http://orcid.org/0000-0002-5854-6503
Abstract
Objective: The literature on eating disorders in older males is still very limited. We assessed the relationship between aging male symptomatology and eating behavior in middle-aged and older men.
Method: We distributed anonymous questionnaires to men aged 40–75 years living in or near Innsbruck, Austria, covering demographic items, current eating disorder symptoms (as defined by DSM-5), and associated measures of eating pathology, body image, and sports activity (including exercise addiction). We also administered the Aging Males’ Symptoms scale (AMS), and classified respondents as “high-AMS” (AMS score ≥37; N = 82) or “low-AMS” (AMS score <37; N = 386).
Results: High-AMS men reported a significantly higher mean current BMI, a greater prevalence of eating disorder symptoms, higher scores on the Eating Disorder Examination Questionnaire, greater risk of exercise addiction, and more negative body image than low-AMS men.
Discussion: We found a marked association between aging-male symptomatology and eating-disorder symptomatology in aging men. Our findings suggest that clinicians should carefully inquire about eating disorder symptoms in men aged 40 and above reporting aging-male symptomatology. Importantly, several men in the study reported “purging” via excessive exercise (as opposed to the more common methods of vomiting or use of laxatives or diuretics), and therefore this should be a subject of inquiry in clinical evaluations. To pursue these findings, subsequent studies of eating disorders in older men should consider assessing endocrinological measures, particularly testosterone levels, and should use longitudinal designs.
Introduction
Eating disorders have long been studied predominately in young females, but the focus of research has now expanded, particularly since the publication of DSM-5 [Citation1], with studies now examining all ages and both genders. For example, recent studies in females have shown that eating disorders do occur through the life span, with prevalence peaks during adolescence and again in middle age [Citation2]. These peaks appear to coincide with the major hormonal changes occurring in puberty and menopause. Both puberty and menopause are discussed as etiological factors in the aging process in women [Citation3–5], and are likely modulated by other recognized factors, such as body image concerns, traumatic events, attachment styles, and sexual issues [Citation6–8].
The literature on eating disorders in males remains limited. At present, studies suggest that there are few gender differences in core eating disorder symptomatology (binging, vomiting, laxative abuse), but males appear to show more premorbid obesity, higher BMI at various stages of their eating disorders, higher age at initial presentation, and more comorbidity as compared to women [Citation9–12]. Some evidence also suggests that men with eating disorders may idealize a masculine shape rather than only a lean shape in anorexia nervosa; may prefer high-protein and high-fat foods in binging rather than sweets as typically reported by women; and may use “atypical” purging methods such as excessive exercise and extreme dietary restriction, as opposed to vomiting or use of laxatives [Citation11,Citation13–15].
Binge eating disorder and eating disorder not otherwise specified appear to account for the majority of adult male eating disorders [Citation10]. However, the “female-centric” nature [Citation10] of diagnostic classifications and instruments regarding eating disorders likely continues to compromise accurate classification of these conditions [Citation16,Citation17], and may also contribute to shame, denial, and perceived stigma in eating-disordered men [Citation10].
The literature on eating disorders in middle-aged and older males is even more limited. Reas and Stedal [Citation18] reviewed case reports of eating disorders in males aged 40–81 years, describing early onset and premorbid obesity in the majority, with a variable course of illness including diagnostic crossover and symptom fluctuation. Mangweth-Matzek et al., in a community study of 470 men aged 40–75 years [Citation19], found a prevalence of 6.8% for eating disorder symptoms (BMI < 18.5, recurrent binging, binging and purging, purging only) as defined by DSM-5.
No studies, to our knowledge, have assessed the association of eating disorders with aging-male symptoms that are often described in the context of “andropause” [Citation20]. Therefore, we sought to assess the relationship between self-reported aging-male symptoms and eating pathology in men aged 40–75 years. We hypothesized that men reporting high levels of aging-male symptoms would show a higher prevalence of eating disorder symptoms as compared to men with low levels of aging-male symptoms.
Methods
Participants and recruitment
We used data from a study previously described [Citation19], in which we distributed questionnaires to men aged 40–75 years. Men were asked to participate in an anonymous study on “health, eating behavior, and sports activity”. We chose three recruitment groups in order to get an adequate number of participants: (1) 1100 Austrian citizens in the Innsbruck area, randomly selected using Census Bureau data; (2) 400 men at the clinical cafeteria of the Medical University Hospital Innsbruck, representing a wide range of socioeconomic and educational levels; and (3) 70 men responding to an article in the major Innsbruck newspaper, inviting interested readers to participate in the study. The response rate for all 1570 distributed questionnaires was 29.9% (24% of Group 1, 37% of Group 2, and 90% of Group 3). All study procedures were approved by the Ethics Commission of the Medical University of Innsbruck.
Instruments
The questionnaire included questions on demographic characteristics; self-reported body dimensions (height, current and lifetime maximum weight, body mass index [BMI], and weight categories); and current eating disorder symptoms as defined in DSM-5 [Citation1]. We assessed four categories of eating pathology: (a) BMI < 18.5, (b) binge eating at least once per week without purging, (c) binge eating with purging, and (4) purging without binge eating (see detailed definitions of these categories in our previous paper). The questionnaire also included the German versions of the Eating Disorder Examination Questionnaire (EDE-Q, [Citation21]); the Center for Epidemiologic Studies Depression Scale (CES-D, [Citation22]); the Exercise Addiction Inventory (EAI, [Citation23]); and questions regarding body image self-perceptions, adapted from the Eating Disorder Examination (EDE, [Citation24]). In addition, we assessed frequency of regular sports activity (defined as at least 30 min of exercise with elevated pulse and sweating) with response options of less than once per week, 1–2 times per week, or ≥3 times per week. Finally, we asked respondents if they were currently in treatment for a medical or psychiatric condition.
The questionnaire packet also included the Aging Males’ Symptoms scale (AMS, [Citation25]), which assesses 17 symptoms of aging and health-related quality of life in older men. This scale was derived from earlier studies of symptoms associated with male hormonal involution [Citation26,Citation27]. Respondents score the severity of each scale item from 1 to 5, and item scores are then added to generate subscale scores for each of three domains (psychological, somato-vegetative, and sexual), together with a total score. Some evidence suggests that higher AMS scores may reflect reduced testosterone levels, as suggested by a study of testosterone treatment in hypogonadal men [Citation28], and by a study assessing AMS scores in men who had been tested for bioavailable testosterone [Citation29]. This latter study suggested that the AMS exhibited a specificity of 83% and a sensitivity of 39% in the detection of androgen deficiency. The AMS is somewhat analogous to the Menopausal Rating Scale for Women [Citation30], and is one of the most widely used scales for assessing the presence and severity of symptoms possibly associated with male hypogonadism [Citation20,Citation31]. A total score ≥50 is considered to indicate severe aging-male symptomatology; 37–49 is judged “moderate”, 27–36 “little”, and ≤26 “none”. For the present study, we defined men as “high-AMS” if they scored in the “moderate” or “severe” range on the instrument (i.e. AMS score ≥37) and “low-AMS” if they scored “little” or “none” (i.e. AMS score < 37).
Statistical analyses
Statistical analysis was performed using IBM SPSS 22 [Citation32]. First, to assess the homogeneity of the total sample of respondents, we compared the three recruitment subgroups (mailed questionnaire respondents, cafeteria respondents, and newspaper respondents) with respect to AMS scores and to the binary grouping variable (high-AMS versus low-AMS) using the Kruskal–Wallis H-test for continuous variables and the Chi Square test for categorical variables. We then compared high-AMS men and low-AMS men on all study variables using the Mann–Whitney U-test for continuous and ordinal variables (e.g. age, BMI, EDE-Q total score, and subscales), Fisher’s exact test for dichotomous variables, and the Chi-square test for all other categorical variables (e.g. level of exercise activity, questions on body image, and self-perception).
Results
On the AMS subscale scores and total scores, and on the proportion of men scoring in our defined AMS ranges, the three recruitment subgroups of men showed no significant differences (). This finding was consistent with the findings from our previous paper [Citation19], which had demonstrated that the three subgroups were similar on all of the other principal outcome variables as well. Accordingly, we pooled the three recruitment subgroups for our subsequent analyses.
Table 1. Characteristics of the three recruitment groups of questionnaire respondents on the Aging Males' Symptoms scale (AMS).
Comparing the 82 (18%) more symptomatic (high-AMS) men with the 386 (82%) less symptomatic (low-AMS) men, we found the two groups similar in demographic features, dieting behavior, and frequency of sports activity (). High-AMS men showed significantly higher CES-D depression scores, more frequent reports of currently receiving medical or psychiatric treatment, and higher current BMI and lifetime maximum BMI compared to the low-AMS group. These differences were expected, because depression, medical treatment, and weight were items that contributed to AMS scores as well. Notably, however, the high-AMS men also showed a significantly higher prevalence of current eating-disorder symptoms, higher EDE-Q scores, and more negative attitudes towards body image (even after adjustment for current BMI) than the low-AMS men. The most prevalent symptoms in the high-AMS men were binging and purging, or purging only. The high-AMS men also displayed higher mean scores on the Exercise Addiction Inventory, with a greater proportion of these men scoring as “symptomatic” or “at risk” for exercise addiction as compared to the low-AMS group.
Table 2. Characteristics of men scoring “high” versus “low” on the Aging Males' Symptoms scale (AMS).
Discussion
We assessed the association of aging male symptomatology with eating pathology and related characteristics in 470 men aged 40–75 years. The subgroup of 82 (18%) men reporting high levels of symptoms on the Aging Males’ Symptoms scale (AMS) reported a markedly greater prevalence of eating disorder symptoms, higher scores on measures of eating pathology and body-image pathology, and possibly an increased risk for exercise addiction – even in comparisons adjusted for current BMI. Collectively, these findings suggest that aging male symptomatology may be associated with eating disorders and related symptomatology in men aged >40 years.
Several possible pathways might account for this association. On the one hand, given evidence that high AMS scores may reflect low testosterone levels, as discussed above [Citation28,Citation29], one might hypothesize that hypogonadism plays a causal role in the development of eating disorder symptoms among older men, because either (a) hypogonadism directly causes eating disorder symptoms or (b) hypogonadism causes other aging-male symptoms, which in turn contribute to eating disorder symptomatology. An alternative hypothesis is that the observed association between aging-male symptoms and eating-disorder symptoms is attributable to some other common underlying factor (e.g. depression, midlife crisis). The present preliminary study cannot discriminate among these hypotheses because we did not measure serum testosterone levels and we utilized a cross-sectional design. Subsequent studies of these phenomena should assess testosterone levels and use a longitudinal design to better delineate the possible causal pathways underlying the association that we have observed.
Our findings suggest that clinicians should carefully inquire about eating disorder symptoms in men aged 40 and above reporting aging-male symptomatology. Also, since some men in our study reported “purging” via excessive exercise (as opposed to the more common methods of vomiting or use of laxatives or diuretics), this should also be a subject of inquiry in a clinical evaluation.
Several limitations of the study should be recognized. First, we used three separate recruitment techniques to secure an adequate sample for the study. Although the three resulting subgroups yielded similar results on virtually all of the questionnaire items, including the AMS, this finding alone does not ensure that the subgroups represented a common reference population, and thus our decision to combine the subgroups for data presentation must be regarded with appropriate caution.
Second, our overall response rate was low, with only about 30% of individuals returning their questionnaires. Thus, the findings are potentially vulnerable to selection bias. However, as noted in our previous paper describing this study sample [Citation19], respondents resembled Austrian men overall on several demographic indices – offering some reassurance that the sample was representative of its source population. Moreover, even if there were substantial selection bias overall, this would still not affect the validity of our comparisons between high-AMS and low-AMS men within the respondent sample, barring the unlikely possibility that there existed differential selection bias associated with the outcome variables of interest (e.g. that high-AMS men with eating pathology would be, say, less likely to return the questionnaire than low-AMS men with the same degree of eating pathology). Third, we did not assess sexual orientation in our respondents, which is a well-recognized factor in male eating disorders [Citation11,Citation33,Citation34] and which should be considered in future studies. Fourth, we did not attempt to assess the age of onset of eating disorders in our respondents, primarily because we were assessing only core eating disorder symptoms, rather than full eating disorder diagnoses on our questionnaire. Finally, we would note that questionnaires regarding eating disorders tend to be designed primarily for use in women. We did not attempt to change or adapt these instruments for our male population, and this consideration must be borne in mind when interpreting our results.
Despite the above limitations, our findings suggest a prominent association between aging male symptomatology and symptoms of eating disorders and related pathology. Studies using endocrinological measures and longitudinal designs would help to elucidate the causes of this association.
Acknowledgements
The study was supported by the Public Health Services of the City of Innsbruck (Austria).
Disclosure statement
No potential conflict of interest was reported by the authors.
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