Body Image Disorders Among Men

Two studies explore this often-neglected territory.

Reprinted from Eating Disorders Review
March/April Volume 27, Number 2
©2016 IAEDP

Eating disorders are often viewed as disorders of women, and thus men’s body image concerns tend to be “underdiagnosed, undertreated and misunderstood,” according to researchers such as Eric Strother et al. (Eat Disord. 2012. 20:346). A prime example is muscle dysmorphia, or MD, which is largely characterized by the obsessive belief that one’s body lacks sufficient muscle mass. This condition can lead to clinical distress and functional impairment among men.

Men with MD usually develop dysfunctional beliefs and behaviors similar to those of women with eating disorders; however, their concerns about body image are expressed in a very different way. Typically men attempt to increase body size and muscle development rather than the pattern more common among women, a drive for thinness.

Men with anorexia nervosa and men with MD have similar clinical profiles (Body Image. 2012. 9:193). In addition, these men adhere to strict diets high in protein and low in fat and also follow a very strict limit on daily calories. They exercise excessively and use binge eating and purging to regulate their emotions.

Several factors also get in the way of making the diagnosis of MD, according to Emilio J. Compte and colleagues in Buenos Aires and Madrid (Int J Eat Disord. 2015. 48:1092). For example, traditional diagnostic instruments assess body dissatisfaction and eating disorders from a female perspective, and the criteria for eating disorders given in the DSM-IV and DSM-5 are not particularly relevant for males with MD. 

Compte and colleagues designed a study to estimate the prevalence of eating disorders among male university students, using a two-stage format with a control group. Their secondary goal was to establish the prevalence of possible cases of MD and to compare the psychological characteristics of men at risk for developing an eating disorder or MD. The researchers found that the prevalence of eating disorders among the university male students was 1.9%, and all the men with an eating disorder had an eating disorder not otherwise specified (EDNOS). The Drive for Muscularity Scale identified possible cases of MD in nearly 7% of the male students. This suggested that drive for muscularity is the male analogue to the drive for thinness noted in women with eating disorders.

The effect of peer perceptions about muscularity

In a separate study, Linda Lin and Frank DeCusati from Emmanuel College, Boston, explored MD and how perceptions of specific peer group preferences are related to men’s body image concerns and behaviors (Am J Men’s Health. 2015. 1:11).

In this study, data on MD and the perceptions of peer muscularity norms were collected from 117 male college students ranging in age from 18 to 22. The students had an average body mass index of 25 kg/m2. Participants viewed nine male figure drawings ranging from very thin to very muscular, and were then asked to identify the drawing that most matched their current shape and also to indicate which matched their ideal shape. Then the students were given the Muscle Appearance Satisfaction Scale (Assessment. 2002. 9:351) to determine symptoms of muscle dysmorphia. This 19-item questionnaire presents statements such as “I would try anything to get my muscles to grow,” and “I must get bigger muscles by any means possible.”

The results showed that men are more likely to view their male peers as having higher standards for muscularity than their female peers and therefore may be more likely to feel inadequate when comparing their bodies with the muscularity preferences of their male peers. This might be a reflection of the different media messages about male muscularity expressed to male and female audiences. Media aimed at male audiences through action movies, video games, and male’s magazines tend to show male characters with very developed muscularity in the male leads. This contrasts with media developed for female audiences, which usually portray male characters with less developed muscularity.

One of the areas the researchers examined was how perceived muscularity preferences of men’s peers were related to symptoms of MD. Contrary to their original hypothesis, the men who perceived their close female peers as preferring greater muscularity were more likely to have symptoms of MD.

A Guided Self-Help Approach for Outpatients

The MOPED program includes a workbook with structured activities.

Reprinted from Eating Disorders Review
March/April Volume 27, Number 2
©2016 IAEDP

As many as 73% of patients receiving outpatient care for an eating disorder drop out before treatment is completed (Clin Psychol Rev. 1998.18:391). Failure to attend outpatient appointments is a costly matter for the healthcare facility, delays treatment and exacerbates symptoms. On the other hand, patients with eating disorders who understand their condition and its treatment are more likely to comply with treatment. Since lack of motivation for recovery is also a factor in dropping out, particularly for those with anorexia nervosa, motivational interviewing techniques have been helpful for engaging patients in treatment.

Physicians at Leicestershire Adult Eating Disorders Service in the United Kingdom have recently developed a motivation and psycho-education self-help manual with structured activities (MOPED) for eating disorders outpatients. The MOPED program was developed for patients with all types of eating disorders. Dr. Nicola Brewin and coworkers compared engagement and completion of treatment rates between a group of patients on a waiting list for treatment who completed the MOPED program and those offered treatment as usual, who were given only a pamphlet describing the MOPED program (Eur Eat Disorders Rev. 20216. Published online before print. doi10.1002/erv.2431). 

The MOPED program involves a workbook with text and guided activities; it differs from other psychoeducational workbooks in that a motivational interviewing style is used throughout. All the activities are designed to increase motivation while providing psycho-education. The underlying goal is to help the patient decide whether she/he wants to change, and by doing so motivate the patient to accept help.

Dr. Brewin and colleagues’ study included 79 female patients who received MOPED after an initial assessment and who were placed on the waiting list for outpatient therapy during the study period. Because of the small numbers of male patients (n=4), no male patients were included. The 79 patients who participated in the MOPED program were then compared with 79 matched (by diagnosis) patients selected in reverse chronological order from the pool of patients assessed and placed on the waiting list for therapy before MOPED was developed. Both groups of patients were assessed by the same clinician using the Clinical Eating Disorders Rating Instrument, or CEDRI.

How well did the program work?

The MOPED manual approach significantly increased the participation of patients and reduced dropout pre-therapy while patients were on the waiting list for treatment. This was particularly true for those with anorexia nervosa. Even though the MOPED group included more students than did the second group, and students more often drop out of treatment, the self-help manual approach still significantly increased the engagement of patients and reduced dropout before therapy began.

The authors also reported that the MOPED program has been adapted for use in an online form (e-MOPED). Future studies might compare the efficacy of the paper form with the online form of the program. Future research could also involve identifying patients who may be more likely to drop out of treatment because of certain personality traits as well as tracing the efficacy of MOPED over time.

Bariatric Surgery for Severe Obesity Growing Among Teens

The Teen LABS study showed impressive results three years after surgery.

Reprinted from Eating Disorders Review
March/April Volume 27, Number 2
©2016 IAEDP

Bariatric surgery for severe obesity has become relatively common in adults, and its use is growing among adolescents. People who have undergone or are contemplating bariatric surgery are frequently encountered by eating disorder clinicians working with adults, and this will undoubtedly be increasingly true for those working with adolescents as well.

The results of a large, multi-center cohort study of bariatric surgery in adolescents, the Teen LABS study, were recently published in the New England Journal of Medicine(NEJM. 2016. 374:113). In this study, held at 5 medical centers, 242 adolescents (mean age: 17 years) and with a mean body mass index, or kg/m2, of 53 underwent bariatric surgery at 5 centers; three-fourths were female. The authors reported three-year outcome data for weight, impact on comorbid medical problems, and complications.

Results three years after surgery

At the three-year follow-up point, the gastric bypass group had a mean 28% weight loss, compared with a mean 26% weight loss among those receiving sleeve gastrectomy. Type II diabetes mellitus remitted in 95% of those who had the disease prior to surgery. Similarly impressive rates of remission were seen for abnormal renal function (86% remission), pre-diabetes mellitus (76% remitted), hypertension (74% remitted) and elevated cholesterol or triglyceride levels (66% remitted). In addition, weight-related quality-of-life ratings improved at three-year follow-up.

There were some complications. First, low ferritin levels were seen in 57%, vitamin A deficiency developed in 16%, and 13% of participants required at least one additional abdominal surgical procedure during the three-year follow-up.

Clearly, there will be more information to come on other outcomes in the Teen LABS study, just as there was in the larger, adult-focused bariatric surgery study, LABS. This information will be valuable in assessing the diverse effects from gastric surgery, including the psychosocial impact. In the meantime, the amount of weight loss achieved at three years and the impact on co-occurring medical problems strongly suggest there will be increasing interest in the use of gastric surgery in adolescents.

Charting the Pattern of Exercise in Stages of Anorexia Nervosa

Patients were significantly more active at weight restoration than at low weight.

Reprinted from Eating Disorders Review
March/April Volume 27, Number 2
©2016 IAEDP

One paradox in the course of anorexia nervosa (AN) is the increased levels of physical activity often reported among these very ill patients. A collaborative team of researchers from the New York State Psychiatric Institute, New York University, and Drexel University have measured physical exercise in AN patients at three time points from admission to follow-up. The researchers measured activity at low-weight, when weight was restored, and post-treatment, and compared these results with those from measured activity among age-matched heathy controls.

Loren M. Gianini, PhD, and her colleagues used a novel accelerometer to measure physical activity at these three time points in 24 women 15 to 49 years of age with DSM-5 AN and 24healthy controls (Int J Eat Disord. 2015. Dec 29. doi: 10.1002).The Intelligent Device for Energy Expenditure and Activity (IDEEA®; Minisun, Fresno, CA) is a microcomputer-based instrument that can identify at least 32 types of physical exercise, as well as the duration and intensity of walking or running. The device continually records for 24 hours, using 5 small sensors taped to the chest, thighs, and feet; the data are then transmitted to a small microcomputer on a waistband or belt.

The patients and controls wore the IDEEA at up to 3 time points: inpatient low-weight (Time 1), inpatient weight-restored (Time 2), and within 2 weeks of weight restoration (90% ideal body weight) on the impatient unit, and at follow-up (Time 3). Total activity time, including time standing and “fidgeting,” was recorded.

Sixty-one patients with AN were in the study; 45 patients wore the IDEEA for 3 consecutive days at low-weight, 35 at weight restoration, and 19 at one month after impatient discharge. Twelve wore the IDEEA at all three time points. Many healthy controls and patients with AN wore the IDEEA for 2 days but then removed it, resulting in a large amount of missing data for the third day of monitoring; thus, only data from the first two days of monitoring was used.

Physical activity across time

Contrary to the authors’ first hypothesis, patients were significantly more active at weight restoration than when they were at low weight. AN patients were also significantly more active at the one-month post-discharge point than at admission. After discharge (Time 3), patients were significantly more active than were healthy controls. The increase in physical activity, according to the authors, was primarily due to an increase in the amount of time spent on their feet, which was primarily composed of time spent standing (the device determined standing and fidgeting).

The authors also determined that elevated physical activity in AN is not directly related to the severity of the disorder or to general pathology. Another finding was that patients were more active during the day but less active at night than were controls. Some theories for this were that patients were more active during the day and then were fatigued in the evening and that patients were less socially active at all times, particularly in the evening. As for body mass index changes, the more time patients with AN spent on their feet (standing and walking), the more quickly they lost weight during the 12 months after discharge. 

This study is the first to identify a relationship between a particular type of objectively measured physical exercise and posttreatment weight. It also is the first to identify a relationship between a particular type of objectively measured physical exercise and posttreatment weight in AN patients. One suggestion from the authors is that inpatient units might develop interventions to limit standing and walking or to help patients stand and walk in a way that doesn’t lead to weight loss. Fidgeting did not differ between patients and controls and did not change with weight restoration; thus, it did not predict weight change after treatment.

Skilled Training for Caregivers May Improve Treatment for Inpatients

Two reports suggest ways to improve outcome by helping caregivers as well as AN patients. 

Reprinted from Eating Disorders Review
March/April Volume 27, Number 2
©2016 IAEDP

A group of British psychologists and eating disorders specialists had a theory: adding a skilled training intervention for caregivers might improve treatment outcome for inpatients with anorexia nervosa (AN). Dr. Nicholas Magill and colleagues recently reported the results of their two-year randomized study comparing treatment as usual versus adding the Experienced Caregivers Helping Others (ECHO) program to inpatient care (Eur Eat Disorders Rev. 2016. 24:122). 

Changes in the National Institute for Clinical Excellence (NICE) guidelines now recommend that inpatient care for eating disorders patients be reserved for those at high medical risk or those who do not respond to outpatient care. Because of the new guidelines, patients admitted for inpatient care may be more severely ill when they are first admitted. Although short-term interventions involving caregivers usually haven’t been very helpful for inpatients (J Psychiatr Prac. 2015. 21:49), the picture improves when family members are involved for longer than a year (PLoS One. 2012. 7, e28249). 

Testing the theory in 15 hospitals

Fourteen of the 15 hospitals that participated in the study have specialist eating disorders inpatient wards (13 adult wards and 1 adolescent ward). One group of patients was assigned to treatment as usual and a second to the ECHO group; patients in the ECHO group were given support immediately after they were randomized to treatment.

The ECHO program provides education and skills for carers through a book and 5 DVDs (3 theoretical and 2 practical), as described in a recent report (Eat Disord. 2015. 12-11. [Note: For more information and a professional version of the DVDs, see www.suceedfoundation.org.] Each family also had five 40-minute telephone coaching sessions (up to 10 per mother and father). Single caregivers had access to up to 10 coaching calls with experienced coaches, who had life experience with eating disorders or with postgraduate-level psychologists. Following the NICE guidelines for aftercare, carers in the treatment as usual arm were given contact information for a leading UK eating disorders charity and offered access to the intervention when treatment was completed.

How results were measured

All participants, patients and caregivers, completed self-report questionnaires and or/blinded interview assessments by mail or telephone at admission, and upon discharge from the inpatient unit, and then at intervals over a 2-year period after the patient was discharged. All patients also completed a short monthly telephone assessment of their core eating symptoms. A total of 268 adult caregivers (178 primary caregivers and 90 secondary caregivers) were recruited, including 144 mothers, 81 fathers, 28 partners, 7 siblings, 5 friends and 3 other relatives. Most carers (69%) lived with the patient. 

How well did the intervention work?

A small-to-moderate degree of improvement was reported among the ECHO group, but this was not statistically significant because of loss to follow-up. Thirty-three percent (59) patients were lost to follow-up at 24 months.

There was a small drop in body mass index (BMI, mg/kg2) after discharge; overall, BMIs were lowest at the 6-month point but had increased above discharge BMIs by 15 months. At the 24-month follow-up point, patients treated in the ECHO group were estimated to have a higher weight, lower levels of eating disorder psychopathology, and lower levels of general distress. 

Once again, none of these differences were statistically significant. Patients in the treatment as usual group had significantly lower BMIs at discharge but the BMIs were comparable in both groups on admission. Some 20% of patients were readmitted for treatment after discharge, and there were 2 deaths during the study.

The authors concluded that providing carers with skills to manage eating disorder symptoms and to provide support following inpatient care is effective for reducing severe malnutrition and for providing respite. Over the long term, educating caregiver may lead to improvement of symptoms in most AN patients. 

Interventions for caregivers

Interventions that equip families and close others with skills to manage eating disorder behavior are showing good potential for improving treatment outcome, according to Dr. Janet Treasure and Dr. Bruno Palazzo Nazar, of King’s College, London (Curr Psychiatry Rep. 2016. 18:16). Dr. Treasure, one of authors of the ECHO report, and Dr. Palazzo concluded this after an extensive literature review on caring/parenting interventions for people with eating disorders.

The authors’’ research showed that carers play a very important role early on, before the person with the eating disorder recognizes that he or she is ill, but when the family has become aware of it. Social aspects may then come into play. For example, family members may unwittingly collude with the eating behaviors by organizing family around eating disorders rules, to cover up the negative consequences of the behaviors. These behaviors also can divide family members, making some shoulder more of the burden while others turn away. Another complication is that interventions often have a selective focus on improving the well-being of the carers or the patient, but not both.

Drs. Treasure and Nazar suggest that interventions for caregivers need to take into account the stage of illness and whether certain interpersonal behaviors that may maintain the disorder, such as accommodation, expressed emotion, or family divisions, are present. Some promising approaches include family-based therapy, the New Maudsley approach, which addresses some maintaining interpersonal behaviors (J Eat Disord. 2013. 1:13), and new interventions that specifically target partners (Int J Eat Disord. 2011. 44:19) are all promising. They also suggest that since most of the work has focused on patients with AN, more work is needed to understand caregiving for patients with bulimia nervosa and binge eating disorder.

UPDATE: Bariatric Surgery Patients Often Have Depression, BED

Reprinted from Eating Disorders Review
March/April Volume 27, Number 2
©2016 IAEDP

According to the results of a study at the University of California, Los Angeles, a sizeable number of persons undergoing bariatric surgery also have depression and/or binge-eating disorder (BED). Dr. Aaron Dawes, a general surgery resident at UCLA, recently reported that an analysis of 68 studies found that almost one-fourth of candidates for gastric bypass or gastric sleeve techniques had a mood-related disorder, usually depression. Another 17% had BED. Dr. Dawes reported his findings in the January 12, 2016 issue of the Journal of the American Medical Association. These figures for depression and BED are both twice as common as in the general U.S. population.

While having a diagnosis of BED might seem to preclude an individual from undergoing bariatric surgery, since food intake has to be strictly limited, people with the disorder fare as well as other patients, Dawes said. That might be partly because some get therapy for their binge-eating, Wolfe said, but added that the surgery also has effects on the nervous and hormonal systems that may help ease bingeing.

Based on the review, people with depression can also improve after surgery. Across seven studies, prevalence of depression dropped by anywhere from 8% to 74% after surgery. The severity of patients' depressive symptoms also fell by 40% to 70%.

Things you can do to support your loved one in need

Studies show the presence of a solid support system is a huge predictor of eating disorder recovery. In fact, research on Family-Based Therapy, where family is not only supportive, but also actively involved in a direct way with restoration of an adolescent, has been shown to be by far the strongest and most effective evidence-based treatment.

But whether you're an adolescent or adult, the presence of support from family and loved ones is likely to be one of the most important factors in recovery. We know that no one gets better alone. We know that our ability to connect helps us recover in every way.

For many people, our family and sometimes our closest friends are the people who form the basis of our support and community that will help us recover. Always remember, eating disorders are an illness. Families do not cause them, but rather they can help cure them.

If you are the support system, there are things you can do to help your loved one suffering from an eating disorder.

1. The person is not the disorder. They remain the same person, regardless of how they suffer. Loving by itself does not, however, create a cure. We must always remember that love is a necessary component, but love alone will not make someone better.

2. If we're helping someone with an eating disorder, we must get support for ourselves. In the same way we must accept that our loved one has an illness, we must accept that our lives are burdened by this illness. Support for us will make us stronger and better able to function.

3. We must be willing to be fully and actively engaged, especially if our family members are adolescents. We must know about the meal plans and treatment strategies for our family members. We must know honesty, transparency and respect are all keys to communicating with loved ones who have this illness. We must be sensitive, firm and avoid all comments about food, body and appearance.

In addition, we must be willing to distract loved ones from the pains of treatment. Our loved ones depend on us to help us create a life worth living and to start building that life at whatever stage of the eating disorder we find ourselves in.

In addition to psychological and family roles, eating disorders are a tremendous financial burden. We need to make sure people have the best possible insurance and understand their benefits. The eating disorder will affect their lives and ours, and sacrifices will be necessary.

On a larger level, we help loved ones by becoming a part of the eating disorder community and working with organizations that support mental health and are committed to increasing high-quality treatment options for everyone.

Wherever you are and whatever you're doing, if you have a loved one with an eating disorder, remember you are their greatest advocate and may be the most important person in their life. Never underestimate your strength and power to help your loved one get the help they need.

Mark Warren, MD