More males with eating disorders; risk factors and diagnosis guidelines for all patients

Males tend to have both a different type of body image distortion and different body image goals. Instead of focusing on thinness, they focus on bulking up.

Eating disorders are increasing among males, making up about a quarter of anorexia nervosa patients and running a greater risk of death, said Brittany K. Badal, M.D., an adolescent medicine physician with Norton Children’s Medical Group – Novak Center.

Later diagnosis in males typically contributes to morbidity, Dr. Badal said during a recent pediatric grand rounds continuing medical education opportunity on disordered eating in adolescents.

Males tend to have both a different type of body image distortion and different body image goals. Instead of focusing on thinness, they focus on bulking up, with highly defined muscles, to gain muscle mass while getting rid of fat tissue, according to Dr. Badal.

Differentiating young men involved in sports and those engaged in disordered eating that interferes with their growth and development takes finesse, according to Dr. Badal.

Disordered eating is also increasing among those in lower socioeconomic groups and among older patients.

The three most common eating disorders are anorexia nervosa, bulimia nervosa, and binge eating disorder.

Anorexia nervosa is a restriction of food intake leading to weight loss, typically resulting in significantly low body weight based on the patient’s growth curves and prior development.

“There’s also this aspect of a fear of becoming fat or a fear of gaining weight,” Dr. Badal said.

“For the majority of adolescents, dieting is inappropriate. This is a period of growth; this is a period of development. We know they have increased caloric needs”

— Brittany K. Badal, M.D.

Anorexia nervosa

Anorexia is associated with higher rates of suicidality and mortality and, among all psychiatric illnesses, has one of the highest rates of morbidity. Young people ages 15 to 24 diagnosed with anorexia nervosa have 10 times the risk of dying compared with their peers. Approximately 5% of individuals with anorexia nervosa die from the disorder, with half of the deaths occurring as the result of suicide.

In the general population, the prevalence of anorexia at any given time is estimated at 1% to 2% among females and 0.1% to 0.3% among males. However, an eight-year study following almost 500 females found 5% met the criteria for anorexia, bulimia or binge eating at some point.

Bulimia nervosa

Bulimia nervosa involves binge eating with an inappropriate compensatory behavior, such as excessive exercise (sometimes called hypergymnasia) or purging via vomiting or laxatives, with the binge eating and compensatory behavior occurring at least once a week for three months, according to criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Bulimia nervosa goes significantly underdiagnosed because it is not accompanied by the same rapid weight changes or weight loss as anorexia nervosa, according to Dr. Badal.

Binge eating disorder

Binge eating disorder entails discrete episodes of binge eating without compensatory behaviors. Binge eating disorder is defined by five criteria:

  • Eating much more rapidly than normal
  • Eating until uncomfortably full
  • Eating large amounts even when not feeling physically hungry
  • Eating alone because of embarrassment at how much is being eaten
  • Feeling disgusted, depressed or guilty after

A patient who meets three of these five criteria once a week for three months, without the ongoing and inappropriate compensatory behaviors associated with anorexia nervosa or bulimia nervosa, is considered to have binge eating disorder, according to the DSM-5.

Patients who meet criteria for anorexia nervosa may have some behaviors related to binge-eating or compensatory behaviors around purging or increased exercise levels. They typically are not diagnosed with anorexia nervosa and bulimia nervosa at the same time, according to Dr. Badal.

Eating disorder risk factors

Risk factors for anorexia nervosa include a first-degree relative with anorexia; individuals with Type 1 diabetes, particularly females; adolescents involved in a sport burning more calories than they are taking in; and a history of dieting.

“For the majority of adolescents, dieting is inappropriate. This is a period of growth; this is a period of development. We know they have increased caloric needs,” Dr. Badal said. “Many people will diet and not develop anorexia, but for some people, those behaviors then become more obsessive and lead to these really intense eating disorder cognitions and beliefs.”

Psychological risk factors include perfectionism, body image dissatisfaction, a personal history of an anxiety disorder and behavioral inflexibility.

Clinical presentations

Potential physical exam findings for someone with anorexia nervosa:

  • Bradycardia, presenting for fainting or dizziness
  • Blood pressure obtained in standing and supine positions show orthostatic changes
  • Weight percentile is significantly below height percentile
  • Bony prominences from lack of subcutaneous tissue
  • Lanugo hair covering the body
  • Scalp hair thinning or dull
  • Fingers cold and bluish in appearance or bluish nail beds in those with dark skin

Whether the patient is seen in the office or in the emergency department, a physician’s job, first and foremost. is deciding whether the patient is stable or needs to be admitted for medical stabilization, according to Dr. Badal.

According to a position paper from the Society for Adolescent Health and Medicine, any one of these findings could justify hospitalization:

  • <75% median body mass index for age and gender
  • Dehydration, electrolyte disturbance
  • Electrocardiogram abnormalities
  • Physiological instability
  • Severe bradycardia (under 50 beats a minute)
  • Hypotension (<90/45mm Hg)
  • Hypothermia (<96 F, 35.6 C)
  • Orthostatic increase in pulse (>20mm Hg systolic or >10mm Hg diastolic)
  • Arrested growth and development
  • Failure of outpatient treatment
  • Acute food refusal
  • Uncontrollable bingeing and purging
  • Acute medical complications of malnutrition such as seizures or pancreatitis
  • Comorbid psychiatric or medical condition that prohibits or limits outpatient treatment

Outpatient management is focused on medical stability, with frequent weight and vital checks. The goals are weight restoration and, for females, the resumption of spontaneous menses. The majority of treatment occurs in a psychologic or therapeutic setting.

“Family-based treatment is really one of the first lines of treatments for adolescents with anorexia nervosa. But depending on that patient, they may need an intensive outpatient program, they may need residential, or they may need some other forms of treatment as well,” Dr. Badal said.


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