Eating disorders in biological males: clinical presentation and consideration of sex differences in a pediatric sample

Clinical characteristics of hospitalized male adolescents and young adults with atypical anorexia nervosa

OBJECTIVE

To describe the clinical characteristics of male adolescents and young adults hospitalized for medical complications of atypical anorexia nervosa (atypical AN) and to compare their clinical characteristics with females with atypical AN and males with anorexia nervosa (AN).

METHOD

A retrospective review of electronic medical records for patients with atypical AN and AN aged 9-25 admitted to the UCSF Eating Disorders Program from May 2012 to August 2020 was conducted.

RESULTS

Among 21 males with atypical AN (mean age 15.1 ± 2.7, mean %mBMI 102.0 ± 11.8), medical complications evidenced by admission laboratory values included anemia (52.9%), vitamin D insufficiency/deficiency (52.6%), and zinc deficiency (31.6%). Compared with females with atypical AN (n = 69), males with atypical AN had longer length of stay (11.4 vs 8.4 days, p = .004), higher prescribed kcal at discharge (4114 vs 3045 kcal, p < .001), lower heart rate nadir (40.0 vs 45.8, p = .038), higher aspartate transaminase (AST, 37.9 vs 26.2 U/L, p = .032), higher alanine transaminase (ALT, 30.6 vs 18.3 U/L, p = .005), and higher rates of anemia (52.9% vs 19.4%, p = .005), with no differences in vitamin D, zinc, and vital signs. Compared with males with AN (n = 40), males with atypical AN had no significant differences in vital signs or laboratory assessments during the hospitalization.

DISCUSSION

Atypical AN in males leads to significant medical comorbidity, and males with atypical AN require longer hospital stays compared to females with atypical AN. Rates of abnormal vital signs and abnormal serum laboratory values during hospital admissions do not differ in males with atypical AN compared to AN.

PUBLIC SIGNIFICANCE

Adolescent and young adult males with atypical anorexia nervosa experience significant medical complications. Males with atypical anorexia nervosa had longer hospitalizations and higher prescribed nutrition at discharge than females. Medical complications of atypical anorexia nervosa in male adolescents and young adults were generally equal to those of male adolescents and young adults with anorexia nervosa. Clinicians should be aware of unique medical complications of males with atypical anorexia nervosa.

Gender Expression, Weight Status, and Risk of Experiencing Eating Disorders among Gender-Diverse Adults Assigned Male at Birth in Bangkok, Thailand

This study examines the association between gender expression, weight status, and the risk of experiencing eating disorders among gender-diverse adults assigned male at birth living in Bangkok, Thailand. Participants completed self-administered questionnaires to provide demographic data and anthropometric measures, and an Eating Attitude Test-26 (EAT-26) to determine the risk of experiencing eating disorders. The associations between gender expression, weight status, and the risk of experiencing eating disorders were analyzed using multivariable logistic regression models. No significant differences were observed in weight-related variables based on gender expression. Participants self-described as feminine/androgynous had lower odds of experiencing a high risk of eating disorders compared to those self-described as masculine (odds ratio (OR) = 0.49; 95% confidence interval (95% CI) = 0.27, 0.88). A higher body mass index (BMI) (OR = 1.07; 95% CI = 1.01, 1.14) and BMI discrepancy (OR = 1.13; 95% CI = 1.03, 1.24) were associated with higher odds of engaging in extreme weight-control behaviors. The risk of experiencing eating disorders among Thai gender-diverse adults assigned male at birth could differ across gender expression and weight status. Further research is needed to expand the understanding of these relationships and develop tailored intervention programs to mitigate the risk.

Current Discoveries and Future Implications of Eating Disorders

Eating disorders (EDs) are characterized by severe disturbances in eating behaviors and can sometimes be fatal. Eating disorders are also associated with distressing thoughts and emotions. They can be severe conditions affecting physical, psychological, and social functions. Preoccupation with food, body weight, and shape may also play an important role in the regulation of eating disorders. Common eating disorders have three major types: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). In some cases, EDs can have serious consequences for an individual's physical and mental health. These disorders often develop during adolescence or early adulthood and affect both males and females, although they are more commonly diagnosed in young adult females. Treatment for EDs typically involves a combination of therapy, nutrition counseling, and medical care. In this narrative review, the authors summarized what is known of EDs and discussed the future directions that may be worth exploring in this emerging area.

Predictors of caregiver burden before starting family-based treatment for adolescent anorexia nervosa and associations with weight gain during treatment

PURPOSE

Caregivers play a pivotal role in the success of family-based treatment (FBT) for anorexia nervosa (AN). Caregiver burden is frequently demonstrated in eating disorders (EDs) and may impact FBT outcomes. This study examined factors associated with caregiver burden before starting FBT and whether pre-treatment caregiver burden was associated with weight gain during FBT.

METHODS

Participants included 114 adolescents with AN or atypical AN (mean age = 15.6 years, SD = 1.4) and a primary caregiver (87.6% mothers) who received FBT in the United States. Before starting treatment, participants completed self-report measures of caregiver burden (via the Eating Disorder Symptom Impact Scale), caregiver anxiety, caregiver depression, and ED symptoms. Clinical characteristics and percentage of target goal weight (%TGW) at FBT session 1 and 3 and 6 months after starting treatment were obtained via retrospective chart review. Hierarchical regressions examined predictors of caregiver burden before FBT initiation. Associations between pre-treatment caregiver burden and %TGW gain at 3 and 6 months after starting FBT were assessed with hierarchical regressions.

RESULTS

Caregiver anxiety (p < 0.001), family history of EDs (p = 0.028), adolescent mental health treatment history (p = 0.024), and ED symptoms (p = 0.042) predicted caregiver burden before starting FBT. Pre-treatment caregiver burden was not associated with %TGW gain at 3 or 6 months. Males demonstrated less %TGW gain than females at 3 months (p = 0.010) and 6 months (p = 0.012).

CONCLUSION

Proactively evaluating caregiver burden before starting FBT is suggested. Providing recommendations and/or referrals for identified caregiver vulnerabilities could indirectly impact FBT progress. Males in FBT could require longer courses of treatment and extra vigilance to this demographic is suggested.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Transgender and other gender diverse adolescents with eating disorders requiring medical stabilization

BACKGROUND

Despite the high prevalence of eating disorders in gender diverse adolescents, little is known about the characteristics of gender diverse youth with eating disorders who require inpatient medical stabilization. The primary objective of this study was to describe the medical, anthropometric, and psychiatric characteristics of gender diverse adolescents hospitalized for eating disorders and compare these characteristics to cisgender peers hospitalized for eating disorders. The secondary objective was to evaluate percent median body mass index as one marker of malnutrition and treatment goal body mass index as a recovery metric between patients' birth-assigned sex and affirmed gender using standardized clinical growth charts.

METHODS

A retrospective chart review was conducted of 463 patients admitted to an inpatient eating disorders medical unit between 2012 and 2020. To compare medical, anthropometric, and psychiatric data between gender diverse and cisgender patients, chi-square/Fisher's exact and t-tests were used. Clinical growth charts matching the patients' birth-assigned sex and affirmed gender identity were used to assess percent of median body mass index and treatment goal body mass index.

RESULTS

Ten patients (2.2%) identified as gender diverse and were younger than cisgender patients [13.6 (1.5) years vs. 15.6 (2.7) years, p = 0.017]. Gender diverse patients were hospitalized with a higher percent median body mass index compared to cisgender peers [97.1% (14.8) vs. 87.9% (13.7), p = 0.037], yet demonstrated equally severe vital sign instability such as bradycardia [44 (8.8) beats per minute vs. 46 (10.6) beats per minute, p = 0.501], systolic hypotension [84 (7.1) mmHg vs. 84 (9.7) mmHg, p = 0.995], and diastolic hypotension [46 (5.8) mmHg vs. 45 (7.3) mmHg, p = 0.884]. Gender diverse patients had a higher prevalence of reported anxiety symptoms compared to cisgender patients (60% vs. 28%, p = 0.037).

CONCLUSIONS

Gender diverse patients demonstrated complications of malnutrition including vital sign instability despite presenting with a higher weight. This is consistent with a greater proportion of gender diverse patients diagnosed with atypical anorexia nervosa compared to cisgender peers. Additionally, psychiatric comorbidities were present among both groups, with a larger percentage of gender diverse patients endorsing anxiety compared to cisgender patients.

Prevalence of pediatric acute-onset neuropsychiatric syndrome (PANS) in children and adolescents with eating disorders

BACKGROUND

Pediatric obsessive-compulsive disorder (OCD) and eating disorder symptoms frequently overlap, clouding diagnostic certainty and hypothesized etiologic factors. Pediatric acute-onset neuropsychiatric syndrome (PANS) is defined by abrupt emergence of core obsessive-compulsive behaviours and/or food restriction with concurrent, ancillary cognitive and behavioral symptoms. Inflammatory and immune processes have putative roles in both PANS and a related described condition with cardinal obsessive-compulsive or tic symptoms, known as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). While prevalence of PANS and PANDAS has been examined in tic, movement disorder and OCD populations, this has not yet been systematically examined in a pediatric eating disorder sample.

OBJECTIVES

To identify the lifetime prevalence of those meeting PANS and/or PANDAS criteria within a pediatric eating disorder cohort.

METHODS

Convenience sampling method was utilized to select consecutive youth (ages 8-18-years) presenting to an interdisciplinary pediatric eating disorder subspecialty program with a confirmed eating disorder and completed parent-report PANS/PANDAS questionnaire (n = 100). A parent-reported measure was used to establish lifetime prevalence rates for PANS and PANDAS. Descriptive and exploratory comparative analyses were conducted between PANS and non-PANS groups. Continuous measures were analyzed using two-tailed independent sample t-tests and categorical measures were analyzed using two-tailed Fisher's exact tests.

RESULTS

Among participants, 52% (n = 52) met PANS criteria and 0% (n = 0) met PANDAS diagnostic criteria. Core, abrupt-onset PANS symptoms included both food restriction and obsessive-compulsive symptoms in 63.5% (n = 33), food restriction only in 25% (n = 13), and obsessive-compulsive symptoms only in 11.5% (n = 6) of participants. In comparison to those who did not meet PANS criteria, those in the PANS subgroup were less likely to be male and more commonly prescribed a selective serotonin reuptake inhibitor medication. Significant group differences did not emerge for onset age, body mass index, eating disorder type or comorbid psychiatric/medical/autoimmune illness.

CONCLUSION

Lifetime prevalence of symptoms in keeping with PANS diagnostic criteria within a pediatric eating disorder cohort was notably higher than that previously reported in OCD or tic disorder cohorts. The overlap between starvation effects and ancillary PANS symptoms may challenge the practical utility of this putative syndrome within the eating disorder population.

Eating Disorders in Hospitalized School-Aged Children and Adolescents during the COVID-19 Pandemic: A Cross-Sectional Study of Discharge Records in Developmental Ages in Italy

Eating disorders (EDs) are characterized by behavioral and cognitive aspects that result in a significant impairment of an individual's well-being. COVID-19 pandemic consequences negatively impacted healthcare services and people's mental health. Particularly, in developmental ages, difficulties in coping with the situation could have had an impact on eating behaviors. Therefore, the aim of this study was to assess EDs' hospitalization trend before, during and after the pandemic peak to evaluate whether it has been influenced. A retrospective cross-sectional study was conducted on the hospital discharge forms of patients from 5 to 19 years old in Piedmont, which is a region in northern Italy. Overall, hospitalization, age, and gender-specific rates due to EDs that occurred in 2020 and 2021 were compared to those that occurred in 2018-2019. Since 2020, there has been a 55% reduction in overall hospitalizations, while the total proportion of EDs admissions has doubled from 2020 to 2021 (from 13.9‱ to 22.2‱). Significant hospitalization rate increases were observed both in 15-19 and in 10-14 females' age groups in 2021. Non-significant increases were observed in all males' age groups. The increase in hospitalizations for EDs should be further investigated, as it might be the tip of an iceberg not yet acknowledged.

Pediatric Avoidant-Restrictive Food Intake Disorder and gastrointestinal-related Somatic Symptom Disorders: Overlap in clinical presentation

Certain presentations of Avoidant/Restrictive Food Intake Disorder (ARFID) and Somatic Symptom and Related Disorders (SSRDs) have conceptual overlap, namely, distress and impairment related to a physical symptom. This study compared characteristics of pediatric patients diagnosed with ARFID to those with gastrointestinal (GI)-related SSRD. A 5-year retrospective chart review at a tertiary care pediatric hospital comparing assessment data of patients with a diagnosis of ARFID (n = 62; 69% girls, M_age = 14.08 years) or a GI-related SSRD (n = 37; 68% girls, M_age = 14.25 years). Patients diagnosed with ARFID had a significantly lower percentage of median BMI than those with GI-related SSRD. Patients diagnosed with ARFID were most often assessed in the Eating Disorders Program, whereas patients diagnosed with an SSRD were most often assessed by Consultation-Liaison Psychiatry. Groups did not differ on demographics, psychiatric diagnoses, illness duration, or pre-assessment services/medications. GI symptoms were common across groups. Patients diagnosed with an SSRD had more co-occurring medical diagnoses. A subset (16%) of patients reported symptoms consistent with both diagnoses. Overlap is observed in the clinical presentation of pediatric patients diagnosed with ARFID or GI-related SSRD. Some group differences emerged, including anthropometric measurements and co-occurring medical conditions. Findings may inform diagnostic classification and treatment approach.

The Reproductive Impact of Eating Disorders in Adolescents

Eating disorders are common, chronic illnesses that frequently arise during adolescence. Because of the impact on nutrition, individuals with eating disorders have significant health consequences, including effects on reproductive health. Adolescent women with eating disorders frequently have menstrual irregularities, though the causes of these abnormalities are complex and vary depending on the type of eating disorder. Teens with eating disorders may have changes in current and future fertility, and eating disorders during pregnancy can have medical and psychologic impacts for both mother and child. Though not well researched, eating disorders in men can affect reproductive health and potentially impact fertility. Lastly, eating disorders in adolescents can have significantly deleterious, irreversible effects on bone health.

Gender differences in symptom presentation and treatment outcome in children and youths with eating disorders

BACKGROUND

To address the gaps in the literature examining eating disorders among males and gender minority youths, a prospective study was designed to assess gender differences in eating disorder symptom presentation and outcomes. Muscularity concerns may be particularly relevant for male youths with eating disorders, and were included in assessment of eating disorder symptom presentation.

METHODS

All cisgender male youths who presented for specialized eating disorder treatment at one of two sites were invited to participate, along with a group of matched cisgender females, and all youths who did not identify with the sex assigned to them at birth. Youths completed measures of eating disorder symptoms, including muscularity concerns, and other psychiatric symptoms at baseline and end of treatment.

RESULTS

A total of 27 males, 28 females and 6 trans youths took part in the study. At baseline, Kruskal-Wallis tests demonstrated that trans youths reported higher scores than cisgender male and female youths on measures of eating pathology (Eating disorder examination-questionnaire (EDE-Q) and the body fat subscale of the male body attitudes scale (MBAS)). These analyses demonstrated that there were no differences between cisgender male and female youths on eating disorder symptoms at baseline. However, repeated measures ANOVA demonstrated that males had greater decreases in eating pathology at discharge than did females, based on self-reported scores on the EDE-Q, MBAS, and Body Change Inventory.

CONCLUSIONS

Gender differences in eating pathology appeared at baseline, with trans youths reporting higher levels of eating pathology than cisgender youths, though no differences between cisgender males and females emerged at baseline for eating disorder symptom presentation. Contrary to expectations, there were no gender differences in measures of muscularity concerns. Males demonstrated greater eating disorder symptom improvements than females, suggesting that male adolescents may have better treatment outcomes than females in some domains.

Parental experiences with their child's eating disorder treatment journey

BACKGROUND

Parents are integral in the treatment of pediatric eating disorders. The current study was conducted to further understand the barriers and facilitators that parents experience in accessing specialized, tertiary level eating disorder treatment for children and adolescents. The goals of the study were to understand the processes leading to diagnosis and treatment, perceived barriers and facilitators to accessing care, and parents' experiences over the course of their child's eating disorder treatment.

METHODS

Ten parents whose children were admitted to a Canadian tertiary level specialized pediatric eating disorders program took part in an exit interview upon their child's completion of treatment in the program. In-depth semi-structured interviews were combined with a visual timeline. Interpretive induction was performed to generate high-level concepts that emerged from the interviews.

RESULTS

Five high-level concepts were identified: (1) delays in identifying eating disorder symptoms, (2) challenges in accessing eating disorder services, (3) the right treatment at the right time, (4) emotional impact on parents, and (5) parental expertise and involvement.

CONCLUSIONS

Several barriers were identified by parents that interfered with treatment, including system-related challenges when accessing specialized eating disorder treatment, concerns about a lack of appropriate mental health support for their child, and difficulties with transitioning between community and tertiary level care. Negative emotions, including guilt and self-blame, were common early in the treatment journey. Themes of parental involvement throughout treatment, and parents taking charge of their child's recovery, emerged across interviews. The results of this study suggest the importance of early identification of eating disorder symptoms, facilitating smoother transitions between levels of care (e.g., community services and hospital-based eating disorder care), and improving clinical decision-making to ensure children and adolescents with eating disorders receive the most appropriate treatment based on their clinical presentation.

β-endorphin differentially contributes to food anticipatory activity in male and female mice undergoing activity-based anorexia

Anorexia nervosa (AN) has a lifetime prevalence of up to 4% and a high mortality rate (~5-10%), yet little is known regarding the etiology of this disease. In an attempt to fill the gaps in knowledge, activity-based anorexia (ABA) in rodents has been a widely used model as it mimics several key features of AN including severely restricted food intake and excessive exercise. Using this model, a role for the hypothalamic proopiomelanocortin (POMC) system has been implicated in the development of ABA as Pomc mRNA is elevated in female rats undergoing the ABA paradigm. Since the Pomc gene product α-MSH potently inhibits food intake, it could be that elevated α-MSH might promote ABA. However, the α-MSH receptor antagonist SHU9119 does not protect against the development of ABA. Interestingly, it has also been shown that female mice lacking the mu opioid receptor (MOR), the primary receptor activated by the Pomc-gene-derived opioid β-endorphin, display blunted food anticipatory behavior (FAA), a key feature of ABA. Thus, we hypothesized that the elevation in Pomc mRNA observed during ABA may lead to increased β-endorphin concentrations and MOR activation to promote ABA. Further, given the known sex differences in AN and ABA, we hypothesized that MORs may contribute differentially in male and female mice. Using wild-type and MOR knockout mice of both sexes, a MOR antagonist and careful analysis of food anticipatory behavior and β-endorphin levels, we found 1) increased Pomc mRNA levels in both female and male mice that underwent ABA, 2) increased β-endorphin in female mice that underwent ABA, and 3) blunted FAA in both sexes in response to MOR genetic deletion yet blunted FAA only in males in response to MOR antagonism. The results presented provide support for both hypotheses and suggest that it may be the β-endorphin resulting from increased Pomc transcription that supports the development of some features of ABA.

Gender-specific approach in psychiatric diseases: Because sex matters

In both animals and human beings, males and females differ in their genetic background and hormonally driven behaviour and show sex-related differences in brain activity and response to internal and external stimuli. Gender-specific medicine has been a neglected dimension of medicine for long time, and only in the last three decades it is receiving the due scientific and clinical attention. Research has recently begun to identify factors that could provide a neurobiological basis for gender-based differences in health and disease and to point to gonadal hormones as important determinants of male-female differences. Animal studies have been of great help in understanding factors contributing to sex-dependent differences and sex hormones action. Here we review and discuss evidence provided by clinical and animal studies in the last two decades showing gender (in humans) and sex (in animals) differences in selected psychiatric disorders, namely eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder), schizophrenia, mood disorders (anxiety, depression, obsessive-compulsive disorder) and neurodevelopmental disorders (autism spectrum disorders, attention-deficit/hyperactivity disorder).

Treating Individuals With Eating Disorders: Part 1

According to the American Psychiatric Association, eating disorders (EDs) are characterized by a persistent disturbance of eating or eating-related behaviors that result in altered consumption or absorption of food and that significantly impair physical health and/or psychosocial functioning. EDs are chronic psychiatric illnesses and are notoriously difficult to treat. The etiology of eating disorders is unknown and thought to be a complex interplay among biological predisposition, environmental and sociocultural factors, neurobiological influences, and psychological factors. Moreover, prevalence of eating disorders is increasing despite variation in prevalence estimates across studies. Nurses are well-positioned to implement appropriate screening for and comprehensive assessment of EDs as well as offer patient-centered treatment options including referrals when indicated. As the first in a two-part series, this article provides an overview of the clinical characteristics of EDs and key areas for assessment and diagnostic considerations. The follow-up article in this series will focus on pharmacological treatment strategies. [Journal of Psychosocial Nursing and Mental Health Services, 58(3), 7-13.].

Feeding and eating disorders

Eating disorders (EDs) are a group of prevalent psychiatric illnesses with an onset in early to late adolescence-a time of significant neural development, physical and psychologic growth, and self-exploration. The etiology and neurobiology of EDs are not well understood, but EDs are recognized as brain-based illnesses with serious acute and long-term consequences if undertreated or ignored. Two EDs, anorexia nervosa (AN) and bulimia nervosa (BN), have historically been the primary EDs of focus. The DSM-5 updated diagnostic criteria for these disorders added two more: binge-eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID). EDs severely impact males as well as females across the weight spectrum. Comorbidity is high; mortality rates for AN and BN are the highest in psychiatric conditions and higher than many medical conditions. Several treatment options are available to treat an ED ranging from inpatient hospitalization to outpatient services and different psychotherapy options. This chapter reviews the diagnostic criteria, clinical presentation, and treatment for these disorders. Where available, sex differences and developmental considerations will be noted. For all EDs, early recognition and swift treatment are necessary to avoid a chronic course.

[Fractures and bone mineral density in childhood]

BACKGROUND

In juvenile idiopathic arthritis and related chronic inflammatory diseases, proinflammatory cytokines inhibit bone formation and stimulate bone resorption. Anti-inflammatory drugs, such as glucocorticoids and nonsteroidal antirheumatic drugs (NSARD) have as a side effect the potential to inhibit growth and maintenance of bone. These issues are of particular importance for the growing skeleton in childhood and adolescence.

OBJECTIVE

This article presents a narrative overview about the dimension of the problem, a critical evaluation of diagnostic procedures and a discussion of available countermeasures.

METHODS

A systematic literature search was carried out and the available evidence was evaluated based on the authors' knowledge and clinical experience as experts in the field.

RESULTS AND CONCLUSION

In recent years solid data have been accumulated with respect to the interpretation of bone mineral density (BMD) measurements in children and adolescents. Based on these data from the literature and given that the radiation exposure is also very low, it is now possible to clinically apply BMD measurements in this population using dual energy X‑ray absorption (DXA) technology for risk evaluation and diagnosis, taking the respective phase of development and body length into consideration. Dynamic measurements over time appear to be especially valuable in the context of individual clinical data. Hence, BMD measurements can be helpful in monitoring bone health, especially in juvenile idiopathic arthritis and other related inflammatory diseases. Apart from the specific indications for extended diagnostics and bone targeted pharmacological treatment, this method can also contribute to the management of preventive measures, such as sufficient calcium and vitamin D intake and targeted exercise interventions. Even in times of extremely effective antirheumatic drugs, children with chronic inflammatory diseases still bear a risk for bone health.