More adolescent boys have eating disorders. Two experts discuss why.
For decades, it was thought that eating disorders mainly, if not exclusively, affected women and girls. Until 2013, the absence of menstruation was long considered an official symptom of anorexia nervosa.
Over the past decade, however, health experts have increasingly recognized that boys and men also suffer from eating disorders, and have gained a better understanding of how differently the disease manifests in that group. A small but growing group of scientists and doctors have dedicated themselves to identifying the problem, assessing its extent and developing treatments.
Recently, two of these experts spoke with The New York Times about how the disease affects adolescent boys, what symptoms and behaviors parents should watch for, and what treatments to consider. Dr. Jason Nagata is a pediatrician at the University of California, San Francisco, who specializes in eating disorders; he is editor-in-chief of the Journal of Eating Disorders and editor of the book “Eating disorders in boys and men.”Dr. Sarah Smith is a child and adolescent psychiatrist at the University of Toronto who specializes in eating disorders; she was the lead author of a study published in JAMA Open Network In December it emerged that the number of hospital admissions for boys with eating disorders increased sharply.
The conversation was condensed and edited for clarity.
The medical and scientific understanding of eating disorders is changing and expanding. What happened?
Dr. Smith: Historically, eating disorders have been primarily conceptualized as anorexia, a disease of adolescent females who want to lose weight for aesthetic reasons.
Dr. Nagata: It is increasingly recognized, especially in the past decade, that some people with body image dissatisfaction do not try to lose weight at all. Some men and boys trying to get big and muscular. In fact, a third of teenage boys in the United States report that they are trying to gain weight and become more muscular. And some of those may develop eating disorders or muscle dysmorphia that can lead to significant psychological problems and physical health complications.
What is muscle dysmorphia?
Dr. Nagata: Also known as bigorexia or reverse anorexia, it is a condition in which a person believes their body is puny or not muscular enough, even if they would objectively be considered fit or athletic by other people.
Dr. Smith: It could be because they want to be fitter for hockey, or because they want to be more muscular or 'cut' from an appearance point of view. The motivation that might drive this behavior may not correspond to being thinner, but we still see very similar behavior. We see the obsessive practice. We are seeing certain types of foods being eliminated. We see clear dietary restrictions. And then there are people who choke or vomit, become afraid of it, or have always been picky eaters and fall off their growth curve. And because children and teens grow and develop so quickly, those changes can lead to some pretty serious medical complications.
These complications can lead to a famine. What does that mean?
Dr. Smith: It is a discrepancy between a person's energy or nutritional needs and what he or she actually puts into their body.
Dr. Nagata: When your body continually uses more energy than it takes in, it can lead to a state of starvation, where your vital organs begin to shut down because they don't have enough energy to sustain themselves. And I think it is not sufficiently recognized that starvation can occur in people who exercise too much without getting enough nutrition.
Is there an overlap here when it comes to boys and athletics?
Dr. Smith: Yes absolutely. I think boys who are athletes are at greater risk for eating disorders because some of these behaviors are normalized to some extent in competitive sports.
Dr. Smith: When it comes to the relationship between over-exercising, under-eating, and physical consequences in athletes with eating disorders, we actually have a term called the “female athlete triad.”
What are the components of the feminine triad?
Dr. Smith: Weight loss, changes in bone density and amenorrhea, which is when women don't menstruate. It is yet another example of our gender bias and the way we have approached this disease.
Dr. Smith, you've done some of the most recent research on eating disorders, including the finding that eating disorders have serious consequences for boys.
Dr. Smith: I looked at more than 11,000 hospital admissions in Ontario for eating disorders in children and adolescents aged 5 to 17 between 2002 and 2019. What I found was that while hospital admissions increased by 139 per cent overall, the largest relative increase occurred among men: their number of hospital admissions increased by a total of 139 percent. Hospital admissions increased by 416 percent. Common causes of hospitalization include indications such as a very low heart rate, abnormal markers of minerals in the blood, or suicidal thoughts.
How is your research in Canada reminiscent of what is happening in the United States?
Dr. Nagata: I imagine our trends are quite similar. We have a recent study which focused on boys hospitalized for eating disorders in the United States. We found that compared to girls who are hospitalized, boys actually have more serious medical complications. Boys have a longer hospital stay, greater heart rate abnormalities and more frequent anemia than girls. That may partly reflect the fact that boys are often identified or diagnosed later.
What do you think is responsible for the increasing number of eating disorders and hospital admissions among boys?
Dr. Nagata: There is a genetic component, a biological component, and there are also social and environmental factors. Overall, one of the biggest changes has been the rise of social media, with young people not only consuming body ideals from the media, but also feeling pressure to produce content and display their own bodies on social media. And I think that created a lot of pressure.
When you meet an adolescent male with an eating disorder, do they recognize their behavior as unhealthy?
Dr. Smith: Eating disorders are usually characterized by a lack of insight. Young people are not aware of the risks of the behavior they exhibit. They often register for care because their parents, teachers, coaches or others are the first to worry. I've had young people on heart monitors argue with me, saying they're not that sick, that they're not that skinny, and that we all overreact when they're with us.
As parents, we try to encourage healthy eating and fitness and try to compensate for excessive screen time. How can we tell when fitness has gone too far?
Dr. Nagata: For people who develop eating disorders or muscle dysmorphia, exercise can be taken to extremes and cause more worry and anxiety than enjoyment. So to me, the warning signs for parents are if their son becomes obsessed or preoccupied with the gym and fitness in a way that worsens their social life, school functioning, and daily functioning. These are cases where excessive exercise can turn into the world of disorder.
What advice do you give to parents who are concerned that their son has a problem?
Dr. Smith: The challenge with eating disorders is that we know that the longer the problem goes untreated, the worse the outcome. There is a natural tendency not to be pushy or risk making matters worse, but I think the sooner parents respond, the better. The risks of overreacting are small considering the very real risks of eating disorders. I advise parents to contact their doctor. I also think that if parents want to learn more, there are good online resources.
Dr. Nagata: Primary care is often the best place to start, as they can perform an initial screening and assessment, check vital signs and labs, and then provide appropriate treatment and referrals as needed. The most common reasons for referral we receive at our specialist eating disorder clinic are when a GP visits a teenager for a regular check-up and notices a significant change in weight or unstable vital signs or labs.
What else would you add?
Dr. Nagata: We need to raise awareness about eating disorders and body image issues in boys because they have traditionally been so under-recognized, under-diagnosed and under-treated. I think it's also important to note that eating disorders can affect people of all genders, races, sexual orientations, ages, and sizes.
Dr. Smith: On an optimistic note, people can recover with access to evidence-based treatments – the sooner the better. Although it is a horrific disease, there is hope in this journey.