Males with Eating Disorders and Exercise

Clinical Characteristics and TreatmentBy Theodore E Weltzin, MD, FAED, FAPA
Medical Director of Eating Disorders Services at Rogers Memorial Hospital and Assistant Clinical Professor of Psychiatry at the Medical College of Wisconsin, Milwaukee

Men with eating disorders conservatively make up approximately 10 percent of anorexia nervosa (AN) and bulimia nervosa (BN) eating disorder patients, with BN being more common than AN.[i]  However for binge eating disorder (BED), rates for males are similar to females.[ii] While the acute presentations for males and females tend to be the same and include weight loss and malnutrition and/or binge eating with compensatory behaviors such as self-induced vomiting and calorie restriction, significant clinical differences are present between male and female eating disorder patients. Evidence indicates that men are as concerned about body image as women.[iii]  However, unlike women whose preferred body image is thin, men’s preferred body image is muscular. Exercise and athletic competition, especially sports that require low body fat or extremes of weight loss, represent a risk for developing disordered eating. [iv][v] [vi]

Exercise concerns are common in males with eating disorders as over 50 percent of males presenting for eating disorder treatment at Rogers Memorial Hospital report problematic exercise behaviors.  As compared to women, men are more susceptible to elements of excessive exercise such as a lack of control, increased tolerance and reduction in alternative activities.[vii]  Signs of excessive exercise include highly structured and repetitive exercise routines that tend to focus more on endurance activities, most commonly running. Patients will often engage in exercise rather than spend time with family, attend school or work. Furthermore, continuing to engage in exercise even when injured or while underweight is common. Increased emotional distress when exercise is limited is common. Also, excessive exercising tends to occur in isolation with a tendency to exercise alone or in secret.

The relationship between body image and exercise is not unique to males who develop eating disorders, nor is it destructive if a well-balanced approach to health and personal growth is used.  Males with eating disorders who have a significant exercise component typically describe two factors that likely increase their risk of developing an eating disorder. First, they reduce food intake incrementally over time, to the point of very low caloric intake and avoidance of fats and often carbohydrates. Second, exercise activities are not aimed at maintaining strength and muscle mass; rather there is an increase in time spent in calorie-burning activities. Both activities will accelerate inadequate nutritional intake and weight loss in the case of AN and binge eating and/or purging in the case of BN, BED and EDNOS.   

For males and females with eating disorders excessive exercise behaviors often need to be addressed as part of treatment and ideally should be individualized based on an assessment of fitness beliefs and behaviors for each patient.  Obtaining collateral information from parents, former providers and coaches is recommended as patients typically minimize these behaviors and oftentimes are reluctant to identify exercise behaviors as dysfunctional.  For treatment of underweight individuals, all but the most quiescent fitness activities are suspended until weight restoration is progressing satisfactorily.  Males with eating disorder presenting for treatment with exercise concerns generally fall into two main groups. First, those that use exercise behaviors in an “addictive”fashion as a mood enhancement. These residents also report a history of behaviors such as lying about their exercise to family and friends and using exercise to avoid difficult emotions. We note that when exercise is discontinued in a structured treatment environment, these residents exhibit moderate to severe symptoms of irritability and sometimes an increase in depression. A second cluster of individuals could be described as “compulsive”exercisers. These individuals have highly ritualized exercise behaviors that create anxiety when disrupted and often have co-occurring obsessive-compulsive symptoms not related to exercise. These individuals are treated with exposure and ritual prevention, aimed at helping patients to not use exercise as a primary way of dealing with feelings of low self-esteem, negative body concerns, insecurity and perfectionism.

Summary:

It is likely that rates of eating disorders in males will continue to increase.[viii] While differences exist in risk factors and symptom expression in males with eating disorders, a growing body of evidence suggests that males respond well to treatment.  However, treatment needs to be individualized including addressing problematic exercise in approximately half of male patients presenting for treatment.  Ideally, this should take place in a setting with other males and with staff experienced in working with males.

The Facts about Males and Eating Disorders

By Leigh Cohn, MAT, CEDS and Stuart B. Murray, DCLINPSYCH, PhD

Search on the web for “males and eating disorders” and you will find plenty of misinformation. The most common problem is that male prevalence figures are outdated and shown as lower than current findings. For example, the National Institute of Health’s MedlinePlus erroneously indicates that only 5 to 10% of people with an eating disorder are male, and they offer no references. The actual number is about 5 times that amount.

Those lower statistics date back to the 1980s, and repeating them today—as so many sites do—misinterprets the prevalence of male eating disorders, further marginalizing men and inhibiting treatment uptake. Let’s get the facts right about males and eating disorders…

How many males, really?

The gold standard for this data is a national, face-to-face household survey from Harvard University of 9,282 people (Hudson, 2007), which showed that 25% of individuals with anorexia nervosa and bulimia and 36% with binge eating disorder were male. But this is just one misconception.

The gap is even closer when it comes to subclinical eating disordered behaviors, according to a review of numerous studies (Mond, 2014). For activities like binge eating, 42-45% of bingers were male; as were 28-100% of individuals who regularly purged. Laxative abuse among genders was nearly even, and fasting for weight loss was endorsed by nearly 40% of the males.

According to Arnold Andersen, the field’s most-respected authority on this topic, many men and women want to change their weight (2000), which is about 80% of the general population. However, unlike women, who almost exclusively want to lose weight, an equal number of guys want to put on pounds of muscle. Clearly, body image issues are equal across gender lines.

It gets worse: our current methods of indexing eating disorder symptoms appear to be female oriented, marginalizing the experience of males (Darcy, 2014). On the most commonly used measures, such as the Eating Disorders Examination (EDE) and Eating Disorders Inventory (EDI), males consistently score lower than what their actual level of illness severity would predict, often due to language that is written for female responses. For example, the EDI has a female bias with questions like, “I think my thighs are too large,” and “I am preoccupied with a desire to be thinner.” Men would more typically be concerned with their waist being muscular, as opposed to being thin. Most don’t worry too much about their thighs.

Not Women’s Diseases

Add to these complicated miscues the fact that men are stigmatized by the idea of having a “woman’s disease” and experience their eating issues silently. So, we really don’t know how many men suffer from eating disorders, but it is obvious that the numbers are much greater than those being thrown around on the web.

The idea that eating disorders are primarily women’s problems has never been true. Actually, the earliest case descriptions of anorexia nervosa by Richard Morton in 1690 included cases of a man and a woman. True, the rise of modern-day eating disorders in the 1980s focused almost exclusively on females, but even then there were men suffering from anorexia and bulimia.

Another misconception is that most males with eating disorders are gay, which places a stigma on straight males with food issues. An oft-cited study (Feldman, 2007) showed a much higher percentage of gay (15%) than heterosexual males (5%) with diagnoses of anorexia, bulimia, and binge eating, but when these percentages are applied to population figures, the majority clearly appears to be heterosexual. Further, recent evidence suggests that gender role endorsement appears significant in the divergence of eating disorder pathology in males, as opposed to sexual preference (Murray et al., 2013).

In this day and age, media objectification and the sexualization of males are just as rampant as for females. Men with eating disorders often suffer from comorbid conditions such as depression, excessive exercise, substance disorders, and anxiety (Weltzin, 2014). Furthermore, many men are so undereducated about eating disorders that they may not even realize that they have one!

Moving in the Right Direction

The good news is that access to treatment is on the rise. A recent study showed that the number of eating disorders treatment facilities treating males increased from 35% in 2000, to 53% in 2007, and 69% in 2013 (Cohn, 2013). Now, the vast majority of professionals who specialize in this field treat males.

Another positive sign toward gender equality is the number of men talking about recovery. Most national associations include resources for males. For example, the National Eating Disorders Association’s website has inspirational “Stories of Hope,” and Project Heal recently awarded a treatment scholarship to their first man. Also, the National Association for Males with Eating Disorders has new, energized leadership and an active volunteer board providing advocacy and support for this underserved population.

In the future, we hope to see increased funding for research and treatment from the National Institute of Mental Health and other sponsors. We’d also like to see gender neutrality in the language that is generally used about eating disorders. Eventually, everyone who needs it will have equal access to recovery, but that can’t happen until information sources provide accurate information about males and eating disorders.

Author Bio

Leigh Cohn, MAT, CEDS coauthored the books Current Findings on Males with Eating Disorders (2014) and Making Weight (2000). He has lectured on this subject at universities and professional conferences throughout the United States and Canada. Perhaps best known as Publisher of Gürze Books and Editor-in-Chief of Eating Disorders: The Journal of Treatment and Prevention, he is the current president of the National Association for Males with Eating Disorders (NAMED).

Stuart B. Murray, DCLINPSYCH, PhD is a postdoctoral research fellow at the University of California, San Diego and Honorary Associate at the University of Sydney. He is co-executive director of the National Association for Males with Eating Disorders (NAMED).