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Eating Disorder in a Young Active Duty Male

Staten, Robert A, MC (FS) USN (Links to an external site.).Military Medicine (Links to an external site.); Oxford Vol. 178, Iss. 7,  (Links to an external site.) (Jul 2013): e884-9.

Abstract

Eating disorders can have atypical presentations, be challenging to diagnose, and often result in treatment delay, as illustrated here. Bulimia nervosa is characterized by binge eating and inappropriate compensatory behaviors, and is ten times more common in females. Studies show increased prevalence over the past decade, with similar prevalence in young military members and civilians. Risk factors include dieting, gender preference, life-altering events, and history of a psychiatric condition. Relatively little research has focused on eating disorders among military males, but factors unique to this group include rigid weight standards, mandatory semiannual personal fitness assessments, and extended deployments. Bulimia and other eating disorders can have subtle or atypical presentations and are often overlooked in males. Other diagnostic obstacles include career concerns and stigma avoidance, along with provider time constraints, inexperience, or discomfort with the issue. Serious medical complications of bulimia are uncommon, but delayed diagnosis can lead to hospitalization and significant morbidity. This case emphasizes the importance of a thorough history and wide differential when faced with an unusual presentation. Recognizing risk factors and incorporating simple screening tools can aid the timely identification and treatment of service members with disordered eating before unit and mission effectiveness are compromised.

INTRODUCTION

Eating disorders and disordered eating behaviors have been the subject of much research, particularly in the last three decades. Military personnel are presumed to be at higher risk for eating disorders because of required weight and body standards, but few studies have examined this disorder in male military members. Eating disorders can be challenging to diagnose for the primary care provider, as those with bulimia often present with other, seemingly unrelated complaints and concerns. This case illustrates the delayed diagnosis of bulimia in a young active duty male, and the following discussion examines the prevalence and risk factors associated with males and military members, as well as diagnostic challenges and accompanying medical complications.

CASE

A 21-year-old Caucasian active duty male, serving with his squadron detachment away from home base, presented to the local Emergency Room with painless bilateral parotid gland enlargement and fatigue. Initial basic lab studies were unre- markable except for an elevated amylase level. His flight surgeon placed him in 9-day quarantine for suspected mumps, titers were drawn, and he received the Measles, Mumps, Rubella vaccine. His symptoms resolved after about 2 weeks, and mumps IgM and IgG antibodies were negative. After return to his home base 3 weeks later, his parotid swell- ing returned, and he also experienced a 10-pound weight loss, neck and inguinal lymphadenopathy, fatigue, and dizziness. Following an episode of syncope, he was admitted to the hospital for further evaluation. Laboratory evaluation showed a hypokalemic, hypochloremic metabolic alkalosis. He was hypotensive with bradycardia and had significant nontender, bilateral parotid gland enlargement. He also had subtle dental erosions. During hospitalization, his electrolytes were corrected, and he underwent an extensive workup. Imaging of his head, chest, abdomen, and pelvis were all normal. An upper endos- copy series with small bowel follow through showed only mild reflux. A trans-thoracic echocardiogram with bubble study was normal. During hospitalization, the patient's mother was contacted, and she revealed he had a diagnosis of dys- thymia and Asperger's syndrome in early adolescence, and an obsession with weight and body image later in adoles- cence. Upon questioning, the patient did admit recent pre- occupation with weight and performance after the previous cycle's Physical Fitness Assessment (PFA), and acknowl- edged frequent purging. Further psychological evaluation from mental health yielded a diagnosis of bulimia nervosa, purging type, and he continued psychiatric care as an out- patient. His parotid swelling diminished, and his electrolyte abnormalities normalized several weeks after reduction of his purging behaviors. He was started on a Selective Serotonin Reuptake Inhibitor (SSRI), and 6 months later was cleared for shipboard deployment with his squadron. Initially, he did well onboard, continuing both medication and cognitive behavioral therapy with a psychologist. However, 5 months into deployment he developed mood changes, and suffered a relapse of binging and purging behavior. After he expressed passive suicidal ideations, he was returned home early from deployment. Although control of his bulimia improved with cognitive behavioral therapy, he was medically discharged for the disorder.

DISCUSSION

The majority of research on eating disorders focuses on female characteristics and behavior. The most common eating disorders are anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified. This patient was diagnosed with bulimia nervosa, which involves a cycle of binge eating and inappropriate compensatory behaviors that occurs twice a week for at least 3 months.1 Inappropriate compensatory behaviors include fasting or excessive exercise for the nonpurging type, and self-induced vomiting, use of diet pills, laxatives, or diuretics for the purging type. Individuals with bulimia are often secretive about their behavior and do not commonly reveal these behaviors during routine history taking. Discussed here are the prevalence of eating disorders, associated risk factors to include those that are specific to males and military members, diagnostic challenges, and medical complications.

Prevalence

Prevalence estimates of bulimia vary widely, and among college aged women have been reported to be 1.3% to 5%.2 Prevalence among adolescent boys and yoimg adult men is approximately 0.2%.3 Several studies have examined the prevalence of eating disorders in the military. Many of these studies employ the Eating Attitudes Test (EAT-26), which is a survey commonly used to identify individuals who are at risk for eating disorders. At the U.S. Military Academy in West Point, New York, the EAT-26 found 19% of female cadets and 2% of male cadets were at risk of developing an eating disorder. This data was similar to students at civilian colleges.4 A survey study of 4,800 U.S. Navy active duty males, assigned both to ships overseas and to hospitals and clinics in the United States, used an adapted version of the Eating Disorder Inventory, which is a self-report measure of psychological and behavioral traits common in anorexia nervosa and bulimia. It yielded prevalence rates for behaviors suggestive of eating disorders to be 2.5% for anorexia nervosa, 6.8% for bulimia nervosa, and 40.8% for eating disorder not otherwise specified. Although this study did not include a diagnostic interview or assessment of subjects, the survey still showed a high prevalence of these respective behaviors. A review of medical record data from the Defense Medical Epidemiology Database looked at International Classification of Diseases (ICD-9) codes for all service members from 1998 to 2006 and showed an incidence rate of any type of eating disorder to be 0.06% among males in the military.6 Entry-level, active duty military personnel are in the age range at highest risk for eating disorders. A cross- sectional anonymous survey of entry-level U.S Army soldiers showed 7% of males endorsed disordered eating (9.8% over- all and 29.6% in females).7 As men comprise 85% of the military,8 there are likely a greater number of men than women with disordered eating in this population.

The incidence of eating disorders in the military has increased since 2001, and there has been an even sharper increase since 2005 (see Fig. 1). It is postulated that the earlier rise is related to tougher fitness standards as well as occupational stressors related to deployment and combat exposures in support of Operation Iraqi Freedom and Opera- tion Enduring Freedom.6 The later increase after 2005 might correlate to tougher PFA policy, but not enough data is avail- able to make this conclusion.

There is data that indicates the prevalence of eating dis- orders is increasing. In November 2010, The American Academy of Pediatrics published "Clinical Report Identification and Management of Eating Disorders in Children and Ado- lescents," which noted a 119 % increase in hospitalizations between 1999 and 2006 for eating disorders in children 12 and under. The report also cited significant increases in the prevalence of eating disorders among minorities and males in the past decade.9

Risk Factors

Weight and exercise history can suggest susceptibility for development of an eating disorder, and there are a number of gender differences to consider. The patient in this case had a normal body mass index of 21.9, but men typically have a history of obesity before developing an eating disorder, while most women have a normal weight history.10 Exercise and athletic competition, particularly involving sports that place a premium on less body fat or lighter weight, are risk factors.11 Elite athletes have at least twice the rate of eating disorders than the general population, with highest rates among "anti- gravitation sports" such as rock climbing, high jump, and pole vaulting.12 Excessive exercise is more prevalent among men, and many who struggle with disordered eating also struggle with muscle dysphoria, a subtype of body dysmorphic dis- order, in which the subject is obsessed with muscle mass or body size.13 Unfortunately marketing and media campaigns have likely influenced body image perceptions in recent years. Men's preferred body image is muscular, whereas women's preferred body image is thinness, and evidence documents that men are as concerned about body image as women.14 An analysis of popular magazine content over the past 30 years revealed an increase in images showing seminaked men,15 and male action figures produced between 1964 and 1998 have steadily become more muscular, portraying the human body in an unrealistic and unattainable form.16

Gender preference has also been shown to be a risk factor. In one of the major literature reviews of bulimia nervosa in males, Carlat and Camargo3 concluded that male bulimics have a higher prevalence of same sex orientation than their female counterparts, and that being gay is a risk factor for bulimia in males. An explanation for this might come from several studies that show gay males report more body dissat- isfaction and place greater emphasis on physical appearance than heterosexual counterparts.17 Recent repeal of the "Don't Ask Don't Tell" policy may allow patients to be more com- fortable with disclosure of sexual preference, and providers should be aware of this potential associated risk factor.

Life-altering events can also trigger an eating disorder, especially for adolescents making major life decisions including employment, college, or joining the military.6 The survey of the 4,800 active duty Navy males mentioned above examined 29 environmental factors, many unique to the military. Many factors were found to be statistically significant predictors of an associated eating disorder. These predictors included (1) vomiting for a fitness testing period or body measurement, (2) failure to be selected for a school or promotion, (3) current laxative use, and (4) prior history or family history of an eating disorder. Other environmental factors significant for survey participants included (1) feeling overweight, (2) rotating shifts, (3) nonavailability of low-fat meals, (4) being assigned to a ship or submarine, and (5) no time for physical fitness except when off duty.5 The patient in this case report had several significant occupational stressors. He was new to the military, had an upcoming spring PFA, and was also just beginning the "work-up" phase of his squadron's deployment cycle, which involves a high-tempo series of detachments and predeployment underway periods aboard ship.

The military lifestyle also adds unique factors that potentially contribute to disordered eating behaviors, such as biennial PFAs and rigid weight standards. With the recent emphasis on downsizing of the military personnel force, com- petition for retention and promotion has intensified. As a result, the consequences for a PFA failure are greater and there is increased pressure to perform well as scores are now included on enlisted performance evaluations and officer fit- ness reports. In 2005, policy for PFA became tougher and included separation after three PFA failures in 4 years. In 2010, new policy mandated no waivers for excess body fat for individuals scoring excellent or outstanding on fitness testing. Since 2005, there has been a reduction in PFA failures from 5.67% in the spring 2005 cycle to 2.77% in the spring 2010 cycle.18 This seems to indicate sailors are responding to the challenge of tougher PFA standards, but this sometimes occurs in unhealthy ways. Use of liposuction, laxatives, and other unhealthy methods has been reported in the media.19

The patient in this case report had a history of dysthymia as well as Asperger's syndrome diagnosed in early adolescence. Psychiatric comorbidity is very common in eating disorders. Males, similar to females, are at increased risk for depression, anxiety disorders, and alcohol and substance abuse. Generally high rates of co-occurrence between eating disorders and personality disorders are reported, although with considerable variability that ranges between 21% and 97%.20 Individuals with bulimia are more likely to have a cluster ? diagnosis (dramatic/erratic), whereas individuals with anorexia are more likely to have a cluster C diagnosis (anxious/fearful ).21 Specifically in military personnel, a study of entry-level soldiers showed an association between dis- ordered eating and previous history of psychiatric treatment and some form of abuse, most often verbal and physical.7 Bulimics have an increased prevalence of associated psychiatric conditions with depressive symptoms, and impaired social functioning is fairly prominent.22

Diagnostic Challenges

Patients with unrecognized bulimia are a diagnostic challenge because they often present for evaluation and treatment of physical complaints that are seemingly unrelated. Several reports in the literature describe cases in which patients were evaluated and then treated for a lengthy period of time before receiving the correct diagnosis. In one case report, a woman who secretly binged and purged since the age of 15 went through extensive evaluations and treatment modalities for parotid swelling, including roimds of radiation treatment, before her history of purging was revealed 19 years later.23

A study of 135 males hospitalized with an eating disorder notes that males with bulimia felt ashamed of having a ste- reotypically female eating disorder.24 Males are less likely to seek help for emotional problems, and often struggle for years with eating disorders before seeking help. The correct diagnosis is often overlooked in males because of sociocul- tural stereotypes held by both patients and providers.10

Military personnel face additional diagnostic obstacles. The Department of Defense lists eating disorder as a psychiatric condition, and diagnosis can be grounds for discharge from service. Service members wishing to remain in the military may avoid seeking treatment out of concern for their job and military careers, especially with current economic pressures. Providers may also be reluctant to assign an eating disorder diagnosis because of the potential negative direct impact on a service member's career. For this reason, eating disorders are likely to be under-represented in diagnosis databases.

Primary care providers may not be comfortable initiating screening, or may feel they do not have enough time to appropriately screen for eating disorders. Simple and easy to remember screening tools such as the SCOFF clinical prediction guide (see Fig. 2 for acronym), or Eating Disorder Screen for Primary Care (ESP) questionnaire have shown good clinical validity to raise suspicion of an eating disorder so that further evaluation can be initiated.25

Most patients with bulimia have few, if any, physical signs of their condition. However, certain signs are more commonly present in bulimics that could lead a physician to suspect the disorder. These include (1) dental erosions from exposure to regurgitation of gastric acid contents, (2) skin lesions or changes on the dorsum of the hand from contact with the incisor teeth during repeated self-induced vomiting, known as Russell's sign, and (3) parotid hypertrophy. The etiology of parotid hypertrophy is still uncertain, but the incidence with bulimia is 10% to 15%, with persistent and disfiguring parotid enlargement occurring in less than 0.5%.26 It is possible that involvement of these glands is more common, but may be frequently overlooked on physical examination, even though patients may be able to detect the enlargement. Parotid enlargement usually occurs 2 to 6 days after a binge-purge episode, but the course is variable, with resolution usually dependent on abstinence from binge-purge behaviors.27 Risk for permanent parotid enlargement increases with frequent and regular binge-purge episodes, and can exacerbate existing body image issues for bulimics. The patient in this case had parotid hypertrophy and tooth enamel erosions, but no abnormal skin findings on his hands.

Medical Complications

Significant electrolyte abnormalities also occur in individ- uals with severe bulimia. Hypochloremic metabolic alkalosis most commonly occurs from frequent emesis episodes. Laboratory analysis can also show elevated amylase levels and hypokalemia. This patient had lab values consistent with these findings.

Bulimia nervosa is associated with serious psychological and physical morbidity. Malnutrition causes the majority of the medical findings, including weakness, fatigue, dizziness, easy bruising, difficulty with concentration and memory, low body temperature, hypoglycemia, anemia, and hypotension. Gastrointestinal problems including esophageal tears, gastri- tis, and reflux are not uncommon. Rare complications include myopathies from abuse of ipecac, as well as ruptured esoph- agus and pneumomediastinum from vomiting. Table I lists potential medical complications of bulimia.28 Experiencing any of these issues can have significant effects on a service member's performance both in training and combat.

CONCLUSION

Identifying male eating disorders such as bulimia during routine clinical practice is challenging, given the atypical and subtle presentation, the stigma against self-reporting, and the tendency of health care providers to overlook symptoms. Individuals with personal risk factors such as dieting, extreme exercise routines, and psychiatric history may be more susceptible, as well as gay men. Risk is also elevated by environmental risk factors to include proximity to the PFA cycle, recent introduction to the military, and operational assignments. Health care providers should keep these factors in mind when caring for active duty personnel and consider incorporating validated screening tools as appropriate when obtaining a medical history.

It is also important for recruiters to be aware of factors that may contribute to disordered eating and very carefully con- sider accession of members with a history of illness that might not be compatible with commonly encountered stressors of military life. Medical providers should also keep eating dis- orders on the differential diagnosis when faced with weight changes or other nonspecific presenting complaints during the PFA cycle. Additionally, physical fitness training should be conducted regularly throughout the year to promote year- round fitness and discourage acute episodes of disordered eating. Finally, impromptu PFA testing might be helpful in preventing these acute behaviors.

Males typically have more of a delayed presentation than females, and while serious medical complications of bulimia nervosa are uncommon, hospitalization and significant mor- bidity may develop if diagnosis is delayed, resulting in loss of the warfighter from the unit. Screening tools such as the SCOFF or ESP questionnaire may be helpful, but consider- ation may be given to development and validation of a screening tool more specific for males.

References

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AuthorAffiliation

LCDR Robert A. Staten, MC (FS) USN

Fleet Surgical Team Eight, 1084 Pocahontas Street, Building IA, Room 8, Norfolk, VA 23511.

Some portions of this case study were presented at the 2011 Uniformed Services Academy of Family Physicians Annual Conference, April 3-8, 2011, Palm Springs, CA.

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government,

doi: 10.7205/MILMED-D-12-00543