Eating Disorders in Men

An Underestimated Problem, an Unseen Need

Background: Eating disorders are seen mainly as a problem affecting women, not just by the public at large, but also in specialized circles. Although it is true that more women than men suffer from all types of eating disorder, pertinent reviews have clearly shown that they do indeed occur in men, and that the available evidence on the matter is limited. The stigmatization of men with eating disorders makes it harder for these men, and for the relevant professionals, to recognize the symptoms and to seek or provide help.

Methods: This review is based on publications retrieved by a selective search in PubMed on the epidemiological, diagnostic, clinical, and therapeutic aspects of eating disorders in men.

Results: Current estimated lifetime prevalences in men are 0.2% for anorexia nervosa, 0.6% for bulimia nervosa, and 1% for binge-eating disorder; the corresponding figures for women are 1.4%, 1.9%, and 2.8%. Men and women may display different manifestations. Women are thought to be mainly seeking a slim figure and weight reduction; men, a muscular build. The established German-language screening and diagnostic tools, however, do not cover the types of symptoms that are more common in men. Little is known about whether treatment yields comparable results in men and women.

Conclusion: It is important to combat the stigmatization of men with eating disorders and to remove the obstacles to their appropriate diagnosis and treatment. The current methods of screening and diagnosis need to be adapted to take account of the special aspects of abnormal eating behavior in men. It remains unclear whether and how the disorder-specific treatment of these conditions in men should differ from their treatment in women.

The treatment of eating disorders presents an increasing challenge to the public healthcare system. The most common forms of disordered eating and weight control behaviors are binge eating disorder (BED), bulimia nervosa (BN), and anorexia nervosa (AN) (Table 1). These forms are characterized, for example, by a distorted perception of body image, restricted eating, eating binges, self induced vomiting, misuse of laxatives, or excessive sports activity (1). Persons who are affected will suffer substantial physical and mental impairments (2), partly as a result of comorbid malnutrition, which may exacerbate osteoporosis, for example, or subsequent to obesity which, for example, increases the risk of diabetes. Underweight, overweight, or drastic changes in weight can be a reason to suspect eating disorders but are not necessary characteristics or reliable indicators.

Table 1

Criteria for anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder, and muscle dysmorphia

In the public’s perception as well as in specialized circles, eating disorders are traditionally viewed as disorders affecting women (3), but pertinent review articles have clearly shown that they also occur in men and that the evidence is limited (4, 5, 6). For this reason it is important that doctors of all specialties are informed about eating disorders in men and acquire basic competencies for tackling these adequately/appropriately. This review article summarizes from a clinical-scientific perspective selected events and unanswered questions regarding the specific symptoms, the diagnostic evaluation, and the treatment of men with eating disorders.

Method

We undertook a selective literature search in PubMed for studies published in German and English that appeared between January 2000 and May 2023, using the search terms “eating disorders AND (men or male)”. We gave preference to systematic reviews, meta-analyses, and controlled trials that focused explicitly on eating disorders in men.

Furthermore we included relevant studies on the prevalence of eating disorders, relevant studies from our working group, and the S3 guideline for the diagnosis and treatment of eating disorders. As we are aware of the gaps in the evidence we present a narrative summary of selected results that illustrate the clinical relevance and the need for healthcare provision and research. Where available we report effect sizes (OR, odds ratios) and 95% confidence intervals (in square brackets).

Results

Epidemiology

In contrast to common perception, eating disorders affect not only girls and young women but also older adults, persons in gender and sexual minorities (LGBTQ+ persons), persons in ethnically diverse groups, and men (3). A systematic review of all general population based prevalence studies published between 2000 and 2018 that used validated diagnostic instruments (7), estimated the worldwide lifetime prevalence of eating disorders in men to be 0.2% (anorexia), 0.6% (bulimia), 1.0% (binge eating disorder), and 3.6% (eating disorders not otherwise specified, which do not meet the criteria for the complete picture of other categories). By comparison, women’s rates are 1.4% (anorexia), 1.9% (bulimia), 2.8% (binge eating), and 4.3% (eating disorders not otherwise specified), but according to the Global Burden of Diseases Study (8) the global, age-standardized 12-month prevalence of anorexia and bulimia in men rose to higher values percentage-wise, from 96.7 [69.2; 128.0]/100,000 in 1990 to 117.9 [84.6; 156.1]/100,000 in 2019 (about 22%). In women during the comparison period an increase from 205.8/100,00 to 231.5/100,000 was documented (about 12%) (9). The estimated 12-month prevalence of binge eating disorder in Germany in 2013 was 100/100,000 in men as well as in women (10). The ratio of men:women therefore varies overall between 1:2 and about 1:4. The fact that this ratio is rarely reflected in clinical treatment settings indicates potential under-provision.

Recent data from the COPSY Study (11) have shown an increase in symptoms of eating disorders in boys in Germany as a result of the COVID pandemic (OR 1.75 [1.18; 2.58]) and a decrease among girls (OR 0.45 [0.33; 0.61]. The extent to which the increase in symptoms has led to a differential increase in diagnoses is currently not clear. In the UK, for example, eating disorders fell in boys and rose in girls as a result of the pandemic (12).

For the US, a registry study provides indications of an increased prevalence of eating disordered behaviors in men from marginalized ethnic and cultural groups, especially as regards bulimia (lifetime prevalence in men from a Latin-American background: 1.73% versus Western men: 0.08%) (13). A review of culture-comparison studies concluded that weight control behavior and binge eating affect men from marginalized ethnic groups to a greater extent (14). A further review showed that rates of eating disorders in homosexual or bisexual men are higher than in heterosexual men (15). According to a meta-analysis, symptoms of an eating disorder are more strongly pronounced in trans men than in trans women and cis women (16). The degree to which sociocultural factors entail different risks for eating disorders for men and women is not sufficiently known.

An initial case-control study recently compared the risk of death between men and women over a time period of ca 6–12 years (17). The age and sex standardized death risk (OR) was increased for men with anorexia (4.93 [2.36; 9.07]) and also for women with anorexia (5.29 [4.32; 6.40]), bulimia (1.57 [1.15; 2.09]) und eating disorders not otherwise specified (EDNOS) (1.91 [1.38; 2.59]). Because of the small case numbers in men in the study (188 men versus 5296 women), however, it may be assumed that the death rates in men with bulimia (1.42 [0.39; 3.63]) und EDNOS (1.93 [0.40; 5.65])—which did not reach significance, similarly to those in women—can be explained with the fact that the study was insufficiently powered. The survival period for men with anorexia was shorter than for women.

Symptoms

Disturbances in body schema—that is, a distorted perception of one’s own body—are regularly present in persons with eating disorders. In spite of similar causes of eating disorders in men and women, indications are—according to two narrative reviews—that the extent of body schema disorders and associated dysfunctional behavior patterns are guided by different culturally shaped body ideals (18, 19). While women are thought to be mainly seeking a thinner body (slim figure ideal), men are thought to focus on muscle definition (that is, with a low body fact percentage, but not a classically “thin”) body (mesomorph body type—V shape: broad shoulders, musclebound chest and upper arms, and a narrow waist). Recent network analyses of larger samples from the general population have shown that muscle related attitudes (the desire for more muscle mass) and behaviors (excessive weight training, use of food supplements, and/or anabolic steroids) are associated with symptoms of eating disorders, such as body dissatisfaction, restricted eating, and binge-purge behaviors (20,21). Indications exists that these associations might be more pronounced in men of a homosexual orientation (22). Since these studies had a cross sectional design, however, no conclusions can be drawn about the predictive power of muscle related worries for eating disorder symptoms.

According to comparison studies, a great phenotypic overlap exists between eating disorders in men and so-called muscle dysmorphia (23). Muscle dysmorphia is characterized by the worry of not being muscular enough or the fear of losing muscle mass, even in persons who are objectively muscular (24). Disordered eating behavior can also occur in muscle dysmorphia, but in this scenario the individual obsessive preoccupation with one’s own muscles (not weight) is at the forefront (Table 1).

The clinical relevance of muscle related behavior is also underlined by the retrospective evaluation of the adverse events reporting system of the US Food and Drug Administration. An analysis of 977 reports showed that intake of preparations to build muscle or reduce weight was associated with medical complications (7.6% hospital admission, 1.84% life threatening events, 0.61% death) (25).

Diagnostic instruments

It is often difficult to diagnose reliably eating disorders in men because of the partly differing symptoms and the sliding transition from healthy to pathologic behavior, because many people play sports or exercise, follow dietary rules, or are unhappy about their figure. Currently diagnostic criteria no longer (categorically) exclude men (1), but established German-language screening and diagnostic instruments—for example, the Eating Disorder Examination-Questionnaire (EDE-Q)—are only partially validated for men (26) and mostly do not record the named symptoms that are more common in men (27). A recently published study by Laskowksi et al (28)—the first to investigate the factor structure of the German -language EDE-Q for men with eating disorders—confirmed body dissatisfaction and (more) weight related concerns as independent dimensions, which indicates further causes of body dissatisfaction in men (for example, the desire for a muscular build) that have to date not been reflected here. The EDE-Q and similar instruments can therefore not adequately reflect eating disorders in men (as well as, partly, in women too[29]) and should only be used with relevant reservations. For individual dimensional eating disorder-related questionnaires, more liberal cut-off values for men have been suggested so as to identify suspected cases earlier on (26).

Independently of the need for new and further developments of German-language instruments that considers common symptoms in men, it should be assessed in the individual case scenario whether a specific behavior (for example, undertaking weight training/strength sports, adhering to certain dietary rules) indicates a risk to physical or psychosocial health or a subjective psychological strain that should prompt treatment , and whether the criteria of an eating disorder (Table 1) are met (30).

Treatment

Psychotherapy is generally the most important building block in treating eating disorders. In case of high-grade anorexia and malnutrition, inpatients nutrition management is required (30). Psychotherapeutic approaches with meta-analytically confirmed effectiveness (vis-à-vis “treatment as usual”) are:

• Psychotherapeutic guideline methods, such as cognitive behavior therapy for anorexia, bulimia, and binge eating disorders in adults, as well as bulimia in minors
• Psychodynamic psychotherapy for anorexia in adults
• Family based approaches for anorexia, bulimia in minors.
• Interpersonal therapy for anorexia, bulimia, binge eating in adults.

No indications exist that any specific psychotherapeutic approach is superior (4, 5, 6, 30). Table 2 summarizes the expected effects of therapy for primary outcomes.

Table 2

Therapeutic effects for primary result parameters of psychotherapeutic treatment of anorexia nervosa, bulimia nervosa, und binge eating disorder

The recommendation of the current S3 guideline for the diagnosis and treatment of eating disorders is based essentially on clinical studies, in which—according to our own calculations—men account for about 10.5%, 5%, and less than 1% of the samples with binge eating disorder, anorexia, or bulimia (3). Since to date, only sparse insights exist into the comparability of treatment results in men and women, the question of whether treatment approaches should consider to a greater extent the sex of affected persons and associated symptoms and the etiology remains currently unanswered. A retrospective cohort study by Halbeisen et al (31) recently found in men with anorexia a partially larger reduction in eating related cognitions and a greater normalization of weight (=primary treatment objective in by definition underweight persons with anorexia) than in women. Strobel et al (32) concluded similar results (a higher body weighty at the end of treatment in men with anorexia than in women), with the authors not finding any differences in the remission rates of eating disordered behavior between men and women over the long term (40% men vs 41% women). Men with bulimia over the long term—that is, 1 year after completing specific treatment for eating disorders—had comparable remission rates of their eating disorder (28.6%) as women (25.7%) (33). In men with binge eating disorder, greater normalization of weight was observed (not a central treatment objective in binge eating disorder)and partly a greater reduction in eating disorder related cognitions (31, 34). The extent to which the observed comparability in general and the differences are associated with therapeutic adherence, personality factors, or sex associated physiologic parameters cannot be conclusively assessed because of the lack of relevant studies. Since thus far no indications exist that existing therapeutic services are less effective in men, it seems practical to follow the current guidelines.

Discussion

Eating disorders do affect men, but phenotypic differences between the sexes that are not considered in commonly used diagnostic instruments can hamper an early diagnosis. Effects on care provision and treatment results have not been sufficiently researched because of the lack of primary data. Impressions of affected persons (systematically summarized by Richardson and Paslaki [35) underline the need for paying attention ion a more targeted way to eating disorders in men in healthcare context. The double stigmatization—the shame of the disorder on the one hand and the conflict with masculine identity of the other—makes it unlikely in the medical and therapeutic context that men mention their eating disorder symptoms themselves. Consequently, the challenge for doctors to probe for eating disorders in men, to mention them when suspected, and to refer men to suitable treatment (36) is even greater (case report eBox).

eBox

Case Report of a Patient With an Eating Disorder

Recognizing eating disorders, taking them seriously, and addressing them

Men with eating disorders may attend doctors’ practices for non-specific complaints, such as digestive problems or mood swings (37). If they present with serious weight loss or gain, a notable increase in muscle mass, or excessive amounts of exercise it is recommended to discuss open and in a non-discriminatory way eating behavior, weight, and body, and to take concerns and stresses seriously. Not all criteria (Table 1) have to be met mandatorily to diagnose an eating disorder; one can, for example, diagnose an “Other Specified Feeding or Eating Disorder” [OSFED]). Body mass index (BMI) alone is not a reliable indicator, because even if they have a normal or higher BMI, men (as well as women) can display eating disordered behaviors in terms of food intake and exercise as well as signs of malnutrition. Excessive sport that is practiced in spite of injuries, at inappropriate times, accompanied by neglect of tasks and duties is still more socially acceptable in boys and men than it is in girls and women (38) and can cover up underlying fears about weight and figure/shape (39).

Indications exist that men are tendentially less open than women to the idea of psychotherapy (4). For this reason it is recommended that professional helpers look for options to improve men’s readiness to undergo treatment, for example by:

• Using special skills (for example, self disclosure, normalization of symptoms)
• Linguistic adjustments (using male oriented metaphors, for example, sports based ones)
• Conversational/communication styles that are most appealing to men (for example, et eye level, clear/transparent, task and target oriented) (40).

Qualitative data show that men experience breaking the silence as a relief later on—even though they initially find it disagreeable (35). In the psychotherapy setting one approach may be to raise aspects of sex specific socialization and convictions as regards the term “masculinity” so as to develop an understanding of fundamental convictions and cognitions that sustain eating disordered behavior in men and increase the risk of relapses.

Referral to appropriate support services is required

Treatment should be offered early on in order to prevent a chronic course (30). Referral to appropriate services depends also on the severity of the disorder. In cases where patients do not represent an acute danger to themselves—for example, as a result of extreme underweight, comorbid self-harming behavior, and/or suicidality—outpatient psychotherapy can be initiated. To bridge waiting times, referral to advice centers or local self help groups can be helpful; these are, however, extremely rare to come by for men. Information on such local services can be found on the website of the Federal Centre [sic] for Health Education (BZgA—(www.bzgaessstoerungen.de/hilfe-finden/suche-nach-beratungsstellen) and the Landesfachstelle Essstörungen NRW [the specialist state office for eating disorders North Rhine–Westphalia—www.landesfachstelle-essstoerungen-nrw.de/infothek).

Consider treatment settings

According to qualitative reports, treatment services and information materials for eating disorders are still mostly directed at women (35). Being the only man in a treatment setting may lead to serious reticence in group therapies and foster/facilitate/promote experiences of marginalization (35). Special group therapy services, family sessions for fathers and their sons, and the intentional involvement of female and male friends or men’s partners can contribute to minimizing a feeling of exclusion. The empirical evidence for creating such typically male treatment services is lacking, however. To shape information provision, psychoeducation, and treatment context in a way that is accessible to men should, however, become more of a given in view of increasing case numbers.

Conclusions

Although eating disorders in men are increasingly finding attention, more research is needed of the development, diagnosis, and treatment in men. We also need a public discourse on the topic eating disorders in men so that information can become more accessible and stigma can be reduced. An inclusive approach that takes those affected seriously as unique individuals might lower barriers to treatment. Furthermore, more research is needed that includes the perspectives of men from diverse backgrounds—among others, regarding ethnic-cultural belonging/identity, sexual/gender identification, and sexual preferences.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 21 June 2023, revised version accepted on 9 November 2023.

Translated from the original German by Birte Twisselmann, PhD.

Corresponding author
Prof. Dr. med. Georgios Paslakis, MBA

Universitätsklinik für Psychosomatische Medizin und Psychotherapie

Medizin Campus OWL, Ruhr-Universität Bochum

Virchowstraße 65, 32312 Lübbecke

Cite this as:
Halbeisen G, Laskowski N, Brandt G, Waschescio U, Paslakis G: Eating disorders in men—an underestimated problem, an unseen need. Dtsch Arztebl Int 2024; 121: 86–91. DOI: 10.3238/arztebl.m2023.0246

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