For decades, eating disorders were thought to primarily, if not exclusively, afflict women and girls. In fact, until 2013, missed periods had long been considered an official symptom of anorexia nervosa.
However, over the past decade, health experts have increasingly recognized that boys and men also suffer from eating disorders and have better understood how differently the disease manifests in this group. A small but growing body of scientists and doctors have dedicated themselves to identifying the problem, evaluating its scope, and developing treatments.
Recently, two of these experts spoke to The New York Times about how the disease affects teenage boys, what symptoms and behaviors parents should look for, and what treatments they should consider. Dr. Jason Nagata is a pediatrician at the University of California, San Francisco who specializes in eating disorders. 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. was the lead author on a study published in JAMA Open Network in December which saw steep increases in the hospitalization rates of boys with eating disorders.
The conversation has been condensed and edited for clarity.
Medical and scientific understanding of eating disorders is changing and expanding. What happened?
Dr. Smith: Historically, eating disorders have mostly been seen as anorexia, which has been presented as a disease of adolescent women who want to lose weight for cosmetic reasons.
Dr. Nagata: It has become increasingly recognized, particularly in the last decade or so, that some people with body image dissatisfaction are not trying to lose weight at all. Some men and boys they try to get big and muscular. In fact, one-third of teenage boys in the United States report that they are trying to bulk up and become more muscular. And a subset of them may develop eating disorders or muscle dysmorphia that can lead to significant psychological distress and physical complications.
What is muscular dysmorphia?
Dr. Nagata: Also known as anorexia nervosa or anorexia nervosa, it is a disorder where someone believes their body is thin or not muscular enough, even if they would objectively be considered fit or athletic by other people.
Dr. Smith: It may be because they want to be more fit for hockey or because they want to be more muscular or “cut” in terms of appearance. The motivation that may be driving these behaviors may not align with being thinner, but we still see very similar behaviors. We see obsessive exercise. We are seeing the elimination of certain types of food. We see intense dietary self-restraint. And then there are those who choke or throw up, are afraid of it, or have always been picky and fall off their growth curve. And because children and teens grow and develop so quickly, these changes can lead to very serious medical complications.
These complications can lead to starvation. What does this mean?
Dr. Smith: It’s a mismatch between someone’s energy needs or nutrient needs and what they actually put into their body.
Dr. Nagata: When your body constantly puts out 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’s totally under-recognized that starvation can happen among people who exercise too much without getting enough nutrition.
So, is there an overlap here in terms of boys and athletics?
Dr. Smith: Yes, absolutely. I think boys who are athletes are at greater risk for eating disorders because to some extent, some of these behaviors are normalized in competitive sports.
Dr. Smith: When it comes to the relationship between over-exercising, under-eating and the physical consequences among athletes with eating disorders, we actually have a term called the “female athlete triad”.
What are the components of the female triad?
Dr. Smith: Weight loss, changes in bone density and amenorrhea, which is when women do not have periods. It’s another example of our gender bias and how we’ve approached this disease.
Dr. Smith, you have done some of the most informed research on eating disorders, including the finding that eating disorders severely affect boys.
Dr. Smith: I looked at over 11,000 Ontario hospitalizations for eating disorders of children and adolescents aged 5 to 17 from 2002 to 2019. What I found was that while hospitalization rates increased by 139% overall, the largest relative increase was among males: hospitalizations increased by 416%. Common reasons for hospitalization will include indications such as a very low heart rate, abnormal mineral markers in their blood, or suicidal ideation.
To what extent does your research in Canada suggest what is happening in the United States?
Dr. Nagata: I imagine our tendencies are quite similar. We have a recent study which focused on boys being treated for eating disorders in the United States. We found that, compared to hospitalized girls, boys actually have more serious medical complications. Boys have longer hospital stays, greater heart rhythm abnormalities, and higher rates of anemia than girls. This may in part reflect that boys are often identified or diagnosed later.
What do you think accounts for the increasing incidence of eating disorders and hospitalizations in 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 advent of social media, where young people not only consume body ideals from the media, but feel pressured to produce content and display their own bodies on social media. And I think that has added a lot of pressure.
When you meet a teenage male with an eating disorder, do they recognize his behavior as unhealthy?
Dr. Smith: More often than not, eating disorders tend to be characterized by a lack of insight. Young people do not appreciate the dangers of the behaviors they engage in. Often, they present for care because their parents or teachers or coaches or others are concerned first. I’ve had guys on heart monitors who argue with me and say they’re not that good, they’re not that thin, and that we’re all overreacting around them.
As parents, we try to encourage healthy eating and fitness and try to offset 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 extreme and can cause more anxiety and preoccupation than enjoyment. So, for me, the red flags for parents are if their son becomes obsessed or involved with fitness and fitness in a way that impairs their social life, school functioning, and daily functioning. These are cases where too much exercise can turn into a world of disorder.
What advice do you have for parents who are worried that their son might have a problem?
Dr. Smith: The challenge with eating disorders is that we know that the longer the issue goes untreated, the worse the outcome. There is a natural tendency to not be intrusive or risk making things worse, but I think the sooner parents respond, the better. The risks of overreaction are small, given the very real dangers of eating disorders. I would recommend that parents see their primary care provider. 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 because they can do an initial screening and assessment, check vital signs and labs, and then provide appropriate treatment and referrals as needed. The most common referrals we receive to our eating disorder specialty clinic are when a primary care physician visits an adolescent for their routine 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 it has 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, with access to evidence-based treatment—the sooner the better—people can recover. Although it is a horrible disease, there is hope in this journey.