Assistant Professor Jason Nagata Thanks so much  for the opportunity to talk about eating disorders   in boys and men for Clinicians. As an overview  of today’s talk, I will start with two clinical   cases, then briefly discuss the background,  epidemiology, symptom presentation, assessment,   treatment, medical complications, and medical  guidelines for eating disorders in boys and men. So, let’s start off with a clinical case.  This is a patient who we’ll call Ashley,   a 16-year-old female who described feeling  fat, despite weighing less than 50kg. Her   goal is to lose an additional 15kg  of weight. In order to achieve this,   she would skip breakfast and lunch each day,  restricting to less than 500 calories per day.   And if she consumed more than 500 calories per  day, she would vomit or use laxatives after meals. Ashley’s case illustrates the classic  disordered eating behaviours for weight   loss, which include fasting or skipping  meals, severe restriction of food intake,   vomiting, laxatives and diuretics.  These are some of the classic,   typical weight loss behaviours that  we associate with eating disorders. Next, I want to turn to another case, who we’ll  call Johnny, also a 16-year-old, but he is a male   on the wrestling team, who was referred to our  eating disorders clinic. When we asked him about   all the typical behaviours for weight loss, such  as fasting, restricting, vomiting or diuretics,   he denied all of them. However, his parents report  that he has become obsessed with his appearance,   but in pursuit of achieving muscularity. He  attempts to eat 3,000 calories per day of   mainly protein, egg whites, whey protein powder  and shakes. He’s tried to eliminate fats and   carbs from his diet. In addition to wrestling  practice with the team for two hours a day,   he then goes to the gym to weightlift on this  own for an additional three hours per day. So, what do we call this? Is this  anorexia nervosa? Does Johnny have   an eating disorder? I performed a literature  review on eating disorders in boys and men,   and found that the vast majority  of body image and eating disorder   research is focused on thinness and  weight loss, particularly in females,   but there is – this is very understudied  and under-recognised in male populations. The masculine body ideal has become increasingly  large and muscular. To illustrate this point,   I will cite the work of Harrison Pope at Harvard,  who examined trends in muscularity of male   action figures over time. Here we see Batman and  Superman action figures from prior to 2000. Now,   we see the Batman and Superman figurines  our current children play with. Pope found   that over a 30-year period, boys’ action  figures have become increasingly muscular,   with larger biceps, shoulders, chests and  more defined abdominal and serratus muscles. Social media is also a new phenomenon in the  last decade that has contributed to pressures   for boys’ body image. The limited data that  we know about social media and body image,   particularly in teenage boys and young men, is  that boys are more likely to allow for public   followings, male selfies are more likely to be  full-body photos that show their muscularity,   and the majority of male body image-related  Instagram posts depict muscularity and leanness.   Instagram use in boys and men is associated  with meal skipping, disordered eating,   muscle dissatisfaction, and  use of anabolic steroids. Originally, the Facebook files that were released  by Frances Haugen, in terms of the Facebook   whistleblower, focused on effects of Facebook and  other social media platforms on teenage girls.   But, recently, there’s been more recognition that  these same mechanisms can affect boys and men.   To achieve the idealised muscular body type, boys  and men may engage in muscle-enhancing behaviours,   including protein overconsumption, dietary  restriction of carbohydrates and fats, appearance   and performance-enhancing drugs and substances,  such as anabolic steroids, androstenedione   and creatine, as well as compulsive exercise. Next, I’m going to talk about the epidemiology   of muscle-enhancing behaviours, and how common  these are. In the United States, we surveyed   adolescents and young adults in a nationally  representative sample of 20,000 young people,   and found that, overall, almost 30%, and actually  over 30% by ages 20 to 22, of boys and young men,   report that they’re trying to gain weight or  build muscularity. This is much higher than the   rate in girls. In order to achieve this, many  boys and men, also about 30% by ages 20 to 22,   are engaging in some sort of muscle building  behaviour, which can include working out or   excessive exercise to build muscularity, as well  as supplements and drugs to promote muscularity. Next, I’m going to talk about symptoms  and presentations in males versus females   in terms of eating disorders. So, some  of the most commonly recognised eating   disorders include anorexia nervosa, bulimia  nervosa, and binge eating disorder. However,   there are some special considerations that we  should recognise in the presentation of males   when it comes to these diagnoses. So, first  of all, in anorexia nervosa, there’s a core   fear of weight gain and a drive for fitness. I  think it’s important to note that BMI may not   be as low in males, and so there may be more  in the category of atypical anorexia nervosa. In terms of bulimia nervosa, the  conceptualisation of binge eating   may be that the bin – the objective  binge size could be larger in males,   and males may be less likely to engage in the  typical purging behaviours, such as vomiting,   laxatives or diuretics, but may actually present  more with exercise or muscle-building supplements   as a purging behaviour. And, finally, in  binge eating disorder, the conceptualisation   of the binge size may be larger in males,  and less connected to emotional eating. So, just as a summary, these are the  diagnostic criteria for anorexia nervosa,   and on the right side are some of the unique male  considerations that we’ve mentioned. So, BMI may   not – and weight may not be as low as males,  particularly because many of them are actually   not trying to lose weight, but, in fact, trying to  gain muscularity. And that intense fear of gaining   weight or becoming fat may not necessarily  be in terms of a goal of thinness, but,   in fact, a goal of leanness, as it relates to as  – obscuring one’s muscularity. And then, finally,   in terms of reporting shape or weight concerns,  males may report shape concerns over weight   concerns, particularly given that the thinness  ideal is less applicable to many male populations. In terms of bulimia nervosa, as we mentioned,   the volume of food consumption during  binge eating could be different and even   larger for males relative to females. And it’s  important to note that males may not consider   what their – their binge eating behaviours  as actually binge episodes, they could be   termed “cheat meals” and deemed positive in  the context of muscularity-oriented goals. Excessive exercise is a common compensatory  behaviour in male populations, as well as   appearance and performance-enhancing drugs. And  we’ve already mentioned that for binge eating   disorder, the volume of food consumption  may be larger in males than females,   and they may conceptualise this as “cheat meals.” Finally, I wanted to recognise that many of  the muscularity-oriented disordered eating   behaviours may not actually be captured by our  traditional eating disorder diagnoses. And so,   I think it’s important to realise that to  assess for these behaviours, screen for them,   and recognise that at excess, some of these  behaviours could lead to disordered eating. One other diagnosis that I wanted  to mention is muscle dysmorphia,   which is more colloquially known as bigorexia or  reverse anorexia. This is technically a subtype   of body dysmorphic disorder in the DSM-5, and is  characterised by a preoccupation or obsession with   insufficient muscularity, though in many cases  an individual’s build is objectively normal,   or even muscular. Muscle dysmorphia  is more common in males than females,   and may present with engagement  in muscle-enhancing behaviours. I wanted to briefly overview some assessment tools  that could be used for boys and men in terms of   eating disorders, muscle dysmorphia and related  symptomatology. One thing to note is that many   of the measures that were developed for eating  disorders were originally designed for female   samples. And so, some options are to modify  existing measures to be more appropriate for   males, using traditional measures, but being  aware of potential bias or incompleteness,   and then using some of the few  measures that have been developed   specifically and validated for both males  and females, and using some in combination. So, in terms of assessing  eating disorder symptoms,   the – perhaps one of the most commonly using –  used measures is the Eating Disorder Examination   Questionnaire. I also wanted to note  that the Muscularity Oriented Eating   Test was designed specifically to measure  muscularity-oriented eating concerns,   which may not be captured in the Eating Disorder  Examination. In terms of body image related   measures that are applicable to males, there is  a Male Body Attitudes Scale, as well as a Drive   for Muscularity Scale, which can capture some of  those unique phenomenon in males. Then, finally,   in terms of assessing muscle dysmorphia, two  measures that have been designed to assess   this is – are the Muscle Dysmorphic Disorder  Inventory and the Muscle Dysmorphia Inventory. Next, wanted to talk about some treatment  considerations for males. Overall,   we know that males are less likely to seek  treatment. There is a double stigma for   males with eating disorders. There is already  the stigma for eating disorders, in general,   and then there’s a second stigma because  eating disorders are a feminised disease,   and recognition may not be as  apparent in male populations. I think it’s important to note that there  actually aren’t specific treatments or   controlled trials that have been tested  in male populations, and oftentimes,   in the larger trials, sex differences in  outcomes are not usually examined. However,   treatment response for males tends  to be similar than in females. Some considerations to factor in include  addressing concerns about muscular – masculinity   and muscularity. So, there may be shame about  symptoms and reluctance to focus on emotions. And,   in the group setting, I think it’s also important  to understand the group dynamics. And so, in some   situations, a male patient with an eating disorder  may be the only person in the group who is   male-identifying, and so that’s one consideration,  particularly if the group is mostly female. And,   also, if possible, consider having a male  and female Clinician to co-lead the group.  Next, wanted to talk about acute medical  complications of eating disorders in male   populations. Overall, eating disorders can  cause significant medical complications,   affecting every organ system in the body.  But there’s limited and growing research   that has examined medical complications  of eating disorders in boys and men. Overall, the limited data does show that  eating disorders in boys and men can affect   your heart or cardiac system, including  a lower heartrate, lower blood pressure,   and orthostatic vital signs, and neurologic  changes, including structural brain changes,   haematologic or blood changes such as anaemia,  low platelets and low white blood cell count,   including no – neutropenia, gastrointestinal  and liver complications, including slow gastric   emptying and elevated liver enzymes, which  in extreme cases, can lead to liver failure.   Electrolyte abnormalities such as hypokalaemia,  hypophosphatemia, or hypomagnesemia, as well as   considerations for refeeding syndrome,  are also present in male populations. In terms of endocrine complications,  the growth suppression can occur and   abnormalities in thyroid regulation, as  well as lower testosterone and libido can   also take effect. And, finally, in terms of  skeletal complications, we have noted higher   risks of fracture in males with eating  disorders, as well as lower bone density. This is all extremely important because,  unfortunately, in male populations,   there is an elevated mortality, so 13% of  males with anorexia nervosa, unfortunately,   will die from it, as well as 11% of those with  bulimia nervosa. And standardised mortality rates   in males with anorexia nervosa are six to eight  times higher than the male reference population. I wanted to note that traditionally,  eating disorder guidelines have been   focused on female samples, but in the last few  years, there have been more specific guidance   for males and boys and men. And so, I  just wanted to mention that recently,   the Society for Adolescent Health and  Medicine has updated their guidelines to   be more inclusive of boys and men. We worked  on this book, which is a clinical reference   for Clinicians taking care of boys and men with  eating disorders. And this is the 2022 Society   for Adolescent Health and Medicine guidance  that includes, for the first time, a position   and statement on eating disorders in boys and men,  particularly for their medical considerations. Overall, I wanted to thank a large number  of collaborators who have helped with   the research and guideline development,  particularly for this slide presentation,   as well as a number of students  and trainees in my lab group,   and a number of funders who  have supported this research. Thank you so much for your time.