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Network Analysis of Males and Eating Disorder Symptoms

When you think of the term “eating disorder”, what words come to mind? Perhaps you think of descriptors like girls, women, thin, body image, and lean. If you read a case description of someone with an eating disorder, how often would you guess the case description described a female vs. a male? It’s likely your mind would have a stronger association between eating disorder + girls/women/female, as compared to eating disorder + boys/men/male. And it’s true: girls and women are more likely to be affected by eating disorders than boys and men. However, the gender gap of eating disorder prevalence is closer than you may think—males account for roughly 20–25% of affected individuals (Hudson et al., 2007; Mohler-Kuo et al., 2016; Udo & Grilo, 2018). Importantly, one reason why male eating disorders are lesser known than female eating disorders may be because of differences in core eating disorder symptoms (for a thorough review, see Murray et al., 2017). In collaboration with a team of excellent colleagues (Natalie Perkins, Jason Lavender, and April Smith), I led a study that identified core eating disorder symptoms among men, and I’m excited to tell you more about it.

This study used something called network analysis to identify core eating disorder symptoms. Network analysis is a statistical technique that identifies how individual symptoms interact with one another. Through empirical methods, network analysis specifically identifies the symptom(s) that have the strongest connections to other symptoms in the network, which is important because these highly-connected symptoms may be those that cause the development of several other symptoms in the network. For example, network analysis findings among women indicate that eating disorder symptoms like shape and weight overvaluation—where people feel like their shape or weight is extremely important to how they judge themselves as people—are highly related to several other symptoms, like fearing weight gain and dieting.

Even though network analysis shows promise to better understand core symptoms of eating disorders, males have been very under-represented in eating disorder network studies. Without including boys and men in our research studies, we can’t know whether the symptom-level interactions identified among women are operating similarly for boys and men. Our study identified specific eating disorder symptoms that may be the main drivers of eating disorders in men. To do this, our symptom network included items that are typically used to assess eating disorders, while also including items that capture experiences that seem to be important to men’s experiences, such as items related to male (vs. female) body ideals.

In western society, the male body ideal is muscular and lean. This is in contrast to the female body ideal, which is thin and marked by having a low weight. To achieve these different body ideals, males and females may engage in specific eating disorder behaviors. Dietary restriction and purging may be used to lose weight and achieve a thin body ideal, whereas eating large quantities of specific foods (e.g., those high in protein), lifting weights, and exercising intensely may be used to gain muscle mass and achieve a muscular body ideal. Most of the measures that are commonly used to assess eating disorders do an excellent job of assessing attitudes and behaviors associated with achieving a thin body ideal, but few incorporate items that assess attitudes and behaviors associated with achieving a muscular body ideal (please see the great work of Dr. Kelsie Forbush for an exception). In our study, we used a “both–and” approach, where we included items in the network that are commonly used in eating disorder research (but lack male/muscularity specificity) while also including items that capture muscularity-related body ideals, dissatisfaction, and behaviors.

The results of our study were quite interesting. We found the items with the greatest importance in the network—i.e., items that were most strongly associated with all other items—were shape overvaluation (believing a person’s body shape is one of their most important qualities), wanting to lose weight, fearing losing control over eating, feeling guilty for missing a weight training session, and using dietary supplements. The first three symptoms (shape overvaluation, wanting to lose weight, and fear of losing control over eating) were expected to be important, based on previous research. But the most interesting part of the results was that the last two symptoms (feeling guilty for missing weight training and using dietary supplements) came from measures assessing male/muscularity-specific eating disorder symptoms. This may mean that to most accurately diagnose, understand, and treat eating disorders among males, we need to be paying attention to some of the things we already pay attention to for female eating disorders (e.g., shape overvaluation, valuing weight loss) while also increasing the attention we pay to things like dissatisfaction about one’s body not being “muscular enough” or “lean enough” and the behaviors that may arise from this dissatisfaction (e.g., intense and strict weight lifting schedules, supplement use).

More broadly, one implication of these results is that as a field we may need to expand our theoretical models of eating disorders. Rather than our models specifying that pursuit of a thin body is the driver of all eating disorder symptoms (which is a belief ranging from implicit to explicit in current theoretical models of eating disorders), we may better conceptualize male and female symptoms by specifying that pursuit of any body ideal (thin, muscular, lean, etc.) could lead people to engage in specific eating and exercise behaviors to achieve that ideal. For some people, these experiences may result in clinically significant eating pathology. Such an expansion could bring necessary growth and diversity to our field, and ultimately help us impact more people through more accurately assessing, diagnosing, treating, and preventing eating disorders.

To my mind, one of the most problematic stereotypes about eating disorders is that they are “female diseases.” There is a kernel of truth to this stereotype, as eating disorders do affect more females than males. However, the fact that a sex difference exists doesn’t mean that males don’t develop eating disorders, and it also doesn’t mean that eating disorders present exactly the same in men and women. My hope is that by conducting research like what my colleagues and I did here, we can help the eating disorders field better recognize the similarities and differences between male and female eating disorders, so that we can make sure that we’re providing the most thorough and effective assessment and treatment for all affected individuals.

About the Author: Lauren Forrest, MA is a PhD candidate in clinical psychology at Miami University. She is currently completing her predoctoral clinical psychology internship at Yale University School of Medicine, where she is specializing in dialectical behavior therapy. Lauren’s research seeks to identify why and how eating disorders are maintained and co-occur with other forms of psychopathology. To answer these research questions, Lauren enjoys using various research methodologies and advanced statistical techniques, like network analysis and machine learning methods. For more information about the male eating disorder network study or additional studies, email Lauren at forresln@miamioh.edu.