RELATIONSHIP BETWEEN SYMPTOMS OF MUSCLE DYSMORPHIA AND BODY
COMPOSITION IN HIGH VOLUME WEIGHTLIFTERS
by
Sarah Horton
A Senior Honors Project Presented to the
Honors College
East Carolina University
In Partial Fulfillment of the
Requirements for
Graduation with Honors
by
Sarah Horton
Greenville, NC
May 2015
Approved by:
Dr. Laurel Wentz, PhD, RD, CSSD, LDN
Nutrition Science Department, College of Human Ecology
Relationship between symptoms of muscle dysmorphia and body composition
2
Introduction
Historically, body image issues have been strictly related to women. Men have been
thought to be immune to extreme thoughts of wanting to change their body. However, it has
become clear in recent research that, in fact, men are exposed to just as much pressure to obtain a
certain physique as women are (Grieve, F., Truba, N., & Bowersox, S., 2009). Therefore, body
image disorders like muscle dysmorphia are surfacing. Muscle dysmorphia (MD) is a subtype of
body dysmorphia disorder that is described by McCreary, D.R., et al. as a cluster of attitudes and
behaviors most often experienced by males who are already more muscular than most other men,
yet still desire to be bigger. For these attitudes and behaviors to be considered alarming, they
must interfere with the individual’s personal lives (2007). Those with MD behaviors commonly
spend so many hours in the weight room that they often have trouble maintaining social and
intimate relationships (Grieve, F., Truba, N., & Bowersox, S., 2009). These individuals also have
thoughts of physical inadequacy and commonly display obsessive behaviors related to fitnessrelated activities, diet regiments, and how their body is displayed (Hildebrandt, T., Schlundt, D.,
Langenbucher, J., and Chung, T., 2006). Muscle dysmorphia can be present in any individual,
but is most commonly seen in frequent gym-goers and weightlifters (McCreary, D.R., et al.,
2006; Pope, et al., 2005) It is important to note that not all men who are looking to improve their
physique are experiencing or have experienced MD (Baghurst, T., 2008). Compared to other
forms of disordered body image, muscle dysmorphia is poorly researched.
Most of the research to date has focused on the mental aspect of the disorder, such as
feelings of anxiety, depression, and traumatic experiences associated with obsessive behavior
(Wolke, D., Sapouna, M., 2008; Pope, et al., 2005; McCreary, D.R., et al., 2007). It has been
found that many individuals experiencing MD have been harshly judged or criticized on their
Relationship between symptoms of muscle dysmorphia and body composition
appearance as a child (Wolke, D., Sapouna, M., 2008). Thus, as they grow older, they aim to
demonstrate hard work, dramatic self-improvement, and extreme ambition (Baghurst, T., 2008).
Often times the measures taken to obtain this image of a perfect physique include excessive
exercising, obsessing over food intake, frequent body examination, unnecessary hair removal,
and frequent weighing (Grieve, F., Truba, N., & Bowersox, S., 2009). These behaviors are
outlined in figure 1.
Exercise
Dependence
Supplements
Physique
Protection
Pharmalogical
Abuse
Dietary
Constraints
Body
Size/Symmetry
Body
Dissatisfaction
Muscle
Dysmorphia
Self-Esteem
Figure 1. A conceptual model of behavioral characteristics of muscle dysmorphia (Baghurst, T., 2008).
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Relationship between symptoms of muscle dysmorphia and body composition
4
Previously, the physiological and physical effects of muscle dysmorphia have gained the
attention of researchers; therefore, a gap exists in the literature to quantify muscle, bone, and
adipose mass in weightlifters showing symptoms of muscle dysmorphia. This project aims to
quantify non-invasive anthropometric measurements in healthy and disordered weightlifters to
determine methods for identifying individuals a high risk of muscle dysmorphia.
Methodology
The hypothesis was tested by recruiting high volume weightlifters from the East Carolina
University Student Recreation Center, conducting anthropometric measurements, and asking
them to complete a survey addressing body perception and eating habits. Study subjects were
recruited if they were male or female students performing resistance training a minimum of 4
days per week, for at least 30 minutes each session. Subjects were required to have a body mass
of 71.5 kg or greater because previous research has shown that those below this weight typically
do not display symptoms of muscle dysmorphia (Baghurst, T. and Lirgg, C., 2009). This study
was approved by East Carolina University IRB prior to any data collection.
To recruit subjects, IRB-approved flyers containing minimum criteria and the principal
investigator’s contact information were placed in the front office of the ECU Student Recreation
Center. Weight room staff members received the flyer via e-mail, and they were asked to spread
recruitment information by word of mouth. We recruited eight subjects meeting our inclusion
criteria.
Prior to any measurements taken, subjects granted their consent and completed a survey
on characteristics associated with muscle dysmorphia. The survey pertaining to body perception
was the Muscle Dysmorphic Disorder Inventory (MDDI), shown in figure 2, obtained from the
Icahn School of Medicine (Varangis, E., 2015). Because a serious weightlifter’s lifestyle is more
Relationship between symptoms of muscle dysmorphia and body composition
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than just lifting weights, each subject’s nutritional habits and dietary supplements were also selfrecorded.
Participants then underwent a non-invasive body composition assessment, which
followed the procedures of the International Society for the Advancement of Kinanthropometry.
Anthropometry was performed by a level 2 trained anthropometrist. The assessment quantified
muscle mass, adipose mass, bone mass and muscle to bone ratio. Variable included height,
sitting height with a 38.3 cm box, large bone breadth with Campbell 20 sliding-branch calipers
(Rosscraft, SRL), small bone breadth with Campbell 10 sliding-branch calipers (Rosscraft, SRL),
head, arm, leg, and torso girths with non-extendible measuring tapes, and skinfolds with
Harpenden calipers. Duplicate measurements of every variable were taken to ensure accuracy. If
there was any difference in trials, the mean of the two was taken. If there was more than 1 unit
difference in the first two measurements, a third trial was run. Measurement sessions took
approximately one hour per subject.
Relationship between symptoms of muscle dysmorphia and body composition
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MDDI
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):
1) I think my body is too small.
2) I wear loose clothing so that people cannot see my
body.
3) I hate my body.
4) I wish I could get bigger.
5)
6)
I think my chest is too small.
I think my legs are too thin.
7)
8)
9)
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.
10) I feel anxious when I miss one or more workout days.
11) I pass up social events with my 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.
Figure 2: MDDI questionnaire. Questions 1, 4, 5, 6, and 8 relate to drive for size; questions 2, 3,
7, and 9 relate to functional impairment; questions 10, 11, 12, and 13 relate to appearance
intolerance. Higher sum of scores means subject is more likely to show signs of muscle
dysmorphia (Varangis, E., 2015).
Once measurements were complete, the data was entered into a Microsoft Excel
spreadsheet for analyzing. The spreadsheet used for this study was previously created by Francis
Holway (Holway, F., & Garavaglia, R., 2009). By entering the skin folds, bone girths, bone
lengths, and circumferences measured, formulas in the spreadsheet calculated the amount of
bone, muscle, adipose, skin, and residual mass of each subject. ISAK-validated formulas
calculated muscle-to-bone ratio, body mass index, and body fat percentage for each subject.
Subject’s phantom z-scores, where “0” is the mean measurement for stature, were proportionally
adjusted to a unisex individual of any population at 170 cm. We expected that subjects who
Relationship between symptoms of muscle dysmorphia and body composition
7
scored higher on the MDDI questionnaire would have higher muscle mass, lower adipose mass,
and an unhealthy muscle to bone ratio compared to those who did not display disordered body
perceptions.
Results
The spreadsheet in which subject’s anthropometric measurements were entered was able
to produce visual representations of tissue breakdown, shown in Figure 3. The same spreadsheet
was able to give visual representations of phantom z-scores for each measurement taken. The
number of standard deviations from the mean skinfolds, bone girths, bone lengths, and
circumferences are indicated by the colored points in Figures 4-7.
Body Composition Breakdown
Residual Mass
16%
Muscle Mass
51%
Bone Mass
12%
Adipose Mass
17%
Skin Mass
4%
Figure 3: Breakdown of subject NG0318 body compostition based on ISAK measurements. Each
subject’s body composition was broken down in a similar graph.
Relationship between symptoms of muscle dysmorphia and body composition
Circumference Z-Scores
Head
Neck
Arm relaxed
Arm flexed and tensed
Forearm
Wrist
Chest
Waist (minimum)
Abdominal (maximum)
Gluteal (Hip) (maximum)
Thigh (upper)
Mid-thigh
Calf (maximum)
Ankle (minimum)
-4
-3
-2
-1
0
1
2
3
4
Figure 4: Subject NG0318 phantom z-scores for ISAK circumference measurements.
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Relationship between symptoms of muscle dysmorphia and body composition
Skinfold Z-Scores
Triceps
Subscapular
Biceps
Iliac crest
Supraspinale
Abdominal
Front thigh
Medial calf
-4
-3
-2
-1
0
1
2
3
4
Figure 5: Subject NG0318 phantom z-scores for ISAK skinfold measurements.
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Relationship between symptoms of muscle dysmorphia and body composition
Bone Length Z-Scores
Acromiale-radiale
Radiale-stylion radiale
Midstylion-dactylion
Iliospinale height
Trochanterion height
Trochanterion-tibiale laterale
Tibiale laterale height
Tibiale mediale-sphyrion
tibiale
Foot
-4
-3
-2
-1
0
1
2
3
4
Figure 6: Subject NG0318 phantom z-scores for ISAK bone length measurements.
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Relationship between symptoms of muscle dysmorphia and body composition
Bone Girth Z-Scores
Biacromial
Transverse chest
Anterior-posterior chest
depth
Biiliocristal
Humerus (biepicondylar)
Femur (biepicondylar)
Wrist (bistiloid)
Ankle (bimaleolar)
Hand
-4
-3
-2
-1
0
1
2
3
4
Figure 7: Subject NG0318 phantom z-scores for ISAK bone girth measurements.
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Relationship between symptoms of muscle dysmorphia and body composition
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Each subject’s MDDI summed score was compared to their muscle-to-bone ratio, adipose
mass, and muscle mass, shown in Figure 8.
MDDI SUMMED
MUSCLE-TO-
% MUSCLE
% ADIPOSE
SCORE
BONE RATIO
MASS
MASS
NG0318
38
4.256
51.23%
17.02%
RB0321
25
4.735
51.44%
17.75%
JW0228
25
3.453
45.22%
21.48%
RW0617
32
4.230
51.14%
16.57%
KC0211
30
4.456
51.13%
18.88%
JG0098
27
5.930
55.49%
14.61%
TS0025
37
4.525
49.46%
20.51%
SC0210
32
4.850
52.79%
17.54%
SUBJECT ID
Figure 8: Subject’s score from MDDI survey related to their muscle-to-bone ratio.
The amount of muscle mass in each subject ranged from 45% to 55%. The subject with
the highest muscle-to-bone ratio had the greatest percentage of muscle mass in their body,
whereas the subject with the lowest muscle-to-bone ratio had the lowest percent of muscle mass.
Percent adipose mass did not follow the same direction. Although it was found that the subject
with the highest amount of muscle mass also had the lowest amount of adipose mass and the
subject with the lowest amount of muscle had the highest amount of adipose mass, the subjects
that fell in between the extremes did not follow any kind of pattern. The subject with the highest
MDDI score had an adipose mass that was close to the median (17.02%, median=17.28%), and
followed a similar trend for muscle mass (51.23%, median=52.01%).The subjects with the
lowest MDDI scores had very different body compositions.
Seven out of the eight subjects reported taking protein powder or creatine supplements on
a daily basis. The subject with the highest muscle-to-bone ratio reported using Selective
Relationship between symptoms of muscle dysmorphia and body composition
13
Androgen Receptor Modulators (SARMs) daily. Other supplements reported to be in use by
every subject included energy drinks and pre-workout stimulants. Subjects RB0321, JG0098,
TS0025, and SC0210, the four subjects with the highest bone-to-muscle ratio, all reported similar
dietary habits. All reported consuming chicken or turkey more than 4 times per week in the past
month, consuming whole grains more than 3 times per day in the past month, vegetables 1-3
times per day in the past month, and fruit 1-3 times per day in the past month. Only small
amounts (1-2 times in the past month) of red meat, nuts, and pork were reported as being
consumed.
When subjects were asked to report their current exercise regimen, all had similar
schedules. Their workouts tend to last, on average, 1.5-2 hours. Frequency of workouts was
identical for all subjects at 6-7 days per week. The subject with the highest muscle-to-bone ratio
reported spending the longest amount of time working out, which was 2.5-3.5 hours. The same
subject only spends his workout time weightlifting. The other subjects reported doing a mixture
of weightlifting and cardio. Lastly, subjects were asked to report how intense they would
consider their usual workout to be on a scale of 1 (leisure walking) to 5 (feelings of nausea). On
average, subjects reported between a 3 and a 4.
Discussion
Overall, the proposed hypothesis was unsupported from the results of this study. Previous
research revealed a gap where body composition could be taken into account when looking into
characteristics of those experiencing MD. Those that scored higher on the MDDI questionnaire
were experiencing feelings described in other studies. These behaviors include anxiety when
workouts are missed, thinking certain parts of their bodies are too small, feeling like they have
too much body fat, and a level of shyness when shirtless around their peers. Other traits seen in
Relationship between symptoms of muscle dysmorphia and body composition
14
this sample were frequent workouts, spending multiple hours in the gym, and a clean diet. It is
unclear whether these behaviors are obsessive enough to say that they could be experiencing
muscle dysmorphia. Some of the extreme behaviors seen in other research, such as steroid use,
passing up opportunities to meet new people, extreme supplement consumption, and multiple
gym visits each day (Grieve, F., Truba, N., & Bowersox, S., 2009; Baghurst, T., 2008;
McCreary, D., et al., 2007) were not seen in our subjects.
The vague results of this study provide an opportunity for further research, where a larger
sample size could be utilized and other qualified surveys could be given to subjects. It would
also be helpful to see how weightlifter’s body perception changes as they gain more muscle mass
over time. This would require a much longer time frame, as well as the possibility of extending
the age group beyond college-age.
There is no medical diagnosis for MD; therefore, future researchers should provide
athletes with more extensive surveys to accurately diagnose their disorder. Muscle dysmorphia is
just as detrimental to one’s physical and mental health as anorexia nervosa and bulimia nervosa.
Those experiencing this type of obsessive behavior should be referred to a dietitian and therapist
that are familiar with how to treat it.
Relationship between symptoms of muscle dysmorphia and body composition
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References
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