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Eating Disorders in Males - Dr. Anna Vinter

We have known for a long time that popular culture promotes unrealistic and impossible ideals for women, but this notion has become very true for men as well. Most practitioners are familiar with the statistic that ten percent of eating disorders occur in males. However, a recent Harvard study found that approximately 25 percent of people with eating disorders are male.
 

Most practitioners are familiar with the statistic that ten percent of eating disorders occur in males. However, a recent Harvard study found that approximately 25 percent of people with eating disorders are male. (Hudson et al, 2007)

Despite the increased incidence of eating disorders in men and boys, identification and diagnosis among this growing cohort are still subject to traditional gender constructs.

Even clinicians, especially those unfamiliar with treating eating disorders, are vulnerable to only identifying eating disorders in patients who fit a particular ethnicity, physical appearance and female gender.

The professional community must reframe its cultural and social constructs related to who suffers from eating disorders. Professionals must be aware of factors fueling increased incidence, patient characteristics, risk factors and medical complications.

Increased understanding of eating disorder pathology in men and boys among the professional community is an important first step in helping these patients access the specialized care they need and deserve.

Why are eating disorders increasing in men and boys?

​Among adolescent boys, two-thirds are dissatisfied with their bodies. We have known for a long time that popular culture promotes unrealistic and impossible ideals for women, but this notion has become very true for men as well.

Body image — is subjective—it is the picture of ourselves that we form in our minds.
Body ideal — is a culturally determined vision of what is considered to be the most attractive and perfect body shape.

The body ideal for men is excessively muscular while extremely trim. The number of men’s magazines emphasizing appearance has increased, and advertisements are more frequently depicting men as sexual objects (Blond, 2008). Even children’s characters and action figures are more muscular and unrealistic now than they were historically.

Case in point—when I was young, my favorite superhero Aqua Man was just a strong guy in a suit. In today’s depictions I hardly recognize him—his suit is bulging at the seams with veiny muscles, and his waist is smaller than his head!

 How do we know that these images are having an impact on pathology? In other words, we are all exposed to the same images, so why don’t we all have eating disorders?

A meta-analysis of 15 studies (Blond, 2008) found that exposure to images of ideal male bodies has a small but significant effect on young men’s body satisfaction. Males that were dissatisfied with their appearance at baseline were found to be at increased risk for image-induced dissatisfaction, while boys and men who develop eating disorders were more vulnerable to the ideals promoted by popular culture.

In a study between males with anorexia nervosa and controls, Body Ideals were identical, but males with anorexia perceived themselves as almost twice as heavy as they actually were. (Furnham & Calnan, 1998) This finding helps to dispel the notion that vanity plays a role in eating disorders—if this were true, the body ideal would be different between the two groups.

How do eating disorders present in males?

We know this about eating disorders—a biological or temperamental predisposition can be unveiled by external influences. Among males with eating disorders, premorbid patient characteristics include a history of obesity or being overweight, often with a history of weight-related teasing or bullying.

While eating disorders can and do occur at all stages of the lifecycle in males, puberty is a particularly common time for onset of the illness. In normal puberty, boys gain an average of 50 to 60 pounds and grow 12 to 14 inches.

Involvement in high-risk groups also characterizes many male eating disorder patients, including:

  • Appearance-based jobs (modeling, acting)
  • Food-related jobs
  • Jobs traditionally held by women
  • Sports where aesthetics relate to scoring or where there are weight requirements for performance or participation (ie. figure skating diving, gymnastics, body building, wrestling, swimming)

Regarding sexuality, there is a widespread misperception that eating disorders are more common in homosexual men. The reality is that most men with eating disorders are not gay, and most gay men do not have eating disorders.

However, homosexual men are over-represented in male patients with eating disorders.  This may be due to several factors, including a culture of idealized bodies and greater pressure to be thin in the gay community, as well as increased body dissatisfaction, perhaps due to the internalized homophobia of a critical larger culture. Conflict regarding gender or sexual identity is a risk factor for eating disorders as well.

With regard to eating disorders in young boys, children with eating disorders are more likely to be males than adolescents with eating disorders. Selective (“picky”) eaters are more likely to be boys than girls, and the syndrome has been associated with later development anorexia nervosa.

Risk factors for early life feeding problems include neurodevelopmental problems (including autism spectrum disorders and sensory integration issues), medical comorbidities, and character traits (including being obsessional, anxious, easily overstimulated/distracted).

While all eating disorder symptoms occur in males, a 2012 study found that purposeful restriction was by far the most common behavior, demonstrated by 96 percent of men with eating disorders. 40 percent engaged in over-exercise, while only 23 percent engaged in purging (including laxative abuse) and 15 percent engaged in bingeing. (Norris et al, 2012)

What medical complications of eating disorders commonly occur in males?

The most serious medical complications of eating disorders are related to cardiac issues, frequently indicated by low heart rate. The previous change is important, because the low heart rate itself is not the medical problem, but an indicator of underlying medical problems.

The notion of the “athletic heart” is more prominent in males— they will often be told by misinformed health care providers that their low heart rate is due to their athletic pursuits.  However, this explanation can and must be refuted by the practitioner screening for an eating disorder by performing a simple orthostatic BP/pulse. An athlete’s heart rate will not increase by 30 to 40 points from the act of lying down to standing up. The presence of other signs of energy conservation like lowered body temperature and cold extremities signs of energy conservation like lowered body temperature and cold extremities  can also help refute the “athletic heart” rationale for low heart rate associated with eating disordered behaviors.

Endocrine dysfunction is another common medical complication of eating disorders in males.  Low testosterone places males at increased risk for osteoporosis because this hormone is a protective factor against low bone mineral density. One study found that males at admission were more likely to have low bone mineral density and osteoporosis than females (Mehler, 2008).

What can professionals do in their practices to support identification and treatment of eating disorders in males?

  • Simply put, lack of awareness equals a lack of diagnosis. Just this year, a study confirmed the role of gendered constructions of eating disorders in delayed help-seeking in men and boys. Understand that eating disorders can and do occur in boys and men. Consider this a diagnosis even when your patient does not acknowledge an eating disorder—symptoms of this illness include denial, lack of awareness and ambivalence about treatment.
  • Early intervention is critical to lasting recovery. Delayed treatment leads to bad outcomes—a 2012 study found that half of all male patients had to be admitted to the hospital for medical or psychiatric stabilization at initial presentation.
  • The sooner a male patient’s eating disorder is treated, the better their prognosis and the less likely they patient will have long-term illness recurrence. A recent cohort study found that outcomes for all eating disorders were actually better among men than women when remission was measured by weight restoration and self-reported relapse (Stoving et al, 2001).
  • Know your eating disorder treatment resources—both local and national—and assist in the coordination of referrals and post-discharge care.
Anna Vinter, Medical Director, Eating Recovery CenterDr. Anna Vinter is the Medical Director and adult psychiatrist for Eating Recovery Center, California’s Partial Hospitalization and Intensive Outpatient Programs.​
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