Elsevier

Body Image

Volume 44, March 2023, Pages 178-186
Body Image

Muscle dysmorphia symptomatology among a national sample of Canadian adolescents and young adults

https://doi.org/10.1016/j.bodyim.2023.01.001 Get rights and content

Highlights

  • We studied muscle dysmorphia (MD) symptomatology in a national Canadian sample.

  • MD symptomatology was highest among men.

  • MD symptomatology was highest among those who reported lifetime steroid use.

  • Lower body mass index was associated with greater MD symptomatology.

  • South Asian and Middle Eastern identities were associated with greater MD symptomatology.

Abstract

The aim of this study was to describe muscle dysmorphia (MD) symptomatology among a large, diverse, and national sample of adolescents and young adults in Canada. Data from the Canadian Study of Adolescent Health Behaviors (N = 2256) were analyzed. MD symptomatology was assessed using the Muscle Dysmorphic Disorder Inventory (MDDI). Men (mean [M] = 33.9, standard deviation [SD] = 8.6) reported significantly greater overall MD symptomatology compared to women (M = 30.1, SD = 7.3) and transgender/gender non-conforming (TGNC; M = 31.5, SD = 7.6) participants. Similarly, the prevalence of clinical MD risk was also highest among men (25.7 %). In regression analyses, participants who identified as South Asian (B 1.97, 95 % confidence interval [CI] 0.41, 3.52) or Middle Eastern (B 2.92, 95 % CI 0.50,5.35), compared to White participants, or identified as gay or lesbian (B 2.65, 95 % CI 1.19, 4.10), compared to heterosexual participants, had greater MD symptomatology. Findings are the first to describe the MD symptomatology among Canadian adolescents and young adults. Health care and public health professionals should be aware of the overall high occurrence of MD symptomatology in this sample, and future research is needed to continue to describe MD among Canadian young people.

Introduction

Muscle dysmorphia (MD) is characterized by the pathological pursuit of muscularity. The cardinal symptom of MD is the preoccupation of insufficient muscle size and definition, resulting in marked distress, as well as a significant drive for muscularity (American Psychiatric Association, 2013, Pope et al., 1997). Categorized as a specifier of Body Dysmorphic Disorder (American Psychiatric Association, 2013), core MD symptoms may include compulsive exercise and weight training, specific dieting to build and maintain muscularity, use of appearance- and performance-enhancing drugs and substances (APEDS), and overall functional impairment (Cafri et al., 2008, Pope et al., 2005, Pope et al., 1997). To date, much of the research on MD symptomatology has been limited to bodybuilders (Cafri et al., 2008, Mitchell et al., 2017, Olivardia et al., 2000, Pope et al., 2005) and data among large community samples is lacking, particularly in Canada. This presents an important gap to be filled with future research. Specifically, more research is needed to describe the sociodemographic characteristics of individuals who report greater MD symptomatology to improve assessment, prevention, and intervention efforts.

It has been well documented that individuals with MD and who engage in MD-related symptoms are overwhelmingly boys and men (Ganson et al., 2021, Ganson and Nagata, 2022, Glazer et al., 2021, Mitchison et al., 2021, Nagata et al., 2019, Nagata et al., 2020, Tod et al., 2016). Indeed, the ideal male body is one that emphasizes bulk muscularity and leanness (Murray et al., 2017, Nagata et al., 2020), likely explaining the disproportionate prevalence of MD symptomatology among males. However, girls and women can also experience MD and engage in MD-related symptoms (Gruber, 2007, Gruber and Pope, 1999, Mitchison et al., 2021), and recent research has documented that transgender adult men have similar, and at times greater, MD symptomatology in relation to cisgender men (Amodeo et al., 2022). This research underscores a need for more research on gender diverse samples to delineate differences in MD symptomatology across genders.

In addition, there is a dearth of literature on MD symptomatology across sexual identities and diverse racial and ethnic identities. However, research has documented that sexual minority individuals (i.e., those who identify as gay or lesbian, bisexual, queer, etc.), compared to their heterosexual peers, are often at greater risk of body dissatisfaction, including muscle dissatisfaction, eating disorder psychopathology, and use of APEDS (Blashill et al., 2017, Calzo et al., 2013, Calzo et al., 2015, Hazzard et al., 2020, Nagata et al., 2020). This may indicate that sexual minority individuals are at greater risk of MD symptomatology, given the centrality of body dissatisfaction in presentations of MD. Similarly, individuals across races and ethnicities experience body image concerns, and many boys and men who do not identify as White report high engagement in weight-gain and muscle-building behaviors (Ganson et al., 2021, Ganson et al., 2022, Nagata et al., 2020, Nagata et al., 2022, Ricciardelli et al., 2007). This prior research emphasizes that more investigations among diverse samples are needed to explore potential differences in MD presentations across sexual identities and races and ethnicities.

Another factor that may be crucially related to MD is body mass (Grieve, 2007). While body mass index (BMI) is unable to differentiate between fat mass and muscle mass (Ganson et al., 2019), a low BMI suggests a smaller body size. Within the context of MD symptomatology, those with a smaller body may have desire to increase their body size through building muscle (Cafri et al., 2005). Additionally, lower BMI has been shown to be associated with weight gain attempts and muscle-building behaviors (Ganson et al., 2021, Nagata et al., 2020, Nagata et al., 2022), which are common MD behaviors. Conversely, higher BMI is often associated with increased body dissatisfaction, as well as weight stigma, and thus, attempts to alter one’s body to fit the sociocultural ideal (Calzo et al., 2012, Spahlholz et al., 2016). Within this context, both low and high BMI may be relevant to MD symptomatology as individuals across the weight spectrum may be attempting to achieve the muscular body ideal.

As discussed, the literature on the sociodemographic correlates of MD symptomatology, while growing, remains relatively scant, particularly among community samples. There remains a need to delineate the sociodemographic characteristics of adolescents and young adults who experience MD symptomatology. This age group is particularly important as it is a key developmental time period where body dissatisfaction is high (Bucchianeri et al., 2013, Wang et al., 2019) and the onset of MD is common (i.e., the age of onset is typically roughly 19 years old; Tod et al., 2016). Additionally, there is an overall small percent of the general population who experience a clinical diagnosis of MD, while the individual attitudes and behaviors (i.e., symptoms) of MD are relatively common (Pope et al., 2017). For example, 2.2 % of Australian adolescents in a recent study met clinical criteria for MD (Mitchison et al., 2021), which is significantly lower than the prevalence of high engagement in weight training (Ganson, Rodgers, et al., 2022), APEDS use (Calzo et al., 2016, Ganson and Nagata, 2022, Nagata et al., 2020), weight gain attempts (Ganson et al., 2021, Nagata et al., 2019), as well as muscle dissatisfaction and drive for muscularity (Eik-Nes et al., 2018, Frederick et al., 2007), all of which characterize MD symptomatology. Additionally, investigating symptomatology on a spectrum is important given the psychosocial distress and impairment of MD symptoms (Tod et al., 2016). Therefore, it is important to determine the occurrence of MD symptomatology (i.e., as a continuous phenomenon) in the general population.

The Muscle Dysmorphic Disorder Inventory (MDDI) is a widely used measure of MD symptomatology (Hildebrandt et al., 2004). Specifically, the MDDI includes three subscales (Drive for Size, Appearance Intolerance, and Functional Impairment), as well as a total score, that capture attitudes and behaviors related to MD, with higher scores indicating greater MD symptomatology (Hildebrandt et al., 2004). Additionally, prior research has used a clinical MD cut-off score of ≥ 40 on the MDDI total score (Longobardi et al., 2017, Nagata et al., 2021, Varangis et al., 2012, Zeeck et al., 2018), which may afford healthcare professionals with a potential initial screening tool for MD. Therefore, the use of MDDI scores to capture MD symptomatology in relation to key sociodemographic correlates can inform intervention and prevention efforts among healthcare and public health professionals, as well as potentially new clinical cut-off points.

Therefore, the aims of this study were:

1. To describe the occurrence of MD symptomatology and clinical risk among a national sample of adolescents and young adults in Canada. It was hypothesized that men would report greater unadjusted MD symptomatology compared to women and transgender/gender non-conforming (TGNC) participants. Given the dearth of literature, there was no a priori hypothesis of how prevalent MD clinical risk would be among the sample.

2. To determine whether lifetime anabolic-androgenic steroid use (AAS) is more common among those with greater MD symptomatology. It was hypothesized that those who report any lifetime AAS use would have higher MDDI scores in both unadjusted and adjusted analyses.

3. To determine the sociodemographic characteristics of Canadian adolescents and young adults associated with MD symptomatology. It was hypothesized that those with lower BMIs and men would be more likely to report greater MD symptomatology in adjusted analyses. No other a priori hypothesis were established for aim three.

Section snippets

Methods

Participants included 2256 adolescents and young adults from the Canadian Study of Adolescent Health Behaviors, a wide-ranging survey investigating the social and behavioral health of young people who completed an online survey via Qualtrics. The sample was recruited via Instagram and Snapchat advertisements, without targeting specific populations, from November to December 2021. Advertisements invited participants to complete a survey related to eating, exercise, and health behaviors.

Results

The overall sample had a mean age of 22.9 (SD = 3.9) and mean BMI of 24.6 (SD = 5.1). More than half the sample were women (55.7 %), with 37.6 % men and 6.7 % identifying as TGNC. The majority of the sample identified as White (61.5 %) and heterosexual (59.6 %). Full sample sociodemographic characteristics can be reviewed in Table 1.

Results for aim one showed that participants had an average MDDI total score of 31.6 (SD = 8.0). For the subscales, the average scores were 10.8 (SD = 5.2) for

Discussion

This study is one of the few to investigate MD symptomatology among a community sample of adolescents and young adults. Findings for aim one showed that MD symptomatology, measured using the MDDI, was relatively common among the sample, with an average score of 31.6 among the overall sample, with men reporting greater total MD symptomatology compared to women and TGNC participants, which confirms our study hypothesis. Indeed, the mean MDDI scores across genders were highly variant. Men in our

Conclusion

Among a national sample of Canadian adolescents and young adults, MD symptomatology was relatively common, particularly among boys and men. MD symptomatology differed based on several sociodemographic characteristics, including lower BMI, those of South Asian and Middle Eastern descent, and sexual minority identities. Findings have important implications for professionals. More research is needed to understand the psychological and social factors associated with MD symptomatology among

Funding

This study was funded by the Connaught New Researcher Award (#41707) at the University of Toronto.

CRediT authorship contribution statement

KTG: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Writing - original draft; Writing - review & editing. LH: Conceptualization; Visualization; Writing - original draft; Writing - review & editing. MLC: Conceptualization; Writing - review & editing. RFR: Conceptualization; Writing - review & editing. SBM: Conceptualization; Writing - review & editing. JMN:

Conflicts of interests

All authors report no conflicts of interest.

References (83)

  • D.L. Grammas et al.

    Internalization of messages from society and perfectionism as predictors of male body image

    Body Image

    (2009)
  • A.J. Gruber et al.

    Compulsive weight lifting and anabolic drug abuse among women rape victims

    Comprehensive Psychiatry

    (1999)
  • T. Hildebrandt et al.

    Muscularity concerns among men: Development of attitudinal and perceptual measures

    Body Image

    (2004)
  • C. Longobardi et al.

    Muscle dysmorphia and psychopathology: Findings from an Italian sample of male bodybuilders

    Psychiatry Research

    (2017)
  • J.K. McGuire et al.

    Body image in transgender young people: Findings from a qualitative, community based study

    Body Image

    (2016)
  • S.B. Murray et al.

    The enigma of male eating disorders: A critical review and synthesis

    Clinical Psychology Review

    (2017)
  • J.M. Nagata et al.

    Boys, bulk, and body ideals: Sex differences in weight-gain attempts among adolescents in the United States

    Journal of Adolescent Health

    (2019)
  • J.M. Nagata et al.

    Psychometric validation of the muscle dysmorphic disorder inventory (MDDI) among U.S. transgender men

    Body Image

    (2022)
  • J.M. Nagata et al.

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

    Preventive Medicine Reports

    (2022)
  • C.G. Pope et al.

    Clinical features of muscle dysmorphia among males with body dysmorphic disorder

    Body Image

    (2005)
  • H.G. Pope et al.

    Muscle dysmorphia: An underrecognized form of body dysmorphic disorder

    Psychosomatics

    (1997)
  • L.A. Ricciardelli et al.

    The role of ethnicity and culture in body image and disordered eating among males

    Clinical Psychology Review

    (2007)
  • K.A. Romano et al.

    Examining associations among weight stigma, weight bias internalization, body dissatisfaction, and eating disorder symptoms: Does weight status matter

    Body Image

    (2021)
  • J.S. Santelli et al.

    Guidelines for adolescent health research: A position paper of the society for adolescent medicine

    Journal of Adolescent Health

    (2003)
  • A. Toulany et al.

    Acute care visits for eating disorders among children and adolescents after the onset of the COVID-19 pandemic

    Journal of Adolescent Health

    (2022)
  • T.L. Tylka et al.

    Support for an expanded Tripartite Influence Model with gay men

    Body Image

    (2012)
  • M. Alegría et al.

    Social determinants of mental health: Where we are and where we need to go

    Current Psychiatry Reports

    (2018)
  • P.D. Allison

    Missing data

    (2002)
  • Diagnostic and statistical manual of mental disorders

    (2013)
  • A.L. Amodeo et al.

    Muscle dysmorphia: What about transgender people?

    Culture, Health and Sexuality

    (2022)
  • H.L. Barnett et al.

    Body type preferences in Asian and Caucasian college students

    Sex Roles

    (2001)
  • A.J. Blashill et al.

    Anabolic steroid misuse among US adolescent boys: Disparities by sexual orientation and race/ethnicity

    American Journal of Public Health

    (2017)
  • F. Bozsik et al.

    Thin is in? Think again: The rising importance of muscularity in the thin ideal female body

    Sex Roles

    (2018)
  • N.L. Burke et al.

    Socioeconomic status and eating disorder prevalence: At the intersections of gender identity, sexual orientation, and race/ethnicity

    Psychological Medicine

    (2022)
  • J.P. Calzo et al.

    Sexual orientation disparities in eating disorder symptoms among adolescent boys and girls in the UK

    European Child and Adolescent Psychiatry

    (2018)
  • J.P. Calzo et al.

    Development of muscularity and weight concerns in heterosexual and sexual minority males

    Health Psychology

    (2013)
  • J.P. Calzo et al.

    Patterns of body image concerns and disordered weight- and shape-related behaviors in heterosexual and sexual minority adolescent males

    Developmental Psychology

    (2015)
  • J.P. Calzo et al.

    Gender conformity and use of laxatives and muscle-building products in adolescents and young adults

    Pediatrics

    (2016)
  • E.J. Compte et al.

    Psychometric evaluation of the Muscle Dysmorphic Disorder Inventory (MDDI) among gender-expansive people

    Journal of Eating Disorders

    (2022)
  • T.T. Eik-Nes et al.

    Prospective health associations of drive for muscularity in young adult males

    International Journal of Eating Disorders

    (2018)
  • D.A. Frederick et al.

    Desiring the muscular ideal: Men’s body satisfaction in the United States, Ukraine, and Ghana

    Psychology of Men and Masculinity

    (2007)
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