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Counseling Men With Eating Disorders

By Karen Giles-Smith, MS, RD

Boys and men often have issues with eating, weight, and body image, which can lead to eating disorders. Here’s what to look for in your patients and tips on where to go from there.

When people think of eating disorders, more than likely they conjure images of teenage girls or young women who are struggling with a poor body image. But as you probably know, eating disorders affect almost as many males as females.

The first national survey of individuals with eating disorders found that 0.9% of women and 0.3% of men reported having anorexia nervosa at some point in their lives; 1.5% of women and 0.5% of men had bulimia nervosa; and 3.5% of women and 2% of men had binge-eating disorder.1

The same study indicates that over the past 20 years, the number of men diagnosed with eating disorders has more than doubled. “In the past, about 10% of those with anorexia nervosa and bulimia were men,” says Christopher Clark, executive director of the National Association for Males With Eating Disorders. “Since 2000, it’s increased to 25%.”

With society’s emphasis on a thinner, fitter male physique—think six-pack abs—boys and men may experience pressure to obtain the “perfect body” that has plagued women for years. “Men and women can be equally dissatisfied with their bodies,” Clark says. “Whereas most women who are dissatisfied with their bodies want to lose weight, about half of the men who are dissatisfied with their bodies want to lose weight and about half want to gain weight.”

Research suggests that men are increasingly receiving media messages about dieting, a muscular “ideal,” and plastic surgery options such as pectoral and calf implants.2-4 “Men are receiving more media messages about bulking-up products and also dieting products,” Clark says. 

In May 2010, New York Magazine reported on a mannequin designer who’s creating male forms that are far from realistic: The mannequins have 27-inch waists, whereas the average waist size of the American male in 2006 was 39.7 inches.

Risk Factors
Experts believe messages from the media can trigger an eating disorder in those who are susceptible. “For an eating disorder to develop, there must be a predisposition  and something that triggers it,” says Melanie Jacob, RD, CSSD, a private practitioner  in Troy, Michigan, and coauthor of The Academy of Nutrition and Dietetics’ (the  Academy) practice paper on eating disorders.5 "Not everyone exposed to media images of thin ideals or bulked up male bodies will get an eating disorder. Some are predisposed with certain personality and temperament traits, such as being perfectionistic or rule-based. They are more vulnerable especially if they have co-occuring depression, anxiety or compulsive disorders. We now know that genetics contributes to the risk of getting an eating disorder - it loads the gun. Then, the trigger may be an event or situation like the desire to be healthy,  the desire to look a certain way, being teased, or anything that causes  inadequate nutrition like losing too much weight.”

Overlooked and Undertreated
Often, parents, coaches, and doctors overlook eating disorders in boys and young adult men. “It can look like they’re doing fine, working hard, and being dedicated because [males usually] become more focused and dedicated to schoolwork and sports,” Jacob says. In addition, men may not recognize their symptoms or may be reluctant to seek professional help. Boys often are taught to hide feelings of fear, uncertainty, and sadness, Jacob says. “And there’s the stigma that eating disorders are a female problem.”

Jessica Setnick, MS, RD, CSSD, CEDRD, an eating disorders specialist with a private practice in Dallas and the education and training director of Ranch 2300 Collegiate Eating Disorders Treatment Program, agrees: “It’s a mistake to think it’s a women’s problem or limited to any demographic. Eating disorders don’t discriminate, but people do—accidentally. When a 16-year-old boy loses 20 lbs, people think of Crohn’s disease or HIV but not an eating disorder. There are just as many men with eating disorders as women. Men just fly under the radar.”

According to the Academy’s position paper on eating disorders, “Eating disorders require early diagnosis and immediate and effective treatment. Current research shows that the sooner eating disorder behaviors are stopped and nutrition and physical health restored the better the prognosis and the better a person responds to psychotherapy.”6

Only one in 10 people with eating disorders receive treatment.7 “And males with eating disorders surely are an underserved group,” Jacob adds.

Signs and Symptoms
Because boys and men often are overlooked and underdiagnosed, it’s important for RDs to know the signs and symptoms. “Sometimes eating disorders in males look more like body dysmorphia or body dissatisfaction,” Setnick says. “There are two extremes in the spectrum: slender or very muscular—with possible eating issues and steroid use. Also, binge eating in males often is undetected because they have a higher metabolism, and it takes a long time to become significantly overweight. So many males with eating disorders appear to be a normal weight as well.”

“Males are more apt to present as compulsive exercisers,” adds Molly Kellogg, RD, LCSW, a psychotherapist and nutritionist in private practice in Philadelphia and a motivational interviewing trainer. “And that gets mixed up with sports and obsessive compulsive disorder. Watch for weight that goes up and down a lot. If a boy or man is heavy, often they’ll do something radical with food or exercise, lose the weight, and then regain it.”

Of note is that eating disorders may occur without obvious signs and symptoms.8

Making Referrals
If you suspect a client has an eating disorder after taking a thorough patient history, “spend a few minutes exploring what’s going on from the patient’s point of view,” Kellogg says. “Look for what the person wants and needs, and ask permission to provide information. Explain that eating disorders is an area of specialty, and you want them to get the very best care.”

“Know in advance who to refer the patient to; be more aware of the signs, and be more proactive,” Setnick says. “If you see what you think are signs of an eating disorder, gently ask the patient if they’ve considered that perhaps they have an eating disorder.”

Jacob says dietitians are trained to identify warning signs of eating disorders, but they’re not in a position to diagnose. So it’s a good idea to refer clients you believe may have an eating disorder to a therapist for a full psychological assessment and treatment plan. “Ideally, these therapists should be a part of the Academy for Eating Disorders (www.aedweb.org).”

After reviewing a therapist’s feedback, Jacob recommends RDs decide whether to refer to another RD or to become part of the treatment team based on a self-evaluation of knowledge and skills.

Tough Nut to Crack
According to the Academy’s practice paper, eating disorders are one of the toughest illnesses to treat. The practice paper states, “RDs need to pursue advanced training, mentoring, case consultation, and supervision in order to be effective in treating this population.”5

“RDs need to understand eating disorders,” Setnick says. “Although [they] don’t have to specialize in eating disorders in order to work with these patients, RDs must work with a good treatment team and get support from others working in this area.”

Kellogg says “because it’s a challenging area and you work with patients long term, most RDs soon discover the need to also be well-trained in counseling.”

“There’s a lack of training and inconsistencies in training in eating disorders for RDs,” Jacob says. “But initiatives to develop protocols for advanced training, mentoring, and certification are in process.”

— Karen Giles-Smith, MS, RD, is a freelance writer and Certified Wellcoach


Requirements for Success

RDs who want to counsel clients with eating disorders or who are already doing so require specialized training and must call on the assistance and expertise of other qualified health professionals. The following are examples of what dietitians should do:

• Seek ongoing supervision with a clinical psychologist trained in eating disorders.

• Learn how to work with a treatment team that includes a therapist who specializes in eating disorders, a physician, and possibly a psychiatrist.

• Posses maturity, good clinical judgment, and good counseling skills.

• Understand effective interventions with and without a meal plan.

• Recognize symptoms of malnutrition (physical, behavioral, and emotional) and refeeding.

• Identify the effects of laxative and diuretic abuse and purging on the body and metabolism.

• Understand metabolic rate and everything that affects it.

• Be aware of food myths and misinformation.

• Assess dehydration and fluid shifts associated with refeeding and reducing purging.

• Learn about the role of exercise and recovery.

• Be able to adjust the treatment plan based on the patient’s age, stage of illness, and severity of symptoms.


ADA Pocket Guide to Eating Disorders by Jessica Setnick, MS, RD, CSSD

• “American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Disordered Eating and Eating Disorders (DE and ED)” in the Journal of the American Dietetic Association, August 2011

• Eating Disorders Boot Camp and Advanced Eating Disorders Boot Camp (www.understandingnutrition.com)

Eating Disorders: Critical Points for Early Recognition and Medical Risk Management in the Care of Individuals With Eating Disorders by the Academy for Eating Disorders, May 2011

• International Association of Eating Disorder Professionals (www.iaedp.com), which provides certification in eating disorders for RDs (CEDRD credential)

• “Nutrition Intervention in the Treatment of Eating Disorders” — Position and Practice Papers of the American Dietetic Association (now the Academy of Nutrition and Dietetics)

• The Renfrew Center Foundation Annual Conference for Professionals in Philadelphia (www.renfrewcenter.com)


1. Hudson JI, Hiripi E, Pope HG, Jr Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61(3):348-358.

2. Agliata D, Tantleff-Dunn S, The impact of media exposure on males’ body image. J Soc Clin Psychol. 2004;23(1):7-22.

3. Derenne J, Beresin EV. Body image, media, and eating disorders. Acad Psychiatry. 2006;30(3):257-261.

4. Harvey JA, Robinson JD. Eating disorders in men: current considerations. J Clin Psychol Med Settings. 2003;10(4):297-306.

5. Waterhous TS, Jacob MA. American Dietetic Association practice paper: Nutrition intervention in the treatment of eating disorders. Academy of Nutrition and Dietetics website.  http://www.eatright.org/Members/content.aspx?id=6442464620. August 2011.

6. Ozier AD, Henry BW. American Dietetic Association. Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011;111(8):1236-1241.

7. Noordenbos G, Oldenhave A, Muschter J, Terpstra N. Characteristics and treatment of patients with chronic eating disorders. Eat Disord. 2002;10(1):15-29.

8. Eating Disorders: Critical Points for Early Recognition and Medical Risk Management in the Care of Individuals With Eating Disorders, 2nd ed. Academy for Eating Disorders website. http://www.aedweb.org/AM/Template.cfm?Section=Medical_Care_Standards&Template
. May 2011.