EVALUATION OF THE PREVALENCE OF MUSCLE DYSMORPHIA SYMPTOMATOLOGY AND THE ASSOCIATION WITH DIETARY INTAKE IN COLLEGE AGE MALES
A thesis submitted to the Kent State University College of Education, Health, and Human Services in partial fulfillment of the requirements for the degree Master of Science in Nutrition and Dietetics
By
Ashley Rickard
August 2014
A thesis written by
Ashley Deanna Rickard
B.S., The Pennsylvania State University, 2012
M.S. Kent State University, 2014
Approved by
______, Director, Master’s Thesis Committee Amy Miracle
______, Member, Master’s Thesis Committee Natalie Caine-Bish
______, Member, Master’s Thesis Committee Lisa Chinn
Accepted by
______, Director, School of Health Sciences Lynne Rowan
______, Dean, College of Education, Health and Human Services Daniel Mahony
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RICKARD, ASHLEY DEANNA, M.S., August 2014 Nutrition and Dietetics
EVALUATION OF THE PREVALENCE OF MUSCLE DYSMORPHIA SYMPTOMATOLOGY AND THE ASSOCIATION WITH DIETARY INTAKE IN COLLEGE AGE MALES (107 pp.)
Director of Thesis: Amy Miracle, Ph.D., R.D., CSSD
The purpose of this study was to evaluate the prevalence of muscle dysmorphia
(MD) symptomatology in men with varying exercise levels and to evaluate the association between MD symptomatology and dietary intake. College aged males
(n=110) completed an online survey including demographic information, an instrument for identifying MD symptomatology known as the Muscle Dysmorphia Disorder
Inventory (MDDI), and a food frequency questionnaire (FFQ). For statistical analysis, participants were grouped in three different ways: 1) cardiovascular exercise level, 2) weightlifting level, and 3) MDDI score.
It was found that 12.73% (n=14) of the study population had MDDI scores indicating high levels of MD symptomatology. This prevalence is higher than previously reported and could reveal that the proportion of men struggling with MD is higher than previously thought. When participants were categorized by weightlifting level, the high weightlifting group exhibited significantly higher MDDI scores than the low weightlifting group. The high weightlifting group also had a higher percentage of intake from protein than the other study groups. This could indicate that weightlifting levels
may be used as an indicator of MD symptomatology and that high protein intake may be a dietary strategy used by men with MD. This study also demonstrated that men who scored high or moderate on the MDDI had significantly higher energy intake than those who scored low, and men with low and moderate MDDI scores consumed a significantly higher percentage of their diet from carbohydrate than men with high MDDI scores.
ACKNOWLEDGEMENTS
It is with immense gratitude that I acknowledge the constant support, both personally and professionally, of my thesis adviser, Dr. Amy Miracle. I could not have asked for a better advisor to guide me through this process, and I am truly thankful for your guidance and the opportunity I have had to work with you. I would also like to thank my committee members, Dr. Natalie Caine-Bish and Dr. Lisa Chinn, for guiding me, providing me with valuable input and advice, and challenging me throughout this process. Additionally, I would like to thank Dr. Nancy Burzminski for her ceaseless encouragement and support throughout my dietetic internship and graduate studies. I have truly been blessed beyond belief with a group of professors who are far above average and have facilitated my growth throughout this season of life.
A huge thank you goes out to Kristin Yeager and her statistical and qualitative software consulting team at the Kent State University library. Your guidance and assistance throughout this process were irreplaceable, and you helped turn an collection of abstract ideas into a practical reality.
It is during difficult times that we gain new perspectives in life, and through these two years, I have come to appreciate my wonderful parents in a completely new way.
Mom and Dad, I am grateful for the depths of your love for me, for your unending support, and for the faith you always have in me. I cannot thank you enough for your constant provision, for demonstrating the importance of hard work and perseverance, and for doing small things with great love. I love you so, so very much. To Bobby, Nana,
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and Mike, thank you for always supporting me and loving me in all circumstances. I am truly blessed with the most wonderful family for which anyone could ask.
Above all, I thank God for his absolute sovereignty and his relentless pursuit of my heart. I am thankful that he continually refuses to give up on me and will be faithful to complete the work he has begun in me and through me. “He has made everything beautiful in its time. He has also set eternity in the human heart; yet no one can fathom what God has done from beginning to end.” – Ecclesiastes 3:11
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TABLE OF CONTENTS
ACKNOWLEDGEMENTS …………………………………………………………….. iii
LIST OF FIGURES ……………………………………………………………………... vii
LIST OF TABLES ………………………………………………………………………. viii
CHAPTER
I. INTRODUCTION ...... 1 Statement of the Problem ...... 5 Hypotheses ...... 5 Definition of Terms ...... 5
II. LITERATURE REVIEW …….………………………………………...…... 7 Male Physique and the Emphasis on Muscularity ...... 7 Masculinity and Muscularity from a Cultural Perspective ...... 7 Muscularity and Body Image in Males ...... 9 Eating Disorders in Males ...... 11 Muscle Dysmorphia ...... 13 The History of Muscle Dysmorphia ...... 13 Muscle Dysmorphia in the DSM-V ……………………………………. 17 Prevalence of Muscle Dysmorphia ...... 17 Research on the Characteristics of Men with Muscle Dysmorphia ...... 18 Demographics...... 18 Attitudes and behaviors...... 19 Mirror checking...... 22 Anabolic steroid use...... 23 Eating attitudes and nutrition habits in MD...... 24 Psychological Profile of Men with MD ...... 26 Etiology of Muscle Dysmorphia ...... 28 Conceptual Models Illustrating the Development of MD ...... 28 Research on Contributing Factors ...... 31 Self-objectification...... 31 Perfectionism...... 33 Media pressure and ideal body internalization...... 33 Childhood experience...... 34 Participation in sport...... 36 Interaction between body dissatisfaction, body distortion, and self- esteem...... 37 Tools for Identifying and Measuring Muscle Dysmorphia ...... 39 v
III. METHODS ...... 46 Participants ...... 46 Study Recruitment ...... 47 Questionnaire Design ………………………………………………...... 48 Subject Demographics and Characteristics ...... 48 Muscle Dysmorphia Disorder Inventory …………………………...…... 48 Block Food Frequency Questionnaire ...... 49 Experimental Design ...... 49 Statistical Analysis …………………………………………………………. 51
IV. JOURNAL ARTICLE ...... 52 Introduction ………………………………………………………………… 52 Methods……………………………………………………………………... 54 Participants ...... 54 Study Recruitment ...... 55 Questionnaire Design …………………………………….……...... 56 Subject demographics and characteristics...... 56 Muscle dysmorphia disorder inventory. …………………...…... 56 Block food frequency questionnaire...... 57 Experimental Design ...... 57 Statistical Analysis …………………..…………………………………. 59 Results ……………………………………………………………………… 59 Discussion ………………………………………………………………….. 65 Clinical Applications ……………………………………………………….. 75
APPENDICES ...... 78 APPENDIX A. MUSCLE DYSMORPHIA DISORDER INVENTORY …………. 79 APPENDIX B. STUDY CONSENT FORM ………………………………………. 81 APPENDIX C. DEMOGRAPHIC, EXERCISE, AND MD-RELATED QUESTIONS …………………………………………………………………... 84
REFERENCES ...... 89
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LIST OF FIGURES
Figure Page
1. Grieve’s conceptual model of the development of MD …………………………. 29
2. Lantz, Rhea, and Mayhew’s conceptual model of the development of MD ..….... 30
3. Cafri’s conceptual model of the development of risky body change strategies .... 31
4. Thompson and Gray’s Contour Drawing Rating Scale …………………………. 42
5. Hildebrandt et al.’s Bodybuilder Image Grid …………………………………… 43
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LIST OF TABLES Table Page
1. Demographic Characteristics of Kent State University Male Study Participants .. 61
2. Mean and Standard Deviations of Muscle Dysmorphia Disorder Inventory Score (MDDI) and Percentage of Dietary Intake Variables with Participants Grouped by Cardiovascular Exercise Level (n=110) ……………………..…....…………. 62
3. Mean and Standard Deviations of Muscle Dysmorphia Disorder Inventory Score (MDDI) and Percentage of Dietary Intake Variables with Participants Grouped by Weightlifting Level (n=107) …………………………………………………. 63
4. Mean and Standard Deviations of Percentage of Dietary Intake Variables with Participants Grouped by Muscle Dysmorphia Disorder Score (MDDI) (n=110) .. 63
5. Pearson Correlation Coefficients between Muscle Dysmorphia Disorder Inventory Score (MDDI) and Percentage of Dietary Intake Variables (n=110) … 64
6. Distribution of Muscle Dysmorphia Disorder Inventory Scores (MDDI) Between Varying Exercise Levels with Participants Grouped by Cardiovascular and Weightlifting Level …………………………………………………………. 65
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CHAPTER I
INTRODUCTION
In the past, the prevailing idea that unhealthy body image and disordered eating patterns only affect women meant that most of the research on body image disturbances was done in that population. Recently, however, researchers have demonstrated that men also experience pressures to look a certain way and the resulting body image disturbances
(Dakanalis et al., 2013; Goltz, Stenzel, & Schneider, 2013; Grieve, 2007). Whereas many women feel societal pressure to reach a thinner, smaller body size, the opposite is true for men, many of whom feel pressure to achieve a higher level of muscularity
(Stanford & McCabe, 2005; Stanford & McCabe, 2002; Cafri, Strauss, & Thompson,
2002; Pope, Gruber, Mangeweth, et al., 2000). The etiology of this pressure is multifaceted including factors such as media messages or the influence of professional sports, and research indicates that a man’s level of muscularity is often used to appraise his masculinity, power, dominance, strength, and overall lack of femininity (Mishkind et al., 1986, Pope, Phillips, Olivardia, 2000; Wesely, 2001).
Striving to maintain a perceived adequately muscular physique drives some men to employ unhealthy strategies for managing weight and increasing muscularity, and this is the origin from which a condition known as muscle dysmorphia (MD) arises. MD is a body image disturbance in which individuals perceive themselves to lack muscularity and become preoccupied with increasing their musculature to reach what they consider an ideal body frame (Olivardia, 2001; Grieve & Shacklette, 2012; Grieve, 2007; Grieve,
Truba, & Bowersox, 2009; Pope, Gruber, Choi, Olivardia, & Phillips, 1997). Behaviors 1 2 which result from this distorted self-image may include excessive weightlifting, performance-enhancing drug use, frequent mirror-checking, and many others, and these behaviors, as well as the underlying psychological issues, put the physical, mental, and emotional wellbeing of these men at risk (Olivardia, 2001). The strict fitness and nutrition regimens inherent in MD commonly interrupt the lives and functioning of men, negatively impacting social, occupational, and recreational areas of life (Olivardia, 2001;
Pope et al., 1997). Research has shown that men with MD report sacrificing important life events to workout, avoiding social situations in which their physique may be exposed, and struggling in relationships due to intense self-consciousness, as well as many reporting many other life-altering effects of MD (Cafri et al., 2005; Giardino &
Prociano, 2012; Olivardia, 2001; Pope et al., 1997).
Although a larger body of research exists surrounding body image disturbances and eating disorders in women, researchers are learning more and more about these issues in men. Preti and colleagues (2009) found the prevalence of anorexia nervosa in men to be 0%, bulimia nervosa to be 0.12%, and binge eating disorders to be 1.22%, while
Hudson and colleagues (2007) found the prevalence of anorexia nervosa in men to be
0.3%, bulimia nervosa to be 0.5%, and binge eating disorders to be 4.0%. A 2013 study by Leichty and Lee (2013) found the prevalence of an eating disorder diagnosis in men to be 0.49%.
Although these percentages appear small, in the American population at large, it could indicate that tens of thousands or even millions of men fit the criteria for disordered eating. The National Eating Disorders Association and the National Association of
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Anorexia Nervosa and Associated Disorders estimate that between 24 and 30 million individuals in the United States suffer from an eating disorder and of these, 10-15% are male (National Eating Disorders Association; National Association of Anorexia Nervosa and Associated Disorders, 2013). There are also other subclinical and atypical types of eating disorders, and experts believe that these conditions are even more common, although many men with these will never be diagnosed or receive help (National Institute for Clinical Excellence, 2004).
This information does give some indication that men experience body image disturbances and disordered eating patterns, but it is important to keep in mind that MD is distinct from eating disorders. MD was not included in the American Psychiatric
Association’s DSM-IV because experts could not come to a consensus on its classification, debating between a form of Body Dysmorphic Disorder (BDD), an eating disorder, or on the spectrum of obsessive compulsive disorders (Nieuwoudt, Zhou,
Coutts, & Booker, 2012). After considering the growing body of evidence in support of the diagnostic validity of MD, it was added to the most recently published DSM-V as a specifier of BDD (American Psychiatric Association, 2013).
The first researchers to identify MD were Pope, Katz, and Hudson (1993). They conducted a study to examine the psychiatric effects of anabolic steroids of bodybuilders, but noticed a curious condition affecting a select group of the men. Some of the bodybuilders had body image disturbances in that they perceived themselves to be smaller and weaker than they were in reality. The researchers coined the term “reverse anorexia” to describe the syndrome because it seemed that these men had disordered
4 body images which were the opposite of those individuals who suffered from anorexia nervosa. In 1997, Pope et al. wrote a follow up article in which “reverse anorexia” was renamed Muscle Dysmorphia because the researchers felt that it more accurately described the syndrome they observed. Muscle Dysmorphia and eating disorders are similar in that they both involve a preoccupation with perceived defects of the body and the use of various techniques to attempt to change this defect, but they differ in that while eating disorders lead the individual to focus on a pathological pattern of eating, individuals with MD develop a pathological pattern of exercise, with diet as a secondary focus (Pope, Gruber, Choi, Olivardia, Phillips, 1997).
Research on the prevalence of MD has primarily focused on bodybuilders.
Conducting the Structured Clinical Interview for the DSM-III-R (SCID) to examine
“reverse anorexia” symptoms, Pope and Katz (1994) estimated that the prevalence of MD within a weightlifting population could be as high as 10%. Even if it was found to be lower, similar to the estimated proportion of men who suffer from eating disorders such as anorexia nervosa or bulimia nervosa, this would still indicate that millions of men suffer from MD. In addition, there may be many more men who have a subclinical presentation of MD, exhibiting the disordered traits but to a lesser severity. Since Pope and colleagues (1993) first studied MD using the SCID, several researchers have developed instruments for assessing MD symptoms, with the most well-known being the
Muscle Dysmorphia Disorder Inventory (MDDI) by Hildebrandt, Langenbucher, and
Schlundt (2004), and these tools could help researchers to better understand the prevalence of both MD and subclinical MD in varying populations.
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Statement of the Problem
Because MD has primarily been studied in bodybuilding or competitive athlete populations, there is very little known about MD’s prevalence in other sport environments or the general population. For this reason, this study will seek to examine the prevalence of MD-related traits in recreationally exercising men and non-exercising men. In addition, another gap in the present knowledge about MD is the relationship between MD-related traits and dietary intake. Research has demonstrated that MD causes alterations in behaviors such as weightlifting habits and anabolic steroid use, but it is unknown how MD-related traits impact the diet of men or whether there is an impact at all. The current study will take the first steps toward understanding the prevalence of
MD in men with varying exercise levels and the association between MD and nutrition status by evaluating the consumption patterns of men who exhibit the characteristics.
Hypotheses
1. The prevalence of MD will be higher in high recreationally exercising men
than in low recreationally exercising men or sedentary men.
2. Higher scores on an MD inventory will be related to intake of increased total
calories and differences in macronutrient distribution.
Definition of Terms
Muscularity: The extent to which the build of one’s body is characterized by well- developed muscle tissue, typically enhanced by weight training or other athletic activities.
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Low Cardiovascular Exerciser: An individual participating in recreational exercise or organized team sports who accumulates 150-299 minutes of moderate- intensity cardiovascular exercise per week, with the lower bound defined by the 2008
Physical Activity Guidelines for Americans. NCAA Division I athletes are excluded from this category.
High Cardiovascular Exerciser: An individual participating in recreational exercise or organized team sports who accumulates 300 or more minutes of moderate intensity cardiovascular exercise per week. NCAA Division I athletes are excluded from this category.
Sedentary Individual: An individual who may or may not participate in recreational exercise or organized team sports who accumulates less than 150 minutes of moderate-intensity cardiovascular exercise per week, based on the 2008 Physical Activity
Guidelines for Americans.
Low Weightlifting Individual: An individual participating in recreational weightlifting who accumulates 0-1.5 hours of weightlifting activity per week.
Moderate Weightlifting Individual: An individual participating in recreational weightlifting who accumulates 1.6-4.5 hours of weightlifting activity per week.
High Weightlifting Individual: An individual participating in recreational weightlifting who accumulates 4.6 or more hours of weightlifting activity per week.
CHAPTER II
LITERATURE REVIEW
Male Physique and the Emphasis on Muscularity
Masculinity and Muscularity from a Cultural Perspective
Traditionally, a muscular physique has been one of the fundamental aspects of male gender identity. Western culture dictates that men should be dominant, powerful, strong, unemotional, and confident (Mishkind, Rodin, Silberstein, & Striegel-Moore,
1986; Nesbitt & Penn, 2000; Rosenkrantz, Bee, Vogel, & Broverman, 1968). In 1968,
Rosenkrantz, Bee, Vogel, and Broverman (1968) conducted a study to examine the stereotypical characteristics associated with masculinity and found that these included aggressiveness, independence, competitiveness, “feelings not easily hurt”, “acts as a leader”, “never cries”, and others. Decades later, Nesbitt and Penn (2000) partially repeated this experiment to see how the masculine stereotype had changed over the years.
Although there were fewer gender stereotypes than in the previous study, there still exists a high level of agreement on what makes a male “masculine” (Nesbitt & Penn, 2000).
Muscularity intertwines with the cultural view of masculinity because as
Mishkind and colleagues (1986) state, “A muscular physique may serve as a symbolic embodiment of these personal characteristics.” Darden demonstrated that individuals rate mesomorphic body types as more masculine than other somatotypes. Taking this a step further, researchers have found that people associate traits thought to be more masculine with adolescent boys who exhibited a mesomorphic body type, rather than endomorphic or ectomorphic (Darden, 1972; Hanley, 1951). Other, more recent research has 7 8 demonstrated similar findings, linking musculature with the perception of masculine traits such as power, dominance, and virility (Alexander, 2003; McCreary & Sasse, 2000;
Mishkind et al., 1986; Petrie, et al., 1996;).
Leit, Pope, and Gray (2001) examined Playgirl centerfolds to investigate cultural trends in the ideal male body over a span of 25 years. As time went on, centerfolds had increased body mass index (BMI) and decreased body fat, with the most notable change occurring in muscularity as the fat free mass index (FFMI) of the models increased sharply over the time period (Leit et al., 2001). This reflects changes in the cultural expectation for a masculine body, indicating that it has become increasingly muscular as time has progressed. Leit, Pope, and Gray (2001) corroborated this finding with trends observed in magazines, action figures, and other forms of media over time, as well as the likelihood that anabolic steroid use has contributed (Leit et al., 2001). Leit and colleagues (2001) also touched upon the notion that because women have gained equality with men in most areas of life, this makes a muscular appearance all the more important as a distinguisher between masculinity and femininity. As described by Klein (1993):
“The path taken by those wishing to accrue flesh has much more to do with
gender insecurities. To be male has, in our culture, been linked with dangerous
and demanding occupations and roles, such as frontiersman, soldier, policeman
and doctor. But the golden era when ‘men were men’ has passed, and the
powerful roles traditionally the exclusive province of men have vanished,
weakened or are no longer gender-specific. Accordingly, many bodybuilding
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men have clutched to themselves the only trait that gives them hegemony over
women; their size.” (Klein, 1993, pp. 36)
Muscularity and Body Image in Males
In addition to males being evaluated by others based on the functional dimensions of their muscularity, they commonly view themselves along this same axis, forming a strong connection between physical build and masculinity (Kurtz, 1969; Lerner, Orlos, &
Knapp, 1976). As stated by Mishkind and colleagues (1986):
“…they experience an intimate relationship between body image and potency—
that is, masculinity—with the muscular mesomorph representing the masculine
ideal. A man who fails to resemble the body ideal is, by implication, failing to
live up to sex-role norms, and may thus experience the consequences of violating
such norms.” (Mishkind et al., 1986, pp. 550)
For many men, their views about their body, perceived level of muscularity, and ideal physique have an impact on self-esteem. During a study of male college students aged 18-30, Olivardia, Pope, Borowicki, and Cohane (2004) demonstrated a negative correlation between body dissatisfaction variables and men’s self-esteem. Having higher levels of muscle displeasure, muscle belittlement, dislike of one’s body proportions, or feelings of fatness, as well as higher body dissatisfaction according to the Eating
Disorders Inventory (EDI), was related to lower levels of self-esteem (Olivardia, Pope,
Borowiecki, & Cohane, 2004). Additionally, men who perceived themselves as having a higher FFMI measurement had higher self-esteem levels, suggesting that fat free mass contributes to a man’s view of self (Olivardia et al., 2004). Chittester and Hausenblas
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(2009) found similar results in college-aged men, suggesting that drive for muscularity was correlated with self-esteem; men with higher drive for muscularity exhibited lower self-esteem, again indicating that male self-esteem is interrelated with muscularity.
A common finding in male body image research is that men have both an image of their current body and an image of their ideal body, and these two typically do not match. Pope et al. (2000) measured body image perception in undergraduate male students from the United States, France, and Austria, with their conclusions confirming this idea. Men perceived themselves as being slightly, although significantly, more muscular (1.2 kg/m2) than they were in reality, but this discrepancy was small compared to the perceived difference between their current FFMI and their ideal FFMI (Pope et al.,
2000). Men described their ideal FFMI as being on average 3.4 kg/m2 greater than their own, amounting to 27-29 pounds of additional muscle mass (Pope et al., 2000). They also indicated that they believed women prefer a FFMI of approximately 3.6 kg/m2 greater than their own, or about 27-32 pounds of muscle mass on top of their current measurement (Pope et al., 2000).
Cafri, Strauss, and Thompson (2002) also demonstrated that men desired to be more muscular than they were in reality. The study used a somatromorphic matrix and found that men, dissatisfied with their current level of muscularity, desired an average of
15 additional pounds of muscle (Cafri, Strauss, & Thompson, 2002). Frederick and colleagues (2007) used silhouette measures to examine body satisfaction as it relates to muscularity and body fat in college-age males from the United States, Ukraine, and
Ghana. 90% of the men from the United States desired a higher level of muscularity,
11 while 69% of Ukrainian and 49% of Ghanaian men shared in this desire (Frederick et al.,
2007). An interesting finding of this study was that men who embraced a more traditional view of masculinity and male roles were also more likely to value muscularity in male bodies and desire to increase their own muscularity (Frederick et al., 2007).
A man’s body image seems to be, in part, affected by the individual’s physique.
Watkins, Christie, and Chally (2008) conducted a study examining the impact of BMI on cognitive and affective dimensions of body image in college men. A significant relationship between BMI and body image was found, with higher BMIs being associated with more negative body image and weight or shape concern (Watkins, Christie, &
Chally, 2008). Additionally, men who had BMIs classifying them as underweight, overweight, or obese had significantly more body dissatisfaction than their normal- weight counterparts (Watkins et al., 2008). Huddy, Nieman, and Johnson (1993) demonstrated that body fat also contributed to male body image in college students, revealing a negative linear relationship between body image and body fat percentage, especially for the non-athletes (Huddy, Nieman, & Johnson, 1993). The researchers also found that athletes had relatively higher body image scores than nonathletes, possibly because their “body image is more closely tied to their athletic accomplishments than to physical attributes” (Huddy et al., 1993).
Eating Disorders in Males
Eating disorders and disordered eating behaviors have traditionally been associated with women, yet the literature has revealed that men suffer from these conditions as well. According to the National Eating Disorders Association, 10 million
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American men will suffer from an eating disorder of clinical severity at some point in their life, and about 10% of eating disorder patients treated by mental health professionals are males (National Eating Disorders Association, n.d.). According to Thompson,
Brugha, and Palmer (2009), men are most likely to develop eating disorders between the ages of 16 and 24, and Hudson, Hiripi, Pope, and Kessler (2007) confirmed this fact by finding a median age of onset for all types of eating disorders of 18 to 21. Although the late teens and early twenties are the most common years for an eating disorder, they can develop in men of all ages (Dalgliesh & Nutt, 2013).
A variety of researchers have sought to determine the prevalence of eating disorders and disordered eating behaviors in men. Liechty and Lee (2013) examined the longitudinal predictors of dieting and eating pathology in young male adults in the United
States and found the prevalence of dieting (11.3%), extreme weight loss behaviors
(1.42%), binge eating (5.10%), and eating disorder diagnosis (0.49%). Preti et al. (2009) and Hudson et al. (2007) estimated the prevalence of specific types of eating disorders in men; Preti et al. (2009) found the prevalence of anorexia nervosa to be 0%, bulimia nervosa to be 0.12%, and binge eating disorder to be 1.22%, while Hudson and colleagues (2007) estimated the prevalence of anorexia nervosa at 0.3%, bulimia nervosa at 0.5%, and binge eating disorders at 4.0%. These percentages may seem diminutive, yet in the American population at large, this could signify that millions of men fall into one of these categories of disordered eating. The concern also exists that even more men have subclinical or atypical forms of eating disorders. Experts believe that these conditions are even more common than clinically severe eating disorders and that men
13 with these conditions are less likely to be diagnosed or receive treatment (National
Institute of Clinical Excellence, 2004).
The statistics on eating disorders in men indicate that contrary to traditional views, eating disorders, as well as body image disturbances, are not just a problem for women but affect men as well. Although distinct from eating disorders, Muscle
Dysmorphia is one form of body image disturbance that has come to light over the past two decades.
Muscle Dysmorphia
The History of Muscle Dysmorphia
Muscle Dysmorphia (MD) is a body image disturbance characterized by a perceived lack of muscularity and a preoccupation with increasing musculature (Grieve,
2007; Grieve & Shacklette, 2012; Grieve, Truba, & Bowersox, 2009; Olivardia, 2001;
Pope, Gruber, Choi, Olivardia, & Phillips, 1997). Mainly observed in men, individuals with MD have a strong and typically irrational belief that they are too small or skinny, despite often having an above-average level of muscularity (Murray, et al., 2013). This condition was first identified by Pope, Katz, and Hudson (1993) in a sample of bodybuilders. The researchers noticed that many of the bodybuilders in their study exhibited a set of cognitive and behavioral traits similar, albeit opposite, to those seen in anorexia nervosa patients (Choi, Pope, & Olivardia, 2002; Dakanalis & Riva, 2013;
Olivardia, Pope, & Hudson, 2000). While anorexic individuals have a pathological concern with being too large and have an intense fear of gaining weight, the men in the study demonstrated the same level of concern with being inadequately muscular and
14 increasing lean body mass, leading Pope and colleagues (1993) to term the disorder
“reverse anorexia”. Soon after, this condition was re-conceptualized as “Muscle
Dysmorphia” (MD), and the first diagnostic criteria were proposed:
1. “The person has a preoccupation with the idea that one’s body is not
sufficiently lean and muscular. Characteristic associated behaviors include
long hours of lifting weights and excessive attention to diet.
2. The preoccupation causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning, as demonstrated
by at least two of the following four criteria: (a) the individual frequently
gives up important social, occupational, or recreational activities because of a
compulsive need to maintain his or her workout and diet schedule; (b) the
individual avoids situations where his or her body is exposed to others, or
endures such situations only with marked distress or intense anxiety; (c) the
preoccupation about the inadequacy of body size or musculature causes
clinically significant distress or impairment in social, occupational, or other
important areas of functioning; (d) the individual continues to work out, diet,
or use ergogenic (performance-enhancing) substances despite knowledge of
adverse physical or psychological consequences.
3. The primary focus of the preoccupation and behaviors is on being too small or
inadequately muscular, as distinguished from fear of being fat, as in anorexia
nervosa, or a primary preoccupation only with other aspects of appearance, as
in other forms of BDD. “ (Pope et al., 1997, pp. 556)
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One reason for the shift from “reverse anorexia” to MD was that eating disturbances were seen as secondary to the diagnosis rather than as a core feature of the condition, but this debate is still occurring between researchers in the field (Murray, et al., 2012; Olivardia, 2001). Since the onset of MD-related research, experts have had a difficult time characterizing MD due to its multifaceted nature. The American
Psychiatric Association recognizes MD, yet it was not included in the fourth version of the Diagnostic and Statistical Manual for Mental Disorders (DSM) because experts were unable to come to a consensus on whether the condition should be classified as a form of
Body Dysmorphic Disorder (BDD), an obsessive compulsive spectrum disorder, or an eating disorder (Murray, Rieger, Touyz, & Garcia, 2010; Murray & Touyz, 2013;
Nieuwoudt, Zhou, Coutts, & Booker, 2012).
Pope et al. (1997) proposed that MD should be classified as a form of BDD because of the similarities between the two conditions. In BDD, individuals are preoccupied with a part of the body which is perceived to be defective, and this preoccupation typically leads to compulsive behaviors to correct the defect; these might include excessive exercise, dieting, or steroid use (Olivardia et al., 2000). In MD, the preoccupation is focused on overall muscularity, and the compulsive behaviors often include excessive weightlifting to address the supposed flaw (Olivardia et al., 2000).
Researchers in support of classifying MD as an Obsessive Compulsive Disorder (OCD) argue that the compulsion to achieve a muscular physique is severe and time consuming enough to impair normal life functioning, as seen in OCD (Nieuwoudt et al., 2012).
Similar to OCD patients, individuals with MD experience a significant disruption in
16 many areas of life including social, occupational, and recreational as a result of the condition and its compulsions (Pope et al., 1997). Some researchers feel strongly about classifying MD within the eating disorder spectrum and believe that MD could help delineate categories within Eating Disorders Not Otherwise Specified (EDNOS) (Murray
& Touyz, 2013). These individuals argue that the pathological patterns of eating and exercise in MD are comparative to those of eating disorders, despite having a different directionality (Murray & Touyz, 2013).
“Indeed, men who pathologically pursue hypermuscularity consistently endorse a
strikingly similar psychological profile to that of eating disordered patients,
including a similarly elevated profile of perfectionistic, obsessive, and anhedonic
traits, and sustained and elevated preoccupations with body image, diet, and
exercise (Davis & Scott-Robertson, 2000; Mangweth et al., 2001). Furthermore,
men with muscle dysmorphia closely resemble men with an eating disorder on a
wide range of indices of eating disorder pathology (e.g., exhibiting similar scores
on Eating Disorder Inventory subscales), suggesting that ‘the term ‘reverse
anorexia’ may be apt, as the pursuit of ‘bigness’ shows remarkable parallels to the
pursuit of thinness’.” (Murray et al., 2010, pp. 485-486)
Some of the dietary behaviors characteristic of men with MD include but are not limited to following a rigid diet plan with high protein, low fat, and specific calorie goals, eating very often even when not experiencing hunger, compensating for deviations from the diet (i.e. additional exercise), and experiencing pervasive anxiety, guilt, or distress when the diet is not followed precisely (Mangweth et al., 2001; Mossley, 2009; Murray et
17 al., 2010; Pope et al., 1997). Researchers in favor of classifying MD under the umbrella of eating disorders believe that these eating patterns and attitudes are key to the condition rather than secondary (Nieuwoudt, Zhou, Coutts, & Booker, 2012).
Muscle Dysmorphia in the DSM-V
The American Psychiatric Association released the fifth edition of the DSM in
2013, and for the first time, MD was included within the diagnostic codes (American
Psychiatric Association, 2013). Although it wasn’t identified as a distinct disorder, it was added as a specifier of BDD and is appropriate for use when the “individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular” (Amerian Psychiatric Association, 2013). This inclusion reflects the increasing amount of literature in support of MD and its clinical implications (Nemeroff et al., 2013; Phillips et al., 2010).
Prevalence of Muscle Dysmorphia
The prevalence of MD is still largely unclear due to the lack of consistency in the literature. The results of early examinations suggested that the prevalence of MD among bodybuilders is approximately 10%, but Grieve, Truba, and Bowersox (2009) suggested that this should be considered the upper limit (Pope & Katz, 1994). Olivardia (2001) suggested two other estimates of MD prevalence: (a) 500,000 men in the United States, based on approximately 5 million men holding a gym membership and 5% of weightlifters meeting the criteria for MD and (b) 90,000 men in the United States based on an estimated 1 million men with BDD and 9% of men with BDD having MD (Pope et
18 al., 1997; Pope, Phillips, & Olivardia, 2000). Grieve, Truba, and Bowersox (2009) brought up another important idea when considering the prevalence of MD:
“… even a much lower level of prevalence, say that commensurate with anorexia
nervosa (between 0.5% and 1.0% of the population; APA, 2000), still indicates
that millions of men suffer from the disorder and are in need of treatment.
Further, prevalence rates do not take into account subclinical presentations of the
disorder. There are likely to be many more men who experience problems with
body image who do not meet diagnostic criteria for muscle dysmorphia, but for
whom intervention can lead to a healthier lifestyle.” (Grieve et al., 2009, pp. 307)
A study conducted by Goodale, Watkins, and Cardinal (2001) provides an example of a number of college students with subclinical levels of MD, and it is likely that considering individuals with subclinical MD would vastly increase the prevalence of the condition in the United States. Ultimately, more research will need to be done in the general population to develop a clearer picture of the widespread prevalence of MD.
Research on the Characteristics of Men with Muscle Dysmorphia
Demographics. During a case-control study on MD in male weightlifters,
Olivardia, Pope, and Hudson (2000) gained some insight into the demographics of men with MD. The researchers found that the average age of onset among the 24 subjects with MD was 19.4 years old (Olivardia et al., 2000). In the study, the men with MD and the normal comparison men were similar in characteristics including current age, height, weight, body fat percentage, marital status, education level, and race, but a statistically significant difference did exist in the muscularity of the men as measured by FFMI
19
(Olivardia et al., 2000). The men exhibiting MD had a mean FFMI of 25.2% while the men in the control group had a mean FFMI of 22.9% (Olivardia et al., 2000).
Cafri, Olivardia, and Thompson (2008) examined the symptom characteristics and psychiatric comorbidities exhibited in men with MD and demonstrated an average age of onset at 19.7, very similar to the age reported by Olivardia, Pope, and Hudson (2000).
The men with current MD, past MD, and no history of MD were similar in their demographic characteristics, although men with current or past MD had higher body weight than men with no history of MD (198.9 lb and 199.19 lb, respectively versus
180.38 lb), and men with current MD had higher BMIs than men with past MD or no history of MD (28.40 versus 26.75 and 26.36, respectively) (Cafri, Olivardia, &
Thompson, 2008).
In a study comparing various psychological and behavioral differences between men with MD, men with anorexia nervosa, and control gym-using men, Murray and colleagues (2012) found that the main demographic difference between these men was in
BMI. The MD group exhibited an average BMI of 32.40, which was significantly greater than the BMIs of men with anorexia nervosa (17.45) and the gym-using controls (26.01)
(Murray et al., 2012).
Attitudes and behaviors. In many cases, strict fitness and nutrition regimens and psychopathology interfere with the normal lives and functioning of men with MD. The symptoms of MD may cause disruptions in any or all areas of life, including social, occupational, or recreational (Olivardia, 2001; Pope et al., 1997). Men may feel compelled to maintain rigorous exercise and weightlifting routines, working out for long
20 hours and sacrificing important life events (Olivardia, 2001). For instance, Olivardia
(2001) discussed a man who missed his child’s birth because he could not bring himself to miss a workout, as well as an honors student who skipped a final exam to maintain his workout schedule. Of the 24 men with MD examined by Olivardia, Pope, and Hudson
(2000), 100% of the men had “given up enjoyable activities in order to go to the gym to get bigger.” Considering this level of sacrifice, it is evident the impact that MD can have on affected men.
Socially and recreationally, MD can also negatively impact the daily lives of men.
Spending an excessive amount of time weight training may cause men to neglect current relationships or prevent them from making new acquaintances (Grieve et al., 2009).
Additionally, some of the behavioral manifestations of MD are attempts by men to hide their physique from others (Cafri et al., 2005; Pope et al., 1997). These behaviors might include wearing heavy clothing or multiple layers to appear larger or avoid revealing the body to others (Giardino & Procidano, 2012; Pope et al., 1997). This could also mean that men with MD are so distressed at revealing their physique that they avoid going to the beach, swimming pools, locker rooms, and other social settings or forming romantic relationships, all contexts under which camouflaging the body would be more challenging (Cafri et al., 2005; Giardino & Procidano, 2012; Pope et al., 1997).
Very often, men with MD miss social functions with friends, family, and significant others due to the high degree of distress and anxiety that social situations cause through the fear of being perceived as too small (Olivardia, 2001). In fact,
Olivardia, Pope, and Hudson (2000) mentioned an individual with MD who skipped his
21 high school reunion because he feared being seen as small by his classmates. MD can also affect the relationships of men due to their intense self-consciousness and comparison with others (Olivardia, 2001; Pope et al., 1997). Poor body image can cause men with MD to struggle in relationships, particularly intimate relationships, because they are ashamed of their musculaturity which they perceive as inadequate (Pope et al.,
1997). Olivardia (2001) mentioned that some men with MD have reported being housebound for several days due to self-consciousness of their fitness level and anxiety with leaving the house feeling “so out of shape.” The constant scrutiny of their own bodies in comparison to others can also impede men socially because they enter a spiral of self-criticism, feelings of inadequacy, and further scrutiny (Olivardia, 2001). This psychopathology may, in turn, cause men to become withdrawn and suffer from depression and anxiety (Olivardia, 2001)
MD may also lead to professional disruptions. Olivardia, Pope, and Hudson
(2000) found that two men out of the 24 participants with MD had actually given up the opportunity to hold a well-paying professional job in order to work at a gymnasium where they were able to lift weights. Other researchers describe a lawyer who lost his job because he refused to shorten his 3-4 hour workout during lunch and a man who was fired because he would not stop making protein shakes every hour at work (Olivardia,
2001). Additionally, MD may cause men to miss important work events due to anxiety related to their physique, necessary deviations in workout schedules, difficulty maintaining a regimented diet, or various other reasons (Giardino & Procidano, 2012;
Pope et al., 1997). What these life disruptions all have in common is that the
22 psychopathology in MD makes the fear of getting smaller or failing to gain muscularity seem more severe than the consequences of their actions, and even though men may regret missing important events, the compulsions keep them captive to their physique
(Olivardia, 2001).
Mirror checking. Another very common behavioral manifestation of MD is mirror checking (Pope et al., 1997). Incessant mirror gazing, commonly paired with pinching muscle or fat to evaluate size, is a technique used by individuals with body image disturbances to repeatedly scrutinize their appearance and gauge body size
(Hildebrandt, Walker, Alfano, Delinsky, & Bannon, 2010). Olivardia, Pope, and Hudson
(2000) reported that weightlifters with MD checked the mirror 9.2 times per day on average, compared to only 3.4 times daily for their non-MD counterparts. Veale and
Riley (2001) sought to examine the psychopathology of mirror gazing in individuals suffering from BDD and gained some insight into the psychology of mirror checking:
“Prior to gazing BDD patients are driven by the hope that they will look different;
the desire to know exactly how they look; a belief that they will feel worse if they
resist gazing and the desire to camouflage themselves. They were more likely to
focus their attention on an internal impression or feeling (rather than their external
reflection in the mirror) and on specific parts of their appearance.” (Veale &
Riley, 2001, pp. 1381).
Mirror gazing in men with MD does not necessarily require a mirror, with some men reporting the use of other types of reflective surfaces (Olivardia et al., 2000; Veale
& Riley, 2001). Body checking may also be done using CDs, cutlery, store windows, or
23 pocket mirrors, and Olivardia (2001) actually discussed a man who had been in multiple automobile accidents due to incessant mirror checking with a large hand-held mirror he kept in his car (Olivardia et al., 2000; Veale & Riley, 2001).
Anabolic steroid use. A dangerous health behavior commonly related to MD is the use of anabolic steroids or other performance enhancing substances. Men with MD who perceive themselves as inadequately muscular may resort to using illicit substances such as anabolic androgenic steroids, sex hormones, or other substances to enhance their muscularity (Grieve et al., 2009). Anabolic androgenic steroids attract men with MD because they enable the users to achieve a level of muscularity that they would otherwise be unable to reach (Rohman, 2009). Additionally, more and more men are taking steroids for appearance purposes rather than for performance improvements, as evidenced by Kanayama and colleagues referring to them as “body image drugs” (Kanayama, Pope,
& Hudson, 2001).
A study conducted to compare the characteristics of men with both BDD and MD to those with only BDD looked at steroid abuse or dependence (Pope et al., 2005). Of the men with MD, 21.4%, reported steroid abuse or dependence while none of the non-MD participants reported any use of steroids (Pope et al., 2005). Olivardia, Pope, and Hudson
(2000) found an even larger percentage of men with MD that reported anabolic steroid use, at 46% versus 7% of men without MD. The study participants with MD who had used steroids reported an average age of first use of 20.3 years, although this ranged from
15 to 27 (Olivardia et al., 2000). Eight of these men had MD at least a year before using
24 steroids, while one man developed MD at least a year after the onset of steroid use and two developed MD in the same year as the onset of steroid use (Olivardia et al., 2000).
More research needs to be conducted to determine whether MD is a cause or effect of anabolic steroid use because currently, the relationship is unclear. In a personal communication with Lebur Rohman in 2007, Roberto Olivardia, PhD discussed the results of the previous study, stating the fact that “in 73% of the cases, MD preceded the steroid use” but also that men can develop MD after discontinuing anabolic steroids because they become so accustomed to “a certain level of muscularity, that when they ceased steroid use, they became so preoccupied with their bodies” (Rohman, 2009).
Additionally, it is difficult to secure an accurate estimation of the proportion of men with
MD who use anabolic steroids due to the controversial nature of the subject. Because steroids are banned from competition and could lead to negative consequences for the athlete, men may be less likely to report steroid usage truthfully (Kuennen & Waldron,
2007).
Eating attitudes and nutrition habits in MD. As previously mentioned, MD was originally referred to as “reverse anorexia” due to the pathological eating patterns which commonly accompany the condition (Pope et al., 1993). Murray et al. (2012) conducted a study to compare the similarities in symptomatology between men with MD and those with anorexia nervosa in regards to eating, exercise, shape, and weight. Using the Eating Disorders Examination-Questionnaire (EDE-Q) which was reversed in polarity to measure male concerns rather than female, the researchers demonstrated that men with
MD and anorexia nervosa shared widespread similarities in dietary psychopathology;
25 both groups exhibited a higher level of eating disorder and MD symptomatology than the control gym-using group, scoring significantly higher than the controls on total EDE-Q score, the Dietary Restraint subscale, the Weight Concern subscale, and the Shape
Concern subscale (Murray et al., 2012). When comparing the men with MD and those with anorexia nervosa without considering the control group, there were no significant differences between the groups for the total EDE-Q, Dietary Restraint subscale, Weight
Concern subscale, or Shape Concern subscale scores, while anorexic men score significantly higher on the Eating Concern subscale (Murray et al., 2012). This study also demonstrated that there was significant correlation between full scale MD symptomatology and global eating disorder symptomatology (Murray et al., 2012).
Additionally, Olivardia, Pope, Borowiecki, and Cohane (2004) conducted a study to explore the relationship between the body image concerns and psychological traits in men, including eating disorder symptoms as measured by the Eating Disorder Inventory
(EDI). They found that muscle belittlement, a psychological trait characteristic of men with MD, was significantly positively correlated with EDI scores for Drive for Thinness,
Bulimia, Body Dissatisfaction, Ineffectiveness, Interpersonal Distrust, and Total EDI
(Olivardia et al., 2004). These results provide support for the idea that the eating attitudes in both MD and disordered eating share similarities.
After conducting a review to identify the dietary strategies of individuals with
MD, Contesini et al. (2013) found that “The main feeding characteristics of a person with muscle dysmorphia is the hyperprotein and hypolipidic diets with the consumption of dietary supplements in order to increase muscle mass and reduce body fat mass.”
26
Similarly, Murray, Maguire, Russell and Touyz (2012) stated the following regarding food behaviors in MD:
“The eating psychopathology inherent in muscle dysmorphia presentations
includes rigid employment of food rules, including rigid consumption of
calculated amounts of protein per kilogram of bodyweight, rigid restriction of
non-protein rich food, and eating every few hours whether hungry or not (Mosley,
2009), and a marked escalation in muscle dysmorphia symptomatology caused by
disruption of dietary intake alone, irrespective of exercise status, has also been
observed (Murray, Rieger, & Touyz, et al., in press).” (Murray, Maguire, Russell,
& Touyz, 2012, pp. 69)
Many men with MD make financial sacrifices to maintain their regimented diets
(Pope, et al., 1997). Nutritional supplements and ergogenic drugs, such as anabolic steroids, are costly, yet many men with MD continue to use these substances despite having to lower their standard of living (Pope et al., 1997).
In general, the existing literature lacks information about what men with MD actually eat. The macronutrient compositions of the diets, use of dietary supplements, nutrition knowledge, and sources of dietary information of these individuals are largely unknown, and have not been explored empirically. More research must be conducted on men with MD to develop a clearer picture about their nutritional status.
Psychological Profile of Men with MD
Olivardia, Pope, and Hudson (2000) used the Structured Clinical Interview for
DSM-IV (SCID) to evaluate the current and past psychological health of male
27 participants with MD. They found that men with MD reported significantly higher rates of major mood disorders (58%), anxiety disorders (29%), and eating disorders (29%) than men without MD (20%, 3%, and 0%, respectively) (Olivardia et al., 2000). Cafri et al.
(2008) also utilized the SCID and found that men with MD reported higher rates of mood and anxiety disorders. 65% of the men with MD reported major depressive disorder,
17% panic disorder, 9% post-traumatic stress disorder, 4% obsessive-compulsive disorder, 4% specific phobia, 4% social phobia, and 4% generalized anxiety disorder
(Cafri et al, 2008). Pope and colleagues (2005) demonstrated that men with MD have poorer scores on quality of life measures and are more likely to have a history of suicide attempt. Olivardia and colleagues (2000) also found that men with MD reported greater pathology on the EDI, indicating similar psychology to eating disorder patients and therefore, the likelihood of traits such as perfectionism, maturity fears, feelings of ineffectiveness, and drive for thinness (Olivardia, 2001).
Olivardia, Pope, and Hudson (2000) demonstrated that weightlifters with MD had prominent obsessive compulsive pathology. Of the 24 weightlifters with MD in the study, 50% reported thinking about their level of muscularity at least three hours per day, and 54% reported having “little” or “no” control over the compulsiveness of their fitness and dietary routines (2000). The MD group spent an average of 325 minutes per day (or approximately 5.4 hours) having thoughts of being too small or wanting to increase their muscularity (Olivardia et al., 2000). This is contrasted to the 41.2 minutes per day that the weightlifters without MD spent having these thoughts (Olivardia et al., 2000). In seeking to identify the awareness that men with MD have of their condition, these
28 researchers found that 42% of the participants with MD had “excellent” or “good” insight into their psychopathology, acknowledging the inaccuracies in the way they perceive their physique. On the other hand, 50% had “fair” or “poor” insight, absolutely certain that they lacked muscularity even if they had above average musculature (Olivardia et al.,
2000).
Etiology of Muscle Dysmorphia
Conceptual Models Illustrating the Development of MD
MD is a complex condition, and there are many variables which contribute to its development. For this reason, a number of researchers have devised conceptual models to explain its etiology, with one of the most well known created by Frederick Grieve
(2007). His model outlining the development of MD contains four categories of causative factors, including psychological, socioenvironmental, emotional, and physiological, which are based on the biopsychosocial model of psychopathology
(Grieve, 2007; Kiesler, 1999). Psychological factors include: (a) body dissatisfaction, (b) ideal body internalization, (c) self-esteem, (d) body distortion, (e) perfectionism, and (f) drive for muscularity (Grieve, 2007). Socioenvironmental factors include: (a) media influences and (b) sports participation (Grieve, 2007). Emotional factors and physiological factors include negative affect and body mass, respectively (Grieve, 2007).
Figure 1, adapted from Grieve (2007), displays the relationships between the various causative factors.
29
Muscle Dysmorphia
Perfectionism Body Distortion Negative Affect
Body Mass Body Dissatisfaction Low Self-Esteem
Sport Participation Media Pressure Ideal Body
Figure 1. Grieve’s conceptual model of the development of MD. This figure, which is adapted from Grieve (2007), depicts the proposed relationships between the many factors which are thought to contribute to MD development.
Grieve cautions that this model is based on proposed relationships and that many of these factors require more research to definitively link them to MD. Despite this fact, it acts as a good starting point for researchers to expound upon, and adequately demonstrates multifaceted nature of MD.
Similarly to Grieve (2007), Olivardia (2001) proposed a biopsychosocial etiological model of MD development (Kiesler, 1999). The researcher cites similarities to the obsessive-compulsive disorder spectrum in that there is likely a biological or genetic factor which predisposes the individual to the condition (Olivardia, 2001). The psychological, socioenvironmental, and emotional factors mentioned by Olivardia (2001) include low self-esteem, issues with masculinity, drive for muscularity, appearance- related societal and media pressures, extreme body-image consciousness, and major body-image distortion.
30
Lantz, Rhea, and Mayhew (2001) devised a model of the development of MD with precipitating variables, psychobehavioral characteristics, and negative outcomes including self-esteem, body dissatisfaction, body size and symmetry, dietary constraints, use of psychopharmacological aids, use of dietary supplements, exercise dependence, physique protection, and alienation, and narcissism. The model is displayed in Figure 2.
Pharmacological Use Supplement Use Dietary Behavior
Nutrition Physique Concerns
Physique Protection Exercise Dependence Body Size/Symmetry
Figure 2. Lantz, Rhea, and Mayhew’s conceptual model of the development of MD. This figure, which is adapted from Lantz, Rhea, and Mayhew (2001), depicts the proposed reciprocal relationship between nutrition and physique concerns with the elements that contribute to these factors.
A fourth model of note was devised by Cafri and colleagues (2005). This model attempts to explain the factors which contribute to risky body change strategies in males to achieve a lean, muscular figure (Cafri et al., 2005). Although not specific to MD as are the previous models, this model seeks to examine the etiology and effects of different risky behavioral outcomes including steroid/steroid precursor/ephedrine use, dieting to lose weight, and dieting to increase muscularity, which are all likely to occur in men with
MD (Cafri et al., 2005). This model is displayed in Figure 3.
31
Biological Factors 1. Body Composition or Psychological BMI Functioning 2. Pubertal Growth 1. Negative 3. Pubertal Timing Affect 2. Self-esteem
Health Risk Behaviors 1. Steroids 2. Steroid Precursors Societal Factors Body Image 3. Ephedrine 1. Media Influence Social Body Dissatisfaction 4. Dieting to Lose 2. Peer and Comparison 1. Muscularity Weight Parental 2. Body Fat 5. Dieting to Gain Influences Weight 3. Teasing 6. Dieting to Increase 4. Peer Popularity muscularity
Sports 1. Organized Team Sports 2. Informal Team Sports 3. Weightlifting
Figure 3. Cafri’s conceptual model of the development of risky body change strategies. This figure, which is adapted from Cafri (2005), depicts the factors which are proposed to increase the risk of men adopting risky health behaviors as a catalyst for body change. The solid lines represent relationships with stronger evidence in the literature while the dashed lines represent relationships with less empirical support.
Overall, the Grieve model seems to be the most comprehensive conceptualization of MD to date and encompasses the many aspects addressed in the models by Olivardia,
Lantz, Rhea, and Mayhew, and Cafri and colleagues.
Research on Contributing Factors
Self-objectification. Self-objectification has previously been explored as an etiological factor in female eating disorders, and several researchers believe it can contribute to MD in males, as well. First proposed by Fredrickson & Roberts (1997), the
32 objectification theory states that culture and the media objectify women by placing emphasis on their physical appearance. This, in turn, causes women to internalize this representation and view themselves only in terms of physical appearance (Fredrickson &
Roberts, 1997). Morry and Staska (2001) demonstrated that, similarly to women, men also internalize ideas about physical appearance from the media, particularly fitness magazines. This internalization is then related to body dissatisfaction, self- objectification, and eating attitudes in men (Morry & Staska, 2001).
Strelan and Hargreaves (2005) also demonstrated that the Objectification Theory may be sensibly applied to men, resulting in a significant negative relationship between self-objectification, as well as appearance-related reasons for exercise, and body esteem in both men and women. Grieve and Helmick (2008) then conducted a study which examined the relationship between self-objectification and symptoms of MD in men.
The study sample was composed of 74 college students from various universities, 23 of whom were student athletes; men in the high self-objectification group, as measured by the Self-Objectification Questionnaire, reported significantly higher levels of MD symptoms than men in the low self-objectification group (Grieve & Helmick, 2008).
An additional study by Oehlhof and colleagues (2009) examined the relationship between self-objectification and one’s desired body shape. Of the 72 male college students included in the study, men with higher self-objectification scores desired a more muscular body shape than men who scored lower on the self-objectification measure
(Oehlhof, Musher-Eizenman, Neufeld, & Hauser, 2009). The findings of this study suggest that self-objectification can be a contributing factor to the development of MD.
33
Perfectionism. As stated by Frost, Marten, Lahart, and Rosenblate (1990):
“Perfectionism involves high standards of performance which are accompanied
by tendencies for overly critical evaluations of one’s own behavior. The
psychological problems associated with perfectionism are probably more closely
associated with these critical evaluation tendencies than with the setting of
excessively high standards.” (Frost, Marten, Lahart, & Rosenblate, 1990, pp.
450)
When considering this statement in relation to the development of MD, it would imply that men who are perfectionists in regards to their body shape would strive to reach an unattainably muscular physique. If unsuccessful at achieving this body shape or size perceived as ideal, these men would likely to have a high level of overly critical self- evaluation. Although many researchers implicate perfectionism in MD development, not enough research has been conducted to conclusively support this idea. It has been found, however, that perfectionism as measured by the Multidimensional Perfectionism Scale has a direct relationship with the level of MD symptoms as measured by the Muscle
Dysmorphia Inventory (Henson, 2003; Kuennen & Waldron, 2007). Grieve (2007) hypothesized that perfectionism impacts the development of MD directly as the individual seeks the “perfect” body and indirectly through the man’s body dissatisfaction when his actual physique does not match his perceived “perfect” physique.
Media pressure and ideal body internalization. As defined by Grieve (2007), ideal body internalization “involves the acceptance of the cultural ideal” in regards to physique, and this cultural ideal is highly driven by the media. Over the past few
34 decades, cultural expectations for the male physique have become increasingly muscular, to an unattainable level for many men (Harrison, Pope, Phillips, & Olivardia, 2000; Leit et al., 2001; Pope et al., 1999). Numerous studies have shown that this trend of ideal appearance-based media images has a deleterious effect on males. Agliata and Tantleff-
Dunn (2004) demonstrated that a sample of men age 17 to 27 years old who were exposed to ideal image advertisements had higher levels of muscle dissatisfaction and depression than those who were exposed to neutral ads. Lorenzen, Grieve, and Thomas
(2004) found that men aged 18 to 32 years old rated their body satisfaction as lower after viewing images of muscular models, while viewing images of average men had no significant effect on body satisfaction.
Arbour and Martin Ginis (2006) conducted a study to examine how exposure to muscular and hypermuscular images impacted body image in university students, and these researchers found a relationship between pre-existing muscularity concerns and the effect that exposure to muscular images had on men. Those with previous muscle or body dissatisfaction experienced a greater increase in muscularity dissatisfaction and body dissatisfaction after exposure to muscular images compared to those who had little pre-existing muscularity concerns (Arbour & Martin Ginis, 2006). Overall, these studies exhibit how media pressure on men to attain an increasingly muscular physique has a negative impact on male body image and can contribute to MD development when culturally-dictated ideal body image is internalized by men.
Childhood experience. There has been little research on, and therefore little knowledge about, the effect that childhood experience has on the development of MD. It
35 would be logical, however, to assume that there is some connection due to the current understanding of the relationship between childhood neglect and abuse and BDD (Didie et al., 2006). Additionally, it has been estimated that 30% of eating disorder patients were victims of past sexual abuse, although this research has mostly been conducted on females (Connors & Morse, 1993). Olivardia, Pope, and Hudson (2000) compared the family environments and childhood experiences of weightlifters with and without MD.
Men with MD reported less favorable relationships with their mothers, and 33% of them reported that mother-child violence occurred either “sometimes” or “often” compared to
3% of control group subjects (Olivardia et al., 2000). In addition, 29% of men with MD reported that mother-father violence occurred either “sometimes” or “often”, as opposed to only 3% of the non-MD men (Olivardia et al., 2000).
Wolke and Sapouna (2008) sought to examine the impact that childhood bullying had on the development of MD in bodybuilders. It was demonstrated that men who were regularly a victim of childhood bullying, particularly physical bullying, had higher MDI scores than other men (Wolke & Sapouna, 2008). Additionally, men who were victims of bullying exhibited greater psychopathology in general (Wolke & Sapouna, 2008).
Wolke and Sapouna (2008) “showed that if bodybuilders had experienced regular victimization and had increasing MDI symptoms, then global psychopathology was over proportionally raised and self-esteem was especially low.”
Several studies have examined the roles of parents and peers in impacting the strategies that adolescent males utilize for weight change. McCabe and Ricciardelli
(2003) found that perceived pressure from parents and peers to either gain or lose weight
36 predicted the use of strategies to achieve this respective weight change. Field and colleagues (2001) sought to prospectively examine different influences on weight concerns and frequent dieting in children ages 9 to 14. It was determined that boys who felt that it was important to their father that they not be fat had an increased likelihood of becoming a constant dieter within the 1-year time period of the study (Field et al., 2001).
Similarly, Wetheim et al. (2002) conducted a study to examine parental influence on dieting and weight loss in children, and it was found that parental encouragement to diet was associated with greater drive for thinness and body dissatisfaction in children independent of gender.
Peer and parental influences, teasing, and peer popularity are all included under the societal factors category of Cafri et al.’s (2005) model, yet there has been limited research exploring the true role that childhood experience plays in the development of
MD in particular.
Participation in sport. The type of sport a male athlete participates in can impact the development of MD because it dictates the type of weight or physique pressures the athlete experiences. It is thought that disordered eating behavior is most likely to occur in “sports in which aesthetics are critical to the judging or scoring process, sports where the athlete has to make weight for competition and sports in which low body fat is deemed advantageous to performance” (Baum, 2006). Similarly, MD is thought to occur in sports in which athletes need to maintain a certain weight, body size, or level of muscle mass and those that emphasize strength, either for the sake of performance or for other reasons (Grieve et al., 2009; Leone, Sedory, & Gray, 2005). Galli and colleagues
37
(2011) examined weight pressures in collegiate NCAA Division I male athletes. It was reported that endurance sport athletes (cross-country, track, and swimming) and power sport athletes (football and downhill skiing) experienced more appearance pressures than athletes in ball game sports (basketball, baseball, soccer, volleyball, hockey, and lacrosse)
(Galli, Reel, Petrie, Greenleaf, & Carter, 2011). The researchers also found that power athletes reported experiencing more weight pressures from coaches and teammates than athletes who were involved in endurance or ball game sports (Galli et al., 2011).
As stated by Grieve (2007):
“In addition, athletes share many of the psychological factors that could increase
the likelihood of MD. These factors include a high level of competitiveness, a
high need for control, and perfectionistic tendencies…Sport participation directly
influences body mass/adiposity and ideal body internalization. Sport participation
exposes individuals to the social ideal of muscularity. In addition, there is some
reinforcement for obtaining and maintaining the ideal body shape, as performance
tends to improve with muscularity.” (Grieve, 2007, pp. 73)
These factors are reasons why sport participation plays a role in the development of MD in male athletes and point to the likelihood that athletes in sports such as football, wrestling, or bodybuilding may be at more risk than others.
Interaction between body dissatisfaction, body distortion, and self-esteem.
Research has shown that body dissatisfaction, body distortion, and self-esteem interact in the development of MD. Grieve, Truba, and Bowersox (2009) refer to body dissatisfaction as the “driving force” behind MD. Body dissatisfaction is the difference
38 which exists between an individual’s ideal body and actual physique, and the larger the discrepancy between these two, the greater the likelihood that the person will turn to drastic measures to decrease the gap (Grieve, 2007; Grieve et al., & Bowersox, 2009;
Keeton, Cash, & Brown, 1990). In the case of men with MD, men who are underweight, or perceive themselves to lack muscularity, would be at greatest risk for MD because they would likely have the highest levels of body dissatisfaction (Grieve, 2007).
A study by Harmatz, Gronendyke, and Thomas (1985) proved this to be true, demonstrating that college men who were underweight experienced the most body dissatisfaction, having very poor self-images which were equally as negative as those of overweight females. Research has revealed that men with MD have greater levels of body dissatisfaction and poorer body images than men without MD (Olivardia et al.,
2000). Olivardia and colleagues (2000) saw trends in the way men with MD answered questions about their body satisfaction; to the question “I really like my body”, 52% of the MD group answered “disagree” or “disagree somewhat” versus only 20% of the control group, while to the question “how dissatisfied are you with the way your body is proportioned?”, 46% of men with MD answered “totally” or “mostly” while only 10% of control participants answered this way (Olivardia et al., 2000).
Body distortion also plays a role in the development of MD because it has a negative impact on body dissatisfaction (Grieve, 2007). When men underestimate their level of muscle mass due to a distorted perception, body dissatisfaction is likely to follow
(Grieve et al., 2009). Research has revealed that men tend to view themselves as smaller than they are in reality. McCreary and Sadava (2001) demonstrated that 25% of men
39 with a normal weight perceived themselves as underweight, while 48% of men who were overweight considered themselves to be of normal weight. Madrigal et al. (2000) demonstrated that 65.2% of men underestimated their weight. Men who perceive themselves as much less muscular than they are in reality are at risk for MD because they view the discrepancy between their current and ideal physique as much larger than it is in actuality; this would increase the likelihood that they participate in behaviors characteristic of MD to decrease this discrepancy.
Low self-esteem contributes to the development of MD because it can provide some of the motivation for body change behaviors which characterize MD. This is especially apparent in individuals whose self-esteem is based on physical appearance
(Grieve, 2007). Research has demonstrated that men with low self-esteem report higher levels of body dissatisfaction variables, with some of these including muscle belittlement, muscle displeasure, dissatisfaction with body proportions, feeling fat or out of shape, and not liking one’s body (Olivardia et al., 2004). High levels of all of these variables would be expected in men with MD, so the relationship between self-esteem and MD is observable. According to Grieve (2007), low self-esteem is affected by body dissatisfaction which is, in turn, affected by body distortion, exhibiting the multifaceted relationship between body dissatisfaction, body distortion, and self-esteem in the development of MD.
Tools for Identifying and Measuring Muscle Dysmorphia
As MD has come to the forefront of body image research, numerous screening tools and inventories have been developed to identify MD-related traits in different
40 individuals. There have been several Muscle Dysmorphia measures published, with the most well known one created by Schlundt, Woodford, & Brownlee (2000). The Muscle
Dysmorphic Inventory (MDI) is composed of 16 items assessing the individual’s level of distress and discomfort with being insufficiently muscular. Each of the items are self- reported on a five-point Likert scale (0: never, 1: rarely, 2: occasionally, 3: frequently, and 4: always) with total scores ranging from 0 to 64 and higher scores representing a higher preoccupation with muscularity (Schlundt, Woodford, & Brownlee, 2000).
This scale was then adapted by Hildebrandt, Langenbucher, and Schlundt (2004) and named the Muscle Dysmorphia Disorder Inventory (MDDI) (Hildebrandt,
Langenbucher, & Schlundt, 2004). The MDDI assesses MD characteristics using a three- factor approach, addressing cognitive, emotional, and behavioral aspects of the condition.
A new feature of the MDDI compared to the DMI is that it includes items that deal with functional impairment (Hildebrandt et al., 2004; Santarnecchi & Dèttore, 2012). The three subscales utilized in this inventory include desire for size (DFS), appearance intolerance (AI), and functional impairment (FI), and the inventory as a whole was created in accordance with the current knowledge of the thought processes, emotional effects, and behavioral deviations found in MD (Hildebrandt et al., 2004). Hildebrandt and colleagues describe each of the subscales:
“The desire for size (DFS) subscale consists of questions concerning thoughts of
being smaller, less muscular, and weaker than desired, or wishes to increase size
and strength. The thinking style represented by this subscale is consistent with
the preoccupations about inadequate size in MD as described by Pope et al.
41
(1997). The appearance intolerance (AI) subscale consists of questions regarding
negative beliefs about one’s body and resulting appearance anxiety or body
exposure avoidance. The negative cognitions and behavioral manifestations of
core negative beliefs about one’s body are consistent with features in MD, such as
wearing baggy clothes to the beach or belief that one’s body is ugly and
distasteful. Finally, the functional impairment (FI) subscale consists of questions
about behaviors related to maintaining exercise routines, interference of negative
emotions when deviating from exercise routines, or avoidance of social situations
because of negative feelings and preoccupation with one’s body.” (Hildebrandt,
Langenbucher, & Schlundt, 2004, pp. 170)
The complete list of items included in the MDDI are included in Appendix A.
The tool was found to have good convergent and divergent validity for MD and seems to be a short, reliable measure of the symptoms associated with this type of body image disturbance (Hildebrandt et al., 2004). Limitations mentioned by the researchers included a lack of validation in females or clinically diagnosed individuals, indicating that although it can be used to measure symptoms, it cannot yet be used as a diagnostic tool (Hildebrandt et al., 2004).
Along with the MDDI, Hildebrandt and colleagues (2004) also developed the
Bodybuilder Image Grid (BIG). This tool can be used to evaluate perceptual body image disturbance in men and the perceived attractiveness of the male body (Hildebrandt,
2004). The BIG is based on the Contour Drawing Rating Scale developed by Thompson and Gray in 1995 (Hildebrandt et al., 2004; Thompson & Gray, 1995). This scale,
42 exhibited in Figure 4, consists of nine front-view contour drawings of both the male and female figures, enabling researchers to measure certain elements of body image perception and body dissatisfaction (Thompson & Gray, 1995).
Figure 4. Thompson and Gray’s Contour Drawing Rating Scale. This scale was developed by Thompson and Gray (1995) to measure elements of body image perception and body dissatisfaction.
Hildebrandt et al. (2004) mention at least 21 contour drawing scales previously in existence, but Thompson and Gray’s (1995) aim in developing the Contour Drawing
Rating Scale was to increase the detail of each of the figures, highlight smaller differences between adjacent figures, and increase the consistency of size differences between consecutive figures on the scale. Hildebrandt and colleagues (2004) also used these principles to create the Bodybuilder Image Grid (BIG), exhibited in Figure 5.
43
Figure 5. Hildebrandt et al.’s Bodybuilder Image Grid. This contour drawing instrument depicts male figures with different levels of adiposity and muscularity to measure body image disturbances in males.
This instrument contains thirty contour figure drawings of male bodies with different dimensions of muscularity and body fat, and individuals are instructed to select four figures from the grid: (a) the one that best represents their current body type, (b) the one that best represents their ideal body type, (c) the one that is most attractive, and (d) the one that is most attractive to the opposite sex (Hildebrandt et al., 2004). The researchers demonstrated that the BIG was a reliable measure of body image disturbances in males wanting to be leaner and more muscular and had both convergent and divergent validity (Hildebrandt et al., 2004). Limitations of the BIG mentioned by the developers
44 included a lack of validation in a sample of individuals clinically diagnosed with MD and a lack of data on the attractiveness measures. (Hildebrandt et al., 2004).
Researchers may also complement these MD-specific measures with a variety of other instruments. The Eating Disorder Inventory (EDI) is a very well-known and widely utilized questionnaire measuring the presence of symptoms and psychological characteristics associated with eating disorders (Clausen, Rosenvinge, Friborg, &
Rokkedal, 2011). Garner, Olmsted, and Polivy (1983) created the first version of the self-report EDI questionnaire with subscales including (a) drive for thinness, (b) bulimia,
(c) body dissatisfaction, (d) ineffectiveness, (e) perfectionism, (f) interpersonal distrust, and (g) interoceptive awareness, (h) maturity fears. Garner (1991) then updated the questionnaire by adding subscales for (a) asceticism, (b) impulse regulation, and (c) social insecurity, naming the updated instrument the EDI-2. The latest update of the EDI, known as the EDI-3, was edited to improve its reliability across cultures and seeks to measure the symptomatology and psychology associated with eating disorders using new subscales relevant to current eating disorder theory (Garner, 2004). These subscales include (a) low self-esteem, (b) personal alienation, (c) interpersonal insecurity, (d) interpersonal alienation, (e) interoceptive deficits, (f) emotional dysregulation, (g) perfectionism, (h) asceticism, and (i) maturity fear (Garner, 2004).
Another tool which was devised to measure body image concerns related to muscularity was the Drive for Muscularity Scale (McCreary & Sasse, 2000). This 15- item instrument measuring muscularity-oriented attitudes and behaviors is based on drive for thinness measures, such as the subscale found on the EDI (McCreary, Sasse, Saucier,
45
Dorsch, 2004). Because many empirical investigations have demonstrated that men are concerned with increasing muscularity rather than increasing thinness such as female populations, the Drive for Muscularity Scale is more appropriate for use with a population of men with MD than instruments which measure drive for thinness
(McCreary et al., 2004). The 15 items included in the drive for muscularity include the following:
1. “I wish I were more muscular.” 2. “I lift weights to build more muscle.” 3. “I use protein or energy supplements.” 4. “I drink weight gain or protein shakes.” 5. “I try to consume as many calories as I can in a day.” 6. “I feel guilty if I miss a weight-training session.” 7. “I think I would feel more confident if I had more muscle mass.” 8. “I think I work out with weights too often.” 9. “I think I would look better if I gained 10 pounds in bulk.” 10. “I think about taking anabolic steroids.” 11. “I think I would feel stronger if I gained a little more muscle mass.” 12. “I think that my weight-training schedule interferes with other aspects of my life.” 13. “I think that my arms are not muscular enough.” 14. “I think that my chest is not muscular enough.” 15. “I think that my legs are not muscular enough.”
(McCreary et al., 2004, pp. 50)
Additional measures which may be used in the study of MD include the
Rosenberg Self-Esteem Scale (Rosenberg, 1965; Rosenberg, 1989), Male Body Attitudes
Scale (Tylka, Bergeron, & Schwartz, 2005), Muscle Appearance Satisfaction Scale
(Mayville et al., 2002), Swansea Muscularity Attitudes Questionnaire (Edwards &
Launder, 2000), or Social Physique Anxiety Scale (Hart, Leary, & Rejeski, 1989), to name a few.
CHAPTER III
METHODS
Participants
To be eligible for the study, participants were required to be male college students aged 18-24 attending Kent State University. Exclusion criteria included: (1) a previous eating disorder diagnosis; (2) a previous obsessive compulsive disorder diagnosis. In the current study, three different methods for grouping participants were utilized.
First, participants were classified as either a low recreational exerciser, high recreational exerciser, or sedentary individual. Low recreational exercisers accumulated
2.50-4.99 hours of moderate-intensity cardiovascular exercise per week, with the lower cut-off being dictated by the 2008 Physical Activity Guidelines for Americans (U.S.
Department of Health and Human Services, 2008). High recreational exercisers accumulated 5 or more hours of moderate-intensity cardiovascular exercise per week.
Sedentary individuals were those which did not meet the exercise levels dictated by the
2008 Physical Activity Guideline for Americans, accumulating less than 2.5 hours of moderate-intensity cardiovascular exercise per week (U.S. Department of Health and
Human Services, 2008).
The second grouping scheme for this study was by weightlifting behaviors, creating low weightlifting, moderate weightlifting, and high weightlifting groups. The low weightlifting group members accumulated 0-1.5 hours of weightlifting per week, the moderate weightlifting group members accumulated 1.6-4.5 hours of weightlifting per week, and the high weightlifting group members accumulated 4.6 or more hours of 46 47 weightlifting per week. Unlike cardiovascular exercise, there is a lack of nationally recognized guidelines for weightlifting amount per week, so for the purposes of this study, natural cutoffs in the data were used to create the weightlifting groups.
The third grouping method used in this study was by MDDI score. As suggested by the author of the MDDI in personal correspondence, a cutoff of 39 may be used to assign participants to the high MDDI group in this study; participants who scored above
39 were categorized as high MDDI. On the low end of the spectrum, participants with
MDDI scores lower than 20 were assigned to the low MDDI group, creating high and low groups which were similar in size (n=14 and n=12, respectively). This cut off was established because scoring lower than a 20 on the MDDI indicates that the participant selected one, the lowest number on the scale, more than any other number. For instance, a score of 13 would indicate that the participant answered one for every item, and a score of 19 would indicate that the participant answered one for seven items and two for six items. A score of 20 would indicate that the participant answered two seven times and one six times, placing them in the moderate MDDI group. The participants who scored between the upper and lower cutoffs were classified as having moderate MDDI scores.
This study was approved by the Kent State Institutional Review Board, and volunteers were required to provide consent.
Study Recruitment
Several methods of participant recruitment were used for this study.
Electronically, a study announcement was posted on FlashLine, an online web portal for
Kent State University, and sent out through several different Kent State email databases
48 to inform students of the study. Posters were another method of participant recruitment that this study utilized. Posters providing study information and researcher contact information were displayed in various locations on campus, particularly in areas with high foot traffic such as the Kent State Student Center. Digital signage was exhibited in the Kent State Student Recreation and Wellness Center to recruit recreational exercisers.
One last recruitment technique which was used for this study was in-person presentations. The researcher gave five-minute presentations to large classes on campus to recruit potential subjects.
Questionnaire Design
Subject Demographics and Characteristics
The first section of the questionnaire included information about subject demographics and characteristics. These items included: (1) age; (2) academic major; (3) height; (4) weight; (5) past and current mental health diagnoses; (7) exposure to nutrition in the academic setting; (6) exercise level; (7) sport participation.
Muscle Dysmorphia Disorder Inventory
Originally adapted from Schlundt, Woodford, & Brownlee’s (2000) Muscle
Dysmorphic Inventory (MDI), the Muscle Dysmorphia Disorder Inventory (MDDI) is a
13-item questionnaire developed to assess MD characteristics. Permission to utilize the
MDDI for this study was obtained from the author, and the 13-items, all of which used a
1 to 5 likert scale, were put into an electronic format for participant completion. The complete list of items is included in Appendix A.
49
Block Food Frequency Questionnaire
The 2005 version of the Block Food Frequency Questionnaire (FFQ) was used to assess the dietary intake of participants. Originally developed by Dr. Gladys Block of the
National Cancer Institute, the Block FFQ is a dietary questionnaire based on NHANES
1999-2002 dietary recall data (NutritionQuest, 2013). It took participants approximately
30 minutes to complete and once analyzed, provided information about the individual’s customary energy, macronutrient, and micronutrient intake (NutritionQuest, 2013). Over the past few decades, several studies have verified the validity of the Block FFQ in accurately assessing dietary intake (Block, Woods, Potosky, & Clifford, 1990; Bourcher et al., 2006; Johnson, Herring, Ibrahim, & Siega-Riz, 2007; Mares-Perlman et al., 1993;
Subar et al., 2001).
For this particular study, the electronic format of the Block FFQ via
NutritionQuest’s Data-on-Demand server was used for several reasons. The fees involved for both the paper-and-pencil format and the electronic format were comparable, but the electronic version provided instant analysis of the data and secure 24-7 access to all of the data (NutritionQuest, 2013). Because the data was electronically collected and reported, this reduced the administration time and respondent burden and enabled the data to be more easily analyzed by the researcher (NutritionQuest, 2013).
Experimental Design
This was a quantitative, non-experimental, cross-sectional study examining the prevalence of MD-related traits college age men and the association between these traits and dietary intake. To access the online survey, participants were directed to the
50 electronic homepage of the study. At this page, they were provided with general information about the study and researcher contact information. To participate in the study, they were prompted to click a proceed button and were then redirected to the beginning of the online survey.
In total, the survey consisted of three different sections. The first two sections were administered by Qualtrics, an online survey software. Upon providing informed consent, participants answered demographic questions (i.e. age, major, sport participation, exercise habits) in the first section and completed the Muscle Dysmorphia
Disorder Inventory (MDDI) in the second section. At this point in the survey, participants were redirected to an online version of the 2005 full-length Block Food
Frequency Questionnaire (FFQ), the third and final section of the survey. Participants answered questions about food items they normally consume, the frequency with which they consume them, and the amount consumed. NutritionQuest, the company which markets the Block FFQ, had specialized software which analyzed the results of the FFQ and provided participants with a customized nutrition report, displaying information on the participant’s average intake of calories, fat, protein, carbohydrate, and other nutrients.
In order to keep the survey completely anonymous, computerized, and streamlined, the randomizer, embedded data, and branching functions on Qualtrics were used to assign random subject IDs to participants to be able to link the results collected from Qualtrics and NutritionQuest in the analysis process. Permission to utilize the
MDDI was obtained from the author, and an account was purchased through
NutritionQuest to utilize the Block FFQ. In total, the three parts of this study’s survey
51 took participants approximately 30 minutes. Once the data collection phase of the study was concluded, the study website was removed.
Statistical Analysis
SPSS statistical software was used to analyze the data collected in this study.
Descriptive statistics were utilized for the subject demographic and characteristics data.
A one-way ANOVA was used to analyze data from the FFQ. The group means for total energy intake, percentage of intake from protein, percentage of intake from carbohydrate, and percentage of intake from fat were compared. A one-way ANOVA was used to analyze MDDI scores, comparing the mean scores for each of the three study groups. To compare MD symptoms and dietary intake, a Pearson r correlation was run to determine whether a relationship existed between MDDI score and FFQ results for percentages of the diet composed of protein, carbohydrate, and fat. Additionally, those individuals from any of the study groups with high scores on the MDDI were grouped and had correlations between MDDI score and dietary intake of energy, protein, carbohydrate, and fat calculated and analyzed. A chi-squared test was also used to evaluate the distribution on
MDDI scores throughout the exercise level groups when categorized by cardiovascular activity and weightlifting activity.
CHAPTER IV
JOURNAL ARTICLE
Introduction
In the past, the prevailing idea that unhealthy body image and disordered eating patterns only impact women meant that the majority of research on this topic was done in female populations. Recently, however, researchers have demonstrated that men can also fall victim to body image disturbances and eating disorders, as well (Dakanalis et al.,
2013; Goltz, Stenzel, & Schneider, 2013; Grieve, 2007). Whereas many women feel societal pressure to reach a thinner, smaller body size, the opposite is true for men, many of whom feel pressure to achieve a higher level of muscularity (Stanford & McCabe,
2005; Stanford & McCabe, 2002; Cafri, Strauss, & Thompson, 2002; Pope, Gruber,
Mangeweth, et al., 2000).
Muscle dysmorphia (MD) is a body image disturbance in which individuals perceive themselves as lacking musculature and become preoccupied with increasing their muscularity to reach what they consider an ideal body frame (Olivardia, 2001;
Grieve & Shacklette, 2012; Grieve, 2007; Grieve, Truba, & Bowersox, 2009; Pope,
Gruber, Choi, Olivardia, & Phillips, 1997). Striving to achieve this desired physique drives some men to employ unhealthy strategies for managing weight and increasing muscularity including excessive weightlifting, performance-enhancing drug use, and frequent mirror-checking, as well as many others; these behaviors and the underlying psychological issues inherent in MD put the physical, mental, and emotional wellbeing of these men at risk (Olivardia, 2001). The strict fitness and nutrition regimens in MD 52 53 commonly interrupt the lives and functioning of men and negatively impact social, occupational, and recreational areas of life (Olivardia, 2001; Pope et al., 1997). For instance, research has shown that men with MD report sacrificing important life events to workout, avoiding social situations in which their physique may be exposed, and struggling in relationships due to intense self-consciousness (Cafri et al., 2005; Giardino
& Prociano, 2012; Olivardia, 2001; Pope et al., 1997).
The body of research surrounding MD has grown in the past few years, but it still remains quite limited. Pope and Katz (1994), the first researchers to identify MD, estimate that the prevalence within a weightlifting population could be as high as 10%.
Because MD has primarily been studied in bodybuilding or competitive athlete populations, the prevalence of MD in recreationally exercising men or sedentary individuals is unknown. Additionally, an area in which there has been little to no research conducted is the relationship between MD and nutrition. MD has been associated with detrimental habits such as excessive exercise and anabolic steroid use, but it is unknown whether a relationship exists between MD and unhealthy dietary behaviors (Olivardia, 2001).
The purpose of this study is twofold: 1) to evaluate the prevalence of MD symptomatology in men with varying exercise levels; 2) to evaluate the association between MD symptomatology and dietary intake patterns. The hypotheses for this study are: 1) The prevalence of MD will be higher in high recreationally exercising men than in low recreationally exercising or non-exercising men; 2) Higher scores on MD inventories
54 will be related to intake of increased total calories and grams of protein and decreased percentage of calories from fat.
Methods
Participants
To be eligible for the study, participants were required to be male college students aged 18-24 attending Kent State University. Exclusion criteria included: (1) a previous eating disorder diagnosis; (2) a previous obsessive compulsive disorder diagnosis. In the current study, three different methods for grouping participants were utilized.
First, participants were classified as either a low recreational exerciser, high recreational exerciser, or sedentary individual. Low recreational exercisers accumulated
2.50-4.99 hours of moderate-intensity cardiovascular exercise per week, with the lower cut-off being dictated by the 2008 Physical Activity Guidelines for Americans (U.S.
Department of Health and Human Services, 2008). High recreational exercisers accumulated 5 or more hours of moderate-intensity cardiovascular exercise per week.
Sedentary individuals were those which did not meet the exercise levels dictated by the
2008 Physical Activity Guideline for Americans, accumulating less than 2.5 hours of moderate-intensity cardiovascular exercise per week (U.S. Department of Health and
Human Services, 2008).
The second grouping scheme for this study was by weightlifting behaviors, creating low weightlifting, moderate weightlifting, and high weightlifting groups. The low weightlifting group members accumulated 0-1.5 hours of weightlifting per week, the moderate weightlifting group members accumulated 1.6-4.5 hours of weightlifting per
55 week, and the high weightlifting group members accumulated 4.6 or more hours of weightlifting per week. Unlike cardiovascular exercise, there is a lack of nationally recognized guidelines for weightlifting amount per week, so for the purposes of this study, natural cutoffs in the data were used to create the weightlifting groups.
The third grouping method used in this study was by MDDI score. As suggested by the author of the MDDI in personal correspondence, a cutoff of 39 may be used to assign participants to the high MDDI group in this study; participants who scored above
39 were categorized as high MDDI. On the low end of the spectrum, participants with
MDDI scores lower than 20 were assigned to the low MDDI group, creating high and low groups which were similar in size (n=14 and n=12, respectively). This cut off was established because scoring lower than a 20 on the MDDI indicates that the participant selected one, the lowest number on the scale, more than any other number. For instance, a score of 13 would indicate that the participant answered one for every item, and a score of 19 would indicate that the participant answered one for seven items and two for six items. A score of 20 would indicate that the participant answered two seven times and one six times, placing them in the moderate MDDI group. The participants who scored between the upper and lower cutoffs were classified as having moderate MDDI scores.
This study was approved by the Kent State Institutional Review Board, and volunteers were required to provide consent.
Study Recruitment
Several methods of participant recruitment were used for this study.
Electronically, a study announcement was posted on FlashLine, an online web portal for
56
Kent State University, and sent out through several different Kent State email databases to inform students of the study. Posters were another method of participant recruitment that this study utilized. Posters providing study information and researcher contact information were displayed in various locations on campus, particularly in areas with high foot traffic such as the Kent State Student Center. Digital signage was exhibited in the Kent State Student Recreation and Wellness Center to recruit recreational exercisers.
One last recruitment technique which was used for this study was in-person presentations. The researcher gave five-minute presentations to large classes on campus to recruit potential subjects.
Questionnaire Design
Subject demographics and characteristics. The first section of the questionnaire included information about subject demographics and characteristics.
These items included: (1) age; (2) academic major; (3) height; (4) weight; (5) past and current mental health diagnoses; (7) exposure to nutrition in the academic setting; (6) exercise level; (7) sport participation.
Muscle dysmorphia disorder inventory. Originally adapted from Schlundt,
Woodford, & Brownlee’s (2000) Muscle Dysmorphic Inventory (MDI), the Muscle
Dysmorphia Disorder Inventory (MDDI) is a 13-item questionnaire developed to assess
MD characteristics. Permission to utilize the MDDI for this study was obtained from the author, and the 13-items, all of which used a 1 to 5 likert scale, were put into an electronic format for participant completion. The complete list of items is included in
Appendix A.
57
Block food frequency questionnaire. The 2005 version of the Block Food
Frequency Questionnaire (FFQ) was used to assess the dietary intake of participants.
Originally developed by Dr. Gladys Block of the National Cancer Institute, the Block
FFQ is a dietary questionnaire based on NHANES 1999-2002 dietary recall data
(NutritionQuest, 2013). It took participants approximately 30 minutes to complete and once analyzed, provided information about the individual’s customary energy, macronutrient, and micronutrient intake (NutritionQuest, 2013). Over the past few decades, several studies have verified the validity of the Block FFQ in accurately assessing dietary intake (Block, Woods, Potosky, & Clifford, 1990; Bourcher et al., 2006;
Johnson, Herring, Ibrahim, & Siega-Riz, 2007; Mares-Perlman et al., 1993; Subar et al.,
2001).
For this particular study, the electronic format of the Block FFQ via
NutritionQuest’s Data-on-Demand server was used for several reasons. The fees involved for both the paper-and-pencil format and the electronic format were comparable, but the electronic version provided instant analysis of the data and secure 24-7 access to all of the data (NutritionQuest, 2013). Because the data was electronically collected and reported, this reduced the administration time and respondent burden and enabled the data to be more easily analyzed by the researcher (NutritionQuest, 2013).
Experimental Design
This was a quantitative, non-experimental, post-test only design study examining the prevalence of MD-related traits college age men and the association between these traits and dietary intake. To access the online survey, participants were directed to the
58 electronic homepage of the study. At this page, they were provided with general information about the study and researcher contact information. To participate in the study, they were prompted to click a proceed button and were then redirected to the beginning of the online survey.
In total, the survey consisted of three different sections. The first two sections were administered by Qualtrics, an online survey software. Upon providing informed consent, participants answered demographic questions (i.e. age, major, sport participation, exercise habits) in the first section and completed the Muscle Dysmorphia
Disorder Inventory (MDDI) in the second section. At this point in the survey, participants were redirected to an online version of the 2005 full-length Block Food
Frequency Questionnaire (FFQ), the third and final section of the survey. Participants answered questions about food items they normally consume, the frequency with which they consume them, and the amount consumed. NutritionQuest, the company which markets the Block FFQ, had specialized software which analyzed the results of the FFQ and provided participants with a customized nutrition report, displaying information on the participant’s average intake of calories, fat, protein, carbohydrate, and other nutrients.
In order to keep the survey completely anonymous, computerized, and streamline, the randomizer, embedded data, and branching functions on Qualtrics were used to assign random subject IDs to participants to be able to link the results collected from Qualtrics and NutritionQuest in the analysis process. Permission to utilize the MDDI was obtained from the author, and an account was purchased through NutritionQuest to utilize the
Block FFQ. In total, the three parts of this study’s survey took participants
59 approximately 30 minutes. Once the data collection phase of the study was concluded, the study website was removed.
Statistical Analysis
SPSS statistical software was used to analyze the data collected in this study.
Descriptive statistics were utilized for the subject demographic and characteristics data.
A one-way ANOVA was used to analyze data from the FFQ. The group means for total energy intake, percentage of intake from protein, percentage of intake from carbohydrate, and percentage of intake from fat were compared. A one-way ANOVA was used to analyze MDDI scores, comparing the mean scores for each of the three study groups. To compare MD symptoms and dietary intake, a Pearson r correlation was run to determine whether a relationship existed between MDDI score and FFQ results for percentages of the diet composed of protein, carbohydrate, and fat. Additionally, those individuals from any of the study groups with high scores on the MDDI were grouped and had correlations between MDDI score and dietary intake of energy, protein, carbohydrate, and fat calculated and analyzed. A chi-squared test was also used to evaluate the distribution on
MDDI scores throughout the exercise level groups when categorized by cardiovascular activity and weightlifting activity.
Results
In total, 154 individuals accessed the study survey. Of these individuals, 118 participants completed the entire survey, including the demographic information, the
MDDI, and the FFQ. Of those who completed the survey, four were NCAA division I athletes and were excluded because this study sought to examine intentional recreational
60 exercise rather than competitive sport participation. Two participants were excluded for having previously been diagnosed with an eating disorder, BDD, or MD. One individual was excluded because there was no demographic information disclosed, preventing the participant from being categorized into any of the groups. One individual was excluded because he was out of the study age range at 31 years old. This resulted in a final study sample of 110 participants. Additionally, three participants did not provide enough information about their weightlifting behavior to categorize them into one of the three study groups. This resulted in an n of 107 when men were classified by the amount of accumulated weightlifting time per week.
Table 1 displays the demographic characteristics of the study sample. The anthropometric results in this study indicate that this population is likely representative of college age males; the findings for average height, weight, and BMI are similar to results previously reported by other researchers (Greene et al., 2011; Johnson et al., 2014;
Morrell et al., 2012; Mozumdar & Liguori, 2011). Additionally, the wide variety of academic areas of study reported on the survey further contributes to the representative nature of the sample.
61
Table 1. Demographic Characteristics of Kent State University Male Study Participants n Mean Standard Deviation Age (in years) 110 21.02 1.81 Height (in inches) 110 71.69 9.79 Weight (in pounds) 109 184.96 36.85 BMI 109 25.91 4.46 Academic Year 109 3.04 1.37 Academic Major by College (n=104) n % College of Applied Engineering, Sustainability, and Technology 11 10.58% College of Architecture and Environmental Design 2 1.92% College of the Arts 1 0.96% College of Arts and Sciences 23 22.12% College of Business Administration 25 24.04% College of Communication and Information 4 3.85% College of Education, Health, and Human Services 26 25% College of Nursing 10 9.62% Other 2 1.92%
Table 2 displays the means and standard deviations of the variables MDDI score, energy intake, percentage of intake from protein, percentage of intake from fat, and percentage of intake from carbohydrate when participants were grouped by the amount of cardiovascular exercise accumulated in one week. At a p value of <0.05, there was only one significant difference between mean scores of the three groups, and this difference was exhibited in total energy intake. Men in the high exercising group consumed a significantly greater amount of energy on average than did men in the sedentary or low exercising group. There were no significant differences in the group means for MDDI score, percentage of intake from protein, percentage of intake from fat, or percentage of intake from carbohydrate between the groups based on cardiovascular exercise level.
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Table 2. Mean and Standard Deviations of Muscle Dysmorphia Disorder Inventory Score (MDDI) and Percentage of Dietary Intake Variables with Participants Grouped by Cardiovascular Exercise Level (n=110) All Sedentary Low High F P Participants Individuals Cardiovascular Cardiovascular value (n=110) (n=32) Exercisers Exercisers (n=38) (n=40) MDDI 30.15±8.44 30.09±8.19 30.45±9.00 29.93±8.32 0.038 0.963 Total Energy 2194.91± 1997.17±856.28 2042.08±916.27 2498.30±989.94a 3.384 0.038 Intake (kcal) 947.39 Protein (%) 16.07±3.07 15.89±2.50 15.66±2.91 16.61±3.58 1.007 0.369 Fat (%) 35.69±6.16 36.73±5.00 35.72±7.48 34.84±5.62 0.831 0.438 Carbohydrate 47.03±7.93 46.60±7.15 46.84±9.03 47.57±7.59 0.147 0.863 (%) Values are presented as mean ± standard deviation a Significantly greater than Sedentary Individuals and Low Exercisers.
Table 3 exhibits the results of an ANOVA comparing group means for MDDI score and dietary intake variables when participants were grouped based on the time they accumulate of weightlifting per week. The high weightlifting group exhibited significantly higher MDDI scores than the low weightlifting group but not the moderate weightlifting group, although it was trending toward significance with a p value of p=0.057. The high weightlifting group also had a higher percentage of intake from protein than both the low weightlifters and moderate weightlifters. None of the other group means were significantly different for total energy intake, percentage of intake from fat, or percentage of intake from carbohydrate.
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Table 3. Mean and Standard Deviations of Muscle Dysmorphia Disorder Inventory Score (MDDI) and Percentage of Dietary Intake Variables with Participants Grouped by Weightlifting Level (n=107) All Low Moderate High F P Participants Weightlifting Weightlifting Weightlifting value (n=107) Individuals Individuals Individuals (n=36) (n=30) (n=41) MDDI 30.33±8.45 26.94±6.22 29.90±8.64 33.61±8.94a 6.658 0.002 Total Energy 2199.25± 1982.10±853.16 2242.68±1181.18 2358.13±827.27 1.554 0.216 Intake (kcal) 952.16 Protein (%) 16.14±3.07 15.00±2.28 15.84±2.85 17.35±3.44b 6.445 0.002 Fat (%) 35.72±6.19 36.35±5.02 36.04±5.55 34.94±7.50 0.549 0.579 Carbohydrate 46.90±7.93 48.08±6.99 46.58±7.90 46.09±8.75 0.634 0.532 (%) Values are presented as mean ± standard deviation a Significantly greater than Low Weightlifters. b Significantly greater than Low Weightlifters and Moderate Weightlifters.
Table 4 exhibits the results of an ANOVA comparing group means for the third grouping scheme of the study. When subjects were categorized based on their scores on the MDDI, the high group, above the cutoff of 39, contained 14 participants (12.73% of study participants). This statistical test demonstrated that men who scored high or moderate on the MDDI had significantly higher energy intake than those who scored low.
Additionally, men with low and moderate MDDI scores consumed a significantly higher percentage of their diet from carbohydrate than men with high MDDI scores.
Table 4. Mean and Standard Deviations of Percentage of Dietary Intake Variables with Participants Grouped by Muscle Dysmorphia Disorder Score (MDDI) (n=110) All Low MDDI Moderate High MDDI Score F P Participants Score (n=12) MDDI Score (n=14) value (n=110) (n=84) Total Energy 2194.91± 1538.41±631.80 2246±895.22a 2448.56±1259.69a 3.679 0.028 Intake (kcal) 947.39 Protein (%) 16.07±3.07 15.63±2.37 15.89±2.86 17.57±4.35 1.986 0.142 from Fat (%) 35.69±6.16 34.41±5.19 35.72±5.91 36.61±8.37 0.412 0.663 Carbohydrate 47.03±7.93 49.65±6.63b 47.41±7.65b 42.56±9.39 3.077 0.050 (%) Values are presented as mean ± standard deviation a Significantly greater than Low MDDI. b Significantly greater than High MDDI.
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In order to examine the association between MDDI score and the dietary intake variables of total energy intake, percentage of intake from protein, percentage of intake from fat, and percentage of intake from carbohydrate, a Pearson correlation test was completed, with the results exhibited in Table 5. A moderate correlation demonstrated a negative relationship between percentage of intake from carbohydrate and percentage of intake from fat (r=-0.749). There were also moderate correlations between percentage of intake from fat and from protein (r=0.424) and between percentage of intake from carbohydrate and from protein (r=-0.575).
Table 5. Pearson Correlation Coefficients between Muscle Dysmorphia Disorder Inventory Score (MDDI) and Percentage of Dietary Intake Variables (n=110) MDDI Score Total Energy Percentage of Percentage of Percentage of Intake (kcal) Intake from Intake from Intake from Protein (%) Fat (%) Carbohydrate (%) MDDI - 0.181 0.200* 0.087 -0.249* Total Energy 0.181 - 0.016 0.105 -0.050 Intake (kcal) Protein (%) 0.200* 0.016 - 0.424** -0.575** Fat (%) 0.087 0.105 0.424** - -0.749** Carbohydrate (%) -0.249* -0.050 -0.575** -0.749** - *Correlation is significant at the 0.05 level. **Correlation is significant at the 0.01 level.
Table 6 displays the results of a chi-squared analysis of the distribution of MDDI scores when participants were grouped by cardiovascular exercise levels and weightlifting levels. When participants were categorized by time accumulated in cardiovascular exercise per week, the X2 of 1.576 with a p value of 0.813 indicated that the distribution of MDDI scores was fairly even between groups. It did not suggest that the high exercising group had a higher proportion of high MDDI scores than the other groups. When participants were categorized by weightlifting level, the X2 of 8.587 with
65 a p value of 0.072 revealed that although there was not a significant difference in the distribution of MDDI scores among the groups, the data did seem to be trending in this direction. Of the exercise level groups examined, the high weightlifting group did have the highest proportion of high MDDI scorers at 24.39%, but this did not quite reach the significance level of <0.05.
Table 6. Distribution of Muscle Dysmorphia Disorder Inventory Scores (MDDI) Between Varying Exercise Levels with Participants Grouped by Cardiovascular and Weightlifting Level. MDDI Low (n) Moderate High (n) Total X2 P value (n) Cardiovascular Level Low 6.06%(2) 81.82%(27) 12.12%(4) 33 1.576 0.813 (n=109) Moderate 11.11%(4) 75.00%(27) 13.89%(5) 36 High 15.00%(6) 72.50%(29) 12.50%(5) 40 Weightlifting Level Low 11.11%(4) 86.11%(31) 2.78%(1) 36 8.587 0.072 (n=107) Moderate 13.33%(4) 76.67%(23) 10.00%(3) 30 High 7.32%(3) 68.29%(28) 24.39%(10) 41 Values are presented as percentages with the number of participants in each group presented in parentheses
Discussion
The purpose of this study was to both evaluate the prevalence of MD symptomatology in college age men with varying exercise levels and to evaluate the relationship between MD symptomatology and dietary intake patterns. The first hypothesis in this study was that the prevalence of MD would be higher in those accumulating the highest amount of recreational exercise, as opposed to those with low levels of recreational exercise or sedentary individuals. This hypothesis was developed with the idea that men with higher levels of MD symptoms would be driven to exercise more, working toward their perceived “ideal” physique.
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This was also the reason for excluding NCAA division I athletes from this study.
Division I athletes are required to attend practices and to participate in a certain level of exercise as part of a team, yet this study sought to examine the body image of men who choose to exercise and determine their own physical activity levels independent of requirements set on them by a coach or trainer. Additionally, it would stand to reason that although some division I male athletes may be concerned with their appearance, they are likely driven by more of a performance factor rather than body image. Several studies have demonstrated that appearance is a driving factor behind recreational exercise in men, and for this reason, it is possible that this population is at a high risk for MD- related symptomatology (Egli et al., 2011; Kilpatrick, Hebert, & Bartholomew, 2005).
Additionally, research has not yet examined MD in sedentary men, so it is unknown the level of MD-related symptomatology which would appear in this population.
The second hypothesis in this study was that higher scores on the MDDI would be associated with increased intake of total calories and differences in macronutrient distribution. This hypothesis was determined with the logic that men striving to increase their muscularity would consume a greater amount of calories to support their goal of increased muscle mass. Similarly, it was expected that men looking to achieve an “ideal” physique would desire to increase their muscle mass while becoming “leaner” and may employ a diet which is high in protein and lower in carbohydrates and fat to achieve their goal.
This hypothesis was consistent with the small body of knowledge surrounding eating attitudes and nutrition habits in MD. MD was originally referred to as “reverse
67 anorexia” due to the pathological eating patterns which commonly accompany the condition (Pope et al., 1993). Contesini et al. (2013) found that men diagnosed with MD typically consumed hyperprotein, hypolipidic diets, accompanied by dietary supplements aimed at increasing muscle mass while simultaneously reducing body fat. Similarly,
Murray et al. (2012) and Mosley (2009) noted eating psychopathology in men with MD including the utilization of rigid food rules, consuming strict levels of the different macronutrients, particularly protein, and eating regularly even when not hungry. Men with MD have also demonstrated an increase in MD-related symptomatology when their rigid dietary intake is disrupted, regardless of exercise status (Mosley et al., 2009; Murray et al., 2012). In general, the existing literature provides information about the disruption that MD-related traits have on nutrition habits but lacks information on the actual dietary intake of men with MD. The macronutrient compositions of the diets consumed by these individuals were largely unknown, giving rise to the current study.
Based on an MDDI cut-off of 39 as suggested by Hildebrandt in personal correspondence, 12.73% (n=14) of the men in this study had MDDI scores which may be indicative of high levels of MD symptomatology. Particularly in the high weightlifting group, 24.39% of the men in this group exhibited MDDI scores above the cut-off of 39.
Although this was not quite significantly different than the other groups (p=0.072), the trend may indicate that men who weightlift the most are at the highest risk for MD- related symptomatology, as would be expected. This could be due to the fact that their psychopathology inclines them toward accumulating greater amounts of weightlifting per week than men with less MD-related symptoms. For this reason, it may be important for
68 practitioners to be particularly vigilant when working with members of a high weightlifting population. Additionally, it is important to consider the possibility that some degree of self-selecting occurred in participant recruitment of this study. Men experiencing some degree of body image disturbance or eating pathology may have been more inclined to participate in the study than other men, which could have slightly inflated the prevalence of high MDDI scores in this study.
Leone, Sedory, and Gray (2005) discuss the idea that MD is typically found in individuals heavily engaged in muscle development activities and provides a list of questions which athletic trainers can ask men suspected to have MD. These questions encompass the areas of social avoidance, time, and diet and other practices to corroborate traits or habits the athletic trainer has already noticed in the individual, with many of these questions paralleling topics addressed by the MDDI (Leone, Sedory, & Gray,
2005).
Although the MDDI cannot yet be used to definitively diagnose MD, these results may reveal that the proportion of men struggling with MD, particularly those who are recreational exercisers, may be higher than currently thought (Hildebrandt,
Langenbucher, & Schlundt, 2004). The prevalence of MD is still largely unclear due to the lack of consistency in the literature. The results of early examinations suggested that the prevalence of MD among bodybuilders is approximately 10%, but Grieve, Truba, and
Bowersox (2009) suggested that this should be considered the upper limit (Pope & Katz,
1994). Olivardia (2001) suggested two other estimates of MD prevalence: (a) 500,000 men in the United States, based on approximately 5 million men holding a gym
69 membership and 5% of weightlifters meeting the criteria for MD and (b) 90,000 men in the United States based on an estimated 1 million men with BDD and 9% of men with
BDD having MD (Pope et al., 1997; Pope, Phillips, & Olivardia, 2000).
Grieve, Truba, and Bowersox (2009) addressed another important idea when considering the prevalence of MD: even if the prevalence of MD is low and commensurate with that of anorexia nervosa, this still could mean that millions of men suffer from this disorder. Additionally, there are likely many more men who suffer from a subclinical presentation of MD, not quite meeting the diagnostic criteria for MD but still being negatively affected by this body image disruption (Grieve et al, 2009). A study conducted by Goodale, Watkins, and Cardinal (2001) provided an example of a number of college students with subclinical levels of MD, and it is likely that considering individuals with subclinical MD would vastly increase the prevalence of the condition in the United States. Ultimately, more research will need to be done in the general population to develop a clearer picture of the widespread prevalence of MD.
One of the findings of this study was that there was no significant association between MD symptomatology and cardiovascular exercise level. The fact that MDDI score was not related to the accumulated amount of cardiovascular exercise may mean that cardiovascular exercise is a poor indicator of body image disturbance in men.
Conversely, when men were grouped by their amount of weightlifting per week, there was a significant relationship between exercise level and MD symptomatology (p=0.002).
This result was not unexpected because men with a higher level of MD pathopsychology would be more likely to spend large amounts of time weightlifting in order to achieve
70 their desired physique, making time spent weightlifting per week a more effective indicator of MD-related symptomatology than cardiovascular exercise.
Another interesting idea to consider when evaluating exercise level as an indicator of MD-related pathopsychology was presented by Holland, Brown, and Keel (2014).
During a study to examine the relationship between disordered eating and detrimental exercise patterns, the researchers found that the compulsive and compensatory nature of unhealthy exercise was a better indicator of eating pathology than the actual time spent exercising (Holland, Brown, & Keel, 2014). Although MD is yet to be definitively linked to particular dietary intake patterns, it is likely that the body image disturbance of the condition impacts nutritional status in some way, suggesting that motivations behind exercise, as opposed to the amount of exercise, may be a useful indicator of MD psychopathology.
One major goal of this study was to evaluate the relationship between MD symptomatology and dietary intake of macronutrients because to date, this has not yet been evaluated. There were some significant results discovered, but there also seemed to be some limitations to the data. As previously discussed, it seemed that grouping individuals based on weightlifting exercise rather than cardiovascular exercise was a more effective method of predicting MD symptomatology, and therefore, more effective for the purposes of this study. The high weightlifting group consumed a significantly higher percentage of their diet as protein than either the moderate weightlifting group or the low weightlifting group (p=0.002), and because there was a significant difference in
MDDI scores between the high weightlifters and the low weightlifters (p=0.002), MD
71 symptomatology could have contributed to the increased percentage of intake from protein. This result was expected based on the current knowledge of the nutrition attitudes of men with MD, but it is of note that despite the portion of the diet from protein being greater in men with higher weightlifting amounts, it was not high enough to be considered “hyperprotein” as might have been predicted (Contesini et al., 2013; Murray et al., 2012; Mosley, 2009). The acceptable macronutrient distribution range for protein for men 19-30 years of age is 10-35%, so the mean percentage intake from protein of the men in the high weightlifting group (17.35%±3.44%) was not even at the upper end of the range recommended for the general population (National Research Council, 2005).
When participants were grouped based on MDDI score, the high scoring group and the moderate scoring group consumed significantly greater energy intakes than the low scoring group (p=0.028), and the high scoring group consumed a significantly lower portion of their diet from carbohydrate (p=0.050). The trend in energy intake increasing as MDDI score increases was expected because men with higher scores, and therefore a stronger desire to gain musculature, would likely attempt to do this through higher energy intake. The significant difference in percentage of diet as carbohydrate may suggest that men with high MD symptomatology use a low-carbohydrate diet as a strategy for achieving the physique they perceive as ideal.
The relationship between MD symptomatology and dietary intake was also evaluated using a Pearson correlation of the study variables. Overall, MDDI score was not strongly correlated with any of the dietary intake parameters, and this could indicate that MD-related psychopathology does not actually translate to dietary intake. This could
72 also indicate that the dietary intake reported in the study contains some inaccuracies. The
Pearson correlation did demonstrate some significant correlations between dietary intake variables. There was a moderate positive correlation between percentage of intake from fat and from protein (r=0.424) and moderate negative correlation between percentage of intake from carbohydrate and protein (r=-0.575) as well as percentage of intake from carbohydrate and from fat (r=-0.749).
In considering the results of this study, it is important to take into account the limitations inherent in the use of 39 as the MDDI score cut-off. To date, the body of research regarding MD has not yet provided professionals with a definitive cut-off for the diagnosis of MD, so cut-offs that indicate a high level of MD symptomatology may or may not be associated with a definitive diagnosis of the condition. The cut-off selected for this study was based on expert opinion in considering unpublished data, and it will require further study to determine its validity as a predictor of high MD symptomatology.
Additionally, using cut-offs could increase the probability of individuals with high MDDI scores without MD being included in the group of participants thought to suffer from
MD, while men with lower MDDI scores with MD may not be included. This points to the fact that likely, structured clinical interviewing such as used by Pope et al. (1997) is still the most effective way of diagnosing men with MD in the absence of a thoroughly validated screening instrument.
In this study, there was some concern over the accuracy of the dietary intake data reported by study participants. The mean reported energy intakes in this study were much lower than would be anticipated for college age men, and this could point to the
73 fact that measuring dietary intake in a real world situation is notoriously difficult.
Several studies have demonstrated the tendency of FFQs to underestimate dietary intake in different populations, likely due to errors inherent in surveys based on self-reported information. A review by Trabulsi and Schoeller (2001) examined studies which compared the accuracies of different methods of dietary assessment instruments when assessed against doubly labeled water. Among the studies mentioned in the review using
FFQ, each reported significant amounts of underreporting.
Kroke et al. (1999) found that FFQs underreported energy intake by 19% in its study sample of adult men and women. Another study mentioned in the review was conducted by Bathalon et al. (2000), and it found that FFQ introduced the largest amount of underreporting of the dietary assessment methods. Carlsen et al. (2010) found that
FFQ underestimated energy intake by approximately 11% in adult men and women.
Arab and colleagues (2011) found that the rate of underreporting of more than 30% of calories on a FFQ was 34% in black adults and 52% in white adults.
Despite the tendency to underestimate dietary intake, FFQs are still validated instruments, and the benefits of the tool for this study were as follows: 1) this method of dietary assessment allowed the participants to be kept completely anonymous, 2) completing a FFQ decreased the respondent’s burden over methods of dietary intake collection such as food diaries, 3) use of a FFQ decreased the time needed to analyze dietary intake of the participants.
In future studies, it may be beneficial to refine the way energy intake and diet composition are measured in this population. Freedman and colleagues (2011) suggested
74 ways to combat the errors inherent in dietary measurement including regression calibration techniques and addressing the non-classical measurement errors found in dietary assessment as well as the loss of statistical power. There may also be some value in utilizing two different methods of dietary intake analysis simultaneously. For instance,
Carroll and colleagues suggested that using multiple 24-hour recalls and a FFQ simultaneously could provide data with better accuracy than using either of the these methods independently. Using metabolic parameters, such as the doubly labeled water method for determining energy expenditure in conjunction with energy intake and body composition, may be the next step to consider for evaluating dietary intake, but this also reduces anonymity of participants, which could be important considering that this research focuses on body image disturbances.
In addition to refining the way energy intake data is collected, another limitation of this study which points to the need of further study is the use of caloric intake without evaluating caloric needs. The caloric data collected in this study provided a starting point for evaluating dietary intake in this population, but because every individual has a different metabolism and therefore different energy needs, it is not only important to evaluate the amount of energy they consume but also how this amount compares to their needs. Future studies should select appropriate methods for evaluating energy needs based on such factors as sex, height, weight, age, and activity level. Evaluating how men’s energy intake compares to their needs may be more telling of dietary patterns as they relate to MD symptomatology than energy intake alone.
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Another valuable area of further study would be to examine the relationship between exercise motivation and MDDI score. As mentioned previously, research regarding disordered eating and exercise patterns has demonstrated that the emotional qualities of exercise, including the compulsiveness and compensatory nature, may be a more effective indicator of eating pathology than the actual time spent doing exercise
(Holland, Brown, & Keel, 2014). This may also be the case in men with MD, and therefore, this would be an important area for further study.
Clinical Applications
This study was the first to examine the relationship between MD symptomatology and dietary intake patterns in men with varying exercise levels, and there were several significant findings. Participants who reported greater levels of weightlifting had significantly higher scores for MD-related symptoms than those who reported lower levels; this provides evidence that weightlifting level may be an effective indicator of body image disturbances, particularly MD, in college age men. Some of the findings related to dietary intake included: (1) men in the high weightlifting group had a significantly greater percentage of intake from protein than low or moderate weightlifters; (2) individuals with both moderate and high scores for MD symptomatology had greater energy intakes than those with low scores; (3) individuals with high levels of MD symptomatology had a significantly smaller percentage of intake from carbohydrate than individuals with low or moderate levels of MD symptomatology.
In this study, the prevalence of college age men reporting high levels of MD- related symptomatology was 12.73%. Although there is currently no validated
76 instrument for the diagnosis of MD, the prevalence of high levels of symptomatology demonstrated in this study suggests that MD may be a more widespread issue for college age men than has previously been reported. With this in mind, it is important for clinicians to familiarize themselves with MD and the warning signs and symptoms of this condition. For decades, a general misunderstanding about men and body image has led to the pervasive stereotype that body image disturbances are a “female problem” and struggling with body image is not “masculine”. On the contrary, an increasing number of men are developing problems with body image, and clinicians play an important role in disseminating correct information about body image disturbances, including MD, to raise awareness of this problem within male populations and dispute current stereotypes.
Particularly for practitioners in the areas of health, nutrition, exercise, and psychology, it is important for clinicians to be vigilant in looking for the signs of MD, not only to treat men with the condition but also to prevent others with the beginning stages from progressing to more severe, debilitating forms.
Because there is still no validated instrument for definitively diagnosing MD, the role of the practitioner is of utmost importance, with the best way of diagnosing MD still being patient interviews and the use of clinical experience and judgment. Instruments for evaluating MD-related symptomatology, such as the MDDI utilized in this study, should continue to be refined and tested in order to increase the reliability of diagnosing MD, but until this can be done, tools such as the MDDI can be utilized as screening tools to test for men who may have MD or be at risk for developing the condition. Being able to screen for MD is important, but above all, clinicians are responsible for staying up-to-
77 date with the literature surrounding MD and contribute to the dissemination of science- based information combating stereotypes about body image disturbances in men.
APPENDICES
APPENDIX A
MUSCLE DYSMORPHIA DISORDER INVENTORY
Appendix A
Muscle Dysmorphia Disorder Inventory
Please rate the following statements to best indicate how you typically think, feel, or
1 2 3 4 5 1. I think my body is too small
2. I wear loose clothing so that people can’t see my body
3. I hate my body
4. I wish I could get bigger
5. I think my chest is too small
6. I think my legs are too thin
7. I feel like I have too much body fat
8. I wish my arms were bigger
9. I am very shy about letting people see me with my shirt off
10. I feel anxious when I miss one or more workout days
11. I pass up social activities with friends because of my workout schedule
12. I feel depressed when I miss one or more workout days
13. I pass up chances to meet new people because of my workout schedule behave on a scale from 1-5 (1 meaning never, 5 meaning always):
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APPENDIX B
STUDY CONSENT FORM
Appendix B
Study Consent Form
EVALUATION OF THE PREVALENCE OF MUSCLE DYSMORPHIA SYMPTOMATOLOGY AND THE ASSOCIATION WITH DIETARY INTAKE IN COLLEGE MEN
Welcome to “Evaluation of the prevalence of muscle dysmorphia symptomatology and the association with dietary intake in college men”, a web-based study examining dietary patterns and muscle dysmorphia symptoms in 18-24 year old men at Kent State University. Before taking part in this study, please read the consent form below and click “I Agree” at the bottom of the page if you understand the statements and freely consent to participate in the study.
Consent Form This study involves a web-based survey examining the prevalence of muscle dysmorphia symptoms and the association with dietary intake patterns in college men aged 18-24. The principal investigator is Dr. Amy Miracle of Kent State University, and it has been approved by the Kent State University Institutional Review Board. No deception is involved, and the study involves no more than minimal risk to participants (i.e., the level of risk encountered in daily life).
Participation in this study typically takes 40 minutes and is strictly anonymous. Participants will complete an online survey including questions on basic demographic information, muscle dysmorphia-related symptoms, and dietary intake. At the end of the study, participants will have access to an analysis of their dietary intake, including calories, carbohydrates, protein, fat, vitamins, and minerals.
All responses are treated as confidential, and in no case will responses from individual participants be identified. Rather, all data will be pooled and published in aggregate form only. Participants should be aware, however, that the experiment is not being run from a “secure” https server of the kind typically used to handle credit card transactions, so there is a small possibility that responses could be viewed by unauthorized third parties (e.g., computer hackers).
Participation in this study is completely voluntary, and refusal to take part in the study involves no penalty or loss of benefits to which participants are otherwise entitled. Participants may withdraw from the study at any time without penalty or loss of benefits to which they are otherwise entitled. There is no monetary compensation for participation in this study.
If participants have further question about this study or their rights, or if they wish to lodge a complaint or concern, they may contact Ashley Rickard at [email protected] or the principal
82 83 investigator, Dr. Amy Miracle at [email protected] or (330) 672-2649. The Kent State University Institutional Review Board can be contacted at (330) 672-2704.
If you are 18 years of age or older, understand the statements above, and freely consent to participate in the study, click on the "I Agree" button to begin the study.
APPENDIX C
DEMOGRAPHIC, EXERCISE, AND MD-RELATED QUESTIONS
Appendix C
Demographic, Exercise, and MD-Related Questions
Demographic Questions
What is your age?
What is your height (in feet and inches)?
What is your current weight (in pounds)?
What is your academic year in school? Freshman Sophomore Junior Senior 5th Year Senior Graduate
List your academic major(s) and minor(s) (if applicable).
Have you taken a nutrition course in college? Yes, if yes, how many? ______ No
Have you taken any college course in which nutrition was a component, chapter, or unit? Yes, if yes, how many? ______ No
Did you have nutrition included in any high school course? Yes, if yes, how many? ______ No
Have you ever been diagnosed with an eating disorder?
Yes No
85 86
Have you even been diagnosed with Body Dysmorphic Disorder or Muscle Dysmorphia? Yes No
Are you a Kent State NCAA division I athlete? Yes No
Exercise-Related Questions
On average, how many days per week do you get cardiovascular exercise of at least moderate intensity (somewhat hard to very, very hard exercise)? 0 1 2 3 4 5 6 7
On the days you perform cardiovascular exercise of at least moderate intensity, how many sessions do you do per day on average? 1 2 3 or more n/a
Approximately, how many total hours of cardiovascular exercise (of at least moderate intensity) do you get per week?
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On average, how many days per week do you weightlift? 0 1 2 3 4 5 6 7
On the days you weightlift, how many sessions do you do per day on average? 1 2 3 or more n/a
Approximately, how many total hours of weightlifting do you get per week?
Muscle Dysmorphia Dysorder Inventory
Please rate the following statements to best indicate how you typically think, feel, or behave on a scale from 1-5 (1 meaning never, 5 meaning always). Your answers are confidential, so please be as honest as possible.
88
Never Rarely Sometimes Often Always 1 2 3 4 5
I think my body is too small.
I wear loose clothing so that people can't see my body. I hate my body. I wish I could get bigger. I think my chest is too small. I think my legs are too thin. I feel like I have too much body fat. I wish my arms were bigger. I am very shy about letting people see me with my shirt off. I feel anxious when I miss one or more workout days. I pass up social activities with friends because of my workout schedule. I feel depressed when I miss one or more workout days. I pass up chances to meet new people because of my workout schedule.
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