Muscle-Enhancing Behaviors More Common Among Teens Than Previously Thought

The use of muscle-enhancing behaviors among middle and high school boys and girls - including such unhealthy behaviors as using protein powders or shakes, steroids, and other muscle-enhancing substances - is substantially higher than previously reported, a new study finds.¹

Analyzing the responses of 2,793 adolescents at 20 public middle and high schools in the Minneapolis/St. Paul metropolitan area during the 2009-2010 school year to a series of five questions about muscle-enhancing behaviors, two healthy (changing eating patterns and exercising more) and three unhealthy (using protein powders or shakes, taking steroids, or employing another muscle-building substance such as creatine, amino acids, HMB, DHEA, or growth hormone), researchers at the University of Minnesota and Columbia University found that almost all students surveyed (90% of boys, 80% of girls) reported doing at least 1 behavior with this as the goal, and up to one-third reported the use of unhealthy methods.

"Muscle enhancement was particularly high among boys and those involved in sports teams," said lead author Marla E. Eisenberg, ScD, MPH, , an assistant professor in pediatrics in the division of Adolescent Health and Medicine at the University of Minnesota School of Medicine, findings consistent with earlier studies.  But, she said, "use was not limited to these groups," which "suggests that, in addition to a 'thin ideal' and focus on leanness, muscularity is an important component of body satisfaction for both genders."  

"If they're interested in developing muscle at 13, 14, and 15, what are they going to be doing at 18 or 20?" wonders Eisenberg. "Are they going to be doing something more dangerous?" 

Advocacy group not surprised

"When we call school officials, athletic directors, coaches and others to tell them about the steroid problem and to try to convince them to have us in to speak with their kids about the dangers of steroids and other appearance and performance enhancing drugs, it is way too common for us to be told that 'we don't have a steroid problem in our school,'" said Don Hooton, President of the Taylor Hooton Foundation, a non-profit group dedicated to educating about the dangers of anabolic steroids and other appearance- and performance-enhancing drugs (APEDs).

Writing in the group's monthly newsletter, Hooton, whose son Taylor committed suicide after abusing steroids, says, "Adults seem to be oblivious to the epidemic that is underway among our youth, an epidemic driven by social pressure - to be more buff, to make the athletic team, to earn a scholarship. Poor messages are being sent by role models that tell our kids that 'it's okay' to use drugs to help them achieve their objectives. And, not surprisingly, our kids are keeping their steroid use secret from adults, just like their role models do!"

Hooton, for one, wasn't suprised by the University of Minnesota study's findings: "We identified this high rate of steroid usage over 5 years ago," he says, noting, that he used the same 5-6% figure that the U of M confirmed in their study as far back as 2005, when he testified at the now-infamous Congressional hearings on steroids in baseball.

Study findings   

Boys 

Among boys more than two-thirds reported changing their eating to increase their muscle size or tone, including 11.6% who did this often, and more than 90% who exercised more, four out of ten who reported doing so often.

• 37.4% used protein powders or shakes;
• 5.9% reported using steroids; 
• 10.5% said they used some other muscle enhancing-substance;
• High school boys had significantly greater odds of using protein powder/shades and other muscle-enhancing substances than those in middle school;
• Asian boys (primarily among) had elevated odds of steroid use compared with whites;
• Overweight and obese boys were more likely to report muscle-enhancing behaviors than boys of average BMI;
• Those participating in sports teams were significantly more likely to report more muscle-enhancing behaviors than those not involved in sports.  The use of 3 or more behaviors was more than twice as high among boys who played sports than those who did not. 

Girls

Among girls:

• a large majority changed their eating and exercise habits;
• 21.2% reported using protein powders;
• 4.6% used steroids; 
• 5.5% used other muscle-enhancing substances;
• high school girls had lower odds of using protein powders than those in middle school;
• girls who are obese (or overweight, in the case of protein use) had significantly higher odds of reporting these behaviors than those of average weight; and
• sports team participation was positively associated with changing eating, exercising, and using protein powders/shakes.  

BMI was significantly associated with changing eating, protein powders, and steroid use in boys and with changing eating, exercising, and protein powders in girls, associations which the study said could reflect increased muscle mass rather than obesity (particularly in males) or the greater use of a variety of weight control and body change strategies by overweight and obese teens than their average-weight peers.

"Interestingly, [our] study did not find significant clustering of muscle-enhancing behaviors within schools," said Eisenberg, which suggests that, "rather than being driven by a particular sports team coach or other features of a school social landscape, muscle-enhancing behaviors are widespread and influenced by factors beyond school, likely encompassing social and cultural variables such as media messages and social norms of behavior more broadly."  

Recommendations

The study authors made the following recommendations:

• Pediatricians and other health care providers should ask their adolescent patients about muscle-enhancing behaviors.  While changing eating and exercise patterns done with the goal of increasing muscle mass may be seemingly healthy and beneficial, compulsive or excessive use is cause for concern because it may be a precursor to the development of more severe and unhealthy behaviors over time;
• Health care providers should counsel adolescent patients about appropriate exercise, general nutrition, and the lack of efficacy and potential dangers of muscle-enhancement products.  "Given the observed association with sports participation, sports physicals (e.g. pre-participation physical evaluations or PPEs) may present a particularly salient opportunity to initiate these conversations," the study says.
• Develop prevention and intervention programs targeting muscle-enhancing behaviors. 
  • Such programs are needed, say the authors, for both boys and girls, and should include parents, teachers, and coaches as well as youth themselves.  
  • Broadening existing body image programs to address muscularity as well as thinness would be an appropriate and cost-effective approach. 
  • While physical activity in youth should be promoted because of its desirable benefits in terms of health and body composition, the emphasis should be on moderation and the focus should be on skill development, fitness, and general health, rather than development of a muscular appearance.
  • Because of the higher rates of muscle-enhancing behaviors among Asian youth, culturally relevant messages should be incorporated into programs which target communities where rates are highest.
  • Prevention activities should target coaches, sports teams, and their parents, given the significantly higher prevalence of muscle-enhancing behaviors among sports participants. 

Limitations

The study comes with some limitations:

• 20% of the survey respondents were Asian (primarily Hmong), a group which had lower representation in other recent studies;
• the sample was largely of lower economic status, a group that had not been separately reported in earlier studies;
• data came from a single state, and, as a result, may not be representative of muscle-enhancing behaviors elsewhere in the United States;
• all measures were self-reported, including the use of illegal substances, which may have led to underreporting;
• more detailed measures of muscle-enhancing behaviors and body weight were not assessed, including whether respondents who changed their eating adopted healthy or unhealthy dietary changes, and the use of several other muscle-enhancing substances besides steroids, were assessed as a single item; and
• the measure of BMI did not distinguish obesity from weight from muscle mass, so that it was possible that the associations seen were due to increased muscle resulting from the behaviors being studied.

1.  Eisenberg M, Wall M, Neumark-Sztainer D. Muscle-enhancing Behaviors Among Adolescent Girls and Boys.  Pediatrics 2012;130(6). DOI: 10.1542/peds2012-0095)(published online ahead of print)(accessed November 19, 2012) 

Posted November 19, 2012; revised November 20, 2012 to include a new section on the Taylor Hooton Foundation's reaction to the study.