THE COMMON PERCEPTION might be that eating disorders tend to mostly be overwhelmingly experienced by women – but that’s not the case.

According to the Health Research Board’s (HRB) 2020 hospital admissions report, 13% of adult admissions due to an eating disorder were males. And studies have shown that men may account for 25% of those suffering from anorexia or bulimia nervosa.

And a report published by the Irish Medical Journal showed that between March and September 2020, 40% of patient hospital admissions suffering from an eating disorder were male, “considerably higher than any other year”.

So why the gap, and why are men under-presenting? Dr Ciara Mahon, a postdoctoral researcher in the Youth Mental Health Lab at University College Dublin, told The Journal that she has found the secretive nature of eating disorders paired with the stigma surrounding male eating disorders has left men showing low levels of “help-seeking tendencies”.

“An eating disorder likes to maintain itself, so it drives the secrecy,” she explained. “And that can be really hard for families as well, because oftentimes there’s this denial that there is an issue.”

With mental health difficulties in general, reaching out and asking for help, it tends to be something that is not as done by men. They struggle to show any sign of weakness or vulnerability.

While increased awareness of mental illnesses has somewhat destigmatised the idea of men seeking help. Dr Mahon believes Irish culture hasn’t “quite reached that point for eating disorders”.

“The stigma and shame currently associated with mental illnesses are magnified with eating disorders,” she said.

“There are men in our society living with disordered eating patterns, but they’re not presenting clinically and think that seeking help for a seemingly ‘effeminate’ disorder conflicts with their masculinity. So they may feel that they have it under control or that they can manage it without clinical intervention, which is nearly never the case,” she said.

In a 2016 report using a sample of adolescent boys with eating disorders, 52% of those surveyed showed vital physical signs that met the criteria for urgent medical admission.

This high level of acute medical complications in males with an eating disorder is indicative of their delayed treatment seeking.

Speaking to Bodywhys for Eating Disorder Awareness Week 2021, Cormac Ryan, a former Dublin hurler, and mental health/eating disorder advocate recalled reaching his “breaking point” after years of disordered eating.

“I wish I could say I held my hand up early and took the brave step but I only sought help when I fell over,” he said.

Mark Smyth, a clinical psychologist who works primarily with adolescents, highlighted the importance of diagnosing an ED before it fully manifests and takes hold, noting that the longer an ED goes untreated, the poorer the prognosis.

“By the time men with an eating disorder seek treatment or a loved one expresses concern, a lot of damage medically can be done in terms of the body from being deprived of necessary food nutrients for such a prolonged period of time,” he said.

Adam Fare, who has advocated greater awareness of eating disorders in males after developing an eating disorder at the age of 12, stressed the importance of developing “support networks” around men.

“We should be actively checking our friends to see if they’re struggling with their eating because they often don’t know they are until they are in a crisis.”

“If you notice any problematic changes in someone’s actions or what someone’s doing, that’s the time you should intervene,” he advised.

Unfortunately, due to the secretive nature of eating disorders and men’s unwillingness to recognise or seek immediate help for their disordered eating, greater responsibility must fall upon loved ones and health care professionals to educate themselves and highlight the physical and behavioural signs that someone may be engaging in disordered patterns of eating or exercising.

Males with anorexia nervosa carry a sixfold higher risk of premature death compared to the general population.

They face a myriad of medical complications associated with disordered eating patterns, compulsive exercise, and low help-seeking tendencies.

These complications, if left untreated, can have fatal consequences.

Health risks

While research on the subject is minimal, eating disorders have been found to most notably affect the cardiovascular system and bone health.

In the 2016 report that used a sample of adolescent boys with eating disorders, 39% were bradycardic.

Bradycardia, which is characterised by a slower than normal heart rate, has also been reported among adolescent men with muscularity-orientated disordered eating patterns and instances of excessive exercise.

The report also found that while the median BMI of the subjects was “relatively high” at 88.8%, the mean percentage of body weight lost was 20.0%, “consistent with severe malnutrition”.

Adam Fare recalled that his heart rate was as low as 30 beats per minute for a period of two and half years. Doctors consider a low heart rate to be roughly 60 beats per minute.

“I’ve been diagnosed with atypical anorexia and the only difference between atypical anorexia and anorexia is someone’s body weight and BMI. Same illness,” he said.

“I was really really unwell at what would be classed as a ‘normal’ body weight.”

Males with eating disorders have also been found to display severe skeletal and bone deficiencies, most notably shown by low levels of bone mineral density.

Prolonged periods of low bone mineral density can lead to osteoporosis, a bone disease that is often associated with a decrease in bone strength that can increase the risk of fractures.

These deficiencies are mainly due to the adverse effect eating disorders have on testosterone levels. Testosterone, a male sex hormone, plays a significant developmental role in the body, and is essential in regulating bone mass as well as muscle size and strength, fat distribution and sex drive.

Deficiencies in testosterone also hinder the process of masculinisation in adolescent boys during puberty, which can lead to developmental issues.

Fare noted his deficiency lasted five years during an important developmental stage in his life. “I’ve never properly developed as an adult, and I never will. So I’ve got huge physical effects because of it.”

While these physical factors contribute to eating disorders having the highest mortality rate of all mental illnesses, psychological issues associated with eating disorders actually pose a greater threat.

According to the HSE, 20% of those suffering from an eating disorder die by suicide.

Parents and loved ones

Shutterstock / Olegs Ri Shutterstock / Olegs Ri / Olegs Ri

Bodywhys has developed extensive resources for parents, general practitioners and dentists. In its parental resource, Bodywhys highlighted the need for “parental support to be forthcoming,” if their son displays any disordered eating patterns.

They also stressed the importance that “the eating disorder is acknowledged as being a serious issue as opposed to a phase of any sort”.

For parents and loved ones, multiple behaviours are outlined that may help raise suspicion that an eating disorder is present.

Joanna Fortune, a clinical psychotherapist with over 15 years of experience working with children and adolescents, noted that while they may not in and of themselves indicate that something is wrong, parents and loved ones must be vigilant to “patterns of disordered behaviour”.

These disordered behaviours can manifest in many different ways depending on the condition and are very individualistic in nature.

Fortune found in patients suffering from bulimia, a loved one should raise concern if someone is immediately leaving the table after eating or going to the bathroom following a meal.

In her work, Fortune also looks for sudden and dramatic changes in eating behaviour, like imposing dietary restrictions on certain foods.

“Those suffering might say ‘Oh, I’m gonna go vegetarian, or I’m gonna go vegan, or I’m gonna do this healthy eating plan, I’m going to eat protein only and start using supplements, or I’m going go keto’,” she said.

I’m not saying changing your diet or exercise patterns to try and be healthier always leads to the development of an eating disorder and I’m certainly not demonising exercise, but if it’s a very sudden and drastic change, it could be perceived as a red flag, especially if someone displays visible anxiety about maintaining them.

This anxiety about maintaining exercise and diet plans can often become clear when a loved one continues to excessively work out, or exercises despite being sick or injured.

A 2014 study found that 67% of avoidant/restrictive food intake disorder (ARFID) diagnoses were accounted for by males.

ARFID, once referred to as Selective Eating Disorder, is characterised by highly selective eating habits, which some may incorrectly classify as “picky eating”.

While the condition is more common in children, it can manifest itself in adulthood and exhibits many of the compulsive behaviours seen in anorexia, bulimia, and muscle dysmorphia.

She also urged loved ones to be “watch for any abnormal rituals around eating.”

She said: “If they have to eat at a certain place or they have to be sitting at the same seat, or meals have to be eaten at an exact time every day, they have to eat alone, not with family – things like that are significant”.

Male eating disorders have been intrinsically linked to excessive compulsive exercise and muscle dysmorphia as well as restrictive eating, something parents must also look out for.

In cases of muscle dysmorphia, those suffering compulsively strive for traditionally male-centric body ideals, like a lean, low-fat build with high muscle mass and definition, and are often never satisfied with their musculature.

This is in stark contrast to ‘typical’ anorexia and bulimia, in which those suffering often strive to maintain a low body weight or ‘thinness’.

The ideals of muscle dysmorphia sufferers are often pursued through extreme dietary restrictions and excessive exercise. Recent research in Argentina has shown that muscularity-orientated eating disorders are actually rising as rapidly in men as thinness-orientated eating disorders in women.

A 2012 study that compared men with muscle dysmorphia and anorexia found that they demonstrated widespread “symptomatic similarities, spanning the domains of disturbed body image, disordered eating, and compulsive exercise behaviour.”

The only differences they found were consistent with the “opposing physiques pursued in each condition”

Smyth said that if the overexercising “tends to be solely motivated by trying to get down to a specific idealised weight or body shape to an unhealthily obsessive level, there is a problem”.

“Over-exercising, because they fear putting on weight or losing muscle mass is hugely common,” he said.

Fortune added that loved ones must be mindful of when exercise comes from a place of obligation and compulsion, instead of health and enjoyment.

“You need to get curious and think, ‘when did that change?’”

While behavioural patterns can be indicative of an eating disorder, psychological changes can also indicate that something may be wrong.

Smyth highlighted the harmful psychological effects of dietary restriction, citing food as “the body’s main source of energy that is essential in managing emotion”, adding that malnourishment due to an eating disorder can lead to “severe emotional dysregulation”.

In young boys especially, you may notice an increase in irritation and emotional distress, they will be more irritable, especially if confronted about their eating.

Poor levels of concentration is also something to look out for.

Dr Mahon highlighted that “all or nothing, black and white” thinking can also be seen in those suffering from an eating disorder.

“There’s no middle ground, no negotiation at all.”

She added that the feelings of secrecy, distress and shame associated with an eating disorder can also lead to higher instances of social isolation.

 A 2017 report also found that, for example, men suffering from muscle dysmorphia displayed “significantly less desire for social interactions,” due to their anxiety around social comparisons.

This often manifests in men sacrificing their social lives and career obligations to maintain their workout routine or dietary restrictions.

“Someone who may have previously been social, confident and outgoing might withdraw into themselves and not want to talk or engage in social activities that they used to. And again, eating disorders are kind of these isolating things, so people often can pull back from family and friends as well,” Dr Mahon said.

Physical effects

The physical and medical symptoms and effects of eating disorders, especially in men, are often difficult to identify.

Males visiting a GP will most likely exhibit presentations other than the eating disorder itself, but these presentations may be medical complications or symptoms of an underlying eating disorder

When symptoms are identified, it can often prove even more difficult to ascertain that disordered eating patterns may be the cause.

This can often lead to a misdiagnosis.

In its 2006 report ‘A Vision for Change’ the HSE described GPs in community-based primary care as “gatekeepers” to the mental health service.

This means that GPs are essentially the first line of defence when it comes to eating disorder detection and diagnosis, and must be extremely vigilant to the physical and medical signs that are indicative of an eating disorder.

While significant weight loss is cited as a main indicative factor that a patient may have an eating disorder, men’s tendency to develop ‘atypical’ eating disorders means that this may not be as effective.

In Bodywhys’ resource for general practitioners, they outline various medical symptoms that patients may present to their GP, that may be associated with an eating disorder.

1 in 2 cases of binge eating disorders are men, meaning that fluctuations in weight, be it loss or gain can be a warning sign for both loved ones and medical professionals.

Patients with cardiovascular-related symptoms like chest pains, numbness, heart palpitations, dizziness when performing certain movements and shortness of breath, or gastrointestinal discomfort or constipation may also be of concern.

Frequent fractures, loss of sex drive, erectile dysfunction, or stunted growth in adolescents as mentioned earlier, can also be indicative of low testosterone levels and may be the result of an eating disorder.

Taking an inquisitive approach

Joanna Fortune stressed that if suspicion is raised regarding the presence of an eating disorder in an individual, both loved ones and medical professionals must proceed with extreme care and caution.

“It’s important to take an inquisitive stance. Because again, they will be slow to talk or open up or even try to dismiss it and play it off as something else,” she said.

In her work, Fortune tries to “connect with the person behind the eating disorder” noting that defining patients by their disorder can prove problematic, especially when the condition is stigmatised.

“Something that comes up a lot in my work are people with eating disorders who are like, nobody thinks about me, I don’t even know who I am anymore,” she said.

“You need to know and understand the person to understand what’s underpinning and driving the overt behaviour of restricted eating or excessive exercise, or whatever the disordered pattern is. Whether your a parent, loved one, or doctor who is trying to express concern, you have to build that connection and a trust-based way of working.”

If you are struggling with your body image or the themes of this article affected you, call the Bodywhys – the Eating Disorder Association of Ireland Helpline at (01) 210-7906 or email alex@bodywhys.ie.