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. Author manuscript; available in PMC: 2016 Sep 1.
Published in final edited form as: Int J Eat Disord. 2015 May 8;48(6):790–794. doi: 10.1002/eat.22424

Comparison of Overweight and Obese Military-Dependent and Civilian Adolescent Girls with Loss-of-Control Eating

Natasha A Schvey 1,2, Tracy Sbrocco 1, Mark Stephens 1, Edny J Bryant 1, Rachel Ress 1,2, Elena A Spieker 3, Allison Conforte 1, Jennifer L Bakalar 1, Courtney K Pickworth 2, Marissa Barmine 1, David Klein 4, Sheila M Brady 2, Jack A Yanovski 1,2, Marian Tanofsky-Kraff 1,2
PMCID: PMC4543400  NIHMSID: NIHMS682456  PMID: 25955761

Abstract

Objective

Limited data suggest that the children of U.S. service members may be at increased risk for disordered-eating. To date, no study has directly compared adolescent military-dependents to their civilian peers along measures of eating pathology and associated correlates. We, therefore, compared overweight and obese adolescent female military-dependents to their civilian counterparts along measures of eating-related pathology and psychosocial functioning.

Method

Adolescent females with a BMI between the 85th and 97th percentiles and who reported loss-of-control eating completed interview and questionnaire assessments of eating-related and general psychopathology.

Results

23 military-dependents and 105 civilians participated. Controlling for age, race, and BMI-z, military-dependents reported significantly more binge episodes per month (p<.01), as well as greater eating-concern, shape-concern, and weight-concern (p’s<.01) than civilians. Military-dependents also reported more severe depression (p<.05).

Discussion

Adolescent female military-dependents may be particularly vulnerable to disordered-eating compared to civilian peers. This potential vulnerability should be considered when assessing military-dependents.

Keywords: Military dependents, adolescents, loss of control and binge eating, disordered-eating, overweight, obesity

Children of military personnel face unique stressors and experience high rates of substance abuse, bullying, victimization, gang affiliation, and reduced access to support services (1–6), which may adversely affect physical and psychological health. As limited data suggest that military families may be at increased risk for eating disorders (EDs) (e.g., anorexia and bulimia nervosa, misuse of diuretics/diet pills) and obesity (7–10), and EDs among parents contribute to eating pathology in their children (11–13), military-dependents may be especially vulnerable to eating disturbances. However, no study has directly compared overweight adolescent military-dependents to their civilian counterparts on eating-related psychopathology, depression, and social adjustment. Therefore, we compared female adolescent military-dependents and civilians, all of whom were at high-risk for adult obesity (14, 15) (16). Based on extant research reporting stress and psychopathology among military-dependents (4), we hypothesized that military-dependents would present with greater impairment compared to their civilian counterparts.

Methods

Participants and Procedures

Samples of convenience were drawn from two contemporaneously-conducted studies with common measures; a pilot study of military-dependents (NCT02334202) (17), and an efficacy trial of civilians (NCT00680979) (18). Baseline data were collected from girls prior to participation in programs designed to prevent EDs and excess weight gain. Recruitment strategies and exclusion/inclusion criteria are described elsewhere (17, 18). Both studies employed similar language on advertisements, and utilized flyers and mailings to local families. Military-dependents were also recruited via mailings to TRICARE enrollees with 12–17y children. Adolescent assent and parent/guardian consent were provided. Both protocols were approved by the USU IRB. The civilian protocol was also approved by the NICHD IRB and secondary approval for the military study was provided by the FBCH Research Office.

The presence of LOC was required for study participation in the civilian efficacy study, whereas the presence of either LOC or ≥ 2 LOC-related behaviors (e.g., eating in response to negative affect (19)) was required for the military-dependent pilot trial. In order to match the two groups for the present analyses, we included only military dependents who reported LOC within the past month as assessed by the EDE, and individuals with a BMI between the 85th and 97th percentile.

Civilian girls were assessed at USU and the NIH Clinical Center (Bethesda, MD) (20). Military-dependents were seen at the Family Medicine clinic at the FBCH (Fort Belvoir, Virginia). All girls underwent the following:

Anthropometric measurements

Height and fasting weight were obtained and used to compute BMI and BMI standard deviation scores (BMI-z). Abdominal waist-circumference (WC) was measured according to convention (21).

The Eating Disorder Examination V.14 OD/C.2, EDE, (22) was administered to assess the presence of binge-eating-disorder (BED: ≥ 1 episode of binge-eating/week in the absence of compensatory behaviors over the past 3 months) (23), and the presence and number of objective binge-episodes (OBE), subjective binge-episodes (SBE), and overeating-episodes (OO), over the past 3 months. The EDE yields restraint, eating-concern, shape-concern, weight-concern subscales, and a global score. The EDE has excellent psychometric properties (24), and demonstrated good reliability (α=.88) in the present sample.

Beck Depression Inventory (25) assesses current depressive symptoms. Scores range from 0–63; higher scores indicate greater depression. The measure has demonstrated excellent reliability and validity (26) and showed good internal consistency in the present sample (α=.86).

Social Adjustment Scale (SAS)-Self-Report (27) measures satisfaction and functioning in: school, friendships, and family (subscales), over the past 2 weeks. Subscales range from 1–5. The SAS has been used with adolescents (28) and demonstrated good reliability in the present sample (α=.83).

Exploratory Metabolic Assessment

The FBCH and the NIH Clinical Research Center utilize slightly different assay techniques for determination of insulin and glucose concentrations. For the civilian trial, plasma for glucose was collected in tubes containing powdered sodium fluoride and measured by the NIH Clinical Center laboratory using a Hitachi 917 analyzer (Roche Diagnostics Indianapolis). Insulin concentrations were determined using a commercially-available immunochemiluminometric assay purchased from Diagnostic Product Corp., Los Angeles and calibrated against insulin reference preparation 66/304. The insulin assay uses a monoclonal anti-insulin antibody and was run on an Immulite2000 machine (Diagnostic Product Corp., Los Angeles). For the military trial, plasma glucose levels were collected in serum separator tubes and measured by the FBCH laboratory using an enzymatic hexokinase method on a COBAS 6000 analyzer (Roche Diagnostics Indianapolis). Insulin concentrations were collected in serum separator tubes and measured by the Walter Reed National Military Medical Center laboratory using an electro-chemilluminescence immunoassay method on a COBAS 8000 (Roche Diagnostics Indianapolis).

Data Analysis

Analyses were conducted using SPSS v.22 (29). Outliers (<5%) were adjusted to fall 1.5 times the interquartile range (IQR). Eating episodes were log-transformed (base10). ANCOVA, accounting for BMI-z, race, and age, were used to examine group differences in EDE, depression, and SAS scores. Chi-square and Fisher’s exact tests were used to determine the likelihood of meeting criteria for BED (23), hyperinsulinemia (fasting insulin ≥15 µU/L), and insulin resistance (homeostatic model assessment of insulin resistance (HOMA-IR) ≥ 3.16 ) controlling for BMI-z, race, age, depression, and WC. Differences were considered significant when p values were ≤0.05. All tests were two-tailed.

Results

Twenty-three overweight and obese military-dependents and 105 overweight and obese civilians did not differ on demographic variables (Table 1).

Table 1.

Descriptive Statistics

Civilians Military Dependents
Mean SD N M SD N F
Age (y) 14.49 1.64 105 14.66 1.72 23 .215
BMI (kg/m2) 27.20 2.39 105 27.98 2.31 23 2.02
BMI %ile 92.94 3.62 105 94.39 2.39 23 3.34
Waist Circumference (cm) 85.75 8.49 99 86.66 8.34 23 .217
Race % % 2.71
  White -- -- 62 -- -- 52
  Black -- -- 24 -- -- 22
  Asian -- -- 3 -- -- 0
  Multiple -- -- 9 -- -- 17
  Other/Unknown -- -- 4 -- -- 9
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Note: BMI = Body mass index (kg/m2); BMI %ile = Body Mass Index Percentile

M = mean; SD = standard deviation.

Statistical test conducted: one-way analysis of variance.

**

p < .01

*

p < .05

Accounting for age, race, and BMI-z, military-dependents reported more OBEs over the past 3 months compared to civilians (median (IQR)=.00 (2.0) vs .00 (.33) episodes/month; F (4,127)=7.93, p=.006; η2=.05). Groups did not differ with regard to number of SBEs or OOs (p’s > .05). More military-dependents (17%) met criteria for BED (23) compared to civilians (2%) (χ2=10.13, Fisher’s p=.01, Cramer’s V=.28). Compared to civilians, military-dependents reported greater EDE eating- (p=.001), shape-(p<.001), and weight- (p=.001) concern, and global score (p<.001). Groups did not differ on EDE restraint (p=.30). (Table 2).

Table 2.

Dependent Variables, Controlling for Relevant Covariates

Civilians Military Dependents
Mean SD N M SD N F
Objective Binge Episodes/Month a .26 .53 105 1.06 1.83 23 7.93**
Subjective Binge Episodes/Month a 2.41 2.79 105 2.67 2.47 23 .47
Objective Overeating Episodes/Month a .09 .30 105 .13 .43 23 .01
Eating Disorder Examination Interview
  Restraint a 1.14 .89 105 1.39 .83 23 1.07
  Eating-Concern a .81 .93 105 1.58 1.36 23 10.14**
  Shape-Concern a 1.93 1.23 105 3.02 1.58 23 12.74**
  Weight-Concern a 1.96 1.18 105 2.85 1.39 23 8.74**
  Global Score a 1.46 .83 105 2.21 1.09 23 12.44**
Depressive Symptoms b 10.81 6.59 90 14.17 7.77 23 4.17*
Social Adjustment Scale
  School a 1.75 .52 81 1.92 .62 17 1.43
  Family a 1.89 .63 105 2.00 .72 20 .59
  Friendships a 1.87 .52 105 2.14 .50 20 3.64
  Romantic Relationships a 3.72 1.02 102 3.85 .78 20 .26
  Total a 2.03 .42 105 2.22 .46 20 2.52
Fasting Insulin (µIU/mL) b 12.39 6.62 85 17.01 5.70 19 7.08**
Fasting Glucose (mg/dL) b 87.06 5.92 89 86.89 5.84 19 .02
HOMA-IR b 2.71 1.46 84 3.65 1.27 19 6.81**
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Note: HOMA-IR = homeostatic model assessment of insulin resistance

M = mean; SD = standard deviation

Statistical test conducted: one-way analysis of covariance

a

covariates = Age, Race, BMI-Z

b

covariates = Age, Race, BMI-Z, Waist Circumference, Depression

**

p < .01

*

p < .05

Military-dependents reported greater depressive symptoms (median (IQR)=15.00 (11.0) vs 10.00 (9.0), F (5,121)=4.17, p=.044; η2=.03), after controlling for BMI-z, race, and age. Military-dependents did not differ from civilians on the SAS school or family subscales (p’s > .05). The difference in the friendship subscale approached significance (median (IQR)=2.11 (.64) vs 1.78 (.78), F (5,118)=3.64, p=.059), such that military-dependents reported marginally worse functioning in friendships (Table 2).

Accounting for BMI-z, race, age, depression, and WC, military-dependents had greater fasting insulin (median (IQR)=18.50 (8.8) vs 10.90 (9.9) uIU/mL, F (6,105)=7.84, p=.006; η2=.06). More military-dependents (63%) had hyperinsulinemia (30), compared to civilians (31%) (χ2=6.94, Fisher’s p=.016, Cramer’s V=.25). Accounting for BMI-z, race, age, depression, and WC, military-dependents also had greater HOMA-IR (median (IQR)=3.84(1.89) vs 2.48 (2.17), F (6,102)=6.82, p=.01, η2=.06). More military-dependents (63%) had clinically elevated insulin resistance (HOMA-IR ≥ 3.16 (31, 32)), compared to civilians (33%) (χ2=6.21, Fisher’s p=.018, Cramer’s V=.24). Groups did not differ in fasting glucose (p’s > .05) (Table 2).

Discussion

In this comparison of overweight and obese military-dependent and civilian adolescents, children of service-members reported greater disordered-eating and depression. Military-dependents reported more OBEs per month, and were more likely to meet criteria for BED (23). Results must be interpreted with caution due to the low rate of BED and the unequal sample sizes. As binge-eating during youth predicts excess weight and adiposity gain (33), military-dependents may be at especially high-risk for inappropriate weight gain. Military-dependents also reported greater disordered-eating attitudes. Since weight-related concerns may predict the onset of EDs (15, 34), military-dependents may have multiple risk factors for the development of EDs and obesity. As children’s eating behaviors are influenced by those of their parents via epigenetic mechanisms (13) and learned behaviors (11), eating pathology reported by military-dependents may be partially explained by the high rates of EDs observed among service-members (7, 9, 35, 36).

Although results should be considered with caution due to the use of slightly different assays, a greater proportion of military-dependents had hyperinsulinemia and clinically elevated insulin resistance. Thus, overweight military-dependents may be vulnerable for the development metabolic disorders. Chronic stress may mediate the relationship between military life and metabolic risk (37). Depressive symptoms have also been linked to (38), and predictive of (39), insulin resistance in youth. Indeed, the daughters of service-members reported greater depression; in fact, military-dependents’ depression scores placed them in the mild depression range, whereas civilian adolescents’ scores indicated only minimal depression (25). Together, our findings are consistent with research indicating that military-dependents face additional stressors compared to civilian peers (4, 5). Prospective data are required to examine whether psychosocial stress associated with military life provides a mechanism for the development of EDs.

Strengths include the interview assessment of eating pathology, and the racially-diverse samples. Limitations include the use of cross-sectional data, and different assays for metabolic indices. The unequal sample distributions of may also be a limitation. Finally, the inclusion criterion of LOC limits generalizability to other overweight girls. However, the high prevalence of LOC and the adverse outcomes for those whose LOC persists (16, 33, 40), render this an important group to study.

In conclusion, overweight female adolescent military-dependents with LOC may be at greater risk for disordered-eating than their civilian peers. As adolescent girls are already vulnerable to EDs (34), overweight (41), and depression (42), any unique risks faced by military-dependents is important to identify.

Acknowledgments

Research support: National Institute of Diabetes and Digestive and Kidney Diseases 1R01DK080906 (to MT-K), the USUHS grant R072IC (to MT-K), Center Project Program, USUHS grant 72NC-01 (to TS), the Eunice Kennedy Shriver National Institute of Child Health and Human Development Intramural Research Program Z1A-HD-00641 to JAY).

Footnotes

The authors report no competing interests.

Disclaimer: The opinions and assertions expressed herein are those of the authors and are not to be construed as reflecting the views of USUHS or the U.S. Department of Defense.

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