Boys at Risk

Excerpt from The Parent's Guide to Eating Disorders

Sixteen-year-old Travis and his family relocated to a rural college town several years ago from their home on a Montana Indian reservation. Travis seemed to make the transition with ease. He was well liked, was admired for his abilities on the baseball field, and had a number of close friends. With so much seemingly going for him, Travis's bulimia was easy to miss. He was a normal-weight, healthy-looking teenage boy who had spent his formative years in a culture that does not value thinness. Proud to call himself an Indian rather than the more politically correct Native American, Travis grew up riding horses, chasing cows, and going to powwows.

The first few times Travis's friends caught him in the bathroom throwing up, they believed he had the flu or had eaten something that didn't agree with him. But after enough of these episodes, they finally put two and two together and came to the undeniable conclusion that Travis had an eating disorder. Bulimia was the last thing anyone thought he would struggle with, yet here he was suffering from a case so severe that eventually he was regularly noticing blood in his vomit. When Travis's friends finally approached him with their concerns, he himself had become frightened and desperately wanted to quit. The intervention of his friends was the push he needed; he was ready to take their advice and confide in his parents.

As Travis's story illustrates, the face of eating disorders has changed and is continuing to change. I have worked with many boys and men, as well as young people representing a diverse set of backgrounds. An eating disorder is now an equal-opportunity disease.

In fact, one of the most striking new developments in the field of eating disorders is that experts are finally beginning to acknowledge that the number of men and boys suffering from eating disorders is much higher than previously thought. Where once it was believed that about 10 percent of eating disorder sufferers were male, that figure is now assessed at closer to one-fourth, or even higher. Most experts in the field of male eating disorders believe that the number has always been higher than reported, and that as male eating disorders have become more public and the stigma attached to them has decreased, more males have been seeking treatment in recent years. Even now however, many men and women suffer from their eating disorders in private, afraid to admit to a disease that, like depression and addiction, is still wrongly perceived as a disease of personal weakness or self-absorption.

The growing number of boys with both disordered eating and eating disorders does not come as a surprise when you consider the way that dieting and thinness are marketed with almost equal vigor to men as they are to women today. Neither does the corresponding rise in body dissatisfaction that researchers have documented among boys and young men.

In this chapter, we will discuss some of the reasons for this widely commented- on increase in male eating disorders, and how boys' disorders differ from those of girls. We will also introduce some approaches that work best with boys.

Throughout this chapter, we will emphasize this point: When an eating disorder becomes full-blown, the issues you face as parents remain much the same, regardless of the gender of your child.

Common Traits and Beliefs of the Eating-Disordered Boy

Most of the boys I see as patients took their drive to improve sports performance too far, losing dangerous amounts of weight through overexercise and limited food intake. They are often more obsessed with altering their body shape than being focused on weight loss. Studies show that among boys with body image disorders (which put them at risk for an eating disorder) half want to lose weight, and half want to gain weight. Usually, the goal is to attain a highly-muscled body without fat. Some begin their obsession with fitness and muscle building after being teased about their weight and body shape by family members or peers. Others go overboard trying to avoid weight gain and diet-related health problems experienced by their fathers. A substantial number of the boys I have seen express concerns and beliefs identical to those of the typical eating-disordered girl: they believe wholeheartedly that losing weight will improve their appearance and self-esteem.

While their numbers are increasing, for boys the good news is that, in my experience at least, they are more open to getting treatment and seem less "girl's" disease than in past years.

How Are Boys' Eating Disorders Different from Girls'?

Although boys and girls appear to develop and experience eating disorders in much the same way, share a similar disease course, and respond to treatment in the same way, there are some important differences. It is rarer for boys to diet their way into an eating disorder, as girls usually do. When boys develop an eating disorder, they most often have additional risk factors that induce their eating disorder. (For a list of these risk factors, see next page.)

Another difference is that while nonathletic boys are less likely to be at risk for an eating disorder, some studies have shown that nonathletic girls face roughly as much risk as athletic girls. Perhaps more important than this subtle difference is the fact that both boys and girls who are involved in so-called "lean" sports such as wrestling, gymnastics, long-distance running, or crew, where staying thin is an important factor to success, the risk of an eating disorder is

Protective Factors in Boys

Going through puberty can trigger an eating disorder in both boys and girls. Because boys reach puberty later than girls, however, they tend to develop eating disorders later, and so are better prepared emotionally to deal with physical changes.

Researchers have noticed a difference between boys and girls as they mature after puberty. As boys mature, their body image dissatisfaction diminishes, while the opposite is true for girls, who become increasingly displeased with

One reason boys feel better about their bodies as they mature is that any body dissatisfaction they feel usually stems from the desire to be more muscular, not to be thin. As boys mature, they do in fact become more muscular and shed fat, which makes them feel better about their bodies. These changes are more culturally-acceptable than the increase in body fat that girls experience.

For this same reason, boys who physically mature early seem to have higher levels of body satisfaction, while early development in a girl is considered a risk factor for an eating disorder.

Another protective factor may be that because boys and men naturally have higher metabolic rates than girls and women, they can, with modest adjustments in food intake, lose weight, or maintain a stable body weight more easily than girls and women do. This fact, plus the finding that average weight boys tend to be satisfied with their physical appearance and weight, may make them less tempted to try extreme eating-disordered behaviors.

Factors That Put Boys at Risk for Eating Disorders

While we have some idea why girls are more susceptible to eating disorders than boys, a more perplexing question is why some boys are at risk for disordered eating and eating disorders and others are not. The following are factors that are known to put boys at risk for eating disorders:

• Being chubby as children and/or experiencing teasing about body size
• Having a higher-than-average body weight
• Body dissatisfaction
• Participation in high-risk sports that favor thinness or include weight classes, such as wrestling, boxing, crew, bodybuilding, weightlifting, gymnastics, figure skating, or long-distance running
• Depression
• Recent data shows that alcohol abuse may be a significant risk factor for males, possibly more so than for females

Shame and Invisibility: Obstacles to Treatment

One concern about boys who diet or engage in other behaviors that could foreshadow an eating disorder is that their problem may go unnoticed because parents, teachers, coaches, and even doctors and other adults in the child's life may believe that eating disorders are a "girl problem." Although we have noted that this shame about male eating disorders seems to be diminishing somewhat, shame still keeps boys from admitting they have eating problems and keeps others from detecting those problems, even very obvious ones.

Anorexia Among Boys

Connor, bright and inquisitive, was homeschooled until he was 11, when he and his parents agreed he needed the stimulus of the local junior high. Connor was excited about finally joining his peers and was happy that a few friends from his rural neighborhood would be in his new class. Yet he was also nervous about this transition. Once there, he felt out of control and lost. Controlling his eating was his response to the distress, just as it is for young women who develop full-blown disorders when they enter a new school or go away to college.

Today, looking back on this difficult period, Connor says that his interest in calories, fat grams, and losing weight made sense. He needed something he was certain he could master, and there was no doubt that he was good at losing weight. Connor says he could see that his parents were worried, but it was not until his doctor told him, in no uncertain terms, that he was too thin and needed to gain weight that he understood the seriousness of his situation. Connor is an example of how an early intervention can be effective. His parents simply needed the doctor's help in getting Connor's attention; once that was Kent's story is more typical for a boy than for a girl and illustrates the way that a susceptible boy can get into trouble with food. Kent became aware that his naturally chubby physique was a "problem" when, at 12, his track coach patted Kent's tummy and said, "Your times would be better if you got rid of that."

"That should be easy to deal with," Kent thought. "I'll just skip dessert." Weight loss was easy for Kent, who, just by giving up dessert, lost enough weight for his coach to notice. Boys, as we have noted, usually lose weight quickly because of their naturally fast metabolisms. Pleased with the positive feedback his weight loss generated, Kent decided to give up snacking. Although missing his afternoon snack left him feeling a little light-headed at track practice, he really didn't mind; besides, he was able to lose another five pounds. Soon, losing weight felt like a game: if Kent didn't lose at least a little when he checked his weight before bed, he promised himself that he would eat a little less the following day. Fortunately, Kent's parents, aware that distance running was a sport that could spawn an eating disorder, were keeping an eye on him. They intervened before Kent had done any real damage to his health. "Sorry, Kent," they told him matter-of-factly when he protested, "we are not going to allow you to lose any more weight." Kent's parents let the coach know of their concerns, making it clear that Kent's health depended on preventing even an ounce of further weight loss. Since young athletes rarely complain to coaches about weight-loss induced symptoms, such as dizziness or fatigue, the coach often remains in the dark.

Bulimia Among Boys

Rod was in his last year of high school when he fell prey to bulimia. He told me he first learned about self-induced vomiting as a method of weight loss from his teammates on the crew team. When the season was over, the other boys stopped their disordered behaviors, but Rod, to his dismay, found that he could not.

Bulimic boys tend to be less concerned with strict weight control than eating- disordered girls and are less likely to use laxatives, but they are more likely to engage in excessive exercise than girls. You should be suspicious, therefore, if your son dramatically increases his exercise or begins to restrict food choices.

I came to know Heath, who had been bulimic since ninth grade, when he was a college student. Heath told me that his shame about having an eating disorder kept him from confiding in his parents when he lived at home. Even now, with access to confidential counseling, he had difficulty accepting treatment for his "girl's disorder." My own experience with parents of boys is that they are likely to take bulimic and anorexic behaviors in their sons appropriately seriously. Ironically, this is not always true of parents of girls, who may look at these behaviors as simply a rite of passage that most girls experience these days. When parents are matter-of-fact about their son's eating disorder and are careful not to repeat gender-based stereotypes, boys can quickly grasp that cultural pressures on boys and girls in this day and age are becoming increasingly similar.

Binge Eating Among Boys

The higher percentage of boys and men who binge eat (they account for 40 percent of all binge eaters) compared to other eating-disordered behaviors can probably be explained by several reasons:
It is more culturally acceptable for boys and men to eat large quantities of food than it is for girls and women.

Boys and men, with their faster metabolisms, are less likely to gain weight if they occasionally binge. Therefore, they are less likely to worry about binge eating affecting their weight, but it is more likely that bingeing will become

These cultural, attitudinal, and physiological factors may protect boys from bulimia, and also may explain why binge eating is the only eating disorder category in which the incidence among boys and men almost reaches parity with girls and women.

Disordered Eating Among Boys

As with disordered eating among the general population, it is hard to come by consistent figures for the number of boys who suffer from disordered eating. What we do know is that a substantial number of boys are clearly dieting, and therefore are at risk for developing eating problems. Several recent studies have documented an increase in men and boys who admit they have dieted to lose weight.

Compared to non-eating-disordered boys, boys with disordered eating have been found to be more dissatisfied with their bodies even if they are normal weight, restrained in their eating, perfectionistic, more depressed, and have more difficulty distinguishing between emotions and physical sensations. An example of the latter symptom would be that they might confuse disappointment with hunger, which could lead to bingeing when disappointed, angry, or depressed. These findings replicate the symptoms found in girls who suffer from disordered eating, a fact that has led researchers to conclude that boys

Boys and the "Adonis Complex"

A variation on male body image and eating problems is that of boys who show increased interest in fitness, sports, and muscle building. Instead of feeling too large, they consistently underestimate their own size and feel ashamed of being too small and puny. To remedy this perceived fault, they may overexercise, compulsively lift weights, and use diets and supplements that purport to build muscle. This commonly seen syndrome (known to experts as muscle dysmorphia) has been dubbed the "Adonis complex" by Harrison Pope, Katharine Phillips, and Roberto Olivardia, researchers at Harvard and Brown universities who have written a book with this title.

Boys who suffer from the Adonis complex have an obsession with appearance that leads to what Dr. Pope terms a kind of "reverse anorexia." Usually, they use muscle building and fitness magazines or other weight lifters (who are convinced that their own special diet explains their success) as their guides on how to restrict their diets. Their disordered eating often takes the form of extreme diets, either high in protein or low in fat, or both. They may also restrict other foods they believe are unhealthy. Currently, the high-protein diets that are popular with muscle builders are those that advise almost total abstinence from breads, cereals, and other high-carbohydrate foods, and

Most of the protein supplements favored by body-building boys, while no better than high-protein foods, have so far not been known to be damaging to the health of the user when used properly. However, we do know that if they are overused, they can cause kidney damage. Several of my patients who have overused protein supplements have had abnormal kidney function tests. Fortunately, in each case, kidney function returned to normal soon after as the boy stopped using the protein supplements. Another popular supplement among male athletes is creatine. Makers of this product advertise creatine for its ability to increase muscle mass. Creatine is extracted from the protein found in meats and is presumed safe, although the effects of long-term use of creatine pills are unknown. Use of this supplement is of concern to researchers who worry about young people taking large doses of a concentrated substance that has not been tested for long-term side effects. Recently, the FDA has implicated creatine supplements in several cases of severe dehydration.

Another highly dangerous supplement used by athletes to increase performance and energy as well as for weight loss is ephedra (sometimes referred to as ephedrine), which is an amphetamine derived from the Chinese herb ma huang. For years now, the FDA has warned that ephedra-containing products are not safe, can be addictive, and can lead to high blood pressure, heart attack, stroke, and even death. In 2004, the FDA banned sales of ephedra. Ephedra manufacturers have responded with lawsuits, but the courts have ruled in favor of the FDA ban. As a result, ephedra is harder to buy over the counter now, but can still be purchased over the internet.

With ephedra no longer widely available, other supplements are filling the void. I usually first hear about the newest ones from my patients. Evan, a young-looking 14-year-old, told me about bitter orange, an ingredient often found in products labeled "ephedra-free." The active components in bitter orange are very similar to those in ephedra and are potentially as dangerous, increasing the risk of heart attacks, stroke and death.

I have had patients tell me they are taking chitosan, chromium, guar gum, hoodia, green tea extract, country mallow (which contains ephedra), and CLA (a fatty acid). Most of these supplements claim to raise metabolism, burn fat, suppress appetite or build muscle. Since they are considered food supplements, none of them are regulated by the FDA, and none of them have been proven to work or to be safe, especially over the long term.

Chitosan, CLA, green tea extract, and guar gum all are known to cause gastrointestinal problems such as vomiting, diarrhea, and indigestion. Ephedra, bitter orange, and country mallow (also known as heartleaf ) are probably the most dangerous of those I have listed. Many of these products have been found to be devoid of the active ingredient for which they are purchased. I suggest parents talk honestly to their children (especially if your child frequents a gym) about the dangerous nature of supplements. "Just say no" is good advice.

Boys may also use any of the many hormonal preparations (DHEA and other adrenal hormones are popular) available by mail order or at health food stores. Often, these products are marketed as "legal steroids," with promises that they will increase muscle mass. Yet so far, supplemental adrenal hormones have not lived up to those promises. One concern among researchers is that supplemental adrenal hormones may increase blood cholesterol levels.

Some boys may even use illegal and dangerous anabolic steroids. Steroids are dangerous in the short term mostly because of the mood changes, aggressiveness, and even violence they can cause. The most serious long-term health consequences are high cholesterol and possibly prostate and liver cancer. Boys who diet are more likely to use steroids than boys who do not diet, researchers have found.

When I first met 16-year-old Morgan, he described himself as a "gym rat" who spent all his free time at the local gym, even though he was well aware that the gym atmosphere, with its focus on weight loss and physical appearance, was not helping him in his year-long battle with bulimia. When we met again a month later, Morgan confessed that he had been using ephedra on the recommendation of one of his college-age friends at the gym. He described how, on the supplement, he could binge and still lose weight, but admitted that he was worried about how "spacey and hyper" it made him feel. I asked about the other common complaints of ephedra users: headaches, insomnia, and racing heart. Yes, he replied, he had them all. Morgan said that the most disappointing part of his experience with the supplement was that when he stopped taking it the week before, he gained back all the weight and five pounds more.

Boys and Bone Mineral Density

Surprisingly, new studies indicate that eating-disordered boys may be at an even higher risk of developing low bone mineral density than girls. Low bone mineral density in both boys and girls can lead to osteopenia or osteoporosis, a weakening of the bones, making a person vulnerable to painful and debilitating fractures. While explanations are still speculative, it appears that testosterone levels, which are lowered in boys with eating disorders, are a key factor in producing this higher risk. Another surprise is that among eating-disordered boys, those with bulimia seem to be at as high a risk of losing bone density as those with anorexia. In this respect, boys differ from girls, who are more likely to suffer from low bone density if they are anorexic rather than bulimic.

Arnold Andersen, the respected expert on eating disorders in males, advises that boys with eating disorders have bone-density tests performed. If bone mineral density is found to be low, he also advises that contact sports and other high-impact activities be limited until bone density improves. As a way to stop bone loss and even build bone mass, Andersen also highly recommends strength training during treatment for male eating disorders, although

Treatment Approaches That Work with Boys

As we noted earlier, the treatment approaches for eating-disordered girls work equally well with boys. I would also add that you should certainly not tease your son about having a "girl's disease" and make sure his siblings do not do so either. As we have shown in this chapter, this is simply not true. You should make sure your child knows that eating disorders do occur among boys and are, in fact, not uncommon. You should be aware that your son may be likely to abuse exercise, and you should be watchful of the use of dangerous supplements. You should also remember that although your son may not be trying to lose weight, he may be trying to alter his body shape, which can also lead to eating problems.

Homosexual Boys and Eating Disorders

Homosexual males boys have a higher risk for eating disorders because of the high value gay culture places on thinness and physical attractiveness. Researchers have also concluded that homosexuality in boys may exacerbate an eating disorder.

Parents should remember that heterosexual boys get eating disorders, too. You should be careful not to assume that the fact that your son is struggling with an eating problem means he is gay.