Taking Stock of Dietary Supplements' Harmful Effects on Children, Adolescents, and Young Adults

Diet pills and deception: A content analysis of weight-loss, muscle-building, and cleanse and detox supplements videos on TikTok

The promotion of harmful dieting-related products, including weight-loss, muscle-building, and cleanse/detox supplements, is pervasive across TikTok. Use of these products has been associated with eating pathology, and in some instances, increased risk of an eating disorder diagnosis. To inform eating disorders prevention and public health intervention, a content analysis was conducted to analyze the promotional features of the most viewed videos as of June 2022 in the U.S. across popular dieting product-related hashtags (#dietpills, #preworkout, #detox) (N = 233 videos). Investigators watched and coded videos using a codebook that captured details about featured individuals, product claims and details, and other video elements (e.g., language, use of popular music). Descriptive statistics were obtained to analyze trends within and across product hashtags. A total of 78 #dietpills, 86 #preworkout, and 69 #detox videos met study criteria. Videos promoting weight-loss and cleanse/detox products overwhelmingly featured feminine-presenting (70.5 % and 71 %, respectively) and thin (35.9 % and 44.9 %) individuals, while #preworkout video subjects were mostly masculine-presenting (73.3 %) and muscular (61.6 %). Most did not disclose their credentials (93.6 %) nor identify whether the promotion of the product was sponsored by the retailer (95.7 %). The vast majority of videos (97 %) did not provide any scientific evidence to support health- and appearance-related claims. The most popular videos promoting dieting-related supplements on TikTok overwhelmingly make unsubstantiated health claims, posing substantial risks for social media users who are vulnerable to their usage and associated health risks, including engagement in disordered eating.

Adolescents' perceptions of the credibility of informational content on fitness and dietary supplements: The impact of banner and native advertising

INTRODUCTION

The assessment of online health-related information presents a significant challenge for today's youth. Using the Processing of Commercial Media Content (PCMC) model, we investigated the impact of advertising on the perceived credibility of informational content concerning fitness (in boys) and dietary supplements (in girls).

METHODS

In a survey-based preregistered experiment, 681 Czech adolescents (aged 13-18, 52% girls) were randomly assigned to three groups and exposed to websites with a banner ad, a native ad, or simple informational text without an ad.

RESULTS

The presence of ads on websites diminishes the perceived credibility of informational content. While we did not observe the difference between banner and native advertising, we found one gender-specific difference. Specifically, boys perceive informational content linked with native ads as more credible compared to girls. Additionally, no difference was found between younger and older adolescents. Adolescents demonstrated success in identifying both types of advertisements, irrespective of their age.

CONCLUSIONS

The findings are discussed in light of individual differences and various approaches to processing online content. It appears that adolescents are accustomed to native advertising, which seamlessly integrates with traditional banner ads. Moreover, it is plausible that boys assess advertising texts more heuristically and less systematically than girls. Contrary to PCMC expectations, even younger adolescents seem to possess sufficient skills to identify the advertisements.

Prevalence and correlates of appearance- and performance-enhancing drugs and substances use among a national sample of college students aged 18-30

Objective: To identify the lifetime prevalence and correlates of appearance- and performance-enhancing drugs and substances (APEDS) use among a national sample of US college and university students. Participants: Student participants from the 2020-2021 Healthy Minds Study (N = 7,401; ages 18-30 years). Methods: Lifetime prevalence of five forms of APEDS was estimated. Modified Poisson regression analyses were conducted to determine the sociodemographic correlates of protein and creatine supplement use. Results: Lifetime protein (23.8%) and creatine (7.7%) supplement use were most common among the sample. Older age within young adulthood, male sex, perceiving oneself to be normal weight or somewhat overweight, any athletics participation, and 2-3 or ≥ 5 h/week of exercise were associated with greater likelihood of lifetime protein and creatine supplement use. Conclusions: Awareness and prevention efforts on the potential harms of APEDS use are needed on campuses, particularly among males and those who participate in athletics and high-frequency exercise.

Pain experiences of marginalized children in the emergency department: A scoping review protocol

INTRODUCTION

Pain affects all children, and in hospitals across North America, this pain is often undertreated. Children who visit the emergency department (ED) experience similar undertreatment, and they will often experience a painful procedure as part of their diagnostic journey. Further, children and their caregivers who experience social injustices through marginalization are more likely to experience healthcare disparities in their pain management. Still, most of our knowledge about children's pain management comes from research focused on well-educated, white children and caregivers from a middle- or upper-class background. The aim of this scoping review is to identify, map, and describe existing research on (a) how aspects of marginalization are documented in randomized controlled trials related to children's pain and (b) to understand the pain treatment and experiences of marginalized children and their caregivers in the ED setting.

METHODS AND ANALYSIS

The review will follow Joanna Briggs Institute methodology for scoping reviews using the Participant, Concept, Context (PCC) framework and key terms related to children, youth, pain, ED, and aspects of marginalization. We will search Medline, Embase, PsychInfo, CINAHL, Web of Science, Cochrane Library Trials, iPortal, and Native Health Database for articles published in the last 10 years to identify records that meet our inclusion criteria. We will screen articles in a two-step process using two reviewers during the abstract and full-text screening stages. Data will be extracted using Covidence for data management and we will use a narrative approach to synthesize the data.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. Findings will be disseminated in academic manuscripts, at academic conferences, and with partners and knowledge users including funders of pain research and healthcare professionals. Results of this scoping review will inform subsequent quantitative and qualitative studies regarding pain experiences and treatment of marginalized children in the ED.

Eating Disorders in Men

BACKGROUND

Eating disorders are seen mainly as a problem affecting women, not just by the public at large, but also in specialized circles. Although it is true that more women than men suffer from all types of eating disorder, pertinent reviews have clearly shown that they do indeed occur in men, and that the available evidence on the matter is limited. The stigmatization of men with eating disorders makes it harder for these men, and for the relevant professionals, to recognize the symptoms and to seek or provide help.

METHODS

This review is based on publications retrieved by a selective search in PubMed on the epidemiological, diagnostic, clinical, and therapeutic aspects of eating disorders in men.

RESULTS

Current estimated lifetime prevalences in men are 0.2% for anorexia nervosa, 0.6% for bulimia nervosa, and 1% for bingeeating disorder; the corresponding figures for women are 1.4%, 1.9%, and 2.8%. Men and women may display different manifestations. Women are thought to be mainly seeking a slim figure and weight reduction; men, a muscular build. The established Germanlanguage screening and diagnostic tools, however, do not cover the types of symptoms that are more common in men. Little is known about whether treatment yields comparable results in men and women.

CONCLUSION

It is important to combat the stigmati - zation of men with eating disorders and to remove the obstacles to their appropriate diagnosis and treatment. The current methods of screening and diagnosis need to be adapted to take account of the special aspects of abnormal eating behavior in men. It remains unclear whether and how the disorderspecific treatment of these conditions in men should differ from their treatment in women.

Economic costs associated with unhealthy weight control behaviors among Australian adolescents

OBJECTIVE

This study explored the relationship between unhealthy weight control behaviors (UWCBs) and their associated economic costs among adolescents using the 2014-2018 Longitudinal Study of Australian Children (LSAC).

METHODS

LSAC data in Wave 6 (n = 3538 adolescents aged 14-15 years), Wave 7 n = 3089 adolescents aged 16-17 years), and Wave 8 (n = 3037 adolescents aged 18-19 years) were derived from a representative sample of Australian adolescents. UWCBs were measured using the self-reported Branched Eating Disorder Test questionnaire. UWCBs were sub-classified into having fasting behaviors, using weight loss supplements or purging behaviors. Economic costs include healthcare and productivity costs to caregivers. Healthcare costs were measured using data from the Medicare and Pharmaceutical Benefits, which includes both medical and pharmaceutical costs. Productivity losses were measured using caregivers' lost leisure time due to UWCBs among adolescents.

RESULTS

The mixed effect model identified statistically significant higher economic costs (mean difference = $453, 95% CIs $154, $752), higher health care costs (mean difference = $399, 95% CIs $102, $695), and higher productivity costs (mean difference = $59, 95% CIs $29, $90) for adolescents with UWCBs compared to their peers with no UWCBs. Subgroup analysis revealed that higher costs were associated with fasting and purging behaviors.

DISCUSSION

UWCBs were associated with increased economic costs during adolescence. Our finding suggests there should be a policy focus on tackling UWCBs to reduce the economic burden on the healthcare system and society.

PUBLIC SIGNIFICANCE

The study contributes to existing knowledge by investigating the direct healthcare costs and productivity losses associated with unhealthy weight control behaviors in Australian adolescents (14-18 years old) using a dataset that follows Australian adolescents over time. We found that engaging in unhealthy weight control behaviors such as fasting, using weight loss supplements, and purging was linked to higher costs among adolescents, suggesting policies should focus on addressing these behaviors.

Protein supplement intake by non-athlete gym attendees in Jazan region: misconceptions and gender differences

BACKGROUND

Protein supplements (PSs) have gained widespread popularity among non-athlete gym attendees, who often perceive them as essential tools for muscle growth and recovery. However, misinformation surrounding PSs may lead to inappropriate use and negative health consequences. This study aimed to assess whether non-athlete gym attendees using PSs have greater misconceptions than non-users while also examining the prevalence of PS consumption and gender differences.

METHODS

A cross-sectional study of 387 participants in the Jazan region was conducted. Customers of 10 fitness centers were screened with a questionnaire comprising questions to measure PS misconceptions. Participants were divided into PS users and non-users. Data were analyzed using descriptive statistics and the Chi-square test to assess the associations between variables. An independent t-test was used to compare the PS Misconception Index Score between the two groups.

RESULTS

A total of 82.4% of non-athlete gym attendees consumed at least one PS. Our findings revealed a significant association between gender and PS utilization (P<0.001), with a higher proportion of females (90.8%) consuming PS than males (77.6%). PS users had a significantly lower PS Misconception Index Score than non-users (26.8 vs. 28.3; P=0.006), indicating that PS users had a higher number of misconceptions. The internet (41.37%) and coaches (gym instructors/trainers) (34.48%) were the most common sources of information about PSs, with muscle gain being the primary reason for consumption (82.75%).

CONCLUSIONS

PS consumption is highly prevalent among non-athlete gym attendees in the Jazan region, with many individuals having misconceptions about their benefits and potential risks. Targeted educational interventions are needed to promote evidence-based knowledge about PSs for gym attendees, as well as for coaches, given that they were among the primary sources of information on supplements.

Analyzing Social Media Policies on Muscle-Building Drugs and Dietary Supplements

BACKGROUND

Use of legal and illegal muscle-building drugs and dietary supplements has been linked to many adverse health and social outcomes. Research has shown that social media use is associated with the use of these drugs and dietary supplements; however, it remains unknown whether social media companies have specific policies related to the content and advertising of muscle-building drugs and dietary supplements on their platforms. Therefore, this study aimed to assess the content and advertising policies of eight popular social media companies related to muscle-building drugs and dietary supplements.

METHODS

Content and advertising policies for YouTube, TikTok, Instagram, Snapchat, Facebook, Twitter, Twitch, and Reddit were analyzed in November 2022 to determine whether there were any provisions related to legal (e.g., whey protein) and illegal (e.g., anabolic-androgenic steroids) muscle-building drugs and dietary supplements. Policies were classified as either none, restricted, or prohibited.

RESULTS

All eight social media platforms had explicit policies prohibiting user-generated content and advertising of illicit drugs and substances (e.g., anabolic-androgenic steroids). User-generated content and advertising policies related to legal muscle-building dietary supplements across the platforms varied; however, none of the eight social media companies had a specific policy regarding user content.

CONCLUSIONS

Findings underscore the need for stronger social media content and advertising policies related to legal muscle-building dietary supplements.

The presence of doping agents in dietary supplements: A glimpse into the Brazilian situation

Dietary supplements (DS) are intended for healthy people to maintain or improve their overall health. Its consumption is widespread in large part of the general population and at all levels of athletes. Nevertheless, DS use can also pose health risks to individuals and, in the case of athletes, may lead to adverse analytical findings (AAFs) due to the possibility of DS contamination or adulteration with doping agents banned by the World Anti-Doping Agency. Although educational initiatives are being performed in Brazil to warn the sports community about inadvertent doping cases, AAFs connected to the DS administration have been increasingly growing. The findings of DS analyzed by the Brazilian Doping Control Laboratory (LBCD), between 2017 and 2022, after Testing Authorities (TAs) analysis requests, showed an alarming number of tainted samples. Diuretics were the most common adulterants found in all supplement types. However, the profile of prohibited substances in manufactured and compounded dietary supplements (MDS and CDS, respectively) were distinct, with stimulants being most prevalent in MDS and anabolic agents in CDS products. Additionally, MDS samples generally presented higher estimated concentrations of banned substances (mg/g) than CDS samples (μg/g). The common practice of DS intake by athletes continues to be of great concern for a doping-free sport, given the high prevalence of prohibited substances detected in the analyzed samples by the LBCD. The current Brazilian scenario reinforces the importance of raising awareness in the sports community of the possible consequences of an unintentional doping case linked to DS use.

Associations between weight discrimination and the use of potentially harmful dietary supplements during the COVID-19 pandemic in the United States

The dietary supplements industry disproportionately markets potentially harmful products promising weight loss, cleansing/detoxing, and boosted energy and immunity to women. The COVID-19 pandemic heightened consumer concerns around health and body weight, which may have increased women's risks of using supplements, particularly if they had a higher weight and experienced weight discrimination. This study aimed to estimate inequities in prevalence and change in use of weight-loss, cleanse/detox, immunity, and energy supplements in the first year of the pandemic and to assess the extent to which the relationship between weight and supplement use differs across discrimination experiences. We drew upon longitudinal data from cisgender women in the U.S. COVID-19 Pandemic Substudy of the Nurses' Health Study II and 3 and Growing Up Today Study cohorts, collected over 5 waves from April/May 2020 to April 2021 (N = 51,814). Modified Poisson generalized estimating equation models, adjusted for age, cohort, race/ethnicity, wave, and Census region, estimated the relative excess risk due to interaction (RERI) between weight status and weight discrimination on prevalence of supplement use. Weight status categories were derived from body mass index (BMI), and weight discrimination was assessed using the attributions item of the Everyday Discrimination Scale. Baseline prevalence of supplement use was 2.7% for weight-loss, 3.3% for cleanse/detox, 4.2% for energy, and 22.6% for immune. Respondents with BMIs of 25-29.9 kg/m2 and 30-34.9 kg/m2 who experienced weight discrimination had RERI values of 0.89 (95% CI 0.14, 1.65) and 1.00 (95% CI 0.25, 1.75) for weight-loss and 0.57 (95% CI 0.13, 1.02) and 0.60 (95% CI 0.19, 1.01) for energy supplements, respectively, indicating this group had excess risk of use compared to lower BMI respondents who experienced no weight discrimination. The findings demonstrate the disproportionate impact of weight discrimination on use of potentially harmful supplements among cisgender women with higher weights during the pandemic.

Prevalence of adulteration in dietary supplements and recommendations for safe supplement practices in sport

The prevalence of dietary supplement use among athletes continues to rise with 60-80% of athletes often reporting current or previous use of dietary supplements. While select dietary ingredients have been shown to improve acute performance and enhance training adaptations over time, it is important to still consider the risk vs. reward for athletes before opting to consume a dietary supplement. Previous work has indicated that certain dietary supplements may pose risks for inadvertent doping, may be susceptible to mislabelling, could be banned by certain governing bodies of sport, or pose health risks for certain populations. The purpose of the current narrative review is to summarize the prevalence of adulteration in dietary sport supplement products, outline the risks of inadvertent doping for athletes, and highlight best practices regarding safe supplementation strategies. Analytical studies have found anywhere from 14 to 50% of samples analyzed from dietary supplement products have tested positive for anabolic agents or other prohibited substances. It is important for the consumer to adhere to safe supplementation strategies, which include following serving size recommendations, cross-referencing ingredient profiles with the list of prohibited substances, choosing quality products that have been verified by a third-party certification program, and being cognizant of consuming multiple dietary supplement products with overlapping ingredient profiles. Once these practices have been considered, it is reasonable for an athlete to utilize dietary supplements as a strategy to optimize performance and health, with a low risk of failing a drug test (adverse analytical finding) and experiencing adverse events.

Economic Value of Initial Implementation Activities for Proposed Ban on Sales of Over-The-Counter Diet Pills and Muscle-Building Supplements to Minors

Introduction

Over-the-counter diet pills, weight-loss supplements, and muscle-building supplements often contain harmful ingredients and are associated with eating disorder diagnoses and other negative health outcomes. This study estimated the value of state initial implementation activities, for example, regulation development, to implement a ban on the sale of dangerous over-the-counter diet pills and muscle-building supplements to minors.

Methods

We enumerated minimum, best, and maximum values for 22 inputs among 11 activities state employees may undertake if the legislation were signed into law. For employment costs, we estimated staff hours on the basis of data from 10 key informants and obtained salary ranges from a state government website. Data were collected and analyzed between September 2021 and January 2022. We calculated 95% CIs using 10,000 Monte Carlo simulations that varied inputs simultaneously and probabilistically. We conducted two sensitivity analyses using all minimum and all maximum salaries.

Results

The estimated value of state start-up activities was $47,536 (95% CI=$36,831-$57,381). Inputs with the largest impact on this estimate corresponded to combinations of the highest salary and greatest hours per task.

Conclusions

The state's one-time opportunity cost to initiate this age-restriction policy would be minimal considering potential health gains. Sensitivity analyses did not change the conclusion, especially if the state produces subregulations linked to existing law rather than new regulations.

Prevalence, correlates and common conditions associated with adolescent dietary supplement use: a cross-sectional survey in Bangladesh

OBJECTIVE

There is a broad spectrum of dietary supplements (DS) and their accessibility worldwide. However, little is known about the prevalence of DS use among Bangladeshi adolescents. This study estimates the prevalence, correlates and common conditions related to DS use.

DESIGN

A cross-sectional, convenient sampling strategy was adopted using an interviewer-administered, structured questionnaire.

SETTING

Kurigram and Patuakhali districts of Bangladesh.

PARTICIPANTS

702 adolescents aged 10-19 years.

RESULTS

The overall prevalence of DS use was 83 %. The majority of participants (93·4 %) agreed that DS were good for health, and 28·3 % reported general health and well-being as the reason for using DS. The most frequently used supplements were multivitamins (38·6 %) and Ca (37 %). DS use was more common among adolescents who had ≤5 siblings, good health status, no chronic diseases, a positive impression that DS are good for health and who had the tendency to encourage DS to others. DS use was also higher among those who received DS information from healthcare providers, professional literature, friends, family and relatives.

CONCLUSIONS

The prevalence of DS use is relatively higher among Bangladeshi adolescents compared to Bangladeshi adults and adolescents from other countries, highlighting the inclination towards DS use. Guidelines for safe DS use for adolescents are warranted to control DS use and prevent adverse effects.

Eating Disorders and Dietary Supplements: A Review of the Science

Disordered eating is a serious health concern globally. The etiology is complex and multidimensional and differs somewhat for each specific eating disorder. Several risk factors have been identified which include psychological, genetic, biochemical, environmental, and sociocultural factors. Poor body image, low self-esteem, teasing, family dynamics, and exposure to media images have also been identified as risk factors. While it is enticing to consider a single behavioral risk factor, doing so fails to consider the documented environmental, social, psychological, biological, and cultural factors that contribute to the development of an eating disorder in a multidimensional and complex integration that is undoubtedly unique to everyone. Focusing only on any one factor without taking the complex etiology into account is remiss. For example, it has been suggested that the use of dietary supplements may lead to eating disorders, despite a lack of evidence to support this conjecture. Therefore, the purpose of this review is to examine the evidence-based risk factors for eating disorders and discuss why connecting dietary supplements to eating disorder etiology is not supported by the scientific literature and may interfere with treatment. Established, effective prevention and treatment approaches for eating disorders should be the focus of public health initiatives in this domain.

Financial precarity, food insecurity, and psychological distress prospectively linked with use of potentially dangerous dietary supplements during the pandemic in the US

Introduction

Supplements sold with claims to promote weight loss, cleansing/detoxing, increased energy, or boosted immunity can be dangerous, and consumers experiencing extreme stressors may be especially vulnerable to deceptive claims. The purpose of our study was to investigate associations of financial strain and psychological distress during the COVID-19 pandemic with use of supplements sold for weight loss, cleanse/detox, energy, or immunity.

Methods

We used repeated-measures data gathered over five survey waves from April/May 2020-April 2021 from the COVID-19 Substudy (N = 54,951), within three prospective US national cohorts (Nurses' Health Study 2, Nurses' Health Study 3, and Growing Up Today Study), to investigate longitudinal associations between financial strain and psychological distress and risk of use of potentially dangerous types of supplements. Surveys assessed use of supplements prior to and during the first year of the pandemic, as well as financial precarity, food insecurity, depressive and anxiety symptoms, perceived stress, and daily hassles. We fit sociodemographic-adjusted modified Poisson GEE models to estimate risk ratios (RRs) and 95% confidence intervals (CIs) for associations between baseline or lagged time-varying predictors and prevalent or incident (i.e., new-onset) use of each supplement type.

Results

At baseline in April/May 2020, soon after pandemic onset, current use of supplement types was: weight loss 2.7%; cleanse/detox 3.2%; energy 4.4%; immune 22.6%. By the end of the study period, cumulative incidence was: weight loss 3.5%; cleanse/detox 3.7%; energy 4.5%; immune 21.3%. In prevalent-use analyses, financial precarity, food insecurity, and psychological distress were associated with up to 2.4 times the risk of use of these types of supplements across the study period. Similarly, in incident-use analyses, financial precarity and psychological distress were associated with up to 2.1 times the risk of initiating use; whereas, high food insecurity was associated with nearly 1.8 times higher risk of onset of weight-loss supplements use but was not associated with onset of use of other types of supplements.

Discussion

We found consistent evidence that during the first year of the pandemic, participants experiencing elevated financial strain and psychological distress were at heightened risk of initiating use of potentially dangerous types of supplements. Our findings raise concerns about deceptive claims about the safety and product effectiveness by manufacturers of these supplements to profit from vulnerable consumers during the pandemic.

Prevalence of dietary supplement use and knowledge, attitudes, practice (KAP) and associated factors in student population: A cross-sectional study

Dietary supplements (DSs) intake has been increasing worldwide despite no consensus evidence for the efficacy and safety of disease prevention, control, or treatment in nutrient-replete populations. This study aimed to determine the prevalence of DSs use, knowledge, attitude, and practice (KAP) and associated factors among university students in Jordan. A national cross-sectional study was carried over across universities in Jordan. Participants completed a valid and reliable online questionnaire (Cronbach's alpha = 0.802 and correlation coefficients between 0.72 and 0.26). Univariate analyses were used to determine the relationship between variables. Multivariable regression was carried out to identify significant factors contributing DSs usage. A total of 448 university students completed the study (73.7% females). More than half of the students used DSs (60.9%), with single-nutrient ingredient supplements being the most commonly used type. The primary motivators were maintaining health and most students reported no side effects associated with consumption. The results revealed poor knowledge, a negative attitude towards DSs usage among all participants, even non-users, and high-risk practices among the DSs users. Normal weight and overweight individuals were more likely to use DSs (OR:2.88, 95%CI:1.61-5.16, OR:1.95, 95%CI:1.01-3.79, respectively). Low and medium-family income categories were more likely to use DSs than those in the high-income category (OR: 0.04, 95%CI: 0.02-0.07, OR: 0.06, 95CI:0.03-0.11, respectively). Undergraduate students were more likely to use DSs than postgraduate students (OR:5.56, 95%CI:3.19-9.69). In this study, a high prevalence of DSs use was highlighted. The results suggest that nutrition education is required to improve awareness of DSs and to promote safe practices.

The Hospitalized Adolescent

This clinical report provides pediatricians evidence-based information on the developmentally appropriate, comprehensive clinical care for hospitalized adolescents. Included in this report are opportunities and challenges facing pediatricians when caring for specific hospitalized adolescent populations. The companion policy statement, “The Hospitalized Adolescent,” includes detailed descriptions of adolescent hospital admission demographics, personnel recommendations, and hospital setting and design advice, as well as sections on educational services, legal and ethical matters, and transitions to adult facilities.

Use of Legal Appearance- and Performance-Enhancing Drugs and Substances: Findings from the Canadian Study of Adolescent Health Behaviors

BACKGROUND

Use of appearance- and performance-enhancing drugs and substances (APEDS) is common among adolescent and young adults. Many APEDS are legally sold "over-the-counter," however research has documented contamination of legal APEDS and many adverse effects of use. Despite this, little research has been conducted on legal APEDS use in Canada, particularly regarding the prevalence and sociodemographic predictors of use, which was the aim of this study.

METHODS

Data from the Canadian Study of Adolescent Health Behaviors (N = 2,731) were analyzed. Prevalence and frequency of use of 10 common APEDS in the past 12 months were estimated overall and across genders. Multiple modified Poisson regression analyses were conducted to determine the sociodemographic predictors of APEDS use.

RESULTS

Overall, use of caffeine was most common among the sample (71.3%), along with protein bars (63.4%), and whey protein powders or protein shakes (63.1%). Boys and men reported greater prevalence of use of eight of the 10 APEDS, with the exception of diuretics or water pills and probiotics, compared to girls and women and transgender/gender non-confirming participants. Over three quarters (82.5%) of boys and men reported use of whey protein powders or protein shakes and 50.3% reported use of creatine monohydrate. Use of APEDS varied based on several key sociodemographic identifiers.

CONCLUSIONS

This study is the first to document legal APEDS use among a sample of Canadian adolescents and young adults, providing important implications for health care and policymaking professionals. Further research is needed to gain greater insight into APEDS use among Canadian young people.

Performance-Enhancing Substance Use and Intimate Partner Violence: A Prospective Cohort Study

Research has shown that performance-enhancing substance (PES) use, including anabolic-androgenic steroids (AAS), is associated with interpersonal violence (e.g., fighting). This study aimed to determine whether legal PES use and AAS use are associated with intimate partner violence (IPV) involvement cross-sectionally and over seven-year follow-up in a nationally representative prospective cohort study. Data from the National Longitudinal Study of Adolescent to Adult Health (N = 12,288) were analyzed (2021). Logistic regression analyses were conducted to determine the associations between legal PES use and AAS use at Wave III (2001-2002; ages 18-26) and IPV victimization (five variables) and IPV perpetration (five variables) at Wave III and Wave IV (2008-2009; ages 24-32), adjusting for relevant demographic and confounding variables. Results from cross-sectional analyses showed that legal PES use and AAS use were associated with higher odds of both any IPV victimization and sexual IPV victimization, and both any IPV perpetration and physical IPV perpetration by pushing or shoving a partner. Results from prospective analyses showed that AAS use, but not legal PES use, was associated with higher odds of all five IPV victimization variables (any IPV victimization: adjusted odds ratio [AOR] 1.72, 95% confidence interval [CI]1.04-2.84; two forms of physical abuse: 1: AOR 2.01, 95% CI 1.15-3.50; 2: AOR 2.11, 95% CI 1.06-4.21; incurring an injury from IPV victimization: AOR 4.90, 95% CI 1.71-14.01; and sexual IPV victimization AOR 2.44, 95% CI 1.05-5.65), as well as three IPV perpetration variables (any IPV perpetration: AOR 2.11, 95% CI 105-4.23; one form of physical abuse perpetration: AOR 2.58, 95% CI 1.06-6.27; and sexual IPV perpetration: AOR 3.80, 95% CI 1.44-10.02). These results emphasize the adverse social and interpersonal risks associated with PES use. Continued research, health care, and public health prevention and intervention efforts to reduce the use of PES and occurrence of IPV are warranted.

Use of appearance- and performance-enhancing drugs and substances is associated with eating disorder symptomatology among U.S. college students

PURPOSE

Body ideals for both men and women are continuing to emphasize muscularity and leanness, which has resulted in the high prevalence of appearance- and performance-enhancing drugs and substances (APEDS) use, particularly among young men. Overall, little research has investigated the individual associations between specific APEDS use and eating disorder symptomatology, including among the high-risk population of young adult college students, which was the aim of this study.

METHODS

Data from the 2020-2021 Healthy Minds Study (N = 7394) were analyzed. Five indicators of lifetime APEDS use were assessed, and a cumulative sum score was constructed. Eating disorder symptomatology was assessed via the SCOFF questionnaire. A total of 14 modified Poisson regression analyses were estimated to determine the association between APEDS use and a positive eating disorder screen among women and men.

RESULTS

Lifetime use of protein supplements and diuretics or water pills were associated with a positive eating disorder screen among both women and men, while use of non-steroid synthetic muscle enhancers was associated with a positive eating disorder screen among men and creatine supplement use was associated with a positive eating disorder screen among women. The risk of a positive eating disorder screen was highest among men who reported use of five APEDS in their lifetime.

CONCLUSIONS

Lifetime use of APEDS is associated with eating disorder symptomatology among a national sample of U.S. college and university students. Prevention and intervention efforts are needed to address the link between these potentially harmful behaviors.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Performance-Enhancing Substance Use and Sexual Risk Behaviors among U.S. Men: Results from a Prospective Cohort Study

Performance-enhancing substance (PES) use is common among young men and prior research has documented cross-sectional associations between anabolic-androgenic steroid (AAS) use and sexual risk behaviors. However, this relationship remains understudied among a longitudinal cohort of young adult men, and research on prospective associations between legal PES (e.g., creatine) use and sexual risk behaviors is lacking. The current study addressed these oversights using data from the National Longitudinal Study of Adolescent to Adult Health (N = 5,451). AAS use and legal PES use were assessed at Wave III (ages 18-26) and 10 indicators of sexual risk behavior were assessed at seven-year follow up (Wave IV; ages 24-32). Linear and logistic regression analyses were conducted adjusting for demographic and behavioral confounders. Participants who reported AAS use and legal PES use had significantly higher number of one-time sexual partners and higher odds of multiple sex partners around the same time in the past 12 months. Participants who reported AAS use had higher odds of any STI in the past 12 months. These results extend prior research on the risk behaviors and adverse effects of PES use. Health care professionals should assess for PES use among young adult men and provide guidance on healthful sexual behaviors.

Lack of supplement regulation: A potential for ethical and physiological repercussions

Background: The sale and utilization of dietary and fitness supplements in America, with industry revenue totaling 140.3 billion in 2020 alone, has proven significant. Unfortunately, these supplements are not held to high standards of manufacturing or marketing, leading to ethical, financial, and physiological repercussions for consumers. Aim: The aim of this study is to discuss specific examples of a prevalent issue within the supplementation industry; we suggest the implementation of regulatory processes in the sale and marketing of such products. Methods: Studies from 2007 to 2021 which illustrate positive or negative effects of specific supplements based on gross revenue or a high level of publicity were analyzed. Results: Within this paper, we outline potential regulations which could assist in mitigating the negative impact that a lack of oversight has precipitated. These regulations include an initial approval request which reviews supplement ingredients, effects, risks, and therapeutic index. Conclusion: If the proposed regulations are introduced, the data collected via supplement applications may be utilized in classifying the supplement by its risk before it is marketed to the general population with supervision by pharmacists when indicated, ultimately reducing the adverse effects of inappropriate supplementation.

Disproportionate Use of Over-the-counter Diet Pills Among Latinx Youth and Increased Use Over Time Among Latinx Females: Results of US National Study

PURPOSE

Over-the-counter diet pills are target-marketed to Latinx communities, raising concerns about youth use of these harmful products.

METHODS

Multivariable logistic models estimated odds ratios (ORs) of diet-pill use in a representative sample of US Latinx and White students (2009-2013; N = 33,824).

RESULTS

Latinx students had 30%-40% higher odds of past-30-day diet-pill use than White peers (males: OR = 1.39; 95% confidence interval = 1.10, 1.76, females: OR = 1.34; 95% confidence interval = 1.12, 1.61), and inequities among females widened, with one in 10 Latinx females reporting past-30-day use by 2013 (10.0% Latinx females vs. 6.2% White non-Latinx females).

DISCUSSION

Higher prevalence of over-the-counter diet-pill use in Latinx relative to white youth-and increasing use over time for Latinx females-underscores the need for stronger restrictions on marketing and sale to youth.

Problematic muscularity-oriented behaviors: Overview, key gaps, and ideas for future research

Problematic muscularity-oriented behaviors, such as excessive weightlifting and muscle-building supplement and substance use (e.g., creatine, steroids), are common among young people, particularly boys and men. Theoretical models of eating disorders, and their constructs, are helpful in conceptualizing a number of risk factors that may increase the likelihood of developing problematic muscularity-oriented behaviors; however, these models lack a clear delineation of the factors that may specifically lead to the initiation and pursuit of these behaviors. This paper provides a brief overview of the theoretical models that have usefully framed research on problematic muscularity-oriented behaviors and the risk factors that been identified through this work. In addition, it identifies gaps related to understanding the factors leading to the initiation and continued or discontinued engagement in these behaviors, and it provides ideas for future research to help fill these gaps. Understanding the ways in which risk factors combine sequentially and interactively, to produce pathways to problematic muscularity-oriented behaviors is crucial for researchers to strengthen theoretical understandings of these behaviors, to inform intervention efforts, and guide policy and practice to decrease their rates among youth.

Early Gender Differences in Valuing Strength

Being strong is a prominent male stereotype that children learn early in life; however, it is unknown as to when children start to value being strong and when gender differences in valuing strength might emerge. In the current study, we interviewed an ethnically diverse sample of 168 3-5 year-olds (88 girls, 80 boys) to address this gap in the literature. Results showed that boys as young as age 3 generally valued strength more than girls: (1) boys, on average, said it was more important to be strong than girls did, and (2) boys were more likely to prefer strength-related occupations than girls. Boys were also more likely to select boys than girls as the gender who cares more about physical strength. Additionally, with age, both girls and boys demonstrated knowledge of the stereotype that boys care about physical strength, with girls also being less likely to associate being a girl with being strong. Overall, the results suggest that valuing physical strength starts in early childhood, and gender differences in valuing strength are evident at the eve of gender identity development. Possible implications for boys' later well-being and health are discussed.

Appearance and Performance Enhancing Drugs and Substances: The Role of the School Nurse

The purpose of this article is to provide the school nurse with the ability to recognize performance and appearance enhancing substance use and understand treatment and prevention strategies to reduce associated health risks. The use of appearance and performance enhancing drugs and substances, also known as "doping," has been an ethical and health issue in sports for many years. It is vital that school nurses learn to recognize performance and appearance enhancing substance use to ensure student athletes and exercisers receive the care and education they need. Commonly used performance and appearance enhancing substances include anabolic-androgenic steroids, stimulants, diuretics, growth hormone, and supplements. Signs and symptoms that may look similar to other health concerns include palpitations, stunted growth, acne, severe headaches, muscle cramps, dizziness, and dehydration, but some long-term severe complications occur as well. Doping can lead to severe and sometimes permanent organ damage, including liver, kidney, and heart disease. The school nurse can play a key role by working with parents, coaches, school counselors, and educators to foster an anti-doping culture.

Muscle-building behaviors from adolescence to emerging adulthood: a prospective cohort study

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Muscle-building behaviors in adolescence to emerging adulthood were studied.

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Starting muscle-building behaviors is common from adolescence to emerging adulthood.

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Prevalence of any protein powder/shakes use was 55.1% in males and 33.0% in females.

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Prevalence of any steroids use was 6.7% in males and 5.4% in females.

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Protein powder consumption was associated with future use of steroids.

This study aimed to identify patterns of change in muscle-building behaviors from adolescence to emerging adulthood and determine what adolescent factors predict new-onset muscle-building behavior in emerging adulthood. Prospective cohort data from a diverse sample of 1,535 participants followed from adolescence (baseline, M_age = 14.4 ± 2.0 years) to emerging adulthood (follow-up, M_age = 22.1 ± 2.0 years) from the population-based EAT 2010–2018 (Eating and Activity over Time) study were analyzed. Changes in muscle-building behavior were identified (starting, stopping, persistent use, or never use). Log-binomial regression models examined adolescent predictors of starting (i.e., new-onset) muscle-building behaviors in emerging adulthood. Prevalence of any use in adolescence (EAT 2010) and/or emerging adulthood (EAT 2018) was 55.1% (males) and 33.0% (females) for protein powder/shakes, 6.7% (males) and 5.4% (females) for steroids, and 19.4% (males) and 6.5% (females) for other muscle-building substances (e.g., creatine, amino acids). In particular, 22.6% (males) and 13.7% (females) started protein powder/shakes, 2.2% (males) and 1.0% (females) started steroid use, and 9.0% (males) and 2.0% (females) started other muscle-building substances during emerging adulthood. Adolescent protein powder/shake consumption was associated with starting steroids/other muscle-building substances use in emerging adulthood in males (adjusted risk ratio [ARR] 2.09, 95% confidence interval [CI] 1.29–3.39) and females (ARR 4.81, 95% CI 2.01–11.48). Adolescent use of protein powders/shakes may lead to a two- to five-fold higher risk of new use of steroids and other muscle-building products in emerging adulthood. Clinicians, parents, and coaches should assess for use of muscle-building behaviors in adolescents and emerging adults and discourage use of harmful products.

Appearance and performance-enhancing drugs and supplements (APEDS): Lifetime use and associations with eating disorder and muscle dysmorphia symptoms among cisgender sexual minority people

PURPOSE

Appearance and performance-enhancing drugs and supplements (APEDS) are used to enhance muscle growth, athletic performance, and physical appearance. The aim of this study was to examine the lifetime use of APEDS and associations with eating disorder and muscle dysmorphia symptoms among cisgender sexual minority people.

METHODS

Participants were cisgender sexual minority people (1090 gay men, 100 bisexual plus men, 564 lesbian women, and 507 bisexual plus women) recruited from The PRIDE Study in 2018 who reported lifetime APEDS use and completed the Eating Disorder Examination-Questionnaire (EDE-Q) and the Muscle Dysmorphic Disorder Inventory (MDDI). Regression analyses stratified by gender and sexual orientation examined associations of any APEDS use with EDE-Q and MDDI scores.

RESULTS

Lifetime APEDS use was common across the four groups of cisgender sexual minority people (44% of gay men, 42% of bisexual plus men, 29% of lesbian women, and 30% of bisexual plus women). Protein supplements and creatine supplements were the most commonly used APEDS. Any APEDS use was associated with higher EDE-Q scores on one or more subscales in all sexual minority groups. Further, any APEDS use was associated with higher MDDI Total Scores in all groups; any APEDS use was associated with all MDDI subscale scores in cisgender gay men only.

DISCUSSION

APEDS use is common and associated with eating disorder and muscle dysmorphia symptoms in sexual minority men and women, thus highlighting the importance of assessing for these behaviors and symptoms among these populations in clinical settings.

Protein, Creatine, and Dieting Supplements Among Adolescents: Use and Associations With Eating Disorder Risk Factors, Exercise-, and Sports Participation, and Immigrant Status

Objective: This study aimed to estimate the number of weekly users of protein, creatine, and dieting supplements and to explore whether weekly use was related to eating disorder (ED) risk factors, exercise, sports participation, and immigrant status.

Methods: In total, 629 and 1,060 high school boys and girls, respectively, self-reported weekly frequency of protein, creatine, and dieting supplement use, and weight and shape concerns, appearance internalization and pressure, self-esteem, mental distress, physical activity level, exercise context, and the type and weekly frequency of sport played. Multiple hierarchical regression analyses were performed to investigate explanatory factors for supplement use.

Results: More boys than girls used protein and creatine supplements. Immigrant boys had more frequent use of all supplements than non-immigrant boys, and immigrant girls used creatine supplements more frequently than non-immigrant girls. In total, 23–40 and 5–6% of the variation in the weekly frequency of supplement use in boys and girls, respectively, was explained by immigrant status, ED risk factors, and exercise and sports participation. More frequent use of protein, creatine and dieting supplements in boys was significantly explained by more weight and shape concerns, fitness center exercise, and weight-sensitive sports participation. Depending on the type of supplement, more frequent use of supplements in girls was significantly explained by lower self-esteem, more engagement in weight-sensitive sports, and less engagement in general sport and exercise activities.

Conclusion: Weekly supplement use was common and more frequent among boys than girls. The weekly use of protein, creatine, and dieting supplements was related to ED risk factors, exercise and sports participation, and immigrant status in boys but not in girls.

Peer-to-Peer Social Media Communication About Dietary Supplements Used for Weight Loss and Sports Performance Among Military Personnel: Pilot Content Analysis of 11 Years of Posts on Reddit

Background

Over 60% of military personnel in the United States currently use dietary supplements. Two types of dietary supplements, weight loss and sports performance (WLSP) supplements, are commonly used by military personnel despite the associated serious adverse effects such as dehydration and stroke.

Objective

To understand peer-to-peer communication about WLSP supplements among military personnel, we conducted a pilot study using the social media website, Reddit.

Methods

A total of 64 relevant posts and 243 comments from 2009 to 2019 were collected from 6 military subreddits. The posts were coded for year of posting, subreddit, and content consistent with the following themes: resources about supplement safety and regulation, discernability of supplement use through drug testing, serious adverse effects, brand names or identifiers, and reasons for supplement use.

Results

A primary concern posted by personnel who used supplements was uncertainty about the supplements that were not detectable on a drug test. Supplements to improve workout performance were the most frequently used.

Conclusions

Our pilot study suggests that military personnel may seek out peer advice about WLSP supplements on Reddit and spread misinformation about the safety and effectiveness of these products through this platform. Future directions for the monitoring of WLSP supplement use in military personnel are discussed.

Addressing psychosocial health in the treatment and care of adolescents with obesity

Obesity affects 158 million youth worldwide and is associated with psychosocial comorbidity. This review describes weight management options utilized by adolescents, including both self-directed weight loss and medically supervised obesity treatment interventions, and associated psychosocial impacts. A majority of adolescents with obesity attempt to manage weight on their own, primarily through attempting weight loss, sometimes with supplement use. Approaches such as these are associated with a degree of risk, disordered eating behaviors, and further weight gain. In contrast, medically supervised multicomponent interventions are associated with improved psychosocial health, including quality of life, self-esteem, and body image, and reduced symptoms of depression, anxiety, and eating disorders. Few studies utilizing antiobesity pharmacotherapy have reported psychosocial outcomes, and trials of bariatric surgery show some early improvements with a need for sustained psychological support following surgery. Greater access to medically supervised treatment services is required to facilitate obesity care for adolescents. Early data on psychosocial health and obesity treatment offer promising outcomes; however, larger randomized controlled trials and longer-term data are needed. Future research should include both physiological and psychosocial outcomes to assess impact of interventions on the holistic health of adolescents with obesity.

A content analysis of marketing on the packages of dietary supplements for weight loss and muscle building

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Weight loss dietary supplement packages have a high prevalence of marketing claims.

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Such claims are potentially misleading and lack scientific evidence.

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Products with the FDA disclaimers and warnings displayed more claims on average.

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FDA disclaimers and warnings are never displayed on the front of the package.

Most dietary supplements for weight loss and muscle growth lack scientific evidence in support of product claims and contain ingredients that can be harmful to health. Many people, however, still use these products. This paper aims to address a gap in the knowledge of the number and types of marketing claims appearing on dietary supplements for weight loss and muscle building and how they relate to the presence of an FDA disclaimer. We identified all products (n = 110) found in the weight loss and muscle building section of three stores (a pharmacy, supermarket, and superstore) in the Boston, MA area during 2013. We performed a content analysis to assess the presence of marketing claims displayed on product packaging, including claims about weight loss, safety, quality, and scientific evidence. Warnings and the FDA disclaimer were also coded. We found that, on average, products displayed 6.5 claims. Among weight loss- and muscle building- related claims, claims about reducing weight, BMI, or body fat were most common (60.9%), followed by protein claims (40.0%). Nearly half of the products made claims that scientific research supported product use. Products with the FDA disclaimer (53.6%) or a warning for vulnerable populations (56.4%) had a higher average number of claims compared to products without the disclaimer or warning (p < 0.001). Dietary supplements for weight loss and muscle building displayed many marketing claims promising weight loss despite a lack of scientific evidence that such products can be used safely and effectively. Greater FDA regulation of these marketing claims are needed.

The Use of Dietary Supplements in Fitness Practitioners: A Cross-Sectional Observation Study

This study was aimed at evaluating the prevalence of use of dietary supplements (DSs) among gym users and gym instructors involved in body shaping-oriented fitness training. Furthermore, this study aimed to verify whether differences existed in the prevalence and in the types of DSs used in both gym users and gym instructors involved in body shaping-oriented fitness competitions vs. those not involved in fitness competitions. A survey was distributed to 316 participants, composed of 89 gym instructors and 227 gym users of both genders aged 27.3 ± 7.7. Among these participants, 52 were involved in competitions and 248 were not, while 16 participants did not specify either way. The results showed a high prevalence in the use of DSs in the population considered, with 85.4% of the participants declaring they used DSs, with high heterogeneity in the numbers and in the combinations used. No differences were found between gym instructors and gym users, or between participants involved and those not involved in competitions. The results indicate that DSs are widely used by persons involved in body shaping-oriented fitness training. The results also suggest that the majority of the participants decided individually which DSs to use.

Trends in Nutrient- and Non-Nutrient-Containing Dietary Supplement Use among US Children from 1999 to 2016

OBJECTIVES

To characterize dietary supplement use among US children, including product type, motivations, user characteristics, and trends over time with a primary focus on non-vitamin/non-mineral dietary supplements (NVNM).

STUDY DESIGN

Overall, NVNM, and vitamin and/or mineral dietary supplement only (VM-only) use; motivations for use; and trends in use over time were examined in children (≤19 years of age) using the National Health and Nutrition Examination Survey 1999-2016 data (n = 42 510).

RESULTS

Between 1999 and 2016, overall dietary supplement and VM-only dietary supplement use among all children remained relatively stable at ∼30%; yet, NVNM dietary supplement use increased from 2.9% to 6.4%, mainly due to increased use of omega-3 polyunsaturated fatty acids. NVNM use was greater in boys than in girls (3.9% vs 3.3%), and greater in older children than in younger children (Ptrend < .0001), the opposite of what was observed with VM-only dietary supplement use. Although both user groups shared 2 primary motivations, both motivations were reported by a significantly greater percent of vitamin and/or mineral dietary supplement users vs NVNM users: to maintain health (38.7% vs 23.1%) and to improve health (33.1% vs 22.6%). NVNM users were much more likely to use dietary supplement for relaxation, stress, and sleep; for mental health; and for colon and bowel health.

CONCLUSIONS

Although the prevalence of any dietary supplement and VM-only dietary supplement use among US children has both remained stable, the prevalence of NVNM use has increased substantially over time. Yet, NVNM use remains relatively low overall. NVNM use exhibited different patterns by sex, age, and motivations when compared with vitamin and/or mineral dietary supplement use. Despite increasing NVNM use, high-quality evidence supporting their use is lacking, especially in children.

Impact of Fear of Contracting COVID-19 and Complying with the Rules of Isolation on Nutritional Behaviors of Polish Adults

The aim of the study was to examine whether, and to what extent, fear of contracting Covid-19 and compliance with the mandatory rules of isolation affected Polish adults' nutritional behaviors. The online study was carried out during the first wave of the pandemic on a sample of 926 adults. Through cluster analysis, three groups of respondents were isolated: 1. People who fear a Covid-19 infection and follow the isolation rules (FFR), 2. People moderately afraid of the disease and following the rules loosely (MFFR), 3. People who are not afraid of the infection and do not follow the rules of isolation. (NFFR). The clusters were profiled with consideration of different aspects of eating behaviors as well as socio-demographic and economic features. The results of the study show a close relationship between the level of fear of contracting Covid-19 and the degree to which isolation rules are followed. These two factors were found to have a significant impact on eating behaviors, such as food purchases, eating patterns, and levels of consumption. It was stated that the FFR group changed their eating behaviors the most in terms of food purchasing, eating habits (excluding diversity and quality of diet), and food product consumption. The greatest stability in the majority of the analyzed areas of nutritional behaviors was observed in the MFFR cluster. The NFFR group shown the greatest decrease both in regularity and quality of their meals. This group also exhibited a significant increase in the consumption of alcoholic beverages. The results of the study can be useful in the decision making process when introducing restrictions or managing information. They also point to the need for extensive nutritional education focused on explaining the relationship between nutrition and health during a pandemic.

Erectile Dysfunction in a Sample of Sexually Active Young Adult Men from a U.S. Cohort: Demographic, Metabolic and Mental Health Correlates

PURPOSE

Little is understood about physiological and psychological correlates of erectile dysfunction among younger men. We examined prevalence and correlates of erectile dysfunction in a large U.S. sample of 18 to 31-year-old men.

MATERIALS AND METHODS

Erectile dysfunction prevalence and severity (defined using the International Index of Erectile Function-5 scale) were examined in cross-sectional survey data from 2,660 sexually active men, age 18 to 31 years, from the 2013 Growing Up Today Study. Erectile dysfunction medication and supplement use were self-reported. Multivariable models estimated associations of moderate-to-severe erectile dysfunction with demographic (age, marital status), metabolic (body mass index, waist circumference, history of diabetes, hypertension, hypercholesterolemia) and mental health (depression, anxiety, antidepressant use, tranquilizer use) variables.

RESULTS

Among sexually active men 11.3% reported mild erectile dysfunction and 2.9% reported moderate-to-severe erectile dysfunction. Married/partnered men had 65% lower odds of erectile dysfunction compared to single men. Adjusting for history of depression, antidepressant use was associated with more than 3 times the odds of moderate-to-severe erectile dysfunction. Anxiety was associated with greater odds of moderate-to-severe erectile dysfunction, as was tranquilizer use. Few men (2%) reported using erectile dysfunction medication or supplements. However, among them, 29.7% misused prescription erectile dysfunction medication. Limitations include reliance upon cross-sectional data and the sample's limited racial/ethnic and socioeconomic diversity.

CONCLUSIONS

Erectile dysfunction was common in a large sample of sexually active young adult men from a U.S. cohort and was associated with relationship status and mental health. Health providers should screen for erectile dysfunction in young men, and monitor use of prescription erectile dysfunction medications and supplements for sexual functioning.

Associations between Adverse Childhood Experiences and Performance-Enhancing Substance Use among Young Adults

BACKGROUND AND OBJECTIVE

Adverse childhood experiences (ACEs) are associated with negative health outcomes, yet their associations with performance-enhancing substance (PES) use are unclear. This study aimed to determine whether ACEs predict greater use of legal and illegal PES in young adults.

METHODS

We analyzed data from the National Longitudinal Study of Adolescent to Adult Health (n = 14,322), Waves I (1994-1995) and III (2001-2002). ACEs included childhood sexual abuse, physical abuse, two neglect indicators, and cumulative ACEs. Legal (e.g. creatine monohydrate) and illegal (e.g. non-prescription anabolic-androgenic steroids; AAS) PES use was assessed.

RESULTS

Sexual abuse had the greatest effect and predicted higher odds of legal PES use (men: adjusted odds ratio [AOR] 1.66, 95% confidence interval [CI] 1.06-2.59; women: AOR 3.74, 95% CI 1.63-8.59) and AAS use (men: AOR 8.89, 95% CI 5.37-14.72; women: AOR 5.73, 95% CI 2.31-14.18). Among men, a history of physical abuse (AOR 3.04, 95% CI 2.05-4.52), being left alone by a parent/guardian (AOR 2.33, 95% CI 1.50-3.60), and basic needs not being met (AOR 3.47, 95% CI 2.30-5.23) predicted higher odds of AAS use. Among women, basic needs not being met (AOR 2.94, 95% CI 1.43-6.04) predicted higher odds of AAS use. Among both men and women, greater number of cumulative ACEs predicted higher odds of both legal and illegal PES use.

CONCLUSIONS

ACEs predict greater PES use among young adults. Clinicians should monitor for PES use among those who have experienced ACEs and provide psychoeducation on the adverse effects associated with PES use.

Associations between legal performance-enhancing substance use and future cardiovascular disease risk factors in young adults: A prospective cohort study

BACKGROUND

Legal performance-enhancing substances (PES), such as creatine, are commonly used by adolescents and young adults. As PES are mostly unregulated by the US Food and Drug Administration, there has been limited empirical attention devoted to examining their long-term safety and health outcomes. Preliminary studies have demonstrated associations between PES use and severe medical events, including hospitalizations and death. PES could be linked to cardiovascular disease (CVD), the most common cause of mortality in the US, by altering the myocardium, vasculature, or metabolism. The objective of this study was to examine prospective associations between the use of legal PES in young adulthood and CVD risk factors at seven-year follow-up.

MATERIALS AND METHODS

Nationally representative longitudinal cohort data from the National Longitudinal Study of Adolescent to Adult Health, Waves III (2001-2002) and IV (2008), were analyzed. Regression models determined the prospective association between the use of legal PES (e.g. creatine monohydrate) and CVD risk factors (e.g. body mass index, diabetes, hypertension, hyperlipidemia), adjusting for relevant covariates.

RESULTS

Among the diverse sample of 11,996 male and female participants, no significant differences by PES use in body mass index, diabetes, hypertension, or hyperlipidemia were noted at Wave III. In unadjusted comparisons, legal PES users (versus non-users) were more likely to be White, be male, be college educated, drink alcohol, and engage in weightlifting, exercise, individual sports, team sports, and other strength training. There were no significant prospective associations between legal PES use at Wave III and body mass index, hemoglobin A1c, systolic and diastolic blood pressure, and cholesterol (total, HDL, LDL, triglycerides) deciles at seven-year follow-up (Wave IV), adjusting for demographics, health behaviors, and Wave III CVD risk factors. Similarly, there were no significant prospective associations between legal PES use and diabetes, hypertension, or hyperlipidemia based on objective measures or self-reported medications and diagnoses, adjusting for demographics, health behaviors, and Wave III CVD risk.

CONCLUSIONS

We do not find evidence for a prospective association between legal PES use and CVD risk factors in young adults over seven years of follow-up, including BMI, diabetes, hypertension, or hyperlipidemia. It should be noted that legal PES use was operationalized dichotomously and as one broad category, which did not account for frequency, amount, or duration of use. Given the lack of regulation and clinical trials data, observational studies can provide much needed data to inform the safety and long-term health associations of legal PES use and, in turn, inform clinical guidance and policy.

Lessons for Local Policy Initiatives to Address Dietary Supplement Use Among Adolescents: A Qualitative Study of Stakeholders' Perceptions

PURPOSE

Weight-loss and muscle-building dietary supplements can have adverse health consequences for youth. At a time, when the Food and Drug Administration is considering increasing oversight of dietary supplements, this study aimed to explore community stakeholders' perceptions about the use of and access to such supplements among adolescents and to identify challenges and opportunities to engage stakeholders with policy initiatives to curtail youth access to supplements at the local level.

METHOD

We conducted 32 key informant semistructured interviews in four municipalities in Massachusetts with purposefully selected participants representing three categories of community stakeholders who could contribute to policy agenda setting at the local level: policy professionals, youth service providers, and young adults aged 18-25 years who used weight-loss or muscle-building supplements as minors. Interviews were audio-recorded, transcribed, deidentified, and analyzed using thematic analysis approach, facilitated by Dedoose software.

RESULTS

Community stakeholders reported wide availability and easy access to dietary supplements. Most participants were unaware of health risks. Many stakeholders did not perceive the use of these products as an issue impacting youth in their communities. The challenges identified in engaging stakeholders were competing concerns on the policy agenda, limited capacity of stakeholders, and uncertainty about who is accountable for the problem.

CONCLUSION

This study indicates the need for complementary, multipronged approaches at the municipal level to address the problem of weak regulation and easy access to potentially dangerous weight-loss and muscle-building supplements for youth.

Legal Performance-Enhancing Substances and Substance Use Problems Among Young Adults

BACKGROUND

Legal performance-enhancing substance(s) (PES) (eg, creatine) are widely used among adolescent boys and young men; however, little is known about their temporal associations with substance use behaviors.

METHODS

We analyzed prospective cohort data from the National Longitudinal Study of Adolescent to Adult Health, Waves I to IV (1994-2008). Logistic regressions were used to first assess adolescent substance use (Wave I) and use of legal PES (Wave III) and second to assess use of legal PES (Wave III) and subsequent substance use-associated risk behaviors (Wave IV), adjusting for potential confounders.

RESULTS

Among the sample of 12 133 young adults aged 18 to 26 years, 16.1% of young men and 1.2% of young women reported using legal PES in the past year. Adolescent alcohol use was prospectively associated with legal PES use in young men (odds ratio 1.39; 95% confidence interval [CI] 1.13-1.70). Among young men, legal PES use was prospectively associated with higher odds of problematic alcohol use and drinking-related risk behaviors, including binge drinking (adjusted odds ratio [aOR] 1.35; 95% CI 1.07-1.71), injurious and risky behaviors (aOR 1.78; 95% CI 1.43-2.21), legal problems (aOR 1.52; 95% CI 1.08-2.13), cutting down on activities and socialization (aOR 1.91; 95% CI 1.36-2.78), and emotional or physical health problems (aOR 1.44; 95% CI 1.04-1.99). Among young women, legal PES use was prospectively associated with higher odds of emotional or physical health problems (aOR 3.00; 95% CI 1.20-7.44).

CONCLUSIONS

Use of legal PES should be considered a gateway to future problematic alcohol use and drinking-related risk behaviors, particularly among young men.

The Associations Among Individual Factors, Media Literacy, and Dietary Supplement Use Among College Students: Cross-Sectional Study

Background

The mass media have been condemned for encouraging young people to take dietary supplements (DS). Media literacy, which includes authors and audiences (AA), messages and meanings (MM), and representation and reality (RR) domains, is a new approach to teaching young adults to make better informed health decisions. However, it is not clear which domains are the most important for media literacy education.

Objective

The purpose of this study is to investigate the associations among individual factors, media literacy, and DS use.

Methods

The survey instrument included demographic items, the DS Media Literacy Scale (DSMLS), and DS use items (users or nonusers, types of DS, current use of DS, and intention to use DS in the future). The DSMLS is an 11-item instrument designed to assess college students’ AA, MM, and RR media literacy in relation to DS. A total of 467 Taiwanese college students participated in the study. Descriptive statistical analysis, logistic regression analysis, and multiple regression analysis were conducted.

Results

A total of 338/467 (72.4%) participants reported using DS, and 176/467 (37.7%) consumed 3 or more supplements. Moreover, the MM media literacy domain was associated with having been a DS user (odds ratio 0.63, P=.002), current DS use (β=–.10, P=.02), and intention to use DS in the future (β=–.12, P=.011). Finally, perceived importance of health was positively related to current DS use (β=.18, P=.001) and intention to use DS in the future (β=.18, P=.001).

Conclusions

This study showed that the majority of Taiwanese college students were DS users and used multiple types of supplements. Moreover, students with lower MM media literacy were more likely to be DS users, to take DS more frequently, and to have higher intentions for future frequent DS use. Finally, those who placed extreme importance on health were more likely to take DS frequently and have higher intentions for future frequent DS use.

Adolescent body image: influencing factors and the clinician's role

PURPOSE OF REVIEW

Body image is a crucial part of adolescent development for teens all over the world. Studies show that negative body image impacts many aspects of adolescent health and that anticipatory guidance about body image is important at the annual health maintenance exam visit. Weight bias is closely tied to body image and is associated with negative health effects as well; research shows weight bias is a problem throughout healthcare. The purpose of this review is to discuss influencing factors on adolescent body image and to explore interventions to promote positive body image.

RECENT FINDINGS

Research shows that adolescent body image is shaped by media influence, athletics and personal relationships. Studies have also begun to show that negative and positive body image are separate entities, and that overall health outcomes seem to be better in adolescents with positive body image. In thinking about intervention, there are ways to promote positive body image in the provider--patient interaction, within the school and community, in healthcare education, and at the societal level.

SUMMARY

Body image is an incredibly important aspect of adolescent health, and clinicians should be aware of ways to help promote positive body image in adolescents.

Adverse Events Reported to the United States Food and Drug Administration Related to Caffeine-Containing Products

OBJECTIVE

To examine differences in the frequency and severity of federally reported adverse events between caffeine-containing and non-caffeine-containing products while also identifying the category of caffeine-containing products associated with the highest frequency and severity of adverse events.

PATIENTS AND METHODS

All adverse event reports that met specified eligibility criteria and were submitted to the Center for Food Safety and Applied Nutrition Adverse Event Reporting System between January 1, 2014, and June 29, 2018, were extracted. In this retrospective observational study, the most severe adverse event experienced, an ordinal variable, was categorized into death, life-threatening, hospitalization/disability, and emergency department visit. A nonproportional odds model was used to compare the odds of caffeine-containing products being associated with more severe adverse events relative to a noncaffeine group. The analysis is of data only from those reporting adverse events and may or may not be representative of the entire population exposed to these products, which is not known from the examined data.

RESULTS

Energy and preworkout products saw a significant increase in the odds of the adverse event experienced being death rather than the other less severe outcomes relative to the noncaffeinated group. Those products, along with weight loss products, had greater odds of the adverse event being death or life-threatening vs the less severe outcomes relative to the noncaffeinated group.

CONCLUSION

Caffeine-containing products have a greater association with severe adverse events compared with non-caffeine-containing products. Exposure to preworkout and weight loss products had greater odds of being associated with a more serious adverse event relative to noncaffeinated products. Health care practitioners should use these outcomes to better inform and educate patients about the many factors related to caffeine intake and adverse outcomes.

Supplement (mis)use in adolescents

PURPOSE OF REVIEW

Dietary supplement usage by adolescents has been on the rise in the last decade and is expected to continue to grow, although the evidence of their benefits in healthy individuals remains unclear. This review aims to spread awareness about the poorly regulated supplements and their effects on the health of adolescents to minimize medical hazards.

RECENT FINDINGS

In this review, we have attempted to summarize some of the commonly consumed supplements, their alleged benefits, effects and side effects, along with the motivation that drives adolescents into consuming them.

SUMMARY

The widespread use of dietary supplements among adolescents, in the background of lack of knowledge and medical guidance, predisposes adolescents to significant health risks. Although supplements may be necessary and safely consumed in certain specific situations, most healthy adolescents do not need them. The lack of regulation of supplements encourages contamination and ensures indiscriminate, easy access.

Prevalence and correlates of muscle-enhancing behaviors among adolescents and young adults in the United States

OBJECTIVES

To determine the prevalence of muscle-enhancing behaviors in adolescents and young adults using a nationally representative sample in the USA and to examine differences by sex, race/ethnicity, age, socioeconomic status, body mass index, and participation in team sports.

METHODS

Prospective cohort data from the National Longitudinal Study of Adolescent to Adult Health, Waves I through III (1994-2002) were analyzed. Engagement in muscle-enhancing behaviors including dietary changes, exercise and weightlifting, supplement use, performance-enhancing substances, and anabolic androgenic steroids were recorded. Multiple logistic regression models using generalized estimating equations, incorporating robust standard errors with clustering by school and within persons, and using national sample weighting, were used to determine associations with muscle-enhancing behaviors across three data collection waves.

RESULTS

Of the 18,924 adolescents at baseline, 29.2% of males and 7.0% of females reported weight gain attempts, while 25.2% of males and 3.8% of females reported any muscle-enhancing behavior. All muscle-enhancing behaviors were more common in males compared to females (p<0.001). Among young men 18-26 years old, 15.6% reported using legal performance enhancing substances and 2.7% reported using androgenic anabolic steroids. Factors that were associated with muscle-enhancing behaviors in males across three data collection waves included Black or Hispanic/Latino race/ethnicity, age over 14 years, higher parental education, lower body mass index, and participation in team sports.

CONCLUSIONS

Muscle-enhancing behaviors ranging from dietary changes to supplement and androgenic anabolic steroid use are common among adolescent and young adult males. Clinicians should consider screening for muscle-enhancing behaviors in these populations.