Eating disorders in adolescent boys and young men: an update

Abstract

Purpose of review

To review the recent literature on eating disorders and disordered eating behaviors among adolescent boys and young men, including epidemiology, assessment, medical complications, treatment outcomes, and special populations.

Recent findings

Body image concerns in males may involve muscularity, and muscle-enhancing goals and behaviors are common among adolescent boys and young men. Recent measures, such as the Muscularity Oriented Eating Test (MOET), have been developed and validated to assess for muscularity-oriented disordered eating. Medical complications of eating disorders can affect all organ systems in males. Eating disorder treatment guidance may lack specificity to males, leading to worse treatment outcomes in this population. Male populations that may have elevated risk of eating disorders and disordered eating behaviors include athletes and racial/ethnic, sexual, and gender minorities.

Summary

Eating disorders and disordered eating behaviors in males may present differently than in females, particularly with muscularity-oriented disordered eating. Treatment of eating disorders in males may be adapted to address unique concerns in males.

INTRODUCTION

Eating disorders (ED) are thought to be among the most gendered of mental health disorders [1], with strong associations with femininity. Eating disorder diagnoses include, but are not limited to, anorexia nervosa (AN), atypical anorexia nervosa (AAN), bulimia nervosa (BN), binge eating disorder (BED), and avoidant/restrictive food intake disorder (ARFID) according to the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5) [2]. Despite decades of research focusing exclusively on female populations, unique body image and disordered eating concerns are increasingly recognized in male populations. Males may have a higher drive for muscularity [3] which may, in extreme cases, lead to muscle dysmorphic disorder [4].

The purpose of this article is to review recent literature on eating disorders and disordered eating behaviors among male populations, with special consideration related to adolescent boys and young men. In particular, we review the epidemiology, assessment, medical complications, treatment, and special populations related to male eating disorders.

FINDINGS

Epidemiology

Although there has traditionally been a paucity of research on male body image and disordered eating behaviors in community settings [5], some recent literature has shed light on the epidemiology of these phenomena. A study of Australian adolescents estimated the prevalence rates of DSM-5 eating disorder diagnoses by gender. Among adolescent boys, 12.8% met criteria for any eating disorder diagnosis, including other specified feeding and eating disorder (OSFED, 8.5%), night eating syndrome (4.9%), bulimia nervosa (1.8%), unspecified feeding and eating disorder (UFED, 1.3%), and atypical anorexia nervosa (1.2%) [6]**. Nationally representative surveys in the USA demonstrate that 30% of adolescent boys report trying to gain weight or bulk up, including 40% of boys objectively considered normal weight by body mass index (BMI) [7]. Nearly 22% of young men report engaging in muscle-enhancing behaviors, including eating more or differently to build muscle (17%), supplement use (7%), and androgenic-anabolic steroid use (3%) [8]. Among young men, overweight and obesity may be associated with disordered eating behaviors. Overall, 15% of young men with BMI ≥ 25 report engaging in disordered eating behaviors including fasting, skipping meals, vomiting, laxatives, diuretics, or binge-eating [9]. In comparison, 8% of young men with BMI < 25 report engaging in disordered eating behaviors.

Assessment

A recent review article provides an overview of assessment measures for men with eating disorders, including body image measures, muscularity-oriented measures, and eating disorder measures [4]. Examples of assessment tools that can be used in male populations include the Eating Disorders Examination Questionnaire (EDE-Q) and Muscle Dysmorphic Disorder Inventory (MDDI) [4]. Given the diversity of populations affected by eating disorders, the EDE-Q [10] and MDDI [11] have been translated and validated in Spanish for Latin American male populations.

While the under-recognition of EDs among males has been well documented [12], recent years have seen some important advances. Existing assessment instruments are insensitive towards disordered eating that is oriented towards the pursuit of muscularity. Indeed, with the hyper-muscular body ideals being pervasively portrayed to males, disordered eating symptoms are increasingly muscularity-centric. To this end, the recent development of the muscularity-oriented eating test (MOET) offers important new insights on the measurement of disordered eating attitudes and behaviors that are intended to increase muscular density or leanness [13]*. The MOET is a 15-item measure which dually captures behaviors related to the development of muscularity and the reduction of body adiposity - which enhances the visibility of muscularity (Table 1).

Table 1. The Muscularity Oriented Eating Test (MOET).

Instructions: Please read each statement carefully and circle the number that best indicates how true each statement is of you. Please answer all the questions as honestly as you can, as they apply to you in the last 4 weeks. (0 = never true, 1 = rarely true, 2 = sometimes true, 3 = usually true, 4 = always true)

1)	I have recorded the macro-nutritional values of everything that I ate.	0	1	2	3	4
2)	I have used meal replacement supplements when I felt full.	0	1	2	3	4
3)	What I ate has influenced how I think about myself as a person.	0	1	2	3	4
4)	There are definite foods I have avoided eating due to worry about how they might affect my shape or weight.	0	1	2	3	4
5)	I have felt less anxious about eating out if I knew the macro-nutritional content of the food at the restaurant.	0	1	2	3	4
6)	I have taken my own food out with me to social events in case the food on offer is inconsistent with my diet plan.	0	1	2	3	4
7)	I cannot achieve my body ideal unless I exert complete control over everything I eat.	0	1	2	3	4
8)	I have pre-cooked several meals in advance to ensure that I don’t deviate from my diet plan.	0	1	2	3	4
9)	I have continued eating despite feeling full, in attempting to influence my muscularity.	0	1	2	3	4
10)	I have felt anxious when I run out of protein-based supplements.	0	1	2	3	4
11)	I have been deliberately trying to limit the overall volume of some foods, so that my muscles look more defined.	0	1	2	3	4
12)	If I broke any of my food rules, I attempted to make up for it at my next meal.	0	1	2	3	4
13)	I have felt anxious about others knowing the rules I have around what I eat.	0	1	2	3	4
14)	Other people don’t seem to understand how important my food choices are to me.	0	1	2	3	4
15)	Ensuring proper adherence to my dietary ideals is more important to me than adhering to a work schedule.	0	1	2	3	4

Global MOET scores are formed by calculating the mean score of all items. Murray SB, Brown TA, Blashill AJ, et al. The development and validation of the muscularity-oriented eating test: A novel measure of muscularity-oriented disordered eating. Int J Eat Disord 2019, 52:1389–1398.

Medical Complications

Medical complications of eating disorders, particularly related to malnutrition, can affect every organ system in the body [14]. In one clinical sample of adolescent boys with EDs, over half (52%) had vital sign instability that met Society for Adolescent Health and Medicine hospital admission criteria [15]. Bradycardia was present in 39% and orthostatic heart rate changes were present in 12% of the sample. Bradycardia requiring hospital admission criteria has also been reported among adolescent boys with muscularity-oriented disordered eating [16], and hours of exercise per week is associated with bradycardia among adolescents with eating disorders [17]. Forty percent of adolescent boys with eating disorders had abnormal total cholesterol levels [15], and binge eating has been shown to be associated with hyperlipidemia in young men [18].

Electrolyte abnormalities are common in adolescent boys with eating disorders; one fourth had low potassium, 5% had low phosphorus, and 10% had low calcium [15]. In terms of hematologic abnormalities, one third were anemic, 24% leukopenic, 19% thrombocytopenic, and 10% neutropenic [15]. Gastrointestinal complications in males with eating disorders include elevated liver enzymes [19], impaired gastric emptying [20], and superior mesenteric artery syndrome [21].

Skeletal and bone complications have been documented in males with eating disorders. Significant deficits in bone mineral density [22], lean mass, and fat mass index [23] have been documented in adolescent boys with anorexia nervosa. Adolescent samples including boys have demonstrated that bone mineral density is higher in atypical anorexia nervosa versus anorexia nervosa [24], and that weight bearing exercise and participation in team sports may be protective of bone mineral density at the hip and whole body bone mineral content [25]. In adult men, low bone mineral density Z scores (<−2 at ≥1 site) have been documented in men with anorexia nervosa (65%), atypical anorexia nervosa, (33%), and ARFID (18%) [26]. Men with anorexia nervosa over age 40 have greater fracture risk compared to healthy controls over age 40 [27].

Treatment

Medical guidelines specific to male populations are lacking, and are mostly based on research and clinical experience with females [28]. Some clinical guidance still use criterion, such as amenorrhea, which are not applicable to males [28]. For instance, the Society for Adolescent Health and Medicine medical update for restrictive eating disorders indicates that dual-energy X-ray absorptiometry (DXA) scans should be conducted to monitor bone health when there has been a loss of menses for six or more months [29]. While this does not provide specific guidance on how to monitor bone health among adolescent boys, clinical practice guidelines produced by the National Institute for Health and Care Excellence [30] and the Royal Australian and New Zealand College of Psychiatrists [31] indicate that duration of illness may be a more effective measure of when to obtain a DXA scan. Additional areas where clinical guidance is lacking for adolescent boys and young men include using BMI and weight loss as a measure of malnutrition and severity of illness, refeeding protocols, and the assessment and treatment of performance-enhancing substances (PES) use [28].

In documenting treatment outcomes among males with EDs, few randomized controlled trials exist. In fact, most randomized controlled trials have actively excluded male patients on the basis of their purported atypicality [12]. Qualitative research demonstrates that men with eating disorders report feeling like “the odd one out” or “atypical’ in current female-dominated treatment environments [32]. Recently, however, a large dataset documenting clinical outcomes among a transdiagnostic sample of 110 males was reported. These data suggest comparable remission rates among males and females with anorexia nervosa by the end of treatment (at approximately 40% remission [33]), although more males demonstrated clinically significant disordered eating at follow-up. Males with bulimia nervosa demonstrated marginally less favorable remission relative to females with bulimia nervosa (44% remission by end of treatment, versus 50%). Importantly, however, standardized mortality rates were higher in males with anorexia nervosa relative to both females with anorexia nervosa, and males with bulimia nervosa [34], suggesting that anorexia nervosa in males may be particularly pernicious. In another study, men with eating disorders at 12-month follow-up had partial recovery (19%) or full recovery (14%) [35].

Special Populations

There are several unique populations that are important to highlight when considering eating disorders among adolescent boys and young men. First, recent research has begun to identify the unique disordered eating and weight gain behaviors that are prevalent among adolescent boys and young men, particularly athletes. Weight gain behaviors among adolescent and young adult males may be driven by body ideals that emphasize muscularity and leanness [36]. Among collegiate male athletes, baseball, cycling, and wrestling were sports with the most players reporting elevated eating disorder symptoms in a clinical range [37]. Among competitive collegiate male athletes, nearly half report current supplement use [38]. Sports supplement use in male athletes is associated with greater eating disorder symptoms [38]. Use of legal performance-enhancing supplements is associated with future use of anabolic-androgenic steroids [39]. Little is known about long-term health consequences of performance-enhancing supplements, as the Food and Drug Administration do not review dietary supplements for effectiveness or safety [40]. Adolescent boys may be more likely to engage in individually driven exercise compared to females. This may be exacerbated by athletic norms associated with sports that emphasize muscularity and strength (i.e. American football) or weight control and loss (i.e. wrestling) [17, 36].

A second area of importance to highlight is EDs among racially and ethnically diverse adolescent boys. This area of knowledge remains largely sparse, as there is a dearth of research solely investigating specific racial/ethnic adolescent populations and eating disorders. This is in part due to continued sociocultural narratives that EDs primarily impact White, affluent, adolescent females. Thus, there remains an urgent need to conduct robust and rigorous research on the unique differences among adolescent males with EDs across racial/ethnic identities. However, current research indicates that disordered eating behaviors may be particularly prevalent among non-White adolescent boys. One study among a population of adolescents from Minnesota found that disordered eating behaviors were highest among Asian boys (43%), followed by Black boys (38.5%), Hispanic boys (35%), and lastly, White boys (33%) [41]. Using the National Youth Risk Behavior Surveillance Survey (YRBS), another recent study found that Black/African American and Hispanic/Latino boys had higher prevalence rates and risk ratios of purging behaviors and fasting behaviors compared to White boys [42]**. This study also found that Hispanic/Latino boys had higher, while Black/African American boys had nearly identical, prevalence rates and risk ratios of diet pill use compared to their White peers [42]. Given the results from these studies, it is evident that additional research is needed to develop a stronger understanding of the nuances of EDs among racially and ethnically diverse male populations.

EDs have been documented among sexual minority males. In general, research has continued to indicate that sexual minority adolescent boys experience body dissatisfaction, EDs, and disordered weight control behaviors [43]. Research from the United Kingdom has found that gay or bisexual, as well as mostly heterosexual, boys had significantly greater odds of dieting behaviors compared to their completely heterosexual peers [44]*. Similarly, body dissatisfaction and pressure to increase muscularity was highest among mostly heterosexual and gay or bisexual boys [44]. Lastly, gay and bisexual boys and mostly heterosexual boys had the greatest odds of any binge-eating behaviors compared to their completely heterosexual peers [44]. Similarly, among a national sample of adolescent boys in the United States, boys who identify as gay, bisexual, or not sure had greater odds of reporting fasting behaviors. Further, adolescent boys who identify as bisexual or not sure of their sexual orientation had greater odds of using steroids compared to their heterosexual peers [45]. More specific results from the state of Connecticut [46] and Massachusetts [47] found that sexual minority adolescent boys had greater odds of ED and weight control behaviors compared to their heterosexual peers. In terms of adult men, eating disorder attitudes and behaviors have been shown to be elevated among gay men compared to the general population of men [48]. Despite this evidence, there remains a paucity of research on the epidemiology, treatment, and prevention of EDs among sexual minority adolescent boys and young men.

A final area of importance to highlight is the intersection of gender with EDs. Masculine gender norms are associated with muscle-enhancing behaviors [49]. Transgender men may therefore desire a masculine-appearing build and engage in muscle-enhancing behaviors such as bodybuilding [50]. Transgender men may experience dissatisfaction with several body features such as genitalia, body hair, body shape, facial features, and extremities [51]. Young adult transgender men have also been shown to report high rates of binge eating (35%), fasting (34%), and vomiting (7%) [52]. A review article has previously summarized body image and eating disorders in sexual and gender minority youth [53].

CONCLUSION

Emerging research demonstrates that males with eating disorders have unique concerns with regards to disordered eating and body image. Clinical guidance for eating disorders has not yet become individualized to address these unique concerns [28], and future research should develop male-specific screening, treatment guidance, and interventions to improve health outcomes in this underserved population.

Key Points.

• Body image concerns in males may involve muscularity; muscle-enhancing goals and behaviors are common among adolescent boys and young men.

• Recent measures, such as the Muscularity Oriented Eating Test (MOET), have been developed and validated to assess for muscularity-oriented disordered eating.

• Medical complications of eating disorders can affect all organ systems in males and there are inadequate medical management guidelines for adolescent boys and young men.

• Male populations that may have elevated risk of eating disorders and disordered eating behaviors include athletes and racial/ethnic, sexual, and gender minorities.