GI Joe Meets Barbie: Disordered Eating is Not Just a “Female” Issue Dr. Mary Pritchard Boise State University

“Just tell her to stop…” 17 years ago … McCreary and Sasse (2000) changed the way we think about body dissatisfaction Body dissatisfaction  unhealthy attempts to alter appearance  subclinical eating disorders  clinically diagnosable eating disorders a pivotal study by McCreary and Sasse changed the way we think about body dissatisfaction and eating disorders in men Dieting, excessive exercise, steroid and supplement use

Body Dissatisfaction Body Image: “the picture of our own body which we form in our mind” Body Dissatisfaction: dissatisfaction with one’s size, weight, shape, features, etc. Discrepancy between perception of reality and perceptions of the “ideal” Most common cause of disordered eating Begins to emerge in girls around ages 6-8 Begins to emerge in boys around ages 8-10

Body dissatisfaction Body dissatisfaction has become normative in today’s society, with over 90% of U.S. collegiate women and 80% of U.S. college- aged men reporting body and weight dissatisfaction In the past, research has suggested that men and women may experience body dissatisfaction in different ways: Drive for thinness v. Drive for muscularity However, this oversimplifies the issue…

Drive for thinness/Leanness 90-95% of women want to be thinner than they are 2/3rds of men want to lose weight

As a result… Between ages 3 and 5, children know “thin” is good and “fat” is bad 50% of girls and 33% of boys age 6 to 8 want to be thinner than they currently are 1 in 4 children have tried something to lose weight by age 7 80% of 10-year-old girls have dieted to lose weight But it’s not just wanting to be thinner anymore….

Drive for muscularity/tone McCreary and Sasse’s ground breaking research Lean and toned - 90% of men want to be more muscular; 78% of women want to be more muscular

What we know: Boys In boys, desire for bigger muscles increases slightly each year across adolescence, beginning at age 9 Adolescent male anabolic steroid use (approximately 4-6%) is comparable to the combined lifetime prevalence of anorexia and bulimia nervosa in adolescent females 35% of adolescent males reported using products to build muscles and improve appearance By age 16, 30% of boys have tried to gain muscle mass

What we know: girls In girls, desire for muscularity is present to a slightly lesser extent and is stable over time Similar to boys, about 30% of adolescent females (aged 12-18) want to gain muscle mass 2-4% of adolescent females have used steroids 21% of adolescent females reported using products to build muscles and improve appearance

Subclinical eating disorders

Body dysmorphic disorder Sufferers are excessively concerned about appearance, in particular perceived flaws of face, hair, and skin. BDD is thought to be a subtype of obsessive- compulsive disorder BDD often includes social phobias. Sufferers are shy and withdrawn in new situations and with unfamiliar people. Differences in the brains of those who suffer Deficiencies in visual processing Working memory deficits Poorer planning and decision making https://bdd.iocdf.org/professionals/neurobiology-of-bdd/

Body dysmorphic disorder Very conservative guesstimate: Affects 2% of people in the U.S. Strikes males and females equally. 70% of cases appear before age eighteen. BDD sufferers are at elevated risk for depression, anxiety, and suicide. In some cases they undergo multiple, unnecessary plastic surgeries.

Muscle dysmorphic disorder (bigorexia) People with this disorder obsess about being small and undeveloped. Marked differences in the brains of those who suffer Lift weights, do resistance training, and exercise compulsively. They may take steroids or other muscle-building drugs. A subtype of body dysmorphic disorder

Muscle dysmorphic disorder More common in males than females Almost everyone with MDD also suffers from depression. The constant preoccupation with perceived smallness interferes with school and career accomplishments. In almost all cases, people with muscle dysmorphia are not small at all.

Clinically diagnosable eating disorders

Anorexia Nervosa Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or expected. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. Disturbance in the way one's body weight or shape is experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight.

Anorexia Nervosa Subtypes: F50.01 Restricting Type: During the last three months, the individual has not engaged in binge-eating or purging behavior (self-induced vomiting or misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. F50.02 Binge Eating/Purging Type: During the last three months, the individual has engaged in recurrent episodes of binge-eating or purging behavior.

Anorexia nervosa: the stats Prevalence rates in Western countries range from 0.1% to 5.7% in female subjects. Depending on the study, lifetime prevalence averages to about .3% in men. Males represent 25% of individuals with AN Age range: as young as 6 and as old as 90s

bulimia Nervosa Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most individuals would eat during a similar period of time under similar circumstances. A sense of lack of control over eating during the episode, (e.g., a feeling that one cannot stop eating or control what or how much one is eating). Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise. The binge eating and inappropriate compensatory behavior both occur, on average, at least once a week for 3 months. Self evaluation is unduly influenced by body shape and weight.

Bulimia nervous: the stats 4% college-aged women have bulimia Prevalence rates in Western countries range from 0% to 2.1% in males (0.5% average) and from 0.3% to 7.3% in females. Males represent 25% of individuals with BN Men are less likely than women to engage in “typical” bulimic compensatory behaviors

Binge-eating disorder Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most individuals would eat during a similar period of time under similar circumstances. A sense of lack of control over eating during the episode, (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Binge-eating disorder The binge-eating episodes are associated with three (or more) of the following: Eating much more rapidly than normal Eating until feeling uncomfortably full Eating large amounts of food when not physically hungry. Eating alone because of feeling embarrassed by how much one is eating. Feeling disgusted with oneself, depressed, or very guilty afterward Marked distress regarding binge-eating is present The binge eating occurs, on average, at least once a week for 3 months.

Binge eating disorder: the stats 1-4% of women in the United States; 2% of men Approximately 36-50% of those with BED are men 30% of women who seek treatment to lose weight Men are less likely to report feeling out of control and more likely to report anger triggering a binge than are women

Other specified feeding or eating disorder This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class.

The stats In the United States, 20 million women and 10 million men will suffer from a clinically significant eating disorder at some time in their life Depending on the study, female-to-male ratio of current screening criteria is between 4-to- 1 and 2-to-1

The stats Here’s the problem: Tests were designed for women Bias in diagnosis Men are afraid to admit they have a problem Masculinity may be threatened Men may not recognize what they are experiencing is an eating disorder Researchers are beginning to understand that ED in men are misunderstood, misrepresented, and miscounted

Is this a new problem? Sort of… cases of probable male anorexia nervosa were described as early as the 17th and 18th centuries But ED weren’t even recognized until late 1880s (anorexia hysteria – females only), then not an official category until the DSM-3 in the 1980s

What factors relate to the development of ED in men? Weight history Sexual orientation History of sexual abuse History of chemical dependency Depression Athletic status Media more likely to have been overweight at some point

Diagnosis and treatment Because men may not present as “typical” ED patients, diagnosis is challenging Treatment options: CBT All-male group therapy Pharmaceuticals Initial reports suggest recovery might be higher in men

Future directions Prevention programs targeting boys Media literacy for boys Better isolating differences in risk factors for men and women Need to address social stigmas More focused study of treatment options for men Educate health care providers Better/different training programs for clinicians who treat men with ED