Clinical Aspects of Eating Disorders

### **Chapter 4**

## Clinical Aspects of Anorexia and Bulimia in Men

*Val Bellman*

### **Abstract**

Men account for approximately 20% of people with Anorexia Nervosa (AN) and 30% of people with Bulimia Nervosa (BN). The clinical features of eating disorders (EDs) in men and women have many similarities but also some interesting and important differences. Men with eating disorders face persistent stigmatization because of the stereotype that EDs are "female" conditions. Most structured risk assessment tools for AN/BN likely reinforce gender stereotypes by better reflecting female symptoms. Moreover, gender similarities and differences in EDs have received scant investigation. Clearly, this form of disordered eating can put men in danger of experiencing a wide range of negative outcomes. Due to this lack of knowledge, these patients usually go undiagnosed and undertreated for ten or more years. These clinical differences are evident in the processes related to treatment initiation, retention, completion, and outcomes. Therefore, we discussed how the manifestation and progression of male eating disorders can be influenced by social context, including family and work relationships, interactions with social institutions. Treatment recommendations are discussed in the context of gender-based physiological differences, behavioral differences, comorbidities, and men-specific conditions.

**Keywords:** anorexia, bulimia, men, gender-specific aspects, rehabilitation

### **1. Introduction**

Eating disorders (EDs) are complicated conditions that are multifactorial and affect individuals of any age or gender [1]. Historically, the stereotype of individuals with EDs has been affluent, middle-class, Caucasian female adolescents; however, the incidence of EDs in males is increasing, yet there is a disproportionate representation of males in ED research and clinical guidelines [2]. These illnesses are associated with personal, familial, and societal costs, with Anorexia Nervosa (AN) and Bulimia Nervosa (BN) being classified as two common EDs in the male population [3].

### **2. Epidemiology**

Roughly 10 million males in the United States will experience an ED throughout their lifetime. In a study that included 36,000 adults in the U.S., the ED lifetime incidence in men was approximately 1.2%. In Canada, males account for up to 20% of ED cases, while males account for 20–25% of ED cases in the UK. These numbers may be even greater, as men may experience feelings of shame surrounding their ED because of the stigma associated with the condition. Traditionally, EDs are thought only to be present in females. Therefore, having an ED as a male may feel emasculating, preventing many men from seeking treatment and support for their illness [1].

The frequency of these different EDs in males varies across studies. For example, the literature demonstrates that females are three times likelier to have BED, while other research indicates that males make up to 40 percent of all BED cases. Regardless, BED is much more prevalent in males than AN or BN. Additionally, male EDs sometimes present with what is known as muscle dysmorphia, which refers to the societal ideal that men should be highly muscular with low body fat. Men seeking this appearance may engage in strict disordered eating, which can eventually lead to an ED [1].

AN is typically associated with having an emaciated and thin figure, specifically in females. Men, however, usually prefer a more muscular and lean appearance over appearing thin. Likewise, only 4.9 percent of high school boys overvalue body weight compared to 24.3 percent of girls of the same age. However, AN can still occur in men, and AN screening and definitions do not always consider how AN presentation may differ in men [3].

For example, the Diagnostic and Statistical Manual of Mental Disorders (DSM) historically excluded males from an AN diagnosis, and until 2013, amenorrhea was a diagnostic criterion [2]. Endocrine dysfunction is another female-specific criterion that has since been removed [3]. On the other hand, BN has a lifetime prevalence of up to 1.6 percent in males. Among all BN cases, males account for roughly one-third of all cases [3]. BN most commonly presents in males as excessive exercise, as opposed to laxative use or vomiting, which is more frequently seen in females [2].

### **3. Clinical presentations**

Research has demonstrated that the symptoms of EDs among males are as severe as females; hence, it is important for clinicians to implement more screening and education efforts among males who have EDs. In a study assessing the 5.5-year outcome of AN in male versus female adolescent inpatients, it was found that both genders follow a similar course: Both have a similar age at admission, age at ED onset, and duration of illness [4]. Another study showed that the onset of AN in men occurs between the ages of 14–18 years, while bulimia occurs at the late stage of adulthood. Unfortunately, most screening strategies focus on thinness-oriented behaviors and caloric restriction and do not consider male-specific eating patterns and differences in body image and self-perception. Men's average scores on the ED screening scales are always lower than women's—even though they receive the same standardized tests and adequate attention during the evaluation process [5, 6].

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) contains diagnostic criteria for mental health disorders [1]. The criteria for AN and BN are summarized in **Table 1**.

The DSM-5 also includes severity specifiers (i.e., mild, moderate, severe, extreme) for AN and BN, which are determined by weight status (AN) and frequency of inappropriate compensatory behaviors (BN) [1]. **Table 2** summarizes the severity specifiers for both EDs.

The revisions in the DSM 5 addressed the clinical utility of a diagnostic criteria set for EDs, allowing more male patients to be properly diagnosed [7, 8].


*Clinical Aspects of Anorexia and Bulimia in Men DOI: http://dx.doi.org/10.5772/intechopen.106841*

> **Table 1.** *Diagnostic criteria for AN and BN.*


### **Table 2.**

*Severity specifiers for AN and BN.*


#### **Table 3.**

*Characteristics of AN and BN in men.*

*Clinical Aspects of Anorexia and Bulimia in Men DOI: http://dx.doi.org/10.5772/intechopen.106841*

Males are often unaware that their eating patterns and associated behaviors are characteristic of an ED [9]. They tend to develop a pattern of binging and purging behaviors, commonly described as coping mechanisms with daily stressors [10].

Many men report that they put off going to their PCP for as long as possible, even when they are experiencing life-threatening symptoms. They also tend to ignore mental health problems and seek help less often than women for mental health challenges [2]. The gender-specific characteristics of AN vs. BN are summarized in **Table 3**.

Both genders, male and female, with EDs were found to have a similar level of unhappiness with themselves. As EDs involve a major focus on weight, body shape, fat percentage, and distribution, they lead to dangerous behavioral adaptations. A lack of gender-appropriate information and resources for men with EDs as an additional stressor has been reported in the literature [32].

In another study that reported on the mortality of DSM-IV EDs among a large sample of males aged 16–61 and females aged 14–65, mortality rates for males were higher than in females, respectively, for AN and BN [33]. It was also found that compared to females, males with anorexia or bulimia showed shorter survival times. In the AN study, remission after 5.5 years was more frequent in males than in females [4]. Also, males with AN were found to have a shorter duration of ED and a shorter period of inpatient treatment [4].

### **4. Medical and psychiatric comorbidities in men with EDs**

Men with ED suffer from many psychiatric disorders (including anxiety, depression, post-traumatic stress disorder (PTSD), and substance abuse) compared to the general population. Male EDs and related comorbidities are often underdiagnosed, undertreated, and misunderstood by many clinicians [34]. Moreover, men with AN and psychiatric comorbidity may exhibit a ninefold increase in mortality if left untreated [35].

Previous studies of men with ED have found that 56–95% of patients with an ED also receive a diagnosis for at least one more psychiatric disorder. The prevalence of psychiatric comorbidity in men with ED ranges widely from 2 to 27% for depression [36, 37] and 32–43% for anxiety disorders [37, 38]. Research has also demonstrated that up to 36% of male veterans with AN are diagnosed with schizophrenia or other psychotic disorders [39]. Other psychiatric comorbidities associated with AN include PTSD, substance use disorders, sexual dysfunction, and self-harming behaviors.

The most common psychiatric comorbidities of BN include MDD (50%), phobias (50%), PTSD (45%), attention-deficit/hyperactivity disorder (ADHD) (35%) [40], personality disorders (31%), anxiety disorders, and substance use problems (overall 61%, including 46% alcohol and 20% cocaine) [29]. Other authors have also reported similar rates of psychiatric comorbidity for men versus women with BN [36, 39].

Studies have shown that about 30% of male patients who have had EDs have been sexually abused in the past. These childhood traumatic experiences cause overall dissatisfaction with appearance and distort eating behaviors in the male population [41, 42]. Finally, 17% of patients with BN reported having suicidal thoughts, so identifying other commodities with EDs is necessary for the treatment of the disease [43].

While EDs can result in significant medical complications within every body system, the greatest impact on health is often observed in the cardiovascular, neurological, and skeletal systems. **Table 4** summarizes the comorbid somatic conditions and syndromes associated with AN and BN in men.


#### **Table 4.**

*Somatic signs and symptoms of AN and BN in male patients.*

### **5. Special considerations**

### **5.1 Sports and eating disorders**

In sports, low body weight and leanness are often regarded as advantageous from a performance perspective. This can be observed in endurance-based sports (e.g., distance running and cycling), weight-based sports (e.g., wrestling and jockeys), antigravitational sports (e.g., long jump and high jump), and others where leanness has been associated with improved performance outcomes [44]. Sometimes, sport-related requirements place an unnecessary burden on athletes, resulting in the increased likelihood of developing EDs [45–47].

EDs are especially common in bodybuilding, as it promotes leanness and muscularity as a method of scoring and performance and encourages the development of exercise and nutrition-related behaviors that may adversely affect one's overall mental health.

*Clinical Aspects of Anorexia and Bulimia in Men DOI: http://dx.doi.org/10.5772/intechopen.106841*

A recent scoping review examined the prevalence of male athletes reporting disordered symptoms, subclinical EDs, and clinical EDs; prevalence rates ranged from 0 to 85.5%, 1.5–11.0%, and 1.3–32.5%, respectively [48]. Furthermore, the prevalence of EDs in male weight-sensitive sports versus less weight-sensitive sports ranged from 5 to 50% and 0–31%, respectively [49–53]. Interestingly, the prevalence of EDs among the general male population was only 2.2% (range, 0.8–6.5i%) [54].

Men who exhibit behaviors associated with a negative body image (e.g., body image dissatisfaction, preoccupation/obsession with specific body areas, body checking, and negative self-talk), or have psychological or personality features such as low self-esteem, fear of negative evaluation, depression, and impulsivity may be at an increased risk of EDs [44, 55–58]. Further, socio-cultural factors, such as the ideal male body size/shape (i.e, muscular, lean, and V-shaped physique [broad shoulders and narrow waist]), also contribute to the increased propensity for EDs. This is further pronounced in male sports, whereas outward and physical appearances can impact perceptions related to performance [44, 48].

### **5.2 Role of sexual orientation**

When looking at the possibly distinct viewpoints of males with EDs, one thing to explore is their self-perceived sexual orientation. According to research, LGBTQ adults and youths are more prone to developing mental illnesses because of the increased stress generated by prejudice and stigma [59].

Most characteristics of males and females with EDs appear to be similar; however, homosexuality or bisexuality appears to be a risk factor in males, specifically for those with BN. In a study conducted at Massachusetts General Hospital, 42% of male bulimic patients were identified as either homosexual or bisexual, and 58% of anorexic patients were identified as asexual [28]. Biologically, there may be similarities in brain structure between homosexual men and heterosexual women, and homosexual men may react to environmental stressors in a feminine way, thus increasing their risk of EDs [28].

Because of stigma, prejudice, and proximal stresses, homosexuality plays a role in males' appearance and the progression, or severity of EDs. As a result, they have been largely ignored in therapy and diagnosis, contributing to the disorder's severity [34]. ED stereotypes impede the provision of evidence-based treatment for males, thus falling short of the success of gender-specific conditions. Compared to females with EDs, the general population may see men with ED as gay or bisexual and label them as "weak" or mentally disabled. Males are expected to hide their weaknesses in today's environment, especially shame and despair, which relate to the stigma of being "feminine." In homosexual and bisexual males, "minority" stress and stigma are also linked to binge eating behaviors [59].

Reportedly, 54% of LGBT male teenagers have been diagnosed with EDs [60]. They are caught in a vicious loop of exercising for weight reduction to improve their health, only to end up on a "runaway diet" that leads to self-starvation [60].

### **5.3 Identification, assessment, and differential diagnosis**

Risks of disordered eating and associated clinical EDs should not be discounted among male patients, and increased vigilance regarding the screening and subsequent management of both subclinical and clinical conditions is warranted. Male EDs are present in a range of settings, and collateral information should be obtained to justify

#### **Figure 1.**

*Standardized rating scales for EDs in men [61–75].*

the diagnosis. Underreporting ED symptoms impedes appropriate diagnosis, treatment, and research in this area.

When assessing an eating disorder, the clinician is expected to use all available methods to determine whether a male patient has an eating disorder. However, standardized diagnostic tools should not be used as the main screening method due to challenges with reliability and variability in clinical presentations. **Figure 1** outlines the standardized rating scales for EDs in men.

It is recommended to avoid using single measures such as BMI, the degree of weight loss/gain or duration of illness in the justification of the diagnosis. General medical conditions and other psychiatric disorders can simulate the binging, purging behaviors, disturbed food intake, and other compensatory reactions seen in EDs. Healthcare providers are expected to assess patients' physical health, the possibility of underdiagnosed medical conditions, and evaluate the risk factors associated with disturbed eating behaviors.

**Figure 2** outlines the differential diagnoses of AN and BN in accordance with their presentations.

Approaching EDs using a multidisciplinary approach (e.g., the inclusion of a healthcare provider, dietitian, mental health specialist, etc.) allows for a patientcentered approach to care and should be prioritized. Sometimes, men with AN and BN may require a higher level of care due to medical instability. These challenging patients require a unique collaboration between many specialists, and general hospital units or inpatient psychiatric facilities may not be set up to provide appropriate care. The decision to hospitalize should be made only when all psychiatric and medical factors are considered. One of the most important factors is a progressive decline in oral intake and weight despite interventions, a history of weight instability, and comorbid psychiatric and/or medical conditions.

More than 50% of male adolescents with EDs who present to the clinic for treatment result in the need for immediate hospitalization due to significant delays in treatment [76]. The American Academy of Pediatrics released the criteria for

*Clinical Aspects of Anorexia and Bulimia in Men DOI: http://dx.doi.org/10.5772/intechopen.106841*

**Figure 2.** *Differential diagnosis of AN and BN in men.*

inpatient treatment in 2014 [77]. Unfortunately, gender-specific criteria for hospitalization are still unavailable. Generally speaking, the patient is expected to be hospitalized when one or more of the following criteria are met:

	- a.Severe bradycardia (HR <50 BPM daytime; <45 BPM at night)
	- b.Hypotension (90/45 mm Hg)
	- c.Hypothermia (body temperature, 96°F, 35.6°C)
	- d.Orthostatic hypotension

As many as half of patients who survive hospitalization for ED experience prolonged work absence, financial difficulty, or emotional effects, each of which may further impede recovery. Iwajomo et al. reported that mortality after hospitalization for an eating disorder was five times higher compared to the general population [78]. Specifically, mortality rates were higher for males with AN and BN. Other authors also concluded that mortality rates for male patients with BN were higher than for their female counterparts [79]. Finally, a recent study confirmed that inpatient mortality for males with AN was twice as high as in the female population [80].

### **6. Treatment of men with anorexia and bulimia**

The goal of the treatment is to attain improved eating habits and overall physical and psychological well-being. In the treatment process for an ED, one of the first steps is understanding and admitting that the patient has an ED and identifying the need for a change. EDs in men may remain unidentified and undiagnosed as men are prone to hiding their symptoms due to the fear of judgment and shame of having a female disease [34]. It is important to raise public awareness about male EDs and to help motivate male patients to accept and get help.

Studies show a significant difference between the health of men and the health of women, as men are less likely to seek treatment for mental health problems. Many male patients with AN or BN tend to underuse professional services, despite their susceptibility to these types of illnesses. Most male patients deny that they are sick, resist treatment (usually medication and/or talk therapy), and demonstrate indirect support-seeking patterns (e.g., pushed into treatment by spouse) [81].

Multidisciplinary care teams consisting of a physician, dietician, and mental health providers are encouraged. Healthcare providers play a key role in the detection of EDs in men, as they are the first professionals men encounter. Stabilizing nutrition and weight in the early phases of recovery and searching for balance between rest, sleep, and activity are also crucial steps [81]. Interpersonal changes, especially in acquiring more flexibility in social relations, and learning how to distance from difficult relationships, may also be helpful. Another important step is being able to better recognize and understand one's own personal needs, and have increased selfcare and self-regulation, as that can help with opening up strict cognitive schemas, and ultimately lead to a better relationship with food [81].

Unfortunately, there are no gender-specific practice guidelines or standards of care for men with EDs [6]. **Table 5** summarizes the general treatment guidelines for anorexia and bulimia.

The traditional treatment for ED has largely been female-focused and sometimes unsuited for men, as they require a gender-sensitized treatment approach [32].

**Level of Intervention American Psychiatric Association (APA) [82] World Federation of Societies of Biological Psychiatry (WFSBP) [83] The National Institute for Health and Care Excellence's (NICE) [84]** Anorexia Nervosa First-line • Nutritional rehabilitation: restore weight, adjust eating pattern with a goal to achieve consistent weight gain 2–3 lb./ week for hospitalized patients and 0.5–1 lb. in outpatient setting • Psychosocial interventions • Promotility agents (e.g., metoclopramide) for bloating and abdominal discomfort that occur during refeeding No clear evidence to combine psychotherapy with pharmacotherapy • Psychoeducation with eating disorder focused CBT, Maudsley Anorexia Nervosa for adults, or specialist supportive clinical malnutrition • For children and young people, psychotherapy with AN-focused family therapy • No hyperfocus on medications • Consider the impact of malnutrition on medications Second-line • SSRI are not advantageous for weight gain in patients who are receiving inpatient treatment • SSRI in combination with psychotherapy are recommended for persistent depressive, anxiety and/or obsessive- compulsive disorder (OCD) like symptoms • Second generation antipsychotics may be considered in patients with treatment-resistant inability to gain weight, severe obsessional/delusional thinking and denial • Adjunctive pharmacotherapy for comorbid conditions • Olanzapine may be considered for weight gain • Low-dose quetiapine may cause improvement with minimal side effects • Prokinetic agents may improve gastric emptying • Zinc supplements may improve weight gain and affective symptoms • Adults: psychotherapy with eating disorder focused focal psychodynamic therapy • Children/young adults: ED-focused CBT; adolescent-focused psychotherapy for AN

*Clinical Aspects of Anorexia and Bulimia in Men DOI: http://dx.doi.org/10.5772/intechopen.106841*


**Table 5.**

*Treatment guidelines for AN and BN.*

However, some authors have concluded that male and female patients may benefit equally from the same types of therapy [34]. Nevertheless, men want to be treated with dignity and with an acknowledgment of their value as individuals. Many of them do not want to be treated differently because of gender. One of the most widely cited elements of disrespect mentioned by patients is simply failing to pay attention to their needs by leaving them unattended or ignored [85].

Some patients believe that receiving a formal diagnosis can boost their self-image and self-esteem and motivate them to continue treatment [86]. Moreover, good quality therapeutic alliance is one of the most robust predictors of positive treatment outcomes in men with EDs—which is typically a reduction of primary symptoms of EDs [32]. Male patients who are actively engaged in treatment demonstrate improvements in their symptoms and quality of life. Interestingly, success rates are generally higher for men than women [87, 88]. The stigma of men with EDs and body image issues has yet to be overcome.

Gender-specific treatment groups can be considered an important treatment option: sensitive to all of these issues and addressing the unique needs of each patient in a comfortable and supportive environment [85]. Interestingly, most male patients prefer mixed-gender treatment groups [85]. Although gender mismatching

### *Clinical Aspects of Anorexia and Bulimia in Men DOI: http://dx.doi.org/10.5772/intechopen.106841*

(male patient-female therapist) does not impair the therapeutic alliance, male psychotherapists can bring that male-to-male relationship into the treatment process, and that can be extremely transformative. Male patients may need to have therapeutic interventions repeated multiple times before they understand why they are engaged in compulsive exercises or eating in a specific way. Thankfully, male patients with EDs who are engaged in recovery believe that therapy is the best investment that they have ever made [81].

It is important to discuss men's thinking about wanting to be highly muscular and other potential symptoms of body dysmorphic disorders. Not only do men see themselves as healthy, but most look very healthy from an outward perspective [34]. Research has shown that men with AN and BN disorders experience multiple problems with sexual functioning in both the physiological (e.g., erectile dysfunction) and psychological (e.g., anxiety) dimensions of sexuality [86]. When men enter the treatment process, they do not always give providers the chance to understand the reasoning behind these clinical symptoms and their risks and to find a potential solution. While the presence of erectile dysfunction may signal potentially serious medical conditions, EDs are frequently overlooked.

Despite the widespread penetration of specialized testing in health care, there has been no empirical research to date investigating the impact of quality of evidence on the strength of treatment recommendations for patients with EDs. Previous clinical recommendations for treating men with EDs also emphasized the role of testosterone [89] and genetic vulnerability [90]. However, neither factor is accurate enough at this stage to make individual predictions about how a person's symptoms will respond to treatment over time.

### **7. Conclusion**

Demographic survey statistics show that around 10 million men and boys in the United States suffer from EDs and distorted eating practices. AN and BN affect persons of many identities; discrepancies have been discovered in specific marginalized groups, such as gender and sexual minorities. These patients experience various forms of stress, including significant stigma and social victimization. Moreover, men from various sexual minorities are overrepresented in the ED literature because they tend to seek treatment more often than the general population.

Men are disproportionately affected by EDs due to shame, social norms, and prejudice, all of which contribute to the manifestation, prognosis, and severity of bulimia and anorexia. Moreover, underreporting ED symptoms impedes appropriate diagnosis, treatment, and research in this area.

*Recent Updates in Eating Disorders*

### **Author details**

Val Bellman1,2

1 Department of Psychiatry, University of Missouri Kansas City, Kansas City, MO, USA

2 California Southern University, Costa Mesa, CA, USA

\*Address all correspondence to: val.bellmanmd@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Clinical Aspects of Anorexia and Bulimia in Men DOI: http://dx.doi.org/10.5772/intechopen.106841*

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## **Chapter 5** Dietary Patterns

*Amra Ćatović*

### **Abstract**

Dietary patterns are defined as the quantities, proportions, variety, or combination of different foods, drinks, and nutrients in diets, and the frequency with which they are habitually consumed. Many social, demographic, and individual factors can have influence dietary patterns. A variety of food choices may benefit or harm health over time. Inappropriate dietary patterns are associated with risk of negative consequences in terms of diet-related chronic diseases, like cardiovascular disease, obesity, type 2 diabetes, and/or cancer. Dietary restriction behaviors can result in eating disorders including anorexia nervosa, bulimia nervosa, and binge eating disorder. Diet patterns are usually fairly well established, but they can change. Understanding of human nutrition can help to create eating patterns that help to achieve and maintain a healthy weight, reduce the risk of developing chronic diseases, and promote good health.

**Keywords:** dietary assessment, food choices, diet quality

### **1. Introduction**

Health risk can be defined as "a factor that raises the probability of adverse health outcomes" [1]. Risk can be connected with the causal chain of events over time, consisting of socioeconomic factors, environmental and community conditions, and individual behavior. These risk roots may be used as intervention points [2]. Behaviors with a strong influence on health are tobacco use, alcohol consumption, physical activity and diet, sexual practices, and disease screening [3]. An essential factor of human physical and mental development is diet. It is fundamental to human health and wellbeing across the lifespan [4].

Diet refers to the foods and beverages a person consumes, eats and drinks. Specific kind of diet is designed with the types of foods and beverages a person chooses, like vegetarian diet, a weight-loss diet. Thus, the term diet does not mean a restrictive food plan associated with weight loss. Dietary patterns are defined as the amounts, proportions, variety, or combination of different foods, beverages, and nutrients in the diet, and the frequency with which they are commonly consumed. Many social, demographic, and individual factors can influence dietary patterns. Not individual food selections, but the balance of foods selected over time can benefit or harm health [5].

Deterioration of health is associated with inadequate nutrition. The term 'nutritional disorders' covers a wide range of conditions that are primarily nutritional or nutrition is an important factor in their etiology. They may include deficiencies or excesses in the diet, chronic diseases that have been stimulated by a dietary

component, as well as developmental abnormalities in which diet has no role in etiology, but for which specific dietary intervention is an essential part of management (e.g., phenylketonuria), the interaction of foods and nutrients with drugs, food allergies. Eating disorders are not primarily nutritional disorders, but have important nutritional effects and significant metabolic consequences [6].

The medical and psychiatric consequences of eating disorders are numerous. Some consequences can be reversed with weight restoration and resumption of normal eating behaviors. On the other hand, other complications, such as low bone mineral density (BMD), can persist after disease resolution causing is associated prolonged increased fracture risk [7]. Some form of ED can progress in severe obesity [8].

Eating disorders can affect people of all body weights and shapes. They can occur even in people, who look healthy, such as athletes. The origin of eating disorders has not been fully elucidated. Risk factors for all eating disorders involve a combination of genetic, biological, behavioral, psychological, and social issues [9]. These factors may interact differently in different people, causing specific dietary behaviors.

Psychometric test, so called the Eating Attitudes Test (EAT-26) is in use to identify the risk of eating disorders based on attitudes, feelings and behaviors related to eating. It is the most widely used standardized test, focused to examine socio-cultural factors in the development and maintenance of eating disorders. There is children's version of the eating attitude test applicable in patients as young as 8 years old [10, 11]. With developing diagnostic criteria avoidant/restrictive food intake disorder can be distinguished from anorexia nervosa, bulimia nervosa, and binge-eating disorder [12].

Traditionally, inadequate nutrition has been simplified to identify health outcome primarily associated with a single nutrient or food. In last two decades, the focus for quantifying dietary exposures has shifted from single nutrients or foods to dietary patterns as dietary patterns can be more closely associated with overall health status and disease risk than consumption of individual foods or nutrients [13]. To have insight into overall diet it is necessary to analysis not only the foods, food groups, and nutrients, but also their combination and variety; and the frequency and quantity with which they are habitually consumed [14].

Analyzing food consumption as dietary patterns may provide a comprehensive approach to disease prevention or treatment. It can enhance conceptual understanding of human dietary practice, and provide guidance for nutrition intervention and education. The overall patterns of dietary intake might be easy for the public to interpret or translate into diets. Therefore, an emphasis on foods and beverages has improved translation to dietary recommendations for the general population [13, 14].

### **2. Dietary assessment methods**

It is difficult to measure human behavior, especially to measure dietary exposures and capture the effects of eating behaviors. Diet intake of humans is assessed by objective observation and subjective report.

Objective observation can be done using a duplicate diet approach or food consumption record. Duplicate diet approach with direct analysis gives actual intake information throughout a specific period. Inherent strength is possibility of measurement of dietary exposures (e.g., environmental contaminants), but it not suitable for large-scale studies. Food consumption record is objective observation that ought to be done by trained staff at the household level. It obtains actual intake

### *Dietary Patterns DOI: http://dx.doi.org/10.5772/intechopen.108367*

information throughout a specific period, but on individual level dietary consumption is not accurate. It is method of choice for those with low literacy or those who prepare most meals at home, and it is not suitable among those frequently eat outside the home [15].

Subjective assessment is possible using real-time recording (food diaries) or methods of recall. Self-reported recall methods can be in form of open-ended surveys such as 24 hours dietary recall - 24HR, dietary record - DR, dietary history since early life, or closed-ended surveys including food frequency questionnaire (FFQ ). 24-Hour dietary recall uses open-ended questionnaires. It ought to be administered by a trained interviewer to obtain actual intake information over the previous 24 hours. However, there is possible recall bias as well as possible interviewer bias. Dietary record is subjective measure based on use of open-ended, self- administered questionnaires, so there is relatively large respondent burden (literacy and high motivation required, possible under-reporting). This method provides detailed intake data throughout a specific period. Dietary history has two parts: open- and closed-ended questionnaires administered by a trained interviewer. By this method, it is possible to assess usual dietary intake over a relatively long period [15].

Widely used direct assessment of dietary intake is FFQ. FFQ can has self- or interviewer- administered format. It is method of choice for large epidemiological studies to assess usual dietary intake estimated over a relatively long period (e.g., 6 months or 1 year). As diet can be influenced by social or individual factors, the FFQ should be developed specifically according to the interests of the research. FFQ can be foodbased or dish-based, and focus may be on the intake of specific nutrients, or dietary exposures related to a certain disease. Semi-quantitative FFQs collecting data on the average portion sizes are in a closed format, and the simple FFQs that solely asks about the frequency or quantitative FFQs that queries about the amount of food consumption are based on completely open-ended questions [15, 16].

### **2.1 Meal patterns**

To capture the interaction of nutrients and bioactive compounds within the whole diet, as people consume combinations of foods as meals and snacks, it is important to analyze meal patterns. To analyze contributions of meal patterns (also referred to as eating patterns) to energy and nutrient intakes and overall diet quality first the characterization, definition and measurement of 'meals' ought to be described. Meal may mean different things according cultural background, so different dimensions of meal patterns are in use to standardized criteria (for example, time-of day, number of hot/cold eating events). A main meal (for example, breakfast, lunch or dinner) or a smaller-sized meal (for example, supper or snack) are used to describe individuals' eating patterns. The terms 'eating occasion' (EO) or 'eating event' are used in defining any occasion where food or drink is consumed, so incorporates all meal types. A minimum energy criterion as part of the meal definition also can be included. According to this criterion, EO is only treated as an EO if it contributes a minimum amount of energy (for example, 210 kJ). The different definitions of an EO greatly affected the results of the association between eating frequency and BMI.

Meals are multidimensional and can be classified according to three constructs: (1) patterning (for example, frequency, spacing, regularity, skipping, timing); (2) format (for example, types of food combinations, sequencing of foods, nutrient profile/content); and (3) context (for example, eating with others or with the family, eating in front of the television or out of the home). However, due to the

limited dietary assessment methods available, most research has focused on meal patterning [17].

Two major eating patterns were identified, which were qualitatively similar across the two FFQs and the diet records. So called 'prudent pattern' is characterized by a higher intake of vegetables, fruits, legumes, whole grains, and fish, whereas so called 'western pattern', is characterized by a higher intake of processed meat, red meat, butter, high-fat dairy products, eggs, and refined grains [14].

The methods of choice to assess meals are food diaries and 24 h recalls with collection data on time of eating, and contextual information (for example, location of eating, presence of others), as well as self-identified meals. FFQ provide estimates of the frequency and types of foods that are usually consumed, and there is need for additional questionnaires to collect information on meal patterns [15].

There are some modifications of assessing eating patterns included in The Eating Disorder Examination (EDE). Besides questions related to meal frequency (breakfast, lunch, and evening meal) and snack frequency (midmorning, afternoon and evening), there are those assesing binge eating or purging behaviors (frequency of self-induced vomiting, laxative misuse, diuretic misuse, driven exercise, fasting, subjective and objective meassure of binge eating episodes) [18].

Evaluation of the eating behaviors patients ought to include analysis of 1) nutrient intake (protein, fat, carbohydrates, vitamins, and minerals) 2) dietary quality (nutrient density, percentage of dietary energy derived from the macronutrients protein, fat, and carbohydrates), and 3) food groups as sources for the macronutrients.

Dietary variables are quantitative and qualitative. The quantitative variables include energy and nutrients intake (weight units), and nutrient density per 4.2 MJ/1000 kcal. The qualitative variables are the relative distribution of energy between macronutrients (E%), the selection of food items and food groups, as well as calculation of nutrients per their sources [19].

### **2.2 Diet quality index**

Diet quality index is the most common measure used to assess overall diet quality. It is constructed on the basis of prevailing dietary recommendations, thus it is a summary score of the degree to which an individual's diet conforms to specific dietary recommendations. It reflects an individual's adherence to the dietary guidelines for the country of the sample population (for example, the Healthy Eating Index (HEI), and the Dietary Guidelines Index (DGI)), or adherence to other dietary recommendation: a traditional Mediterranean diet score; Dietary Approaches to Stop Hypertension diet score; a dietary approach to prevent heart disease diet score (Optimal Macronutrient Intake Trial to Prevent Heart Disease score) [14].

### **3. Eating patterns in ED**

Main characteristic of anorectics eating behavior is a restriction of overall food intake, while vomiting/purging and intermittent starvation of bulimics is main mechanism of avoiding weight gain. The most commonly findings of food restriction are specific carbohydrate avoidance and, to a lesser degree, fat exclusion. However, anorectics and bulimics differ from each other with regard to food consumption patterns. Bulimics avoid bread and cereals, so they have less of their protein, fat, and carbohydrate energy from the bread/cereal group. On the other hand, anorectics

### *Dietary Patterns DOI: http://dx.doi.org/10.5772/intechopen.108367*

prefer bread and cereals, at the same time trying to eliminate fat from their diets. Bread and cereals are thus the distinguishing feature between the ED groups.

The bread/cereal avoiding can be explain with bulimics attitude that carbohydrates from bread and cereals are particularly "fattening". Even their fear of carbohydrates, their diet contains a substantial proportion of carbohydrates from fruits and vegetables. Mostly, bulimics rate vegetables, fruit, lean meat as "safe", while cookies, bread, cakes, and fried are consider as "forbidden" foods. Consequence of this is that if the bulimic eats anything outside her preestablished dietary "allowance," she immediately resorts to binge eating. As the food choice among bulimics has often been demonstrated to be very narrow the non-purged diet consisted mainly of salads and diet sodas.

Anorectics on the other hand, have often been found to eat the same food every day, with explicated fear of "fatty" products [19, 20].

### **3.1 Eating patterns in individuals with anorexia nervosa**

The mean generalization of AN is caloric restriction that resulted in weight loss. Restriction is greater during the more severe phases of the disorder. Beyond this restriction great variability in the diet patterns can be found. A regular meal and snack pattern can have approximately six eating episodes per day, in form of three meals and three snacks per day. Mostly, regular meals pattern is associated with a high-quality diet but restricted calorie. Inadequate calories during each eating episode are due to nature of insufficient quantities, or low caloric density food choices. This mainly rigid dietary pattern is caracteristic of restrictive type AN. Irregular eating patterns have fewer eating episodes on purge-only days, and more eating episodes on binge days (with or without purging) [16, 17]. Thus, less regular eating patterns are associated with loss of control eating. Meals are skipped with long intervals without eating at binge eating/purging type AN. Those with the BE/P type consume breakfast and dinner significantly less often than those with restricting type, and consume mid-morning snack and mid-afternoon sack significantly less often than those with restricting type. Among those with AN-BE/P, skipping dinner is associated with a greater number of binge eating episodes, while skipping breakfast is associated with a greater number of purging episodes. It may be the main mechanism associated with the development and maintenance of binge eating and purging. This mechanism suggests that dietary restraint leads to binge eating, which may lead to purging, and this in turn leads to a vicious cycle of increased efforts to restrict eating again. There is possibility that AN-BE/P often have higher eating disorder severity, more co-morbidities and worse prognosis than patients with AN-R [18].

Beside caloric restriction stereotyped food choices are characteristic of AN. Some food groups are chosen less often like bread and cereals, meat, cured meats, fatty foods, sweet foods and fried foods, but vegetables are chosen more often. Diet intake analyze has shown that restrictive anorexic females have a lower macronutrients intake than do healthy people, and illness duration specialy negatively correlats with the amount of fat in the diet. On the other hand, the relationship between unsaturated and saturated fats (MUFA + PUFA/SFA) is not significantly different between patients and healthy people. There are significant differences in some micronutrients content between the groups. There is tendency of lower intake of vitamin A and vitamin C, as well as sodium, phosphorus, zinc, copper, and selenium. It is established that, compared to controls, lower proportion of patients reached the DRI for

thiamine, vitamin B6, calcium, iron and copper, although a higher proportion of patients reached the DRI for folate. Not only the majority of patients do not reach the DRI for pantothenic acid, folate, vitamin D, calcium, magnesium, iron, iodine and zinc, but that something similar occurs among healthy people [21, 22].

Not only AN, but avoidant/restrictive food intake disorder (ARFID) represents with avoidant or restrictive eating, but it is clearly different from AN. In patients with ARFID there are no disturbed cognitions about weight and/or shape, or a wish to lose weight. There are similar physical signs and symptoms as at AN patients, due to semi-starvation, like weight loss or lack of weight gain, nutritional deficiencies, reliance on tube feeding or oral nutritional supplements and/or disturbances in psychosocial functioning. On the other hand, ARFID patients are younger than AN patients and have a greater percentage of males. There are specific behaviors and symptoms in the ARFID group, including food avoidance, decreased appetite, abdominal pain, and emetophobia. While the degree of malnutrition is similar to that of patients with AN, those with ARFID have a greater dependence on nutritional supplements, fears of vomiting and/or choking, and texture/sensory issues pertaining to food. It can be explained by body preoccupation with somatic concerns. Some children express fears of physical illness due to issues related to shape/weight, e.g. high cholesterol and/or obesity leading to heart isease, either because of personal experiences with relatives or information in their school curriculum. Sometimes, worries about being fat, can be connected with events in the family's medical history, like recent myocardial infarction at an overweight relative. This event can be processed making illogical associations based on the cognitive developmental stage. This knowledge may then trigger restrictive eating behaviors. Thorough history-taking can often elicit this information [23].

### **3.2 Eating patterns in individuals with bulimia**

The bulimics eating pattern can be described as intermittent starvation (i.e. non-purged diet during the restrictive or compensatory phase), interrupted by bouts of binge eating [18]. In the single-course normal meal, bulimics eat less on average than healthy nonbulimics. In patients with BN, objective food consumption ranges, in a sence of total energy consumption, as well as of energy intake per binge episode and the frequency of binge episodes. There is significant difference in the calories consumed by patients with BN during binge episodes compared to nonbinge meals [24, 25].

Thus, objective food consumption in a laboratory setting ranged from 7101 to 9360 kcal per 24 h and from 3030 to 4479 kcal per binge episode. However, subjective food records showed total energy consumption to range from 3117 to 4275 kcal per day and from 1173 to 2415 kcal per binge episode [22].

Even energy deprivation and malnutrition are often thought to be key factors in the maintenance of bulimia nervosa, it is unclear how much energy is actually available to BN patients' metabolism because the contribution of food consumed during binge eating is hard to evaluated [26].

### **3.3 Differences in binge behavior between bulimia nervosa and binge-eating disorder subjects**

Binge eating is defined as the consumption of a large amount of food in a short period of time accompanied by a sense of lack of control over eating [12].

### *Dietary Patterns DOI: http://dx.doi.org/10.5772/intechopen.108367*

Binge eating has historically been associated with bulimia nervosa and the bulimia nervosa subjects eat more than BED subjects when presented with the same types of foods. It can be explained with fact that they allow themselves to purge following a binge. The frequency of binge episodes among individuals with BN ranged from 5.7 to 10.9 episodes per week, while the frequency of binge episodes among BED ranges from 10.7 to 17 episodes per 28 days [25].

Bulimics consumed increased caloric intake mainly because 37% of their meals were greater than 1000 calories. The binge foods consisted primarily of sweet desserts and snacks with a high fat content. This is connected with the avoidance of forbidden sugar and carbohydrate foods during nonbinge periods so cravings for these foods are reflected in their binges.

Thus, the binges of bulimics are higher in carbohydrates and sugar than those of individuals with BED. Generally, those with BED eat more fat, less protein, and an equal amount of carbohydrates when compared to nonbinge eaters what can be associated with their preference to choose foods eaten at a meal for binges [27, 28].

A disruption of circadian feeding patterns in sense that large meals are consumed mostly during the afternoon and evening have been seen at BN and BED. According to the diagnostic criteria, individuals with NES (night eating syndrome) should consume at least 25% of their total caloric intake after the evening meal. However, a delay in the circadian pattern of food intake (NES) may not be simply a variant of BED or BN but rather a separate entity that may lead to a more severe disorder [25].

### **4. Conclusions**

Two EDs, anorexia nervosa (AN) and bulimia nervosa (BN), have historically been the primary EDs of focus. The DSM-5 updated diagnostic criteria for these disorders added two more: binge-eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID) [12, 29].

Based on past versions of the DSM over 50% of patients met criteria for Eating Disorder Not Otherwise Specified (EDNOS). Recognition new disorders makes possibility to take a developmental, or life-span, approach to all disorders.

Patients with ARFID are less likely to report typical ED symptoms, e.g. purging behaviors and excessive exercise. They are younger, and a higher likelihood of being male. Children and adolescents with ARFID are more likely to present at a younger age with significant weight loss or failure to gain appropriate weight, are more dependent on oral or enteral nutritional supplementation, and have significantly more fears of choking and/or vomiting, and texture and/or sensitivity issues regarding food. They do not have body image distortion. However, some of them have body preoccupation with somatic concerns. Thus, evaluation of a young patient with possible ARFID versus AN, include probe about body concerns that need to be distinguished from body image distortion [23].

Disturbances in eating patterns is main characteristic of EDs. Dietary behaviors differ across the eating disorder diagnostic spectrum. For identification and classification of each EDs, it is important to define the associated eating patterns. Individuals with AN typically follow rigid dietary behaviors in meaning their meal times are fixed, they reduce portion sizes, they choose low caloric food. On the other hand, individuals with BN and BED tend to have more chaotic and inconsistent dietary behaviors and greater intra-individual variability. When they are not engaging in binge eating, individuals with AN-BE/P and BN have been found to attempt to restrict their caloric intake for the purpose of weight control, whereas individuals with BED have been found to be less likely to reduce their food consumption outside of binge eating with a slight tendency towards overeating [30].

The detailed description of the disturbances in eating behavior not only helps to identify diagnostic criteria associated with each disorder, but also provide a foundation for the development of treatment interventions [29]. Individuals who restrict caloric intake or consume meals and snacks with irregular frequency tend to engage in more frequent binge eating episodes. An irregular meal pattern of less than three meals a day is associated with more binge-eating episodes Specific dietary restriction behaviors, like reducing caloric intake by reducing portion sizes can increase risk for binge eating behaviors. Thus, it is important to identify dietary restriction behaviors that are associated with the onset of binge eating to cease it. A decrease in dietary restriction is a critical component for a successful reduction of binge eating behaviors across eating disorder diagnoses [30].

### **Conflict of interest**

The author declares that she has no competing interests.

### **Abbreviations**


*Dietary Patterns DOI: http://dx.doi.org/10.5772/intechopen.108367*

### **Author details**

Amra Ćatović Faculty of Medicine, Department of Hygiene, University of Sarajevo, Sarajevo, Bosnia and Herzegovina

\*Address all correspondence to: amra.catovic@mf.unsa.ba

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### Section 3
