If your image of a teenager who is at-risk for developing an eating disorder is an affluent, caucasian girl who gets good grades, is a dancer (maybe a gymnast), and likes to be "perfect," it's no wonder—this is often the image the media portrays. But these preconceived notions may be causing parents to dismiss harmful signs of disordered eating in their sons.
"In reality, eating disorders can affect persons of all races, ethnicities, genders, and across socioeconomic strata," says Jason Nagata, M.D., MSc, assistant professor in the division of adolescent and young adult medicine at UCSF Benioff Children's Hospitals. An often-cited statistic states that approximately 10 percent of those treated for eating disorders are male. Many experts, however, believe that as many as 25 to 40 percent of people with eating disorders are males, according to the National Association for Males with Eating Disorders.
Why the disconnect?
"Eating disorders in males are often overlooked or misdiagnosed by clinicians," says Rebecca Rialon Berry, Ph.D., clinical assistant professor in the department of child and adolescent psychiatry at the NYU Child Study Center at Hassenfeld Children's Hospital at NYU Langone. Boys and men may also be less likely to seek treatment. "Because of the stigma placed on mental health issues and the thought that 'eating disorders are for girls,' teen boys may resist coming to see me," says Sarah Gleason, RD, LD, CEDRD, an eating disorders dietitian in Saint Charles, Missouri.
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Another challenge is that eating disorders often present differently in boys than in girls; as a result, their behavior may be seen as normal or even healthy by the adults in their life. In girls, eating disorders tend to be focused on weight loss; for boys, the goal may be the opposite. "The idealized body image for many boys is big and muscular, which may lead to disordered eating behaviors to build muscle," says Dr. Nagata, though eating disorders do occur in boys looking to lose weight as well.
Even doctors may have trouble when it comes to diagnosing eating disorders in boys. "Many assessment tools that are currently standard practice to diagnose eating disorders are geared toward females and based on weight loss behaviors with the goal to be thin," says Dr. Nagata. Up until recently, the criteria to diagnose anorexia nervosa even included "loss of menstrual" periods—a biologically impossible criteria that kept males from getting a proper diagnosis.
Who's most at risk?
The types of eating disorders that boys are susceptible to vary. "Teenage boys can experience anorexia nervosa, bulimia nervosa, binge eating disorder (BED), and muscle dysmorphia," says Dr. Nagata. And while anorexia and bulimia are far more common in females, that's not true across all types of eating disorders. "Males make up about 40 percent of individuals with BED," says Dr. Berry. Muscle dysmorphia, or the preoccupation that one's body is not lean or muscular, is a far more common issue in males. Around 60 percent of teen boys reported frequently using muscle-enhancing behavior, finds a study from the University of Minnesota; researchers noted muscle-enhancing behavior across all ethnic, socioeconomic, and social groups across twenty schools. A 2019 study published in the International Journal of Eating Disorders found that 22 percent of male young adults reported disordered eating behavior focused on muscle gain.
Some boys are at higher risk than others, experts say, though no one is immune to the possibility. Athletes, in general, are at an increased risk, particularly those who participate in sports that promote bigger and more muscular bodies like football, or with weight cutoffs like wrestling. Being on a team, however, is not the only risk. "Teenage boys who have been teased for overweight are at a higher risk for disordered eating behaviors for weight loss such as vomiting, fasting, skipping meals, and using laxatives or diuretics," says Dr. Nagata.
Signs of eating disorders in boys
"As a general rule, I encourage parents and caregivers to look for significant changes in their child's behaviors and attitudes around eating or with their mood, like increased irritability or anxiety about eating, and for disruption in activities of daily living or traditional routines or social activities," says Dr. Berry. Here are some specific red flags experts suggest looking out for:
- Excessive focus on time spent exercising, particularly if using exercise to compensate for food he's eaten
- Changes in attitude around foods he used to enjoy
- Elimination of certain food groups from his diet
- Eating larger amounts of food than usual
- Increased preoccupation with cooking shows, recipes, or a need to prepare his own meals
- Going to the bathroom in the middle of meals, or right after; this may be a sign of purging
- Obsessively reading nutrition information or counting calories
- Constantly weighing himself or looking in the mirror
- Avoiding social gatherings involving food, including family meals or eating at restaurants
- Stressing out over missing a workout
- Exercising even when injured
- Using anabolic steroids or growth hormones
- Feeling weak or tired
- Preoccupation with size, weight, or appearance in a way that worsens his quality of life
What to do if you suspect disordered eating
For starters, let your child's doctor know if you have concerns—and be specific. Your pediatrician may not ask about or notice your son's muscle-enhancing or weight-loss behaviors. Alert her if you have concerns. "Parents should raise these issues with a healthcare provider who may be able to assess for an eating disorder and provide appropriate referrals," says Dr. Nagata. Another resource is the National Eating Disorders Association helpline (1-800-931-2237), which can also provide guidance.
Once you're connected with the right mental health professional, he or she will likely work with your son using therapeutic interventions and family-based treatment to establish an environment that supports healthy eating habits and body image. "I help males work toward changing their body image ideal through forming a new understanding of masculinity and placing more value on personal qualities rather than appearance," says Dr. Berry. Research shows that boys and men respond well to the same eating disorder treatments that have been successful for females, Dr. Berry adds, however, it's helpful to look for a practitioner who has experience with and can address issues specific to boys.
A qualified registered dietitian (RD or RDN) who specializes in eating disorders is another important part of the care team. He or she will focus on the physiology of the growing body to help the child and family understand nutrient needs. "I emphasize that eating behaviors may be "helping" underlying anxiety, depression, or OCD, but the body and brain need food to survive and thrive," says Gleason. A dietitian will also look at eating patterns to help the family strategize balanced meals, or even (pending your family's permission) work with school staff to get them on board with scheduling a snack break or other needs your child may have during the day.
It's not always easy to spot an eating disorder, even when you know the signs. In moderation, some behaviors to lose weight or build muscle may not be "disordered," says Dr. Nagata. But when these behaviors lead to psychological distress, preoccupations, or obsessions, that can snowball into an eating disorder. Check in with your child's healthcare provider to determine how to respond to any changes you see in your son, and always discourage extremes when it comes to diet and exercise—for your child and yourself.