On this episode of the CMAJ Podcast, Dr. Blair Bigham and Dr. Mojola Omole closely examine anorexia nervosa in male adolescents, a topic that frequently escapes notice. Their discussion highlights the disorder's prevalence, especially among high-risk groups like LGBTQ+ individuals and those from varied racial and ethnic backgrounds. It also underscores the severity of anorexia nervosa in young males and stresses the critical need for early recognition and intervention.
This episode features an in-depth conversation with Sterling Renzoni, a fourth-year biochemistry student at Trent University, who shares his personal journey through diagnosis, treatment, and recovery from anorexia nervosa. Sterling's narrative provides valuable insights into the complexities of identifying and treating the disorder in males, highlighting the societal and personal challenges that can impede recognition and care.
Next, Drs. Omole and Bigham speak with Dr. Basil Kadoura, an adolescent medicine physician at BC Children's Hospital and the lead author of the article in CMAJ entitled, "Anorexia nervosa in adolescent males." He discusses diagnostic challenges, the distinct clinical presentation in males versus females, and the need for tailored approaches for effective treatment. Kadoura's insights contribute to a nuanced understanding of anorexia nervosa's impact on male adolescents and the critical role of healthcare professionals in facilitating early intervention and support.
This episode is structured to provide medical professionals with a deeper understanding of anorexia nervosa in male adolescents, underscoring the need for awareness and specialized care approaches. It serves as a resource for clinicians seeking to enhance their diagnostic and treatment strategies for this often-overlooked condition.
This podcast has been sponsored by the Yarmouth Region Medical Professional Recruitment Partnership. Click here for more information.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
On this episode of the CMAJ Podcast, Dr. Blair Bigham and Dr. Mojola Omole closely examine anorexia nervosa in male adolescents, a topic that frequently escapes notice. Their discussion highlights the disorder's prevalence, especially among high-risk groups like LGBTQ+ individuals and those from varied racial and ethnic backgrounds. It also underscores the severity of anorexia nervosa in young males and stresses the critical need for early recognition and intervention.
This episode features an in-depth conversation with Sterling Renzoni, a fourth-year biochemistry student at Trent University, who shares his personal journey through diagnosis, treatment, and recovery from anorexia nervosa. Sterling's narrative provides valuable insights into the complexities of identifying and treating the disorder in males, highlighting the societal and personal challenges that can impede recognition and care.
Next, Drs. Omole and Bigham speak with Dr. Basil Kadoura, an adolescent medicine physician at BC Children's Hospital and the lead author of the article in CMAJ entitled, "Anorexia nervosa in adolescent males." He discusses diagnostic challenges, the distinct clinical presentation in males versus females, and the need for tailored approaches for effective treatment. Kadoura's insights contribute to a nuanced understanding of anorexia nervosa's impact on male adolescents and the critical role of healthcare professionals in facilitating early intervention and support.
This episode is structured to provide medical professionals with a deeper understanding of anorexia nervosa in male adolescents, underscoring the need for awareness and specialized care approaches. It serves as a resource for clinicians seeking to enhance their diagnostic and treatment strategies for this often-overlooked condition.
This podcast has been sponsored by the Yarmouth Region Medical Professional Recruitment Partnership. Click here for more information.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Dr. Blair Bigham:
I'm Blair Bigham.
Dr. Mojola Omole:
I'm Mojola Omole. This is the CMAJ Podcast.
So we're focusing on something today that's often not discussed. This is anorexia nervosa in male adolescence.
Dr. Blair Bigham:
Usually Jola, when we talk about anorexia, we talk about it affecting females.
Dr. Mojola Omole:
Yeah.
Dr. Blair Bigham:
But this article specifically addresses adolescent males.
Dr. Mojola Omole:
Yes, and it goes further and talks about the high risk population when we're talking about, I'm assuming cisgender males, talking about those who are, queer, LGBQTIA, and also those of racial and ethnic diversity tend to have a higher rate of anorexia nervosa.
Dr. Blair Bigham:
And the impact can be pretty severe with six times higher mortality in young men who have anorexia compared to the general population.
Dr. Mojola Omole:
And I'm curious to ask the author if part of that is just if there's something physiological or part of that is just the delay in diagnosis because it seems as if it might be harder to identify anorexia in male patients.
Dr. Blair Bigham:
Well, not only do we have the author as a guest today, we'll also be speaking to someone who has struggled with anorexia nervosa as an adolescent. He's going to share a story, some very important stuff coming right up.
Dr. Mojola Omole:
Before we speak to the lead author of the article in the CMAJ, we're fortunate to have the opportunity to hear firsthand about the experience of anorexia nervosa from an adolescent male's perspective. Sterling Renzoni is a fourth year biochemistry student at Trent University. Sterling, thank you so much for joining us today and sharing your story.
Sterling Renzoni:
Yeah, thanks for having me, Jola. I appreciate it.
Dr. Mojola Omole:
So just take us back to the beginning. When did your experience with anorexia nervosa start?
Sterling Renzoni:
Yeah, my experience in the mental health care system first began about grade eight, making the transition to high school. And as a growing man, I wanted to fit in with the cool athletic kids in school. I was trying out for the cross country running team and I wanted to eat a little bit better, exercise a bit more and try to be that healthy cool kid that I saw in school and on social media. But started off innocent. "Oh, let's eat a little bit less of this, a little bit more of that and exercise a little bit more," But one thing I've also struggled with is the perfectionist tendencies. And so I always want to do better. I always want to eat a little bit healthier and exercise a bit more. And things began to spiral out of control and it became quite restrictive and obsessive over what I was eating and quite obsessive around how much exercise I was doing.
And that went on for probably about six to eight months before it became really physically obvious that I wasn't doing very well. And so my parents brought me to my family doctor with concerns surrounding my low weight and my sickly appearance during the winter of my grade nine year. And after a physical exam, blood work, the family doctor realized that I was medically unwell and so I went to our local hospital. From there, I was admitted and I was almost discharged unfortunately, but I was lucky that someone made a call to a larger, more specialized hospital and I was referred to them and they recognized that I was sick with an eating disorder and not just this athletic kid who maybe just wasn't eating enough by chance. And so I was lucky to be referred to them. I was sent down there for more intensive inpatient treatment for my eating disorder. And from there that began a cycle of being in and out of inpatient and outpatient care for the next three years.
And I’d get to the point in inpatient care where I'd be at a high enough weight that I was medically stable, discharged, go to outpatient care, further weight restoration. But when I was in outpatient care, I never quite got to the point where I was mentally well enough to be independent of treatment. And so I struggled with that cycle of getting better physically and then relapsing until the end of grade 12 where I was able to access more specialized, lived in eating disorder treatment where I was able to get more of the therapeutic support I needed to recover.
Dr. Mojola Omole:
I just want to stop and just go through certain points to just ask specific questions. So you said that it all started when you wanted to fit in with the cool kids. It's been a while since I was in high school, four years ago. Was there a culture of this amongst males? I hear it with girls, but was there a culture around looking a certain way, being a certain way, people talking about these types of things with each other?
Sterling Renzoni:
Yeah, there totally is that pressure to look a certain way and as a male, at least for me personally, I felt a lot of pressure to be this ripped man with a six pack. And there's also that pressure being on a cross country running team, there's some pressure maybe not directly said by anyone, but there's pressure I felt to be thinner, eat healthier, exercise more. And I think that proved to be really hard, not only in leading towards the development of my eating disorder, but also in making it harder to recover because to recover from an eating disorder, you have to eat a lot more. You have to eat a lot more foods that society deems as "unhealthy" and you can't exercise, or at least I couldn't exercise very much during my recovery in order to overcome that compulsive exercise piece. And so not only did society and the media pressure lead to me developing in the first place, it also made it harder to recover from it as well.
Dr. Mojola Omole:
When you said that your parents started noticing a change in you, was it just physical or was there something also mentally that was different in you?
Sterling Renzoni:
Yeah, so I think the physical signs were probably the most obvious to my parents at least, and those around me when looking very thin. The behavioral part was maybe a little bit subtle because part of my illness was hiding the symptoms of the eating disorder as well. And so some of the behavioral changes that I experienced at the time were things like eating less, eating in secret more, even lying about what I was eating, lying about how much I was exercising. But I think that part of the illness that was trying to conceal itself made it harder for my parents and even the medical professionals to realize what was going on.
Dr. Mojola Omole:
And what did it feel like inside of you mentally at this point?
Sterling Renzoni:
Yeah, so the weird part I guess for me and maybe others experiences too, but I was unaware of how sick I was even right up until being admitted to the hospital. Being in the hospital, there's this feeling of not even being sick enough, not realizing how sick I am and not feeling sick enough to need treatment. And so at the time if you asked me if I was sick or if I had an eating disorder, I'd say, "Oh, no, no." And it's only now looking back at it that I can see the changes. I think at the time because things progressed somewhat slowly, eat a little bit healthier the next day, exercise a little bit more, it was harder to realize what was actually happening over time.
Dr. Blair Bigham:
Was there a moment where a light bulb switched on and you realized how sick you were?
Sterling Renzoni:
I don't think it's until after I recovered and that's where I realized how sick I was because at the time there's this eating disorder voice inside of me that was like, "You need to get sick or you need to eat less, exercise more," all the time. So I never felt that I was sick enough and so it's hard to have that light bulb moment when you're not all there. The eating disorder consumed a lot of my thoughts at the time.
Dr. Mojola Omole:
When you first went to your family doctor, what was that experience?
Sterling Renzoni:
I was in a little bit of disbelief of what was happening. I didn't quite realize that I needed to be there and needing to be getting the help I did and there was a lot of pressure from the, I don't want to say eating disorder voice in my head, to mask my symptoms. If they would ask, "How often are you eating" or "How often are you exercising?" There was a lot of pressure that I felt from the eating disorder to lie about those things and to conceal the illness. And so it was a tense situation because I was saying one thing, the disorder was almost saying one thing and my parents were saying another. And so it presented, I'm sure, a challenge to my family doctor to discern what was actually happening because of that concealment part of the illness.
Dr. Mojola Omole:
So how did you feel from the family's concern about you, your family doctor's concern about you, how did that make you feel?
Sterling Renzoni:
I think at the time, often treatment goes against the eating disorder in a way, and so at the time, I identified with the eating disorder in a way or is a large part of me. And so as you get told that you're going to have to go into treatment for it, it doesn't feel very good because that's something you've, or at least in my case, I've identified with and it's a big part of my life and they're saying, "Oh, we got to treat this. We got to make sure you get better." And that was something that felt really scary to me at the time. So I think it was a scary experience at the time, but looking back on it, I'm really grateful and I feel lucky that I got the care I did receive.
Dr. Mojola Omole:
So you've mentioned that you did inpatient treatment and then there were some other treatments once you were outpatient that became effective for you. How effective were the different treatments that you had and what part would you say is what has you here with us today?
Sterling Renzoni:
Yeah, so I think every part of it played a role. Certainly, the inpatient care. I guess even starting with the family doctor visits, those were what helped me get care in the first place. If it wasn't for my family doctor recognizing how unwell, I probably wouldn't be here either. If it wasn't for the larger more specialized care center referring me to them or recognizing that I needed more intensive inpatient care, I also wouldn't be here either. And that inpatient care was really essential for that medical stabilization piece. I really needed that. I was fairly physically unwell, mentally unwell, and that inpatient care provided that stabilization I needed, and for the most part, the outpatient care I received, some of it was helpful, some of it wasn't though.
I think the challenge was, often with these programs, I would get to a point where I was physically well and my heart rate was fine, the weight was at a good number, but it's sometimes hard to assess how mentally unwell someone is with a eating disorder, especially if part of the illness in my case was concealing the illness. And so someone would ask, "Oh, how are your thoughts around food?" I would say, "Oh, they're great," but in reality they might not have been. And so that was the hard part without some of the outpatient care is being discharged to the point where I wasn't mentally well enough where my thoughts around food weren't at a healthy state.
Dr. Mojola Omole:
Looking back, did you know that, let's say, for that example, your thoughts around food weren't good and you were trying to conceal or did you honestly think, "No, I'm good"?
Sterling Renzoni:
It's a hard question to answer because looking back now, I know those thoughts around food weren't healthy, but at the time it's hard to be aware of it when the eating disorder was my voice as I was going through those times. And so I knew if they were saying, "Oh, are your thoughts around food? Do you think that all foods are healthy?" or whatever, I would say, "Oh sure," but I knew even at the time, that that's not what I thought. And so there was that active conscious concealment of it brought on by the eating disorder for sure.
Dr. Blair Bigham:
Sterling, you mentioned that the general hospital almost sent you home before sending you to the larger hospital. What do you think tipped them off to how sick you were and that you really needed that transfer to a children's hospital?
Sterling Renzoni:
Yeah, the fact that the children's hospital had a specialized eating disorder unit and I had imagine this issue is something they see often where they have these young adults who are maybe don't say they're sick but are sick. I think it's a combination of the physical signs and they maybe recognized that the denial of the eating disorder was not something that would prevent me from getting care. I guess they recognized that. Even though I thought I didn't have an eating disorder, they recognized I still could have one.
Dr. Blair Bigham:
Were there other guys on the inpatient unit?
Dr. Mojola Omole:
I was so curious about this.
Sterling Renzoni:
There was only one. So I was admitted several times to the specialist children's hospital and there was only twice. There were two other guys I met, but we were definitely a minority on the unit for sure.
Dr. Blair Bigham:
How did that affect the experience you had of being hospitalized?
Sterling Renzoni:
That's a good question. For the most part, there wasn't a strong effect. I think one thing that I noticed is that a lot of the maybe unit activities were more female centric. Maybe we're doing a lot of arts and crafts or something and it's just not something that I'm just not a very arts and crafty person.
Dr. Mojola Omole:
Honestly, neither am I. Neither do I.
Sterling Renzoni:
But whether that's because of the fact that not a lot of guys go through or not is, I don't know, not necessarily obvious, but a lot of the things for the most part that some of the women or young women or people were going through, I could also relate to, in a way. A lot of the same symptoms that we shared as well, and so I could relate to them for most aspects. I think one thing that I struggle with particularly as a male was a lot of compulsive exercising and that was something that maybe stood out as something that wasn't so common on the unit, but I think for the most part, I didn't face a lot of challenges because I was a male on a mostly female eating disorder unit.
Dr. Mojola Omole:
Now that you do a lot of advocacy work, do you think there's something unique about the cis male experience with anorexia?
Sterling Renzoni:
It's hard to say. It's hard to say where there's something unique about it, but I think in contrast to what I saw others going through on these, I think there were maybe some differences in terms of the pressure behind it. I think what I've heard from some other people and maybe cis females is that there's pressure to be thin, but I think I felt a lot of pressure to be muscular and that morphed into this eating disorder, the anorexia. And I think-
Dr. Mojola Omole:
Can you explain that to me? How did that work in your brain? You're like, "Okay, I want to be a gym bro, but I'm not going to eat and I'm going to exercise a lot."
Sterling Renzoni:
Yeah, no, it's the weird part about eating disorders for sure, at least in my case, there's not very much logic behind it. I think it was almost like a switch flipped in my brain from initially being like, "Oh, I'm going to eat healthier, eat a lot more protein, exercise more." Something just flipped and it started, "If eating protein is good for you, then therefore I should be eating only protein," and it's weird, it's all or nothing, black and white, perfectionist tendencies just jumped right onto that. It makes no sense, but it's what happened. I think maybe that makes it harder too if someone asks you as a screening question, "Do you want to be thinner?" And I say, "Oh no, I just want to be more muscular and stronger." Maybe that, because of the pressure that led to the disorder, if I say that, it makes it harder to recognize that this is anorexia.
Dr. Mojola Omole:
Which actually leads me to my next question. What do you think physicians should keep in mind when assessing young males for anorexia nervosa?
Sterling Renzoni:
Yeah, I think there's an importance to that muscle building exercise piece too. It is something really important to screen for, I think. And recognizing that part of the illness might be denying the nature of the illness. It might be concealing it, and I think that goes for both men, women and everyone in general that part of the illness might be concealment. So keeping an eye out for that and making sure if you're speaking with an adolescent, maybe you ask their parents for their perspective as well. For sure.
Dr. Mojola Omole:
You do a lot of advocacy and speaking about this issue, which I just want to commend you. That's extremely brave to be vulnerable and to share something that other people might not feel comfortable sharing. So I just want to say thank you, first of all, for your bravery. What do you think others going through it need to hear?
Sterling Renzoni:
Yeah, I think it's important to know if you're someone going through it, that there's hope. Often when I was really sick, it felt like the eating disorder was all I knew, and during the recovery process, there's a lot of ups and downs and sometimes it felt like during the down times that things were just getting worse. For me, I had to give up going for runs, being outside to be stuck in a hospital to get better, and at that point it was hard to have hope that things were really going to get better because eating disorder was all I felt that I knew at the time, and so it would've been nice to have someone telling me who's been through it before, that there was hope for recovering into a life where food and exercise are not something I had to think about all the time and where I could be generally happy and go back to enjoying the things I did before my illness and also have the opportunity to carve out a new identity for myself, which has been a really refreshing experience since recovering.
Dr. Blair Bigham:
It's amazing. You're quite the leader on this.
Sterling Renzoni:
Thank you.
Dr. Blair Bigham:
You've made quite a remarkable recovery.
Sterling Renzoni:
Thank you.
Dr. Blair Bigham:
Are there still days that you struggle?
Sterling Renzoni:
So I think I no longer struggle with the food and exercise piece, but there is every once in a while where you're having a rough day and you go to the cafeteria at school and you see all these calorie counts everywhere, and there's this thing inside of me that still wants to do the mental mass sometimes add up things and compare, but at that point, I think back to where that got me and I'm like, "Oh dear, we're not going back there."
Dr. Mojola Omole:
I actually didn't know they have those in the cafeteria?
Sterling Renzoni:
Oh yeah, they're everywhere. It made the recovery process so much harder having that everywhere and trying to tell myself not to do it. But I think on those days it's having the skills to realize maybe I can ask someone to pick for me what to eat that day or I'll just have what the daily special is. Taking that choice off of me on those days where it's hard to decide. And I think that's really helped.
Dr. Mojola Omole:
Thank you so much for sharing your story with us Sterling. Sterling Renzoni spoke to us today from Peterborough, Ontario.
Dr. Blair Bigham:
Dr. Basil Kadoura is the lead author of the practice article in CMAJ, entitled, “Anorexia nervosa in adolescent males”. He's an adolescent medicine physician at BC Children's Hospital. Basil, thank you so much for joining us today.
Dr. Basil Kadoura:
Thank you for having me.
Dr. Blair Bigham:
Let me ask what ran through your mind listening to Sterling's story?
Dr. Basil Kadoura:
The first thing that went through my mind is like Jola had mentioned, how brave Sterling was to be able to share this story. Mental health is so stigmatized and particularly eating disorders in adolescent boys, and when I say boys, I do mean cis males. It's so stigmatized that people don't talk about it. And to see Sterling really have that full journey of initially not being taken so seriously, then being taken almost too seriously for his liking and then coming around and recognizing how this treatment really did save his life was something that we see in many of the boys that we treat for anorexia nervosa.
Dr. Blair Bigham:
I know that there's a lot of nuances in all of this, which I want to dig into, but let's start at the 30,000 foot view. If you were having to write a Royal College exam, I know we've all put that behind us, but what would be the main difference for anorexia nervosa in males versus females?
Dr. Basil Kadoura:
So I think the main difference is sometimes the motivation.
Dr. Blair Bigham:
Oh, okay.
Dr. Basil Kadoura:
When we think of a female presentation of anorexia nervosa, we're really emphasizing an idealism of thinness and a flat stomach and being as small as possible, whereas the male presentation while there is weight loss, and we can talk about the nuance in the diagnosis as well, but it's really about leanness and muscularity and having a six pack and having broad shoulders, but a very small waste and really controlling your food and your nutrition. And when we look at the role exercise plays, we definitely see exercise in many female presentations, but it often has a very central role in the weight loss when it comes to male presentations, they tend to be more rule driven, more rigid and more compulsive with their exercise. They are more likely to come from a racialized background as opposed to a White background in female presentations, and they're more likely to use substance use like even prescribed stimulants to help suppress their appetite as needed.
Dr. Blair Bigham:
Now let's get into some of the nuances. What should family doctors and general practitioners have in mind when they're trying to find this picture, this clinical syndrome that quite honestly, can be difficult to identify? What are some of the giveaways that they should be paying attention to?
Dr. Basil Kadoura:
Great question. Our recommendation in general is anytime you're seeing a teenager, you're completing that social history and in that you're reviewing eating and body image. And for a lot of these guys, they won't say, "Oh, I want to be thin" or "I'm too fat and I want to lose weight," but you might notice that they want to go to the gym, they want to eat more protein. They might be using supplements to try to increase their muscle mass, and they're not afraid to gain weight. However, they only want to gain muscle. They're not willing to gain weight for their whole body.
Dr. Blair Bigham:
So what are your go-to specific questions? Do you have any tricks when you're trying to elicit this history that can help identify this really tricky diagnosis of anorexia nervosa in males?
Dr. Basil Kadoura:
Yeah, I'll start off pretty basic and just say, "Tell me, what does your diet look like in a day? What food are you eating throughout your day? How are you feeling about your body?" It's really common for adolescents at this stage to start to be aware of how their body looks and start to compare it to others. And sometimes people will have feelings about that. "How do you feel about your body? What do you really like about it? What's something that you wish you could change? Have you ever done something to try to change that? What would you do?" And then being able to explore stuff that comes up or any red flags that might come up with regards to, "I think I am a little pudgy around the waist" or "I get made fun of because I'm short and so I feel like I gain weight and it's all in my hips," or whatever. Okay, maybe not hips.
Dr. Mojola Omole:
Something that just keeps popping to mind is when you're describing these young males who might be having anorexia nervosa is that we are in such a society and a culture that you're talking about people using stimulants, caffeine, going to the gym, over exercising, this seems like what, I would say, literally 90% of what I see in social media and the world. So how do you tease that out and then to what extent does that cloud our judgment that males maybe are developing more severe consequences because they're delayed in the diagnosis? So that was a lot of questions, sorry.
Dr. Basil Kadoura:
I think you're absolutely right, Jola, that there is a culture of disordered eating that is pervasive throughout our society. I know I get questions from patients, from family members, from people who I would say don't have eating disorders but have intermittent disordered eating because there's such a diet culture and a fat phobic culture that we live in. The difference is when it comes to a point of potential harm and danger, and when I see them, their heart rate is in the 30s and when they sleep, their heart rate is in the 20s, and we've heard of patients where, due to delays in care, their heart stopped and they ended up needing to be resuscitated in the community and required a PICU admission.
And so I remember speaking with many patients who I'd say, "This is a very real risk," and they'd say, "Well, no, I'm fine. I feel great." And that's part of that sneakiness that Sterling talked about, that this anorexia nervosa is so sneaky and it hides even from the person that it's taking control over. It hides what it's doing and the body is so good at adapting for so long that you really don't feel that, so you're not able to recognize that a doctor's telling you you're at risk of dying and anorexia is the most mortal eating disorder, a very high death rate, and you're like, "No, that's not going to happen to me."
Dr. Blair Bigham:
Let's talk a little bit more about these delayed diagnoses and just how sick people can get if they're not treated. What do you think some of the reasons are for males more often than females not being diagnosed right off the hop or early enough and ending up in that severe state?
Dr. Basil Kadoura:
It's really multifactorial. From a patient perspective, there's a lot of shame and isolation. Even if there's some inkling and some insight in the back of their mind and really, like a lot of psychiatric disorders, insight is blunted, is really impacted. Even if there is some small insight in there, there's that shame of, "This shouldn't be happening to me. Boys don't get anorexia. This isn't what I see on TV or in the movies." And so you actually see a decrease in help seeking behaviors. Parents think, "Oh, you're really active," and a lot of the time, boys will use exercise as a form of affect regulation or to support their mood. They're like, "Oh, you're a moody team. You need to go for a run. You need to go for a swim." And they'll actually encourage that or encourage weight loss. And so parents will also delay help seeking behaviors.
When they do present, we're so conditioned to believe that anorexia nervosa, the typical presentation is a young thin White woman that we don't think of it. And so we think, "Oh, you just have an athletic heart. That's why your heart rate is in the 40s and 30s. And then when they finally do get recognized, things have gotten so severe and we know from the literature there's not a ton of literature, but we know from the literature that adolescent boys will have to eat a significantly amount more because you're now not only taking in caloric requirements for your growth and development, which is high to be an adolescent boy, but you're now having to play catch up for all that time that you missed and to restore your muscle in your fat stores and support your vital organ growth.
And so there's a delay in help seeking behaviors, a delay to diagnosis, and then even in treatment, they have to be treated for longer and at higher rates to be able to get there. And then again, because there's such a difficulty with the diagnosis, there's not always buy-in and for eating disorders in adolescents with the main treatment being a family-based treatment, it really means the parents have to take control of that nutrition. And so if the parents don't have that buy-in, then we see that treatment isn't as effective. And also, we know that for the patients, the more rejecting they are of treatment, the harder it's going to be for their parents and the harder treatment's going to be.
Dr. Blair Bigham:
Let's dig into the treatments here. Sterling gave us some of his experiences, a bit of a rollercoaster, a couple of relapses. Tell us about the treatment for males. Is it significantly different for females?
Dr. Basil Kadoura:
So the actual treatment model would be similar. At the end of the day, you need your nutrition and you need to be restful because your weight needs to restore so that your vital organs can recover and your brain can recover and your heart can recover and you can continue to move on with your life. When we look at boys and treatment, there are some differences. Again, we mentioned the higher caloric needs for recovery, and also there tend to be more relapses with exercise, and so that really impacts the ability for recovery to happen. As you can imagine, energy going out is higher than energy going in and energy needs, and so they end up not doing so well in needing readmission. When you're that malnourished, your body's quite fragile, so even walking can be too much for your body and using up too much caloric energy for your recovery to properly happen. And so if you imagine someone biking and walking and running, you can imagine how hard it's going to be to recover.
Dr. Blair Bigham:
So what are your tricks for getting someone who's so into going to the gym, so into running, so into exercise, and not only do they have to eat more, but now you're telling them to do less. How do you help people grapple with that?
Dr. Basil Kadoura:
It's really hard. I'm not going to lie. I think it's really hard for them and it's really hard for parents and it's hard for us. This is something that brings them community, brings them joy, and we know that if they continue doing it could be what brings them death. I guess that sounds really dramatic, but-
Dr. Blair Bigham:
But people die from this condition, right?
Dr. Basil Kadoura:
That's exactly right. We recognize that anorexia nervosa has a mortality rate of about 10%, and some studies show a crude mortality rate of 15% in males. It's one of the most deadly psychiatric disorders, but we do have a chance of cure in adolescence, which is why we fight so hard and we take treatment so seriously.
Dr. Mojola Omole:
When you say you have a chance of cure, can you explain that, just what does that look like?
Dr. Basil Kadoura:
Yeah, so clinical numbers might vary, but the literature says that about 50% of people who go through family-based treatment will recover fully the first time. About another 25% of those people will need to go through a second time and will recover. And then you have about a quarter who tend to be, I don't love the term treatment resistant, but who struggle with treatment and it tends to be less effective for them and they need to go on to other forms of therapy.
Dr. Mojola Omole:
You had mentioned earlier that anorexia nervosa is more common in racialized boys. Do we know why we see that pattern and does that presentation look differently than maybe a White boy?
Dr. Basil Kadoura:
We don't know. That's something that again, is seen in literature that is available, but I don't think we have a specific answer, at least one that I know, as to why we see that.
Dr. Mojola Omole:
What's the most supportive way a physician can connect to these young males in terms of trying to support them to get treatment?
Dr. Basil Kadoura:
This is where some motivational interviewing comes into play, so it's important to be able to understand what's important to them and understand what their goals are. Typically, these people are very ambitious. They have lofty goals, whether it's related to their academic-
Dr. Mojola Omole:
Future doctors.
Dr. Basil Kadoura:
You know it. Whether it's related to their academic or their career goals or their sports goals, they really often have big goals, and so it's often working with them to say, "This isn't working." For example, I think Sterling also talked about being an athlete and at some point, the malnutrition got to him and initially it was to try to perform better, but at some point your body just can't perform the way it was before. Sometimes that's a good starter to be able to say, "Listen, your body needs more nutrition. You want to be good at this sport, and I want you to get back to it, and we need to do this right, otherwise this might limit your life because even if we don't fully weight restore and your heart is still impacted, that's going to have lifelong implications, and I don't want you to be dealing with this when you're 40. We have a chance to deal with this properly now and for you to live the life that you should have lived if this never came into your life," and really show that you care about them and their potential.
Dr. Blair Bigham:
This must be so hard on parents as well. What do you say to parents? What do they need to know as they're helping their kids through this?
Dr. Basil Kadoura:
This is really tough on parents, and I will try to take a moment to be able to chat with a parent alone if I can, and if the teen is comfortable with that, to be able to offer a little bit of support. And really that's something that we recommend or we really encourage in families is recognize who are your supports? You can't go through this alone. This is a life stopping disorder. We talk about cancer and chemotherapy and how that's a life stopping diagnosis and people stop their lives and they go through treatments, and it's really similar here. Parents are having to take time off work. They have to be available for six meals a day to be able to supervise and feed their children. And so we let them know that this is a marathon and you need to be taking care of yourself as well, because if you're not taking care of yourself, you're not going to be able to come up against this eating disorder and support your child.
Dr. Mojola Omole:
So if a family doctor sees a teen and maybe they don't feel comfortable, should they refer to a pediatrician who might have more of the arsenal in their toolbox to help manage as a stop gap waiting for a referral for outpatient treatment?
Dr. Basil Kadoura:
I think it depends on what's available in your community. If you have a community eating disorder program that's going to be able to offer certain supports early on, then it makes sense to not have an in-between and to be able to just get them connected. And ultimately, we need the growth charts from the family physician, we need to understand the historical growth data, and so it really is helpful to have that referral coming from a primary care person who's known that person, who's known that teen for quite some time. If there's going to be a long wait time and there is a feeling of helplessness, then I would encourage them to call their local center to be able to get some support.
Dr. Blair Bigham:
Basil, thank you so much for joining us today.
Dr. Mojola Omole:
Thank you so much.
Dr. Basil Kadoura:
No, thank you for having me. It was so lovely getting to chat with you folks, and I hope this will be helpful for some primary care and other healthcare folks that might be seeing these patients.
Dr. Blair Bigham:
No doubt. Dr. Basil Kadoura is an adolescent medicine physician at BC Children's Hospital.
Dr. Mojola Omole:
So Blair, both the interview with Dr. Kadoura and Sterling has really been thought provoking. What are your initial reactions being that you're also a cis male?
Dr. Blair Bigham:
Well, I mean, certainly as a teenager, even now as a 38-year-old, I think a lot of people do feel pressure to have that body that you always see on TV and in the movies. I guess what I'm most struck by is Sterling's recovery, his insight into his compulsive desires to meet a certain standard and to understand that the things that he was doing to achieve that was so harmful. I mean, we only spoke to him for a few minutes, but he sounds so cured. He sounds so much better, and I'm so inspired by that. And then he comes onto our show to talk about it is just amazing.
But at the same time, I'm struck having known many people who have suffered from eating disorders, it is such a difficult and long journey to recover from. I'm just so grateful that we have these specialized programs that can commit the dedication and expertise needed to help people get better, but as always, access is paramount. And I know that as an emergency doctor, we've had parents and their kids come in with concerns around eating disorders, and it's very difficult to connect them to a care pathway that is expedited and has some dignity to it.
Dr. Mojola Omole:
For sure. I think for me, what really struck me was just actually how insidious the era that we're in in terms of fat phobia and body image and how that is also not just affecting young girls, but also young boys.
Dr. Blair Bigham:
Maybe on the men's side, it's not so much fat phobia as it is, muscle philia, like this idea that you have to be this upside down triangle with big muscles in your shoulders and deltoids-
Dr. Mojola Omole:
But to get that, you can't have fat on you.
Dr. Blair Bigham:
Well, that's true, but it's hard to know what the difference is between wanting to be a healthy muscular individual versus having that societal influence on you where you become ill.
Dr. Mojola Omole:
And I think that that's a slope, right?
Dr. Blair Bigham:
Mm-hmm.
Dr. Mojola Omole:
It's challenging and it's easy to start off, similar to what Sterling said to just, "I want to be a better runner. I want to be more lean. I want to be more athletic," to it becoming, taking over your life and becoming a psychiatric diagnosis. So I do think as parents, as physicians, that we do have to be vigilant and make sure that we also are examples of healthy and balanced, I think something like Ashley White had said, "Body acceptance." Not positivity, but just body acceptance. So if we model that, our kids and our patients could hopefully have the same point of view.
That's it for today's episode of the CMAJ podcast. If you like what you heard, please give us, don't give a five star, I don't want five stars, I want six stars.
Dr. Blair Bigham:
Six stars and all the hearts.
Dr. Mojola Omole:
Six stars.
Dr. Blair Bigham:
Thumbs up.
Dr. Mojola Omole:
Yes, hearts, everything. Wherever you get your podcasts, share it with your networks and leave a comment, but don't say mean comments because-
Dr. Blair Bigham:
Oh, no. Good comments only.
Dr. Mojola Omole:
Yeah, we're sensitive people. The CMAJ podcast is produced for CMAJ by our wonderful producer at Podcraft Productions. Thanks so much for listening. I'm Mojola Omole.
Dr. Blair Bigham:
I'm Blair Bigham.
Dr. Mojola Omole:
Be well.