BIGOREXIA AND COMMON MALE EATING DISORDERS: MYTHS, RISKS, TREATMENT AND MORE

Medically Reviewed by Dr. Rosmy Barrios - September 2, 2024

Male eating disorders are a lot more common than society would have us believe. The stigma surrounding these conditions has slowed down medical progress, creating a divide that ought to be done away with in order to help men in need.

The following discussion attempts to bust myths pertaining to male eating disorders, as well as review the differences in presentation between men and women with similar health concerns. Risk factors, causes and treatment options for male eating disorders are all discussed below.

General Risk Factors for Male Eating Disorders

Risk factors for male eating disorders and body dysmorphic disorders are similar, yet experienced differently on average to that of women. Common ones include^[1]:

• Unbalanced Notions of Masculinity. Men often feel an overwhelmingly greater sense of shame in response to underlying causes of any eating disorder by comparison to women due to the general public perception of masculinity. Vulnerability, emotionality, low esteem and health complaints are typically not included in this ideal, encouraging men to suppress these elements, if present. In this respect, men are far less likely than women to admit to having problems with their body image, which increases the risk of acquiring a related disorder and of seeking appropriate help.
• Early Media Exposure. Mass media has consistently created an unrealistic concept of body image, using models that are often too thin to be considered healthy. In the case of men, male models and action figures have become increasingly more muscular over the last few decades, further distorting a natural male body image. Children and teenagers are particularly susceptible to mass media icons, as they are still developing a sense of body confidence and awareness.
• Lack of Awareness. It should be noted that female bias and lack of awareness on male eating disorders serves as a substantial risk factor for men predisposed to them. Many men are unaware of male eating disorders themselves, which makes it easier for minor disordered eating habits to develop into a major health condition. Friends, families and even physicians contribute to this lack of awareness and close off avenues of treatment, giving rise to an increased risk of severe disease.
• Childhood Obesity. Men with eating and body image disorders typically experienced a period of obesity in their lives, especially common during childhood. In susceptible males, this often sets the tone later in life for excessive body building and/or unhealthy eating behaviors that result in being underweight. This directly contrasts women with eating disorders, who often only perceive themselves to be fat or undesirable, irrespective of whether true or not. Men are also more likely than women to rely on compensatory behaviors, such as exercise, in order to overcome body ailments, which increases the propensity for obesity to induce a body dysmorphic disorder such as bigorexia.
• Depression. Depression of any kind is largely connected to self-esteem and body image. In studies, major depressive disorder was the number one mood disorder associated with eating disorders^[2]. Many diseases, including obesity, include depression as a comorbid condition or symptom. Depression in men has strong associations with erectile dysfunction and/or feeling sexually impotent, as well as a reduction in life satisfaction, low self-esteem and self-sabotage in the work place. Furthermore, societal notions of masculinity encourage male depression due to promoting suppression of vulnerability. This increases the risk of bigorexia and eating disorders in men, who may attempt to compensate by bolstering their body image and/or through binge comfort eating.
• Other Psychiatric Conditions. Eating disorders are highly associated with other psychiatric conditions, including mood, anxiety and personality disorders. The risk of developing an eating disorder increases with the presence of any of these conditions, as does the risk of acquiring an additional psychiatric condition with an eating disorder.
• Substance Abuse Disorders. Depression and substance abuse classically go hand-in-hand. Substance abuse disorders are highly associated with eating disorders and are often used as a means to lose weight and instill a fake sense of confidence. Unfortunately, they also promote depression and through the course of addiction, begin to undermine the person’s sense of control and self-esteem. Moreover, many addictive substances detract from physical health and increase either body decay or weight gain, which additionally demotes body image.
• Sexual Abuse. Sexuality has the ability to substantially affect the way in which one perceives their body image. Thus, it’s no surprise that research reveals that eating disorders and body dysmorphic disorders are far more likely in those with a history of sexual abuse^{[3] [4] [5]}. It is estimated that 30% of individuals with these conditions suffered sexual abuse in childhood^[6]. Unfortunately, the majority of those who are sexually abused do not disclose this information until much later on after developing eating and body dysmorphic disorders. This is especially true of male patients, who are unlikely to report victimization. However, patients who report sexual abuse earlier on tended to stand a lower risk of developing an eating disorder and have a better prognosis.
• Physical Trauma. Aside from sexual abuse, other kinds of physical trauma can increase the risk of developing an eating disorder. Childhood bullying is a frequent occurrence that happens more often to boys than girls. Males are likely to respond to physical violence by attempting to become stronger and more “masculine” in order to protect themselves from future acts of aggression. In some men, this can pave the way for bigorexia (excessive body building) or eating disorders, depending on the context of the trauma and the self-esteem of the man.
• Age. For males, the risk for acquiring an eating disorder is higher after puberty; whereas for females, the comparative risk is lower. For both genders, onset at older ages is a common risk factor for developing lifelong eating disorders with a worse prognosis. The majority of those with eating disorders acquire them by age 21-25. If present by the time the person reaches 40, the risk for lifelong disease doubles, as does the risk of concurrent mortality^[7].
• Athletes. Male athletes appear to be at a higher risk for acquiring body dysmorphic disorders alongside eating disorders. It is typically a lot more difficult for healthcare practitioners to diagnose these conditions in athletes, as the nature of their careers requires them to build muscle and maintain a higher-than-average fat-free mass. In some athletic industries, low body weight is desirable in order to outperform competition, as seen in dancers, gymnasts, runners and martial artists. As a result, it’s much easier for male athletes to hide the nature of any potential eating disorders, however the prognosis is often worse for them and has a noticeable impact on athletic performance.^[8]

Overview of Common Male Eating Disorders and Body Dysmorphic Disorder

Both eating disorders and body dysmorphic disorders typically have body image and self-esteem as central themes. In men particularly, bigorexia and eating disorders are intricately related to one another, as highlighted below.

Bigorexia and Body Dysmorphic Disorder

Bigorexia (also referred to as muscle dysmorphia) is the most common subtype of body dysmorphic disorder to affect men. Body dysmorphic disorder is a psychiatric condition defined as having a severe preoccupation with a perceived defect or flaw in one’s appearance that is either not seen or barely noticeable by others.^[9]

In bigorexia, the person perceives their muscles as being too small or inadequate. As a consequence, the condition is characterized by an obsessive need to build muscle, however even successful attempts often do not correct the person’s perception of muscle insufficiency. Female body-builders are also affected by bigorexia, however it is estimated that close to 90% of affected individuals are male. Other names for bigorexia include reverse anorexia and machismo nervosa.

Symptoms

Symptoms of bigorexia are similar to that of body dysmorphic disorder, with an intense focus on muscularity. Examples include:

• Excessive weight-lifting
• Loss of control over excessive weight-lifting and/or physical activity
• Spending 3-8 hours a day thinking of becoming more muscular
• Excessively checking muscles in the mirror
• Camouflaging or hiding physique in public through wearing baggy or concealing clothes
• Avoiding people due to feeling physically inadequate
• Practicing a strict diet regimen in order to build muscle
• Making use of anabolic steroids or other (illegal) drugs aimed at building muscle

Severe cases of bigorexia interfere with the person’s ability to hold relationships and can also result in job losses. Those with bigorexia are likely to have a comorbid mood, anxiety and/or substance abuse disorder.

Bigorexia as an Eating Disorder. Some experts are uncertain as to whether bigorexia ought to be classified as an eating disorder or a body dysmorphic disorder. This is because males with eating disorders often pursue muscularity, and likewise, disordered eating is a common symptom of bigorexia. There is also a very high incidence of eating disorders in men with bigorexia, as highlighted in studies focused on male athletes and bodybuilders.^[10] However, studies report that eating disorders are still more common than bigorexia (muscle dysmorphia)^[11] and other sources indicate that bigorexia is a prime risk factor for male eating disorders^[12]. It is likely that either of them increase the risk of acquiring the other, adding to the doubt for bigorexia’s classification.

Bulking and Cutting. A common dietary trend observed among those with bigorexia includes “bulking and cutting.” In this scenario, the individual consumes an unbalanced protein-heavy diet, aimed at bulking up muscle mass. Often times, this bulking leads to an increase in weight and detracts from muscularity, resulting in reduced body image satisfaction. The individual then tries cutting, which involves dietary restriction aimed at reducing body fat and enhancing muscle visibility. This phase also typically fails to promote optimal muscularity, and conspires to create a catch 22 cycle.^[13]

The Cheat Meal. In some instances of bigorexia, the concept of a “cheat meal” overlaps with bulimic tendencies and may also be seen in males with bulimia. The cheat meal is an occasional deviation from a strict muscle-building diet, intended to thwart metabolic adaptation to a low-calorie diet by flooding the body with a high amount every now and then. This is thought to contribute towards depletion of fat and enhance muscle building. A cheat meal can be seen as a binge-eating episode, and extreme physical activity often follows as a compensatory behavior in both bulimic and bigorexic men.

Causes

Little is known about the causes of muscle dysmorphia or body dysmorphia. In general, studies on body dysmorphia highlight that visual-spatial processing areas of the brain hone in more on detail than on a holistic view. Other brain alterations in those with the disorder are indicative of higher anxiety levels, synonymous with the symptoms experienced by the patient.

Psychologically, muscle dysmorphia has been associated with a similar psychology amongst men with the condition. Most suffered some kind of traumatic or unpleasant experience at a young age that contributed towards making them feel unsafe (e.g. bullying, violence, abuse). Their natural response was to become bigger and stronger in order to protect themselves.

The other possible psychological cause would be a sense of inadequacy pertaining to reproductive success. For some, enhancing muscularity may improve the chances of securing a partner through increasing physical attractiveness, capacity and perceived safety to the partner.^[14]

Treatment Options

There are no known treatment options for muscle dysmorphia and it is unlikely that those with the condition seek help for it. Some researchers suggest treating it like a type of body dysmorphic disorder, in which case, psychotherapy^[15], cognitive behavioral therapy, dialectic behavioral therapy and sometimes an antidepressant (often an SSRI) are indicated.

Other sources dispute the classification of the disorder, suggesting that it can also be classified as an eating disorder or another psychiatric condition such as obsessive-compulsive disorder or anxiety disorder.^[16] If the patient displays symptoms that overlap with another disorder, they may benefit from treatment modifications that target the nature of their condition.

The disordered eating aspect of bigorexia ought to be tackled like an eating disorder. Just like any part of the body, muscles require stable dietary patterns and consistent exercise to flourish. A nutritionist may be helpful in correcting flaws in the person’s perception of a healthy muscle-building diet. A personal trainer can also assist in developing muscles properly and in a wholesome manner. However, a psychotherapist is still a likely requirement, as the underlying issue is often related to perceived muscle insufficiency.

If muscle dysmorphia is present with generalized body dysmorphia, it ought to be noted that cosmetic surgery often does not correct the underlying psychological nature of the problem and sometimes makes the disorder worse.

Prognosis

Body dysmorphic disorders are known to be lifelong conditions with little case for remission. Patients that undergo psychological and pharmaceutical treatment experience a better prognosis than those that don’t, displaying better functionality in life by comparison.

However, eating disorders tend to have a far better prognosis, when treated for.

Anorexia Nervosa

Anorexia nervosa can be characterized as both an eating disorder and a body dysmorphic disorder. Patients with anorexia fear weight gain and obsess over weight loss, conveying a distorted body image in which they continuously perceive themselves as obese. This often leads to habits of extreme dietary restriction and a dangerously low BMI. The individual does not recognize the severity of their low weight and often still obsesses over becoming thinner.^[17]

Anorexia is perhaps one of the most famous eating disorders for having a female bias in research literature. This is highlighted by the fact that one of the main defining symptoms used to be the absence of menses in females with the disorder. As a result, men were hardly ever diagnosed with anorexia until the definition in the DSM-5 was updated in 2013, in spite of comprising up to 25% of all cases.

Symptoms

Those with anorexia typically practice extreme dietary restriction that borders on starvation in order to lose weight. Excessive bouts of exercise with the aim of weight loss may also be a presenting symptom.

Males with anorexia often obsess over being muscular (instead of thin or emaciated), in conjunction with attempting to lose weight. Therefore men with the condition are likelier to do more exercise than women, with less severe dietary restriction practices. Studies highlight that men with anorexia typically have a higher BMI as a result of muscle, which may make it more difficult to diagnose in males.^[18]

Other symptoms of anorexia nervosa include:

• Associating thinness (females) or leanness (males) with self-esteem
• Linking weight loss with self-control
• Cold intolerance
• Constipation
• Fatigue
• Irritability
• Edema of the extremities

Those with the condition limit food portion sizes and obsess over counting calories. Purging behaviors are frequently associated with anorexia, such as self-induced vomiting or laxative abuse. In anorexic men, use of anabolic steroids and a protein-oriented diet in order to build muscle is fairly common.

Complications of anorexia include heart problems, skin conditions, growth deformities, reduced immune function, lower cognition and brain atrophy, neuropathies, osteoporosis and electrolyte imbalances. Anorexia nervosa is also linked with physical health conditions, including anemia, cancer, osteoporosis and fibromyalgia.

Female patients are prone to amenorrhea, while low testosterone and/or sexual impotence is often observed in male patients. However, not all patients convey these symptoms.

Causes

Alterations in brain function have been observed in many anorexic patients, believed to be related to physical underlying mechanisms of the disorder. These include:

• Deficits in dopamine which decrease the reward associated with eating
• Deficits in serotonin which lower impulse control and increase neuroticism
• Associations between brain areas governing appetite and fear
• Reductions in brain activity governing habitual behavior

These changes in neurochemistry have been linked to environmental risk factors (listed above), and the way they impact individuals with certain genes that overlap with anxiety disorders such as schizophrenia and neuroticism. Low educational status also appears to play a role in promoting anorexia, through giving rise to misconceptions pertaining to diet and body weight.

Treatment Options

Treatment includes nutritional rehabilitation for deficiencies and psychotherapy for correcting behavioral problems.

In extreme cases, hospitalization and the use of psychiatric medications is highly indicated. Patients that have undergone extreme starvation are often at risk of refeeding syndrome during nutritional rehabilitation and may require intravenous therapy to balance electrolytes. Those that are unable to stop compulsive purging or restrictive behaviors are prescribed antipsychotics until symptoms abate or improve. Psychotherapy may be useful after stability has been achieved.

Prognosis

75% of patients experience remission within 5 years of therapy, with a good prognosis. Older patients, those with a longer disease history, and psychiatric patients run a higher risk of relapse and may go on to develop another eating disorder. Prognosis is poor in these patients due to medical complications and an increased risk of mortality. 25% of deaths pertaining to anorexia nervosa are the result of suicide.

Bulimia Nervosa

Bulimia nervosa is an eating disorder characterized by episodes of binge-eating, followed by inappropriate compensatory behavior to prevent weight gain. The disorder often affects adolescent girls, however some data indicates that 10-30% of cases affect men and adolescent boys.^{[19] [20]}

Symptoms

Bulimia nervosa can be broken down into two stages^[21]:

1. Binge eating episodes, characterized by:

• Abnormally large consumption of food compared to most people within a similar time frame and under similar conditions.
• Loss of control during the episode
• Frequency of at least once a week for more than 3 months

2. Compensatory weight loss behavior, including:

• Purging (self-induced vomiting)
• Laxative or diuretic abuse
• Fasting
• Extreme physical activity

Common symptoms of such behavior includes:

• Sore throat
• Fatigue and lethargy
• Headache
• Dehydration
• Constipation
• Abdominal pain
• Bloating
• Dry skin
• Dental erosion
• Hair loss
• Edema
• Nose bleeds
• Hypotension
• Cardiac arrhythmia

Symptoms of bulimia were similar in both males and females^[22], with slight differences. Some data suggest that men with the condition were less concerned with “the perfect weight” and less trusting of others (more secretive) than their female counterparts.^[23] As seen in other eating disorders, men with the condition were more likely to use exercise as a compensatory behavior for binge-eating, and therefore tend to have more weight^[24] than bulimic women.

A study revealed that 35-37% of those with bulimia nervosa stand a chance for developing symptoms of ADHD.^[25] Similar symptoms were seen in other eating disorder types, but only those that shared a strong overlap with symptoms of bulimia (i.e. binging/purging behaviors).

Complications of bulimia include salivary gland hypertrophy, problems using esophageal muscles, Irritable Bowel Syndrome, GERD, Mallory-Weiss syndrome, and esophageal rupture. Bulimia may increase the risk of pancreatitis, diabetes, and congestive heart failure.

Causes

Underlying physical causes of bulimia are multifactorial and similar to those of anorexia nervosa. One difference may be related to interoceptive function in the insula (or the ability to perceive neurological stimulus in the gut) which likely contributes towards binging and purging behaviors. This overlaps with the brain scans of those with binge eating disorder, which is synonymous with severe addiction to food (often high in fat and/or sugar)^[26].

Studies reveal that men are likelier to undergo binge eating episodes as a result of a substance abuse disorder. By contrast, women were likelier to resort to binge eating in response to negative emotion.^[27]

Treatment Options

Frontline treatment involves treating problems arising from the initial presentation of bulimia. Rehydration is often an important priority, as is correcting electrolyte abnormalities. Severe cases may require hospitalization and intravenous therapy. Constipation can be treated with the use of laxatives, unless laxative abuse was the main mode of purging used by the patient.

Common long-term therapies for bulimia pertain to the use of antidepressant, such as SSRI’s. Fluoxetine is the only FDA approved medication for treating bulimia, proving to be more effective than placebo at higher doses.

As with the other eating disorders mentioned above, psychotherapy and cognitive-behavioral therapy are effective for treating bulimic patients. For adolescents, family based therapy showed promising results in reversing symptoms of bulimia.^[28]

Prognosis

Prognosis for bulimia is generally good, with the majority of those with the condition recovering within 5 years.

One study suggests that males with bulimia may suffer a slightly worse prognosis than females with the condition.^[29] This may pertain to the way in which treatment is often oriented towards treating females (see considerations below).

Male-Specific Treatment Considerations

Most psychological therapies and treatments for eating disorders are geared towards treating females. One primary concern is that men with these conditions are often muscle-oriented with regard to their weight and dietary habits, while treatments focus on individuals that are thinness-oriented (a feminine approach).

Furthermore, men typically display a lower degree of anxiety by comparison to women, as well as being more goal-oriented with regards to treating the condition^[30]. Studies reveal that communities and healthcare professionals both diminish male eating disorder symptoms in response to patients seeking help, which also served to detract from therapies.^[31] Many men are misdiagnosed as a result, which can lead to a number of serious complications.

Programs designed with a focus on promoting a healthy male body image in male participants are required by healthcare providers for better success. Physicians should attempt a non-judgmental approach to men with these conditions in order to enhance treatment possibilities and outcomes.  Men may also respond better to a step-by-step action plan that they can easily follow towards recovery. Common themes in successful recoveries revolved around: accepting physical appearance, regaining self-worth and accepting any losses or grievances incurred by the disorder.

Education on diet, nutrition and healthy exercise regimens which aim to promote optimal health and well-being (as opposed to muscularity) are also important to include, for both structure and re-identification.

Community and practitioner awareness is vital in order to facilitate men in need of treatment, to lessen the social stigma attached to male eating disorders and to improve masculine body image ideals. Many men are not even aware that they have an eating disorder, and are likewise in need of awareness in order to know when to seek help^[32]. Group therapies proved to be more effective in some cases than not, particularly with regard to reinventing body image and identity.

Conclusion

Male eating disorders are more prevalent throughout the population than was previously thought, in men and adolescents of all ages. Due to limited awareness, social stigma and a lack of research, men with eating disorders have been entirely under-represented. Unlike their female counterparts, males are generally muscle-oriented and striving to gain the ideal masculine body. Therefore, presentation of symptoms vary greatly in men with these conditions by comparison to women. Raising awareness on male eating disorders will go a long way towards helping men with these conditions seek help and in improving outcomes. Treatment should be structured around aiding the patient in developing a healthy male body image.

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