Abstract
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.
Funding source: American Academy of Pediatrics
Funding source: American Pediatric Society
Funding source: American Heart Association
Award Identifier / Grant number: CDA34760281
Funding source: National Institutes of Health
Award Identifier / Grant number: K23 MH115184
Award Identifier / Grant number: R01HD082166-02
Award Identifier / Grant number: K12HD00085033
Funding source: National Health and Medical Research Council
Award Identifier / Grant number: 1121538
Funding source: University of Melbourne
Award Identifier / Grant number: 603758
Funding source: Eunice Kennedy Shriver National Institute of Child Health and Human Development
Award Identifier / Grant number: P01-HD31921
Acknowledgments
J.M.N. is a participant in the Pediatric Scientist Development Program (K12HD00085033), funded by the American Academy of Pediatrics and the American Pediatric Society, and a recipient of the American Heart Association Career Development Award (CDA34760281). S.B.M. was supported by the National Institutes of Health (K23 MH115184). A.K.G. was supported by the National Institutes of Health (R01HD082166-02). S.G. is supported by a National Health and Medical Research Council Early Career Fellowship (grant number: 1121538) and a University of Melbourne Early Career Grant (grant number: 603758). Special thanks to Rebecca Schauer for assistance with the analyses and John Boscardin for biostatistical advice. This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill, and funded by grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Information on how to obtain the Add Health data files is available on the Add Health website (http://www.cpc.unc.edu/addhealth). No direct support was received from grant P01-HD31921 for this analysis.
-
Author contributions: Dr. Nagata conceptualized and designed the study, completed the statistical analysis, drafted the initial manuscript, and reviewed and revised the manuscript. Dr. Ganson collaboratively conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. Dr. Vittinghoff completed the statistical analysis, and reviewed and revised the mansuscript. Dr. Mitchison, Dr. Murray, Dr. Griffiths, Dr. Garber, and Dr. Bibbins-Domingo critically reviewed the manuscript for important intellectual content and appropriate statistical analysis, as well as provided manuscript edits. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
-
Ethical approval: The University of North Carolina Institutional Review Board approved all Add Health study procedures.
-
Conflicts of interest: The authors have no conflicts of interest to report.
References
1. Field, AE, Sonneville, KR, Crosby, RD, Swanson, SA, Eddy, KT, Camargo, CA, et al. Prospective associations of concerns about physique and the development of obesity, binge drinking, and drug use among adolescent boys and young adult men. JAMA Pediatr 2014 Jan;168:34–9. https://doi.org/10.1001/jamapediatrics.2013.2915.Search in Google Scholar
2. Girard, M, Rodgers, RF, Chabrol, H. Prospective predictors of body dissatisfaction, drive for thinness, and muscularity concerns among young women in France: a sociocultural model. Body Image 2018 Sep;26:103–10. https://doi.org/10.1016/j.bodyim.2018.07.001.Search in Google Scholar
3. Holland, G, Tiggemann, M. “Strong beats skinny every time”: disordered eating and compulsive exercise in women who post fitspiration on instagram. Int J Eat Disord 2017 Jan;50:76–9. https://doi.org/10.1002/eat.22559.Search in Google Scholar
4. Murray, SB, Nagata, JM, Griffiths, S, Calzo, JP, Brown, TA, Mitchison, D, et al. The enigma of male eating disorders: a critical review and synthesis. Clin Psychol Rev 2017 Nov;57:1–11. https://doi.org/10.1016/j.cpr.2017.08.001.Search in Google Scholar
5. Nagata, JM, Murray, SB, Bibbins-Domingo, K, Garber, AK, Mitchison, D, Griffiths, S. Predictors of muscularity-oriented disordered eating in US young adults: a prospective cohort study. Int J Eat Disord 2019;52:1380–8. https://doi.org/10.1002/eat.23094.Search in Google Scholar
6. Eisenberg, ME, Wall, M, Neumark-Sztainer, D. Muscle-enhancing behaviors among adolescent girls and boys. Pediatrics 2012 Dec;130:1019–26. https://doi.org/10.1542/peds.2012-0095.Search in Google Scholar
7. Calzo, JP, Horton, NJ, Sonneville, KR, Swanson, SA, Crosby, RD, Micali, N, et al. Male eating disorder symptom patterns and health correlates from 13 to 26 years of age. J Am Acad Child Adolesc Psychiatry 2016 Aug;55:693–700.e2. https://doi.org/10.1016/j.jaac.2016.05.011.Search in Google Scholar
8. Pope, HGJr, Wood, RI, Rogol, A, Nyberg, F, Bowers, L, Bhasin, S. Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev 2014 Jun;35:341–75. https://doi.org/10.1210/er.2013-1058.Search in Google Scholar
9. Sagoe, D, Molde, H, Andreassen, CS, Torsheim, T, Pallesen, S. The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis. Ann Epidemiol 2014 May;24:383–98. https://doi.org/10.1016/j.annepidem.2014.01.009.Search in Google Scholar
10. Ganson, KT, Cadet, TJ. Exploring anabolic-androgenic steroid use and teen dating violence among adolescent males. Subst Use Misuse 2019;54:779–86. https://doi.org/10.1080/10826084.2018.1536723.Search in Google Scholar
11. Miller, KE, Barnes, GM, Melnick, MJ, Sabo, DF, Farrell, MP. Gender and racial/ethnic differences in predicting adolescent sexual risk: athletic participation versus exercise. J Health Soc Behav 2002 Dec;43:436–50. https://doi.org/10.2307/3090236.Search in Google Scholar
12. Wong, SS, Zhou, B, Goebert, D, Hishinuma, ES. The risk of adolescent suicide across patterns of drug use: a nationally representative study of high school students in the United States from 1999 to 2009. Soc Psychiatry Psychiatr Epidemiol 2013 Oct;48:1611–20. https://doi.org/10.1007/s00127-013-0721-z.Search in Google Scholar
13. Nagata, JM, Bibbins-Domingo, K, Garber, AK, Griffiths, S, Vittinghoff, E, Murray, SB. Boys, bulk, and body ideals: sex differences in weight gain attempts among adolescents in the United States. J Adolesc Health 2019;64:450–3. https://doi.org/10.1136/bmjpo-2019-rcpch-sahm.4.Search in Google Scholar
14. Murray, SB, Accurso, EC, Griffiths, S, Nagata, JM. Boys, biceps, and bradycardia: the hidden dangers of muscularity-oriented disordered eating. J Adolesc Health 2018 Mar;62:352–5. https://doi.org/10.1016/j.jadohealth.2017.09.025.Search in Google Scholar
15. Harris, KM, Halpern, CT, Whitsel, E, Hussey, J, Tabor, J, Entzel, P, et al. The National Longitudinal Study of Adolescent to Adult Health: research design. 2017; Available from: https://www.cpc.unc.edu/projects/addhealth/design/researchdesign_3618_regular.pdf [Accessed 6 Nov 2020].Search in Google Scholar
16. Chen, P., 2014. Appropriate analysis in add health: correcting for design effects & selecting weights. Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. https://www.cpc.unc.edu/projects/addhealth/events/2014-add-health-users-conference-appropriate-analysis-ping-chen [Accessed 26 Apr 2020].Search in Google Scholar
17. Gooding, HC, Walls, CE, Richmond, TK. Food insecurity and increased BMI in young adult women. Obesity (Silver Spring) 2012 Sep;20:1896–901. https://doi.org/10.1038/oby.2011.233.Search in Google Scholar
18. Mitchison, D, Mond, J. Epidemiology of eating disorders, eating disordered behaviour, and body image disturbance in males: a narrative review. J Eat Disord 2015 May 23;3:20. https://doi.org/10.1186/s40337-015-0058-y.Search in Google Scholar
19. Nagata, JM, Garber, AK, Tabler, J, Murray, SB, Vittinghoff, E, Bibbins-Domingo, K. Disordered eating behaviors and future cardiometabolic risk among young adults with overweight or obesity. Int J Eat Disord 2018;51:931–41. https://doi.org/10.1002/eat.22927.Search in Google Scholar
20. Nagata, JM, Garber, AK, Tabler, J, Murray, SB, Bibbins-Domingo, K. Prevalence and correlates of disordered eating behaviors among young adults with overweight or obesity. J Gen Intern Med 2018;33:1337–43. https://doi.org/10.1007/s11606-018-4465-z.Search in Google Scholar
21. Easterlin, MC, Chung, PJ, Leng, M, Dudovitz, R. Association of team sports participation with long-term mental health outcomes among individuals exposed to adverse childhood experiences. JAMA Pediatr 2019 May 28;173:681. https://doi.org/10.1001/jamapediatrics.2019.1212.Search in Google Scholar
22. Neumark-Sztainer, D, Story, M, Resnick, MD, Blum, RW. Lessons learned about adolescent nutrition from the Minnesota Adolescent Health Survey. J Am Diet Assoc 1998 Dec;98:1449–56. https://doi.org/10.1016/s0002-8223(98)00329-0.Search in Google Scholar
23. Neumark-Sztainer, D. Project EAT 2010 and F-EAT surveys - derived variables and scales. 2010. Available at: http://docs.sph.umn.edu/epich/eat/EAT2010_FEAT_Psychometrics.pdf. [Accessed 2 Jan, 2020].Search in Google Scholar
24. Vittinghoff, E, Glidden, DV, Shiboski, SC, McCulloch, CE. Regression methods in biostatistics: linear, logistic, survival, and repeated measures models, 2nd ed. New York: Springer-Verlag; 2012.10.1007/978-1-4614-1353-0Search in Google Scholar
25. Graubard, BI, Korn, EL. Predictive margins with survey data. Biometrics 1999 Jun;55:652–9. https://doi.org/10.1111/j.0006-341x.1999.00652.x.Search in Google Scholar
26. Harris, KM. The add health study: design and accomplishments. North Carolina: Carolina Population Center, University of North Carolina at Chapel Hill; 2013.Search in Google Scholar
27. Cameron, AC, Miller, DL. A practitioner’s guide to robust inference. J Human Resour 2015;50:317–72. https://doi.org/10.3368/jhr.50.2.317.Search in Google Scholar
28. Neumark-Sztainer, D, Wall, MM, Haines, JI, Story, MT, Sherwood, NE, van den Berg, P A. Shared risk and protective factors for overweight and disordered eating in adolescents. Am J Prev Med 2007 Nov;33:359–69. https://doi.org/10.1016/j.amepre.2007.07.031.Search in Google Scholar
29. Haines, J, Kleinman, KP, Rifas-Shiman, SL, Field, AE, Austin, SB. Examination of shared risk and protective factors for overweight and disordered eating among adolescents. Arch Pediatr Adolesc Med 2010 Apr;164:336–43. https://doi.org/10.1001/archpediatrics.2010.19.Search in Google Scholar
30. Tabler, J, Utz, RL. The influence of adolescent eating disorders or disordered eating behaviors on socioeconomic achievement in early adulthood. Int J Eat Disord 2015 Sep;48:622–32. https://doi.org/10.1002/eat.22395.Search in Google Scholar
31. Smolak, L, Stein, JA. A longitudinal investigation of gender role and muscle building in adolescent boys. Sex Role: J Res 2010;63:738–46. https://doi.org/10.1007/s11199-010-9819-x.Search in Google Scholar
32. Smolak, L, Murnen, SK, Thompson, JK. Sociocultural influences and muscle building in adolescent boys. Psychol Men Masc 2005;6:227–39. https://doi.org/10.1037/1524-9220.6.4.227.Search in Google Scholar
33. Irving, LM, Wall, M, Neumark-Sztainer, D, Story, M. Steroid use among adolescents: findings from Project EAT. J Adolesc Health 2002 Apr;30:243–52. https://doi.org/10.1016/s1054-139x(01)00414-1.Search in Google Scholar
34. Blashill, AJ, Calzo, JP, Griffiths, S, Murray, SB. Anabolic steroid misuse among US adolescent boys: disparities by sexual orientation and race/ethnicity. Am J Public Health 2017 Feb;107:319–21. https://doi.org/10.2105/ajph.2016.303566.Search in Google Scholar
35. Sawyer, SM, Azzopardi, PS, Wickremarathne, D, Patton, GC. The age of adolescence. Lancet Child Adolesc Health 2018 Mar;2:223–8. https://doi.org/10.1016/s2352-4642(18)30022-1.Search in Google Scholar
36. Nagata, JM, Brown, TA, Lavender, JM, Murray, SB. Emerging trends in eating disorders among adolescent boys: muscles, macronutrients, and biohacking. Lancet Child Adolesc Health 2019 Jul;3:444–5. https://doi.org/10.1016/s2352-4642(19)30147-6.Search in Google Scholar
37. Cohen, PA. Hazards of hindsight-monitoring the safety of nutritional supplements. N Engl J Med 2014 Apr;370:1277–80. https://doi.org/10.1056/nejmp1315559.Search in Google Scholar
38. Or, F, Kim, Y, Simms, J, Austin, SB. Taking stock of dietary supplements’ harmful effects on children, adolescents, and young adults. J Adolesc Health 2019;65:455–61. https://doi.org/10.1016/j.jadohealth.2019.03.005.Search in Google Scholar
39. Hildebrandt, T, Harty, S, Langenbucher, JW. Fitness supplements as a gateway substance for anabolic-androgenic steroid use. Psychol Addict Behav 2012 Dec;26:955–62. https://doi.org/10.1037/a0027877.Search in Google Scholar
40. Watson, A, Murnen, SK, College, K. Gender differences in responses to thin, athletic, and hyper-muscular idealized bodies. Body Image 2019 May;30:1–9. https://doi.org/10.1016/j.bodyim.2019.03.010.Search in Google Scholar
41. Ricciardelli, LA, McCabe, MP, Williams, RJ, Thompson, JK. The role of ethnicity and culture in body image and disordered eating among males. Clin Psychol Rev 2007 Jun;27:582–606. https://doi.org/10.1016/j.cpr.2007.01.016.Search in Google Scholar
42. Shaw, H, Ramirez, L, Trost, A, Randall, P, Stice, E. Body image and eating disturbances across ethnic groups: more similarities than differences. Psychol Addict Behav 2004 Mar;18:12–8. https://doi.org/10.1037/0893-164x.18.1.12.Search in Google Scholar
43. Rodgers, RF, Berry, R, Franko, DL. Eating disorders in ethnic minorities: an update. Curr Psychiatry Rep 2018;20:90. https://doi.org/10.1007/s11920-018-0938-3.Search in Google Scholar
44. Anzell, AR, Potteiger, JA, Kraemer, WJ, Otieno, S. Changes in height, body weight, and body composition in American football players from 1942 to 2011. J Strength Cond Res 2013 Feb;27:277–84. https://doi.org/10.1519/jsc.0b013e31827f4c08.Search in Google Scholar
45. Vertalino, M, Eisenberg, ME, Story, M, Neumark-Sztainer, D. Participation in weight-related sports is associated with higher use of unhealthful weight-control behaviors and steroid use. J Am Diet Assoc 2007 Mar;107:434–40. https://doi.org/10.1016/j.jada.2006.12.010.Search in Google Scholar
46. Nagata, JM, Peebles, R, Hill, KB, Gorrell, S, Carlson, JL. Associations between ergogenic supplement use and eating behaviors among university students. Eat Disord 2020;1532–530X: 1–17. https://doi.org/10.1080/10640266.2020.1712637.32129729.Search in Google Scholar
47. Nagata, J, Ganson, K, Gorrell, S, Mitchison, D, Murray, S. Association between legal performance-enhancing substances and use of anabolic-androgenic steroids in young adults. JAMA Pediatr 2020;174. https://doi.org/10.1001/jamapediatrics.2020.0883.Search in Google Scholar
© 2020 Walter de Gruyter GmbH, Berlin/Boston
