ED Cis Males

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Accanto Health | 2021 1

Hiding in Plain Sight:
Eating Disorders in Cis Males
Anna B. Tanner, MD. FAAP, FSAHM, CEDS-S
Vice President, Child and Adolescent Medicine
Accanto Health, the parent company of The Emily Program, Veritas

Collaborative, and Gather Behavioral Health, is the sole planner and
provider of all courses, content, and continuing education credits.
This program is made possible with support from The Emily Program
Foundation.
Confidential | Accanto Health | 2022 z
Disclosures
• I am an employee of Accanto Health, the parent company of
The Emily Program, Veritas Collaborative, and Gather
Behavioral Health.
• I have no other financial disclosures.
3
Confidential | Accanto Health | 2022
Learning Objectives
1. Name one eating disorder behavior that is seen more
commonly in males than females
2. Name one medical complication that is unique to males with
restrictive eating disorders
3. Name one factor that may decrease identification of males
with eating disorders

Past Understanding
• Strother et. al., 2012, Eat Disord
• Males with eating disorders were often
– Underdiagnosed
– Undertreated
– Misunderstood

Research Gap
• Until recently, most research was primarily about cis
women with eating disorders
• Led to major gaps in knowledge and research
• Males were systematically overlooked in eating disorder
research
• Only 26% of PubMed papers on anorexia nervosa from
1900-2010 included males (Warren)

Past Research
• Murray et. al., 2017, Clin Psychol Rev
• Historically eating disorders were perceived as a rare and
atypical in males
• Males have been underrepresented in research
• Impacted clinical practice
• Stigmatization and treatment non-engagement are more
likely

Improving Knowledge
• Sangha et. al., 2019, Am J Mens Health
• Scoping review (articles published 2008 to 2018)
• Identified 568 articles but only 15 empirical studies with a
primary focus on eating disorders in men
• Evidence that eating disorders are an “emergent” issue in
men’s health
• Can no longer presume that males are a negligible
proportion of eating disorders patients
• Void in knowledge contributes to inability to provider
targeted clinical care

Males with Eating Disorders
• Nagata et. al., 2020, Curr Opin Pediatr
• Males have different body image concerns that drive
unique behaviors especially involving muscularity
• Some male populations may be at higher risk of eating
disorders and disordered eating behaviors including
athletes and racial/ethnic, sexual and gender
minorities
• New measures are available to assess behaviors
unique to males
• Medical management guidelines are inadequate for
males, especially for adolescent boys and young men

Decreased Gender Bias in DSM-5
• Revised diagnostic criteria that may have
made diagnosing males less likely
• Such as removal of amenorrhea criteria for AN
• Added new diagnoses that capture eating
disorders often recognized in males
• Such as ARFID and BED
• Incorporated diagnoses that decreased weight
bias which may be more important in
diagnosing males
• Such as inclusion of Atypical Anorexia Nervosa
➢ Changes may have called more attention to

eating disorders in males 10
Prevalence of Eating Disorders
• Galmiche et. al., 2019, Am J Clin Nutr
• Reviewed 94 studies published from 2000 to 2018
• Used 33 selected studies
• Weighted means for lifetime ED
• 8.4% in women
• 2.2% in males
• By diagnosis
• AN 1.4 % for women and 0.2% for men
• BN 1.9% for women and 0.6% for men
• BED 2.8% for women and 1.0% for men
• 12-month prevalence ranges
• 2.2% for women and 0.7% for men
Addition of BED Brings Attention to Males
• Addition of BED as a diagnosis increased attention to eating
disorders in males
• Found that proportion of males reporting a lifetime prevalence
of BED was far greater than AN or BN
– Lifetime prevalence of BED 2% in males
– Some studies show up to 40% of sufferers are men
• These numbers still likely under-report male prevalence
– Males may be less likely to disclose their disorder
– Males may be less likely to access treatment

ARFID Has Also Increased Attention
• Addition of ARFID as a diagnosis also has increased attention
to eating disorders in males
• Overall, cases of ARFID represent about 15% of new eating
disorder cases presenting for treatment
• 20-30% of ARFID patients are male
• These numbers are interesting because these patients often
come to care from concerned parents or providers
– Mean age of diagnosis is 11 years old

Medical Concerns of ARFID
• Presents as limited volume or variety of food
• Can lead to serious medical consequences
– Weight loss and/or growth deceleration
– Nutritional deficiencies
– Dependence of tube feeds or supplements
• Serious medical complications from ARFID have brought
increasing numbers of males into eating disorders care
– May at times need acute medical stabilization
– May present as dependent on tube feeds or supplements
– Additionally, patients may present with significant nutritional
deficiencies and not be underweight

Why are ARFID and BED important to
diagnosing EDs in males?
• Patients are
– Presenting at more similar incident rates
– Presenting with more similar symptoms
– Presenting without focus on body image issues (ARFID)
– Presenting with less focus on presentation weight
– Presenting across a range of ages
– Presenting with significant medical complications across all
• Diagnoses
• Genders
• Ages
• Weights
Removing diagnosis/gender/age/weight bias may
improve recognition of EDs in males
Prevalence in Males
• Ward et. al., 2019, JAMA Netw Open
– Modeling study
– Estimated lifetime prevalence by age 40 years
– Demonstrated eating disorders are very prevalent in males
• 1 in 5 women
• 1 in 7 men
– Initial age at onset highly concentrated in adolescence and
young adulthood
16
Estimated prevalence
• 10 million boys and men in the USA will experience an eating
disorder some time in their life.
• In Canada and in the UK, statistics show males are 20-25% of
cases

Screening for Eating Disorders in Males
• Darcy et. al., 2012, Int J Eat Disord
• Explored the use of the Eating Disorders Examination (EDE)
• Compared 48 adolescent males to 48 adolescent females with
eating disorders
• Found that the males with anorexia nervosa had
– Lower global scores
– Scored lower on shape and weight concerns
– Scored significantly lower on core symptoms such as a desire to
lose weight
• Suggested that more research was needed to understand the
experience of adolescent males with eating disorders

Screening for Eating Disorders in Males
• Smith et. al., 2017, Int J Eat Disord
• Looked at 386 males and 1487 females
• Patients completed the EDE-Q and EDI-3
• Females scored greater severity for eating disorder
psychopathology
• Example question from EDE-Q, “Have you had a definite desire
to have a totally flat stomach?”
• Unclear if due to differences in presentation or differences in
eating disorders
• Identified:
• Need to look at differences in presentation
• Need to develop male specific eating disorder measures

Remember
• Current eating disorders measures are not gender neutral
• Current eating disorders measures were developed for females
and may miss aspects of male psychopathology

Male Specific Assessment Tool
• Stanford and Lemberg, 2012, Eat Disord
• Eating Disorder Assessment for Men (EDAM)
• Assesses for
– Muscle dysphoria
– Body dissatisfaction
– Preoccupation with food
– Binge eating
– Disordered eating
• Correctly predicted an ED in 82% of men

Symptom Presentation Differs
• Unique presentation considerations in males may include:
• Concern for the muscular ideal
• Use of anabolic steroids
• Use of the “cheat meal”
• Presence of exercise compulsion
22
Muscularity and Disordered Eating
• Murray et. al., 2016, Br J Psychiatry
- In males, body dissatisfaction is a key risk factor for eating
disorder pathology
- Body dissatisfaction in males is typically characterized by a
drive for muscularity
- The “ideal male” has become increasing muscular
23
Social and Cultural Influences
• Media and popular culture emphasize lean and muscular body
image ideals
– Television
– Movies
– Magazines
– Computer games
• May promote body dissatisfaction and muscle dysphoria
• Across the age spectrum
– Adolescents struggle to achieve the perfect body
– As men age, they struggle to maintain this

Muscularity concerns
• Glazer et. al., 2021, J Adol Health
• Prospective assessment of 4,489 US males aged 11 to 18 years
• Although less than 1% met diagnostic criteria for BN, BED or
PD at the start of the study, one quarter reported weight
concerns during follow up
– Almost all patients with concerns had muscularity concerns
– Often in addition to a preoccupation with thinness
– This ideal image drives use of anabolic – androgenic steroids
– 11% of patients engaged in the use of muscle building products
– Product use was more common than bulimic behaviors

Impact of Muscular Ideal in Boys
• Natterson, 2019, NY Times
• “Adolescent boys suffer from unrealistic beauty standards too”
- Boys feel body pressure too
- But it takes years for testosterone to turn them into men
- And during adolescence, boys get quiet

Muscularity Oriented Eating Test (MOET)
• Murray et. al., 2019,
Int J Eat Disord
• Noted that eating
disorder symptoms
may be related to
muscularity
• Developed tool to
assess behaviors
around muscularity
and leanness
27
Use of Anabolic Androgenic Steroids
• Murray et. al., 2016, Drug Alcohol Depend
• Anabolic androgenic steroid (AAS) use is associated with
• Negative body image
• Muscularity related psychopathology
• Found that men whose AAS use is driven primarily by
appearance related concerns may be “particularly
dysfunctional”
• Men using AAS for appearance purposes
• Reported greater overall eating disorder psychopathology
• Exhibited greater dietary restraint

Binge Eating Behaviors
• Pila et. al., 2016, Int J Eat Disord
• Looked at over 600 meals posted on Instagram with
#cheatmeal tag
• 54.5% were very large quantities
• 71.3% were calorie dense
• Met criteria for a binge episode
• Additionally, there was an
• Idealization of over consumption
• Strict commitment to fitness
• Reward-based framework around diet and fitness
29
Compulsive Exercise
• Murray et. al., 2013, Advances in Eating Disorders: Theory,
Research and Practice
• Looked at 27 males and 24 females with AN
• Males in the study:
• Reported significantly higher compulsive exercise pathology
• Endorsed more rigid and repetitive exercise habits than females
• Exercise for males:
• May serve an emotional regulation function
• May lead to increased treatment resistance
• May have difficulty in achieving an overall relaxation of rigid and
repetitive cognition and behavior
• Recommended that clinicians treating males pay attention to
the severity and presence of compulsive exercise

Eating Disorder Behaviors in Males
• Restriction
• No differences in extreme caloric restriction and fasting between
adult males and females
• However, reports of extreme restriction are lower in adolescent
males
• Purging
• Vomiting and laxative use are less prevalent in males
• Excessive exercise is equally prevalent, if not higher
• Binge eating
• The most common eating disorder behavior in males
• Prevalence similar to females
• Selective eating
• Common in males
• Prevalence of low variety similar to females

Male Populations at High Risk
• Some male populations may have higher risk of developing an
eating disorder:
– Males with history of higher BMIs
– Non-white adolescent boys
– Gay and bisexual males
– Male athletes
– Psychiatric comorbidities

History of Higher BMIs
• Increased risk of eating disorders in males with prior history
of higher BMIs
• Increased risk if higher BMI was present in childhood
• Driven by a desire to avoid being teased about weight be
peers
• Nagata et. al., 2018, J Gen Int Med
• 15% of young men with a BMI > 25 engaged in disordered
eating behaviors
• 8% of young men with a BMI < 25 engaged in disordered
eating behaviors
33
Differences Across Racial and Ethnic Identities
• Rodgers et. al., 2017, Int J Eat Disord
– Adolescent population study in Minnesota
– Disordered eating may be very prevalent
• Disordered eating behaviors seen in
– 43% of Asian boys
– 38.5% of Black boys
– 35% of Hispanic boys
– 33% of white boys

Gay and Bisexual Males
• Calzo et. al., 2018, Eur Child Adolesc Psychiatry
– Adolescent boys who identified as gay or bisexual had
greater odds of
• Dieting behaviors
• Binge eating behaviors
– Higher rates of body dissatisfaction
– Higher rates of pressure to increase muscularity
• Nagata, et. al., 2020, Eur Eat Disord Rev
– Elevated eating disorder attitudes and behaviors in
cisgender gay men compared to the general population of
men

Risk with Sports in Males
• Increased risk for eating disorders with sports that
– Emphasize appearance
– Emphasize weight requirements
– Emphasize muscularity
– Focus on the individual
– Focus on endurance

Elite Male Athletes
• Karrer et. al., 2020, BMJ Open Sport Exerc Med
• Review of 80 studies
• High prevalence of disordered eating and eating disorders in
male elite athletes
• Prevalence rates up to 32.5% were found in adult male
athletes

Sports at High Risk for Male Eating Disorders
• Bodybuilding
• Distance Running
• Diving
• Gymnastics
• Swimming
• Wrestling

How did your problems begin?
• Sport performance a far more common avenue for boys
(60%) than girls (10%)
• Males may be pressured to lose or gain weight to maximize
athletic performance

Relative Energy Deficiency in Sport (RED-S)
• IOC redefined Female Athlete Triad in 2014
– Redefined as Relative Energy Deficiency in Sport (RED-S)
– Could include male athletes
• Energy deficiency relative to the balance between:
– Energy intake in the form of food
AND
– Energy expenditure for activities of daily living, healthy
body functions, growth and sports activities
• Identified that for male athletes, important to focus on
behavioral signs
– Males lack loss of menses as a marker
– For males, medical concerns can present later

Comorbidities that May Increase Risk
• Psychiatric conditions that may increase risk for males
– Depression
– Anxiety
– OCD
– Mood disorders
• Personality traits that may increase risk
– Perfectionism
– Low self-esteem
• Presence of substance use disorders
– Men with eating disorders are two times more likely to
have a co-morbid substance use disorder

Break

Medical Complications in Males
• Raevuori et. al., 2014, Curr Opin Psychiatry
• Overview of published studies in males with eating disorders
• Males with AN-R presented at higher ages
• Males had higher premorbid weights and BMIs
• Males presented with lower BMIs
• Males were more likely to have fatal outcomes
• Why?
43
Higher Mortality in Males with AN
• Quadflieg et. al., 2019, Int J Eat Disord
– Looked at patients treated on IP ED unit in Germany from 1985 to 2017
• 147 with AN, 81 with BN, 110 with ED-NOS
• Average age at admission was 27 (AN) and 33 (BN and ED-NOS)
• Average age of illness onset was 21 (AN), 20.6 (BN) and 21 (ED-NOS)
– Deaths observed (crude mortality rate)
• 19 males with AN (CMR of 12.9%)
• 9 males with BN (CMR of 11.1%)
• 7 males with ED-NOS (CMR of 6.4%)
• Mortality in males with AN was 6x higher than reference population
• Males with AN died sooner after the onset of the eating disorder than
males with BN or ED-NOS (13 vs 32 years)
• Mortality in male inpatients with eating disorders is high

Why might mortality be higher in males?
• Males may have increased risk related to detection and
treatment especially with restrictive illnesses
– Presenting symptoms may be different in males
• May be missed/elude detection
• May be more reluctant to seek treatment (stigma,
shame)
– Presenting later in illness may increase risk and severity of
medical complications
• Treatment may be less effective for chronic and
advanced symptoms
• May contribute to increased morbidity and mortality

Why might medical guidelines be inadequate?
• Medical guidelines lack unique criteria for males
– BMI
– Weight suppression
– Evaluation of hormone status
• Medical risk criteria lack unique criteria for males
– Acute medical stabilization
– Risk of refeeding syndrome

Minnesota Starvation Experiment 1945

Effects of Extreme Weight Loss
• Keys et. al., 1950, The Biology of Human Starvation
• Physical and psychological effects of extreme weight loss
• Nutrition directly affects mind as well as body
• Starvation dramatically alters personality
• Irritability and neurologic deficits
• Obsessional thinking about food and weight
• Human body is mutable
• Changes in heart rate and blood pressure
• Anemia and edema
• Fatigue and extreme weakness
• Recovery from malnourished state is a long-term process physically
• Psychological manifestations of altered hunger/fullness cues and
deprivation are longer lasting

Medical Complications of Eating Disorders
• Eating disorder medical complications are directly related to
behaviors:
• With restriction, complications relate to severity and
duration of starvation
• With purging, complications relate to method and duration
of purging
• However, with males remember that compulsive exercise
is a common form of purging
• May exacerbate complications of restriction
• May not be recognized as an eating disorder behavior
• No loss of menses as a marker of excessive exercise

Medical Complications of Restriction in Males
• Eating disorders can affect every organ system in the body
• With restriction, medical complications related to starvation
predominate
• Cardiovascular complications
• Electrolyte issues
• Hematologic issues
• Gastrointestinal complications
• Endocrine issues
• Males with restrictive eating disorders have been shown to
have many medical complications similar to females
• However, male patients may have some unique medical
complications

Implications for Medical Management
• SAHM position paper, 2022, J Adolesc Health
– Boys and men with restrictive eating disorders are underdiagnosed
– Distinct clinical presentations have implications for medical
management
• Recommendations
– Medical providers should recognize that restrictive eating
disorders occur in boys and men.
– Medical providers should recognize that boys and men with
restrictive EDs have
• Distinct clinical presentations
• Distinct medical complications
• Distinct considerations for medical management
51
Unique Medical Considerations for Males
• Males with restriction may have unique risk for:
• Cardiovascular complications
• Decreased bone density
• Impaired linear growth
• Increased refeeding risk

Complications of Starvation: Cardiovascular
• Severely malnourished patients lose heart mass
• Sinus bradycardia very common
• Associated with hypotension and hypothermia
• Not an athletic heart, a starving heart
• Reduced exercise capacity
• Improves with weight restoration
• At risk for sudden death
• Likely associated with low heart rate variability
• At risk for congestive heart failure
• Decreased heart mass leads to decreased cardiac output

Cardiovascular Risk for Males
• Vo et. al., 2016, J Adolesc Health
• Over half of boys presenting with eating disorders met SAHM
criteria for acute medical stabilization
• 39% had bradycardia
• 12% had orthostatic heart rate changes
➢ Factors that may put males at increased cardiovascular risk:
• Low heart rate in males may be more likely to be attributed
to an athletic heart
• Males more likely to have compulsive exercise
• No loss of menses to indicate that bradycardia is secondary
to weight loss

Complications of Starvation: Hematologic
• Nagata et. al., 2022, Eat Weight Disord
– Reviewed charts of 601 medical admissions to UCSF
– Results included 87 males, 450 females
– Greater percentage of males had anemia at presentation
• 50% males, 17.6% females
– Important to note
• Average adolescent male hematocrit/hemoglobin higher
than adolescent female
• Symptoms of anemia include tiredness, weakness,
dizziness, shortness of breath and irregular heartbeat
➢ Could worsen some cardiovascular symptoms

Complications of Starvation: Endocrine
• Impact on Hormone Function
• Males may have decreased serum testosterone levels
• May be less often assessed clinically
• Impact on Bone Health
• Many clinical guidelines still use amenorrhea as criterion to
assess bone health
• May be more important to look at duration of illness for bone risk
in males
• Impact on Linear Growth
• Males may be at higher risk for impact on linear height
• Age of illness onset and pubertal timing important

Impact on Hormone Function
• With restrictive eating disorders
– Down regulation of HPG (hypothalamic-pituitary-gonadal) axis
– For males results in decreased serum testosterone levels
• Providers may be less likely to assess clinically
– Asking about symptoms of testosterone function is less common
(libido)
– Asking about symptoms of estrogen function are standard (menses)
• May need to get blood levels to assess adequately
– LH, FSH
– Testosterone (free and total)
• Decreased testosterone levels can result in:
– Delays or cessation of pubertal development
– Decreased sexual function
– Impact on peak bone mineral density
• Testosterone levels normalize with weight restoration

Assessing Hormones in Males
• Nelson et. al., 2021, Int J Eat Disord
– Survey of 104 clinicians
– Less likely to evaluate HPG suppression in male than female
patients with eating disorders
• Less likely to assess SMR (sexual maturity rating)
• Less likely to assess libido (compared to amenorrhea)
• Less likely to check labs (testosterone, LH, FSH)
– Clinicians felt less confident evaluating male hormone function
• Requested better screening tools for males
• Researchers concluded that more guidance is needed to
standardize care for male patients

Impact on Bone Health
• Mehler et. al., 2008, Int J Eat Disord
• Reviewed charts of 70 consecutive male patients
• Compared charts of male patients to females admitted
during the same time period
• 36% of the males had osteopenia of the spine
• 26% of the males had osteoporosis of the spine
• Saw more osteoporosis in males with
• AN-R or AN-B/P diagnosis
• Older ages
• Lower weights
• Longer illness duration
• Increased risk of low bone density predicted by lower BMI
at presentation and longer illness duration
Bone Density in Males
• Schorr et. al., 2019, Clin Endocrinol (Oxf)
– Study on adult men across ED diagnoses
• Demonstrated low bone mineral density (BMD)
– Defined as BMI Z-score < -2 at one or more sites
• 65% of men with anorexia nervosa
• 33% of men with atypical anorexia nervosa
• 18% of men with ARFID
– Factors associated with lower BMD
• Longer illness duration
• Lower BMI
• Low muscle mass
• Low vitamin D levels

Factors Impacting Bone Density in Males
• Decreased bone accrual
• Dysregulation of reproductive hormones
• Impact of stress hormones
• Decreased mechanical loading due to decreased body mass
• Developmental trajectory of bone is disrupted
• 40-60% of peak bone mass normally accrued during adolescence
• 90% of peak bone mass accrued by 20 years of age
• Bone deposition improves with weight restoration and
balanced nutrition, however bone loss may not reverse in
adolescents
• Bisphosphonates may be indicated in males, but only if
testosterone levels are normal

Vitamin D Deficiency
• Nagata et. al., 2022, J Eat Disord
• Retrospective review of patients ages 9-25 admitted for
medical instability
– 93 males, 472 females
• Serum vitamin D level was assessed at admission
– Results for males
• 44.1% had 25-OH Vitamin D level < 30 ng/ml
– Only 1.9% of female patients had levels < 12
• Vitamin D levels are important for bone health
62
Bone Loss in Adolescents is Not Reversible
• Mumford et. al., 2019, J Adolesc Health
• Persisting negative effects on bone health despite recovery of
body weight in adolescents
• Reduced cortical and trabecular bone
• Reduced bone at femoral neck and arms
• Subset of patients with multiple fractures

Impact on Linear Height
• In older adolescents and adults
• Growth is finished
• The body does not have the option to halt or slow growth
when faced with energy insufficiency
• Will see other medical complications as starvation impacts
organ systems
• In children and young adolescents
• Growth is not complete
• The body can slow or halt growth or puberty to conserve
energy
• May see less compromise of other organ systems

Increased Impact on Males - Males Grow Later
• Modan Moses et. al., 2003, Pediatrics
• Males may be at increased risk
• Growth spurt occurs later in male puberty
• Males grow for two years longer

Increased Impact – Male Growth Spurt
Girls Boys
Take off – Take off –

9 years old 11 years old
Peak height Peak height

velocity- velocity-
Age 11 years old Age 13 years old
3.7 inches/year 4.3 inches/year
Tanner stage 2-3 Tanner stage 3-4
Growth spurt Growth spurt

17% of final 18% of final
height height
Up to 13 inches Up to 14 inches
of final height of final height
Confidential | Accanto Health | 2022 - Weintraub, 2010, Pediatr Rev 66
Catch up Growth in Males
• Swenee, 2013, Eur Eat Disord Rev
• Followed weight gain and growth in 46 boys for 1-3 years
• 13 boys who had not started the pubertal growth spurt
• Started catch up growth immediately after nutritional
rehabilitation and weight gain
• After 3 years they had returned to their premorbid growth
curve
• 33 boys who had started their pubertal growth spurt prior to
presentation
• Never caught up in height despite weight gain
• After 3 years they were 4.5 cm shorter than predicted height

Growth in Males with ARFID
• Patients with ARFID may have stunted growth
• May have chronic issues with volume
• Slow growth may not be detected
• Need to assess growth compared to genetic potential
• Need to set weight goals based on expectations for growth,
genetic potential and pubertal development
• Patients who are underweight may need to work on volume
before variety

Complications Worsened by AAS Use
Possible Health Consequences of Anabolic Steroid Misuse in Men
Musculoskeletal system Cardiovascular system
• Short stature (if taken by adolescents) • High blood pressure
• Tendon injury • Blood clots
Psychiatric effects • Heart attacks
• Aggression • Stroke
• Mania Hormonal system
• Delusions • Decreased sperm production
Skin • Enlarged breasts
• Severe acne and cysts • Shrinking of the testicles
• Oily scalp and skin • Male-pattern baldness
69
Complications of Starvation: Metabolic
Javier D. Macias-Toro et. al, “Hydroelectric Disorders secondary to

refeeding syndrome”, Nefrologia (English version), 2013, Vol 33, 279-81.

NICE Criteria for Refeeding Syndrome
For determining patients at high risk for refeeding problems
• Patient has one or more of the following:
– BMI less than 16 kg/m2
– Unintentional weight loss greater than 15% within the last 3-6 months
– Little or no nutritional intake for more than 10 days
– Low levels of potassium, phosphate or magnesium prior to refeeding
• OR Patient has two or more of the following:
– BMI less than 18.5 kg/m2
– Unintentional weight loss greater than 10% within the last 3-6 months
– Little or no nutritional intake for more than 5 days
– A history of alcohol abuse or drug use including insulin, diuretics,
chemotherapy, or antacids

Assessing Refeeding Risk in Males
Male with BMI 16 has z-score -3 Female with BMI 16 has z-score of -2
➢ NICE Criteria Based on BMI not BMI Z-score

➢ May put males at increased risk for later detection of risk of
refeeding syndrome
72
ASPEN Consensus Recommendations, 2020
• da Silva et. al., 2020, Nutr Clin Pract
• May improve detection of refeeding risk in males
• For adolescents, risk of refeeding syndrome based on
– BMI Z-score
– Weight loss is defined as gaining less weight than expected
– Low energy intake is defined as less intake than estimated need
• For adults, risk of refeeding syndrome is based on
– BMI
– Percentage weight loss
– Low caloric intake is defined as less than estimated energy
needs

ASPEN Criteria for Pediatric Patients 2020

ASPEN Criteria for Adult Patients 2020

Implications for Medical Management
• SAHM position paper, 2022, J Adolesc Health
– Adolescent males have greater energy requirements than
females
– However, many refeeding protocols are not gender specific
• Nagata et. al., 2022, Int J Eat Disord
– 588 adolescents admitted to UCSF for medical management
• 16% of admitted patients were male
– Prescribed calories on day of admission were often the same
• However, males had higher estimated energy requirements
– Males had
• Longer lengths of stay
• Greater weight changes
• Higher kcals at discharge
76
Future considerations for Refeeding
• Nagata et. al., 2022, Int J Eat Disord
• Males may need individualized approaches
• Males at risk for longer lengths of medical admission:
– Older age
– Lower admission weight
– Low prescribed kcal at admission
– Lower heart rate at admission
• Additional requirements for improved nutritional
rehabilitation of males
77
The Initial Medical Assessment for Males
• Obtain Weight and Height
– If under age 18, obtain growth charts and evaluate growth
• Calculate BMI
– If under age 18 yo, calculate BMI Z-score
• Obtain vital signs
– Orthostatic heart rate and blood pressure
– Temperature
• Consider lab studies
– Complete blood count
– Electrolytes, liver function tests
– Thyroid function tests
• Evaluate hormone function
– Assess pubertal status (history, SMR)
– Ask about symptoms of testosterone function
– Check labs (LH/FSH, Testosterone levels)
• Consider additional studies
– Electrocardiogram
– Urinalysis
– Bone density
The Initial Medical Plan for Males
• Assess for unstable vital signs
– Do not miss low HR
• Assess for risk of refeeding syndrome
– Look at energy intake compared to need
• When medical stabilization/refeeding is required
– Approach refeeding with an individualized approach
– Remember that males may have higher energy needs
• Assess for growth potential
– Primary goal is to reestablish normal growth and development
• Assess for risk of low bone density
– Consider DEXA especially in males with long illness duration
79
“For too long, we have depended on presentation weight to
guide our clinical concern in patients with restrictive eating
disorders. Indeed, low presentation weight is an evidence-
based predictor of risk in AN. However, it is based on a
body of evidence that does not fully represent the
diversity in shape, size, race, ethnicity and gender of our
patient population today.”
- Garber, 2018, J Adol Health

Future Considerations
Nagata, et. al., 2020, Curr Opin Pediatr
❖ Males with eating disorders have unique body
image concerns and eating disorder behaviors
➢ Future research should continue to evaluate
male-specific screening tools
❖ Males with eating disorders have unique medical
concerns
➢ Future research should help develop male-
specific treatment guidance
❖ Males with eating disorders may have unique
needs not met in current treatment environments
➢ Future research should help develop male-
specific interventions
81
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Take off – Take off –

Peak height Peak height

Growth spurt Growth spurt

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➢ NICE Criteria Based on BMI not BMI Z-score