Military experience strongly influences post-service eating behavior and BMI status in American veterans

Appetite 52 (2009) 280–289

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Military experience strongly influences post-service eating behavior and BMI status in American veterans Chery Smith *, Abby Klosterbuer, Allen S. Levine University of Minnesota, Department of Food Science and Nutrition, 225 FScN, 1334 Eckles Ave, St. Paul, MN 55108-6099, USA

A R T I C L E I N F O

A B S T R A C T

Article history: Received 28 March 2008 Received in revised form 17 October 2008 Accepted 20 October 2008

In-depth interviews were conducted with veterans (n = 64) with an average age of 57 years to investigate eating behavior and food insecurity during military service and examine if it affects post-war eating behavior, and if this contributes to the high incidence of obesity found in veterans. About half of the subjects served during the Vietnam War, while smaller numbers served in WWII, the Korean War, Desert Storm, or other conflicts. The mean BMI was 30.5  6.7 kg/m2. Only 12.5% of participants were classified as normal weight, while 37.5% were overweight, 46.9% were obese, and 3.1% were classified as excessively obese. Five major themes were identified including, (a) military service impacts soldier’s food environment, (b) food insecurity influences eating behavior and food choices, (c) military impacts weight status during and postservice, (d) military service has health consequences, and (e) post-service re-adjustment solutions are needed to ease re-entry into civilian life. ß 2008 Elsevier Ltd. All rights reserved.

Keywords: Eating behavior Military service Veterans Body mass index Obesity Food insecurity

Introduction With the dramatic rise in obesity, this condition has become a major public health concern in the United States (US). Obesity contributes to over 300,000 deaths per year and increases risk of chronic disease, including type 2 diabetes, hypertension, coronary artery disease, osteoarthritis, gall bladder disease, and several cancers including colon, prostrate, and kidney (Nelson, 2006; Wang et al., 2005). Studies have found an association between obesity, reduced quality of life, and early onset of disability (Livingston & Ko, 2002). Obesity is not only common among the general population, but it is also major concern in the military veteran population (Das et al., 2005; Nowicki et al., 2003) with 68.4% of women and 73.0% of men having BMI  25 kg/m2 and 37.4% of women and 32.9% of men having BMI  30 (Das et al., 2005). Over 24.5 million Americans presently serve in one of the five branches (Army, Navy, Marine Corp, Air Force, and Coast Guard) of the US Armed Forces (Census, 2006; Today’s Military, 2007). Each branch has a program known as basic training, ranging in length from 6 weeks in the Air Force to 13 weeks in the Marine Corp, involving intense physical conditioning and classroom instruction to learn the necessary skills for combat (Today’s Military, 2007). Following basic training, but prior to active service, soldiers enter

* Corresponding author. E-mail addresses: [email protected] (C. Smith), [email protected] (A. Klosterbuer), [email protected] (A.S. Levine). 0195-6663/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2008.10.003

specialty schools to become trained in their military occupational specialty (MOS) (Today’s Military, 2007). Military personnel are fed in a variety of ways depending on where they are based and their specific duty assignment. During basic training, soldiers are fed in dining facilities, or mess halls. After training, meal options include mess halls or eating at home or in restaurants (Poos, Costello, & Carlson-Newberry, 1999). During field operations, soldiers are fed operational rations, which since WWII have included C-Rations1, K-Rations2, Long Range Patrol (LRP) food packets3, and more recently, Meals Ready to Eat (MRE)4 (Poos et al., 1999).

1 Ration used from WWII through 1983 consisting of canned food items including ‘‘B’’ or bread units (biscuits, cereals) and ‘‘M’’ or meat units (franks and beans, meat and spaghetti) as well as desserts, powdered beverages, and chewing gum. Cigarettes were included until 1975. C-Rations provided roughly 3600 cal per day. 2 Ration introduced in 1942 and used interchangeably with the C-Ration. Each meal included dried biscuits, cigarettes, gum, sugar, a canned entre´e, and some mealspecific items. The K-Ration was designed as an emergency ration and was calorically deficient for active military personnel, providing around 3000 cal per day. 3 Ration designed for long-range reconnaissance troops as an alternative to the CRation. LRPs were introduced in 1964 and contained pre-cooked, freeze-dried entrees, cereal bars, desserts, and instant beverages. Although LRP packets were designed to be reconstituted with water, they could also be consumed dry. This ration is classified as a restricted-calorie, full-day ration and was intended for periods of up to 10 days. Each provides approximately 1540 cal. 4 MREs replaced C-Rations in 1983. Each contains an entre´e, starch, crackers and a spread (cheese, peanut butter, or jelly), a beverage powder and a sweet dessert. There are a variety of MREs, including traditional meals, ethnic dishes, and vegetarian options. Three meals provide 3600 kcal per day.

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Little research exists as to how eating conditions during the service impact veterans’ food behavior post-service. Previous studies have found that periods of food restriction can result in altered food-related behavior such as binge eating, hoarding food, and suffering food cravings (Keys, 1946; Polivy, Zeitlin, Herman, & Beal, 1994; Sindler, Wellman, & Stier, 2004; Tuschl, 1990). During combat, and especially during detainment in prison camps, soldiers are often subjected to long periods of food insecurity (inability to reliably attain an adequate food supply) and food restrictions (Polivy et al., 1994). With approximately 160,000 troops employed in Iraq (Department of Defense, 2007), it is imperative that we learn more about how military experiences change eating behavior, both short term and long term. The purpose of this study was to investigate eating behavior and food insecurity during military service and examine if it affects post-war eating behavior, and if this contributes to the high incidence of obesity found in veterans. Methodology Two researchers conducted 11 focus group discussions with US veterans who served in the military between World War II and the present. One researcher (CS) facilitated all discussions, while the research assistant (AK) managed tape recording and note taking. Participants were recruited via VA Medical Center, veteran’s residential homes, and by word of mouth. Participants of the focus groups were from mixed eras; for example a focus group could have included 2 WWII, 3 Vietnam, 1 Iraq, and 1 Gulf war veterans. Vietnam veterans were present in all focus groups, accounting for approximately half of our sample and mimicking the national sample of veterans. Having a mixture of veterans from different military eras appeared to engage the group in thoughtful discussions. Sessions lasted approximately 90 min and veterans received compensation for their time. The University of Minnesota’s and the VA Medical Center’s Institutional Review Board for Research Involving Human Subjects approved this study. During focus groups, participants were asked to describe (a) their military experience (when and where they served, experiences in combat situations, length of time in the service, and a typical day in boot camp and in the field), (b) eating conditions during the service, (c) food intake if taken as a prisoner-of-war or if in combat zones or recon units, (d) eating patterns pre-, during, and post-service, (e) weight loss or gain during and after the service, (f) physical activity during and after the service, (g) transition from military to civilian life, and (h) how their military experience has impacted present day dietary and activity behavior and health status outcomes. Anthropometry Height and weight measurements were taken with shoes and outer clothing removed, using standard procedures (Lee & Nieman, 1995). BMI was calculated, weight (kg)/height (m)2 with underweight < 18.5, normal weight  18.5 < 25, overweight  25 < 30, obese  30 < 40, and excessively obese  40 (CDC, 2007). BMI was used as a measure of obesity so that other researchers could make comparisons. While it is not a good measure of adiposity in wellmuscled men and women, most of the veterans in this sample were not routinely exercising and only one was still in the military service, suggesting that higher BMIs reported here do reflect fat rather than muscle. Data analysis Focus groups were audio taped and transcribed verbatim. Transcripts were independently evaluated by two researchers to

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identify common themes (Morgan & Krueger, 1998), and discrepancies were resolved prior to further analysis. Transcripts were coded using Nvivo, a qualitative data analysis program, based on themes that emerged from transcript evaluation. Focus group methodology was used to allow for an in-depth discussion of how military service impacts post-service eating behavior and resulting BMI status. Demographic data was analyzed using the Statistical Package for Social Sciences for Windows (SPSS, v. 11, Chicago, IL, 1999). Results Participant characteristics Sixty-one male and three female American military veterans, with an average age of 57 years participated in the study (Table 1). This sample size was determined adequate because the saturation point was met (i.e. no new information was heard) (Miles & Huberman, 1994). Most participants were Caucasian (72%) and African American (23%) and were unemployed or had annual incomes <$40,000. Most participants had completed high school. About half of the subjects served during the Vietnam War, while smaller numbers served in WWII, the Korean War, Desert Storm, or other conflicts. Most participants self-reported their health as either ‘‘good’’ (30%) or ‘‘poor’’ (34%), and rated their diet quality as either ‘‘very good’’ (31%) or ‘‘good’’ (38%) (Table 1). The mean BMI for the sample was 30.5  6.7 kg/m2. Only 12.5% of participants were classified as normal weight, while 37.5% were overweight, 46.9% were obese, and 3.1% were classified as excessively obese. There were significant differences between self-reported and measured height, weight, and BMI, with participants tending to overestimate height and underestimate weight values (Table 2). Five major themes were identified through evaluation of the focus groups including, (a) military service impacts soldier’s food environment, (b) food insecurity influences eating behavior and food choices, (c) military impacts weight status during and postservice, (d) military service has health consequences, and (e) postservice re-adjustment solutions are needed to ease re-entry into civilian life. Sub-themes arose within each major theme and are discussed under the appropriate theme. Military service impacts soldier’s food environment During military service, soldiers experience varying levels of control over food choice and consumption. In basic training and on bases, food is generally provided in mess halls, but choices and portion sizes may not match one’s personal preferences. Many participants reported exposure to unfamiliar foods upon entering the service, including new types of vegetables, regional American foods, and foreign foods, depending on where the person was stationed. Basic training was seen as a time to ready soldiers for what was to come. As one Vietnam veteran said, ‘‘I just overall saw that we were trained for war. That we were not fed to the extent that we would have liked because in the actual combat, you may not eat for awhile. But we did not starve. We learned how to do with the bare essentials.’’ Era of Service: Discussions revealed that military food service has evolved over the years, both in the mess halls and in operational rations. During the WWII era, mess halls and military bases had few food options; however, more recent veterans reported more choice and greater variety, including ethnic meals and increased availability of fresh fruits and vegetables. Desert Storm veterans discussed modernized food service systems, such as using debit cards to purchase food and delivery services to bring food and alcohol from the Post-Exchange (PX) store to soldiers living on base.

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Table 1 Sample characteristics of US veterans sample (n = 64). Characteristic

Mean (S.D.)

Age (y) Total number of people in householda Number of children in household Height (m) Weight (kg) Body mass index (BMI) (kg/m2)

56.9 (12.6) 1.7 (1.3) 0.3 (1.1) 1.7 (0.1) 91.2 (20.1) 30.5 (6.7) No. (%) of participants

BMI (kg/m2) <18.5 18.5–24.99 25–29.99 30–39.99 40

0 8 24 30 2

Gender Male Female

61 (95.3) 3 (4.7)

Race African American American Indian Caucasian Hispanic Latino

15 1 46 1 1

(23.4) (1.6) (71.9) (1.6) (1.6)

Income Less than $10,000 $10,001–19,999 $20,000–39,999 $40,000–59,000 Greater than $60,000 Unemployed

26 10 10 6 2 10

(40.6) (15.6) (15.6) (9.4) (3.1) (15.6)

Education Some high school Completed high school Some undergraduate/college/technical/vocational school Completed undergraduate/college/technical/vocational school Completed graduate/professional school

4 15 27 13 5

(6.3) (23.4) (42.2) (20.3) (7.8)

Perception of health Excellent Very good Good Fair Poor

3 13 19 22 7

(4.7) (20.3) (29.7) (34.4) (10.9)

Perception of diet quality Excellent Very good Good Fair Poor

3 20 24 15 2

(4.7) (31.3) (37.5) (23.4) (3.1)

Wartime service periodb WWII Korean War Vietnam War Desert Storm Current conflict in the Middle East Other

6 8 33 9 1 14

(9.4) (12.5) (51.6) (14.1) (1.6) (21.9)

Use of operational rations Yes No

41 (64.1) 23 (35.9)

Participation in active combat Yes No

24 (37.5) 40 (62.5)

(0) (12.5) (37.5) (46.9) (3.1)

a Individuals living in institutional settings were counted as having one person in the household. b Total will not sum to sample number as some participants indicated military service during more than one military conflict.

Participants also discussed how differences in rations over the years affected food choice. WWII veterans reported eating primarily C-rations and D bars, which were described as an unappealing chocolate bar. Korean War veterans consumed mainly K-rations. Many Vietnam War veterans reported consuming both C-rations and LRPs. Some expressed concern over the quality of rations, and one stated, ‘‘I can remember getting C-Rations from 1945. And I thought, ‘My god! We’re getting food to eat from the year I was born!’ . . . you know . . . the date on it, and so tended not to eat them and wait until you got something that was either a snack, candy bar, or something like that (Vietnam veteran).’’ Some participants indicated that the introduction of lightweight rations such as LRPs and MREs allowed them to bring more food into the field, but were of concern when water was scarce, such as in Desert Storm, Gulf War, Iraq, or in Vietnam where rivers were highly patrolled by Viet Cong. Veterans from all eras appeared to face challenges regarding food access and food choice. In the most recent wars in arid, desert locations, drinking water storages were also reported to be a problem. As one Iraq veteran reported, ‘‘There were signs all over the base, everywhere you went-in the mess tent, on your way to the mess tent, all around the compound, ‘‘Drink Five-Stay Alive.’’ . . . then they ration you two because there was a water shortage.’’ Military Branch: Participants described different food environments depending on which branch they belonged to. While members of all branches reported receiving large quantities of calorically dense food in the mess halls, the Air Force and Navy veterans were repeatedly cited as having the highest quality food and facilities. These veterans also reported greater variety and choice over portion size and preparation style, such as eggs-toorder. In contrast, Army and Marines veterans commonly reported poor quality food and a lack of choice. One participant highlighted these differences by saying, ‘‘The Air Forces bases that I’ve been on, they have the best food . . . it’s just like a 5 star restaurant. Got your salad bars and all that stuff. We didn’t have that in the Army, you know. I went to Air Force facility; it’s like ‘Wow!’ Wall to wall counters and big ole chairs to sit in. Sit as long as you want to. Somebody come up and pick your tray up for you, and all type of waiting on . . . I would, I would basically glutton myself at the Air Force base ‘cause we didn’t have it, you know? There was greater variety, and it was clean, a cleaner facility (Korean veteran).’’ Physical training requirements also varied among branches. While all veterans reported vigorous physical conditioning during basic training, differences arose once in the service. Veterans of the Army and Marines reported that conditioning continued after basic training, but many Air Force and Navy veterans reported a significant drop in or complete lack of physical training requirements. One Navy veteran noted, ‘‘I think between all the branches, the Navy is the laziest. When you look at them, you know, most of them are overweight because after Boot Camp, they don’t do a damn thing (Vietnam Veteran).’’ Other participants voiced concern over the consequences of a decline in physical activity but maintenance of calorically dense meals in the mess halls during the service. In contrast, those in the Army reported very high levels of physical activity. One Army veteran stated, ‘‘The Drill Instructors, you know, just pushed you on the edge of your mental capacity as well as your physical capacity. I mean, running 20 miles. Always pushing . . . So much, you know, fast, forced marching. Uh, 20 miles for marching exercise . . . whatever. Sometimes we would have to run with our rifles over our heads. Miles. Carry extra weight . . . So it was all conditioning (Gulf War veteran).’’ Occupation: Participants discussed how certain occupations within the service impact the food environment. Former pilots reported food was often restricted during long flight missions due to a lack of restroom facilities and concern over illness. Participants

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Table 2 Veteran’s self-report and actual anthropometric measurements. Self-reported height (m)

Actual height (m)

Self-reported weight (kg)

Actual weight (kg)

Self-reported BMI (kg/m2)

Actual BMI (kg/m2)

Mean  S.D.

Mean  S.D.

Mean  S.D.

Mean  S.D.

Men White African American Other

1.77  0.07 1.79  0.08 1.66  0.05

1.74  0.07 1.76  0.08 1.60  0.07

92.68  21.24 89.20  19.63 73.18  0.64

92.68  21.26 92.75  17.29 77.43  0.93

29.8  7.68 27.9  6.17 26.5  1.48

30.74  7.54 29.8  4.90 30.2  2.08

Women White African American Other

1.50 1.60 1.60

1.55 1.56 1.55

44.55 61.36 75.00

73.63 63.64 78.41

19.8 24.0 29.3

30.8 26.2 32.6

reported using candy bars or other forms of quick energy as meal replacements during these times. Officers also reported limited access to food. One participant stated, ‘‘When I was an officer, one of the things you learn is you, you’re the last to go through the line and the first to be done. So you don’t get very many full meals. A lot of times you just, if it’s going slow for the troops, you just skip it. Ya know, I know officers that brought just peanut butter and jelly with them all the time. And a loaf of bread. And that’s what they existed on (Vietnam veteran).’’ In other situations, officers – namely those not training troops – had benefits with regards to food, such as private mess halls and additional fresh fruits and meats. Former platoon leaders reported unique food situations, such as being responsible for finishing other soldier’s leftovers. One participant stated, ‘‘I was a platoon officer. So I got to, you know, pay for a lot of the mishaps of everybody else . . . So when it come time for lunch, you know, if somebody didn’t eat all on their tray, then I had to eat it . . . I had to stuff it down, so I had a lot of it coming up . . . They called me the Pig. They eat anything (Vietnam veteran).’’ Former cooks reported increased access to food and resultant weight gain due to their position. One stated, ‘‘So then, actually my habits ended up making me gain a lot of weight in my military situation, ‘cause you just, I just started eating more and more and more ‘cause it was always available. I was an actual cook so I had to taste my food, I had to do everything with food, ya know (Vietnam veteran).’’ Cooks also had the ability to control the amount of food others received, and some admitted giving larger or smaller portions based on personal relationships. Those in the field had limited choice, often living on rations. As one veteran said, ‘‘Um, they would drop our C-Rations in and our mail and other supplies - ammunition and all that by helicopter in a big net. And then um, each platoon would be responsible for one man or two men would go up and get the food assigned to our platoon. And they’d bring it back and we were each assigned whatever amount of meals were there. They would split ‘em up so we would all get X number of meals, you know, based upon the total that they dropped in. And then we were allowed to trade the meals amongst each other (Vietnam veteran).’’ Combat Status: Participants reported differences in food available on a military base versus food offered in the field or combat situations. During non-combat situations, veterans reported eating in mess halls, purchasing food at the PX store, or eating at restaurants either on- or off-base. Common on-base meals included hamburgers, hot dogs, roast beef, gravy, and various forms of potatoes. Breakfast was the favorite meal in the mess halls and participants commonly reported consuming eggs, corned beef, bacon, French toast, and biscuits and gravy. When stationed overseas, options also included local foods purchased from street vendors or restaurants. Commonly consumed foods

were kimchi, rice, stir fries, and dog. Participants had varied attitudes towards local foods, ranging from disgust to complete acceptance. During combat and in the field, participants reported very limited food choice. Meals generally consisted of rations, although some reported access to portable mess halls and therefore, at least one hot meal per day. Favorite rations included beans and weenies, beef and ‘‘bolts’’ (potatoes), crackers and cheese, and chicken ala king. During long missions away from base, subjects reported limitations on how much food they could bring due to weight constraints and the priority of ammunition and medical supplies and would resort to eating rat, monkey, dog, or snake meat to survive. Water was also very problematic, as one Desert Storm veteran stated, ‘‘We had to carry enough ammunition for 2 weeks, and then we’d kind of spread the food out over that time. Another problem with the LRPs, a lot of people ate them–they’re supposed to be reconstituted. If they ate things like the pork or the beef, then they would need to be practically medevacked out because it absorbed all the liquid they had in their body. If they were in a hot environment or sweating, then it . . . made them dehydrated. Ya know. So you had to learn to be able to find stuff you could eat or just try things and hope it wouldn’t cause you problems . . . And yeah sometimes you didn’t eat the things that needed to be rehydrated because you needed the water a lot more.’’ Participants reported trading with other soldiers and scavenging off the land to obtain more food in these situations. Other veterans noted that the stress of combat commonly resulted in skipped meals or a loss of appetite. There was also concern over food and water safety while in the field, which resulted in decreased consumption or illness. Local villages were another food source while on patrol, and subjects discussed trading rations with local citizens for various food items. However, many participants reported being in isolated geographical locations and having very limited access to food from either US supply lines or local sources. Food insecurity influences eating behavior and food choices Food insecurity, as described by veterans, occurred during their tour of service and was dependent on occupation and era of service. Those involved in combat, recon units, and held as prisoners-ofwar suffered the most. Veterans described food shortages and adapting taste to environmental conditions because hunger supersedes preferences when shortages exist. Other strategies for coping with food insecurity were eating fast to consume as much food as possible in a short time, eating anything to survive, and learning to stash food. Hunger supersedes taste preferences: During boot camp participants reported learning that hunger supersedes taste preferences and to eat what was available. As one said, ‘‘I can say, like during

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Basic, I took on an appreciation of food that I never liked before . . . because you were so hungry and you burned so many, many calories, that whenever it [food] was available you ate. And I never liked cottage cheese before I went in the military, but I love it now. And I, that’s when I started, because, they had that as much as you could eat. And I remember taking scoop and scoops of it and putting sugar on it just to fill in my stomach. And I never had liked it before that, and now I, to this day I still love it. There’s nothing I don’t like. I like every food. I guess you learn to-your hunger over takes your tastes (Stateside-1975).’’ After training, veterans reported having to eat whatever was available at times. One WWII veteran said, ‘‘Well there were times when we didn’t like what they served, but we ate it because we knew we weren’t going to get anything in between.’’ A Vietnam veteran said, ‘‘. . . And you never know. A lot of times you can get to eat in the village, ya know . . .f or 6 yen you can get fish head soup with rice in it . . . At first [it was difficult]. Once you get over, got over the shock . . . you ate it. Cause if you’re hungry, you’re gonna eat anything. You know it . . . I’ve ate worms and you get hungry, you eat anything . . . cats or dogs.’’ Others reported being so hungry that they ate potatoes/food from dumpsters (WWII, Vietnam, Korean Germany veterans). One WWII veteran spent 10 days in an interrogation camp and while being transported to a POW camp their train was bombed and he and three others managed to escape. As they made their way through Germany, the WWII veteran reported, ‘‘we ate raw potatoes, cabbage, and rutabaga . . . we dug underground and ate.’’ In Korea, alcohol and cigarettes reduced the feelings of hunger as one veteran said, ‘‘Mostly we got beer and alcohol-the companies behind the lines, they would have that. But if it wasn’t for cigarettes, you’d be hungry. See, the cigarettes kept you from eating.’’ Food insecurity was also discussed as a problem during the Gulf War. As one woman said, ‘‘And then it’s, you know, I know when I was over in the Gulf War, when I’d be really hungry, I’d eat one of them [LRPs] and I never recommend this to anybody . . . Taking a full can of the canteen water and you know, and then it just kind of drags in your stomach. And you’re full for all day, but you know.’’ Many veterans reported food insecurity in the field, and a lack of food choice when they returned to base camps. One Vietnam veteran said, ‘‘. . . One can c-ration doesn’t weigh that much, but start putting lots of cans in your rucksack and you got a lot of weight all of a sudden, so that would be one limiting factor right there. Do I really wanna carry all this weight? ‘Cause they, they would give us enough . . . You could theoretically take as much as you wanted in terms of cans. I wouldn’t do that. I would kind of figure out, ya know, we’re gonna get resupplied in 3 days, and just take enough for 2 meals per day of C-rations and then take something like cheese and crackers. Light stuff for, ya know, the afternoon. When we got the LRPs, those were a godsend, because they’re very light . . . ya know, but even then, I would only take enough for a meal, ya know whatever meals would be in 3 days.’’ One Army Air Corp veteran of WWII spoke of hunger during bombing missions, and later when his plane went down and he was taken as a prisoner-of-war. During missions he mentioned that the men would all take D-bars (chocolate bars) with them. He reported, ‘‘It’s the one thing we’d take with us on missions. We couldn’t eat on missions because we had gas masks on - I mean oxygen masks on. But when we finished a mission and got down to a proper altitude where we could take our oxygen masks off, I always took a D bar with me and I, and I ate it. Because some of these missions might be 10 hours long.’’ As prisoners-of-war, men devised a number of strategies to survive. One said, ‘‘In Stalag Luft 3 some of the people did grow a little bit of stuff [garden] . . . the Germans gave us some millet seed to plant outside our barracks and we ground it up. And uh at that

time uh, instead of toothpaste, most people in this country were using tooth powder. So we’d tell our parents to send us tooth powder. Tooth powder contains salt and soda. Soda, we’d use this ground up uh millet seed as flour and we made cakes with the addition of the tooth powder (WWII veteran).’’ Another stated, ‘‘. . . I was very hungry in uh, uh Stalag 7A Moosburg. And I’ll tell you a little story. Right before the Germans were ready to surrender, uh, they came in and they gave us an issue of sausage. And they had never given us an issue of sausage before. And it looked like fairly good sausage. And they did it uh late in the afternoon and then uh, the next day the American came in and the camp surrendered. There was a little fight, but not much. And first thing they send in was a medical officer. ‘What food do you have to eat?’ So we showed them the sausage and they said it’s not fit to eat and they took it and threw it in the garbage can. And I says, ‘What are you replacing it with?’ ‘Well we don’t have anything to give you because our plans for the food is for POWs several miles away. Several hundred miles away.’ So when they left, I went to the garbage can and I got my sausage back. I wanted to eat something . . . (WWII veteran).’’ Food insecurity was associated with weight loss during the service. As one said, ‘‘Well I lost, I lost weight definitely, out in war and in maneuvers and all that kind of stuff . . . Well, sometimes we didn’t really think about food a whole lot. We were thinking about what was going to be out there, and watching the whole perimeter, ya know. And making sure we didn’t run in to anybody . . . Ya know. Special ops you can’t take prisoners. So, you want to make sure you don’t run into somebody you’re going to have to kill . . . so we would be, we were just active so much and up so long at times. Some people took speed or some people took, what do you call it? Caffeine pills. I didn’t take either one of those, so, I stayed awake, but I paid for it. Of course they paid for it too (Vietnam veteran).’’ Stashing/hoarding food: Keeping a food ‘‘stash’’ as the veterans called it, was a strategy used by some during the service, but for most it was a response occurring post-service to assure they would never be food insecure again. One described his post-service hoarding by saying, ‘‘Cookies, right under my bed, I got a drawer under my bed that I keep it in. Not because I have to hide ‘em from other people . . . It’s safety. It’s security for me to know that I have them there . . . no one can tell me what I can eat, what I can’t eat . . . (Vietnam veteran).’’ Another said, ‘‘I have a big stash . . . a big stash of canned goods, just in case all hell breaks loose (Gulf war veteran).’’ One man lost considerable weight as a POW, but because of permanent damage to his stomach, remained thin after the war. He reported that despite having difficulty eating, he always carried food with him, ‘‘I found it difficult to eat much. I’ve found some old correspondence of mine, and then in it I say that my stomach sometimes doesn’t take food but . . . for months I was always with food. I carried food with me . . . didn’t eat it much, but I didn’t wanna miss a meal . . . And even now, at home my pantry is full . . . I could go longer than 30 days (WWII veteran).’’ Many veterans continue to be preoccupied with food and their carefully maintained their stashes post-service. As one said, ‘‘Oh well, I, I keep a stash. I mean, it’s, it’s just common nature for me that I have to have a stash . . . and I rotate it very, almost every week I’m putting a little bit more there, but I’m a rotate it at the same time (Vietnam veteran).’’ Food insecurity during military service was associated with changed eating behavior post-service. Participants reported several strategies to cope with food insecurity including hoarding food, dreaming of food, overeating when tasty food was/is available, substitution imagery (picturing they were eating a favorite food instead mess or rations), and having a preference for sweets, status foods, or comfort foods. Food dreams were reported

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by veterans from all military eras, but especially by those who were in POW camps or in combat units. As one Vietnam veteran stated, ‘‘When we were eating those C-Rats, I would imagine I was back in Philadelphia eating a cheese steak . . . when we were in the field, ‘cause we went out and lived on the C-Rats for 10–15 days at a stretch . . . I would dream of a hamburger from McDonalds . . . you know.’’ These behavioral changes contribute to weight gain and will be discussed in the next section. As one said, ‘‘Well I put it this way. This has held true for me ever since. That I swore to the man upstairs that if I ever got home I would never ever bitch about food again [for] as long as I live, and I never have. And you can put anything in front of me and I’ll eat it (Korean War).’’ Military impacts weight status during and post-service Changes in eating behavior during the military appear to impact veteran’s weight status, both in the service, and post-service. Weight loss during the service was common among those who experienced food insecurity or deprivation in the field or as prisoners-of-war; while weight gain was reported by military cooks and kitchen help. Eating fast in times of duress: Many participants reported learning to eat fast during boot camp, which then became a survival mechanism to pack in calories when in stressful environments. As one man said, ‘‘Well, Boot Camp for me, yeah. It was real fast. I mean everything was fast. Getting up in the morning was fast. You had, they pushed you. Everything was rush, rush, rush, push you. Um, you get up close to your buddy, push you right through the chow line . . . You only had a certain amount to eat and get the heck out. And, and the rest of the day was just like that. I mean, PT, the whole thing . . . We had 15 min in and out (Germany).’’ Others reported 5–10 min. As one said, ‘‘you just sit down, eat, and get out as fast as you can (Korean veteran).’’ Many veterans who were in combat or stressful environments reported having to eat fast to survive. One Vietnam veteran, selfdescribed as a tunnel rat in Chuchi, said, ‘‘I’ve had nothing but nightmares . . . Maneuverable, that’s what they called me . . . My health is bad. Uh, I told ya that you ate so fast . . . and I was in the position where I got to force people to eat fast to get out on the job . . .’’ This behavior continued post-service. He went on to say, ‘‘And the bad thing about it . . . I ate fast when I got out, and I caused my kids to do that too.’’ High carbohydrate diets: Many veterans believed the highcarbohydrate, high-fat diet provided during the service was responsible for unhealthy diets post-service. One said, ‘‘I noticed everything was, had a lot of starch. Everything, you know, uh, hashbrowns in the morning, French fries in the afternoon. Potatoes . . . mashed potatoes or french fries in the evening. So, I mean, a lot of starches . . . you know, so diabetes runs high in the military and you see why (Germany-1985).’’ Many ate a lot and gained weight in the service, and after the service, they could not stop the eating habit. As one said, ‘‘Yeah, the potatoes, and, and things like that. And I did, like I said I only like weighed 89 pounds or 90 pounds when I, before I went in the service. And by the time I got out of the service I weighed 130. And yet I was exercising and calisthenics every morning. I was still, I could fit into my fatigues and I was, I was trim. Then after that I used to, I ate junk food. ‘Cause I do not like to cooking either (Stateside-1976).’’ Many noted that the rations were high calorie as well, ‘‘. . . the MREs were, were packed full of calories . . . they had more than, more than the usual normal amount of calories. Especially like the energy bar things or the dessert bars (Vietnam veteran).’’ Overeating or binging when food was available: Many participants reported giving in to pressure to clean their plates during boot camp and overeating when food was available to compensate

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for times without food. After the service, most veterans could not decrease their caloric consumption, despite declines in energy expenditure. Some reported that food was readily available and so they ate constantly. As one Navy veteran said, ‘‘Usually on Navy ships it’s just like every place else, ya know. On the Enterprise when you’re feeding in the neighborhood of 20,000 meals a day, you can eat 24 h a day. Although most of that is sliders and hot dogs.’’ In contrast, some felt they could not get enough to eat after their service was over. As one Korean veteran reported, ‘‘I went back to New Orleans and lived there for 3 or 4 years and it’s like an eating frenzy there. And I guess next to sex, I like food the next best thing. I realllly like food . . . I love eating . . . I love to eat.’’ Another said, ‘‘I remember when we were discharged, we came to Minneapolis, and a buddy of mine and I went to a White Castle. You know what they are? And we started eating fried eggs and hash browns and bacon. We didn’t quit until we’d had 12 eggs.’’ Preference for status foods, sweets, and junk food: While veterans described some food aversions, almost all had a preference, almost a passion, for sweets and status foods. Many veterans carried chocolate bars and candy in their pockets. Some said they always have something sweet on them, no matter where they go. Many reported having cravings for status foods (steaks, fries, burgers) and sweets during the service and believed that having munchies was a response to drugs used for a mental escape or given to them by the military to keep them alert at night. As one said, ‘‘Sweets is now the, the weakness because you tend to give yourself a treat, maybe we want something, and giving the best that I can and do, you know. And then I’ll, you know, wait until if you have an opportunity, you take the biggest, the best, and the most expensive that you can (Korean veteran).’’ Some hide their preferred foods, even from spouses, ‘‘I got, I got a back bedroom. And I got a closet in there and my wife is about 5’2 and she can’t reach the way top shelf up there [all laugh]. Not even with a chair! Because you gotta get right inside the closet, and that’s where I keep my good stuff. The sweets, candy bar, cookies [and] potato chips (Vietnam veteran).’’ Shift in activity patterns: A commonly voiced problem was that in the military, they were very active; however, post-service they decreased their activity with no downward shift in caloric intake. One Gulf war veteran said, ‘‘Well, I guess the only exercise I’ve gotten since I’ve been out of the service is opening and closing the refrigerator door several times a day.’’ As another said, ‘‘I’ve been, for the past couple years, going through sort of roller coaster rides with weight. So I’m in the peak now, sort of a real high point of being fat. But one of the things is just getting old and one of things is . . . yeah, definitely the amount of exercise and I mean, you don’t have to worry about keeping within weight limits or doing the, you know, running three miles, or five miles, or ten miles or whatever (Stateside veteran-1983).’’ Another veteran loved to run prior to the service, but after going through boot camp, he can no longer stomach it. Military service has health consequences Participants reported that their military experiences strained both their physical and psychological health. Many reported receiving disability payments for injuries and disease related to their service. Subjects identified numerous factors linking their service to their current health status. Psychological health: Participants believed their military service negatively impacted their psychological health both while enlisted and in the years after. Soldiers reported being under extreme stress because of combat, experience with death and serious injury, and pressure from senior soldiers and superiors. Many reported using coping mechanisms such as alcohol and drugs to lessen their

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anxiety. One Vietnam veteran stated, ‘‘We had a lot of beer when we came back. I came back out of the field on five occasions and I was pretty much just a steady drunk.’’ Others reported taking alcohol into the field to ‘‘take the edge off of being out in the tree’’, or using marijuana as ‘‘a release after an operation.’’ Many reported acquiring addictions while in the service, including smoking, alcohol, and drugs. Smoking addictions were blamed on the availability of cigarettes in C-rations and an environment that encouraged smoking. One veteran stated, ‘‘That was one of the things that I picked up in the service. I started smoking because they would say, ‘if you got ‘em, burn ‘em’ and ‘the smoking lamp is now lit (Korean veteran).’’’ Another recalled, ‘‘I had a Drill Sergeant put one [cigarette] in my mouth and said, ‘You’re not a man if you don’t smoke it.’ And that’s where it all started (WWII veteran).’’ For many veterans, the stress of service extended well after leaving the military. A large number reported being diagnosed with post-traumatic stress disorder (PTSD) or displaying numerous symptoms. Many suffered from depression, sleep disorders, or flashbacks. One veteran reported, ‘‘I dream of events. Things that happened to me while I was in the service or things that was going on . . . and they be very powerful dreams. It’s like I’m right there, you know. Just eating food at, during the middle of the night brings back a lot of memories. And some of them are very hard memories. Some of them, some memories that, you know, that sometimes you wake up after you eat, after you ate that meal, and prior to the morning you wake up, sometimes you wake up in tears (Vietnam veteran).’’ Others noted that their PTSD was often triggered by smells, foods, or sights reminiscent of one’s time in the service. A Vietnam veteran stated, ‘‘For me, I couldn’t eat rice until I was 40 years old. And anytime I was around Oriental people I would get horribly nervous. I mean my palms would start sweating and I’d just um, so, but that’s the type of effects – psychological effect (Vietnam veteran).’’ Many participants noted that stress and depression disrupted their lives and kept them from participating in favorite activities or maintaining normal schedules. Soldiers reported continuing to use coping mechanisms to deal with military stress even today. A large number used smoking as a stress reliever, and many admitted to being current or recovering alcoholics. As one veteran reported, ‘‘Alcohol was the way I medicated when I first came home. Then I went to gambling. You would not believe.’’ Food was also cited as a tool for dealing with stress. One veteran stated, ‘‘A lot of things you can do to medicate, and food is one of them. And I have seen people uh, for sure, who turned to food as an escape from their mental pain that they have in the military (Vietnam veteran).’’ Physical health: Veterans reported suffering from numerous health problems including obesity, diabetes, hypertension, heart disease, cancer, respiratory ailments, dental problems, high cholesterol, and gastrointestinal disorders. Many felt their service predisposed them to these problems. One veteran stated, ‘‘You had to eat so fast when you were in the service that I have acid reflux real bad now that I can’t sleep . . . Acid reflux could be heartburn. And that heartburn will mess up your heart. That’s one thing I got eating so fast screwed my heart up . . . Just about everybody in our building [veteran’s home] has acid reflux (Vietnam veteran).’’ Others identified the military’s high starch diet as contributing to the development of diabetes and obesity. Military injuries also had a lasting impact on many of the participants’ lives, often preventing them from maintaining high levels of physical activity, and thus have contributed to postservice weight gain. In response to whether they remained active after the service, one veteran stated, ‘‘Well I haven’t. Number one is because I’ve had so many back surgeries. And when, when I was in um, Boot Camp, unlike nowadays, we used to have to run in combat

boots. And the females competed kind of against the guys. We’d train right alongside the guys and so like I got shin splints so bad from running in combat boots, and blisters and stuff that I can’t run anymore and, and for me over in the desert, my asthma is a lot worse, you know. My physical health is just-. . . I mean I would love to be able to run and walk, like I used to and stuff, and I, I just can’t (Iraq veteran).’’ Post-service re-adjustment solutions are needed to ease re-entry into civilian life Almost all participants felt that more needed to be done for the returning veterans. One common complaint was, ‘‘Yeah, it’s like nobody got deprogrammed. You came home and you’re in a shock syndrome where you don’t know what to do. And then, you know, you hear a siren or something, and you go paranoia like crazy (Iran veteran).’’ They suggested counseling, group sessions, and readjustment periods. One said, ‘‘You have a period of debriefing before you get released into society. Absolutely and definitely. Psychiatric and psychological debriefing. And that way you probably can see the early warning signs (Iraq veteran).’’ Most veterans felt that longer re-adjustment periods could help prevent some of the drug and alcohol abuse found among veterans. Many veterans felt the public should be educated about what veterans have gone through so that they would have a better understanding of the issues they face. One said, ‘‘I see guys from my era that are paraplegic, quadriplegic and they’re retired from Vietnam, and I see them in a wheelchair and I’ll break down crying and I’ll give ‘em a hug and say, ‘God bless you for serving the country. ‘Cause us strong guys are gonna help you weak guys.’ And it’s, I can’t explain it, but that fellowship and comradery is a lot (Vietnam veteran).’’ Discussion This study found that military service changed the dietary behavior of most veterans and these behavioral changes contribute to the high prevalence of obesity among veterans. Within this sample we found 87.5% were overweight or obese. Main themes identified in focus groups were (a) military service impacts soldier’s food environment, (b) food insecurity influences eating behavior and food choices, (c) military impacts weight status during and post-service, (d) military service has health consequences, and (e) post-service re-adjustment solutions are needed to ease re-entry into civilian life Military service impacts soldier’s food environment Participants reported significant changes in the military food system over time. In general, variety in the mess halls and access to food outside of traditional cafeterias has increased in recent years. Although participants did report increased access to fresh fruits and vegetables, there has also been increased availability of fried food, fast food, and other less healthful options. Research has shown that the greater the amount and variety of food available, the more people tend to consume (Raynor & Epstein, 2001). During their service veterans learn to eat larger volumes of food and continuation of this practice post-service may be contributing to excessive weight gain. Participants also discussed different experiences depending on branch of service. Those in the Navy and Air Force typically reported greater food choice and less physical activity requirements than those in the Army and Marines and this combination can promote weight gain Although the military has programs to control soldier weight during the service, there appears to be a lack

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of education on proper exercise and eating habits after discharge (Subcommittee on Weight Management, 2004). It is possible that members of branches with more food options and less physical training may have a harder time controlling weight post-service when they are no longer obligated to meet any weight requirements. Food environment was also affected by soldiers’ specific occupation within the service. Cooks reported having the greatest access to food, and many found that they retained the military style of cooking after discharge, preparing and consuming much larger portions than necessary. In contrast, many positions in the service limited access to food. This was especially common among pilots on extended flight missions, officers under time constraints, or soldiers serving in combat situations. These periods of food insecurity can significantly impact eating behavior. Food insecurity influences eating behavior and food choices Food insecurity during military service was discussed in all focus groups, but those serving in combat situations, with recon units, or as prisoners-of-war talked extensively about food scarcity and the impact it has had on their post-service eating behavior. During active field duty, many veterans serving in WWII and Vietnam reported having to make hard choices-carry ammunition, or carry food. For survival purposes they reported choosing ammunition and taking only a limited amount of food, necessitating the need to scavenge. The men in these situations described learning to eat fast during training and believed this eating behavior, as well as overeating when food was available and eating anything if hungry, was instrumental to their survival in the field. Popper, Smits, Meiselman, and Hirsch (1989) reported inadequate caloric intake among soldiers subsisting on rations in the field. Additionally, Popper et al. (1989) found that 68% of combat veterans consumed less food than usual during the first day of combat. Air Force personnel serving during conflict situations faced shorter periods of hunger than combat units on the ground, but still reported eating little before and during missions because of lack of toilet facilities onboard planes and stress suppressing appetite until after mission completion. Those serving in WWII, Vietnam, Desert Storm, and Iraq reported that finding drinking water was often a source of stress. Water is needed to keep hydrated, and more recently, to reconstitute the newer, lighter, dried meal rations. Many veterans in our study reported overeating after periods of food deprivation, and that this behavior continued post service in the form of overeating and eating fast at meals. Food deprivation, either through starvation or self-imposed dieting, has been linked with binge eating and an increased preoccupation with food once food becomes available (Berg, 1993; Favaro, Rodella, & Santonastaso, 2000; Keys, 1946; Polivy, 1996). In a historical study by Keys, Brozek, Henschel, Mickelsen, and Taylor (1950) men were voluntarily placed on a severely restricted diet, resulting in a 26% body weight loss. Observations during the post-starvation phase of the study revealed the men were preoccupied with food and began collecting recipes and pictures of foods (Keys et al., 1950). After the food-restriction period, the men were given access to an unlimited food supply, which resulted in them gorging themselves to their physical limitation. Additionally, Polivy et al. (1994) reported that Canadian soldiers held prisoners-of-war during WWII had binge-eating episodes after their release. Overeating after bouts of food deprivation might be a physiological response to hunger (Tuschl, 1990), but according to our participants it also provides a psychological sense of relief knowing food is available, and gave them a sense of control that they may eat to full or past full if they like-that eating was their choice.

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Those who suffered from food insecurity or periods of hunger also reported that hunger supersedes taste preference, and during those times they would eat anything. Humans generally are neophobic about food (Birch, 1999), but we found that many veterans working under duress and faced with limited access to food would eat whatever was available even if it was considered a non-food substance for their culture. Veterans reported eating foods that they normally would not, such as monkey, dog, cat, rat, and snake meat and eating local foods such as kimchi, aged eggs, and sushi. While many said that they would never eat these foods again, others developed a taste for them. In this study, hunger superseded food preferences and was the impetus to try unfamiliar foods. Others have also found that food restrictive environments can influence food choice resulting in eating foods on hand, even if the food was disliked under normal situations (Keys et al., 1950; Richards & Smith, 2006; Richards & Smith, 2007; Sindler et al., 2004; Smith & Richards, 2008). Military impacts weight status during and post-service While some veterans gained weight in the service, often because of increased muscle mass from training, most involved in combat, recon units, and prisoners-of-war reported losing weight from food deprivation and left the service weighing less than when they entered. However, after their tour of service most reported weight gain, which is reflected in our sample where 87% of the veterans had BMI > 25 kg/m2 and 50% of them fell into the obese and excessively obese categories. Weight gain was described as gradual by some, while others experienced periodic rapid weight gain, often associated with a major event, crisis, or illness. Experience with food insecurity, learning to eat fast, overeating, and eating anything during the service were blamed for permanently changing their dietary habits post-service. To examine the long-term effects of food restriction on eating behaviors, Sindler et al. (2004) conducted focus groups with 25 Holocaust survivors and found that even 50 years after the starvation event, the survivor’s eating behavior was greatly impacted. Post-service many veterans reported food cravings, binge eating episodes and/or nighttime eating patterns, keeping food stashes, or having a preference for sweets, and we believe that these behaviors lead veterans to over consume calories, gain excessive weight, and promote obesity. Holocaust survivors have been reported to have difficulty throwing food away, store excessive amounts of food, crave certain foods, and become anxious when food is unavailable (Sindler et al., 2004). Like our veterans, they described a preoccupation with food and having intense desire for certain foods (cravings) (Sindler et al., 2004). When investigating binge eating with prisoners-of-war, Polivy et al. (1994) found that those who lost the greatest amount of weight during captivity had frequent bouts of binge eating postcaptivity. Almost all veterans had a strong preference for sweets and status foods. Food preferences are related to both physiological (natural response to correct energy and nutrient imbalances) and psychological (hedonic)/social motivations) (Rozin & Vollmecke, 1986; Wansink, Cheney, & Chan, 2003). It is possible that veterans are chronically stressed and/or depressed and eat to reduce their stress. Researchers have reported that stressed people overeat high fat and high carbohydrate (high sugar content) comfort foods to distract from the distress (Wansink et al., 2003). Alcohol and drugs were reportedly used as escape mechanisms for the reality of war, and are also blamed for increasing preferences for sweets. Many smoked marijuana both during and after the war, and said it was always followed with a craving for sweet or salty foods. Almost half

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of the veterans attending the focus groups carried one or more chocolate bars with them, and said they always had sweets on them. Our veterans are not only influenced by physiological and psychological determinants of food preference, but they may also be strongly influenced by the obesogenic environment they return to post-service. Lowes and Levine (2005) suggested that an environment filled with highly palatable food may result in the activation of the hedonic appetite system and if unrestrained, overeating could lead to weight gain. Once soldiers return to the US and regain any weight loss, they report still feeling the after-effects of food deprivation. Veterans also described sleep deprivation, dreaming of food, and using substitution imagery and these events may have altered eating behavior. Tiggeman and Kemps (2005) recently reported that visual or olfactory imagery tasks can reduce cravings for foods. Thus, conjuring up images of desired foods by veterans in the field may be an adaptive response to their food situation. Sindler et al. (2004) also found that food dreams were common among Holocaust victims. Demont (1960) found that dream deprivation results in the development of voracious appetites and resulted in weight gain in their subjects. Both dreaming of food, along with not dreaming at all because of stress or lack of sleep in the field or captivity, may play a role in the alteration of dietary behaviors. Military service has health consequences Participants reported experiencing numerous physical and psychological health problems in the years during and following their service. Many reported substance use or abuse either originating in the service or occurring after. Bray, Marsden, and Peterson (1991) compared substance use in military personnel and civilians and found that those in the military were nearly twice as likely as civilians to be heavy drinkers and were significantly more likely to be smokers or heavy smokers. Consistent with our findings, Haddock et al. (2005) reported a high rate of smoking initiation for nonsmokers entering a military basic training program. This is particularly disturbing in light of the association between smoking and cancer. Harris, Hebert, and Wynder (1989) reported that the incidence of lung cancer is 76% higher in male veterans utilizing the VA medical system as compared to other males in the Surveillance, Epidemiology, and End Results cancer registry. This suggests measures are needed to prevent or mitigate smoking in military personnel to avoid premature deaths and increased healthcare costs. Research has also found a strong association between smoking and drinking, and engaging in one behavior has been found to predict the other (Dawson, 2000). Alcohol use is highly prevalent in the military population and was commonly reported in this study’s sample. Heavy drinking has been found to increase the risk for injury and decrease productivity, which could be detrimental both during the service and afterwards (Dawson, 2000; Williams, Bella, & Amoroso, 2000). It has also been associated with decreased overall health and strained social and familial relationships (Bray et al., 1991). Tessler, Rosenheck, and Gamache (2005) reported that despite a consistent high need for substance abuse services among veterans, the proportion of veterans in treatment has declined in recent years along with decreased delivery of these services within the Veteran’s Health Administration. This indicates a need to increase the availability of services to meet the current demand. A large number of veterans also discussed diagnosis with PTSD or suffering symptoms such as flashbacks, difficulty sleeping, or avoidance and numbing behaviors. Prior studies have found an increased prevalence of PTSD in war veterans as compared to the general population (Trief, Ouimette, Wade, Shanahan, & Weinstock, 2006). PTSD is often associated with alcohol problems and

poorer quality of life, both on a physical and psychosocial basis (Schnurr et al., 2000; Schnurr, Hayes, Lunney, McFall, & Uddo, 2006). Schnurr et al. (2000) reported a relationship between PTSD and higher rates of cardiovascular, musculoskeletal, dermatological, and gastrointestinal problems in war veterans. Our veterans felt that PTSD and eating behavior were interconnected. Many reported that eating certain foods, particularly rice, would trigger an instant flashback to Vietnam or Korea. PTSD represents a major burden on this population, yet Murdoch, Hodges, Cowper, and Sayer (2005) reported significant disparities in PTSD disability awards, which could result in limited access to treatment. It was recently suggested that PTSD appears to be a risk factor for obesity among veterans (Dobie et al., 2004). Participants also reported diagnosis with a variety of physical health problems, the most common being diabetes and gastrointestinal disorders. Wildi, Tutuian, and Castell (2004) reported that rapid food intake can lead to an increased incidence of gastroesophageal reflux. Thus the forced, rapid eating veterans reported during the service may be responsible for some of the gastroesophageal reflux found among our participants. Type 2 diabetes was also commonly reported among our veterans, and in another study they reported that one in five patients in the VA have diabetes (Miller, Safford, & Pogach, 2004). Because the veteran population appears especially susceptible to this disease, the military should consider teaching positive lifestyle modifications at military discharge and conduct frequent screenings to help prevent or delay this condition. Post-service re-adjustment solutions are needed to ease re-entry into civilian life Veterans face a huge challenge upon return to the US. They are often released from their tour of service without housing, employment, or marriage counseling in place. Additionally, some return with a history of food insecurity, behavioral eating changes, and struggle with PTSD. This, combined with living in an obesogenic environment, places them at high risk for disordered eating and obesity, as reflected in the high obesity rates seen with veterans. America has not been successful in helping veterans navigate this transition. More time and money should be allocated to assist soldiers in reintegrating into American society. Veterans in our sample felt the need for more support groups, education programs, and nutrition classes. Additionally, we need to learn more about how we can assist veterans with behavioral change. More research is needed to understand the psychology of food and hunger and ways to change eating behavior. With easy access to highly palatable food in our obesogenic environment, veterans consume more calories than needed as a response to their history of food insecurity/hunger and we need to provide them with coping strategies as they work their way back into civilian life. Furthermore, most veterans will return home poor. Like other poor people they will face the challenges of the hunger–obesity paradigm. More research is needed to examine this relationship. Lastly, some veterans return to the US having suffered food deprivation, yet they remain thin or normal weight. Why are they able to avoid the obesity trap? More research should work with lean veterans to learn how they have managed to stay lean. Acknowledgments This project could not have been conducted had it not been for the cooperation of veterans and we thank them for sharing their stories and for participating in this project with interest and enthusiasm. We thank the VA Medical staff for their assistance in

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scheduling and recruitment. This project was funded by the Agricultural Experiment Station and Undergraduate Research Opportunity Program at the University of Minnesota.

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