Males With Restrictive Eating Disorders: Barriers to Their Care

Abstract

See Related Article p. 397First described as “Anorexia Hysterica” in 1873 by Sir William Gull, anorexia nervosa was reported as occurring mostly in young women. Males were not mentioned in the description of this disease, and the teaching was that anorexia was a disease of females [[1]Zhang C. What can we learn from the history of male anorexia nervosa?.J Eat Disord. 2014; 2: 138-141Crossref Scopus (9) Google Scholar]. There were few articles describing anorexia in males for more than one century [2Carlat D.J. Camargo C.A. Herzog D.B. Eating disorders in males: A report on 135 patients.Am J Psychiatry. 1997; 154: 1127-1132Crossref PubMed Scopus (370) Google Scholar, 3Darcy A.M. Doyle A.C. Lock J. et al.The eating disorders examination in adolescent males with anorexia nervosa: How does it compare to adolescent females?.Int J Eat Disord. 2012; 45: 110-114Crossref PubMed Scopus (89) Google Scholar, 4Shu C.Y. Limburg K. Harris C. et al.Clinical presentation of eating disorders in young males at a tertiary setting.J Eat Disord. 2015; 3: 39-46Crossref Scopus (12) Google Scholar]. The DSM-IV had a diagnostic criterion for amenorrhea without a comparable medical criterion for males leading to confusion among clinicians although this criterion is now eliminated in DSM-V. See Related Article p. 397 Males with a restrictive eating disorder are reported to be seen infrequently in most clinical settings—at least in comparison to females with the same disorder—even though there is a reported 3:1 lifetime prevalence estimate of DSM-IV anorexia nervosa in women compared to men [[5]Hudson J.I. Hiripi E. Pope H.G. et al.The prevalence and correlates of eating disorders in the national comorbidity survey replication.Bio Psychiatry. 2007; 61: 348-358Abstract Full Text Full Text PDF PubMed Scopus (3339) Google Scholar]. In a population-based sample of twins in Sweden, the prevalence of individuals who met full DSM-IV criteria for anorexia nervosa was determined; e overall prevalence was approximately four females for every male participant [[6]Bulik C.M. Sullivan P.F. Tozzi F. Prevalence, heritability, and prospective risk factors for anorexia nervosa.Arch Gen Psychiatry. 2006; 63: 305-313Crossref PubMed Scopus (409) Google Scholar]. In our division, there are about 20 females seen for restrictive eating disorders compared to each male evaluated. So where are the males with restrictive eating disorders? We suggest they are flying under the radar; we are missing the cues, not asking the right questions nor pursuing the leads. These male patients are going undetected, and some are not presenting for care. We, as well as those who interact with these individuals, are not raising awareness of an eating disorder nor recognizing it. As a result of their lack of diagnosis or care for such eating disorders, male patients may not benefit from gender-specific improved diagnostics, treatment, and prevention strategies as well as inclusion in research studies. In this issue of the Journal of Adolescent Health, Vo et al. [[7]Vo M. Lau J. Rubinstein M. Eating disorders in adolescent and young adult males: Presenting characteristics.J Adolesc Health. 2016; : 397-400Google Scholar] have determined medical criteria that will help break down one barrier to care. The investigators have performed a retrospective chart review of males with restrictive eating disorders ages 11–25 years at first presentation to an outpatient eating disorder program. The mean percent of the median body mass index of the study patients was 88.8% as almost half of the patients had a history of being overweight or obese. Studying vital signs and certain laboratory tests in this group, the most impressive abnormality was bradycardia. The authors report, on average, that the patients were bradycardic. As for laboratory work, one third of the patients tested had a low hematocrit. These findings—bradycardia and an abnormal hematocrit—have been confirmed in a retrospective study at this hospital of adolescent males ages 12–21 at first presentation to the inpatient or outpatient service with a restrictive eating disorder. The practicality and importance of these findings should not be underestimated: by obtaining a standard vital sign—the pulse rate—a flag could be raised in those males who may not appear malnourished nor may not wish to disclose eating disorder behaviors nor recognize that they may have an eating disorder. There is nothing easier to perform nor less invasive than to take vital signs. For the clinician who may not recognize patient behaviors, symptoms or signs suggestive of an eating disorder, bradycardia is now a waving red flag that should lead to further evaluation. That said, the lack of bradycardia at presentation should not be viewed as a sign that a restrictive eating disorder is not present. Vo et al. have helped to remove a barrier to diagnosis, and they have performed a great service to these patients. Once there is confirmation of a restrictive eating disorder in males, treatment options are limited especially for residential-based programs. Although 100 percent of such programs in the United States accept females, only about 20 percent also accept males with a much smaller subset offering male-only treatment groups [8Frisch M.J. Herzog D.B. Franko D.L. Residential treatment for eating disorders.Int J Eat Disord. 2006; 39: 434-442Crossref PubMed Scopus (60) Google Scholar, 9Weltzin T.E. Cornella-Carlson T. Fitzpatrick M.E. et al.Treatment issues and outcomes for males with eating disorders.Eat Disord. 2012; 20: 444-459Crossref Scopus (48) Google Scholar]. In addition, while intensive outpatient and partial hospitalization programs that include males are more readily accessible, most groups are predominately composed of females. Males can feel uncomfortable in such settings given their significantly different experiences regarding body image, sexuality, comorbid conditions as well as coping mechanisms and means of expression. Given these gender differences, it is beneficial to allow males the opportunity to discuss such topics in a single gender setting with a more behavioral and active approach to group therapy [[10]Strother E. Lemberg R. Stanford S.C. et al.Eating disorders in men: Underdiagnosed, undertreated, and misunderstood.Eat Disord. 2012; 20: 346-355Crossref PubMed Scopus (249) Google Scholar]. In addition, there is a paucity of research regarding the medical complications of eating disorders in males such as bone density issues. The first and only case-controlled study of this issue demonstrated decreased bone mineral density at multiple sites as measured by Z-scores in adolescent males with anorexia [[11]Misra M. Katzman D.K. Cord J. et al.Bone metabolism in adolescent boys with anorexia nervosa.J Clin Endocrinol Metab. 2008; 93: 3029-3036Crossref PubMed Scopus (111) Google Scholar]. However, a clinical treatment trial for this issue was suspended at this hospital due to lack of enrollment [[12]Massachusetts General HospitalThe effect of testosterone replacement on bone mineral density in boys and men with anorexia nervosa.in: ClinicalTrials.gov [Internet]. National Library of Medicine (US), Bethesda (MD)2000http://clinicaltrials.gov/show/NCT00853502Google Scholar]. This is in stark contrast to the growing body of literature describing low bone density in females with restrictive eating disorders and exploration of treatment modalities such as estrogen, insulinlike growth factor, dehydroepidandosterone, and bisphosphonates [13Misra M. Klibanski A. Anorexia nervosa and bone.J Endocrinol. 2014; 221: R163-R176Crossref PubMed Scopus (106) Google Scholar, 14Gordon C.M. Grace E. Emans S.J. et al.Effects of oral dehydroepiandrosterone on bone density in young women with anorexia nervosa: A randomized trial.J Clin Endocrinol Metab. 2002; 87: 4935-4941Crossref PubMed Scopus (208) Google Scholar]. One can hope that this study by Vo's group will herald increased recognition of males with restrictive eating disorders ultimately allowing for improved access to this population of appropriate research studies. And finally, most successful eating disorder prevention programs geared toward females focus on perceived pressure to be thin, body dissatisfaction, and the cultural thin ideal [[15]Ciao A.C. Loth K. Neumark-Sztainer D. Preventing eating disorder pathology: Common and unique features of successful eating disorders prevention program.Curr Psychiatry Rep. 2014; 16: 453-476Crossref Scopus (79) Google Scholar]. These approaches would not necessarily be efficacious for males. Rather, it is suggested that eating disorder prevention programs for males focus on lowering levels of body dissatisfaction addressing subjects such as body size and shape, muscularity as well as other physical areas of concern [[16]Dakanalis A. Zanetti A.M. Riva G. et al.Male body dissatisfaction and eating disorder symptomatology: Moderating variables among men.J Health Psychol. 2015; 20: 80-90Crossref Scopus (63) Google Scholar]. Vo et al. have begun to dismantle the barriers to services for males with restrictive eating disorders. Now it is up to each of us in our clinical, research, outreach, advocacy, and educational roles to continue to remove the disparities to these patients' care. Eating Disorders in Adolescent and Young Adult Males: Presenting CharacteristicsJournal of Adolescent HealthVol. 59Issue 4PreviewData on the clinical characteristics of adolescent males with eating disorders are limited. The purpose of this study was to describe the demographic characteristics, presenting vital signs, laboratory results, and relevant risk factors for eating disorders among males presenting to an outpatient adolescent and young adult medicine practice. Full-Text PDF