The enigma of male eating disorders: A critical review and synthesis

Longitudinal relationships between specific domains of interoception and muscle dysmorphia symptoms

Muscle dysmorphia (MD) is a subtype of body dysmorphic disorder (BDD); few risk factors for MD symptom development have been identified. One potential risk factor may be decreased interoceptive sensibility (impaired ability to recognize bodily sensations), which is present across a range of mental disorders. Notably, impaired interoceptive awareness is elevated in populations at-risk for MD. Furthermore, interoception is associated with MD symptoms, and theoretically, interoceptive dysfunction may facilitate engagement in MD symptoms. However, longitudinal research on interoception and MD is scarce, and specific MD symptoms implicated in these relationships are unknown. This study examined longitudinal relationships between specific domains of interoceptive sensibility and MD symptoms. Participants were 255 (26.7% Male; 72.1% Female; 1.2% Non-binary) undergraduates who completed two self-report surveys separated by four weeks. A path model was specified in which seven forms of interoception predicted five MD symptoms. Results suggested that interoceptive sensibility characterized by difficulties attending to bodily sensations and viewing these sensations as distracting predicted MD symptoms like muscle checking, positive attitudes towards using muscle-building substances, and compulsive exercise. Specific forms of impaired interoceptive sensibility may represent a risk factor for MD symptoms. If clinicians can increase the interoceptive abilities of their clients at risk for MD, this may prevent the development of MD symptoms.

Examining the relationship of eating disorder symptoms and perfectionism in men and women using two assessments of eating pathology

Eating disorder (ED) pathology in men is not as well understood or studied as ED pathology in women. One potential reason for this is that most of the traditional assessments used for EDs were developed for and validated with exclusively female samples, meaning that symptoms in men are not as well represented or measured. There are consistent associations between perfectionism and ED symptoms in women, but less is known regarding how these relationships function in men. This study examined whether the relationship of perfectionism to ED symptoms varies by gender using the Eating Disorder Examination-Questionnaire (EDE-Q) and the Eating Pathology Symptom Inventory (EPSI). The EPSI has multiple dimensions that may better capture the presentation of ED symptoms in men. Participants were recruited from a large public university and through Amazon MechanicalTurk. Participants completed a survey battery that included the two eating measures and the self-oriented perfectionism scale from the Hewitt and Flett Multidimensional Perfectionism Scale. Data were analyzed using independent samples t-tests and structural equation modeling. There were significant positive associations between self-oriented perfectionism and all dimensions measured by the EDE-Q and the EPSI. The models were invariant across gender. Implications for further research were discussed.

Associations between muscle-building exercise and concurrent e-cigarette, cigarette, and cannabis use among U.S. adolescents

Physical activity and team sports may be protective of substance use among adolescents, although there is mixed evidence on whether muscle-building exercise is associated with patterns of e-cigarette use (i.e., vaping), cigarette use, and cannabis use. Therefore, this study aimed to determine the association between muscle-building exercise and patterns of concurrent substance use among U.S. adolescents. Cross-sectional data from the 2019 Youth Risk Behavior Survey (N = 8,474) were analyzed in 2022. Muscle-building exercise was assessed by number of days of the behavior in the past week and categorized based on level of engagement (none, low, medium, and high). Concurrent vaping, cigarette use, and cannabis use within the past 30 days were assessed using a combined, four-category variable (no use, any single use, any dual use, and triple use). Multinomial logistic regressions, with coefficients transformed to relative risk ratios (RRR), were conducted to estimate the associations between muscle-building exercise and concurrent substance use among the overall sample, and by sex, while adjusting for relevant sociodemographic variables. Among the overall sample, high engagement (6-7 days) in muscle-building exercise was associated with greater relative risk of any single use (RRR 1.36, 95% confidence interval [CI] 1.06-1.72), any dual use (RRR 1.46, 95% CI 1.10-2.94), and triple use (RRR 1.81, 95% CI 1.05-3.12). While muscle-building exercise was associated with greater relative risk of concurrent patterns of vaping, cigarette use, and cannabis use among adolescent males, there were no significant relationships found among adolescent females. Healthcare professionals should consider this association when treating adolescent males, particularly given the high prevalence of muscle-building exercise and substance use among this group. More research is needed to understand the experiences of adolescent males who report high engagement in muscle-building exercise and substance use to uncover mechanisms of association.

Strengths and weaknesses of the German translation of the Inflexible Eating Questionnaire and of eating disorder assessment in general

Objective

The present article introduces the German translation of the Inflexible Eating Questionnaire (IEQ-G), performs a psychometric evaluation, and explores the relationship of Inflexible Eating to the subscales of the Eating Disorder Examination-Questionnaire (EDE-Q) and Obsessive-Compulsive (OC) symptoms.

Methods

The cross-sectional study was carried out in the German-speaking area. A paper and pencil survey was completed by 612 females and 442 males of the general population.

Results

SEM analyses showed that the IEQ-G allows for calculating a total score and invariance tests were mostly promising. As a side result, the original 4-factorial structure of the EDE-Q could not be replicated, but a 3 dimensional solution proved convincing. From a psychometric point of view, the IEQ-G outperformed the EDE-Q. On a latent level, Inflexible Eating was remarkably strong related to OC-symptoms and the EDE-Q subscales.

Discussion

The detail analyses revealed that Eating Disorder assessment in general lacks subgroup-specific aspects, for instance, regarding gender or dietary preferences, important for early diagnosis and screening of ED. The IEQ-G proved applicable in a German speaking adult population and recommends itself for cross-cultural studies.

"Bulking and cutting" among a national sample of Canadian adolescents and young adults

PURPOSE

First, to characterize the prevalence and incidence of "bulk" and "cut" cycles among Canadian adolescents and young adults. Second, to determine the associations between bulk and cut cycle engagement and drive for muscularity and eating disorder and muscle dysmorphia psychopathology.

METHODS

Data were from the Canadian Study of Adolescent Health Behaviors (2021; N = 2762), a national study of Canadian adolescents and young adults aged 16-30 years (M = 22.9, SD = 3.9). Prevalence and mean incidence of bulk and cut cycles in both the past 12 months and 30 days were estimated. Modified Poisson regressions were estimated to determine the associations between bulk and cut cycle engagement and levels of drive for muscularity and eating disorder and muscle dysmorphia psychopathology.

RESULTS

The sample comprised of 53.5% women, 38.4% men, and 8.1% transgender/gender non-conforming (TGNC) individuals. Nearly half (48.9%) of men and one in five women (21.2%) and TGNC (21.9%) participants reported bulk and cut cycles in the past 12 months. TGNC participants and women reported a greater mean number of bulk and cut cycles completed compared to men. Engagement in bulk and cut cycles was associated with stronger drive for muscularity across the sample, and more severe eating disorder and muscle dysmorphia psychopathology among men and women.

CONCLUSION

Findings underscore the common incidence and accompanying psychopathology of bulk and cut cycles among a community sample of adolescents and young adults in Canada, indicating the need for future research, as well as clinical and public health efforts.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Validation of a new screening questionnaire for disordered eating behaviors in men

PURPOSE

The aim of this study was to develop an instrument to identify disordered eating behaviors (DEB) in college men (hereafter, DEBM-Q).

METHODS

A two-stage project consisting of a diagnostic scale construction (n₁ = 9 for interviews, n₂ = 9 for cognitive laboratory) and a validation study with a cross-sectional sample (N = 570) was carried out. Both semi-structured interviews and a cognitive laboratory with nine participants were conducted to obtain DEBM-Q items. DEBM-Q was applied to 570 freshmen male in Mexico City. Psychometric characteristics and internal consistency (Cronbach's alpha) were analyzed. An item-total correlation value greater than 0.30 was determined, and factor loads greater than 0.40 were considered valid. Exploratory factor analysis (EFA, n₁ = 297) and confirmatory factor analysis (CFA, n₂ = 273) were performed.

RESULTS

Two fixed factors explaining 55.08% of the total variance were extracted. Factor 1, "Drive for Thinness" (8 items), explained 30.84% of the variance, whereas factor 2, "Drive for Muscularity" (8 items), explained 24.23% of the variance. Cronbach's alpha for the whole questionnaire was 0.84. DEBM-Q was correlated with the Dutch Food Restriction Scale (RS) (r = 0.52, p < 0.001), Eating Disorder Examination-Questionnaire (EDE-Q) (r = 0.46, p < 0.001), Emotional Eating Scale (EES) (r = 0.18, p < 0.001), and Negative Affect Subscale (PANAS-X) (r = 0.11, p < 0.005).

CONCLUSION

DEBM-Q is a valid and practical short screening tool (16 items) allowing early identification of disordered eating in young men, thereby facilitating clinical management.

LEVEL OF EVIDENCE

Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Network analysis studies in patients with eating disorders: A systematic review and methodological quality assessment

INTRODUCTION

Network psychometrics has been enthusiastically embraced by researchers studying eating disorders (ED), but a rigorous evaluation of the methodological quality of works is still missing. This systematic review aims to assess the methodological quality of cross-sectional network analysis (NA) studies conducted on ED clinical populations.

METHODS

PRISMA and PICOS criteria were used to retrieve NA studies on ED. Methodological quality was evaluated based on five criteria: variable-selection procedure, network estimation method, stability checks, topological overlap checks, and handling of missing data.

RESULTS

Thirty-three cross-sectional NA studies were included. Most studies focused on populations that were female, white and, with an anorexia nervosa (AN) diagnosis. Depending on how many criteria were satisfied, 27.3% of studies (n = 9) were strictly adherent, 30.3% (n = 10) moderately adherent, 33.3% (n = 11) sufficiently adherent, and 9.1% (n = 3) poorly adherent. Missing topological overlap checks and not reporting missing data represented most unreported criteria, lacking, respectively, in 63.6% and 48.5% of studies.

CONCLUSIONS

Almost all reviewed cross-sectional NA studies on ED report those methodological procedures (variable-selection procedure, network estimation method, stability checks) necessary for a network study to provide reliable results. Nonetheless these minimum reporting data require further improvement. Moreover, elements closely related to the validity of an NA study (controls for topological overlap and management of missing data) are lacking in most studies. Recommendations to overcome such methodological weaknesses in future NA studies on ED are discussed together with the need to conduct NA studies with longitudinal design, to address diversity issues in study samples and heterogeneity of assessment tools.

PUBLIC SIGNIFICANCE

The present work aims to evaluate the quality of ED NA studies to support applications of this approach in ED research. Results show that most studies adopted basic procedures to produce reliable results; however, other important procedures linked to NA study validity were mostly neglected. Network methodology in ED is extremely promising, but future studies should consistently include topological overlap control procedures and provide information on missing data.

Performance-Enhancing Substance Use and Intimate Partner Violence: A Prospective Cohort Study

Research has shown that performance-enhancing substance (PES) use, including anabolic-androgenic steroids (AAS), is associated with interpersonal violence (e.g., fighting). This study aimed to determine whether legal PES use and AAS use are associated with intimate partner violence (IPV) involvement cross-sectionally and over seven-year follow-up in a nationally representative prospective cohort study. Data from the National Longitudinal Study of Adolescent to Adult Health (N = 12,288) were analyzed (2021). Logistic regression analyses were conducted to determine the associations between legal PES use and AAS use at Wave III (2001-2002; ages 18-26) and IPV victimization (five variables) and IPV perpetration (five variables) at Wave III and Wave IV (2008-2009; ages 24-32), adjusting for relevant demographic and confounding variables. Results from cross-sectional analyses showed that legal PES use and AAS use were associated with higher odds of both any IPV victimization and sexual IPV victimization, and both any IPV perpetration and physical IPV perpetration by pushing or shoving a partner. Results from prospective analyses showed that AAS use, but not legal PES use, was associated with higher odds of all five IPV victimization variables (any IPV victimization: adjusted odds ratio [AOR] 1.72, 95% confidence interval [CI]1.04-2.84; two forms of physical abuse: 1: AOR 2.01, 95% CI 1.15-3.50; 2: AOR 2.11, 95% CI 1.06-4.21; incurring an injury from IPV victimization: AOR 4.90, 95% CI 1.71-14.01; and sexual IPV victimization AOR 2.44, 95% CI 1.05-5.65), as well as three IPV perpetration variables (any IPV perpetration: AOR 2.11, 95% CI 105-4.23; one form of physical abuse perpetration: AOR 2.58, 95% CI 1.06-6.27; and sexual IPV perpetration: AOR 3.80, 95% CI 1.44-10.02). These results emphasize the adverse social and interpersonal risks associated with PES use. Continued research, health care, and public health prevention and intervention efforts to reduce the use of PES and occurrence of IPV are warranted.

Examining appearance pressures, thinness and muscularity internalizations, and social comparisons as correlates of drive for muscularity and thinness-oriented disordered eating in Chinese heterosexual men and women: Testing an integrated model

Given existing empirical support for the tripartite influence and social comparison models to explain variance in body dissatisfaction and disordered eating across diverse populations in the Western context, research is needed to describe these models in non-Western populations. The present study tested an integrated model inclusive of appearance pressures, thinness and muscularity internalizations, and social comparisons in relation to drive for muscularity and thinness-oriented disordered eating in heterosexual Chinese adult men (n = 510) and women (n = 473). Separated by gender, two integrated models had good fit statistics per structural equation modeling. In men and women, higher appearance pressures were uniquely related to higher drive for muscularity and thinness-oriented disordered eating. In men and women, higher thinness and muscularity internalizations were uniquely related to higher thinness-oriented disordered eating and drive for muscularity, respectively. In men and women, higher upward body image comparisons were uniquely related to higher drive for muscularity, and in men only, higher downward body image comparisons were uniquely related to higher thinness-oriented disordered eating. The present findings, which extend theories of eating pathology, may aid in improving treatment efforts for body dissatisfaction and disordered eating in heterosexual Chinese adult men and women.

Relationships between eating disorder symptoms, muscle dysmorphia symptoms, and suicidal ideation: A random intercepts cross-lagged panel approach

OBJECTIVE

Eating disorder (ED) symptoms correlate with suicidality; yet the strength of these relationships in men is unclear. Muscle dysmorphia (MD) symptoms may reflect a more accurate index of body-related concerns for men, as they better target muscularity concerns typical of men. However, no studies have tested a model in which ED/MD symptoms and suicidality are simultaneously examined. We longitudinally tested whether ED/MD symptoms were related to suicidal ideation among a community sample of men.

METHODS

Men with MD symptoms (N = 272) were recruited to complete three surveys over 6 weeks. A random intercepts cross-lagged panel model tested predictive associations between ED/MD symptoms and suicidal ideation, while disaggregating between/within-person variance.

RESULTS

ED/MD symptoms were significantly associated with suicidal ideation at the between-subjects level (ED: b = .04; MD: b = .09) and showed significant within-wave covariances with suicidal ideation (ED: b = .02-.04; MD: b = .02-.05). Those who experienced increases in ED symptoms showed increased suicidal ideation at the next wave (b = .32). Those who experienced increases in suicidal ideation showed increases in MD symptoms at the next wave (b = .85).

DISCUSSION

Results highlight ED symptoms as a potential risk factor for suicidal ideation among men. Further, suicidal ideation predicted MD symptoms. ED symptoms may create intra- and interpersonal distress predicting suicidal ideation. Suicidal ideation may lead to muscle-building behaviors to cope with suicidal thoughts. Clinicians should assess for suicidal ideation among men at risk for MD/EDs, and for MD symptoms among those reporting suicidal ideation.

PUBLIC SIGNIFICANCE

Eating disorder (ED) symptoms are related to suicidality, but these relationships are understudied among men. Since men report concerns surrounding muscularity, muscle dysmorphia (MD) may be a better ED index for this population. However, little research has investigated relationships between ED symptoms, MD symptoms, and suicidality among men. This study investigated relationships between ED/MD symptoms and suicidality among 272 men. Results may inform clinical assessment, treatment, and classification of MD.

Prospective associations between loneliness and disordered eating from early adolescence to adulthood

OBJECTIVE

Despite findings from numerous cross-sectional studies suggesting a substantial association between loneliness and different types of disordered eating, much remains unknown about the impact of confounding, the order of cause and effect, and gender differences in the relationship. Thus, this study followed a large, population-based, mixed-gender sample through adolescence and young adulthood, applying a random intercept cross-lagged panel model (RI-CLPM) approach to examine the bidirectional prospective associations between loneliness and disordered eating while ruling out the effect of unmeasured time-invariant confounders.

METHOD

A Norwegian sample of N = 2933 adolescents (54.2% female) was examined across four time points (T1, M_age  = 15.44, grades 7-12; T2, M_age  = 16.93; T3, M_age  = 21.84; and T4, M_age  = 28.33) from 1992 to 2005 using RI-CLPMs for overall disordered eating and specific forms for disordered eating (dieting and bulimic symptoms). Multigroup structural equation models were used to assess gender differences.

RESULTS

For male participants, high levels of loneliness at T1 predicted more overall disordered eating and more dieting at T2. Meanwhile, among female participants, disordered eating and bulimic symptoms at T2 predicted more loneliness at T3, whereas loneliness at T3 predicted more disordered eating and bulimic symptoms at T4, and vice versa.

DISCUSSION

The findings suggest a pattern of bidirectional associations between loneliness and disordered eating that varies by time points, gender, and type of eating problem. Preventive interventions and treatment should consider social factors involved in the onset and maintenance of eating problems in male adolescents and young adult women.

PUBLIC SIGNIFICANCE

This study contributes to the existing knowledge by examining for the first time the dynamic nature of the association between loneliness and disordered eating while accounting for all time-invariant confounding. Our findings reveal a pattern of bidirectional associations between loneliness and disordered eating that appears to vary by developmental period, gender, and type of eating problem. Our findings suggest that social factors have to be taken into account when designing prevention strategies aimed at disordered eating.

Eating disorder psychopathology and negative affect in Iranian college students: a network analysis

BACKGROUND

ED psychopathology is becoming more prevalent in Iran. Negative affect has been found to be an important risk factor in eating disorder (ED) onset in research conducted in Western countries, and is also emerging as a potential vulnerability factor to ED psychopathology in Iran. Network theory offers a novel framework to understand the association between negative affect and ED psychopathology in Iran. The primary aim of the current study was to use network analysis to identify bridge symptoms (i.e., symptoms that activate or weaken symptoms in another cluster) across a negative affect and ED psychopathology network among Iranian college students. We also aimed to identify core symptoms (i.e., nodes that demonstrate the strongest connections to other nodes).

METHOD

Participants were Iranian college students (n = 637; 60.3% women) who completed the Farsi-eating disorder examination-questionnaire and Farsi-negative affect. We estimated a network of ED symptoms and negative affective states and identified bridge and central symptoms.

RESULTS

Hostility and shame emerged as central bridge symptoms across the negative affect and ED psychopathology clusters. The most central nodes were strong desire to lose weight, definite fear of losing control over eating, and binge eating episodes.

CONCLUSION

The negative affective states of hostility and shame may increase vulnerability to ED psychopathology among Iranian college students. Findings have important implications for ED prevention programs that should be examined in future research.

Internet-delivered eating disorders prevention program for adolescent girls with type 1 diabetes: Acceptable and feasible

BACKGROUND

Adolescents with type 1 diabetes are at significantly increased risk for eating disorders and few interventions exist.

OBJECTIVE

This study examined the feasibility, acceptability, and preliminary effects of an internet-based eating disorders prevention program adapted specifically for adolescent girls with type 1 diabetes.

PARTICIPANTS AND METHODS

Thirty-five girls (16.2 ± 1.1 years) participated Body Project (T1D Style), a 4-week program consisting of four adolescent sessions focused on promoting illness acceptance, challenging sociocultural body image pressures, increasing social support, and teaching assertive communication. Caregivers participated in one session focused on fostering body image positivity and a healthy relationship with food. Pre-intervention, post-intervention, and 3-month follow-up surveys assessed disordered eating, body dissatisfaction, thin-ideal internalization, diabetes acceptance, diabetes distress, and quality of life. Cohen's d effect sizes were calculated at post-intervention and follow-up. Program acceptability was assessed at post-intervention. Manual fidelity and homework completion were monitored.

RESULTS

High manual fidelity, retention, and homework completion were achieved. Quantitative and qualitative feedback from teens and caregivers suggested high acceptability. Large effects (d = 1.35-0.83) were observed for dieting, body dissatisfaction, diabetes distress, diabetes acceptance, and diabetes-related quality of life at post-intervention, with large-medium effects (d = 1.16-0.58) at follow-up. Medium-small effects (d = 0.49-0.78) at post-intervention were observed for diabetes-specific disordered eating and thin-ideal internalization, with effects maintained at follow-up.

CONCLUSIONS

Results support the acceptability and feasibility of this targeted eating disorders prevention program for adolescent girls with type 1 diabetes. Future clinical trials are warranted to determine its effectiveness compared to a control condition.

The degree to which the cultural ideal is internalized predicts judgments of male and female physical attractiveness

We used attractiveness judgements as a proxy to visualize the ideal female and male body for male and female participants and investigated how individual differences in the internalization of cultural ideals influence these representations. In the first of two studies, male and female participants judged the attractiveness of 242 male and female computer-generated bodies which varied independently in muscle and adipose. This allowed us to map changes in attractiveness across the complete body composition space, revealing single peaks for the attractiveness of both men and women. In the second study, we asked our participants to choose the most attractive male and female bodies in a method of adjustment task in which they could independently vary muscle and adipose to create the most attractive body. We asked whether individual differences in internalization of cultural ideals, drive for muscularity, eating disorder symptomatology and depressive symptoms could systematically shift the location of peak attractiveness in body composition space. We found a clear preference by both genders for a male body with high muscle and low adipose, and a toned, low adipose female body. The degree of internalization of cultural ideals predicted large individual differences in the composition of the most attractive bodies.

Adolescent and emerging adult perceptions of eating disorder severity and stigma

OBJECTIVE

Eating disorders are one of the deadliest mental health conditions, yet most individuals with eating disorders never receive treatment. Previous research has explored barriers to treatment among individuals diagnosed with eating disorders, but little is known about general adolescent and emerging adult perceptions of eating disorders, as compared to other mental health illnesses, a population at greatest risk for developing an eating disorder, and a population that may be important sources of information or support for peers.

METHOD

A sample of adolescents and emerging adults aged 14-24 years (mean age 19 years) from MyVoice, a national text-message-based cohort (53% female, 38% male, 9% other, race/ethnicity 63% White, 10% Black or African American, 13% Asian, 9% Mixed Race, and 5% Other) provided open-ended responses to questions on the severity of eating disorders as compared to other mental health diagnoses, others' perceptions of eating disorders and potential treatment barriers. Responses were collected using a secure online platform and analyzed using content analysis.

RESULTS

Among respondents (n = 792/1283), 91% felt that eating disorders were a mental health condition and 65% felt that eating disorders were as serious as other mental health conditions, while 21% said they were more serious than other mental health conditions. Responses to questions related to perception and barriers illustrated that beliefs of eating disorders involve blame, stigma, and overall lack of understanding.

DISCUSSION

Findings from this study illustrate that there is a lack of understanding around eating disorders that could be addressed in youth-focused initiatives.

PUBLIC SIGNIFICANCE

Adolescents and emerging adults understand that eating disorders are severe mental illnesses that are not taken seriously by others, especially in comparison with other mental health diagnoses. Adolescents and emerging adults report that individuals with eating disorders are blamed for their condition and face shame and stigma. The lack of understanding around eating disorders should be addressed in youth-focused prevention initiatives.

Sex differences and associations between zinc deficiency and anemia among hospitalized adolescents and young adults with eating disorders

PURPOSE

To determine sex differences in and associations between zinc deficiency and anemia among adolescents and young adults hospitalized for medical complications of eating disorders.

METHODS

We retrospectively reviewed electronic medical records of 601 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical instability, between May 2012 and August 2020. Descriptive statistics, crude, and adjusted logistic regression models were used to assess the association between zinc deficiency (< 55 mcg/dL) and anemia (< 13.6 g/dL in males [M] and < 11.8 g/dL in females [F]).

RESULTS

A total of 87 males and 450 females met eligibility criteria (age 15.98 ± 2.81, 59.4% anorexia nervosa; admission body mass index 17.49 ± 2.82). In unadjusted comparisons, plasma zinc in males and females were not statistically different (M 64.88 ± 14.89 mcg/dL vs F 63.81 ± 13.96 mcg/dL, p = 0.517); moreover, there were no differences in the percentage of males and females with zinc deficiency (M 24.14% vs F 24.89%). However, a greater percentage of males than females were anemic (M 50.00% vs F 17.61%, p < 0.001), with similar findings in the subgroup with anorexia nervosa. In logistic regression models stratified by sex and eating disorder diagnosis, zinc deficiency was significantly associated with anemia in males (AOR 3.43, 95% CI 1.16, 10.13), but not females (AOR 1.47, 95% CI 0.86, 2.54).

CONCLUSIONS

For the first time, we demonstrate that zinc deficiency is equally severe in males compared to females hospitalized with medical complications from eating disorders, with nearly a quarter of inpatients experiencing zinc deficiency. Anemia is more common in males than females hospitalized with eating disorders.

LEVEL OF EVIDENCE

Level V: descriptive cross-sectional study.

Body image and compulsive exercise: are there associations with depression among university students?

PURPOSE

Mental health problems among university students have been reported to be significantly increasing and suggested to be associated with college drop-out. Body dissatisfaction and compulsive exercise are both constructs relevant for mental health problems in general and eating disorders in particular. This study examined associations between body dissatisfaction, compulsive exercise and self-reported symptoms of depression among Swedish university students.

METHODS

Participants (n = 4262) are students in an ongoing cohort study, and data from the baseline assessment were used. Four linear regression models were built to explore the associations between body dissatisfaction, compulsive weight control exercise and depressive symptoms.

RESULTS

Our findings showed that females reported higher levels of body dissatisfaction than males. Body dissatisfaction and compulsive exercise were associated with self-reported symptoms of depression in this non-clinical population. Results showed that compulsive exercise was negatively associated with reported symptoms of depression, while body dissatisfaction was positively associated with symptoms of depression.

CONCLUSION

In line with previous research, there was a gender difference in body dissatisfaction where females displayed higher levels of dissatisfaction than males.  Body dissatisfaction was  positively associated with reported symptoms of depression, suggesting support of previous research indicating body dissatisfaction to increase mental health problems. Compulsive exercise was negatively associated with symptoms of depression suggesting a behavior negatively reinforced, supporting both constructs to be of interest for reported symptoms of depression in a non-clinical population of Swedish university students.

LEVEL OF EVIDENCE

III, cohort study.

TRIAL REGISTRATION

http://clinicaltrials.gov/ID : NCT04465435.

Prevalence of muscle dysmorphia in adolescents: findings from the EveryBODY study

BACKGROUND

We sought to provide the first point prevalence estimates of muscle dysmorphia (MD), a form of body dysmorphic disorder characterized by a preoccupation with perceived insufficient muscularity, in adolescents.

METHODS

Data were taken from a survey of 3618 Australian adolescents (11.172-19.76 years; 49.3% girls). Measures captured demographic characteristics, symptoms of MD and eating disorders, psychological distress and functional impairment. Diagnostic criteria for MD developed by Pope et al. (1997, Psychosomatics, 38(6), 548-557) were applied, entailing preoccupation with insufficient muscularity causing significant levels of distress or disability that cannot be better accounted for by an eating disorder.

RESULTS

The point prevalence of MD was 2.2% [95% confidence interval (CI) 1.6-3.0%] among boys and 1.4% (95% CI 0.9-2.0%) among girls. Prevalence was not associated with gender (V = 0.031) or socioeconomic status (SES) (partial η²< 0.001), but was marginally associated with older age (partial η² = 0.001). Boys with MD were more likely than girls with MD to report severe preoccupation with muscularity (V = 0.259) and a weight-lifting regime that interfered with their life (V = 0.286), whereas girls with MD were more likely to report discomfort with body exposure (V = 0.380).

CONCLUSIONS

While future epidemiological research using diagnostic interviews is needed to verify these estimates, the findings suggest that MD is relatively common from early to late adolescence. Gender differences in MD prevalence may be minimal; however, the symptom profile appears to diverge between boys and girls. These findings provide a platform for future, analytical research designed to inform clinical and public health interventions.

Eating disorder risks and awareness among female elite cyclists: an anonymous survey

Background

Eating disorders (EDs) are an increasingly recognized concern in professional sports. Previous studies suggests that both female gender and endurance sports put athletes at risk. Female elite cyclists are hence of specific interest. The present study aimed at evaluating the distribution of the individual risk of ED in this group. Further the association between individual risk and both the awareness for the topic ED and the deviation from “normal” weight was depicted.

Methods

Female cyclists registered with the Union Cycliste Internationale were contacted via email or facebook and asked to complete a survey comprising age, weight, the Eating-Attitude-Test (EAT-26), and questions regarding ED awareness. The observed distribution of the EAT-26 score was compared to results from previous studies in normal subjects and athletes. The distribution of the ED awareness was described and ED awareness was correlated with the EAT-26 score. Both the deviation from ideal weight and the body mass index (BMI) were correlated with the EAT-26 score.

Results

Of the 409 registered athletes 386 could be contacted, 122 completed the questionnaire. Age ranged from 20-44yrs, BMI from 17.0 to 24.6 kg/m². In the EAT-26, 39 cyclists (32.0%) scored above 20 points indicating a potential benefit from clinical evaluation, 34 cyclists (27.9%) scored 10–19 points suggesting disordered eating. Sixteen athletes (13.2%) had been treated for an ED. About 70% of athletes had been pressured to lose weight. The mean EAT-26 score was above the average observed in normal female populations. It was also above the average observed in many female athlete populations, but lower than in other leanness focussed sports. More than 80%of athletes perceived elite cyclists at risk for developing ED. Increased ED awareness and deviation from the ideal weight were associated with higher EAT-26 scores, but not the body mass index.

Conclusion

Female cyclists are at risk of developing ED and they are aware of this risk. To improve their health and well-being, increased efforts to support elite cyclists and their teams in preventive activities and early detection are crucial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-022-00563-6.

Shifting the Focus: A Pilot Study on the Effects of Positive Body Exposure on Body Satisfaction, Body Attitude, Eating Pathology and Depressive Symptoms in Female Patients with Eating Disorders

One of the most commonly used techniques for the treatment of body image problems in eating disorders (ED) is body exposure (BE). However, evidence of its effectiveness in clinical populations is scarce. In the Positive Body Experience (PBE) protocol, the focus of positive BE is on aesthetic, functional and tactile aspects of the body. The current study evaluates the outcomes of positive BE with regard to changes in attitudinal body image and eating pathology, as well as the factors that influence these changes, in a sample of 84 adult female patients with different EDs who did not receive any other treatment for their EDs during the period in which BE treatment occurred. The results show significant positive changes in attitudinal body image, ED behaviors and depressive symptoms, with depressive symptoms at baseline mediating the changes in attitudinal body image. This study indicates that the PBE protocol is a suitable intervention for reducing negative attitudinal body image in anorexia and bulimia nervosa patients, as well as those with binge eating disorder. Furthermore, the results suggest that positive non-weight-related and functional body satisfaction are strong catalysts for change and that depressive symptoms play an important role in the ability to change. Additional RCTs are needed to gain more insight into the effects of PBE.

Eating Disorders in Children and Adolescent Males: A Peculiar Psychopathological Profile

(1) Background: Eating Disorders (EDs) are severe psychiatric disorders with high rates of mortality, multiple medical and psychiatric comorbidities associated, and often chronic illness. Historically, EDs are among the most gendered of psychiatric illnesses, and male presentations have been perceived as rare and unusual. This perception resulted in the systematic underrepresentation of males in research on Eds, and as consequence, in a scarcity of research investigating clinical and psychological features in this population. (2) Methods: The present study aims to evaluate clinical and psychopathological features in a sample of 287 children and adolescents, 27 males and 260 females with EDs, in order to identify similarities and differences. (3) Results: Males were younger than females, with similar medical and clinical conditions, but a different distribution of typology of EDs in middle childhood and middle adolescents. The Eating Disorders Inventory-3, TAS-20 for alexithymia and CDI for depressive symptoms' profiles are similar, while males showed higher scores at the global indexes of Symptom Checklist 90-Revised test in early adolescence. (4) Conclusions: Results suggest gender-specific similarities and differences in clinical and psychological features in children and adolescent males, which may require specific diagnosis and treatment.

Prevalence and sociodemographic characteristics of moderate and high engagement in muscle-building exercise among adolescents

This study aimed to describe the prevalence and sociodemographic characteristics of U.S. adolescents who engage in frequent muscle-building exercise. Data from the 2019 National Youth Risk Behavior Survey (N = 8474) were analyzed. Frequent muscle-building exercise in the past week (≥ 5 days and 7 days) were assessed. Multivariable logistic analyses were conducted separately by sex to obtain adjusted odds ratios and 95% confidence intervals for the association between key sociodemographic characteristics and muscle-building exercise. Nearly one in five (17.9%) boys, compared to 7.7% of girls, reported seven days of muscle-building exercise in the past week. Patterns of sociodemographic characteristics were associated with seven days of muscle-building exercise in the past week, including weight gain attempts among boys and Hispanic/Latina identity among girls. High engagement in muscle-building exercise is common among adolescents, particularly boys, and varied by sociodemographic characteristics, indicating a need for research to further describe engagement in muscle-building exercise among adolescents.

Does seeking the brawns impact the brain?: An investigation of muscularity-oriented disordered behaviors and cognitive function

Shifts in body-image ideals over the past 30 years towards leaner, muscular bodies have revealed new health behaviors that may be related to cognitive function. This study objective was to investigate prospective associations between a drive for muscularity and/or muscularity-oriented disordered behaviors (MODBs) with cognition. Data were drawn from Add Health, a nationally representative longitudinal cohort dataset. Drive for muscularity and MODB engagement were assessed in emerging adulthood (ages 18-26). Cognition was measured via immediate word recall, delayed-word recall, and number recall at 7-years later (ages 24-32). Analyzes were conducted in 1976 participants with available data. A one-way ANCOVA revealed that those with a drive for muscularity had lower immediate word recall (F(3, 12,819) = 3.845, p = .009) and delayed word recall (F(3, 12,807) = 5.933, p < .001) scores than other weight goal groups adjusting for covariates. Hierarchical linear regressions between individual MODBs and cognitive outcomes showed that legal performance-enhancing substance use (βs = 0.06-0.07, p < .05) and exercise (β = 0.06, p < .05) were positively associated with some cognition scores. Conversely, lifting weights (β = - 0.06, p < .05) and eating different foods than usual (β = - 0.05, p < .05) exhibited negative associations with some of the cognitive outcomes. Future research should be conducted to examine other potential outcomes related to the drive for muscularity and associated MODBs.

An intersectional investigation of Asian American men's muscularity-oriented disordered eating: Associations with gendered racism and masculine norms

Grounded in an intersectional framework, the present study investigated the extent to which racism, gendered racism, and conformity to masculine norms are associated with Asian American men's muscularity-oriented disordered eating. The study also examined if ethnic identity moderated the association between both forms of racism and muscularity-oriented disordered eating. 220 Asian American men completed an online cross-sectional survey that contained the study questionnaires. Hierarchical regression analyses were conducted to examine the associations between our predictor variables and muscularity-oriented disordered eating. Gendered racism, conformity to the masculine norms of playboy, heterosexual presentation and self-reliance were positively associated with muscularity-oriented disordered eating, whereas conformity to power over women was negatively associated. Racism and the remaining masculine norms were not associated with muscularity-oriented disordered eating. Ethnic identity did not moderate the association between either form of racism and muscularity-oriented disordered eating. Given that gendered racism was positively associated with muscularity-oriented disordered eating whereas racism was not, researchers and practitioners may consider prioritizing intersectionality in their understanding of Asian American men's eating pathology. Results emphasize the importance of examining both race and gender in conceptualizing Asian American men's muscularity-oriented disordered eating.Data Availability Statement: Data for this study are available upon request from the first author.

Disordered Eating and Body Dissatisfaction in Transgender and Gender-Expansive Adults: An Evaluation and Integration of the Gender Minority Stress and Resilience and Tripartite Influence Models

Transgender and gender-expansive (TGE) people, including transgender and nonbinary individuals, experience elevated rates of body dissatisfaction and disordered eating compared to cisgender individuals, but little is known about why. To address this research gap, we compared the ability of TGE-specific factors as proposed in the gender minority stress and resilience (GMSR) model, general psychological factors contained in the tripartite influence (TI) model, and an integration of these frameworks to explain body dissatisfaction and disordered eating among TGE individuals. Regression analyses were conducted to test the models' abilities to explain experiences reported in a survey of 93 U.S. TGE adults, including 43 transgender women respondents (46.2%) and 31 transgender men respondents (33.3%). Participants were diverse with regard to age (M = 34.19, SD = 12.02) and ethnoracial background (e.g., 29.0% Hispanic/Latinx, 17.2% Black/African American, 6.5% American Indian/Alaska Native; 5.4% multiracial). Results demonstrated both models' abilities to explain body dissatisfaction and disordered eating independently, except for the relationship between body dissatisfaction and the thinness-oriented TI model. An integration of the models better explained body dissatisfaction and disordered eating compared to either model alone. Notably, some findings did not align with the two frameworks, suggesting existing models may not adequately describe pathways through which disordered eating emerges in TGE populations. Specifically, body dissatisfaction showed no significant relationship with disordered eating and was not well explained by the TI model, and higher gender identity pride was related to greater disordered eating symptoms. Implications for clinical care and future research are discussed.

The 'not-so-healthy' appearance pursuit? Disentangling unique associations of female drive for toned muscularity with disordered eating and compulsive exercise

Today, many women are driven to subscribe to a more athletically oriented appearance ideal hallmarked by muscle tone (referred to as athletic- or fit-looking). However, the constellation of unhealthy eating and exercise behaviors that may accompany the pursuit of toned muscularity among women is not yet well characterized. To address this knowledge gap, our study evaluated the associations among the female drive for toned muscularity and both thinness-oriented disordered eating behaviors (e.g., dietary restriction) and muscularity-oriented disordered eating behaviors (e.g., excessive scrutiny of macro-nutrient values of food), as well as dimensions of compulsive exercise. Participants were 388 Australian undergraduate women who completed an online questionnaire including self-report measures of said constructs. Hierarchical regression models were used to determine whether the drive for toned muscularity accounted for unique variance in eating and exercise behaviors after adjusting for theoretically relevant covariates. Results indicated independent relationships between the drive for toned muscularity and several facets of thinness- and muscularity-oriented disordered eating, as well as compulsive exercise (e.g., exercise rigidity). Our findings further contribute to an emerging literature illustrating that women driven to attain a toned appearance may be vulnerable to engaging in a wide range of maladaptive eating and exercise practices.

Body image as a multidimensional concept: A systematic review of body image facets in eating disorders and muscle dysmorphia

Body image disturbance is core to the psychopathology of eating disorders (EDs), and related disorders such as muscle dysmorphia (MD). Global measures of body image fail to quantify specific aspects of body image disturbance that characterizes EDs, and may be differentially associated to outcomes. The aim of this systematic review was to provide an overview of specific body image facets and synthesize findings from controlled studies that compared clinical ED/MD and control-comparison groups in body image disturbance. One-hundred sixty-seven studies met inclusion criteria, and reported on comparisons among 30,584 individuals in 28 body image facets, which were more broadly grouped into evaluative, perceptual, cognitive-affective and motivational categories for the purpose of the present review. Effect sizes were calculated as Cohen's d for every comparison between ED and control groups. Body dissatisfaction (evaluative category) was the most prevalent facet assessed across studies (62 %), and differences between clinical and control groups were the largest in this category, especially for bulimia nervosa (d = 1.37). Scarcity of studies with male and MD clinical samples, and use of single-item and non-validated measures, should encourage development of instruments for body image facets pertinent to EDs and MD that can be validly applied across gender.

Management of eating disorders for people with higher weight: clinical practice guideline

INTRODUCTION

The prevalence of eating disorders is high in people with higher weight. However, despite this, eating disorders experienced by people with higher weight have been consistently under-recognised and under-treated, and there is little to guide clinicians in the management of eating disorders in this population.

AIM

The aim of this guideline is to synthesise the current best practice approaches to the management of eating disorders in people with higher weight and make evidence-based clinical practice recommendations.

METHODS

The National Eating Disorders Collaboration Steering Committee auspiced a Development Group for a Clinical Practice Guideline for the treatment of eating disorders for people with higher weight. The Development Group followed the 'Guidelines for Guidelines' process outlined by the National Health and Medical Research Council and aim to meet their Standards to be: 1. relevant and useful for decision making; 2. transparent; 3. overseen by a guideline development group; 4. identifying and managing conflicts of interest; 5. focused on health and related outcomes; 6. evidence informed; 7. making actionable recommendations; 8. up-to-date; and, 9. accessible. The development group included people with clinical and/or academic expertise and/or lived experience. The guideline has undergone extensive peer review and consultation over an 18-month period involving reviews by key stakeholders, including experts and organisations with clinical academic and/or lived experience.

RECOMMENDATIONS

Twenty-one clinical recommendations are made and graded according to the National Health and Medical Research Council evidence levels. Strong recommendations were supported for psychological treatment as a first-line treatment approach adults (with bulimia nervosa or binge-eating disorder), adolescents and children. Clinical considerations such as weight stigma, interprofessional collaborative practice and cultural considerations are also discussed.

CONCLUSIONS

This guideline will fill an important gap in the need to better understand and care for people experiencing eating disorders who also have higher weight. This guideline acknowledges deficits in knowledge and consequently the reliance on consensus and lower levels of evidence for many recommendations, and the need for research particularly evaluating weight-neutral and other more recent approaches in this field.

The association between negative body talk and body shame on disordered eating symptoms among college students

Negative body talk (NBT), defined as negative communication about one's body, is associated with disordered eating, yet factors that may enhance these effects are understudied. Using objectification theory as a framework, NBT may reflect a vocal manifestation of self-objectification and endorsement of body shame may enhance the association between NBT and disordered eating. Given relatively consistent NBT and objectification theory-based conclusions across male and female college samples, the current study hypothesized that for college students high in body shame, NBT would be more strongly associated with disordered eating than for those low in body shame. A total of 849 college students (77.4 % female) completed measures of NBT (sex-specific), body shame, and eating disorder symptoms. Negative binomial regressions tested hypotheses separately by sex. Moderation results identified that the association between NBT and eating disorder symptoms was stronger for females reporting lower body shame compared to higher body shame. Among males, only significant main effects of NBT and body shame were observed. Body image and disordered eating preventive interventions may benefit from targeting NBT and/or body shame in males and females, and college females reporting lower body shame may be at greatest risk for the negative impact of NBT.

Examination of perfectionism and self-concept constructs across stages of eating disorder recovery in men: An exploratory study

OBJECTIVE

This study examined perfectionism and self-concept constructs across eating disorder recovery stages in men, using a conceptualization of recovery that encompasses physical, behavioral, and cognitive recovery.

METHOD

Participants were 35 men with an eating disorder history (M_age = 26.60 years, SD = 10.81), categorized as in full recovery, in partial recovery, or with a current eating disorder diagnosis/pathology, and 27 men with no eating disorder history (controls; M_age = 26.44 years, SD = 10.08). Data for determining recovery status were collected from surveys, interviews, and measured weight and height; perfectionism and self-concept were assessed via surveys.

RESULTS

Among the perfectionism constructs, the greatest magnitude of effect sizes involving the fully recovered group was for socially prescribed perfectionism where this group had lower levels of perfectionism than the eating disorder diagnosis/pathology group (Hedge's g = -1.72) or the partially recovered group (Hedge's g = -1.56). For the self-concept constructs, effect sizes involving the fully recovered group and the other recovery status groups were all large (absolute values: 0.76-1.58) and reflected a large magnitude of difference with fully recovered men having higher self-esteem and self-efficacy and lower social comparison than men with a current eating disorder diagnosis or pathology or those partially recovered.

CONCLUSION

Full recovery in men was associated with healthy self-concept constructs and with low socially prescribed perfectionism. Future research with larger samples should seek to replicate these findings and, using a longitudinal design, examine these constructs as potential predictors or maintenance factors of comprehensive eating disorder recovery in men.

Integrating fear of fatness into sociocultural models of body image and eating concerns

To date, sociocultural models of body dissatisfaction and disordered eating have predominantly focused on the pursuit of thinness and have somewhat neglected sociocultural discourse and pressures that increase fear of fatness. Therefore, we tested a model to determine whether sociocultural pressures from media and interpersonal sources were associated with drive for thinness and fear of fatness. We also examined whether beliefs about the controllability of shape and weight were in turn associated with body dissatisfaction and disordered eating. A sample of N = 226 female undergraduate students in the U.S. completed an online survey assessing the variables of interest. After minor modification to the model pathways, the model provided a good fit to the data. Sociocultural influences to pursue thinness and fear fat related to body dissatisfaction and disordered eating through internalization of the thin-ideal and fear of fat. Together, these findings suggest that the pursuit of thinness and fear of fatness are distinct elements in etiologic models of body dissatisfaction and disordered eating. Additional work, including longitudinal research and studies among more diverse groups of individuals, is warranted to further clarify these relationships.

Treatment experiences of male and female youths with eating disorders

OBJECTIVES

The current study was conducted to further understand the experiences of youths with an eating disorder with accessing services and receiving treatment. Participants' perceptions of the role of gender in eating disorder treatment was also assessed.

DESIGN

A prospective mixed methods design was used, with the current report focusing on qualitative interviews.

METHODS

Youths who were receiving services in a specialized paediatric eating disorder program completed a semi-structured interview in combination with a visual lifeline upon their discharge. A process of interpretative induction was employed to derive high-level concepts from the interviews.

RESULTS

A total of 28 youths (15 males and 13 females) completed an interview. Four high-level concepts were identified: (1) unwanted/non-collaborative support, (2) conflicting views, (3) dynamics in relationships (with sub-concepts relating to peers and health professionals), and (4) changing mindset. Although many participants viewed treatment as universal, a subset of participants noted that treatment was tailored towards females.

CONCLUSIONS

Youths shared several challenges that they encountered in their journey to accessing specialized eating disorders treatment, including disagreement with their parents/caregivers and health professionals about treatment plans. Interactions with peers and health professionals represented both a facilitator (e.g., feeling supported and inspired by peers) and a challenge (e.g., negative interactions with professionals). Some youths shared concerns about the female-centric nature of treatment. The results of this study highlight the importance of collaborative care for paediatric eating disorders, and consideration for gender inclusivity in eating disorders treatment.

Transitions from intensive eating disorder treatment settings: qualitative investigation of the experiences and needs of adults with anorexia nervosa and their carers

BACKGROUND

Relapse rates for individuals with anorexia nervosa after intensive hospital treatment (in-patient or full-time day care) are high. Better knowledge about the difficulties and opportunities that arise during this transition is needed to identify factors that support or hinder continued recovery upon discharge.

AIMS

The aim of this study was to explore the experiences of adult patients and their chosen carers on the process of transitioning from intensive eating disorder treatment settings to the community.

METHOD

Semi-structured interviews were conducted with patients with anorexia nervosa (n = 11) discharged from day or in-patient care from specialised eating disorder units across the UK, and their chosen carers (n = 20). Data were analysed with inductive thematic analysis.

RESULTS

Four interrelated themes were identified for both groups. For patients, themes were continuity of care, ambivalence about continued recovery, the value of social support and a call for enhanced transition support. For carers, themes were the impact of the eating disorder on themselves and the family, perceptions of recovery and support post-discharge, the impact of previous treatment and care experiences, and desire to create a supportive transition process.

CONCLUSIONS

The study provides an insight into the unique challenges that individuals with anorexia nervosa face upon leaving intensive treatment. A lack of post-discharge planning, support system and identity formation outside of anorexia nervosa were perceived as barriers to continued recovery. Patients and carers advocated for transition support that incorporates a phased, inclusive approach with accessible professional and social support in the community.

Association of autism diagnosis and polygenic scores with eating disorder severity

Among individuals with eating disorders (ED), those with co‐occurring autism are often considered to have more severe presentations and poorer prognosis. However, previous findings have been contradictory and limited by small sample size and/or cross‐sectional assessment of autistic traits. We examine the hypothesis that autism diagnosis and autism polygenic score (PGS) are associated with increased ED severity in a large ED cohort using a broad range of ED severity indicators. Our cohort included 3189 individuals (64 males) born 1977–2000 with current or previous anorexia nervosa who participated in the Anorexia Nervosa Genetics Initiative‐Sweden (ANGI‐SE) and for whom genotypes and linkage to national registers were available. We identified 134 (4.2%) individuals with registered autism diagnoses. Individuals with confirmed autism diagnosis had significantly more severe ED across three sets of severity indicators. Some of the largest effects were found for the proportion of individuals who attempted suicide and who received tube feeding (higher in autism), and for the time spent in inpatient care (longer in autism). Results for autism PGS were not statistically significant. Adapting ED treatment to the needs of individuals with co‐occurring autism is an important research direction to improve treatment outcome in this group.

Among 3189 Swedish individuals with current or previous anorexia nervosa, those with confirmed autism diagnosis (4.2%) experienced higher eating disorder severity across 27 out of 29 indicators.

Some of the highest risk increases were found for having attempted suicide, having received tube feeding, and time spent in inpatient care for eating disorders.

Repeating the analyses with autism polygenic score instead of autism diagnosis yielded non‐statistically significant results for all 29 eating disorder severity indicators.

Assessment of vitamin D among male adolescents and young adults hospitalized with eating disorders

PURPOSE

Medical complications of eating disorders in males are understudied compared to females, as is the case of vitamin D deficiency. The aim of this study was to assess vitamin D levels among male and female adolescents and young adults hospitalized for medical complications of eating disorders.

METHODS

We retrospectively reviewed electronic medical records of patients aged 9-25 years (N = 565) admitted to the University of California, San Francisco Eating Disorders Program for medical instability, between May 2012 and August 2020. Serum vitamin D (25-hydroxy) level was assessed at admission as was history of prior calcium, vitamin D, or multivitamin supplementation. Linear regression was used to assess factors associated with vitamin D levels.

RESULTS

A total of 93 males and 472 females met eligibility criteria (age 15.5 ± 2.8, 58.8% anorexia nervosa; admission body mass index 17.6 ± 2.91). Among male participants, 44.1% had 25-hydroxyvitamin D levels < 30 ng/mL, 18.3% had 25-hydroxyvitamin D levels < 20 ng/mL, and 8.6% had 25-hydroxyvitamin D levels < 12 ng/mL. There were no significant differences in 25-hydroxyvitamin D levels in males compared to females, except that a lower proportion (1.9%) of female participants had 25-hydroxyvitamin D levels < 12 ng/mL (p = 0.001). Only 3.2% of males reported calcium or vitamin D-specific supplementation prior to hospital admission, while 8.6% reported taking multivitamins. White race, prior calcium/vitamin D supplementation, and higher calcium levels were associated with higher vitamin D levels on admission.

CONCLUSIONS

Nearly half of patients admitted to the hospital for malnutrition secondary to eating disorders presented with low 25-hydroxyvitamin D levels; males were more likely than females to have severe vitamin D deficiency. These findings support vitamin D assessment as part of the routine medical/nutritional evaluation for hospitalized eating disorder patients, with particular attention on male populations.

Performance-Enhancing Substance Use and Sexual Risk Behaviors among U.S. Men: Results from a Prospective Cohort Study

Performance-enhancing substance (PES) use is common among young men and prior research has documented cross-sectional associations between anabolic-androgenic steroid (AAS) use and sexual risk behaviors. However, this relationship remains understudied among a longitudinal cohort of young adult men, and research on prospective associations between legal PES (e.g., creatine) use and sexual risk behaviors is lacking. The current study addressed these oversights using data from the National Longitudinal Study of Adolescent to Adult Health (N = 5,451). AAS use and legal PES use were assessed at Wave III (ages 18-26) and 10 indicators of sexual risk behavior were assessed at seven-year follow up (Wave IV; ages 24-32). Linear and logistic regression analyses were conducted adjusting for demographic and behavioral confounders. Participants who reported AAS use and legal PES use had significantly higher number of one-time sexual partners and higher odds of multiple sex partners around the same time in the past 12 months. Participants who reported AAS use had higher odds of any STI in the past 12 months. These results extend prior research on the risk behaviors and adverse effects of PES use. Health care professionals should assess for PES use among young adult men and provide guidance on healthful sexual behaviors.

Men have eating disorders too: an analysis of online narratives posted by men with eating disorders on YouTube

Eating Disorders (ED) among men are still surrounded by stigma and gender stereotypes, with a common misconception that ED are an exclusively female condition. This study employed a gender-sensitive approach to uncover males' critical needs for effective treatment and recovery. We qualitatively analyzed a sample of twenty-five videos posted on YouTube by men with ED, presenting personal stories of recovery and recovery in-progress. Through thematic analysis of the narratives, we identified three common factors increasing disordered eating behaviors in men: 1) bullying, 2) drive for muscularity, and 3) self-regulation. In addition, we found three major themes related to barriers preventing men from help-seeking: 1) shame and stigma, 2) lack of knowledge and information, and 3) low level of perceived doctor-patient communication. The findings of this study can contribute to the conceptualization of future interventions and recovery programs designed to prevent and treat ED in men.

Behavior Change Around an Online Health Awareness Campaign: A Causal Impact Study

National Eating Disorders Association conducts a NEDAwareness week every year, during which it publishes content on social media and news aimed to raise awareness of eating disorders. Measuring the impact of these actions is vital for maximizing the effectiveness of such interventions. This study is an effort to empirically measure the change in behavior of users who engage with NEDAwareness content, and compare the detected changes between campaigns in two different years. We analyze a total of 35,895 tweets generated during two campaigns of NEDAwareness campaigns in 2019 and 2020. In order to assess the reach of each campaign, we consider the users participating in the campaigns and their number of followers, as well as retweeting engagement. We use the Linguistic Inquiry and Word Count (LIWC) text modeling and causal impact analysis in order to gauge the change in self-expression of users who have interacted with the NEDAwareness content, compared to a baseline group of users. We further enrich our understanding of the users by extracting gender information from their display names. We find that, despite large media corporations (such as MTV and Teen Vogue) participating in the campaign, it is governmental and nonprofit accounts who are among the accounts that attract the most retweets. Whereas the most influential accounts were well-connected in 2019, the 2020 campaign saw little retweeting between such accounts, negatively impacting the reach of the material. Both campaigns engaged women at around 40% and men 17%, supporting previous research showing women to be more likely to share their experiences with eating disorders. Further, women were more likely to mention other health topics within the 15 days of the intervention, including pregnancy and abortion, as well as depression and anxiety, and to discuss the developing COVID pandemic in 2020. Despite the positive message of the campaign, we find that the users who have engaged with this content were more likely to mention the linguistic categories concerning anxiety and risk. Thus, we illustrate the complex, gender-specific effects of NEDAwareness online health intervention campaign on the continued self-expression of its audience and provide actionable insights for potential improvement of such public health efforts.

Developmental trajectories of eating disorder symptoms: A longitudinal study from early adolescence to young adulthood

BACKGROUND

Adolescence is a critical period for the development of eating disorders, but data is lacking on the heterogeneity of their evolution during that time-period. Group-based trajectories can be used to understand how eating disorders emerge and evolve over time. The aim of this study was to identify groups of individuals with distinct levels of eating disorder symptoms between 12 and 20 years and the onset of different types of symptoms. We also studied sex differences in the evolution and course of eating disorder symptoms from early adolescence to adulthood.

METHODS

Using archival data from the QLSCD cohort, trajectories of eating disorder symptomatology were estimated from ages 12 to 20 years using semiparametric models. These trajectories included overall eating disorder symptomatology as measured by the SCOFF (Sick, Control, One Stone, Fat, Food), sex, and symptom-specific trajectories.

RESULTS

Two groups of adolescents following distinct trajectories of eating disorder symptoms were identified. The first trajectory group included 30.9% of youth with sharply rising levels between 12 and 15 years, followed by high levels of symptoms between 15 and 20 years. The second trajectory group included 69.1% of youth with low and stable levels of symptoms between 12 and 20 years. Sex-specific models indicated that the proportion of girls in the high trajectory group was 1.3 times higher than the proportion of boys (42.8% girls vs. 32.3% boys). Trajectories of SCOFF items were similar for loss-of-control eating, feeling overweight, and attributing importance to food. The weight loss item had a different developmental pattern, increasing between 12 and 15 years and then decreasing between 17 and 20 years.

CONCLUSIONS

The largest increase in eating disorder symptoms in adolescence is between the ages of 12 and 15 . Yet, most prevention programs start after 15 years of age. Our findings suggest that, unlike common practices, eating disorder prevention programs should aim to start before puberty.

Screening, assessment and diagnosis in the eating disorders: findings from a rapid review

BACKGROUND

Limited screening practices, minimal eating disorder training in the healthcare professions, and barriers related to help-seeking contribute to persistent low rates of eating disorder detection, significant unmet treatment need, and appreciable associated disease burden. The current review sought to broadly summarise the literature and identify gaps relating to the screening, assessment, and diagnosis of eating disorders within Western healthcare systems.

METHODS

This paper forms part of a Rapid Review series scoping the evidence base for the field of eating disorders, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for studies published between 2009 and mid 2021 in English. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised through purposive sampling. Data from selected studies relating to Screening, Assessment and Diagnosis of eating disorders were synthesised and are disseminated in the current review.

RESULTS

Eighty seven studies were identified, 38% relating to screening and 62% to assessment and diagnosis. The majority of screening studies were conducted in university student samples, showing high prevalence but only modest improvements in help-seeking in those studies that followed up post-screen. In healthcare settings, clinicians continue to have difficulty identifying eating disorder presentations, particularly Binge Eating Disorder, Other Specified Feeding or Eating Disorders, and sub-threshold eating disorders. This is preceded by inadequate and frequently homogenous screening mechanisms and exacerbated by considerable personal and health-system barriers, including self-stigma and lack of resourcing. While all groups are at risk of delayed or no diagnosis, those at particular risk include LGBTQ+ and gender diverse individuals, individuals living in larger bodies, and males.

CONCLUSIONS

A majority of individuals with eating disorders remain undiagnosed and untreated despite a high prevalence of these conditions and increased advocacy in recent years. Research into improving detection and clinician diagnostic skill is extremely limited. Innovative empirical research is strongly recommended to address significant individual and health-system barriers currently preventing appropriate and timely intervention for many. Limited screening in healthcare settings and low rates of eating disorder training in the healthcare professions are just some of the barriers to help-seeking which may contribute to delayed intervention and diagnosis in the eating disorders. This has significant impacts, prolonging treatment when it is finally received, and increasing healthcare costs for both the individual and the healthcare system. The current review is part of a larger Rapid Review series conducted to inform the development of Australia's National Eating Disorders Research and Translation Strategy 2021-2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policy-making and address urgent health concerns. The Rapid Review synthesises the current evidence-base and identifies gaps in eating disorder research and care, in order to guide decision making and address urgent health concerns. This paper gives a critical overview of the scientific literature relating to the current state of screening, assessment, and diagnosis of eating disorders within Western healthcare systems that may inform health policy and research in an Australian context. It covers screening initiatives in both general and high-risk populations; personal, clinician and healthcare system challenges relating to help-seeking; and obstacles to accurate and timely clinical diagnosis across the eating disorders.

Pathways from sociocultural and objectification constructs to body satisfaction among men: The U.S. Body Project I

According to the tripartite influence model, body dissatisfaction is shaped by internalizing cultural appearance ideals stemming from appearance-related family, peer, and media pressures. This model was developed for women, but emerging evidence points to its relevance for men's body image. This study advanced this budding research by (a) integrating muscular-ideal internalization alongside lean-ideal internalization and body surveillance into the model, (b) examining two positive dimensions of body image as outcomes (body image quality of life and appearance evaluation), and (c) testing this model in national online sample of 5293 men. Structural equation modeling supported the model. Family, peer, and media pressures related to higher lean-ideal internalization, which related to higher body surveillance and poorer body image outcomes. Peer and media pressures related to higher muscular-ideal internalization, which related to higher body surveillance but more adaptive body image outcomes. We further examined whether model variables and paths differed based on men's body mass index (BMI). Men with higher BMIs evidenced a stronger path between body surveillance and body image outcomes. These findings highlight the usefulness of sociocultural models for understanding men's body image experiences.

Measurement invariance of body image measures by age, gender, sexual orientation, race, weight status, and age: The U.S. Body Project I

Despite growing interest in comparing body image experiences across diverse groups, limited work has examined whether body image measures operate similarly across different populations, raising important questions about the appropriateness of comparing scale means across demographic groups. This study employed measurement invariance testing to evaluate whether such comparisons are appropriate with existing body image measures. Specifically, multi-group confirmatory factor analysis was conducted using a community sample of 11,620 men and women to test increasing levels of invariance (configural, metric, scalar) across five key demographic variables (age group, gender, sexual orientation, race, weight status) for five commonly used body image measures (the Sociocultural Attitudes Towards Appearance Questionnaire-4, the Body Surveillance subscale of the Objectified Body Consciousness Scale, the Appearance Evaluation and Overweight Preoccupation subscales of the Multidimensional Body-Self Relations Questionnaire, and the Body Image Quality of Life Inventory). Results provided evidence of scalar (i.e., strong) invariance for all five measures across age, gender, sexual orientation, race, and weight status groups, indicating that the latent factors captured by these measures have the same meaning across demographic groups. Findings therefore support the comparison of scale/subscale means across multiple demographic groups for these body image measures.

The relationship between weight bias internalization and healthy and unhealthy weight control behaviours

PURPOSE

Weight bias internalization (WBI) is associated with disordered eating symptomology and motivation to control weight. The relationship between WBI and specific weight control behaviours and how these behaviours differ between men and women is not well understood. The objectives of this study are to determine (1) the relationship between WBI and weight control behaviours, (2) whether weight perception is independently associated with weight control behaviours, and (3) whether these relationships differ between men and women.

METHODS

Canadian adults (N = 161; 52.8% women; body mass index [BMI] = 26.5 ± 4.99 kg/m²) completed questionnaires pertaining to WBI, weight control behaviours (healthy, unhealthy, extreme) and weight perception (accurate, under-, or over-estimation compared with objectively measured BMI). The cross-sectional relationship between (1) WBI or (2) weight perception with the total number of healthy and unhealthy or extreme weight control behaviours, and likelihood of performing specific weight control behaviours were assessed with linear, and logistic regression models, respectively. All analyses were conducted adjusting for age, gender, and race. Subsequent analyses were stratified by sex.

RESULTS

WBI was associated with an increased likelihood of performing exercise for weight loss (OR 2.28, p < 0.05); increased likelihood of skipping meals in women (OR 2.57, p < 0.01), and consuming little amounts of food and food substitutes in men (OR 2.28, p < 0.01 and OR 2.17, p < 0.05, respectively). Weight perception was not associated with weight control behaviours.

CONCLUSIONS

WBI was associated with various weight control behaviours. This study highlights the importance of assessing WBI in clinical practice with patients seeking to manage their weight. Future longitudinal research should be conducted to further understand the behavioural and health effects from WBI.

LEVEL V

Cross-sectional descriptive study.

Demographic and sociocultural predictors of sexuality-related body image and sexual frequency: The U.S. Body Project I

Body image is a critical component of an individual's sexual experiences. This makes it critical to identify demographic and sociocultural correlates of sexuality-related body image: the subjective feelings, cognitions, and evaluations related to one's body in the context of sexual experience. We examined how sexuality-related body image differed by gender, sexual orientation, race, age, and BMI. Four items assessing sexuality-related body image were completed by 11,620 U.S. adults: self-perceived sex appeal of their body, nude appearance satisfaction, and the extent to which they believed that body image positively or negatively affected their sexual enjoyment and feelings of sexual acceptability as a partner. Men reported slightly less nude appearance dissatisfaction and fewer negative effects of body image on sexual enjoyment and sexual acceptability than women, but did not differ in reported sex appeal. Poorer sexuality-related body image was reported by people with higher BMIs, not in relationships, who had sex less frequently, among White compared to Black women and men, and among gay compared to heterosexual men. Data also revealed a subgroup of respondents who reported that their body image had a positive impact on their sex lives. The findings highlight a need for interventions addressing sexuality-related body image.

Sexual orientation differences in pathways from sociocultural and objectification constructs to body satisfaction: The U.S. Body Project I

Objectification theory and the tripartite influence model provide useful frameworks for understanding the body image experiences of men and women. However, there is little systematic investigation of how sexual orientation moderates the links between these constructs and body image satisfaction. It has been hypothesized, for example, that the associations of surveillance (i.e., monitoring of one's appearance due to objectification by others) would be strongest for groups targeted by the male gaze (e.g., gay men, lesbian women, and bisexual men and women). Here we proposed an integrated sociocultural model and examined these pathways in multigroup structural equation models in a national sample of heterosexual, bisexual, and lesbian women (ns = 5395; 598; 213, respectively), and heterosexual, bisexual, and gay men (4869; 194; and 194, respectively) aged 18-65 years. Sexual orientation moderated some of these pathways. The most consistent pattern was that appearance pressures were internalized to a greater extent among bisexual participants. The pathways to poorer body image were generally similar among heterosexual and gay/lesbian men and women. These findings highlight the importance of examining sexual orientation-specific influences on body image across diverse groups, as well as the commonalities in the experiences of men and women across sexual orientations.

Weight gain attempts and substance use behaviors among adults across five countries

Weight gain attempts are common among adolescents, yet a paucity of research has explored these behaviors among adults, particularly in relation to substance use behaviors. To address this gap in the literature, pooled data from the 2018 and 2019 International Food Policy Study (N = 42,108) were analyzed. The association of weight gain attempts in the past 12 months with four important and relatively common substance use behaviors (alcohol use, binge-drinking, cigarette smoking, marijuana use) was examined using multiple modified Poisson regression analyses that adjusted for theoretically relevant covariates. Among men and women, weight gain attempts were associated with a higher likelihood of cigarette smoking in the past 30 days, marijuana use in the past 12 months, and binge-drinking one or more times per month in the past 12 months among men only. Among women, weight gain attempts were associated with a lower likelihood of alcohol use one or more times per month in the past 12 months. Our findings contribute to the literature demonstrating that substance use behaviors are more prevalent among adults who report weight gain attempts in a large international sample.

Demographic and sociocultural predictors of face image satisfaction: The U.S. Body Project I

Despite substantial literature surrounding how people process and perceive faces, there is very little research investigating how people evaluate their own faces. We examined how gender, body mass, race, age, and sexual orientation were linked to people's satisfaction with the appearance of their eyes, nose, facial shape, and face overall among 11,620 adults recruited via Mechanical Turk. Most people mostly or definitely agreed they were happy with their facial appearance. There were notable racial differences, with Asian participants tending to report greater dissatisfaction. For example, only 66% of Asian women and 60% of Asian men mostly or definitely agreed that they were happy with the appearance of their eyes, which was lower than other racial groups. BMI and age were not strongly associated with face satisfaction. Sexual minority men were less satisfied than heterosexual men. About one in four gay and bisexual men, compared to only one in seven heterosexual men, reported dissatisfaction with their overall facial appearance. Men and women with poorer face image engaged in more appearance surveillance, more strongly internalized the thin-ideal, and perceived stronger sociocultural pressures from peers, parents, and media. The current study highlights important sociocultural and demographic factors tied to poorer face image.