Men and Anorexia Nervosa

This story aired very recently on MSNBC--take a look:



Eating disorders are, for the most part, still mainly thought of us a female issue.  However, according to statistics in the 1990's up to 10% of those suffering from an eating disorder were male (around 1 million people), and now it is estimated that number is up with men making up to 25% of all eating disorders.  This is not a small number, and if you have not yet run across it in your school, chances are good that at some point in your career, you will.

What is Anorexia Nervosa?  It is a disease in which a person limits their food intake and often increases their exercise regime, both to an obsessive and compulsive degree, such that they ultimately lose so much weight that not only do they endanger their mental health, but their physical health, as well.  Further, they themselves have very skewed perceptions of how they look, often believing that they are somehow still "too fat," even if they are clearly extremely underweight.  If we look to the DSM-IV-TR, the diagnostic criteria are as follows:

• Refusal to maintain normal body weight, typically indicated by weighing less than 85% of the standard normal body weight for someone of their height and age.
• Intense fear of gaining weight or of becoming fat, even though they are underweight.
• Body weight and size make up the whole self-worth of the person and there are denials of the seriousness of their low weight.
• In postmenarcheal females, an absence of at least three menstrual cycles in a row. (APA, 2000)

These criteria help to identify women with anorexia nervosa, but men are a bit different.  First of all, Criterion D, the missing of menstrual cycles, does not apply to men.  Further, Criterion B, the intense fear of gaining weight, while applicable to some men with anorexia nervosa, is not indicative of how the disease will manifest itself in all:

"Experts say that males with eating disorders tend to obsess over particular body types, rather than weight, and that these types can vary drastically. One may want to be lean, another extremely muscular." (source: www.eatingdisordershelpguide.com/males-boys.html

"You rarely hear from guys about clothes size. The majority of guys I've treated with anorexia say to me, with a straight face, 'I will gain as much weight as you want me to gain, as long as it's muscle,' "--Dr. Ted Weltzein, medical director of eating disorder services at Rogers Memorial Hospital in Wisconsin. (source: www.parentdish.com/2010/12/30/male-anorexia-one-boys-story/)

In other words, guys are more likely to be concerned that they are not bulking up enough or developing that tight swimmer's build more than on the numbers on the scale.  The possible exception, according to the article above, are some gay males, due to the fact that they have similar social, media, and image pressures to those of women.  Additionally, because eating disorders, in general, are thought of as primarily occurring in women, they often go undiagnosed in boys.  Rather, it is often instead classified as depression because of the loss of weight and low-self esteem.  This story from the BBC discusses this concern:

Thus, there are some slight differences between how anorexia nervosa will present between men and women.  However, the root-causes and underlying issues of the disease are the same for both genders.  First, perfectionism to the point of obsession, although with boys it is often with their athletic prowess more so than their grades.  Secondly, extremely low self-esteem and self-worth, which can often be misdiagnosed as depression.  Because of the prevailing attitude across society that eating disorders are strictly women, it is extremely important for school counselors to be aware of the fact that men are also susceptible and to notice the warning signs.  It is not our job to diagnose, and it is certainly not within our expertise to treat, but we, in conjunction with our colleagues, can often begin to notice the symptoms and share our concern with the student and their families.

The challenge can be deciphering what may be a warning behavior in a student and what is just normal adolescent development or healthy concern about maintaining weight and physique for athletic teams or events.  Considerations:

• Weight-loss:  If the weight-loss is associated with a growth spurt, it may just be normal development.  If the weight-loss is associated with an increase in physical activity, such as joining a school team or a performing group that involves a lot of dancing, it may simply be indicative of that.  If, however, there is extreme weight-loss over a relatively short period of time with no noticeable cause, it may be worth asking some questions to gather more information.  It may not be an eating disorder and could indicate another medical problem, but it is worth checking out.
• Obsessions and changes in social behaviors:  You have a young man who has always been interested in sports and working out.  However, as of late, wrestling is all he can talk about, and when he talks about it, he is constantly worrying about staying within his weight class as well as his muscle development.  Further, some of his friends have come to you because he has almost disappeared from their lives, preferring instead to work out and train more, even in the evenings and on weekends.  This is worth gathering more information about.  It is normal for kids to become more focused on sports during a particular season and this can often mean spending less time with friends or on other activities.  However, if it seems to be heading to an extreme, it may be time to check in with the student and their family.
• Eating habits:  These can be harder to evaluate, especially as they get older and are less supervised for things like lunch.  More often than not, I get reports from other students who are worried about their friend and how they seem to have stopped eating.  This may be a time to just take a walk around the lunch room to make your own observation, as well as talk to the student.  Some students just become more health conscious during adolescence and are more particular about what they eat and put into their bodies.  Some students won't eat at school but grab something on their way home, especially if they have early lunch times.  However, if you and others (students, faculty) notice extreme weight-loss combined with a lack of eating, it may be worth sharing some concerns with the family.

How do you start these conversations with students and their families?  Very carefully.  If I've been given concerns about a student from teachers or from students, or if I myself have become worried about a student, I usually ask the student about behaviors and health.  How are you sleeping?  When are you studying?  Do you feel tired a lot? Are you eating breakfast?  Lunch?  Dinner?  What is your exercise routine?  Surprisingly, most of the time the students are fairly honest.  Depending on the level of concern, I may ultimately discuss the situation with the family.  Here is it vitally important to just focus on your observations and the behaviors of the student--do not diagnose and say "your child has an eating disorder."  Instead, express your concern about the weight loss, the extreme work-outs, social changes, and/or feelings that may have been expressed about perfectionism and needing to look a certain way.  The family may give you some information that explains everything, they may share in your worry and want to talk about where to go next, or they may be completely unaware.  It is fine to recommend then that they see a physician to further address the issues involved.  In talking to both students and their parents about this situation, be prepared to meet with some resistance.  Again, eating disorders are still thought of as primarily afflicting women, and if boys are working out and focusing on building muscle-mass to perform better in sports, this may not be seen by many as a concern but rather something to be encouraged.  It may take time and several attempts to help bring the issues into focus.

There are plenty of resources out there for you to gather more information.  I would highly recommend checking out the National Eating Disorders Association website.  They have multiple first-person accounts from men who have suffered from anorexia nervosa and have gone through treatment.  Troy had to go through treatment twice, and Patrick worked hard to be perfect in all areas of his life--athletics and academics.  Both of these men have turned this disease into a calling, now working with others suffering from eating disorders.  These stories can help you and, if they are willing to accept the resources, your students and families realize that men can also have anorexia nervosa.  Further, there are pages on the website that give not only general facts about eating disorders, but also facts about men and eating disorders.  Additionally, there are now more and more treatment programs that are geared towards men.  In the past, some men would be turned away from support groups as they were all women.  Now, there are multiple treatment options for men, such as this one at Rogers Hospital in Wisconsin.  Finally, there are toolkits for educators, parents, and coaches/athletic trainers, full of information about what eating disorders are, what signs to look out for, and where to point students and families when they need help.  Consider sharing these with your counseling colleagues, teachers, and athletic personnel either through e-mail, at a faculty meeting, or at an in-service so that the entire school community can be aware of the signs and the issues.

The following source was cited in this entry:
American Psychiatric Association. (2000).  Diagnostic and Statistical Manual of Mental Disorders (4th ed. text revision).  APA: Arlington, VA.