Anna: 'when men were asked to pick their ideal body type, they chose a picture showing a man with about 28 pounds more muscle than they had on their own bodies'

Anna Paterson, who has anorexia herself, is the author of Fit To Die: Men and Eating Disorders. In an in-depth interview she discusses the warning signs, the trigger times and role of the media, body image and exercise in a problem that affects an increasing number of men.

Are more men getting eating disorders?

There is now a growing number of men. It is still unclear exactly how many as research into men and eating disorders is twenty years behind that of women. Unfortunately some doctors do not recognise that eating disorders are a problem for men and as a result, a number of cases have not been correctly diagnosed.

Men may also find it hard to recognise that they have a problem. Whereas women are constantly kept informed by the media about cases of anorexia and bulimia, men rarely see evidence of the condition. Unfortunately, this means they are less likely to seek help early on in the development of their condition. On average, it seems to be approximately six years before men will seek help for their eating problems and by this time the condition will have become chronic.

When a media campaign highlights the issue of male eating problems though, the number of men seeking help increases dramatically.

What sort of disorders do men have?

Women seem to worry about whether they are fat or ugly but with men it is usually slightly different. They are more concerned with how they see themselves, and their self-worth is linked to how strong, in control and productive they are in their lives. They need to feel a success in all areas of their life — work, exercise, background, friends, home life etc. If a man feels inadequate in different areas of his life then it is possible that problems can develop.

Like women, men suffer from all the various kinds of eating disorders although binge eating seems to be the most prevalent problem. There are also differing concerns for both men and women. Research has shown that women are more concerned with their weight, whereas men tend to focus on their shape and muscle definition.

Men today are spending 58% more on fitness related activities than five years ago. A large percentage of the economy is now dependant on the current fixation with thinness for both men and women.

It has been reported that men's dissatisfaction with their body has tripled over the last thirty years. In increasing numbers, men are having plastic surgery and liposuction has become especially popular. Between 1999 and 2000 there was a 23% increase in the number of cosmetic procedures performed on men. 

It is said that women 'dress to impress' but men in contrast work out to compete with other men. There is a strong competitive element in most men that leaves them feeling inadequate around any man who has a tighter, more muscular body. Men who have smaller bodies are often considered 'weedy' and used in advertising campaigns as figures of fun — for example the 'Mr Muscle' cleaning products campaign. This can lead men to feel that unless they have a strong muscular body, they are a failure.

Men can get all sorts of eating disorders including:

• Anorexia nervosa
• Bulimia nervosa
• Compulsive overeating
• Muscle Dysmorphia
• Body Dysmorphic Disorder
• ED-NOS

Why do men get eating disorders?

Eating disorders in men (as in women) are not about food or weight but are in fact emotional problems. They develop as a way of coping with the conflicts, stresses and pressures in life. An eating disorder may seem like a way of exerting control for a person who feels that their life is out of control. 

People with eating disorders have been known to range from as young as eight to men in their sixties. However, the majority of men state that their problems began during their childhood years. Many remember being overweight in their teens and as a result were singled out and bullied or called names.

It does seem that whereas women are more likely to be at a normal weight when they develop an eating disorder, men are frequently overweight.

The original reasons why they were overweight as children are frequently linked to problems at home, crises at school or difficulty coming to terms with growing up. This low self-esteem coupled with the issues surrounding their weight can lead to eating disorders.

As the numbers of overweight children is increasing, it is very important that teachers and parents are aware of the effect that being overweight can have on a child and the possibility of eating disorders developing.

Like women, men are also at risk of different types of abuse during their childhood years (mental, physical and sexual). Research has shown that many men with eating disorder experienced childhood sexual abuse. This is often an experience which men feel unable to discuss due to feelings of shame. They are concerned that they will be accused of 'bringing the abuse upon themselves'. Often, victims blame themselves and feel certain that others will blame them too.

It is now widely acknowledged that eating disorders are a way of coping with the stresses of life. Traditionally, men are known to turn to drink or possibly drugs as a way of dealing with the issues in their life which they find impossible to solve. In contrast, women are seen as more frequently turning to eating disorders for their 'solution'. It now seems that these boundaries are being to blur however and as society changes and places more importance on men 'looking good', eating disorders are increasing in the male population.

Are there any particular factors to look out for?

The onset of a eating disorder in males is usually due to a specific trigger or set of triggers. For men, these include:

•  Experiences of childhood bullying/teasing due to being overweight.
•  Low self-esteem because of issues during childhood (examples of which are incest, rape or mental torment).
• Parental strictness, especially from a father. This often extends to control over food and ritualised mealtimes.
• Bodybuilding and obsessive exercising.
• Specific occupations such as athletics, dance, horse racing, etc.
• History or family history of being overweight. 
• Difficulties deaing with being gay.
• Having a parent with a serious weight related illness such as heart disease or diabetes.
• A fear of developing sexual feelings. (Anorexia causes a drop in male testosterone levels, which leads to a lack of sexual feelings and desires.)

Stresses frequently increase at specific points in a person's life and this can trigger a dormant eating disorder to become active. For example, a number of men have stated that when they went to college, their eating disorder became worse. 

Other stressful times can be during a relationship break-up, illness of a parent, starting or changing a job and starting or changing a school or college.

For older men, triggers may include: excessive job responsibilities, divorce, marital problems, children leaving for college and the death of a parent or close family member.

Men often change their diet or exercise habits when they see a parent fall ill, especially if the illness is diet or weight related. Fear of having similar health problems such as heart disease or a stroke can cause a man to radically change his dietary habits and this has been shown as a cause of some eating disorders developing.

Does the media and advertising play a part?

Many women now feel free to objectify men's bodies in the way that theirs have been treated for so many years. This has meant that men have started to feel self-conscious about their body shape. They are constantly seeing images in magazines, on billboards and on television of the 'perfect' male body.

It seems that in the same way that women are expected to have the 'perfect' size 8 body, men are expected to have 99.9% lean muscle definition. Men now have their own 'body beautiful' magazines and Men's Health has become a top seller. Like women, men have now started to count calories, exercise daily and constantly compare themselves to the models on the magazine covers.

It seems that it is men in their teens, 20s and 30s who are most affected by such imagery that is now portrayed by adverts and other media agencies. Older men grew up in a time when the male body was hidden.

Do you think the so-called 'ideal' male body shape has changed?

It seems so. A recent study has compared the action figures of the '70s and '80s with those of today and there has been an enormous increase in the musculature.

In 1974, a GI Joe doll (the American equivalent of Action Man) had a 44 inch chest, 31 inch waist and 12 inch biceps. The GI Joe of today has a 50 inch chest, 28 inch waist and 22 inch biceps. It seems that an increase in musculature, especially on the upper body, is the new 'desirable' shape.

Recent male role models have been extremely muscular. Film stars such as Arnold Schwarzenegger, Sylvester Stallone, Dolph Lundgren, Vin Diesel and all the WWE wrestling stars portray the image that large muscles and power are essential masculine traits.

This increasing trend for such muscular bodies is a concern. Some researchers do not believe that it is possible to have a figure of the proportions demonstrated by the dolls without resorting to the use of steroid supplements. Certainly there has been an increase in the number of men resorting to supplements to try and increase their size and muscular definition. Anabolic steroids are very dangerous and can cause psychotic reactions such as hallucinations, manic symptoms and depression.

Is there a relationship between exercise and eating disorders?

Men are far more likely to turn to exercise to deal with their body shape issues than women, who usually choose dieting. When a study was carried out on American college students, it found that 63% of the women were on a diet as opposed to only 16% of the men. However, a large percentage of the men were concerned about being too small and 28% were trying to gain weight, often by bodybuilding methods. The evidence suggests that exercise related illnesses such as muscle dysmorphia are far more common amongst men than women.

Studies have begun to show that bodybuilders share many of the same problems as eating disordered patients. Some have developed muscle dysmorphia or 'reverse anorexia' as it is now often called. This is a condition in which the sufferer feels they can never be large enough. Although they can actually be very muscular, they are convinced that they are small and fragile. These men may increase their protein intake by 20 to 30 times that which is normal and this is very dangerous.

It is becoming more obvious that men feel a need to have a muscular body and equate thinness with weakness and frailty. A study of US college males found that when men were asked to pick their ideal body type, they chose a picture showing a man with approximately 28 pounds more muscle than they had on their own bodies.

Of course there are large numbers of men who do not have traditionally muscular bodies and who do not feel a strong desire to bodybuild. These men can often be left feeling inadequate and with a strong hatred for their own body. It can cause them to strive for a different shape — a lean, toned body. However, this is when problems can develop. Coupled with an already low self-esteem, these young men can take their dieting or exercise routine to an extreme and an eating disorder can result.

Often body image obsessions go unnoticed if the young man appears healthy and is engaging in what we see as healthy behaviours - exercising and watching his diet. While working out regularly is healthy, excessive exercise can be extremely damaging, especially if it is done to try and calm body image fears.

Men have been found to be more at risk of developing an eating disorder if they participate in certain jobs or sports that have weight restrictions, such as wrestling, bodybuilding, swimming, horse racing and gymnastics.

It has been discovered that 8% of male athletes in Norway suffer from some kind of eating disorder. Another survey found that when they questioned athletes in the sports of boxing, weight-lifting, karate, wrestling and judo they found that 82% had used unhealthy methods such as laxatives, diuretics or diet pills to try and control their weight.

Runners are also at an increased risk of developing eating related problems. The National Runners' Survey on Dieting and Eating found that 21% of the men who answered the questionnaire were terrified of gaining weight. In other studies, it was discovered that they also seemed to have a preoccupation with food similar to that of an anorexia sufferer. They would strive to constantly lower their percentage of body fat, even when this was already very low.

Many had lost 25% of their original weight and showed a relentless pursuit of thinness as well as often having a disturbed body image.

A condition known as 'Anorexia athletica' has recently been diagnosed and is specific to athletes. It is characterised by several features similar to Anorexia nervosa but without the self-starvation practises. Their severe weight loss is instead brought about by prolonged and excessive exercising.

Jockeys are also known to use many different methods of weight control prior to a race. Food restriction, excessive sauna usage, laxative and diuretic abuse, appetite suppressants, excessive exercise and self-induced vomiting can cause them to lose up to 7 lbs. in fourteen hours. All of these practices are extremely dangerous and very detrimental to their health.

Some other professions that may cause participants to be more vulnerable to eating disorders are modelling, dancing and being a flight attendant since these all necessitate weight limitations.

What can be done to prevent eating disorders?

The key to prevention for eating disorders is awareness. Parents, teachers, doctors and friends need to be conscious of potential problems in boys and men. There are certain clear warning signs:

• Changes in a person's weight.
• Mood swings — people with eating disorders frequently experience serious and prolonged depression. They often become withdrawn and can spend long periods of time on their own.
• A preoccupation with dieting and food.

Men are traditionally more emotionally withdrawn than women and this means they often find it very difficult to discuss their feelings.

Men have specifically stated that they found it impossible to talk with their peers about their eating problems. They commented that the 'macho' culture meant that they were afraid their friends would think them 'weak' or 'feminine' and that they would lose all their respect.

This is another reason why it is of vital importance to men that they can access good treatment services and talk with sympathetic professionals.

What should you do if you're worried?

I always advise eating disorders sufferers to seek medical help as soon as possible due to the very serious physical and mental damage that is caused by these disorders. I also try to encourage them to talk about their feelings with people who they trust. Eating disorders thrive on secrecy and shame, and the more a you can talk about it with people who you trust, the less power the disorder will have.

The following ideas were of great help during my own recovery:

• Remember that recovery will mean giving up your negative behaviours around food. It will also mean that you need to allow your weight to reach a healthy level for your body. Recovery is not an easy process and it does require lots of support and encouragement from those around you.
• Set yourself realistic goals. Aim to reach small targets so that you feel encouraged and positive about your recovery. If you try to tackle too much then you are likely to fail, which will not help to build your self-esteem.
• Be gentle with yourself. If you do not always reach your targets, do not treat yourself harshly. You are going to find that there are times when you feel unable to make any progress. At these times, just try to stay stable and not take any steps backwards.
• Write yourself a list of all the things that you will be able to do when you are well. It can help to read through this list when you are having a bad day, as it can keep you motivated.
• Try to praise yourself for your achievements. You may have found it hard to praise yourself in the past and frequently focused on your failings instead. Now it is time to look at your progress rather than concentrating on any setbacks that you may have had.
• For people with anorexia, gaining weight is likely to feel very difficult. You may feel intensely guilty and want to disappear into your eating disorder again. The feelings of guilt will pass but only if you face them. As you reach a healthier weight, you will find that food and your body shape will not longer be the sole focus of your life. When you gain weight, you may also find yourself experiencing emotions that were previously hidden by the eating disorder. If you are struggling to cope with these feelings alone, ask your therapist or support network for more help.
• Try to start to take control of your life. You may have previously allowed your eating disorder to rule you life and make all your decisions for you. Now is the time to begin focusing on what you want from your life. Your social life may be very limited and so you may want to slowly start to change that.

Anna Paterson's book is Fit to Die: Men and Eating Disorders (Sage; £12.99; ISBN: 1-904315-40-2). Buy Fit To Die from Amazon

Anna's two previous books, combining her personal experiences with an extensive research interest, were winner and special commendation in the Times Educational Supplement and the National Association for Special Educational Needs.