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Another threat to American teens has been identified: protein shakes, pre-workout concoctions and other supplements. These so-called muscle and body-building products are associated with muscle dysmorphia, according to a new study.

Led by Dr. Kyle Ganson, assistant professor in the Factor-Inwentash Faculty of Social Work at the University of Toronto, the study included mainstream staples found in virtually any nutrition shop: whey protein powders, creatine monohydrate, pre-workout drinks, protein bars, amino acids/branched-chain amino acids (BCAAs), and weight/mass gainers. These products are legal, widely available, and heavily marketed to fitness enthusiasts of all ages.

Ganson previously headed the Canadian Study of Adolescent Health behaviors, designed to examine disordered eating, muscle-building behavior, body image and social health. The goal of the study was to develop research-informed recommendations for public health, healthcare, and policymaking experts to protect the health and well-being of Canada’s young people. Researchers analyzed reports of supplement use and symptoms of muscle dysmorphia in more than 2,700 participants, aged 16 to 30 years. Responses were elicited using the Muscle Dysmorphic Disorder Inventory.

Published last week in the journal PLOS Mental Health, the paper found the association was especially strong between supplements marketed for gaining weight or mass and symptoms of muscle dysmorphic disorder. The symptoms, such as excessive workout time and obsession with food intake increased along with the number of supplements an individual used.

The study also showed that younger people who may not use harmful anabolic steroids may be using other substances to treat their muscle dysmorphic disorder. Contributing to the problem is the belief that supplements are safe, which may not be true.

What is muscle dysmorphic disorder?

Muscle dysmorphia is a mental health condition in which an individual believes that their muscles are too small and underdeveloped. The Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) places muscle dysmorphia in the obsessive-compulsive category.

As a result, people with the disorder obsess about increasing their muscle size, no matter the true state of their physique. A person of any size, even those with well-developed muscles, can have muscle dysmorphia. They fixate on diet and exercise for muscle building at the expense of important aspects of life, such as relationships, work, and education. They may exercise excessively, use dietary supplements to an extreme, and use anabolic steroids.

A 2022 study of more than 3,800 participants aged 11 to 19 years found that 1.4% of girls and 2.2% of boys experience muscle dysmorphia. There is no specific cause of the condition, but some potential contributors include cultural or media influence, low self-esteem, childhood bullying, social isolation, and loneliness.

Symptoms

There’s an extensive list of symptoms. Some of these include:

• Excessive exercise, despite risk of injury or pain.
• Sacrificing career, relationships, financial stability, and personal interests for exercise.
• Fixation on food intake with rigid dietary rules.
• Obsessing about or avoiding mirrors.
• Using excessive dietary supplements marketed as muscle-building products.
• Using anabolic steroids.

Risk Factors

Participants in sports that emphasize appearance are at greater risk of muscle dysmorphia, especially bodybuilders. Other factors include social anxiety, anorexia, and perfectionism. These mental health conditions are commonly associated with muscle dysmorphia:

• Substance use disorder
• Obsessive-compulsive disorder
• Eating disorders
• Mood disorders
• Social anxiety disorder
• Attention deficit hyperactivity disorder (ADHD).

Diagnosis

Muscle dysmorphia is a subtype of body dysmorphic disorder (BDD), so assessment starts with focusing on BDD.

A healthcare professional asks a patient how they feel about their appearance, whether those feelings adversely affect their quality of life, and if they experience repetitive or compulsive thoughts and disorders.

If signs of BDD are present, the doctor may use the Muscle Dysmorphic Disorder Inventory (MDDI) to assess muscle dysmorphia symptoms. These are categorized into three groups: drive for size; appearance intolerance; and functional impairment.

Treatment

Treatment involves:

• Psychotherapy: usually cognitive behavioral therapy (CBT), which is a therapy technique that helps people find new ways to behave by changing their thought patterns. Therapy sessions focus on exploring and developing methods to deal with challenges and behavior in day-to-day life.
• Selective serotonin reuptake inhibitors (SSRIs): these are antidepressant medications like Prozac and Celexa.

Surgical treatment to alter the perceived imperfections is not effective and can worsen the symptoms of muscle dysmorphia.

If a person is showing signs of MD, they may benefit from seeing a healthcare provider who specializes in body image disorders or OCD.

People with BDD may have an increased risk of suicide. A study in 2021 suggests that extends to MD. If you have thoughts about suicide, call the Suicide and Crisis Lifeline 24 hours a day simply by dialing 988.

So, what’s wrong with supplements?

Using supplements to change a body’s appearance has become common. While 2.2% of young adults admit to using steroids, 36.3% use protein powders and shakes. Another 10.1% report that they are using other substances such as creatinine and growth hormones.

Supplements are unregulated and readily available, but many are mislabeled, and tainted with harmful substances such as anabolic steroids.

The U.S. Food and Drug Administration (FDA) does monitor adverse health incidents and sometimes inspects manufacturing facilities. Under the Dietary Supplement Health and Education Act, however, it does not have the power to approve dietary supplements before they enter the marketplace.

There is also a lack of research on the safety and effectiveness of supplements.

Supplements can act as gateway drugs to the use of anabolic steroids. One study found that young adults using supplements for muscle building were three times as likely to start anabolic steroid use seven years later.

Pre-workout supplements often contain caffeine, in amounts equivalent to several cups of coffee.

Some people consume protein powder dry, without mixing in water – a practice called “dry scooping.” It can have toxic effects.

The imagined defect is so real to the person with muscle dysmorphia, it can be hard for them to have insight into the problem. The people around someone with the signs and symptoms of muscle dysmorphia can help by knowing what to look for and bringing it to the attention of the person of concern.