from Psychiatric Times, October 2002
PREVALENCE
In general, eating disorders are much more prevalent among women. Traditionally, approximately ten percent of patients with eating disorders are men (Andersen 1984, Andersen 1997, Gotestam 1995, McNulty 1997, Olivardia 1995, Schuckit 1996, Striegel-Moore 1999a, Striegel-Moore 1999b, Taraldsen 1996, Zuckerman 1986). The percentage of eating disorders in men has risen to about 16% (Andersen 2000). It reports a prevalence of eating disorders between 0 and 40% of men; binge eating disorder (BED) and eating disorder NOS (EDNOS) being the most prevalent (Gotestam 1995, Heatherton 1995, Johnson 1999, Kinzl 1999, McNulty 1997, Striegel-Moore 1999, Taraldsen 1996).
The populations studied may account for some of this variance. Among active duty Navy men, the prevalence of eating disorders is 2.5% for anorexia nervosa (AN), 6.8% for bulimia nervosa (BN), and 40.8% for EDNOS (McNulty 1997). A Norwegian study found the following point prevalences among outpatient men: 0% in AN, 2.7% in BN, 5.3% in BED, and 6.7% EDNOS (Taraldsen 1996).
Another Norwegian study found outpatient men with prevalences of each disorder of less than 1% (Gotestam 1995). The prevalence of eating disorders American men ranges from 0.02% for all eating disorders to 0.4% for BN (Heatherton 1995, Striegel-Moore 1999). Another study found that binge eating behavior more prevalent among males (13% vs 10.9%) (Johnson 1999).
Among inpatients with eating disorders, BN was the most common (46%), followed by EDNOS (32%), and AN (22%) (Carlat 1997). In addition to BN being more prevalent than AN, perhaps BN’s higher morbidity requiring hospitalization accounted for this finding.
A study of Austrian males found that 14.9% met partial criteria for eating disorders. As most of these men were overweight or obese, only 0.8% met full criteria for an eating disorder (Kinzl 1999). Among NCAA athletes, BN was found among 1.1% of females but among no male athletes (Johnson 1999). Disordered eating has been found among other male athletes, particularly in sports in which habitus is important, such as bodybuilders, rowers and race jockeys (Braun 1999, Farrow 1992, King 1987, Mangweth 2001, Sykora 1993).
Whether eating disorders are increasing or decreasing in men is another controversy in the literature. From 1982 to 1992, reduced rates of chronic dieting, disordered eating behaviors and adverse attitudes about body, weight, and shape were observed among men (Heatherton 1995). However, another study found an increase in male AN between 1985 and 1987 of 5% to 10% (Romeo 1994).
PSYCHOSOCIAL STRESSES AND RISK FACTORS
Most of the literature has generally found that adult men and adolescents males similar to their female counterparts in genetics, phenomenology of eating disorders, disordered eating, co-morbidity rates, and dissatisfaction with body image (Geist 1999, Olivardia 1995, Schuckit 1996, Strober 2001, Woodside 1994, Woodside 2001). However, several differences between men and women with eating disorders are apparent.
Compared to females, males with eating disorders have a high prevalence of family members with mood disorders, OCD, other anxiety disorders, and alcohol dependence (Carlat 1997, Farrow 1992, Taraldsen 1996). A personal history of physical and sexual abuse is a controversial risk factor. One study found a slightly higher prevalence of such abuse among men, another no difference in prevalence (Kinzl 1997, Olivardia 1995).
Some adolescent males have disordered eating without significant weight problems, although they have greater body dissatisfaction (Keel 1998). Among male teens, AN and BN can result from the unsuccessful use of weight loss to deal with developmental crises (Andersen 1984). Weight loss may be a manifestation of an attempt to develop their identities. According to Lynn Ponton, MD, Professor of Child Psychiatry at UC San Francisco, "adolescents take risks, in part, to develop and establish their identities. Disordered eating is an insidious form of risk taking behavior in adolescents. Initially, they don’t see this behavior as negative." Dieting and excessive exercise are associated with the onset of BN (APA 2000, Batal 1998, Cowen 1999, Lowe 1998). In male adolescents, motivation for dieting typically arises from their desire for an ideal male body, sports participation, and avoidance of scrutiny from others (Andersen 1984, Farrow 1992). Steroid use is also more common among adolescent males and is associated with disordered eating and parental concerns about weight (Irving 2002). Men are less likely to engage in emotional eating, i.e. eat in response to "negative emotions," such as anxiety, anger, and frustration (Tanofsky 1997).
Other psychosocial issues more important for adolescent males involve sexuality. They are more likely to struggle with sexual identity issues, sexual inactivity, and defensive dieting (Farrow 1992, Herzog 1984).
Although adolescent males and females may use dieting to manage their weight, dieting may affect them differently. Dieting may alter brain serotonin only in women (Goodwin 1987). Therefore, this biological finding may partially explain onset of BN in females after dieting.
Eating disorders have a later onset in males (20.6 vs 17 years) (Braun 1999). Among men in the Navy, the prevalence of eating disorders is independent of rank, job assignment, or age (McNulty 1997). Among college students, a lower stress tolerance is associated with eating disorders (Leal 1995).
The degree of prevalence of eating disorders in gay men is controversial. Perhaps diversity present in this alternative lifestyle contributes to conflicting reports in the literature. Two studies found that eating disorders are not more prevalent among gay men (Carlat 1997, Olivardia 1995). Another study found that gay men were thinner and sought a lower ideal body weight (Herzog 1991). In psychometric testing, gay men had higher scores on Bulimia Test-Revised (BULIT-R) and Body Shape Questionnaire (BSQ) (Russell 2002). Still other studies found higher prevalence of body dissatisfaction and disordered eating, including dieting, binge eating, and purging (French 1996, Siever 1994, Yager 1988). These findings have been attributed to gay community’s greater emphasis on physical attractiveness and thin (Siever 1994). Compared to heterosexual women, lesbians tend to have more positive body images and engage in less dieting and binge eating (French 1996).
PSYCHIATRIC CO-MORBIDITY
The literature has conflicting reports about the prevalence of co-morbidity in men with eating disorders. One study found no significant differences in psychiatric co-morbidity between men and women (Braun 1999). Among male and female adolescents, anxiety and depression have similar prevalence rates (Geist 1999). Another found no higher prevalence of eating disorders among alcohol-dependent men or women (Schuckit 1996).
When comparing men and women with eating disorders, other studies found higher prevalence rates of Axis I disorders, particularly mood disorders and alcohol dependence, among adolescent males and men with eating disorders (Carlat 1997, Geist 1999, Keel 1998, Russell 2002, Striegel-Moore 1999, Tanofsky 1997, Woodside 1994). The prevalence of eating disorders was 17% among male sex offenders (McElroy 1999). Compared to women, men with AN are at higher risk for psychotic disorders, particularly schizophrenia (Striegel-Moore 1999). Men with BN are at higher risk for personality disorders (Carlat 1997, Striegel-Moore 1999). Men with EDNOS have higher rates of comorbid organic mental disorder and psychosis (Striegel-Moore 1999).
DIAGNOSTIC ISSUES
Clinicians tend to have difficulty diagnosing males with eating disorders due to stereotypes about eating disorders affecting only women (Andersen 1999). In general, eating disorder symptoms, relationship status, and quality of life are similar in men and women (Andersen 1984, Farrow 1992, Olivardia 1995, Pope 1986, Robinson 1986, Steiger 1989, Woodside 1994). Other studies have found differences in these demographics. In addition to stereotypes, the symptoms and presentations of eating disorders in men require a high index of suspicion in clinicians. For instance, college men have fewer symptoms of bulimia, such as purging (Johnson 1999, Leal 1995). Men are also less likely to engage in emotional eating, i.e. eat in response to "negative emotions," such as anxiety, anger, and frustration (Tanofsky 1997). Male adolescents have a lower drive for thinness and body dissatisfaction, lower Eating Disorder Inventory-2 (EDI-2) scores (Andersen 1997, Geist 1999). Difficulties in diagnosing AN in male adolescents may account for their higher morbidity (Siegel 1995). Biases toward males with eating disorders may partially account for their shorter inpatient stays (Striegel-Moore 2000).
TREATMENT AND PROGNOSIS
The literature is sparser on treatment and prognosis of eating disorders in men. These are but some of the areas in need of further research. As clinicians, we need a better understanding of the biopsychosocial factors resulting in gender differences in eating disorders.
Men and women respond similarly to treatment and have similar outcomes (Andersen 1997, Woodside 1994). Outcomes are more favorable if patients receive treatment early in the course of the disorder (Andersen 1984, Romeo 1994). However, the antidepressant response rates for men as compared to women is unclear (Andersen 1997).
In the past and even recent past, men were less likely to seek treatment for eating disorders (Siegel 1995, Striegel-Moore 2000). This trend appears to be reversing (Braun 1999). One study found that women spent more days in inpatient units; perhaps male patients with eating disorders feel more alienated and stigmatized over having a "woman’s disease" (Striegel-Moore 2000). It is acceptable to treat men in intensive group settings where most of the patients are women (Woodside 1994). In working with men, addressing their past and future sexual roles, issues with this stigma, and preparing them to return to male social role may be necessary (Andersen 1997).
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