The enigma of male eating disorders: A critical review and synthesis

Attentional Biases Towards Body-Related Stimuli in Healthy Males: A Systematic Review

Recent literature has discussed the role of attentional biases towards body-related stimuli. Specific foci have been on those with high levels of body image concerns and female samples. Unfortunately, there has been limited focus on male samples within existing literature. The aim of the current study was to provide a critical synthesis of the findings of existing studies exploring attentional biases in adult males towards body-related stimuli. Critical synthesis of the findings of 20 studies explored four key methodologies: eye-tracking, dot-probe, visual search, and other methodologies (e.g. ARDPEI task). The current review provides evidence of specific attentional biases towards body-related stimuli in adult males experiencing body image concerns. Similar patterns of attentional biases are also demonstrated in males with body image pathologies. However, there appears to be distinct patterns of attentional biases for male and female participants. It is recommended that future research considers these findings and utilises measures developed specifically for male samples. Furthermore, additional variables require further attention, i.e. reasons for engaging in social comparison and/or engaging in physical activity.

Eating disorders among an online sample of Canadian and American boys and men

There is a continued need to identify the prevalence and sociodemographic correlates of eating disorders, particularly among the under-researched group of boys and men, to inform prevention and intervention efforts. Data from The Study of Boys and Men, a sample of 1553 boys and men aged between 15 and 35 years in Canada and the United States, were analyzed in 2024. Probable eating disorder diagnoses were identified using a previously established algorithm based on current diagnostic criteria. A multivariable logistic regression analysis was used to determine the sociodemographic correlates of meeting the criteria for any probable eating disorder diagnosis. The prevalence of meeting the criteria for any probable eating disorder diagnosis was 21.3 % (95 % confidence interval [CI] 18.7-24.1), while meeting criteria for a probable bulimia nervosa diagnosis had the highest prevalence (5.8 %, 95 % CI 4.6-7.1) and anorexia nervosa had the lowest prevalence (0.34 %, 95 % CI 0.1-0.8). Boys and men who identified as gay (adjusted odds ratio [AOR] 2.28, 95 % CI 1.35-3.85) or bisexual (AOR 2.22, 95 % CI 1.23-3.99) had higher odds of meeting criteria for any probable eating disorder diagnosis, compared to those who did not. Finally, boys and men who had a higher body mass index (BMI) (AOR 1.18, 95 % CI 1.14-1.23) had greater odds of meeting criteria for any probable eating disorder diagnosis. Findings add to the growing understanding of eating disorders among boys and men. Targeted and tailored prevention and intervention programming is needed for sexual minority boys and men, and those with higher BMIs.

Introducing Diagnostic Classification Modeling as an Unsupervised Method for Screening Probable Eating Disorders

Screening for eating disorders (EDs) is an essential part of the prevention and intervention of EDs. Traditional screening methods mostly rely on predefined cutoff scores which have limitations of generalizability and may produce biased results when the cutoff scores are used in populations where the instruments or cutoff scores have not been validated. Compared to the traditional cutoff score approach, the diagnostic classification modeling (DCM) approach can provide psychometric and classification information simultaneously and has been used for diagnosing mental disorders. In the present study, we introduce DCM as an innovative and alternative approach to screening individuals at risk of EDs. To illustrate the practical utility of DCM, we provide two examples: one involving the application of DCM to examine probable ED status from the 12-item Short form of the Eating Disorder Examination-Questionnaire (EDE-QS) to screen probable thinness-oriented EDs and the Muscularity-Oriented Eating Test (MOET) to screen probable muscularity-oriented EDs.

Examining Longitudinal Relations Between Eating Disorder Symptoms and Negative Emotion Variability in Military Members

Up to a third of service members and Veterans experience disordered eating. Disordered eating can be maintained through negative reinforcement of painful and unpleasant emotions such as guilt, shame, sadness, and hostility. Hostility is a negative emotion that may be particularly relevant for service members and Veterans, yet hostility's relation to disordered eating remains understudied. Further, variability in emotions may be particularly relevant, given that variability in emotions is often a stronger predictor of psychopathology than mean levels. Thus, the goal of the present study was to assess a potential bidirectional relationship between disordered eating symptoms and individuals' variability of hostility, stress, anxiety, sadness, and shame. Participants (N = 94, Mage = 32.2, 75.8% men; 81.8% White) completed 30 days of ecological momentary assessment (EMA) with four assessments per day along with baseline and follow-up measures including the Eating Pathology Symptom Interview (EPSI), which assessed eight disordered eating symptom domains. Hierarchical regressions revealed that higher baseline levels of Binge Eating and Excessive Exercise predicted greater intraindividual hostility variability. Further, more hostility variability predicted higher Cognitive Restraint at 1-month follow-up. Baseline disordered eating symptoms were not associated with intraindividual variability in stress, anxiety, sadness, or shame. However, greater intraindividual variability in shame predicted higher Muscle Building at 1-month follow-up. Hostility variability was the only emotion that was predicted by, and predictive of, disordered eating symptoms. These findings suggest that hostility may be a relevant treatment target for service members with disordered eating.

Prevalence and correlates of muscle dysmorphia in a sample of boys and men in Canada and the United States

BACKGROUND

Muscle dysmorphia is a significant mental health condition that has been under-researched in epidemiological, community-based studies. Therefore, this study aimed to identify the prevalence and correlates of probable muscle dysmorphia among a sample of Canadian (n = 784) and American (n = 563) boys and men ages 15-35 years.

METHODS

The sample comprised 1,488 boys and men who completed a variety of measures and items to capture sociodemographic characteristics and muscle dysmorphia symptoms. Diagnostic criteria were applied to identify probable muscle dysmorphia among the sample. Unadjusted (e.g., chi-square tests, independent samples t-tests) and adjusted (e.g., logistic regression) analyses were used to determine the sociodemographic factors (e.g., age, body mass index, gender, race/ethnicity, sexual orientation, education, relationship status, and country) associated with cases of probable muscle dysmorphia.

RESULTS

The prevalence of probable muscle dysmorphia was 2.8% (95% confidence interval 2.0-3.7%). Aside from lower body mass index among those with probable muscle dysmorphia, there were no significant demographic differences between those with and without probable muscle dysmorphia across ages, genders, races/ethnicities, and sexual orientations. Those with probable muscle dysmorphia had significantly higher scores on standardized measures of muscle dysmorphia symptomatology and muscularity-oriented attitudes and behaviors compared to those without probable muscle dysmorphia.

CONCLUSIONS

Findings underscore that muscle dysmorphia may be more prevalent among boys and men in Canada and the United States than previously thought, highlighting the need for more research, prevention, assessment, and intervention efforts. The minimal differences across sociodemographic factors are notable, highlighting the need for an inclusive understanding of muscle dysmorphia.

Muscularity Concerns and Disordered Eating Symptoms in Adult Women: A Network Analysis

This study examined the role of muscularity concerns in eating disorder (ED) symptoms among a sample of women. We expanded on previous research by exploring a broader range of ED symptoms, including orthorexia (ON) and avoidant/restrictive food intake disorder (ARFID). Using network analysis, we analysed data from 308 adult women (18 years or older) who completed muscularity, disordered eating, and sociodemographic assessments. Our findings revealed five interconnected symptom communities reflecting traditional ED symptoms, such as eating concerns and shape and weight overvaluation. Notably, muscularity concerns emerged as a distinct community, emphasising their relevance to ED symptoms in women. Additionally, we identified selective eating tendencies and compulsive healthy eating. Highly central symptoms were rumination about healthy eating, fear and guilt over unhealthy eating, body-related embarrassment, and muscularity concerns (wishing to be heavier, wishing for heavier arms). These results suggest that muscularity concerns could constitute a uniquely identifiable and central diagnostic target for body image concerns and disordered eating in women.

Athletes with eating disorders: clinical-psychopathological features and gender differences

BACKGROUND

Eating disorders (EDs) in the athlete population are often discussed in terms of comparing with non-athlete samples, however little is known regarding their gender clinical differences. Therefore, this study aimed to compare clinical and psychopathological features among athletes with an eating disorder (ED+A), non-athletes with an eating disorder (ED-A) and healthy controls (HCs), in addition to observing gender differences.

METHODS

The sample consisted of 192 participants, all were age and gender matched, ED+A n = 64, ED-A n = 64 and HCs n = 64, with each group consisting of 50 females and 14 males. And each participant completed a face-to-face interview and various self-report questionnaires regarding personality traits (Temperament and Character Inventory-Revised), eating (Eating Disorder Inventory - 2) and general psychopathology (Symptom Checklist 90 - Revised), as well as relevant clinical indexes (lifetime suicidal attempts/ideation and sport activities conducted).

RESULTS

In the ED+A group females had significantly higher eating and general psychopathology compared to males, especially body dissatisfaction (BD) and drive for thinness (DT) (p <.001). Overall, ED+A males had the lowest BD across the 3 groups. In terms of personality traits, ED+A females had significantly higher harm avoidance and lower self-directedness compared to their male counterparts. Lastly, suicidal ideation was significantly higher in ED+A females compared to males.

CONCLUSIONS

These results suggest that it may be imperative to better understand the risk factors in the athletic realm which may lead to the development of EDs, and which factors may be protective as well. It may also be helpful to encourage trainers to include preventive and screening strategies for athletes.

Social epidemiology of early adolescent nutrition

BACKGROUND

This study aimed to investigate associations between sociodemographic factors and dietary intake among a diverse population of early adolescents ages 10-13 years in the United States.

METHODS

We examined data from the Adolescent Brain Cognitive Development (ABCD) Study in Year 2 (2018-2020, ages 10-13 years, N = 10,280). Multivariable linear regression models were conducted to estimate the adjusted associations between sociodemographic factors (age, sex, race and ethnicity, household income, parental education) and dietary intake of various food groups, measured by the Block Kids Food Screener.

RESULTS

Older age among early adolescents was associated with slightly less fruit, whole grain, and dairy and more monounsaturated fat consumption. Male sex was associated with a lower intake of fruit, fruit juice, vegetables, whole grains, and fiber and a higher intake of meat/poultry/fish, added sugars, fat, as well as higher glycemic index and glycemic load compared to female sex. Racial and ethnic minority status, lower household income, and lower parental education were generally associated with less fruit and vegetable consumption and more added sugars.

CONCLUSION

These findings can guide public health interventions to reduce diet quality disparities by targeting key populations and addressing differences according to socioeconomic status, sex, and race.

IMPACT

Sociodemographic disparities in diet quality have been studied, but none have explored sociodemographic associations with specific food groups and components (e.g., different types of fat) in early adolescence. In this demographically diverse sample of 10-13-year-old early adolescents in the US, we found sociodemographic disparities in dietary intake across various food groups. Most notably, male sex, racial and ethnic minority status, lower household income, and lower parental education were associated with less fruit and vegetable consumption and more added sugars.

Disabilities and eating disorders: A theoretical model and call for research

OBJECTIVE

There is an urgent need for research on eating disorders among individuals with disabilities. This paper highlights the lack of research on the relationships between disabilities and EDs, despite their common convergence.

METHOD

In this paper, we aim to 1) highlight the need for further research investigating the relationships between disability status and EDs, 2) describe existing frameworks for conceptualizing disability, 3) utilize such frameworks to propose a novel theoretical model of ED/disability relationships and related sociocultural factors and 4) identify future directions for research in this area.

RESULTS

We propose a multidimensional theoretical model of the relationships between EDs and disabilities. Further, we describe how these relationships are likely influenced by a system of individual factors (e.g., disability (in)visibility, food access, and self-identification) and sociocultural factors (e.g., ableism/discrimination and weight stigma).

DISCUSSION

Scholars are encouraged to test our proposed model and further investigate experiences of disability and ED co-occurrence with participatory research and mixed-methods designs. ED prevention and screening programs, as well as treatment access and efficacy, need to be evaluated for disabled populations. Disability should also be routinely collected as a demographic across studies, and ED measures should be validated and/or developed for individuals with disabilities.

Measuring disordered eating in adolescent boys: a systematic literature review

PURPOSE

The aim of this study was to map which instruments are currently being used to measure disordered eating in adolescent boys as part of a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis.

METHOD

Utilizing the PRISMA review protocol, 174 journal articles were reviewed.

RESULTS

Sixty-seven articles used versions of the Eating Attitudes Test to measure adolescent boys' disordered eating, 32 used versions of the Eating Disorder Examination-Questionnaire, 30 used versions of the Eating Disorder Inventory, 25 used SCOFF, and 10 used the Drive for Muscularity Scale. A plethora of other instruments for measuring disordered eating were utilized as well.

CONCLUSION

Studying adolescent boys' disordered eating by using instruments primarily developed and validated for girls may provide unreliable estimates of the numbers of boys who suffer from disordered eating, which would preclude early intervention. One strength of the reviewed studies was that several used multiple measurements to validate their results. One of the weaknesses was the lack of distinguishing genders among certain groups, such as athletes or patients. Among the opportunities identified was the possibility of expanding on research on the association between puberty and disordered eating, with sports and parents potentially acting as buffers against the onset of disordered eating. A clear threat to research on disordered eating among adolescent boys was the (in)accuracy of the measurements.

The role of negative evaluation fears on associations between societal appearance pressures and disordered eating in university students

Objective: Previous research demonstrates that sociocultural appearance pressures and internalization of appearance ideals lead to disordered eating (DE); however, only a subset of individuals exposed to these influences develop clinically significant DE. Identifying moderators of these associations may increase efficacy of targeted preventions for eating disorders. This study investigated whether the fear of negative evaluation (FNE) moderates these associations. Participants: 567 university students participated between November 2019 and 2020. Methods: Participants completed self-report questionnaires assessing appearance pressures, internalization of appearance ideals, FNE, and DE. Results: There was a significant interaction between appearance pressures and FNE in relation to DE. Individuals with high appearance pressures and high FNE had the highest levels of DE. The interaction between internalization of appearance ideals and FNE did not significantly contribute to DE. Conclusions: Eating disorder prevention programs that address FNE and appearance pressures may have beneficial effects, particularly for university students with heightened FNE.

Investigating the structure of disordered eating symptoms in adult men: A network analysis

OBJECTIVE

Eating disorders (EDs) increasingly emerge as a health risk in men, but there is concern that men's symptoms go unnoticed due to stereotypical perceptions and gender-related differences in symptom presentation. Novel assessments focused particularly on attitudes and behaviours towards increasing muscle size and definition. Using network analysis, this study aimed to corroborate and extend previous findings on disordered eating presentation in men by examining the role of muscularity concerns among an extended range of disordered eating symptoms.

METHOD

N = 294 adult men (18 years or older) completed muscularity-related and disordered eating assessments, among which we included assessments for orthorexic eating and Avoidant/Restrictive Food Intake Disorder for the first time. We selected symptoms empirically, estimated a regularised network, identified symptom communities, evaluated network loadings and bridge centrality estimates, and compared network structures between different groups of participants.

RESULTS

We identified five symptom communities related to muscularity-related concerns, features of core ED psychopathology, and selective eating. Symptoms regarding ruminating about healthy eating, guilt for unhealthy eating, weight overvaluation, concerns about muscularity, and selective eating emerged as highly central.

DISCUSSION

The results largely corroborate previous observations but suggest that muscle-building behaviours are part of a broader cluster of male body shaping and rule-based dieting behaviours.

Low Overlap and High Heterogeneity Across Common Measures of Eating Disorder Pathology: A Content Analysis

This study evaluated symptoms assessed in common measures of eating disorder pathology and tested overlap to evaluate the extent to which measures may be interchangeable. Six measures were included: Bulimia Test-Revised, Eating Attitudes Test-26, Eating Disorder Diagnostic Scale, Eating Disorder Examination Questionnaire, Eating Pathology Symptoms Inventory, and Questionnaire for Eating Disorder Diagnoses. Content overlap was quantitatively estimated using the Jaccard Index. Mean overlap was low (.195), likely due to the wide range of symptoms (87) assessed. The mean overlap of each measure with all others was .117 - .267, and the overlap among individual measures was .083 - .382. Implications of low overlap among measures include variable characterization of eating disorder phenotypes and the risk for lower generalizability of findings due to measurement variability.

Alcohol use disorder, cannabis use disorder, and eating disorder symptoms among male and female college students

BACKGROUND AND OBJECTIVES

Eating disorders (EDs) and substance use disorders are prevalent among college students in the United States, with underlying common mechanisms suggesting co-occurrence of these in the student population. As treatment prognosis of EDs improves when they are identified and treated with early intervention, it is essential to understand which substance use behaviors associate with EDs in students.

METHODS

Using a sample of 471 college students recruited for a study on high risk drinking (i.e., students needed to pregame regularly to be included), we explored the associations between ED symptomatology and two common substances used in this population: alcohol and cannabis. As most research on EDs focuses on female students only or does not separate out males and females, we examined whether sex assigned at birth moderated the association between ED symptomatology and substance use outcomes.

RESULTS

About one-third (32.4%) of the sample screened positive for an ED, with females significantly more likely to screen positive. Males were significantly more likely to screen positive for an alcohol or cannabis use disorder. Screening positive for an ED associated with cannabis use frequency and cannabis use disorder symptoms, but not with alcohol outcomes. Sex moderated the association between ED and cannabis use disorder symptoms, with positive ED screen male students experiencing the highest cannabis use disorder symptoms.

DISCUSSION AND CONCLUSIONS

It is necessary to further assess how sex differences in substance use and ED symptomatology inform each other.

SCIENTIFIC SIGNIFICANCE

Findings underscore the need to assess and screen for cannabis use disorder among students who screen positive for an ED, and, more specifically, with focused attention on male students with ED symptoms.

Cognitive restraint and body dissatisfaction are more strongly related to muscle building behaviors for men than women

Muscle building behaviors are an understudied eating disorder (ED) symptom increasing in prevalence, especially among men. However, little is known about the cognitive ED correlates that may underlie muscle building behaviors and whether these associations differ by gender. We examined associations between cognitive ED symptoms and muscle building behaviors, and whether these associations differ between men and women. In a sample of college students (N = 258), we investigated cross-sectional associations between two core cognitive ED symptoms, body dissatisfaction and cognitive restraint, with muscle building behaviors, and whether binary gender moderated these associations. Data were analyzed using two linear regression models in which muscle building behaviors was entered as the outcome variable. In Model 1, body dissatisfaction, BMI, gender, and the interaction term of body dissatisfaction by gender were entered as predictors. In Model 2, cognitive restraint, BMI, gender, and the interaction term of cognitive restraint by gender were entered as predictors. Results of Model 1 indicated that muscle building behaviors were significantly and independently associated with body dissatisfaction and gender and the association between muscle building and body dissatisfaction was stronger for men. Results of Model 2 indicated that muscle building behaviors were significantly and independently associated with cognitive restraint and gender and the association between muscle building and cognitive restraint was stronger for men. Findings suggest that cognitive restraint and body dissatisfaction may be important prevention and intervention targets for maladaptive muscle building behaviors, particularly among men.

Impact of out-of-home nutrition labelling on people with eating disorders: a systematic review and meta-synthesis

Objectives

Mandatory nutrition labels for out-of-home food consumption have been introduced in several countries to curb rising obesity levels. However, concerns have been raised about the potential negative impacts of such policies on individuals with eating disorders. This review aimed to summarise the literature on the impact of out-of-home nutrition labels on individuals with eating disorders or disordered eating.

Design

A systematic search across eight databases was conducted on 11 October 2023.

Data sources

MEDLINE, EMBASE, APA PsycINFO, Web of Science, ProQuest Dissertations and Theses Global, Scopus and CINAHL. Unpublished studies were searched for on Google Scholar and PsyArXiv.

Eligibility criteria

Studies were included if they assessed the impact of out-of-home nutrition labelling policies on individuals with eating disorders or disordered eating.

Data extraction and synthesis

538 studies were screened, of which 16 studies met inclusion criteria.

Results

The reviewed studies included five experimental/quasi-experimental studies, five cross-sectional studies and six qualitative/mixed-methods studies. Across studies, eating disorder pathology was associated with noticing labels more frequently, paying more attention to caloric intake and more frequent behaviour changes due to caloric values. The metasynthesis identified five themes based on the qualitative findings, being drawn to calories, facilitating the eating disorder, reassurance, social eating and frustration.

Conclusions

The current review summarised the existing literature on the impact of out-of-home nutrition label policies on individuals with eating disorders. The evidence suggests that there is cause for concern regarding negative impacts, particularly for those with restrictive eating disorders, which should be explored further by research and considered by policymakers when making decisions on public health policies.

Network dynamics of self-compassion, anxiety, and depression during eating disorder therapy

BACKGROUND

Recovery processes during residential treatment for eating disorders, especially in patients with a history of maltreatment, are insufficiently understood. This study aimed to explore the temporal relationships among comorbid factors, including depression, anxiety, and self-compassion, with the influence of childhood maltreatment.

METHOD

Using Dynamic Time Warp (DTW), weekly scores from the Symptom Checklist-5, Eating Disorder Examination, and Self-Compassion Scale were analysed over 12 weeks. The study generated undirected and directed networks to identify influential symptoms in a transdiagnostic sample, comparing patients with and without childhood maltreatment.

RESULTS

The study included 124 patients with eating disorders (ED) (97% women), mean age of 30.9 years (SD = 9.7, range 18-61 years). Diagnoses included anorexia nervosa (26%), bulimia nervosa (38%), and other specified feeding and eating disorders (36%). The directed DTW network showed that hopelessness, worrying, and restlessness had the highest out-strength, predicting changes in self-compassion and ED behaviour. In maltreatment cases, hopelessness and low acceptance predicted changes, while worry, restlessness, and nervousness were predictive in non-maltreatment cases.

CONCLUSION

Temporal network analyses suggest that a change in hopelessness, worrying, and restlessness drives symptom improvement in ED behaviour and the development of self-compassion during residential treatment. These processes vary between patients with and without a history of childhood maltreatment separately, indicating the need for further analyses.

Exploring body ideal internalization, sociocultural pressures, and probable muscle dysmorphia in Canadian and American boys and men

This study aimed to determine whether the internalization of body ideals and sociocultural pressures to adhere to body ideals are associated with a greater likelihood of having probable muscle dysmorphia. Cross-sectional data from 1553 boys and men ages 15-35 from Canada and the United States were used. Multiple logistic regression analyses determined the association between the internalization of three body ideals, sociocultural pressures to adhere to body ideals from four sources, and having probable muscle dysmorphia. The odds of having probable muscle dysmorphia were significantly greater for those who internalized the muscular ideal and general attractiveness ideal. Conversely, endorsing the thin/low body fat ideal was significantly associated with lower odds of having probable muscle dysmorphia. Pressure from peers, but no other sources, showed a significant association with greater odds of having probable muscle dysmorphia. Findings expand prior research by investigating correlates of muscle dysmorphia versus muscle dysmorphia symptomatology. The strong association with internalization of the general attractiveness ideal provides new insights into how overall appearance may be highly relevant for boys and men with muscle dysmorphia, warranting future investigation.

The impact of gender-affirming interventions on eating disorder diagnosis risk among transgender and gender-diverse individuals

BACKGROUND

The objective of this study is to evaluate the risk of being diagnosed with an eating disorder among transgender and gender-diverse (TGD) individuals, specifically examining how this risk differs following gender-affirming medical therapy (GAMT).

METHODS

The study utilizes electronic medical record (EMR) data from the TriNetX database. A total of 90,955 TGD individuals were identified in the TriNetX database. TGD individuals were divided into cohorts according to gender-affirming interventions they received. To assess the risk of eating disorder diagnoses across groups, we applied a Cox proportional hazards model with gender-affirming care as a time-varying covariate.

RESULTS

Here we show that transfeminine individuals receiving hormone therapy (HT) have a significantly higher likelihood of being diagnosed with an eating disorder compared to those without intervention (HR:1.67, 95% CI:1.41, 1.98). Conversely, transmasculine individuals on HT exhibit a reduced risk of being diagnosed with an eating disorder relative to those without intervention (HR: 0.83, 95% CI: 0.76, 0.90).

CONCLUSIONS

After undergoing gender-affirming medical therapy, the risk of eating disorder diagnosis increases for transfeminine individuals and decreases for transmasculine individuals. The observed differences in risk between transfeminine and transmasculine individuals on GAMT may be attributed to factors such as gendered societal norms, variations in screening practices, and the physiological effects of hormone therapy on eating disorder symptomatology. Further research is needed to clarify these influences and support tailored interventions.

Hiding in plain sight: eating disorders in diverse populations - a case for comprehensive medical education

BACKGROUND

Training gaps regarding the diagnosis and management of eating disorders in diverse populations, including racial, ethnic, sexual, and gender minoritized groups, have not been thoroughly examined.

OBJECTIVE

This study aimed to examine resident physicians' knowledge and attitudes regarding eating disorders in diverse populations, with a focus on areas for improved training and intervention.

METHODS

Ninety-two resident physicians in internal medicine, emergency medicine, obstetrics/gynecology, psychiatry, and surgery at an academic center completed an online survey from 12/1/2020-3/1/2021, which comprised multiple choice and vignette-style open-ended questions to assess knowledge and attitudes toward the management and clinical presentations of eating disorders. Overall, the survey response rate was 25.7%. Descriptive statistics were reported. Vignette-style questions were analyzed using inductive coding and the frequency of responses was reported.

RESULTS

A minority of resident physicians self-reported confidence in their knowledge of the medical complications (n = 42, 45%), risk factors (n = 38, 41%), and clinical presentations (n = 32, 35%) associated with eating disorders. Responses to vignette-style questions correctly identified relevant management methods (such as electrolyte monitoring and referral to specialty care), but demonstrated limited knowledge of the clinical presentation of eating disorders. Furthermore, most respondents reported a lack of knowledge regarding eating disorders in sexual and gender minoritized patients (n = 68, 73.9%) as well as racial and ethnic minoritized patients (n = 64, 69.6%).

CONCLUSIONS

Our findings suggest concerning gaps in knowledge and confidence among resident physicians with regard to the diagnosis and treatment of eating disorders, particularly in racial, ethnic, sexual, and gender minoritized patients. Moreover, responses to vignette-like questions indicate significant homogeneity in respondents' perceptions of the clinical presentation of eating disorders, reflecting cultural biases which associate eating disorders with underweight, young, female patients. The majority did not feel competent in treating eating disorders in diverse populations and expressed desire for additional training in this area. More research is needed to better understand and address these gaps in eating disorder training, with the goal of increasing equity in patient outcomes.

Invisible walls? Stigma-related perceptions are associated with reduced help-seeking intentions for disordered eating in men

BACKGROUND

Eating disorders (EDs) are increasingly prevalent in men, but men remain underrepresented across many ED-specific treatment settings. Based on the idea that persistent stereotypes, prejudice and discrimination, i.e., stigma against men with EDs, could impede help-seeking behaviors, the present study investigated whether stigma-related perceptions in men are associated with reduced help-seeking intentions for a broad range of disordered eating symptoms.

METHODS

N = 132 adult men participated in a cross-sectional online survey and completed questionnaires on ED psychopathology, muscle dysmorphia, orthorexic eating, stigma-related perceptions of EDs in men, and help-seeking intentions.

RESULTS

Moderator analyses showed that higher stigma-related perceptions were associated with reduced help-seeking intentions in response to increased ED symptom severity. However, this was only the case for traditionally "feminized" ED symptoms (related to thin-body ideals), but not for help-seeking with regard to muscularity-oriented, orthorexic, or avoidant/restrictive disordered eating.

CONCLUSIONS

Stigma may reduce help-seeking intentions with regard to "feminized" ED symptoms. The present findings suggest that perceptions of EDs as "women's diseases" were associated with reduced help-seeking in men. Stigma towards men with EDs could thus be a possible barrier to help-seeking in men, highlighting the relevance of stigma-reducing interventions in clinical and community settings.

Excessive health behaviors in sports: links of orthorexia nervosa and exercise addiction with well-being, exercise activity in sports categories, and gender effects

Background and aims

Orthorexia nervosa (OrNe), the obsessive fixation on healthy eating, and exercise addiction (ExAdd) have been discussed as correlated excessive health behaviors with potential mental health implications. The role of gender-and sports-specific differences remains unclear. This study aimed to investigate the links of ExAdd, OrNe, and the non-pathological interest in healthy eating (healthy orthorexia; HeOr) with well-being and exercise activity in various sports, considering gender effects.

Methods

Data from two cross-sectional online surveys were combined (N = 1,064, 73.5% women, age = 28.23 ± 11.09), measuring ExAdd (Exercise Addiction Inventory Revised), OrNe and HeOr (Teruel Orthorexia Scale), well-being (WHO-5 Well-Being Index), exercise activity and sports (Physical Activity, Exercise, and Sport Questionnaire).

Results

Well-being correlated with OrNe among women (r = -0.291) and not meaningfully with ExAdd and HeOr among men. Gender differences were not significant, except for the higher correlation of ExAdd with exercise activity in resistance and fitness sports among men. Regression analyses revealed that exercise activity, especially in health, resistance and fitness sports, was linked to HeOr, but not to OrNe. ExAdd was associated with exercise activity in endurance, resistance and fitness, ball and team, antigravitation, technical, aesthetic sports, and martial arts.

Discussion

Men's well-being may slightly benefit from ExAdd and an interest in healthy eating, while obsessive healthy eating may reduce women's well-being. Although exercise activity is associated with ExAdd in a wide variety of sports, it does not explain the link between ExAdd and OrNe. Preventive measures should consider gender-specific risks in excessive health behaviors.

The future of the eating disorder field: Inclusive, aware of systems, and personalized

Eating disorders are serious psychiatric illnesses associated with large amounts of suffering, high morbidity, and high mortality rates, signifying a clear need for rapid advancements in the underlying science. Relative to other fields of clinical psychological science, the eating disorder field is new. However, despite the fields' late beginnings, there is growing science in several important areas. The current paper discusses the current literature in three primary areas of importance: (a) diversity and inclusion, (b) systemic and social factors, and (c) treatment personalization. We discuss how these areas have huge potential to push both eating disorder and clinical psychological science in general forward, to improve our underlying understanding of psychological illness, and to enhance treatment access and effectiveness. We call for more research in these areas and end with our vision for the field for the next decade, including areas in need of significant future research.

Muscularity bias internalization moderates the associations of muscularity dissatisfaction with muscularity-oriented disordered eating and psychosocial well-being in men but not women

Prior research demonstrates positive associations between muscularity dissatisfaction and an array of negative health outcomes, including muscularity-oriented disordered eating, eating-related psychosocial impairment, and psychological distress. However, muscularity dissatisfaction differs by gender and is not always linked to these outcomes, indicating the existence of moderators of these associations. We proposed and examined muscularity bias internalization (MBI) as a moderator of these associations. The study included online samples of 450 Chinese men and 450 Chinese women who completed measures assessing MBI, muscularity dissatisfaction, muscularity-oriented disordered eating, eating-related psychosocial impairment, and psychological distress. Pearson correlation analyses examined the bivariate associations among study variables. Multiple linear regression analyses examined the moderating effects of MBI. Results revealed that both muscularity dissatisfaction and MBI were significantly and positively related to all outcome variables, except for a non-significant correlation between muscularity dissatisfaction and psychological distress in women. MBI was a significant moderator in men, not women, with muscularity dissatisfaction being more strongly and positively related to all outcome variables in men reporting higher MBI. Our study provides preliminary evidence supporting gender differences in the role of MBI in the associations of muscularity dissatisfaction with muscularity-oriented eating disorder psychopathology and psychosocial well-being.

Muscularity-oriented disordered eating: investigating body image concerns and the moderating role of emotion dysregulation in cyclists

A lean muscular body of low weight is often associated with performance for cyclists and can be difficult to achieve. Disordered eating for some cyclists may develop in the pursuit of lean muscularity which is perceived to be beneficial to performance. Further, emotion dysregulation may exacerbate negative feelings about body image, increasing the risk of developing disordered eating as a means of controlling weight and shape. While research in athlete populations has been substantial, disordered eating in cyclists is relatively under-explored. The current study examined whether shape and weight concern and drive for leanness were associated with muscularity-oriented disordered eating and whether these relationships were moderated by emotion dysregulation. Interactions between these factors were also investigated. Participants were 139 Australian competitive cyclists (112 males, 27 females, aged 18-68 years) who completed a self-report questionnaire comprised of measures of shape and weight concern, drive for leanness, muscularity-oriented eating and emotion dysregulation variables. Both shape and weight concern and drive for leanness had a unique association with muscularity-oriented disordered eating. Emotion dysregulation was found to have a unique association with muscularity-oriented disordered eating when controlling for drive for leanness, but not when shape and weight concern was controlled. Additionally, emotion dysregulation moderated the association between shape and weight concern and muscularity-oriented disordered eating, whereby the relationship was intensified at higher levels of emotion dysregulation. Our study has extended the literature by indicating that cyclists' desire to attain a lean body is associated with muscularity-oriented disordered eating. Further, emotion dysregulation moderated this link, suggesting it could be a maintaining factor worth addressing.

Fathers' impact on outcomes in the treatment of eating disorders: A scoping review

OBJECTIVE

Male caregivers' participation in eating disorder (ED) treatment for their affected children is less consistent than female caregivers', with unclear effects. To clarify the impact, this scoping review examined literature on male caregiver involvement in ED treatment, focusing on its impact on fathers, treatment processes, and their affected children.

METHODS

A search encompassing English and French peer-reviewed articles from 1990 to 2022 was conducted. Studies distinguishing between mothers and fathers, addressing Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases ED diagnoses, and involving active interventions were included. From 1651 initially identified articles, 251 were retained after abstract and title review, and 45 met all criteria.

RESULTS

Documented outcomes indicated fathers' engagement in ED treatment improved their well-being and family functioning, but these gains were not consistently tied to treatment outcomes. Father attendance, improved caregiving skills, and their expectations of treatment correlated with better outcomes for their affected child.

CONCLUSIONS

Father involvement in ED treatment remains under-explored. This review emphasises fathers' positive impact while highlighting the need to better understand the link with overall patient outcomes. We call for proactive exploration of how to surmount barriers to fathers' involvement and ensure that paternal contributions are optimised in ED treatment alongside those of female caregivers.

Differences in Thinness- and Muscularity-Oriented Eating and Body Image Disturbances and Psychosocial Well-Being in Chinese Sexual Minority Men Reporting Top, Bottom, and Versatile Sexual Self-Labels

In addition to describing sexual partner preferences, sexual self-labels in gay and bisexual (henceforth, sexual minority) men, such as top, bottom, and versatile, are associated with psychological characteristics (e.g., gendered personality traits). No research has explored the association between sexual self-labels and eating and body image disturbances in sexual minority men. Research in sexual minority men from China is particularly valuable and needed due to recent rises in rates of eating and body image disturbances and unique, minority-specific stressors experienced by Chinese sexual minority populations. We adopted an online, cross-sectional study in a sample of sexual minority men from China (N = 403; tops, n = 256, bottoms, n = 95, versatiles, n = 52). Bottoms reported higher thinness internalization, lower muscularity internalization, higher body fat dissatisfaction, and higher psychological distress than tops. Bottoms' weight bias internalization was higher than tops' and versatiles' reports and, compared to versatiles, bottoms also reported higher psychosocial impairment related to eating disorder psychopathology. Compared to versatiles, tops reported higher drive for muscularity and muscularity-oriented disordered eating. Adjusting for age, psychological distress, and psychosocial impairment, tops reported higher muscularity internalization than bottoms and higher drive for muscularity and muscularity-oriented disordered eating than both bottoms and versatiles. Findings suggested unique relations between sexual self-labels and eating and body image disturbances in Chinese sexual minority men. Replication and validation of the temporal order between sexual self-labels and eating and body image disturbances is needed, including assessment of social factors (e.g., femmephobia, minority stress) that may help explain the links between sexual self-labels and eating pathology.

Social cognition and bulimic symptoms in male undergraduate students: The conditional effect of emotion dysregulation

OBJECTIVE

Research demonstrates associations between poor social cognition and eating disorder (ED) pathology. Moreover, research shows that individuals with EDs struggle with emotion regulation. The present study replicates and extends the literature on social cognition and ED pathology, which previously focused largely on symptoms of anorexia nervosa among women while the present study focuses on symptoms of bulimia nervosa among undergraduate men. Further, this study tests the hypothesis that better emotion regulation mitigates the association between social cognition and ED pathology.

METHODS

At a single timepoint, undergraduate males (n = 520) completed a series of questionnaires, and a task assessing mentalising, a key element of social cognition.

RESULTS

Consistent with hypotheses, bulimic symptoms were associated with worse mentalising and worse self-reported emotion regulation. Moreover, the association between mentalising and bulimic symptomatology was conditional on emotion regulation, such that it was strongest among those with more difficulties regulating their emotions.

CONCLUSION

Results are consistent with existing theories that highlight an interplay between interpersonal (e.g., mentalisation) and intrapersonal (e.g., affective functioning) factors in relation to ED symptomatology. Among undergraduate males, bulimic symptoms were associated with worse mentalisation. However, a good ability to regulate emotions interrupted this association.

Camouflaging, not sensory processing or autistic identity, predicts eating disorder symptoms in autistic adults

LAY ABSTRACT

This study aimed to explore the impact of Autistic identity (i.e. feeling like you belong to the Autistic community), sensory profiles (e.g. being over or under responsive to sensations) and camouflaging behaviours (i.e. masking) on eating disorder symptoms in Autistic adults. 180 Autistic people were recruited from the community and NHS. The Autistic people completed online questionnaires measuring Autistic identity, sensory profiles, camouflaging behaviours, autistic traits and eating disorder symptoms. The analysis showed that higher levels of camouflaging behaviour predicted higher levels of eating disorder symptoms. Sensory profiles were related to but did not predict eating disorder symptoms and there was no relationship between level of Autistic identity and eating disorder symptoms. This shows that camouflaging is the most important predictor of eating disorder symptoms in Autistic people, and warrants further exploration.

Taking a Deeper Dive Into OSFED Subtypes: A Meta-Analysis and Systematic Review

OBJECTIVE

To compare all other specified feeding or eating disorders (OSFED) groups (atypical anorexia nervosa [AN], purging disorder [PD], night eating syndrome [NES], subthreshold bulimia nervosa [sub-BN], and subthreshold binge-eating disorder [sub-BED]) to threshold eating disorders (EDs [AN, BN, and BED]) and control groups (CGs) on measures of eating and general psychopathology.

METHOD

We conducted a comprehensive search in PsycINFO, Medline, Embase, and CINAHL on all published studies from January 2013 to February 2024 using DSM-5 diagnostic criteria via clinical interviews or well-established diagnostic tools. We also undertook a quality appraisal using an adapted version of the Downs and Black criteria and registered the review with PROSPERO (ID: CRD42022314495).

RESULTS

Overall, our meta-analyses (n = 33 eligible studies) indicated that the combined OSFED and several specific OSFED subtypes displayed comparable levels of eating psychopathology to full-threshold EDs. Our systematic review (n = 33 eligible studies) found individuals with OSFED to have comparable levels of eating and general psychopathology to full-threshold EDs, but higher levels of eating and general psychopathology than CGs. These findings were specifically attributed to atypical AN and NES. There was a lack of evidence available for sub-BN and sub-BED. Studies mainly met the quality appraisal criteria. The main limitations identified in the included studies were insufficient reporting of their statistical power (78%) and no adjusting for potential confounding factors (67%).

DISCUSSION

Findings support the conceptualization of atypical AN, and NES as clinically significant EDs with similar severity to full-threshold EDs.

A cultural models approach to understanding body fatness perceptions and disordered eating in young South Korean men

OBJECTIVE

The eating disorders field has been limited by a predominant focus on White, Western women, and there is growing recognition of the need to understand cross-cultural variation in key constructs (i.e., ideal body types). A transdisciplinary, cultural models approach systematizes the incorporation of an "emic" perspective (a culture's own understandings of phenomena) into assessments of relationships between body shapes and eating disorders.

METHOD

Eighty-one young South Korean men aged 19-34 years living in Seoul participated in this research. A cultural model of body fatness was identified using cultural consensus analysis during 18 months of ethnographic, mixed-methods fieldwork. Participants also completed questionnaires assessing age, height, weight, sexual identity, university prestige, body dissatisfaction, eating disorder symptoms, and cultural consonance with the Korean cultural model of the ideal male body. Variation in these factors was analyzed using a series of chi-squares and analyses of variance with the culturally defined categories of body fatness as the independent variables.

RESULTS

Cultural consensus analysis found that young South Korean men are consistent in identifying categories of "too thin," "balanced," and "too fat." The "balanced" category contained the lowest proportion of high-prestige university attendees and the highest average cultural consonance. The "too fat" category was characterized by the highest levels of body dissatisfaction and dieting, as well as proportion of probable eating disorders.

DISCUSSION

A cultural models approach identified culturally important factors and patterns in disordered eating among young South Korean men and may be effective for understanding eating disorders in other populations not typically studied.

PUBLIC SIGNIFICANCE

This study applies a systematic, "emic" perspective to young South Korean men's body ideals. Young Korean men share a cultural model of body fatness, and this model frames how they experience risk for eating disorders. This study demonstrates a method for incorporating culture into research on eating disorder risk.

Gay Dating Apps Usage, Body Dissatisfaction, and Disordered Eating in Chinese Young Gay Men

There is a paucity of research on the links between gay dating apps usage and body dissatisfaction and disordered eating, especially for muscularity dissatisfaction and muscularity-oriented disordered eating in non-Western contexts. Thus, this study aimed to evaluate the associations between gay dating apps usage, body image inflexibility, body dissatisfaction, and disordered eating with the inclusion of both body fat and muscularity dissatisfaction and both thinness-and muscularity-oriented disordered eating in a sample of Chinese young gay men. A total of 247 Chinese young gay men (mean age: 21.92 ± 2.74 years) were recruited. Gay dating apps usage, body fat dissatisfaction, muscularity dissatisfaction, body image inflexibility, and thinness-and muscularity-oriented disordered eating were evaluated. Pearson correlation and mediation analyses were conducted. Gay dating apps usage was positively correlated with body fat dissatisfaction (r = .20, p = .002), muscularity dissatisfaction (r = .17, p = .006), thinness-oriented disordered eating (r = .21, p < .001), and muscularity-oriented disordered eating (r = .29, p < .001), and these relationships could be mediated by body image inflexibility. Findings support technologically-informed prevention and intervention strategies for eating and body image disturbances in gay men in the Chinese context.

Examining posttraumatic cognitions as a pathway linking trauma exposure and eating disorder symptoms in veteran men and women: A replication and extension study

Trauma is a risk factor for eating disorders (EDs). Enhanced understanding of the pathways from trauma to EDs could identify important treatment targets. Guided by theory, the present study sought to replicate previous findings identifying posttraumatic stress disorder (PTSD) symptoms and shape/weight overvaluation as important pathways between trauma and ED symptoms and extend this work by investigating the role of posttraumatic cognitions in these associations. The sample included 825 female and 565 male post-9/11 veterans who completed cross-sectional survey measures of trauma, posttraumatic cognitions, PTSD symptoms, shape/weight overvaluation, and ED symptoms. Gender-stratified structural equation models were used to examine direct and indirect pathways from trauma exposure to EDs via PTSD symptoms and shape/weight overvaluation (replication) and posttraumatic cognitions (extension). Results suggested that trauma exposure was indirectly associated with ED symptoms via shape/weight overvaluation and posttraumatic cognitions. There was no indirect association between trauma exposure and ED symptoms via PTSD symptoms. Overall, findings from this study highlight the potential role of posttraumatic cognitions in understanding the association between trauma and ED symptoms. However, future longitudinal research is needed to verify the directionality of these associations and investigate cognitions as a potentially targetable risk mechanism in co-occurring trauma and EDs.

Use of photo filters is associated with muscle dysmorphia symptomatology among adolescents and young adults

It has been documented in the literature that the use of photo filters to alter one's appearance may negatively impact body image and increase the risk for thinness-oriented disordered eating behaviors. However, the prior research has neglected to investigate the association between use of photo filters and muscle dysmorphia symptomatology, which was the aim of this study. Data from the Canadian Study of Adolescent Health Behaviors (2022; N = 912), a national study of adolescents and young adults in Canada, were analyzed. Linear regression analyses revealed that the use of photo filters was associated with greater muscle dysmorphia symptomatology, including total symptomatology and Appearance Intolerance, among the overall sample. Gender significantly moderated the association between photo filter use and muscle dysmorphia symptomatology, whereby boys and young men, compared to girls and young women, who reported photo filter use had greater Drive for Size and Functional Impairment symptomatology. Findings expand prior research by emphasizing that photo filter use is related to muscularity-oriented body image concerns and behaviors. Future research is needed to elucidate the mechanisms that underpin this association.

Is There a Relationship Between Body Mass Index and Eating Disorder Symptoms in Professional Male Fashion Models?

This study is the first to examine the utility of body mass index (BMI) as an indicator of eating disorder (ED) pathology and fitness for employment for professional male fashion models. We assessed the relationship between experimenter-measured BMI, muscle mass, body fat percentage, and ED severity (EDE-Q score) in male models and nonmodels. Except for higher eating concern, the two groups displayed similar EDE-Q scores after controlling for age. Models relative to nonmodels endorsed significantly greater frequency of compulsive exercise and self-induced vomiting as a means of controlling shape or weight. BMI was a poor indicator of body fat percentage in models. Lower BMI in models, and higher BMI in nonmodels, was associated with higher EDE-Q scores. Interestingly, all the male models with clinically significant EDE-Q scores (≥4.0) had >18.5 experimenter-measured BMI. Higher muscle mass in models, and lower muscle mass in nonmodels, was associated with higher EDE-Q scores. Inversely, lower percentage body fat in models, and higher percentage body fat in nonmodels, was associated with higher EDE-Q scores. BMI, muscle mass, and percentage body fat were associated with ED tendencies in male models and nonmodels. Findings also suggest males with clinical ED symptoms would be overlooked if only low BMI (<18.5) was considered. These results may guide the development of more effective mandates to safeguard models' wellbeing, and men generally.

The Role of Central and Peripheral Brain-Derived Neurotrophic Factor (BDNF) as a Biomarker of Anorexia Nervosa Reconceptualized as a Metabo-Psychiatric Disorder

Neurotrophic factors play pivotal roles in shaping brain development and function, with brain-derived neurotrophic factor (BDNF) emerging as a key regulator in various physiological processes. This review explores the intricate relationship between BDNF and anorexia nervosa (AN), a complex psychiatric disorder characterized by disordered eating behaviors and severe medical consequences. Beginning with an overview of BDNF's fundamental functions in neurodevelopment and synaptic plasticity, the review delves into recent clinical and preclinical evidence implicating BDNF in the pathophysiology of AN. Specifically, it examines the impact of BDNF polymorphisms, such as the Val66Met variant, on AN susceptibility, prognosis, and treatment response. Furthermore, the review discusses the interplay between BDNF and stress-related mood disorders, shedding light on the mechanisms underlying AN vulnerability to stress events. Additionally, it explores the involvement of BDNF in metabolic regulation, highlighting its potential implications for understanding the metabolic disturbances observed in AN. Through a comprehensive analysis of clinical data and animal studies, the review elucidates the nuanced role of BDNF in AN etiology and prognosis, emphasizing its potential as a diagnostic and prognostic biomarker. Finally, the review discusses limitations and future directions in BDNF research, underscoring the need for further investigations to elucidate the complex interplay between BDNF signaling and AN pathology.

Thought-shape fusion in residential eating disorder treatment: Cognitive defusion as a mediator between thought-action fusion and treatment outcome

An understudied cognitive bias within eating disorder (ED) psychopathology is Thought-Shape Fusion (TSF), which involves irrational beliefs about the likelihood and moral implications of feared outcomes related to shape, weight, and food. This phenomenon has received less attention within the context of ED treatment, with little known about potential processes of change to address TSF and ultimately promote ED recovery. We propose cognitive defusion as a process of change, a metacognitive process that emphasizes observing thoughts objectively rather than appraising thoughts as absolute truth. We explored whether cognitive defusion, that is, reductions in body image-related cognitive fusion, mediated the relationship between trait-level TSF and treatment outcomes in a transdiagnostic ED sample of adult and adolescent females (N = 130) presenting to residential care. We found that reductions in body image-related cognitive fusion mediates the association between trait-level TSF at baseline and ED severity at discharge. However, when the sample was separated into adolescent and adult subgroups, these results only remained significant for adolescents. These findings underscore the relevance of targeting cognitive defusion as a potential mechanism to address the impact of trait levels of TSF cognitions on ED psychopathology.

Eating Disorder Clinical Presentation and Treatment Outcomes by Gender Identity Among Children, Adolescents, and Young Adults

PURPOSE

Current eating disorder treatment approaches for youth were developed for use with cisgender girls, which limits the understanding of effectiveness for cisgender boys and transgender and gender expansive (TGE) youth. Here, we compare treatment outcomes for cisgender boys and TGE youth with cisgender girls receiving family-based treatment for an eating disorder.

METHODS

Patients were aged 6-24 and either active in treatment or discharged from September 1, 2020, to November 1, 2022 (N = 1,235). Patient exposure to treatment varied given individualized length of treatment. Outcomes include eating disorder symptoms, depression, anxiety, suicidality, caregiver burden, and parental confidence in supervising treatment. Treatment outcomes for cisgender boys and TGE youth were compared with cisgender girls.

RESULTS

Patients included n = 975 cisgender girls, n = 152 cisgender boys, and n = 108 TGE youth. Anorexia nervosa was the most common diagnosis. Cisgender boys reported significantly lower eating disorder (b = -2.7 [-4.1, -1.3]), anxiety (b = -1.6 [-2.2, -0.9]), and depression (b = -1.7 [-2.4, -0.9]) symptoms at admission compared with cisgender girls. TGE patients had significantly higher anxiety (b = 1.08 [0.28, 1.91]) and depression (b = 1.72 [0.78, 2.65]) symptoms compared with cisgender girls. Cisgender boys started with significantly lower suicidal ideation (b = -1.28 [-2.19, -0.43]) and TGE patients with significantly higher suicidal ideation (b = 1.63 [0.76, 2.51]) than cisgender girls. All symptoms improved during treatment and improved at similar rates over time in treatment regardless of gender identity.

DISCUSSION

Early evidence from this study supports the use of family-based treatment for cisgender boys and TGE youth with eating disorders. Further research is needed on the long-term outcomes of this approach for youth of all genders.

A systematic review of eating disorders and family functioning

The purpose of the current review was to address four questions: 1) Are there differences in family functioning or family environment among patients with different eating disorder (ED) diagnoses? 2) Are there differences in the perception of family functioning or family environment among different family members? 3) Is family functioning or family environment related to ED symptomatology? 4) Does family functioning or family environment change as a result of ED treatment? and 4a) If so, does this impact ED treatment outcome? Although most studies found no differences among ED diagnostic groups, those that did generally found worse family functioning among those with binge/purge symptoms than among those with the restricting subtype of anorexia nervosa. Differences in perceptions of family functioning among family members were found, with patients generally reporting worse functioning than their parents. Worse family functioning was generally found to be related to worse ED symptoms. The variety of treatment approaches and different assessments of outcome made it somewhat unclear whether family functioning consistently improves with ED treatment. More research is needed on family functioning and EDs, particularly in understudied groups such as males, and those with ED diagnoses other than anorexia nervosa or bulimia nervosa.

Negative emotional eating patterns in general Chinese adults: A replication and expansion study examining group differences in eating disorder symptomatology, psychosocial impairment, and emotion regulation difficulties

Previous research identified four patterns of negative emotional eating in American and Chinese university students and proposed future directions (e.g., exploring potential differences in emotion regulation across patterns and replicating the patterns in a general, non-student population). Furthermore, prior research has not explored group differences in muscularity-oriented eating disorder symptomatology or psychosocial impairment. Therefore, the present study addressed these gaps in a sample of general Chinese adults, further testing group differences in typical and muscularity-oriented eating disorder symptomatology, psychosocial impairment, and emotion regulation difficulties across patterns of negative emotional eating. A total of 600 Chinese adults were recruited. Latent class analysis (LCA) was used. Results replicated the four patterns of negative emotional eating in previous research, including non-emotional eating (non-EE), emotional over- and under-eating (EOE-EUE), emotional over-eating (EOE), and emotional under-eating (EUE). Significant class differences were identified in eating disorder symptomatology, psychosocial impairment, and emotion regulation difficulties. Specifically, individuals with EOE and EOE-EUE patterns exhibited higher eating disorder symptomatology, higher psychosocial impairment, and more emotion regulation difficulties than those with non-EE and EUE patterns. Therefore, these two classes (i.e., EOE and EOE-EUE), especially the poorly researched EOE-EUE group, should be further examined to elucidate research and clinical applications. Furthermore, findings underscore the role of emotion regulation difficulties in further describing the differences across these negative emotional eating patterns, which can be considered in future interventions for reducing negative emotional eating.

Creatine monohydrate use is prospectively associated with muscle dysmorphia symptomatology

This study aimed to determine the prospective association between creatine monohydrate use and muscle dysmorphia symptomatology among adolescents and young adults in Canada. Data from 912 adolescents and young adults from the Canadian Study of Adolescent Health Behaviors were analyzed. Creatine monohydrate use in the past 12 months was assessed at Wave 1, and muscle dysmorphia symptomatology was measured using the Muscle Dysmorphic Disorder Inventory (MDDI) at Wave 1 and Wave 2. The prospective associations between creatine monohydrate use and the MDDI total score and subscale scores were determined using linear regression analyses. Regression analyses controlled for relevant demographic identifiers, prior substance use, and the corresponding Wave 1 MDDI variable. Creatine monohydrate use at Wave 1 was prospectively associated with both total muscle dysmorphia symptomatology (B 1.34, 95 % CI 0.27, 2.42) and greater Appearance Intolerance (B 0.52, 95 % CI 0.02, 1.03) at Wave 2. Importantly, these findings were independent of prior muscle dysmorphia symptomatology, lifetime anabolic-androgenic steroid use, lifetime cigarette use, and frequency of alcohol use. Creatine monohydrate is commonly used among adolescents and young adults. Findings from this study are among the first to document that creatine monohydrate use may be a risk factor for the development of muscle dysmorphia symptomatology among adolescents and young adults. Health and mental health care professionals may consider assessing for both creatine monohydrate use and muscle dysmorphia symptomatology among adolescents and young adults.

Gender stereotypes in eating disorder recognition

PURPOSE

Eating disorder (ED) awareness is low. We assessed if ED symptom recognition, perceived need for treatment, perceived distress, perceived acceptability, and perceived prevalence differed depending on the gender of the individual with the ED.

METHODS

276 community participants were randomly assigned to one of three gender conditions (female, male, and non-binary), read three vignettes describing three different individuals with ED symptoms [anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED)], and then answered a series of questions related to participants ED symptom recognition, perceived need for treatment, perceived distress associated with having ED symptoms, perceived acceptability (e.g., the extent to which it may not be too bad to have an ED), and perceived prevalence. Mixed ANOVAs and chi-square analyses were conducted to examine differences between groups.

RESULTS

There were no significant main effects of gender condition across the outcome variables. There were main effects of ED type for problem recognition, perceived need for treatment, perceived level of distress, and perceived prevalence, with participants being more likely to recognize a problem in the AN and BN vignettes than the BED vignettes, refer for treatment and rate a higher perceived level of distress in then AN vignette than the BN and BED vignettes, and perceive a higher prevalence rate in the BN vignette than the AN vignette. There was a significant gender by condition interaction for perceived prevalence, with participants rating a higher prevalence of AN in women and non-binary individuals than men and a higher prevalence of BN in women than non-binary individuals and men.

CONCLUSION

These results highlight the importance of education on EDs and awareness that EDs can occur in any individual, regardless of their gender identification.

LEVEL OF EVIDENCE

Level I, experimental study with randomization.

A multi-modal assessment of fear conditioning in adolescent anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is a pernicious psychiatric disorder which is principally characterized by a fear of weight gain. Notwithstanding the centrality of fear in the psychopathology of AN, controlled assessments of negative valence systems are lacking. Herein we assess fear conditioning in adolescent females with AN.

METHOD

Adolescent girls (Mage = 14.6 years, ±1.57) with DSM-5 diagnoses of AN (N = 25) and age-matched control girls (Mage = 14.8 years, ±1.46) with no DSM-5 diagnoses (N = 25) completed structured clinical interviews and participated in a classical three-phase Pavlovian fear conditioning paradigm. Participants with comorbid anxiety disorders were excluded. Skin conductance response (SCR) was measured, alongside self-reported fear, valence, and fear expectancy ratings.

RESULTS

Both groups demonstrated significant differential acquisition across all four measures. Regarding group comparisons, no differences emerged for self-reported fear, valence, and fear expectancy ratings during acquisition, although for SCR, those with AN demonstrated reduced physiological arousal relative to controls. Both groups demonstrated significant differential extinction for unconditioned stimuli (US) expectancy, self-report fear, and self-report valence. No statistically significant group differences were evident during extinction to the conditioned stimuli (CS)+, on any outcome measure. However, controls reported more positive valence to the CS- than those with AN.

CONCLUSIONS

Contrary to our hypotheses, our preliminary assessment did not find support for elevated fear responding among adolescent girls with AN with regards to fear acquisition or extinction. These data suggest that AN in adolescent girls may not be associated with a heightened propensity to acquire fear, but conversely, may suggest that exposure treatments for AN may be helpful, since extinction learning is intact in AN.

PUBLIC SIGNIFICANCE

AN is characterized by fear-related symptoms, including food and weight-related fear, and behavioral avoidance, yet controlled studies assessing fear learning are limited. Our preliminary assessment of adolescent AN indicates no abnormalities in fear learning among adolescents with AN. These findings may inform existing mechanistic models of AN psychopathology, and the development of exposure-based treatments for AN.

Personal risk factors and types of sport associated with drive for thinness and drive for muscularity in NextGen athletes

Introduction

Professional and student-athletes are at risk of developing symptoms of eating disorders (ED), including drive for thinness and muscularity due to personal risk factors (e.g., low self-esteem) and sport-specific characteristics (e.g., sport requirements). However, limited studies have focused on ED symptoms among NextGen athletes (identified in Canada as élite or relève) who compete at the provincial, national, and international levels but are not yet part of national teams. As such, they have access to fewer financial resources and support from their sport federations, which can create additional stress for these athletes. The present study aimed to identify personal risk factors and types of sports associated with (a) drive for thinness and (b) drive for muscularity in NextGen athletes.

Methods

These athletes (n = 254) aged between 14 and 25 years old completed an online questionnaire. Perfectionism, self-esteem in sport, drive for thinness, and drive for muscularity were, respectively, assessed by the Multidimensional Inventory of Perfectionism in Sport, the Sport State Self-Esteem Scale, the Eating Attitude Test-26, and the Drive for Muscularity Scale. Other personal risk factor (e.g., athletic status) were measured using in-house questions. Each personal risk factor was included in two multiple linear regressions, respectively, to determine which factors were most associated with drive for thinness and drive for muscularity.

Results

Analyses revealed that perfectionist aspirations during training were linked to a stronger desire for thinness. In addition, not being in school or not having a job were also linked to a stronger desire for thinness. Several variables were found to be associated with a greater desire for muscularity: being a male athlete, playing team sport, weight category sport or endurance sport (as opposed to esthetic sport), having elite status, being less satisfied with one's current sporting performance and having higher perfectionist aspirations during training.

Discussion

This study offers initial insights into the factors influencing EDs among NextGen athletes, which provides a foundation for deeper exploration and the creation or modification of targeted interventions. These findings can guide sport organizations in creating guidelines and programs to better support the next generation of national athletes (e.g., create programs to help athletes maintain investments outside).

Testing for longitudinal bidirectional associations between self-compassion, self-criticism, and positive body image components

Previous cross-sectional studies have reported associations between self-compassion, self-criticism, and positive body image, yet prospective studies establishing the temporal order of these relationships are missing. The present study sought to clarify the nature of these associations by investigating possible longitudinal bi-directional links between self-compassion, self-criticism, and three components of positive body image (body appreciation, functionality appreciation, and body image flexibility). Data were analyzed from 2982 adult women who completed survey instruments at baseline (T0), four-month follow-up (T1), and eight-month follow-up (T2). Attrition rate ranged from 0-56% across time-points. Cross-lagged panel models were computed to test for bidirectional associations. We found evidence of reciprocal, negative associations between self-criticism and the three components of positive body image across the three time-points. We also found evidence that T0 self-compassion predicted increased body image flexibility and functionality appreciation at T1 (paths were non-significant from T1 to T2), whereas T0 body appreciation predicted increased T1 self-compassion (but was non-significant from T1 to T2). Findings suggest that compassionate and uncritical ways of responding to the self may be relevant precursors and outcomes to positive body image, depending on the timing of assessment, highlighting viable targets for intervention.

Eating disorder symptom dimensions and protective factors: A structural network analysis study

Eating Disorders (EDs) and related symptoms pose a substantial public health concern due to their widespread prevalence among both genders and associated negative outcomes, underscoring the need for effective preventive interventions. In this context, deepening our understanding of the interplay between ED symptoms and related protective factors appears crucial. Therefore, this study employed a structural network analysis approach considering both ED symptom dimensions (i.e., drive for thinness, bulimic symptoms, and body dissatisfaction) and related protective factors (i.e., body and functionality appreciation, intuitive eating, and self-esteem) to shed light on how these factors are interrelated. A community sample of 1391 individuals (34.4% men; Mage = 26.4 years) completed a socio-demographic schedule and self-report questionnaires. The network showed that the nodes with the highest positive expected influence were body and functionality appreciation, while those with the highest negative expected influence were eating for physical rather than emotional reasons and unconditional permission to eat (i.e., two components of intuitive eating). Crucially, the most relevant bridges between the conceptual communities "ED symptom dimensions" and "Protective factors" were the negative relations between (a) eating for physical rather than emotional reasons and bulimic symptoms, (b) unconditional permission to eat and drive for thinness, and (c) body appreciation and body dissatisfaction. Finally, age, gender, and body mass index did not moderate any edge in the network. The practical implications of these findings are discussed, especially in terms of preventive interventions for ED symptoms.

ERP correlates of self-referential processing moderate the association between pubertal status and disordered eating in preadolescence

Preadolescence is a critical period for the onset of puberty and eating-related psychopathology. More advanced pubertal status is associated with elevated eating pathology. However, it was unclear whether this association was moderated by self-referential processing, an important, modifiable cognitive risk for various forms of psychopathology, including eating problems. Further, no study has examined the neural correlates of self-referential processing in relation to eating pathology. To address these gaps, we examined how the association between pubertal status and disordered eating was moderated by self-referential processing in a community sample of 115 nine-to-12-year-old preadolescents (66 girls; mean age/SD = 10.98/1.18 years; 87.5% White). Youths reported their pubertal status and disordered eating behaviors and completed an ERP version of the Self-Referent Encoding Task (SRET) to assess self-referential processing. A Principal Component Analysis of the ERP data identified an anterior late positive potential (LPP) in both the positive and negative SRET conditions. The LPP in the positive condition moderated the positive association between pubertal status and disordered eating behaviors, such that this association was significant for youths with a smaller LPP toward positive self-referential cues, but non-significant for those showing a larger LPP toward positive self-referential cues. These results suggest that a deeper processing of positive self-referential information, indicated by a potentiated LPP, may weaken the negative impact of pubertal status on disordered eating. Our findings also suggest that enhancing positive self-referential processing may be a useful tool in preventing the development of eating pathology in preadolescents, especially for those with more advanced pubertal status.

Validation of the eating pathology symptoms inventory (EPSI) in Swedish adolescents

BACKGROUND

Eating disorders (ED) are associated with symptoms across body image, disordered eating, and exercise-related domains, and while predominantly affecting females, ED in males is also a significant concern. However, popular self-report methods insufficiently capture male presentations. This study aimed (1) to validate the first Swedish translation of the Eating Pathology Symptoms Inventory (EPSI), which was designed to overcome limitations in previous measures, and (2) compare genders gender-specific manifestations of eating pathology, depression, and anxiety in Swedish high-school students.

METHODS

Participants were 359 high-school students (47% males) aged 17.0 years (range 15-21).

RESULTS

Confirmatory factor analysis and correlation patterns showed support for the 8-factor structure and convergent validity, but poorer discriminant validity may suggest caution in interpreting single scales as evidence of ED pathology. Gender comparisons were broadly consistent with previous research.

CONLUSIONS

The Swedish EPSI may be used to asses ED symptoms, but caution is suggested in interpreting some scales in isolation as indicative of ED pathology.

Sex differences in electrolyte abnormalities indicating refeeding syndrome risk among hospitalized adolescents and young adults with eating disorders

BACKGROUND

Refeeding syndrome is the gravest possible medical complication in malnourished patients undergoing refeeding in the hospital. We previously reported that males with malnutrition secondary to eating disorders required more calories and had longer hospital stays than females; however, sex differences in electrolyte abnormalities indicating refeeding syndrome risk remain unknown. The objective of this study was to assess differences in electrolyte abnormalities indicating refeeding syndrome risk among male and female adolescents and young adults with eating disorders hospitalized for medical instability.

METHODS

We retrospectively reviewed the electronic medical records of 558 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical instability between May 2012 and August 2020. Serum was drawn per standard of care between 5 and 7 am each morning and electrolyte abnormalities indicating refeeding syndrome risk were defined as: hypophosphatemia (< 3.0 mg/dL), hypokalemia (< 3.5 mEq/L), and hypomagnesemia (< 1.8 mg/dL). Logistic regression was used to assess factors associated with electrolyte abnormalities indicating refeeding syndrome risk.

RESULTS

Participants included 86 (15.4%) males and 472 (84.6%) females, mean (SD) age 15.5 (2.8) years. Rates of refeeding hypophosphatemia (3.5%), hypokalemia (8.1%), and hypomagnesemia (11.6%) in males hospitalized with eating disorders were low, with no statistically significant differences from females. Older age was associated with higher odds of refeeding hypophosphatemia and hypomagnesemia. Lower percent median body mass index and greater weight suppression at admission were associated with higher odds of refeeding hypophosphatemia.

CONCLUSIONS

Rates of electrolyte abnormalities indicating refeeding syndrome risk were low in males hospitalized for eating disorders and rates did not significantly differ from females. Together with our finding that males have higher caloric requirements and longer hospital length of stay, the finding that electrolyte abnormalities indicating refeeding syndrome risk were not greater in males than females supports future research to evaluate the safety and efficacy of higher calorie and/or faster advancing refeeding protocols for males.