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Military Background Shapes Eating Disorders in VA Oncology
PHOENIX – Veterans are especially vulnerable to disordered eating because of their military backgrounds, a dietician warned US Department of Veterans Affairs (VA) oncology clinicians at the annual meeting of the Association of VA Hematology/Oncology. In fact, an estimated 15% to 25% of veterans meet diagnostic criteria for eating disorders.
“Their experience in the military probably has really shaped the way that they see weight and the stigma behind it,” said Emily Fasciana, MS, RDN, LDN, a registered dietician with the VA based in Wilkes-Barre, Pennsylvania.
When cancer appears, the risk of eating disorders goes up even more, she said. “If we don’t catch eating disorders early on, severe medical problems can occur. In the cancer population, they’re going through enough medical problems as it is.”
Here are things to know about eating disorders in oncology.
Military Life Can Produce a ‘Perfect Storm’ of Risk Factors
Tightly controlled eating environments and food deprivation are often routine in military life. Along with trauma, these can create a “perfect storm of risk factors for eating disorders,” Fasciana said.
During service, for example, “people often will eat as much as they can when they can, sometimes followed by days of not being able to eat,” she said. These are very much like disordered eating behaviors such as binge eating and restricting, and they can place veterans at greater risk.”
She described how service members can develop specific eating patterns during service, such as “midrats” – midnight rations – “meals served during midnight shifts that were the best meal served all day long that they had access to.”
“When I hear veterans who wake up in the middle of the night, and they’re eating, I ask: ‘Did they practice something similar during their military experience?’ They associate that time of the day with enjoyable comfort foods, and that’s what they go to now.”
Vets Can be Haunted by Stigma of Excess Weight
“Making weight” – meeting weight standards – is routine in the military. The pressure to remain under a certain level can have lasting effects on how veterans think about extra pounds, said Kaitlin Ohde, PhD, a clinical health psychologist with the VA Puget Sound Health Care System in Seattle.
“I’ve heard some veterans tell me about getting kicked out of positions because of not being able to make weight. Then they carry this throughout their life, which is really sad,” Ohde said. “When they gain weight during treatment, sometimes it can be really bothersome for them.”
Regular weigh-ins can trouble patients, she said, so it’s important to explain to them why they’re getting on scales: “I’m getting your weight today because I want to see if this medication is doing XYZ.”
She advised colleagues to “make sure they explicitly know why we’re doing it [measuring weight], and how the things we’re using to treat them can impact their weight. This piece of the puzzle sometimes falls off the radar.”
Eating Disorders Can be Catastrophic in Cancer
Untreated eating disorders cause severe medical complications such as malnutrition, hormone dysregulation, low bone density or fractures, bradycardia, gastroparesis, and even anemia, Fasciana said.
There’s a New Category of Eating Disorder
Fasciana highlighted a condition that is underrecognized in oncology: Avoidant/restrictive food intake disorder (ARFID), which refers to patients who stay away from certain foods but not because they’re worried about body image or weight gain. “Patients with ARFID are clinically distinct from those who have anorexia, bulimia, and binge eating disorder,” she noted.
ARFID diagnosis requires food avoidance that leads to at least 1 of these consequences: significant weight loss, nutritional deficiencies, dependence on supplements or tube feeding, or psychosocial impairment.
“Veterans might have a gagging or retching reflex at the sight or smell of certain foods,” Fasciana explained. “They might have difficulty being in the presence of another person eating a nonpreferred food.”
Some cancer patients may be averse to foods of certain temperatures. “You might need to assess why they don’t like the temperature of that food. Why are those foods something that you can’t go to? Are they hurting your teeth? What are they doing to you?”
ARFID patients may also experience social withdrawal around eating. “With a lot of our head and neck cancer patients, especially those with oral cancers and those on feeding tubes, they might feel embarrassed to be around people while eating,” Fasciana said.
She highlighted a 2021 report about 4 cancer survivors with upper abdominal cancers who developed new-onset eating disorders with malnutrition resembling ARFID.
The patients experienced malabsorption, dumping syndrome, and excessive weight loss for 12 months postoperatively without classic body-image concerns. “This is a case example of how eating disorders can evolve in the oncology population,” Fasciana said.
The report said that none of the patients “returned to a healthy weight and/or healthy eating despite extensive team input… The outcomes were poor; 1 patient died, another required admission to a specialist eating disorder admission with a subsequent relapsing-remitting course, and the remaining 2 had complicated chronic courses.”
Treatment: Start With Screening, Then Reframe Thinking
Fasciana highlighted several screening tools, such as SCOFF, BREDS, and one for ARFID.
“Any screen is going to be better than no screen at all, and any question is going to be better than no question at all,” Fasciana said.
She cautioned that “veterans are not going to be so forthcoming about some of their struggles due to stigma and shame because of their past experiences in the military.”
As for therapy, psychological care may not be required, Ohde said. And it’s especially important to “listen to your patients about what they’re going through, and give them space to share.”
For those who could be helped by psychotherapy, she said, “sometimes I introduce it as therapy that can be really brief. Maybe you just need to talk to someone for a few sessions or just get some support around coping with this.”
One strategy is to focus on bringing enjoyment back to eating, she said. For some patients, “eating becomes a chore,” a task performed without joy, alone in a hospital room.
Fasciana emphasized asking questions over time, perhaps through multiple follow-ups, without expecting answers immediately. And she coaxes patients to consider what they hold dear. “I try to get them to think about the meaning that losing or gaining weight has for them, what their values are, and what really matters to them. I link it back to health, healing, and longevity of life.”
Fasciana and Ohde reported they had no disclosures.
PHOENIX – Veterans are especially vulnerable to disordered eating because of their military backgrounds, a dietician warned US Department of Veterans Affairs (VA) oncology clinicians at the annual meeting of the Association of VA Hematology/Oncology. In fact, an estimated 15% to 25% of veterans meet diagnostic criteria for eating disorders.
“Their experience in the military probably has really shaped the way that they see weight and the stigma behind it,” said Emily Fasciana, MS, RDN, LDN, a registered dietician with the VA based in Wilkes-Barre, Pennsylvania.
When cancer appears, the risk of eating disorders goes up even more, she said. “If we don’t catch eating disorders early on, severe medical problems can occur. In the cancer population, they’re going through enough medical problems as it is.”
Here are things to know about eating disorders in oncology.
Military Life Can Produce a ‘Perfect Storm’ of Risk Factors
Tightly controlled eating environments and food deprivation are often routine in military life. Along with trauma, these can create a “perfect storm of risk factors for eating disorders,” Fasciana said.
During service, for example, “people often will eat as much as they can when they can, sometimes followed by days of not being able to eat,” she said. These are very much like disordered eating behaviors such as binge eating and restricting, and they can place veterans at greater risk.”
She described how service members can develop specific eating patterns during service, such as “midrats” – midnight rations – “meals served during midnight shifts that were the best meal served all day long that they had access to.”
“When I hear veterans who wake up in the middle of the night, and they’re eating, I ask: ‘Did they practice something similar during their military experience?’ They associate that time of the day with enjoyable comfort foods, and that’s what they go to now.”
Vets Can be Haunted by Stigma of Excess Weight
“Making weight” – meeting weight standards – is routine in the military. The pressure to remain under a certain level can have lasting effects on how veterans think about extra pounds, said Kaitlin Ohde, PhD, a clinical health psychologist with the VA Puget Sound Health Care System in Seattle.
“I’ve heard some veterans tell me about getting kicked out of positions because of not being able to make weight. Then they carry this throughout their life, which is really sad,” Ohde said. “When they gain weight during treatment, sometimes it can be really bothersome for them.”
Regular weigh-ins can trouble patients, she said, so it’s important to explain to them why they’re getting on scales: “I’m getting your weight today because I want to see if this medication is doing XYZ.”
She advised colleagues to “make sure they explicitly know why we’re doing it [measuring weight], and how the things we’re using to treat them can impact their weight. This piece of the puzzle sometimes falls off the radar.”
Eating Disorders Can be Catastrophic in Cancer
Untreated eating disorders cause severe medical complications such as malnutrition, hormone dysregulation, low bone density or fractures, bradycardia, gastroparesis, and even anemia, Fasciana said.
There’s a New Category of Eating Disorder
Fasciana highlighted a condition that is underrecognized in oncology: Avoidant/restrictive food intake disorder (ARFID), which refers to patients who stay away from certain foods but not because they’re worried about body image or weight gain. “Patients with ARFID are clinically distinct from those who have anorexia, bulimia, and binge eating disorder,” she noted.
ARFID diagnosis requires food avoidance that leads to at least 1 of these consequences: significant weight loss, nutritional deficiencies, dependence on supplements or tube feeding, or psychosocial impairment.
“Veterans might have a gagging or retching reflex at the sight or smell of certain foods,” Fasciana explained. “They might have difficulty being in the presence of another person eating a nonpreferred food.”
Some cancer patients may be averse to foods of certain temperatures. “You might need to assess why they don’t like the temperature of that food. Why are those foods something that you can’t go to? Are they hurting your teeth? What are they doing to you?”
ARFID patients may also experience social withdrawal around eating. “With a lot of our head and neck cancer patients, especially those with oral cancers and those on feeding tubes, they might feel embarrassed to be around people while eating,” Fasciana said.
She highlighted a 2021 report about 4 cancer survivors with upper abdominal cancers who developed new-onset eating disorders with malnutrition resembling ARFID.
The patients experienced malabsorption, dumping syndrome, and excessive weight loss for 12 months postoperatively without classic body-image concerns. “This is a case example of how eating disorders can evolve in the oncology population,” Fasciana said.
The report said that none of the patients “returned to a healthy weight and/or healthy eating despite extensive team input… The outcomes were poor; 1 patient died, another required admission to a specialist eating disorder admission with a subsequent relapsing-remitting course, and the remaining 2 had complicated chronic courses.”
Treatment: Start With Screening, Then Reframe Thinking
Fasciana highlighted several screening tools, such as SCOFF, BREDS, and one for ARFID.
“Any screen is going to be better than no screen at all, and any question is going to be better than no question at all,” Fasciana said.
She cautioned that “veterans are not going to be so forthcoming about some of their struggles due to stigma and shame because of their past experiences in the military.”
As for therapy, psychological care may not be required, Ohde said. And it’s especially important to “listen to your patients about what they’re going through, and give them space to share.”
For those who could be helped by psychotherapy, she said, “sometimes I introduce it as therapy that can be really brief. Maybe you just need to talk to someone for a few sessions or just get some support around coping with this.”
One strategy is to focus on bringing enjoyment back to eating, she said. For some patients, “eating becomes a chore,” a task performed without joy, alone in a hospital room.
Fasciana emphasized asking questions over time, perhaps through multiple follow-ups, without expecting answers immediately. And she coaxes patients to consider what they hold dear. “I try to get them to think about the meaning that losing or gaining weight has for them, what their values are, and what really matters to them. I link it back to health, healing, and longevity of life.”
Fasciana and Ohde reported they had no disclosures.
PHOENIX – Veterans are especially vulnerable to disordered eating because of their military backgrounds, a dietician warned US Department of Veterans Affairs (VA) oncology clinicians at the annual meeting of the Association of VA Hematology/Oncology. In fact, an estimated 15% to 25% of veterans meet diagnostic criteria for eating disorders.
“Their experience in the military probably has really shaped the way that they see weight and the stigma behind it,” said Emily Fasciana, MS, RDN, LDN, a registered dietician with the VA based in Wilkes-Barre, Pennsylvania.
When cancer appears, the risk of eating disorders goes up even more, she said. “If we don’t catch eating disorders early on, severe medical problems can occur. In the cancer population, they’re going through enough medical problems as it is.”
Here are things to know about eating disorders in oncology.
Military Life Can Produce a ‘Perfect Storm’ of Risk Factors
Tightly controlled eating environments and food deprivation are often routine in military life. Along with trauma, these can create a “perfect storm of risk factors for eating disorders,” Fasciana said.
During service, for example, “people often will eat as much as they can when they can, sometimes followed by days of not being able to eat,” she said. These are very much like disordered eating behaviors such as binge eating and restricting, and they can place veterans at greater risk.”
She described how service members can develop specific eating patterns during service, such as “midrats” – midnight rations – “meals served during midnight shifts that were the best meal served all day long that they had access to.”
“When I hear veterans who wake up in the middle of the night, and they’re eating, I ask: ‘Did they practice something similar during their military experience?’ They associate that time of the day with enjoyable comfort foods, and that’s what they go to now.”
Vets Can be Haunted by Stigma of Excess Weight
“Making weight” – meeting weight standards – is routine in the military. The pressure to remain under a certain level can have lasting effects on how veterans think about extra pounds, said Kaitlin Ohde, PhD, a clinical health psychologist with the VA Puget Sound Health Care System in Seattle.
“I’ve heard some veterans tell me about getting kicked out of positions because of not being able to make weight. Then they carry this throughout their life, which is really sad,” Ohde said. “When they gain weight during treatment, sometimes it can be really bothersome for them.”
Regular weigh-ins can trouble patients, she said, so it’s important to explain to them why they’re getting on scales: “I’m getting your weight today because I want to see if this medication is doing XYZ.”
She advised colleagues to “make sure they explicitly know why we’re doing it [measuring weight], and how the things we’re using to treat them can impact their weight. This piece of the puzzle sometimes falls off the radar.”
Eating Disorders Can be Catastrophic in Cancer
Untreated eating disorders cause severe medical complications such as malnutrition, hormone dysregulation, low bone density or fractures, bradycardia, gastroparesis, and even anemia, Fasciana said.
There’s a New Category of Eating Disorder
Fasciana highlighted a condition that is underrecognized in oncology: Avoidant/restrictive food intake disorder (ARFID), which refers to patients who stay away from certain foods but not because they’re worried about body image or weight gain. “Patients with ARFID are clinically distinct from those who have anorexia, bulimia, and binge eating disorder,” she noted.
ARFID diagnosis requires food avoidance that leads to at least 1 of these consequences: significant weight loss, nutritional deficiencies, dependence on supplements or tube feeding, or psychosocial impairment.
“Veterans might have a gagging or retching reflex at the sight or smell of certain foods,” Fasciana explained. “They might have difficulty being in the presence of another person eating a nonpreferred food.”
Some cancer patients may be averse to foods of certain temperatures. “You might need to assess why they don’t like the temperature of that food. Why are those foods something that you can’t go to? Are they hurting your teeth? What are they doing to you?”
ARFID patients may also experience social withdrawal around eating. “With a lot of our head and neck cancer patients, especially those with oral cancers and those on feeding tubes, they might feel embarrassed to be around people while eating,” Fasciana said.
She highlighted a 2021 report about 4 cancer survivors with upper abdominal cancers who developed new-onset eating disorders with malnutrition resembling ARFID.
The patients experienced malabsorption, dumping syndrome, and excessive weight loss for 12 months postoperatively without classic body-image concerns. “This is a case example of how eating disorders can evolve in the oncology population,” Fasciana said.
The report said that none of the patients “returned to a healthy weight and/or healthy eating despite extensive team input… The outcomes were poor; 1 patient died, another required admission to a specialist eating disorder admission with a subsequent relapsing-remitting course, and the remaining 2 had complicated chronic courses.”
Treatment: Start With Screening, Then Reframe Thinking
Fasciana highlighted several screening tools, such as SCOFF, BREDS, and one for ARFID.
“Any screen is going to be better than no screen at all, and any question is going to be better than no question at all,” Fasciana said.
She cautioned that “veterans are not going to be so forthcoming about some of their struggles due to stigma and shame because of their past experiences in the military.”
As for therapy, psychological care may not be required, Ohde said. And it’s especially important to “listen to your patients about what they’re going through, and give them space to share.”
For those who could be helped by psychotherapy, she said, “sometimes I introduce it as therapy that can be really brief. Maybe you just need to talk to someone for a few sessions or just get some support around coping with this.”
One strategy is to focus on bringing enjoyment back to eating, she said. For some patients, “eating becomes a chore,” a task performed without joy, alone in a hospital room.
Fasciana emphasized asking questions over time, perhaps through multiple follow-ups, without expecting answers immediately. And she coaxes patients to consider what they hold dear. “I try to get them to think about the meaning that losing or gaining weight has for them, what their values are, and what really matters to them. I link it back to health, healing, and longevity of life.”
Fasciana and Ohde reported they had no disclosures.
Military Background Shapes Eating Disorders in VA Oncology
Military Background Shapes Eating Disorders in VA Oncology
