More than half of the men present-ing for eating disorder treatment at Rogers Memorial Hospital report problematic exercise behaviors. Men are more susceptible than women to elements of excessive exercise, such as a lack of control, increased tolerance, and reduction in alternative activities.24
Signs of excessive exercise include highly structured and repetitive exercise routines that tend to focus more on endurance activities—most commonly, running. Patients will often engage in exercise rather than spend time with family or attend school or work. Furthermore, these patients continue to engage in exercise even when injured or despite being underweight, and they experience increased emotional distress when exercise is limited. Also, excessive exercising tends to occur in isolation, with a tendency to exercise alone or in secret.
Exercise, body image, and weight loss
The relationship between body image and exercise is not destructive if a well-balanced approach to health and personal growth is used. However, in men who do not have a well-balanced approach, there are 2 factors that may increase their risk for an eating disorder. First, they reduce food intake incrementally over time, to the point of very low calorie intake and avoidance of fats and often carbohydrates. Second, exercise activities are not aimed at maintaining strength and muscle mass; rather, there is an increase in time spent in calorie-burning activities. Both activities will accelerate inadequate nutritional intake and weight loss in patients with anorexia nervosa and appetite dyscontrol or patients with binge eating and purging with bulimia nervosa. The focus on body image and muscle definition is achieved through reduced body fat rather than increased muscle mass. Attempts at increasing food intake, and the associated fears of increasing body fat, can trigger exercise behaviors or purging.
Evaluation and treatment
Several studies suggest that men and women have a similar response to treatment.25-27 In general, treatment for males with eating disorders focuses on 3 important factors:
• Setting nutritional goals aimed at normalizing weight (and therefore normalizing physiology and partially reversing physiological changes associated with weight loss), normalizing food intake, reducing the number of feared foods, and reducing behaviors to compensate for eating or fear of weight gain.
• Identifying and challenging errors in thinking about food, weight, and shape using CBT.
• Identifying obstacles to recovery that ideally should be addressed to improve treatment response and ultimately increase the chances of full recovery.These can be grouped together and include other co-occurring Axis I psychiatric conditions, such as affective, anxiety, or substance abuse disorders; adverse treatment experiences; and traumatic experiences, such as sexual abuse or weight-based victimization.
Weight restoration. Nutritional intervention for males with anorexia nervosa involves stopping weight loss, restoring weight, and normalizing eating behavior. The information available to guide us in determining what is normal weight or a weight that maximizes the chances of recovery from anorexia nervosa is greater for females than for males.28 For females, guidelines for determining body weight for recovery include return of normal menstrual function. For underweight male patients, who are susceptible to hypothalamic hypogonadism and osteoporosis, measurements of serum testosterone levels can be imprecise but helpful in assessing nutritional status. Study findings indicate that patient education concerning the negative impact of malnutrition on physical health can be effective in challenging eating disorder beliefs and facilitating treatment progress.29 An adequate weight history, adolescent growth charts, and family characteristics, can also be helpful.