The medical and scientific understanding of eating disorders is changing and expanding. What happened?
Dr. Smith: Historically, eating disorders have been conceptualized mostly as anorexia, which has been portrayed as an illness of adolescent females who want to lose weight for aesthetic reasons.
Dr. Nagata: There’s increasing recognition, 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 are trying to become large and muscular. In fact, one-third of teenage boys across the United States report that they’re trying to bulk up and get more muscular. And a subset of those may develop eating disorders or muscle dysmorphia that can lead to significant psychological distress and physical health complications.
What is muscle dysmorphia?
Dr. Nagata: Also known as bigorexia or reverse anorexia, it’s a disorder where someone thinks that their body is puny or not muscular enough, even if objectively they would be considered fit or athletic by other people.
Dr. Smith: It might be because they want to be fitter for hockey, or because they want to be more muscular or “cut” from an appearance point of view. The motivation that might guide these behaviors might not align with being thinner, but we still see very similar behaviors. We see the obsessive exercise. We see eliminating certain types of food. We see marked dietary restraint. And then there are those who choke or vomit, become afraid of that, or have always been picky eaters and fall off their growth curve. And because kids and teenagers are growing and developing so quickly, those changes can lead to quite serious medical complications.
These complications can lead to a starvation state. What does that mean?
Dr. Smith: It is a mismatch between someone’s energy or nutrient needs and what they’re actually putting into their body.
Dr. Nagata: When your body is constantly exerting more energy than it is taking in, that can lead to a starvation state where your vital organs begin to shut down because they don’t have enough energy to sustain themselves. And I think it’s underrecognized that starvation can happen among people who exercise too much without getting enough nutrition.
So, is there an overlap here when it comes to boys and athletics?
Dr. Nagata: Yeah, absolutely. I think boys who are athletes have a higher risk of eating disorders, because to some extent, some of these behaviors are normalized in competitive sports.
Dr. Smith: When it comes to the relationship between overexercise, undereating and 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 females aren’t menstruating. It is another example of our gendered bias and how we approached this illness.
Dr. Smith, you’ve done some of the most up-to-date research on eating disorders, including the finding that eating disorders severely impact boys.
Dr. Smith: I looked at over 11,000 hospitalizations in Ontario for eating disorders of children and adolescents aged 5 to 17 from 2002 to 2019. What I found was that while rates of hospitalization increased overall by 139 percent, the largest relative increase was among males: Their rate of hospitalizations rose 416 percent. Common causes of hospitalization would include indications like very low heart rate, abnormal markers of minerals in their blood or suicidal ideation.
To what extent is your research in Canada suggestive of what’s happening in the United States?
Dr. Nagata: I would imagine our trends are pretty 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 girls who are hospitalized, boys actually have more severe medical complications. Boys have longer hospital stays, greater heart-rate abnormalities, and higher rates of anemia than girls. That may partly reflect that boys are often identified or diagnosed later.