Boys, Body Image, and Eating Disorders, feat. Jason Nagata, MD

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Posted in: Hot Topics, Multimedia, Podcast

Topics: Culture + Society, Mental Illness + Psychiatric Disorders

Most teens stress over body image at some point. But when you hear the term “eating disorder” what do you think of? Probably not boys and men. Yet, adolescent boys struggle with body image and disordered eating behaviors nearly just as often as girls do.

Tune in below, or wherever you get your podcasts.

Today we’re joined by special guest Jason Nagata, MD, an adolescent medicine and eating disorder specialist at the University of California, San Francisco. He joins Gene and Khadijah to unpack what every parent should know about disordered eating in boys. They discuss the pressures boys face when it comes to body ideals, the impact of sports culture, and how to recognize signs of an eating disorder in your child.

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Episode Transcript

SPEAKERS: Gene Beresin, MD, MA; Khadijah Booth Watkins, MD, MPH; Jason Nagata, MD


Dr. Jason Nagata  00:01

Teenagers in the 80s and 90s, would watch this material but would generally not expect that they would ever be featured on the cover of a magazine or on a Hollywood movie. But now with social media, there’s additional pressure for teenagers to produce content, not just consume content, and so their bodies are on display more than ever. And I think that this is no more acknowledged in girls than it is in boys.


Gene  00:28

Welcome back to Shrinking it Down: Mental Health Made Simple. I’m Gene Beresin.

Khadijah  00:32

And I’m Khadijah Booth Watkins.

Gene  00:34

And we’re two child and adolescent psychiatrist at the Clay Center for Young Healthy Minds at the Massachusetts General Hospital. Today, we’re going to spend some time on a topic that really doesn’t get enough attention: boys, body image, and eating disorders. So despite the stereotype that eating disorders are a female thing. About one in three people struggling with an eating disorder are male.

Khadijah  01:00

And for eating disorder behaviors that don’t really meet the clinical level of a disorder like things like binge eating, laxative abuse, fasting, these behaviors aren’t nearly as common in men as they are in women. So to help us delve into this a little bit more deeply, we’re pleased to be joined by Dr. Jason Nagata from the University of California, San Francisco who is an expert in eating disorders, and particularly with the focus on boys and men. So welcome to the show. Dr. Jason Nagata.

Dr. Jason Nagata  01:26

Thank you so much for having me.

Gene  01:28

So, Dr. Nagata is a pediatrician and an adolescent medicine specialist who cares for hospitalized adolescents and young adults with eating disorders. He’s also a researcher. And his lab focuses on eating disorders among boys, men, and the LGBTQ+ community. He also studies health consequences of adolescent and young adult behaviors, with the goal of preventing cardiovascular disease and mental illness and later adulthood. So, we’re all about prevention here at the Clay Center and early intervention, you’re really a perfect guest for this because I think what many parents are concerned about with their kids that have eating disorders, is well first how to prevent it. And we can get into the various different factors that go into causation. But also, once it starts, about early intervention.

Khadijah  02:26

So Jason, before we get into our discussion, is there anything else you’d like our listeners to know about you about your background? I mean, I’d love to hear about how you got into this field, or do you have any particular areas of interest?

Dr. Jason Nagata  02:39

Yeah, thank you so much. I actually did get into this field and background because of one of the first patients that I ever cared for as a medical student. I remember that I was in the Adolescent Clinic, in our eating disorders, referral center. And one of the first patients that I followed was a 16 year old male wrestler, he was referred to the eating disorders clinic by his parents, because they were really concerned that he was becoming obsessed with his appearance, he was weighing himself 10 times a day, he would severely fast and restrict food intake in order to make the weight cut offs that were required by the wrestling team. And in addition to you know, varsity wrestling practice for two or three hours a day, he would then spend all of his free time, you know, up to five hours extra in the gym on his own weightlifting. And he started having very restrictive diets, where he would only consume protein like protein powder shakes, and egg whites, but tried to eliminate all fats and carbohydrates. But he was really struggling with this for years, actually. And I think that part of this was masked by sort of normalized behaviors within the wrestling team. But it did get to a point where, you know, it did take over his life, he was obsessed with it. And when he was actually first seen by us in clinic, he did need to be hospitalized because he had had some significant heart and liver complications that require hospitalization. But I remember as a student, you know, trying to give the best care to this young adolescent, trying to read about guidelines for eating disorders in boys and men and how what I could do to help him, and I was actually kind of at a loss because all the guidelines were based on female samples. And they included things like if you have a loss of periods, and this is what you should do. And even back then the diagnosis of anorexia nervosa required the loss of menstrual periods, which obviously doesn’t apply to boys. And so, it was just a big wake up call for me that there was really a big gap in terms of just general knowledge on how to care for and identify eating disorders and boys and men and that really directed my research and career for the rest of my training.

Gene  04:53

So, you know, our first impressions often, are first patients often lead us to where, what we do for careers because they they’re so we’re so impressionable, right, just as human beings. So, I know we want to get into eating disorders. But maybe we could start with a closer look at Boys and body image. Since these are two things that often go hand in hand. And I was reading that in 2002, a national poll of parents and kids, ages eight to 18 found out that in the report, more than two, it’s two to two in three parents perceive their teenage sons to be self-conscious about some aspect of the of their appearance. So, these are just parent perceptions, not the voices of teens, but two out of three is a lot. So, Jason, is that been your experience that, that boys and girls are both highly self-conscious about their appearance and body image?

Dr. Jason Nagata  05:51

Yeah, um, the study that you cited is very much in line with our understanding of body image. And I just wanted to reiterate that I think people are generally more aware that girls, especially teenage girls have body image concerns, predominantly with drive for thinness, and that may lead to weight loss goals. But I think that people are relatively less aware that boys actually have body image goals as well. And, you know, we had a similar study looking at data from the Centers for Disease Control, looking at high school students across the US. And we similarly found that about, you know, unsurprisingly, about two thirds of teenage girls are actually trying to lose weight actively, unfortunately. But we also found that two thirds of teenage boys are trying to change their weight actively. But with boys, there’s different pressures, about a third of boys were trying to lose weight. But a third of boys were actually trying to bulk up and gain weight. So, I think that there’s, there’s more heterogeneity and like differences and what boys are trying to achieve. But there are still a majority of boys, high school boys who are actively trying to change their weight concerns. And I do think that, you know, teenagers are generally more sensitive to their peer influence and appearance, you know, they’re starting to become their own individuals, they may be starting to date, and have like romantic feelings. And so, they’re all these pressures that are actually part of normal development to be more, you know, sensitive and concerned about one’s body. And of course, they’re going through puberty. So, there’s many changes that are going on. And this is sort of why the peak age of onset for eating disorders does tend to be in the adolescent and young adult period during this sensitive window.

Gene  07:38

So, you know, body image is super important. And as you say, it is a normal part of development. And I think that all of our listeners will, kind of either young adults or parents will agree. But yeah, let me ask you this, how much is influenced by other social forces like the media?

Dr. Jason Nagata  08:00

Yeah, I think that the media is one of the big influences in body image, the, the traditional thought is that the media, peers, and families are the big three sort of sociocultural influences into body image. And I think that, you know, the media has been around for a while. But I do think that one recent development in the last couple of decades has been the advent of social media, because I think social media uniquely combines traditional media with peers, because, you know, obviously, many peers are posting on social media and to some extent, family members, maybe posting on social media. But you know, traditionally, if people were consuming media through television, or movies or magazines, they generally were living in a read only environment like, you know, teenagers in the 80s and 90s. And early 2000s, would watch this material but but generally not expect that they would ever be featured on the cover of a magazine or on a Hollywood movie. But now with social media, there’s additional pressure for teenagers to produce content, not just consumed content, and so their bodies are on display more than ever. And I think that this is more acknowledged in girls than it is in boys. A lot of the congressional hearings that have been going on recently that have highlighted the impact of social media on body image, have really focused on studies that have focused on girls and weight loss and how social media may contribute to weight loss pressures and girls but the few studies that have actually looked at this and boys have found similar findings and boys actually do have unique, you know, patterns of use of social media. So, the studies that have looked at this have found that actually boys are more likely than girls to allow for public followings. Their selfies are more likely to display their full body with muscles rather than just their face. And a majority of male body image content does depict muscularity and leanness. And the studies that have looked at the impacts of social media consumption and teenage boys and young men have found that more social media consumption or use has been linked with meal skipping, disordered eating, dissatisfaction of one’s muscles, and even use of anabolic steroids.

Gene  10:18

You know, one thing, one thing about that, I think has really been positive. Is in terms of the media. I mean, we’ve always talked about the negative and the negative impact of the media and the negative impact of, of particularly social media. But you know, I think, and this, perhaps has to do with national trends and with the National Association of eating disorders, there are more there’s more diversity in terms of body shape and size, when television now than there certainly was in the 50s 60s and 70s. And I, I can’t help but, but well, my hypothesis is, is that all of the research that’s been done about the media’s influence on body image from Barbie and Twiggy, and super thin models, and, and the like, has had an impact on on television production, to include a diversity of size shape, you know, and even even in Barbies, I mean, there are there are toys that have changed. Do you find that to be the case, Jason?

Dr. Jason Nagata  11:28

Yeah. Do you think that’s what are? I think you’re right, in that there is more acknowledgement of body diversity. And, you know, there are even terms like body neutrality and body, body positivity. And there are even some influencers or, you know, celebrities who really, I think, endorse this and are really known for this, I do think that it has definitely allowed for a more diverse representation in the media overall. But I do think that there still are these, you know, immense pressures for most young people, and including those who are influencers and celebrities.

Gene  12:06

Well, yeah-

Khadijah  12:07

I think that deliberate diversity that we are seeing is really more apparent in diversity of women and their shapes and their sizes. I don’t know that I and that I’m not the aficionado of all things, TV, but I don’t know that I see so much in terms of diversity and what men’s bodies look like, in film, you know, they always for the most part, unless there’s a, quote unquote stereotypical role, they always look pretty, you know, muscular, you know, well defined. Like, it’s rare that I see a lead role of a man who is supposed to be you know, handsome, charismatic, be someone that doesn’t look like what you know that, quote unquote, ideal is. But I do see it much more when we depict women, whether it’s, you know, singers, deliberately picking a diverse set of background dancers, in fact, backup singers and things like that. But I don’t think we’re doing a good enough job as it relates to boys and men. There really is this kind of lack of attention and awareness to the challenges that boys and men face. So, I guess what, what should a parent know about how body image ideals differ for boys and men? Like, what is the suppose that ideal body type for them?

Dr. Jason Nagata  13:26

Yeah, thank you for raising that. I think you’re absolutely right that when people think about eating disorders, they typically think about weight loss and fitness, which is sort of the feminine ideal body. And that makes sense because a lot of the early research and even the early diagnostic criteria for eating disorders was really more reflective of anorexia nervosa was on female samples where the body ideal is thin, and so you know, when even when we asked about typical disordered eating behaviors, we think about behaviors like fasting, skipping meals, dieting, or you know, taking laxatives or diuretics or vomiting to lose weight. But we don’t think so much about behaviors or goals to gain weight or muscle and you know, the masculine body ideal is actually big and muscular. So, muscle dysmorphia is also known as “bigger-exia”, or reverse anorexia. And this occurs when boy becomes obsessed with the idea that their bodybuilder is too small or not muscular enough. And so, this may lead to a host of other behaviors that are not characterized or included in some of those typical behaviors. We think about disordered eating, like engagement in excess of exercise, or overconsumption of protein while cutting carbs and fats, or using muscle building drugs and supplements like anabolic steroids. And so, these are all things that we I think need to be more aware of, especially in our boys. And I will say that there there is more diversity and heterogeneity in boys. And so, while there are boys who are trying to bulk up and gain weight there are, there definitely are also boys who are trying to lose weight and who can develop anorexia nervosa. So, I think there’s just more of a wide spectrum of presentation of eating disorders and boys.

Khadijah  15:17

I shared with the group last, one of our previous podcasts, I remember my son used to watch the old Hulk, Incredible Hulk TV series, and he used to run around, like flexing his arms and, you know, trying to appear to be muscular. And I think, you know, that idea of this is what a boy, a man should look like, really does start early in terms of what they see and what they hear. So I think that’s really important for us to think about and know.

Dr. Jason Nagata  15:41

Yeah, absolutely. And just to echo that, even male action figures, so Superman, Batman and Marvel Superheroes, studies have shown that actually, the muscularity that in male action figures has increased significantly over the last 30 years. And so, you know, if you think about five to 10 year olds-

Khadijah  16:01

That seems really abnormal.

Dr. Jason Nagata  16:04

Yeah, and so I think, you know, these pressures do start at a very early age.

Gene  16:08

Well, it kind of reminds me also of the Barbies. So, the 1950s, you know, I mean, that was the prototype, you know, kind of a physiological impossibility, like super long legs, like no waist, extraordinarily thin, very long arms, you know. So, I guess toys are an influence. But what about some other influences? You mentioned media. And you mentioned, I think it’s really interesting that the difference between just passive watching and actually interacting is important. But you also mentioned family. And could you talk a little bit about or tell us a little bit about what, what the family influences are? And perhaps certain cultural influences? What kind of families are, are risky?

Dr. Jason Nagata  16:54

Yeah, that’s a great question. I think that eating disorders are very complex, and that they have lots of different potential contributing factors. So, there are genetic, biological and social and environmental factors. So, I guess when we think about families, you know, potentially one linkage is through this genetic component, we do know that there are genetic studies that have shown there is a genetic component to anorexia nervosa. And so, some of these genes can be passed down by families, and there could be more of a predisposition for people who have sort of this already, genetic risk. But in addition to that, I do think that there are also environmental and cultural or social pressures that can also be you know, perpetuated in families, for instance, if there is a emphasis on body image, or certain body ideals, or pressures for losing weight or gaining weight in certain families. And so, you know, whether or not we, as parents think that we have a big influence on our children, actually, one of the biggest influences on our children’s behaviors, is our own behaviors. And so, you know, also having a lot of concern about one’s body and, you know, making dietary changes, you know, our children are watching, even from a young age. And so, I think it’s just also important that people are careful about the way that they, you know, comment on other people’s bodies or their own children’s bodies, because sometimes these can add to pressures. And I think, you know, many people are actually, I think, you know, not poor like, are well intended, but sometimes, especially with a sensitive teenager who might be, you know, have sensitivities to their, their own body, you know, comments about weight loss, or, or, or things like that can be internalized and then can lead to, you know, to more disordered behaviors. So, so anyway, I think it’s just to say that there are, no, there’s no one clear cause of eating disorders, I think there’s a very complex combination of genetics and environmental and social factors. And I will say that the other than the stereotype of eating disorders, primarily affecting girls and women, which, as I’ve mentioned, you know, is should be I think this, you know, we should break that stereotype because we do know that eating disorders can affect people of all genders. I also think that we should, you know, I think there’s also potentially a stereotype that eating disorders affect, you know, people from certain cultures or backgrounds and I also think that there’s limited research on an eating disorders and other cultures, but I do think that that we are seeing more and more that eating disorders can people can affect people of all races and ethnicities and cultural backgrounds and sizes and, and sexual orientations. And so it really can affect you know, diverse um, populations. And we should also be careful not to have stereotypes about eating disorders across other sort of demographic trends.

Khadijah  20:09

Can you speak to maybe the role of the culture of sports in terms of, you know, disordered eating and boys, I think again, about my son who is like playing football, and he’s bulking and he is, you know, trying to, you know, eat more protein, go to the gym more. But, but, you know, I see it being within reason. But I can also see how that can take on a life of its own kind of sort of what you talked about before, but I think then there might be the other side of that, where there might be the pressure to, in an unhealthy way lose weight to be able to make weight for that. Also, I think they do this and football or wrestling, but what is the role in the culture of sports as it relates to boys and eating disordered behavior?

Dr. Jason Nagata  20:53

Yeah, that’s a great question. I do think that athletes in general are at higher risk for eating disorders and disordered eating. And, in boys, we do know that there are a few particular sports that may be a risk, as I mentioned, before, sports that have very specific and rigid weight cut offs, like wrestling or crew were, literally as part of the sport, you have to cut to a certain weight, you know, and you have weigh ins to make that that sort of becomes normalized. And for some people, that can be okay. But for the, you know, the first patient that I mentioned, having to go through the cycles of extreme weight loss, you know, every so often did become part of his normal routine, and then, and then it did develop into a full blown eating disorder. So, I do think that, I think that there’s a spectrum and, you know, in general physical activity, you know, healthy eating are things that we do, you know, encourage in young people in moderation. And, as I mentioned, you know, many majority of youth these days are actively trying to gain weight, or lose weight, or change something about their weight, and not all of them will develop eating disorders, and a vast majority of them won’t. But I do think that there’s a spectrum of, you know, people who are trying to change their eating or exercise behaviors in order to achieve a certain body ideal or a performance ideal in the, in the case of sports, and then it can become a slippery slope, where a subset of those people, you know, it does become a preoccupation or an obsession. And to me, the, where it sort of becomes a disorder or starts to really cause issues is, is if it leads to any kind of social or functional impairment, if it’s starting to really worsen their quality of life, you know, so in general sports and physical activity, you know, should be healthful, it should, you know, release endorphins and make somebody feel better about themselves. But for some subset of people, when it really becomes an obsession, it’s they feel like the patients that I take care of, you know, with, with these issues, say that they feel guilty any, any minute that they’re not spending working out or are eating a certain way, they, you know, feel guilty, and they can’t stop thinking about it. And it leads to, you know, like if they aren’t able to eat meals with their families anymore, or with friends, because they perceive those meals to be not high enough and protein or too high in fat. And it really then detrimentally affects their social life or their schoolwork or their other work. I think that’s when it sort of then tips over into the world of a disorder.

Khadijah  23:31

That there was a 2019 peer reviewed publication, once again, late from UCSF, that share that as many as 60% of boys in the US reported purposefully manipulating their their diet and striving for greater masculinity. How can a parent or coach or or any really caregiver, know this, what we call when we say here at the Clay Center? What are the three W’s so like, What to look for, When to worry, What to do? And you kind of said some of those things, in terms of how we know that it has crossed the line to disordered eating or eating disorder, but what are some of the like, how do we, what do we do? I guess.

Dr. Jason Nagata  24:06

Yeah, so I do think that in terms of the What to look for, you know, as I mentioned, while you can look for the typical weight loss behaviors, which can affect boys and men, so you know, you know, extreme dieting, or restriction or skipping meals, or engagement and vomiting, or, you know, diet pills that can lead to weight loss, I think it’s also important to look for some of the muscle building behaviors, you know, like excessive exercise or use of steroids or other muscle building drugs or supplements, and, and also just extreme diet changes to bulk up and gain muscle. I do think that, When to worry is when, as, as I mentioned a little bit earlier, when they’re not just behaviors, but they develop into preoccupations or obsessions, when they really worsen the young person’s quality of life and it impairs their functioning. and that’s when to worry. And then with regard to the some of the muscle building behaviors, you know, even use of anabolic steroids in any context, you know, without a prescription can be dangerous, because they can have really significant effects on one’s heart and liver and even growth. And so, I think that some of the muscle and performance building drugs are things to worry about, especially in athletes. And then finally, in terms of what to do, I do think that, you know, it’s, if you are able to have a conversation with your child, or a loved one, who you might be having some concerns with, having some open conversations, and also trying to get help, you know, potentially with a pediatrician or primary care provider. And even if they don’t have, you know, specialty expertise in eating disorders, they may be able to do some initial assessments and lab tests, and then provide appropriate referrals as needed.

Gene  26:06

So there was a listener question for you, Jason, on on Instagram, are eating disorders and boys often triggered by internalized anxiety or depression? And, you know, like, for example, I know, we know that, you know, I don’t know if the data is still true, but about 50% of girls with anorexia nervosa would have associated major depression, and 70% ish, with bulimia. So, one question is, is there an association with other psychiatric conditions or disorders, with eating disorders and boys? And are there also differences associated with certain populations? Like, for example, the LGBTQ+ boys are versus heterosexual boys. So how do we one issue is that this is associated disorders, and one issue was certain populations that may be at higher risk.

Dr. Jason Nagata  27:04

Yeah, thank you to the listener for those questions. I think they’re really important questions. And yes, I do think that there is a high co-occurrence of anxiety and depression with eating disorders, including and boys and men, I do think that it is somewhat individualized. And so in some cases, eating disorders can be triggered by anxiety or depression, but in other cases, they can become they can develop on their own right, and perhaps, later be related to anxiety, depression, so I don’t think that there’s a clear, you know, one size fits all answer, I think, for some people, anxiety, depression could be a trigger, but for others, it it’s not. And I will say that it is a little bit, you know, it can be a little bit murky in terms of, there are even symptoms that overlap. So, you know, for instance, you know, if somebody is severely depressed, you know, one of those side effects or symptoms, or core symptoms of that can be like a loss of appetite, and so they may stop eating or do and that can lead to weight loss. And so, then there can be sort of a vicious cycle of, you know, maybe an initial weight loss related to depression that can then, you know, bring on an eating disorder. So, I do think that, you know, there’s a very complex interplay between some of these mental health conditions, but oftentimes, they do co-occur. And then, with regard to the second point about certain populations within boys, there is emerging research on sexual and gender minorities, like, you know, gay, bisexual, and also transgender, young people. And in general, it does seem like they’re within boys, there are higher risks of eating disorders among sexual and gender minority populations, I guess, just start starting to think about transgender youth. I do think that this is actually the population where there might be the highest rates of body dissatisfaction if you imagine somebody is born into a body that, you know, they their gender identity does not agree with so like they’re the sex that was assigned at birth to them is not incongruence with the identity that they feel with their gender. And then there are all these, you know, societal pressures for gender norms, like this masculinity, you know, being big and bulky femininity being thin, you can imagine that that could even lead to more body dissatisfaction, which could then lead to an eating disorder. So, I do think that, you know, transgender youth in particular are at high risk for body dissatisfaction and eating disorders. And, and then also, there have been studies that have looked at, you know, gay and bisexual boys and men. And you know, one of the potential mechanisms for that we talked about peers and the media being a big influence, and we do know that gay, bisexual men actually tend to use social media more than their heterosexual peers, and actually tend to post more. And perhaps, then there are more pressures for some of these body ideals that are perpetuated through the media for for these populations.

Gene  30:17

So, just getting into more the, some of the consequences in the long term of follow ups, you know, we know that, that the number one cause of of death and, and girls and young women in psychiatry is is in eating disorders is suicide. And particularly during periods of recovery. Now that’s if you follow these girls, either, you know, for a long time longitudinally, do we know what what the what the risks are? It’s it’s similar for boys with with eating disorders, is suicide, a concern if you follow them long enough?

Dr. Jason Nagata  31:02

Yes, unfortunately, eating disorders can be life threatening in boys and men as well. And although there’s less research in boys and men than there are in girls and women, I think the biggest study, looking at mortality in male populations from Scandinavia, has found that 13% of males with anorexia nervosa will eventually die from that. And so it is, you know, quite a large mortality rate. And so, it should be something that’s taken very seriously and why it’s important that people get professional help early on. We have also looked at, at teenagers and young adults who have been hospitalized at UC San Francisco where I work. And I’ve also found that actually, perhaps because boys are diagnosed later, and perhaps have had to suffer, you know, with the illness for a longer period of time, before they actually get into care, that actually the presentation of the at least a medical complications of eating disorders. And boys tend to be actually more severe when they are first seen in care whether it’s in the clinic or in the hospital. And so, they tend to actually have like, more significant heart complications, more significant liver complications, and higher rates of anemia. So, a low blood count then, then girls when they are seen in care.

Khadijah  32:24

And you mentioned earlier that there’s so much heterogeneity or so much diversity and how boys present it with respect to eating disorders, can you can you share, or share what a parent might expect in terms of treatment that that their child might receive if they if they have an eating disorder?

Dr. Jason Nagata  32:43

Yes absolutely, I think that ideally because eating disorder are so complex and have a mental health, and physical health and nutrition components. Ideally, an interdisciplinary team that has specialties across mental health and medical management, and nutrition, is ideal. So having a nutritionist, a physician, like a medical provider and a mental health provider, whether its a therapist or a social worker to address all these different aspects of an eating disorder is ideal. But I also realize that these tend to be centered in academic centers so it may be hard to reach for some people, particularly in rural areas. I do think with the advent of telehealth, especially since the pandemic there has been a little more access in terms of being able to do some virtual visits and virtual therapy but I think that there has been a large rise of eating disorder since the pandemic and not enough providers to, with specialty experience, and so I do know that many people have had to wait quite a long time to get into care.

Gene  33:56

And what the outcome of treatment? I mean, I know it’s a general question, but in my experience, you know, and whenever I see a parent, or parents or families, you know, I have to work with them to help them see that this is a marathon, not a sprint, in most cases, what do you see what what advice do you give for parents, you know, to help help them kind of see the bigger picture?

Dr. Jason Nagata  34:26

Yeah, I think that’s a really important question and point and definitely not a one size fits all answer. I think that, you know, for youth or, you know, minors who are still living at home, the first line treatment is really family based treatment or family based therapy. For young adults who maybe are no longer living at home and are more independent than maybe cognitive behavior is the behavioral therapy as the first line with more individualized care. And I will say that, you know, there is a large spectrum and as you said, it’s in most cases, it’s really not going to be a quick fix, it’s going to require a lot of continued engagement in, you know, mental health, medical care and nutritional counseling. And so, I will say that, you know, there’s a big variety in terms of outcomes, you know, some people can make a full recovery, some people do struggle for, you know, for a lot from decades for the rest of their life. And unfortunately, you know, as I mentioned, a tenth, or even a little bit more than a tenth of people ultimately die from the illness. And so, it is very important that they get care. But I do think that the things that are linked with better outcomes are, you know, early diagnosis and treatment, so the early you are, you are able to get into care, and engage in therapy, that, you know, increases one’s risk for making being able to make a full recovery, and then also just continued engagement and care. And so, I do think that part of the struggle is that sometimes people, you know, sort of complete care or, or do not, you know, do a full treatment course, because, you know, they feel like, Oh, I’m sort of better, and they don’t like, you know, continue, or they don’t follow up with care. And so, I do think that it’s also important that, you know, that young people, even if they feel like they’re improved a little bit really do continue to follow up with, with their professional team, to support them throughout the entire journey.

Khadijah  36:30

I love that, that you mentioned or, or I love that Gene that you asked about outcomes, and that you mentioned early intervention, because this is why it is so important for us to be having this very necessary conversation so that parents know, you know, what are their early signs of disordered eating, and their and their, you know, their young children or their boys, and that it can look different for boys than it does for girls. So, I do think this is so important for us to be having this conversation and for parents to be and caregivers to be having this conversation at home as well.

Gene  37:02

So just looking at the time is to wrap up, let me just ask, you know, because we’re using at the Clay Center, we’re using the arts and media to promote education and conversation about issues. Is there a book or a movie or TV show that you can think of Jason, that gets it right? That you know, when it comes to positive body image for teens or appropriately responding to negative body image or eating behaviors? Or that helps families see what’s a healthy way to kind of like, help their help their kids be content with their with your body? I mean, since some of it. Is there anything that you would that you would recommend?

Dr. Jason Nagata  37:50

Yeah, that’s a really great question. And I will say that one of my colleagues, Charlotte Markey, did a couple of years ago, publish a book that’s really geared towards teenage boys. And it’s called Being You the Body Image Book for Boys. And it’s really written to a teen audience. So, it’s really not for parents, it’s for teenagers and young people themselves. But it specifically raises some of these issues that boys might consider, like we mentioned, you know, considerations for athletes or some of the muscle building concerns that that may arise. As you know, teenage boys are going through puberty.


And so, I do think that that’s a good resource that’s really age appropriate and developmentally appropriate for teenage boys. And for parents and caregivers who want to learn more. The National Eating Disorders Association does have specific content about eating disorders in boys and men and muscle dysmorphia in their resources page.

Khadijah  38:49

Well, thank you again, Jason, for the time today, all of this amazing information that you share with us. We’ve really enjoyed having you.

Gene  38:57

And for those of you at home, if you like what you’ve heard today, consider leaving us a review. And we hope that our conversation will help you have yours. I’m Gene Beresin.

Khadijah  39:10

And I’m Khadijah Booth Watkins. Until next time.


Dr. Jason Nagata  39:23

Yeah, I think that one of the things that I referred to when I talked about the Marvel Superheroes is, if you think about the original Batman and Robin like Adam West,


but you know, from like many decades ago, they have kind of normal ish bodies, but if you look at Batman now, you know, they’re really bulky. Like, are you dealing with the Incredible Hulk like they’ve become quite a bit more muscular than they were, you know, several decades ago.



Special thanks to the National Eating Disorders Association (NEDA) for connecting us with special guest Jason Nagata, MD.

Podcast theme music by Gene Beresin, MD, MA

Episode research by Spenser Egnatz

Episode produced by Sara Rattigan

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Gene Beresin

Gene Beresin, Executive Director

Gene Beresin, MD, MA is executive director of The MGH Clay Center for Young Healthy Minds, and a staff child and adolescent psychiatrist at Massachusetts General Hospital. He is also...

To learn more about Gene, or to contact him directly, please see Our Team.

Khadijah Booth Watkins

Khadijah Booth Watkins, Associate Director

Khadijah Booth Watkins, MD, MPH, is associate director of the Clay Center for Young Healthy Minds at Massachusetts General Hospital (MGH), and the Associate Director of the Child and...

To learn more about Khadijah, or to contact her directly, please see Our Team.