REVIEW

CURRENT
OPINION Eating disorders in adolescent boys and young
men: an update
Jason M. Nagata a, Kyle T. Ganson b,c, and Stuart B. Murray d

Purpose of review
To review the recent literature on eating disorders and disordered eating behaviors among adolescent boys
and young men, including epidemiology, assessment, medical complications, treatment outcomes, and
special populations.
Recent findings
Body image concerns in men may involve muscularity, and muscle-enhancing goals and behaviors are
common among adolescent boys and young men. Recent measures, such as the Muscularity Oriented
Downloaded from http://journals.lww.com/co-pediatrics by BhDMf5ePHKbH4TTImqenVFqCQt94uE2A7jgOTVivFK7Kd/HCGfrzW3YAPYFce3dMeH8m2RQordw= on 07/22/2020

Eating Test (MOET) have been developed and validated to assess for muscularity-oriented disordered
eating. Medical complications of eating disorders can affect all organ systems in male populations. Eating
disorders treatment guidance may lack specificity to boys and men, leading to worse treatment outcomes in
these population. Male populations that may have elevated risk of eating disorders and disordered eating
behaviors include athletes and racial/ethnic, sexual, and gender minorities.
Summary
Eating disorders and disordered eating behaviors in boys and men may present differently than in girls and
women, particularly with muscularity-oriented disordered eating. Treatment of eating disorders in boys and
men may be adapted to address their unique concerns.
Keywords
anorexia nervosa, boys, eating disorders, male health, muscle dysmorphic disorder

INTRODUCTION
Eating disorders are thought to be among the most
gendered of mental health disorders [1], with strong
associations with femininity. Eating disorder diag-
noses include, but are not limited to, anorexia nerv-
osa, atypical anorexia nervosa (AAN), bulimia
nervosa, binge-eating disorder (BED), and avoi-
dant/restrictive food intake disorder (ARFID)
according to the Diagnostic and Statistical Manual
of Mental Disorders, 5th Edition (DSM-5) [2]. Despite
decades of research focusing exclusively on female
populations, unique body image and disordered
eating concerns are increasingly recognized in male
populations. Males may have a higher drive for
muscularity [3], which may, in extreme cases, lead
to muscle dysmorphic disorder [4].
The purpose of this article is to review recent
literature on eating disorders and disordered eating
behaviors among male populations, with special con-
sideration related to adolescent boys and young men.
In particular, we review the epidemiology, assess-
ment, medical complications, treatment, and special
populations related to male eating disorders.
FINDINGS
Epidemiology
Although there has traditionally been a paucity of
research on male body image and disordered eating
behaviors in community settings [5], some recent
literature has shed light on the epidemiology of these
phenomena. A study of Australian adolescents esti-
mated the prevalence rates of DSM-5 eating disorder
diagnoses by sex. Among adolescent boys, 12.8% met
criteria for any eating disorder diagnosis, including
a
Division of Adolescent and Young Adult Medicine, Department of
Pediatrics, University of California, San Francisco, San Francisco, Cal-
ifornia, bSchool of Social Work, Simmons University, Boston, Massachu-
setts, cFactor-Inwentash Faculty of Social Work, University of Toronto,
Toronto, ON Canada and dDepartment of Psychiatry and the Behavioral
Sciences, University of Southern California, Los Angeles, California, USA
Correspondence to Jason M. Nagata, 550 16th Street, 4th Floor, Box
0110, San Francisco, CA 94158, USA.
E-mail: jasonmnagata@gmail.com
Curr Opin Pediatr 2020, 32:476–481
DOI:10.1097/MOP.0000000000000911

www.co-pediatrics.com Volume 32  Number 4  August 2020

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 Eating disorders in adolescent boys and young men Nagata et al.
KEY POINTS
 Body image concerns in men may involve muscularity;
muscle-enhancing goals and behaviors are common
among adolescent boys and young men.
 Recent measures, such as the Muscularity Oriented
Eating Test (MOET), have been developed and validated
to assess for muscularity-oriented disordered eating.
 Medical complications of eating disorders can affect all
organ systems in men and there are inadequate
medical management guidelines for adolescent boys
and young men.
 Male populations that may have elevated risk of eating
disorders and disordered eating behaviors include
athletes and racial/ethnic, sexual, and
gender minorities.
other specified feeding and eating disorder (OSFED,
8.5%), night eating syndrome (4.9%), bulimia nerv-
osa (1.8%), unspecified feeding and eating disorder
(UFED, 1.3%), and atypical anorexia nervosa (1.2%)
&&
[6 ]. Nationally representative surveys in the USA
demonstrate that 30% of adolescent boys report try-
ing to gain weight or bulk up, including 40% of boys
who objectively were considered in the normal
weight range by BMI [7]. Nearly 22% of young men
report engaging in muscle-enhancing behaviors,
including eating more or differently to build muscle
(17%), supplement use (7%), and androgenic–ana-
bolic steroid use (3%) [8,9]. Among young men,
overweight and obesity may be associated with dis-
ordered eating behaviors. Overall, 15% of young men
with BMI at least 25 report engaging in disordered
eating behaviors, including fasting, skipping meals,
vomiting, laxatives, diuretics, or binge-eating [10]. In
comparison, 8% of young men with BMI less than 25
report engaging in disordered eating behaviors.
Assessment
A recent review article provides an overview of
assessment measures for men with eating disorders,
including body image measures, muscularity-ori-
ented measures, and eating disorder measures [4].
Examples of assessment tools that can be used in
male populations include the Eating Disorders
Examination Questionnaire (EDE-Q) and Muscle
Dysmorphic Disorder Inventory (MDDI) [4]. Given
the diversity of populations affected by eating dis-
orders, the EDE-Q [11] and MDDI [12] have been
translated and validated in Spanish for Latin Ameri-
can male populations.
Although the under-recognition of eating dis-
orders among boys and men have been well-
1040-8703 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
documented [13], recent years have seen some
important advances. Existing assessment instru-
ments are insensitive towards disordered eating that
is oriented towards the pursuit of muscularity.
Indeed, with the hyper-muscular body ideals being
pervasively portrayed to men, disordered eating
symptoms are increasingly muscularity-centric. To
this end, the recent development of the muscular-
ity-oriented eating test (MOET) offers important
new insights on the measurement of disordered
eating attitudes and behaviors that are intended
&
to increase muscular density or leanness [14 ]. The
MOET is a 15-item measure, which dually captures
behaviors related to the development of muscular-
ity, and the reduction of body adiposity – which
enhances the visibility of muscularity (Table 1).
Medical complications
Medical complications of eating disorders, particu-
larly related to malnutrition, can affect every organ
system in the body [15]. In one clinical sample of
adolescent boys with eating disorders, over half
(52%) had vital sign instability that met Society
for Adolescent Health and Medicine hospital admis-
sion criteria [16]. Bradycardia was present in 39% of
the sample and orthostatic heart rate changes were
present in 12%. Bradycardia requiring hospital
admission criteria has also been reported among
adolescent boys with muscularity-oriented disor-
dered eating [17], and hours of exercise per week
is associated with bradycardia among adolescents
with eating disorders [18]. Forty percent of adoles-
cent boys with eating disorders had abnormal total
cholesterol levels [16], and binge eating has been
shown to be associated with hyperlipidemia in
young men [19].
Electrolyte abnormalities are common in ado-
lescent boys with eating disorders; one fourth had
low potassium, 5% had low phosphorus, and 10%
had low calcium [16]. In terms of hematologic
abnormalities, one-third were anemic, 24% leuko-
penic, 19% thrombocytopenic, and 10% neutrope-
nic [16]. Gastrointestinal complications in men with
eating disorders include elevated liver enzymes [20],
impaired gastric emptying [21], and superior mesen-
teric artery syndrome [22].
Skeletal and bone complications have been
documented in boys and men with eating disorders.
Significant deficits in bone mineral density [23],
lean mass, and fat mass index [24] have been docu-
mented in adolescent boys with anorexia nervosa.
Adolescent samples including boys have demon-
strated that bone mineral density is higher in atypi-
cal anorexia nervosa versus anorexia nervosa [25]
and that weight-bearing exercise and participation
www.co-pediatrics.com 477
Adolescent medicine

Table 1. The Muscularity Oriented Eating Test

(1) I have recorded the macro-nutritional values of everything that I ate. 0 1 2 3 4
(2) I have used meal replacement supplements when I felt full. 0 1 2 3 4
(3) What I ate has influenced how I think about myself as a person. 0 1 2 3 4
(4) There are definite foods I have avoided eating due to worry about 0 1 2 3 4
how they might affect my shape or weight.
(5) I have felt less anxious about eating out if I knew the macro- 0 1 2 3 4
nutritional content of the food at the restaurant.
(6) I have taken my own food out with me to social events in case the 0 1 2 3 4
food on offer is inconsistent with my diet plan.
(7) I cannot achieve my body ideal unless I exert complete control over 0 1 2 3 4
everything I eat.
(8) I have precooked several meals in advance to ensure that I do not 0 1 2 3 4
deviate from my diet plan.
(9) I have continued eating despite feeling full, in attempting to 0 1 2 3 4
influence my muscularity.
(10) I have felt anxious when I run out of protein-based supplements. 0 1 2 3 4
(11) I have been deliberately trying to limit the overall volume of some 0 1 2 3 4
foods, so that my muscles look more defined.
(12) If I broke any of my food rules, I attempted to make up for it at my 0 1 2 3 4
next meal.
(13) I have felt anxious about others knowing the rules I have around 0 1 2 3 4
what I eat.
(14) Other people do not seem to understand how important my food 0 1 2 3 4
choices are to me.
(15) Ensuring proper adherence to my dietary ideals is more important to 0 1 2 3 4
me than adhering to a work schedule.

Instructions: Please read each statement carefully and circle the number that best indicates how true each statement is of you. Please answer all the questions as
honestly as you can, as they apply to you in the last 4 weeks (0 ¼ never true, 1 ¼ rarely true, 2 ¼ sometimes true, 3 ¼ usually true, 4 ¼ always true). The Global
&
Muscularity Oriented Eating Test (MOET) scores are formed by calculating the mean score of all items. Data from [14 ].

in team sports may be protective of bone mineral
density at the hip and whole body bone mineral
content [26]. In adult men, low bone mineral den-
sity Z-scores (<2 at at least one site) have been
documented in men with anorexia nervosa (65%),
atypical anorexia nervosa, (33%), and ARFID (18%)
[27]. Men with anorexia nervosa over age 40 years
have greater fracture risk compared with healthy
controls over age 40 years [28].
Treatment
Medical guidelines specific to male populations are
lacking, and are mostly based on research and clini-
cal experience with women [29]. Some clinical guid-
ance still use criterion, such as amenorrhea, which
are not applicable to male populations [29]. For
instance, the Society for Adolescent Health and
Medicine medical update for restrictive eating dis-
orders indicates that dual-energy X-ray absorptiom-
etry (DXA) scans should be conducted to monitor
bone health when there has been a loss of menses for
6 or more months [30]. Although this does not
provide specific guidance on how to monitor bone
health among adolescent boys, clinical practice
guidelines produced by the National Institute for
Health and Care Excellence [31] and the Royal Aus-
tralian and New Zealand College of Psychiatrists [32]
indicate that duration of illness may be a more
effective measure of when to obtain a DXA scan.
Additional areas where clinical guidance is lacking
for adolescent boys and young men include: using
BMI and weight loss as a measure of malnutrition
and severity of illness, refeeding protocols, and the
assessment and treatment of performance-enhanc-
ing substances (PES) use [29].
In documenting treatment outcomes among
men with eating disorders, few randomized con-
trolled trials exist. In fact, most randomized con-
trolled trials have actively excluded male patients on
the basis of their purported atypicality [12]. Quali-
tative research demonstrates that men with eating
disorders report feeling like ‘the odd one out’ or
‘atypical’ in current female-dominated treatment
environments [33]. Recently, however, a large data-
set documenting clinical outcomes among a trans-
diagnostic sample of 110 men was reported. These
data suggest comparable remission rates among
men and women with anorexia nervosa by the
end of treatment, at approximately 40% remission

478 www.co-pediatrics.com Volume 32  Number 4  August 2020

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 Eating disorders in adolescent boys and young men Nagata et al.
&
[34 ], although more men demonstrated clinically
significant disordered eating at follow-up. Men with
bulimia nervosa demonstrated marginally less
favorable remission relative to women with bulimia
nervosa (44% remission by end of treatment versus
50%). Importantly, however, standardized mortal-
ity rates were higher in men with anorexia nervosa,
relative to both women with anorexia nervosa and
men with bulimia nervosa [35], suggesting that
anorexia nervosa in men may be particularly perni-
cious. In another study, men with eating disorders at
12-month follow-up had partial recovery (19%) or
full recovery (14%) [36].
Special populations
There are several unique populations that are impor-
tant to highlight when considering eating disorders
among adolescent boys and young men. First, recent
research has begun to identify the unique disordered
eating and weight gain behaviors that are prevalent
among adolescent boys and young men, particularly
athletes. Weight gain behaviors among adolescent
and young adult men may be driven by body ideals
that emphasize muscularity and leanness [37].
Among collegiate male athletes, baseball, cycling,
and wrestling were sports with the most players
reporting elevated eating disorder symptoms in a
clinical range [38]. Among competitive collegiate
male athletes, nearly half report current supplement
use [39]. Sports supplement use in male athletes is
associated with higher eating disorder symptoms
[40]. Use of legal performance-enhancing supple-
ments is associated with future use of anabolic–
androgenic steroids [41] and alcohol-related risk
behaviors [42]. Little is known about long-term
health consequences of performance-enhancing
supplements, as the Food and Drug Administration
do not review dietary supplements for effectiveness
or safety [42]. Adolescent boys may be more likely to
engage in individually-driven exercise compared
with girls. This may be exacerbated by athletic
norms associated with sports that emphasize mus-
cularity and strength (i.e. American football) or
weight control and loss (i.e. wrestling) [18,37].
A second area of importance to highlight is
eating disorders among racially and ethnically
diverse adolescent boys. This area of knowledge
remains largely sparse, as there is a dearth of research
solely investigating specific racial/ethnic adolescent
populations and eating disorders. This is in part
because of continued sociocultural narratives that
eating disorders primarily impact white, affluent,
adolescent girls. Thus, there remains an urgent need
to conduct robust and rigorous research on the
unique differences among adolescent boys with
1040-8703 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
eating disorders across racial/ethnic identities. How-
ever, current research indicates that disordered eat-
ing behaviors may be particularly prevalent among
non-white adolescent boys. One study among a pop-
ulation of adolescents from Minnesota found that
disordered eating behaviors were highest among
Asian boys (43%), followed by black boys (38.5%),
Hispanic boys (35%), and, lastly, white boys (33%)
[43]. Using the National Youth Risk Behavior Surveil-
lance Survey (YRBS), another recent study found that
black/African American and Hispanic/Latino boys
had higher prevalence rates and risk ratios of purging
behaviors and fasting behaviors compared with
&&
white boys [44 ]. This study also found that His-
panic/Latino boys had higher, whereas black/African
American boys had nearly identical, prevalence rates
and risk ratios of diet pill use compared with their
&&
white peers [44 ]. Given the results from these stud-
ies, it is evident that additional research is needed
to develop a stronger understanding of the nuances
of eating disorders among racially and ethnically
diverse male populations.
Eating disorders have been documented among
sexual minority boys and men. In general, research
has continued to indicate that sexual minority ado-
lescent boys experience body dissatisfaction, eating
disorders, and disordered weight control behaviors
[45]. Research from the United Kingdom has found
that gay or bisexual, as well as mostly heterosexual
boys, had significantly greater odds of dieting
behaviors compared with their completely hetero-
&
sexual peers [46 ]. Similarly, body dissatisfaction
and pressure to increase muscularity was the highest
among mostly heterosexual and gay or bisexual boys
&
[46 ]. Lastly, gay and bisexual boys and mostly
heterosexual boys had the greatest odds of any
binge-eating behaviors compared with their
&
completely heterosexual peers [46 ]. Similarly,
among a national sample of adolescent boys in
the United States, boys who identify as gay, bisexual,
or not sure had greater odds of reporting fasting
behaviors. Further, adolescent boys who identify as
bisexual or not sure of their sexual orientation had
greater odds of using steroids compared with their
heterosexual peers [47]. More specific results from
the state of Connecticut [48] and Massachusetts [49]
found that sexual minority adolescent boys had
greater odds of eating disorders and weight control
behaviors compared with their heterosexual peers.
In terms of adult men, eating disorder attitudes and
behaviors have been shown to be elevated among
gay men compared with the general population of
men [50]. Despite this evidence, there remains a
paucity of research on the epidemiology, treatment,
and prevention of eating disorders among sexual
minority adolescent boys and young men.
www.co-pediatrics.com 479
Adolescent medicine
A final area of importance to highlight is the
intersection of gender with eating disorders. Mascu-
line gender norms are associated with muscle-
enhancing behaviors [51]. Transgender men may,
therefore, desire a masculine-appearing build and
engage in muscle-enhancing behaviors, such as
bodybuilding [52]. Transgender men may experi-
ence dissatisfaction with several body features, such
as genitalia, body hair, body shape, facial features,
and extremities [53]. Young adult transgender men
have also been shown to report high rates of binge
eating (35%), fasting (34%), and vomiting (7%) [54].
Transgender men have higher eating disorder atti-
tudes than cisgender men [55]. A review article has
previously summarized body image and eating dis-
orders in sexual and gender minority youth [56].
CONCLUSION
Emerging research demonstrates that males with
eating disorders have unique concerns with regards
to disordered eating and body image. Clinical guid-
ance for eating disorders has not yet become indi-
vidualized to address these unique concerns [29],
and future research should develop male-specific
screening, treatment guidance, and interventions
to improve health outcomes in this underserved
population.
Acknowledgements
Thanks to Sam Benabou for editorial assistance.
Financial support and sponsorship
J.M.N. was a participant in the Pediatric Scientist
Development Program (K12HD00085033), funded
by the American Academy of Pediatrics and the Amer-
ican Pediatric Society, and a recipient of the American
Heart Association Career Development Award
(CDA34760281). S.B.M. was supported by the
National Institutes of Health (K23 MH115184).
Conflicts of interest
There are no conflicts of interest.
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