The Aging Male

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Male eating disorders in midlife—possible links

between excessive sports and hormones

Kai K. Kummer & Barbara Mangweth-Matzek

To cite this article: Kai K. Kummer & Barbara Mangweth-Matzek (2023) Male eating disorders
in midlife—possible links between excessive sports and hormones, The Aging Male, 26:1,
2154571, DOI: 10.1080/13685538.2022.2154571

To link to this article: https://doi.org/10.1080/13685538.2022.2154571

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Published online: 15 Feb 2023.

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THE AGING MALE
2023, VOL. 26, NO. 1, 2154571
https://doi.org/10.1080/13685538.2022.2154571

REVIEW

Male eating disorders in midlife—possible links between excessive sports

and hormones
Kai K. Kummera,b and Barbara Mangweth-Matzekb
a
Institute of Physiology, Medical University of Innsbruck, Innsbruck, Austria; bDepartment of Psychiatry, Psychotherapy,
Psychosomatics and Psychological Medicine, University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria

ABSTRACT ARTICLE HISTORY

Although eating disorders were long considered a typical female disorder, it is now clear that Received 4 November 2022
men are also affected. However, the literature on eating disorders in men is still very limited, Revised 29 November 2022
and the actual extent is not known. Even less is known about the epidemiology of eating disor­ Accepted 29 November 2022
ders in older individuals. In this focused review, we will present an update of the available data Published online 14 Decem­
ber 2022
on disordered eating and eating disorders in middle-aged and older males. In addition, we will
highlight the relationship of eating disorders with excessive sports as a purging method of KEYWORDS
choice for this age group and discuss the impact of age-related hormonal imbalances in Eating disorders; male;
aging men. testosterone; age;
excessive sports

Introduction Besides geriatric patients, where due to the wide

In recent decades, the field of eating disorder (ED)
research has experienced a dramatic shift in their diagnos­
tic orientation. While classically EDs were viewed as typical
female-centric psychiatric disorders that only affected very
few and atypical males [1], this view has been revised
toward a wider spectrum of ED manifestations affecting
both sexes. Still, males have been and continue to be
underrepresented in the ED literature [2]. With this
broader view on EDs, also the actual extent of societal
costs based on ED-related treatments is better reflected.
Not only do EDs constitute serious public health problems
that besides strong impact on the affected individuals
also burden families and social support systems, but they
also cause tremendous health care costs [3].
Until now, only few studies have assessed the
prevalence of EDs in the general population, with con­
siderable differences between various geographic
regions [4]. However, female : male ratios were
reported to lie between 3–12 : 1 for anorexia nervosa
(AN), 3–18 : 1 for bulimia nervosa (BN), and 2–6 : 1 for
binge eating disorder (BED), whereas the proportion of
EDs not otherwise specified (EDNOS) was even higher
for males as compared to females [5].
In addition to this increased focus on EDs in males,
emphasis has recently been put on older individuals.
range of medical and pharmacological causes of
weight loss EDs may go undetected [6–8], the majority
of women between 30 and 74 years reported to be
dissatisfied with their weight despite being at normal
weight already in 1998 [9]. For women aged 40 years
and above, prevalence rates between 3 and 4% were
reported [10], and associations with menopausal tran­
sition [11–16] and symptoms have been found [17,18].
Only recently, we have conducted some of the first
epidemiological studies of ED symptoms in older men,
reporting ED symptoms in close to 7% of participants
of a community sample or men attending a gym
[19,20]. Further investigations of the underlying causes
are only slowly gaining traction.
In this focused review article, we will provide an
update on EDs in middle-aged and older males. We
will further highlight excessive exercise as the purging
method of choice and link hormonal changes in mid­
life to the high prevalence of ED symptoms in this
age group.
Eating disorders in middle-aged men
Already in 2015, Reas and Stedal have reviewed data
on male EDs in midlife and beyond [21]. They identi­
fied 16 clinical case reports that documented ED

CONTACT Kai K. Kummer kai.k.kummer@gmail.com Medical University of Innsbruck, Institute of Physiology, Schoepfstrasse 41/EG, Innsbruck
A-6020, Austria
� 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/),
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
2 K. K. KUMMER AND B. MANGWETH-MATZEK
diagnoses of AN, BN, EDNOS, and BED in men aged
40 years and above, with the majority showing psychi­
atric comorbidities including depressive and anxiety
disorders as well as suicidal ideation. Epidemiological
data on this age group are still sparse, with the major­
ity coming either from US [22] or UK national surveys
[23] or military veteran discharge diagnoses [24,25].
Interestingly, the US National Comorbidity Replication
study found that while prevalence rates of AN, BN and
BED were still dramatically more frequent in women
than in men, the lifetime prevalence of sub-threshold
binge eating behavior was even higher in males than
in females [22]. This lack of full ED diagnoses might
be related to the diagnostic tools in use, of which the
majority has been developed and validated in females,
and which do not reflect sex-differences in the presen­
tation of ED symptoms [5]. Although recent revisions
of the diagnostic criteria for EDs try to adapt this cata­
log of symptoms used for diagnosis, like the removal
of the occurrence of amenorrhea as one of the diag­
nostic hallmark criteria for AN [26], we are still far
from sex or gender-specific diagnostics of EDs.
Since the systematic review by Reas and Stedal
[21], only a small number of new publications on this
topic were published. In a recently published 30-year
longitudinal study, Brown et al. [27] found that while
the percentage of women meeting the criteria for any
full ED diagnosis decreased significantly from age 20
to 30 and stabilized form 30 to 50, no such difference
was detected in male participants. Also, while, drive
for thinness decreased for women, it increased for
men. Interestingly, point prevalence of ED diagnoses
at age 50 did not differ between genders.
While in a community study in Cyprus the age
group of 46–60 years showed higher mean total scores
on the Eating Attitude Test (EAT-26 questionnaire)
than younger cohorts, suggesting disordered eating
behavior [28], ED symptoms were found in 7% of par­
ticipants in an Austrian community sample [20]. In a
Dutch population based study, researchers found that
dieting was most prevalent in 45- to 65-year-old men
(31.7–31.9%), whereas fear of weight gain was highest
in 25- to 55-year-old men (43.2–46.1%) [29]. For both
measures, frequencies rose dramatically over the entire
age range (no longitudinal study, based on different
age groups).
Some additional new data exist from groups of
military veterans. Slane et al. [30] showed that both
men and women veterans who engaged in disordered
eating behaviors had high rates of PTSD and major
depressive disorder as compared to veterans without
eating disorders (although here the average age was
30 ± 10); and homelessness might increase the likeli­
hood for EDs [31].
Lastly, it was shown that EDs were associated with
increased risk for fall injuries and fractures in a
Swedish cohort study, which might be due to com­
mon ED side comorbidities like hypotension, arrhyth­
mias, hypoglycemia, peripheral neuropathy, and
osteoporosis [32].
All these findings are in line with the results of
Hilbert et al. [33], who found that in males the peak
total score on the Eating Disorder Examination-
Questionnaire (EDE-Q) occurred at age 55–64, which
means in midlife.
Taken together, the prevalence rates for EDs in
middleaged men are not too far from those of
women. The actual extent will become more apparent,
the more research is performed in this direction.
Although the rates of the classical eating disorders AN
and BN are not the highest, EDNOS as well as BED are
way more frequent and approach prevalence rates of
females. A gender-biased propensity for EDs might
therefore be only artificial, and by adapting criteria
and assessment tools, prevalences might slowly even
out between those gendered groups.
Excessive sports as purging method of choice
in aging males
As we have briefly discussed, diagnostic criteria as
well as assessment tools for EDs have so far mainly
been based on clinical presentations and validations
in female groups, leading to a gender-biased view of
ED symptomatology. While in females the control of
eating behavior is mainly influenced by a socially and
media conveyed image of thinness, the ideal body
image is different for males. For them it is directed
toward a muscular Adonis-like physique, that requires
a combination of losing weight in the sense of reduc­
ing fat content and gaining weight due to increasing
muscle tissue [26]. This combination of leanness and
muscularity is characterized by a “bulking and cutting”
dietary practice, where “bulking” is a phase of exces­
sive protein replenishment and “cutting” restrictive
eating behavior, thereby closely resembling bulimic
binges [26,34,35]. In addition, classical purging meth­
ods, like vomiting or laxative use are applied
after binges.
Interestingly, Mitchison et al. [36] could show that
male sex and age over 45 years was associated with
increased prevalence rates in extreme dieting and
purging, thereby marking this age group as particu­
larly vulnerable to weight control measures. In

addition, we could show in our community sample
[20] that disordered eating was associated with
increased scores on the Exercise Addiction Inventory
[37], suggesting that excessive exercise is indeed used
by our non-clinical sample of aging males as the purg­
ing method of choice. This connection between sports
and disordered eating, although previously described
[38], is further corroborated by reports that around
one fifth of team sports members between 18 and
55 years showed an ED diagnosis [39], and that mili­
tary veterans were more likely to engage in excessive
exercise instead of other purging methods, like vomit­
ing [40]. Also in the context of fitness centers, exces­
sive exercise was found as the predominant
compensation for binging in men with bulimic symp­
toms [19].
Excessive sports activity can therefore be seen as
male-specific characteristics of eating disorders that
may serve as a strategy for acute emotion regulation
counteracting depressive symptoms [41,42].
Midlife hormonal changes—andropause and
eating disorders
In recent years a body of literature has been produced
linking the hormonal change of menopause to female
eating disorders, therefore posing these hormonal
changes as a critical window of susceptibility for the
occurrence of eating disorder symptomatology [10].
The menopause, or climacteric, is an age dependent
cessation of the menstrual period, which is character­
ized by a sharp decrease in the production of the hor­
mones estradiol and progesterone by the ovaries. In
contrast, changes of male hormone levels, most
importantly testosterone, do not show such an abrupt
decrease, but a more gradual decline over years. This
age-dependent reduction in testosterone levels is
termed late-onset hypogonadism (LOH) or testoster­
one deficiency [43,44]. To have a direct equivalent for
menopause, some authors have also called it andro­
pause, although this terminus has been criticized for
inconsistency and not reflecting the actual symp­
toms [45].
The psychological relevance of LOH is made appar­
ent by prevalence rates of 20–31% and the association
with various psychiatric disorders [45]. With the stark
increase of psychological disturbances during middle-
age in men, the connection with aging symptomatol­
ogy became apparent [46]. Although in an early study
andropause has not been associated with specific psy­
chological symptoms, but more with subthreshold
depressive symptoms [47], it has been shown that
THE AGING MALE 3
testosterone replacement therapy can modestly
improve depressive symptoms [48]. Interestingly, low
plasma testosterone levels have been shown to be
bidirectionally associated with obesity, with obese
men being at particularly high risk for developing sec­
ondary hypogonadism and testosterone deficiency
being a cause for the development of obesity [49,50].
This is of special interest as also obesity is associated
with a substantial number of psychological comorbid­
ities [51].
Data showing a direct link between disordered eat­
ing and andropause are sparse. In a community sam­
ple we could recently show that men that showed
high values on the Aging Male’s Symptom scale (AMS)
also showed higher prevalence rates for eating distur­
bances [52], suggesting that also here the psycho­
logical manifestation of age-related decline of
testosterone acts as a critical window for eating dis­
order susceptibility. Indeed, also in young adult men it
was shown that lower testosterone levels significantly
correlated with dysregulated eating symptoms, even
after controlling for depressive symptoms, body mass
index and age [53], whereas initial data on 8–9 year
old children revealed a greater body dissatisfaction
with higher testosterone levels, although this associ­
ation vanished after adjustment for covariates [54].
Although testosterone replacement therapy is able to
change body composition and decrease fat mass in
obese individuals [49,55], its effect on the actual
expression of disordered eating behaviors has so far
not been investigated systematically. And while the
application of low-dose testosterone in female AN
patients did not affect disordered eating symptoms
[56], a possible treatment effect on aging males still
needs to be determined.
Conclusion
The increasing number of reported eating disorders in
males suggests both greater awareness and accept­
ance in the public and professional perception.
However, the systematic investigation of epidemio­
logical differences and risk factors especially in older
age groups is only slowly starting to gain traction.
While prevalence rates of disordered eating in middle-
aged and older males are comparable to females of
the same age group, the strategies they use to control
weight are different, with excessive exercise being
their purging method of choice. Given the apparent
societal trend toward healthy lifestyle behaviors, these
problematic eating and restraint patterns often go
undetected. In addition, the age-dependent decrease
4 K. K. KUMMER AND B. MANGWETH-MATZEK
of testosterone levels in aging males seems to consti­
tute a specific window of susceptibility for disordered
eating, similar to that of menopausal hormone dysre­
gulation in women. Further research is urgently
needed to better understand the relationship between
age and eating disorders, and to provide affected indi­
viduals with adequate therapeutic interventions.
Disclosure statement
No potential conflict of interest was reported by
the author(s).
Funding
The author(s) reported there is no funding associated with
the work featured in this article.
ORCID
Kai K. Kummer http://orcid.org/0000-0002-5854-6503
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