BODY DYSMORPHIC DISORDER, EATING DISORDER RISK, & DIETARY SUPPLEMENT USE IN PHYSICALLY ACTIVE POPULATIONS

Toni M. Torres-McGehee PhD, SCAT, ATCASPH – Associate Dean Diversity, Equity, & Inclusion

Associate Professor – Director of Athletic Training ProgramsPost-Professional Athletic Training Program Director

NO DISCLOSURES

LEARNING OBJECTIVES• Identify signs & symptoms for body image dissatisfaction,

body dysmorphia, and feeding & eating disorders.

• List predisposing risk factors & pathogenic behaviors associated with body image dissatisfaction, body dysmorphia, and feeding & eating disorders.

• Describe potential physical performance & mental health effects, harms, and regulation of dietary supplements.

BODY IMAGE• Body Image

• Negative Body Image

• Body Image Dissatisfaction

• Distorted Body Image

• Body Dysmorphic Disorder

BODY IMAGE PREVALENCE • 9.0-28.4% of men & 13.4-31.8% of women report being

dissatisfied with their overall appearance [1]• 14.7% of male athletes dissatisfied with their bodies [2]• Females’ ideal figures are thinner and less muscular than their

current figures (3)• Males’ ideal figures are more muscular than their current

figures (3)

BODY IMAGE• Body image dissatisfaction may be the strongest predictor of

EDs in athletes (4, 5, 6)

• Aesthetic evaluation is often attached to a lean body composition for females & muscular build for males (7, 8, 9, 10)

• More than 60% of elite female athletes from both leanness focused & non-leanness focused sports have reported body shaming pressure from coaches (11)

• Uniforms and sport classifications have been cited to have a negative effect on body image (11-15)

CHEERLEADING

BODY IMAGE SILHOUETTES

UNIFORM TYPE & BODY IMAGE - CHEERLEADING

0

PERCEPTIONS FROM OTHERS (2021- TORRES-MCGEHEE-UNPUBLISHED DATA –

IN-PROGRESS)

BODY DYSMORPHIC DISORDER (16)

• Preoccupation with one or more perceived defects or flaws in appearance that are not observable or appear only slight to others

• Criterion A: Preoccupied with one or more perceived defects or flaws in their physical appearance

• Criterion B: Excessive repetitive behaviors or mental acts

• Criterion C: Preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

BODY DYSMORPHIC DISORDER(16)Specify If:• With Muscle DysmorphiaSpecify If: • With good or fair insight: the individual recognizes that the body

dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true

• With poor insight: the individual thinks that the body dysmorphic disorder beliefs are probably true

• With absent insight/delusional beliefs: the individual is completely convinced that the body dysmorphic disorder beliefs are true

PREVALENCE BODY DYSMORPHIC DISORDER (16)

• 2.4% in adults (2.5% women & 2.2% in males)• 9% - 15% among dermatology patients• 7% -8% cosmetic surgery patients• 3-16% among international cosmetic surgery patients • 8% adult orthodontia patients• 10% among patients presenting with oral or maxillofacial

surgery

RISK BODY DYSMORPHIC DISORDER (16)

• Environmental

• Genetic & Physiological

• Culture

• Gender

• Suicide Risk

Disordered Eating vs.

Feeding & Eating Disorder

• Feeding & Eating Disorders• Must be clinically diagnosed by a

physician & meet specific DSM-5 Criteria• A preoccupation with eating and weight

control

• Disordered Eating• A wide range of irregular eating behaviors

EATING DISORDERS/DISORDERED EATING

BackgroundFEEDING/EATING DISORDERS VS. DISORDER EATING (17)

• Binge eating• Self-induced vomiting• Misuse of diet pills, laxatives, diuretics, & enemas• Dieting or fasting• Excessive exercise • Losing 20 lbs or more within 6 months

PURGING & PATHOGENIC BEHAVIORS

WHO’S AT RISK? Background

• Females > males • Females are at higher risk for EDs & DE compared

to males, with nearly a 9:1 ratio (18-22)

• Higher risk from birth from preexisting biological and genetic risk factors (e.g., abnormal hormone levels)24

• Other influential risk factors• Cultural & environmental stressors

• Media ideals

• Comorbid Disorders (e.g., depression, anxiety)17,18

• Body image dissatisfaction(4, 5, 6)

FEEDING & EATING DISORDERS (ED)Types of Feeding Disorders16

Pica Rumination Avoidant/Restrictive Food intake Disorder (ARFID)

Types of EDs16

Anorexia Nervosa (AN) Bulimia Nervosa (BN) Binge Eating Disorder (BED)

Additional Food-Related Concerns16

Other Specified Feeding or Eating Disorder (OSFED) Unspecified feeding & eating disorder (UFED) Compulsive Exercise

Background

DIAGNOSTIC CRITERIA FOR EATING DISORDERS(16)

Anorexia Nervosa Bulimia Nervosa• Types

• Restricting type• Binge eating/purging type

• Severity• Mild: BMI ≥17kg/m2

• Moderate: BMI 16–16.99kg/m2

• Severe: BMI 15–15.99kg/m2

• Extreme: BMI <15kg/m2

• Severity• Mild: Average of 1–3 episodes of

inappropriate compensatory behaviors per week.

• Moderate: Average of 4–7 episodes of inappropriate compensatory behaviors per week.

• Severe: Average of 8–13 episodes of inappropriate compensatory behaviors per week.

• Extreme: Average of 14 or more episodes of inappropriate compensatory behaviors per week.

DIAGNOSTIC CRITERIA FOR EATING DISORDERS (16)

Binge Eating DisorderFeeding & Eating Disorders Otherwise Specified

• Severity

• Mild: 1–3 binge-eating episodes per week

• Moderate: 4–7 binge-eating per week

• Severe: 8–13 binge-eating episodes per week

• Extreme: 14 or more binge-eating episodes per week

• Atypical Anorexia Nervosa• Bulimia Nervosa (low frequency

and/or limited duration)• Avoidant/Restrictive Food Intake

Disorder• Binge Eating Disorder (low frequency

and/or limited duration)• Purging Disorder• Orthorexia???

• Symptom characteristics of feeding & ED that cause:• Clinically significant distress or impairments in social,

occupational or other important areas of functioning predominate

• Does not meet the full criteria for feeding & ED category

UNSPECIFIED FEEDING OR EATING DISORDER (16)

BODY IMAGE & ED RISK

• 63.3% proteins• 52.2% vitamins• 39.1% amino acids• 29.8% caffeine • 12.8% teas• 13.1% mineral salts

• 5.9% steroids• 4.9% diuretics• 3% thyroid hormones• 2.3% amphetamine-like products• 1.1% sibutramine (appetite suppressant)

• Higher levels of Muscle Dysmorphia are related to greater ED symptomatology (24)

• High risk for exercise addiction, appearance anxiety, & body dysmorphic disorder (25)• Unsupervised use of fitness products & illicit drugs

SOCIAL PREDICTORS FOR MUSCLE DYSMORPHIA• Sport pressures, negative affect, and body

satisfaction were significant cross-sectional predictors, accounting for 15-34%, respectively of the variance in athlete's muscularity behaviors and body image. (26)

• Muscular Behaviors

• Muscularity Oriented Body Image/Body Dissatisfaction

APPEARANCE & PERFORMANCE ENHANCING DRUGS• Anabolic-androgenic Steroids (AAS)

• Used in conjunction with a number of legal and illegal substances (27)• Over-the-counter fat-burning supplements• Thyroid hormones• Analgesics• Prohormones• Nutritional supplements• Other ancillary drugs designed to reduce the impact of specific side effects

(e.g., antiestrogenic drugs used to prevent abnormal breast enlargements)

NATA’S POSITION STATEMENT: ANABOLIC-ANDROGENIC STEROIDS 28

DIETARY SUPPLEMENTS USE 28

• Correct or prevent nutrient deficiencies that may impair health or performance.

• To achieve a specific & direct performance benefits in competition

• Manipulation of physique

• Alleviation of musculoskeletal pain

• Rapid recovery from injury

• Enhance mood

• Sleep

DIETARY SUPPLEMENT USE 28

ASSESSING EVIDENCE BASE FOR SUPPLEMENT USE (28)

ASSESSING EVIDENCE BASE FOR SUPPLEMENT USE (28)

BODY IMAGE OR BODY DYSMORPHIC DISORDER & DIETARY SUPPLEMENT USE 29

BODY IMAGE OR BODY DYSMORPHIC DISORDER & DIETARY SUPPLEMENT USE

• Systematic review found elite athletes used dietary supplements far more than their non-elite counterparts (31)

• Supplement use was similar for men & women• Amino acids, creatine, ginseng, sports drinks, omega 3 fatty acid

supplements, energy drinks, caffeine, etc.)

RECOMMENDATIONS

• Education: prevent, identify signs & symptoms, and reduce the prevalence of body image dissatisfaction, body dysmorphia, and feeding & EDs.

• Pre-participation behavioral health screening

• If there is underlying mental health signs and symptoms, medical care should be multidimensional.

• Proper nutrition & changes in daily habits should be considered first prior to recommending dietary supplementation.

RECOMMENDATIONS

• Assess the evidence base for the dietary supplement use!

• Clinicians should understand the level of regulation (or lack of) governing the dietary supplement industry at state, federal, international, and sport specific levels within organizations (e.g., high school, NCAA, NAIA, NJCAA, etc.).

• Understand any adverse effects of these dietary supplement and how they may affect mental health and performance.

CONCLUSION • Body image dissatisfaction and body dysmorphia is a precursor

for feeding & EDs.• Physically active populations at risk for body image dissatisfaction

or body dysmorphia are also at risk for engaging in using dietary supplements.

• When physically active populations engage in dietary supplement use, clinicians must try to understand the “why” behind their usage.

• While some supplements assist in the improvement of athletic performance, the higher risk to mental health and athletic safety prohibit their usage in competitive athletes.

QUESTIONSToni M. Torres-McGehee PhD, SCAT, ATC

ASPH – Associate Dean Diversity, Equity, & InclusionDirector of Athletic Training Programs; Post-Professional AT Director

Email: torresmc@mailbox.sc.edu

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