Medical and scientific understanding of eating disorders is changing and expanding. What happened?
Dr. Smith: Historically, eating disorders have mostly been seen as anorexia, which has been presented as a disease of adolescent women who want to lose weight for cosmetic reasons.
Dr. Nagata: It has become increasingly recognized, particularly in the last decade or so, that some people with body image dissatisfaction are not trying to lose weight at all. Some men and boys try to get big and muscular. In fact, one-third of teenage boys in the United States report that they are trying to bulk up and become more muscular. And a subset of them may develop eating disorders or muscle dysmorphia that can lead to significant psychological distress and physical complications.
What is muscular dysmorphia?
Dr. Nagata: Also known as anorexia nervosa or anorexia nervosa, it is a disorder where someone believes their body is thin or not muscular enough, even if they would objectively be considered fit or athletic by other people.
Dr. Smith: It may be because they want to be more fit for hockey or because they want to be more muscular or “cut” in terms of appearance. The motivation that may be driving these behaviors may not align with being thinner, but we still see very similar behaviors. We see obsessive exercise. We are seeing the elimination of certain types of food. We see intense dietary self-restraint. And then there are those who choke or throw up, are afraid of it, or have always been picky and fall off their growth curve. And because children and teens grow and develop so quickly, these changes can lead to very serious medical complications.
These complications can lead to starvation. What does this mean?
Dr. Smith: It’s a mismatch between someone’s energy needs or nutrient needs and what they actually put into their body.
Dr. Nagata: When your body constantly puts out more energy than it takes in, it can lead to a state of starvation where your vital organs begin to shut down because they don’t have enough energy to sustain themselves. And I think it’s totally under-recognized that starvation can happen among people who exercise too much without getting enough nutrition.
So, is there an overlap here in terms of boys and athletics?
Dr. Nagata: Yes, absolutely. I think that boys who are athletes are at greater risk for eating disorders because to some extent, some of these behaviors are normalized in competitive sports.
Dr. Smith: When it comes to the relationship between over-exercising, under-eating and the physical consequences among athletes with eating disorders, we actually have a term called the “female athlete triad”.
What are the components of the female triad?
Dr. Smith: Weight loss, changes in bone density and amenorrhea, which is when women do not have periods. It’s another example of our gender bias and how we’ve approached this disease.
Dr. Smith, you have done some of the most informed research on eating disorders, including the finding that eating disorders severely affect boys.
Dr. Smith: I looked at over 11,000 Ontario hospitalizations for eating disorders of children and adolescents aged 5 to 17 from 2002 to 2019. What I found was that while hospitalization rates increased by 139% overall, the largest relative increase was among males: The hospitalizations increased by 416%. Common reasons for hospitalization will include indications such as a very low heart rate, abnormal mineral markers in their blood, or suicidal ideation.
To what extent does your research in Canada suggest what is happening in the United States?
Dr. Nagata: I imagine our tendencies are quite similar. We have a recent study that focused on boys who were hospitalized for eating disorders in the United States. We found that, compared to hospitalized girls, boys actually have more serious medical complications. Boys have longer hospital stays, greater heart rhythm abnormalities, and higher rates of anemia than girls. This may in part reflect that boys are often identified or diagnosed later.
