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Curr Opin Pediatr. Author manuscript; available in PMC 2021 August 01.
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Published in final edited form as:

Curr Opin Pediatr. 2020 August ; 32(4): 476–481. doi:10.1097/MOP.0000000000000911.

Eating disorders in adolescent boys and young men: an update

Jason M. Nagataa, Kyle T. Gansonb, Stuart B. Murrayc
aDivision of Adolescent and Young Adult Medicine, Department of Pediatrics, University of
California, San Francisco, San Francisco, CA, USA
bSchool of Social Work, Simmons University, Boston, MA, USA
cDepartment of Psychiatry and the Behavioral Sciences, University of Southern California, Los
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Angeles, CA, USA

Abstract
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 males may involve muscularity, and 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 males. Eating disorder treatment guidance may lack
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specificity to males, leading to worse treatment outcomes in this 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 males may present differently
than in females, particularly with muscularity-oriented disordered eating. Treatment of eating
disorders in males may be adapted to address unique concerns in males.

Keywords
Eating disorders; anorexia nervosa; muscle dysmorphic disorder; boys; male health

INTRODUCTION
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Eating disorders (ED) are thought to be among the most gendered of mental health disorders
[1], with strong associations with femininity. Eating disorder diagnoses include, but are not
limited to, anorexia nervosa (AN), atypical anorexia nervosa (AAN), bulimia nervosa (BN),
binge eating disorder (BED), and avoidant/restrictive food intake disorder (ARFID)
according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

Corresponding Author: Jason M. Nagata, 550 16th Street, 4th Floor, Box 0110, San Francisco, California 94158, Telephone: +1 (626)
551-1932, jasonmnagata@gmail.com.
Conflicts of interest
The authors have no conflicts of interest to declare
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(DSM-5) [2]. Despite decades of research focusing exclusively on female populations,

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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 consideration related to adolescent
boys and young men. In particular, we review the epidemiology, assessment, 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
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disordered eating behaviors in community settings [5], some recent literature has shed light
on the epidemiology of these phenomena. A study of Australian adolescents estimated the
prevalence rates of DSM-5 eating disorder diagnoses by gender. Among adolescent boys,
12.8% met criteria for any eating disorder diagnosis, including other specified feeding and
eating disorder (OSFED, 8.5%), night eating syndrome (4.9%), bulimia nervosa (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 trying to gain weight or bulk up, including 40% of boys objectively
considered normal weight by body mass index (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-anabolic steroid use (3%) [8]. Among
young men, overweight and obesity may be associated with disordered eating behaviors.
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Overall, 15% of young men with BMI ≥ 25 report engaging in disordered eating behaviors
including fasting, skipping meals, vomiting, laxatives, diuretics, or binge-eating [9]. In
comparison, 8% of young men with BMI < 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-oriented 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
disorders, the EDE-Q [10] and MDDI [11] have been translated and validated in Spanish for
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Latin American male populations.

While the under-recognition of EDs among males has been well documented [12], recent
years have seen some important advances. Existing assessment instruments are insensitive
towards disordered eating that is oriented towards the pursuit of muscularity. Indeed, with
the hyper-muscular body ideals being pervasively portrayed to males, disordered eating
symptoms are increasingly muscularity-centric. To this end, the recent development of the

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muscularity-oriented eating test (MOET) offers important new insights on the measurement
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of disordered eating attitudes and behaviors that are intended to increase muscular density or
leanness [13]*. The MOET is a 15-item measure which dually captures behaviors related to
the development of muscularity and the reduction of body adiposity - which enhances the
visibility of muscularity (Table 1).

Medical Complications
Medical complications of eating disorders, particularly related to malnutrition, can affect
every organ system in the body [14]. In one clinical sample of adolescent boys with EDs,
over half (52%) had vital sign instability that met Society for Adolescent Health and
Medicine hospital admission criteria [15]. Bradycardia was present in 39% and orthostatic
heart rate changes were present in 12% of the sample. Bradycardia requiring hospital
admission criteria has also been reported among adolescent boys with muscularity-oriented
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disordered eating [16], and hours of exercise per week is associated with bradycardia among
adolescents with eating disorders [17]. Forty percent of adolescent boys with eating
disorders had abnormal total cholesterol levels [15], and binge eating has been shown to be
associated with hyperlipidemia in young men [18].

Electrolyte abnormalities are common in adolescent boys with eating disorders; one fourth
had low potassium, 5% had low phosphorus, and 10% had low calcium [15]. In terms of
hematologic abnormalities, one third were anemic, 24% leukopenic, 19% thrombocytopenic,
and 10% neutropenic [15]. Gastrointestinal complications in males with eating disorders
include elevated liver enzymes [19], impaired gastric emptying [20], and superior mesenteric
artery syndrome [21].

Skeletal and bone complications have been documented in males with eating disorders.
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Significant deficits in bone mineral density [22], lean mass, and fat mass index [23] have
been documented in adolescent boys with anorexia nervosa. Adolescent samples including
boys have demonstrated that bone mineral density is higher in atypical anorexia nervosa
versus anorexia nervosa [24], and that weight bearing exercise and participation in team
sports may be protective of bone mineral density at the hip and whole body bone mineral
content [25]. In adult men, low bone mineral density Z scores (<−2 at ≥1 site) have been
documented in men with anorexia nervosa (65%), atypical anorexia nervosa, (33%), and
ARFID (18%) [26]. Men with anorexia nervosa over age 40 have greater fracture risk
compared to healthy controls over age 40 [27].

Treatment
Medical guidelines specific to male populations are lacking, and are mostly based on
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research and clinical experience with females [28]. Some clinical guidance still use criterion,
such as amenorrhea, which are not applicable to males [28]. For instance, the Society for
Adolescent Health and Medicine medical update for restrictive eating disorders indicates
that dual-energy X-ray absorptiometry (DXA) scans should be conducted to monitor bone
health when there has been a loss of menses for six or more months [29]. While 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 [30]

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and the Royal Australian and New Zealand College of Psychiatrists [31] indicate that
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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-enhancing substances
(PES) use [28].

In documenting treatment outcomes among males with EDs, few randomized controlled
trials exist. In fact, most randomized controlled trials have actively excluded male patients
on the basis of their purported atypicality [12]. Qualitative research demonstrates that men
with eating disorders report feeling like “the odd one out” or “atypical’ in current female-
dominated treatment environments [32]. Recently, however, a large dataset documenting
clinical outcomes among a transdiagnostic sample of 110 males was reported. These data
suggest comparable remission rates among males and females with anorexia nervosa by the
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end of treatment (at approximately 40% remission [33]), although more males demonstrated
clinically significant disordered eating at follow-up. Males with bulimia nervosa
demonstrated marginally less favorable remission relative to females with bulimia nervosa
(44% remission by end of treatment, versus 50%). Importantly, however, standardized
mortality rates were higher in males with anorexia nervosa relative to both females with
anorexia nervosa, and males with bulimia nervosa [34], suggesting that anorexia nervosa in
males may be particularly pernicious. In another study, men with eating disorders at 12-
month follow-up had partial recovery (19%) or full recovery (14%) [35].

Special Populations
There are several unique populations that are important to highlight when considering eating
disorders among adolescent boys and young men. First, recent research has begun to identify
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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 males may be driven by body ideals that emphasize muscularity and leanness
[36]. Among collegiate male athletes, baseball, cycling, and wrestling were sports with the
most players reporting elevated eating disorder symptoms in a clinical range [37]. Among
competitive collegiate male athletes, nearly half report current supplement use [38]. Sports
supplement use in male athletes is associated with greater eating disorder symptoms [38].
Use of legal performance-enhancing supplements is associated with future use of anabolic-
androgenic steroids [39]. 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 [40]. Adolescent boys may be more likely to
engage in individually driven exercise compared to females. This may be exacerbated by
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athletic norms associated with sports that emphasize muscularity and strength (i.e. American
football) or weight control and loss (i.e. wrestling) [17, 36].

A second area of importance to highlight is EDs 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 due to continued sociocultural narratives that EDs primarily impact

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White, affluent, adolescent females. Thus, there remains an urgent need to conduct robust
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and rigorous research on the unique differences among adolescent males with EDs across
racial/ethnic identities. However, current research indicates that disordered eating behaviors
may be particularly prevalent among non-White adolescent boys. One study among a
population 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%) [41]. Using the National Youth Risk Behavior Surveillance
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 to White boys [42]**. This study also found that Hispanic/Latino boys
had higher, while Black/African American boys had nearly identical, prevalence rates and
risk ratios of diet pill use compared to their White peers [42]. Given the results from these
studies, it is evident that additional research is needed to develop a stronger understanding of
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the nuances of EDs among racially and ethnically diverse male populations.

EDs have been documented among sexual minority males. In general, research has
continued to indicate that sexual minority adolescent boys experience body dissatisfaction,
EDs, and disordered weight control behaviors [43]. 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 to their completely heterosexual peers [44]*. Similarly,
body dissatisfaction and pressure to increase muscularity was highest among mostly
heterosexual and gay or bisexual boys [44]. Lastly, gay and bisexual boys and mostly
heterosexual boys had the greatest odds of any binge-eating behaviors compared to their
completely heterosexual peers [44]. 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
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their sexual orientation had greater odds of using steroids compared to their heterosexual
peers [45]. More specific results from the state of Connecticut [46] and Massachusetts [47]
found that sexual minority adolescent boys had greater odds of ED and weight control
behaviors compared to their heterosexual peers. In terms of adult men, eating disorder
attitudes and behaviors have been shown to be elevated among gay men compared to the
general population of men [48]. Despite this evidence, there remains a paucity of research on
the epidemiology, treatment, and prevention of EDs among sexual minority adolescent boys
and young men.

A final area of importance to highlight is the intersection of gender with EDs. Masculine
gender norms are associated with muscle-enhancing behaviors [49]. Transgender men may
therefore desire a masculine-appearing build and engage in muscle-enhancing behaviors
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such as bodybuilding [50]. Transgender men may experience dissatisfaction with several
body features such as genitalia, body hair, body shape, facial features, and extremities [51].
Young adult transgender men have also been shown to report high rates of binge eating
(35%), fasting (34%), and vomiting (7%) [52]. A review article has previously summarized
body image and eating disorders in sexual and gender minority youth [53].

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CONCLUSION
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Emerging research demonstrates that males with eating disorders have unique concerns with
regards to disordered eating and body image. Clinical guidance for eating disorders has not
yet become individualized to address these unique concerns [28], and future research should
develop male-specific screening, treatment guidance, and interventions to improve health
outcomes in this underserved population.

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 American 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).
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Key Points
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• Body image concerns in males 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

males 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
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gender minorities.
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Table 1.
The Muscularity Oriented Eating Test (MOET)
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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 = never true, 1 = rarely true, 2 = sometimes true, 3 = usually true, 4 = always true)

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 how they might affect my shape or weight. 0 1 2 3 4

5) I have felt less anxious about eating out if I knew the macro-nutritional content of the food at the restaurant. 0 1 2 3 4

6) I have taken my own food out with me to social events in case the food on offer is inconsistent with my diet plan. 0 1 2 3 4

7) I cannot achieve my body ideal unless I exert complete control over everything I eat. 0 1 2 3 4

8) I have pre-cooked several meals in advance to ensure that I don’t deviate from my diet plan. 0 1 2 3 4
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9) I have continued eating despite feeling full, in attempting to influence my muscularity. 0 1 2 3 4

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 foods, so that my muscles look more defined. 0 1 2 3 4

12) If I broke any of my food rules, I attempted to make up for it at my next meal. 0 1 2 3 4

13) I have felt anxious about others knowing the rules I have around what I eat. 0 1 2 3 4

14) Other people don’t seem to understand how important my food choices are to me. 0 1 2 3 4

15) Ensuring proper adherence to my dietary ideals is more important to me than adhering to a work schedule. 0 1 2 3 4

Global MOET scores are formed by calculating the mean score of all items. Murray SB, Brown TA, Blashill AJ, et al. The development and
validation of the muscularity-oriented eating test: A novel measure of muscularity-oriented disordered eating. Int J Eat Disord 2019, 52:1389–1398.
Author Manuscript
Author Manuscript

Curr Opin Pediatr. Author manuscript; available in PMC 2021 August 01.