrained eating, frequencies of disordered eating behavior were examined. The variables indicating whether an individual engaged in each type of behavior were recoded as dummy variables. Frequencies were examined by calculating the percent of individuals who reported engaging in each type of compensatory behavior and who met clinically significant cut offs for restrained and binge eating behaviors. Furthermore, to examine whether significant differences existed between the percentages of each disordered eating behavior, chi square analyses were conducted for each outcome (binge eating behavior, restrained eating behavior, and compensatory behaviors).
Hypothesis 3. Hypothesis 3 (i.e., the association between psychopathological symptomatology and disordered eating behavior would be stronger when military related trauma was experienced rather than when non-military related trauma was experienced) could not be examined because all participants in the sample reported experiencing a non-military related trauma (See Figure 1).
Hypothesis 4. Hypothesis 4, the associations between pre-military socioeconomic status and disordered eating behavior (i.e. binge eating, restrained eating, compensatory behaviors, and overall disordered eating) would be stronger when psychopathological symptoms (PTSD and/or
BDD) were high, could not be examined due to an invalid SES measure.
Hypothesis 5. Following the methods employed by Dawson & Richter (2006), moderated multiple regression analyses were used to examine whether females would report higher rates of disordered eating behavior (i.e., Binge Eating, Restrained Eating, Compensatory Behaviors, and
Overall Disordered Eating) than males when levels of psychopathological symptoms (PTSD and/or BDD) were low; but, males and females would report similar levels of disordered eating 19 behavior (i.e., overall disordered eating, compensatory behaviors, restrained and binge eating behaviors) when psychological symptoms (PTSD and/or BDD) were high. The steps outlined by
Dawson and Richer (2006) for moderated multiple regression analyses were as follows:
(1) Regression of the dependent variable (Overall disordered eating, Restrained Eating
Behavior, Binge Eating Behavior, and Compensatory Behaviors) on each of the
independent variables (PTSD or BDD Symptoms).
(2) Creation of the product (or interaction) term between the independent variable and the
moderator variable.
(3) Then, the control variables (Gender, Pre-military food insecurity, Pre-military income,
PTSD Symptoms, and BDD Symptoms) were entered into the first block of the
regression analysis.
(4) The final step prior to data analysis involves placing the interaction term in the second
block.
(5) If the interaction term in the output was significant (p < 0.05), it indicated that the
proposed moderator was a risk factor (Cohen & Cohen, 1975; Peters, O’Connor, & Wise,
1984; Zedeck, 1971 as cited by Dawson & Richter; 2006). 20
CHAPTER III. RESULTS
Preliminary Analyses
The means, standard deviations, and ranges for the key variables in the study are presented in Table 1. Pearson correlations were calculated between all relevant independent and dependent variables (overall disordered eating, compensatory behaviors, restrained and binge eating behaviors, gender, pre-military food insecurity, PTSD symptoms, and BDD symptoms;
Table 2). Frequencies and descriptive statistics were calculated to examine participant demographics and military branch distributions (Table 3). T tests revealed that females had higher scores on overall disordered eating behavior than males (t(376.56) = 2.51, p = .012) and
BDD symptoms (t(376.56) = 2.51, p = .012) and males had higher scores on PTSD symptoms than females (t(376.56) = 2.51, p = .012; see Table 4). Furthermore, individuals that were not active duty reported greater PTSD and BDD symptoms than active duty members (t(376.56) =
2.51, p = .012; See Table 5). There were statistically significant differences between military branches as determined by one-way ANOVAs on the overall disordered eating variable, (F(4,
242) = 2.527, p = .041) and PTSD symptoms (F(2, 242) = 3.540, p = .008; See Table 6). Results of Tukey’s post hoc tests indicated that the mean level of PTSD symptoms was significantly lower among individuals in the Air Force (M = 2.66, SD = 1.36) compared to individuals in the
Army (M = 3.20, SD = 1.54). Tukey’s post-hoc tests did not reveal significant group differences in overall disordered eating.
Predictive Probability (P-P) and scatterplots of all dependent variables (overall disordered eating, compensatory behaviors, restrained and binge eating behaviors) revealed an equal distribution of error terms for all variables except for compensatory behaviors. Each of these variables showed variability in their scores except for non-military related trauma. Almost all of 21 the dependent and independent variable measures were normally distributed with approximately half of the participants not endorsing or receiving very low scores on items and the other half being normally distributed among the higher scoring values. The only variable that did not show sufficient score variability was non-military related trauma, as all participants endorsed having experienced at least one non-military related traumatic event. The error terms for compensatory behaviors were not equally distributed, violating the assumptions of homescadiscity and normality. Results involving the variable compensatory behavior should be interpreted with caution. An examination of the Variance Inflation Factor (VIF) for each dependent variable indicated that all values were below 10, suggesting that regression assumptions were not violated
(Chatterjee & Price, 1991). Lastly, outliers in the data were examined by conducting a visual inspection of box plots. All analyses were conducted with outliers included. Less than 1% of the data was missing, and the missing data consisted of exclusively demographic information (i.e. educational information). There was no missing data for any of the key study variables.
Primary Analyses
Confirmatory Factor Analyses. A confirmatory factor analysis was conducted to examine how well the measured variables indicate the latent variables being assessed. Results showed that the factor loadings of one of the indicator variables (compensatory behaviors) was below 0.40 and the proposed measurement model did not properly fit in order to conduct analyses using SEM (see Table 7 and Figure 2 for fit indices). Since the factor loadings did not meet recommended criteria, SEM could not be conducted (Schreiber, Nora, Stage, Barlow, &
King, 2006). 22
Multiple Regression Analyses.
Hypothesis 1. Multiple regression analyses were then conducted to examine associations between psychopathological symptoms (i.e., PTSD and BDD) and disordered eating behavior
(i.e., overall disordered eating, restrained eating, compensatory behavior, binge eating).
Hypothesis 1 was supported. Psychopathological symptoms were significantly associated with disordered eating behaviors.
Overall Disordered Eating. In the model that examined PTSD symptoms as a risk factor, regression results showed that 55% of the variance in overall disordered eating was explained by
PTSD symptoms, pre-military income, pre-military food insecurity, and gender (R2 = 0.55, F(5,
241) = 69.47, p = .000). PTSD symptoms (β = .879, p = .000) were significantly related to overall disordered eating (See Table 8).
In the model that examined BDD symptoms as a risk factor, regression results showed that 63.8% of the variance in disordered eating was explained by BDD symptoms, pre-military income, pre-military food insecurity, and gender (R2 = 0.663, F (4, 242) = 106.474, p = .000).
BDD symptoms (β = .753, p = .000) were significantly associated with disordered eating behavior (See Table 9).
Compensatory Behavior. In the model that examined PTSD symptoms as a risk factor, regression results showed that 12% of the variance in compensatory behaviors was explained by
PTSD symptoms, pre-military income, pre-military food insecurity, and gender (R2 = 0.125, F
(5, 241) = 6.884, p = .000). PTSD Symptoms (β = 6.077, p = .000) were significantly related to compensatory behaviors (See Table 8).
In the model that examined BDD symptoms as a risk factor, regression results showed that 16% of the variance in compensatory behaviors were explained by BDD symptoms, pre- military income, pre-military food insecurity, and gender (R2 = 0.156, F (4, 242) = 11.174, p 23
=.000). BDD symptoms (β = .372, p < .000 were significantly related to compensatory
behaviors (See Table 9).
Restrained Eating Behavior. In the model that examined PTSD symptoms as a risk
factor, regression results showed that 36.5% of the variance in restrained eating behaviors were
explained by PTSD symptoms, pre-military income, pre-military food insecurity, and gender (R2
= 0.365, F (5, 241) = 27.678, p = .00). Pre-military food insecurity (β = -.169, p = .001) and
PTSD symptoms (β = .496, p =.000) were significantly related to overall disordered eating
behavior (See Table 8).
In the model that examined BDD symptoms as a risk factor, regression results showed
that 36.6% of the variance in restrained eating was explained by BDD symptoms, pre-military
income, pre-military food insecurity, and gender (R2 = 0.366, F (4, 242) = 34.918, p = .000).
Pre-military food insecurity (β = -.596, p < 0.05) and BDD symptoms (β = .946, p < 0.05) were
significantly associated with restrained eating behavior (See Table 9).
Binge Eating Behavior. In the model that examined PTSD symptoms as a risk factor,
regression results showed that 38.9% of the variance in binge eating behavior was explained by
PTSD symptoms, pre-military income, pre-military food insecurity, and gender (R2 = 0.389, F
(5, 241) = 6.655, p = .000). Pre-military food insecurity (β = -.198, p = .000) and PTSD symptoms (β = .569, p = .000) were significantly related to binge eating behaviors (See Table 8).
In the model that examined BDD symptoms as a risk factor, regression results showed that 50.4% of the variance in binge eating behaviors could be explained by BDD symptoms, pre-
military income, pre-military food insecurity, and gender (R2 = 0.504, F (4, 242) = 61.402 p =
.000). Pre-military food insecurity (β = .12, p = .007) and BDD symptoms (β = .666, p = ..000) were significantly associated with binge eating behavior (See Table 9). 24
Hypothesis 2. Hypothesis 2 was partially supported. Fifty-two percent of military
personnel reported engaging in binge eating, 25.5% reported restrained eating, and 23.86% reported engaging in compensatory behaviors. A chi square analysis was performed to determine whether compensatory and binge eating behaviors were significantly more likely to be reported than restrained eating behaviors. Analyses revealed that there was a significant difference between the percent endorsing clinically significant binge eating and clinically significant
restrained eating behavior (X2(1, N = 201) = 15.65, p = .000), such that the frequency of reported
binge eating behaviors was significantly greater than frequency of restrained eating behaviors.
There was also a statistically significant difference between the percentage of individuals
reporting binge eating behavior and compensatory behaviors (X2(1, N = 201) = 61.44, p = .000),
such that the frequency of binge eating behaviors was significantly greater than compensatory
behaviors. Lastly, chi square analyses revealed that there was a significant difference in the
number of individuals that reported restrained eating and compensatory behaviors (X2(1, N =
201) = 118.46, p = .000), such that the frequency of restrained eating behaviors was significantly greater than compensatory behaviors.
Of the individuals who engaged in compensatory behavior, 62.7% vomited, 72.8% used
laxatives, and 45.7% over-exercised. More than half (57%) of the individuals that reported
engaging in compensatory behaviors noted that they partook in more than one behavior. The
mean reported monthly engagement in compensatory behaviors by men was 9.32 and in women
was 4.88. See Table 10 for more information about the prevalence of eating pathology among
women and men and the individual military branches. 25
Moderated Regression Analyses.
Hypothesis 5. To examine whether psychopathological symptoms (PTSD or BDD)
moderated the relationship between gender and disordered eating, moderated multiple regression
analyses were conducted.
Overall Disordered Eating. Regression results showed that female gender was associated with greater disordered eating behavior. Additionally, PTSD moderated the
relationship between overall disordered eating behavior and gender, ΔR2 = .07, p = .000 (See
Table 11). In the model that examined BDD symptoms as a moderator, the interaction term was
insignificant, indicating that BDD did not moderate the relationship between overall disordered
eating behavior and gender, ΔR2 = .001, p =.001 (See Table 12).
Compensatory Behaviors. Regression analyses indicated that PTSD moderated the
relationship between compensatory behaviors and gender, ΔR2 = .042, p = .001 (See Table 11).
In the model that examined BDD symptoms as a moderator, BDD symptoms did not moderate
the relationship between engaging in compensatory behavior and gender, ΔR2 = .006, p =.194
(See Table 12).
Restrained Eating. Regression analyses indicated that PTSD moderated the relationship
between restrained eating behavior and gender, ΔR2 = .038, p = .000 (See Table 11). Regression
results showed that BDD did not moderate the relationship between overall dietary restraint and
gender, ΔR2 = .003, p = .293 (See Table 12).
Binge Eating. A regression analysis revealed that PTSD moderated the relationship
between binge eating behavior and gender, ΔR2 = .042, p = .000 (See Table 11). Results also
showed that BDD moderated the relationship between binge eating behavior and gender, ΔR2
= .010, p =.031 (See Table 12). 26
Summary. The hypothesis that females would exhibit higher rates of disordered eating than males when symptoms of BDD were lower and that rates of disordered eating would be the same for both genders when BDD symptoms were higher was not supported. However, BDD was a significant moderator of the relationship between gender and binge eating. Examination of the interaction plot showed that men reported slightly more binge eating than women when low
BDD symptoms were present; but, when BDD symptoms were high, women reported slightly more binge eating behaviors than men. The plot also showed that both women and men engaged in more binge eating behaviors when BDD symptoms were low than when they were high (See
Figure 3). In addition, BDD was not a moderator of the relationship between gender and overall disordered eating, restrained eating, or compensatory behaviors
The hypothesis that females would exhibit higher rates of disordered eating than males when symptoms of PTSD were lower and that rates of disordered eating would be the same for both genders when PTSD symptoms were higher was partially supported. Examination of interaction plots showed that women reported more overall disordered eating, restrained eating, binge eating and compensatory behaviors than men (See Figures 4, 5, 6, and 7). PTSD was a significant moderator of the relationship between disordered eating variables (i.e., overall disordered eating, retrained eating, compensatory behaviors, and binge eating) and gender. Plots suggested that, among women, greater PTSD symptoms were associated with greater disordered eating (i.e., overall, binge, restrained, and compensatory behaviors), but PTSD symptoms had no effect on overall disordered eating, restrained, and binge eating in men. Thus, rates of overall disordered eating, restrained eating, and binge eating in men were similar at high and low levels of PTSD symptoms. However, PTSD symptoms were associated with greater compensatory behaviors in men. 27
CHAPTER IV. DISCUSSION
It is well understood that military personnel are at higher risk for disordered eating behavior than those in the civilian population (Bartlett, 2015). However, research has yet to identify the specific types of disordered eating behaviors (retrained eating, binge eating, and compensatory behaviors) in this population. Findings of the present study revealed, consistent with previous research (Mitchell et al., 2016; Campagna, 2016), that PTSD and BDD symptoms were significantly associated with all types of disordered eating behavior (overall disordered eating, restrained eating, binge eating, and compensatory behaviors) after controlling for several related factors (i.e., pre-military SES, gender, and pre-military food insecurity). Furthermore,
PTSD and BDD symptoms were found to moderate the association between gender and disordered eating outcomes.
In the present sample, over 50% of military men and women reported engaging in clinically significant disordered eating behavior. Approximately one–quarter of the sample
(25.7% of men and 18.8% of women) reported engaging in compensatory behaviors. The most common compensatory behavior reported by men was inappropriate use of laxatives (20.2%).
The most common compensatory behavior reported by women was vomiting to control one’s shape or weight (14.1%). Restrained eating behavior was more commonly reported by men
(40%) than women (35%). However, overall disordered eating behaviors were reported more among women (73.4%) than men (62.3%). Notably, in the current military sample, prevalence rates of disordered eating behaviors were similar among males and females, which is notable given that males typically report fewer disordered eating behaviors than women in civilian samples (Smink, Van Hoeken, & Hoek, 2012). 28
Rates of eating disorders are comparable among males and females in samples of athletes
who are expected to make weight (Baum, 2006). Given that the military has an expectation that
soldiers meet a certain body weight, similar to athletes, it is possible that the increased
prevalence of disordered eating may be a function of the culture. Other research has indicated
that the physical appearance expectations of western culture that are often thought to increase
eating disorders in women (Bordo, 2004) may impact men in similar ways. The military has an
expectation that their members, particularly men, should maintain a masculine physique. Thus,
western body image ideals extend to men as well as women (Baum, 2006), and as such may
impact the military population more so than in civilian samples of males who are less exposed to
these bodily expectations.
As it was aforementioned, PTSD symptoms were found to be associated with restrained eating, binge eating, compensatory behaviors, and overall disordered eating even when controlling for socioeconomic variables (pre-military income, pre-military food insecurity) and
gender. These findings are consistent with the self-medication hypothesis, which suggests that
individuals with PTSD may eat high calorie foods to alleviate psychological pain (Brewerton,
2011). These results are also consistent with the fear conditioning hypothesis which suggests that
disordered eating behaviors are a response to extreme fear conditioning, a shared symptom of
both PTSD and AN (Strober, 2004; Blechert, 2007). Furthermore, BDD symptoms were associated with all disordered eating outcomes (restrained eating, binge eating, compensatory behaviors, and overall disordered eating) when controlling for socioeconomic variables and gender. These findings are consistent with research indicating that BDD is a significant risk factor for development of disordered eating symptoms (Campagna, 2016). 29
Findings revealed that psychopathological symptoms (PTSD and BDD) moderated the relationship between gender and disordered eating behaviors. BDD symptoms were associated with less binge eating among men and women. Additionally, men reported more binge eating symptoms than women when they had low symptoms of BDD; but, women reported more binge eating behaviors than men when BDD symptoms were high. BDD did not moderate the association between gender and other types of disordered eating. Previous research has indicated that BDD symptoms are associated with restrained eating and compensatory behaviors among men and women (Phillips, Menard, & Fay, 2006), but there is little research examining the association of BDD symptoms and binge eating behavior. Future research should seek to examine how BDD symptoms increase risk for binge eating among women, but not men.
However, BDD was associated with greater reports of all other types of disordered eating behavior (overall disordered eating, restrained eating, and compensatory behaviors).
As noted above, women were more likely than men to engage in overall disordered eating, restrained eating, binge eating, and compensatory behaviors. However, PTSD symptoms moderated the effect of gender on disordered eating. Women were more likely to engage in disordered eating behaviors when PTSD symptoms were high than when they were low. Among men, PTSD symptoms were not associated with increased overall disordered eating, restrained eating, or binge eating behaviors. However, when PTSD symptoms were high, men reported a significant increase in compensatory behaviors.
These findings are of interest warranting future research to explore the previously suggested notion by Callahan (2009) that the socialization of women in the military during basic training supports a culture that encourages bulimia (Callahan, 2009). However, findings also suggest that men may be at higher risk for engaging in compensatory behaviors as well when 30 psychopathological symptoms of PTSD are higher. Given the lower rates of disordered eating behaviors among civilian men, even in the presence of psychopathology such as PTSD (Mitchell et al., 2012) than women, future research should explore the cultural influences in military samples that may account for these findings in this unique population.
Previous research has indicated that women are at higher risk for PTSD in the military
(Haskell, Gordon, & Mattocks, 2010) and among civilians (Fullerton & Colleagues, 2001) than men. It has also been suggested that PTSD manifests differently in men and women (Gwadz,
Nish, Leonard, & Strauss, 2007 as cited by Levine & Land, 2013). Research has indicated that women experience PTSD symptoms more frequently and for a longer period of time than men due to higher psychological reactivity (Lilly, Pole, Best, Metzler, & Marmar, 2009). The differences in the experiences of PTSD symptoms may alter disordered eating outcomes as well.
Further, given that PTSD manifests for women in the form of differences in psychological reactivity, it may be that one form of said reactivity manifests through disordered eating behavior. This suggestion is consistent with the differential vulnerability hypothesis which suggests that females may experience the same stressors as males, but react in a different manner leading to poorer health outcomes (McDonough & Walters, 2001; Turner & Avison, 1987).
Future research should explore how the differences in psychological reactivity in PTSD between genders may influence disordered eating outcomes in this population.
Furthermore, given the common presence of clinical levels of disordered eating behavior in military samples, future work should seek to better understand the mechanisms driving the prevalence of these behaviors in this population. In any population in which the prevalence rates of behavior are far greater than national estimates, cultural influences should be examined as potential catalysts. Thus, future research should examine aspects of military culture that may 31 influence one's eating behavior and thoughts surrounding eating and food related behaviors.
Possible factors to examine include food accessibility while deployed and at basic training, expectations for weight maintenance, and language surrounding health behaviors among military personnel.
Although it was not a direct aim of the current study, pre-military food insecurity was examined as a predictor of disordered eating. Pre-military food insecurity, which is highly associated with lower SES, was significantly associated with all types of disordered eating outcomes except for compensatory behaviors. If food availability and security are one of the main ways SES impacts eating behaviors (Alaimo, Olson, & Frongillo, 2001) and those from lower SES backgrounds were not impacted by food insecurity, it may help explain why their food habits were unaffected. Future research should examine whether food insecurity moderates the relationship between lower SES and disordered eating behavior.
Limitations
It should be noted that there were a several limitations to the study. To begin, the study used a screening tool to confirm that all individuals who completed the survey were military personnel, given that only 4% of mTurk users are a part of this population (Levay, Freese, &
Druckman, 2016). Further, as it was aforementioned, over 4,000 individuals did not correctly answer the questions in the military screener. It is possible that a few individuals may have known the answers to the screener and completed the survey without being a military member.
However, it is also possible that some individuals who were actually military members of the population may have been screened out because they did not know the answers to some of the screening questions. Given this limitation, and the low base rate of military personnel on mTurk
(Levay, Freese, & Druckman, 2016), individuals included in this study may have specific sample 32 characteristics that aren’t generalizable to the entire population of military personnel. Future research should consider using alternative methods for recruiting military personnel on mTurk.
For example, Amazon mTurk provides a built in screener in which only military personnel will be presented with the survey but will not be made aware of the fact that it is available to them because of their military status. However, there is little research to support the use of these methods for military personnel recruitment using this method. Given the limitations of using the military screening questions, future research should examine the efficacy of the built in mTurk screener. Furthermore, participants may have been primed to consider their eating behaviors while deployed or at basic training during the survey given that they completed the screener. Future research on mTurk with this population should consider using the automatic military mTurk screener to prevent concerns about priming the participants to think specifically of their military experiences.
Additionally, all data was collected using self-report methods. As is the case with all self- report research, it is possible that responses to survey items were exaggerated or false. Thus, temporal precedence of proposed risk factors was unable to be determined given the cross sectional design. Furthermore, given that all individuals endorsed a criterion A trauma on the
THQ, it is likely they were answering questions on the PCL-M in regard to the criterion A trauma they had reported. Unfortunately, neither the PCL-C or PCL-M asks specifically which traumatic experience the participant has in mind as they respond to the questions. Given that researchers cannot definitively say that participants were answering these questions in response to a criterion A trauma, the results from the PCL-M may not be only describing PTSD symptoms as they relate to criterion A traumatic experiences. Future research should ask participants to describe the traumatic event they are thinking of while answering items on the PCL. 33
Notably, the survey asked participants to recall food insecurity experiences from prior to military involvement. Given that the time since joining the military ranged from being active
duty members to greater than 30 years in this sample, it is possible that some people remembered these experiences more accurately than others. Moreover, the individuals who are using mTurk
are limited to individuals who are aware of the resource and are users of the online website.
Usage of mTurk requires a level of computer based knowledge, which some members of the population may not have, thus limiting the sample to only those who use mTurk and are computer savvy. Given the cultural shift in computer based knowledge over the past few decades, it is likely that these recruitment methods did not reach military personnel that are less exposed to things on the internet. This may limit the generalizability of findings to all military
members.
Further, the food insecurity measure was altered to assess pre-military experiences and the trauma history questionnaire was altered to assess whether the event that occurred was
related or unrelated to military involvement for the specific purposes of the study. It is possible that these alterations may have negatively influenced the results by not being validated in a military sample. Lastly, it should be noted that the variables indicating overall disordered eating
and dietary restraint were highly correlated (r = .86, p < 0.05). Given this high correlation,
findings involving the variable overall disordered eating may extend more so restrained eating
behaviors than other types of disordered eating (i.e. binge eating and compensatory behaviors).
However, in light of these limitations, the study yielded some interesting findings that future
research should seek to replicate.
34
Conclusions
U.S. military personnel are at high risk for development of disordered eating behaviors.
Prevalence estimates for eating disorders in military populations are substantially greater than civilian populations. Given the detrimental effects of disordered eating habits on the human body
(i.e. reduced bone density, muscle loss, kidney failure, electrolyte imbalance, increased risk for heart failure, high/low blood pressure, gastric and esophageal rupture, tooth decay, peptic ulcers and pancreatitis, diabetes, and poor cholesterol; NEDA, 2016), it is necessary to learn more about the risk factors for these behaviors in this population to support future prevention and interventions for disordered eating among military personnel.
Previous research has indicated that gender, pre-military socioeconomic status, pre- military food insecurity, PTSD symptoms, BDD symptoms, and trauma history are associated with disordered eating in this population. However, none of this research has indicated how each factors are associated with certain types of disordered eating outcomes (restrained eating, binge eating, and compensatory behaviors). Results provided insight as to how each of these variables influence specific disordered eating outcomes in military personnel. Findings warrant future research regarding military culture as a potential influence on the development and maintenance of disordered eating behaviors in this population. 35
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APPENDIX A. MEASURES
Military Screening Questionnaire 1. What is the acronym for the locations where final physicals are taken prior to shipping off for basic training (four letters)? 2. What is the acronym for the generic term the military uses for various job fields (three letters)? 3. Please put the following officer ranks in order (participants will be given visual insignia to rank order) 4. Please put the following enlisted ranks in order (participants will be given visual insignia to rank order) 5. In which state was your basic training located? 49
Demographic Questionnaire 1. What is your gender? Male, Female 2. What is your age? 3. What is your race/ethnicity? African American, Asian, Caucasian, Hispanic, Middle Eastern, Other 4. What is the highest level of education that you have obtained? Less than high school, High school, Some college or university, bachelor’s degree, Graduate level training 5. What was the highest level of education you obtained prior to joining the military? Less than high school, High school, Some college or university, bachelor’s degree, Graduate level training 6. What is your annual household income (yourself or parents)? $24,999 or less, $25,000 to $49,999, $50,000 to $74,999, $75,000 or more 7. What was your household income prior to joining the military? $24,999 or less, $25,000 to $49,999, $50,000 to $74,999, $75,000 or more 8. What is your height in feet? 9. What is your weight in pounds? 10. What is your current employment status? Part-time, Full-time, Unemployed, Student, Other a. If employed (part-time or full-time), what type of job do you hold? How many hours per week do you work? 11. What was your occupation prior to joining the military? 12. What is your relationship status? Single, Married, Divorced, Widowed 13. What branch of the military were you a part of? 14. If you are a veteran, how long has it been since you were in the military? <1 year, 2-5 years, 5-10 years, 10-20 years, 20-30 years, >30 years. 15. What is the highest rank you obtained in the military? 16. What was your military rank at discharge? (Please type N/A if you have never been discharged) 17. What were your reasons for joining the military? 50
Eating Disorder Examination Questionnaire The following questions are concerned with the past four weeks (28 days) only. Please read each question carefully. Please answer all of the questions. Please only choose one answer for each question. 0 1 2 3 4 5 6
No Days 1-5 Days 6-12 Days 12-15 Days 16-22 Days 23-27 Days Every Day
1. ...have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)? 2. ...have you gone for long periods of time (8 waking hours or more) without eating anything at all in order to influence your weight or shape? 3. ...have you tried to exclude from your diet any foods that you like in order to influence your shape or weight (whether or not you have succeeded)? 4. ...have you tried to follow definite rules regarding your eating (for example, a calorie limit) in order to influence your shape or weight (whether or not you have succeeded)? 5. ...have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight? 6. ...have you had a definite desire to have a totally flat stomach? 7. ...has thinking about food, eating, or calories made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)? 8. ...has thinking about shape or weight made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)? 9. ...have you had a definite fear of losing control over eating? 10. ...have you had a definite fear that you might gain weight? 11. ...have you felt fat? 12. ...have you had a strong desire to lose weight?
Questions 13-18: Please fill in the appropriate number in the boxes to the right. Remember that the questions only refer to the past four weeks (28 days).
Over the past few weeks (28 days) …
13. …how many times have you eaten what other people would regard as an unusually large amount of food (given the circumstances)? 14. ...On how many of these times did you have a sense of having lost control over your eating (at the time that you were eating)? 51
15. Over the past 28 days, on how many DAYS have such episodes of overeating occurred (i.e., you have eaten an unusually large amount of food AND have had a sense of loss of control at the time)? 16. Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape or weight? 17. Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape or weight? 18. Over the past 28 days, how many times have you exercised in a "driven" or "compulsive" way as a means of controlling your weight, shape, or amount of fat or to burn off calories?
Questions 19 to 21: Please select the appropriate response for each question. Please note that for these questions, the term "binge eating" means eating what others would regard as an unusually large amount of food for the circumstances, accompanied by a sense of having lost control over eating.
0 1 2 3 4 5 6
No Days 1-5 Days 6-12 Days 12-15 16-22 23-27 Every Days Days Days Day
19. Over the past 28 days, on how many days have you eaten in secret (i.e., furtively)? [Do not count episodes of binge eating] 20. On what proportion of the times that you have eaten have you felt guilty (felt that you've done wrong) because of its effect on your shape or weight? [Do not count episodes of binge eating] 21. Over the past 28 days, how concerned have you been about other people seeing you eat? [Do not count episodes of binge eating]
Questions 22 to 28: Please select the appropriate response to the right. Remember that the questions only refer to the past four weeks (28 days).
22. ...has your weight influenced how you think about (judge) yourself as a person? 23. ...has your shape influenced how you think (judge) yourself as a person? 24. ...how much would it have upset you if you had been asked to weigh yourself once a week (no more, or less often) for the next four weeks? 25. ...how dissatisfied have you been with your weight? 26. ...have you been dissatisfied with your shape? 27. ...how uncomfortable have you felt seeing your body (for example, seeing your shape in the mirror, in a shop window reflection, while undressing, or taking a bath or shower? 28. ...how uncomfortable have you felt about others seeing your shape or figure (for example, in communal changing rooms, when swimming, or wearing tight clothes)? 52
Binge Eating Scale Below are groups of numbered statements. Read all of the statements in each group and mark on this sheet the one that best describes the way you feel about the problems you have controlling your eating behavior.
1. a) I don’t feel self-conscious about my weight or body size when I’m with others. b) I feel concerned about how I look to others, but it normally does not make me feel disappointed with myself. c) I do get self-conscious about my appearance and weight which makes me feel disappointed in myself. d) I feel very self-conscious about my weight and frequently, I feel intense shame and disgust for myself. I try to avoid social contacts because of my self-consciousness. 2. a) I don’t have any difficulty eating slowly in the proper manner. b) Although I seem to “gobble down” foods, I don’t end up feeling stuffed because of eating too much. c) A t times, I tend to eat quickly and then, I feel uncomfortably full afterwards. d) I have the habit of bolting down my food, without really chewing it. When this happens I usually feel uncomfortably stuffed because I’ve eaten too much. 3. a) I feel capable to control my eating urges when I want to. b) I feel like I have failed to control my eating more than the average person. c) I feel utterly helpless when it comes to feeling in control of my eating urges. d) Because I feel so helpless about controlling my eating I have become very desperate about trying to get in control. 4. a) I don’t have the habit of eating when I’m bored. b) I sometimes eat when I’m bored, but often I’m able to “get busy” and get my mind off food. c) I have a regular habit of eating when I’m bored, but occasionally, I can use some other activity to get my mind off eating. d) Even though I’m not physically hungry, 1 get a hungry feeling in my mouth that only seems to be satisfied when I eat a food, like a sandwich, that fills my mouth. Sometimes, when I eat the food to satisfy my mouth hunger, I then spit the food out, so I won’t gain weight. 5. a) I’m usually physically hungry when I eat something. b) Occasionally, I eat something on impulse even though I really am not hungry. c) I have the regular habit of eating foods, that I might not really enjoy, to satisfy a hungry feeling even though physically, I don’t need the food. d) Even though I’m not physically hungry, 1 get a hungry feeling in my mouth that only seems to be satisfied when I eat a food, like a sandwich, that fills my mouth. Sometimes, when I eat the food to satisfy my mouth hunger, I then spit the food out, so I won’t gain weight. 6. e) I don’t feel any guilt or self-hate after I overeat. f) After I overeat, occasionally I feel guilt or self-hate. g) Almost all the time I experience strong guilt or self-hate after I overeat. 7. a) I don’t lose total control of my eating when dieting even after periods when I overeat. b) Sometimes when I eat a “forbidden food” on a diet, I feel like I “blew it” and eat even more. c) Frequently, I have the habit of saying to myself, “I’ve blown it now, why not go all the way” when I overeat on a diet. When that happens, I eat even more. d) I have a regular habit of starting strict diets for myself, but I break the diets by going on an eating binge. My life seems to be either a “feast” or “famine.” 8. a) I rarely eat so much food that I feel uncomfortably stuffed afterwards. b) Usually about once a month, I eat such a quantity of food, I end up feeling very stuffed. c) I have regular periods during the month when I eat large amounts of food, either at mealtime or at snacks. 53
d) I eat so much food that I regularly feel quite uncomfortable after eating and sometimes a bit nauseous. 9. a) My level of calorie intake does not go up very high or go down very low on a regular basis. b) Sometimes after I overeat, I will try to reduce my caloric intake to almost nothing to compensate for the excess calories I’ve eaten. c) I have a regular habit of overeating during the night. It seems that my routine is not to be hungry in the morning but overeat in the evening. d) In my adult years, I have had week-long periods where I practically starve myself. This follows periods when I overeat. It seems I live a life of either “feast or famine.” 10. a) I usually am able to stop eating when I want to. I know when “enough is enough.” b) Every so often, I experience a compulsion to eat which I can’t seem to control. c) Frequently, I experience strong urges to eat which I seem unable to control, but at other times I can control my eating urges. d) I feel incapable of controlling urges to eat. I have a fear of not being able to stop eating voluntarily. 11. a) I don’t have any problem stopping eating when I feel full. b) I usually can stop eating when I feel full but occasionally overeat leaving me feeling uncomfortably stuffed. c) I have a problem stopping eating once I start and usually I feel uncomfortably stuffed after I eat a meal. d) Because I have a problem not being able to stop eating when I want, I sometimes have to induce vomiting to relieve my stuffed feeling. 12. a) I seem to eat just as much when I’m with others (family, social gatherings) as when I’m by myself. b) Sometimes, when I’m with other persons, I don’t eat as much as I want to eat because I’m self-conscious about my eating. c) Frequently, I eat only a small amount of food when others are present, because I’m very embarrassed about my eating. d) I feel so ashamed about overeating that I pick times to overeat when I know no one will see me. I feel like a “closet eater.” 13. a) I eat three meals a day with only an occasional between meal snack. b) I eat 3 meals a day, but I also normally snack between meals. c) When I am snacking heavily, I get in the habit of skipping regular meals. d) There are regular periods when I seem to be continually eating, with no planned meals. 14. a) I don’t think much about trying to control unwanted eating urges. b) At least some of the time, I feel my thoughts are pre-occupied with trying to control my eating urges. c) I feel that frequently I spend much time thinking about how much I ate or about trying not to eat anymore. d) It seems to me that most of my waking hours are pre-occupied by thoughts about eating or not eating. I feel like I’m constantly struggling not to eat. 15. a) I don’t think about food a great deal. b) I have strong cravings for food, but they last only for brief periods of time. c) I have days when I can’t seem to think about anything else but food. d) Most of my days seem to be pre-occupied with thoughts about food. I feel like I live to eat. 16. a) I usually know whether or not I’m physically hungry. I take the right portion of food to satisfy me. b) Occasionally, I feel uncertain about knowing whether or not I’m physically hungry. At these times it’s hard to know how much food I should take to satisfy me. c) Even though I might know how many calories I should eat, I don’t have any idea what is a “normal” amount of food for me. 54
Trauma History Questionnaire The following is a series of questions about serious or traumatic life events. These types of events actually occur with some regularity, although we would like to believe they are rare, and they affect how people feel about, react to, and/or think about things subsequently. Knowing about the occurrence of such events, and reactions to them, will help us to develop programs for prevention, education, and other services. The questionnaire is divided into questions covering crime experiences, general disaster and trauma questions, and questions about physical and sexual experiences. For each event, please indicate whether it happened and, if it did whether this event was military related or was unrelated to military involvement. If the event has been experienced during military involvement and outside of military involvement, please check both items. Military related trauma refers to any experience that occurred while at basic training, on active duty, or during other military related situations or environments that you were exposed to. Military related trauma does not include trauma that occurred while you were a veteran unless being a veteran or member of the military was directly related to the traumatic event that was experienced.
If you selected yes, please select the following boxes to indicate if the event was Select One military or non-military related. Select both if the event happened in both contexts. Military Non-Military Related Related Has anyone ever tried to take something directly from you by using force or the threat of force, No Yes ______such as a stick-up or mugging? Has anyone ever attempted to rob you or actually robbed you (i.e., stolen your personal No Yes ______belongings)? Has anyone ever attempted to or succeeded in breaking into your home when you were not No Yes ______there? Has anyone ever attempted to or succeed in breaking into your home while you were there? No Yes ______
Have you ever had a serious accident at work, in a car, or somewhere else? No Yes ______Have you ever experienced a natural disaster such as a tornado, hurricane, flood or major earthquake, etc., where you felt you or your loved ones were in danger of death or injury? No Yes ______Have you ever experienced a “man-made” disaster such as a train crash, building collapse, bank robbery, fire, etc., where you felt you or your loved ones were in danger of death or No Yes ______injury? (If yes, please specify below) ______Have you ever been exposed to dangerous chemicals or radioactivity that might threaten your No Yes ______health? Have you ever been in any other situation in which you were seriously injured? No Yes ______Have you ever been in any other situation in which you feared you might be killed or seriously injured? No Yes ______Have you ever seen someone seriously injured or killed? No Yes ______Have you ever seen dead bodies (other than at a funeral) or had to handle dead bodies for any No Yes ______reason? Have you ever had a close friend or family member murdered, or killed by a drunk driver? No Yes ______Have you ever had a spouse, romantic partner, or child die? No Yes ______Have you ever had a serious or life-threatening illness? No Yes ______Have you ever received news of a serious injury, life-threatening illness, or unexpected death No Yes ______of someone close to you? 55
Have you ever had to engage in combat while in military service in an official or unofficial No Yes ______war zone? Has anyone ever made you have intercourse or oral or anal sex against your will? No Yes ______Has anyone ever touched private parts of your body, or made you touch theirs, under force or No Yes ______threat? Other than incidents mentioned in Questions 18 and 19, have there been any other situations in No Yes ______which another person tried to force you to have an unwanted sexual contact? Has anyone, including family members or friends, ever attacked you with a gun, knife, or some No Yes ______other weapon? Has anyone, including family members or friends, ever attacked you without a weapon and No Yes ______seriously injured you? Has anyone in your family ever beaten, spanked, or pushed you hard enough to cause injury? No Yes ______Have you experienced any other extraordinarily stressful situation or event that is not covered No Yes ______above? 56
Post-Traumatic Stress Disorder Checklist (Military) Below is a list of problems and complaints that veterans sometimes have in response to stressful experiences. Please read each one carefully, and circle one of the numbers to the right to indicate how much you have bothered by that problem in the past month.
Not at all A little bit Moderately Quite a bit Extremely
Repeated, disturbing 1 2 3 4 5 memories, thoughts, or images of a stressful military experience? Repeated, disturbing 1 2 3 4 5 dreams of a stressful military experience? Suddenly acting or 1 2 3 4 5 feeling as if a stressful military experience were happening again (as if you were reliving it)? Feeling very upset 1 2 3 4 5 when something reminded you of a stressful military experience? Having physical 1 2 3 4 5 reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful military experience? Avoid thinking about or 1 2 3 4 5 talking about a stressful military experience or avoid having feelings related to it? Avoid activities or 1 2 3 4 5 talking about a stressful military experience or avoid having feelings related to it? Trouble remembering 1 2 3 4 5 important parts of a stressful military experience? Loss of interest in 1 2 3 4 5 things that you used to enjoy? Feeling distant or cut 1 2 3 4 5 off from other people? Feeling emotionally 1 2 3 4 5 numb or being unable to have loving feelings for those close to you? Feeling as if your future 1 2 3 4 5 will somehow be cut short? Trouble falling or 1 2 3 4 5 staying asleep? Feeling irritable or 1 2 3 4 5 having angry outbursts? 57
Having difficulty 1 2 3 4 5 concentrating? Being “super alert” or 1 2 3 4 5 watchful on guard? Feeling jumpy or easily 1 2 3 4 5 startled? 58
Yale-Brown Obsessive Compulsive Scale Modified For Body Dysmorphic Disorder
None Mild (Less than 1 Moderate (1-3 Severe Extreme hr./day) hrs./day) (greater than 3 (greater than and up to 8 8 hrs./day) hrs./day)
1. How much of your 0 1 2 3 4 time is occupied by thoughts about a defect of flaw in your appearance? None Mild, slight Moderate Severe, causes Extreme, interference with interference with substantial incapacitatin social, occupational, or social, impairment in g role activities, but occupational, or social, overall performance role occupational, not impaired performance, but or role still manageable performance 2. How much do your 0 1 2 3 4 thoughts about your body defect(s) interfere with your social or work (role) functioning? 2a. Is there anything i. Spending Time with Friends (Yes/No) you aren’t doing or ii. Dating (Yes/No) can’t do because of iii. Attending Social Functions (Yes/No) them? (answer iv. Doing things w/family in and outside of home (Yes/No) yes/no to the v. Going to school/work each day (Yes/No) following) vi. Being on time for or missing school/work (Yes/No) vii. Focusing at school/work (Yes/No) viii. Productivity at school/work (Yes/No) ix. Doing homework or maintaining grades (Yes/No) x. Daily activities (Yes/No) None Mild, Not too Moderate, Severe, very Extreme, disturbing disturbing disturbing disabling distress 3. How much distress 0 1 2 3 4 do your thoughts about your body defect(s) cause you? Makes an effort Tries to resist most of Makes some Yields to all Completely to always resist, the time effort to resist such thoughts and willingly or symptoms so without yields to all minimal doesn’t attempting to such need to actively control them thoughts resist but yields with some reluctance 4. How much of an 0 1 2 3 4 effort do you make to resist these thoughts? How often do you try to disregard them or turn your attention away from these thoughts attempting to control them but as they enter your mind? Complete Much Control, usually Moderate Little control, No control, control, no need be able to stop or control, rarely experienced for control divert these thoughts sometimes able successful in as because thoughts with some effort and to stop or divert stopping completely are so minimal concentration these thoughts thoughts, can involuntary, only divert rarely able to even 59
attention with momentarily difficulty divert attention 5. How much control 0 1 2 3 4 do you have over your thoughts about your body How successful are you in stopping or diverting these thoughts? 5a. How successful 0 1 2 3 4 are you in stopping or diverting these thoughts? None Mild (Less than 1 Moderate (1-3 Severe Extreme hr./day) hrs./day) (greater than 3 (greater than and up to 8 8 hrs./day) hrs./day) 6. How much time do 0 1 2 3 4 you spend in activities related to your concern over your appearance? 6a. Make a check mark i. ___Checking mirrors/other surfaces next to all activities that apply. ii. ___Grooming activities iii. ___Applying makeup iv. ___Excessive Exercise (time beyond 1 hr. a day) v. ___Camouflaging with clothing/other cover vi. ___Scrutinizing others' appearance (comparing) vii. ___Questioning others about/discussing your appearance viii. ___Picking at skin ix. ___Other ______None Mild, slight Moderate Severe, causes Extreme, interference with interference with substantial incapacitatin social, occupational, or social, impairment in g role activities, but occupational, or social, overall performance role occupational, not impaired performance, but or role still manageable performance 7. How much do these 0 1 2 3 4 activities interfere with your social or work (role) functioning? None Mild, only slightly Moderate, Severe, Extreme, anxious if behavior reports that prominent and incapacitatin prevented anxiety would very g anxiety mount but disturbing from any remain increase in intervention manageable if anxiety is aimed at behavior is behavior is modifying prevented interrupted activity 8. How would you feel 0 1 2 3 4 if you were prevented from performing the above stated activities? How anxious would you become? Makes an effort Tries to resist most of Makes some Yields to all Completely to always resist, the time effort to resist such thoughts and willingly or symptoms so without yields to all minimal doesn’t attempting to behaviors need to actively control them related to resist but yields with body defect some reluctance 60
9. How much of an 0 1 2 3 4 effort do you make to resist these activities? Complete Much control, Moderate Little control, No control, control, or experiences pressure to control, strong very strong drive to control is perform the behavior, pressure to drive to perform unnecessary but usually able to perform perform behavior because exercise voluntary behavior, can behavior, must experienced symptoms are control over it control it only be carried to as mild with difficulty. comp completely involuntary and overpowerin g, rarely able to even momentarily delay activity. 10. How strong is the 0 1 2 3 4 drive to perform these behaviors? How much control do you have over them? 61
U.S. Household Food Security Survey Module: Six-Item Short Form For these statements, please indicate whether the statement was often true, sometimes true, or never true for you/your household before you joined the military.
Often True Sometimes True Never True Don’t Know 1. The food that (I/we) bought just 1 2 3 4 didn’t last, and (I/we) didn’t have money to get more. 2. (I/we) couldn’t afford to eat 1 2 3 4 balanced meals. 3. (You/you or other adults in 1 2 3 4 your household) ever cut the size of your meals or skip meals because there wasn't enough money for food
Almost Every Some Months Only One or Two Month but Not Every Months Don’t Know Month 4. If yes to number 3, how often 1 2 3 4 did this happen? 5. Yes No Don’t Know 6. Did you ever eat less than you 1 2 3 X felt you should because there wasn't enough money for food? 7. Were you every hungry but 1 2 3 X didn't eat because there wasn't enough money for food? 62
APPENDIX B. HSRB FORM FOR ORIGINAL APPLICATION 63
APPENDIX C. CONSENT FORM 64
APPENDIX D. TABLES
Table 1. Summary of descriptive statistics for the core study variables.
N Range Mean Standard Variables Deviation Restrained Eating 247 1-7 3.153 1.735 Overall Disordered Eating 247 1-7 2.978 1.506 Compensatory Behaviors 247 1-303 8.174 26.04 Binge Eating 247 1-3.69 1.773 .5901 PTSD Symptoms 247 1- 2.184 1.121 BDD Symptoms 247 4.59 .58- 2.153 .9428 Pre-Military Food Insecurity 247 0-2.674.50 1.951 .3664 65
Table 2. Intercorrelations among independent and dependent variables.
Variable 1 2 3 4 5 6 7 8 1. Gender -- 2. PTSD Symptoms -.10 -- 3. BDD Symptoms -.00 .81** -- 4. Food Insecurity -.06 .21** .25** -- 5. Overall ED -.02 .72** .79** .27** -- 6. Compensatory -.07 .33** .23 .23 .26** -- 7. Restrained -.03 .57** .19** .19** .86** .23** -- 8. Binge Eating .02 .58** .29** .29** .70** .28** .51** -- Note. Food Insecurity = Pre-military food insecurity, Overall ED = Index of overall disordered eating behavior, Compensatory = Compensatory Behaviors, Restrained = Restrained Eating, Binge = Binge Eating. Male = 0, Female = 1. ***p < 0.001, **p < 0.01, * p < 0.05 66
Table 3. Demographic Information for participants based on military branch.
Variables Total Sample Air Force Army Coast Guard Marine Corps Navy % of sample 100% (n = 18.6% (n = 46) 55.1% (n = 136) 2.4% (n= 6) 6.5% (n = 16) 17.4% (n =43) 247) Gender Male 74.1% (n 82.6% (n= 38) 72.1% (n = 98) 83.3% (n =5) 62.5% (n = 10) 74.4% (n = 32) =183) Female 25.9% (n = 64) 17.4% (n = 8) 27.9% (n = 38) 16.7% (n = 1) 37.5% (n = 6) 25.6% (n = 11) Age <20 0.8% (n = 2) 0% (n = 0) 0.7% (n = 1) 0% (n = 0) 0% (n = 0) 2.1% (n = 1) 20-29 31.2% (n = 77) 34.8% (n = 16) 27.2% (n = 37) 50% (n = 3) 43.8% (n = 7) 32.6% (n = 14) 30-39 48.6% (n = 43.5% (n = 20) 53.7% (n =73) 50% (n = 3) 37.5% (n = 6) 41.9% (n = 18) 120) 40-49 11.3% (n = 28) 4.3% (n =2) 11% (n = 15) 0% (n = 0) 12.5% (n = 2) 20.9% (n = 9) 50-59 5.7% (n = 14) 10.9% (n =5) 5.9% (n = 8) 0% (n = 0) 6.3% (n = 1) 0% (n = 0) 60 2.4% (n = 6) 6.5% (n = 3) 1.5% (n = 2) 0% (n = 0) 0% (n = 0) 2.3% (n = 1) Race African American 17.8% (n = 44) 8.7% (n = 4) 21.3% (n = 29) 0% (n = 0) 18.8% (n = 8) 18.6% (8) Asian Caucasian 3.6% (n = 9) 0% (n = 0) 5.9% (n = 8) 0% (n = 0) 0% (n = 0) 2.3% (n = 1) 67.6% (n = 80.4% (n = 37) 62.5% (n =85) 83.3% (n = 5) 75% (n = 12) 65.1% (n = 28) 167) Hispanic 8.1% (n = 20) 6.5% (n = 3) 8.1% (n =11) 16.7% (n = 1) 6.3% (n = 1) 9.3% (n =4) Other 2.8% (n = 7) 4.3% (n = 2) 2.2% (n = 3) 0% (n = 0) 0% (n = 0) 4.7% (n = 2) Military Status Active Duty 17% (n = 42) 8.7% (n = 4) 17.6% (n = 24) 50% (n = 3) 31.3% (n = 5) 14 %(n = 6) 1-4 years 36% (n = 89) 19% (n = 41.3) 53% (n = 39) 0% (n = 0) 37.5% (n = 6) 25.6% (n = 11) 5-10 years 24.3% (n = 60) 26.1% (n = 12) 19.9% (n = 27) 50% (n = 3) 6.3% (n = 1) 39.5% (n = 17) 10-20 years 11.3% (n = 28) 6.5% (n =3) 10.3% (n = 14) 50% (n = 3) 6.3% (n = 1) 39.5% (n = 17) 20-30 years 8.1% (n = 20) 6.5% (n =3) 11% (n = 15) 0% (n = 0) 0% (n = 0) 4.7% (n = 2) 30 years 3.2% (n = 8) 10.9% (n = 5) 2.2% (n = 3) 0% (n = 0) 0% (n = 0) 3.2% (n = 8) Sexual Trauma Military Related 13% (n = 32) 13% (n = 6) 10.3% (n = 14) 0% (n = 0) 0% (n = 0) 27.9% (n = 12) Non-Military 14.2% (n = 35) 15.2% (n = 7) 10.3% (n = 14) 16.7% (n = 1) 0% (n = 0) 30.2% (n = 13) Related 67
Table 4. T-tests examining gender differences in key study variables.
Gender Key Study Variables Male Female Mean (SD) Mean (SD) Overall ED Scale 2.96 (1.58)* 3.02 (1.29)* Dietary Restraint 3.18 (1.76) 3.05 (1.65) Binge Eating 1.76 (.597) 1.79 (.57) Compensatory Behaviors 9.33 (29. 39) 4.87 (11.78) Pre-Military Food 6.29 (2.18) 6.00 (1.86) Insecurity PTSD Symptoms 2.24 (1.19)** 1.99 (.912)** BDD Symptoms 2.15 (.99)** 2.16 (.76)** ***p < .001, ** p < .01, * p < .05. 68
Table 5. T-tests examining differences between active duty and non-active duty military personnel on key study variables.
Military Status Key Study Variables Active Duty – Non-Active Duty – Mean (SD) Mean (SD) Overall ED Scale 2.42 (1.28) 3.09 (1.52) Dietary Restraint 2.85 (1.75) 3.21 (1.73) Binge Eating 1.81 (0.59) 1.67 (.87) Compensatory Behaviors 4.00 (6.91) 9.03 (28.36) Pre-Military Food 6.32 (2.15) 2.07 (.99) Insecurity PTSD Symptoms 1.67 (.87)** 2.28 (1.14)** BDD Symptoms 1.76 (.66)** 2.23 (.97)** ***p < .001, ** p < .01, * p < .05. 69
Table 6. Differences between military branches among key study variables.
Key Study Variables Sum of Mean Square Squares df F Overall ED Scale Between Subjects 22.401 4 5.600 2.527* Within Subjects 536.264 242 3.026 Total 558.665 246 Dietary Restraint Between Subjects 8.954 4 2.238 .740 Within Subjects 732.342 242 3.026 Total 741.295 246 Binge Eating Between Subjects 1.328 4 .332 .953 Within Subjects 84.324 242 .348 Total 85.652 246 Compensatory Behaviors Between Subjects 4124.356 4 1031.089 1.533 Within Subjects 162785.158 242 672.666 Total 166909.514 246 Pre-Military Food Between Subjects 13.388 4 3.347 .752 Insecurity Within Subjects 1076.806 242 4.450 Total 1090.194 246 PTSD Symptoms Between Subjects 17.330 4 4.332 3.540** Within Subjects 296.192 242 1.224 Total 313.522 246 BDD Symptoms Between Subjects 8.206 4 2.052 2.359 Within Subjects 210.499 242 .870 Total 218.705 246 ***p < .001, ** p < .01, * p < .05. 70
Table 7. Goodness of Fit indices for proposed structural models.
NFI TLI CFI RMSEA Model Fit Indices .804 .439 .813 .185
Note. NFI = Normed Fit Index; TLI=Tucker-Lewis Index; CFI=Bentler's Comparative Fit Index, RMSEA = Root Mean Square Error of Approximation. 71 Table 8. Multiple Regression Examining the Association between PTSD Symptoms and Disordered Eating.
2 2 R R adj B SE B β DV: Overall ED .55 .54 Constant -.185 .319 Gender .328 .149 .096 Pre-Military Food Insecurity .095 .032 .133** Pre-Military Income .080 .068 .055 PTSD Symptoms .879 .065 .654*** DV: Restrained Eating .34 .33 Constant .620 .445 Gender .111 .208 .028 Pre-Military Food Insecurity .061 .044 .074 Pre-Military Income .095 .095 .056 PTSD Symptoms .769 .093 .496*** DV: Compensatory Behaviors .12 .10 Constant -4.299 7.726 Gender -2.622 3.606 -.044 Pre-Military Food Insecurity -.566 .766 -.046 Pre-Military Income 1.982 1.643 .078 PTSD Symptoms 7.036 1.527 .305*** DV: Binge Eating .39 .38 Constant .661 .146 Gender .114 .068 .085 Pre-Military Food Insecurity .052 .014 .184*** Pre-Military Income .008 .031 .013 PTSD Symptoms .289 .029 .554*** Note. Male = 0, Female =1. ***p < 0.001, ** p < 0.01, 72
Table 9. Multiple Regression Analyses Examining the Association between BDD Symptoms and Disordered Eating.
2 2 R R adj B SE B β DV: Overall ED .64 .63 Constant -.253 .286 Gender .075 .133 .022 Pre-Military Food .059 .029 .082** Insecurity Pre-Military Income .090 .060 .061 BDD Symptoms 1.204 .067 .753*** DV: Restrained Eating .37 .36 Constant .602 .436 Gender -.115 .203 -.029 Pre-Military Food .034 .044 .041 Insecurity Pre-Military Income .119 .091 .070 BDD Symptoms 1.045 .103 .567*** DV: Compensatory .16 .14 Behaviors Constant -5.661 7.544 Gender -4.646 3.518 -.078 Pre-Military Food -.961 .758 -.078 Insecurity Pre-Military Income 1.766 1.584 .266 BDD Symptoms 10.277 1.775 .372*** DV: Binge Eating .50 .49 Constant .610 .131 Gender .032 .061 .024 Pre-Military Food .036 .013 .129** Insecurity Pre-Military Income .028 .001 .985 BDD Symptoms .417 .031 .666*** Note. Male = 0, Female =1. ***p < 0.001, **p < 0.01 73
Table 10. Summary of disordered eating behaviors reported by males and females.
Variables Gender Total Sample Air Army Coast Marine Navy Force Guard Corps Overall ED Female 73.4% (n = 87.5% (n = 81.6% (n = 31) 0% (n = 0) 33.3% (n = 2) 73.4% (n = 47) Scale 47) 7) Male 62.3% (n = 52.6% (n = 68.4% (n = 67) 40% (n = 2) 60% (n = 6) 59.4% (n = 19) 114) 20) Dietary Female 34.4% (n = 50% 28.9% (n = 11) 0% (n = 0) 16.7% (n = 1) 54.5% (n = 6) Restraint 22) (n = 4) Male 39.9% (n = 28.9% (n = 48% (n = 47) 20% (n = 1) 20% (n = 2) 37.5% (n = 12) 73) 11) Shape Concern Female 45.3% (n = 62.5% (n = 47.4% (n = 18) 0% (n = 0) 16.7% (n = 1) 45.5% (n = 5) 29) 5) Male 32.8% (n = 23.7% (n = 37.8% (n = 37) 20% (n = 1) 20% (n = 2) 34.4% (n = 11) 60) 9) Weight Concern Female 46.9% (n = 62.5% (n = 47.4% (n = 18) 0% (n = 0) 16.7% (n = 1) 54.5% (n = 6) 30) 5) Male 31.1% (n = 21.1% (n = 34.7% (n = 34) 20% (n = 1) 20% (n = 2) 37.5% (n = 12) 57) 8) Eating Concern Female 9.4% (n = 6) 12.5% (n = 7.9% (n = 3) 0% (n = 0) 0% (n = 0) 18.2% (n = 2) 1) Male 20.8% (n = 7.9% (n = 68.4% (n = 26) 2.6% (n = 1) 0% (n = 0) 21.1% (n = 8) 38) 3) Binge Eating Female 53.1% (n = 62.5% (n = 52.6% (n = 20) 0% (n = 0) 16.7% (n = 1) 100% (n = 6) 34) 5) Male 52.5% (n = 50% (n = 52% (n = 51) 40% (n = 2) 50% (n = 5) 59.4% (n = 19) 96) 19) Compensatory Female 18.8% (n = 25% (n = 10.5% (n = 4) 0% (n = 0) 16.7% (n = 1) 45.5% (n = 5) 12) 2) Male 25.7% (n = 21.1% (n = 25.5% (n = 25) 20% (n = 1) 20% (n = 2) 34.4% (n = 11) 47) 8) Vomit Female 14.1% (n = 9) 25% (n = 10.5% (n = 4) 0% (n = 0) 16.7% (n = 1) 18.2% (n = 2) 2) Male 15.3% (n = 13.2% (n = 13.3% (n = 12) 20% (n = 1) 10% (n = 1) 25% (n = 8) 28) 5) Laxative Female 9.4% (n = 6) 25% (n = 2.6% (n = 1) 0% (n = 0) 16.7% (n = 1) 18.2% (n = 2) 2) Male 20.2% (n = 13.2% (n = 20.4% (n = 20) 20% (n = 1) 10% (n = 1) 31.3% (n = 10) 37) 5) Over-exercise Female 10.9 %(n = 7) 12.5% (n = 14.3% (n = 1) 0% (n = 0) 0% (n = 0) 45.4% (n = 5) 1) Male 10.9 % (n = 10.5% (n = 9.25 (n = 9) 0% (n = 0) 20% (n = 2) 21.6% (n = 5) 20) 4) Note. Overall ED Scale = overall disordered eating behavior index, compensatory = compensatory behaviors. All percentages indicate that the individual met clinical cut offs for that variable. 74
Table 11. PTSD symptoms as a moderator of the relationship between gender and disordered eating.
Β R2 Δ R2 F / Δ F PTSD as moderator DV: Overall ED Step 1 .550 .550 74.040*** Gender .337* PTSD Symptoms -.920*** Step 2 .621 .071*** 44.980*** Gender 1.770*** PTSD Symptoms -.515*** Gender*PTSD .719*** DV: Restrained Eating Step 1 .338 .338 30.938*** Gender .119* PTSD Symptoms -.837*** Step 2 .376 .038*** 14.707*** Gender 1.330*** PTSD Symptoms -.495*** Gender*PTSD .607*** DV: Compensatory Behaviors Step 1 .117 .117 8.003*** Gender -2.550 PTSD Symptoms -.560*** Step 2 .158 .041*** 11.839*** Gender 16.38* PTSD Symptoms -1.729 Gender*PTSD 9.502** DV: Binge Eating Step 1 .618 .382 37.463*** Gender .117 PTSD Symptoms -.290*** Step 2 .424 .042*** 17.428*** Gender .548*** PTSD Symptoms -.168*** Gender*PTSD .216*** Note. Male = 0, Female =1, ***p < 0.001, **p < 0.01, * p < 0.05 75
Table 12. BDD symptoms as a moderator of the relationship between gender and disordered eating.
Β R2 Δ R2 F / Δ F BDD as moderator DV: Overall ED Step 1 .631 .631 138.764*** Gender .057 BDD Symptoms - 1.239*** Step 2 .627 .001 .771 Gender .058* BDD Symptoms - 1.117*** Gender*BDD -.146 DV: Restrained Eating Step 1 .364 .364 46.440*** Gender -.126 BDD Symptoms - 1.065*** Step 2 .367 .003*** 1.111 Gender -.123 BDD Symptoms -.844*** Gender*BDD -.264 DV: Compensatory Behaviors Step 1 .150 .150 14.327*** Gender -4.341 BDD Symptoms - 9.699*** Step 2 .156 .006*** 1.698 Gender -4.285 BDD Symptoms -4.970 Gender*BDD -5.658 DV: Binge Eating Step 1 .488 .482 77.289*** Gender .020 BDD Symptoms -.438*** Step 2 .498 .010*** 4.688* Gender .019 BDD Symptoms -.576*** Gender*BDD .164* Note. Male = 0, Female =1, ***p < 0.001, **p < 0.01, * p < 0.05 76
APPENDIX E. FIGURES
45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% Percent of Sample Exposed Sample of Percent 5.00% 0.00%
Traumatic Event
Military Related Experience Non-Military Related Experience
Figure 1. Reported exposure to serious traumatic events on the Trauma History Questionnaire (THQ). Note. Threat of Force = Experienced someone trying to take something from you by threat of force (i.e., being mugged); DD = Drunk Driver. 77
Figure 2. Factor Loadings from Confirmatory Factor Analysis. 78
6 Male
5 Female
4
3
2 Binge Eating Behavior
1
0 Low BDD Symptoms High BDD Symptoms
Figure 3. BDD symptoms as a moderator of the relationship between gender and binge eating behavior. 79
BDD Symptoms
b = .164, p = .031, 95% CI [.015, .314]
Binge Eating Gender Behavior
Direct Effect, b = -.576, p = .000
Figure 4. Moderation analysis depicting BDD symptoms as a moderator of the relationship between gender and binge eating behavior. 80
6 Male
5 Female
4
3
2
1 Overall Disordered Eating Behavior Disordered Overall
0 Low PTSD Symptoms High PTSD Symptoms
Figure 5. PTSD symptoms as a moderator of the relationship between gender and disordered eating. 81
PTSD Symptoms
b = .719, p = 000, 95% CI [.508, .930]
Disordered Eating Gender Behavior
Direct Effect, b = -.515, p = .000
Figure 6. Moderation analysis depicting PTSD symptoms as a moderator of the relationship between gender and disordered eating. 82
6 Male
5 Female
4
3
Restraned Eating Behavior Restraned Eating 2
1
0 Low PTSD Symptoms High PTSD Symptoms
Figure 7. PTSD symptoms as a moderator of the relationship between gender and restrained eating. 83
PTSD Symptoms
b = .607, p = 000, 95% CI [.295, .919]
Restrained Eating Gender Behavior
Direct Effect, b = -.495, p = .000
Figure 8. Moderation analysis depicting PTSD symptoms as a moderator of the relationship between gender and restrained eating. 84
Figure 9. PTSD symptoms as a moderator of the relationship between gender and binge eating behavior. 85
PTSD Symptoms
b = .216, p = 000, 95% CI [.114, .318]
Binge Eating Gender Behavior
Direct Effect, b = -.168 p = .000
Figure 10. Moderation analysis depicting PTSD symptoms as a moderator of the relationship between gender and binge eating behavior. 86
40 Male 35 Female 30
25
20
15
10
5 Number of ompensatory Behaviors Engage in Last Month Last in Engage Behaviors ompensatory of Number 0 Low PTSD Symptoms High PTSD Symptoms
Figure 11. PTSD symptoms as a moderator of the relationship between gender and compensatory behaviors. Note. Y axis reflects the number of times an individual reported engaging in compensatory behaviors over the past 28 days. 87
PTSD Symptoms
b = 9,502, p = .001, 95% CI [4.062, 14.941
Compensatory Gender Behaviors
Direct Effect, b = -1.729, p = .425
Figure 12. Moderatoin analysis depicting PTSD symptoms as a moderator of the relationship between gender and compensatory behaviors.