Abstract
Purpose
Body ideals for both men and women are continuing to emphasize muscularity and leanness, which has resulted in the high prevalence of appearance- and performance-enhancing drugs and substances (APEDS) use, particularly among young men. Overall, little research has investigated the individual associations between specific APEDS use and eating disorder symptomatology, including among the high-risk population of young adult college students, which was the aim of this study.
Methods
Data from the 2020–2021 Healthy Minds Study (N = 7394) were analyzed. Five indicators of lifetime APEDS use were assessed, and a cumulative sum score was constructed. Eating disorder symptomatology was assessed via the SCOFF questionnaire. A total of 14 modified Poisson regression analyses were estimated to determine the association between APEDS use and a positive eating disorder screen among women and men.
Results
Lifetime use of protein supplements and diuretics or water pills were associated with a positive eating disorder screen among both women and men, while use of non-steroid synthetic muscle enhancers was associated with a positive eating disorder screen among men and creatine supplement use was associated with a positive eating disorder screen among women. The risk of a positive eating disorder screen was highest among men who reported use of five APEDS in their lifetime.
Conclusions
Lifetime use of APEDS is associated with eating disorder symptomatology among a national sample of U.S. college and university students. Prevention and intervention efforts are needed to address the link between these potentially harmful behaviors.
Level of evidence
Level V, cross-sectional descriptive study.
Keywords: Steroids, Creatine, Whey protein, Clenbuterol, Eating disorders, College students
Introduction
Recent research has documented an evolving body ideal for both men and women that place special emphasis on muscularity. Specifically, for men, this body ideal is characterized by a highly muscular and lean build [1], while a fit-looking and toned muscularity has become more prominent for women [2]. Given these body ideals, and in conjunction with the continued pattern of body dissatisfaction among adolescents and young adults [3], the use of appearance- and performance-enhancing drugs and substances (APEDS) have become increasingly prevalent. This may in part be attributed to the unregulated and easily accessible nature of “legal” and “over-the-counter” dietary substances, such as protein or creatine powders [4]. For example, nearly 16% of males, compared to roughly 1% of females, aged 18–26 years report using legal muscle-building supplements [5]. Moreover, lifetime illicit use of anabolic–androgenic steroids (hereafter steroids) has doubled from 2017 to 2020 to nearly 2% among adolescents [6], and between 1 and 3% of college-age young adults report lifetime use [5, 7]. While there is evidence of the adverse health and social correlates of steroid use [8, 9], recent research underscores the adverse outcomes associated with legal APEDS use. These include problematic alcohol use [10], criminal offending [11], sexual health risk behaviors [12], and severe medical events (e.g., disability, hospitalization, emergency room visits) and death [13].
Despite the common use of APEDS, and the potential adverse health and social correlates of their use, to date there remains little contemporary research on the use of specific individual APEDS, including whether use is associated with eating disorder symptomatology. The lack of research is particularly apparent when considering the use of legal dietary substances (e.g., whey protein, creatine) and among large, non-clinical samples of young adults (i.e., ages 18–30 years). This age range is particularly important as is represents a key developmental time period where the use of APEDS is common [5] and the risk of eating disorder development is high [14]. Therefore, the aim of this study was to determine the association between lifetime use of five forms of legal and illegal APEDS and eating disorder symptomatology among a large, non-clinical sample of college students. Given the limited prior research and exploratory nature of this study, there were no specific a priori hypotheses.
Methods
Data from the 2020–2021 Healthy Minds Study (HMS) were analyzed. HMS is an annual, cross-sectional survey of college and university students across the United States (U.S.). The HMS questionnaire is module-based with 3 standard modules that all participating institutions complete and 16 elective modules that participating institutions can choose from. Given this questionnaire design, only a select number of participants (N = 7394) were included in the present analysis, representing those who completed the elective modules that included the items assessing APEDS use (Substance Use module) and eating disorder symptomatology (Eating and Body Image module). Cumulatively, the sample comprised data from 18 colleges and universities across nine states in the U.S. Informed consent was gathered from all participants and HMS was approved by the Institutional Review Boards of all participating institutions. No further ethics approval was needed given the data are publicly available and anonymous. Further details on HMS methods can be found elsewhere [15].
Measures
Criterion variable
Eating disorder symptomatology was measured using the five-item SCOFF questionnaire [16]. The five items are described in Table 1. In keeping with previous research utilizing this measure, a positive eating disorder screen was determined by a score of two or more “yes” responses, resulting in a dichotomous variable (negative [0] versus positive [1] screen) [16].
Table 1.
Descriptive characteristics of participating students aged 18–30 in the 2020–2021 Healthy Minds Study (N = 7394)
| Women (n = 5178) | Men (n = 2216) | p a | |
|---|---|---|---|
| % | % | ||
| Age (range 18–30), m (SD) | 21.1 (3.0) | 21.0 (2.4) | 0.089 |
| Race/ethnicity | 0.016 | ||
| White non-Hispanic | 69.1 | 72.0 | |
| Black non-Hispanic | 8.1 | 5.1 | |
| Hispanic | 7.0 | 5.7 | |
| Asian | 6.7 | 7.0 | |
| Other | 1.8 | 2.6 | |
| Multi-racial | 7.3 | 7.6 | |
| Sexual orientation | < 0.001 | ||
| Heterosexual | 75.6 | 85.4 | |
| Gay or lesbian | 4.0 | 5.9 | |
| Bisexual | 13.3 | 4.5 | |
| Queer, questioning, or other | 7.1 | 4.2 | |
| Any athletics participation | 12.2 | 30.8 | < 0.001 |
| Any illicit drug use, past 30 days | 16.5 | 21.1 | 0.007 |
| Any alcohol use, past 30 days | 42.4 | 48.6 | 0.003 |
| Appearance- and performance-enhancing drugs and substances | |||
| Steroid use, lifetime | 0.1 | 0.2 | 0.260 |
| Use of other synthetic muscle-enhancers, lifetime | 0.03 | 0.7 | < 0.001 |
| Protein supplement use, lifetime | 16.3 | 32.4 | < 0.001 |
| Creatine supplement use, lifetime | 1.7 | 14.6 | < 0.001 |
| Diuretic or water pill use, lifetime | 2.2 | 1.0 | 0.031 |
| Appearance- and performance-enhancing drugs and substances sum score | < 0.001 | ||
| 0 | 82.6 | 66.6 | |
| 1 | 14.8 | 19.2 | |
| 2 | 2.2 | 13.0 | |
| 3 | 0.3 | 1.0 | |
| 4 | 0.0 | 0.2 | |
| 5 | 0.0 | 0.0 | |
| Positive eating disorder screen, ≥ 2 on SCOFFb | 31.5 | 20.4 | < 0.001 |
Preconstructed nonresponse sample weighting was applied to analyses
Differences between sex determined using chi-square tests for categorical variables and independent samples t tests for continuous variables
SCOFF items include, (a) “Do you ever make yourself sick because you feel uncomfortably full?” (b) “Do you worry that you have lost control over how much you eat?” (c) “Have you recently lost more than 15 pounds in a 3-month period?” (d) “Do you believe yourself to be fat when others say you are too thin?” (e) “Would you say that food dominates your life?”
Predictor variable
APEDS use was assessed using the question, “Have you ever used the following drugs/supplements for the purpose of enhancing appearance or performance? (Select all that apply).” Potential response options included, “Anabolic Steroids;” “Other synthetic muscle-enhancers (such as clenbuterol, human growth hormone);” “Protein supplements (such as whey protein, protein shakes, protein bars);” “Creatine supplements (such has creatine monohydrate, creatine ethyl ester, and others);” “Diuretics/Water Pills (such as furosemide [Lasix], hydrochlorothiazide, spironolactone, and others);” and “I have never used these drugs or supplements.” Responses to each APEDS type was coded as no (0) or yes (1). Additionally, each of the five APEDS were added to create a sum score (range 0–5).
Demographic and control variables
Demographic variables included age (restricted to 18–30 years), race/ethnicity, and sexual orientation. Control variables including any athletics participation, any illicit drug use in the past 30 days, and any alcohol use in the past 30 days. The demographic and control variables were included based on prior research relevant to eating disorders and APEDS use [5, 10, 11], as well as being significantly correlated (p < 0.05) with the criterion and predictor variables.
Statistical analysis
A total of 14 modified Poisson regression models were estimated to determine the association between APEDS use (each individual substance and the sum score) as the predictor variables and a positive eating disorder screen as the criterion variable. The modified Poisson regression with robust error variance permits the interpretation of the exponentiated regression coefficients as risk ratios [17] with corresponding 95% confidence intervals. All analyses were stratified by sex given prior differences in prevalence of APEDS use and eating disorders among men and women [5, 14] and adjusted for the demographic and control variables. All analyses utilized preconstructed nonresponse sample weighting [15] and were conducted using Stata 17.
Results
Among the demographically diverse sample of college students (Table 1), men had a significantly higher prevalence of lifetime use of other synthetic muscle enhancers (0.7%), protein supplements (32.4%), and creatine supplements (14.6%), while women had a significantly higher prevalence of lifetime diuretics or water pill use (2.2%). There was no significant difference between prevalence of lifetime steroid use between men (0.2%) and women (0.1%). Men reported use of a greater cumulative number of APEDS in their lifetime. Women had a significantly higher prevalence of a positive eating disorder screen (31.5%) compared to men (20.4%).
Results from regression analyses showed several significant associations between lifetime APEDS use and a positive eating disorder screen (Table 2). Among women, lifetime use of protein supplements, creatine supplements, and diuretics or water pills were associated with a positive eating disorder screen. Among men, lifetime use of other synthetic muscle enhancers, protein supplements, and diuretics or water pills were associated with a positive eating disorder screen. Overall, greater cumulative lifetime use of APEDS was associated with a positive eating disorder screen among both women and men. Finally, in supplementary analyses that included all APEDS in a single model, results showed that lifetime use of other synthetic muscle enhancers and protein supplements were associated with a positive eating disorder screen among men, while lifetime use of diuretics or water pills was associated with a positive eating disorder screen among men and women (see Supplementary Table 1).
Table 2.
Associations between use of appearance- and performance-enhancing drugs and substances and a positive eating disorder screen among participating students aged 18–30 in the 2020–2021 Healthy Minds Study (N = 7394)
| Women | Men | |
|---|---|---|
| RRa (95% CI) | RRa (95% CI) | |
| Steroid use, lifetime | 1.27 (0.86–1.86) | 0.32 (0.02–4.13) |
| Use of other synthetic muscle-enhancers, lifetime | 1.19 (0.33–4.27) | 3.54 (2.35–5.12) |
| Protein supplement use, lifetime | 1.21 (1.06–1.39) | 1.55 (1.18–2.03) |
| Creatine supplement use, lifetime | 1.36 (1.01–1.83) | 1.34 (0.95–1.88) |
| Diuretic or water pill use, lifetime | 1.99 (1.64–2.42) | 3.64 (1.87–7.09) |
| Appearance- and performance-enhancing drugs and substances use sum scale | ||
| 0 | Ref. | Ref. |
| 1 | 1.17 (1.01–1.35) | 1.48 (1.04–2.10) |
| 2 | 1.84 (1.50–2.26) | 1.43 (0.98–2.09) |
| 3 | 1.46 (0.78–2.75) | 3.18 (1.80–5.64) |
| 4 | – | 5.90 (4.05–8.60) |
| 5 | – | – |
Preconstructed nonresponse sample weighting was applied to analyses. The RR in each cell represents the abbreviated output from a series of modified Poisson regression models with robust error variance specifying use of appearance- and performance-enhancing drugs and substances as the predictor variables and a positive eating disorder screen as the criterion variable. Thus, the table represents the outputs from 12 Poisson regression models in total. To confirm results were not influenced by issues of multiple comparisons, sensitivity analyses were conducted with 99% CI. All results remained the same as 1.00 was not included in the 99% CI
Statistical significance (p < 0.05) is indicated if 1.00 is not included within the 95% CI. Statistically significant findings are bolded
RR risk ratio, CI confidence interval
Adjusted for age, race/ethnicity, sexual orientation, any athletics participation, any illicit drug use, past 30 days, and any alcohol use, past 2 weeks
Discussion
The findings from this study illustrate that a lifetime history of APEDS use is associated with eating disorder symptomatology among a national sample of U.S. college students. Overall, the lifetime use of legal and over-the-counter APEDS, such as protein supplements, creatine supplements, and diuretics or water pills, were associated with a positive eating disorder screen. This is concerning as these particular APEDS are often advertised as healthy, and are readily available and easily accessible to the public, despite known adverse health effects [13]. Additionally, many of these supplements can be contaminated with stimulants or steroids and mislabeled [18, 19], amplifying the risks of their use. However, among men, lifetime use of other synthetic muscle-enhancers, such as clenbuterol or human growth hormone, both of which are illegal for non-medical use, was associated with over a threefold greater risk of a positive eating disorder screen, while lifetime illicit steroid use was not associated with a positive eating disorder screen among men nor women. Research has pointed to the differing functions of steroid and clenbuterol use, which may explain these findings. For example, steroid use has a longstanding link to more functional usage (i.e., increasing muscular bulk) [20], whereas clenbuterol is notorious for its ability to reduce body fat [21], aligning more with traditional eating disorder symptomatology. Relatedly, the lack of a significant difference in the prevalence of lifetime steroid use between men and women is a unique finding that may indicate a changing pattern of use as body image ideals for women evolve further to the fit and toned-muscular ideal [2].
Many individuals, particularly men, use multiple APEDS to increase their muscle-mass and/or tone [1]. Consistent with this prior research, findings from this study show that men overall reported higher prevalence of lifetime use of multiple APEDS compared to women, and that men who used a greater number of APEDS in their lifetime had higher risk of a positive eating disorder screen. Specifically, the risk of a positive eating disorder screen increased nearly sixfold for men who used four APEDS in their lifetime, while the risk of a positive eating disorder screen increased nearly two-fold for women who used two APEDS in their lifetime. It is likely that those who use a greater number of APEDS have a higher degree of body and/or muscle dissatisfaction, thus explaining the greater cumulative use. Interestingly, despite having a lower overall prevalence compared to women, men who used diuretics or water pills in their lifetime had over a threefold greater risk of a positive eating disorder screen, which was lower than the nearly two-fold greater risk among women in adjusted analyses. Indeed, diuretics or water pills can reduce body water, which would be used to reduce weight, as well as make muscles look more defined and toned. Similarly, as with prior research [22], the lifetime use of diuretics or water pills among women was associated with a nearly two-fold greater risk of a positive eating disorder screen.
Strengths and limitations
The findings from this study accord with the notion of muscularity-oriented disordered eating behaviors as an alternate presentation of disordered eating, and underscore its overlap with broader eating disorder symptomatology [23]. However, there are limitations to be noted. First, the SCOFF questionnaire is a screening tool that does not provide a comprehensive evaluation of eating disorder symptomatology compared to other eating disorder measures (e.g., Eating Disorder Examination Questionnaire), as well as does not measure muscularity-oriented disordered eating. The SCOFF items are primarily oriented towards capturing thinness-related eating disorder symptomatology, and not muscularity-oriented behaviors, which is of particular theoretical relevance to this study. Therefore, the associations found in this study may be smaller than those in studies that use an eating disorder instrument focused on capturing muscularity-oriented behaviors (e.g., Muscularity-Oriented Eating Test). However, given the short nature of the questionnaire, the SCOFF is a practical screening tool that can be easily implemented into college health settings and large-scale survey research. Second, the data are cross-sectional and there are differing reference periods for the items (i.e., the APEDS use item measured lifetime use, while the SCOFF measured contemporaneous eating disorder risk). These limitations preclude causal and temporal conclusions. Fourth, there is the potential for nonresponse bias due to HMS participant recruitment and sampling methods. However, we applied preconstructed nonresponse sample weighting to all our analyses to reduce the threat of bias, and surveys with large sampling frames (i.e., HMS) often obtain reliable results [24]. Relatedly, the sample comprised of currently enrolled college students, therefore, the generalizability of the findings may be limited to non-college-enrolled adolescents and young adults. Strengths of this study include the use of a large, national sample of college and university students representing campuses across geographic regions of the U.S. Additionally, the item assessing APEDS use included several distinct and commonly used substances, allowing for precision to test which types were more strongly associated with eating disorder symptomatology.
Conclusions
Lifetime use of APEDS is associated with eating disorder symptomatology among a large, national sample of college and university students in the U.S. These findings highlight the need for public health efforts to bring wider public awareness of the risks associated with APEDS use. Additionally, regulation is needed to curtail the sale of APEDS to young people, such as those proposed by several state legislatures (see for example, “Dietary Supplements for Weight Loss and Over-the-Counter Diet Pills” in California and “An Act Protecting Children from Harmful Diet Pills and Muscle-Building Supplements” in Massachusetts). Healthcare professionals should be aware of the evolving body ideals for both college men and women that emphasize muscularity and assess for accompanying APEDS use and eating disorder symptomatology to ensure proper intervention is provided.
Supplementary Material
What is already known on this subject?
Use of appearance- and performance-enhancing drugs and substances (APEDS) is common among adolescents and young adults, particularly boys and men. Individuals commonly use APEDS for the purpose of increasing muscle mass, tone, and definition to align with preconceived body ideals.
What this study adds?
College women and men who reported APEDS use had greater risk of screening positive for an eating disorder. This included the use of protein supplements, which was mostly commonly used among both women and men and are easily accessible and unregulated. Among both women and men, the risk of a positive eating disorder screen was highest among those who reported use of multiple APEDS. Health care and public health professionals should be aware of the overlap between APEDS use and eating disorder symptomatology to ensure proper prevention, assessment, and
Funding
JMN is supported by the National Institutes of Health (K08HL159350) and the American Heart Association (CDA34760281). No funding was used to support this research.
Footnotes
Conflict of interest
All authors declare no conflicts of interest.
Research involving human participants
Healthy Minds Study was approved by the Health Sciences and Behavioral Sciences Institutional Review Board at the University of Michigan and all participating institutions. This study is exempt from research ethics approval given the data is publicly available and unidentifiable.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Availability of data and materials
The Healthy Minds Study is available to researchers. Please visit http://healthymindsnetwork.org for more information.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The Healthy Minds Study is available to researchers. Please visit http://healthymindsnetwork.org for more information.