Muscle dysmorphia symptomatology: a cross-cultural study in Mexico and the United States.
Muscle diseases (Health aspects)
Bodybuilding (Health aspects)
Obsessive-compulsive disorder (Care and treatment)
Obsessive-compulsive disorder (Health aspects)
Men (Health aspects)
Giardino, Joseph C.
Procidano, Mary E.
|Publication:||Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 Men's Studies Press ISSN: 1532-6306|
|Issue:||Date: Spring, 2012 Source Volume: 11 Source Issue: 1|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: Mexico; United States Geographic Code: 1MEX Mexico; 1USA United States|
This cross-cultural study examined the nature and correlates of
muscle dysmorphia (MD) in Mexicans who lift weights, compared
symptomatology in Mexicans to that in Americans, and investigated the
roles of bodybuilding and acculturation in the presentation of MD
symptoms. The sample consisted of 46 Mexicans and 67 Americans who lift
weights (N = 113). Participants completed measures regarding symptoms of
MD, engagement in bodybuilding, acculturation, exercise dependency,
eating pathology, and steroid use. Contrary to predictions, results
indicated similar occurrences of MD symptoms in both samples. MD
symptoms were correlated with bodybuilding, exercise dependence and
eating pathology in both Mexican and American men, as well as American
women. Engagement in bodybuilding in men was similar in both samples;
however, in the American sample, bodybuilding behaviors were more
related to MD. Acculturation to American culture was not related to
symptoms of MD. Steroid use was greater in both samples than in previous
studies. Findings are discussed in terms of cross-cultural and clinical
Keywords: muscle dysmorphia, bodybuilding, body image, weightlifters, steroids
Since the identification and description of eating disorders, these illnesses have been considered "women's diseases," (Pope, Phillips, & Olivardia, 2000a, p. 18). Research has shown however, that men too suffer from body image dissatisfaction, have preoccupations or insecurities about their bodies, and may even have distortions about their own body image. Men's preoccupations have been found to be different from those of women (Olivardia, 2001). Men have an increasing need to be more muscular (Cafri, Thompson, Ricciardelli, McCabe, Smolak, & Yesalis, 2005; Pope et al., 2000a). Researchers have identified a new disorder resulting from the excessive preoccupation on muscularity and body size: muscle dysmorphia (Pope, Gruber, Choi, Olivardia, & Phillips, 1997). Despite the growing literature on muscle dysmorphia (MD), there is still much to be learned about the disorder. Almost all the research on MD has been conducted within the United States and little is known about how the disorder manifests in other countries. Comparing MD among individuals in the U.S. with individuals from other countries is important for understanding the etiology of the disorder and may inform treatment.
Virtually no studies have been conducted comparing MD in Mexico and the United States. This study investigated the nature and correlates of MD symptomatology in Mexicans who lift weights and the relationship to an American sample. Mexico is of particular interest because of "Americanization" over the past twenty years (Contreras, 2009). Since the enactment of the North American Free Trade Agreement (NAFTA), Mexico has seen increased numbers of American companies, changes in consumer trends, increased American media, democratization of their political process, and the increased adoption of English phrases (Contreras, 2009). Increased exposure to American culture may place Mexicans at higher risk for body image disorders. Past research with Latinos has demonstrated that awareness of American cultural ideals of appearance is associated with increased body dissatisfaction (Warren, Castillo, & Gleaves, 2010). Similarly, acculturation to American culture is related to higher rates of eating disorders (Canchelin, Phinney, Schug, & Striegel-Moore, 2006), and greater eating disorder symptomatology (Ayala, Mickens, Galindo, & Elder, 2007; Jane, Hunter, and Lozzi, 1999) in Latinos.
Mexicans who lift weights may adopt practices associated with bodybuilding through contact with American culture. Bodybuilding has a historical presence in the United States and has been accepted into mainstream American fitness culture (Mosley, 2009). MD was initially identified in bodybuilders (Pope et al., 2000a) and bodybuilding has been frequently associated with MD or symptoms of MD (Baghurst & Lirgg, 2009; Hitzeroth, Wessels, Zungu-Dirwayi, Oosthuizen, & Stein, 2001; Lantz, Rhea, & Cornelius, 2002). It is possible that Mexicans who lift weights adopt bodybuilding practices via exposure to American culture, which, in turn, places them at higher risk for MD. This study investigated the role of acculturation to American culture among Mexicans who lift weights and the relation to bodybuilding and MD symptoms.
MALE BODY DISSATISFACTION: A CROSS-CULTURAL ISSUE
A study of body dissatisfaction in the United States found that over 90% of college men in the Midwest, Northeast, and Southwest reported dissatisfaction with their muscularity (Frederick et al., 2007). Dissatisfaction with muscularity is not exclusive to the United States. Frederick et al. (2007) found that about 70% of Ukrainian and about half of Ghana-Jan college-aged men were dissatisfied with their muscularity. A cross-cultural study of college-aged men in Austria, France, and the United States also found a high prevalence of body dissatisfaction in other countries. Men in all three countries desired bodies with an average of 28 pounds more muscle than their own bodies (Pope et al., 2000b).
Few studies have investigated body dissatisfaction among Mexican men. Baile, Monroy, and Garay (2005) investigated body dissatisfaction among male gym users in seven different community gyms in Guadalajara, MX. The researchers administered a translated version of the Adonis Complex questionnaire, a measure of body image satisfaction (Pope et al., 2000a). Results indicated that 50% of Mexican male gym users were moderately worried about their body image and 10%-percent were critically worried. These levels of body dissatisfaction were similar to those found in American samples (Baile et al., 2005). A large community-based study in Mexico City found an increase in males' preoccupation with gaining weight: 5.4% in 1997 to 11.5% in 2003 (Unikel-Santoncini, Bojorquez-Chapela, Villatoro-Velazquez, Fleiz-Bautista, & Icaza, 2006). The Mexican National Health and Nutrition Survey found excessive exercising behavior in 2.4% of 19-year-olds males (Barriguete-Melendez et al. 2009); becoming dependent on exercise has been associated with body image dissatisfaction in males across the lifespan (McCabe & Ricciardelli, 2004). Although few in number, these studies suggest an increasing trend toward preoccupation with body image among Mexican men.
Muscle Dysmorphia (MD) is a disorder that evolves from the excessive preoccupation with one's muscularity and leanness (Pope et al., 1997). It was originally identified as "bigorexia" or "reverse anorexia nervosa," when first seen in clinical cases (Pope et al., 2000a; Pope et al., 1997). This is primarily because it shares a symptomatology very similar to that of anorexia, except where in anorexia the "intense fear" is of being fat or gaining weight, in muscle dysmorphia the "intense fear" is of not being big and muscular enough and having too much body fat (American Psychiatric Association [DSM-IV-TR], 2000; Pope et al., 1997). This "intense fear" is accompanied by exercise dependent behaviors, especially weight lifting, and "excessive attention to diet" (Pope et al., 1997). For full diagnostic criteria see Appendix A.
MD is currently conceived as a subset of Body Dysmorphic Disorder (BDD; Pope et al., 1997). According to the DSM-IV-TR (2000), individuals with BDD have an excessive preoccupation with "an imagined defect in appearance." This may be a particular part of the body with a slight physical anomaly that causes clinically significant distress or impairment. In individuals with MD the "imagined defect" is inadequate muscularity. These individuals are distressed to the point where they will avoid situations in which their bodies will be exposed, such as going to the beach or changing in the locker room. They may wear heavy clothing in the middle of summer to avoid exposing their bodies or may wear extra layers of clothes to make them look bigger. They may pass up important social or work-related events to exercise or because dieting may be compromised. (Pope et al., 1997; Pope et al., 2000a)
Research suggests that MD be further classified as an obsessive compulsive spectrum disorder (OCSD) within the classification as BDD (Chandler, Derryberry, Grieve, & Pegg, 2009; Hildebrandt, Schlundt, Langenbucher, & Chung, 2006; Maida & Armstrong, 2005). Chandler et al. (2009) and Maida and Armstrong (2005) found a strong positive relationship between MD and obsessive-compulsive symptomatology; Maida and Armstrong (2005) found no correlation between MD and a measure of somatoform disorders. Likewise, Hildebrandt et al. (2006) found that individuals with MD had more obsessive-compulsive symptomatology. Obsessions include excessive thinking about muscularity (Cafri, Olivardia, Thompson, 2008; Olivardia, Pope, & Hudson, 2000): Cafri et al. (2008) found that about two thirds of men with MD spent more than three hours per day thinking about their muscularity. Compulsions include body checking (Olivardia, Pope, & Hudson, 2000; Walker, Anderson, & Hildebrandt, 2009), excessive weightlifting, and excessive control over diet (Cafri et al., 2008; Olivardia et al., 2000). Men with MD have little or no control over weightlifting activities and avoid people, activities, and places associated with body appearance (Cafri et al., 2008).
Anabolic-androgenic steroid use is associated with MD and is commonly a symptom of the disorder (Kanayama, Barry, Hudson, & Pope, 2006; Olivardia et al., 2000; Rohman, 2009). In the Olivardia et al. (2000) study, approximately half of individuals with MD reported a history of steroid use, as opposed to only 7% of weightlifters without MD. In about three fourths of these men, MD preceded the use of steroids (Olivardia et al., 2000). Long-term or heavy steroid users appear to present with more symptoms of MD than short-term users (Kanayama et al., 2006). Anabolic steroid use is typically preceded by use of other illicit substances (Kanayama, Pope, Cohane, & Hudson, 2003) and many users engage in "stacking," or taking several different steroids at once to increase muscularity and decrease body fat (Kouri, Pope, & Katz, 1994; Pope et al., 2000a). The fact that so many men are willing to expose themselves to such dangers to achieve bigger, more muscular bodies is a clear indication of the gravity of MD, and prevalence in different cultures will be hard to determine without further research.
The last estimated prevalence rate of MD was reported in 2001 at approximately 500,000 American men (Olivardia, 2001). Some researchers have identified subclinical levels of MD in greater numbers among college populations (Goodale, Watkins, & Cardinal, 2001). College men are at particular risk, especially since some research suggests an onset age for the disorder at 19.4 [+ or -] 3.6 years (Olivardia et al., 2000). Prevalence is difficult to estimate however, due to the lack of research regarding muscle dysmorphia symptoms in general populations.
BODYBUILDING AND MD
Since the identification of muscle dysmorphia, researchers have questioned the role of bodybuilding in the disorder. Bodybuilding has been defined as the pursuit of muscular physique through a weight training regime and tailored nutrition program (Mosley, 2009). Case studies of male bodybuilders led to the initial identification of MD (first known as "reverse anorexia;" Pope et al., 2000a) and criteria for the disorder were later developed in populations of bodybuilders (Pope et al., 1997). The Muscle Appearance Satisfaction Scale (MASS; Mayville, Williamson, White, Netermeyer, & Drab, 2002), an instrument designed to assess for symptoms of MD, contains a subscale related to dependence on bodybuilding.
Mosley (2009) described MD as primarily affecting male bodybuilders. Lantz et al. (2002) found MD to be more common in bodybuilders than power lifters. Rates appear to be lower in weightlifters as well. Hildebrandt et al. (2006) found that only about 18% of weightlifters presented with symptoms of MD. Hitzeroth et al. (2001) assessed for MD in an amateur bodybuilding competition and found that over half of participants presented with the disorder. Competing in bodybuilding competition may not be necessary, however. Recreational male bodybuilders showed similar preoccupation with weight and body shape, as well as similar rates of extreme body modification practices when compared to competitive male bodybuilders (Goldfield, Blouin, & Woodside, 2006). Similarly, natural bodybuilders compared to non-natural bodybuilders (i.e., use anabolic androgenic steroids) showed equal concern with traits associated with MD (Baghurst & Lirgg, 2009).
Mosley (2009) examined MD through the historical development of bodybuilding in the United States. He described bodybuilding as a subculture based primarily in Southern California until the late 1970s. Bodybuilding gained exposure in mainstream culture via the release of "Pumping Iron," a documentary on the bodybuilding lifestyle featuring Arnold Schwarzegger. Mosley described Schwarznegger's subsequent fame in Hollywood as a catalyst for mainstream acceptance of bodybuilding in American fitness culture.
Today, cultural acceptance of bodybuilding is evidenced through media. Media specifically related to bodybuilding is arguably greatest in the United States. The majority of bodybuilding magazines, including Flex, Ironman, Muscle & Fitness, and many others are American publications (Flex Online, 2011; Iron Man Magazine, 2011; Muscular & Fitness, 2011). Bodybuilding.com, a super site for bodybuilding literature, supplement sales, and advertising, is also an American organization. The site offers more than 25,000 pages of bodybuilding and fitness information and claims ranking as the number one visited website in the world for bodybuilding and fitness, as well as standing as the number one sports nutrition e-retailer (Bodybuilding.com, 2011).
Given the acceptance of bodybuilding in mainstream American fitness culture (Mosley, 2009), it is possible that individuals who exercise, especially individuals who lift weights, may respond to bodybuilding practices without necessarily considering themselves bodybuilders (e.g., measuring body parts, adherence to bodybuilding diets). Adoption of bodybuilding practices may increase risk for MD, as suggested by Mosley (2009). Further, the presence of bodybuilding in American culture may result in transmission of bodybuilding practices to other cultures. Cultures, such as Mexican culture, that are particularly influenced by American culture (Contreras, 2009) may adopt bodybuilding practices, and thus, be at risk for MD. The effects of acculturation to American body image ideals on the development of body image dissatisfaction and eating disorders among Latino cultures have been described in the literature.
ACCULTURATION AND BODY IMAGE
Acculturation has been defined as a "complex, multidimensional process of learning that occurs when individuals and groups come into continuous contact with different societies" (Stephenson, 2000). In Latinos, contact with American cultural ideals of appearance has been related to increased body image dissatisfaction (Warren et al., 2010). Mexican American females who were highly behaviorally acculturated to American culture (e.g., eat American foods, wear American clothes, watch American media) were likely to be aware of and internalized American cultural values of appearance (i.e., thin physique). Conversely, low acculturated females had lower levels of awareness and internalization of American cultural values of appearance (Warren et al., 2010).
Pepper & Ruiz (2007) investigated the role of acculturation in antifat attitudes. Antifat attitudes are negative perceptions of overweight and obese individuals. Pepper and Ruiz compared groups of Latinas in the U.S. based on acculturation levels to American culture. They found that highly acculturated Latinas had significantly greater antifat attitudes compared to low acculturated Latinas and bilcultural Latinas. Highly acculturated Latinas had similar antifat attitudes to European Americans. (Pepper & Ruiz, 2007)
Not only do body dissatisfaction and antifat attitudes appear to increase as Latinas have more contact with American culture (Warren et al., 2010; Pepper & Ruiz), but the risk for eating disorders also increases. Studies have found that highly acculturated Latinas have higher rates of eating disorders (Canchelin et al., 2006) and greater eating disorder symptomatology (Ayala et al., 2007; Jane, et al., 1999) compared to less acculturated Latinas. Among Mexican American females, orientation toward American culture predicted eating disorders, whereas orientation toward Mexican culture did not predict eating disorders (Canchelin et al., 2006).
As has been demonstrated with Latina women, it is possible that the trend toward body dissatisfaction in Mexican men (Baile et al., 2005; Unikel-Santoncini et al., 2006) may be related to acculturation to American culture.
PURPOSE OF PRESENT STUDY
The purpose of the present study was to investigate the nature and correlates of MD symptomatology in Mexicans who lift weights, compare symptomatology in Mexicans to that in Americans, and investigate the roles of bodybuilding and acculturation in the presentation of MD symptoms.
Bodybuilding appears important to the development of muscle dysmorphia (Mosley, 2009) and therefore, this study was designed to assess engagement in bodybuilding practices. Currently measures do exist to measure bodybuilding, including the bodybuilding dependence subscale of the Muscle Appearance Satisfaction Scale (MASS; Mayville et al., 2002) and the Bodybuilding Dependence Scale (Smith & Hale, 2004). However, these scales were designed to measure dependence on bodybuilding. Few measures exist to assess engagement in bodybuilding based on dietary practices, supplement use, or training monitoring used by bodybuilders. Therefore, this study addressed prior limitations by analyzing engagement in bodybuilding based on these types of behaviors and their relationships with MD symptomatology.
Individuals who lift weights may do so for varying fitness, health, or other reasons; whereas, bodybuilders are individuals that pursue a muscular physique through a weight training regime and tailored nutrition program (Mosley, 2009). Past literature has examined MD in populations of bodybuilders (Baghurst & Lirgg, 2009; Hitzeroth et al., 2001; Lantz et al., 2002; Pope et al., 2000a); however, few studies have investigated the ways in which other fitness groups respond to practices more characteristic of bodybuilders. Individuals who lift weights may engage in bodybuilding practices without necessarily considering themselves bodybuilders because of the availability of bodybuilding media (e.g., Bodybuilding.com, 2011) and the acceptance of bodybuilding in mainstream American fitness culture (Mosley, 2009). To address this prior limitation, this study targeted individuals who lift weights, as this group likely outnumbers that of bodybuilders.
More specifically, individuals in university gyms were targeted in this study. College populations are of particular interest given the suggested onset age for MD (19.4 [+ or -] 3.6 years Olivardia et al., 2000), the identification of greater subclinical symptoms of MD in college populations (Goodale et al., 2001), as well as the ready access to university gyms and fitness equipment.
Finally, Hitzeroth et al. (2001) found a high prevalence of MD among women bodybuilders. Three out of the four women bodybuilder participants presented with the disorder. Due to the small sample size, these results could not be generalized to other groups of women. This study explored MD symptomatology in women who lift weights. Based on existing literature, several hypotheses were tested.
Hypothesis 1. It was predicted that American men would both present more MD symptoms, and engage in more bodybuilding behaviors than Mexican men based on the historic presence of bodybuilding in the U.S. (Mosley, 2009).
Hypothesis 2. For Mexican men, it was predicted that MD symptoms would be related to acculturation to American culture. That is, it was expected that exposure to American culture would be a risk factor for MD symptoms. Prior research suggests that exposure to American culture is a related to body image dissatisfaction (Warren et al., 2010), higher rates of eating disorders (Canchelin et al., 2006), and greater eating disorder symptomatology (Ayala et al., 2007; Jane, et al., 1999).
Hypothesis 3. It was predicted that in both cultures, men's MD symptoms would be associated with bodybuilding behaviors, exercise dependence, and eating pathology (based on typical presentation of MD; see Olivardia, 2001, Pope et al., 1997, and Pope et al., 2000a).
Hypothesis 4. Regarding gender differences, it was predicted that men in both cultures would have higher levels of MD symptoms than women (as MD is more typically found in men; Pope et al., 2000a).
Hypothesis 5. It was predicted that women's MD symptoms would also be related to bodybuilding behaviors, exercise dependence, and eating pathology (based on typical presentation of MD; see Olivardia, 2001, Pope et al., 1997, and Pope et al., 2000a).
Hypothesis 6. It was predicted that steroid users would present with more symptoms of MD in both cultures. Among weightlifters with MD, Olivardia et al. (2000) found that approximately half reported a history of steroid use.
The sample consisted of 46 participants recruited from the university gym of a major private institution in Mexico City, MX. Thirty-five participants were men with a mean age of 23.34 (SD = 4.26, age range: 19-35); 11 were women with a mean age of 22.18 (SD = 2.40, age range = 18-27). Individuals over the age of 35 (n = 4) were excluded to ensure relative balance in age between the Mexican and American samples. The ethnic/racial composition was 71.7% Mexican or Latino/Hispanic, 8.7% Mestizo (mixed ethnicities with Spanish roots), 4.3% Caucasian, and 15.2% non-responders. Of the participants, 6.5% were graduate students and 4.3% were alumni. All other participants were enrolled in undergraduate programs. Based on the tuition expenses listed on the university website, it is likely that students were primarily from families of middle to upper socioeconomic status.
In New York City, 67 participants were recruited from the on-campus gym of a major private university. Forty-three were men with a mean age of 20.47 (SD = 2.26, age range: 18 -30); 24 were women with a mean age of 20.17 (SD = 1.37, age range: 18-22). The ethnic/racial composition was 77.5% Caucasian, 6% Latino/Hispanic, 6% African American, and 10.5% other (including: Indian, African, Jamaican, Asian, or other ethic/racial identity). An additional 4.5% reported Latino or Hispanic as a secondary ethnic/racial identity. Ninety-one percent of participants were undergraduate students, 4.5% were faculty, and another 4.5% were alumni or graduate students. Based on statistics from the university website, students at this university are primarily from families of middle socioeconomic status. Although the University is located in New York City, over 40% of enrollment is out of state.
Demographic information questionnaire. The demographic information questionnaire constructed for study asked for information regarding age, sex, university status, and primary and secondary ethnic or racial identity.
Muscle Appearance Satisfaction Scale (MASS; Mayville et al., 2002). The MASS is used to assess symptoms of muscle dysmorphia. It is operationalized based on the DSM-IV-TR (2000) criteria for body dysmorphic disorder (BDD), and considered to be a subset of BDD. The MASS is a 19 item self-report measure that is divided into five subscales: Bodybuilding Dependence, Muscle Checking, Substance Abuse, Injury, and Muscle Satisfaction. The injury subscale refers to the perceived need to engage in exercise even when physically injured. The measure demonstrates construct validity based on factor analyses that confirms that the subscales correspond to unique factors; significant correlations with other body image and behavioral measures also exist (Mayville et al., 2002). The internal reliability for this study was as follows: Mexican sample [alpha] = .86, American sample [alpha] = .91.
Bodybuilding Index (BBI). The BBI was constructed for this study and is a measure of engagement in behaviors specifically related to bodybuilding. Items were composed based on examination of a major bodybuilding magazine. The bodybuilding magazine reviewed is marketed toward "hardcore" bodybuilders as opposed to other fitness magazines of the same publisher. The BBI contains 14 items regarding supplement or drug use, diet regulation, and body measuring. Some items were composed to reflect the use of supplements that were regularly advertised in the magazine, including protein, prohormones, creatine, fat burners, and amino acids (See Appendix B for full measure).
Diet regulation was a major content area of the magazine and recognized as essential to muscular growth. Diets stressed the importance of higher calorie and higher protein consumption. Diet regulation was incorporated into the BBI in questions regarding the number of meals eaten daily, amount of protein consumed, and the importance of meal times. Questions regarding body measuring referred to taking body fat percentage, taking photos to mark visual training progress (i.e., muscle growth or muscle definition), physically measuring certain body parts with a tape measure, and calculating BMI. These behaviors were regularly cited as means to evaluate progress as a bodybuilder in the publication.
The BBI utilizes a 6-point Likert scale (1 = Never and 6 = Always) and the maximum possible score is 84. Six degrees of measurement were chosen over five to prevent responses in the middle or of indecisive nature. The maximum score in this study was 48 and minimum was 0; the range was 48.
The original scale contained 15 items; however, one item regarding weight training twice daily was removed. While many types of athletes exercise twice in one day, weight training twice a day or "splits" are usually reserved to bodybuilders. This item possessed a low item-total correlation, r = .21, and was therefore removed. Item total correlations for all remaining items ranged from .43 to .69. Despite only preliminary application of this measure, internal reliability for the BBI was as follows: Mexican sample [alpha] = .85; American sample [alpha] = .89. The measure was correlated with bodybuilding dependence (based on the Bodybuilding Dependence subscale of the MASS; see results), eating pathology, and exercise dependence in American men and women. It was correlated with eating pathology in Mexican men (see Table 2).
Stephenson Multigroup Acculturation Scale (SMAS; Stephenson, 2000). The SMAS is a measure of the degree of immersion in both dominant and ethnic societies. It is a 32-item scale with two factors. Factor 1 assesses retention of, or immersion in, ethnic society. Factor 2 assesses adoption of, or immersion in a dominant society. In this study, the dominant society was identified as American society. Items containing the word "Anglo" were replaced by "American" in the Spanish version or omitted where unnecessary, as it is merely a clarification for individuals completing the measure in the United States and would have likely caused confusion in another culture. The measure was determined to have high internal consistency reliability for both factors: 0.97 for retention of ethnic society and 0.90 for immersion in American society (Stephenson, 2000). Stephenson (2000) demonstrated construct validity through correlations between generational status, immersion in ethnic society, and immersion in dominant society. In the current study, internal reliability was as follows: Mexican sample [alpha] = .78, American sample [alpha] = .92.
Exercise Dependence Scale (EDS; Hausenblas & Downs, 2000). The EDS is a 21-item scale that measures dependency to exercise on seven different subscales: tolerance, withdrawal, intention, loss of control, time, conflict, and consistency. A pattern of maladaptive exercise that causes clinically significant impairment in social or occupational functioning is characterized by high scores on three or more of the subscales. The EDS is measured on a 6-point Likert scale where 1 equals "Never" and 6 equals "Always." The scale can be used to classify individuals into three groups: At risk for exercise dependence, nondependent symptomatic individuals, and nondependent individuals. The scale has been shown to have test-retest reliability (r = .92, p = .001) and internal reliability ([alpha] = .95) in different studies. It also possesses content and concurrent validity (Hausenblas & Downs, 2002). The internal reliability for this study was as follows: Mexican sample [alpha] = .91, American sample [alpha] = .94.
Eating Attitudes Test (EAT; Garner, Olmsted, Bohr, & Garfinkel, 1982). The EAT is a measure used to screen for tendency toward eating disorders, including bulimia nervosa and anorexia nervosa. It also contains clinical variables relating to self-perception of body shape and weight. It is used as the screening instrument of choice for eating disorder by the National Eating Disorders Screening Project (National Mental Illness Screening Project, 1999). The EAT is a 26-item scale that tests for three factors: dieting, bulimia and food preoccupation, and oral control. Score ranges are from 0 to 78 and a composite score of [greater than or equal to] 20 indicates a tendency for weight disorder and dieting behavior (Garner et al., 1982). A 2005 study by Doninger, Enders, and Burnett with athletes further divided the EAT to encompass a five factor model (Drive for Thinness, Food Preoccupation, Others' Perceptions, Purging Behavior, and Dieting Behavior Factors). In this study of women college athletes, internal consistency reliability coefficients ranged from .70 to .88 for the subscales of the five-factor model. The study also found the measure to have convergent validity based on several different criteria (Doninger et al., 2005). The validity and reliability of the EAT have also been confirmed among men and women cross-culturally (Kayano et al., 2008). The internal reliability of the EAT for this study was as follows: Mexican sample [alpha] = .91, American sample [alpha] = .90.
Design and Procedure
Researchers used a cross-cultural survey design in conducting this study. A standard back-translation was used in translating all materials, including surveys and consent forms. The nature of the research was not disclosed to participants, but rather was presented as study on knowledge of exercise and diet. This was to prevent false responding on the surveys. Awareness of the nature of the study may have caused men to respond in ways consistent to the social stigma.
The surveys were distributed in the university gyms and therefore little exclusion criteria were necessary. Given that weightlifting is identified in the proposed diagnostic criteria for MD (Pope et al., 1997), only individuals who lifted weights regularly were included in the study. Individuals who only participated in cardiovascular activities were excluded. As compensation for completing the survey, participants were offered the choice of a protein bar or protein shake. The study was first administered in Mexico City and two weeks later in New York City.
Descriptive Statistics and Preliminary Analysis
Descriptive statistics are presented in Table 1. (1,2) Table 2 presents a summary of correlations of all variables.
Cultural factors in men's MD symptoms. Contrary to our expectations, American men neither presented more symptoms of muscle dysmorphia, t (76) = 1.25,p = .22, d = .29, nor engaged in more bodybuilding behaviors than Mexican men, t (74) = 1.49, p = .14, d = .35. The first hypothesis was not supported. Acculturation (i.e., exposure to U.S. culture) did not help to explain MD symptoms in Mexican men, for whom the relationship between MASS scores and SMAS Dominant Society Immersion was nonsignificant, r (33) = .04, p = .83. The second hypothesis was not supported.
Correlates of MD symptoms in men. As we predicted, men's MD symptoms were related to bodybuilding behavior in both Mexican men, r (33) = .37, p = .031, and American men, r (41) = .65, p < .001. Similarly, results supported our expectation that men's MD symptoms would be positively correlated with exercise dependence and eating pathology in both cultures. For Mexican men, MD symptoms were related to exercise dependence, r (33) = .62, p < .001, and eating pathology, r (33) = .44, p = .009, but not exercise dependence, r (33) = .35, p = .069. For American men, MD symptoms were positively correlated with both exercise dependence, r (41) = .74,p < .001) and eating pathology, r (41) = .50,p = .001. Hypothesis 3 was supported.
Gender differences and correlates of MD symptoms in women. We predicted that in both cultures, men would report higher levels MD symptoms than women. As predicted, American men reported significantly more MD symptoms than American women, t (65) = 3.15, p = .002, d = .78. Similarly, Mexican men reported significantly more MD symptoms than Mexican women, t (44) = 2.09, p = .043. Hypothesis 4 was confirmed for both the American and Mexican samples.
The hypothesized relationship between MD symptoms and bodybuilding behavior was confirmed for American women, r (22) = .57, p = .004. For American women, MD symptoms were also positively correlated with both exercise dependence, r (22) = .67, p < .001, and eating pathology, r (22) = .58,p = .003. For Mexican women, no significant correlations were found between MD symptoms and bodybuilding behavior, exercise dependence, or eating pathology. Hypothesis 5 was confirmed for the American women, but not Mexican women.
Steroid use. Table 3 summarizes self-reported usage of anabolic steroids and other dangerous substances. Reported usage by men of fat burners, testosterone, and anabolic steroids was higher in both cultures than in Cafri, van den Berg, and Thompson (2006). Likewise, anabolic steroid usage was greater in both cultures than that found Olivardia et al. (2000).
We expected that in both cultures, steroid users would report more MD symptoms. This expectation was confirmed for American men: Steroid users (n = 6) presented significantly more symptoms of MD than nonusers (n = 37), t (41) = 2.70, p = .010, d = .84. For Mexican men, the number of steroid users was only 3. No difference was found when compared with nonusers (n = 32), t (33) = .29,p = .78, d = .10, but this is likely due to the smaller size of the Mexican sample. No women in either sample reported steroid use. Hypothesis 6 was supported for American men.
The Bodybuilding Index. Since the newly constructed Bodybuilding Index (BBI) was used for the first time in this study, we examined its construct validity through its correlations with other measures. The measure was correlated with bodybuilding dependence (based on the Bodybuilding Dependence subscale of the MASS; r = .60, p < .001 for American men; r = .56,p = .005 for American women), eating pathology, and exercise dependence in American men and women, and eating pathology in Mexican men (see Table 2).
Because some correlations seemed more robust for certain groups (e.g., BBI-MASS, r (41) = .65 for American men versus r (33) = .37 for Mexican men; see Table 2), Fisher's r to z transformations were used to compare significant correlations between groups. The BBI-MASS relationship was significantly greater for American men compared to Mexican men, z = 1.63, p = .05. Only one other significant finding emerged from the z transformation analyses: The correlation between SMAS Factor 1 and SMAS Factor 2 was significantly greater for American men compared to Mexican men, z = 2.85, p = .002.
Given the more robust BBI-MASS relationship for American men compared to Mexican men, patterns between individual items of the BBI and total MASS scores were examined. Results are presented in Table 4.
Results from this study indicated little difference between the presence of muscle dysmorphia symptoms in men who lift weights in university populations in Mexico and the United States. American men were predicted to present more symptoms of MD based on an assumption that bodybuilding was more prevalent in the United States (see Mosley, 2009). Bodybuilding behaviors were predicted to be greater in American men than in Mexican men based on scores on the Bodybuilding Index (BBI). No significant differences were found, however, between the groups for either symptoms of MD or bodybuilding.
Acculturation was unrelated to MD symptoms: The similarity between symptoms in Mexican men and American men was not explained by acculturation to American culture. Mexicans in this sample, rather, may have had similar access to the same media that individuals in universities in United States have. American culture is often considered a global culture. Mexicans in this sample were likely exposed to very similar media images as Americans and would therefore not necessarily need to attend to American culture; they may have already considered aspects of American culture to be aspects of their own culture.
While differences were not found between cultures in regards to the amount of engagement in bodybuilding, within each culture, men who engaged in more bodybuilding presented with more symptoms of muscle dysmorphia. This is consistent with previous research describing bodybuilding as typically present in individuals with MD (Mosley, 2009), as well as findings suggesting a high prevalence of MD in bodybuilders (Hitzeroth et al., 2001). One major difference between this study and the study by Hitzeroth et al. (2001) was that the samples recruited consisted of all types of individuals who lift weights; it was not exclusively bodybuilders. This may be relevant for the generalizability of this study. Individuals who lift weights likely outnumber bodybuilders by a significant percentage worldwide. The mean ages of participants in this study were 23.34 (SD = 4.26) for Mexican men and 20.47 (SD = 2.26) for American men, which is similar to the estimated age of onset for MD (19.4 [+ or -] 3.6; Olivardia, 2001). Individuals with MD engage in long hours of weightlifting (Pope et al., 1997). Students in universities generally have access to university gyms, which in turn facilitate engagement in weight lifting; such access may not otherwise be available to individuals of the same age group without access to university gyms. Further, Goodale et al. (2001) identified greater numbers of subclinical cases of MD among college students. Targeting interventions to larger groups of individuals who lift weights, as opposed to only bodybuilders, may help identify subclinical levels of muscle dysmorphia early on, before they become full-blown cases.
For American men and women and Mexican men, MD symptoms were related to bodybuilding behavior, exercise dependence and eating pathology. The nonsignificance of these relationships for Mexican women was likely due to the small sample size. These results show that muscle dysmorphia appears to be operating in similar ways cross-culturally.
Steroid usage was notably high among men in both samples and was a predictor of MD symptoms in American men. This was consistent with the findings of Olivardia et al. (2000). In Mexico City, 42.9% of men reported use of fat burners, 11.4% reported testosterone or prohormone use, and 8.6% reported use of anabolic steroids. In New York City, 30.2% of men reported use of fat burners, 14% reported testosterone or prohormone use, and a striking 14% reported anabolic steroid use. While Cafri et al. (2006) found a 6% rate for fat burners, 4.5 % rate for prohomones, and 2.6% rate for steroids, this study found even higher rates for all substances in both cultures. Given the higher mean age of men in this study (Mexican men, M = 23.34; American men, M = 20.47) compared to the adolescents (ages 13-18) studied in Cafri et al., this suggests an increase in substance use among males who lift weights as they enter their twenties. Olivardia et al. found anabolic steroid use as high as 7% in weightlifters. This rate was still below that found among Mexican and American men in this study. If anabolic steroid use is typically preceded by use of other illicit substances (Kanayama et al., 2003) and muscle dysmorphia precedes the use of steroids (Olivardia et al., 2000), adequate assessment and treatment of MD early on may prevent the progression toward harmful substance abuse.
The higher usage of fat burners and lower usage of anabolic steroids in Mexican men may implicate cultural differences. For example, American men in the northeast may be more concerned with gaining muscular mass (hence the greater usage of anabolic steroids); whereas, Mexican men may use more fat burners to obtain a lean muscular appearance. In both instances, there appears to be a focus on both muscularity and leanness, which are criteria for diagnosis of MD (Pope et al., 1997).
It should also be considered that although reporting for substance abuse was particularly high, it is likely that some men still did not report use of certain substances. Underreporting is common among men who abuse steroids and other substances (Pope et al., 2000a). Rates of substance abuse in these samples were likely even higher than those found in this study.
While further research is needed on the cross-cultural presence of muscle dysmorphia, the presence of symptoms in college-aged Mexicans and Americans in this study is particularly concerning. If greater numbers of subclinical cases have already been identified in college weightlifters (Goodale et al., 2001) and positive correlations exist to a similar degree between MD symptoms, bodybuilding behavior, exercise dependence, and eating pathology in university populations in both Mexico City and New York City, such similarities likely exist in other cultures. Subclinical cases may be as prevalent in other countries and likely operate as they do in Mexico City and New York City. Muscle dysmorphia is not a disorder specific to the United States and requires further attention from researchers and clinicians. Furthermore, such findings implicate an underestimated prevalence of eating and image disorders in general, in men cross-culturally. While past studies have implicated a cross-cultural presence of body dissatisfaction (Baile et al., 2005; Pope et al., 2000a; Pope et al., 2000b; Frederick et al., 2007;), few studies have investigated actual symptomatology of MD cross-culturally. This study along with future cross-cultural studies will help to better estimate the prevalence of MD and subclinical cases among high risk populations, especially individuals who lift weights at universities.
A more robust relationship between the BBI and MASS existed for American men: Twelve items in the BBI were found to have higher and more significant correlations with MD symptoms. These correlations between MD symptoms and bodybuilding behaviors in American men may indicate that while obsessions about body image may not differ between these groups, the behavioral manifestations appear to have greater consequences in American men. American men presented several more behavioral compulsions highly related to MD. This finding is consistent with research investigating obsessive-compulsive symptomatology in MD and affirms the classification of muscle dysmorphia as an obsessive-compulsive-spectrum disorder within the body dysmorphic disorder classification (Chandler et al., 2009; Hildebrandt et al., 2006; Maida & Armstrong, 2005).
More behavioral compulsions may implicate a particular knowledge of bodybuilding in American men with MD. They point to the influence of bodybuilding-specific media in the behavioral manifestations of the disorder. While access to images of muscular men may not differ cross-culturally (i.e., Mexicans can view the same muscular men on TV and in movies; also the same reasoning that discounted acculturation), specific marketing for bodybuilding products and domestic manufacturing of these products may allow for greater access and exposure to bodybuilding media among American men. This is turn would lead not only to a gaining of more specific knowledge about bodybuilding, but also the development of greater and more varied behavioral compulsions. For example, American men presenting with MD symptoms may seek to buy more bodybuilding products, learn more techniques to monitor their diets, and learn more methods to measure their bodies (see Table 4) than men in other cultures.
The cross-cultural differences again may therefore be along the lines of behavioral manifestations of the disorder, as opposed to obsessions over muscular appearance. Past research has demonstrated the role of American media in body dissatisfaction (Baird & Grieve, 2006; Leit, Pope, & Gray, 2001; Lorenzen, Grieve, & Thomas, 2004). It is likely that Mexicans have access to this same media and may be at similar risk for developing obsessions about muscular appearance. Mexicans may not, however, have the same access to bodybuilding media or the same specific knowledge of bodybuilding. While bodybuilding is accepted in mainstream American fitness culture (Mosley, 2009), little is known about the presence in Mexican culture. Future research should investigate differences in compulsions and the role of media specifically related to bodybuilding.
The Body Building Index, while newly constructed, received construct validation in two cultures, and may be helpful in determining cross-cultural differences between the behavioral manifestations of MD in future investigations. The measure was also found to possess a high internal reliability.
Some limitations in this study should be considered. The Mexican sample used in this study was likely not representative of the Mexican population. Participants were recruited from a private university where tuitions costs almost certainly excluded people of low socioeconomic status. However, the sample may have been representative of individuals in university populations in Mexico. University students are likely at higher risk for MD than other populations (Goodale et al., 2001). They often have access to university weight rooms and also represent a mean age nearly identical to the suggested age of onset for MD (Olivardia, 2001). Access to a weight room may be particularly important for individuals in Mexico, because public gyms are likely not as prevalent as in the United States.
Another limitation of this study was the small sample size of Mexican women. Women weightlifters were difficult to recruit in the Mexican sample. This may be because women in Mexico likely engage in less weightlifting than American women. American women may have greater exposure to the specific bodybuilding media already described, and therefore place more value on muscular appearance. They may, for example, be interested in training with weights to stay lean and toned.
This study has several implications for cross-cultural research on MD. The researchers' predictions were incorrect regarding the presence of MD in Mexico. This finding suggests that MD is likely present and operating in a similar manner in other cultures as it is in the United States. The dangers of muscle dysmorphia should not be underestimated. The high number of men in this study abusing substances to increase their muscularity, including illegal anabolic steroids, is beyond worrisome and warrants more attention to body image disorders in men.
This study may also have clinical implications. Classification of MD on the obsessive-compulsive-spectrum of BDD may assist clinicians in the treatment of both compulsions and the underlying obsessions associated with MD. American men appear to be manifesting compulsive behaviors in different ways than men in other cultures. Bodybuilding appears to have a central role in the compulsive behaviors highly associated with MD symptoms in American men. Clinicians may use the BBI or similar measures to help identify the various compulsions of individuals with MD. Attention should be paid to the time spent exercising, the types of exercise, subscriptions to bodybuilding magazines, use of bodybuilding products and supplements, adherence to bodybuilding diets, and the ways in which clients may attend to a bodybuilding culture. Clinicians may explain symptoms of MD through assessment of bodybuilding behavior, exercise dependence, and eating pathology. The implementation of cognitive-behavioral treatments may be effective in the remittance of obsessions and compulsions associated with MD. Prevention programs in high schools and universities may help to circumvent escalation of substance abuse and development of MD symptoms.
DIAGNOSTIC CRITERIA FOR MUSCLE DYSMORPHIA (POPE ET AL., 1997)
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.
B. The preoccupation is manifested by at least two of the following four criteria:
1. 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.
2. The individual avoids situations where his or her body is exposed to others, or endures such situations only with marked distress or intense anxiety.
3. The preoccupation about the inadequacy of both size or musculature causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The individual continues to work out, diet, or use ergogenic (performance enhancing) substances despite knowledge of adverse physical or psychological consequences.
C. 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 body dsymorphic disorder.
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(1) Missing data were estimated using mean imputation. In the Spanish version of the survey, one item was missing from the MASS and one from the EAT. For these two items imputation was used based on individuals' mean scores from the other items in each scale.
(2) Other than mean differences presented in the context of hypothesis testing, the only significant difference that emerged from the data in Table 1 was that American women scored significantly higher than American men on the EAT, t (65) = 2.07, p = .04.
JOSEPH C. GIARDINO, M.S.Ed. * and MARY E. PROCIDANO, Ph.D. *
* Fordham University.
Correspondence concerning this article should be addressed to Joseph C. Giardino, Psychological and Educational Services, 113 West 60th Street, Room 1016, Fordham University-Lincoln Center, New York, NY 10023. Email: firstname.lastname@example.org
APPENDIX B BODY BUILDING INDEX Never Rarely Sometimes 1. I have taken amino acid supplements 1 2 3 to improve muscle gains. 2. I count my calories from protein, 1 2 3 carbohydrates, and fat. 3. I eat five to seven meals spread 1 2 3 evenly throughout the day. 4. I maximize muscle gains by consuming 1 2 3 between 1 and 1.5 grams of protein per pound in body weight each day. (2 - 3 grams of protein per kilogram) 5. I take creatine supplements. 1 2 3 6. I use caffeine based fat-burners to 1 2 3 help reduce body fat percentage. (ex. - Hydroxycut, Lipo 6) 7. I take protein supplements on a 1 2 3 regular basis to meet my dietary needs. 8. I weight train twice daily to maximize 1 2 3 my gains. 9. I take testosterone boosters or 1 2 3 prohormones to raise my testosterone levels. 10. I closely monitor my meal times. 1 2 3 11. I measure my body fat percentage. 1 2 3 12. I take photos of my body to monitor 1 2 3 training progress. 13. I measure the size of certain body 1 2 3 parts, such as my arms or chest, to record my progress. 14. I monitor my body mass index (BMI). 1 2 3 15. I take anabolic steroids for lean 1 2 3 muscle gains. Often Usually Always 1. I have taken amino acid supplements 4 5 6 to improve muscle gains. 2. I count my calories from protein, 4 5 6 carbohydrates, and fat. 3. I eat five to seven meals spread 4 5 6 evenly throughout the day. 4. I maximize muscle gains by consuming 4 5 6 between 1 and 1.5 grams of protein per pound in body weight each day. (2 - 3 grams of protein per kilogram) 5. I take creatine supplements. 4 5 6 6. I use caffeine based fat-burners to 4 5 6 help reduce body fat percentage. (ex. - Hydroxycut, Lipo 6) 7. I take protein supplements on a 4 5 6 regular basis to meet my dietary needs. 8. I weight train twice daily to maximize 4 5 6 my gains. 9. I take testosterone boosters or 4 5 6 prohormones to raise my testosterone levels. 10. I closely monitor my meal times. 4 5 6 11. I measure my body fat percentage. 4 5 6 12. I take photos of my body to monitor 4 5 6 training progress. 13. I measure the size of certain body 4 5 6 parts, such as my arms or chest, to record my progress. 14. I monitor my body mass index (BMI). 4 5 6 15. I take anabolic steroids for lean 4 5 6 muscle gains.
Table 1 Descriptive Statistics Mexican Men American Men (n = 35) (n = 43) Measure M SD M SD MASS 25.77 12.48 29.42 13.10 BBI 19.68 10.34 16.00 12.07 SMAS-Factor 1 41.41 4.61 36.49 8.69 SMAS-Factor 2 31.91 5.08 35.92 8.58 EDS 36.79 14.15 37.04 18.17 EAT 7.62 7.64 6.72 5.80 Mexican Women American Women (n = 11) (n = 24) Measure M SD M SD MASS 17.26 9.06 19.44 11.10 BBI 8.90 6.37 7.70 5.65 SMAS-Factor 1 40.90 3.48 38.79 7.66 SMAS-Factor 2 29.10 5.38 39.00 6.38 EDS 26.36 15.44 31.98 15.84 EAT 6.17 5.80 9.75 9.24 Note. MASS = Muscle Appearance Satisfaction Scale; BBI = Bodybuilding Index; SMAS Factor 1 = Retention of Ethnic Society, Factor 2 = Immersion in American society; EDS = Exercise Dependence Scale; EAT = Eating Attitudes Test. Table 2 Summary of Correlations Mexican Men (n = 35) 1 2 3 4 5 6 l. MASS 1 .37 * .01 .04 .62 ** .51 ** 2. BBI 1 .12 .11 .35 .44 ** 3. SMAS Factor 1 1 .55 ** -.19 -.19 4. SMAS Factor 2 1 -.01 -.21 5. EDS 1 .54 ** 6. EAT 1 Mexican Women (n = 11) 1 2 3 4 5 6 1. MASS 1 .23 .04 .34 .57 .42 2. BBI 1 .39 .39 -.14 -.31 3. SMAS Factor 1 1 .60 -.17 0 4. SMAS Factor 2 1 .27 -.02 5. EDS 1 .35 6. EAT 1 American Men (n = 43) 1 2 3 4 5 6 1. MASS 1 .65 ** .16 .20 .74 ** .50 ** 2. BBI 1 .11 .19 .55 ** .47 ** 3. SMAS Factor I 1 .86 ** .26 -.01 4. SMAS Factor 2 1 .30 -.02 5. EDS 1 .47 ** 6. EAT 1 American Women (n = 24) 1 2 3 4 5 6 1. MASS 1 .57 ** .06 .01 .67 ** .58 ** 2. BBI 1 -.19 -.09 .65 ** .72 ** 3. SMAS Factor 1 1 .88 ** -.32 -.14 4. SMAS Factor 2 1 -.31 -.07 5. EDS 1 .61 ** 6. EAT 1 Note. * p < .05, ** p < .01. MASS = Muscle Appearance Satisfaction Scale; BBI = Bodybuilding Index; SMAS Factor 1 = Retention of Ethnic Society, Factor 2 = Immersion in American society; EDS = Exercise Dependence Scale; EAT = Eating Attitudes Test. Table 3 Self-Reported Steroid and Substance Use American Mexican American Mexican Men Men Women Women (n = 35) (n = 43) (n = 11) (n = 24) Substance # % # % # % # % Fat Burners 15 42.9 1 30.2 13 9.1 5 20.9 Testosterone or Prohormones 4 11.4 0 14 6 0 0 0 Anabolic Steroids 3 8.6 0 14 6 0 0 0 Note. # equals the number of individuals self-reporting usage. % equals the percentage of users for each sample. Table 4 Summary of Correlations between Individual Items of BBI and MASS BBI items MASS Score MASS Score Mexican Men American Men Amino Acids .27 .57# ** Counting Calories .32 .52# ** Eating 5 to 7 meals -.02 .38# * Consume 1 - 1.5 grams protein per pound .34 * .53# ** Creatine .32 .41# ** Fat-Burners .34 * .39# * Protein Supplements .14 .53# ** Testosterone/Prohormones .21 .24 Monitor Meal Times .05 .56# ** Measure Body Fat % .23 .42# ** Take Photos of Body .34# * .28 Measure Body Parts .32 .44# ** Monitor BMI .22 .44# ** Steroids .06 .30# * Note. * p < .05, ** p < .01. BBI = Bodybuilding Index; MASS = Muscle Appearance Satisfaction Scale. The fifteen items for the BBI can be found in detail in the Appendix. Correlations that were higher for one group of men are bolded. Note: Correlations that were higher for one group of men are indicated with #.
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