Eating Behaviors 17 (2015) 115–118
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PTSD and depression symptoms are associated with binge eating among US Iraq and Afghanistan veterans Katherine D. Hoerster a,b,⁎, Matthew Jakupcak a,b, Robert Hanson c, Miles McFall a,b, Gayle Reiber c,d, Katherine S. Hall e,f, Karin M. Nelson c,g,h a
VA Puget Sound Healthcare System, Seattle Division, Mental Health Service, 1660 S. Columbian Way, Seattle, WA 98108, United States University of Washington, Department of Psychiatry and Behavioral Sciences, 1959 NE Paciﬁc Street, Box 356560, Rm BB1644, Seattle, WA 98195, United States VA Puget Sound Healthcare System, Seattle Division, Research and Development Service, 1660 S. Columbian Way, Seattle, WA 98108, United States d University of Washington School of Public Health, Departments of Health Services and Epidemiology, 1959 NE Paciﬁc Street, Box 356560, Rm BB1644, Seattle, WA 98195, United States e Durham Veterans Affairs Medical Center Geriatric Research, Education, and Clinical Center, 508 Fulton St., Durham, NC 27705, United States f Duke University Medical Center, Department of Medicine, 201 Trent Drive, Box 3003 DUMC, Rm 3502 Busse Building, Durham, NC 27710, United States g VA Puget Sound Healthcare System, General Internal Medicine Service, 1660 S. Columbian Way, Seattle, WA 98108, United States h University of Washington Department of Medicine, 1959 N.E. Paciﬁc St. Seattle, WA 98195, United States b c
a r t i c l e
i n f o
Article history: Received 16 July 2014 Received in revised form 25 November 2014 Accepted 28 January 2015 Available online 4 February 2015 Keywords: Veterans Post-traumatic stress disorder Depression Obesity Binge eating
a b s t r a c t Objective: US Iraq and Afghanistan Veterans with post-traumatic stress disorder (PTSD) and depression are at increased risk for obesity. Understanding the contribution of health behaviors to this relationship will enhance efforts to prevent and reduce obesity. Therefore, we examined the association of PTSD and depression symptoms with binge eating, a risk factor for obesity, among Iraq/Afghanistan Veterans. Method: Iraq/Afghanistan Veterans were assessed at intake to the VA Puget Sound Healthcare System-Seattle post-deployment clinic (May 2004–January 2007). The Patient Health Questionnaire was used to measure depression and binge eating symptoms, and the PTSD Checklist-Military Version assessed PTSD symptoms. Results: The majority of the sample (N = 332) was male (91.5%) and Caucasian (72.6%), with an average age of 31.1 (SD = 8.5) years; 16.3% met depression screening criteria, 37.8% met PTSD screening criteria, and 8.4% met binge eating screening criteria. In adjusted models, those meeting depression (odds ratio (OR) = 7.53; 95% CI = 2.69, 21.04; p b .001) and PTSD (OR = 3.37; 95% CI = 1.34, 8.46; p = .01) screening criteria were more likely to meet binge eating screening criteria. Continuous measures of PTSD and depression symptom severity were also associated with meeting binge eating screening criteria (ps b .05). Conclusion: PTSD and depression are common conditions among Iraq/Afghanistan Veterans. In the present study, PTSD and depression symptoms were associated with meeting binge eating screening criteria, identifying a possible pathway by which psychiatric conditions lead to disproportionate burden of overweight and obesity in this Veteran cohort. Tailored dietary behavior interventions may be needed for Iraq/Afghanistan Veterans with co-morbid obesity and psychiatric conditions. Published by Elsevier Ltd.
1. Introduction The health of United States Veterans is poorer than that of the general population (Hoerster, Lehavot, et al., 2012; Lehavot, Hoerster, Nelson, Jakupcak, & Simpson, 2012). Veterans with post-traumatic stress disorder (PTSD) and depression are at particularly high risk for being overweight or obese and for having related conditions, including the relatively younger cohort of returning Veterans who served in the
⁎ Corresponding author at: 1660 S. Columbian Way (S-116), Seattle, WA 98108, United States. Tel.: +1 206 277 4203; fax: +1 484 733 5241. E-mail addresses: [email protected]
(K.D. Hoerster), [email protected]
(M. Jakupcak), [email protected]
(R. Hanson), [email protected]
(M. McFall), [email protected]
(G. Reiber), [email protected]
(K.S. Hall), [email protected]
http://dx.doi.org/10.1016/j.eatbeh.2015.01.005 1471-0153/Published by Elsevier Ltd.
Iraq and Afghanistan Wars (Cohen, Marmar, Ren, Bertenthal, & Seal, 2009; Maguen et al., 2013). Addressing the disproportionate burden of overweight and obesity among Iraq/Afghanistan Veterans with psychiatric conditions is a high public health priority. The association of PTSD and depression with overweight and obesity is complex, and includes both physiological and behavioral pathways (Dedert, Calhoun, Watkins, Sherwood, & Beckham, 2010; Rheingold, Acierno, & Resnick, 2004). Modiﬁable behavioral pathways may include alcohol misuse (Rheingold et al., 2004) and physical inactivity (Hoerster, Jakupcak, McFall, Unutzer, & Nelson, 2012). Dietary behavior plays an important role in the etiology and maintenance of overweight/ obesity, but our understanding of the role of dietary behavior in the pathway between psychiatric illness and overweight/obesity for Veterans is limited. Depression is associated with binge eating among Veterans (Higgins et al., 2013; Rosenberger & Dorﬂinger, 2013) and
K.D. Hoerster et al. / Eating Behaviors 17 (2015) 115–118
emerging evidence indicates that PTSD is associated with eating fewer fruits, engaging in emotional eating, and having more guilt following overeating compared to those without PTSD (Godfrey, Lindamer, Mostouﬁ, & Afari, 2013; Talbot, Maguen, Epel, Metzler, & Neylan, 2013). Little is known about the associations of PTSD and depression with dietary behavior among Iraq/Afghanistan Veterans, although a recent study showed that Iraq/Afghanistan Veterans with depression and PTSD are more likely to have co-morbid eating disorders than those without mental health conditions (Maguen et al., 2012). Binge eating may place individuals at higher risk of overweight or obesity (de Zwaan, 2001). No published studies have examined whether PTSD and/or depression symptoms are associated with binge eating among Iraq/Afghanistan Veterans. The goal of the current study is to assess the association between symptoms of these common psychiatric conditions and binge eating among Iraq/Afghanistan Veterans. 2. Methods We assessed Iraq/Afghanistan Veterans at intake to the VA Puget Sound Healthcare System, Seattle (VAPSHCS) post-deployment clinic (May 2004–January 2007; N = 337). Veterans missing data on the binge eating questions (n = 5) were excluded. The ﬁnal analysis sample was N = 332. VAPSHCS's Institutional Review Board approved this study.
2.1. Measures PTSD symptoms were assessed with the PTSD Checklist-Military Version (PCL-M) (National Center for PTSD, 2010), and depression and binge eating symptoms were assessed with the Patient Health Questionnaire (PHQ) (Spitzer, Kroenke, & Williams, 1999). Standard cutoffs were used to identify those meeting screening criteria for PTSD and depression and they were non-mutually exclusive categories. Socio-demographic measures were age; sex; race (Caucasian, AfricanAmerican, Other); marital, employment, and educational status; income; and branch of service. The study outcome was meeting PHQ screening criteria for binge eating, deﬁned as responding afﬁrmatively to the statements “Do you often feel that you can't control what or how much you eat?”, “Do you often eat, within any 2-hour period, what most people would regard as an unusually large amount of food?”, and “Has this been as often, on average, as twice a week for the last 3 months?” without engaging in purging behavior. 2.2. Statistical analyses Descriptive, bivariate, and multivariate analyses were performed in SPSS V22.0. Independent associations of PTSD and depression measures with meeting binge eating criteria were examined in separate logistic regression analyses due to multicollinearity between PTSD and depression symptom severity scores (r = .82). Models were adjusted for all sociodemographic characteristics.
3. Results Tables 1 and 2 present sample characteristics and bivariate associations with meeting binge eating criteria for continuous and categorical variables, respectively. The majority of participants were male, Caucasian, and/or employed, and had at least some college education, an annual income less than $35,000, and/or had served in the Army. Approximately half were married. Nearly 40% met PTSD screening criteria, 16.3% met depression screening criteria, and 8.4% met binge eating screening criteria. In adjusted models, meeting depression (odds ratio (OR) = 7.53; 95% CI = 2.69, 21.04; p b .001) and PTSD (OR = 3.37; 95% CI = 1.34, 8.46; p = .01) screening criteria were signiﬁcantly associated with increased odds of meeting binge eating screening criteria. In addition, continuous measures of depression (OR = 1.20; 95% CI = 1.11, 1.30; p b .001) and PTSD (OR = 1.05; 95% CI = 1.02, 1.08; p = .001) symptom severity were signiﬁcantly associated with meeting binge eating screening criteria. 4. Discussion The present study demonstrates that PTSD and depression symptoms are associated with binge eating among Iraq/Afghanistan Veterans, elucidating a potential pathway by which these psychiatric conditions contribute to the disproportionate burden of obesity in this population (Maguen et al., 2013). Findings are consistent with prior work showing that depression is associated with binge eating among Veterans (Higgins et al., 2013; Rosenberger & Dorﬂinger, 2013) and that stress and PTSD are associated with poor dietary behaviors, emotional eating, and emotional consequences of overeating (Godfrey et al., 2013; Sinha & Jastreboff, 2013; Talbot et al., 2013). Poor eating behavior among those with psychiatric conditions may represent attempts to manage distress and affect through the use of food, similar to mechanisms involved in addiction (Sinha & Jastreboff, 2013). While only 8.4% of the sample met binge eating screening criteria, this rate is higher than prevalence in the general population (2–5%) (de Zwaan, 2001). Moreover, rates of meeting binge eating screening criteria were substantially higher among those meeting PTSD (14.6%) and depression (26.4%) screening criteria. Addressing this issue is critically important, given the high burden of obesity and related illness among Veterans with psychiatric conditions (Cohen et al., 2009; Maguen et al., 2013), including higher rates of premature mortality for those with PTSD (Kilbourne, Ignacio, Kim, & Blow, 2009). 4.1. Limitations and strengths This study has several limitations, including the cross-sectional study design and the use of a clinical sample that may be unique, thereby limiting generalizability. Because this study relied on self-report intake data from routine clinical care, PTSD, depressive, and binge eating symptoms were not conﬁrmed with an in-person clinical interview. Moreover, this sample was assessed prior to the release of the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) psychiatric condition diagnostic criteria (American Psychiatric Association,
Table 1 Sample characteristics and bivariate associations with binge eating among Iraq and Afghanistan veterans: continuous variables (VA Puget Sound Healthcare System, Seattle; May 2004– January 2007). Variable
Total sample (N = 332) Not meeting binge eating screening criteria (N = 304) Meeting binge eating screening criteria (N = 28) p-Value (T-test) Mean (SD)
Age 31.1 (8.5) 42.9 (19.1) PTSD symptomsa b Depression symptoms 10.5 (7.6)
31.0 (8.5) 41.6 (18.9) 9.8 (7.3)
31.6 (8.6) 57.0 (15.4) 18.4 (5.8)
Possible scores range from 17–85, with greater scores reﬂecting greater PTSD symptom severity. Possible scores range from 0–27, with greater scores reﬂecting greater depression symptom severity.
0.72 b.001 b.001
K.D. Hoerster et al. / Eating Behaviors 17 (2015) 115–118
Table 2 Sample characteristics and bivariate associations with binge eating among Iraq and Afghanistan veterans: categorical variables (VA Puget Sound Healthcare System, Seattle; May 2004– January 2007; N = 332). Variable Depression screening criteriaa Does not meet criteria Meets criteria PTSD screening criteriab Does not meet criteria Meets criteria Sex Male Female Race/ethnicity White African-American Other Marital status Married or cohabitating Not married/not cohabitating Military branch Army Marines Other Educational attainment Less than high school (h.s.) Completed h.s.; no college Some college ≥4 years college Employment status Employed Unemployed Annual household income $0–$24,999 $25,000–$34,999 ≥$35,000 a b
N (%) meeting binge eating screening criteria (N = 28; 8.4%)
13 (4.8%) 14 (26.4%)
10 (5.0%) 18 (14.6%)
26 (8.6%) 2 (7.1%)
228 31 55
72.6 9.9 17.5
17 (7.5%) 2 (6.5%) 7 (12.7%)
19 (11.1%) 9 (5.6%)
248 32 49
75.4 9.7 14.9
21 (8.5%) 3 (9.4%) 4 (8.2%)
3 75 169 59
1.0 24.5 55.2 19.3
0 (0%) 3 (4.0%) 17 (10.1%) 5 (8.5%)
16 (7.6%) 12 (10.3%)
133 59 133
40.9 18.2 40.9
9 (6.8%) 2 (3.4%) 17 (12.8%)
p-Value (Chi-square) b.001
Those with a score of at least 20 on the PHQ-9 were classiﬁed as meeting screening criteria for depression. Those with a score of at least 50 on the PTSD Checklist-Military Version were classiﬁed as meeting screening criteria for PTSD.
2013); as such, current screening criteria for PTSD, depression, and binge eating symptoms were not assessed in this sample. In addition, we did not assess height or weight in this sample, which would have provided important additional details regarding the health consequences of binge eating in this population. Future research is needed on the association of PTSD and depressive symptomatology with binge eating and binge eating disorder, as well as with other problematic or disordered eating behaviors. Such studies should be conducted in other Veteran samples, and use more rigorous measurement procedures, including clinical interview based on current DSM-5 criteria and anthropometric measurement (e.g., height and weight). These limitations notwithstanding, this paper provides important and novel data on the association between symptoms of two highly prevalent psychiatric conditions and meeting binge eating screening criteria among Iraq/Afghanistan Veterans. 4.2. Conclusions Given their increased risk for overweight and obesity (Maguen et al., 2013), and the present study's ﬁndings, Iraq/Afghanistan Veterans with depression and PTSD should be screened for binge eating. Likewise, Veterans presenting for treatment of disordered eating and/or weight loss should be screened for psychiatric conditions. It may be necessary to provide targeted and tailored dietary interventions to Iraq/Afghanistan Veterans with PTSD and/or depression who also engage in binge eating in order to adequately address unique barriers to behavior change and disproportionate burden of overweight and obesity in these Veterans. A recent analysis of the VA's MOVE! behavioral weight loss program demonstrated poorer weight loss outcomes for Veterans with PTSD and other mental health conditions compared to those with no mental health conditions (Hoerster et al., 2014). Such ﬁndings underscore the
potential need for tailored behavior change approaches. Prior research has shown tremendous beneﬁt of health behavior interventions tailored to the needs of Veterans with psychiatric conditions. For example, McFall et al. (2010) demonstrated substantial beneﬁts from tailored smoking cessation for Veterans with PTSD. In addition to being integrated into the PTSD care setting, this intervention provides additional content to address issues uniquely relevant to those with PTSD (e.g., education regarding the mental health beneﬁts of quitting tobacco use; encouragement to explore how PTSD and other psychiatric symptoms lead to tobacco use; strategies for coping with PTSD and other psychiatric symptoms) (McFall et al., 2010). The present study suggests such an approach may be needed to address co-morbid binge eating and PTSD/ depression. A recent study found that delivering the evidence-based psychotherapy Acceptance and Commitment Therapy to Veterans engaging in binge eating, incorporating content speciﬁcally targeting binge eating, improved binge eating symptoms, depression, global psychological distress, body mass index, and functioning (Gundy Cuneo, Johnson Wright, Backhaus, Godfrey, & Afari, 2014). Such tailored behavioral weight management or lifestyle interventions may also beneﬁt psychiatric symptoms and functioning, given that weight loss appears to result in reduced PTSD and depressive symptoms (Johannessen & Berntsen, 2013). Further research is needed to understand why PTSD and depression symptoms are associated with binge eating among Iraq/Afghanistan Veterans and how this issue can be addressed through evidence-based lifestyle interventions.
Role of funding sources There was no funding for this paper. This material is the result of work supported by resources from VA Puget Sound Healthcare System. Dr. Hall is funded by a Career Development Award from the Rehabilitation Research and Development Service of the Department of Veterans Affairs (2RX001316). The funders had no role in the study design,
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collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Contributors The ﬁrst author initiated the manuscript and oversaw all aspects of it, and ran all analyses. Author #2 performed the initial data collection for this study. All authors contributed to the conceptualization, data interpretation, and writing and editing of this manuscript. All authors approved the ﬁnal manuscript. Conﬂict of interest The authors declare that there are no conﬂicts of interest.
References American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Cohen, B.E., Marmar, C., Ren, L., Bertenthal, D., & Seal, K.H. (2009). Association of cardiovascular risk factors with mental health diagnoses in Iraq and Afghanistan war veterans using VA health care. JAMA, 302, 489–492. de Zwaan, M. (2001). Binge eating disorder and obesity. International Journal of Obesity and Related Metabolic Disorders, 25(Suppl. 1), S51–S55. Dedert, E.A., Calhoun, P.S., Watkins, L.L., Sherwood, A., & Beckham, J.C. (2010). Posttraumatic stress disorder, cardiovascular, and metabolic disease: A review of the evidence. Annals of Behavioral Medicine, 39, 61–78. Godfrey, K.M., Lindamer, L.A., Mostouﬁ, S., & Afari, N. (2013). Posttraumatic stress disorder and health: A preliminary study of group differences in health and health behaviors. Annals of General Psychiatry, 12, 30. Gundy Cuneo, J. M., Johnson Wright, L., Backhaus, A., Godfrey, K., & Afari, N. (2014). Feasibility and outcomes of Acceptance and Commitment Therapy for binge eating symptoms in obese Veterans. In K. Hoerster (Chair), Mental health considerations for optimizing behavioral weight management interventions with obese veterans, symposium presented at the 35th annual meeting of the Society of Behavioral Medicine, Philadelphia, PA. Annals of Behavioral Medicine 47, s145. Higgins, D.M., Dorﬂinger, L., MacGregor, K.L., Heapy, A.A., Goulet, J.L., & Ruser, C. (2013). Binge eating behavior among a national sample of overweight and obese veterans. Obesity (Silver Spring), 21, 900–903. Hoerster, K., Jakupcak, M., McFall, M., Unutzer, J., & Nelson, K. (2012). Mental health and somatic symptom severity are associated with reduced physical activity among US Iraq and Afghanistan veterans. Preventive Medicine, 55, 450–452.
Hoerster, K.D., Lai, Z., Goodrich, D.E., Damschroder, L.J., Littman, A.J., Klingaman, E.A., et al. (2014). Weight loss after participation in a national VA weight management program among Veterans with or without PTSD. Psychiatric Services, 65, 1385–1388. Hoerster, K.D., Lehavot, K., Simpson, T., McFall, M., Reiber, G., & Nelson, K.M. (2012). Health and health behavior differences: U.S. military, veteran, and civilian men. American Journal of Preventive Medicine, 43, 483–489. Johannessen, K.B., & Berntsen, D. (2013). Losing the symptoms: Weight loss and decrease in posttraumatic stress disorder symptoms. Journal of Clinical Psychology, 69, 655–660. Kilbourne, A.M., Ignacio, R.V., Kim, H.M., & Blow, F.C. (2009). Datapoints: Are VA patients with serious mental illness dying younger? Psychiatric Services, 60, 589. Lehavot, K., Hoerster, K.D., Nelson, K.M., Jakupcak, M., & Simpson, T.L. (2012). Health indicators for military, veteran, and civilian women. American Journal of Preventive Medicine, 42, 473–480. Maguen, S., Cohen, B., Cohen, G., Madden, E., Bertenthal, D., & Seal, K. (2012). Eating disorders and psychiatric comorbidity among Iraq and Afghanistan veterans. Women's Health Issues, 22, e403–e406. Maguen, S., Madden, E., Cohen, B., Bertenthal, D., Neylan, T., Talbot, L., et al. (2013). The relationship between body mass index and mental health among Iraq and Afghanistan veterans. Journal of General Internal Medicine, 28(Suppl. 2), S563–S570. McFall, M., Saxon, A.J., Malte, C.A., Chow, B., Bailey, S., Baker, D.G., et al. (2010). Integrating tobacco cessation into mental health care for posttraumatic stress disorder: A randomized controlled trial. JAMA, 304, 2485–2493. National Center for PTSD (2010). PTSD checklist (PCL). PTSD checklist (PCL). http://www.ptsd.va.gov/professional/pages/assessments/assessment-pdf/ pcl-handout.pdf (Accessed October 10, 2013) Rheingold, A.A., Acierno, R., & Resnick, H.S. (2004). Trauma, posttraumatic stress disorder, and health risk behaviors. In P.P. Schnurr, & B.L. Green (Eds.), Trauma and health: Physical health consequences of exposure to extreme stress (pp. 217–243). Washington, DC: American Psychological Association. Rosenberger, P.H., & Dorﬂinger, L. (2013). Psychosocial factors associated with binge eating among overweight and obese male veterans. Eating Behaviors, 14, 401–404. Sinha, R., & Jastreboff, A.M. (2013). Stress as a common risk factor for obesity and addiction. Biological Psychiatry, 73, 827–835. Spitzer, R.L., Kroenke, K., & Williams, J.B. (1999). Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire. JAMA, 282, 1737–1744. Talbot, L.S., Maguen, S., Epel, E.S., Metzler, T.J., & Neylan, T.C. (2013). Posttraumatic stress disorder is associated with emotional eating. Journal of Traumatic Stress, 26, 521–525.