Males make up about a third of the population struggling with eating disorders in the United States. While these conditions often start during the teen years, by some estimates, as many as 14% of American men experience an eating disorder by age 40, and they may be more likely to die from it than women. Yet, recognition of this mental illness is not where it should be according to male eating disorder expert Jason Nagata.

This is especially true for muscle dysmorphia, he says, a disorder that overwhelmingly affects males and is characterized by a hyperfixation on building muscles. It is categorized under obsessive-compulsive and related disorders in the diagnostic manual for psychiatric illnesses, known as the DSM, though it frequently also involves extreme dieting.

For Nagata, an associate professor of pediatrics in the Division of Adolescent and Young Adult Medicine at the University of California, San Francisco and an eating disorders hospitalist at UCSF Benioff Children’s Hospital, one major solution is reclassifying muscle dysmorphia as an eating disorder in the upcoming sixth edition of the DSM. He believes this change would make doctors more likely to properly identify patients who need support and refer them to specialists, and improve insurance coverage.

But this proposal is debated within the field, with some experts arguing that muscle dysmorphia should be kept under its current classification because it is accurate as is and can be combined with an eating disorder diagnosis when needed.

Nagata recently talked with STAT about his campaign to bring greater visibility to the needs of boys and men with muscle dysmorphia. This interview has been edited for length and clarity.

Tell us more about the current muscle dysmorphia classification.

In order to formally be diagnosed with muscle dysmorphia, you have to meet several specific criteria: a preoccupation with muscularity or being insufficiently muscular; repetitive behaviors like mirror-checking or weight-checking, constant comparisons to others’ muscularity; and clinically significant distress or impairment in social, occupational, or other areas of functioning. The final criterion is that it cannot be better explained by an eating disorder or eating disorder symptoms. This last criterion makes them mutually exclusive: If you meet criteria for an eating disorder based on the DSM currently, then you cannot also have muscle dysmorphia.

How do you view the connection between muscle dysmorphia and eating disorders?

Muscle dysmorphia is the formal DSM diagnosis, but many people refer to it as “bigorexia” or “reverse anorexia.” In anorexia nervosa, someone wants to lose weight and feels fat even if they’re objectively skinny. Muscle dysmorphia is thought to be the reverse: Someone might be objectively muscular, but they view themselves as scrawny.

There are a number of eating behaviors, some of which might be considered disordered eating behaviors, that people trying to become muscular often engage in. This could look like having a high-protein diet, cutting carbohydrates, cutting fats, and “biohacking” strategies like “bulking and cutting” and intermittent fasting.

**Can you explain your stance on why this condition should be reclassified? **

In the history of medicine, we’re always seeing new things and adapting as we go. The introduction of muscle dysmorphia into the DSM, regardless of where it is placed, was a positive step. But now that we have had that classification for 13 years, we can continue to improve.

The main challenge with the definition is the mutual exclusivity. You can’t really separate exercise and nutrition; they go hand in hand. Some people have an eating disorder, or disordered eating, because they’re trying to become muscular, and there is no specific eating disorder diagnosis that captures muscularity concerns. The terminology medical providers use matters.

If we take a step back from the specific definitions in the DSM, there’s a spectrum we need to be aware of. It’s much more common for people to have some combination of muscularity concerns and a change in their eating in a disordered way. But currently only the tip of the iceberg formally meets the full muscle dysmorphia criteria.

**Have you seen this play out in your clinical practice? **

I work primarily in an eating disorders treatment center. We have seen an increasing number of boys and men in the last several years. But because there’s no muscularity-oriented eating disorder in the DSM, their formal diagnosis is “unspecified feeding and eating disorder,” or UFED. This diagnosis is not specific to muscularity and is a conglomeration of everything else.

Many of the boys and men we care for are also endorsing muscularity concerns and engaging in performance-enhancing drug or supplement use, and excessive exercise. Some of them would meet all the muscle dysmorphia criteria except for the last one, that they cannot have an eating disorder.

What does the treatment process for muscle dysmorphia look like now?

There’s very limited treatment access because there are only a handful of studies on it. There are also very few muscle dysmorphia specialists in the world, and I’m not aware of muscle dysmorphia treatment centers. Typically people are either seeing a general mental health provider, who is not necessarily a specialist in muscle dysmorphia, or they are going to eating disorder treatment centers like ours.

For anyone with an eating disorder or body image issue, there’s some stigma related to getting care. Boys often feel a double stigma, because they don’t want to be outed as having a condition that has a feminized association. Because these issues are less recognized in boys and men than they are in girls, there can also be delays in identification and in getting care and treatment.

When it is identified, these boys and men are often at eating disorder treatment centers where the majority of other patients are being treated for anorexia nervosa, or have very specific concerns about weight loss and thinness. It’s already an isolating experience to be struggling with this issue, and then, in treatment — in that group setting — that feeling is exacerbated by not being able to have other people you can relate to.

Is there also concern about insurance?

Health care providers have to bill or code for diagnoses and, currently, if you were to follow the DSM-5 definition, you should not be coding for muscle dysmorphia and an eating disorder. In practice, if they’re seeing both symptoms, some providers will code for both. But this puts them in a difficult position, because they’re coding things that aren’t in alignment with the DSM. This could theoretically get them in trouble for misdiagnosis and attract more scrutiny by insurance companies. We should not be putting providers in a position where they have to do things inconsistent with the DSM — and risk being audited by insurance companies — just to get patients the treatment they need.

**How would changing the DSM classification lead to better treatment? **

It’s impossible to say for sure, but an expected benefit is that it might make it easier for boys and men to get care through eating disorder programs, or alongside general programs, or new body dysmorphic disorder programs. We might be able to provide them with better, more individualized, nuanced care.

A formal recognition of some sort of muscularity-oriented disordered-eating diagnosis can also lead to more studies within the eating disorder field. Right now, because it’s all coded as “unspecified,” there aren’t the same kind of studies or treatments being developed. Standardizing the diagnostic criteria would also allow for more specific clinician training and more surveillance in national studies or surveys, which could lead to more specific treatment pathways. In the long run, without more recognition of this condition, boys and men will continue to struggle in silence.

What other changes regarding muscle dysmorphia are you advocating?

Within the eating disorder field, I’d like to see more recognition of the muscularity-oriented eating components. Traditionally, eating disorder screening questions are really focused on weight loss. But adding a few questions that routinely ask about supplement use, performance-enhancing drug use, and excessive or compulsive exercise could help improve identification and earlier diagnosis in pediatric and adult primary care.

Overall, I’d also like to see better recognition of the diversity of eating disorders across genders, race, ethnicity, and socioeconomic status — not just the stereotypical white, thin, female presentation. The field has also made immense research progress in the last two decades, but there’s still room for improvement.

STAT’s coverage of health challenges facing men and boys is supported by Rise Together, a donor advised fund sponsored and administered by National Philanthropic Trust and established by Richard Reeves, founding president of the American Institute for Boys and Men; and by the Boston Foundation. Our financial supporters are not involved in any decisions about our journalism.