Fitness supplements as a gateway substance for anabolic-androgenic steroid use

A mixed-methods longitudinal examination of weight-related self-monitoring and disordered eating among a population-based sample of emerging adults

BACKGROUND

Weight-related self-monitoring (WRSM) apps are used by millions, but the effects of their use remain unclear. This study examined longitudinal relationships between WRSM and disordered eating among a population-based sample of emerging adults.

METHODS

Participants (n = 138) were recruited from EAT 2010-2018 (Eating and Activity over Time study) to participate in a mixed-methods (quantitative and qualitative) longitudinal study to understand the impacts of WRSM. In 2018, participants (Mage=21.7 ± 1.9 years) reported motivations for use and types of WRSM apps used. Dependent variables collected in 2022 (Mage=25.7 ± 1.9 years) included past year total number of disordered weight control behaviors, disordered muscle building behaviors, compulsive exercise, and binge eating. Linear and logistic regressions were used adjusting for sociodemographics, body mass index, and baseline disordered eating. Semi-structured interviews (n = 25) were analyzed using inductive thematic analysis.

RESULTS

Participants using WRSM apps for weight management demonstrated an increase in disordered weight control behaviors over time (β = 0.894, p = .012). Using WRSM apps for "healthy" eating was marginally associated with an increase in disordered weight control behaviors. (β = 0.673, p = .052). Qualitatively, participants reported varied temporality between WRSM and disordered eating, but believed that app use encouraged restriction/binge cycles and normalized disordered eating.

CONCLUSIONS

Findings suggest there may be individual variation in the relationships between WRSM and disordered eating, but that using WRSM apps with the motivation of managing eating or weight may increase disordered eating in some. Additionally, WRSM apps may normalize or encourage disordered eating. Therefore, safeguards, including screening and monitoring, are needed to ensure WRSM does not cause or escalate harm among WRSM users.

Adaptation and validation of the muscle dysmorphic disorder inventory in a population of French athletes (MDDI-Fr)

INTRODUCTION

Muscle dysmorphia, a theme mainly investigated by Anglo-Saxon research, is a specific body dysmorphic disorder that characterizes individuals who think they are insufficiently muscular and lean. Understudied in francophone countries, tools translated and validated in French to measure the symptomatology of muscle dysmorphia remain rare.

OBJECTIVES

The aim of this study was the translation into French and the psychometric validation of a tool evaluating muscle dysmorphia, the Muscle Dysmorphic Disorder Inventory (MDDI-Fr), through 13 items divided into three dimensions: the "Drive For Size" (DFS), the "Appearance Intolerance" (AI) and the "Functional Impairment" (FI).

METHODOLOGY

A first translation step was conducted, followed by two cross-sectional studies conducted in France. In both of the latter studies, a sociodemographic questionnaire and the Muscle Dysmorphic Disorder Inventory - French version (MDDI-Fr) were administered. The first study included 342 university students (Mage=20.9; SDage=2.9), and 1822 athletes for the second study (Mage=23.9; SDage=5.9). Validation was performed using internal consistency measures and confirmatory factor analysis.

RESULTS

The correlation matrices showed good significant results between items and dimensions. The three dimensions appeared distinct from each other with significant intra-dimension correlations. The internal consistency of the tool and its three dimensions show valid Cronbach's alphas (study 1: DFS=0.79, AI=0.74, FI=0.75, MDDI=0.74; study 2: DFS=0.72, AI=0.75, FI=0.83, MDDI=0.75). In addition, the tri-factor analysis shows significant and promising scores for the tool in three dimensions and 13 items for study 1 (χ2/df=4.67, CFI=0.85, TLI=0.83, RMSEA=0.10, SRMR=0.00), as for study 2 (χ2/df=16.08, CFI=0.87, TLI=0.84, RMSEA=0.09, SRMR=.06). Gender analyses were conducted on study 2, which showed that the DFS subscale (items 1, 4, 5) and the AI subscale (items 6 and 9) presented the greatest differences in factor loadings between genders.

CONCLUSION

The translation, as well as the validation of the MDDI-Fr structured with 13 items and three dimensions, showed significantly satisfying results for its adaptation in French in a population of French men and women practicing weight training. However, the "Appearance Intolerance" dimension shows moderate links with the global tool, which should be investigated in future studies. Although the psychometric properties of the MDDI-Fr are promising, additional research is needed to gain a better understanding of gender differences in the results, especially for the DFS dimension.

Dietary supplementation habits in international natural bodybuilders during pre-competition

Bodybuilding is characterized by high-rates of sport supplementation. This is the first study to compare the supplementation patterns of winners (WB) and non-winners (NWB) among international natural bodybuilders during contest preparation. Fifty-six natural bodybuilders (5 women) (age = 28.85 ± 8.03 years; final body mass = 71.50 ± 10.28 kg), 19 WB (athletes who had achieved victory in an official natural bodybuilding championship at least once) and 37 NWB (athletes who never achieved victory), from 18 countries (55.36% from Spain) responded to this cross-sectional online survey related to their nutritional habits, strategies and supplementation practices. WB were significantly older (p = 0.024), completed more competitive seasons (p = 0.027) and participated in more competitions in the last contest year (p = 0.011). There were no significant differences between WB and NWB for years training for bodybuilding (p = 0.055), weeks of dieting for competition (p = 0.392), and body weight at the start (p = 0.553) and end (p = 0.330) of the season. Beverage and supplement consumption, purchasing patterns, and information sources did not differ between groups (p > 0.05). In conclusion, natural bodybuilding WB tended to be older and had more competitive experience, but shared similar supplementation protocols to NWB. Athletes' supplementation patterns were influenced by different sources of information. However, these natural bodybuilders mainly purchased their supplements through the internet without guidance from a coach or dietitian.

Online information and availability of three doping substances (anabolic agents) in sports: role of pharmacies

Background: The Internet has become an important source for easy access to doping substances, where people and athletes may acquire, outside pharmacies and without a (medical) prescription. These online websites do not always offer quality-assured products, and are outside the regular distribution channels of medicines. The aim of this study was to estimate the availability and accessible information on the Internet about the sale of three doping substances (oxandrolone, DHEA, androstenedione). Methods: Cross-sectional exploratory study, being an observation at a point in time of the online availability of these three doping substances (WADA S1 category: anabolic agents), purchased from Spain, Puerto Rico, Canada, United States, Ukraine and Russia. The characteristics of the websites, the countries the webs sold to, the pharmaceutical forms offered and the recommendations for its use were analyzed by using a computer tool designed ad hoc. Results: There were significant differences between countries in the number of webpages that sold the products (Chi-square test, p < 0.05). Oxandrolone was available for purchase mainly when buying from Spain (27.12%) and Ukraine (26.58%), in websites dedicated to sports (77.26%). For DHEA, most of the pages offered it if the search was done from Canada (23.34%) and Russia (21.44%). Products containing androstenedione or DHEA are claimed to enhance sports performance or for sports use without providing details. Compared to the total number of websites checked, the proportion of pharmacies offering these products was low, ranging from 4.86% for DHEA to 15.79% for androstenedione. Conclusion: The three substances selected are easily available without control through the Internet. Only a small number of websites offering them were online pharmacies, and requested a prescription. Most of the doping substances are purchased from the country where they are requested. Product information described benefits for sports performance, but did not do the same with their side effects. It would be advisable for these products to be sold through pharmacies, to guarantee their quality and provide evidence-based information on their safe use, benefits and risks, and only with a prescription. Athletes should be encouraged to consult health professionals about those supplements suitable for their type of training and sports objectives.

Self-Affirmation and Image/Performance Enhancing Drug Use in Recreational Exercise

Objectives: The use of image and performance enhancement drugs (IPEDs) in recreational sport represents an emerging public health and societal problem. The present study investigated whether self-affirmation changed exercisers' intentions to use IPEDs, via the effects of mental construal and message acceptance. Method: Sixty-eight exercisers who self-reported IPEDs use participated in the study and were randomly assigned to either a self-affirmation or a control group. All participants read a health-related message about the 10 consequences of IPEDs and subsequently completed a survey measuring message acceptance, mental construal, doping intentions and IPEDs-related social cognitive variables. Results: There were no significant differences between the self-affirmed and the control groups. Hierarchical linear regression analysis further showed that message acceptance, subjective norms, and situational temptation were significantly associated with intentions to use IPEDs. Conclusion: Our findings raise the possibility that for recreational exercisers IPED's use is seen mostly as a health-related matter than a socio-moral transgression.

The association between eating disorders and perfectionism in adults: A systematic review and meta-analysis

OBJECTIVE

Dimensions of perfectionism are associated with the onset and maintenance of eating disorder pathology in both clinical and non-clinical samples. The aim of this study was to conduct a systematic review and meta-analysis of the association between perfectionism and eating disorders in adults.

METHOD

A literature search was conducted using the PsycINFO, Medline, Scopus, Embase, Web of Science and ProQuest databases. Ninety-five studies met the inclusion criteria and included a total sample of 32,840 participants (clinical eating disorder diagnosis N = 2414, non-clinical N = 30,428). Correlation coefficients (r) for the association between eating disorders and perfectionism were pooled. A meta-analysis to determine the association between two dimensions of perfectionism and eating disorder symptoms was conducted. Subgroup analyses were conducted with studies using clinical samples, and studies using the Eating Disorder Examination Questionnaire.

RESULTS

The pooled effect size for the association between perfectionistic concerns and eating disorder symptoms was r = 0.33 [0.30, 0.37]; and r = 0.20 [0.14, 0.25] for the association between perfectionistic strivings and eating disorder symptoms. In the clinical subgroup analyses the effect sizes were r = 0.40 [0.22, 0.58]; and r = 0.35 [0.26, 0.44] respectively. Medium to high heterogeneity was identified across all subgroup analyses and a significant level of publication bias was also identified.

DISCUSSION

The findings indicate both perfectionistic strivings and perfectionistic concerns have significant associations with eating disorders, and further support the argument that both dimensions of perfectionism are important factors in the prevention and treatment of eating disorders.

Investigating anabolic-androgenic steroid dependence and muscle dysmorphia with network analysis among male weightlifters

BACKGROUND

Anabolic-androgenic steroid (AAS) dependence has numerous adverse health consequences, and may be driven in part by body image concerns, primarily muscle dysmorphia. This study aims to further understand and identify potential clinical targets using network analyses of AAS dependence and muscle dysmorphia symptoms in males who used AAS and weightlifting controls.

METHODS

A sample of 153 men who currently or previously used AAS and 88 weight-lifting controls were recruited through social media and relevant online forums, and via posters and flyers distributed in select gyms in Oslo, Norway. Symptoms of AAS dependence and muscle dysmorphia were assessed using clinical interviews and standardized questionnaires. Severity of muscle dysmorphia symptoms were compared between the groups using independent samples t-tests. The following symptom networks were computed using Gaussian graphical modeling or mixed graphical modeling: (1) AAS dependence symptoms among men with AAS use (2) muscle dysmorphia symptoms among men with AAS use and weight-lifting controls in two separate networks, which were compared using a network comparison test, and (3) AAS dependence and muscle dysmorphia symptoms among men with AAS use.

RESULTS

In a network of AAS dependence symptoms, continuing use despite physical and mental side effects, using longer than planned, tolerance, and work/life interference were the most central symptoms. When comparing symptom structures of muscle dysmorphia between those who used AAS and controls, the most central symptoms in each group were exercise dependence and size/symmetry concerns, respectively. Men with AAS use demonstrated elevated muscle dysmorphia symptoms compared to controls, indicating that both the severity and structure of symptoms differ between these groups. In a network including both AAS dependence and muscle dysmorphia symptoms, no significant connections between symptom groups were identified.

CONCLUSIONS

AAS dependence is complex, with correlated somatic and psychological challenges driving the symptom network, indicating that alleviating physical and mental health concerns during both AAS use and cessation is an important clinical target. Muscle dysmorphia symptoms related to taking action (diet, exercise, and supplement use) appear to cluster together more for those who use AAS than those who do not.

Androgenic-anabolic steroids use among bodybuilders in western Iran: application of ridge logistic regression model

INTRODUCTION

Nowadays, the use of androgenic-anabolic steroids (AAS) by competitive and non-competitive bodybuilders and its side effects have become a major public health problem. Many studies have focused on determining the role and severity of various factors in AAS use, but the existence of collinearity between the factors leads to the non-significance of important factors. The study aimed to determine factors affecting the androgenic-anabolic steroids use in Iranian bodybuilders.

METHOD

This descriptive-analytical study was performed on 280 male bodybuilders (142 non-competitive and 138 competitive bodybuilders) in Hamadan, west of Iran, in 2016. The participations were recruited a multistage sampling method. A self-administrated questionnaire was used, which included parts such as intrapersonal, interpersonal, and behavioral factors affecting on AAS use. To solve the consequences of collinearity was used ridge logistic regression model (RLRM) in R.3.5.1 software.

RESULTS

The mean age of bodybuilders was 25.21 years (SD = 6.31). The prevalence rate of AAS use among non-competitive and competitive bodybuilders was 27.5% and 34.1%, respectively. Factors such as age, time of starting bodybuilding, attitude, physical self-concept, behavioral intention, coach and friend use AAS, alcohol consumption, and supplement use were associated with AAS use among non-competitive and competitive bodybuilders.

CONCLUSION

The results of the study indicated that a combination of intrapersonal, interpersonal and behavioral factors was effective on the androgenic-anabolic steroids use among Iranian bodybuilders. Adequate education about the side effects of AAS and improvement of individual skills seem to be helpful in reducing AAS use.

Athletes' use of analgesics is related to doping attitudes, competitive anxiety, and situational opportunity

This study aimed to investigate athletes' hypothetical use of non-steroidal anti-inflammatory drugs (NSAIDs), a behavior similar to doping, and its association with doping attitudes, competitive anxiety and situational opportunity. One hundred twenty-two sport science students completed an online survey assessing biographical information, doping attitudes, and competitive anxiety. Students' intention to use analgesics was measured via two different hypothetical situations using the vignette technique. The favorable situation included an absence of potential witnesses and presence of an attractive good whereas witnesses were present in the unfavorable situation and an attractive goal was absent. The results of two hierarchical multiple regression models showed that doping attitudes and competitive anxiety, especially worry, predicted the use of analgesics. In the situation featuring a favorable opportunity, worry was the strongest predictor, whereas in the situation of an unfavorable opportunity, doping attitudes was the strongest predictor for using NSAIDs. Results indicate that NSAID use is associated with positive attitudes toward doping and competitive anxiety, and that it is situationally dependent. Future research perspectives and practical implications are discussed.

Correlates of weight-related self-monitoring application use during emerging adulthood in a population-based sample

PURPOSE

This study was designed to examine (1) the types of technologies or other applications (apps) emerging adults use to track their eating, physical activity, or weight; (2) who uses these apps and (3) whether eating and weight-related concerns during adolescence predict app use in emerging adulthood.

METHODS

Longitudinal survey data were obtained from EAT 2010-2018 (Eating and Activity over Time study, N = 1428), a population-based sample of ethnically/racially and socioeconomically diverse adolescents (mean age: 14.5 ± 2.0 years), who were followed into emerging adulthood (mean age: 22.0 ± 2.0 years). Data were used to examine sociodemographic correlates of physical activity- and dietary-focused app use. Adjusted, gender-stratified logistic regressions were used to investigate longitudinal relationships between eating and weight-related concerns in adolescence and app use in emerging adulthood.

RESULTS

Compared to men, women were more likely to use physical activity- (23.2 versus 12.5%, p < 0.001) and dietary-focused apps (16.1 versus 5.5%, p < 0.001). Among women, eating and weight-related concerns in adolescence, particularly unhealthy muscle-building behaviors (OR = 1.73, 95% CI 1.03-2.92), were associated with later dietary-focused app use. Among men, use of other muscle-building behaviors and body dissatisfaction in adolescence predicted use of physical activity- (OR_{other muscle-building} = 1.60, 95% CI 1.03-2.49 and OR_{body dissatisfaction} = 1.67, 95% CI 1.06-2.65) and dietary-focused (OR_{other muscle-building} = 2.18, 95% CI 1.07-4.47 and OR_{body dissatisfaction} = 2.35, 95% CI 1.12-4.92) apps 8 years later.

CONCLUSIONS

Eating and weight-related concerns may predict later use of physical activity- and dietary-focused apps; future research is needed to understand whether use of such apps further increases eating and weight-related concerns.

LEVEL OF EVIDENCE

III, well-designed longitudinal cohort study.

Appearance and performance-enhancing drugs and supplements, eating disorders, and muscle dysmorphia among gender minority people

OBJECTIVE

Appearance and performance-enhancing drugs and supplements (APEDS) can be 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 gender minority people.

METHOD

Participants were 1653 gender minority individuals (1120 gender-expansive [defined as a broad range of gender identities that are generally situated outside of the woman-man gender binary, e.g., genderqueer, nonbinary] people, 352 transgender men, and 181 transgender women) recruited from The Population Research in Identity and Disparities for Equality Study in 2018. Regression analyses stratified by gender identity examined associations of any APEDS use with eating disorder and muscle dysmorphia symptom scores.

RESULTS

Lifetime APEDS use was common across groups (30.7% of gender-expansive people, 45.2% of transgender men, and 14.9% of transgender women). Protein supplements and creatine supplements were the most commonly used APEDS. Among gender-expansive people and transgender men, lifetime use of any APEDS was significantly associated with higher eating disorder scores, dietary restraint, binge eating, compelled/driven exercise, and muscle dysmorphia symptoms. Any APEDS use was additionally associated with laxative use among gender-expansive people. Among transgender women, use of any APEDS was not significantly associated with eating disorder or muscle dysmorphia symptoms.

DISCUSSION

APEDS use is common and associated with eating disorder and muscle dysmorphia symptoms in gender-expansive people and transgender men, thus highlighting the importance of assessing for these behaviors and symptoms among these populations, particularly in clinical settings.

PUBLIC SIGNIFICANCE

This study aimed to examine APEDS use among gender minority people. We found that 30.7% of gender-expansive (e.g., nonbinary) people, 45.2% of transgender men, and 14.9% of transgender women reported lifetime APEDS use, which was associated with eating disorder and muscle dysmorphia symptoms in transgender men and gender-expansive people. Clinicians should assess for these behaviors in gender minority populations.

[Interdisciplinary and Psychiatric Treatment of Anabolic Androgenic Steroids Users]

Interdisciplinary and Psychiatric Treatment of Anabolic Androgenic Steroids Users Abstract. The prevalence of anabolic androgenic steroid (AAS; anabolic steroids) use in recreational sports is underestimated. Due to the influence of social media, an increase in AAS use in recreational sports and in the general population is to be expected. AAS use is associated with significant physical and mental health consequences, and the psychiatric consequences include the risk of developing addictive behaviour. The widespread stigmatization of AAS use also by professionals often undermines users' trust in physicians and drives them into the arms of so-called "gurus." The tightening of anti-doping practices in sports and an exclusively prohibitive stance have so far failed to convincingly curb the problem in recreational sports. Harm reduction strategies could help patients to get the help they need from primary care providers.

Interdisciplinary and Psychiatric Treatment of Anabolic Androgenic Steroids Users

The prevalence of anabolic androgenic steroid (AAS; anabolic steroids) use in recreational sports is underestimated. Due to the influence of social media, an increase in AAS use in recreational sports and in the general population is to be expected. AAS use is associated with significant physical and mental health consequences, and the psychiatric consequences include the risk of developing addictive behaviour. The widespread stigmatization of AAS use also by professionals often undermines users' trust in physicians and drives them into the arms of so-called "gurus." The tightening of anti-doping practices in sports and an exclusively prohibitive stance have so far failed to convincingly curb the problem in recreational sports. Harm reduction strategies could help patients to get the help they need from primary care providers.

Toxicological Characterization of GHB as a Performance-Enhancing Drug

Performance-enhancing drugs (PEDs) are represented by several compounds used to ameliorate the image, the appearance, or an athletic or non-athletic performance. Gamma-hydroxybutyrate (GHB) is an endogenous molecule first used as anesthetic and then marketed as a nutritional supplement with a wide diffusion in the bodybuilding community. The aim of the present work is to provide a toxicological characterization of the use of GHB as a PED, including the scientific basis for its use, the patterns of use/abuse, and the health risks arising from its consumption in this peculiar recreative setting. A literature search was performed on multiple databases including experimental studies on humans and animals as well as epidemiological reports and forensic case reports/series. Experimental studies demonstrated that the use of GHB as a PED is motivated by the release of growth hormone and the induction of sleep. However, the panel of desired performance-related effects was much wider in real cases and epidemiological studies. Even though the use of GHB among bodybuilders has decreased, its use to enhance some kind of performance, particularly sexual ones or social-communicative ones, as well as means to increase mood and perceived energy, is still common.

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.

Motivators of Indiscriminate and Unsafe Supplement Use among Young Australians

BACKGROUND

There is growing concern about the self-administration of supplements, which can often be indiscriminate, counterproductive to health, and serve as a gateway to more harmful drugs and substances. Research suggests that high uptake of performance- and image-enhancing drugs (PIEDs) is correlated with body image to accentuate masculinity. This study provides insights into limiting unhealthy supplement usage. This research identifies reasons for casual unhealthy supplement use among young adult Australians through the Theory of Planned Behavior (TPB) lens, providing practitioners with insights into developing interventions to deter their use.

METHOD

Semi-structured in-depth interviews were conducted with ten participants aged between 18 and 40, using a convenience sample. Leximancer analysis was used to assess word co-occurrence and map to TPB constructs.

RESULTS

Leximancer identified positive attitudes, social norms, and perceived behavioral control towards supplement usage. Key themes that influenced supplement use were weight loss, body image, nutrition, training, education, challenges, need, and time. Furthermore, using TPB constructs, affective and instrumental attitudes and prevailing norms were observed when investigating what would cause an individual to use supplements in an unhealthy manner.

CONCLUSION

Through understanding the motivations of indiscriminate supplement use across the Australian population, the study has uncovered several social factors that may reduce or limit the practice of unsafe supplement usage.

Refined Analysis of a Cross-Sectional Doping Survey Among Recreational Triathletes: Support for the Nutritional Supplement Gateway Hypothesis

Introduction: The current literature provides no consensus that nutritional supplements (NS) may provide a gateway to doping. In particular, studies in recreational athletes are lacking. Within a previous cross-sectional empirical study, our group provided first evidence that the use of NS may provide a gateway for the use of doping substances in recreational triathletes. For the present paper, we refine the analysis of the triathletes’ survey in order to provide evidence for a NS gateway hypothesis in recreational athletes.

Methods: A self-report, paper-and-pencil questionnaire was distributed to a sample of 2,997 competitive ironman and half-ironman (n = 1,076; 36.1%) triathletes. The randomized response technique (RRT) was used to assess the 12-month prevalence estimate for the use of doping substances. The prevalence for the use of NS was assessed by using direct questioning. Two-tailed (α = 0.05) large-sample z-tests were performed to assess whether the estimated prevalence for the use of doping substances differs significantly between users and nonusers of NS.

Results: The 12-month prevalence estimate for the use of doping substances is significantly higher in athletes who report using NS (20.6%) compared to those who do not (11.4%; z = 2.595, p = 0.0097).

Conclusion: The present results are consistent with the hypothesis that the use of NS provides a gateway to the use of doping substances. Therefore, doping prevention concepts should not primarily focus on preventing the use of doping substances per se, but should start one step earlier, namely by the use of NS.

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.

Body-Related Attentional Bias among Men with High and Low Muscularity Dissatisfaction

Previous studies have found gender differences in body-related attentional bias (AB), with women showing AB towards weight-related body parts. However, few studies have assessed the relationship between body-related AB and muscularity dissatisfaction (MD) in men. This study aimed to assess the presence of muscle-related AB in men, using a combination of a virtual reality (VR) embodiment-based technique and eye-tracking (ET) technology. Twenty men with high MD and 20 with low MD, owned a virtual avatar that had the same silhouette and body mass index as the participant. To analyze the gaze data, muscle-related areas of interest (M-AOIs) and nonmuscle-related areas of interest (NM-AOIs) were defined. The complete fixation time and the number of fixations on each AOI were recorded. Mixed between (group)-within (AOI_condition) analyses of variance showed a statistically significant interaction between group and time (p < 0.05) in both AB measures. Follow-up analyses revealed an AB towards M-AOIs only in men with high MD. Overall, men with high MD spent more time looking and displayed a higher number of fixations on M-AOIs, specifically the chest and shoulders, compared to men with low MD. This study provides new information about the relationship between MD and body-related AB in men. Combining VR with ET technologies presents interesting opportunities in the study of body image in men.

Anabolic androgenic steroid abuse in the United Kingdom: An update

Anabolic androgenic steroids (AASs) are prescribed for medical conditions related to low testosterone. Abuse of AASs has surged as they become recognised as potent image enhancement drugs. The primary goal of most abusers is to obtain a more attractive outward appearance. Abuse is complex. There are a vast range of AAS substances illegally available, the nature of their true composition is difficult to evaluate. Users follow dosing patterns which incorporate a number of different AASs, in addition to other pharmaceutical substances believed to complement the desired physical effects or manage unwanted effects. Animal work and medical case reports suggest potential to cause serious hepatotoxicity, plus possible neurotoxicity, nephrotoxicity and damage to the cardiovascular and reproductive systems. As the long-term AASs users reach maturity, further controlled experimentation, with larger sample sizes, is required. Data gathering should be directed towards the most vulnerable group of AAS users, females and adolescent boys.

Exploring the Progressive Use of Performance Enhancing Substances by High-Performance Athletes

Background: Given implications associated with the use of performance-enhancing substances (PESs), stakeholders must remain informed about usage precipitants and anticipate conditions signaling athlete vulnerability to hazardous exposures. Objectives: To gain deeper qualitative insight into high-level athlete PES usage; explore the variables leading them to escalate their PES use regimens; reveal PES experiences during their careers and, unlike other studies, not to focus exclusively on "doping" as measured by the use of WADA-banned substances. Methods: A macro life course-based framework from which the data could emerge through a thematic coding analysis was utilized. Sixteen narrative life course histories of recently retired high-performance athletes report on the factors impelling their escalation in PES use, including for some, the first use of banned PES. Results: Informant reports, thematically coded, reveal performance maximization urgency to be a central factor in escalating PES use, driven by four variables: Requirements, Opportunities, Influencers and Outcomes. These variables each comprise two key components that stimulate an urgency ecosystem affecting an athlete's proximity to an escalation threshold. Conclusions/Importance: Such a comprehensive investigation of PES use precipitants has not previously been undertaken. Advances in PES use were instantiated by a substantive, sometimes radical and often sudden increase in urgency to improve performance related to output requirements, specific demands, knowledge and access, timing windows, the competitive landscape, loyalty to coaches, efficiency expectations and likelihood of detection. This study informs incremental models of doping, the use of which is encouraged in order to analyze life course narratives to better understand athlete behaviors.

The association between muscle dysmorphia and eating disorder symptomatology: A systematic review and meta-analysis

BACKGROUND AND AIMS

Research shows inconsistent findings about the link between muscle dysmorphia (MD) and eating disorder (ED) symptomatology. The aim of this study is to synthesize the scientific evidence available on this topic, the researchers conducted a systematic review and meta-analysis.

METHODS

The literature search enabled us to identify 39 published articles, which provided 36 independent estimations of the correlation between the two variables.

RESULTS

Our analysis found a positive association between MD and ED symptoms (r₊ = .36; 95% CI = 0.30, 0.41). Moderator analyses showed that the type of sample and the tools for assessing MD and ED were statistically associated with the MD-ED effect sizes. The methodological quality of the studies exhibited a positive, statistically significant association with the MD-ED effect sizes.

CONCLUSIONS

Higher levels of MD were related to greater ED symptomatology, but several study characteristics may moderate the association between the two variables. In this study, we discuss limitations and implications for clinical practice and future research.

Men's reflections on their body image at different life stages: A thematic analysis of interview accounts from middle-aged men

This study investigates how men's body image develops over time. A total of 14 men aged between 45 and 67 years completed in-depth interviews where they discussed their body image since childhood, prompted in some cases by photographs of themselves at different ages that they brought to the interviews. Transcripts were analysed using inductive thematic analysis. From the participants' accounts, it was evident that body concerns did not steadily improve or worsen, but waxed and waned over time. Results are discussed in relation to understanding changing body concerns in men's lives, and the implications of these for future research and practice.

Asessing the male body image: Spanish validation of two instruments

Despite the literature suggesting that body dissatisfaction is increasing among males, only few measures on specific body image concerns in men have been validated in Spanish male populations. The aim of this study was to reassess the factor structure of the Spanish versions of the Muscle Dysmorphic Disorder Inventory (MMDI) and the Adonis Complex Questionnaire (ACQ). A cross-sectional study was conducted among 298 Sport Sciences male students to examine: reliability, the factorial structure, and several evidences of validity -concurrent and convergent- of both scales. The questionnaires present adequate reliability. The three-factor structure proposed for the MMDI was replicated. Nevertheless, the confirmatory factor analysis supports a second-order factor structure for the ACQ instead of the three-factor structure proposed. Moreover, the MDDI shows greater association than ACQ with the variables studied. This study represents an advance in the use of adequate and reliable scales of body image tools in the Hispanic population.

Appearance/Image- and Performance-Enhancing Drug Users: A Forensic Approach

Image- and performance-enhancing drugs include a wide range of substances used to promote physical changes to enhance appearance. Anabolic androgen steroids are the most widely used image- and performance-enhancing drugs along with a wide variety of additional substances. The aim of this study was to identify the pathological changes pertaining to the cardiovascular system possibly involved in the death and characterize the substances associated with steroid use and their possible role in the death. A series of deaths involving image- and performance-enhancing drug users were selected. Nandrolone and testosterone were the most frequently identified steroids. The most commonly illegal drugs found were tetrahydrocannabinol, cocaine, and methadone. Antidepressants, opioids, benzodiazepines, and barbiturates were also found. These findings highlight that results obtained from postmortem investigations should be meticulously evaluated to understand the weight that each identified substance may have played in the death process and exclude any alternative causes of death.

Prospective health associations of drive for muscularity in young adult males

OBJECTIVE

The objective of the study was to estimate prospective associations of drive for muscularity measured in 2013 and related health outcomes (depressive symptoms, overeating, binge eating, purging, binge drinking, and use of muscle-building products [e.g., creatine and steroids]) measured in 2014.

METHOD

The data come from a U.S. national large prospective cohort study, the Growing Up Today Study (GUTS) and included 2,460 males aged 18-32 years. Muscularity concerns were assessed with The Drive for Muscularity Scale (item responses ranging from 1 = Never to 6 = Always), which measures the degree of the respondents' preoccupation with increasing their muscularity.

RESULTS

Gay and bisexual males presented with higher drive for muscularity compared to heterosexual males (β = 0.30, 95% CI = 0.17, 0.43, p < .0001). Prospective analysis using generalized estimating equations indicated that each unit increase in drive for muscularity was associated with increased odds of exhibiting significant depressive symptoms (OR = 1.23, 95% CI = 1.05-1.44, p = .01), binge drinking (OR = 1.21, 95% CI = 1.02-1.45, p = .03), dieting (OR = 1.17, 95% CI = 1.01, 1.35, p = .04), and use of muscle-building products (OR = 4.49, 95% CI = 3.74, 5.40, p < .0001).

DISCUSSION

The drive for muscularity appears to be relatively prevalent across adolescence and early adulthood in males and is associated with broad and substantial health consequences. Muscularity-oriented concerns should be carefully considered when assessing and treating males with body image dissatisfaction.

Boost Me: Prevalence and Reasons for the Use of Stimulant Containing Pre Workout Supplements Among Fitness Studio Visitors in Mainz (Germany)

The rapidly increasing interest in fitness related sports over the past few years has been accompanied by a booming industry of nutritional supplements. Many of these substances have unproven benefits and are even potentially harmful to the user. The aim of this study was to determine the prevalence and reasons for nutritional supplement (NS) use among fitness studio visitors in Mainz (Germany), emphasizing new multi-ingredient based supplements such as pre workout boosters (PWBs). Some of the PWBs contain stimulants such as DMAA, N,α-DEPEA, DMAE and DMBA with so far unknown risks, harms and benefits. Four-Hundred and Ninety Two participants in 13 fitness studios completed a questionnaire on the use of nutritional supplements. Descriptive statistics and chi-square tests were used to examine differences in supplement use regarding training- and intake-reasons. About 57.0% of the participants reported the use of NS during the last 4 weeks. The all-time prevalence of creatine use was 28.7%, whereas 12.2% of the participants stated creatine use during the past 4 weeks. The all-time prevalence of PWB intake was 25.8%, whereas the last month prevalence was 11.8%. Among the group of PWB users, 20.5% stated to search specifically for substances such as DMAA, N,α-DEPEA, DMAE or DMBA. Logistic regression analysis showed positive relations between creatine use and the predictor variables gender, strength training and bodybuilding, as well as the stated exercisers' training reasons to increase physical- and sports-performance, and quality of life. PWB consumption was related to the variables gender, training frequency, and the reason for sports performance enhancement. Specific ingredient focus was related to the predictor variables competition participation and increase of mental performance. The results of the study show a high prevalence of PWB consumption among fitness studios visitors, which is comparable with creatine use. The predicting variables for consumption seem to be slightly different between the supplements, especially if the users are searching for stimulating agents. The current findings help to create preliminary consumption patterns and can help to identify potential endangered fitness studio visitors for prevention and risk communication, especially for PWBs.

Impact of inherent aspects of body image, eating behavior and perceived health competence on quality of life of university students

The aim of this study was to assess the impact of inherent aspects of body image, eating behavior and perceived health competence on quality of life of university students. Participants completed the instruments Body Shape Questionnaire (reduced version, BSQ-8B), Male Body Dissatisfaction Scale (reduced version, MBDS-R), Three-Factor Eating Questionnaire (reduced version, TFEQ-18), Perceived Health Competence Scale (bifactorial version, PHCS-B), World Health Organization Quality of Life Questionnaire-Short Form (WHOQoL-bref) and a questionnaire for characterization of sample. Psychometric properties of instruments were previously evaluated by confirmatory factor analysis. A hypothetical model for each sex was developed and tested. In both model surveys the aspects of the body image (BSQ-8B: body shape concern; MBDS-R: musculature and general body appearance), of eating behavior (TFEQ-18: cognitive restriction, emotional eating, and uncontrolled eating) and of the perceived health competence (PHCS-B: expectations of achieving the desired health results and competence in health behaviors) were used as direct predictors on quality of life (WHOQoL-bref). The variables age, medication use for body change, food supplement use for body change, and body mass index (BMI) were inserted in the aspects of the body image. The variables course shift, initial expectation regarding the course, self-reported performance in the course, concomitant work activities to studies, and economic class were inserted into the quality of life. The model surveys were evaluated using structural equation modeling. A level of significance of 5% was used. A total of 2,198 university students (female = 63.5%), including 1,151 Brazilians and 1,047 Portuguese, participated of study (locally representative samples). The average age of women was 20.8 ± 2.4 years and of men was 21.3 ± 3.3 years. The psychometric properties of the instruments were adequate, except for the PHCS, which was adjusted for each sex. The models presented variance explained of 54% and 49% for women and men, respectively. In both sexes, the students' perceived health competence and academic variables contributed significantly to their quality of life, and age, BMI, and medication and supplement use were significant factors relating to how a student views his or her body image. Women's quality of life was associated with body shape concern and emotional eating aspects. Men's quality of life was associated with general body appearance and cognitive restriction aspects. These results can be used to create and implement educational programs to improve quality of life of university students.

Psychosocial correlates of gap time to anabolic-androgenic steroid use

OBJECTIVE

Theoretically, legal supplement use precedes and increases the risk for illicit appearance and performance enhancing drug (APED) use-also referred to as the gateway hypothesis. Little is known about associations between the speed of progression, or gap time, from legal to illicit APED use, and psychological risk factors, such as sociocultural influence, eating disorders, body image disturbance, and impulsivity.

METHOD

The sample taken from two studies included 172 active steroid users (n = 143) and intense-exercising healthy controls (n = 29) between the ages of 18 and 60 (M = 34.16, SD = 10.43), the majority of whom were male (91.9%). Participants, retrospectively, reported APED use and completed measures assessing psychological and behavioral factors, including eating concern, muscle dysmorphia, and impulsivity. Participants had a gap time from initial APED use to anabolic-androgenic steroid (AAS) use that ranged from 0 to 38 years.

RESULTS

Continuous survival analysis indicated that interactions between self- versus other sociocultural influence on APED onset and both higher eating concern and impulsivity are associated with a shorter gap time from initial legal to illicit APED use.

DISCUSSION

The results indicate the potential value in developing different strategies for individuals with other sociocultural versus self-influence on illicit APED use, and among more impulsive and eating-concerned APED users. Future research is needed to assess different trajectories of APED use, such that eating-concerned and impulsive individuals who perceive less other sociocultural influence may be at greatest risk for a speedier progression to AAS use.

Influence of knowledge and beliefs on consumption of performance enhancing agents in north-western Saudi Arabia

BACKGROUND

Consumption of performance enhancing agents (PEAs) has a wide range of negative health consequences, but knowledge of these consequences among gym users of PEAs in Saudi Arabia is not well understood.

OBJECTIVES

Identify the knowledge, awareness, beliefs and attitudes of gym users about negative health consequences of using PEAs, and the relationship between these factors and use of these agents.

DESIGN

Cross-sectional study.

SETTING

Five gyms in Madinah city, Saudi Arabia.

SUBJECTS AND METHODS

Convenience sampling was used to recruit gym users. An electronic self-administered questionnaire was used to collect data.

MAIN OUTCOME MEASURE(S)

Level of knowledge about the negative health consequences of PEAs among gym users.

RESULTS

About 70% of 316 participants had used one or more of PEAs over the last six months. Of those, about 68.4% used protein powder supplements and 48.1% used energy drinks. Participants who believed that protein powder supplements (c2=52.3, P < .01) and energy drinks (c2=35.2, P < .01) had health hazards used these agents less often than others during the six months preceding data collection. Participants who had less knowledge about the negative health consequences were more likely to use protein powder supplement (t=2.38, P=.018). On the other hand, those who were more knowledgeable about the negative health consequences of insulin, were more likely to use insulin (t=2.45, P=.015).

CONCLUSION

Misuse of PEAs is widespread among gym users in Saudi Arabia. Improving the level of knowledge and awareness of possible serious health consequences would hopefully lead to reduced PEA consumption.

LIMITATIONS

The temporal sequence of cause and effect could not be determined in a cross sectional study. Convenience sampling in a single city limited the generalizability of the findings to all regions of Saudi Arabia.

Effects of the exposure to self- and other-referential bodies on state body image and negative affect in resistance-trained men

Previous body image research suggests that first, exposure to body stimuli can negatively affect men's body satisfaction and second, body concerns are associated with dysfunctional gaze behavior. To date, however, the effects of self- vs. other-referential body stimuli and of gaze behavior on body image in men under exposure conditions have not been investigated. Therefore, 49 weight-trained men were presented with pictures of their own and other bodies of different builds (i.e., normal, muscular, hyper-muscular) while being eye-tracked. Participants completed pre- and post-exposure measures of body image and affect. Results indicated that one's own and the muscular body negatively affected men's body image to a comparable degree. Exposure to one's own body also led to increased negative affect. Increased attention toward disliked own body parts was associated with a more negative post-exposure body image and affect. These results suggest a crucial role of critical self-examination in maintaining body dissatisfaction.

Research-to-policy translation for prevention of disordered weight and shape control behaviors: A case example targeting dietary supplements sold for weight loss and muscle building

New approaches to universal eating disorders prevention and interventions targeting macro-environmental change are greatly needed, and research-to-policy translation efforts hold promise for advancing both of these goals. This paper describes as a policy-translation case example an academic-community-government partnership of the Strategic Training Initiative for the Prevention of Eating Disorders, Multi-Service Eating Disorders Association, and the office of Massachusetts Representative Kay Khan, all based in Massachusetts, USA. The partnership's research-to-policy translation project focused on dietary supplements sold for weight loss and muscle building, which have been linked with serious injury and death in consumers. Youth and people of all ages with eating disorders and body dysmorphic disorder may be especially vulnerable to use these products due to deceptive promises of fast and safe weight loss and muscle gain. The research-to-policy translation project was informed by a triggers-to-action framework to establish the evidentiary base of harm to consumers, operationalize policy solutions to mitigate harm through legislation, and generate political will to support action through legislation introduced in the Massachusetts legislature to restrict sales of weight-loss and muscle-building dietary supplements. The paper concludes with lessons learned from this unique policy translation effort for the prevention of disordered weight and shape control behaviors and offers recommendations for next steps for the field to advance research and practice for universal, macro-environmentally targeted prevention.

The Dangerous Mix of Adolescents and Dietary Supplements for Weight Loss and Muscle Building: Legal Strategies for State Action

Adolescents use dietary supplements marketed for weight loss or muscle building, but these are not recommended by physicians. These products are often ineffective, adulterated, mislabeled, or have unclear dosing recommendations, and consumers have suffered injury and death as a consequence. When Congress passed the Dietary Supplement Health and Education Act, it stripped the Food and Drug Administration of its premarket authority, rendering regulatory controls too weak to adequately protect consumers. State government intervention is thus warranted. This article reviews studies reporting on Americans' use of dietary supplements marketed for weight loss or muscle building, notes the particular dangers these products pose to the youth, and suggests that states can build on their historical enactment of regulatory controls for products with potential health consequences to protect the public and especially young people from unsafe and mislabeled dietary supplements.

Effectiveness and implementation of a community-based prevention programme targeting anabolic androgenic steroid use in gyms: study protocol of a quasi-experimental control group study

Background

During the past decades, concerns about increased anabolic androgenic steroid (AAS) use among recreational sportspeople have been raised, yet there is a paucity of AAS prevention efforts targeting this group. Accordingly, doping prevention efforts aimed at gyms have been recommended. The overall objective of the present project is to examine a prevention programme named 100% Pure Hard Training (100% PHT), which targets AAS use among recreational sportspeople training in gyms. Specifically, the project aims to: 1) assess the prevalence of AAS, and its associations with alcohol, illicit drugs, and nutritional supplements use; 2) examine whether 100% PHT can decrease AAS use in gyms, and 3) provide insights into which factors facilitate and/or impede implementation of the programme.

Methods/design

The intervention group consists of 27 gyms, and 27 gyms serve as controls. Intervention gyms take part in 100% PHT, a community-based programme involving several components: (a) training of key stakeholders (i.e., gym staff, gym owners, local police, and municipal prevention coordinators) regarding AAS use; (b) developing an action plan for AAS prevention for each gym; (c) certification of gyms that follow 100% PHT; (d) cooperative relationship between stakeholders; (e) annual follow-up of gyms. The project consists of two studies: Study A will examine the prevalence of AAS use and the effectiveness of 100% PHT (aims 1 and 2), and data for Study A will be collected using questionnaires distributed to gym attendees at two assessment points: baseline (pre-intervention) and follow-up (post-intervention). Study B will evaluate the implementation of 100% PHT (aim 3), and semi-structured interviews with participating stakeholders will be carried out post-intervention.

Discussion

Knowledge gained from the present project can be used to develop community-based doping prevention efforts aimed at recreational sportspeople training in gyms. Furthermore, it can provide insights into which factors are important for successful implementation of AAS prevention programmes that target gyms. Results are also expected to yield information on the prevalence of AAS use as well as associations between the use of AAS and other licit and illicit substances, including nutritional supplements, among recreational sportspeople.

Trial registration

The study was registered retrospectively at isrctn.com (Identifier: ISRCTN11655041; Registration date: 3 November 2016;).

Electronic supplementary material

The online version of this article (doi:10.1186/s13102-016-0062-9) contains supplementary material, which is available to authorized users.

[Muscle Dysmorphia and Use of Ergogenics Substances. A Systematic Review]

The use of ergogenic substances (UES) is not restricted to achieving a better athletic performance, but also it is a behavior for body changing through muscle development; however, little is known about the relationship between muscle dysmorphia (MD) and UES. Therefore, it was conducted a systematic review of those empirical papers that have studied this relationship over the last decade (2004-2014). First it is highlighted that of the 22 articles analyzed, only 13 explicitly aimed this interest. Besides, although the documented data outlined some relevant aspects such as the existence of a high co-occurrence (60-90%) between MD and UES. In general, the evidence is still incipient and uncertain, mainly because of the large disparity between the methodologies of the studies, particularly in terms of indicators, parameters and measures utilized to assess UES within the context of MD.

Use of Performance-Enhancing Substances

Performance-enhancing substances (PESs) are used commonly by children and adolescents in attempts to improve athletic performance. More recent data reveal that these same substances often are used for appearance-related reasons as well. PESs include both legal over-the-counter dietary supplements and illicit pharmacologic agents. This report reviews the current epidemiology of PES use in the pediatric population, as well as information on those PESs in most common use. Concerns regarding use of legal PESs include high rates of product contamination, correlation with future use of anabolic androgenic steroids, and adverse effects on the focus and experience of youth sports participation. The physical maturation and endogenous hormone production that occur in adolescence are associated with large improvements in strength and athletic performance. For most young athletes, PES use does not produce significant gains over those seen with the onset of puberty and adherence to an appropriate nutrition and training program.