Thousands of service members suffer from anorexia, bulimia, or other eating disorders. At greatest risk: those who are young, female, and under combat stress.
At 23, Marine Lieutenant Theresa Larson was in Fallujah, Iraq leading a platoon of 54 Marines, most of them men.
It was 2005, she was escorting female insurgents and leading convoys.
Larson was also living with bulimia -- binging on MREs, buffets in the base dining hall, and anything else she could find.
"It's food; you consume it," she said. "Whatever can be consumed can be thrown up."
Like many people with eating disorders, Larson's problem evolved over time. As a young Marine and fitness competitor, she dieted down to a super lean physique. But she later started to gain weight.
"It wasn't a lot, but you could still tell," she said. "When you're in a male dominated world they see that, and I'm 22 and I didn't want to show weakness. We're heading to war. I had to be perfect. I had to be the best."
As the deployment went on, Larson's binging and purging increased. She saw a mental health counselor in Iraq, but he didn't help.
"It was like, 'You're throwing up? Why you would do that?'" she said. "They were used to seeing trauma and post-traumatic stress. I began to realize no one understands this."
Larson knew she was out of control. Her eating disorder had taken over. She worried that if she made a bad decision someone might get hurt.
Larson told her commander she needed to get out of Iraq to get well.
She was medically evacuated from Fallujah and started treatment, but was forced to leave the Marines.
"Going from being a very good Marine with good fit tests and taking care of her Marines to all of a sudden, 'She needs to be cared for; well, too bad so sad. We got to get you out. We don't know what the Hell's wrong with you and you're a liability now,'" she said.
Ingredients for eating disorders: weight limits, combat stress
A 2013 Department of Defense study found that more than 3500 service members were diagnosed with eating disorders in the previous ten years. In 2015 alone, the number was 1,041.
Larson may not have realized it, but according to researchers she was part of the highest risk group: young, female and under combat stress.
A study from the Defense Health Agency concluded that the disorders occur with "surprising frequency."
Over time anorexia and bulimia can cause debilitating health effects and in severe cases even death. While the numbers remain comparable to the general population, military life presents challenges that may increase a person's risk, such as combat stress, intense pressure to perform and strict weight limits.
"They'll actually use their eating disorder to support what they need for those physical requirements," said Dr. Neeru Bakshi, the medical director at Eating Recovery Center in Bellevue, Washington, an intensive outpatient and residential care facility.
She described vets who were in the gym six hours a day to meet their physical requirements. "That's actually a form of their eating disorder," she said.
And part of the problem, Bakshi says, is that it works for them: Thinner, leaner troops tend to get ahead; the heavier ones might get reprimanded. And Bakshi said the armed forces do a poor job providing early intervention for troops who start to develop eating problems.
"Within the military there's this lack of awareness and support that's available for the ongoing treatment. So it's just this set up for the person to be actively engaging in their eating disorder and not getting any kind of help," she said.
Colette Candy is trying to change that. She's a psychologist at Madigan Army Medical Center in Tacoma, and is one of a handful who treat eating disorders. She said many of the soldiers she sees have kept their condition secret throughout their military careers, for as long as 20 years in one case.
Candy is currently treating ten soldiers - a caseload that's now large enough that she's started her first eating disorder therapy group and added a dietitian to the care team.
She can't help everybody. She said about a third of her patients have to seek a higher level of care outside the military.
But Candy said she's also had remarkable successes. "I've had a guy with a 17-year history turn it around just with outpatient treatments," she said. "So you can never tell who's going to respond."
Starting a conversation
It took years, but Larson is one of those service members who did respond.
A decade after her discharge from the Marines, she owns a physical therapy and wellness company in San Diego and teaches an adaptive exercise class to fellow vets once a week.
Larson said helping veterans who are struggling to adjust to limb loss or other limitations is an important part of her life and recovery.
She said she hasn't purged in years. She now blogs and gives speeches about her experience with bulimia in the military.
"I'm very proud of my service and the people I got to work with for the most part," she said. "And I don't blame the Marine Corps for anything.
"I think things could have been much better, but that's why we're starting this conversation," Larson said, "to get people help before they're broken."
This story was produced as part of the American Homefront Project, a collaboration of North Carolina Public Radio/WUNC, Southern California Public Radio, and KUOW Seattle.