Assessing the prevalence of disordered eating in males continues to be a complex puzzle. Below, I try to make sense of what we can learn from the research literature to date, the latest piece published being two years ago now.
A key concern of policy makers and healthcare services is that of actual numbers of men with disordered eating. There seems to be an overall assertion that the number of males receiving care from eating disorder services has grown in more recent years (Cohn and Lemberg, 2014). This may suggest that the occurrence of cases meeting clinical criteria has increased. However, this view is not shared by everyone in the field. Elsewhere it is reported that the numbers of men presenting for treatment remain stable, it is simply that greater media attention has led to a perception that clinical cases have grown (Strumia, 2011). This requires further scrutiny, therefore, as it appears that a definitive statement about prevalence of male disordered eating is not possible.
Historically, in US studies an overall rise has been observed in hospital admissions for eating disorders (Zhao, 2011), with males accounting for up to 8% of the clinical intake at one eating disorder service in the late 1970s to the 1980s (Andersen, 1985). From the mid-80s into the late 1990s male cases presenting for treatment had increased from virtually nothing to 6.7% of cases, when medical records were retrospectively analysed (Braun et al., 1999). In the UK, during a similar time frame Bryant-Waugh reported an unusually high finding: thirteen males in a total of forty-eight cases (Bryant-Waugh, 1992). This appears to be contradictory to other findings, which evidence no significant increase in males with eating disorders over time. A specialised eating disorders service in Leicester reported a steady rate of 5% of male patients 1987-2007 when they examined service medical records (Button et al., 2008). It should be noted that these refer to specific services with their own intake profiles and circumstances, which could account for such differing conclusions on prevalence within clinical samples. None of these studies was designed to investigate males as part of a larger, generalised population.
Not surprisingly then, at the beginning of the twenty-first century specialists were being understandably cautious about general prevalence, preferring to state that actual rates were simply unknown (Garvin and Striegel-Moore, 2001). Since then, however, research has taken up this challenge and designed studies to offer insights into just how much of a problem male eating disorders actually are, although this body of work continues to be particularly scarce (Hoek and Van Hoeken, 2003) due to, I would posit, two issues: firstly, the difficulties in ‘measuring’ a mental health disorder, which often go under-reported (Wilkins & Kemple, 2011; Ray, 2004). Secondly, the problem of nosology within the larger eating disorders field is a factor. It is certainly difficult to measure the incidence rates of something that clinicians and researchers struggle to classify and, therefore, diagnose. Generally, eating disorders are subject to ongoing debate regarding threshold criteria for diagnosis (Freeman, 2005). If this is the case with the better-established field of female eating disorders, then this certainly continues to be a problem when reliably identifying males who have these disorders (Anderson & Bulik, 2004 – 2).
This is not to say that there are no current data available on males. Much of our understanding about prevalence is drawn from studying community samples. Studies have been able to test broadly representative populations of men using data produced from ongoing national health monitoring, such as the National Health Omnibus survey in Australia, where men now account for a “substantial minority” of people who had an eating disorder, representing 23-41% of people showing eating disorder features (Mitchison et al., 2013: 377). Alternatively, retrospectively gathered health and medical records about a population have suggested rates of occurrence. A study in Finland discerned that one in four hundred adolescent males experienced eating disorder features and body image disruption (Raevuori et al, 2009).
Another confounding factor when attempting to understand prevalence is the fragmented nature of eating disorders themselves. Studies, due to issues of scope and access to data, often report on specific conditions within an overall umbrella term of ‘eating disorders’. One such study focused specifically on features of binge-eating behaviours and aimed to map incidence rates using 908 male pupils across 23 schools in the US. It found that 10% of the group reported behaviours associated with bingeing and just under half had engaged in forms of purging (Pearson et al., 2010). Whilst this is promising in terms of illustrating the potential for developing future risk of specifically binge-related conditions in future it cannot be taken as a rate of occurrence for ‘eating disorders’ in young males generally. A much earlier study attempted to report incidence but struggles to offer detailed data on males. It does provide somewhat vague findings that rates of BED occur similarly between males and females, though what this frequency is is less specific (Taraldsen et al., 1996).
Exchanging binge-eating for the less-specific category of Eating Disorders Not Otherwise Specified changes the picture again. Out of a random sample of men accessing their general practitioners for treatment only 1.2% had an eating disorder (Hay et al., 2005). This suggests that searching for disordered eating symptoms in a general population will produce higher rates than if a clinical population is examined. However, the sheer inconsistency between analysing community versus clinical samples is neatly illustrated by Andersen. He gives rates of one male for every six female cases in community samples of eating disorder pathology. Whereas clinical samples show that between 10%-20% of cases seen are male (Andersen, 2002). This wide range is puzzling, given that clinical samples usually accrue data in the form of medical notes and records and begs the question how many cases have there been in total in the medical system in the US or the UK? And how many of these have been male? To what extent is the difference attributable to the differing contexts of the US and the UK? Recent UK data that drew on NHS hospital admissions suggests that perhaps the clinical picture is closer to the lower end of the range suggested by Andersen. Of the 2,579 admissions in 2009-2010, 10% were young males (Henderson, 2012). This appears to give credence to the ‘substantial minority’ observation by Mitchison et al. above but does not appear to support a conclusion of an exponential increase over time.
A penultimate useful observation about the lack of coherent information on prevalence can be gleaned using published sources that rely on secondary analysis. Of the twelve male-focused literature review articles I was able to study, the topic of prevalence appears to be either omitted or statements about rates in males are hard to interpret. This perhaps reflects the lack of coherent obtainable data the reviewers were able to locate. In Table 1, I have summarised the review papers, beginning with the most current. Where necessary I have preserved statements about the data verbatim.
Table 1 Eating Disorders in Males Literature Reviews – Prevalence Data
|Sweeting et al.||2015||▪ 10-25% of eating disorder cases are male from total number of cases reported of 60,000-2.7 million depending on source.
▪ This suggests large range – anything from 6000 men and up-over may have EDs.
▪ The analysis points out how variable the findings are between scientific reports and media figures.
|Darcy||2011||▪ 10% of eating disorder cases are male, representing a female/male ratio of 9:1;
▪ Ratio in community samples of males are healthy/eating-disordered 4:1.
|Jones and Morgan||2010||▪ 10% to 20% of anorexia and bulimia cases are male;
▪ 40% of BED cases are male.
|Freeman||2005||▪ 5% to 10% of eating disorder cases are male.|
|Weltzin et al.||2005||▪ 2% to 4% of the population of anorexia or bulimia;
▪ 10% of these cases are male – bulimia is more common;
▪ 5% of the population may have Eating Disorder Not-Otherwise-Specified (EDNOS);
▪ BED rates in men are similar to rates in women.
|Ray||2004||▪ 1% to 3% of people in industrialised countries have an eating disorder.
▪ 10% to 15% of eating disordered cases are male;
▪ 9% to 11% of community sample met diagnostic criteria for eating disorders;
|Muise et al.||2003||▪ female/male ratio of anorexia is 2:1 when including atypical diagnosis;
▪ female/male ratio of anorexia is 35:15 in adolescent cases.
|Harvey and Robinson||2003||▪ 0.4% to 1.1% of bulimia cases are men.|
|Petrie and Rogers||2001||▪ 10% of anorexia and bulimia cases are male;
▪ 25% of Binge-eating Disorder (BED) are men;
|Williamson||1999||No data given.|
|Heffernan||1994||No data given.|
|Scott||1986||▪ 38% of university students in an all-male sample reported binge-eating.|
|Sterling and Segal||1985||No data given.|
Collecting all these papers’ observations together in one place reveals how difficult it is to provide a meaningful appraisal, given the patchwork nature of findings. Ratios are given in certain articles, whilst in others percentage ranges are presented with no supporting figures about total numbers of population. In some cases, eating disorder cases generally are cited; in others rates of specific disorders, such as bulimia or anorexia, are calculated. Often, throughout the male eating disorder literature, only imprecise conclusions about prevalence are arrived at. This means actual rates of eating disorder that would require treatment and support are only implied. This seems to be due to equivocal data or because actual eating disorders requiring support, treatment and recovery are not actually being measured. As an example of the former, a study with sixty-two male cases described its sample as “very small” and therefore was unable to offer any straightforward conclusions (Woodside et al., 2001: 572). When there is a more statistically viable sample utilised rates are more simply and clearly articulated. In a review of military personnel medical records in the US only 0.06% of male service members requiring medical treatment were reported as being seen for eating disorders treatment over a nine year span (Antczak and Brininger, 2008). Of course, this relates to one specific societal group and whilst the rate is definitively measured, the results are not automatically indicative of the rest of the population. The latter means that only potential, subclinical eating problems are being investigated, such as the paper that reported a ratio of three women to every one man with eating issues (Locker et al., 2012). This ratio was calculated from a sample comprised of students on campus who responded to instruments designed to detect indicators of disordered eating and compare women and men’s results. This is clearly not the same as being able to offer insights on the numbers of men whose lives are actually being affected by disordered eating. In essence, whether using community or clinical samples, male eating disorders are not seen to be scientifically viable for firm conclusions about prevalence. This may be why so many of the studies on male eating disorders have been case-based until more recently.