A comparison between young males and females with anorexia nervosa in a clinical setting

Abstract

Background

Knowledge of eating disorders in young and adolescent males is sparse.

Aim

To investigate clinical presentations in males and females with anorexia nervosa (AN).

Methods

Using a retrospective case-control design, data were collected from case records for 41 males diagnosed with AN. Data for a comparison group of 41 females with AN were collected, matched to the males by age and date at admission. The collected data covered demographic, medical, psychiatric, and treatment information.

Results

No differences were found between the sexes in the percentage of expected weight (%EBW) at admission or discharge, or in psychiatric comorbidity. Treatment duration was equal for both sexes, but males received fewer treatment sessions than did females.

Conclusion

These results indicate that the clinical presentations of young males and females with AN were very similar in terms of clinical characteristics.

Impact Statement

• What is already known about this subject? Research on AN in male children and adolescents is sparse. Previous studies comparing male and female patients with EDs have found both differences and similarities between sexes.

• What does this study add? This study found few differences in terms of clinical presentation of AN between the sexes.

Keywords:

• Anorexia nervosa
• sexes
• retrospective record study
• eating disorders

Introduction

Anorexia nervosa (AN) is a serious psychiatric disorder that usually has its onset in late childhood or adolescence. AN is a restrictive eating disorder (ED) that can impair physical health as well as social, emotional, and cognitive development, with an impact on identity and self-concept [1]. AN is characterized by severe disturbances in eating and weight-regulating behaviors, initially often due to body dissatisfaction and the patient’s over-evaluation of the need for a specific body shape or weight [2]. The diagnostic criteria for AN are underweight, a drive for thinness, a persistent behavior that interferes with weight gain, and disturbed body perception [3]. These characteristic features are often considered gender specific, which may contribute to the assumption that AN expresses itself differently in males compared with females.

Over the last 40 years, scientists have studied gender differences in EDs, suggesting that there are more similarities than differences between the sexes, but studies have often used small samples and limited data [4]. Previous studies have estimated the proportion of males in the ED population to be around 10% [5], but a nationwide study from the USA in 2007 suggested that 25% of the ED population are males [6]. Males present different characteristics compared with females concerning their perception of body weight and shape [7], being more likely to focus on building muscles in the upper part of the body [8,9]. Findings conclude that females are more likely to strive to be thin than are males, but a recent study concluded that there were no gender differences when muscularity concerns were measured [10]. However, research on EDs in young males under age 18 is sparse. Existing findings confirm more similarities than differences between males and females with ED [4]; for example, both males and females experience similar psychological impairments in their social life when afflicted by EDs [10], but males are more likely to focus on functional aspects of their body [11], rather than on aesthetics [12]. A study from 2015 based on a large clinical database examined psychiatric comorbidities in males and females with an ED, finding that almost 70% presented with at least one psychiatric comorbidity [13].

Adolescence, when AN often has its onset, is a period in life when the individual undergoes many challenges. At this time, physical changes (e.g. in height, weight, body composition, and body fat distribution) appear differently between males and females [14]. Such changes can give rise to body dissatisfaction, which is one of many risk factors for developing an ED [15]. Weight-regulating behavior and restrictive food intake are also symptoms usually present at the start of AN, which can result in severe medical consequences and delayed puberty [16]. Females with pre-pubertal onset of AN and primary amenorrhea are at risk of stunted growth; males with long-standing malnutrition run the same risk of stunted growth [17,18].

Only a few studies have examined treatment of adolescent males with EDs. A review of 18 studies of short- and long-term outcomes in males with AN faced methodological challenge [19] as several aspects of treatment and the reported results differed between the reviewed studies, for example, follow-up length, outcome definition, and mortality rate. These methodological differences between studies make it hard to compare their findings in a meaningful way. A retrospective cohort study of sex differences in outcome found that males recovered more quickly [20], and similar results concerning outcomes in males compared with females were found in a 2021 study in which no sex differences were found in baseline ED symptoms [21].

In an interview study of male perceptions of causes of illness and recovery [22–24], males’ perceptions of causes were attributed to body dissatisfaction, self-dissatisfaction, family climate, and stressful events [23]. Associated factors contributing to their recovery were body acceptance, a more relaxed attitude towards food, and a satisfactory social life [22,24]. This is in line with the findings of earlier studies of females with EDs [25].

The results of these previous studies are somewhat variable, so further studies are obviously needed. Accordingly, the aim of this study is to investigate differences, at admission, in clinical presentations between males and females with AN when admitted to treatment at a child and adolescent psychiatric unit specializing in severe EDs. We further aimed to investigate the clinical presentations at discharge and whether the treatment received differed between the sexes.

Methods

A retrospective case-control design was used, in which data were collected from the case records of males and females at admission and discharge. All patients included in the study had been admitted to a regional child and adolescent psychiatry ED unit in Lund, Sweden.

Participants

The regional ED unit in Lund started operation in 1983. As of the end of 2016, 1475 children and adolescents (106 males and 1369 females) aged 4.6–17.8 years had been admitted. Inclusion criteria for the study were two registered visits to the ED unit. Regarding the 106 males, two had made only one registered visit, four died after discharge between the ages of 20 and 35, and four had emigrated, leaving a total of 96 males eligible for the study. They were sent letters (twice) containing information about the study and a request for consent to examine their records. Forty-one former male patients gave their written consent. Two females for each male, matched by age and date at admission, were contacted the same way with an information letter containing a request for consent to read their records. Sixty-one females gave their written consent, and the first of each two matched females to give consent was selected; thus, 41 female former patients constituted the comparison group. Both males and females were contacted between June 2014 and October 2016. By that time, most former patients were 18 years or older, and in the case of younger former patients, their parents gave consent to read the children’s records. Due to long submission processes, the article has not been published until now. The study was approved by the Regional Ethics Review Board at Lund University (reg. no. 2012/598).

Data selection

Demographic, medical, psychiatric, and treatment data were collected through a retrospective case record review; age at admission and age at discharge were also recorded. Medical data covered highest ever weight as well as height and weight at admission and discharge.

Psychiatric data covered ED diagnosis at admission, whereas data on psychiatric comorbidities were collected only at discharge. Of the 82 participants, 68 had been admitted before 2013. Since these 68 individuals had originally been diagnosed according to DSM-III (n= 2), DSM-III-R (n= 4), and DMS-IV (n= 62), they were re-diagnosed according to DSM-5 [3]. They had been diagnosed and re-diagnosed by psychiatrists specializing in child and adolescent psychiatry specifically focused on EDs.

Treatment data covered treatment duration measured in months, number of therapy sessions, and type of therapy received (i.e. family-based, individual, and physiotherapy sessions). The number of days in the inpatient ward was measured from date at admission to date at discharge.

Before admission

Information on the maximum weight before admission was gathered from individual growth charts. In Sweden, children’s weight and height are documented every third year, from birth up to the age of 19 years [26]. Pediatric care and school nurses measure the individuals over the years, and the data are plotted on individual growth charts. The parents were asked to bring these charts to the ED unit at admission.

At admission

The patients’ weight, height, and medical status (i.e. heart function and blood pressure) were measured by trained nurses at admission. A body perception examination was initially performed by a physiotherapist. Psychiatric diagnoses were assigned by a child psychiatrist in a family interview session with the rest of the team in the room, sometimes behind a one-way screen, to obtain shared knowledge of the family, parental problems of feeding the child/adolescent, and the specific somatic status of the patient. The treatment received at the beginning of the recovery process was family-based treatment, offered to all families with a conflicted child/adolescent from certified family therapists specializing in child and adolescent psychiatry; such sessions often continued throughout the treatment process. Following weight, heart rate and blood pressure every week (twice a week if needed to avoid medical danger), and a family session was performed to empower the parents.

End of treatment

At the end of treatment, ED diagnoses, comorbid psychiatric diagnoses, duration of treatment, and number of different treatment sessions in outpatient care were determined and documented, as well as number of days in inpatient care, separated from outpatient care by another unit. Any of the 82 included patients who had not recovered by end of treatment were referred for ongoing care at their home clinic.

Statistical analysis

All analyses were conducted using IBM SPSS Statistics 24 for Windows (IBM, Armonk, NY), with Student’s t-test used when calculating significance. Statistical significance was defined as p < 0.05.

Results

Of the total of 82 participants, 41 males and 41 females were diagnosed with AN at admission. The highest percentage of expected weight (%EBW = normal BMI for age and sex, compared to the patient’s current BMI) [26,27] before illness did not differ between the sexes; %EBW readings at admission and discharge did not differ between the sexes either, as shown in Table 1.

Table 1. Clinical characteristics of males and females with AN.

	Total AN group	Males	Females
	Mean (SD)	Mean (SD)	Mean (SD)	p (males/females)
N	82	41	41
Age at admission (years)	13.5 (2.1)	13.6 (2.2)	13.4 (1.9)	0.624
Highest %EBW before illness	107.5 (19.3)	109.4 (23.8)	105.2 (12.3)	0.343
%EBW at admission	84.0 (8.5)	85.3 (9.1)	82.8 (7.7)	0.186
%EBW at discharge	95.3 (11.0)	95.6 (12.6)	94.9 (9.3)	0.770

%EBW: percentage of expected weight; AN: anorexia nervosa.

Statistical significance at p < 0.05.

The duration of treatment, measured in months and days, did not differ between the sexes, and the length of inpatient care measured in days also did not differ between the sexes, as shown in Table 2.

Table 2. Treatment received for males and females with AN.

	Total AN group	Males	Females
	Mean (range, SD)	Mean (range, SD)	Mean (range, SD)	p (males/females)
N	82	41	41
Treatment duration (months)	24.0 (1–72, 16.7)	22.2 (1–72, 14.5)	25.7 (1–72, 18.6)	0.347
Treatment sessions	42.5 (2–192, 34.4)	36.2 (2–100, 24.9)	48.8 (3–192, 41.1)	0.097
Family sessions	23.9 (1–75, 18.4)	22.4 (1–71, 18.0)	25.3 (2–75, 18.9)	0.475
Individual sessions	6.4 (0–135, 17.2)	3.0 (0–25, 5.1)	9.7 (0–135, 23.4)	0.079
Physiotherapy	11.3 (0–56, 12.3)	10.2 (0–35, 9.8)	12.8 (0–56, 14.3)	0.344
N	23	11	12
Inpatient care (days)	38.3 (4–94, 28.9)	39.7 (4–84, 25.2)	36.9 (10–94, 33.1)	–

AN: anorexia nervosa.

Statistical significance at p < 0.05.

The number of outpatient treatment sessions was analyzed in terms of both total number and type of treatment intervention, i.e. family-based, individual, and physiotherapy sessions. The analysis showed no significant differences between males and females in terms of the number of individual sessions. Males and females also participated in individual physiotherapy sessions, with no difference being found between the sexes in the number of sessions recorded.

Discussion

This study aimed to compare males and females with AN in a clinical setting. Our results are in many respects similar to those of other studies comparing sex differences in adolescents with EDs [5,8]. At both admission and discharge, the %EBW was similar in both sexes. There were no differences in treatment duration between the sexes. These findings strengthen research showing that there are more similarities than differences between males and females with AN in a clinical setting.

There was a tendency for males to receive fewer individual sessions than did females; perhaps the difference in the number of individual sessions between the sexes would have been significant if the sample had been larger.

To improve our general knowledge of males with ED, future studies would benefit if clinicians used gender-specific assessment questionnaires [28–30]. The interview section of questionnaires could be used to deepen our understanding of gender-specific symptomatology. The tendency for males to receive fewer individual sessions may reflect a potential stigmatization documented among male patients, expressing shame at having a disease more prevalent in females [31]. In a qualitative study of 10 young males aged 16–25 years, the males reported delayed help-seeking and failure to recognize the illness on the part of both the male patients and the professionals who should detect the ED [32].

Strengths and limitations

One strength of this study is that the participating males and females were admitted and treated at the same unit, which specialized in treating AN. Another strength is the treatment received, in that both sexes were treated using the same family-based methods. It would be beneficial for the results to be generalized and compared with those from other similar units around the world to generate broader knowledge of how young males present with AN in clinical practice, for example, through a multi-center study using common design and gender-specific instruments.

An obvious limitation of the study is its small sample and the fact that half of the eligible group of former male patients declined to participate. Another limitation is that we did not find any patients presenting atypical AN in our sample [33], i.e. former overweight patients whose underweight status is overlooked.

Conclusion

In this study in a clinical setting, young males and females with AN were found to be very similar, supporting the findings of previous studies.

Ethical approval

The study was approved by the Regional Ethics Review Board at Lund University (reg. 14 no. 2012/598).

Patient consent

Informed consent was obtained from all participants included in the study. For younger patients, informed consent was also obtained from the parents.

Author contributions

KW, UW, MR, EW, and PJ were responsible for the conception and design. KW was responsible for the data collection and, with UW, for the data analysis. All authors contributed to the writing of the manuscript, and all authors read and approved the final manuscript.

Disclosure statement

The authors declare that they have no conflict of interest.

Additional information

Funding

Financial support was provided by the Lindhaga Foundation and the Sten Theander Foundation.

Notes on contributors

Karin Wallin

Karin Wallin is a social worker, licensed psychotherapist, teacher and supervisor in CBT. She has worked clinically with treatment of eating disordered patients for 30 years. She conducts research in eating disorders, only.

Ulf Wallin

Ulf Wallin is a child psychiatrist and licensed family psychotherapist and has worked with eating disorders for 35 years. He conducts research in family treatment and anorexia nervosa and is head of research and development for the Centre of Eating Disorders Psychiatry Skåne, in Lund, Sweden.

Elisabet Wentz

Elisabet Wentz is a professor of psychiatry with a focus on eating disorders since 30 years at University of Gothenburg, Sweden. She is licensed as a specialist in child and adolescent psychiatry and adult psychiatry. She is a chief physician at the Eating disorder unit for adults at Sahlgrenska University Hospital.

Maria Råstam

Maria Råstam is a senior professor with a clinical focus on child and adolescent eating disorders and neurodevelopmental dysfunctions, since 40 years. She conducts research on anorexia nervosa and comorbidity.

Per Johnsson

Per Johnsson is licensed psychologist and senior lecture at Lund University, Sweden, and has worked clinically with eating disorders for 35 years. He conducts research in resilience, eating disorders, shared reading and health and diabetes in youth.