Johnny, a 16-year-old male wrestler, was referred to our eating disorders clinic. When asked about the “typical” disordered eating behaviors for weight loss –including fasting, restricting, vomiting, or diuretics — he denied all of them. However, his parents reported that he was obsessed with his appearance in pursuit of becoming muscular. He ate 2000 calories of mainly protein and tried to eliminate fats and carbohydrates from his diet, which mainly consisted of egg whites, whey protein powder, and protein shakes. In addition to varsity wrestling practice two hours per day, he went to the gym to weightlift three more hours per day. Johnny had been experiencing these symptoms for nine months before anyone noticed he was struggling and needed help.

Although many people assume that body dissatisfaction and eating disorders only affect girls and women, Johnny’s story highlights unique pressures that boys and men face. While feminine gender norms and body ideals may lead to pressures for girls and women to lose weight and become thin, masculine gender norms and body ideals may lead to pressures for boys and men to bulk up and become muscular. In fact, a third of teenage boys report trying to gain weight while a quarter report engagement in muscle-building behaviours to achieve these goals.

Pressures stemming from the masculine body ideal can come from peers, families, and the media. This idealized masculine body type is increasingly muscular. Over the past several decades, superheroes in movies and children’s action figures have become increasingly muscular. Further, social media has led to unique appearance pressures for boys and men. Most male body image-related content on social media depicts muscularity and leanness. Male selfies are more likely to show muscles than female selfies. Thus, Instagram use in boys and men may lead to body dissatisfaction, disordered eating behaviours, and use of anabolic steroids. When taken to the extreme, the obsessive pursuit of muscularity can lead to muscle dysmorphia, also known as “bigorexia” or “reverse anorexia,” which is characterized by a preoccupation with insufficient muscularity.

In order to achieve the muscular body ideal, boys and men may engage in muscle-building behaviours, such as excessive exercise and protein overconsumption while limiting intake of carbs and fats. Boys and men can also use appearance and performance-enhancing drugs and supplements including anabolic steroids, creatine, and protein supplements.

Boys and men may also develop the classic eating disorders, such as anorexia nervosa, which is characterized by one believing they are too fat and engaging in unhealthy weight loss behaviours like fasting, skipping meals, vomiting, or using diuretics or diet pills to lose weight. Eating disorders can lead to significant psychological and physical health consequences. When one enters a starvation state, their vital organs can be compromised, leading to dangerous changes in one’s heart rate, blood pressure, liver function, bone health, and many other complications. Unfortunately, eating disorders are often missed in boys and men due to lack of recognition, research, and guidance in these populations.

Warning signs for an eating disorder include when someone becomes preoccupied or obsessed with their weight, appearance, food, or exercise in a way that worsens their quality of life. People experiencing eating disorders may withdraw from activities they normally enjoy due to these concerns with their appearance or behaviours to control their weight. If you or a loved one experiences any of these symptoms, please seek help from a medical or mental health professional.

Additional Resources and Readings

Jason Nagata, MD, MSc, is an Assistant Professor of Pediatrics at the University of California, San Francisco, specialising in adolescent and young adult medicine. He researches eating disorders, body image, and muscle-enhancing behaviours in boys, men, and LGBTQ+ people. He edited the book Eating Disorders in Boys and Men. 

He has published over 200 articles in academic journals, including JAMA and The Lancet, and his research has been covered by The New York Times, CNN, NPR, NBC, ABC, and CBS News. He co-founded the International Association for Adolescent Health Young Professionals Network. He is the recipient of the American Academy of Pediatrics Emerging Leader in Adolescent Health Award and the International Association for Adolescent Health Young Professionals Prize.

Twitter: @jasonmnagata.