Eighteen months ago, Alex Levy, then 19, fell while rock-climbing, injuring his foot. He was midway through his freshman year at college in California. Levy loved to hike, cycle and run. He played Ultimate Frisbee on a school team.
The foot injury didn't only snap bones and rupture ligaments. It snapped off physical activity and ruptured social interaction.
"I thought, 'I don't want to fall out of shape, so I'll eat less, eat healthier,' " Levy says.
"I started to lose weight. That became a matter of pride. People would comment. I would feel good, though I was essentially starving myself."
What Levy had tried to control began controlling him.
"I was restricting, my body was malnourished, the injuries piled up. I'm a musician, but I had nerve damage in my hands. I couldn't play music. By the time summer came around, instead of one injury, I had six." Carpal tunnel and tendinitis plagued ankles, elbows, a shoulder. The summer camp he had always attended was out of the question.
"I never thought I'd have an eating disorder," Levy says. "As a guy, I thought, men don't have that. I can't have that. That's what made me hide it.
"I didn't consider that all this was happening because I was malnourishing myself."
Dr. Kimberli McCallum, founder and director of McCallum Place eating disorder centers in St. Louis, Mo., guesses 80 percent of eating disorders in men go undiagnosed.
"It's hard to know. We need more research. There are many barriers to recognition of the illness, even to access to care." Out of 50 residential treatment centers, only five that McCallum knows of admit men.
"I really think men and boys aren't getting treatment at all. Instead they're worked up for gastrointestinal problems, or told their pulse is low because they're athletic, or sent for psychotherapy that's not specialized.
"Sometimes the primary care doctor will think it's an endocrine or thyroid problem. They don't think to screen young men for eating disorder."
A study of 2,822 students on a large university campus found 3.6 percent of men had eating disorders. The female to male ratio was 3-to-1.
The most widely quoted study, according to the National Eating Disorders Association, shows men represent 25 percent of all anorexia and bulimia nervosa cases, and 36 percent of binge eating disorders.
Dr. Brad E.R. Smith, medical director of the multilocation Rogers Memorial Hospital behavioral health system, agrees research is needed on numbers.
"Even the best statistics, which range from 5 to 25 percent, are probably a gross underestimate of the percentage of anorexics who are men."
In early stages, eating disorders can be devilishly difficult to diagnose. It often starts with positive intentions to become healthier. Some sports emphasize leanness for performance or aesthetics. Extra training can precipitate weight loss.
"Many people start out with those patterns, and everything turns out fine," Smith says. McCallum concurs, saying most athletes naturally become hungrier and eat more when in training.
But some become engrossed with caloric intake and body shape. The obsession begins to affect daily life, to the exclusion of relationships and activities. Men with eating disorders are less likely to lose weight in an alarming way and more likely to try to sculpt their muscles. Men at risk are more likely to have been overweight before.
"They desire to look different, and they get caught in this trap, this illness," Smith says.
Also, they begin to hide.
Levy didn't realize he had an eating disorder. Thinking it would all go away if he could just heal his injuries, Levy ricocheted between college and home, as his eating ricocheted between restrict and binge. For a full semester, he stayed at normal weight.
"That helped hide the problem because no one could see what was wrong with me." Then social and academic pressure increased, and Levy gained 30 pounds in 30 days.
"I woke up and thought, this is unacceptable." Levy sought out the student-services dietitian, who recommended a residential facility.
When should parents seek help? Smith and McCallum say early signs can include rigid eating rules, a quick change in weight, excessive exercise, using diet pills or laxatives and hiding food.
Experts stress that developing an eating disorder is not a choice, but recovery is, and recovery is possible.
"There was this idea I had to be strong enough to fix this on my own," Levy says. "I saw therapy as unnecessary and a sign of weakness to engage in it. Turns out, I needed it."
Today, Levy is excited about his summer job in Manhattan and returning to college.