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). 3 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 5 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 6 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. 8 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. 9 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. 10 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. 11 Relationship between symptoms of muscle dysmorphia and body composition 12 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. 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