Eating disorders are serious psychiatric disorders that are associated with a range of significant health problems, including elevated mortality and suicide rates. A recent systematic review found prevalence rates of eating disorders among Veteran and Service Members to be comparable to or higher than prevalence estimates for the general population. Our pilot data, as well as published data by others, has demonstrated that 15-25% of Veterans meet diagnostic criteria for eating disorders when assessed, in contrast to Veteran electronic medical record data that reveals eating disorders are underdiagnosed. At the same time, the proportion of Veterans in the Veterans Health Administration (VHA) with eating disorders are increasing due to several factors, including the growing number of women in the military, expansions of eating disorder diagnostic criteria, and increasing numbers of Veterans affected by risk factors for eating disorders that are characteristic of military life. Although eating disorders are not thought of as service-related conditions that may also impact male Veterans, poor eating habits under stressful conditions while in the military can set the foundation for disordered eating behavior and trajectories of weight gain post-military in both female and male Veterans. Currently, there are no VHA recommended guidelines for eating disorder screening or diagnosis. Consequently, eating disorders in Veterans may be undetected, resulting in insufficient or delayed treatment, and in the worst case, premature death. Eating disorders identification and treatment has been identified as a top priority by facility-level stakeholders from mental health. In response, VHA Mental Health Services and Women?s Health Services are disseminating a clinician training program for the multidisciplinary care of eating disorders. While the ultimate goal is to implement this training nationwide, the health services challenge is how to best establish a clinical pathway that includes targeted screening and diagnosis to best identify Veterans who need this specialty care. Our goal is to develop an evidence-based clinical pathway to identify eating disorders in the Veteran population that will aid in standardizing care and improving outcomes for Veterans. We will use a mixed methods approach with three specific aims.
The first aim will be to further develop and validate a primary care eating disorder screen for DSM-5 that is generalizable for Veterans.
The second aim will be to validate a self-report measure of eating disorders that assesses for all DSM-5 diagnostic criteria and is generalizable for Veterans.
The third aim will be to assess how to best implement the screen and measure across VHA for clinical practice. In our quantitative study (Aims 1 and 2), we will recruit Veterans from the San Francisco VA Healthcare System and VA Connecticut Healthcare System. Veterans (N=400) will complete a series of questionnaires to identify eating disorder symptoms. A random subset of those with and without probable eating disorders (n=156) will be invited to participate in a gold-standard diagnostic clinical interview to validate the proposed screen and self-report measure for the full spectrum of eating disorder diagnoses. In order to revalidate the screen, we will subsequently recruit Veterans from a national Veteran sample to complete the proposed screen and self-report diagnostic measure (N=400). Concurrently for our qualitative study (Aim 3), we will interview stakeholders (N=38; VHA patients, providers, and leaders) on how to best implement the screen and self-report diagnostic measure across multiple VHA-user entry points (Primary Care, Mental Health, Women?s Clinic, and the VA National Weight Management Program, MOVE!).
Our aims will allow us to fill a gap through partnered work and stakeholder feedback, and help build a clinical pathway to identify Veterans that may be falling through the cracks and not getting the care that they need. This project meets several strategies consistent with the VHA Blueprint for Excellence including meeting the ?unique needs? of Veterans, providing a clinical pathway for ?high quality, Veteran-centered care,? and ?leading the nation in research and treatment of military service-related conditions.?

Public Health Relevance

The objective of this study is to develop an evidence-based clinical pathway to address eating disorders in VHA that will aid in standardizing care and improving outcomes for Veterans. Our aims are to develop and validate screening and diagnostic tools for DSM-5 eating disorders, and to determine how to best implement these tools for treatment referral. Up to one-quarter of Veterans may meet diagnostic criteria for current eating disorders, with a disproportionate prevalence in Veterans with overweight and/or mental health problems. However, there are no validated measures for this population and no systematic way to identify eating disorders within VHA. As such, eating disorders may be undetected, resulting in insufficient or delayed treatment, and consequently exacerbating or prolonging potentially life-threatening symptoms. Identification of Veterans with eating disorders is a health services gap that needs to be urgently addressed. This project complements VHA?s current initiative to disseminate multidisciplinary eating disorder training to VHA providers.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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HSR-4 Mental and Behavioral Health (HSR4)
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VA Connecticut Healthcare System
West Haven
United States
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