More and more teenagers have eating disorders. Two experts discuss why.


For decades, eating disorders were thought to primarily, if not exclusively, affect women and girls. In fact, until 2013, loss of menstruation was long considered an official symptom of anorexia nervosa.

However, over the past decade, health experts have increasingly recognized that boys and men also suffer from eating disorders and have gained a better understanding of how differently the illness presents in that group. A small but growing group of scientists and doctors have dedicated themselves to identifying the problem, assessing its extent and developing treatments.

Recently, two of these experts spoke with The New York Times about how the disease is affecting adolescent boys, what symptoms and behaviors parents should look for, and what treatments to consider. Dr. Jason Nagata is a pediatrician at the University of California, San Francisco who specializes in eating disorders; He is senior editor of the Journal of Eating Disorders and editor of the book “Eating disorders in boys and men.Dr. Sarah Smith is a child and adolescent psychiatrist at the University of Toronto specializing in eating disorders; she was the main author of a study published in JAMA Open Network in December that showed sharp increases in hospitalization rates for children with eating disorders.

The conversation has been condensed and edited for clarity.

The medical and scientific understanding of eating disorders is changing and expanding. What happened?

Dr. Smith: Historically, eating disorders have been conceptualized primarily as anorexia, which has been described as an illness of adolescent women who want to lose weight for aesthetic reasons.

Dr. Nagata: There is increasing recognition, especially in the last decade, that some people with body image dissatisfaction do not try to lose weight at all. Some men and boys They are trying to get big and muscular. In fact, one-third of teenagers in the United States report that they are trying to bulk up and become more muscular. And a subset of them may develop eating disorders or muscle dysmorphia that can lead to significant psychological distress and physical health complications.

What is muscle dysmorphia?

Dr. Nagata: Also known as bigorexia or reverse anorexia, it is a disorder in which someone thinks their body is weak or not muscular enough, even if objectively other people would consider them fit or athletic.

Dr. Smith: It may be because they want to be in better shape for hockey, or because they want to be more muscular or “cut” from an appearance standpoint. The motivation that might guide these behaviors may not align with being thinner, but we still see very similar behaviors. We see the obsessive exercise. We see eliminating certain types of foods. We see a marked dietary restriction. And then there are those who choke or vomit, are afraid of it or have always been picky eaters and fall off their growth curve. And because children and teens grow and develop so quickly, those changes can lead to some pretty serious medical complications.

These complications can lead to a state of starvation. What does that mean?

Dr. Smith: It is a mismatch between a person’s energy or nutrient needs and what they are actually putting into their body.

Dr. Nagata: When your body constantly exerts more energy than it absorbs, that can lead to a state of starvation in which your vital organs begin to shut down because they don’t have enough energy to sustain themselves. And I think there’s not enough recognition that starvation can occur among people who exercise too much without getting enough nutrition.

So is there an overlap between children and athletics?

Dr. Smith: Yes absolutely. I think kids who are athletes are at higher risk for eating disorders because, to some extent, some of these behaviors are normalized in competitive sports.

Dr. Smith: When it comes to the relationship between overexercising, undereating, and physical consequences among athletes with eating disorders, we actually have a term called the “female athlete triad.”

What are the components of the feminine triad?

Dr. Smith: Weight loss, changes in bone density, and amenorrhea, which is when women do not menstruate. It’s another example of our gender bias and how we approach this disease.

Dr. Smith, you have done some of the most up-to-date research on eating disorders, including the finding that eating disorders severely affect children.

Dr. Smith: I looked at more than 11,000 hospitalizations in Ontario for eating disorders among children and adolescents aged 5 to 17 between 2002 and 2019. What I found was that while hospitalization rates increased overall by 139 per cent, the largest relative increase was occurred among men: their rate of hospitalizations increased by 416 percent. Common causes of hospitalization would include indications such as very low heart rate, abnormal blood mineral markers, or suicidal ideation.

To what extent does your research in Canada suggest what is happening in the United States?

Dr. Nagata: I imagine our tendencies are quite similar. Have a recent study which focused on children who were hospitalized for eating disorders in the United States. We found that compared to hospitalized girls, boys actually have more serious medical complications. Boys have longer hospital stays, greater heart rhythm abnormalities, and higher rates of anemia than girls. This may partly reflect that children are often identified or diagnosed later.

What do you think is responsible for the increasing incidence of eating disorders and hospitalizations among children?

Dr. Nagata: There is a genetic component, a biological component and there are also social and environmental factors. Overall, one of the biggest changes has been the advent of social media, where young people not only consume body ideals from the media, but also feel pressure to produce content and display their own bodies on social media. And I think that has added a lot of pressure.

When you meet a teenager with an eating disorder, do you recognize their behavior as unhealthy?

Dr. Smith: More often than not, eating disorders tend to be characterized by a lack of insight. Young people do not appreciate the risks of the behaviors they adopt. Often, they come for care because their parents, teachers, coaches, or other people worry first. I’ve had young people with heart monitors argue with me and tell me that they’re not that bad, that they’re not that skinny, and that we all overreact around them.

As parents, we try to encourage healthy eating and physical exercise, and we try to compensate for excessive screen time. How can we know when fitness has gone too far?

Dr. Nagata: For people who develop eating disorders or muscle dysmorphia, exercise can be taken to the extreme and cause more worry than enjoyment. So to me, the red flags for parents are if your child starts to obsess or worry about the gym and fitness in a way that makes their social life, school functioning, and daily functioning worse. Those are cases where excessive exercise can fall into the world of disorder.

What advice do you have for parents who fear their child may have a problem?

Dr. Smith: The challenge with eating disorders is that we know that the longer the problem goes untreated, the worse the outcome will be. There is a natural inclination to not be intrusive or risk making things worse, but I think the sooner parents respond, the better. The risks of overreacting are small given the very real risks of eating disorders. I would recommend that parents contact their primary care provider. I also think that if parents want to learn more, there are good resources online.

Dr. Nagata: Primary care is often the best place to start, because they can perform an initial evaluation and examination, check vital signs and laboratory tests, and then provide appropriate treatment and necessary referrals. The most common reasons for referral we receive at our eating disorder clinic are a primary care doctor who visits an adolescent for their regular checkup and notices a significant change in weight or vital signs or unstable labs.

What else would you add?

Dr. Nagata: We need to raise awareness about eating disorders and body image issues in children because they have traditionally been underrecognized, underdiagnosed, and undertreated. I think it’s also important to note that eating disorders can affect people of all genders, races, sexual orientations, ages, and sizes.

Dr. Smith: Optimistically, with access to evidence-based treatment (the sooner the better), people can recover. Although it is a horrible disease, there is hope in this journey.

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