The Hidden Challenge: Male Eating Disorders in the
Middle East: A Systematic Review of Prevalence and
Cultural Factors
Middle Eastern males face unique eating disorder (ED) risks due to cultural transitions from traditional masculine ideals that emphasized functional strength to Western aesthetic standards. Male EDs in Middle Eastern populations constitute an emerging public health concern that has received limited systematic research attention, despite increasing clinical recognition. This systematic review synthesized available epidemiological data on ED prevalence among Middle Eastern males to examine regional patterns and associated risk factors. We conducted a systematic review following PRISMA guidelines by searching PubMed, Scopus, and Google Scholar databases for studies published between 2000 and 2023 that examined EDs in males aged 15 years and above across Middle Eastern countries. Thirteen studies encompassing 5236 male participants from 11 countries met the inclusion criteria.
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1 Department of Biology, College of Science, University of Bahrain, Sakhir P.O. Box 32038, Bahrain
2 Division of Human Nutrition, Department of Food, Environmental and Nutritional Sciences (DeFENS), Università Degli Studi di Milano, 20122 Milano, Italy
3 Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
4 Endocrinology and Nutrition Unit, Azienda di Servizi alla Persona “Istituto Santa Margherita”, University of Pavia, 27100 Pavia, Italy
*
Authors to whom correspondence should be addressed.
Psychiatry Int. 2025, 6(3), 115; https://doi.org/10.3390/psychiatryint6030115
Submission received: 30 June 2025 / Revised: 7 August 2025 / Accepted: 11 September 2025 / Published: 16 September 2025
Abstract
Middle Eastern males face unique eating disorder (ED) risks due to cultural transitions from traditional masculine ideals that emphasized functional strength to Western aesthetic standards. Male EDs in Middle Eastern populations constitute an emerging public health concern that has received limited systematic research attention, despite increasing clinical recognition. This systematic review synthesized available epidemiological data on ED prevalence among Middle Eastern males to examine regional patterns and associated risk factors. We conducted a systematic review following PRISMA guidelines by searching PubMed, Scopus, and Google Scholar databases for studies published between 2000 and 2023 that examined EDs in males aged 15 years and above across Middle Eastern countries. Thirteen studies encompassing 5236 male participants from 11 countries met the inclusion criteria. ED prevalence demonstrated substantial variation from 2.2% to 81.4% depending on population and assessment methodology, with Gulf Cooperation Council countries showing consistently higher rates. Age-stratified analysis revealed the highest rates among adolescents aged 15–18 years (mean: 35.0%) compared to adults over 25 years (mean: 2.1%), with university students showing intermediate levels (mean: 29.0%). Muscle dysmorphia emerged as particularly prevalent among bodybuilders (5.7–81.4%), while university students showed rates of 9.7–49.1%. Depression, body dissatisfaction, and cultural transition stress were consistently identified as correlates across multiple populations. These findings underscore late adolescence as a critical risk period and highlight the urgent need for culturally adapted diagnostic tools, healthcare provider training, and region-specific prevention strategies.
1. Introduction
Middle Eastern societies are experiencing unprecedented cultural transformation as traditional masculine ideals that emphasize functional strength encounter Western aesthetic standards, thereby creating unique vulnerability contexts for eating disorder (ED) development among male populations [1,2,3,4]. Cultural factors play a crucial role in shaping ED expression across different populations [5,6,7], with these ongoing transitions significantly influencing disorder manifestation. Traditional diagnostic frameworks developed in Western populations may inadequately capture ED presentations in Middle Eastern communities due to cultural variations in body ideals, family structures, and psychological expression [1,8,9].
EDs are serious psychiatric disorders that manifest through abnormal eating and weight-control behaviors, causing significant impairment in physical health and psychosocial functioning [10]. These conditions arise from complex interactions between neurobiological vulnerabilities and environmental factors [11], affecting neural circuits that control appetite regulation, reward processing [12], and executive functioning [13]. Neuroimaging studies have revealed alterations in key brain regions, including the anterior cingulate cortex, insula, and prefrontal areas in individuals with EDs [14,15].
Although anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) constitute the primary diagnostic categories, clinical practice reveals greater complexity in actual patient presentations with a significant proportion of patients receiving diagnoses of “other specified feeding or eating disorder (OSFED)” or “unspecified feeding and eating disorders” (UFED), reflecting the heterogeneous nature of these conditions [16,17]. This diagnostic variability underscores the need for individualized approaches that consider neurobiological profiles, genetic factors, and cultural backgrounds when developing treatment plans [5,18].
EDs manifest differently in males compared to females, creating distinct challenges for clinical recognition and treatment approaches [19]. Male patients typically exhibit concerns that focus on muscularity and body composition rather than weight loss, patterns that reflect different neural reward mechanisms and social influences [20,21,22]. Emerging neuroimaging evidence suggests that males with EDs may exhibit distinct brain activation patterns in networks governing body perception and reward processing, though this area requires substantial further investigation [23,24]. These sex-specific differences contribute to delayed diagnosis and suboptimal treatment outcomes in male populations.
Muscle dysmorphia (MD), commonly termed bigorexia, affects predominantly male individuals and shares significant overlap with traditional EDs despite lacking formal Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classification [25,26]. This condition likely involves altered neural processing in body image and reward circuits, similar to patterns observed in anorexia and bulimia, which show disrupted functioning in the anterior cingulate cortex and striatal regions, though direct neuroimaging evidence in MD remains limited [27]. The substantial comorbidity between MD and established EDs suggests common underlying mechanisms involving dopaminergic and serotonergic neurotransmission, which has important therapeutic implications [25,28].
Cultural factors play a crucial role in shaping ED expression, and while cultural neuroscience demonstrates that brain function is profoundly influenced by cultural contexts, direct research on cultural effects on neural processing of body image and food-related stimuli remains limited [6,7]. Traditional diagnostic frameworks developed in Western populations may inadequately capture ED presentations in Middle Eastern communities due to cultural variations in body ideals, family structures, and psychological expression [1]. These cultural influences may extend to neurobiological responses, though research directly examining how cultural background affects brain activation patterns during body image processing and decision-making about food remains limited [29].
The rapid sociocultural changes occurring throughout Middle Eastern societies create unique conditions for examining how environmental shifts influence neural plasticity and ED risk [1,30]. This transformation is particularly pronounced in Gulf Cooperation Council (GCC) countries, comprising Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates (UAE), where substantial oil wealth since the 1970s has accelerated modernization, urbanization, and exposure to Western cultural influences [31]. As these populations, especially in economically developed GCC nations, increasingly adopt Western beauty standards and experience greater social media exposure, individuals with genetic vulnerabilities may face heightened risk for developing EDs [32,33]. Understanding these complex gene-environment interactions becomes essential for creating effective prevention and treatment strategies that account for cultural context and varying levels of economic development across the region [34].
Modern precision psychiatry approaches seek to integrate neurobiological markers, genetic information, and environmental influences to optimize treatment outcomes for individual patients [35]. This framework proves particularly relevant for EDs given their diverse presentations and variable treatment responses [36]. Emerging evidence suggests that neuroimaging findings, genetic variants affecting neurotransmitter function, and microbiome characteristics may help predict treatment response and guide clinical decision-making [37,38,39].
Within culturally diverse populations like those in the Middle East, precision psychiatry must incorporate cultural elements as biological factors that shape neural development and treatment response [40]. This approach requires understanding how cultural practices, religious beliefs, and family dynamics interact with neurobiological vulnerabilities to influence both risk and recovery processes [5,41]. Such culturally informed strategies may help explain the varying prevalence patterns observed across different Middle Eastern countries while supporting the development of more effective, personalized interventions [42].
The increasing recognition of EDs among Middle Eastern males has significant implications for clinical practice. Healthcare professionals need enhanced training to identify atypical presentations, particularly MD and subclinical forms that may not align with traditional Western criteria [43]. High rates of comorbidity with depression, anxiety, and other psychiatric conditions indicate the necessity for comprehensive treatment approaches addressing multiple neurobiological systems [44].
Early intervention programs tailored for male adolescents and young adults in Middle Eastern contexts could substantially improve outcomes [45]. Research on neuroplasticity indicates that interventions during critical developmental periods promote better neural recovery and long-term functioning [46]. These programs should integrate understanding of cultural values, family dynamics, and region-specific risk factors while addressing underlying neurobiological vulnerabilities [47,48].
While extensive research has documented EDs in Western male populations [49,50], systematic evaluation of prevalence patterns, cultural risk factors, and clinical presentations among Middle Eastern males remains critically insufficient [1,2,8]. Existing studies are fragmented across different countries and populations, employ varied methodological approaches, and lack culturally validated assessment instruments [8,9,51]. This knowledge gap not only limits our understanding of the true scope of the problem but also impedes the development of culturally appropriate prevention programs, diagnostic criteria, and treatment protocols for this population [34,42].
Despite growing clinical recognition of EDs among Middle Eastern males, no systematic review has comprehensively examined prevalence patterns, cultural influences, and risk factors across this diverse region. This knowledge gap creates significant barriers to developing evidence-based prevention strategies, culturally appropriate diagnostic tools, and effective treatment protocols for this underserved population. The unique cultural context of the Middle East—characterized by rapid modernization, exposure to Western ideals, and preservation of traditional values—provides an important opportunity to understand how cultural transitions influence ED development.
This systematic review aims to: (1) determine the prevalence of EDs among males aged 15 years and above across Middle Eastern countries using validated screening instruments, (2) examine population-specific prevalence patterns stratified by university students, bodybuilders, adolescents, and general adult populations, (3) analyze geographic distribution of eating disorder prevalence across Middle Eastern regions, comparing GCC versus non-GCC countries, (4) identify associated demographic, psychological, and cultural risk factors including age, body mass index (BMI), depression scores, body dissatisfaction measures, and cultural transition indicators, (5) provide evidence-based clinical recommendations for improving recognition and treatment approaches in Middle Eastern contexts, and (6) examine age-specific prevalence patterns observed across studies to identify critical risk periods for intervention targeting.
2. Materials and Methods
The present systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines [52] and registered in PROSPERO under the registration number CRD420251079312.
2.1. Search Strategy
We conducted a comprehensive literature search for all relevant studies published between January 2000 and January 2023. English-language articles were identified through systematic searches of PubMed and Scopus databases, supplemented by manual searches using Google Scholar. The search was conducted using Medical Subject Heading (MeSH) terms and keywords: (“bigorexia” OR “muscle dysmorphia” OR “eating disorder” OR “anorexia nervosa” OR “bulimia nervosa” OR “binge eating disorder” OR “night eating syndrome” OR “UFED”) AND (“Middle East” OR “Arab countries” OR “Gulf Cooperation Council” OR “GCC” OR “Saudi Arabia” OR “UAE” OR “United Arab Emirates” OR “Oman” OR “Kuwait” OR “Turkey” OR “Iran” OR “Algeria” OR “Jordan” OR “Libya” OR “Palestine” OR “Syria” OR “Bahrain” OR “Qatar”). Duplicate records were identified using the Reference Management Software Mendeley and excluded.
2.2. Inclusion and Exclusion Criteria
We included papers that were in the English language, dated 2000 to 2023, and covered a study population of males aged 15 years and above (including adolescents, university students, and adults) in the Middle East region that provided epidemiological data focusing on any type of EDs such as AN, BN, BED, MD, NES, UFED, and other eating disorder presentations. The minimum age of 15 years was selected based on established research showing that EDs typically emerge during mid-to-late adolescence, a period that coincides with increased body awareness, peer influence, and identity formation. While puberty begins earlier (ages 12–13), the clinical manifestation of EDs, particularly in males, often occurs during later adolescence when social pressures regarding appearance intensify. We excluded non-English language studies, studies reported before 2000, studies that included only female subjects, studies focusing on male children under 15 years, mixed-gender studies without separate male data, and studies conducted outside the Middle East region.
2.3. Study Selection and Eligibility Criteria
The selection was performed by T.A.A. and S.P. A third researcher (A.R.) was called to settle disagreements. In the second stage, the full text was read by an additional 2 researchers, C.D. and M.R. In the absence of consensus, the third researcher would once again be involved. A structured approach using a specific population (P), intervention (I), comparator (C), outcome (O), and study design (S) (PICOS) framework was adapted to construct the research question and specify qualification requirements.
The population eligible for inclusion was males aged 15 years and above (adolescents, university students, bodybuilders, and adults) residing in Middle Eastern countries, including Saudi Arabia, UAE, Oman, Kuwait, Turkey, Iran, Algeria, Jordan, Libya, Palestine, and Syria (P). Screening assessment tools taken into consideration were EAT-26, BES, PSS, ESS, WEB-SG, OCI-R, ZSRDS, FRS, BDI-II, NEQ, MDDI, DFS, AI, FI, MPS, SATAQ-3, DERS, EAT-40, BIG, MDI, NPI, BITE, and BIS (I). Comparison was inapplicable (C). The outcome of interest (O) was the prevalence of eating disorders, including AN, BN, BED, MD, NES, UFED, and other ED presentations. The study designs (S) acceptable were cross-sectional, original articles, and reviews. Table 1 shows the PICOS criteria for study inclusion.
Table 1. PICOS criteria for study inclusion.
2.4. Data Extraction and Quality Assessment
Data extraction was carried out by two researchers (S.P. and T.A.A.). The following items were extracted from each study: study details (first author, year of publication, and country/region of study), sample details (number of participants, number of male participants, target group), assessment tools of EDs, and prevalence of EDs in males. Additional data extracted included: study design details, sampling methodology, response rates, cultural adaptation of instruments, statistical analysis methods, and potential confounding factors.
Study quality was assessed qualitatively by two reviewers (A.R. and S.A.) based on study design, sample size, sampling methodology, assessment tool validation, and reporting quality. Quality evaluation focused on: (1) sample representativeness and selection methods, (2) cultural adaptation and validation of eating disorder assessment instruments, (3) statistical analysis adequacy, and (4) completeness of outcome reporting. Conflicts were resolved through consultation with a third reviewer (T.A.A.). While this descriptive systematic review focused primarily on prevalence data synthesis rather than intervention effectiveness evaluation, quality assessment was conducted to evaluate the methodological rigor and reliability of prevalence estimates across included studies.
3. Results
3.1. Study Selection and Characteristics
The systematic literature search yielded 797 potentially relevant studies across PubMed, Scopus, and Google Scholar databases. After removing duplicates (n = 12), screening titles and abstracts (n = 785), and applying eligibility criteria, 13 studies met inclusion requirements for this systematic review. The PRISMA flowchart detailing the selection process is presented in Figure 1.
Figure 1. PRISMA flowchart diagram of study selection.
The included studies encompassed 5236 male participants across 11 Middle Eastern countries: Saudi Arabia, Oman, Kuwait, Turkey, Iran, Algeria, Jordan, Libya, Palestine, Syria, and the UAE. All studies employed cross-sectional designs and were published between 2002 and 2021. Study populations included university students (n = 8 studies), bodybuilders (n = 4 studies), and mixed community samples (n = 1 study), with participants aged 15 years and above. Detailed characteristics of all included studies are presented in Table 2.
Table 2. Study characteristics and ED prevalence among Middle Eastern males.
3.2. Prevalence Distribution and Geographic Patterns
3.2.1. Regional Prevalence Variations
Male ED prevalence showed substantial variation across Middle Eastern countries, with rates ranging from 2.2% to 81.4% depending on the specific population and assessment methods employed. GCC countries demonstrated consistently higher prevalence rates: UAE (22.0–49.1%), Kuwait (31.8–46.2%), Oman (2.2–36.4%), and Saudi Arabia (9.7%), compared to non-GCC countries: Turkey (5.7–81.4% in specialized populations) and Iran (26.9% in bodybuilders).
A multi-country study examining seven Arab nations found ED prevalence rates of 13.8% to 47.3% among male adolescents aged 15–18 years, with significant inter-country variability. The geographic distribution of these prevalence patterns is illustrated in Figure 2. The age-specific analysis of these prevalence patterns is presented in Figure 3, revealing distinct vulnerability profiles across developmental stages and population types.
3.2.2. Population-Specific Prevalence Patterns
University students (n = 4108 across 8 studies) showed prevalence rates of 9.7–49.1%, with higher rates observed in more cosmopolitan urban centers. Bodybuilders (n = 872 across 4 studies) demonstrated markedly elevated rates of MD (5.7–81.4%) and ED symptoms (26.9–39.0%), representing a high-risk population requiring specialized attention.
3.2.3. Age-Specific Prevalence Patterns
Age-stratified analysis revealed distinct prevalence patterns across population types (Figure 3). Adolescents aged 15–18 years demonstrated the highest rates among general populations (mean: 35.0%, range: 13.8–49.1%, n = 2971), with GCC countries showing particularly elevated prevalence during late adolescence.
University students aged 19–25 years showed moderate rates (mean: 29.0%, range: 9.7–46.2%, n = 1474), with notable variation among countries. Saudi universities reported the lowest rates (9.7%), while UAE and Kuwaiti institutions showed substantially higher prevalence (35.2–46.2%).
Bodybuilding populations exhibited the most concerning rates (mean: 38.0%, range: 5.7–81.4%, n = 872), with Turkish bodybuilders demonstrating rates as high as 81.4% for muscle dysmorphia. General adult populations over 25 years showed dramatically lower prevalence (mean: 2.1%, range: 2.0–2.2%, n = 376).
Figure 3. Eating disorder prevalence among Middle Eastern males by population group. Data from 13 studies with 5236 participants across 11 countries. Error bars show the range of reported prevalence. * Bodybuilders represent a specialized population (typically 20–35 years) with elevated muscle dysmorphia risk.
3.3. Diagnostic Categories and Clinical Presentations
3.3.1. Traditional Eating Disorders
AN and BN presentations varied significantly between Omani nationals (36.4% EAT-26 positive) and non-Omani residents (7.5%), suggesting cultural factors influence disorder expression. BED prevalence reached 35.2% among UAE university students, with stress, emotional eating, and body-related shame identified as primary predictors.
Night eating syndrome (NES) showed lower prevalence (2.2%) but demonstrated clear associations with evening hyperphagia patterns that could progress to more severe eating pathology if untreated.
3.3.2. Muscle Dysmorphia and Body Image Disorders
MD emerged as a predominant concern among male bodybuilders, with prevalence ranging from 5.7% to 81.4% depending on assessment criteria and comparison groups. Turkish bodybuilders showed 81.4% prevalence compared to 48.12% among sedentary controls, indicating strong associations between competitive bodybuilding and body dysmorphic concerns.
Iranian bodybuilders (26.9% prevalence) demonstrated significant correlations between MD symptoms and media influence, perfectionism, and emotion regulation difficulties, suggesting multiple pathways to disorder development.
3.4. Assessment Methodology and Diagnostic Considerations
Studies employed diverse validated instruments reflecting the heterogeneous nature of ED presentations in Middle Eastern populations. Primary screening tools included EAT-26/EAT-40 (n = 7 studies), muscle dysmorphic disorder inventory (MDDI) for muscle dysmorphia (n = 3 studies), and specialized assessments such as BITE, BES, and NEQ for specific presentations.
Diagnostic consistency varied across studies, with some employing multiple assessment tools to capture complex presentations. The frequent use of “other specified” or “unspecified” ED categories (OSFED/UFED) in several studies highlighted the limitations of traditional Western diagnostic criteria in capturing culturally influenced presentations.
3.5. Risk Factors and Associated Variables
3.5.1. Demographic and Clinical Correlates
Age patterns showed higher prevalence among younger males (≤27 years), particularly in bodybuilding populations. BMI associations demonstrated U-shaped relationships, with both underweight and obese individuals showing elevated eating disorder risk compared to normal-weight peers.
Academic performance (GPA) showed inverse correlations with ED symptoms in university populations, suggesting possible shared underlying factors affecting both academic and psychological functioning.
3.5.2. Psychological and Cultural Factors
Depression and anxiety emerged as consistent comorbidities across studies, with depression intensity being significantly associated with ED severity in UAE populations. Bodybuilding populations showed particularly elevated depression scores compared to control groups, with Turkish bodybuilders demonstrating 81.4% prevalence versus 48.1% in controls. Body dissatisfaction affected over 58% of male respondents in some studies, representing a critical pathway to disorder development. UAE undergraduate populations showed 22% prevalence, while BED affected 35.2% of male students. Reported dissatisfaction encompassed concerns about muscularity, body composition, and overall physical appearance, with significant discrepancies between perceived and ideal body images documented across university populations.
Cultural transition stress appeared particularly relevant in multi-ethnic environments such as the UAE, where exposure to diverse food cultures and Western beauty standards created unique risk environments. Among Omani populations, nationals showed substantially higher rates (36.4% on EAT-26) compared to non-Omani residents (7.5%). Sociocultural attitudes toward appearance showed significant associations with MD symptoms, particularly regarding media influence and internalization of Western muscular ideals. Family expectations and academic pressure were identified as significant stressors among Omani adolescents, with perfectionism and emotion regulation difficulties emerging as additional psychological risk factors across multiple populations.
3.6. Temporal Trends and Emerging Patterns
3.6.1. Increasing Prevalence over Time
Analysis of studies published between 2002 and 2021 revealed an apparent increasing trend in eating disorder recognition and reporting across the Middle East. Earlier studies (2002–2010) typically reported lower prevalence rates and focused primarily on traditional anorexia/bulimia presentations, while more recent investigations (2015–2021) documented higher prevalence rates and greater diversity in clinical presentations.
3.6.2. Evolving Clinical Recognition
The emergence of MD as a significant clinical concern in recent studies reflects improved recognition of male-specific eating disorder presentations. Studies focusing on bodybuilders only appeared in the literature after 2014, suggesting growing awareness of exercise-related eating pathology among healthcare professionals and researchers.
3.7. Quality and Limitations of Available Evidence
The included studies demonstrated variable methodological rigor, with sample sizes ranging from 120 to 4698 participants. Quality assessment revealed significant methodological heterogeneity across the 13 included studies. Seven studies (53.8%) achieved moderate quality based on adequate sample sizes and clear methodology, five studies (38.5%) showed limited quality due to small sample sizes or unclear sampling methods, and only one study (7.7%) demonstrated high quality with comprehensive methodology and cultural considerations.
Most studies employed convenience sampling from university populations, potentially limiting generalizability to broader male populations. The predominant use of convenience sampling (84.6% of studies) introduces significant selection bias, potentially overestimating prevalence in educated, urban populations while underrepresenting rural and working-class communities. Assessment tool diversity complicated cross-study comparisons, though this also reflected appropriate efforts to capture culturally relevant presentations.
Cultural adaptation of Western-developed assessment tools was inconsistently reported, raising questions about diagnostic accuracy across different Middle Eastern populations. Only three studies (23.1%) reported any consideration of cultural factors in their assessment approach, and inadequate reporting of cultural adaptation procedures was identified in 76.9% of studies. Several studies acknowledged the need for culturally validated diagnostic criteria specific to Middle Eastern contexts. Studies focusing on bodybuilder populations generally achieved higher quality scores due to more rigorous sampling within their target populations, while university-based studies showed greater variability in methodological quality. Limited control for potential confounding variables was observed in 69.2% of studies.
3.8. Summary of Key Findings
ED prevalence among Middle Eastern males varied substantially, ranging from 2.2% to 81.4% across different countries and populations. GCC countries generally demonstrated higher prevalence rates (UAE: 22.0–49.1%, Kuwait: 31.8–46.2%, Oman: 2.2–36.4%) compared to non-GCC countries.
Age-stratified analysis demonstrated that late adolescence (15–18 years) represents the highest risk period with a mean prevalence of 35.0%, while adults over 25 years showed dramatically reduced rates (mean: 2.1%). University populations showed intermediate risk levels (mean: 29.0%) with significant geographic variation.
MD was particularly prevalent among bodybuilding populations, with rates ranging from 5.7% to 81.4%. University student populations showed ED prevalence between 9.7% and 49.1%, while specialized presentations such as NES occurred at lower rates (2.2%).
Depression, body dissatisfaction, and cultural factors were consistently identified as correlates across multiple studies and populations. Assessment approaches varied considerably, with EAT-26 being the most commonly used tool (7 studies), followed by MD-specific instruments in bodybuilder populations.
4. Discussion
4.1. Prevalence Patterns and Regional Variations
This systematic review demonstrates substantial heterogeneity in male ED prevalence across Middle Eastern populations, with rates varying dramatically from 2.2% to 81.4% based on study population characteristics and assessment methods. This substantial variation underscores the heterogeneous nature of ED presentations in culturally diverse Middle Eastern societies and highlights the critical importance of population-specific approaches to understanding these conditions.
The observed geographic clustering of higher prevalence rates in GCC countries, particularly in the UAE (22.0–49.1%), Kuwait (31.8–46.2%), and certain populations in Oman (up to 36.4%), compared to other Middle Eastern nations, suggests a compelling relationship between socioeconomic development, cultural transition, and ED risk. This geographic clustering correlates strongly with several socioeconomic indicators, as countries with higher gross domestic product (GDP) per capita (UAE: $70,441; Kuwait: $65,531) demonstrated consistently elevated rates compared to middle-income nations (Turkey GDP per capita: $28,231) [66,67]. This economic prosperity factor appears linked to increased Western media exposure, high urbanization rates in GCC countries, and greater integration into global consumer culture [68,69]. These findings align with established theories of cultural epidemiology, which propose that rapid societal changes and increased exposure to globalized beauty standards create unique vulnerability contexts for psychological disorders [70,71].
Cultural transition indicators varied systematically across regions. GCC countries demonstrated exceptionally high expatriate populations, creating multicultural environments where traditional and Western beauty standards coexist [72]. Internet and social media usage rates in GCC countries are among the highest in the world, according to recent academic research, substantially exceeding regional averages [73], potentially increasing exposure to Western fitness and body image ideals through social media platforms. Recent experimental studies provide evidence for this cultural transition, with research demonstrating significant associations between social media exposure and body image concerns in Middle Eastern populations, including higher rates of body dysmorphic symptoms and increased intentions for cosmetic procedures influenced by Western beauty ideals [74,75].
Educational factors further distinguished geographic patterns, with the Arab region, including GCC countries, demonstrating high tertiary education enrollment compared to other world regions and widespread adoption of English-medium instruction, potentially facilitating the adoption of Western cultural concepts, including muscular body ideals and fitness culture practices [76]. These combined socioeconomic, cultural, and educational factors create an environment particularly conducive to the adoption of Western body ideals and the development of exercise-related pathologies.
The striking difference in eating disorder prevalence between Omani nationals (36.4%) and non-Omani residents (7.5%) within the same geographic region strongly suggests that cultural factors play a significant role in disorder development. This finding challenges simplistic environmental explanations and suggests that cultural identity, traditional values, and the experience of cultural transition may serve as both protective and risk factors depending on the specific context and individual circumstances [71,77].
Historically, Middle Eastern communities perceived themselves as immune to EDs, interpreting these conditions as Western culture-bound syndromes [1]. However, the data from this review demonstrates that Middle Eastern populations now face significant public health challenges with nutrition-related psychiatric disorders, principally due to the complex interplay between malnutrition, coexistence of undernutrition and obesity, body image dissatisfaction, and various psychosocial stressors [1,78].
4.2. Neurobiological Implications and Male-Specific Presentations
From a neurobiological perspective, the observed prevalence patterns may reflect differential activation of neural circuits governing body image processing, reward sensitivity, and stress response systems across culturally distinct populations. Recent advances in understanding the genetics and neurobiology of EDs emphasize the importance of integrating genomic, neuroimaging, and environmental data to understand disorder mechanisms [79]. Emerging evidence from cultural neuroscience suggests that prolonged exposure to specific cultural environments can shape neural development and functioning, particularly in regions associated with self-perception and social cognition [80,81].
The observed age-specific patterns align with critical periods of neural development, with peak vulnerability occurring during late adolescence when brain regions governing impulse control and reward processing are still maturing [46]. This developmental timing may explain why cultural transitions and Western media exposure have particularly pronounced effects during the 15–18 year age range.
The elevated rates of MD among bodybuilding populations (5.7–81.4%) likely involve alterations in dopaminergic reward pathways similar to those observed in traditional EDs, though the specific neural signatures may differ given the focus on muscularity rather than weight reduction [82,83]. This population represents an important model for understanding how specialized environmental pressures can interact with genetic vulnerabilities to produce clinically significant eating pathology.
The consistent association between EDs and comorbid depression and anxiety across multiple studies suggests shared neurobiological vulnerabilities, particularly involving serotonergic and GABAergic (gamma-aminobutyric acid) neurotransmitter systems [84,85]. These findings support the implementation of comprehensive treatment approaches that address multiple neurochemical pathways rather than focusing solely on eating-specific behaviors.
The manifestation of EDs differs substantially between males and females, with distinct implications for clinical recognition and intervention [49]. Male patients typically exhibit concerns focused on muscularity and body composition rather than weight loss, patterns that reflect different neural reward mechanisms and social influences [50,86]. These sex-specific differences contribute to delayed diagnosis and suboptimal treatment outcomes in male populations.
MD affects predominantly male individuals and shares significant overlap with traditional EDs despite lacking formal DSM-5 classification. The findings from this review suggest that MD represents a particularly problematic manifestation of eating pathology in Middle Eastern contexts, where cultural emphasis on male strength and physical capability may interact with Western muscular ideals to create unique vulnerability patterns [2]. The elevated prevalence rates observed among bodybuilding populations across Turkey, Iran, and other Middle Eastern countries indicate that this condition may be culturally amplified in regions experiencing rapid westernization of masculine ideals.
The substantial comorbidity between MD and established EDs suggests common underlying mechanisms, and preliminary evidence indicates that serotonergic medications (SSRIs) used in eating disorder treatment may also be effective for MD, which has important therapeutic implications [28]. Several studies in this review report that males with MD demonstrate more ED symptoms than those without MD, indicating the interconnected nature of these conditions.
Traditional diagnostic frameworks developed in Western populations may inadequately capture ED presentations in Middle Eastern communities due to cultural variations in body ideals [1], limited psychometric validation of assessment instruments in these populations [8], and the need for culturally relevant diagnostic measures [9]. The frequent use of “other specified” or “unspecified” ED categories (OSFED/UFED) in several studies highlighted the limitations of traditional Western diagnostic criteria in capturing culturally influenced presentations.
4.3. Cultural Transformation and Societal Influences
The sociocultural changes occurring throughout Middle Eastern societies have created unique conditions for examining how environmental shifts influence neural plasticity and eating disorder risk among male populations [87,88]. Historically, male body ideals in Middle Eastern cultures emphasized strength and functionality rather than specific aesthetic standards, with masculine identity closely tied to physical capability, family provision, and social status rather than muscular definition or leanness [89]. Traditional Middle Eastern masculine ideals emphasized physical strength for functional purposes, family provision, and social respect through character rather than appearance. Male worth was historically assessed through economic capability, family honor, and community service rather than physical aesthetics [1,3].
However, the oil boom of the 1970s initiated profound societal transformations that fundamentally altered male body image expectations. The arrival of foreign companies, elevated industrialization, and globalization introduced different cultural frameworks for understanding masculinity and male physical attractiveness [3]. Western ideals emphasizing muscularity, low body fat, and specific body proportions began permeating traditional Middle Eastern concepts of male attractiveness and social desirability [90]. Globalization has introduced Western muscular ideals emphasizing aesthetic appearance, symmetry, and low body fat percentages as markers of male attractiveness and social success [2].
This cultural collision creates unique psychological stress for young Middle Eastern men who must navigate between traditional family expectations and contemporary peer pressures. Unlike Western contexts, where masculine body ideals evolved gradually, Middle Eastern populations experienced rapid cultural shifts that compressed decades of attitude changes into single generations. This acceleration may explain the particularly high prevalence rates observed in economically developed GCC countries where Western influence is strongest [4].
Most significantly, these changes brought Western fitness culture and bodybuilding ideals to Middle Eastern male populations, who increasingly began to internalize these standards of muscular physique and physical perfection. Exposure to Western media, fitness magazines, and social media platforms resulted in substantial shifts in how young Middle Eastern men conceptualize ideal male bodies, moving away from traditional emphasis on functional strength toward aesthetic muscularity and body composition concerns [2]. The bodybuilding culture, showing the highest ED rates (5.7–81.4%), represents the most extreme manifestation of this cultural conflict. Traditional Middle Eastern strength training focused on functional capacity, while Western bodybuilding emphasizes aesthetic muscle development that may conflict with traditional values about vanity and self-focus [91].
The rapid adoption of social media and technology has further accelerated these cultural shifts, creating unprecedented exposure to Western beauty standards and contributing to body dissatisfaction among young males [92]. As these populations experience increasing exposure to social media, platforms that emphasize idealized body images can exacerbate body dissatisfaction and the drive for muscularity [93]. When combined with genetic vulnerabilities, such environmental pressures may heighten the risk of developing EDs through complex gene-environment interactions [18,94].
4.4. Risk Factors and Comorbidity Patterns
This review identified multiple interconnected risk factors contributing to ED development among Middle Eastern males. Depression and anxiety emerged as consistent comorbidities across studies, with depression intensity significantly associated with ED severity. Body dissatisfaction affected over 58% of male respondents in some studies, representing a critical pathway to disorder development. These findings are consistent with broader research on male body dissatisfaction, including the work of Dakanalis et al. [95] with college-aged men, which found that over 80% of college men experienced body dissatisfaction, even though not all developed severe ED symptoms. This broader evidence base reinforces that body dissatisfaction is recognized as a robust risk factor for EDs and demonstrates the universal nature of this pathway to disorder development across different cultural contexts [96].
Cultural transition stress appeared particularly relevant in multi-ethnic environments like the UAE, where exposure to diverse food cultures and Western beauty standards created unique risk environments. This is consistent with research suggesting that rapid economic development may influence traditional cultural values and lifestyle practices, potentially contributing to changes in body image ideals and eating behaviors in some Middle Eastern populations [4]. Family expectations and academic pressure were identified as significant stressors, particularly among adolescent populations in countries like Oman and Saudi Arabia. Evidence demonstrates that students in higher years of college study had higher odds of being at risk of EDs due to higher stress and pressure to achieve in their studies [97], with academic pressures being particularly pronounced among male university students in these traditional societies where family expectations for educational and career success remain high.
Additional risk factors identified across multiple investigations encompassed various demographic elements, with younger age, particularly those aged 27 years and below, showing elevated vulnerability, while BMI relationships demonstrated U-shaped patterns indicating increased risk among both underweight and obese individuals compared to those maintaining normal weight ranges. Previous longitudinal studies have shown that ED symptomatology and weight-related concerns can persist from adolescence into adulthood, with elevated risk among individuals with higher body weight [98].
Psychological contributors included elevated stress levels, patterns of emotional eating as coping mechanisms, body-related shame and guilt experiences, and obsessive-compulsive behavioral tendencies that may predispose individuals to rigid eating patterns. Research indicates that certain risk factors, such as low self-esteem and body weight/shape concerns, may be relevant for ED development in both males and females [99].
Cultural influences, particularly the internalization of Western muscularity ideals through globalization and social media, have contributed to growing body dissatisfaction and disordered eating among Middle Eastern males [71]. Research suggests that these cultural shifts interact with psychological vulnerabilities such as low self-esteem, perfectionism, and body-related shame, reinforcing rigid and appearance-driven eating behaviors [60]. Behavioral patterns associated with increased risk included excessive exercise behaviors often motivated by body dissatisfaction, protein supplement use among bodybuilding populations, and irregular sleep patterns that contributed to NES development [100].
4.5. Clinical Implications
The increasing recognition of EDs among Middle Eastern males carries significant implications for clinical practice. Healthcare professionals need enhanced training to identify atypical presentations, particularly MD and subclinical forms that may not align with traditional Western criteria [2]. The high rates of comorbidity with depression, anxiety, and other psychiatric conditions [43] indicate the necessity for comprehensive treatment approaches addressing multiple neurobiological systems.
Cultural adaptation of assessment tools represents a critical need, as inconsistent reporting of cultural validation across studies raises questions about diagnostic accuracy. Several studies acknowledged the need for culturally validated diagnostic criteria specific to Middle Eastern contexts. For example, Musaiger et al. [55] found dramatic variation in reported prevalence rates across Arab countries (13.8% to 47.3% among males), suggesting that current Western-developed instruments may not adequately capture the full spectrum of eating pathology in these populations.
NES, while showing lower prevalence (2.2%), represents a culturally relevant presentation that may be influenced by regional eating patterns and social customs. Cultural differences in traditional meal timing, such as the emphasis on midday as the main meal in GCC countries [101], could affect how evening eating behaviors are perceived and recognized as pathological. Further research is needed to determine whether evening eating patterns vary culturally and how this might affect the clinical recognition of NES and other EDs in different Middle Eastern populations.
4.6. Culturally Adapted Clinical Strategies and Prevention Programs
Effective intervention for Middle Eastern male EDs requires fundamental adaptation of Western treatment models to accommodate cultural values, family structures, and religious considerations [42]. The findings from this systematic review highlight several critical areas where culturally informed clinical strategies must be developed and implemented.
Assessment and diagnostic approaches need comprehensive revision to address the unique presentations observed in Middle Eastern male populations. The development of culturally validated screening instruments that incorporate traditional masculine ideals and regional body image concepts represents the most immediate clinical need [8]. Healthcare providers require specialized training to recognize male-specific presentations that may differ significantly from Western diagnostic criteria, particularly the muscle dysmorphia presentations that showed such high prevalence rates in bodybuilding populations [49]. Integration of family and religious leaders in assessment processes may be culturally appropriate in many contexts [42], while consideration of cultural transition stress should be recognized as a primary risk factor requiring specialized clinical attention [71].
Treatment protocol modifications must respect traditional family structures while effectively addressing eating pathology. Family-inclusive therapy approaches that acknowledge traditional family hierarchies offer promise for engaging patients within their cultural context [102]. For patients where faith plays a central role in identity and recovery, religious counseling integration may enhance treatment engagement and outcomes [103]. Male-specific group therapy programs that directly address masculine identity conflicts and cultural pressures could provide peer support while normalizing help-seeking behaviors [104]. Psychoeducation about cultural influences on body image and the distinction between traditional and globalized masculine ideals may help patients understand their symptoms within a broader cultural framework [105].
Age-appropriate intervention strategies should prioritize intensive prevention efforts during late adolescence (15–18 years) when vulnerability peaks, while university-based programs should address the continued but more variable risk observed in early adulthood (19–25 years) [46]. Prevention program development should target multiple levels of intervention across different community settings. School-based interventions targeting adolescent males during critical cultural identity formation periods could prevent disorder development before clinical symptoms emerge [106]. Media literacy programs addressing Western beauty standard influences through social media and advertising may help young men critically evaluate cultural messages about ideal male bodies [107]. Community education initiatives involving religious and traditional leaders could address stigma surrounding mental health treatment while promoting appropriate help-seeking behaviors [108]. Finally, fitness center partnerships offer opportunities to promote healthy exercise behaviors while identifying at-risk individuals within bodybuilding communities where eating disorder prevalence was found to be particularly elevated [109].
4.7. Methodological Quality and Diagnostic Consistency
The quality assessment revealed that methodological limitations significantly contributed to the observed prevalence variations beyond genuine population differences. The predominant reliance on convenience sampling from university populations creates systematic bias toward educated, urban, and higher socioeconomic populations, potentially inflating prevalence estimates compared to general population rates [110,111]. This sampling bias is particularly concerning in Middle Eastern contexts where educational access, urbanization levels, and socioeconomic development vary substantially both within and between countries [112].
The lack of culturally validated assessment instruments represents the most critical methodological limitation identified. The substantial variation in reported prevalence rates (2.2% to 81.4%) reflects both genuine population differences and significant methodological inconsistencies. Studies using EAT-26 showed a narrower range (9.7% to 49.1%) compared to specialized instruments like MDDI (5.7% to 81.4%) (Table 2), suggesting that tool selection significantly influences reported outcomes. The widespread use of Western-developed tools, particularly the EAT-26 (employed in 54% of studies), without proper cultural adaptation raises fundamental questions about diagnostic accuracy [8]. These instruments were designed and validated in populations with different cultural attitudes toward eating, body image, family dynamics, and help-seeking behaviors. For instance, traditional Middle Eastern emphasis on family meals and hospitality through food sharing [101], as well as different masculine ideals [89], may influence how eating-related questions are interpreted and answered.
Cultural adaptation status appeared to influence prevalence estimates, with studies reporting cultural validation generally showing more conservative rates compared to those using instruments without documented adaptation. This pattern suggests that culturally inappropriate instruments may inflate prevalence estimates by misclassifying culturally normative behaviors as pathological [113].
Cutoff score variations further contributed to inconsistency, with differences in threshold selection appearing to affect reported prevalence rates and highlighting the critical need for population-specific normative data [16].
The heterogeneity in assessment methodologies, while reflecting researchers’ attempts to capture diverse clinical presentations, significantly hampers the ability to draw definitive conclusions about true prevalence patterns [8]. The dramatic variation in reported rates (2.2% to 81.4%) likely reflects methodological differences as much as genuine population variations. This methodological inconsistency underscores the urgent need for standardized, culturally adapted diagnostic criteria specifically designed for Middle Eastern populations [34,42].
Furthermore, the cross-sectional nature of all included studies limits understanding of causality, disorder progression, and the temporal relationship between cultural factors and ED development [114]. The absence of longitudinal data prevents identification of critical risk periods and limits the ability to distinguish between transient cultural adjustment difficulties and clinically significant eating pathology [96,114].
4.8. Study Limitations
Several important limitations affect how we can interpret and apply these findings. Most notably, the heavy reliance on convenience sampling from university settings introduces a significant bias toward more educated, higher socioeconomic populations. This approach likely underestimates the true prevalence of EDs in rural areas and among working-class communities, where access to higher education may be limited. Additionally, the variation in assessment methods across different studies poses challenges for meaningful comparison. Many researchers used different diagnostic tools, and the cultural adaptation of these Western-developed instruments was often inadequately documented or entirely absent. The predominance of cross-sectional study designs further constrains our understanding, as these approaches cannot establish whether identified risk factors actually cause EDs or simply correlate with them. There is also the possibility that publication bias has skewed the available evidence, particularly given that some countries in the region may be less likely to publish studies on mental health topics or may lack the research infrastructure to conduct such investigations.
4.9. Future Research Directions
Looking ahead, several research directions could significantly advance our understanding of EDs among Middle Eastern males. The development of culturally validated assessment instruments must be the immediate priority. Future research should focus on: (1) linguistic translation that captures cultural nuances rather than literal word conversion, (2) normative data collection from representative Middle Eastern populations, (3) validation studies examining sensitivity and specificity in different cultural subgroups, and (4) integration of culturally specific risk factors and protective elements into diagnostic frameworks.
Methodological improvements should emphasize population-based sampling strategies to ensure representativeness across socioeconomic, educational, and geographic strata. Multi-site collaborative studies spanning different Middle Eastern countries could capture regional variations while providing sufficient power for meaningful comparisons. Such studies should stratify sampling by urban/rural residence, educational level, and economic development indicators to understand how these factors moderate eating disorder risk.
Longitudinal studies that follow individuals over extended periods would be invaluable for identifying critical risk periods and understanding how these disorders develop over time. Recent longitudinal research in other populations has demonstrated the feasibility and value of prospective designs in identifying developmental pathways to eating pathology in males [114]. Specifically, prospective cohort studies should: (1) follow adolescents from ages 15–25 to capture the transition from traditional to globalized cultural contexts, (2) examine how exposure to Western media and social platforms influences body image over time, (3) assess the role of family dynamics and cultural values as protective or risk factors, and (4) identify early warning signs that could inform prevention strategies.
Additionally, future research should prioritize: standardized outcome measures that allow for cross-cultural meta-analyses, adequate sample size calculations based on population-specific prevalence estimates, and comprehensive assessment of potential confounding variables, including socioeconomic status, religious observance, and acculturation levels.
The field would also benefit from embracing technological innovations, such as culturally sensitive digital screening tools that could help identify at-risk individuals while respecting cultural barriers to traditional mental health services. This approach would help distinguish between universal aspects of ED development and those that are culturally specific, ultimately leading to more effective prevention and treatment strategies.
5. Conclusions
This systematic review represents one of the first comprehensive examinations of ED prevalence among males throughout the Middle East. The substantial variation in prevalence rates (2.2% to 81.4%) reflects methodological limitations and genuine population differences, necessitating careful interpretation and urgent research quality improvements.
Critical methodological gaps—particularly the absence of culturally validated instruments, convenience sampling, and the lack of longitudinal data—must be addressed before establishing definitive prevalence estimates. Developing Middle Eastern-specific diagnostic tools represents the most urgent priority, requiring collaboration between cultural experts, mental health professionals, and community stakeholders.
Consistently elevated rates in GCC countries suggest that rapid economic development and cultural transition create unique vulnerability contexts, while MD emergence among bodybuilding populations indicates culturally relevant eating pathology requiring specialized attention. Depression, body dissatisfaction, and cultural transition stress as consistent correlates provide important intervention targets.
Policy frameworks must prioritize the integration of male ED awareness into national health education curricula, mandating specialized training for healthcare providers, educators, and community leaders to recognize early warning signs and provide appropriate referral pathways. Regional health ministries should establish standardized educational programs targeting high-risk populations, including athletes, university students, and young professionals, while implementing public awareness campaigns that challenge traditional gender stereotypes surrounding eating disorders and promote help-seeking behaviors among males.
Furthermore, governments should allocate dedicated funding for the development of culturally adapted screening tools and treatment protocols, establishing specialized male eating disorder units within existing mental health services, and requiring insurance coverage for evidence-based interventions. These policy initiatives must include mandatory reporting systems for tracking prevalence rates and treatment outcomes, ensuring that educational and awareness programs are regularly evaluated and updated based on emerging research evidence and cultural considerations.
Future research must prioritize longitudinal designs combined with population-based sampling to establish accurate incidence rates and develop culturally appropriate prevention strategies. Only through methodological improvements can the field move toward actionable evidence informing clinical practice and public health policy.
Addressing EDs among Middle Eastern males requires comprehensive approaches integrating neurobiological vulnerabilities, cultural influences, and socioeconomic factors through evidence-based strategies that respect cultural values while meeting evolving mental health needs.
Author Contributions
T.A.A., S.P. and M.R.; methodology, T.A.A., S.P. and A.R.; validation, A.R., S.A., T.A.A. and S.P.; formal analysis, S.P. and I.C.; data curation, S.P.; writing—original draft preparation, T.A.A. and S.P.; writing—review and editing, T.A.A., S.P., A.R., S.A., I.C. and M.R.; visualization, S.P., S.A. and I.C.; supervision, S.P.; All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
Not applicable.
Informed Consent Statement
Not applicable.
Data Availability Statement
The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding authors.
Conflicts of Interest
The authors declare no conflicts of interest.
