Eating Disorders Within the UK Armed Forces
Eating disorders (EDs), are a serious mental health condition, that can impact anyone regardless of age, background, or circumstances [1]. According to Beat, the nation’s leading eating disorder charity, an estimated 1.25 million [2], or roughly 2% of people in the UK, have an ED. However, it is difficult to draw any firm conclusions on how common EDs are in society due to the incomplete nature of ED research.
While several factors are noted to trigger or worsen ED behaviours, two important areas are: social or cultural factors, and significant life or traumatic events [1]. One profession where both factors are heightened is the Armed Forces. Serving and ex-Service personnel are exposed to many physical and psychological stressors which could increase the risk of EDs [3]. Despite this, there is little research to understand the prevalence, related factors, and needs of this group. Due to the unique nature of military Service and civilian transition processes, Serving and ex-Service personnel may face unique issues and require specific tailored support. It is therefore important to understand the current research landscape surrounding EDs in the UK Armed Forces, what gaps exist, and where further research is needed.
What are Eating Disorders and what is Disordered Eating?
When exploring the ED spectrum, it is first important to understand exactly what is meant by the terms Eating Disorder and Disordered Eating.
An Eating Disorder (ED) is defined by the NHS as, “a mental health condition where…the control of food (is used) to cope with feelings and other situations” [4]. An ED, when diagnosed, will usually be defined as a specific disorder with the most common being anorexia nervosa, bulimia, and binge eating disorder (BED) (Box 1).
On the other hand, Disordered Eating (DE), has some key differences to an ED. The Mayo Clinic has defined DE as “a wide range of behaviours that involve eating in a way that prevents full participation in life activities or impairs healthy growth and development,” however they do not fully constitute an ED [5]. Put simply DE and ED exist on a spectrum, individuals can engage in DE behaviours or patterns without reaching criteria for a fully diagnosed ED. These behaviours can include things like irregular eating patterns, rigid rituals around eating, chronic dieting, and meal skipping.
In essence, while both EDs and DE indicate that individuals are engaging in problematic eating behaviours, the severity of their behaviours differentiates whether they fall under DE or ED.
How Eating Disorders affect the UK Armed Forces Community:
Research about EDs amongst the UK Armed Forces community is very limited. Existing studies have a strong focus on Servicewomen and how the physically and psychologically demanding nature of the Armed Forces affects ED prevalence [6]. Additionally, most research to date has focused on the experiences of currently Serving personnel, with little ED or DE focused research with ex-Serving populations.
Current existing UK research comprises two studies using the same cohort of 3,022 UK Servicewomen [6, 7]. This research found that approximately 34% of those in the survey were at risk of DE, 13% were at elevated risk of an ED, and 3% had been clinically diagnosed with an ED. Taken together, this puts 50% of the women surveyed at risk of engaging in some level of DE [6]. Among this, Servicewomen at higher risk of an ED were assessed to have an overall increased risk of bone stress injury or other musculoskeletal injury [7]. The researchers theorised that this was possibly because EDs are known to be associated with a decrease in bone mass [7]. In addition to this, 52% of those at high risk of EDs exhibited symptoms of anxiety, and 54% showed symptoms of depression, indicating a potential correlation between EDs and other common mental disorders [6]. Overall, the research found that those of younger age, higher body mass, lower rank, lower sleep levels, and high volumes of exercise, had increased risk for the development of ED or DE behaviours [6]. While limited, these findings give insight into how military life may exacerbate the occurrence of EDs.
Similar DE like behaviours were also observed in a study of the use of performance and image-enhancing drugs (PIEDs) in the UK Armed Forces [8]. The study, involving thirteen male and one female UK ex-Service personnel, found that many had used PIEDs for body image and Service-related requirements e.g. some participants noted they used PIEDs for ‘cutting’ or losing weight quickly, as well as for controlling their appetite for image-related reasons. Additionally, cultural, and Service-related pressures, feelings of inadequacy, and the desire to fit in were also cited as motivations [8]. Although this study did not specifically focus on EDs, the sentiments expressed provide further evidence of how Service may impact the development or exacerbation of DE in UK Armed Forces (ex)-personnel.
Eating Disorders in the United States Armed Forces:
Given the current limited nature of UK based research, looking to evidence from another somewhat comparable nation may reveal areas for needed focus in the UK. Like the UK, other Global North countries also have limited evidence about EDs within their Armed Forces. While countries such as Hungary [9] and Australia [10] have some related work, overall, the landscape remains sparce. The one exception is the United States (US), which has a much larger depth of research focused on EDs among their Serving and ex-Service populations. However, it is important to note that due to notable differences in culture and military experiences between the UK and US, comparison with the US should be taken with caution.
When looking at prevalence in the US military an observational study published in 2018 and conducted from 2013 to 2017, found the incidence of ED to be 2.7% [11]. While a six-year study between 2016-2021 of US active duty and reserve personnel found the occurrence rate as 6.2 cases per 10,000 per year with the rate of ED diagnosis increasing over time [3]. Another survey of Iraq and Afghanistan war era Veterans found rates as high as 32.8% in women and 18.8% in men [12]. All US studies found the rates to be higher in female Service personnel, with the 2018 study finding the highest incident rates in non-Hispanic white Servicewomen, Marine Corps members, junior enlisted or junior officers, and combat-specific occupations [11].
As noted above, evidence indicates that exposure to traumatic events may increase the risk of EDs, thus US research has sought to understand this connection. In a survey of 642 nationally representative US male trauma exposed Veterans, approximately 4% met criteria for a probable ED. A strong association was found between multiple trauma experiences and increased ED symptoms. Additionally, this research found evidence for a unique association between non-combat related military-trauma (e.g., an accident, traumatic loss, or moral injury) and ED symptoms. The authors therefore highlighted the importance of screening for disordered eating among male Veterans, particularly those with a history of non-combat military related trauma [13, 14].
In addition to trauma, military cultural factors have been investigated for their association with ED and DE behaviours. A 2015 systematic review found that the strict weight and physical fitness requirements of US Service life seemed to have a possible influence on problematic eating habits [15], which may be amplified for those with pre-existing DE attitudes and behaviours like binge eating [16]. These findings also indicated that fear of promotion based or other types of consequences for not meeting these requirements, further exacerbated DE-like behaviours [15].
For US Service members, evidence also indicates that eating behaviours during Service may impact eating behaviours in post-Service life [17]. For example, that the lack of consistent personal control surrounding eating while in the military, as well as focus on physical fitness and body image to ‘make weight’ may have an impact on Service personnel developing unhealthy relationships with both food and eating habits [18]. A 2009 focus group study with 61 male and three female US ex-Service members, who Served in varying eras between World War II and the time of the research, found that military Service changed the dietary behaviour of most participants and that those changes contributed to obesity. Poor quality diets, learning to eat fast, and food scarcity/insecurity during Service led some Veterans to develop binging habits to compensate when food was available, which continued into post-Service life. This combined with Veterans exercising less, was reported to lead to weight gain [19]. More recent research from 2021 observed similar findings to the 2009 study. With a cohort of 161 male and 57 female Iraq and Afghanistan era Veterans, the research indicated that influence from superiors during Service had the possibility to impact DE behaviour development. Specifically, commanding officers directly encouraging personnel to engage in problematic behaviours such as excessive exercise and eating. This was compounded by things such as differential treatment due to weight such as losing ‘privileges’ due to weight or being put on rigorous weight loss programmes. This negative treatment was assessed to have the potential to develop into perpetual fear surrounding food, fitness, and weight [18].
Finally, structural issues may exist in the screening, diagnosis, and treatment process for Veterans with EDs. In a study involving 16 Veterans (n = 8 men; n = 8 women) who had a Veterans Health Administration (VHA) electronic health record ED diagnosis, the majority reported self-initiating conversations with healthcare providers about eating and weight concerns, and that they initially self-diagnosed their ED. Many of those who had been diagnosed with an ED prior to military Service reported that their military experiences had reignited their symptoms [20]. As many of the Veterans were overweight, treatment referrals were almost universally for being overweight rather than for an eating disorder, often leaving participants feeling misunderstood and marginalised [20]. For those who had sought treatment during Service, they were often suggested to use ‘12-step’ or other addiction management programs rather than specialised care. As part of the study, participants were asked to provide feedback on a protype of a new ED screening tool, for which the majority were enthusiastic about, noting that conversations needed to be non-stigmatising [20].
Where can research go from here?
Currently there are around 183,230 Serving personnel [21] and roughly 2 million ex-Service personnel across the UK [22]. Assuming that the occurrence rate is the same as the UK general population, this means there are likely around 3,665 Serving and 40,000 Veterans affected by EDs in the UK. As there are no current overarching estimates of prevalence across groups, a full understanding of potential support needs is not understood. Due to this lack of understanding, there may be a gap with those affected not receiving needed relevant healthcare. Therefore, it is key that more research takes place to understand the prevalence, demographics, and associated factors of both current and former UK Service personnel to ensure the necessary policy and provision is in place to support them.
Current available research from the US and the UK suggests that some factors associated with military Service, such as potential exposure to traumatic events, weight and fitness requirements, and perceived cultural expectations, may impact the development of problematic eating habits for a large minority of Service personnel. It is therefore key to learn not only of the prevalence rates, but also what are the best steps for prevention, alleviation, and treatment.
Research must seek to understand what factors are associated with an increased risk of experiencing EDs and DE among UK military Serving and ex-Serving populations. Particularly there should be focus on the role of structural and cultural demands of the UK Armed Forces, and how this may vary by Service branch, and Service-related experiences. This should include efforts to understand the role of messaging and education around eating habits, diet, exercise, weight and body ideals. Additionally, understanding the role of transition to civilian life and how experiences with EDs and DE may change post-Service is needed.
Evidence indicates that mental health stigma continues to exist among UK Serving personnel and Veterans when it comes to seeking help for mental health disorders [23]. Specifically, that those who are most probable for meeting the criteria for a diagnosis are the most likely to feel stigmatised and least likely to seek help. Therefore, more research should be conducted on the current effectiveness of screening, treatment, and outcomes of those seeking treatment for EDs within military and Veteran specific health services. This should include increasing awareness among those providing support to and working with the Armed Forces community of the possible increased risk, risk factors, and experiences of EDs and DE among Serving and ex-Service personnel. Additionally, understanding if any specific stigma or stereotypes related to ED exist within military culture and healthcare, is important. Doing this could help lower barriers to care, may enable individuals to identify if they have a problem, and give them the vocabulary needed to seek treatment. While currently there are no UK Armed Forces ED specific support Services, in 2020 the RAF launched its own Eating Disorders Network; the creation of groups like these may be a step towards the destigmatisation of EDs and their treatment in the Armed Forces .
If you, or someone you know, has been affected by an eating disorder you can contact the BEAT talk or text helplines for confidential support.
Many thanks to Katie Edwards (Coventry University & The University of Warwick) for providing a thoughtful input on and review of this news feature. Katie is a third-year Trainee Clinical Psychologist at Coventry University/University of Warwick. Her thesis explores the experiences of problematic eating and exercise behaviours in UK male Veterans.
References
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[2] BEAT. (2022). How Many People Have an Eating Disorder in the UK? Beat. Available at (Link)
[3] Bauman, V., Thompson, K. A., Sunderland, K. W., Thornton, J. A., Schvey, N. A., Nana Amma Sekyere, Funk, W., Pav, V., Brydum, R., Klein, D. A., Tanofsky‐Kraff, M., & Lavender, J. M. (2024). Incidence and prevalence of eating disorders among U.S. military service members, 2016–2021. The International Journal of Eating Disorders. Available at (Link)
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[5] Schmitd, Tara. (2024, February 15). What is disordered eating and when does it become an eating disorder? Mayo Clinic Press. Available at (Link)
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[8] Whyte, I., Pattinson, E., Leyland, S., Soos, I., & Ling, J. (2020). Performance and image enhancing drugs use in military veterans. University of Sunderland. Available at (Link)
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[21] Quarterly service personnel statistics 1 April 2024. (n.d.). GOV.UK. Available at (Link)
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