Body Image, Binge Eating, and Bulimia Nervosa in Male Bodybuilders

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for the attitudinal and environmental effects of the gym on eating-related ... peted in a bodybuilding competition and had no plans to do so in the next 12 months.
Original Research

Body Image, Binge Eating, and Bulimia Nervosa in Male Bodybuilders Gary S Goldfield, PhD1,2, Arthur G Blouin, PhD2, D Blake Woodside, MD3 Objective: Male bodybuilders (MBB) exhibit more severe body dissatisfaction, bulimic eating behaviour, and negative psychological characteristics, compared with male athletic and nonathletic control subjects, but few studies have directly compared MBB and men with eating disorders. This study compared men with bulimia nervosa (MBN), competitive male bodybuilders (CMBB), and recreational male bodybuilders (RMBB) on a broad range of eating attitudes and behaviours and psychological characteristics to more accurately determine similarities and differences among these groups. Method: Anonymous questionnaires, designed to assess eating attitudes, body image, weight and shape preoccupation, prevalence of binge eating, weight loss practices, lifetime rates of eating disorders, anabolic androgenic steroid (AAS) use, and general psychological factors, were completed by 22 MBN, 27 CMBB, and 25 RMBB. Results: High rates of weight and shape preoccupation, extreme body modification practices, binge eating, and bulimia nervosa (BN) were reported among MBB, especially among those who competed. CMBB reported higher rates of binge eating, BN, and AAS use compared with RMBB, but exhibited less eating-related and general psychopathology compared with MBN. Few psychological differences were found between CMBB and RMBB. Conclusions: MBB, especially competitors, and MBN appear to share many eating-related features but few general psychological ones. Longitudinal research is needed to determine whether men with a history of disordered eating or BN disproportionately gravitate to competitive bodybuilding and (or) whether competitive bodybuilding fosters disordered eating, BN, and AAS use. (Can J Psychiatry 2006;51:160–168) Information on funding and support and author affiliations appears at the end of the article.

Clinical Implications · Bodybuilding among men is associated with an increased risk of body dissatisfaction, weight and shape preoccupation, and pathological eating behaviours. · Compared with RMBB, CMBB are more likely to engage in binge eating and meet criteria for BN during their lifetime · CMBB are also at higher risk of using AAS, compared with RMBB, but the high prevalence of use in RMBB indicates the use of steroids for cosmetic reasons. Limitations · A clinical sample of eating disorder patients and a community-based sample of MBB comprised the overall sample. The differences in recruitment may have biased the results. · Diagnostic criteria for BN was established by self-report without a confirmatory clinical interview; thus, the prevalence and severity of binge eating and abnormal weight control practices may be overestimated or underestimated. · The sample of MBB was relatively small; therefore, results may not represent the studied populations.

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Body Image, Binge Eating, and Bulimia Nervosa in Male Bodybuilders

Key Words: bodybuilding, body image, binge eating, bulimia nervosa, anabolic androgenic steroids arge-scale surveys reveal that male body dissatisfaction has increased dramatically during the last 3 decades, from 15% to 43%, making current rates almost comparable to those found in women (1). There is converging evidence from cross-sectional and experimental research that exposure to the exceptionally thin beauty standards for women as advertised in the media, as well as exposure to the lean and muscular male ideal, increases body dissatisfaction and negative affect in both women and men (2–6). Female body dissatisfaction typically manifests in feeling too heavy or fat with a concomitant desire to be thinner (7), while most young men seek to be leaner, yet larger and more muscular (4). These expressions of body dissatisfaction are consistent with standards of attractiveness for each sex. The high prevalence of body dissatisfaction is concerning, given that body image issues are often the driving force underlying disordered eating, compensatory bulimic behaviours, full-blown eating disorders (8), and use of AAS (9).

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In response to this hypermesomorphic somatype portrayed as the masculine ideal, many adolescent and young adult men are engaging in serious weight training or bodybuilding (10).

Abbreviations used in this article AAS

anabolic androgenic steroids

AN

anorexia nervosa

ANCOVA

analysis of covariance

ANOVA

analysis of variance

ASQ

Anabolic Steroid Questionnaire

BDI

Beck Depression Inventory

BMI

body mass index

BN

bulimia nervosa

C-DIS

Computerized Diagnostic Interview Schedule

CMBB

competitive male bodybuilders

df

degrees of freedom

EDI

Eating Disorder Inventory

MANCOVA

multivariate analysis of covariance

MANOVA

multivariate analysis of variance

MBB

male bodybuilders

MBN

men with bulimia nervosa

NIMH-DIS

National Institute of Mental Health Diagnostic Interview Schedule

RMBB

recreational male bodybuilders

SD

standard deviation

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This may have important implications for psychological health, given that activities or sports that require overinvestment in body shape and physical appearance have been noted as a risk factor for developing disordered eating or eating disorders (11). Uncontrolled research indicates that MBB report high rates of body dissatisfaction (12), weight and shape preoccupation (13), and unhealthy methods of body modification practices, such as strict dieting and dehydration methods (13) and AAS use (14). Controlled studies show inconsistent findings, with data showing greater body dissatisfaction or disordered eating in MBB in comparison with male athletic and nonathletic groups (15), while other data show that MBB exhibit a more positive body image, compared with active exercisers (16) and nonactive control subjects (17). Regarding psychological characteristics, evidence suggests that, compared with control subjects, MBB report more narcissism (18); hypermasculine beliefs and homophobia (19); ineffectiveness (14); and elevated scores on obsessionality, perfectionism, and anhedonia (18). However, the differences between CMBB and RMBB in terms of eating behaviour or general psychological characteristics have not been well studied; thus, the psychological effects of pursuing the hypermesomorphic and masculine ideal imposed on CMBB remains unknown. When combined, there is evidence that MBB exhibit a psychological profile resembling people with eating disorders. Valid conclusions regarding the degree of concordance of eating-related and psychological profiles between MBB and individuals with eating disorders requires that these groups be directly compared, but only 2 such studies exist. Davis and Robertson found no significant differences between female patients with AN and CMBB in terms of obsessionality, perfectionisms, anhedonia, and narcissism, but both of these groups scored significantly higher than control subjects (18). However, Davis and Robertson found that CMBB reported more positive perceptions of self-worth and body image, compared with women with anorexia (18). In the second study, Mangweth and others found that MBB displayed higher rates of body dissatisfaction and weight preoccupation than nonathletic male control subjects, but lower rates than men with a history of eating disorders (20). Men with eating disorders reported higher rates of psychiatric disorders than both MBB and control subjects, while MBB reported more mood disorders than control subjects (20). The proposed study is designed to build on past research by comparing and contrasting CMBB, RMBB, and MBN on a broad scope of eating attitudes and behaviour and general psychological characteristics in order to further identify similarities and differences among these groups. The current study differs from the Davis and Robertson and the Mangweth and others (20) studies in 161

The Canadian Journal of Psychiatry—Original Research

several important ways. First, the current study focuses less on general psychological characteristics or psychiatric disorders and assesses a broader measure of eating-related behaviours, including binge eating, dieting, and compensatory behaviours designed to prevent weight gain common in eating disorders (that is, excessive exercise, vomiting, and diuretic and laxative use). Second, as opposed to other studies that used either women with AN (18) or men with several eating disorders (20), the current study used an eating disorder group solely comprising men with BN. We believe the most relevant comparison group is men with BN because our previous research showed elevations on the Bulimia subscale of the EDI and because CMBB eat a very restricted diet that may predispose them to binge eating (21) and compensatory behaviours designed to prevent weight gain in fat from binges. Also, one cannot meet criteria for AN and still be a bodybuilder, but a bodybuilder may still meet the criteria for BN, which suggests that BN may be a more appropriate comparison group. Third, the current study compares MBB and MBN chosen from the same culture and data collected during the same time period, whereas previous research compared Austrian MBB to American men with eating disorders. Thus the current study better controls for effects of current sociocultural norms on eating-related behaviour. Fourth, we decided to include RMBB as a comparison group instead of nonathletic control subjects used in previous research (18,19) for 2 main reasons: research has already shown that MBB exhibit more disordered eating than other athletes and nonathletic control subjects, and the current design controls for the attitudinal and environmental effects of the gym on eating-related parameters to better isolate the effects of competition on selected dependent measures. We predicted that CMBB would exhibit an eating and psychological profile that was similar to, though less severe than, men with BN and more pathological than that of RMBB.

Methods Subjects The volunteer sample of 74 participants comprised 22 MBN, 27 CMBB, and 25 RMBB. MBB were recruited from flyers posted in gymnasia in Ottawa, Ontario. The clinical sample consisted of volunteers who sought treatment from eating disorder clinics located in large hospitals in Ottawa and Toronto. MBN recruited from Ottawa and Toronto did not significantly differ in demographic variables, eating-related pathology, or general psychological characteristics and were therefore combined to form one group. All 22 men (100%) met the DSM-III-R lifetime criteria for BN as assessed by clinician interview, were symptomatic at the time of testing, defined as currently engaging in binge eating at least once weekly in the past 3 months, were persistently 162

overconcerned with body shape or weight, and were using at least one compensatory method of weight control (that is, purging) within the 2 weeks prior to assessment. Owing to insufficient numbers of men seeking treatment of eating disorders during the study period, men who had previously presented for treatment at the clinics were contacted and invited to participate, but all were symptomatic according to the aforementioned criteria. After complete description of the study, participants gave their written informed consent. This study was approved by the research ethics boards at Carleton University, the Ottawa Hospital, and the Toronto Hospital. Procedure MBB were recruited by posting advertisements in local gymnasia. They were given a cover letter describing the purpose of the study as to examine “eating attitudes and behavior, weight loss practices, general psychological characteristics, as well prevalence of current and past use of anabolic androgenic steroid use, and attitudes toward steroid use in recreational and competitive bodybuilders.” To protect their anonymity, bodybuilders were instructed not to include their name or contact information on any of the surveys, and they were guaranteed that data obtained would only be available to study staff. Any publication of data would involve aggregated data so that no individual could be identified. Inclusion criteria for the CMBB group required a person to be either actively training for a competition or to have competed within the past 12 months. RMBB were defined as those people who engaged in traditional forms of weight training (for example, free weights or nautilus) at least twice weekly for 7 months or more (although all did significantly more) and who had never competed in a bodybuilding competition and had no plans to do so in the next 12 months. Patients presenting for treatment at the eating disorder clinics in Ottawa and Toronto were randomly approached to participate in the study. During the patients’ initial assessments, a clinical interview was conducted in order to verify the BN diagnosis. Previous patients with BN who were not in treatment were contacted and invited to participate in a telephone screening interview. Those who were symptomatic according to the above criteria, and also interested, were mailed questionnaires and instructed to complete and return them by mail in prestamped envelopes. These procedures also applied to MBB. Participants were not financially remunerated for their participation. Measurement Instruments Subjects completed an assessment package containing a brief demographics questionnaire, the BDI (22), and the EDI (23), to assess eating-related attitudes and psychological factors associated with eating disorders. A paper and pencil version W Can J Psychiatry, Vol 51, No 3, March 2006

Body Image, Binge Eating, and Bulimia Nervosa in Male Bodybuilders

Table 1 Demographic and weight training characteristics of the sample MBN n = 22

CMBB n = 27

RMBB n = 25

Variable

Mean

SD

Mean

SD

Mean

SD

Agea,b

33.6

8.9

26.7

5.0

24.9

5.0

Educationa,b

4.0

1.5

4.9

1.4

5.1

1.1

Height (cm)a,c

178.6

5.7

173.3

7.4

176.4

6.1

Weight (kg)

82.2

30.4

93.6

16.1

82.8

18.4

BMI

25.8

9.6

31.1

4.5

26.6

5.3

MBN compared with CMBB, P < 0.05; bMBN compared with RMBB, P < 0.05; cCMBB comapred with RMBB, P < 0.05

a

of the Eating Disorder section of the validated C-DIS (24), which was derived from the NIMH-DIS (25,26), was administered to examine the prevalence of bulimic eating practices, weight and shape preoccupation, and lifetime rates of BN based on DSM-III-R criteria (24). A bodybuilding questionnaire designed to classify MBB as competitive or recreational was used. Previous research has shown this instrument to have good discriminative validity (14). The ASQ (27) was expanded to assess a wider range of motivations for using AAS, as well as capturing possible effects of AAS, data for which are reported elsewhere (28). In addition, the 6-item Drive for Bulk scale was developed as a modification of the Body Dissatisfaction scale of the EDI. The direction of items was reversed (for example, “too big” changed to “too small”) and references to body parts were adapted to the masculine (mesomorphic) ideal. This scale was sensitive in previous research, significantly discriminating MBB from both runners and martial artists (14). Finally, a 5-item Drive for Tone subscale was developed and assessed participants’ desire for leaner and more toned body parts with the same 5-point likert rating scale as the EDI. Analytic Plan MANOVA was used to test the effects of Group (MBN, CMBB, RMBB) on 2 categories of dependent measures: eating-related attitudes and behaviour, which included the Drive for Thinness, Bulimia, and Body Dissatisfaction subscales of the EDI, as well as the Drive for Bulk and Drive for Muscle Tone scales developed for this study; and general psychological factors commonly observed in, but not specific to, eating disorders, such as depression, ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness, and maturity fears. Significant multivariate findings (P < 0.05, 2-tailed) were followed by ANOVA and multiple comparison post hoc Can J Psychiatry, Vol 51, No 3, March 2006 W

tests using Tukey’s tests. Owing to differences in demographics among groups and high intercorrelations among demographic characteristics and outcome measures, analyses (ANCOVA and MANCOVA) were conducted with age, BMI, and education as covariates with a pattern of results emerging that was identical to those that did not use covariates; thus, results are presented without covariates to maximize statistical power. The prevalence of AAS use and bulimic symptoms across groups was examined by chi-square analyses.

Results Demographic and Weight Training Characteristics Table 1 shows the demographic characteristics of each group. MBN were significantly older than MBB. CMBB had significantly higher BMI (assessed by self-report) than MBN and RMBB, with no differences between MBN and RMBB. Both bodybuilding groups reported a significantly higher level of education (some college courses to college graduate) compared with MBN (high school graduate to some college courses). CMBB lifted weights more frequently (weekly) than RMBB and MBN (mean 4.7, SD 0.71, compared with mean 3.9, SD 0.78), but no differences among bodybuilding groups were found for number of years in which participants had lifted weights (mean 8.6, SD 3.9, compared with mean 6.8, SD 4.7) or duration (minutes) of their workout (mean 86.5, SD 41.7, compared with mean 78.0, SD 21.4). Body Image and Eating Attitudes Table 2 displays the results of eating-related and general psychological factors analyzed across conditions. MANOVA (Wilk’s Lambda) revealed a significant main effect of group (F10,134 = 5.97; P < 0.001). ANOVA and Tukey’s post hoc tests indicated that, compared with either bodybuilding 163

The Canadian Journal of Psychiatry—Original Research

Table 2 Mean (SD) scores of eating-related and psychological factors across groups MBN n = 22 Variable

CMBB n = 27

RMBB n = 25

Mean

SD

Mean

SD

Mean

SD

9.1

6.5

3.5

3.8

3.2

3.9

6.1

5.6

1.2

1.7

1.2

2.6

10.5

6.7

4.6

3.6

4.9

3.3

22.2

9.6

28.9

6.1

29.0

5.8

20.6

6.8

23.8

6.5

24.5

6.2

Ineffectivenessa,b

10.6

8.5

2.2

3.8

1.8

2.9

Pefectionism

5.3

4.3

6.8

4.8

7.1

4.4

6.8

4.9

3.4

3.9

3.2

2.6

Interoceptive awareness

8.4

6.8

2.3

3.6

2.8

4.7

Maturity fearsa.b

7.1

6.8

2.8

3.1

3.4

3.6

21.2

11.9

6.2

6.4

4.2

3.4

Eating-related measures Drive for thinnessa,b Bulimia

a,b

Body dissatisfactiona,b Drive for bulk

a,b

Drive for tone Psychological measures

Interpersonal distrusta,b a,b

Depression

a,b

a MBN compared with CMBB, P < 0.05; bMBN compared with RMBB, P < 0.05; All measures are from EDI, except that depression was measured by the BDI, P < 0.05

condition, MBN reported significantly higher scores on all subscales of the EDI, with no significant differences between bodybuilding groups on these measures. As expected, both CMBB and RMBB reported significantly more Drive for Bulk and than MBN (P < 0.001), but CMBB did not report higher scores than RMBB. Interestingly, there were no significant differences among groups on Drive for Muscle Tone. Psychological Factors As shown in Table 2, MANOVA revealed a significant main effect of Group (F 12,130 = 4.7; P < 0.001). ANOVA and post hoc comparisons using Tukey’s tests revealed MBN reported significantly higher scores on all psychological factors (except perfectionism), compared with either bodybuilder group. CMBB and RMBB did not differ significantly on any of the general psychological variables. Prevalence of Eating Pathology in MBBs Although many eating disorder symptoms exhibited by MBB were significantly less prevalent in comparison with MBN, eating disturbances and preoccupation with weight and shape 164

were common among CMBB and RMBB. Table 3 shows the lifetime prevalence and symptoms of BN across groups. Steroid Use The prevalence of admitted AAS use among MBB was 40% (21 of 52), a rate significantly higher than the 4% (1 of 22) reported for MBN. As expected, steroid use was more prevalent in CMBB compared with RMBB (59% compared with 24%; c2 = 6.1, df 1; P < 0.05).

Discussion Owing to the exceptionally lean and muscular standards that currently exist for CMBB, we hypothesized that CMBB would exhibit more body dissatisfaction and extreme eating and weight-control practices, compared with RMBB, but less than those with BN. This hypothesis was partially confirmed, but fewer differences than expected were obtained between MBN and CMBB, as well as between bodybuilding conditions. Nevertheless, several important differences among bodybuilding groups, as well as similarities between MBN and MBB, were found. W Can J Psychiatry, Vol 51, No 3, March 2006

Body Image, Binge Eating, and Bulimia Nervosa in Male Bodybuilders

Table 3 Prevalence of bulimia nervosa and bulimic symptoms MBN n = 22

CMBB n = 27

RMBB n = 25

Characteristic

n

%

n

%

n

%

Have ever met criteria for BNa,b,c

22

100

8

29.6

2

8.0

Have ever met criteria for EDNOS

0

0

1

3.5

3

12.0

22

100

13

48.0

5

20.0

17

77.3

5

38.5

1

20.0

21

95.5

8

61.5

2

40.0

22

100

9

33.3

4

16.0

9

40.9

5

18.5

3

12.0

Worried eating too much and (or) being too fat

22

100

17

63.0

18

72.0

Overconcerned with shape and (or) weight

22

100

22

84.6

20

80.0

Body shape affects self-esteema,b

22

100

16

61.5

16

64.0

Body shape as important as friends and work

19

86.4

20

76.9

16

64.0

Vigorous exercise

19

86.4

15

55.5

15

60.0

Strict dieting

17

77.3

14

52.5

13

52.0

Diuretics

3

13.6

5

18.5

2

8.0

6

28.6

1

4.0

2

8.0

21

95.5

0

0.0

0

0.0

Have ever binged

a,b,c

Depressed after bingea,b Angry after binge

a,b

One binge weekly in the last 3 monthsa,b,c Two binges weekly in the last 3 months

b

Regular use of weight-loss methods in past

Laxativesa,b Vomiting

a,b

a MBN compared with CMBB, P < 0.05; bMBN compared with RMBB, P < 0.05; cCMBBs compared with RMBB, P < 0.05. EDNOS = Eating disorder not otherwise specified

Perhaps the most striking and unique finding is that almost 30% of CMBB met criteria for BN at some point in their lifetime, a rate that is significantly higher than the 8% reported by RMBB, and also markedly higher than rates reported for athletic male groups (29) and men in the population, according to self-reported diagnoses (30). The high prevalence of BN in the RMBB group indicates that body dissatisfaction and engaging in unhealthy eating and weight-control practices in pursuit of the lean and muscular male ideal cannot be attributed solely to competition but may also be motivated more by personal reasons relating to overvaluing weight and shape. Diagnostic criteria for BN were based on the DSM-III-R, but careful examination of data reveals that all CMBB would have also met the DSM-IV diagnostic criteria for BN (6 with purging subtype and 2 with nonpurging type). Interestingly, while Mangweth and others found no incidence of eating disorders Can J Psychiatry, Vol 51, No 3, March 2006 W

in their sample of MBB (20), Pope and others found that 3% of MBB reported a history of AN (31), a rate markedly (150 times) higher than the 0.02% rate typically found in North American men (30). Lifetime rates of binge eating and prevalence of binge eating (once weekly) in the 3 months preceding testing were higher, as predicted, in CMBB compared with RMBB. Restraint theory predicts that strict dieting, either by avoiding forbidden foods or by caloric restriction—both common in competitive bodybuilding to reduce body fat during the season—would predispose CMBB to binge eating by increasing deprivation of desired high-calorie or high-carbohydrate foods or decreasing sensitivity to internal cues such as hunger and satiation (21). Although strict dieting was highly prevalent in this group, rates were just as high for RMBB; thus, the elevated 165

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rates of binge eating seen in CMBB are not likely to be attributed to strict dieting alone. Depression and negative affect are additional psychological factors implicated in the precipitation and maintenance of binge eating (32). While CMBB did not score in the clinical range for depression, they were almost twice as likely to feel depressed after binge eating. Thus it is possible that feeling depressed after binge eating, perhaps owing to a loss of control over eating and (or) anticipation of weight gain in fat, predisposed CMBB to subsequent binges, but this hypothesis needs to be explored in future research.

fat, highlighting the severity of eating pathology in MBB. On a related note, despite higher AAS use in CMBB, as expected, almost 25% of RMBB used AAS even though they had no desire to enter competitions. This provides more evidence that the RMBB motivation for these unhealthy eating and body modification practices was to attain a more attractive body for cosmetic, rather than competitive, purposes. The unexpectedly high acuity of eating-related symptoms exhibited by the RMBB likely accounted for the lack of differences between CMBB and RMBBs observed in the present study.

Important similarities and differences in body image and weight and shape preoccupation across groups were found. A unique and interesting finding was that no differences among MBN and bodybuilding groups were found in the prevalence of being overconcerned with weight and shape or ratings that body shape was as important as friends or work. Moreover, no group differences were found for the desire to obtain a more toned and lean body, indicating that MBB, who were already large with toned musculature, were as dissatisfied with their muscle tone as MBN. This marked acuity of body dissatisfaction and preoccupation with weight and shape observed in MBB was associated with AAS use, reflecting a constellation of symptoms and behaviour that is consistent with the muscle dysmorphia syndrome described by Pope and others (12). Pope and others (31) hypothesized that MBB may be at greater risk for body dysmorphic symptoms as a whole and that sociocultural factors at a particular time may determine whether they move in the anorexic or “reverse anorexic” direction.

MBN exhibited far more general psychopathology than CMBB and RMBB, but no differences were found among groups in terms of perfectionism, which was elevated in all groups. These findings are partially consistent with previous research (18,20). For example, Mangweth and others, found higher rates of mood disorders in men with eating disorders, compared with MBB, but no differences among these groups in rates of alcohol or drug abuse, anxiety disorders, or sexual dysfunction (20). Davis and Robertson also found no differences between women with eating disorders and MBB on narcissism, obssessionality, or anhedonia (18), suggesting that some MBB not only share unhealthy eating and weight control practices as those with BN, but also exhibit some overlap in psychological characteristics.

As expected, differences were found in the way body dissatisfaction was manifested between MBN and MBB. MBN scored higher on the Body Dissatisfaction subscale of the EDI, which emphasizes feeling too fat and a desire to be slimmer. CMBB and RMBB scored higher on the Drive for Bulk scale, indicating a perception of being smaller than ideal and a strong desire to enhance the size of various upper body parts that reflect masculinity (for example, shoulders, biceps, and chest). Similar results were obtained in previous research (18,20). The discrepancy in Drive for Bulk but similarity in Drive for Muscle Tone may explain why many MBB simultaneously engage in bulimic weight-control practices and AAS use, while MBN engage in bulimic weight-control practices without the concomitant use of steroids. In this context, MBB who endorse both traditional bulimic weightcontrol practices in conjunction with AAS use may be at greater risk to suffer adverse medical and psychiatric consequences of steroid use (33,34), compared with MBN alone. Although MBN were more likely to purge via laxatives and vomiting, it was surprising that no differences were found between MBN and MBB in the lifetime prevalence of using vigorous exercise, strict dieting, or diuretics to lose weight or 166

This study has several limitations. Ideally, MBN would have been recruited from the community to match recruitment methods for MBB, but the low prevalence of eating disorders in men would have made it difficult to achieve the necessary sample size required for comparison with MBB. Thus we relied on using a clinical sample of MBN, and these differences in recruitment may have biased the results. Typically, treatment seekers are more symptomatic and have more psychiatric comorbidity than those meeting eating disorder diagnostic criteria who do not seek treatment (35,36), which may explain, at least in part, the differences among the MBN group and MBB groups. However, a lack of differences emerged on some eating-related measures between MBB and MBN, underscoring the high degree of eating-related psychopathology exhibited by MBB. Homosexual orientation has been identified as a risk factor in men with eating disorders (37) but was not measured in this study; thus, the effects of sexual orientation on eating pathology in MBB remain unknown. Diagnostic criteria for BN in MBB was established by self-report without a confirmatory clinical interview; thus, the prevalence and severity of binge eating and abnormal weight-control practices may be overestimated (38, 39) or underestimated (40,41) when compared with structured clinical interviews. Nevertheless, the prevalence of BN and related symptoms was much higher in CMBB than rates found in other athletic and nonathletic male populations that used self-report, indicating that this growing subgroup of men W Can J Psychiatry, Vol 51, No 3, March 2006

Body Image, Binge Eating, and Bulimia Nervosa in Male Bodybuilders

exhibits substantial psychiatric morbidity, which warrants more careful study. Finally, the sample of MBB was relatively small; thus, results may not be representative of the bodybuilding population, though findings are generally consistent with previous research. In summary, body dissatisfaction, weight and shape preoccupation, strict dieting, AAS use, binge eating, and a history of full-blown BN were highly prevalent in CMBB and, to a lesser extent, in RMBB. Moreover, MBB exhibited levels of weight and shape preoccupation, body dissatisfaction, disordered eating, and perfectionism similar to MBN, indicating that the current group of MBB share many eating-related features but fewer general psychological characteristics with those having BN. Taken together, our findings suggest that there is a subgroup of MBB, especially those who have competed, who may be at increased risk of developing unhealthy eating and weight-control practices, including binge eating or full-blown BN. Longitudinal research is needed to determine whether men with a history of BN or subclinical manifestations of BN disproportionately gravitate toward bodybuilding and AAS use as a vehicle to meet personal or societal standards of attractiveness and (or) whether the pursuit of the exceptionally lean and hypermesomorphic bodybuilding ideal fosters bulimic attitudes, eating behaviours, and AAS use. Funding and Support This study was funded, in part, by an Applied Sport Research grant from Sport Canada awarded to Dr Blouin and Dr Goldfield, as well as a New Investigator award from the Canadian Institutes of Health Research awarded to Dr Goldfield. Acknowledgements The authors thank Paula Cloutier, Stephanie Leclaire, Dr Hollie Raynor, and Dr Paddi O’Hara for their assistance in preparation of this manuscript.

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10. Pope HG, Jr, Gruber AJ, Choi P, Olivardia R, Phillips KA. Muscle dysmorphia. An underrecognized form of body dysmorphic disorder. Psychosomatics 1997;38:548–57. 11. Brownell KD, Rodin J, Wilmore J. Eating, body weight and performance in athletes: disorders of modern society. Philadelphia (PA): Lea and Febiger; 1992. 12. Klein AM. Fear and self-loathing in Southern California: narcissism and fascism in bodybuilding subculture. J Psychoanal Anthropol 1987;10:117–37. 13. Andersen RE, Barlett SJ, Morgan GD, Brownell KD. Weight loss, psychological, and nutritional patterns in competitive male body builders. Int J Eating Disord 1995;18:49–57. 14. Blouin AG, Goldfield GS. Body image and steroid use in male bodybuilders. Int J Eating Disord 1995;18:159–65. 15. Loosemore, DJ, Moriarty, D. Body dissatisfaction and body image distortion in selected group of males. CAHPER 1990; 11:11–5. 16. Pasman L, Thompson JK. 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Psychiatric and medical effects of anabolic-androgenic steroid use: a controlled study of 160 athletes. Arch Gen Psychiatry 1994;51:375–82. 35. Fairburn CG, Welch SL, Norman PA, O’Connor ME, Doll HA. Bias and bulimia nervosa: how typical are clinic cases? Am J Psychiatry 1996;153:386–91. 36. Perkins PS, Klump KL, Iacono WG, McGue M. Personality traits in women with anorexia nervosa: evidence for a treatment-seeking bias? Int J Eating Disord 2005;37:32–7. 37. Carlat DJ, Camargo CA, Jr. Review of bulimia nervosa in males. Am J Psychiatry 1991;148:831–43. 38. Black CM, Wilson GT. Assessment of eating disorders: interview versus questionnaire. Int J Eating Disord 1996;20:43–50. 39. Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire? Int J Eating Disord 1994;16:363–70. 40. Carter JC, Aime AA, Mills JS. Assessment of bulimia nervosa: a comparison of interview and self-report questionnaire methods. Int J Eating Disord 2001;30:187–92. 41. 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Manuscript received April 2005, revised, and accepted August 2005. 1 Investigator, Children=s Hospital of Eastern Ontario Research Institute, Mental Health Research, Ottawa, Ontario; Adjunct Research Professor, Department of Human Kinetics, University of Ottawa, School of Human Kinetics, Ottawa, Ontario. 2 Adjunct Research Professor, Department of Psychology, Carleton University, Ottawa, Ontario.

Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario. Address for Correspondence: Dr GS Goldfield, CHEO Research Institute, Mental Health Research, 401 Smyth Road, Ottawa, ON, K1H 8L1, [email protected]

Résumé : L’image corporelle, l’alimentation excessive et la boulimie chez les culturistes masculins Objectif : Les culturistes masculins (CM) présentent une insatisfaction corporelle, un comportement alimentaire boulimique et des caractéristiques psychologiques négatives plus graves, comparés à des sujets témoins masculins athlétiques et non athlétiques, mais peu d’études ont comparé directement les CM avec des hommes souffrant de troubles alimentaires. Cette étude a comparé des hommes souffrant de boulimie (HB), des hommes culturistes de compétition (HCC) et des hommes culturistes récréatifs (HCR) relativement à une vaste gamme d’habitudes et de comportements alimentaires, et de caractéristiques psychologiques pour déterminer plus précisément les similitudes et les différences entre ces groupes. Méthode : Des questionnaires anonymes, destinés à évaluer les habitudes alimentaires, l’image corporelle, les préoccupations de poids et de forme, la prévalence des épisodes d’alimentation excessive, les méthodes de perte de poids, les taux à vie de troubles alimentaires, l’utilisation de stéroïdes anabolisants androgéniques (SAA), et les facteurs psychologiques généraux ont été remplis par 22 HB, 27 HCC, et 25 HCR. Résultats : Des taux élevés de préoccupations de poids et de forme, des méthodes extrêmes de modification du corps, des épisodes d’alimentation excessive et la boulimie ont été déclarés par les HC, en particulier par ceux qui étaient en compétition. Les HCC ont déclaré des taux plus élevés d’épisodes d’alimentation excessive, de boulimie et d’utilisation de SAA, comparativement aux HCR, mais présentaient moins de psychopathologie liée à l’alimentation et générale, comparativement aux HB. Peu de différences psychologiques ont été observées entre les HCC et les HCR. Conclusions : Les HC, surtout les compétiteurs, et les HB semblent partager de nombreux traits liés à l’alimentation, mais peu de caractéristiques psychologiques. Une étude longitudinale est nécessaire pour déterminer si les hommes ayant des antécédents d’alimentation déréglée ou de boulimie s’adonnent à la compétition culturiste de façon disproportionnée, ou si le culturisme de compétition favorise l’alimentation déréglée, la boulimie et l’utilisation de SAA.

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