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Atypical presentation: Identifying anorexia in men

A case report of men presenting in the emergency department with symptoms of anorexia were initially misdiagnosed
A case report of men presenting in the emergency department with symptoms of anorexia were initially misdiagnosedPhoto by Joe Raedle/Getty Images

There is increasing recognition that males suffer from eating disorders and that these disorders cannot be thought as 'women's problems,' but an article appearing in Clinical Endocrinology News on May 21 highlights the importance of understanding how male presentation with an eating disorder may differ. Without proper differential diagnosis on behalf of physicians, these serious disorders could be easily missed and left untreated or misdiagnosed.

This article emanated from clinical cases presented at the annual meeting of the American Association of Clinical Endocrinologists. The cases in question were four men in their early 20's who presented in the emergency department with abnormal thyroid results, high cortisol levels, hypogonadism, extremely low heart rates (in the 20s and 30s), and hypothermia. Since only one of the cases had a prior history of anorexia in his medical chart, the initial thought was not anorexia.

Since eating disorders weren't forefront on the physicians' minds, two of the men were scheduled to have a pacemaker implanted - a very invasive procedure - before the endocrinologists correctly diagnosed them with anorexia. Since most of the resulting cardiac and endocrine dysfunctions could be remedied with increased nutrition, providing the correct diagnosis prevented the men from undergoing risky procedures and, instead, directed them to the care they needed.

The typical patients presenting with anorexia are still thought to be women, but the proportion of men suffering from anorexia is probably at 25% due to underreporting and misdiagnosis, instead of the 10% it is thought to be. Amenorrhea is a diagnostic criteria for women for anorexia, but hypogonadism is not a similar criteria for men, leading to an inherent bias in diagnosis based on sex.

Women are also more likely to strive for the thin-ideal, use laxatives, diuretics, and purging to maintain a low body weight, whereas men are aiming for a more muscular ideal (with low body fat) and are therefore more likely to participate in excessive exercise rather than other compensatory behaviors. Because of the differences in presentation, if the patient does not provide information regarding their eating disorder (and due to stigma, especially for men, very few are willing to volunteer their histories), physicians are often ill-equipped to properly diagnose.

This lack of communication between patient and doctor must be remedied in order to improve correct diagnoses and care for men suffering from anorexia or other eating disorders. Training interventions for physicians should include information on the presentation style and differing symptomatology among males with eating disorders and ideas for what tests can be used to indicate the likelihood of an eating disorder diagnosis. Additionally, physicians must be aware of the increased stigma men face when suffering from eating disorders and efforts must be made to alleviate that stigma.

Until the medical community is adequately provided with the knowledge and resources to make correct differential diagnoses of eating disorders, and patients feel comfortable sharing their history with physicians, there is a danger of misdiagnosis and improper treatment. It is essential that this gap in knowledge is filled to improve the care we provide to those suffering from eating disorders.