"I know it does more harm than good, so why do I still do it?" asks Nigel Owens, a Welsh international rugby union referee who has struggled with bulimia nervosa for 27 years.
Owens is not alone. Despite a successful sporting career that has allowed him to travel internationally, he's one of a growing number of men seeking treatment for the devastating disorder. At the pinnacle of his career, during a match between Australia and New Zealand in 2015, few knew of his internal battles.
"I'm known for being a steely, authoritative and, I hope, fair referee," Owens, 46, told the BBC. "As I walked onto the pitch that day, no one would have believed that I was battling the creeping return of my bulimia."
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Eating disorders are typically seen as a problem affecting impressionable teenage girls. Yet a BBC Panorama investigation found that at least 871 men in the UK were referred for help for the first time last year, a 43 per cent rise since 2014.
All kinds of men suffer from eating disorders – young teenage boys, professional boxers, big names in rugby – and this makes it particularly important to break the silence surrounding men who battle with these disorders.
What is an eating disorder?
Eating disorders are characterised by "an abnormal attitude towards food that causes someone to change their eating habits and behaviour," the NHS says.
The main eating disorders are anorexia, bulimia and binge eating, according to BEAT, an eating disorder charity, and the most recent version of the Diagnostic Statistic Manual of Mental Disorders.
Here are the top three:
- Anorexia nervosa: a person attempts to keep their body weight low by restricting calorie intake. This can occur alongside excessive exercising.
- Bulimia nervosa: a person strives to control their weight by "purging" (vomiting or taking laxatives) after they eat.
- Binge eating disorder: a person overeats on a regular and compulsive basis, citing a loss of control.
How common are such disorders among men?
According to BBC research, about 400,000 of the 1.6million people who suffer from eating disorders are men and boys. BEAT estimates that between 10 and 25 per cent of those affected by eating disorders are male.
Exact figures are hard to find. Some medical experts believe men are less likely to come forward and fearful of stigma.
"One of our concerns is that diagnostic criteria for eating disorders are entirely based on female traits," Nadia Micali, a senior lecturer at the Behavioural and Brain Sciences Unit at University College London, told The Guardian.
"To get an anorexia diagnosis, you need to be afraid of getting fat. But masculine concerns can include wanting a lean or defined physique, and males who become fixated with achieving that by excessive use of supplements, hormones or starvation may be dismissed by doctors."
What are the causes of eating disorders among men?
According to the charity MGEDT ('men get eating disorders too!'), there has been little detailed research on why males develop eating disorders. But eating disorders are believed to be "a coping mechanism, or an expression of, underlying emotional stress – this is applicable to males as much as it is females," MGEDT says.
The charity identifies common risk factors, including being bullied about one's weight or appearance, dieting and social expectations about appearance. It also says that participation in a sport that demands a particular body build or fitness level can put men at risk.
Other causes, BEAT says, are genetics and personality traits, especially competitiveness, perfectionism and low self-esteem.
How to detect a disorder
NHS doctors have a five-point questionnaire to help identify people who may have an eating disorder.
- Do you make yourself sick because you feel uncomfortably full?
- Do you worry you have lost control over how much you eat?
- Have you recently lost more than one stone (six kilograms) in a three-month period?
- Do you believe yourself to be fat when others say you are too thin?
- Would you say food dominates your life?
If you answer "yes" to two or more of these questions, you may have an eating disorder, according to the NHS website.
Where to get treatment
The NHS website contains a long list of resources including 15 "useful links" to find support services in various regions.
BEAT operates helplines for adults and younger callers and its website also lists support services and resources.
How can I help a family member or friend?
The NHS website offers advice for friends and family members of those with eating disorders in addition to listing resources. It says that people with eating disorders "will eventually have to get professional help from a doctor, practice nurse, or a school or college nurse."
"The earlier your friend or relative embarks on the treatment programme and the more they engage with it, the better their chances of making a good recovery," the NHS says.
BEAT also encourages friends and family to offer emotional support and encourage sufferers to seek professional help.
"It is usually very difficult for people with eating disorders to get better on their own. It is important that you find professional help and support as soon as possible," BEAT advises.
