Eating Disorders in Men: A Community-Based Study

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1 Eating Disorders in Men: A Community-Based Study TAHANY M. GADALLA University of Toronto This study examines the prevalence of disordered eating attitudes and behaviors and their associations with socio-demographic characteristics, body weight and physical activity in a nationally representative sample of Canadian men. The study considers gender differences in dieting behaviors and level and intensity of physical exercise. Results indicate that risk for eating disorders is associated with men s age, stress level, living arrangement, body weight and engagement in daily physical exercise. Men at risk for eating disorders adopt fewer oral control and dietary restrain behaviors, are less preoccupied with body shape, and show less desire for thinness compared to women. There was no gender difference in engaging in compensatory behaviors such as vomiting, level or intensity of physical exercise. Keywords: eating disorders, men, community studies Eating disorders (ED) are much more common among women than men and have long been assumed to be found exclusively in women. Consequently, few studies have focused on such disorders in men and even fewer attempted to compare men with and without ED or men and women with these disorders. However, with the increasing pressure on men to be fit and to look muscular, there is evidence that body dissatisfaction and ED in men are increasing (O Dea & Abraham, 2002). Men have been reported to comprise between 5-10 percent of individuals with ED in clinical settings (Geist, Heinmaa, Katzman & Stephens, 1999; Woodside, 2002), with significantly more gay and bisexual men suffering from these disorders compared with heterosexual men (Feldman & Meyer, 2007). However, there is evidence that more men in the general population have ED (Woodside, Garfinkel, Lin et al., 2001) and that ED in men are under-diagnosed and under-treated (Weltzin, Weisensel, Franczyk, Burnett, Klitz, & Bean, 2005; Woodside, 2004). Men may not seek treatment due to experiencing fewer severe symptoms or because they may not consider themselves at risk for eating disorders (Woodside). Other barriers to seeking treatment may include cultural biases and lack of treatment settings that are dedicated for men with ED (Weltzin et al.). Tahany M. Gadalla, University of Toronto. Correspondence concerning this article should be addressed to Tahany M. Gadalla, Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St. W, Toronto, Ontario, Canada M5S 1V4. tahany.gadalla@utoronto.ca International Journal of Men s Health, Vol. 8, No. 1, Spring 2009, by the Men s Studies Press, LLC. All rights reserved. jmh /$14.00 DOI: /jmh Url: 72

2 EATING DISORDERS IN MEN Barry, Grilo, and Masheb (2002) examined gender differences in patients with binge eating disorder and reported that men and women did not differ on measures of eating-related features such as eating concerns, shape or weight concerns. Similar results were found in an earlier study (Tanofsky, Wilfley, Spurrell, Welch, & Brownell, 1997). No gender differences on other clinical variables such as age of onset, frequency of various symptoms or duration of illness were found (Barry et al.; Geist et al., 1999; Olivardia, Pope, Mandweth, & Hudson, 1995; Woodside, 2001). Like women with ED (Gruber, Pope, Borowiecki, & Cohane, 2001), men with ED were found to have an exaggerated perception of their body fat compared to controls (Mangweth, Hausmann, Walch et al., 2004). However, women with binge eating disorder reported significantly greater body image dissatisfaction and drive for thinness compared to men with the same disorder (Barry et al.). Gender differences in risk factors for ED and body dissatisfaction such as self-esteem, perfectionism and mass-media influence have been suggested (Elgin & Pritchard, 2006). Specifically, self-esteem, perfectionism and mass-media influence were related to disordered eating behavior in women, whereas only perfectionism and mass-media influence were related to disordered eating behavior in men. In addition, self-esteem and mass-media influence were related to body image dissatisfaction in women, whereas perfectionism and mass media influence were related to body image dissatisfaction in men (Elgin & Pritchard). Lower socio-economic status and single marital status have been indicated as risk factors for ED in both genders. For example, Lindblad, Lindberg and Hjern (2006) found a higher proportion of single-parent families and families in need of child welfare among families of male patients with anorexia nervosa compared to the general population. Male and female patients with binge eating disorder reported similar rates of concurrent depression (Barry et al., 2002; Fontenelle, Mendlowicz, de Menezes, et al., 2003). Further, in a national sample of Canadians, being at risk for ED was associated with significantly higher odds of major depression for both genders (Gadalla, 2008). However, more male patients than female patients met the criteria for at least one Axis I diagnosis (Tanofsky et al., 1997). In clinical samples with binge eating disorder, men reported higher lifetime prevalence of substance abuse compared with women (Gadalla). However, data from a community sample showed that the risk for ED was significantly associated with substance dependence for women, but not for men (Gadalla & Piran, 2007). Gender differences in eating attitudes and behaviors toward food among eating disordered individuals have also been suggested. Weltzin et al. (2005) found that men were less likely than women to engage in typical compensatory behaviors such as vomiting and more likely to engage in activities such as excessive exercise to control their body weight. They also found that men were more likely than women to binge eat rather than restrict food intake. Conversely, in a small-scale study of substance abuse patients in a treatment setting, men and women reported similar levels of engagement in binge eating and compensatory behaviors; however, the women showed more disturbed attitudes about body weight and shape (Jackson & Grilo, 2002). 73

3 GADALLA Commitment to physical exercise has been linked to disordered eating attitudes and behaviors, particularly in men. It has been viewed as a predictor, a risk factor, and/or a symptom of ED (Asci, Tuzun, & Koca, 2006; Davis, Katzman, Kaptein, et al., 1997; McLaren, Gauvin, & White, 2001; Woodside, 2004). The temporal sequence of exercise and disordered eating behaviors as well as gender differences, if any, in the strength of their association are yet to be determined. Most research on ED in men has been based on case studies and small clinical samples, and did not include appropriate control groups (Woodside et al., 2001). Since clinical-based studies are affected by sampling biases, researchers have therefore highlighted the role of population-based studies in exploring the prevalence of disordered eating patterns and their associated behaviors (Dansky, Brewerton, & Kilpatrick, 2000; Woodside, 2002). To the author s knowledge, only one published study used a community-based sample to compare characteristics of men with and without ED (Woodside et al., 2001). This study aimed to add to existing research in a number of ways. First, it examined socio-demographic characteristics, body weight and level of physical exercise in men who were identified as being at risk for ED compared with those not at risk for ED. Second, the study explored gender differences in dieting behaviors and levels of physical activity exhibited by men and women at risk for ED. The study utilized a nationally representative sample of Canadians to achieve its objectives. Data Methods Research was based on secondary analyses of data collected by Statistics Canada in cycle 1.2 of the Canadian Community Health Survey (CCHS) on Mental-Health and Well-being (Statistics Canada, 2002). The survey used a multistage, stratified cluster sample in which the dwelling was the final sampling unit. The sample was stratified by province, and by urban versus rural regions within each province. The survey, which was conducted in 2002, had 36,984 respondents representing approximately 98 percent of the Canadian population aged 15 or older who resided in private dwellings in the ten provinces. Of the respondents 16,773 were men. Residents of the three territories, persons living in Indian Reserves or Crown Lands, residents of institutions, fulltime members of the Canadian Armed Forces, and residents of some remote regions were excluded from the survey. Data were collected mostly in face-to-face interviews using the Computer Assisted Personal Interviewing method. Data collection by phone was only used when travel was prohibitive or the respondent refused a personal interview. Sampling weights, published by Statistics Canada, corrected for over-sampling and non-response, thus producing estimates which are representative of the Canadian population and not just the sample itself. Measures Each respondent was asked whether there ever was a time when he or she had a strong fear or a great deal of concern about being too fat or overweight. If the answer 74

4 EATING DISORDERS IN MEN was Yes, the respondent was asked whether that feeling had occurred in the 12 months prior to the interview. Respondents who reported being concerned about their weight during the 12-month period were administered the Eating Attitude Test module (EAT-26) developed by Garner Olmsted, Bohr, and Garfinkel(1982). The EAT-26 is a widely used standardized measure of the extent of symptoms and concerns characteristic of ED. It yields a score that ranges between zero and 78. Individuals scoring 20 or above are considered at risk for having an eating disorder (Garner et al.). The 26 items on the instrument comprise three subscales: dieting (14 items), bulimia and food preoccupation (6 items), and oral control (6 items). The predictors investigated in this study included demographic characteristics as well as indicators of body weight, physical activities, and stress level. Demographic characteristics included respondent s age, gender, living arrangements [living alone, living with a partner, single parent], length of time in Canada, education level, and income adequacy. (The last variable was derived by Statistics Canada based on total household income relative to the number of people in the household: low/middle low vs. middle high/high. The total household income was compared with the low income cutoff for a household of the same size. The low-income cutoff is defined as the income below which a family is likely to spend 20 percentage points more of its income on food, shelter and clothing than the average family [Statistics Canada, 2002]). Respondents were also asked to rate their daily stress level: none/a bit vs. quite a bit/extremely. Standard body weight was calculated based on the person s BMI such that each person was classified as underweight (BMI < 18), of adequate weight (18 BMI < 25), or overweight (BMI 25). The BMI was calculated based on participants self-reported height and weight. Two measures of physical activities were used: participation in daily leisure activity that lasted more than 15 minutes and physical activity index, which measures the individual s energy expenditure (EE) in his or her leisure physical activities: active (EE 3.0), moderately active (1.5 EE < 3.0), inactive (0.0 EE < 1.5). The EE of participants leisure activities was calculated using the frequency and time per session of the physical activity as well as its metabolic energy cost. Metabolic energy cost (MET) was expressed as a multiple of the resting metabolic rate. Thus, an activity of 4 MET requires 4 times the amount of energy compared to when the body is at rest. Survey participants were not asked to specify the intensity level of their activities; therefore, the MET values calculated here correspond to the low intensity value of each activity. This approach was adopted because individuals tend to overestimate the intensity, frequency and duration of their activities (Statistics Canada, 2002). In short, the amount of energy used in a 15-minute session of each leisure activity (MET) was calculated and multiplied by the number of sessions to determine the total energy expenditure (EE) corresponding to each activity. Analysis of Data Pearson chi-square tests, Fisher s exact tests (used when the expected cell count is less than 5, a required assumption for using the Pearson chi-square test), and t-tests 75

5 GADALLA were used to assess the statistical significance of the association between risk of ED and indicators of socio-demographic factors, body weight and physical activity in men, as well as to examine gender differences in the frequencies of disordered eating behaviors in individuals at risk for ED. Multiple logistic regression models were used to examine factors associated with being at risk for ED in men. In order to control for Type I error and due to the large number of significance tests performed, findings with significance levels between 0.01 and 0.05 were considered marginal, while findings with significance levels less than 0.01 were considered of statistical importance. Results A sample of 16,773 men was used in this study. Among them, 2,549 (15.2 percent) expressed having had a strong fear of being too fat at some point in their lives. Approximately one half (50.6 percent) of these men experienced this fear during the 12- month period prior to the interview. Of these, 88 men scored 20 or more on EAT-26, and hence, were identified as being at risk for ED. Cronbach s alpha reliability coefficients of the EAT-26 in this study were Using the sampling weights described in the data section (above), it can be estimated that in 2002, 64,381 men living in Canada were at risk for ED. Table 1 presents a comparison of men who were identified as being at risk for ED (EAT-26 score: 20) with men who were not at risk for ED (EAT-26 score: < 20) on socio-demographic characteristics, body weight and level of physical activity. The data in this table show that the age distributions of the two groups were significantly different (chi-square = 18.37, df = 2, p < ) with more men at risk for ED between the ages of 25 and 44 years. More unattached men were at risk for ED (chi-square = 5.82, df = 2, p = 0.05) compared to men living with family. Self-rated stress was significantly higher (chi-square = 9.49, df = 1, p = 0.002) in men at risk for ED compared with men who were not at risk for ED. Length of time in Canada since immigration, education level and income were not associated with being at risk for ED. The mean BMI for men who scored 20 or more on EAT-26 (Mean = 30.65, SD = 6.44) was significantly higher than that for men who scored less than 20 (Mean = 26.55, SD = 4.23) (t = 5.47, df = 73, p < ). Comparing the standard weight distribution of the two groups, however, indicated that significantly more men at risk for ED were either underweight or overweight compared to those not at risk for ED (chi-square = 14.40, df = 2, p = 0.001) (see Table 1). More men at risk for ED engaged in daily physical activity compared to men not at risk for ED (chi-square = 5.95, df = 1, p = 0.02). In addition, energy expenditure in leisure activities (physical activity index) was significantly associated EAT-26 score (chi-square = 10.15, df = 2, p = 0.006), with more men at risk for eating disorder shaving energy expenditure of 3.0 units or more. All variables that were found to have a significance at a level of 0.05 or less in the above bivariate tests were included in a forward selection multiple logistic regression model, with risk for ED as the dependent variable. Results of this analysis showed in a multivariate context that men between the ages of 25 and 44 years, unattached men, 76

6 EATING DISORDERS IN MEN Table 1 Association between Risk for Eating Disorders (EAT-26 score < 20 versus 20) and Socio-demographic Characteristics, Body Weight and Physical Activity in Canadian Men and men under stress had elevated odds of being at risk for ED (see Table 2). The odds of being at risk for ED among men years old were about 2.5 times higher than the odds among younger or older men. Overweight men were more than three times more likely to be at risk for ED than men with adequate weight, and men who exercised daily were two times more likely to be at risk for ED than men who did not. 77 EAT-26 score: Number (%) Score 20 Score < 20 Age*** years 5 (5.7) 2,870 (17.2) years 53 (59.8) 6,457 (38.7) 45 years and above 30 (34.5) 7,358 (44.1) Education level Less than high school 19 (21.6) 4,167 (25.3) High school graduate 13 (14.8) 2,971 (18.0) Some post-secondary 5 (5.7) 1,426 (8.6) Post secondary graduate 51 (58.0) 7,931 (48.1) Living arrangement* Unattached 23 (26.4) 2,870 (17.2) Couple 62 (70.1) 12,781 (76.6) Single parent 3 (3.4) 1,034 (6.2) Length of time in Canada 0-9 years 8 (9.2) 1,034 (6.2) 10 years or more 10 (11.5) 2,620 (15.7) Canadian 69 (79.3) 13,030 (78.1) Income adequacy Low income 5 (6.0) 1,318 (7.9) Middle or high income 83 (94.0) 15,367 (92.1) Self-rated stress** None / a bit 57 (64.8) 13,081 (78.4) Quite a bit / extremely 31 (35.2) 3,604 (21.6) Standard weight** Underweight 1 (1.4) 83 (0.5) Adequate weight 17 (18.9) 6,674 (40.0) Overweight 70 (79.7) 9,944 (59.6) Physical activity index** Active 39 (44.3) 4,822 (28.9) Moderately active 19 (21.6) 4,355 (26.1) Inactive 30 (34.1) 7,508 (45.0) Daily physical activity>15 minutes* Yes 42 (47.7) 5,890 (35.3) No 46 (52.3) 10,795 (64.7) Total 88 16,685 * p < 0.05, ** p < 0.005, *** p <

7 GADALLA Table 2 Multiple Logistic Regression Results for Factors Associated with Risk for Eating Disorders among Canadian Men (N = 16,773) Gender Differences in Dieting Behaviors and Levels of Physical Activity Five hundred seventy-four women scored 20 or more on the EAT-26 and their mean score (Mean = 28.51, SD = 7.20) was significantly higher than men s (Mean = 25.93, SD = 4.88) (t = 4.29, df = 152, p < ). A comparison of men s and women s answers to the items on the EAT-26 revealed that women reported significantly higher frequencies of engaging in 8 of the 26 activities measured by the scale, while men reported significantly higher frequencies of engaging in only three of the activities mentioned (see Table 3). Although more men than women reported vomiting after eating (4.5 percent versus 1.9 percent), the difference was not statistically significant (p = 0.12). There was no significant difference in the distribution of standard body weight between men and women at risk for ED. Although slightly more men than women reported participation in leisure activities (chi-square = 4.65, df = 1, p = 0.031), neither engaging in regular daily activity nor energy expended in these activities (physical activity index) were significantly different between men and women. Discussion This study used a representative sample of Canadians to examine the association between risk for ED and socio-demographic characteristics, body weight and level of 78 Odds ratio (95% CI) Age years 1.12 (0.38, 3.31) years 2.49 (1.45, 4.29)** 45 years and above Living arrangement Unattached Couple 0.46 (0.28, 0.76)** Single parent 0.44 (0.14, 1.43) Self-rated stress None / a bit Quite a bit / extremely 1.63 (1.01, 2.63)* Standard weight Underweight 4.48 (0.47, 41.67) Adequate weight Overweight 3.23 (1.79, 5.81)*** Daily physical activity > 15 minutes Yes 1.90 (1.20, 3.02)** No * p < 0.05, ** p < 0.005, *** p <

8 EATING DISORDERS IN MEN Table 3 Gender Differences in Frequency of Engaging in Dieting Behaviors among Individuals Who scored 20 or higher on EAT-26 (88 men and 574 women) Chi-square (df) p-value Dieting behaviors I was terrified about being overweight (3) I felt extremely guilty about eating (3) < I thought about burning up calories when I exercise* (3) I was preoccupied with the thought of having fat on my body (3) I engaged in dieting behaviors* (3) I took longer than others to eat meals (3) < Oral control behaviors I avoided eating even when hungry (3) I displayed self control around food (3) < I cut my food into small pieces 9.85 (3) Bulimia / food preoccupation I gave too much time and thought to food (3) I enjoyed trying new rich foods* (3) < * Men reported higher frequencies of engagement. physical exercise in men, as well as to explore gender differences in dieting behaviors and levels of physical activity exhibited by men and women at risk for ED. Similar to findings of previous studies (Geist et al., 1999; Woodside, 2002), men in this sample comprised 13.3 percent of those identified as being at risk for ED. Overweight men were three times more likely to be at risk for ED, a result which is consistent with that found in a sample of overweight military men (Warner, Warner, Matuszak, Rachal, Flynn, & Grieger,, 2007). Results of this study indicated that unattached men, men between the ages of years, men who were underweight or overweight, experiencing high levels of stress, and/or engaging in daily physical exercise had elevated risk for ED. These results are in line with previous reports (Woodside, 2001; Reagan & Hersch, 2005; Lindblad et al., 2006). Results also indicated lack of association between low income and risk for ED in men. This is in contrast to the finding reported by Lindblad et al. However, these authors used receipt of child welfare assistance as a measure of low income, which probably reflects a lower cutoff than the one used in this research. Similar to previous reports (Woodside, 2002), women at risk for ED scored higher on EAT-26 than men. Men who were at risk for ED in this study had a mean score of on EAT-26, which is very similar to the mean of 26.6 reported by Olivardia et al. (1997) for men with ED. Comparisons of the frequencies of adopting specific dieting behaviors showed that women adopted more oral control and dietary restraint behav- 79

9 GADALLA iors, were more preoccupied with body shape, and showed more desire for thinness compared to men. Unlike previous findings (Weltzin et al., 2005), there were no gender differences in engaging in typical compensatory behavior such as level or intensity of physical exercise. However, significantly more men than women reported thinking about burning calories when they exercised. Also, unlike previous reports (Weltzin et al.), the proportion of men at risk for ED who engaged in vomiting as a compensatory behavior was higher than that of women, albeit not significantly so. The lack of a gender differences in vomiting behavior could be an artifact of the very small numbers of men and women who reported engaging in this behavior (4 men, 11 women). This study has a number of limitations. First, a specific pattern of disordered eating in men could not be determined. Although the Eating Attitude Test (Garner et al., 1982) is a widely used and psychometrically tested measure for assessing risk for ED, it does not provide diagnostic information of specific patterns of ED. Second, the crosssectional nature of the data precluded an examination of the underlying mechanisms and temporal relations that may explain observed associations. Although the measures used in this study were subject to errors of recall, the data were collected using the Computer- Assisted Personal Interviewing method, which is known to reduce reporting bias (Grucza, Przybeck, & Cloninger, 2007). Although ED have traditionally been assumed to exist only in women, their prevalence in men is increasing. Findings of this study suggest that health care providers should screen men at high risk for possible ED. Healthcare officials should increase awareness of the signs and symptoms of ED among men as well as increase their efforts to identify and remove barriers to men seeking treatment for the disorders. References Asci, F. H., Tuzun, M., & Koca, C. (2006). An examination of eating attitudes and physical activity levels of Turkish university students with regard to self-presentational concern. Eating Behaviors, 7(4), Barry, D. T., Grilo, C. M., & Masheb, R. M. (2002). Gender differences in patients with binge eating disorder. International Journal of Eating Disorders, 31, Dansky, B. S., Brewerton, T. D., & Kilpatrick, D. G. (2000). Comorbidity of bulimia nervosa and alcohol use disorders: results from the National Women s Study. International Journal of Eating Disorders, 27, Davis, C., Katzman, D. K., Kaptein, S., Kirsh, C., Brewer, H., Kalmbach, K., et al. (1997). The prevalence of high-level exercise in the eating disorders: Etiological implications. Comprehensive Psychiatry, 38, Elgin, J., & Pritchard, M. (2006). Gender differences in disordered eating and its correlates. Eating & Weight Disorders: EWD, 11(3), e96-e101. Feldman, M. B., & Meyer, I. H. (2007). Eating disorders in diverse lesbian, gay and bisexual populations. International Journal of Eating Disorders, 40, Fontenelle, L. F., Mendlowicz, M. V., de Menezes, G. B., Papelbaum, M., Freitas, S. R., Godoy- Matos, A., et al. (2003). Psychiatric comorbidity in a Brazilian sample of patients with bingeeating disorder. Psychiatry Research, 119, Gadalla, T. M. (2008). Psychiatric comorbidity in eating disorders: A comparison of men and women. Journal of Men s Health, 5(3),

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