The Modern Natural Bodybuilder: Dietary Intake, Supplement Usage, Training Demands, and Their Health Implications

THE MODERN NATURAL BODYBUILDER: DIETARY
INTAKE, SUPPLEMENT USAGE, TRAINING DEMANDS,
AND THEIR HEALTH IMPLICATIONS
Lachlan James Mitchell
BAppSc (Ex&SpSci) / BSc (Nut&Diet) (Hons)
The University of Sydney, 2008
A thesis submitted in fulfilment of the requirements for the degree of
Doctor of Philosophy (PhD)
Discipline of Exercise and Sport Science
Faculty of Health Sciences
The University of Sydney
2018
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STATEMENT OF ORIGINALITY
I, Lachlan Mitchell, hereby declare that this thesis is my own work and does not, to the best
of my knowledge, contain material from any other source unless due acknowledgement is
made. This thesis was completed under the guidelines set out by The University of Sydney,
and has not been submitted to any other university or institution as a part or a whole
requirement for any higher degree.
For works that are either published, in press or currently under review and contain multiple
authors, I declare that I was the principal researcher of all the manuscripts included in this
thesis.
Name ______Lachlan Mitchell___
Signed
Date ____19/2/2018__________
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ACKNOWLEDGEMENTS
The production of this thesis was a long journey, with many twists and turns. Achieving this
would not have occurred without the help and support of many individuals from both within
and outside of the University.
Firstly, I must express my deepest gratitude to my primary supervisor Associate Professor
Helen O’Connor. I was fortunate to develop a good relationship with you during my
undergraduate studies, and throughout the subsequent years of working in many different
settings I remained in contact with you expressing my interest in undertaking postgraduate
studies. After accommodating my desire to travel and live overseas, you presented me with
an opportunity which will define my professional career – to begin my doctoral candidature.
Throughout the subsequent four years you have provided an unending well of knowledge,
experience and encouragement, which has driven me to work hard and produce a thesis for
which you and I are both proud. Some of the most pleasing and rewarding moments of my
candidature were receiving your positive feedback about my work. You have taught me
essential skills as an academic and as a dietitian which I will use moving forward in my
career, and I hope I will be given the opportunity to continue to work with you in the future. I
look forward to sharing a Gatortail with you at the next SDA conference!
To my associate supervisor Dr Daniel Hackett, you have been so valuable in bouncing ideas
off, and providing a second opinion on my studies and the direction of my candidature. I have
thoroughly enjoyed our weights room conversations, although they tended to lead to extended
rest periods between sets! To my second associate supervisor, Associate Professor Nathan
Johnson, your advice during the final stages of my candidature were pearls of wisdom. I have
no doubt the suggestions and recommendations you provided will benefit me in my career as
an academic. I also enjoyed the relaxed nature of our teaching together!
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I would like to sincerely thank Dr Stuart Murray from University of California for accepting
my invitation to collaborate with us on our research. Without your help this thesis would not
be at the standard it is. The work you have put in in the muscle dysmorphia research was
pivotal in the success we have achieved. Similarly I wish to thank Associate Professor Gary
Slater from University of Sunshine Coast for all your help in interpreting physiology and
body composition findings from my research. I look forward to continuing our working
relationship in the future. To Dr Tania Prvan and Professor Jenny Peats who both assisted me
at different times in statistical analysis, thank you for all your help. I would like to thank
Professor Melinda Manore from Oregon State University who was so helpful in having my
research accepted for dissemination at the ACSM annual meetings in 2016 and 2017. I would
also like to thank Associate Professor Ollie Jay, whom was very open in discussing the
research and academic environment with me, providing important advice and insight which I
have taken on board. It would be remiss of me not to thank Sports Dietitians Australia, whom
provided the grant for which this research was conducted.
I have been fortunate to befriend many other PhD students during my candidature, whom I
have been able to share many conversations and laughs with throughout the years, ultimately
providing a welcome distraction from the onerous thesis task. To the three other students in
H111 – Claire, Matt and Caitlin, thank you for establishing such a productive work
environment! I would also like to mention Tim who was always happy to discuss the
intricacies and discrepancies of resistance training and programming in the strength and
conditioning world.
Finally I would like to take the opportunity to thank a few people who helped me on a
personal level throughout my candidature. To mum and dad, although I don’t think you ever
fully understood what I was doing, you always offered encouragement and showed an interest
in my work, as well as motivated me to finish (perhaps with the ulterior motive of having me
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finally move out of home!). The opportunities I have been presented with in life are
predominantly as a result of what you have given me. This thesis is no exception, so thank
you once again. To my brothers and sister, and extended family, thank you for showing an
interest in my work and offering your well wishes throughout. To Sarah, thank you for all the
help, support, encouragement, and kind words you provided me during a large component of
my candidature. You were always excited to hear how my work was progressing, and proud
of me for my achievements and drive to continue. I hope in some way you are happy in what
I have compiled in this thesis.
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TABLE OF CONTENTS
STATEMENT OF ORIGINALITY ...........................................................................................ii
ACKNOWLEDGEMENTS ..................................................................................................... iii
TABLE OF CONTENTS .......................................................................................................... vi
LIST OF ABBREVIATIONS .................................................................................................... x
LIST OF TABLES ...................................................................................................................xii
LIST OF FIGURES ................................................................................................................ xiv
ABSTRACT......................................................................................................................... xviii
PUBLICATIONS ARISING FROM THIS THESIS ............................................................. xxv
OTHER PUBLICATIONS DURING CANDIDATURE ..................................................... xxvi
CHAPTERS OF THIS THESIS PUBLISHED AS MANUSCRIPTS ................................xxvii
CHAPTER 1. ............................................................................................................................. 1
Introduction ............................................................................................ 1
Introduction ....................................................................................... 2
Thesis Aims....................................................................................... 4
Specific Hypotheses .......................................................................... 5
Significance of this Research ............................................................ 5
CHAPTER 2. ............................................................................................................................. 8
Background Literature ........................................................................... 8
Literature Review .............................................................................. 9
Summary ......................................................................................... 23
CHAPTER 3. ........................................................................................................................... 25
Muscle Dysmorphia Symptomatology and Associated Psychological

Features in Bodybuilders and Non-Bodybuilder Resistance Trainers: A
Systematic Review and Meta-analysis................................................. 25
Abstract ........................................................................................... 26
Introduction ..................................................................................... 28
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Methods ........................................................................................... 30
Results ............................................................................................. 35
Discussion ....................................................................................... 92
Conclusion ...................................................................................... 98
Acknowledgements ......................................................................... 98
Conflict of Interest .......................................................................... 98
CHAPTER 4. ........................................................................................................................... 99
Correlates of Muscle Dysmorphia Symptomatology in Natural

Bodybuilders: Distinguishing Factors in the Pursuit of Hyper-
Muscularity .......................................................................................... 99
Abstract ......................................................................................... 100
Introduction ................................................................................... 101
Methods ......................................................................................... 103
Results ........................................................................................... 106
Discussion ..................................................................................... 108
Conclusion .................................................................................... 111
Acknowledgements ....................................................................... 112
Conflict of Interest ........................................................................ 112
CHAPTER 5. ......................................................................................................................... 113
Do Bodybuilders Use Evidence Based Nutrition Strategies to

Manipulate Physique? ........................................................................ 113
Abstract ......................................................................................... 114
Introduction ................................................................................... 116
Methods ......................................................................................... 117
Results ........................................................................................... 120
Discussion ..................................................................................... 134
Conclusion .................................................................................... 139
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Conflict of Interest ........................................................................ 139
CHAPTER 6. ......................................................................................................................... 140
Physiological Implications of Preparing for a Natural Male

Bodybuilding Competition................................................................. 140
Abstract ......................................................................................... 141
Introduction ................................................................................... 142
Methods ......................................................................................... 144
Results ........................................................................................... 148
Discussion ..................................................................................... 159
Conclusion .................................................................................... 165
Conflicts of Interest ....................................................................... 165
CHAPTER 7. ......................................................................................................................... 166
Longitudinal Trends in Muscle Dysmorphia Symptomatology in

Bodybuilders During Preparation for a Bodybuilding Contest: An
Exploratory Pilot Study...................................................................... 166
Abstract ......................................................................................... 167
Introduction ................................................................................... 168
Methods ......................................................................................... 170
Results ........................................................................................... 173
Discussion ..................................................................................... 178
Conclusion .................................................................................... 181
Conflicts of Interest ....................................................................... 181
CHAPTER 8. ......................................................................................................................... 182
Conclusions ........................................................................................ 182
Summary of Findings .................................................................... 183
Practical Implications .................................................................... 188
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Study Limitations .......................................................................... 189
Future Research ............................................................................. 192
REFERENCES ...................................................................................................................... 194
APPENDICES ....................................................................................................................... 221
Appendix A: Supplementary Material for Chapter 3 .................... 222
Appendix B: Supplementary Material for Chapter 4 .................... 227
Appendix C: Supplementary Material for Chapter 5 .................... 256
Appendix D: Supplementary Material for Chapters 6 and 7......... 277
Appendix E: Published Manuscripts Related to this Thesis ......... 305
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LIST OF ABBREVIATIONS
AAS Anabolic-androgenic steroids
AgRP Agouti-related protein
BB Bodybuilder
BIA Bioelectrical impedance analysis
BIG Bodybuilder Image Grid
BIG-O Bodybuilder Image Grid - Original
BMI Body mass index
CART Cocaine- and amphetamine-regulated transcript
CI Confidence interval
CRH Corticotropin releasing hormone
DXA Dual-energy x-ray absorptiometry
EAT-26 Eating Attitudes Test 26 items
ECF Extracellular fluid
ED Eating disorder
ES Effect size
ICF Intracellular fluid
MASS Muscle Appearance Satisfaction Scale
MD Muscle dysmorphia
MDI Muscle Dysmorphia Inventory
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MDDI Muscle Dysmorphic Disorder Inventory
MDSQ Muscle Dysmorphia Symptom Questionnaire
NBBRT Non-bodybuilder resistance trainer
NEAT Non-exercise activity thermogenesis
NPY Neuropeptide y
POMC Proopiomelanocortin
RMR Resting metabolic rate
SD Standard deviation
SNS Sympathetic nervous system
T3 Triiodothyronine
TBW Total body water
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LIST OF TABLES
Table 3.1 Participant characteristics of bodybuilders
Table 3.2 Participant characteristics of non-bodybuilder resistance trainers
Table 3.3 Muscle dysmorphia assessment results of bodybuilders
Table 3.4 Muscle dysmorphia assessment results of non-bodybuilder resistance trainers
Table 3.5 Muscle dysmorphia and psychological traits in bodybuilders and non-
bodybuilder resistance trainers
Table 3.6 Effect size of differences in Muscle Dysmorphia Inventory subscale scores
between bodybuilders and non-bodybuilder resistance trained individuals
Table 3.7 Effect size of differences in Muscle Dysmorphic Disorder Inventory subscale
scores between bodybuilders and non-bodybuilders
Table 3.8 Effect size of differences in Muscle Appearance Satisfaction Scale subscale
scores between bodybuilders and non-bodybuilders
Table 3.9 Effect size of differences in Muscle Dysmorphic Disorder Inventory subscale
scores between competitive and non-competitive bodybuilders
Table 3.10 Effect size of difference in Muscle Dysmorphia Inventory subscale scores
between expert and novice bodybuilders
Table 3.11 Effect size of difference in Muscle Appearance Satisfaction Scale and Muscle
Dysmorphia Inventory subscale scores between male and female non-
bodybuilder resistance trainers (NBBRT)
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Table 3.12 Effect size of difference in Muscle Dysmorphic Disorder Inventory subscale
scores between training day and rest day in non-bodybuilder resistance trainers
(NBBRT)
Table 3.13 Effect size of differences in Bodybuilder Image Grid subscale scores between
bodybuilders and controls
Table 4.1 Demographic characteristics, training volume, EAT-26 and MDDI results of
participants (n = 60)
Table 4.2 Explanatory variables of the MDDI total score (simultaneous multiple linear
regression)
Table 5.1 Individual participant characteristics of seven experienced male, natural
bodybuilders participating in in-depth interviews
Table 5.2 Thematic summary of dietary practices and sources of dietary education, in
seven experienced male, competitive natural bodybuilders participating in in-
depth interviews.
Table 6.1 Dietary intake during competition preparation and recovery
Table 6.2 Body composition, resting metabolic rate, and blood parameters during
competition preparation and recovery.
Table 7.1 MDDI, EAT-26, and BIG-O current, ideal and discrepancy index scores, in 9
male natural bodybuilders during 16 weeks of competition preparation
Table 7.2 Body composition and diet composition in 9 male natural bodybuilders during
16 weeks of competition preparation.
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LIST OF FIGURES
Figure 1.1 Diagrammatic description of the Chapter structure of this Thesis, including
Hypotheses addressed in each Chapter.
Figure 2.1 An advertisement for “The Sandow Trocadero Vaudevilles” performance,
circa 1894
Figure 2.2 Components of total energy expenditure (TEE), and the physiological and
behavioural responses to energy restriction which reduce TEE. A reduction in
fat mass and lean mass resulting from continued energy restriction reduces
RMR directly through a reduction in metabolically active tissue [32, 33]. Total
reduction in RMR is typically greater than that which can be predicted based
on reductions in tissue mass, a phenomenon referred to as adaptive
thermogenesis [32]. Reductions in thyroid hormones, in particular T3, occur
during energy restriction, causing a reduction in thermogenesis and metabolic
rate [35, 36]. Energy restriction results in a reduction in energy expenditure of
activity (EEA) through reductions in non-exercise activities, such as fidgeting
[36], while the energy cost of activity is reduced through an increase in work
efficiency [31, 40]. Dotted line indicates a reducing effect. Expenditure values
are approximate. EAT, exercise activity thermogenesis; EEA, energy
expenditure of activity; NEAT, non-exercise activity thermogenesis; RMR,
resting metabolic rate; T3, triiodothyronine; TEE, total energy expenditure;
TEF thermic effect of food.
Figure 3.1 Flowchart showing the process for inclusion of studies
Figure 3.2 Meta-analysis of the pooled effect of BB vs. NBBRT on the dietary behaviour
subscale of the Muscle Dysmorphia Inventory. Data are presented as
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standardised mean difference (ES) and 95% confidence interval (95% CI).
NBBRT, Non-bodybuilding resistance trainer; BB, Bodybuilder; ES, effect
size
Figure 3.3 Meta-analysis of the pooled effect of BB vs. NBBRT on the supplement use
size
Figure 3.4 Meta-analysis of the pooled effect of BB vs. NBBRT on the exercise
dependence subscale of the Muscle Dysmorphia Inventory. Data are presented
as standardised mean difference (ES) and 95% confidence interval (95% CI).
size
Figure 3.5 Meta-analysis of the pooled effect of BB vs. NBBRT on the pharmacological
use subscale of the Muscle Dysmorphia Inventory. Data are presented as
size
Figure 3.6 Meta-analysis of the pooled effect of BB vs. NBBRT on the size/symmetry
size
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Figure 3.7 Meta-analysis of the pooled effect of BB vs. NBBRT on the physique
protection subscale of the Muscle Dysmorphia Inventory. Data are presented
as standardised mean difference (ES) and 95% confidence interval (95% CI).
size
Figure 5.1 Doughnut chart representation of the stages of bodybuilding preparation,
including key dietary strategies used, as reported by seven experienced male,
competitive natural bodybuilders participating in in-depth interviews. Duration
of stages are approximate and vary between bodybuilders.
Figure 6.1 Body composition and resting metabolic rate changes. Enclosed dots indicate
individual data; bars indicate mean. Effect sizes indicate changes in mean.
Body mass, lean mass, fat mass, measured using dual-energy x-ray
absorptiometry. RMR, resting metabolic rate. d indicates effect size between
time points.
Figure 6.2 Serum hormone changes. Enclosed dots indicate individual data; bars indicate
mean. Effect sizes indicate changes in mean. d indicates effect size between
time points.
Figure 7.1 a. MDDI and b. EAT-26 changes during 16 weeks of bodybuilding
competition preparation. Enclosed dots indicate individual data; bars indicate
mean; horizontal dotted line indicates threshold for a high level of concern
about dieting, body weight, and problematic behaviours. PRE16, PRE12,
PRE8, PRE4 and PRE1 indicate 16, 12, 8, 4, and 1 week(s) before
competition.
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Figure 7.2 Correlations between PRE16 MDDI total score, and the change in energy and
fat intake. MDDI, muscle dysmorphic disorder inventory.
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ABSTRACT
Bodybuilding is an ancient sport with modern day popularity. The sport has evolved over the
centuries to its modern version, where participants are judged not by objective feats of
exertion, but subjectively based on their physique. Routine poses are performed, where
bodybuilders are critiqued on muscularity, leanness and symmetry. The preparation for a
bodybuilding contest typically consists of an extended off-season where participants aim to
gain muscle mass and thus achieve a high degree of muscularity, followed by the in-season
period commonly highlighted by a strict diet and training regimen, aimed at reducing body
fat whilst maintaining muscle mass to achieve an extremely lean yet muscular physique. A
branch of bodybuilding which has become increasingly popular is natural bodybuilding,
where participants are screened for use of appearance and performance enhancing drugs and
are required to rely solely on exercise and diet to achieve their physique goals.
Evidence supports the use of diet and exercise to achieve weight loss in clinical and athletic
populations. Although this weight loss is primarily through loss of fat mass, a portion of this
loss, particularly in already lean individuals, can be lean mass. Lean mass is metabolically
active, and reductions in lean mass, as well as total mass, through periods of energy deficit
are known to reduce resting metabolic rate. Additionally, a continued negative energy
balance decreases anabolic and anorexigenic hormones, and increases orexigenic hormones.
Consequently, further reductions in fat mass is limited, and fat mass deposition is promoted,
by these physiological responses.
Muscle dysmorphia is an increasingly recognised psychiatric disorder, recently included in
the Diagnostic and Statistical Manual of Mental Disorders as a form of body dysmorphic
disorder. It is most centrally characterised by a distorted self-perception, whereby the
individual believes themselves to be small and weak, often despite well-developed
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muscularity, and a concomitant pathological drive for muscularity and leanness. In
individuals with muscle dysmorphia, attitudinal and behavioural symptoms echo these
characteristics. Meticulous exercise and dietary practices are devised and fastidiously
monitored to achieve a mesomorphic body, while deviation from either food or exercise
regimen is associated with marked anxiety. Due to the implicit overlap between muscle
dysmorphia and bodybuilding in regards to the pursuit of a muscular and lean body, the two
have often been conflated. Therefore, it remains pertinent to differentiate between muscle
dysmorphia and a non-pathological pursuit of muscularity.
Despite the growing popularity of bodybuilding, the literature examining this population
remains scarce and dated, with a large proportion of studies in bodybuilders having
investigated health outcomes associated with use of anabolic steroids. The diet of
bodybuilders has been rarely examined since the 1990’s, and only a small number of studies,
primarily case studies, have documented the effects of training and diet on physiology during
competition preparation. Bodybuilders are known to achieve extremes of body composition,
however the strategies used to achieve this outcome, and the physiological effects of these
strategies, remain under described. Moreover, studies of muscle dysmorphia in bodybuilders
are limited in number and depth. Hence, this thesis aimed to add to the current body of topic-
related research by: (1) systematically reviewing muscle dysmorphia symptomatology in
bodybuilders and non-bodybuilder resistance trainers; (2) deconstructing the inference that
bodybuilding and symptoms of muscle dysmorphia are synonymous by identifying correlates
of muscle dysmorphia symptomatology in natural bodybuilders; (3) examining the dietary
strategies used by experienced natural bodybuilders, and pertinently, the purported rationale
behind these strategies; and (4) describing the body composition, physiology, and psychology
responses to the dietary and training practices employed by male natural bodybuilders during
the preparation and recovery from a bodybuilding competition.
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A systematic search of the literature found 31 studies that measured muscle dysmorphia
symptomatology using a validated questionnaire in bodybuilders or non-bodybuilder
resistance trainers. Findings from the systematic review indicated muscle dysmorphia
symptomatology was greater in bodybuilders than non-bodybuilder resistance trainers (effect
size (ES) = 0.53-1.12; p ≤ 0.01). Evidence supported muscle dysmorphia symptoms were
higher in competitive bodybuilders than non-competitive bodybuilders (ES = -1.09-1.42; p <
0.001). Symptoms of muscle dysmorphia were associated with anxiety, depression,
neuroticism, perfectionism, and low self-esteem. It remains unclear whether these
characteristics are exacerbated by bodybuilding, or whether individuals with these
characteristics are attracted to the bodybuilding environment.
Following on from the systematic review, a cross-sectional survey study was conducted to
assess muscle dysmorphia and eating disorder symptoms, and identify correlates of muscle
dysmorphia symptomatology in male, natural bodybuilders. The primary aim was to
deconstruct the inference that bodybuilding and symptoms of muscle dysmorphia are
synonymous. The survey was completed by 99 participants, of which 60 were eligible for
inclusion. Regression analysis identified the rate at which bodybuilders lose weight during
preparation (β = 0.307), and eating disorder symptoms (β = 0.298), were both positively
correlated with muscle dysmorphia symptomatology, while bodybuilding experience (β = -
0.257) was negatively associated with muscle dysmorphia symptomatology. The model
explained 20.8% of the variation in muscle dysmorphia symptoms. These results suggest it is
the presence of disordered eating psychopathology that may differentiate between
bodybuilders with and without muscle dysmorphia symptomatology. Extending on this, the
results suggest that those bodybuilders who lose weight more rapidly during competition,
which may indicate pathological eating behaviours, may be more likely to display muscle
dysmorphia symptoms. If bodybuilding participation is unable to appease muscularity related
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symptoms in individuals displaying features of muscle dysmorphia, long-term participation is
unlikely. Such a scenario may explain the negative association identified between
bodybuilding experience and muscle dysmorphia symptomatology. An alternative
explanation for this negative association may be that participation in bodybuilding has a
protective effect, whereby muscle dysmorphia symptoms are reduced with continued
participation.
To examine the dietary strategies used during competition preparation, the third study of this
thesis used a qualitative study design, where in-depth interviews were performed with seven
experienced, male natural bodybuilders. In particular, the rationale behind the use of the
dietary strategies was discussed, as were the sources of dietary education used by
bodybuilders. The off-season period was highlighted by large, frequent meals containing high
amounts of protein with adequate carbohydrate to permit high training loads and achieve
muscle gain. Energy intake was progressively reduced during the in-season via a reduction in
carbohydrate and fat intake to assist in loss of body fat. To off-set declines in metabolic rate
and fatigue, weekly re-feed days with higher carbohydrate were included. In the final “peak
week” before competition, more specific strategies were adopted including fluid and sodium
manipulation and carbohydrate loading to achieve the leanest possible physique. Dietary
restriction gave way to disinhibition or discrete eating binges post-competition. These
bodybuilders reported the use of predominantly evidence based strategies. Additionally,
novel strategies such as weekly re-feed days to enhance fat loss, and sodium and fluid
manipulation, warrant further investigation to evaluate their efficacy and safety.
To extend on the dietary strategies described in Study 3, a longitudinal observational study
was conducted, which examined the body composition and physiological responses to
competition preparation and recovery. Nine competitive natural bodybuilders (29.0 ± 9.5 yrs,
83.7 ± 8.9 kg, and 6.0 ± 6.6 years bodybuilding experience) were assessed on three occasions
xxi
before the contest, and once after the contest. Measures included body composition (dual
energy x-ray absorptiometry, bioelectrical impedance analysis, anthropometry), resting
metabolic rate, blood parameters, and food and training diaries. A significant reduction in fat
mass occurred during the pre-contest period (mean reduction = 3.5 kg, d = 1.3), while only a
small reduction in lean mass occurred during the final 8 weeks of contest preparation (mean
reduction = 0.9 kg, d = 0.1). Despite reductions in total and fat mass, no significant changes
in the resting metabolic rate of participants were identified, which may reflect the relative
maintenance of lean mass during preparation. The success of the participants in reducing fat
mass, while still maintaining lean mass and metabolic rate is likely attributed to the high
protein intake and regular high intensity resistance training. Large reductions in total serum
testosterone, free serum testosterone, and serum insulin-like growth factor-1 were found
during the pre-contest period (mean reduction = 38.0%, d = 1.6; mean reduction = 50.3%, d =
1.5; mean reduction = 26.2%, d = 0.9, respectively). Interestingly, no changes were detected
in cortisol, insulin, leptin or adiponectin. Five participants dropped below the reference range
for serum testosterone concentration during the pre-competition period, indicating that
despite relative maintenance of lean mass and metabolic rate, participants progressed to an
anti-anabolic state.
In order to extend the findings of Studies 1 and 2, muscle dysmorphia, disordered eating, and
physique perception were assessed on five separate occasions during the 16 week pre-
competition period in the longitudinal study. Muscle dysmorphia, disordered eating, and fat
and muscle perception were shown to remain constant throughout the pre-competition period,
despite significant changes in body composition, most notably reduction in fat mass.
Furthermore, greater muscle dysmorphia symptomatology in the early periods of preparation
was associated with a subsequently greater reduction in energy and fat intake. These findings
xxii
suggest there may be a distinct disconnect between actual body composition and attitudes
towards muscularity.
Outcomes of this series of studies identify the nutritional and dietary strategies employed by
bodybuilders during the competition preparation cycle. Muscular hypertrophy is reported to
be achieved during the off-season through the application of progressive resistance training
coupled with high energy and protein intake. During the in-season, it was identified that fat
mass is progressively reduced through diet and training manipulations, resulting in the
achievement of extremely low fat mass, often to the extremes of known body fat levels.
Using this approach, bodybuilders in this cohort were also successful at maintaining lean
mass during this period of negative energy balance, despite reductions in anabolic hormones.
Resting metabolic rate changes may vary, however in this cohort no significant changes were
discovered, suggesting the maintenance of lean mass and resistance training volume may
prevent adaptive downgrades in resting metabolic rate during periods of prolonged energy
deficit. The systematic review and cross-sectional studies highlighted that muscle dysmorphia
symptoms may be present in the bodybuilding population; however, not all bodybuilders
display these symptoms. Hence, it is not the activity of bodybuilding itself that is a
pathological endeavour, rather, the context of bodybuilding may attract those susceptible to
the development of muscle dysmorphia symptoms. Particular behaviours, such as rapid
reductions in body weight, and pathological eating habits, may predict muscle dysmorphia
symptoms in bodybuilders. The outcomes of this series of studies must be considered with
the limitation of the small sample size included, therefore caution is required when drawing
such conclusions with the broader bodybuilding population.
The findings of this thesis suggest several identified strategies are worthy of further
investigation. The maintenance of lean mass during a prolonged period of energy restriction
described in Study 3 is likely attributed to the use of a high protein diet in addition to intense
xxiii
resistance exercise. Further examination of these strategies in bodybuilders, and in other
population groups, including athletes aiming to reduce body fat for competition, may provide
detailed evidence for their efficacy and recommended use. The use of a re-feed day, or
intermittent fasting, and hormonal and metabolic responses associated with short-term energy
restoration, warrant investigation to determine benefits for weight loss whilst maintaining
lean mass in both lean athletic and obese populations. Further corroboration of the correlates
of muscle dysmorphia symptoms identified in this set of studies is required. Examination of
these correlates in a broader population group, including individuals displaying greater
muscle dysmorphia symptomatology, may add evidence to the debate over the nosological
classification of muscle dysmorphia. Ongoing longitudinal research into muscle dysmorphia
is required to confirm the findings described in Study 3.
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PUBLICATIONS ARISING FROM THIS THESIS
Published manuscripts:
1. Mitchell L, Murray SB, Cobley S, Hackett D, Gifford J, Capling L, O’Connor H.
Muscle dysmorphia symptomatology and associated psychological features in
bodybuilders and non-bodybuilder resistance trainers: A systematic review and meta-
analysis. Sports Med 2017; 47(2): 233-259. https://doi.org/10.1007/s40279-016-0564-
2. Mitchell L, Murray S, Hoon M, Hackett D, Prvan T, O’Connor H. Correlates of
muscle dysmorphia symptomatology in natural bodybuilders: Distinguishing factors
in the pursuit of hyper-muscularity. Body Image 2017; 22: 1-5.
http://dx.doi.org/10.1016/j.bodyim.2017.04.003
3. Mitchell L, Hackett D, Gifford J, Estermann F, O’Connor H. Do bodybuilders use
evidence-based nutrition strategies to manipulate physique? Sports 2017; 5: 76.
https://doi.org/10.3390/sports5040076
4. Mitchell L, Slater G, Hackett D, Johnson N, O’Connor H. Physiological implications
of preparing for a natural male bodybuilding competition. Eur J Sport Sci 2018; In
Press. https://doi.org/10.1080/17461391.2018.1444095
Conference presentations – oral:
5. Mitchell L, Murray S, Hoon M, Hackett D, Prvan T, O’Connor H. Behavioral
predictors of muscle dysmorphia symptomatology in natural bodybuilders. Med Sci
Sport Exer 2017; 49(5S): 201. https://doi.org/10.1249/01.mss.0000518793.83710.8e
Conference presentations – poster:
6. Mitchell L, Cobley S, Hackett D, Gifford J, Capling L, Murray SB, O’Connor H.
Muscle dysmorphia symptoms in bodybuilders and non-bodybuilder resistance

xxv
trainers, and associated psychological characteristics: A systematic review and meta-
analysis. Med Sci Sport Exer 2016; 48(5S): 892. https://doi.org/10.1007/s40279-016-
0564-3
OTHER PUBLICATIONS DURING CANDIDATURE
Published manuscripts:
1. Spendlove J, Mitchell L, Gifford J, Hackett D, Slater G, Cobley S, O’Connor H.
Dietary intake of competitive bodybuilders. Sports Med 2015; 45(7): 1041-63.
https://doi.org/10.1007/s40279-015-0329-4
2. Amirthalingam T, Mavros Y, Wilson GC, Clarke JL, Mitchell L, Hackett DA. Effects
of a modified German volume training program on muscular hypertrophy and
strength. J Strength Cond Res 2017; 31(11): 3109-19.
https://doi.org/10.1519/JSC.0000000000001747
3. Hackett, DA, Armithalingam T, Mitchell L, Mavros Y, Wilson GC, Halaki M. Effects
of different high volume resistance training programs on muscle strength and
hypertrophy. Sports 2018; 6(1): 7. https://doi.org/10.3390/sports6010007
xxvi
CHAPTERS OF THIS THESIS PUBLISHED AS
MANUSCRIPTS
The work presented in Chapter 3 of this thesis is based on the published manuscript Mitchell
L, Murray SB, Cobley S, Hackett D, Gifford J, Capling L, O’Connor H. Muscle dysmorphia
symptomatology and associated psychological features in bodybuilders and non-bodybuilder
resistance trainers: A systematic review and meta-analysis. Sports Med 2017; 47(2): 233-259.
I co-designed the study with the co-authors, collected the data with assistance from L.
Capling, interpreted the data with S. Murray, and wrote the drafts of the manuscript.
L, Murray S, Hoon M, Hackett D, Prvan T, O’Connor H. Correlates of muscle dysmorphia
symptomatology in natural bodybuilders: Distinguishing factors in the pursuit of hyper-
muscularity. Body Image 2017; 22: 1-5. I co-designed the study with the co-authors, analysed
the data with assistance from T. Prvan, and wrote the drafts for the manuscript.
L, Hackett D, Gifford J, Estermann F, O’Connor H. Do bodybuilders use evidence-based
nutrition strategies to manipulate physique? Sports 2017. 5: 76. I co-designed the study with
the co-authors, collected the data with assistance from H. O’Connor and D. Hackett, analysed
the data with assistance from F. Estermann, and wrote the drafts of the manuscript.
L, Slater G, Hackett D, Johnson N, O’Connor H. Physiological implications of preparing for
a natural male bodybuilding competition. Eur J of Sport Sci 2018; In Press. I co-designed the
study with the co-authors, collected the data, analysed the data, and wrote the drafts of the
manuscript.
xxvii
Name Lachlan Mitchell___
Signed
Date ___19/2/2018__________
As supervisor for the candidature upon which this thesis is based, I can confirm that the
above authorship attribution statements are correct.
Name _____Helen O’Connor____
Signed
Date ___19/2/2018___________
xxviii
CHAPTER 1.
Introduction
1
INTRODUCTION
The popularity of bodybuilding has consistently grown throughout the previous decades [1].
The expansion of the sport in the 1970’s to include drug-tested contests, and the addition of
less extreme physique categories such as fitness and muscle model, as well as the broader
inclusion of female athletes, has seen competition participation numbers continue to increase
worldwide [1]. Additionally, bodybuilding practices have become more common in the
general population, with the benefits of dietary manipulation and resistance training for wider
sports performance as well as general health benefits now increasingly recognised [2-8].
Competitive bodybuilders (BB) are judged on their muscularity and leanness, and employ
structured diet and exercise regimens to achieve the ideal competition physique [9,10]. A
long-term approach to competition preparation is taken. An extended off-season aiming to
achieve muscular hypertrophy and thus a high degree of muscularity is followed by an in-
season period aimed at reducing fat mass while maintaining muscle mass. Early research into
these athletes suggested a high energy and protein intake was typically consumed. To reduce
body fat levels the in-season period leading to competition, it has been reported that a
reduction in energy intake occurs, commonly through the implementation of a low fat diet
and a reduction in carbohydrate intake [10]. Previous evidence has suggested a high volume
resistance training schedule is implemented throughout the off-season and in-season to build
and maintain muscle mass, while aerobic exercise is incorporated into the training regimen in
the months leading to competition to assist in reduction of body fat [9].
More recent research into the practices of modern BB has been limited. Case studies have
documented individual dietary and training routines of natural BB, with the inclusion of
hormonal and metabolic responses. Large reductions in total body, fat and lean mass have
been shown to coincide with competition preparation. General reductions in anabolic and
2
orexigenic hormones have been described, along with reductions in resting metabolic rate
(RMR) [11-13]. However, case studies may be limited in their generalisability to the broader
bodybuilding community.
In addition to the physiological parameters which have been investigated in BB, several body
image-related conditions have been the focus of research. Muscle dysmorphia (MD), a
psychiatric disorder characterised by a self-perception of inadequate muscularity and
subsequent obsessive behaviours focussed on increasing muscle mass and leanness [14], has
been increasingly recognised. Due to the contextual similarities between bodybuilding and
MD, BB have been the primary population in which MD has been examined, as well as
strength based athletes such as powerlifters [15]. It has been estimated that 10% of studied
males display MD symptoms [16]. It has yet to be determined if the sport of bodybuilding
increases the risk of developing MD symptoms, or if the sport of bodybuilding attracts those
at risk of, or already displaying MD symptoms. Indeed, the sport of bodybuilding itself has
been described as a pathological habit, leading to a potentially greater incidence of MD in BB
than other population groups, including strength-trained athletes [15]. At this stage though, it
is unconfirmed whether MD symptomatology is greater in BB than non-bodybuilder
resistance trainers (NBBRT). Further, it is unknown whether MD symptoms are influenced
by competition preparation. It has been demonstrated that an acute training session can
reduce MD symptoms [17], however no longitudinal measures have been performed in BB.
Given the high degree of muscularity and extreme leanness achieved in competition
preparation, it is reasonable to hypothesise that symptoms of MD would reduce as individuals
move closer to their ideal physique. However, it is also possible for the ideal physique to
become increasingly extreme as body fat levels reduce, resulting in a cycle of increased
symptoms and further extreme behaviours.
3
Despite the popularity of the sport of bodybuilding, and the success achieved by these
athletes in modifying their body composition, recent studies into training and dietary
practices employed by BB are generally limited to small cohorts and case studies. Preparation
strategies employed by BB remain largely undocumented, while there is limited evidence for
the changes in metabolism and physiology which coincide with the body composition
modification in this population group. Furthermore, the body image related changes which
accompany these body composition shifts are yet to be determined.
THESIS AIMS
The primary aim of this thesis was to examine dietary and exercise practices of male natural
BB, and assess the physiological and psychological effects of these practices. This thesis
contains a series of studies that describe the dietary and training protocols used by this target
population during preparation and recovery from bodybuilding competition. Changes in body
composition, physiology and body image related concerns which take place during this
period of time are also assessed. Approaches including in-depth interviews, food and training
diaries, direct physiological measures of metabolism and hormones, and self-report
questionnaires, were used to achieve the following specific aims of each study:
1. systematically review and compare evidence of MD symptomatology in BB and
NBBRT, and identify psychological features associated with MD in these
populations;
2. identify correlates of MD symptoms in male, competitive natural BB;
3. identify and describe the dietary and supplement strategies used by experienced
natural BB during a competitive season, and their purported rationale;
4
4. assess the body composition and physiological changes that occur during preparation
and recovery from a natural bodybuilding competition; and
5. assess changes in MD and disordered eating symptoms during preparation for a
natural bodybuilding competition.
SPECIFIC HYPOTHESES
1. Bodybuilders will present greater MD symptomatology than NBBRT.
2. Eating disorder symptoms will be associated with increased MD symptoms, but not a
non-pathological pursuit of muscularity (that is, bodybuilding).
3. Drug-free BB will follow structured, strict and periodised dietary and exercise
protocols during preparation for competition, some of which may have limited or no
evidence base. Energy intake will be progressively reduced as competition
approaches.
4. Fat mass will significantly reduce during competition preparation, with concomitant
reductions in lean mass. Metabolic rate and anabolic hormones will reduce in
conjunction with these body composition changes.
5. Competition preparation will ameliorate MD and disordered eating symptoms.
SIGNIFICANCE OF THIS RESEARCH
The dietary and training habits of modern BB are largely undocumented. Outcomes from this
research will provide greater insight into the methods used during competition preparation by
natural BB which can be used by health practitioners such as dietitians to provide advice and
recommendations, and also to further research in the fields of diet and exercise in weight
category sports. This research may also serve to uncover novel strategies used by BB to
5
achieve their body composition outcomes which as yet remain undocumented in literature.
Such strategies may warrant further research with the potential of providing
recommendations for other population groups, especially for the development of lean mass
and reduction in body fat.
6
Figure 1.1. Diagrammatic description of the Chapter structure of this Thesis, including Hypotheses addressed in each Chapter.
7
CHAPTER 2.
Background Literature
8
Chapter 2: Background Literature
LITERATURE REVIEW
Introduction to bodybuilding
Bodybuilding has long been considered a niche sport, with extreme body composition
outcomes matched by extreme preparatory behaviours. However, in recent decades,
mainstream popularity of the sport has increased, reflected by the increased participation
numbers [1]. Competitive BB are judged on their physique while performing a routine set of
physical poses with success based on muscular size, symmetry and definition [9]. A
fastidious pursuit of muscularity is often seen amongst BB, who have been shown to commit
to a rigorous training regimen, coupled with a strict diet and supplement program [10].
Appearance and performance enhancing drugs such as anabolic androgenic steroids (AAS)
may also be used by BB to achieve body composition goals [18,19].
Bodybuilders undertake a long-term approach to prepare for competition. The primary off-
season goal is to build muscle mass, with less of a focus on fat mass. Training and dietary
approaches are matched with this hypertrophic pursuit. The in-season goals shift to a gradual
reduction in fat mass, whilst attempting to maintain muscle mass. This is reportedly achieved
through a progressive reduction in energy intake, intense resistance training, and an increase
in aerobic exercise [1,10].
History of bodybuilding
Modern bodybuilding is reported to have commenced in the late 1800’s with Eugen Sandow,
a Prussian born physical culturist recognised as the “father of modern bodybuilding” [20].
Sandow was the first strongman to combine demonstrations of great strength with staged
displays of his so called “exquisite”, lean and muscular physique [20]. Although Sandow
pioneered the idea of “muscle display performances”, analogous to current day posing
routines used by BB, it was the Vaudeville promoter Flo Ziefgfeld who recognised the wider
9
commercial potential of showcasing Sandow's muscular and proportioned body as a top
billing stage act [20]. Ziefgfeld recognised that audiences were just as captivated with
Sandow's appearance as his strength. Sandow eventually went on to start his own
gymnasium, bodybuilding magazine, and write training manuals on bodybuilding [20].
Figure 2.1. An advertisement for “The Sandow Trocadero Vaudevilles” performance, circa
1894. Source www.art.com
The popularity of muscularity displays increased through Sandow and his successors.
Combined with the development of interest in physical activity from a health perspective in
the mid-19th century, the muscular physique became an ideal which was a popular aspiration
[20]. Spectators were no longer outside observers, rather they had an interest and capacity to
be potential participants [20]. As the sport of bodybuilding emerged, comparisons between
10
participants became inevitable. With this, a number of set poses were developed as a means
of directly comparing bodybuilding participants [20].
By the 1950's, the first supplements tailored for athletes came into wider use [21]. Although
different diet approaches were still emerging, protein foods and supplements became a major
emphasis in bodybuilding from the 1950's [21]. Notably, also around this time another
important development was the emergence of AAS which were the first of a range of other
drugs (e.g. insulin, insulin-like growth factor 1, growth hormone) available to BB to push the
boundaries on muscle development and definition [22].
In the late 1970's, bodybuilding widened its scope to incorporate a drug free, natural
bodybuilding competition [23]. This change was prompted by concerns about the negative
health effects of drug use in bodybuilding [23]. The physiques of competitors had also
reached such an extreme that they were no longer aesthetically pleasing to a wider audience
resulting in a downturn in participant and spectator popularity [20]. The introduction of other,
less extreme in muscularity bodybuilding categories has followed (e.g. figure/physique,
sports/fitness, and swimsuit/bikini). In 2013, the Mr Olympia contest, regarded as the most
prestigious bodybuilding competition, introduced a physique category for men, one which
aims to attract competitors with less extreme physiques and more consistent with the ethos of
the Grecian ideal for which historically bodybuilding seeks to replicate. Higher participation
of women, especially in newer bodybuilding categories, is evident [24]. The popularity of
natural bodybuilding is rapidly increasing. In 2013, over 200 amateur natural bodybuilding
contests took place in the United States, with this number expected to increase annually [1].
11
Bodybuilding competition
Bodybuilding competitors are allocated into categories based on height, weight, or age. BB
competing in natural federations are randomly selected to undergo urine tests for use of
banned substances. In Australian federations, the Australian Sports Anti-Doping Authority is
responsible for implementing the World Anti-Doping Code, with competitors subject to The
Code and Prohibited List developed by the World Anti-Doping Agency [25]. Competitors are
judged in two rounds – the muscularity and the symmetry rounds. In the muscularity round,
competitors complete a routine of set poses to display their muscularity and leanness. In this
round, judges compare competitors based on muscularity – the shape, thickness and quality
of muscle; proportion – the balance of one muscle group to another; definition – muscle
separation, definition and vascularity; and balance – left side of the body compared to the
right, front of the body compared to the rear [26]. In the symmetry round competitors stand
before the judges and are observed from four angles – the front, each side, and the rear. In
this round judgement is based on structural flaws – faults within the competitor’s skeletal
structure; proportion – the balance of one muscle group to another; balance – the left side of
the body compared to the right, the front of the body compared to the rear; and symmetry –
the competitor’s overall shape and line [26].
Diet and bodybuilding
The dietary intake of BB has been reported as structured and periodised [10]. Specific energy
and macronutrient targets are commonly followed during each phase of competition
preparation. During the off-season BB typically focus on increasing muscle mass, with less
regard to body fat levels. Their dietary intake reflects this, with previous reports
demonstrating overall energy intake to be high, with high volumes of protein, fat and
12
carbohydrate consumed. A recent systematic review reported the highest energy and protein
intakes occurred during the off-season. Similarly, carbohydrate and fat intakes were highest
during this period [10]. The in-season focus shifts to reducing fat mass whilst maintaining
muscle mass. Dietary patterns are reported to shift with this change in focus. In order to
achieve fat loss, BB report a reduction in energy intake during the in-season, with
carbohydrate and fat intake substantially lower than off-season values [10]. In contrast, case
studies and a systematic review suggest protein intake remains similar to intakes during the
off-season [10,11,13]. During this competition preparation period, BB have been shown to
monitor their intake through the use of food diaries and food scales, to ensure energy and
macronutrient goals are met [11]. The post-competition period is less structured than the in-
season. Case studies have demonstrated food intake to be less routinely monitored, with less
concern shown for energy and macronutrient targets [13]. Total energy intake is greatly
increased in the immediate post-competition period [27], with body weight typically
increasing. On the day of competition, a group of 45 male BB self-reported a typical weight
regain after competition of 5.9 kg [28], while in a prospective study, a small group of female
BB demonstrated on average a 3.9 kg increase in body weight in the three weeks post-
competition [27]. Although the dietary intake of BB has been described [10], the majority of
this evidence is dated, with few studies published in recent years. As such, the dietary habits
of modern BB remains largely undocumented.
Dietary supplements are synonymous with bodybuilding. Supplements aimed to aid
accumulation of muscle mass, improve exercise performance, and complement usual dietary
intake are used [9]. In a previous sample of 127 male BB, a self-report survey showed all
participants consumed dietary supplements [9]. On average 3.4 ± 0.9 supplements were used
during the off-season, and 3.7 ± 1.2 supplements were used during the six weeks pre-
competition. The most popular supplements used during the off-season were protein shakes,
13
creatine, branched chain amino acids and glutamine. Similar supplements were most popular
during the pre-competition period, with the addition of ephedrine-containing/caffeine-
containing products [9].
Training regimens of bodybuilders
Empirical literature regarding the training routines of BB is scarce. The exercise routine of
BB is reported to reflect their specific, periodised goals. A cross-sectional, self-report survey
of 127 competitive male BB showed that during the off-season, a time committed to muscular
hypertrophy, BB typically use a high volume resistance training program, with very low
volumes of aerobic exercise. A split routine is commonly adopted, whereby each training
session focuses on specific muscle groups [9]. Four to five sessions were reported to be
performed per week, allowing each muscle group to be trained once or twice per week
[9,11,13]. The set and repetition range target hypertrophy, with most BB performing 7-12
repetition maximum (RM) for 3-6 sets per exercise, and 4-5 exercises per muscle group [9].
As BB progress into their in-season, training routines shift to reflect the goal of reducing fat
mass while maintaining muscle mass. Small modifications are typically made to the
resistance training program, including reductions in set number to 3-4 sets per exercise, and
an increase in repetitions to 7-15 RM per set [9]. The resistance training protocol aims to
maintain muscle mass despite remaining in a long-term energy deficit. To aid fat loss, it is
common for aerobic training to be significantly increased. A combination of high intensity
interval training, and low to moderate intensity steady state exercise was implemented in a
large group of competitive male BB during the in-season [9]. Frequency of aerobic training
varies during the in-season, with greater than five sessions per week reported [9,11]. In
addition to resistance and aerobic training, case studies show BB commonly incorporate
14
posing practice into their regimen during the in-season preparation [12]. This involves
repeatedly holding isometric contractions of the major muscle groups for 30-60 seconds
while the limbs and torso are in a position intended to make the muscles appear large and
defined [13].
Body composition changes in bodybuilding
BB achieve significant changes in body composition during competition preparation.
Although the weight of each individual competitor varies based on their competition weight
category, all participants follow a similar trend of increasing lean mass in the off-season, then
subsequently reducing total mass, primarily in the form of fat mass, during the in-season [1].
These reductions in fat mass allow BB to reach the extremes of body composition. Several
cohort studies have described the changes in body composition during competition
preparation. Based on surface anthropometry and hydrodensitometry measures, a 3.8 kg
reduction in fat mass was reported during competition preparation in a small group of male
BB, with a mean reduction in lean mass of 1.6 kg [29]. Similarly, male BB assessed 10 weeks
and five days prior to competition using hydrodensitometry and dual-energy x-ray
absorptiometry (DXA) lost on average 6.9 kg of total body mass, with fat mass accounting
for 4.5 kg (64% of total mass lost) [30]. More recently, case studies have documented
significant reductions in fat mass, with concomitant reductions in lean mass, during
competition preparation of male natural BB. In some cases, lean mass accounted for 43% of
total mass lost [11-13]. Further cohort studies in modern BB are required to corroborate these
case study findings.
15
Adaptive responses to energy restriction (Effects of weight loss on metabolism, energy
expenditure and hormones)
Total energy expenditure is a combination of three factors – the resting metabolic rate
(RMR), the thermic effect of food, and the energy expenditure of activity (Figure 2.2). The
energy expenditure of activity can be further divided into exercise activity thermogenesis and
non-exercise activity thermogenesis [31]. The RMR is by far the greatest component of total
energy expenditure, with approximately 60% of energy expended accounted for by the RMR
[32]. The RMR is influenced by total mass, and its constituent components of fat mass and
fat free mass.
A reduction in fat mass through restriction in energy intake is suggested to be detected by the
body through a series of neuroendocrine pathways. This reduction initiates adaptive processes
which have the effect of preventing further reductions in stored body fat. One such process is
a reduction in metabolic rate beyond those decreases accounted for by changes in fat mass
and fat free mass. This is termed adaptive thermogenesis [33,34], and it has been suggested
that the greater the energy deficit and reduction in body fat, the greater the reduction in RMR
[33].
Maintenance of the reduced body weight is opposed by this adaptive thermogenesis, which
has been shown to reduce the magnitude of the negative energy balance. Reductions in
sympathetic nervous system (SNS) tone and increases in parasympathetic nervous system
tone have been associated with the reduced body weight [32]. These changes in autonomic
nervous system tone may account for a significant fraction of the hypometabolic state
through direct effects on skeletal muscle, and/or indirectly through effects on circulating
thyroid hormones [32].
16
Figure 2.2. Components of total energy expenditure (TEE), and the physiological and
behavioural responses to energy restriction which reduce TEE. A reduction in fat mass and
lean mass resulting from continued energy restriction reduces RMR directly through a
reduction in metabolically active tissue [32, 33]. Total reduction in RMR is typically greater
than that which can be predicted based on reductions in tissue mass, a phenomenon referred
to as adaptive thermogenesis [32]. Reductions in thyroid hormones, in particular T3, occur
during energy restriction, causing a reduction in thermogenesis and metabolic rate [35, 36].
Energy restriction results in a reduction in energy expenditure of activity (EEA) through
reductions in non-exercise activities, such as fidgeting [36], while the energy cost of activity
is reduced through an increase in work efficiency [31, 40]. Dotted line indicates a reducing
effect. Expenditure values are approximate. EAT, exercise activity thermogenesis; EEA,
energy expenditure of activity; NEAT, non-exercise activity thermogenesis; RMR, resting
metabolic rate; T3, triiodothyronine; TEE, total energy expenditure; TEF thermic effect of
food.
17
Thyroid hormones, particularly triiodothyronine (T3), play an important role in regulating
metabolic rate. Circulating thyroid hormones have been shown to reduce during energy
restriction, leading to a reduction in thermogenesis and overall metabolic rate [35,36].
Testosterone and insulin-like growth factor 1 (IGF-1) are typically reduced during energy
restriction, signalling an anti-anabolic effect. This signal likely promotes fat deposition and
the loss of lean mass [35].
Hormonal responses to energy restriction extend their effects to appetite and food intake.
Leptin is a hormone secreted primarily from adipose tissue, and has been demonstrated to
signal the amount of fat stored in adipocytes [37,38]. Reductions in body fat resulting from
energy restriction reduces circulating leptin levels. Evidence suggests the reduced leptin
concentration stimulates an increase in appetite through expression of orexigenic and
inhibition of anorexigenic neuropeptides from the hypothalamus [37]. Orexigenic
neuropeptides under control of leptin include Agouti-related protein (AgRP) and
neuropeptide Y (NPY). Anorexigenic neuropeptides under control of leptin include
proopiomelanocortin (POMC) and corticotropin-releasing hormone (CRH) [37]. Ghrelin is an
appetite stimulating hormone secreted from the stomach to indicate short term energy
availability. Levels have been shown to be increased in periods of hunger and pre-prandial,
and reduced post-prandial. During periods of weight loss and energy restriction, increased
circulating ghrelin concentrations have been demonstrated. Ghrelin stimulates neurones
expressing NPY and AgRP, and has an inhibitory effect on POMC and CRH neurones.
Through these effects, the increased concentrations of ghrelin resulting from energy
restriction may function to stimulate appetite and food intake after weight loss [37]. It is
suggested that the changes in leptin and ghrelin concentrations, and the resultant
neuropeptide expression, work in coordination to defend body weight and stimulate appetite
during periods of energy restriction and weight loss [39].
18
The energy expenditure of activity is also modified as a result of energy restriction and
weight loss. Reductions have been seen in non-exercise activity thermogenesis, such as
fidgeting and daily activities, after weight loss [36]. In addition to reduced activity, increases
are observed in work efficiency. Less energy may be expended for the same amount of work,
thereby reducing the energy cost of activity [31,40]. The mechanisms behind these reductions
in activity and increased work efficiency are suggested to be similar to those involved in
altered appetite and food intake during energy restriction. Sensory information regarding
availability of food and energy are mediated in the hypothalamus, in particular the arcuate
nucleus, where two important cell types are located [31]. Cells containing orexigenic peptides
such as NPY and AgRP, and cells containing anorexigenic peptides such as POMC and
cocaine- and amphetamine-regulated transcript (CART) are located in this hypothalamic
region. Leptin acts on the hypothalamus to increase anorexigenic neuropeptide expression,
which may increase physical activity and reduce work efficiency [31]. Conversely ghrelin
acts on the hypothalamus to increase orexigenic neuropeptide expression, which may
decrease physical activity and increase work efficiency [31]. During periods of energy
restriction and weight loss, leptin concentrations are reduced and ghrelin concentrations are
increased, mediating this reduced energy expenditure [31]. This reduced energy expenditure
opposes the change in body weight [31], and is supported by the autonomic nervous system,
in particular the SNS for which suppressed activity has been shown during energy restriction
[41]. At the skeletal muscle level, increased work efficiency appears to be in part associated
with uncoupling proteins, some of which show reduced expression during energy restriction
[42].
Evidence supports altered autonomic nervous system output during energy restriction and
weight loss. Specifically, reduced SNS activity has been shown, evidenced by reduced
circulating catecholamine concentration, increased heart rate variability, reduced muscle
19
sympathetic nerve activity and reduced heart rate [41]. Leptin acts to stimulate SNS activity,
while NPY acts to reduce SNS activity. Reduced leptin and increased NPY concentrations
associated with energy restriction and weight loss may hence reduce overall SNS activity
[41]. Reduced SNS activity in part mediates the reduction in RMR associated with energy
restriction and weight loss. Reduced SNS activity may also act to increase food intake [41].
Thus alterations in SNS activity are suggested to oppose reductions in body weight by
modifying the energy deficit.
The adaptive responses to energy restriction and weight loss are many, widespread and
interrelated. Changes in hormone concentrations are suggested to act on the hypothalamus to
stimulate hunger and food intake via expression of orexigenic neuropeptides and inhibition of
anorexigenic neuropeptides. Other hormones have been shown to reduce metabolic rate,
reduce lean mass and increase fat deposition. Reductions in sympathetic tone, and increases
in parasympathetic tone, have been demonstrated. Behavioural changes are observed, with
energy expenditure of activity decreased through a combination of reduced physical activity
and an increase in work efficiency. These changes in activity energy expenditure are
suggested to be instigated by similar hormone and neurone mechanisms as those which
increase food intake. The combination of these interrelated processes actively opposes further
reductions in body mass, by modifying the energy balance to promote weight gain.
These metabolic and hormonal adaptations have been reported in BB in a small number of
cohort and case studies. Reductions in RMR were found after a 14 week competition
preparation in a 21 year old male BB. During the continual energy deficit, a 6.7 kg and 5.0 kg
reduction in fat and lean mass occurred, respectively, resulting in a 752 kJ·d-1 reduction in
RMR [12]. Similarly, during a six month competition preparation, a 26 year old male BB
reduced fat mass from 15.2 kg to 4.0 kg, and fat free mass from 87.7 kg to 84.8 kg [13]. This
weight loss resulted in a 38% decrease in RMR after three months, with a further reduction to
20
53% of the baseline value at six months. In the three months following competition, fat mass
and fat free mass increased, with RMR returning to 66% of the baseline value [13]. Hormonal
changes were reported in the same case study. Circulating testosterone concentration reduced
from 9.22 ng·ml-1 at six months pre-competition to 2.27 ng·ml-1 at competition. Weight
regain in the three months after competition was in conjunction with an increase in
testosterone to 8.7 ng·ml-1. Ghrelin and leptin concentrations showed similar but opposite
trends during the six month competition preparation. Ghrelin was increased from 633
pmol·ml-1 to 882 pmol·ml-1, while leptin reduced from 2.58 ng·ml-1 to 1.36 ng·ml-1.
Similarly, both insulin and T3 were reduced during the weight reduction period [13]. Due to
the limited number of studies, in particular those using sample sizes greater than n = 1,
further research is required to corroborate these findings in order to better understand the
adaptive physiological responses to energy restriction and exercise in lean muscular
individuals.
Psychological factors in bodybuilding
Due to the strict and often extreme nature of bodybuilding, particularly in regards to diet and
exercise, certain psychological symptoms and conditions have been linked to the sport,
including muscle dysmorphia (MD), and disordered eating. MD is characterised by a
disturbed body image perception, whereby one believes they are small and weak, when in
fact they are large and strong [14]. Associated with this is a pathological pursuit of a hyper-
muscular body [43]. Individuals experiencing MD commit to extreme exercise and dietary
regimens aimed at accumulating muscle mass [14,44,45], which may include dietary
supplements and the use of AAS [46,47]. What differentiates MD from a non-pathological
desire to increase muscle mass is the overvaluation of the ideal body shape and a
21
disproportionate influence of one’s body in determining self-worth [44]. This overvaluation
and desire to increase muscularity causes clinically significant impairment or distress in daily
functioning. Social and occupational engagements are often given up in order to follow
exercise and diet regimens, and significant levels of anxiety are experienced when such
regimens are not maintained [44]. Feelings of inadequate muscularity also produce significant
anxiety, which drive the ongoing muscularity pursuit.
Muscle dysmorphia was first described in 1993 in a group of male BB who reported feeling
small and weak despite being large and muscular [19]. The authors described this as “reverse
anorexia” due to the similar but reverse body-related concerns and behaviours as those
suffering from anorexia nervosa. The condition was later termed “muscle dysmorphia” after
subsequent research, and tentative diagnostic criteria were developed based on pre-existing
diagnostic criteria for body dysmorphic disorder [14]. More recently MD was identified in
the diagnostic and statistical manual of mental disorders 5th edition (DSM-V) as a form of
body dysmorphic disorder.
As BB follow a similarly meticulous approach to physique development as individuals with
MD, it is intuitive to suggest bodybuilding as a sport and context may appeal to those
exhibiting MD symptoms. Comparatively greater MD symptoms have been reported in BB
than power lifters [15], fitness lifters [48], non-training individuals [49,50], and college
football players [51]. As yet though, it remains unclear whether bodybuilding is a cause of
MD development, or if the sport of bodybuilding attracts those predisposed to, or already
displaying symptoms of, MD. Additionally, MD research is limited to cross-sectional studies,
with no evidence of changes in MD symptoms over time, particularly with changes in body
composition.
22
Sports which place a high emphasis on body shape and appearance are known to be risk
factors for the development of disordered eating and eating disorders (ED) [52]. The sport of
bodybuilding is no exception, with disordered eating behaviours described in both male and
female BB [53,54]. However, currently evidence is unclear as to the comparative extent of
disordered eating symptoms in BB. Male BB have shown an increased expression of
behaviours associated with disordered eating, including perfectionism, compared to non-
athletic controls [55]. Female BB have demonstrated increased bulimia symptoms compared
with female weight trainers, although no differences were seen in other disordered eating
behaviours [54]. Crucially though, a sample of competitive male BB displayed a
psychological profile similar to that of female anorexia nervosa patients, apart from increased
self-esteem and body satisfaction [56]. Despite these studies, there remains a paucity of
evidence of pathological eating behaviours in competitive BB. Due to a lack of longitudinal
studies, as yet evidence is limited to determine whether individuals with eating disorders, or a
history of disordered eating, are drawn to bodybuilding, or if the sport fosters behaviours and
attitudes associated with disordered eating.
SUMMARY
BB are suggested to commit to structured and often meticulous diet and training regimens in
order to achieve the lean, muscular physique required for competition success. In doing so,
BB typically experience significant reductions in fat mass with concomitant moderate to large
reductions in lean mass when transitioning from off-season to competition condition. During
periods of prolonged energy deficit, reductions in RMR and anabolic and anorexigenic
hormones including testosterone and leptin, and increases in orexigenic hormones such as
ghrelin, have been reported. These changes are an adaptive response, which may assist the
23
body in preventing further reductions in fat mass. A limited number of studies, primarily as
case studies and small cohorts, have described these physiological responses in competitive
BB produced during the in-season period, where dietary and training modifications are
enforced to create an energy deficit and thus achieve reductions in fat mass.
Due to the similarities in muscularity enhancing pursuits, MD has become synonymous with
bodybuilding. However, due to the infancy of MD research, limited attitudinal and
behavioural associates of MD symptoms have been identified. Furthermore, the temporal
characteristics of MD have not been investigated in general or in a bodybuilding context.
Although MD has become increasingly recognised, much is still unknown about this
condition.
The popularity and participation in the sport of bodybuilding has steadily increased.
However, contemporary research on the dietary and training practices of competitive natural
BB remains limited. Subsequently, evidence of the physiological and psychological
consequences of these practices has been largely examined in case studies. Given the body
composition outcomes achieved by this population, extending the current body of topic-
related literature focussed on this population is warranted, and may identify hitherto
undocumented practices which warrant further investigation. Furthermore, identification of
such practices may offer opportunities to extend these findings to both athletic and non-
athletic populations aiming to reduce fat mass whilst maintaining muscle mass.
24
CHAPTER 3.
Muscle Dysmorphia Symptomatology and Associated Psychological
Features in Bodybuilders and Non-Bodybuilder Resistance Trainers: A
Systematic Review and Meta-analysis
25
Chapter 3: Systematic Review
ABSTRACT
Background: Associated with a self-perceived lack of size and muscularity, muscle
dysmorphia (MD) is characterised by a preoccupation with and pursuit of a hyper-
mesomorphic body. MD symptoms may hypothetically be more prevalent in bodybuilders
(BB) than non-bodybuilder resistance trainers (NBBRT).
Objective: Compare MD symptomatology in BB to NBBRT, and identify psychological and
other characteristics associated with MD in these groups.
Methods: Relevant databases were searched from earliest record to February 2015 for studies
examining MD symptoms in BB and/or NBBRT. Included studies needed to assess MD using
a psychometrically validated assessment tool. Study quality was evaluated using an adapted
version of the validated Downs & Black tool. Between-group standardized mean difference
[effect sizes (ES)] and 95% confidence intervals (CI) for each MD subscale were calculated.
Meta-analysis was performed when five or more studies used the same MD tool. Data
describing psychological or other characteristics associated with MD were also extracted.
Results: Of the 2135 studies initially identified, 31, analysing data on 5880 participants (BB:
n = 1895, NBBRT: n = 3523, controls: n = 462) were eligible for inclusion, though study
quality was generally poor-moderate (range 7-19/22). Most participants were male (90%).
Eight different MD assessment tools were used. Meta-analysis for five studies all using the
Muscle Dysmorphia Inventory (MDI) revealed there was a medium to large pooled ES for
greater MD symptomatology in BB than NBBRT on all MDI subscales (ES: 0.53 to 1.12; p ≤
0.01). Competitive BB scored higher than non-competitive BB (ES = 1.21, 95% CI: 0.82-
1.60; p < 0.001). MD symptoms were associated with anxiety (r: 0.32 to 0.42; p ≤ 0.01),
social physique anxiety (r: 0.26 to 0.75; p < 0.01), depression (r: 0.23 to 0.53; p ≤ 0.01),
neuroticism (r: 0.38; p < 0.001) and perfectionism (r: 0.35; p < 0.05) and inversely associated
with self-concept (r: -0.32 to -0.36; p < 0.01) and self-esteem (r: -0.42 to -0.47; p < 0.01).
26
Conclusions: There was greater MD symptomatology in BB than NBBRT. Anxiety and
social physique anxiety, depression, neuroticism and perfectionism were positively associated
with MD, while self-concept and self-esteem were negatively associated. It remains unclear
whether these characteristics are exacerbated by bodybuilding, or whether individuals with
these characteristics are attracted to the bodybuilding context.
27
INTRODUCTION
Societal expectations of the ideal physique for men and women have evolved over time
[57,58]. A large body of research has identified the ideal male physique as mesomorphic,
strong, athletic and lean [59-61]. For females there is an increasing acceptability of a lean and
muscular physique, progressing from the previously idealized thin and toned body [59,62].
The rewards for attaining this ideal physique, and the pressure associated with achieving it,
drive attempts to alter body size and shape, and particularly for males, increase muscle size
and strength [59,62]. This is achieved through dietary modifications as well as exercise,
especially resistance training. The popularity of muscularity enhancing pursuits has steadily
increased. Evidence suggests that resistance training is one of the most common worldwide
fitness trends [63], the use of muscle-building dietary supplements such as protein and
creatine is common [64,65], and the prevalence of anabolic-androgenic steroid (AAS) use in
adolescents and adults is predicted to be high [66,67].
Muscle dysmorphia (MD) is characterized by a pathological preoccupation with, and pursuit
of, a lean, hyper-muscular body, coupled with the belief that one is insufficiently muscular
[43]. Individuals engage in obsessive behaviours regarding nutrition, exercise, and often AAS
use in order to achieve this mesomorphic body [46,47]. Whilst muscle dissatisfaction is
increasingly common amongst males [68,69], the distinguishing characteristics differentiating
MD from a non-pathological desire to increase muscle mass are the overvaluation of the ideal
body shape, and a disproportionate influence of one’s body in determining self-worth [44]. In
conjunction with this is a disturbed body-image perception, whereby individuals have a core
belief that they are insufficiently muscular, when in fact they are large and strong [14].
Compensatory efforts to allay the anxiety associated with this belief include engagement in
rigid, pathological eating and exercise practices [14,15,45] and often also excessive use of
dietary supplements and AAS [46,47]. Mild deviation from these regimes results in marked
28
distress [14]. The body dissatisfaction is associated with other behavioural symptoms,
including declining social, occupational or recreational activities in order to maintain workout
and diet schedules, and avoiding situations where the body is exposed, such as the locker
room or beach [14].
A similarly fastidious pursuit of hyper-muscularity is often seen amongst bodybuilders (BB),
who commit to a rigorous diet and training regimen with the aim to achieve a highly
muscular, lean, symmetrical and well-proportioned physique [10]. In competitive
bodybuilding, participants pose before a panel of judges, who score each entrant on the basis
of muscular size, definition, development and symmetry [10]. Individuals may rely heavily
on the use of supplements to attain the most muscular and sculpted physique, and a subgroup
of BB use appearance and performance enhancing drugs designed to aid in the accumulation
of muscle mass, including AAS [18,70,71]. Thus, it is logical to suggest that bodybuilding as
a context and process may appeal to those with MD symptoms, either seeking body image
satisfaction or removal of existing symptoms; but likewise, the performance and social
context itself could also increase the manifestation of MD symptomatology and associated
behaviours.
In delineating between the pathological pursuit of muscularity, and a sport that covets the
cultivation of muscle mass, the history of MD has been intertwined with bodybuilding since
its recognition in the early 1990s. The first reported cases of MD were in a group of BB who
described beliefs of appearing small and weak despite the reality of them being physically
large and muscular [19]. The authors identified these BB as suffering from a ‘reverse
anorexia’, due to the similar but reverse body-related concerns and behaviours as those
suffering from anorexia nervosa. Subsequent research led to the renaming of the condition as
MD based on the thesis that compulsive exercise was more central in MD than pathological
eating [14], with tentative diagnostic criteria formalizing the nosological integrity of this
29
cluster of symptoms. Since then, the disorder has been often measured in BB, as well as
power lifters [15], recreational weight trainers [48], college footballers [51], and non-trained
individuals [50].
Given the increasing popularity of resistance training to improve muscularity, both within the
general community and in athletes, and the well-documented benefits of increased muscle
mass and reduced fat mass for chronic disease prevention [8], a critical endeavour lies in
accurately delineating between healthful muscularity-enhancing pursuits versus pathological
endeavours. While several reviews of MD have been published spanning both its nosological
status [45,72] and aetiological underpinning [44,73], few have explicitly addressed the
distinction between a pathological versus non-pathological pursuit of hyper-muscularity, and
many have conflated the terms bodybuilding and MD. An inadequate distinction between
such pursuits is of great clinical and empirical significance, as the pathologizing of normative
muscularity enhancing pursuits likely augments the existing stigma related to muscularity-
related body image concerns [74], in addition to confounding treatment studies. Therefore,
the primary aim of this study was to conduct a systematic review with meta-analysis to
compare MD symptomatology between BB and non-bodybuilder resistance trainers
(NBBRT). Such a comparison will determine if engagement in bodybuilding results in more
severe MD symptomatology. A secondary aim was to identify psychological features and
other characteristics associated with MD in BB and NBBRT.
METHODS
Design
A systematic literature search was conducted by one researcher (LM) to identify studies
examining MD in BB and resistance trained individuals. Databases searched from earliest
record until February 2015 were: Medline (Ovid), PsycINFO(Ovid), CINAHL (EBSCO),
30
Proquest 5000 (via Proquest central), Scopus, PubMed, SPORTDiscus (EBSCO), and Web of
Science.
The search strategy combined the following keywords (Appendix A1): (muscle dysmorphia,
bigorexia, reverse anorexia, Adonis complex, manorexia, male eating disorder) and
(bodybuilding, body building, bodybuilder, body builder, strength training, weight training,
resistance training, progressive training, progressive resistance, weight lifting, athlete).
Reference lists of all retrieved papers were manually searched for potentially additional
eligible papers. Following the search a PRISMA [75] informed systematic review process
was completed.
Inclusion and Exclusion criteria
Included studies were required to describe MD in participants defined by study authors as BB
or NBBRT. Studies could be descriptive, cross-sectional, case study or longitudinal design.
Baseline measurement of MD from randomised controlled trials or intervention studies was
also eligible for inclusion. Studies were included if they measured MD using a
psychometrically validated scale of MD symptomatology. Studies were considered eligible if
participants were in any phase of training, competition preparation or competition recovery.
Due to the large number of magazine and newspaper articles, television and radio transcripts,
the search was limited to full-text peer-reviewed journal manuscripts. Theses were excluded.
Manuscripts from all languages were included.
After eliminating duplicates, the search results were screened by one reviewer (LM) against
the eligibility criteria. Those references that could not be eliminated by title and abstract were
retrieved and independently reviewed for inclusion.
Data Extraction and Conversions
31
Data relating to the manuscript, namely author(s), date of publication, and country where the
study was conducted were recorded. The institution country of the first author was used as the
country if this was not described in the text. Data extracted from each paper included
participant characteristics (age, sex, hours of training per week, years of training, competition
calibre, weight, height, body composition and ethnicity), MD assessment tools utilized and
scores, data on assessed psychological features (perfectionism, anxiety, self-esteem,
neuroticism, self-concept, depression, extraversion) including the psychological assessment
tool utilized and correlation (Pearson’s r) with MD score. Likewise, any information related
to AAS and other performance enhancing substance use, and comorbid diagnoses were
extracted. All data were independently extracted from each paper by two of four researchers
(LM, DH, SC, LC) with disagreements resolved by discussion with a third researcher (HO).
In cases where journal articles contained insufficient information, attempts were made to
contact authors to obtain missing details. In some studies, data for MD scores were not
presented in numerical form, but rather in graphical format. In this instance, graphs were
enlarged, and data obtained using a ruler, in duplicate. Anthropometrical parameters reported
in imperial units (e.g., pounds, inches) were converted to kg and cm (1 kg = 2.2 pounds; 1 cm
= 0.3937 inches). Body mass index (BMI) was calculated (weight/height2) from the mean
height (m) and body mass (kg). Extracted data were presented as mean and standard
deviation (SD) when SD was reported. Weighted means were calculated for age,
anthropometric variables, and training history.
Assessment of methodological quality
The methodological quality of the 31 papers which met inclusion criteria were assessed by
two of three researchers (LM, JG, LC) using a modified version of an assessment scale
devised by Downs and Black [76]. One researcher (LM) assessed all papers. Two others (JG,
32
LC) shared the parallel assessment of the 31 papers. In using the scale, 16 of the 27 items of
the original checklist were retained. Items 4, 8, 9, 13, 14, 15, 17, 19, 23, 24 and 26 were
excluded based on their lack of relevance to the included studies. These items were excluded
as they related to interventions (items 4, 8, 13, 14, 17, 19, 23, 24), follow-up assessments (9,
26) and blinding of subjects and measurers (14, 15). An additional seven items were included
from a secondary checklist [77] as these items were relevant to the assessment of the
literature included in this study. The seven items were:
• “If cohort or cross-sectional study, were groups comparable on important
confounding factors and/or were pre-existing differences accounted for by using
appropriate adjustments in statistical analysis?”
• “Were psychological measures appropriate to the question and outcome of concern?”
(Modified from “nutrition measures”)
• “Were the observations and measurements based on standard, valid and reliable data
collection instruments/procedures?”
• “Was clinical significance as well as statistical significance reported?”
• “Is there a discussion of findings?”
• “Are study biases and study limitations identified and discussed?”
• “Were the sources of funding and investigators’ affiliations described?”
Each reviewer checked for internal (intra-rater) validity across items for each paper.
Differences in scores between researchers were discussed, with disagreements resolved via
discussion with a third researcher (HO) for consensus.
Analyses
In order to descriptively compare MD symptomatology between BB and NBBRT, and to
identify characteristics associated with MD, the between-group standardized mean difference,
33
or effect size (ES), and 95% confidence interval (CI) were calculated for each subscale of
MD tools used in studies which provided sufficient data. Extracted data (mean, standard
deviation and sample size) were transferred to Comprehensive Meta-Analysis Version 2
software (Biostat, 2005, Englewood, USA) for calculation of ES and 95% CI. In studies
where sufficient data (i.e. mean, standard deviation or sample size) were not present, no data
analysis was conducted, instead raw data were extracted and tabulated. Extracted correlation
data between MD score and psychological features were used to identify associations
between MD symptomatology and psychological features. These correlations were not
analysed, instead raw data (Pearson’s r) were extracted and tabulated.
Meta-analyses
In order to quantitatively compare MD symptomatology between BB and NBBRT, meta-
analyses of mean differences of Muscle Dysmorphia Inventory (MDI) subscales between BB
and NBBRT were performed. Meta-analyses of mean differences of other scales were not
performed due to an inadequate number of studies using each of these scales to compare BB
with NBBRT to warrant meta-analysis. Comprehensive Meta-Analysis was used for all
pairwise comparisons in the quantitative analysis. Standardized mean differences (ES),
standard error, variance, and 95% CI were calculated. An invariance random effects model
was applied, assuming that studies drew on divergent populations and contexts and
potentially included different research designs. Forest plots were generated to display ES and
95% CI results of each study, and the pooled estimate. The pooled estimate was described
based on Cohen’s suggestions [78], whereby a small ES was > 0.2, a medium ES was > 0.5,
and a large ES was > 0.8. A positive ES indicated an effect favouring BB, whereas a negative
ES indicated an effect favouring NBBRT. The Q statistic (with df and p value) provided a test
of the null hypothesis that all studies shared a common effect size. If all studies shared a
34
similar effect size, the Q value would be approximately equal to the degrees of freedom. The
I2 statistic identified the proportion of the observed variance reflecting differences in true
effect sizes as opposed to sampling error. Moderate to high values (i.e., ≥ 0.50) were
considered as demarcating the likelihood of heterogeneity.
To maintain independence, only one BB group and one NBBRT group were included in the
meta-analysis from each paper. Where more than one group was present in a study: 1)
competitive BB were selected; 2) non-AAS users were selected; 3) NBBRT for a sport were
not selected.
RESULTS
Identification and Selection of Studies
The original search netted 2135 potential articles. An additional article was included after
hand searching the reference list of all retrieved papers. After the removal of duplicates (n =
624), a further 1431 were excluded after screening title and abstract. The full text of the
remaining 81 articles was retrieved. Of these, 50 were excluded due to not meeting the
eligibility criteria, resulting in 31 eligible manuscripts. A summary of the systematic
PRISMA process is shown in Figure 3.1.
35
Records identified through Additional studies identified

database searching through other sources
(n = 2135) (n = 1)
Records after duplicates removed

(n = 1512)
Studies excluded based on

title or abstract (n = 1431)
Full-text articles assessed

for eligibility
(n = 81) Full-text articles excluded
(n = 50)
- No muscle dysmorphia
assessment tool (42)
- Participants not resistance
trained (6)
- Only abstract available (1)
- No manuscript available (1)
Studies included in qualitative
synthesis
(n = 31)
Studies included in quantitative

synthesis (meta-analysis)
(n = 5)
Figure 3.1. Flowchart showing the process for inclusion of studies
Evaluation of Methodological Quality
Methodological quality was evaluated in 29 of the 31 studies. Two studies [79,80] could not
be rated as an adequate English translation of all text was not available. The mean quality
rating score was 12.2 (SD ± 2.5) from a possible 22 (Appendix A). All studies described the
36
main outcomes to be measured, described the main findings in the results, and discussed the
findings. All but one study specified their hypotheses [47], and all but one study used
appropriate statistical tests [81]. The lowest scores were for items “Were the subjects asked to
participate in the study representative of the entire population?” (mean score 0.03 ± 0.19),
“Were those subjects who were prepared to participate representative of the entire population
from which they were recruited?” (mean score 0.07 ± 0.26), and “Was there adequate
adjustment for confounding in the analyses from which the main findings were drawn?”
(mean score 0.07 ± 0.26).
Demographic characteristics, Competition Phase/Calibre, and Drug Use
Participant demographic characteristics are outlined in Tables 3.1 and 3.2 for studies
including BB and NBBRT, respectively. The 31 studies described a total of 5880 participants
(BB n = 1895, NBBRT n = 3523, non-training controls n = 462). The weighted mean age of
all participants was 28 ± 7.6 years. The male and female BB were 30.9 ± 8.6 and 34.2 ± 8.7
years, respectively. The male and female NBBRT were 27.3 ± 7.4 and 22.2 ± 5.5 years,
respectively. The male and female non-training controls were 23.7 ± 4.4 and 27.3 ± 6.2 years,
respectively. Of the 31 studies, 21 described men, one described women, and the remaining
nine studies described both men and women. A large number of studies were conducted in
Europe (n = 14) and the US (n = 12), while two were from Brazil, and one each from
Australia, Chile and Korea. The BB had trained for a mean of 10.8 years (range 4-16) and the
NBBRT five years (range 2.5-9). Use of anabolic agents was reported in seven of the 31
studies [17,47,49,51,55,82,83], with two of these studies also reporting or implying no steroid
use via participants competing in drug tested competition, leaving the drug-taking status of
the remaining 24 studies unknown.
37
Eight of 31 studies reported participant calibre [15,48,50,51,55,82,84,85]. Participants were
identified as national [15,85], professional [51], expert [48], novice [48], competitive or non-
competitive [50,55,82,84] (see Tables 3.1 and 3.2). One study reported the competition phase
of participants [15] with the remaining 30 studies not identifying the phase of training or
competition cycle.
Anthropometric and Body Composition Characteristics
The weighted mean height of male and female BB was 175.4 cm (range 154.9-180.6) and
156.2 cm (range 150-168.3), respectively, for male and female NBBRT was 178.6 cm (range
172.7-185.6) and 165.6 cm (range 153-168.2), respectively, and for the male non-training
controls was 181.4cm (range 180.5-181.6). Height was not reported for female non-training
controls in any of the studies. The weighted mean body mass, BMI and percent fat of male
BB was 90.9 kg (range 81.8-96.1), 29.7 kg·m-2 (range 24.6-37.5), and 9.8% (range 9.4-10.3).
In male NBBRT, these parameters were 86.9 kg (range 75.9-103.2), 27.2 kg·m-2 (range 25.1-
30.0), and 12.9% (range 10.3-18.4). In male non-training controls, weighted mean body mass
and BMI were 76.5 kg (range 75.6-80), 23.5 kg·m-2 (range 22.9-25). The weighted mean
body mass and BMI for female BB were 65.5 kg (range 63.6-69) and 27 kg·m-2 (range 24.4-
28.3). For female NBBRT, these parameters were 64.2 kg (range 61.9-70.9), and 23.6 kg·m-2
(range 22-28.4), respectively. For female non-training controls weighted mean BMI was 22.7
kg·m-2 (range 18.7-26.5). Body fat was not reported for females or non-training controls in
any of the studies, nor was body mass for female non-training controls.
38
Table 3.1. Participant characteristics of bodybuilders
Reference Group n Sex Age, y Country Weight, kg Height, cm BMI, %Fat Training, y Calibre Drug
kg/m2 use
Babusa and BB 60 M 27.7±7.53 Hungary 88.5±14.73 180.6±7.23 27.13 NC 18.3%
Tury [55] yes
Control 60 M 27.8 ±7.45 80±12.47 180.5±8.62 24.55 NS
Boyda and BB 51 M 31.33±8.06 UK NS
Shevlin [89] [18-55]
Castro- BB 154 M, F 24.97±6.9 Spain NS
Lopez et al. [16-49]
[79]
Gonzalez- BB and 734 M, F 30.92±9.41 Spain 73.73±12.07 171±8.47 25.2 NS
Marti et al. weightlifters
[90]
Lopez- BB 154 M, F 24.97±6.9 Spain NS
Barajas et [16-49]
al. [91]
39
Wolke and BB 200 M 29.8±9.1 UK 92.9±15.13 177.83±7.55 29.28±4.49 NS
Sapouna [16-62]
[92]
Baghurst et Non-natural 47 M US 96.13±13.44 167.41±35.36 34.33 10.28 16.02±10.26 P Yes
al. [51] BB ±2.36
Natural BB 65 M 32.22±11.12 87.56±11.33 173.86±20.75 28.97 9.43±3.11 12.97.76 80.3% P No
Weight train 115 M 29.78±10.22 88.7±15.58 177.62±12.93 28.12 12.83±7.04 8.51±8.16 NS
for physique
Footballers 66 M 20.5±4.41 103.15±18.57 185.55±8.31 29.96 10.31±4.38 5.68±2.44 NCAA
collegiate
Cella et al. BB 119 M 30.63±7.85 Italy NS
[86]
Non-BB 98 M 30.86±8.669 NS
Davies and Former 30 M 30[18-48] UK NC No
Smith [82] AAS-users
AAS users 30 M 30[18-70] NC Yes
Hale et al. Expert BB 26 F 18-48 US 7.95±5.65 E
[48]
40
Novice BB 29 F 18-48 7.48±5.23 NV
Fitness 19 F 18-48 3.96±3.16 NS
lifters
Lantz et al. BB 100 M, F 30.99±7.22 US 12.75±4.49 N
[15]
Powerlifters 68 M, F 31.68±6.62 15.53±7.74 N
Santarnecchi Competitive 60 M 33±7 [23- Italy 27.93 C
and Dettore BB 41]
[50]
Non- 60 M 32±10 [23- 24.6 NC
competitive 36]
BB
Control 60 M 33±8± [24- 25.02 NS
(non- 37]
training)
Skemp et al. Appearance 51 M, F 35.3 US 77 159.77 30.16 C, NC
[84] enhancement
Performance 82 M, F 27.4 86.05 172.72 28.84 C, NC
enhancement
41
Soler et al. BB 25 M 30.8±5.45 Brazil 81.8±17.24 174±7.0 27.76±5.03 11.12±6.87 N
[85]
Gymgoers 151 M 27.66±6.54 82.87±13.11 177±7.0 26.72±4.24 6.25±5.62 NS
Data are presented as mean ± SD [range]. BMI, body mass index; BB, bodybuilder; M, male; F, female; C, competitive; NC, non-competitive; E, expert; NV, novice; P,
professional; NS, not stated; N, national; NCAA, National Collegiate Athletic Association; AAS, anabolic-androgenic steroids
Table 3.2. Participant characteristics of non-bodybuilder resistance trainers
Reference Group n Sex Age, y Country Weight, kg Height, cm BMI, kg/m2 %Fat Training, y Drug
use
Babusa et al. Weightlifters 289 M 28±7.43 Hungary 87.8±14.76 179.6±6.06 27.2±4.13 6.1±6.08 10% yes
[49]
Controls 240 M 20.3±2.78 75.6±14.7 181.6±7.48 22.9±3.98
Cafri et al. Weightlifters 23 M US
[102] with MD
Weightlifters 28 M
without MD
Hildebrandt Weightlifters 237 M 32.64±12.37 US 26.7±4.35 12.52±5.6 8.92±7.94
et al. [93]
Kanayama AAS users 48 M 29.3±6.5 US Yes
et al. [83]
42
Non-users 41 M 30.1±10.5 No
Kim et al. Resistance 429 M Korea
[80] trained
Kuennen Resistance 49 M 28.27±8.35 US 93.71±14.07 179±0.7 29.25 18.36±6.14
and trained
Waldrom
[94]
Maida and Resistance 106 M 18-45 US
Armstrong trained
[95]
Segura- Male gain 52 M 27.2±6.8 Italy 23.6±2.8
Garcia et al.
[88]
Male lose 34 M 28.4±7 26.5±2.2
Female lose 48 F 28.6±5.8 21.6±2.9
Eating 20 F 22.1±5.6 18.7±2.9
disorder
Thomas et Resistance 146 M 22.8±5.0 UK 82±11.1 180±7.0 25.1±3.0 2.9±1.9
al. [17] trained
43
De Lima et Resistance 23 M 24±3.8 Brazil 75.9±9.4
al. [98] trained
Giardino Male 35 M 23.34±4.26 Mexico
and Mexican
Procidano
[81]
Female 11 F 22.18±2.4 Mexico
Mexican
Male US 43 M 20.47±2.26 US
Female US 24 F 20.17±1.37 US
Nieuwoudt Resistance 648 M 29.5±10.1 Australia
et al. [99] trained
Olivardia et Weightlifters 24 M 25.4±3.7 US 89.63±16.36 175.51±6.86 28.94 13.1±5.4 46% yes
al. [47] with MD
Weightlifters 30 M 25.4±3.2 US 84.54±16.27 177.29±6.1 26.98 14.1±6 7% yes
without MD
Robert et al. Male 55 M 24.06±7.96 US 83.45±14.72 181.23±6.81 25.32±3.73 3.85±1.22
[97]
Female 59 F 21.88±5.34 61.93±7.54 168.22±7.1 22.02±2.67 3.49±1.28
44
Skemp et al. Male 79 M 31.7 US 93.0 175.6 30.16
[84]
Female 54 F 29.3 67.23 158.28 26.84
Thomas et Resistance 30 M 20.93±2.6 UK 86.87±10.59 176.0±1.0 28.04 3.57±2.53 13% yes
al. [96] trained
Tod and Resistance 294 M 20.5±3.1 UK 2.47±2.4
Edwards trained
[100]
Valdes et al. Male 112 M 18-25 Chile
[101]
Female 88 F 18-25 Chile
Data are presented as mean ± SD [range]. BMI, body mass index; M, male; F, female; MD, muscle dysmorphia; AAS, anabolic-androgenic steroids
45
Muscle Dysmorphia Assessment Tools
In the 31 studies, eight different tools were used to assess MD. The most commonly used
tools were the MDI (n = 11) and the Muscle Appearance Satisfaction Scale (MASS) (n = 11).
Other tools used were the Muscle Dysmorphic Disorder Inventory (MDDI) (n = 6), the
Adonis Complex Questionnaire (n = 3), the Bodybuilder Image Grid (BIG) (n = 2), the
Muscle Dysmorphia Questionnaire (n = 2), the Muscle Dysmorphia Symptom Questionnaire
(MDSQ) (n = 2) and the Muscle Appearance Satisfaction Scale-6 (n = 1).
Muscle Dysmorphia
The results of MD symptom severity assessment are presented in Tables 3.3-3.5.
Computations of standardized mean difference, ES and 95% CI are presented in Tables 6-13.
Do bodybuilders display more muscle dysmorphia symptoms than non-bodybuilders?
Eight of 31 studies compared prevalence of MD symptoms in BB and non-BB, each of which
provided sufficient data to enable calculation of ES [15,48,50,51,55,84-86]. The BB groups
comprised of competitive, non-competitive, steroid using, non-steroid using, expert, novice,
male and female bodybuilders. Non-bodybuilders ranged from non-training controls and
recreational fitness lifters, to competitive powerlifters and collegiate footballers. Of the eight
studies, four tools were used to measure MD symptoms: MDI (n = 4), MDDI (n = 1), MASS
(n = 1), MDDI and BIG (n = 1), and MDI and MASS (n = 1).
The MD subscale scores of the BB are summarised in Table 3.3. Five studies assessed MD
using the MDI in BB and NBBRT [15,48,51,84,86]. In the case of the dietary behaviour
subscale, all five studies showed a significant ES of BB on subscale score (ES range: 0.66 to
1.96, p < 0.001) [15,48,51,84,86]. Similarly, for the supplement use subscale all five studies
showed a positive ES of BB (ES range: 0.1 to 2.35), four of which were significant (p ≤
46
0.002) [48,51,84,86]. Four of five studies showed a positive ES of BB for the
pharmacological use subscale (ES range: -0.1 to 0.99), three of which were significant (p <
0.001) [15,84,86]. On the exercise dependence subscale, three of the four studies showed a
significant positive ES of BB (ES range: 0.03 to 2.15, p ≤ 0.006) [48,84,86]. For the
size/symmetry subscale, all five studies showed a positive ES of BB (ES range: 0.09 to 1.67),
of which four were significant (p ≤ 0.04) [15,48,84,86]. The final subscale, physique
protection, also had an ES favouring BB in all five studies (ES range: 0.07 to 1.13), with a
significant difference in four studies (p ≤ 0.021) [15,48,84,86] (Table 3.6).
Two studies assessed MD using the MDDI in BB [50,85] (Table 3.7). One study used
NBBRT as a comparison group [85], while the second study used non-training controls as a
comparison group [50]. Results for these studies varied. BB showed a positive ES on MDDI
total in both studies (ES range: 0.03 to 3.62), but only one of these was significant (p <
0.001) [50]. In the case of the drive for size subscale, one study showed a significant positive
ES of BB (ES range: -0.05 to 2.47, p < 0.001) [50]. The ES for the appearance intolerance
subscale significantly favoured BB in one study (ES: - 0.07 to 1.2, p < 0.001) [50]. Both
studies showed an ES favouring BB on the functional impairment subscale (ES range: 0.26 to
2.945), one of which was significant (p < 0.001) [50].
47
Table 3.3. Muscle dysmorphia assessment results of bodybuilders
Reference Group n Tool Subscale Results Main findings
Baghurst et al. Non-natural BB 47 MDI Dietary behaviour 23.04±3.37 Non-natural BB significantly higher (p<0.05) than
[51] Supplement use 17.85±3.83 natural BB on pharmacological subscale, significantly
Pharmacological use 6.29±2.57 higher (p<0.05) than weight training for physique on all
Size/symmetry 21.15±4.92 subscales except physique protection and
Physique protection 14.38±5.53 size/symmetry, significantly higher (p<0.05) than
football on all subscales except physique protection
Natural BB 65 MDI Dietary behaviour 23.35±4.73 Natural BB significantly higher (p<0.05) than weight
Supplement use 16.63±3.99 training for physique on dietary behaviour, supplement
Pharmacological use 3.65±1.38 use. Significantly higher (p<0.05) than football for all
Size/symmetry 20.02±5.14 subscales except physique protection and
Physique protection 13.46±4.82 pharmacological use
Weight training 115 MDI Dietary behaviour 20.17±4.89 Significantly higher (p<0.05) than football for dietary
for physique Supplement use 13.82±4.96 behaviour, size/symmetry
(NBBRT) Pharmacological use 3.79±1.47
Size/symmetry 19.52±5.67
Physique protection 13.08±5.79±
48
Football 66 MDI Dietary behaviour 16.56±4.85 Significantly higher (p<0.05) than natural BB for
Supplement use 12.3±4.6 dietary behaviour, size/symmetry
Pharmacological use 5.62±4.03
Physique protection 17.38±5.62
Cella et al. BB 119 MDI Dietary behaviour 22.45±5.52 n=4 (3.4%) met MD diagnostic criteria
[86] MASS Supplement use 16.49±5.97 BB significantly higher (p≤0.003) scores on all MDI
Pharmacological use 4.71±3.25 subscales, significantly higher (p<0.001) scores on all
Exercise dependence 18.61±4.27 MASS subscales except muscle satisfaction
MASS total 55.72±16.93
Bodybuilding dependence 14.41±5.64
Muscle checking 10.21±5.08
Substance use 9.73±4.55
Injury 9.09±3.64
Muscle satisfaction 11.25±3.26
NBBRT 98 MDI Dietary behaviour 10.98±8.86
MASS Supplement use 6.6±3.51
49
Exercise dependence 9.96±5.17
MASS total 33.02±9.4
Bodybuilding dependence 8.02±3.54
Injury 5.11±3.13
BB, AAS users MDI Dietary behaviour 24.26 AAS users significantly higher (p<0.05) on all MDI
MASS Supplement use 19.0 subscales except exercise dependence, significantly
Exercise dependence 19.21 higher (p≤0.003) on all MASS subscales except muscle
Size/symmetry 21.44 satisfaction
Physique protection 19.74
Bodybuilding dependence 17.47
Muscle checking 12.3
Substance use 12.79
Injury 10.88
50
Muscle satisfaction 11.02
BB, AAS non- MDI Dietary behaviour 21.43
users MASS Supplement use 15.07
Exercise dependence 18.28
Size/symmetry 15.41
Bodybuilding dependence 12.68
Muscle checking 9.03
Substance use 8.0
Injury 8.08
Muscle satisfaction 11.38
Hale et al. Expert BB 26 MDI Dietary behaviour 23.92±3.78 Expert and novice BB significantly higher (p<0.05)
[48] Supplement use 18.42±4.82 than fitness lifters on all subscales except
Pharmacological use 4.27±1.71 pharmacological use and physique protection
Exercise dependence 19.54±3.64 No difference between expert and novice BB
Novice BB 29 MDI Dietary behaviour 21.44±5.32
Supplement use 14.1±6.21
51
Fitness lifters 19 MDI Dietary behaviour 13.89±6.39
(NBBRT) Supplement use 7.86±3.77
Lantz et al. BB 100 MDI Dietary behaviour 32.9±8.15 BB significantly higher (p<0.001) than powerlifters on
[15] Supplement use 15.59±5.15 all subscales except supplement use and exercise
Pharmacological use 12.76±4.56 dependence
Powerlifters 68 MDI Dietary behaviour 26.16±7.89
(NBBRT) Supplement use 15.15±6.62
52
Skemp et al. Appearance 51 MDI Dietary behaviour 20±6 Appearance enhancement significantly higher (p<0.01)
[84] enhancement Supplement use 13±6 than performance enhancement on all MDI subscales
athletes (BB) Pharmacological use 4±1
Exercise dependence 17±4
Size/symmetry 15±6
Pharmacology use 10±4
Performance 82 MDI Dietary behaviour 15±6
enhancement Supplement use 10±5
athletes Pharmacological use 3±1
(NBBRT) Exercise dependence 15±4
Size/symmetry 13±5
Physique protection 8±3
Male weight 79 MDI Dietary behaviour 17±6 Males significantly higher (p<0.05) than females on
trainers Supplement use 12±5 supplement use, physique protection, size/symmetry
(NBBRT) Pharmacological use 3±1
53
Size/symmetry 16±6
Female weight 54 MDI Dietary behaviour 17±7
trainers Supplement use 10±6
(NBBRT) Pharmacological use 4±1
Size/symmetry 11±4
Santarnecchi Competitive BB 60 MDDI MDDI total 38.5±7.97 Competitive BB significantly higher (p<0.01) than non-
et al. [50] BIG Drive for size 15.45±4.78 competitive and non-training controls on MDDI total
Appearance intolerance 10.32±3.9 and all subscales, current muscle mass, ideal muscle
Functional impairment 11.87±3.58 mass, most attractive muscle mass indices of BIG
Current body type – fat 27.33±17.84 Significantly lower (p<0.001) than non-competitive BB
Current body type – muscle 64.33±12.12 and non-training individuals on all fat indices of BIG
mass
Ideal body type – fat 14.33±9.63
Ideal body type – muscle 75.17±16.0
mass
15.33±9.47
54
Most attractive body type –
fat 69.0±16.12
muscle mass 19.0±11.75
Most attractive to women –
fat 51.67±13.92
muscle mass
Non-competitive 60 MDDI MDDI total 29.6±6.56 Non-competitive BB significantly higher (p<0.01) than
BB BIG Drive for size 10.0±4.0 non-training individuals on MDDI total and all
Appearance intolerance 14.63±3.95 subscales, and current, ideal and most attractive muscle
Functional impairment 6.32±4.17 mass BIG indices
Current body type – fat 41.67±18.33 Significantly lower (p<0.05) than non-training
Current body type – muscle 46.83±18.55 individuals on current and ideal fat indices
mass
mass
32.5±17.31
55
fat 53.17±9.11
fat 47.33±14.36
muscle mass
Non-training 60 MDDI MDDI total 16.1±3.45
individuals BIG Drive for size 5.83±2.66
Appearance intolerance 6.23±2.79
Functional impairment 3.57±1.68
Current body type – fat 50.67±18.4
Current body type – muscle 29.33±15.17
mass
mass
38.0±18.48
56
fat 45.33±15.35
fat 50.67±14.25
muscle mass
Soler et al. BB 25 MDDI MDDI total 45.5±12.53 No difference between BB and NBBRT for MDDI total
[85] Drive for size 19.1±6.1 and all MDDI subscales
NBBRT 151 MDDI MDDI total 45.92±12.43
Drive for size 18.76±7.22
Babusa et al. BB 60 MASS MASS total 47.9±13.21 BB significantly higher (p<0.001) than undergraduate
[55] Bodybuilding dependence 12.8±4.18 students on MASS total and all subscales except
Muscle checking 7.8±3.95 muscle satisfaction
57
Injury risk 9.2±3.42
Non-BB 60 MASS MASS total 33.2±7.88
undergraduate Bodybuilding dependence 7.2±3.01
students Muscle checking 5.2±2.32
Davies et al. BB, former AAS 30 MDI Dietary behaviour 21.9 No significant differences between former AAS-users
[82] users Supplement use 17.1 and current AAS users
Pharmacological use 6.2
Size/symmetry 21.7
BB, current 30 MDI Dietary behaviour 21.2
AAS users Supplement use 16.5
Pharmacological use 7.6
58
Size/symmetry 20.5
Data are presented as mean ± SD. BB, bodybuilder; NBBRT, non-bodybuilder resistance trainer; AAS, anabolic androgenic steroid; MDI, Muscle Dysmorphia Inventory;
MASS, Muscle Appearance Satisfaction Scale; MDDI, Muscle Dysmorphic Disorder Inventory; BIG, Bodybuilder Image Grid; MD, muscle dysmorphia; SD, standard
deviation
59
Two studies used the MASS to assess MD in BB [55,86] (Table 3.8). One study used
NBBRT as a comparison group [86], while the second study compared BB to non-training
controls [55]. The MASS total score showed a significant ES of BB in both studies (ES
range: 1.34 to 1.61, p < 0.001) [55,86]. The ES for bodybuilding dependence significantly
favoured BB in both studies (ES range: 1.33 to 1.53, p < 0.001) [55,86]. Both also showed a
significant positive ES of BB on muscle checking (ES range: 0.8 to 1.2, p < 0.001) [55,86].
The substance use ES significantly favoured BB (ES = 1.27, p < 0.001) [55,86]. For injury
risk, both studies showed a significant positive ES of BB (ES range: 0.9 to 1.25, p < 0.001)
[55,86]. The ES for muscle satisfaction significantly favoured BB in one of the studies (ES
range: -0.03 to 0.53, p < 0.001) [86].
60
Table 3.4. Muscle dysmorphia assessment results of non-bodybuilder resistance trainers
Reference Group n Tool Subscale Results Main findings
de Lima et al. [98] NBBRT 23 MASS n=4 (17%) demonstrated positive risk for MD
Cafri et al. [102] NBBRT, MD 23 MASS Bodybuilding dependence 26.07±3.63 MD group significantly higher (p<0.01) on
MDDI Muscle checking 20.13± 5.18 bodybuilding dependence, muscle checking,
Substance use 16.53±7.31 muscle satisfaction and functional impairment
Injury risk 13.87±5.14 subscales than non-MD
NBBRT, no MD 28 MASS Bodybuilding dependence 19.53±5.56
MDDI Muscle checking 13.67±5.61
Giardino et al. [81] NBBRT, Mexican men 35 MASS MASS total 25.77±12.48 Mexican men significantly higher (p=0.043)
NBBRT, Mexican women 11 MASS MASS total 17.26±9.06 MASS total than Mexican women
NBBRT, US men 43 MASS MASS total 29.42±13.1 US men significantly higher (p=0.002) MASS
NBBRT, US women 24 MASS MASS total 19.44±11.1 total than US women
61
Nieuwoudt et al. NBBRT 648 MASS MASS total 66.5±19.05 n=110 (17%) at risk for MD
[99] Bodybuilding dependence 18.46±6.21
Robert et al. [97] NBBRT M 55 MASS MASS total 42.56±12.35 Males significantly higher (p<0.05) than
NBBRT F 59 MASS MASS total 38.76±9.31 females on MASS total
Thomas et al. [17] NBBRT, training day 30 MDDI Drive for size 15.87±3.67 All subscale scores significantly higher
Appearance intolerance 8.97±2.79 (p<0.05) on rest day than training day
NBBRT, rest day 30 MDDI Drive for size 18.0±4.4
Tod et al. [100] NBBRT 294 MASS Bodybuilding dependence 12.15±5.5
Valdes et al. [101] NBBRT M 112 ACQ 56.3% mild concern
43.7% moderate
concern
62
NBBRT F 88 ACQ 53.4% mild concern
46.6% moderate
concern
Kanayama et al. NBBRT, AAS users 48 MDQ Preoccupied with body size n=43(90%) More AAS users answered yes to first two
[83] Always covers body with n=19(40%) questions than non-users
clothes
Gives up pleasurable n=11(23%)
activities
NBBRT, AAS non-users 41 MDQ Preoccupied with body size n=26(63%)
Always covers body with n=5(12%)
clothes n=3(7%)
Gives up pleasurable
activities
Olivardia et al. NBBRT, MD 24 MDSQ Weigh-ins per week 5.0±3.9 MD group showed significantly more
[47] Mirror checks per day 9.2±7.5 symptoms (p<0.001) of muscle dysmorphia
Minutes per day 325.0±337 than non-MD group
preoccupied with thoughts
of being too small
NBBRT, no MD 30 MDSQ Weigh-ins per week 2.0±2.0
63
Mirror checks per day 3.4±3.3
Minutes per day 41.2±173
preoccupied with thoughts
of being too small
Segura-Garcia et al. Men gaining weight 52 MDI Dietary behaviour 13.5±7 No significant difference between men
[88] Supplement use 10±6.5 gaining weight and men losing weight on all
Pharmacological use 3.3±2.5 subscales
Exercise dependence 16.5±5.5 Men gaining weight significantly higher
Size/symmetry 14±7.5 (p<0.001) than female groups on all MDI
Physique protection 10±5.5 subscales except pharmacological use and
Men losing weight 34 MDI Dietary behaviour 12.5±6.25 physique protection
Supplement use 7.5±5.5 Men losing weight significantly higher
Pharmacological use 3.5±2 (p<0.001) than ED group on exercise
Exercise dependence 13.7±5.75 dependence
Size/symmetry 12±5.75
Women losing weight 48 MDI Dietary behaviour 9.75±4.75
Supplement use 5±2.75
Pharmacological use 3.8±2
64
Size/symmetry 8.6±4
Women ED 20 MDI Dietary behaviour 9±3.5
Supplement use 4.7±2.1
Pharmacological use 3.5±1
Size/symmetry 9±4
Data are presented as mean ± standard deviation (except where otherwise indicated). NBBRT, non-bodybuilder resistance trainer; MASS, Muscle Appearance Satisfaction
Scale; MD, Muscle dysmorphia; US, United States; MDDI, Muscle Dysmorphic Disorder Inventory; ACQ, Adonis Complex Questionnaire; MDQ, Muscle Dysmorphia
Questionnaire; MDSQ, Muscle Dysmorphia Symptom Questionnaire; MDI, Muscle Dysmorphia Inventory; ED, Eating disorder; M, male; F, female; AAS, anabolic-
androgenic steroid
65
One study used the BIG to assess MD symptoms in BB and non-training controls [50]. The
ES showed BB scored higher on all muscle indices (ES range: 0.07 to 2.53), all of which
were significant (p < 0.001) except the subscale assessing ‘most attractive to women’. There
was a significant negative ES for BB on all indices related to fat mass (ES range: -0.87 to -
1.93, p < 0.001).
Meta-analysis
Meta-analyses were conducted on studies comparing BB to NBBRT using the MDI (n = 5)
[15,48,51,84,86]. Meta-analysis of studies using other MD instruments was considered
implausible as too few used other instruments, and they contained subscales that were too
heterogeneous to pool, thus including these studies in the analyses would introduce bias [87].
The pooled overall estimates for each subscale consistently indicated medium to large mean
differences, with higher MD symptoms in BB relative to NBBRT samples (Figures 3.2-3.7).
A large pooled ES was evident for dietary behaviour (ES = 1.12, 95% CI: 0.69 to 1.55; p <
0.001). Assessment of heterogeneity yielded a significant finding (Q = 27.41; df = 4; p <
0.001), with I2 = 85.41%. A large pooled ES was evident for supplement use (ES = 1.08, 95%
CI: 0.31 to 1.84; p = 0.006), and there was evidence of significant heterogeneity (Q = 88.61;
df = 4; p < 0.001; I2 = 95.49%).
66
Figure 3.2 Meta-analysis of the pooled effect of BB vs. NBBRT on the dietary behaviour
subscale of the Muscle Dysmorphia Inventory. Data are presented as standardised mean
difference (ES) and 95% confidence interval (95% CI). NBBRT, Non-bodybuilding
resistance trainer; BB, Bodybuilder; ES, effect size
Figure 3.3 Meta-analysis of the pooled effect of BB vs. NBBRT on the supplement use
67
A large pooled ES was also evident for exercise dependence (ES = 1.1, 95% CI: 0.12 to 2.08;
p = 0.03), with evidence of significant heterogeneity (Q = 80.17; df = 3; p < 0.001; I2 =
96.23%). A medium pooled ES was evident for pharmacological use (ES = 0.53, 95% CI:
0.14 to 0.91; p = 0.007), with heterogeneity significant (Q = 24.62; df = 4; p < 0.001; I2 =
83.75%).
Figure 3.4 Meta-analysis of the pooled effect of BB vs. NBBRT on the exercise dependence
Fig. 3.5 Meta-analysis of the pooled effect of BB vs. NBBRT on the pharmacological use
68
A large pooled ES was evident for size/symmetry (ES = 0.83, 95% CI: 0.2 to 1.46; p = 0.01),
with evidence of significant heterogeneity (Q = 63.48; df = 4; p < 0.001; I2 = 93.7%). A
medium pooled ES was also evident for physique protection (ES = 0.59, 95% CI: 0.2 to 0.98;
p = 0.003), with heterogeneity significant (Q = 25.32; df = 4; p < 0.001; I2 = 84.2%).
Figure 3.6 Meta-analysis of the pooled effect of BB vs. NBBRT on the size/symmetry
Figure 3.7 Meta-analysis of the pooled effect of BB vs. NBBRT on the physique protection
69
Due to the small study number, further investigations into the heterogeneity were not
conducted.
Do non-bodybuilder resistance trainers display more muscle dysmorphia symptoms than non-
resistance trained individuals?
One study compared symptoms of MD in resistance trained and non-resistance trained
individuals. Using the MDI, Segura-García, et al. [88] found no significant differences in MD
symptoms between males training to gain weight and males training to lose weight. However,
males training to gain weight scored significantly higher on all MDI subscales except
physique protection and pharmacological use than females training to lose weight and
females with a diagnosed eating disorder (anorexia nervosa and bulimia nervosa).
70
Table 3.5. Muscle dysmorphia and psychological traits in bodybuilders and non-bodybuilder resistance trainers
Reference Group N Tool Subscale Results Main findings
Babusa et al. BB 60 MASS MASS total 47.9±13.21 No perfectionism-MD correlation. BB higher
[55] EDI Perfectionism 6.3±3.85 perfectionism than undergraduate students
Non-BB undergraduate 60 MASS total 33.2±7.88
students Perfectionism 4.1±2.89
Boyda et al. BB 51 MASS MASS total 59.09±14.82 Anxiety correlated with MD (r=0.42, p<0.01)
[89] DASS Depression
Anxiety
Castro-Lopez BB 154 ACQ ACQ total Neuroticism correlated with MD (r=0.38,
et al. [79] NEO 5- Neuroticism 28.21±7.3 p<0.001)
FPI Extraversion 39.59±5.36
71
Gonzalez- BB, NBBRT 734 MASS MASS total General self-concept (r range: -0.2 to -0.5,
Marti et al. PSCS Bodybuilding dependence p<0.01) and general physical self-concept (r
[90] Muscle checking range: -0.16 to -0.53, p<0.01) negatively
Substance use correlated with MASS total and all subscales
Injury risk
Muscle satisfaction
General self-concept
General physical self-
concept
Lopez-Barajes BB 154 ACQ ACQ total 18.67±3.63 MD correlated with state anxiety (r=0.25,
et al. [91] STAI State anxiety p<0.01), emotional self-concept (r=-0.23,
SCQ-5 Trait anxiety p<0.01) and academic-occupational self-concept
Emotional self-concept (r=0.14, p<0.05)
Academic-occupational
self-concept
Wolke et al. BB 100 MDI MDI total 25.28±12.83 MD correlated with depression (r=0.38, p<0.01),
[92] RSES Self esteem 32.88±5.24 anxiety (r=0.32, p<0.01)
SC90 Depression 10.88±10.06 Negative correlation with self-esteem (r=-0.46,
Anxiety 7.87±7.15 p<0.01)
72
Babusa et al. Weightlifters 289 MASS Muscle satisfaction Self-esteem negatively correlated with all MASS
[49] RSES Substance use subscales except injury risk (r range: -0.12 to -
Injury risk 0.31, p<0.05)
Muscle checking
Bodybuilding dependence
Self-esteem
Hildebrandt et Dysmorphic 40 MDDI Drive for size 14.87±4.12 Dysmorphic group higher than all other groups
al. [93] BIG-O Appearance intolerance 13.67±5.17 on each MDDI subscale
SPAS Functional impairment 15.49±4.37 Significantly higher (p<0.001) than all groups
Desired muscle 0.72±0.72 except fat concern group on social physique
Desired fat 1.3±0.97 anxiety
Social physique anxiety 34.72±7.34
Muscular concern 63 Drive for size 11.31±4.8
Desired muscle 1.12±0.4
Desired fat 0.69±0.98
73
Fat concern 66 Drive for size 5.5±4.82
Desired muscle -0.29±0.71
Normal-behavioural 38 Drive for size 5.47±3.8
Desired muscle -0.13±0.41
Normal 30 Drive for size 4.8±3.25
Desired muscle 0.5±0.73
74
Kuennen et al. Resistance trained 49 MDI Dietary behaviour 3.38±1.13 Negative association between self-esteem and
[94] RSES Supplement use 3.18±1.41 size/symmetry (r=-0.42, p<0.01), physique
NPI Pharmacological use 1.13±0.3 protection (r=-0.39, p<0.01).
MPS Exercise dependence 4.42±0.87 Perfectionism associated with exercise
Size/symmetry 3.59±1.1 dependence (r=0.35, p<0.05)
Self-esteem 0.95±0.66
Narcissism 19.82±6.64
Perfectionism 2.98±0.49
Kim et al. [80] Resistance trained 429 MDI Depression associated with MD (r=0.53,
BDI p<0.001)
Maida et al. Resistance trained 106 MDSQ n=26(25%) Perfectionism (r=0.41, p<0.01), depression
[95] heightened MD (r=0.36, p<0.01), anxiety (r=0.39, p<0.01) each
symptoms associated with MD
EDI Perfectionism 5.2±0.16
BSI Depression 0.21±0.33
Anxiety 0.26±0.31
75
Thomas et al. Resistance trained 146 MDI Dietary behaviour 2.91±1.14 Social physique anxiety associated with
[96] MASS- Supplement use 3.02±1.38 supplement use (r=0.26, p<0.05), size/symmetry
6 Exercise dependence 3.7±1.1 (r=0.36, p<0.05), physique protection (r=0.75,
SPAS Size/symmetry 3.3±1.17 p<0.05), and overall MD (r=0.29, p<0.05)
MASS-6 2.88±0.91
Data are presented as mean ± SD (except where otherwise indicated). BB, bodybuilder; NBBRT, non-bodybuilder resistance trainer; MASS, Muscle Appearance Satisfaction
Scale; ACQ, Adonis Complex Questionnaire; MDI, Muscle Dysmorphia Inventory; MDDI, Muscle Dysmorphic Disorder Inventory; BIG-O, Bodybuilder Image Grid
Original; MDSQ, Muscle Dysmorphia Symptom Questionnaire; MASS-6, Muscle Appearance Satisfaction Scale 6 items; EDI, Eating Disorder Inventory; DASS, Depression
Anxiety Stress Scale; NEO 5-FPI, NEO 5 Factor Personality Inventory; PSCS, Physical Self-Concept Scale; STAI, State Trait Anxiety Inventory; SCQ-5, Self-Concept
Questionnaire 5; RSES, Rosenberg Global Self-Esteem Scale; SC90, Symptom Checklist 90; SPAS, Social Physique Anxiety Scale; NPI, Narcissistic Personality Inventory;
MPS, Multidimensional Perfectionism Scale; BDI, Beck Depression Inventory; BSI, Brief Symptom Inventory; MD, muscle dysmorphia
76
Table 3.6. Effect size of differences in Muscle Dysmorphia Inventory subscale scores between bodybuilders and non-bodybuilder resistance
trained individuals
Reference Comparison Scale Subscale Hedges’ g p value
Baghurst et Natural BB vs MDI Dietary behaviour 0.66±0.16 [0.35 to 0.97] <0.001
al. [51] NBBRT(WTP) Supplement use 0.6±0.16 [0.28 to 0.91] <0.001
Pharmacological use -0.1±0.16 [-0.4 to 0.21] 0.531
Size/symmetry 0.09±.016 [-0.21 to 0.39] 0.557
Physique protection 0.07±0.16 [-0.23 to 0.37] 0.654
Cella et al. BB vs NBBRT (non- MDI Dietary behaviour 1.58±0.16 [1.28 to 1.89] <0.001
[86] BB) Supplement use 1.97±0.17 [1.64 to 2.29] <0.001
Pharmacological use 0.65±0.14 [0.38 to 0.93] <0.001
Exercise dependence 1.83±0.16 [1.52 to 2.15] <0.001
Size/symmetry 1.63±0.16 [1.32 to 1.94] <0.001
Physique protection 1.13±0.15 [0.84 to 1.42] <0.001
Hale et al. BB(expert) vs MDI Dietary behaviour 1.96±0.36 [1.25 to 2.66] <0.001
[48] NBBRT(FL) Supplement use 2.35±0.39 [1.59 to 3.11] <0.001
Pharmacological use 0.37±0.3 [-0.21 to 0.96] 0.211
Exercise dependence 2.15±0.37 [1.42 to 2.88] <0.001
Size/symmetry 1.67±0.35 [1.0 to 2.35] <0.001
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Physique protection 0.7±0.31 [0.1 to 1.3] 0.021
Lantz et al. BB vs NBBRT(PL) MDI Dietary behaviour 0.83±0.16 [0.52 to 1.15] <0.001
[15] Supplement use 0.1±0.16 [-0.21 to 0.41] 0.517
Exercise dependence 0.03±0.16 [-0.28 to 0.34] 0.839
Size/symmetry 0.5±0.16 [0.19 to 0.81] 0.002
Skemp et al. BB(AE) vs MDI Dietary behaviour 0.83±0.18 [0.47 to 1.19] <0.001
[84] NBBRT(PE) Supplement use 0.55±0.18 [0.2 to 0.91] 0.002
Exercise dependence 0.5±0.18 [0.15 to 0.85] 0.006
Size/symmetry 0.37±0.18 [0.02 to 0.72] 0.04
Data are presented as standardised mean difference (ES) ± SE (95% CI). BB, bodybuilder; NBBRT, non-bodybuilder resistance trainer; WTP, weight trainers for physique;
FL, fitness lifters; PL, powerlifters; AE, appearance enhancement; PE, performance enhancement; MDI, Muscle Dysmorphia Inventory; ES, effect size; SE, standard error;
CI, confidence interval
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Table 3.7. Effect size of differences in Muscle Dysmorphic Disorder Inventory subscale scores between bodybuilders and non-bodybuilders
Reference Comparison Scale Subscales Hedges’ g p value
Santarnecchi BB(competing) vs MDDI Total 3.62±0.3 [3.04 to 4.21] <0.001
et al. [50] controls (non-training) Drive for size 2.47±0.24 [2.0 to 2.95] <0.001
Appearance intolerance 1.2±0.2 [0.81 to 1.59] <0.001
Functional impairment 2.95±0.26 [2.43 to 3.47] <0.001
Soler et al. BB vs NBBRT (gym MDDI Total 0.03±0.22 [-0.39 to 0.46] 0.877
[85] goers) Drive for size -0.05±0.22 [-0.48 to 0.37] 0.802
Appearance intolerance -0.07±0.22 [-0.49 to 0.35] 0.745
Functional impairment 0.26±0.22 [-0.16 to 0.69] 0.223
Data are presented as standardised mean difference (ES) ± SE (95% CI). BB, bodybuilder; NBBRT, non-bodybuilder resistance trainer; MDDI, Muscle Dysmorphia Disorder
Inventory; ES, effect size; SE, standard error; CI, confidence interval
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Table 3.8. Effect size of differences in Muscle Appearance Satisfaction Scale subscale scores between bodybuilders and non-bodybuilders
Babusa et BB (non-competitive) MASS Total 1.34±0.2 [0.95 to 1.74] <0.001
al. [55] vs controls (students, Bodybuilding dependence 1.53± 0.21 [1.12 to 1.93] <0.001
non-bodybuilders) Muscle checking 0.8±0.19 [0.43 to 1.17] <0.001
Substance use 1.27±0.2 [0.88 to 1.66] <0.001
Injury 0.9±0.19 [0.53 to 1.27] <0.001
Muscle satisfaction -0.03±0.18 [-0.39 to 0.32] 0.854
Cella et al. BB vs NBBRT (non- MASS Total 1.61±0.16 [1.3 to 1.92] <0.001
[86] BB) Bodybuilding dependence 1.33±0.15 [1.03 to 1.62] <0.001
Muscle checking 1.2±0.15 [0.91 to 1.49] <0.001
Substance use 1.27±0.15 [0.97 to 1.56] <0.001
Injury 1.25±0.15 [0.96 to 1.56] <0.001
Muscle satisfaction 0.53±0.14[0.26 to 0.8] <0.001
Data are presented as standardised mean difference (ES) ± SE (95% CI). BB, bodybuilder; NBBRT, non-bodybuilder resistance trainer; MASS, Muscle Appearance
Satisfaction Scale; ES, effect size; SE, standard error; CI, confidence interval
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Does bodybuilding calibre affect muscle dysmorphia symptoms?
One study used the MDDI and BIG to compare symptoms of MD between competitive and
non-competitive BB [50]. The ES significantly favoured competitive BB on MDDI total
score, drive for size and functional impairment subscales (ES range: 1.21 to 1.42, p < 0.001),
but significantly favoured non-competitive BB on the appearance intolerance subscale (ES: -
1.09, p < 0.001; Table 3.9). The competitive BB showed a positive ES for each of the BIG
indices related to muscle (ES range: 0.31 to 1.65), of which three – current muscle, ideal
muscle and most attractive muscle – were significant (p < 0.001). The competitive BB also
showed a significant negative ES on all four indices related to fat – current, ideal, most
attractive and most attractive to women (ES range: -0.79 to -1.22, p < 0.001) – suggesting
lower current, ideal, most attractive and most attractive to women body fat percentage than
non-competitive BB. One study [48] compared symptoms of MD between expert (defined as
having competed in 10 or more bodybuilding competitions) and novice (defined as having
competed in three or less competitions) BB, using the MDI, noting a greater effect size in the
dietary behaviour, supplement use, exercise dependence and size/symmetry subscales
amongst expert BB (ES range: -0.16 to 0.76), however only supplement use and exercise
dependence were significant (p ≤ 0.01; Table 3.10).
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Table 3.9. Effect size of differences in Muscle Dysmorphic Disorder Inventory subscale scores between competitive and non-competitive
bodybuilders
Santarnecchi BB(competing) vs MDDI Total 1.21±0.2 [0.82 to 1.6] <0.001
et al. [50] BB(non-competing) Drive for size 1.23±0.2 [0.84 to 1.62] <0.001
Appearance intolerance -1.09±0.2 [-1.47 to -0.71] <0.001
Functional impairment 1.42±0.2 [1.02 to 1.82] <0.001
Data are presented as standardised mean difference (ES) ± SE (95% CI). BB, bodybuilder; MDDI, Muscle Dysmorphic Disorder Inventory; ES, effect size; SE, standard
error; CI, confidence interval
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Table 3.10. Effect size of difference in Muscle Dysmorphia Inventory subscale scores between expert and novice bodybuilders
Hale et al. BB(expert) vs MDI Dietary behaviour 0.53±0.27 [-0.01 to 1.06] 0.053
[48] BB(novice) Supplement use 0.76±0.28 [0.22 to 1.3] 0.006
Pharmacological use -0.03±0.27 [-0.55 to 0.49] 0.907
Exercise dependence 0.71±0.28 [0.17 to 1.24] 0.01
Size/symmetry 0.25±0.27 [-0.27 to 0.78] 0.348
Physique protection -0.16±0.27 [-0.68 to 0.37] 0.559
Data are presented as standardised mean difference (ES) ± SE (95% CI). BB, bodybuilder; MDI, Muscle Dysmorphia Inventory; ES, effect size; SE, standard error; CI,
confidence interval
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What psychological features are associated with muscle dysmorphia in bodybuilders and
non-bodybuilder resistance trainers?
Of the studies included in analyses, six examined the association (reporting correlation
coefficient, r) between psychological features and MD symptoms in BB [55,79,89-92] (Table
3.5). A wide range of features were examined, although many of these were investigated in
only one study [55,79,92]. Features most commonly examined were self-concept (n = 4),
including general, physical, emotional and academic-occupational self-concept [90,91], and
anxiety (n = 3) [89,91,92]. Other features reported were self-esteem [92], depression [89],
neuroticism [79], extraversion [79] and perfectionism [55] (n = 1 for each). Features
positively correlated with MD were academic-occupational self-concept (r = 0.14), anxiety (r
range: 0.32 to 0.42), depression (r range: 0.23 to 0.53) and neuroticism (r = 0.38) [89,91,92].
Factors negatively associated with muscle dysmorphia were general, physical and emotional
self-concept, and self-esteem (r range: -0.18 to -0.57) [90-92]. No association was found
between extraversion and MD [79], or perfectionism and MD [55].
Six of 31 studies examined psychological features and MD in NBBRT [49,80,93-96] (see
Table 3.5). Features most commonly reported were anxiety (n = 3) [93,95,96], perfectionism
(n = 2) [94,95], self-esteem (n = 2) [49,94], and depression (n = 2) [80,95]. The final feature
reported was narcissism (n = 1) [94]. Features positively associated with MD were anxiety
and social physique anxiety (r range: 0.26 to 0.75) [93,95,96], perfectionism (r range: 0.35 to
0.57) [94,95], and depression (r range: 0.36 to 0.53) [80,95]. Self-esteem was negatively
associated with MD (r range: -0.12 to -0.42) [49,94]. No association was reported between
narcissism and MD [94].
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Do anabolic-androgenic steroid users display more muscle dysmorphia symptoms than non-
anabolic-androgenic steroid users?
Four of 31 studies compared BB based on steroid use (AAS users versus non-users)
[51,55,82,86], using either the MDI (n = 3) or the MASS (n = 2). Insufficient data were
available in these studies to calculate mean difference and 95% CI. There was a lack of
consistency in differences between users and non-users across these papers. Cella,
Iannaccone and Cotrufo [86] identified that steroid users scored higher than non-users on all
MDI subscales except exercise dependence, while Baghurst and Lirgg [51] reported higher
pharmacological use in non-natural BB. Steroid users scored higher than non-users on the
MASS total [55] and on all MASS subscales except muscle satisfaction [86]. Conversely,
Davies and Smith [82] showed no significant difference on all MDI subscales between
current steroid users and former steroid users.
Kanayama, Barry, Hudson and Pope [83] compared resistance trained individuals based on
AAS use on the three item MD Questionnaire and found AAS users responded significantly
more affirmatively to MD symptoms questions than non-users.
Do male and female non-bodybuilder resistance trainers display different muscle dysmorphia
symptoms?
Three of 31 studies compared MD symptoms in male and female NBBRT [81,84,97]. The
MASS total score showed an ES favouring males in two studies [81,97] (ES range: 0.35 to
0.79), one of which was significant (p ≤ 0.04) [81]. Skemp, Mikat, Schenck and Kramer [84]
found a positive ES for males on the supplement use, pharmacological use, size/symmetry
and physique protection subscales of the MDI (ES range: 0.28 to 0.99), and with significance
for pharmacological use and size/symmetry (p = 0.001) [84]. There was no difference for
dietary behaviour and exercise dependence (ES= 0) [84] (Table 3.11).
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Do muscle dysmorphia symptoms vary with the proximity of resistance training?
One of 31 studies examined the effect of proximity of resistance exercise on symptoms of
MD (Table 3.12). Thomas, Tod and Lavallee [17] used the MDDI to assess symptoms of MD
in resistance trained males on both a training and a rest day, finding a significant increase in
scores for the drive for size subscale of the MDDI on the rest day (ES: 0.52, p < 0.05). The
appearance intolerance and functional impairment subscales also both showed an ES
favouring higher scores on the rest day, however neither of these was significant (ES range:
0.18 to 0.35).
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Table 3.11. Effect size of difference in Muscle Appearance Satisfaction Scale and Muscle Dysmorphia Inventory subscale scores between male
and female non-bodybuilder resistance trainers (NBBRT)
Giardino et US males vs US MASS Total 0.79±0.26 [0.28 to 1.31] 0.002
al. [81] females
Giardino et Mexican males vs MASS Total 0.71±0.35 [0.03 to 1.39] 0.041
al. [81] Mexican females
Robert et al. Males vs females MASS Total 0.35±0.19 [-0.02 to 0.72] 0.064
[97]
Skemp et al. Males vs females MDI Dietary behaviour 0±0.28 [-0.54 to 0.54] 1.0
[84] Supplement use 0.36±0.28 [-0.19 to 0.9] 0.201
Pharmacological use -0.99±0.29 [-1.56 to -0.41] 0.001
Exercise dependence 0±0.28 [-0.54 to 0.54] 0.314
Size/symmetry 0.97±0.29 [0.4 to 1.54] 0.001
Physique protection 0.28±0.28 [-0.26 to 0.82] 0.314
Data are presented as standardised mean difference (ES) ± SE (95% CI). US, United States of America; NBBRT, non-bodybuilder resistance trainer; MASS, Muscle
Appearance Satisfaction Scale; MDI, Muscle Dysmorphia Inventory; ES, effect size; SE, standard error; CI, confidence interval
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Table 3.12. Effect size of difference in Muscle Dysmorphic Disorder Inventory subscale scores between training day and rest day in non-
bodybuilder resistance trainers (NBBRT)
Thomas et Training day vs rest day MDDI Drive for size 0.52±0.26 [0.01 to 1.03] 0.045
al. [17] (NBBRT) Appearance intolerance 0.35±0.26 [-0.15 to 0.86] 0.168
Functional impairment 0.18±0.26 [-0.32 to 0.68] 0.49
Data are presented as standardised mean difference (ES) ± SE (95% CI). NBBRT, non-bodybuilder resistance trainer; MDDI, Muscle Dysmorphic Disorder Inventory; ES,
effect size; SE, standard error; CI, confidence interval
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How severe are muscle dysmorphia symptoms?
Four of 31 studies reported the severity of MD symptoms in NBBRT, using the MASS (n =
3), and the Adonis Complex Questionnaire (n = 1) [98-101]. Mean scores were as follows:
MASS total = 66.5/133, muscle checking = 11.62/28, bodybuilding dependence = 18.46/35,
substance use = 12.43/28, injury risk = 11.63/21, muscle satisfaction = 12.61/21 [99];
bodybuilding dependence = 12.15/35, muscle satisfaction = 8.49/21 [100]. Based on MASS
score, 17% were classified as ‘at risk’ of MD [99], and 17.4% demonstrated ‘positive risk’
for MD [98]. Using the Adonis Complex Questionnaire, Valdés, Lagos, Gedda, Cárcamo,
Millapi and Webar [101] classified 56.3% of males as of ‘mild concern’ and 43.7% as of
‘moderate concern’, while 53.4% of females were of ‘mild concern’ and 46.6% of ‘moderate
concern’.
How do muscle dysmorphia symptoms vary between non-bodybuilder resistance trainers
diagnosed with muscle dysmorphia and non-bodybuilder resistance trainers without muscle
dysmorphia?
Three of the 31 studies grouped NBBRT based on a researcher determined MD diagnosis
[47,102], or on variables associated with MD [93]. Three tools were used to assess MD
symptoms in these studies – MDDI (n = 2), MASS ( n= 1), MDSQ (n = 1). Muscle
dysmorphic NBBRT scored higher than non-muscle dysmorphic NBBRT on the
bodybuilding dependence, muscle checking and muscle satisfaction subscales of the MASS,
the functional impairment subscale of the MDDI [102], all of the subscales of the MDDI
[93], and on all questions of the MDSQ [47].
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Table 3.13. Effect size of differences in Bodybuilder Image Grid subscale scores between bodybuilders and controls
Santarnecchi BB(competing) vs BIG Current body type – fat -0.79±0.19 [-1.16 to 0.42] <0.001
et al. [50] BB (non-competing) Current body type – muscle 1.11±0.2 [0.73-1.49] <0.001
mass
Ideal body type – fat -1.16±0.2 [-1.55 to -0.78] <0.001
Ideal body type – muscle 1.65±0.21 [1.23 to 2.06] <0.001
mass
Most attractive body type – -1.22±0.2 [-1.61 to -0.84] <0.001
fat
Most attractive body type – 1.2±0.2 [0.82 to 1.59] <0.001
muscle mass
Most attractive to women – -0.84±0.19 [-1.21 to -0.46] <0.001
fat
Most attractive to women – 0.31±0.18 [-0.05 to 0.66] 0.095
muscle mass
Santarnecchi BB(competing) vs BIG Current body type – fat -1.28±0.2 [-1.67 to -0.89] <0.001
et al. [50] Non-training controls Current body type – muscle 2.53±0.24 [2.05 to 3.01] <0.001
mass
90
Ideal body type – fat -1.93±0.21 [-2.15 to -1.31] <0.001
Ideal body type – muscle 2.0±0.22 [1.56 to 2.44] <0.001
mass
Most attractive body type – -1.53±0.21 [-2.01 to -1.19] <0.001
fat
Most attractive body type – 1.49±0.21 [1.09 to 1.9] <0.001
muscle mass
Most attractive to women – -0.87±0.19 [-1.25 to -0.5] <0.001
fat
Most attractive to women – 0.07±0.18 [-0.29 to 0.43] 0.697
muscle mass
Data are presented as standardised mean difference (ES) ± SE (95% CI). BB, bodybuilder; BIG, Bodybuilder Image Grid; ES, effect size; SE, standard error; CI, confidence
interval
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DISCUSSION
The aim of the present analysis was to firstly compare the existing evidence-base pertaining to
MD symptomatology in BB versus NBBRT, and secondly, to identify psychological and other
characteristics associated with MD symptomatology in these respective groups. We collated data
from 1895 BB participants (male n = 1597, female n = 298), 3523 non-bodybuilding resistance
trainers (male n = 3341, female n = 182), and 462 non-training controls (male n = 360, female n
= 102) making this the largest systematic review of the literature on MD. Given the ongoing
conflation of bodybuilding and MD, and the potential scope for pathologizing normative
muscularity-enhancing pursuits, this review is important. Critically, results illustrate that BB
reported greater MD symptomatology relative to NBBRT, with consistently larger effect sizes on
most indices of MD symptomatology. With inconsistent use of measures of MD
symptomatology precluding a large-scale meta-analysis, the data available from studies using the
MDI [103] showed a moderate to large effect size (ES range: 0.53 to 1.12, p ≤ 0.01) where BB
reported greater MD symptom severity on all of the MDI subscales. Overall, the results indicate
that BB have a higher risk of MD symptomatology when compared to NBBRT and non-training
controls. This study also assessed psychological features linked with MD. Several features
including anxiety, depression and perfectionism were positively and self-esteem negatively
associated with MD. These associations were similar in both BB and NBBRT. However, the
association between the psychological features and MD was not strong (r ≤ 0.53) and a minority
of the papers assessed psychological features indicating that there is scope to explore this further.
As anticipated, the male and female BB had a higher BMI (male BB: 29.7 kg·m-2, female BB: 27
kg·m-2) than the NBBRT (male NBBRT: 27.2 kg·m-2, female NBBRT: 23.6 kg·m-2). Similarly,
male BB were leaner than male NBBRT (male BB: 9.8% fat, male NBBRT: 12.9% fat), however
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no studies presented body composition data for females. None of the papers reported the weight
class of BB competitors, and only 7 of 31 studies reported on the use of AAS in their cohorts.
This limits the capacity to interpret the range of mass reported and also the variance in mass
associated with participation in natural or non-natural competition. The mass and adiposity of the
participants in this study were comparable to those reported in a recent systematic review on diet
and supplement use in bodybuilding [10], indicating that the physique characteristics of the
sample of BB in this review and analysis are consistent with other published literature in this
population. Although we identified few studies reporting on elite competitors, the body
composition characteristics of this group would be expected to be more extreme. Timing of the
body composition measurement is an important consideration for BB competitors, as extreme
leanness is reported to be a feature only in the weeks and days immediately before competition
[11,13,104,105]. Since phase of competition preparation is an important parameter for
interpretation and assessment of body composition characteristics, it is possible that symptoms of
MD vary across a competition cycle in conjunction with change in body composition. We
identified no studies that had assessed this aspect. Failure to identify phase of training may likely
limit the interpretation of MD scores.
Bodybuilders and non-bodybuilders
Of the eight studies comparing BB to non-BB included in this review, six used a resistance
trained comparison group (NBBRT). Five of these comparison studies found greater MD
symptomatology in BB than in NBBRT, demonstrated by significant ES on most, if not all,
subscales of the MD assessment tools used (ES range: 0.03 to 2.35). The meta-analysis
combined data from five studies, all of which used the MDI to compare a bodybuilding cohort
(361 BB in total) to a resistance trained, non-bodybuilding cohort (368 NBBRT in total). The
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pooled estimate for each subscale of the MDI showed a medium to large effect of bodybuilding
on MD symptoms (ES range: 0.53 to 1.12). Significant heterogeneity was present in the meta-
analysis, likely due to the small sample size in some of the included studies, variation in the
calibre of participants and variation in levels of engagement in bodybuilding behaviours.
However the calculated ES from the studies and the pooled data provide evidence to show MD
symptomatology is more prevalent in BB than in NBBRT. When comparing the non-training
control participants their scores on the MD tools were generally lower than those of both BB and
NBBRT. Overall, the data support that engagement in bodybuilding is associated with a higher
risk of characteristics associated with MD. However, it is important to note that this association
does not imply causality, and a plausible explanation may posit that those with a predisposition
to MD may be attracted to bodybuilding, with participation in bodybuilding, in turn, potentially
exacerbating symptoms. For instance, anecdotal reports and ethnographic studies illustrate
accounts of those with predispositions towards body image concerns gravitating towards
bodybuilding with the purpose of bolstering self-esteem or a sense of masculinity; involvement
in bodybuilding gym culture may subsequently exacerbate MD symptomatology [106].
Psychological features
Psychological features associated with MD were examined in 12 of the 31 identified studies. A
range of features were investigated, with many often assessed in only a small number of studies.
Associated features were similar across both BB and NBBRT. Anxiety, depression, neuroticism
and perfectionism were all associated with symptoms of MD, while low self-esteem was
associated with greater MD symptoms.
The MD literature has focussed primarily on BB due to the seemingly similar pursuits of BB and
those with MD. This has led to a conflation of the two, and often a misrepresentation of
94
bodybuilding as a sport. The psychological features associated with MD identified in this review
are not always typical of BB and NBBRT. Frequency and intensity of symptoms of anxiety and
social physique anxiety in BB have been found to be lesser than, or comparable to, recreational
weight trainers, recreationally active individuals, and non-exercisers [107-109]. Levels of
depression are no different in BB than resistance trained and non-resistance trained individuals
[54,107,110]. Self-esteem levels in BB have been reported to be higher than [56,108], lower than
[110] and no different to [110], active and inactive individuals. These differences in
psychological characteristics of BB with and without MD highlight an important difference
between the participation in bodybuilding and MD, a difference which previously has not been
well defined. These findings suggest that the pursuit of a lean, muscular physique in
bodybuilding is not in itself associated with psychological comorbidity; rather it is a non-
pathological commitment to an intense training and nutrition plan. When individuals expressing
these psychological characteristics take part in this intense program, the potential for developing
MD may increase. The evidence to date suggests that although MD symptomatology appears to
be higher in BB than NBBRT and non-training controls, BB may not necessarily possess or
acquire the psychological features associated with MD such as depression, anxiety and low self-
esteem, suggesting that distinct underlying factors underpin the greater MD symptomatology in
the bodybuilding samples informing this study. By identifying the psychological characteristics
associated with MD in BB and NBBRT, this review better enables clinicians and researchers to
differentiate individuals committed to bodybuilding and resistance training activities from
individuals who may be suffering from, or at risk of, MD.
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Anabolic Androgenic Steroids
Use of AAS has been recognised as a component of MD, and hence has been included in
proposed diagnostic criteria [14]. Whether AAS use is a cause or an effect of MD has yet to be
determined, however evidence suggests AAS use is a perpetuating factor of MD [111].
Insufficient data were available to calculate effect size in the five studies examining AAS use
and MD. The available results are inconsistent regarding comparative rates of MD in AAS users
and non-users. Five of the 31 studies compared users to non-users, four of which were in a
bodybuilding sample. As expected, the AAS users scored higher than non-users on MDI and
MASS subscales related to pharmacological use [51,55]. Other results varied, showing either no
difference between users and non-users, or increased symptoms in users. If indeed steroid use is
a perpetuating factor in MD, individuals displaying symptoms of MD would likely turn to AAS
use to address their perceived lack of size and muscularity. However, higher overall and subscale
scores in AAS users suggest that use of appearance and performance enhancing drugs may not
be an effective means of reducing other symptoms of MD. The increases in muscle mass and
strength associated with AAS use may not reduce the poor self-perception of MD sufferers, only
perpetuating the positive feedback loop. Users may continue to perceive their bodies as small,
despite the expected gains in muscle mass, thus maintaining or even increasing MD symptoms,
and potentially leading to increased AAS usage [111]. Cella, Iannaccone and Cotrufo [86] found
that current steroid users did not score lower than former steroid users, which seems to support
this assertion. In this study, the use of steroids did not alleviate MD symptoms, and cessation of
steroid use did not result in a relapse of MD symptoms, indicating steroid use may not be an
effective means of coping with MD.
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There were notable limitations of the present analysis. Some of the included studies only crudely
defined the BB calibre of participants, and the body composition and training data suggest they
were not highly engaged with the sport. Very few studies commented on the training or
competition phase of participants, BB were often not described as competitive or non-
competitive, and only one study distinguished between training and non-training days. In
addition, no longitudinal data were identified. This limits the assessment of how
symptomatology may vary over a competition cycle. Longitudinal data may also provide
information on how the competitive bodybuilding environment may exacerbate symptoms.
Steroid use is common in bodybuilding [70] however 24 of the 31 studies included in the review
did not state the drug taking status of participants. There was also a risk of undisclosed steroid
use in those studies which did present drug usage information (as this was self-reported). There
was a sex bias towards recruitment of male BB and resistance trainers, although this likely
mirrors sex participation in competitive bodybuilding. Many of the mixed sex samples grouped
the data, rather than separating by sex. More mixed and female samples would better enable
insight into differences between males and females in MD. Overall, the quality of the literature
informing the study was low to moderate. Further to this, meta-analysis was only able to be
conducted on five of the 31 studies and significant heterogeneity was identified. This limits the
strength of the evidence. Weaknesses including inadequate assessment of athlete calibre, use of
AAS and the influence of competition phase on MD symptoms limit the capacity to evaluate the
influence of these factors.
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CONCLUSION
This systematic review and meta-analysis supports that BB have greater MD symptomatology
than NBBRT. Psychological characteristics associated with MD have been identified in BB and
NBBRT. Nevertheless, those with severe MD symptomatology show a greater array of
psychiatric comorbidity, including anxiety, depression, perfectionism and low self-esteem, which
may be relevant in delineating between pathological and non-pathological muscularity pursuits.
We suggest that bodybuilding may attract susceptible individuals, and may also be relevant in
cultivating advanced symptomatology in BB with the cluster of psychological features associated
with MD. Further evidence is required to definitively elucidate whether bodybuilding is a cause
of MD, or whether the sport of bodybuilding attracts those predisposed to MD. Longitudinal
studies, controlling for the effect of training and non-training days, would enable measurement
of changes in MD symptoms over different stages of bodybuilding preparation and further
explicate the nature of the relationship between bodybuilding and MD symptoms.
ACKNOWLEDGEMENTS
The authors would like to acknowledge funding support of Sports Dietitians Australia, which
assisted in the preparation of this manuscript.
CONFLICT OF INTEREST
Lachlan Mitchell, Stuart B. Murray, Stephen Cobley, Daniel Hackett, Janelle Gifford, Louise
Capling and Helen O’Connor declare that they have no conflicts of interest directly relevant to
the content of this review.
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CHAPTER 4.
Correlates of Muscle Dysmorphia Symptomatology in Natural Bodybuilders:
Distinguishing Factors in the Pursuit of Hyper-Muscularity
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Chapter 4: Correlates of Muscle Dysmorphia Symptomatology
ABSTRACT
Background: Muscle dysmorphia (MD) is characterised by the pathological pursuit of
muscularity and leanness, which includes eating- and exercise-related practices. The aim of this
cross-sectional study was to identify correlations of MD symptomatology in natural bodybuilders
(BB).
Method: An online survey assessing diet, supplementation and training practices, and MD and
eating disorder symptoms was completed by male BB with recent experience competing in a
drug-tested competition.
Results: Sixty participants (age 29.6 ± 7.1years) completed the survey. Eating disorder scores (β
= 0.298), rate of pre-competition weight loss (β = 0.307) and number of competitions (β = -
0.257) were significant predictors of MD.
Conclusion: The association between the EAT-26 and MDDI underscores the salience of
disordered eating pathology in presentations of MD. Supporting this, greater rate of pre-
competition weight loss, which may reflect disordered eating practices, is also associated with
MD symptomatology. The inverse association of competition experience suggests novice BB
may display increased MD symptomatology.
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INTRODUCTION
The ideal male physique is represented by a mesomorphic and lean body [59,60]. Societal
expectations relating to this body ideal, and the reward associated with its achievement, drive
attempts to increase muscular size and shape through muscularity enhancing pursuits [59].
Similarly, in the context of athletic performance, pressures may relate to both body image and
muscularity-oriented pursuits [112]. In pathological extremes, muscle dysmorphia (MD) is
thought to encapsulate the disordered pursuit of muscularity, and is most centrally characterized
by a distorted self-perception, whereby one believes themselves to be small and weak, often
despite well-developed muscularity, and a concomitant pathological drive for muscularity and
leanness [14]. Attitudinal and behavioural symptoms echo these characteristics. Meticulous
exercise and dietary practices are adhered to, and fastidiously monitored, in aiming to optimise
muscular development, while deviation from either food or exercise regimen is associated with
marked anxiety [14].
MD is nosologically linked to the eating disorders (ED), and eating practices are known to
centrally exacerbate MD symptomatology [113]. Further, pathological exercise practices in MD
are known to serve similar emotional regulatory functions to those reported in anorexia nervosa
[114]. Perhaps crucially, MD and ED feature weight and shape concern, appearance intolerance,
dietary restraint, compulsive exercise, and functional impairment [115], suggesting a broad
conceptual similarity, despite symptoms being oriented towards antonymic physique extremes.
Data relating to the elevated risk of ED in some athletic pursuits has been instrumental in
shaping preventative efforts [116], although importantly, fewer data exist relating to risk factors
for MD. Existing evidence suggests that MD may affect a broad range of athletic groups,
including for instance footballers and weightlifters [51]. However, perhaps the greatest implicit
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overlap between MD and athletic pursuits lies in bodybuilding, where both are oriented towards
the pursuit of hypermuscularity and leanness. As with MD, bodybuilding is synonymous with
steroid use, although a proportion of bodybuilders (BB) compete in drug-tested federations,
where use of performance enhancing drugs is prohibited. Though BB and those afflicted with
MD may pursue similar body composition outcomes, a recent systematic review illustrates that
engagement in the sport of bodybuilding is not in itself a pathological endeavour [117]. As such,
identifying attitudes and behaviours associated with MD symptomatology is of crucial
importance [117].
BB typically follow periodised nutrition and training routines to achieve muscular hypertrophy
during the off-season, and leanness during the in-season [10]. The meticulous exercise observed
in MD has been shown to reflect the training volume of BB [86]. Frequent, longer duration
training sessions may highlight the regimen of individuals displaying increased MD
symptomatology, a process adopted to target hypermuscularity as well as leanness during
competition preparation.
Given the nosological similarities between MD and ED [113-115], borrowing a broader ED
framework may be of use in identifying attitudinal and behavioural associations with MD
symptomatology. However, few studies have examined potential disordered eating practices in
BB, and fewer still have specifically examined this in natural BB. Given the association between
steroid use and image-related psychopathology [118], assessing correlates of MD
symptomatology in natural BB provides critical evidence of pathological behaviours independent
of appearance and performance enhancing substance use. One such behaviour implicated in ED
symptomatology is one’s rate of weight loss [119]. In a bodybuilding context, a rapid loss of
weight during the in-season period, indicated by greater weight loss per week of preparation,
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may reflect an intolerance towards maintaining a reduced weight, and thus symptomatic
behaviour. As such, a rapid weight loss leading to competition may delay and limit the period of
time spent at a reduced body weight, and may act to reduce the noted anxiety associated with
reduced muscularity.
Addressing this gap, the present study aimed to identify correlates of MD symptomatology in
natural BB, which would provide crucial data relevant in deconstructing the inference that
bodybuilding and symptoms of MD are synonymous. In light of existing evidence, we
hypothesized that ED symptoms would be associated with MD symptomatology, but not a non-
pathological pursuit of muscularity (i.e., bodybuilding).
METHODS
Participants
Participants were male, aged 18 years or over, and had competed in at least one natural
bodybuilding contest within the previous 18 months. Participants were recruited through
distribution of the survey link online via social media, and at the Australasian Natural
Bodybuilding national titles in October 2015, as part of a broader ongoing study in natural BB.
Ethics approval was obtained from the University of Sydney Human Ethics Committee (project
2015/732). Informed consent was obtained on entry to the survey, which was open between
October 2015-September 2016.
A total of 319 individuals logged onto the survey. Of these, 178 failed to meet inclusion criteria
and therefore did not progress to question 1. A further 42 met inclusion however failed to
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complete > 25% of survey items and were excluded from analysis. All remaining 99 participants
completed the survey, however 39 of these failed to meet study inclusion criteria, leaving 60
(60.6% of completers) participants included in the analysis. Reasons for exclusion at this latter
point were not competing in the bodybuilding category (28/39 completers), no recent
competition experience (10/39 completers), and competing in a non-drug tested competition
(1/39 completers). Demographic characteristics of included participants are presented in Table
4.1.
Survey items
Participant training routine and demographics, including highest historical weight, competition
weight, in-season duration, and bodybuilding history, were assessed using an adapted version of
a self-report questionnaire that our group previously developed [9].
The Muscle Dysmorphic Disorder Inventory (MDDI) [120] is a 13-item questionnaire measure
of MD symptomatology that comprises 3 subscales; drive for size, appearance intolerance, and
functional impairment. Total scores range from 13 to 65, with higher scores reflecting greater
MD psychopathology. The MDDI was selected to assess MD symptoms as it encompasses the
perceptual, cognitive, emotional and behavioural disturbances related to the desire to be more
lean and muscular apparent in MD. As such, the subscales of the MDDI provide measurements
of the thoughts, feelings and behaviours related to MD, and hence predict these three separate
constructs of MD [120]. Therefore this tool is consistent with the multidimensional definition of
body image disturbance in MD [120]. The questionnaire is not a diagnostic tool but has been
widely used to identify individuals displaying symptoms associated with MD [17,50,85]. The
MDDI yields good psychometric properties, with test-retest reliability previously reported to
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range from 0.81 to 0.87 [120]. In the present study, internal consistency was acceptable (α =
0.81).
The Eating Attitudes Test 26-Items (EAT-26) [121] is a self-report questionnaire assessing
disordered eating symptoms. Total scores range from 0 to 78, with higher scores indicating
increased ED psychopathology. The EAT-26 contains three subscales: dieting, bulimia and food
preoccupation, and oral control. Consistent with previous research relating to ED attitudes and
cognitions, behavioural questions additional to the 26 items were not added to the EAT-26 in the
present study [122,123]. The EAT-26 was selected due to its accuracy in self-reported testing of
non-clinical populations [122], and its previous use in assessing disordered eating symptoms in
resistance trained men [99]. While not a diagnostic tool, a score of 20 or above indicates a high
level of concern about dieting, body weight, and problematic behaviours. The EAT-26
demonstrates good psychometric properties, and in the present study, acceptable internal
consistency was noted (α = 0.78).
Analysis
Mean and standard deviation scores were calculated for demographic and assessment instrument
(MDDI, EAT-26) data. Weight suppression was calculated as highest historical weight minus
reported competition weight. A rate of weight loss, defined as the average number of kilograms
of body mass lost per week during the in-season, was calculated as a function of weight
suppression divided by in-season duration. Training volume was calculated as a product of
number of training sessions per week and training session duration.
Pearson’s correlations were calculated to investigate interrelationships between MDDI and
survey variables. Simultaneous multiple linear regression analysis was performed to further
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investigate the relationship between MDDI total score and survey variables. Based on the
hypotheses, correlation outcomes, and symptoms of MD, EAT-26 total score, total in-season
training volume, rate of weight loss, and number of competitions were set as independent
variables. The standardised residual versus fitted values plot suggested the fitted model was
adequate and the normal probability plot of standardised residuals suggested the normality
assumption held so valid inferences can be made. Analyses were conducted using IBM SPSS
statistics version 22 (IBM SPSS; Chicago, Illinois). Significance was set at p < 0.05.
RESULTS
Mean scores for the EAT-26 were low (8.5 ± 6.3), while mean scores for the MDDI were
moderate (35.2 ± 8.0), although scores for both scales ranged widely (1-32 and 15-55,
respectively). Five participants scored at or above 20 on the EAT-26 (Table 4.1). There were
significant correlations between MDDI total score and EAT-26 total score (r = 0.31, p < 0.05),
weight suppression (r = 0.259, p < 0.05), rate of weight loss (r = 0.297, p < 0.05), and number of
contests completed (r = -0.32, p < 0.05).
The multiple regression considering the dependent variable MDDI total score and the
independent variables EAT-26 total score, in-season training volume, rate of weight loss, and
number of competitions, reached significance (F (4, 54) = 4.819, p < 0.01). The model included
EAT-26 total score (β = 0.298), rate of weight loss (β = 0.307), and number of competitions (β =
-0.257). There was no association between MDDI total score and in-season training volume. The
adjusted R2 of the model with the three included variables was 0.208 (Table 4.2).
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Table 4.1. Demographic characteristics, training volume, EAT-26 and MDDI results of participants (n = 60)
Mean ± SD 95% C.I. Range
Age (years) 29.6 ± 7.1 27.6 - 31.1 19-55
Current weight (kg) 85.0 ± 11.4 81.9 - 87.8 62-122
Current BMI (kg/m2) 27.5 ± 3.6 26.6 - 28.4 23-42
Highest weight (kg) 90.0 ± 11.5 87.6 - 93.45 66-132
Competition weight (kg) 75.8 ± 8.5 76.7 - 78.2 55-106
Years bodybuilding (years) 3.7 ± 3.2 2.8 - 4.5 1-15
Number of contests 4.0 ± 3.9 3.1 - 4.9 1-15
In-season duration (weeks) 23.0 ± 9.0 20.8 - 25.4 12-50
Off-season training volume (mins/week) 351.9 ± 57.8 337-9 - 367.1 240-480
In-season training volume (mins/week) 487.1 ± 117.8 458.7 - 515.8 285-900
EAT-26 8.5 ± 6.3 7.0 - 10.1 1-32
MDDI 35.2 ± 8.0 33.3 - 37.4 15-55
BMI, body mass index; EAT-26, Eating Attitudes Test 26-Items; MDDI, Muscle Dysmorphic Disorder Inventory; SD, standard
deviation; C.I., confidence interval.
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Table 4.2. Explanatory variables of the MDDI total score (simultaneous multiple linear regression)
Independent variable β p
EAT-26 0.298 0.018
Rate of weight loss 0.307 0.012
Total in-season training volume -0.102 0.393
Number of competitions -0.257 0.04
Adjusted R2 0.208
EAT-26, Eating Attitudes Test 26-Items
DISCUSSION
Main findings
The purpose of the present study was to identify correlates of MD symptomatology within a
sample of those pursuing a hyper-muscular body without the use of performance enhancing
drugs, specifically, competitive natural BB. In light of evidence suggesting an overlap between
ED symptomatology and MD psychopathology [81], our primary aims were to assess the
associations between disordered eating attitudes and behaviours and MD symptoms in
competitive, male, natural BB. A key finding of this study was the significant and positive
association of ED pathology with MD symptomatology, supporting the thesis that MD
symptomatology may include pathological eating attitudes and behaviours [81]. Interestingly,
our results also revealed that the rapidity of weight loss during competition preparation was
associated with MD symptoms, while conversely, no association was found between training
volume and MDDI. The wide range of MDDI scores reported in this sample supports previous
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research which indicates that participation in bodybuilding does not in itself infer MD; rather, a
proportion of participants may display increased MD symptomatology [117].
Muscle dysmorphia and eating disorder psychopathology
The moderate but wide range in MDDI scores in this sample (35.2 ± 8.0, 15-55) is comparable to
a sample of 60 competitive BB (38.5 ± 8.0), higher than 60 non-competitive BB (29.6 ± 6.6)
[50], and relatively higher than 25 BB and 126 resistance trained non-bodybuilders assessed
using a 21 item MDDI (45.5 ± 12.5, 45.9 ± 12.4, respectively) [85].
The notion that disordered eating psychopathology was found to be significantly associated with
MD symptomatology in this sample of competitive natural BB yields significant implications.
This result supports our hypothesis, and extends previous research that identified correlations
between disordered eating and MD in resistance trained samples [81], ultimately underscoring
the salience of disordered eating pathology in presentations of MD symptomatology. Although
steroid use has been accepted as an indicator for drive for muscularity and MD, natural BB have
previously demonstrated similar MD symptomatology to non-natural BB [51]. The association
found between EAT-26 and MDDI in this natural sample indicates those BB less likely to adopt
pharmacological practices in the pursuit of muscularity may still be at risk of other pathological
behaviours. Further, our results also suggest that the intensive nutritional regimens employed by
BB may not in themselves indicate psychopathology, but rather, it is when the eating behaviours
become disordered that MD symptomatology may increase. Further research is required to
examine this speculation. Given that ED symptomatology temporally fluctuates over time
dependent on the degree of engagement in safety- and symptomatic-behaviours [124], disordered
eating behaviours associated with MD would likely fluctuate too. This fluctuation would suggest
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the severity of MD symptomatology may vary in association with this ED variability, as well as
training and competition status [17].
Rate of weight loss
This is the first study to examine associations between rate of weight loss and symptoms of MD.
The rate at which participants reduced their body weight during competition preparation showed
the highest association with MD symptomatology. This may reflect, among BB experiencing
MD, an intolerance towards maintaining a lower body weight, due to the noted fear of loss of
muscularity [113]. If so, rather than taking a titrated approach to weight loss during competition
preparation, a rapid reduction in weight may assuage distress associated with reduced muscular
size by minimizing the period of reduced weight. The rapid reduction in weight is likely
mediated by significant dietary restraint, further underscoring the pathological nature of this
weight loss, and the potential link between MD and ED symptomatology. The association of rate
of weight loss suggests that what may differentiate BB displaying increased MD
symptomatology is the time period committed to achieve their weight loss. A rapid transition
between the extremes of size and leanness may be desired by those expressing greater MD
symptomatology.
Competition experience
Competition experience was inversely associated with MD symptomatology, suggesting
participants who had competed fewer times scored higher on the MDDI. This result opposes
those found in a previous study, which demonstrated no difference in MD symptoms between
experienced and novice female BB [48]. Gender-related aspects may moderate the associations
found in this study, therefore female muscularity concerns and bodybuilding require additional
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investigation. One possible explanation for this inverse association is that individuals susceptible
to, or already exhibiting features of MD, are drawn to the sport of bodybuilding in hopes of
appeasing symptoms. However, their cognitive and behavioral symptoms may impede longer-
term engagement in the sport, thus they discontinue competing. An alternative explanation may
be that MD symptoms are reduced as BB continue participation in the sport, suggesting longer-
term engagement in bodybuilding may help to alleviate MD behaviours.
The limitations of this study include a modest sample size (n = 60) which requires consideration
when interpreting the non-significant findings. A larger sample would have increased statistical
power to assess the association of the non-significant findings. The online, self-report nature of
the survey may preclude a confirmation of all participants meeting the specific competitive
bodybuilding inclusion criteria. Finally, a cross-sectional study design was employed and data
were not collected at a standardised time point during competition preparation. Symptoms of MD
may vary based on preparation phase and proximity of competition.
CONCLUSION
In conclusion, this study identified unique associations between ED psychopathology, rate of
weight loss, and bodybuilding experience, and MD symptomatology in a sample of male natural
BB. Longitudinal studies are vital to assess fluctuations in MD and ED symptoms during
competition preparation, and to directly assess the association between rate of weight loss and
MD symptomatology.
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ACKNOWLEDGEMENTS
This work was supported by a grant from Sports Dietitians Australia. The authors declare that
Sports Dietitians Australia had no influence on any part of the data analysis or interpretation
processes, including conclusions drawn.
HOC receives payments from Sports Dietitians Australia for professional presentations delivered
in a continuing education course for Sports Dietitians. All other authors declare no competing or
conflicts of interest.
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CHAPTER 5.
Do Bodybuilders Use Evidence Based Nutrition Strategies to Manipulate
Physique?
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Chapter 5: Dietary Strategies of Experienced Natural Bodybuilders
ABSTRACT
Background: Competitive bodybuilders (BB) undergo strict dietary and training practices to
achieve an extremely lean and muscular physique. The purpose of this study was to identify and
describe different dietary strategies used by BB, their rationale, and the sources of information
from which these strategies are gathered.
Method: In-depth interviews were conducted with seven experienced (10.4 ± 3.4 years
bodybuilding experience), male, natural BB. Participants were asked about training, dietary and
supplement practices, and information resources for bodybuilding strategies. Interviews were
transcribed verbatim and analysed using qualitative content analysis.
Results: During the off-season, energy intake was higher and less restricted than during the in-
season to aid in muscle hypertrophy. There was a focus on high protein intake with adequate
carbohydrate to permit high training loads. To create an energy deficit and loss of fat mass,
energy intake was gradually and progressively reduced during the in-season via a reduction in
carbohydrate and fat intake. The rationale for weekly higher carbohydrate re-feed days was to
off-set declines in metabolic rate and fatigue, while in the final “peak week” before competition,
the reasoning for fluid and sodium manipulation and carbohydrate loading was to enhance the
appearance of leanness and vascularity. Other BB, coaches and the internet were significant
sources of information.
Conclusion: Despite the common perception of extreme, non-evidence based regimens, these BB
reported predominantly using strategies which are recognised as evidence based, developed over
many years of experience. Additionally, novel strategies such as weekly re-feed days to enhance
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fat loss, and sodium and fluid manipulation, warrant further investigation to evaluate their
efficacy and safety.
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INTRODUCTION
Competitive bodybuilders (BB) undergo strict dietary and training practices to achieve an
extremely lean, muscular and symmetrical physique [10]. Along with resistance and aerobic
exercise [9], targeted energy and macronutrient intakes are followed to accumulate muscle mass
in the off-season, and reduce fat mass in the in-season [10]. However the specific dietary
strategies employed by BB and their underpinning rationale remain poorly understood.
Contemporary literature examining the dietary intakes of BB is limited [10], and given the
unique nature of competitive bodybuilding, it may be inappropriate to draw dietary parallels
from other sports. Although BB have been reported to follow extreme, non-evidence based
approaches, several dietary strategies developed in bodybuilding have recently been
scientifically validated, such as frequent dosing of protein [2], and intake of protein around
training [3]. Identifying the dietary strategies of modern BB, and exploring their underpinning
rationale, will provide exercise, sport and nutrition practitioners with an understanding of current
bodybuilding methods and insights to assist with negotiating practical and effective ways to
work towards bodybuilding goals. Furthermore, identifying such strategies will also generate
hypotheses for future research.
In-depth interviews allow a deep exploration of the discussed topic, enable the researchers to
enter new areas and produce rich data, with an additional benefit of uncovering practices that had
not been anticipated [125,126]. The purpose of this study was to use in-depth interviews to
identify and describe different dietary strategies used by male, natural BB, their rationale, and
the sources of education from which these strategies are gathered.
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METHODS
Participants were purposively selected by the research team based on expertise and experience in
competitive bodybuilding. To recruit participants, experienced BB known to the researchers
from previous studies were invited to participate. Adverts were placed on the website and social
media page of Australasian Natural Bodybuilding, and distributed at the Australasian Natural
Bodybuilding national titles in October 2015. To be included, participants needed to be male,
natural (drug-free) BB, aged 18 years and older, with five or more years of bodybuilding
experience. Participants were required to have competed in the bodybuilding category at national
or international level contests of drug-tested federations.
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Table 5.1. Individual participant characteristics of seven experienced male, natural bodybuilders participating in in-depth interviews
Participant Age (years) Years of Number of Competition category Level of competition and
bodybuilding competitions competition success
Oliver 43 8 15 Masters; weight category National (fourth place)
Luke 40 17 15 Opens; weight category International (winner); Pro card
Kyle 25 7 15 Opens; weight category International (winner); Pro card
Keith 22 7 8 Teenage; junior National (winner)
Ben 30 13 12 Opens; weight category National (fourth place)
Harry 32 10 9 Opens; weight category State (winner); Pro card
Will 65 11 26 Grand masters; ultra-grand masters International (winner)
Masters, >40 years; Teenage, <19 years; Junior, 19-22 years; Grand masters, >50 years; Ultra-grand masters, >60 years
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Procedures
The interviews were conducted by three members of the research team between March 2015 and
February 2016. Interviews (78-124 minutes) were held by telephone or Skype. The combined
duration of all interviews was 11 hours. Interviews captured participant demographic
characteristics including age, years of bodybuilding experience, number of previous
competitions, and competition success. Participants were asked about their training, dietary,
supplement and competition preparation practices, the rationale behind these practices, and
where they obtained information about nutrition and training. By the end of the last interview, no
new major themes were emerging. Saturation was confirmed following coding of the data,
therefore the decision was made to cease further data collection.
Analysis
All interviews were digitally recorded and transcribed by a commercial transcription service
(waywithwords.com). Transcripts were returned to participants for verification and correction to
ensure the transcription correctly reflected the content of their interview. One participant
returned the transcript with minor emendations which was included in the analysis. Notes were
taken during all interviews and used to clarify transcription errors, and to confirm the meaning of
spoken phrases during the coding process. To protect the identity of the participants a
pseudonym was used in the final transcripts. All interviews were conducted prior to thematic
analysis via qualitative content analysis using qualitative data analysis software (NVivo version
10.0, QSR International PTY Ltd., Doncaster, Australia, 2012). Coding was undertaken by one
researcher (LM) with assistance from a second (FE) and overseen by a third researcher
experienced in qualitative research (JG), who reviewed any queries. As coding of data
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proceeded, underlying themes emerged as participants discussed topics introduced by the
interviewers, and was not constrained by the original structure of the interview. Identification of
themes recurring through and across interviews was achieved through a process of reading,
coding, code category refinement, rereading and code checking, and analysis of developing
concepts. A coding journal with an audit trail of changes in coding and code refinement was
maintained by the primary coder (LM) to maintain transparency of the qualitative analysis
process.
Counts of coded talk were available from the analysis software by grouping for diet, training,
supplements, and information and education. Counts within themes could have more than one
section of speech by the same participant. To avoid researcher bias during the data interpretation
process based on pre-conceived ideas of bodybuilding practices, identified themes were sent to
participants, who confirmed correct interpretation.
Ethical approval was received from the University of Sydney Human Ethics Committee, project
number 2014/968. Written informed consent was provided by all participants. Participation was
voluntary and identity of participants and confidentiality of their responses was ensured.
RESULTS
A total of seven BB (10.4 ± 3.4 years bodybuilding experience) meeting inclusion criteria
responded to advertisements and consented to participate. Participant characteristics are
summarised in Table 5.1. Four participants had competed at national, and three at international
level. Two participants had competed professionally, with an additional one participant eligible
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to compete professionally. Example quotes are presented in Table 5.2. Selected quotes were
representative of themes identified during interviews.
Diet
Off-season
All participants consumed four to six meals per day, with a targeted energy and macro nutrient
intake aimed to support muscular hypertrophy, “I’ve got 250 [g/day] protein, and at the moment
I’ll divvy my fats and carbs up, so 250 [g] protein, 680 [g] carb and about 100, 110 [g] on fats,
somewhere there,” (Keith). Each meal featured a large serving of a high protein food and a large
serving of vegetables, “In the morning I start off with 100 grams of oats and six whole eggs.
That’s at around about 7:00 am. At 9:30 am will be 200 grams of salmon and 200 grams of green
veg,” (Luke). The off-season diet contained a wide variety of foods, including processed foods
such as ice cream, and was less regimented than the in-season.
In-season
While the pattern and style of the diet was similar to the off-season, the in-season intake was
more structured, “It’s more structured, it’s perfect” (Kyle), and usually carefully measured, “I
will split a grain of rice, if it made it hit exactly the grammage (sic) I want,” (Keith). Serving
sizes were also reduced as competition approached.
Progressive reductions in carbohydrate and fat intake were used to create then maintain an
energy deficit to elicit fat loss (Figure 5.1). Protein intake remained similar to the off-season to
prevent loss of lean mass. Carbohydrate intake was carefully timed around exercise (pre-, during
and post-training) to ensure training was optimised.
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Figure 5.1. Doughnut chart representation of the stages of bodybuilding preparation, including key dietary strategies used, as reported
by seven experienced male, competitive natural bodybuilders participating in in-depth interviews. Duration of stages are approximate
and vary between bodybuilders.
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Re-feed days
Re-feed days were commonly used during the in-season and primarily aimed to increase energy
intake through elevated carbohydrate consumption. Participants discussed positive outcomes
including increased glycogen stores which aid training performance, mental recovery, and
prevention of further adaptive downgrades in energy expenditure, stimulating weight loss. One
participant described it as a “metabolic jumpstart” (Oliver). Compared to preparations without
re-feed days, participants discussed consuming more total energy, over a shorter preparation,
achieving better fat loss and muscle retention using weekly re-feed days.
Peak week
The week prior to the contest was defined as a “peak week” where particular short-term
strategies were used to achieve the leanest possible appearance. Six participants used a modified
carbohydrate loading regimen (tapered training and increased carbohydrate intake) [127] in order
to increase glycogen and theoretically increase muscle volume. Four participants had previously
used the classic loading method, which involved a three day glycogen depletion and then super-
compensation [128], however found this did not produce significant changes in appearance,
describing this method as, “stressful,” (Ben) “mentally that would be really bad,” (Kyle) and,
“you’re just a wreck” (Luke).
All seven participants discussed the practice of water loading and cutting during peak week.
Users of this strategy consumed more than 10 litres of water per day early in the week, then
reduced water intake each day leading into the contest. The rationale for this strategy was to
increase fluid excretion and to “go after subcutaneous water” (Will), which would purportedly
provide a leaner, more vascular appearance. Results were not effective enough for these
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participants to warrant continuation of this strategy in subsequent competition preparations.
Other participants commented that the idea of water loading and cutting does not make sense
physiologically: “muscle is about 70% water. If you were dehydrated, the muscles are going to
look smaller as well,” (Harry).
Sodium manipulation was another strategy used during the peak week to reduce body water and
produce a leaner appearance. Three participants discussed previously using this strategy,
whereby sodium intake was greatly increased for three days, followed by a complete restriction
of salt for three days. However, they each reported that the results were inconsistent, and
discontinued the strategy.
Competition day
Six participants discussed diet strategies used on the day of competition. Two consumed sodium
prior to posing on stage to get a greater “pump”. Small doses of high glycaemic index
carbohydrates were consumed by two participants. One justified this by saying, “That was just to
keep you ticking, when you’re feeling that depleted, just to keep you propped up,” (Oliver) while
the other participant commented, “That’s for sugars, to get the pump” (Kyle). Two participants
did not change from their usual intake on competition day.
Post-competition
Participants reported the post-competition diet was more relaxed (n = 5), and included some
“treat” foods not consumed during the in-season. Overindulgence and the experience of feeling
physically sick from the change in diet pattern (n = 2) was reported. Weight regain was common
and could be substantial (8-10 kg over three weeks in one case). Limited time off dieting was
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reported by three participants to avoid detrimental physique changes. Participants reported
negative changes in physique were common post-competition.
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Table 5.2. Thematic summary of dietary practices and sources of dietary education, in seven experienced male, competitive natural
bodybuilders participating in in-depth interviews.
Themes Subthemes Number of Indicative quotes

references
Off-season
Meals 47 “Lunch would be, again, probably a 200 gram chicken breast, one cooked cup of brown rice
and maybe about 100 grams of green veggies… Meal four, which is afternoon tea, which, prior
to gym, is exactly the same as the meal before, the lunch meal, so the chicken, rice, veggie
one, then after gym, which would be dinner, would be usually a meat, a red meat, so a steak,
maybe a 200 gram, you know, rump steak, another cooked cup of brown rice and some veggies,
and that’s dinner.” (Luke)
“I have a dose of protein and carbohydrate with each meal…for protein I usually cycle between
a few different sources. I use whey protein, and then of course the one that is salmon, white
flesh fish, kangaroo and beef, they're going to be my primary, I’ll cycle between those different
protein sources” (Keith)
Carbohydrates 6 “I dose my carbohydrate really high, because I want to make sure that my glucose metabolism
is the best it possibly can be, because I will always diet on a high carbohydrate template to
keep my training intensity high.” (Keith)
Protein 3 “Anywhere from 2.2 to 2.9 grams per kilo body weight. That’s not total lean mass but just my
total body weight.” (Keith)
Fat 3 “I will direct my fat anywhere from 0.5 to a maximum 1.2 grams per kilo, so I keep my fats
relatively moderate.” (Keith)
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Energy 3 “So I might sit at anywhere from, I used to sit at between 4500 and 5000 calories [per day] in
my off season.” (Keith)
In-season
Meals 34 “Each meal, just to start cutting the calories a little bit. The egg yolks would go from the eggs
at night, just down to egg white, just, again, to start cutting some calories, and they would
slowly go down, so in four eggs would go only three yolks. And then a couple of weeks later
it’ll be down to two yolks and then one yolk.” (Luke)
Carbohydrates 16 “The carb value will slowly come down. Around training, it’s going to remain quite high and
in the morning it’s high-ish. But, yes, the carb value will slowly come down.” (Kyle)
“Usually I make a drop, and I will either dig from fats, or carbs, or a combination of. I’m
generally in favor of dropping carbohydrates initially and then digging into fats later,” (Keith)
“I don't have an issue with energy when I have my carbs around my training time, so pre-,
intra- and post-workout is when I consume the majority of my carbohydrates through the day,”
(Luke)
“I will actually introduce more carbohydrate for fuel, you know, to fuel the requirement to get
through, say, a 35-minute interval session,” (Oliver)
Protein 7 “I normally keep protein static. I’ll set it slightly higher than the off-season at the start of my
prep and then just keep it the same throughout even if I lose weight. So if you were to look at
it from a gram per kilogram basis, it would look like it’s going up, but it’s the same gram
amount. So I’ll start at 225 grams protein and just keep that throughout, so that will be roughly
like 2.3, 2.4 grams per kg,” (Harry)
Fat 7 “I think I start with my fat probably around 25% [of energy] and then it might get as low as
15% to 20% at the end… So a day at the very end might be 40 grams of fat.” (Harry)
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“So for example, I might start [the in-season] with my fat around 65 grams [per day] and then
that will only get decreased by maximum of 25 grams while the carbohydrates can drop from,
you know, 250 [g] at the start or 275 [g] all the way down to 100 [g] at the end on my low
days,” (Harry)
Energy 15 “So I probably start on average about 2400-2500 calories [per day] across the seven days,
and I probably finish around 2000 or 1900 [per day] with probably a two-fold increase in
cardio.” (Harry)
Refeed days
Refeed days 32 “I have one day that’s closer to my, like my off-season calories. So that might be like 2800
calories on a day predominantly increasing carbohydrate. That’s to kind of stimulate further
losses to prevent some of the downgrades in my energy expenditure you could say, and to
replenish glycogen, to feel mentally refreshed, to get a break in.” (Harry)
Peak week
Carbohydrate 39 “So normally, I will increase my carbohydrates early in the week, sometime around Tuesday
loading or Wednesday for Saturday show, taper them back down but not all the way down where
they were at the lowest low. So maybe 400 [grams] for a day and then down to say 350 [g/d],
300 [g/d], 250 [g/d], and then on Friday and Saturday, the show, I will be closer to 300 or the
400 [g/d] range to kind of fill back out. So it’s basically kind of like a modified carb loading
strategy an endurance athlete would use.” (Harry)
“The idea is to, you know, wring out the sponge, I suppose, of the last stage of leaning out in
those depletion days, and they would be paired with high volume gym work, and the theory
behind it was, apparently, to swell the muscle belly, it’s not a vascular thing, it was actually
just increased overall fullness of the muscle once you flooded it with carbohydrate.” (Oliver)
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“He felt I looked my best, you know, 24 hours prior to the competition, so all these little things
you've sort of got to take note of and you think, all right, I look this good now, it'll be even
better tomorrow, and in my case it wasn’t, and you think, well, maybe we just do a carb load
of two days next time around instead of three, if that works perfectly for that timeframe.”
(Oliver)
Water loading 17 “So then the water is still going in around about ten litres a day… then the water would start
to, the water would start to cut back again as well and that was, sort of, you know, Thursday
might still be up around about the ten litres, but then Friday and Saturday, Friday might cut
down to around about four litres and then Saturday was two litres prior to, sort of, two o’clock
or something like that… And then, you know, nothing, yes.” (Luke)
“Muscle is 70% water and I’m not aware of any mechanism that tells the body to go after
subcutaneous water. If you’re going to dehydrate, it’s going to be from everywhere and why
are you pulling 70, you know, why are you pulling so much volume out of your muscles
because you’re really wanting your muscles to be volumised?” (Will)
“Those things don’t work for me,” (Ben)
“A terrible, terrible thing to put your body through,” (Luke)
Sodium 12 “So on the Monday, Tuesday, Wednesday would be salt in each meal, with probably around
manipulation about two grams of salt, a gram, yes, one or two grams of salt with each meal, which was great,
but then by Wednesday, oh man, you’ve just had this salty fishy chicken meal, it’s just
absolutely disgusting and terrible. And then on the Thursday, Friday, Saturday, the salt would
be dropped out.” (Luke)
“It’s such a variable which can be really, really… Completely screw you up… Like, if you
diet for 16 weeks and then the last two days you mess around with your sodium, and then you
come on the stage bloated, it’s such a… It’s such a bummer.” (Kyle)
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Post-competition
Post-competition 15 “You kind of work yourself up into a frenzy,” (Ben)
“It’s not so much hunger, it’s more so flavour. It’s more sort of like I want a pizza because I
haven’t had it in months,” (Kyle)
“We eat everything we haven’t eaten all year,” (Will)
Supplements
Protein powders 23 “I take, obviously, protein powders. I take WPI [whey protein isolate] just because it’s, you
know, it’s fast to absorb, or whatever… And then obviously, yes, and then obviously casein
at night.” (Kyle)
Creatine 15 “I don't think I’ve stopped taking creatine monohydrate since 2004 to be honest.” (Harry)
“The only thing I ever saw a result from was Creatine. My wife would always say, ‘You’ve
started using that Creatine again, haven't you?’ I’d say, ‘Why?’ She’d say, ‘Oh, you’ve got
that swollen look about you, you know, that volumised look.’” (Will)
Glutamine 10 “Glutamine is ten grams post training in the off-season. Once I’m in diet mode for comp,
especially the last four or five weeks, I up that to around about 40 grams a day.” (Luke)
“It’s supposed to help with your immune system and anti-catabolic, so being on a lower
calorie diet, I’m trying to stop muscle catabolism and Glutamine is supposed to help out.
And the last three times that I’ve dieted, I’ve, before that, the last four weeks I used to
always get sick, always catch a cold or something. The last three times I’ve dieted, I’ve
upped, had 40 grams of Glutamine a day for the last four or five weeks and I haven't gotten
sick.” (Luke)
Pre-workouts 9 “And it worked really well. It was, I was really focused in the gym… I just wanted to keep
on training. I was just thinking about training, thinking about what I was doing at that time
and was getting really into, into that workout.” (Luke)
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“I’m quite sensitive to caffeine by itself and I’ve had some of those pre-workouts and not
gotten to sleep until one or two o’clock in the morning and that’s having had it at 4:30 in the
afternoon, five o’clock in the afternoon. So I’ve actually stayed away from those because of
that.” (Luke)
Sources of education
Other 15 “He’s just been competing for, I don’t know, like, a lot of years, so, yes. He kind of, he is the
bodybuilders guy who I’ll run everything by him. If I have an idea, like, should I do this maybe with my,
you know, carbs, or whatever, I’ll run it by him first and he’ll give the okay or he’ll say,
maybe just try this.” (Kyle)
“They might have good body parts and, you know, if you get your legs looking like that or
your back looking like that and you see what sport they’ve come from or what type of
training they do for that body part, but then again, it may just come down to a genetic
predisposition for that particular body part.” (Luke)
Internet 15 “When I first got into it, I was not nearly as versed in the, I guess, the empirical evidence
kind of way of thinking. I was reading posts online, bodybuilding.com forums. I was a
regular on it.” (Harry)
“Just Googling, you know, bodybuilding, you’ll get a… you will get some good information
but you… they don't necessarily know what is good and what’s bad.” (Harry)
“The internet’s going to be everyone’s first port of call,” (Kyle)
“The internet is littered with online gurus,” (Oliver)
“It then just comes back to social media, and it's the problem what I call the good-looking
trainer. So the most popular ones with the most likes, whatever, let's face it, they’re the good-
looking blokes or the good-looking girls, most of which, unfortunately, don’t have that much
between their ears but they have a huge following because most of their posts they’ve got
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their shirt off or they walk around in a bikini and everyone thinks they look great, so
whatever they’re about to tell you must be good, rather than some rough-headed coach who's
in his 60s who's done this sort of stuff all his life,” (Oliver)
“He’s 17 years old and he’s following all these guys on Instagram and Facebook and things
like that, and I don't think they know. I’ve told him, ‘Mate, he’s not natural. Sure, have that
as an attainable goal in your mind. If you fall short of that, you’re still going to be looking
great.’ But I said, ‘Be under no illusion that that is natural,’ so I think a lot of the guys don't
know. They’re naive to it,” (Luke)
Science and 7 “I did very quickly gravitate towards more what I perceived to be more science-based and
evidence based evidence-based approaches rather than just what were the big guys doing. To me, it was
sources relatively intuitive that some genetic freak on a butt load of steroids and what worked for
him would probably not be the same thing as what works for a more or less average
bodybuilder who wasn’t going to be taking drugs.” (Harry)
Coaches 6 “There’s not a whole lot of open information and sort of themes it's just passed down from
coaches in a tradition… I suppose I learn the majority of what I do through coaches and
colleagues I worked with over time.” (Keith)
“There are also a lot of “coaches” out there who don't, who are the same as them, you know.
Most people, they compete in one or two shows and, you know, read a few magazine articles
and they think they know how to be a coach. So the average coach is not a… the average
coach doesn't even have a bachelor degree to be honest.” (Harry)
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Supplements
All participants used one or more dietary supplements. In total, 18 different supplement types
were mentioned. Creatine (3-15 g/d) was used by all participants with doses consumed either
pre- or post-workout, with a meal, or a combination of these. Protein powders were also used by
all participants either as a post-training supplement (n = 4) or as a source of protein during meals
(n = 4). “Pre-workout” supplements designed to stimulate enhanced training was discussed by
four participants, one of which used these for their caffeine content, while the others
discontinued use due to side effects (insomnia, increased and variable heart rate, and increased
respiratory rate). Participants reported these experiences were: “absolutely horrible” (Ben), “I
just can’t stand it, frankly,” (Will) and “it’s counter-productive, so I don’t use it” (Will). Other
supplements more commonly used were fish oil (four participants), glutamine (three participants)
and testosterone boosters (three participants).
Sources of education
The most commonly reported sources of education were the internet including bodybuilding and
strength and conditioning websites and forums (n = 5), successful BB (n = 4), and bodybuilding
coaches (n = 4). The quality of information available on the internet was considered to be both
reputable and non-reputable. Concerns were raised by two participants regarding information on
social media, where images and information may be unrealistic and deceptive, and potentially
damaging for novices. Bodybuilding coaches were also commonly used, although one participant
commented on the varying levels of coach knowledge, with many relying on their own
competition experience.
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DISCUSSION
The rationale and use of several key dietary strategies emerged from this study, including regular
doses of protein throughout the day to maximise accrual and maintenance of lean mass, and
utilising carbohydrate foods as a fuel source pre-, during and post-exercise. Weekly re-feed days
were implemented during the in-season, to provide both a psychological rest and reportedly
assist with fat loss. During the peak week BB followed extreme strategies including water and
sodium manipulation in an attempt to achieve the leanest physique.
Throughout both the off-season and in-season, participants reported consuming large, frequent
servings of protein to build and maintain muscle mass, which is empirically supported in the
research literature [2]. The optimal dose to achieve this maximal muscle protein synthesis is
accepted to be 20-30 g of high quality protein [2,129], with studies supporting that protein
ingestion above this dose is oxidised [129]. Recent findings suggest the amount of muscle mass
trained may be a determinant of protein requirements post-exercise. Greater myofibrillar
fractional synthetic rate was achieved with a 40 versus 20 g dose of whey protein following
whole-body resistance exercise [130]. Therefore, a dose up to 40 g may produce increased
protein synthesis following resistance exercise incorporating large amounts of muscle, such as
those followed by BB.
The high protein meals consumed by participants in this study likely exceeded the 20-40 g dose
for maximal protein synthesis, potentially resulting in increased protein oxidation. However, the
anabolic response to protein ingestion is a combination of protein synthesis and breakdown.
Greater protein net balance has been produced from a 70 g versus 40 g dose of protein, primarily
by decreasing the rate of protein breakdown [131]. Therefore, the frequent higher dosed protein
meals consumed by BB may not only assist in supporting protein synthesis but also in reducing
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protein degradation during heavy resistance training. Furthermore, protein consumed by
participants was primarily as part of a mixed nutrient meal, rather than a pure protein meal
typically prescribed in the laboratory setting [2,129,130]. Carbohydrate and fat consumed in
these meals would slow the digestive process, and time course of amino acid delivery to muscle
cells. Any protein consumed in addition to the optimal 20-40 g dose for muscle protein synthesis
in these mixed meals may be utilised for anabolic processes over the time course of digestion.
A protein intake of 2.3-3.1 g/kg of fat free mass has been suggested to be the most protective
against losses of lean tissue during energy restriction in lean resistance trained athletes [132]. A
higher protein requirement may be justified for BB during competition preparation, as they
perform resistance and cardiovascular training, reduce energy intake, and achieve a lean
condition [1]. Therefore the higher protein intake during the in-season to prevent loss of muscle
mass in these participants may be justified.
During the in-season period, carbohydrate consumption was carefully timed around exercise.
Glycogen is an important fuel substrate during resistance training [133], with glycogen depletion
reported to reduce exercise performance [134]. Carbohydrate supplementation before and during
resistance exercise improves performance of high volume, exhaustive exercise [135,136], a
characteristic typical of bodybuilding training [9]. During in-season energy restriction,
carbohydrate consumption following resistance training would assist in the replenishment of
muscle glycogen, facilitating improved recovery and enhanced capacity to maintain training
volume and intensity in subsequent sessions [137]. BB commonly perform multiple training
sessions in a single day during the in-season, typically an aerobic and a resistance training
session [9], therefore post-exercise carbohydrate ingestion would be important for maintaining
training consistency.
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Study participants discussed using a weekly re-feed day during the in-season period to boost
training performance, provide a mental rest, and assist in body fat reductions. Intermittent energy
restriction for weight loss has garnered significant recent clinical and research interest due to its
hypothetical capacity to alleviate metabolic and behavioural adaptations associated with reduced
energy intake. These adaptations include increased appetite associated with neuropeptide
expression [138-140], reduced energy cost of physical activity [141], and hormonal effects that
promote fat deposition and loss of lean mass [138,139]. Intermittent energy restriction, or
“metabolic rest periods,” have been shown to achieve similar weight and fat loss as continuous
energy restriction, despite a higher overall energy intake [140,141]. Animal studies have shown
that acute energy restoration (< 24 hours) can attenuate, or even abolish the orexigenic
neuropeptide expression resulting from energy restriction [39,142]. The short-term restoration of
energy balance, particularly through increased carbohydrate ingestion, would also increase
intramuscular glycogen stores allowing greater resistance exercise performance [143].
During the peak week, participants discussed the use of several strategies to assist in achieving a
lean, vascular appearance. Carbohydrate loading, and fluid and sodium manipulation had all
been used by participants, with varying success. Only one empirical study has directly assessed
changes in muscle girth from carbohydrate loading, finding no significant changes in relaxed or
tensed muscle girths following a three-day carbohydrate depletion and subsequent three-day
carbohydrate load [144]. This suggests carbohydrate loading may not produce the desired
increase in muscle volume. Fluid and sodium manipulation to enhance visual appearance has not
been empirically studied, however the desired improvement in muscle size and definition may
not be obtained. Manipulating fluid intake to cause dehydration will result in a loss of fluid from
all compartments, not just subcutaneous tissue [145,146]. Muscle water content is reduced [145],
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which may reduce muscle volume, an undesirable outcome for a competitive BB. Additionally,
plasma volume is decreased with dehydration [145]; the common practice of “pumping up” prior
to posing on stage may be less effective in increasing muscle size due to the detrimental effects
of reduced plasma volume on muscle blood flow and volume [1]. Similarly, the manipulations in
sodium consumption will not change the volume of the intracellular or extracellular
compartments, only modifying urinary sodium output [147].
In the weeks following competition, participants reported an increased energy intake from a
wider variety of foods, often leading to significant weight regain. Daily energy intake in the first
two days post-competition was approximately twice that of the four weeks pre-competition in
female BB, with an increase in body mass of 3.9 kg in the three weeks after competition [27].
Similarly, an average weight regain of 5.9 kg was reported in a group of male BB, with 46% of
these participants reporting binge eating episodes in the days immediately following competing
[28].
Supplement use, predominantly creatine and protein powders, was common amongst the BB
interviewed, while “pre-workout” formulas had been trialled, with unwanted side-effects
commonly reported. Protein and creatine supplementation have been demonstrated to be
effective for increasing lean mass and strength [148,149]. The efficacy of so-called “pre-
workout” supplements is yet to be confirmed. These products contain a combination of key
ingredients such as creatine, caffeine, arginine, β-alanine and selected plant extracts [1,150,151].
Efficacy would be dependent on the supplement ingredients, and some produce side effects such
as acute increases in blood pressure and difficulty sleeping [150].
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BB have historically relied on magazines, other successful competitors, and more recently the
internet, for information on dietary strategies [10]. This study identified the internet, in particular
bodybuilding and strength and conditioning websites and forums, as a primary source of
education, as well as other BB and coaches. In addition to the internet [152], athletes have
previously identified family members, other athletes, coaches and registered dietitians as
important sources of information regarding nutrition and dietary supplements [64,153,154].
Dietitians were not identified as sources of information by participants in this study, suggesting
that their role needs better promotion amongst BB. With skills in dietary assessment, planning
and body composition measurement, as well as evidence based strategies demonstrated to assist
in the accrual of lean mass, dietitians have much expertise to provide BB, particularly novices
who were considered by participants in this study to be vulnerable to inappropriate strategies
promoted on the internet.
Study limitations include use of a small, homogeneous sample. Experienced BB were
purposively sampled, therefore these results may not reflect the wider bodybuilding population,
particularly inexperienced BB. Six of the seven participants had taken part in previous research
which may introduce bias towards BB with greater access to education and inclined to follow a
more evidence-based approach. Due to this potential bias, further research in a wider
bodybuilding population is warranted.
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CONCLUSION
Despite the common perception that BB follow extreme, unproven methods, the experienced BB
in this study reported predominantly using dietary strategies which are recognised as evidence
based. Inexperienced BB however may be vulnerable to more extreme strategies based on advice
which is widely disseminated on the internet and social media.
Novel strategies identified in this study warrant further investigation. Intermittent energy
restriction, and hormonal responses associated with short-term energy restoration, should be
studied to determine benefits for weight loss whilst maintaining lean mass in both lean-athletic
and obese populations. Peak week strategies implemented by BB, such as fluid and sodium
manipulation, require further investigation to determine their efficacy and safety.
ACKNOWLEDGEMENTS
This work was supported by the Sports Dietitians Australia.
The authors declare no conflicts of interest. HOC receives payments from Sports Dietitians
Australia for professional presentations delivered in a continuing education course for Sports
Dietitians.
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CHAPTER 6.
Physiological Implications of Preparing for a Natural Male Bodybuilding
Competition
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Chapter 6: Physiological Implications of Competition Preparation
ABSTRACT
Background: This study aimed to describe the body composition and physiological changes
which take place during the in-season and recovery periods of a group of natural bodybuilders.
Method: Natural male bodybuilders (n = 9) were assessed 16 (PRE16), 8 (8PRE) and 1 (PRE1)
week(s) before, and 4 (POST4) weeks after a bodybuilding competition. Assessments included
body composition, resting metabolic rate (RMR), serum hormones, and seven day weighed food
and training diaries. Change in parameters were assessed using repeated measures analysis of
variance.
Results: Dietary protein intake remained high throughout the study period (2.8 - 3.1 g·kg-1·d-1).
Fat mass was significantly reduced from PRE16 to PRE1 (8.8 ± 3.1 vs. 5.3 ± 2.4 kg, p < 0.01).
There was a small decrease in lean mass from PRE8 to PRE1 (71.8 ± 9.1 vs. 70.9 ± 9.1 kg, p <
0.05). No changes in RMR were observed (p > 0.05). Large reductions in total- and free-
testosterone (16.4 ± 4.4 vs. 10.1 ± 3.6 nmol·L-1, p < 0.05; 229.3 ± 72.4 vs. 116.8 ± 76.9 pmol·L-1,
p < 0.05), and IGF-1 (27.0 ± 7.7 vs. 19.9 ± 7.6 nmol·L-1, p < 0.05) occurred between PRE16 and
PRE1. Lean mass and IGF-1 increased from PRE1 to POST4 (70.9 ± 9.1 vs. 72.5 ± 8.5 kg, p <
0.05; 19.9 ± 7.6 vs. 25.4 ± 9.3 nmol·L-1, p < 0.05).
Conclusion: Despite substantial reductions in fat mass, participants maintained almost all of their
lean mass. The reduction in anabolic hormone concentration is likely attributable to the
prolonged negative energy balance, despite a high dietary protein intake.
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INTRODUCTION
Athlete physique traits have been associated with success in a variety of sports, including
swimming [155], track and field [156], and rugby [157,158], as well as aesthetically judged
sports such as gymnastics [159] and bodybuilding [160]. Competitive BB are judged on
muscular size, symmetry and leanness, and employ a long-term approach to competition
preparation [9]. In doing so, BB achieve the pinnacle of body composition translation for
physique-based athletes: extreme leanness and hypermuscularity [13]. Rigorous diet and training
practices are followed, and a range of dietary supplements are utilised [9,10]. The off-season
period, lasting months to years, targets hypertrophy, and is characterised by an energy dense,
high protein diet, plus large volumes of high intensity resistance training [9,10,161]. The in-
season focuses on reductions in fat mass while maintaining lean mass through manipulation of
diet and exercise variables [9,10]. In-season duration varies between athletes, typically lasting
12-26 weeks [161].
Given the extreme outcomes achieved, efforts have been made to describe the diet and training
programs employed by BB, along with physiological adaptations that occur during the in-season.
Early evidence from longitudinal research using small cohorts of males and females suggested
BB make progressive reductions in energy intake, and increases in aerobic training volume,
which are associated with desired decreases in fat mass during this phase [105,162]. More recent
evidence has corroborated this and further shown that significant changes in anabolic hormone
concentrations occur [163]. However, numerous studies have also suggested that BB may
experience significant loss of lean mass during the in-season period [105], which is an
undesirable outcome considering that they are judged on muscularity as well as leanness. On the
basis of case study observations, there appears to be large associated reductions in resting
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metabolic rate (RMR) [12], which is likely a compensatory physiological response to reduce
energy expenditure and mitigate the energy deficit, ultimately preventing further reductions in
body mass [35]. From a bodybuilding perspective, this may limit fat mass loss, while potentially
impeding muscle mass maintenance.
Although behavioural changes of BB, and their physiological associations, have individually
been described, comprehensive longitudinal data in natural BB is currently limited to small
cohorts and case studies [11-13,105,162,163]. Given the increasing popularity of competitive
bodybuilding [1], and the success of BB in achieving high degrees of muscularity and leanness,
gaining more data to inform and potentially better understand bodybuilding practices and the
physiological implications is warranted.
Taking current evidence into account, there is a need to document longitudinal physiological
responses of male, natural BB to competition preparation. Thus, utilising a cohort of high calibre
competitors, this prospective study aimed to describe the body composition and physiological
changes experienced by male, natural BB during the in-season and recovery periods of a
bodybuilding contest. Based on documented changes associated with long-term energy
restriction and high energy expenditure, we hypothesised the BB would experience large
reductions in fat mass with concomitant reductions in lean mass, RMR, and anabolic hormones
during the in-season period.
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METHODS
Participants
To be eligible for inclusion, participants had to be male, drug-free BB, ≥18 years of age,
preparing for competition in a natural federation. Recruitment methods included advertisements
on the website and social media page of the Australasian Natural Bodybuilding and other social
media pages. Advertisements were distributed at the Australasian Natural Bodybuilding national
contest in October 2015, and to a database of BB held by the researchers from previous studies.
Written informed consent was provided by all participants. Ethics approval was obtained from
the University of Sydney Human Ethics Committee, project number 2015/425.
Procedures
A detailed description of testing protocols is included in Appendix D. Four testing sessions were
conducted over a 20 week period. Three tests occurred during competition preparation (16, 8 and
1 week(s) pre-competition), and one occurred during competition recovery (4 weeks post-
competition). The 16 week pre-competition testing duration was selected based on previous
reports indicating average in-season preparation periods of 16 weeks in natural BB [161].
Participants presented to the laboratory between 0600-0800 hours after a 12 hour food and fluid
fast, and having been instructed to abstain from caffeine, alcohol and exercise for 12 hours.
Participants were advised to avoid physical activity, such as walking, jogging and cycling, the
morning of assessment. A urine sample was collected upon arrival. All participants presented in
a euhydrated state, confirmed via urinary specific gravity assessment (UG-α, Atago, Japan).
Stature (WS220S stadiometer, Wedderburn, Sydney, Australia) and mass (Wildcat, Mettler
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Toledo, Ohio, United States) in swimwear were measured according to standardised protocols
[164], before a battery of examinations was performed in the following order.
Bioelectrical Impedance Analysis (BIA)
After 10 minutes rest in a supine position, bioimpedance spectroscopy was used to estimate total
body water (TBW), intracellular fluid (ICF), and extracellular fluid (ECF). According to
manufacturer recommendations (IMP SFB7, ImpediMed, Queensland, Australia), dual tab
electrodes were placed on the hand and foot on the right side of the body. The device scans 256
frequencies, and utilises Cole modelling with Hanai mixture theory . The average of three trials
was used to calculate TBW, ICF, and ECF. Values were calculated internal to the BIA device.
Resting Metabolic Rate (Resting energy expenditure)
Resting energy expenditure was estimated using indirect calorimetry with a metabolic cart
(Quark CPET, COSMED, Rome, Italy). Participants remained rested after BIA measurement in
the same position. Expired respiratory gas analysis began with the participant instructed to
breathe normally. Expired air was collected using a face mask for 30 minutes, measured at 30-
second intervals. A five minute period with VO2 and VCO2 coefficient of variation ≤ 10% during
the second 15 minutes was used to quantify resting energy expenditure and respiratory exchange
ratio [165]. Participants were instructed to lie still but not fall asleep. The gas analyser was
calibrated immediately prior to testing with a known gas concentration (5% CO2, 16% O2, 79%
N2), and a three litre calibration syringe (Hans Rudolf, USA) was used to calibrate the volume
transducer. Testing took place in a quiet, dimly lit, thermo-neutral room.
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Dual-energy X-Ray Absorptiometry (DXA)
A whole body DXA scanner, (Lunar Prodigy, GE Medical Systems, Madison, WI) was used to
estimate body composition. Total fat mass and lean mass were determined using the system's
software package (enCORE 2011 version 13.60.033; GE Healthcare). The DXA was calibrated
with phantoms as per manufacturer guidelines each day prior to measurement. Participants were
placed in a standardised position on the scanning bed (feet neutral, ankles strapped together,
arms straight, palms down and isolated from the body, face up with neutral chin) [166], wearing
only swimwear. Measurements were performed by a licensed operator, with excellent test-retest
reliability for fat mass (ICC: 0.998; CV: 3.7%) and lean mass (ICC: 0.999; CV: 3.7%). The
typical error of measurement for a Lunar Prodigy established by repeat measurements has been
reported as 0.4% and 1.9% for lean mass and fat mass, respectively [167].
Anthropometry
An accredited anthropometrist (level 1 ISAK) with a technical error of measurement of 2.4%
used surface anthropometry (Harpenden skinfold calipers, Baty International, West Sussex, UK)
to quantify subcutaneous fat thickness according to the ISAK level 1 protocol which includes
eight skinfolds (triceps, subscapular, biceps, iliac crest, supraspinale, mid-abdominal, front thigh
and medial calf sites) [164]. Measurements were made in duplicate, with the mean value reported
if within 5% variation. In the case of greater than 5% variation between measures, a third
measurement was taken, and the median measure reported.
Blood parameters
Venous blood samples were obtained by venepuncture from the antecubital vein. Samples were
centrifuged, then serum separated and stored at -80°C for later analysis at a NATA accredited
146
hospital laboratory. Testosterone, sex hormone binding globulin and cortisol were measured
using a competitive electrochemiluminescence immunoassay on a Cobas 8000 analyser (Roche,
Manheim, Germany). Free testosterone was calculated using the measured testosterone and sex
hormone binding globulin values. Insulin-like growth factor-1 (IGF-1) was measured using a
sandwich chemiluminescence immunoassay on a Liaison XL analyser (DiaSorin, Italy). Leptin
and adiponectin were analysed by commercially available radioimmunoassay kits (EMD
Millipore, Billerica, USA). Insulin was analysed by chemiluminescent microparticle
immunoassay using an Architect System (Abbot Laboratories, Abbot Park, USA). Blood lipids
were analysed by an enzymatic colorimetric assay on a Cobas 8000 analyser (Roche, Manheim,
Germany).
Diet and Exercise
Seven-day weighed food and training diaries were completed at each time point. Participants
documented all food, fluid and supplements consumed during the seven day period. All
resistance and aerobic exercise was documented in the training diary. Food diaries were analysed
using the FoodWorks program (Version 8; Xyris Software, Brisbane, Australia), and included
analysis of reported dietary supplement consumption. Macronutrient intake distribution was
calculated as reported elsewhere [168]. However in brief, reported foods were separated into
eating occasions, with macronutrient totals for each eating occasion extracted from the
FoodWorks program. Resistance training volume (repetitions·weight·sets) was determined for
the total body, upper body (exercises using predominantly upper body muscles) and lower body
(exercises using predominantly lower body muscles).
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Analysis
Means and standard deviations were calculated for all test parameters. Normality of data was
assessed using the Shapiro-Wilk test. Independent samples t-tests were performed to test for
differences between participants who commenced their in-season diet prior to baseline testing,
and those who had not. For normally distributed data, repeated measures analysis of variance
were performed to test for changes between time points, with Greenhouse-Geiser corrections
used when the assumption of sphericity was violated. Where significant change was detected,
post hoc pairwise comparisons with Bonferroni correction were performed. Where data were not
normally distributed, Friedman analyses of variance by ranks were run, and Wilcoxon sign-rank
test with Bonferroni correction were performed where significant differences were detected.
Relative effect sizes (Cohen’s d) were calculated for all significant findings using the following
formula: (mean value1 – mean value2)·pooled SD-1. Effect sizes were considered small (0.2),
medium (0.5), or large (0.8) [78]. Missing data were imputed using the last result carried forward
method. Analyses were conducted using IBM SPSS statistics version 22 (IBM SPSS; Chicago,
Illinois, USA). Significance was set at p < 0.05.
RESULTS
Eleven BB consented to participate in the study. Two withdrew after baseline testing due to
withdrawal from competition, with the remaining nine (29.0 ± 9.5 years, 177.9 ± 2.5 cm, 83.7 ±
8.9 kg, 6.0 ± 6.6 years bodybuilding participation) included in analyses. Results are displayed
with zero representing the time of competition, therefore PRE16 represents the measurement
occurring 16 weeks before competition, POST4 represents the measurement occurring four
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weeks after competition. Two participants failed to return for POST4 testing. Eight participants
competed at a national competition in their respective divisions, with three placing in the top 10,
two placing third, two placing second, and one placing first. The ninth participant placed third at
an international competition.
Diet
Four participants had commenced their in-season diet prior to PRE16 measurements, three
commenced during the week of PRE16 measurements, while the remaining two commenced
after PRE16 measurements. Dietary intake is presented in Table 6.1. There were no significant
differences in dietary intake at PRE16, or changes in dietary intake from PRE16 to PRE1,
between participants who commenced their in-season diet before versus during or after PRE16 (p
> 0.05). Energy and macronutrient values include contributions from supplements. There were
no significant differences in energy intake across measurement points (p = 0.071). No significant
changes in total (g·d-1) or relative (g·kg·d-1) protein intake were detected (p = 0.506 and p =
0.625, respectively). There were no significant differences in carbohydrate or fat intake during
pre-competition, however significant differences were detected between PRE8 and POST4 time
points for total (p = 0.035, d = -0.8) and relative (p = 0.032, d = -0.8) carbohydrate values.
Energy and macronutrient distribution results are presented in Table 6.1. Throughout in-season
testing, participants consumed 5.2 ± 1 meals·d-1. Across all participants and meals consumed
during testing, 81.3 ± 19.8% of meals were above the 0.25 g·kg-1 of protein threshold [169].
Dietary supplements were used during the pre- (n = 7) and post-competition (n = 8) periods.
Dietary supplement contribution to total daily intake is presented in Table 6.1. The most
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commonly used dietary supplements were whey protein (n = 7), creatine (n = 5), branched chain
amino acids (n = 4), and glutamine (n = 3).
Four participants reported implementing a “re-feed” day or meal during the PRE16 and PRE8
testing weeks. On these days, there was a 46.2 ± 21.0% increase in energy, a 114 ± 41% increase
in carbohydrate, and a 63 ± 66% increase in fat, while protein was reduced by 4 ± 11%.
Reported training volumes are presented in Table 6.1. No significant differences in resistance
training volume were found between testing points (p > 0.10). A significant difference in aerobic
training volume was found (p = 0.01), however post hoc analysis with Bonferroni correction
failed to reach significance (p > 0.10).
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Table 6.1. Dietary intake during competition preparation and recovery.
PRE16 PRE8 PRE1 POST4
Energy (kJ·d-1) 12,585 ± 4,222 11,294 ± 3,192 11,690 ± 3,470 13,738 ± 3,398
Energy from supplements (kJ·d-1) 1,242 ± 1,674 1,043 ± 1,325 1,098 ± 1,686 1,069 ± 1,264
Energy (kJ·meal-1) 2,051 (75–12,506) 2,085 (20–6,767) 2,058 (270–7,358) 2,261 (15–9,729)
Protein (g·d-1) 266.9 ± 89.1 245.6 ± 82.0 263.4 ± 101.9 259.3 ± 109.3
Protein (g·kg-1·d-1) 3.0 ± 0.7 2.8 ± 0.6 3.1 ± 0.9 2.7 ± 0.9
Protein from supplements (g·d-1) 40.5 ± 42.7 42.5 ± 49.4 39.2 ± 43.0 35.7 ± 31.2
Protein (g·meal-1) 49 (0–162) 49 (0–160) 47 (2–136) 41 (0–127)
Protein (g·kg-1·meal-1) 0.6 (0–2.05) 0.6 (0–2.1) 0.6 (0–1.9) 0.5 (0–1.5)
Carbohydrate (g·d-1) 242.8 ± 100.2 206.0 ± 91.3 232.2 ± 99.8 310.1 ± 150.8b†
Carbohydrate (g·kg-1·d-1) 2.9 ± 1.2 2.6 ± 1.2 3.0 ± 1.4 3.8 ± 1.9 b†
Carbohydrate (g·meal-1) 42 (0–305) 34 (0–253) 40 (0–331) 46 (0–270)
Carbohydrate from supplements 18.8 ± 29.3 10.6 ± 14.7 14.9 ± 26.7 14.5 ± 21.0
(g·d-1)
Fat (g·d-1) 97.6 ± 58.2 88.7 ± 48.6 79.5 ± 47.8 102.8 ± 42.8
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Fat from supplements (g·d-1) 6.4 ± 14.5 4.1 ± 7.3 7.1 ± 16.6 6.2 ± 13.2
Fat (g·meal-1) 13 (0–155) 14 (0–94) 11 (0–60) 18 (0–91)
Resistance training volume (kg·week-1) 82,461 ± 34,582 94,317 ± 44,240 66,553 ± 41,996 79,620 ± 45,304
Upper body (kg·week-1) 39,958 ± 17,232 42,368 ± 19,647 32,753 ± 14,385 37,432 ± 15,384
Lower body (kg·week-1) 42,503 ± 24,234 51,247 ± 37,997 33,800 ± 33,697 41,735 ± 34,225
Aerobic training volume 65 ± 72 135 ± 131 143 ± 146 3±7
(minutes·week-1)
Data are presented as mean ± SD, or median (range). Dietary values include contribution of supplements. Resistance training volume
calculated as (resistance · repetitions · sets). a significantly different to PRE16; b significantly different to PRE8; c significantly
different to PRE1. † p < 0.05; ‡ p < 0.01.
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Body composition
Body composition results are presented in Table 6.2 and Figure 6.1. On average, 85 ± 38% of
mass lost during pre-competition testing was fat mass (range 29–136%). Medium, large, and
small reductions in subcutaneous adiposity estimated by anthropometry occurred between
PRE16 and PRE8, PRE16 and PRE1, and PRE8 and PRE1 (p = 0.018, d = 0.5; p = 0.004, d =
0.9; p = 0.01, d = 0.4, respectively). No significant changes were found for TBW, ECF or ICF (p
> 0.1). There were no differences in fat mass, lean mass, percentage change in fat mass or lean
mass, or proportion of mass lost as fat mass, between participants who commenced their in-
season diet before versus during or after PRE16 (p > 0.05).
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Table 6.2. Body composition, resting metabolic rate, and blood parameters during competition preparation and recovery.
Reference PRE16 PRE8 PRE1 POST4

range
Body Composition
DXA Total mass (kg) 83.7 ± 8.9 81.8 ± 9.1 79.6 ± 9.0a‡,b† 83.0 ± 7.7c‡
Fat mass (kg) 8.8 ± 3.1 6.6 ± 2.4 5.3 ± 2.4a‡ 7.1 ± 3.0c†
Lean mass (kg) 71.4 ± 8.9 71.8 ± 9.1 70.9 ± 9.1b† 72.5 ± 8.5c†
BIA TBW (L) 54.3 ± 6.9 54.6 ± 7.0 53.7 ± 6.7 54.8 ±6.3
ECF (L) 21.4 ± 2.5 21.4 ±2.8 21.0 ±2.5 21.7 ± 2.3
ICF (L) 32.9 ± 4.5 33.2 ± 4.4 32.7 ± 4.3 33.1 ± 4.2
Skinfolds Sum of 8 sites (mm) 47.7 ± 12.7 42.0 ± 11.4a† 37.3 ± 11.1a‡,b† 43.3 ± 15.8
Resting Metabolic Rate
kJ·d-1 10,036.3 ± 1,592.0 9,706.4 ± 1,728.4 9,805.1 ± 1,800.6 10,160.0 ± 1,313.8
kJ·kg-1·d-1 120.4 ± 18.7 119.5 ± 23.6 123.5 ± 19.1 123.1 ± 19.0
kJ·kg lean mass-1·d-1 141.2 ± 20.2 136.2 ± 25.0 139.2 ± 22.4 141.5 ± 21.3
Hormones
Testosterone (nmol·L-1) 10.0 - 30.0 16.4 ± 4.4 11.5 ± 5.3 10.1 ± 3.6a† 15.1 ± 4.5
Free testosterone (pmol·L-1) 80 - 370 229.3 ± 72.4 153.9 ± 85.4 116.8 ± 76.9a† 220.2 ± 95.4
IGF-1 (nmol·L-1) 14.2 - 58.8 27.0 ± 7.7 23.4 ± 7.4 19.9 ± 7.6a† 25.4 ± 9.3c†
Cortisol (nmol·L-1) 170 - 500 358.0 ± 107.8 328.7 ± 71.7 364.8 ± 74.0 314.9 ± 109.9
Insulin (pmol·L-1) 10 - 96 24.1 ± 7.4 20.7 ± 5.5 18.0 ± 7.0 39.7 ± 15.7
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Leptin (ng·mL-1) 2.0 - 5.6 2.8 ± 1.9 2.8 ± 1.6 3.2 ± 2.0 4.1 ± 2.5
Adiponectin (µg·mL-1) 3.0 - 30.0 13.8 ± 5.0 14.3 ± 4.6 19.0 ± 12.6 22.2 ± 11.1
Lipids
Total Cholesterol (mmol·L-1) ≤ 5.2 4.0 ± 0.8 3.9 ± 0.8 4.0 ± 0.9 4.1 ± 0.8
HDL (mmol·L-1) 1.0 - 2.5 1.5 ± 0.4 1.4 ± 0.3 1.7 ± 0.4 1.7 ± 0.5
LDL (mmol·L-1) ≤ 3.5 2.2 ± 0.6 2.2 ± 0.9 2.1 ± 0.7 2.1 ± 0.6
Triglycerides (mmol·L-1) ≤ 2.5 0.7 ± 0.3 0.6 ± 0.2 0.5 ± 0.2 0.8 ± 0.4
Mean ± SD for all values. Total mass, fat mass, lean mass measured by DXA; TBW, ECF and ICF measured by BIA. Resting
metabolic rate presented as total and relative (total mass, lean mass). a significantly different to PRE16; b significantly different to
PRE8; c significantly different to PRE1. † p<0.05; ‡ p<0.01. DXA, dual-energy x-ray absorptiometry; BIA, bioelectrical impedance
analysis; TBW, total body water; ECF, extracellular fluid; ICF, intracellular fluid; RMR, resting metabolic rate; HDL, high density
lipoprotein; LDL, low density lipoprotein.
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Resting metabolic rate.
No significant changes in RMR were detected across the study period when assessed absolute (p
= 0.87) or relative to lean mass (p = 0.91; Table 6.2, Figure 6.1). No differences were found for
RMR or percentage change in RMR between participants who commenced their in-season diet
before versus during or after PRE16 (p > 0.05).
Blood parameters
Blood parameter results are presented in Table 6.2 and Figure 6.2. Five, four and one participant
dropped below reference ranges for serum testosterone, free testosterone and IGF-1
concentrations during pre-competition testing, respectively. No differences were found in blood
parameters or percentage change in blood parameters between participants who commenced their
in-season diet before versus during or after PRE16 (p > 0.05).
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a. b.
d = 0 .4 5
d = 0 .2 4 d = 0 .1
d = -0 .4 1 90 d = -0 .2
100
80
L e a n M a ss (k g )
90
B o d y M a s s (k g )
80 70
70 60
60 50
PRE16 PRE8 PRE1 PO ST4 PRE16 PRE8 PRE1 PO ST4
T im e T im e
c. d.
d = 1 .3
d = -0 .7
15
15000
12 12000
F a t M a ss (kg )
)
-1
9 9000
R M R (k J ⋅d
6 6000
3 3000
0 0
PRE16 PRE8 PRE1 PO ST4 PRE16 PRE8 PRE1 PO ST4
T im e
T im e
Figure 6.1. Body composition and resting metabolic rate changes. Enclosed dots indicate
individual data; bars indicate mean. Effect sizes indicate changes in mean. Body mass, lean
mass, fat mass, measured using dual-energy x-ray absorptiometry. RMR, resting metabolic rate.
d indicates effect size between time points.
157
a. b.
d = 1 .6
24 d = 1 .5
400
)
-1
)
-1
20
F r e e t e s t o s t e r o n e (p m o l⋅L
T e s t o s t e r o n e (n m o l⋅L
300
16
12
200
8
100
4
0
0
PRE16 PRE8 PRE1 PO ST4
PRE16 PRE8 PRE1 PO ST4
T im e
T im e
c. d = 0 .9
d.
d = -0 .6
50 600
40 500
)
-1
)
-1
C o r t is o l ( n m o l⋅L
IG F - 1 ( n m o l⋅L
400
30
300
20
200
10
100
0 0
P R E16 PRE8 PRE1 PO ST4 PRE16 PRE8 PRE1 PO ST4
T im e T im e
Figure 6.2. Serum hormone changes. Enclosed dots indicate individual data; bars indicate mean.
Effect sizes indicate changes in mean. d indicates effect size between time points.
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DISCUSSION
This prospective study aimed to describe body composition and physiological changes in male,
natural BB during competition preparation and recovery. We hypothesised large reductions in fat
mass, with concomitant reductions in lean mass, RMR and anabolic hormones during the in-
season period. BB in this study lost significant amounts of fat mass, with only small losses in
lean mass, and no change in RMR. During the four months of pre-competition measurement, all
participants reduced fat mass to low levels, in some cases to the lower limits of human fat mass
[170]. There was large variability in the proportion of body mass lost as fat, although the average
ratio was high (85 ± 38%, range 31–136%). Despite these body composition changes, RMR
remained unchanged throughout the competition preparation period, while serum testosterone
and IGF-1 concentrations were significantly reduced. These findings are valuable, given the
paucity of longitudinal research in natural BB.
Body composition
As hypothesised, there were significant reductions in fat mass measured via DXA (mean
reduction = 3.5 kg). Similarly, a moderate reduction in the sum of eight skinfolds occurred (mean
reduction = 10.7 mm). The fat mass loss documented in this study was small relative to those
previously reported, likely resulting from the shorter assessment period. In case reports, natural
BB have been shown to lose up to 10.4 kg of fat mass during competition preparation [11-13].
The BB in our study were at a moderately low fat mass at PRE16, which may also account for
the smaller reductions (8.8 ± 3.1 kg compared with 11.7–15.9 kg in case studies). Further, four
participants had commenced their in-season dieting at PRE16 which would in part explain the
low initial fat mass and smaller reduction in fat mass.
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A common and undesired side-effect of prolonged energy restriction is a loss of lean mass. This
is particularly evident in lean individuals, including natural BB [11,12]. Indeed, amongst lean
individuals in an energy deficit, the ratio of lean to total mass lost typically increases [171].
However, the BB in this cohort were mostly successful at maintaining lean mass. Fat loss
accounted for 85% of total mass lost, although this varied widely between participants (range
29–136%). There were no statistical changes in lean mass seen between PRE16 and PRE8, and
only a small reduction between PRE8 and PRE1 (mean difference = 0.9 kg, d = 0.1). Reductions
in lean mass in the previously cited natural BB case studies ranged from 2.8–6.6 kg [11-13]. The
success of the BB in our study in maintaining lean mass may be attributed to a small energy
deficit used throughout the in-season. A smaller energy deficit during a period of weight
reduction has been demonstrated as an effective mechanism for maintaining lean mass [172].
The maintenance of lean mass is even more significant considering the low fat mass observed at
PRE16, given previous research demonstrates leaner individuals lose a proportionately greater
amount of lean mass during an energy deficit [170].
A second possible explanation for the lean mass maintenance is the high dietary protein intake. A
higher protein intake has been demonstrated as an effective mechanism for limiting lean mass
loss during energy restriction in resistance trained individuals [173]. In athletes, to optimise the
ratio of lean mass to fat mass loss during an energy deficit, a protein intake of 1.8–2.7 g·kg-1·d-1
has been suggested [174]. In already lean individuals, a protein intake dependent on fat free mass
has been proposed: 2.3–3.1 g·kg fat free mass-1·day-1 may be effective in achieving lean mass
maintenance during an energy deficit [132]. Throughout this study, participants consumed 2.8–
3.1 g·kg-1·d-1, and 3.3–3.6 g·kg lean mass-1·day-1, thus met or exceeded these recommendations.
160
This high protein intake and smaller overall energy deficit would help negate physiological
adaptations associated with weight loss which drive a reduction in lean mass.
In conjunction with an increased total protein intake, distribution of protein is reported to be an
effective means of maximising muscle protein synthesis [2]. Participants in this study ate 5.2 ± 1
meals·d-1, with 81.3 ± 19.8% of meals surpassing the 0.25 g·kg-1 dose recommended [169],
facilitating conditions for building and maintaining lean mass, despite remaining in negative
energy balance. The inclusion of a high protein post-exercise meal would also assist in
increasing muscle protein synthesis [175].
Regular high intensity resistance training would aid in attenuation of lean mass reduction in these
BB. Study participants maintained a high volume of resistance training (Table 6.1). The muscle
protein synthesis response to protein is reduced during an energy deficit. However, resistance
exercise during the energy deficit has been demonstrated to stimulate protein synthesis to rates
similar to those during energy balance [176]. This uninhibited muscle protein synthesis response
to protein ingestion associated with resistance training would counter the catabolic effects of a
negative energy balance, and hence assist in the maintenance of lean mass.
Resting metabolic rate
Reductions in RMR are typically seen during periods of energy restriction and weight loss [177],
which is attributed to changes in lean mass and fat mass. Our results showed no change in RMR
during the pre-competition period (mean difference 231 kJ·d-1). This result contrasts those found
in previous BB case studies, where small (752 kJ·d-1) and large reductions (4746 kJ·d-1) have
been reported [12,13]. Maintenance of RMR in the current study is likely attributable to the very
small reductions in lean mass observed, and the high intensity resistance training performed
161
throughout the pre-competition period [178]. Resistance training during a period of negative
energy balance has been shown to alleviate reductions in 24 hour resting energy expenditure
[178]. By maintaining lean mass, and subsequently resting energy expenditure, the BB in this
study required smaller reductions in energy intake to maintain an overall negative energy
balance. This smaller energy deficit would result in continued fat mass reductions, while limiting
reductions in lean mass and subsequently RMR, thereby producing a positive feedback cycle
allowing the achievement of body composition modification.
Blood parameters
Circulating anabolic hormone concentrations are sensitive to energy status. Periods of short-term
energy deficit may produce acute reductions in testosterone, which are accentuated when the
energy deficit is prolonged [35,179]. This anti-anabolic response aids in reducing protein
synthesis and energy expenditure [180], and may correspond with a loss of lean mass [35].
During the pre-competition period, total and free testosterone reduced by 38% and 49%,
respectively, while IGF-1 reduced by 26%. These reductions compare to the reduction in
testosterone measured during a six month competition preparation of a male BB (75% reduction)
[13]; while a 15% mean reduction in testosterone was found in seven male BB during the final
11 weeks of competition preparation [163].
The hormonal response to energy restriction is likely attributable to low energy availability
[181]. Similar reductions in serum testosterone to those found in this study are evident in
competitive jockeys, who undertake periods of energy restriction resulting in low energy
availability in order to make weight [182]. As no significant reductions in energy intake were
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found, and exercise energy expenditure was unable to be accurately evaluated, low energy
availability cannot be confirmed in this study.
Despite reductions in anabolic hormone concentrations, BB in this study were still able to
prevent large losses of lean mass, indicating the lean mass response to a continual energy deficit
was not associated with changes in testosterone or IGF-1 concentrations. It also suggests the high
protein intake and resistance training program employed by participants was sufficient to
counteract the anti-anabolic effects of these hormonal changes.
The rapid return to baseline values for testosterone and IGF-1 concentrations post-competition is
also of significance. This may reflect energy deficit cessation. One case study has examined
hormonal changes after a bodybuilding competition, finding testosterone increased to 94% of
baseline concentrations after three months of increased energy intake [13]. A similar restoration
of testosterone concentration was found among army rangers during 2–6 weeks of recovery from
an eight week period of high energy expenditure and low energy intake [183]. The rapid increase
of anabolic hormone concentrations after competition observed in our study suggest there may
be no significant physiological detriment associated with a short-term reduction in anabolic
hormones when protein intake and resistance training are maintained.
Limitations of this study include a modest sample size (n = 9) which requires consideration when
interpreting the non-significant findings. With a larger sample size, trends identified may reach
statistical significance, and thus provide more insight into the changes which occur during
competition preparation and recovery. A 12-hour exercise-free period in preparation for testing
was implemented, due to the high frequency exercise regimen employed by participants. This
limited time frame relative to current guidance [165] may have inflated RMR results, as
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metabolic rate may remain elevated for up to 48 hours following resistance exercise [165].
Additionally, a face mask was used to collect expired gas for RMR assessment, rather than a
ventilated hood, although this may not significantly affect results [165]. The lack of statistically
significant change in dietary intake during pre-competition testing may be attributed to the
testing timeline. Strategies used by participants during the PRE1 testing week incorporate an
increased carbohydrate and hence energy intake. Rather than observing a decrease in energy
intake between PRE8 and PRE1 as predicted, a small, insignificant increase was observed. One
may speculate that a modified testing timeline, including testing two weeks before the contest,
would observe significant reductions in energy, carbohydrate, and fat intake compared to PRE16
values. More frequent testing, for example every two to four weeks leading to competition as
used in previous case studies [11], may allow closer observation of changes. The modest sample
size of this study may also explain the insignificant changes in dietary parameters. The inability
to determine energy expenditure of participants from exercise parameters limits the calculation
of energy balance of participants. Including a measure of energy expenditure, such as a wearable
monitor for estimating total energy expenditure, would allow calculation of energy balance, and
a more detailed insight into the nature of body composition and physiology changes occurring
during competition preparation. Several participants in this study had commenced in-season
dieting before PRE16, therefore this time point does not reflect a true off-season status in these
participants, thus changes observed may not encompass total changes typically occurring from
off-season to competition. The use of DXA to assess lean mass during dietary manipulation is
limited due to the inability to differentiate glycogen associated lean mass from protein lean mass,
and therefore changes in muscle glycogen content will increase measures of lean mass [184].
Although a 12-hour fast was implemented prior to testing, muscle glycogen stores need to be
164
considered when interpreting the lean mass results. However there were no significant changes in
TBW and ICF, which suggests lean mass changes are likely not attributable to glycogen changes.
CONCLUSION
These BB demonstrated significant reductions in fat mass with only small reductions in lean
mass. We suggest that the maintenance of resistance training volume and an evenly distributed,
high protein intake during the competition preparation may have provided a stimulus to maintain
lean mass whilst reducing fat mass. A subsequent outcome of maintaining lean mass was
maintenance of RMR, likely enabling participants to continue with only small reductions in
energy intake. Assessing the effect of preparation strategies employed by these BB in other
athlete populations may help identify recommendations that assist in modification of body
composition.
ACKNOWLEDGEMENTS
This work was supported by Sports Dietitians Australia.
CONFLICTS OF INTEREST
The authors report no conflict of interest. HOC and GS receive payments from Sports Dietitians
Australia for professional presentations delivered in a continuing education course for Sports
Dietitians
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CHAPTER 7.
Longitudinal Trends in Muscle Dysmorphia Symptomatology in Bodybuilders
During Preparation for a Bodybuilding Contest: An Exploratory Pilot Study
166
Chapter 7: Longitudinal Trends in Muscle Dysmorphia Symptomatology
ABSTRACT
Background: Muscle dysmorphia (MD) is characterised by a distorted self-perception and a drive
for muscularity. Symptoms of MD are yet to be examined longitudinally, in particular during a
period of significant body composition change. The aim of this pilot study was to document
trajectories of MD and eating disorder (ED) symptomatology in bodybuilders (BB) during
contest preparation.
Method: Male, drug-free BB (n = 9) participated in this exploratory pilot study conducted during
the final 16 weeks of competition preparation. Assessments included body composition, diet, and
MD and ED symptomatology. Repeated measures linear mixed modelling was used to derive
estimates of change during competition preparation, while Pearson correlations were used to
assess relationships between MD symptoms and body composition and dietary changes.
Results: No significant changes were found for MD and ED symptomatology, or fat and muscle
discrepancy indices. MD symptomatology was negatively correlated with change in energy (r = -
0.707) and fat (r = -0.713) intake.
Conclusion: Despite body composition shifting towards extreme leanness and muscularity, these
BB were not less concerned about their physique, instead displaying a robustness of MD
symptoms. BB displaying increased MD symptomatology may present a disconnect between
actual body composition and attitudes around muscularity.
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INTRODUCTION
Body dissatisfaction in males is now increasingly recognised [185]. Unlike females, male
dissatisfaction typically presents as a desire to increase muscularity and leanness, reflecting the
current ideal male physique [59]. This ideal male physique is typically defined as muscular, lean
and athletic [59,60]. Muscularity enhancing endeavours, driven by the pursuit of this ideal
physique, include dietary and exercise interventions. The pathological extreme of this pursuit is
muscle dysmorphia (MD), characterised by (i) a distorted self-perception, whereby one views
themselves as small and weak, often despite well-developed muscularity, and (ii) a concomitant
drive for muscularity [14]. Attitudinal and behavioural symptoms reflect this self-perception, and
include meticulous training and dietary schedules, and marked anxiety experienced upon
deviation from these regimens [14].
In the context of athletic performance, sport pressures regarding size and shape may also drive
muscularity-enhancing behaviours and attitudes [112]. Participation in sports with a focus on
increased muscularity and strength may facilitate MD symptomatology, with evidence
suggesting MD may affect a broad range of athletic groups, including footballers and
powerlifters [51]. The greatest implicit overlap between MD and athletics lies in the sport of
bodybuilding, where success is dependent on muscular size, symmetry and leanness.
Bodybuilders (BB) employ a structured, long-term approach to competition, transitioning from
an off-season phase which targets muscular hypertrophy, through to an in-season phase that
targets extreme leanness and maintenance of muscle mass [161]. A rigorous training routine is
developed, and strict dietary practices are engaged in order to achieve these physical outcomes
[161].
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Both BB and those afflicted with MD are oriented towards extreme muscularity and leanness,
although participation in bodybuilding is not in itself a pathological endeavour [117].
Furthermore, disordered eating behaviours are associated with MD symptomatology, and
pathological eating is central in presentations of MD symptoms in BB [186]. To date though, no
study has examined the trajectory of MD symptomatology throughout a period of significant
body composition change. Previous research has demonstrated resistance training to ameliorate
MD symptoms [17], while eating disorder (ED) symptomatology has been shown to fluctuate
based on the engagement in safety- and symptomatic-behaviour [124]. The in-season period of
competition preparation entails engagement in extreme diet and exercise behaviours, and
achievement of a lean and muscular physique. Based on this engagement, coupled with the noted
drive for muscularity and leanness synonymous with MD [14], alterations in MD symptoms may
result during this period. Thus, it is essential to determine whether prolonged engagement in
extreme dietary and exercise behaviours, resulting in a body composition shift towards the lean
and muscular ideal physique, promote alterations in MD symptomatology. Given the diet and
exercise habits embraced, and the extreme body composition outcomes achieved by BB [187],
the in-season period is an ideal context to examine the trajectory of MD symptomatology during
a period of significant body composition change.
The aims of this exploratory pilot study were to document trajectories of MD and ED
symptomatology in a small sample of BB during bodybuilding contest preparation. Due to the
absence of empirical evidence in this domain, no a priori hypotheses were developed.
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METHODS
Participants
Participants were male, at least 18 years of age, drug-free and actively competing BB.
Recruitment efforts included advertisements on websites and social media pages of bodybuilding
organizations, and the distribution of flyers at the Australasian Natural Bodybuilding national
contest in October 2015 and to a database of BB held by the researchers from previous studies.
Written informed consent was provided by all participants. Ethics approval was obtained from
the University of Sydney Human Ethics Committee, project number 2015/425.
Procedures
A detailed description of testing protocols is included in Appendix D. Data collection occurred
on five occasions over a 16 week period, at 16 (PRE16), 12 (PRE12), 8 (PRE8), 4 (PRE4), and 1
(PRE1) week(s) before competition. This timeline accords with evidence indicating a typical
bodybuilding contest preparation period of approximately 16 weeks [161]. To control for the
potentially moderating effect of resistance training on MD symptomatology [17], all measures
were completed on a day in which participants had exercised.
Assessment tools
The Muscle Dysmorphic Disorder Inventory (MDDI) [120] is a validated and widely-used 13-
item questionnaire measure of MD symptomatology that comprises three subscales; drive for
size, appearance intolerance, and functional impairment. Total scores range from 13 to 65, with
higher scores reflecting greater MD psychopathology. The MDDI yields good psychometric
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properties, although in the present study internal consistency was questionable (Cronbach’s α =
0.67). However, given the exploratory nature of the study this level was considered sufficient.
The Bodybuilder Image Grid - Original (BIG-O) [120] was designed to measure perceptual body
image disturbance in males and perceived attractiveness of the male body to both men and
women. The grid contains 30 silhouettes varying in degrees of adiposity along the x-axis and
muscularity along the y-axis, ranging from “extremely low body fat” to “extremely high body
fat”, and from “extremely low muscle mass” to “extremely high muscle mass”. Participants were
asked to select the silhouette which best represents (a) their current body type, and (b) their ideal
body type. To measure perceptual disturbance, a discrepancy index was calculated for body fat
(current fat - ideal fat = desired fat) and muscle mass (ideal muscle - current muscle = desired
muscle) by subtracting the corresponding column and row scores. A higher index score indicates
a greater discrepancy.
The Eating Attitudes Test 26-Items (EAT-26) [121] is a self-report questionnaire assessing
disordered eating symptoms. The EAT-26 contains three subscales: dieting, bulimia and food
preoccupation, and oral control. Total scores range from 0 to 78, with higher scores indicating
increased ED psychopathology. While not a diagnostic tool, a score of 20 or above indicates a
high level of concern about dieting, body weight, and problematic behaviours. The EAT-26
demonstrates good psychometric properties, and in the present study internal consistency was
good (Cronbach’s α = 0.84).
Body composition (total mass, fat mass and lean mass) was analysed via dual energy x-ray
absorptiometry (DXA) during PRE16, PRE8 and PRE1. A detailed procedure is discussed in
Chapter 6.
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A seven-day weighed food record was completed by all participants during PRE16, PRE8, and
PRE1. Participants were instructed to document all food, fluid and supplements consumed during
the seven day period. Food diaries were analysed using the FoodWorks program (Version 8;
Xyris Software Pty, Ltd, Brisbane, Queensland, Australia), and included analysis of reported
dietary supplement consumption.
Analysis
Means and standard deviations were calculated for all test parameters. A repeated measures
linear mixed model was used to derive estimates of changes in the mean MDDI total score, using
an autoregressive first order covariance structure and time as the repeated variable. The model
included the fixed factors of time, and the covariates EAT-26 score and years of bodybuilding
experience. Where significant changes were detected, post hoc pairwise comparisons with
Bonferroni correction were performed. To examine the relationship between MD symptoms and
changes in body composition and diet, Pearson correlations were performed between MDDI total
score at PRE16, and percent change for body composition and dietary parameters. To explore
associations between self-perceived body composition (BIG-O) and measured body composition,
Pearson correlations were performed between BIG-O indices of current and ideal fat and muscle,
fat and muscle discrepancies, and indices of body composition measured via DXA. Analyses
were conducted using IBM SPSS statistics version 22 (IBM SPSS; Chicago, Illinois, USA).
Significance was set at p < 0.05.
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RESULTS
Eleven BB consented to participate in the case series. Two participants withdrew after baseline
testing due to withdrawal from competition, with the remaining nine BB (29.0 ± 9.5 years, 177.9
± 2.5 cm, 83.7 ± 8.9 kg, 6.0 ± 6.6 years bodybuilding participation) included in analyses. Eight
of the nine participants were competing at a national level, with the remaining participant
competing at an international level.
Mean and standard deviation results for MDDI, EAT-26 and BIG-O are presented in Table 7.1.
Repeated measures linear mixed modelling adjusting for EAT-26 score and bodybuilding
experience found no effect for time on MDDI score, F(4, 17.641) = 1.417, p = 0.269 (Fig. 7.1a).
Similarly, no effect for time on EAT-26 score was found when adjusting for MDDI score and
bodybuilding experience, F(4, 26.152) = 1.152, p = 0.355. Seven of the nine participants scored
at or above the EAT-26 cut-off score of 20 for a high level of concern about dieting, body
weight, and problematic behaviours at least once during competition preparation (Fig. 7.1b). No
effects for time on fat discrepancy index (F(4, 23.302) = 1.277, p = 0.307), or muscle
discrepancy index (F(4, 25.6) = 0.822, p = 0.523), were found when adjusting for EAT-26 score
and bodybuilding experience.
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Table 7.1. MDDI, EAT-26, and BIG-O current, ideal and discrepancy index scores, in 9 male natural bodybuilders during 16 weeks of
competition preparation.
PRE16 PRE12 PRE8 PRE4 PRE1

MDDI total 42.0 ± 5.0 40.3 ± 6.5 40.1 ± 5.2 41.1 ± 5.7 39.8 ± 4.6
EAT-26 total 15.7 ± 8.5 16.4 ± 10.2 20.4 ± 11.1 20.3 ± 8.6 20.1 ± 8.1
Current fat 2.33 ± 0.7 1.88 ± 0.6 1.78 ± 0.6 1.5 ± 1.3 1.14 ± 0.4
Current muscle 3.11 ± 0.6 3.13 ± 0.6 3.44 ± 0.5 3.13 ± 0.6 3.29 ± 0.5
Ideal fat 1.44 ± 0.7 1.13 ± 0.3 1.44 ± 0.7 1.13 ± 0.3 1.43 ± 0.5
Ideal muscle 3.78 ± 0.6 3.88 ± 0.6 3.89 ± 0.6 3.75 ± 0.4 3.71 ± 0.5
Fat discrepancy 0.89 ± 0.8 0.75 ± 0.7 0.33 ± 0.9 0.38 ± 1.4 0.56 ± 1.4
Muscle discrepancy 0.67 ± 0.7 0.75 ± 0.4 0.44 ± 0.7 0.63 ± 0.5 0.22 ± 0.7
Data are presented as mean ± SD. PRE16, PRE12, PRE8, PRE4 and PRE1 indicate 16, 12, 8, 4, and 1 week(s) before competition.
MDDI, muscle dysmorphic disorder inventory; EAT-26, eating attitudes test 26 items.
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a.
60
50
M D D I T o ta l S c o re
40
30
20
10
0
P R E 16 P R E 12 PRE8 PRE4 PRE1
T im e
b.
50
40
E A T -2 6 T o ta l
30
20
10
0
P R E 16 P R E 12 PRE8 PRE4 PRE1
T im e
Figure 7.1. a. MDDI and b. EAT-26 changes during 16 weeks of bodybuilding competition
preparation. Enclosed dots indicate individual data; bars indicate mean; horizontal dotted line
indicates threshold for a high level of concern about dieting, body weight, and problematic
behaviours. PRE16, PRE12, PRE8, PRE4 and PRE1 indicate 16, 12, 8, 4, and 1 week(s) before
competition.
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Significant correlations were found between PRE16 MDDI score and percent change in energy
intake (r = -0.707, p = 0.045), and percent change in fat intake (r = -0.713, p = 0.031), indicating
that those scoring higher at baseline on the MDDI showed a greater reduction in energy and fat
intake during contest preparation (Fig. 7.2). A significant correlation was found between the
change in BIG-O current fat index and the measured change in fat mass (r = 0.84, p = 0.005). No
significant correlations were found between changes in BIG-O discrepancy indices and total
mass (p > 0.1), fat mass (p > 0.1), or lean mass (p > 0.1).
40
E n e rg y ( r = -0 .7 0 7 )
∆ E n e rg y , F a t in ta k e (% )
F a t ( r = -0 .7 1 3 )
20
-2 0
-4 0
30 35 40 45 50 55
M DDI
Figure 7.2. Correlations between PRE16 MDDI total score, and the change in energy and fat
intake. MDDI, muscle dysmorphic disorder inventory.
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Body composition and dietary assessment results are presented in Table 7.2. Repeated measures
linear mixed modelling found a significant effect for time on fat mass, F(2, 15.585) = 12.411, p
= 0.001. Post hoc pairwise comparison with Bonferroni correction indicated significant
reductions in fat mass from PRE16 to PRE8 (p = 0.003), and from PRE16 to PRE1 (p < 0.001).
Similarly, there was a significant effect for time on total body mass, F(2, 16.004) = 11.642, p =
0.001. Post hoc comparison indicated significant reductions from PRE16 to PRE8 (p = 0.021),
PRE16 to PRE1 (p = 0.001), and PRE8 to PRE1 (p = 0.006). A significant effect for time was
found on lean mass, F(2, 16.001) = 5.419, p = 0.016, with post hoc analysis indicating a
significant reduction from PRE8 to PRE1 (p = 0.022).
Table 7.2. Body composition and diet composition in 9 male natural bodybuilders during 16
weeks of competition preparation.
PRE16 PRE8 PRE1

Body mass (kg) 83.7 ± 8.9 81.8 ± 9.1a 79.6 ± 9.0a,b
Fat mass (kg) 8.8 ± 3.1 6.6 ± 2.4a 5.3 ± 2.4a
Lean mass (kg) 71.4 ± 8.9 71.8 ± 9.1 70.9 ± 9.1b
Energy intake (kJ·d-1) 12,585 ± 4,222 11,294 ± 3,192 11,690 ± 3,470
Protein intake (g·d-1) 266.9 ± 89.1 245.6 ± 82.0 263.4 ± 101.9
Carbohydrate intake (g·d-1) 242.8 ± 100.2 206.0 ± 91.3 232.2 ± 99.8
Fat intake (g·d-1) 97.6 ± 58.2 88.7 ± 48.6 79.5 ± 47.8
Data are presented as mean ± SD. a indicates significant difference to PRE16, b indicates
significant difference to PRE8. PRE16, PRE8 and PRE1 indicate 16, 8 and 1 week(s) before
competition.
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DISCUSSION
The primary purpose of this novel pilot study was to assess the trajectory of MD and ED
symptomatology during a period of significant body composition change, that is, during
preparation for a natural bodybuilding competition. The BB in this pilot study showed no
significant change in MD symptoms during 16 weeks of competition preparation. Similarly,
there was no significant change in ED symptoms.
Overall MD symptomatology in this sample of natural BB was moderate, although higher than
those reported recently in a similar sample of competitive natural BB (35.2 ± 8.0) [186], and
higher than a sample of competitive (38.5 ± 8.0) and non-competitive BB (29.6 ± 6.6) [50].
Importantly, our findings suggest that MD symptoms do not change as a function of body
composition, as competition preparation progresses. This suggests a robustness of MD
symptomatology despite physiological changes that are intended to better display one’s
muscularity. An alternative explanation to the preserved symptomatology level is that the MDDI
assessment tool may not be sensitive enough to identify changes in MD symptomatology over a
short assessment duration.
Previous findings suggest a lability of MD symptomatology, with demonstrable shifts following
engagement in resistance training sessions [17]. This fluctuation has been attributed to the short-
term increase in muscle size resulting from increased muscle blood flow, in addition to the
compensatory property of resistance training in allaying concerns around potential muscle loss
[17]. Since bodybuilding contest preparation yields significant reductions in fat mass, it is
intuitive to expect this shift in body composition towards the ideal physique to reduce MD
symptomatology. However, in this small sample of BB, no such reduction occurred. These
findings suggest that attitudinal features of MD may be unrelated to one’s actual physical
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condition. Due to the lack of longitudinal studies currently published, such findings have not
previously been reported, however may be explained by the disconnect between actual physique
and perceived physique that is central in MD [14]. A primary distinctive characteristic
differentiating MD from a non-pathological pursuit of muscularity is a misconceived self-
perception of insufficient muscularity. Such a perception drives efforts to increase muscularity as
well as leanness [14]. Based on this defining characteristic, a reduction in fat mass shifting body
composition towards the ideal lean and muscular physique may not ameliorate the self-
determined necessity to maintain an aggressive diet and exercise program in individuals
displaying increased MD symptomatology. Thus, the distinct attitudinal features of MD may not
be in response to, but rather in spite of, actual physique.
BB in this sample demonstrating higher MD symptomatology at baseline testing subsequently
reduced their energy and fat intake to a greater extent than those demonstrating lower
symptomatology, further adding to the growing literature relating to MD symptoms and the
salience of dietary practices [81,113,115]. Given the noted drive for muscularity as well as
leanness in those with MD [93], a greater reduction in energy and fat intake may be suggestive of
a desire for increased fat loss, or a greater reluctance to gradually titrate overall body size down
to contest condition before the 16-week window prior to contests. This remains an important
question for future research endeavours.
Although significant correlations were found between MD symptomatology and subsequent
dietary manipulation, no changes in pathological eating practices were identified during
competition preparation and recovery. This may reflect the nature of the eating behaviours
exhibited by BB. Symptoms of ED have been demonstrated to fluctuate based on engagement in
symptomatic behaviour in a clinical population [124]. However, although a strict dietary protocol
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is maintained by BB in order to achieve competition success, this intense nutrition regimen does
not in itself indicate psychopathology. Therefore, engagement in dietary behaviours aimed at
achieving competition physique are not likely to produce changes in ED symptoms. The nature
of the EAT-26 may also explain the lack of change in ED symptomatology displayed in this
study. Items used in the tool may reflect bodybuilding practice, not pathological eating
behaviours. Rather than indicating disordered eating habits, the dietary manipulations elicited by
BB during preparation for competition are a means of achieving the body composition
modification required to reach competition physique.
Limitations of this pilot study include a small sample size (n = 9), necessitating appropriate
caution when interpreting these findings. However, this must be considered in conjunction with
the noted extreme difficulty in conducting studies of BB during contest preparation.
Notwithstanding, a larger sample size would provide greater power to assess changes. The EAT-
26 has been previously validated in females, although widely used in male cohorts. However it
contains items which may not reflect pathological eating in the bodybuilding context, such as “I
am aware of the calorie content of the food I eat.” As such, this should be considered when
interpreting the ED outcomes. The internal consistency of the MDDI was found to be low in this
study, which must be considered when interpreting the results. Nevertheless, this pilot study
represents the most rigorous and only longitudinal investigation of MD symptomatology in BB
to date, employing an extremely comprehensive battery of assessments. Such a comprehensive
assessment protocol may prove difficult to conduct with a larger sample size due to participant
restrictions during BB competition preparation, however ongoing research should seek to
confirm these results given the importance of this area of research.
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CONCLUSION
In this sample of male, natural BB, no significant changes in MD or ED symptomatology were
observed, despite significant reductions in total and fat mass during competition preparation.
Similarly, no perceptual change in fat and muscle indices were found. Together this suggests that
although body composition shifted towards extreme leanness and muscularity in these BB, these
changes did not ameliorate concern about their physique. BB displaying increased MD
symptomatology may present a disconnect between actual body composition and attitudes
around muscularity. Future research should aim to repeat these measures using a larger sample
size, including individuals presenting with high MD symptomatology, to confirm these findings.
ACKNOWLEDGEMENTS
This work was supported by a grant from Sports Dietitians Australia.
CONFLICTS OF INTEREST
HOC receives payments from Sports Dietitians Australia for professional presentations delivered
in a continuing education course for Sports Dietitians. All other authors declare no competing or
conflicts of interest.
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CHAPTER 8.
Conclusions
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Chapter 8: Conclusions
SUMMARY OF FINDINGS
Participation in the sport of bodybuilding has increased in recent years, and this trend is likely to
continue. However, there is limited contemporary research examining the dietary and training
practices of male BB, as well as the physiological implications of these practices. Furthermore,
there is much to be explored in the area of body image and psychology of BB, specifically in the
areas of MD and disordered eating. To date, research into this population has largely focussed on
the negative effects of AAS use, from both a physiological and psychological perspective. More
recent evidence has emerged of the body composition outcomes achieved during competition
preparation, with a small number of studies also documenting hormonal and metabolic
adaptations to prolonged negative energy balance during the in-season period, primarily as case
studies and small cohorts. Research into bodybuilding and MD has described MD characteristics
in BB, and compared symptomatology between BB and other populations. To address the
paucity of research in this demographic, this thesis contains a series of studies investigating the
dietary strategies employed by male, natural BB, and their effects on body composition and
physiology during competition preparation, as well as the psychological implications of
competitive bodybuilding.
The primary aims of the studies in this thesis were to:
1. systematically review and compare evidence of MD symptomatology in BB and NBBRT,
and identify psychological features associated with MD in these populations;
2. identify correlates of MD symptoms in male, competitive natural BB;
3. identify and describe different dietary and supplement strategies used by experienced
natural BB during a competitive season, and their purported rationale;
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4. assess the body composition and physiological changes that occur during preparation and
recovery from a natural bodybuilding competition; and
5. assess changes in MD and disordered eating symptoms during preparation for a natural
bodybuilding competition.
Findings of the systematic review and meta-analysis in Chapter 3 support Hypothesis 1 that BB
present greater MD symptomatology than NBBRT. Furthermore, the evidence shows those
demonstrating greater MD symptomatology show a greater array of psychological comorbidities
including anxiety, depression, perfectionism and low self-esteem. These findings, in particular
those psychological comorbidities associated with increased MD symptomatology, may be
relevant in delineating between a pathological and non-pathological pursuit of muscularity. The
evidence is as yet unable to determine if bodybuilding is a cause of MD, or if the sport of
bodybuilding attracts those predisposed to its development. However, these findings suggest that
the sport of bodybuilding likely attracts susceptible individuals, while also cultivating advanced
MD symptomatology in BB displaying the cluster of psychological features associated with MD.
This systematic review and meta-analysis highlights the need for ongoing research, particularly
longitudinal research, to further analyse the nature of the relationship between bodybuilding and
MD symptoms, particularly in reference to stages of competition preparation and body
composition changes.
To examine the association between MD symptomatology and demographic, dietary and training
characteristics of male natural BB, the cross-sectional study described in Chapter 4 was
conducted to address the second aim of this thesis. Results of this study identified three
significant correlates of MD symptomatology. It was demonstrated that disordered eating
symptoms were associated with MD symptomatology, thus confirming Hypothesis 2 of this
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thesis. Similarly, the rate of weight loss during competition preparation was also associated with
MD symptomatology. Bodybuilding experience, in the form of years of competing, was
negatively associated with MD symptomatology. These findings extend previous research
linking ED psychopathology with MD symptomatology, and underscore the salience of
disordered eating pathology in presentations of MD symptomatology. This may indicate that the
intense nutrition regimen employed by BB does not itself indicate psychopathology, rather it is
when eating behaviours become disordered that MD symptomatology may increase. The
significant association of rate of weight loss is a key behavioural finding with clinical
implications. A rapid rate of weight loss is likely mediated by significant dietary restraint, which
further highlights the disordered eating and MD symptomatology link. The association of weight
loss rapidity suggests there may be a potential intolerance towards maintaining a reduced body
weight, likely due to the noted fear of loss of muscularity in MD. As such, delaying and limiting
the weight loss period prior to competition will reduce the period of time spent at a lower body
weight, potentially mitigating any anxiety experienced as a result of reduced size and
muscularity. The findings of this cross-sectional study further highlight the need for longitudinal
research in a bodybuilding sample. Such research may demonstrate temporal changes in MD
symptomatology, in particular relative to changes in body composition, engagement in
significant dietary and exercise practices, and the effect of competition preparation phase.
Due to the paucity of contemporary evidence of the dietary practices of natural BB, the
qualitative study described in Chapter 5 was conducted to address the third aim of this thesis.
The findings support experienced competitive BB using dietary strategies predominantly
recognised as evidence-based. A high, distributed protein intake was maintained throughout the
off-season and in-season to develop and maintain muscle mass, with periodised carbohydrate
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consumption ensuring effective training sessions. Progressive reductions in energy intake were
achieved by moderating carbohydrate and fat consumption. Novel dietary strategies were
identified, including the use of a weekly re-feed day to provide a psychological rest, increase
muscle glycogen, and purportedly offset declines in metabolic rate associated with prolonged
energy restriction. Thus, Hypothesis 3 of this thesis was in part confirmed by the structured and
periodised dietary program followed by participants. The second component of Hypothesis 3 was
confirmed by identifying questionable strategies used by participants during the peak week
period, including sodium and fluid manipulation. These strategies warrant further investigation
to describe their safety and efficacy. Finally, the primary sources of nutrition education were
identified, and included the internet, other BB and coaches. These findings indicate experienced
BB, over the course of their careers, have developed dietary regimens which incorporate
primarily evidence-based strategies. Despite this, misinformation and extreme practices remain
common in the sport, with novice athletes more vulnerable to these extreme practices, which are
widely disseminated on the internet and social media, often from non-reputable sources.
To examine in detail the body composition, physiological and psychological changes which
occur during preparation for a bodybuilding competition, the longitudinal study described in
Chapters 6 and 7 was conducted. During the 16 week pre-competition period, insignificant
reductions in dietary energy intake occurred, with protein intake maintained at a high volume. As
was hypothesised (Hypothesis 4 of this thesis), significant reductions in fat mass occurred.
However, opposing Hypothesis 4, only small reductions in lean mass were detected. Likely due
to the maintenance of lean mass, insignificant changes in RMR occurred during this period.
Serum anabolic hormone concentrations, specifically testosterone and IGF-1, were significantly
reduced, which may be associated with low energy availability, and confirm the final component
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of Hypothesis 4. In the four weeks following competition, lean mass, testosterone and IGF-1 all
increased towards PRE16 values, which may have reflected cessation of a negative energy
balance. These findings demonstrated the success of natural BB in maintaining lean mass whilst
reducing fat mass during preparation for competition, which is ultimately the goal during this
period. Implementing a high and distributed protein intake appeared to ameliorate reductions in
lean mass typically observed during a prolonged period of negative energy balance. Maintaining
a high resistance training volume provided an ongoing stimulus for muscle protein synthesis,
which, coupled with the high protein intake, produced a cellular environment conducive to
limited lean mass loss. These findings add further evidence to the use of an increased protein
intake during weight reduction to limit muscle loss.
This study also demonstrated the rigidity of MD symptomatology during a period of significant
body composition modification. Despite reducing fat mass with limited change in lean mass, and
thus progressing towards the ideal lean and muscular physique, this cohort of natural BB showed
no change in MD symptomatology. Additionally, there was no change observed in disordered
eating pathology, nor fat and muscle perception indices. These findings oppose Hypothesis 5,
and suggest there may be a disconnect between actual body composition and attitudes around
muscularity. Another interesting finding from this study was the correlation identified between
MD symptomatology and subsequent reductions in energy and fat intake during competition
preparation. This adds to the growing literature relating to MD symptoms and the salience of
dietary practices.
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PRACTICAL IMPLICATIONS
The findings from this thesis have identified previously undocumented dietary practices
commonly used by competitive BB. Identifying these practices better equips dietitians to work
with BB in prescribing evidence based recommendations, as well as safely manoeuvring through
the use of practices for which safety and efficacy is currently unknown. The findings of the
qualitative study described in Chapter 5 also highlights the need to promote the role of dietitians
to BB. The sample of BB in this study were experienced and followed predominantly evidence-
based practices, however the study confirmed there is a large amount of misinformation
regarding dietary strategies in the bodybuilding community. Therefore promoting the role of
dietitians, in particular their knowledge and skills in body composition assessment and evidence-
based guidelines for accrual of lean mass, would be beneficial for BB. This may be particularly
important for novice BB who may be more vulnerable to the use of inappropriate strategies.
As demonstrated by the longitudinal study described in Chapter 6, natural BB display a capacity
to reduce fat mass to the lower extremities of human body fat levels, whilst concomitantly
limiting the loss of lean mass. Preparation practices of these BB highlight the importance of
maintaining an increased and distributed protein intake during a period of reduced energy intake,
whilst maintaining a high volume of resistance training, in order to stimulate the loss of fat mass
and the maintenance of lean mass. As such, these strategies may be considered, along with
specific individual dietary requirements, in athletes who target a progressive reduction in fat
mass, with minimal reduction of lean mass. Re-feed days documented in the qualitative study
described in Chapter 5 were employed by several participants in the longitudinal study. Given
the practice is safe, and presents benefits including a psychological recovery and increased
training capacity, as well as a potential for improved weight loss efficiency, such a practice may
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be implemented during a weight reduction period in athletes. Doing so under the supervision of a
dietitian may be recommended in order to ensure appropriate modifications to dietary intake,
such as carbohydrate and protein volume, are included during the implementation of such a
strategy.
The investigations into MD in BB described in Chapters 3, 4 and 7 identified significant practical
implications. Firstly, the sport of bodybuilding may attract individuals predisposed to the
development of MD, while BB displaying psychological characteristics such as anxiety,
depression and low self-esteem may have an increased risk of developing a pathological pursuit
of muscularity. Secondly, behavioural characteristics such as pathological eating habits and the
rate of weight loss may play important roles in the manifestation of MD symptomatology.
Therefore, coaches and clinicians should be observant of these psychological and behavioural
characteristics in individuals participating in the sport of bodybuilding, or individuals aiming to
commence participation in bodybuilding. Finally, dietary habits adopted by BB during
preparation, including increased reductions in energy and fat intake, were found to be associated
with increased MD symptomatology. Together with the association of weight loss rapidity, it
appears important for coaches, dietitians, and clinicians to monitor the dietary habits and
behaviours of BB to ensure their relationship with food and eating does not progress to a
pathological state.
STUDY LIMITATIONS
Low statistical power was a primary limitation of the studies described in Chapters 4, 6 and 7.
The small sample size in these two studies require consideration when interpreting the non-
189
significant associations, and non-significant changes, respectively. Difficulty with recruitment
was the primary factor in limiting the sample size, particularly with the longitudinal study. This
was despite use of multiple recruitment strategies, including advertisement on the website and
social media pages of the Australasian Natural Bodybuilding Association over a 16 month
period, distribution of study flyers at the Australasian Natural Bodybuilding Association national
contest, and to a database of BB known from previous research. The significant time
commitment required for the study was reported as a common reason for declining participation.
Additionally, withdrawal from competition preparation was also reported as a common reason
for declining participation and attrition in the longitudinal study. Few studies have examined the
body composition and physiology of BB during competition preparation. Difficulty with
recruitment may explain the lack of studies, as well as a potential aversion of this demographic
to participate in scientific research. Given the significant outcomes, in particular with regards to
body composition, more research into this demographic is likely to identify practical strategies
capable of being translated into other populations.
Due to limited statistical power the cross-sectional study design of Chapter 4 was unable to
identify predictors of MD symptomatology. Furthermore, the significant correlations are unable
to provide evidence of causality of these associations. Due to the non-standardised timing of
survey completion, variability in reported symptoms may have occurred based on preparation
phase and proximity to competition.
The non-significant dietary and physiology changes identified in Chapter 6 may be attributed to
the timeline of investigation in this study. An expected reduction in energy, carbohydrate and fat
intake between PRE8 and PRE1 testing points was not observed. This may be due to an
increased dietary intake in the final week of competition preparation, which was reflected by the
190
non-significant increase in energy and carbohydrate values at this measure, potentially
influencing RMR. A modified testing timeline, such as testing two weeks prior to competition,
may have detected these expected dietary and physiology changes. Also associated with the
study timeline, several participants had commenced their in-season preparation prior to the
PRE16 testing point. Therefore this measure may not reflect a true off-season status for these
participants. No measure of energy expenditure was conducted in this study which prohibited
any calculations of energy balance and energy availability, limiting the interpretation of
physiological adaptations which occurred during the testing period.
Dietary intake in the longitudinal study described in Chapters 6 and 7 was measured using seven
day weighed food records. Although a diet record is considered the gold standard of dietary
assessment, there are limitations inherent to this tool. Significant compliance is required of
participants to complete a food record accurately, and compliance is often reduced when
recording periods extend longer than four days. Food diaries are time consuming, and require a
high level of literacy. Additionally, the burden of completing weighed food records can often
lead to changes in dietary intake. However, participants were highly motivated to complete this
assessment given the importance of tracking dietary intake for athletic competition, and mostly
experienced in using such a tool. Furthermore, participants often consumed the same foods each
day, which would reduce participant burden. Therefore the diet assessment data reported in
Chapters 6 and 7 is likely accurate and a true reflection of diet for these athletes. In a similar
manner, measurement of exercise is limited by the use of a seven day exercise diary. Such a tool
is time consuming and places significant burden on participants. Due to this burden, there is a
risk that participants report exercise that is programmed to be completed, rather than is actually
completed. Wearable activity monitors were initially included in the longitudinal study to reduce
191
such limitations associated with the exercise diaries (see Appendix D), however poor compliance
and loss of equipment by participants forced this tool to be withdrawn from the study protocol.
The internal consistency measures of the assessment tools used in study described in Chapter 7
were lower than reported in previous literature. Although these values were considered
acceptable due to the exploratory nature of the study, however as such, these psychometric
properties must be considered when interpreting the findings of this study.
FUTURE RESEARCH
The outcomes of this thesis have implications for future research in bodybuilding, as well as
other athletic populations which require body composition modification. The qualitative study
described in Chapter 5 identified novel dietary strategies which have been developed and used in
the bodybuilding industry, but as yet have not been empirically investigated. Of particular
interest is the use of a weekly re-feed day, which is reported to assist in relieving metabolic
adaptations associated with prolonged energy restriction. Hormonal and neuroendocrine
responses to these “metabolic rest periods” have been examined in animal models, with
promising findings reported. Detailed investigation into the effect of this dietary strategy on
RMR and total energy expenditure, weight loss efficiency and ultimately total weight loss is
warranted. The response of hormones, in particular the appetite hormones leptin and ghrelin, to
this re-feed strategy may help to elucidate its effects on weight loss. Given a primary explanation
for ineffective dietary interventions is dietary adherence, re-feed days may present a potential
solution to this issue, and thus a further area of exploration in this regard. The inclusion of fluid
and sodium manipulation in the peak week period of competition preparation requires specific
192
investigation to determine their safety and efficacy. Examining the effect of these strategies on
total body water, urinary output, and hormones such as renin and aldosterone is warranted.
Importantly, blood chemistry should be examined in relation to this strategy to determine any
potential safety issues.
Due to the modest sample size included in the longitudinal study described in Chapters 6 and 7,
more research is required to confirm the findings of these Chapters. In particular, examining the
changes in MD symptomatology during competition preparation in a larger sample size,
including individuals demonstrating greater MD symptomatology, will provide further evidence
of the temporal characteristics of MD. A larger sample size will also allow a more direct
assessment of the rate of weight loss and MD symptomatology in BB, based on the outcomes of
the cross-sectional study described in Chapter 4.
Including a direct measure of energy expenditure in future research would allow the calculation
of energy balance and energy availability. These measures would provide great insight into the
physiological and metabolic responses during the bodybuilding competition preparation period,
and further explain the outcomes discussed in Chapter 6.
In lean individuals undergoing an energy deficit through diet and exercise, an increased protein
intake has been demonstrated to moderate the loss of muscle mass. The BB participating in the
longitudinal study described in Chapter 6 consumed a very high and distributed protein intake,
which likely contributed to the maintenance of lean mass and subsequently RMR. Future
research examining the effect of different doses of protein intake during a prolonged energy
deficit, with and without the inclusion of resistance training, would serve to provide more
specific guidelines for dietary prescription for BB, and other individuals requiring similar body
composition modification.
193
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loss during weight loss in athletes. Med. Sci. Sports Exerc. 2010, 42, 326-337,
10.1249/MSS.0b013e3181b2ef8e.
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adaptation. J. Sports Sci. 2011, 29 Suppl 1, S29-38,
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175. Burd, N.A.; Tang, J.E.; Moore, D.R.; Phillips, S.M. Exercise training and protein
metabolism: influences of contraction, protein intake, and sex-based differences. J. Appl.
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176. Areta, J.L.; Burke, L.M.; Camera, D.M.; West, D.W.; Crawshay, S.; Moore, D.R.;
Stellingwerff, T.; Phillips, S.M.; Hawley, J.A.; Coffey, V.G. Reduced resting skeletal
muscle protein synthesis is rescued by resistance exercise and protein ingestion following
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10.1152/ajpendo.00590.2013.
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789X.2009.00654.x.
178. Bryner, R.W.; Ullrich, I.H.; Sauers, J.; Donley, D.; Hornsby, G.; Kolar, M.; Yeater, R.
Effects of resistance vs. aerobic training combined with an 800 calorie liquid diet on lean
body mass and resting metabolic rate. J. Am. Coll. Nutr. 1999, 18, 115-121,
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179. Henning, P.C.; Margolis, L.M.; McClung, J.P.; Young, A.J.; Pasiakos, S.M. High protein
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180. Mauras, N.; Hayes, V.; Welch, S.; Rini, A.; Helgeson, K.; Dokler, M.; Veldhuis, J.D.;
Urban, R.J. Testosterone deficiency in young men: marked alterations in whole body
protein kinetics, strength, and adiposity. J. Clin. Endocrinol. Metab. 1998, 83, 1886-1892,
https://dx.doi.org/10.1210/jcem.83.6.4892.
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2012, 30, 534-542, 10.1007/s00774-012-0354-4.
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Nutritional, lifestyle, and weight control practices of professional jockeys. J. Sports Sci.
2011, 29, 791-799, 10.1080/02640414.2011.560173.
183. Henning, P.C.; Scofield, D.E.; Spiering, B.A.; Staab, J.S.; Matheny, R.W., Jr.; Smith,
M.A.; Bhasin, S.; Nindl, B.C. Recovery of endocrine and inflammatory mediators
following an extended energy deficit. J. Clin. Endocrinol. Metab. 2014, 99, 956-964,
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184. Bone, J.L.; Ross, M.L.; Tomcik, K.A.; Jeacocke, N.A.; Hopkins, W.G.; Burke, L.M.
Manipulation of Muscle Creatine and Glycogen Changes DXA Estimates of Body
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185. Frederick, D.A.; Buchanan, G.M.; Sadehgi-Azar, L.; Peplau, L.A.; Haselton, M.G.;
Berezovskaya, A. Desiring the muscular ideal: Men’s body dissatisfaction in the United
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186. Mitchell, L.; Murray, S.B.; Hoon, M.; Hackett, D.; Prvan, T.; O'Connor, H. Correlates of
muscle dysmorphia symptomatology in natural bodybuilders: Distinguishing factors in the
pursuit of hyper-muscularity. Body Image 2017, 22, 1-5,
187. Mitchell, L.; Slater, G.; Hackett, D.; Johnson, N.; O'Connor, H. Physiological implications
of preparing for a natural male bodybuilding competition. Eur. J. Sport Sci. 2017,
https://doi.org/10.1080/17461391.2018.1444095.
220
APPENDICES
221
Appendix A: Supplementary Material for Chapter 3
APPENDIX A: SUPPLEMENTARY MATERIAL FOR CHAPTER 3
A1. MEDLINE electronic search strategy
A2. Methodological quality ratings
222
A1. Electronic search strategy used to search the MEDLINE database with no limits. Similar
strategies were used for other electronic information sources, modified to comply with search
rules of each database
1. Keyword – Muscle dysmorphia
2. Keyword – Bigorexia
3. Keyword – Reverse anorexia
4. Keyword – Adonis complex
5. Keyword – Manorexia
6. Keyword – Male eating disorder
7. Keyword – Bodybuilding
8. Keyword – Body building
9. Keyword – Bodybuilder
10. Keyword – Body builder
11. Keyword – Strength training
12. Keyword – Weight training
13. Keyword – Resistance training
14. Keyword – Progressive training
15. Keyword – Progressive resistance
16. Keyword – Weight lifting
17. Keyword – Athlete
18. 1 OR 2 OR 3 OR 4 OR 5 OR 6
19. 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17
20. 18 AND 19
223
A2. Methodological quality ratings
Data collection
Statistical tests
Representative
characteristics
Data dredging
Main findings
representative
of population
Participating
confounders
appropriate
Hypothesis
procedures
probability
variability
Reference
described
described
described
described
Outcome
Principal
Random
reported
reported
subjects
Subject
Actual
stated
Boyda et al. (2011) 1 1 1 1 1 1 1 0 0 1 1 1
Gonzalez-Marti et al. 1 1 0 0 1 0 0 0 0 1 1 1
(2014)
Lopez-Barajes et al. 1 1 0 0 1 0 0 0 0 1 1 0
(2012)
Wolke et al. (2008) 1 1 0 0 1 1 0 0 0 1 1 1
Babusa et al. (2012) 1 1 0 0 1 1 1 0 0 1 1 1
Baghurst et al. (2009) 1 1 1 1 1 1 1 0 1 1 1 1
Cella et al. (2012) 1 1 1 0 1 0 1 0 0 1 1 1
Davies et al. (2011) 1 1 0 0 1 0 0 0 0 1 1 1
Hale et al. (2013) 1 1 0 0 1 1 1 0 0 1 1 1
Lantz et al. (2002) 1 1 0 0 1 1 1 0 0 1 1 1
Santarnecchi et al. (2012) 1 1 0 0 1 1 1 0 0 1 1 1
Skemp et al. (2013) 1 1 1 0 1 1 1 0 0 1 1 1
Soler et al. (2013) 1 1 1 1 1 1 1 1 0 1 1 1
Babusa et al. (2012) 1 1 0 0 1 1 0 0 0 1 1 1
Cafri et al. (2008) 1 1 1 1 1 1 1 0 0 1 1 1
De Lima et al. (2010) 1 1 1 0 1 1 1 0 0 0 1 1
Giardino et al. (2012) 1 1 0 1 1 1 1 0 0 0 0 1
Hildebrandt et al. (2006) 1 1 0 0 1 1 1 0 1 1 1 1
Kanayama et al. (2006) 1 1 0 0 1 1 1 0 0 1 1 0
Kuennen et al. (2007) 1 1 0 0 1 1 1 0 0 1 1 1
Maida et al. (2005) 1 1 0 0 1 1 0 0 0 1 1 0
Nieuwoldt et al. (2015) 1 1 1 0 1 1 1 0 0 0 1 1
Olivardia et al. (2000) 0 1 1 0 1 1 1 0 0 1 1 0
Robert et al. (2009) 1 1 0 0 1 1 0 0 0 1 1 0
Segura-Garcia et al. 1 1 1 0 1 1 1 0 0 1 1 1
(2010)
Thomas et al. (2014) 1 1 1 0 1 1 0 0 0 1 1 1
Thomas et al. (2011) 1 1 0 0 1 1 1 0 0 1 1 1
224
Tod et al. (2014) 1 1 0 0 1 1 0 0 0 1 1 1
Valdes et al. (2013) 1 1 0 0 1 0 0 0 0 0 1 0
Mean 0.97 1 0.38 0.17 1 0.83 0.66 0.03 0.07 0.9 0.97 0.79
SD 0.19 0 0.49 0.38 0 0.38 0.48 0.19 0.26 0.31 0.19 0.41
Median
Range
Groups comparable on
Discussion of findings
Groups recruited from
Source of funding and

Groups recruited over
measures appropriate
significance reported
affiliations described
limitations discussed
Clinical & statistical
confounding factors
same period of time
Study biases and

Sufficient power
same population
Adjustment for
Psychological
confounding
Reference
Total
Boyda et al. (2011) 1 0 0 0 0 1 0 1 1 0 14
Gonzalez-Marti et al. 1 0 0 0 0 1 0 1 0 0 9
(2014)
Lopez-Barajes et al. (2012) 0 0 0 0 0 1 1 1 0 0 8
Wolke et al. (2008) 1 0 0 0 0 1 1 1 1 0 12
Babusa et al. (2012) 0 0 0 0 0 1 0 1 0 1 11
Baghurst et al. (2009) 0 0 0 0 0 1 0 1 1 0 14
Cella et al. (2012) 1 0 0 0 0 1 0 1 0 0 11
Davies et al. (2011) 0 0 0 0 0 1 1 1 1 0 10
Hale et al. (2013) 0 0 0 1 0 1 1 1 1 1 14
Lantz et al. (2002) 0 0 0 0 0 1 1 1 1 0 12
Santarnecchi et al. (2012) 0 0 0 0 0 1 1 1 0 1 12
Skemp et al. (2013) 0 0 0 1 0 1 1 1 0 0 13
Soler et al. (2013) 1 0 0 0 0 1 0 1 1 0 15
Babusa et al. (2012) 0 0 0 0 0 1 0 1 1 0 10
Cafri et al. (2008) 1 0 1 1 1 1 1 1 1 1 19
De Lima et al. (2010) 0 1 0 0 0 1 0 1 0 1 12
Giardino et al. (2012) 1 1 0 0 0 1 1 1 1 0 12
Hildebrandt et al. (2006) 0 0 0 1 0 1 1 1 1 0 14
Kanayama et al. (2006) 1 0 1 0 1 1 1 1 1 1 15
Kuennen et al. (2007) 1 0 0 1 0 1 1 1 1 0 14
Maida et al. (2005) 1 0 0 0 0 0 1 1 0 0 9
225
Nieuwoldt et al. (2015) 1 1 0 0 0 1 1 1 1 0 14
Olivardia et al. (2000) 1 0 0 0 0 0 0 1 1 0 10
Robert et al. (2009) 1 1 0 0 0 1 0 1 1 0 11
Segura-Garcia et al. (2010) 1 0 0 0 0 1 1 1 0 0 13
Thomas et al. (2014) 1 0 0 1 0 1 1 1 1 1 15
Thomas et al. (2011) 1 0 0 0 1 1 1 1 0 0 13
Tod et al. (2014) 1 0 0 0 0 1 1 1 0 1 12
Valdes et al. (2013) 1 0 0 0 0 0 1 1 0 0 7
Mean 0.62 0.14 0.07 0.21 0.1 0.9 0.66 1 0.59 0.28 12.24
SD 0.49 0.35 0.26 0.41 0.31 0.31 0.48 0 0.5 0.45 2.5
Median 12
Range 7-19
SD, standard deviation
226
Appendix B: Supplementary Material for Chapter 4
APPENDIX B: SUPPLEMENTARY MATERIAL FOR CHAPTER 4
B1. Study protocol for the cross-sectional study
B2. Participant information sheet for the cross-sectional study
B3. Online survey for the cross-sectional study
B4. Advertisement flyer for the cross-sectional study
227
B1. Study protocol for the cross-sectional study
Correlates of Muscle Dysmorphia Symptomatology in Natural

Bodybuilders: Distinguishing factors in the Pursuit of Hyper-
Muscularity
228
Method
A. Study Design
Training Routines, Nutritional Practices, Eating Attitudes and Body Image of Competitive Male
Bodybuilders is a cross-sectional study investigating training, nutrition, supplementation
practices, and body image and eating attitudes of male, natural bodybuilders.
Data is collected through an anonymous online survey. The survey typically takes 20-30 minutes
to complete. The survey is run through an online platform (surveymonkey.com).
B. Participants
Participants will be recruited using the following methods:
• Flyers posted on the ANB official Facebook page, and subsequently “shared” by
Facebook users, and bodybuilders.
• Flyers will be distributed at the ANB national contests in October 2015.
• Word of mouth advertisement
Inclusion criteria
• Male, aged 18 years or older
• Natural (drug free) bodybuilders
• Have competed in a natural (drug tested) bodybuilding competition in the past 18 months.
Exclusion criteria
• Have not competed in a natural competition in the past 18 months
• Fitness model division
Study consent
Following the survey link on the study flyer takes potential participants to the opening page of
the survey. The opening page of the survey ask questions to confirm eligibility based on the
inclusion criteria. Those whom meet eligibility are shown the participant information statement
and asked if they consent to participate. Upon providing consent, participants are directed to the
remainder of the survey.
C. Study Parameters
229
The survey contains questions separated into five sections.
1. Training practices.
These questions gather information about the resistance training and aerobic training frequency,
duration, intensity and techniques used.
2. Nutritional practices
These questions ask about specific dietary habits. Questions gather information about any special
diets participants follow, any foods participants avoid, food preparation habits, and sources of
dietary information.
3. Ergogenic aids
This section gathers information about dietary supplements used by participants. Questions ask
about the types of supplements used, what stage of the season they are used, and why they are
used. This section also gathers information about the use of performance enhancing drugs.
Participants can choose to leave these specific questions unanswered.
4. Body image and Eating attitudes
This section contains two validated questionnaires, the Eating Attitude Test 26 items and the
Muscle Dysmorphic Disorder Inventory.
4.1 Eating Attitude Test 26
The Eating Attitude Test-26 (EAT-26) is a 26 item questionnaire. The EAT-26 uses a 6-point
Likert-type scale for responses, ranging from “never” to “always”. The questions are preceded
by the statement, “Please respond to each of the following statements. For each question, select
the option that most closely describes how the statement applies to you right now.”
4.2 Muscle Dysmorphic Disorder Inventory
The Muscle Dysmorphic Disorder Inventory (MDDI) is a brief, 13 item questionnaire. The
MDDI uses a 5 point Likert-type scale for responses, ranging from “never” to “always”. The
questions are preceded by the statement, “Please respond to each of the following statements. For
each question, select the option that most closely describes how the statement applies to you
right now.”
5. Demographic Information
This section gathers basic demographic information including age, height, weight, changes in
weight during competition preparation, and bodybuilding experience.
Storage of Data
Data collected from the survey on the online platform will be extracted into Microsoft Excel and
stored on the secure, password protected laptop of the researcher.
230
Figure B1. Flowchart of recruitment and study methods
231
D. Breakdown of Assessment Process
1. Pre-testing
1.1 Participant follows online link to opening page of survey, responds to eligibility questions.
1.2 If eligible, participant is asked to provide consent.
1.3 Participant is directed to data collection questions of survey.
2. Data collection
2.1 Participant completes all five sections of survey.
2.2 Participant provides contact details if they wish to receive results of survey.
2.3 Participant is directed to exit page.
E. Scripts
Initial email script to people expressing interest in study participation
“Hello [insert name],
Thank you for expressing interest in taking part in our study, Training Routines, Nutritional
Practices, Eating Attitudes and Body Image of Competitive Male Bodybuilders. Our study
involves a short, 20 minute survey conducted online. The study aims to describe the training,
nutrition, and supplement practices, and assess body image and eating attitudes of male
bodybuilders. Participation is completely voluntary, and responses remain anonymous.
The survey can be accessed using the following link:
https://www.surveymonkey.com/r/8SVBBLK
If you would like further information about the study, please provide a contact number and I will
give you a call at a time that suits you. Alternatively please feel free to contact me at your
convenience on 0431 363 027.
Kind regards,
Lachlan Mitchell”
F. Collection Forms
Assessment
• Survey questionnaire
232
B2. Participant information sheet for the cross-sectional study
Discipline of Exercise and Sports Science

Faculty of Health Sciences
ABN 15 211 513 464

____________________________________________________________________________________________________________________
Dr. Helen O’ Connor

Chief Investigator
Room H111
Building C43
NSW 2006 AUSTRALIA
Telephone: +61 2 9036 7364
Facsimile: +61 2 9351 9204
Email: [email protected]
Web: http://www.sydney.edu.au/
Training Routines, Nutritional Practices, Eating Attitudes and Body Image of Competitive
Male Bodybuilders
PARTICIPANT INFORMATION STATEMENT
(1) What is the study about?
This study involves the completion of an anonymous online survey designed to assess the exercise and
nutritional habits of bodybuilders who regularly participate in competitions, as well as body image and
eating attitudes amongst this population. This study aims to make a valuable contribution to the science
of modern bodybuilding, and we hope the information you provide will give insight for sports scientists
and sports dietitians into the practicalities of the sport.
As a competitive bodybuilder, you have been invited to participate in this study.
(2) Who is carrying out the study?
The study is being conducted by Dr. Helen O’ Connor and Mr. Lachlan Mitchell (PhD candidate) from
The University of Sydney, Dr. Matthew Hoon from the Australian Catholic University and Dr. Gary
Slater from the University of the Sunshine Coast. This study is likely to form part of Mr. Lachlan
Mitchell’s doctoral thesis.
233
(3) What does the study involve/how much time will it take?
Participation in the study will require the completion of an anonymous online survey, which is expected
to take approximately 20-30 min.
(4) Is there any risk associated with the study?
As the study is anonymous and survey based, we do not expect any risks associated with the study. A
section of the survey will ask if you use performance enhancing drugs. We remind you that this survey
is anonymous and your answers will not be identifiable, so we encourage you to answer these questions
openly. However, if you do not wish to, you will have the option to skip over these parts. Additionally,
certain questions will ask you about body image. However, if you are concerned or experience any
distress after completing the questions, please contact the researchers using the details provided to
coordinate an appropriate course of action, which may include consultation with a medical professional.
(5) Can I withdraw from the study?
Being in this study is completely voluntary - you are not under any obligation to take the survey. If you
do begin the survey and do not wish to complete it, you may withdraw at any time without affecting
your relationship with The University of Sydney or the researchers. You can withdraw your responses
any time before you have submitted the questionnaire and your data will also not be saved. Once you
have submitted it, your responses cannot be withdrawn because they are anonymous and therefore we
will not be able to tell which one is yours.
(6) Will anyone else know the results?
All aspects of the study will be strictly confidential and only the researchers will have access to any data
collected.
A report of the study may be submitted for publication, but individual participants will not be
identifiable in such a report. Should you choose to, you may provide your contact details upon
completion of the survey, and a summary of the study findings will be provided to you (once available).
(7) Will the study benefit me?
A prize draw will be offered to participants of the study (should they wish to submit their contact details
into the draw after completion of the survey), with 5 x $100 Westfield gift cards available. Your name
and contact details, stored separately from the survey data, will be used only to contact you if you have
won a prize. Winners will be selected randomly following completion of the data collection and the
winners will be notified.
(8) Can I tell other people about the study?
Yes and the researchers do encourage you to pass on information to those you believe are suitable for
this project. The chief investigator’s contact details are available below should you/they require more
information.
(9) What if I require further information about the study or my involvement in it?
If you would like to know more about this study at any stage, please feel free to contact:
Mr. Lachlan Mitchell [email protected] +61 2 9036 7358

234
Dr. Helen O’ Connor [email protected] +61 2 9351 9625
(10) What if I have a complaint or any concerns?
Any person with concerns or complaints about the conduct of a research study can contact The
Manager, Human Ethics Administration, University of Sydney on +61 2 8627 8176 (Telephone); +61
2 8627 8177 (Facsimile) or [email protected] (Email).
Version 2
Date: 21/9/2015
235
B3. Online survey for the cross-sectional study
Training Routines, Nutritional Practices, Eating Attitudes and Body Image of Competitive
Male Bodybuilders
Welcome to the online survey about bodybuilding training, nutrition and body image; a study run by
researchers from the University of Sydney, University of the Sunshine Coast and the Australian Catholic
University. Before you continue:
 Are you Male

 Over 18 yrs
 Have you participated in a bodybuilding contest in the last 18 months
 Compete naturally (i.e. you have not used any prohibited substances in the past 24 months)
 If ≥1 not ticked, direct to exclusion page (please see final

page)
 If ALL TICKED, proceed below

Based on your
submitted
information, you are eligible to participate in our survey. Before you do, we ask you to kindly read the
below information detailing the requirements of the study and your legal rights as a participant; which
may help you decide if you wish to take part in the research.
This study involves the completion of an anonymous online survey designed to assess the exercise and
nutritional habits of bodybuilders who regularly participate in competitions, as well as body image and
eating attitudes amongst this population. This study aims to make a valuable contribution to the science of
modern bodybuilding, and we hope the information you provide will give insight for sports scientists and
sports dietitians into the practicalities of the sport.
As a competitive bodybuilder, you have been invited to participate in this study.
The study is being conducted by Dr. Helen O’ Connor and Mr. Lachlan Mitchell (PhD candidate) from The
University of Sydney, Dr. Gary Slater from the University of the Sunshine Coast and Dr. Matthew Hoon
from the Australian Catholic University. This study is likely to form part of Mr. Lachlan Mitchell’s
doctorial research.
236
(13) What does the study involve/how much time will it take?
Participation in the study will require the completion of an anonymous online survey, which is expected to
take approximately 20-30 min.
(14) Is there any risk associated with the study?
As the study is anonymous and survey based, we do not expect any risks associated with the study. A
section of the survey will ask if you use performance enhancing drugs. We remind you that this survey is
anonymous and your answers will not be identifiable, so we encourage you to answer these questions
openly. However, if you do not wish to answer these items, you will have the option to skip over these
parts. Additionally, certain questions will ask you about body image. However, if you are concerned or
experience any distress after completing the questions, please contact the researchers using the details
provided to coordinate an appropriate course of action, which may include consultation with a medical
professional.
Being in this study is completely voluntary - you are not under any obligation to take the survey. If you do
begin the survey and do not wish to complete it, you may withdraw at any time without affecting your
relationship with The University of Sydney or the researchers. You can withdraw your responses any time
before you have submitted the questionnaire and your data will also not be saved. Once you have submitted
it, your responses cannot be withdrawn because they are anonymous and therefore we will not be able to
tell which one is yours.
All aspects of the study will be strictly confidential and only the researchers will have access to any data
collected.
A report of the study may be submitted for publication, but individual participants will not be identifiable
in such a report. Should you choose to, you may provide your contact details upon completion of the survey,
and a summary of the study findings will be provided to you (once available).
A prize draw will be offered to participants of the study (should they wish to submit their contact details
into the draw after completion of the survey), with 5 x $100 Westfield gift cards available. Your name and
contact details, stored separately from the survey data, will be used only to contact you if you have won a
prize. Winners will be selected randomly following completion of the data collection and the winners will
be notified.
237
Yes and the researchers do encourage you to pass on information to those you believe are suitable for this
project. The chief investigator’s contact details are available below should you/they require more
information.
(19) What if I require further information about the study or my involvement in it?
If you would like to know more about this study at any stage, please feel free to contact:

Any person with concerns or complaints about the conduct of a research study can contact The Manager,
Human Ethics Administration, University of Sydney on +61 2 8627 8176 (Telephone); +61 2 8627 8177
(Facsimile) or [email protected] (Email).
Consent
By giving your consent to take part in this study you are telling us that you:
 Understand what you have read.
 Agree to take part in the research study as outlined above.
 Agree to the use of your personal information as described.
 Yes, I consent to participate in the study  GOES TO NEXT SECTION

 No, I do not agree to participate in the study  EXIT PAGE (see final page)
238
Bodybuilding Survey
The participant of this survey MUST have competed in a bodybuilding contest.
Your answers and experiences are important to us.
To help us read your answers, please type in your response where indicated
Please put a cross in the appropriate box(es)  Yes  No
Resistance Training Practices
What is your maximum bench

press lift (1RM)? _________________ kg  Unsure
What is your maximum squat

lift (1RM)? _________________ kg  Unsure
Do you perform whole body  Split  Whole body  Both

training sessions or split routines?
During your off-season, how Sessions per  2-3  4-5  6-7  8-9  +10
many resistance training week
sessions do you perform per Time per  <20  20-30  30-40  40-50
week and what is the average session  50-60  60-90  +90
time of each session? (mins)
During your in-season, how Sessions per  2-3  4-5  6-7  8-9  +10
many resistance training week
sessions do you perform per Time per  <20  20-30  30-40  40-50
week and what is the average session  50-60  60-90  +90
time of each session? (mins)
Do you use any of the listed  Giant sets  Super sets  Forced reps
advanced overload techniques in  Negatives  21’s  Timed reps
your training?  Partial reps  Pre exhaustion  Post exhaustion
sets sets
 Pyramids  Breakdowns  None
 Other _____________________________________
239
If yes, when do you perform them (e.g. in-season, off-season, high volume week, low volume
week, peak-week) and for what exercises?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________
What is the Exercises per muscle 1  2-3  4-5  ≥6

general group
training
intensity you Sets per exercise  1-2  3-4  5-6  ≥7
use during the
off-season? Reps to failure per set  1-3  4-6  7-9  10-12  13-15
(Repetition Max)
Recovery time     
between sets (secs) 30-60 61-120 121-180 181-300 ≥ 301
Do you modify your training during the  Yes  No

off-season by lifting heavier loads with
lower repetitions (1-5RM)?
Do you periodise your training during  Yes  No

the off-season?
If yes, please describe how:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What is the general Exercises per 1  2-3  4-5  ≥6

training intensity muscle group
you use during the Sets per  1-2  3-4  5-6  ≥7
in-season? exercise
Reps to failure  1-3  4-6  7-9  10-12  13-15
per set (RM)
240
Recovery time     
between sets 30-60 61-120 121-180 181-300 ≥ 301
(secs)
When do you start your ________weeks

in-season (weeks before
the competition)?
Aerobic (Cardio)Training Practices
Do you perform any aerobic exercise  Yes  No

in your training?
Describe the aerobic exercise that you perform below:
Off-Season In-Season
Exercise  Walking  Walking

Type  Jogging/running  Jogging/running
 Cycling  Cycling
 Swimming  Swimming
 Rowing  Rowing
 Cross trainer  Cross trainer
 Skipping  Skipping
 Boxing  Boxing
 Other______  Other_____
Sessions      
per week 1-2 2-4 ≥5 1-2 2-4 ≥5
Time per session    

(mins) 10-20 20-30 10-20 20-30
   
30-45 > 45 30-45 > 45
241
Perceived  Low (6-11/20)  Low (6-11/20)
intensity of  Moderate (12-15/20)  Moderate (12-15/20)
exercise  High (16-20/20)  High (16-20/20)
Do you ever perform fasted cardio sessions?

 No
 Yes: ________ times a week
Where do you get your training advice from? (You may select more than one)
 Other bodybuilders  Coach  Personal trainer
 Online blog/forum  Scientific publications  Exercise scientist
 Family/friends  Health food store  Doctor
 Magazines
 Other: ________________
242
Dietary practices
Food intake
Do you follow any special diets? (You may select more than one)
 High protein  Atkins  Low-calorie

 High-carb  Carb-cycling  High-calorie
 Vegan  Lacto-ovo  Salt reduced
 Paleo vegetarian  Gluten free
 Low-Carb  No sugar  Dairy free
 Vegetarian  Carb re-feeding
 Food allergy/intolerance. Please describe:____________
 Other:_____________________________________________
 I do not follow a special diet
If you indicated that you do follow a special diet, could you please explain why you are
following it?:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you avoid/limit quantity any of the following food groups (grains, cereals, dairy, fats, oils,
starchy vegetables)? (You may select more than one)
 Bread  Treats e.g.
 Grains / cereals cakes/lollies
 Dairy (e.g.  Alcohol
milk, cheese,  Fast food
yoghurt)  I do not generally
 Fats / Oils restrict any food groups
 Starch
vegetables (e.g.
potato, sweet
potato
 Fruits
 Red meat (e.g.
beef lamb)
 White meat
(e.g. chicken,
turkey, pork)
 Seafood (e.g.
fish, prawns,
crab)
243
 Other:_____________________________________________
If you indicated that you avoid certain food groups, could you please explain why you do so?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
How often do you eat out/takeaway?

During off-season____________ times per month
During in-season________________ times per month
Who most often prepares your food?

 Only me  Partner  Family member
 Special food service  Restaurants
Do you weigh your food in the off season?  Never  Some of the time  Most of the
time  All the time
Do you weigh your food during the in-season?  Never  Some of the time  Most
of the time  All the time
Where do you get your dietary advice from? (You may select more than one)
 Coach  Other body builders
 Dietitian  Exercise Scientist
 Doctor  Personal trainer
 Alternative medical practitioner (e.g. naturopath)
 Family/friends  Online blog/forums
 Scientific publications  Magazines
 Health food store  Supplement Store
 Other: ________________
Dietary Supplements
Do you use  Yes  No

supplements?
What supplements do you use during the off-season, and in-season? (Tick appropriate boxes)
244
Off-season In season
Protein powders
Whey
Casein
Amino Acids
Other
Pre workouts
Caffeine
Creatine
Beta-alanine
Other
Herbal Remedy
Testosterone boosters
Other
General
Vitamins
Mineral
Glucosamine
Glutamine
HMB
BCAA
Omega 3/fish oil
Carnitine
Arginine
d-aspartic acid
Probiotics
Other
If you indicated ‘other’ above, could you please list other supplements you may take:
______________________________________________________________________________
______________________________________________________________________________
Why do you take supplements?

 Aid training
 Improve muscle size
 Avoid nutrient deficiencies
 Meal replacement
 Fat loss
 Boost recovery
245
 Feel better
 Stay healthy
 Other________________
Have you ever used  Yes  No  Prefer to not disclose

performance
enhancing drugs?
What drugs did you _________________________________________________

use? _________________________________________________
_________________________________________________
Why did you use these drugs? _____________________________________
246
Eating Attitudes Test 26 Items (EAT-26)

Instructions: Please respond to each of the following statements. Circle the response
choice that best describes you
Never Rarely Some Often Very Alway
times often s
1. I am terrified about being 1 2 3 4 5 6
overweight
2. I avoid eating when I am 1 2 3 4 5 6
hungry
3. I find myself preoccupied with 1 2 3 4 5 6
food
4. I have gone on eating binges 1 2 3 4 5 6
where I feel that I may not be
able to stop
5. I cut my food into small 1 2 3 4 5 6
pieces
6. I am aware of the calorie 1 2 3 4 5 6
content of foods that I eat
7. I particularly avoid foods with 1 2 3 4 5 6
high carbohydrate content
8. I feel that others would prefer 1 2 3 4 5 6
I ate more
9. I vomit after I have eaten 1 2 3 4 5 6
10. I feel extremely guilty after 1 2 3 4 5 6

eating
11. I am preoccupied with a 1 2 3 4 5 6
desire to be thinner
12. I think about burning up 1 2 3 4 5 6
calories when I exercise
13. Other people think that I am 1 2 3 4 5 6
too thin
14. I am preoccupied with the 1 2 3 4 5 6
thought of having fat on my
body
15. I take longer than others to 1 2 3 4 5 6
eat meals
247
16. I avoid foods with sugar in 1 2 3 4 5 6

them
17. I eat diet foods 1 2 3 4 5 6
18. I feel that food controls my 1 2 3 4 5 6

life
19. I display self-control around 1 2 3 4 5 6
food
20. I feel that others pressure me 1 2 3 4 5 6
to eat
21. I give too much time and 1 2 3 4 5 6
thought to food
22. I feel uncomfortable after 1 2 3 4 5 6
eating sweets
23. I engage in dieting behaviour 1 2 3 4 5 6
24. I like my stomach to be 1 2 3 4 5 6
empty
25. I enjoy trying new rich foods 1 2 3 4 5 6
26. I have the impulse to vomit 1 2 3 4 5 6
after meals
248
Body Image
Instructions: Please respond to each of the following statements. Circle the response
choice that best describes you
Never Rarely Sometime Often Alway
s s
1. I think my body is too small 1 2 3 4 5
2. I wear loose clothing so that people 1 2 3 4 5

cannot see my body
3. I hate my body 1 2 3 4 5
4. I wish I could get bigger 1 2 3 4 5
5. I think my chest is too small 1 2 3 4 5
6. I think my legs are too thin 1 2 3 4 5
7. I feel like I have too much body fat 1 2 3 4 5
8. I wish my arms were bigger 1 2 3 4 5
9. I am very shy about letting people 1 2 3 4 5

see me with my shirt off
10. I feel anxious when I miss one or 1 2 3 4 5
more workout days
11. I pass up social activities (eg. 1 2 3 4 5
Watching football games, eating
dinner, going to see a movie) with
friends because of my workout
schedule
12. I feel depressed when I miss one 1 2 3 4 5
or more workout days
13. I pass up chances to meet new 1 2 3 4 5
people because of my workout
schedule
249
Background Information
What is your age? ________ yrs
What is your height? ______________cm
What is your current weight? _____________ kg
How does your weight vary over the season:

Stage weight _________
Max weight ________
How many weeks before comp do you commence _____________ wks

cutting?
At what age did you start lifting weights? ________________
How many years have you been competing in ___________________ yrs

bodybuilding?
Why did you  Always interested  Approached by  To increase

begin another bodybuilder muscle/body weight
bodybuilding?  To lose weight  To improve body  To improve self esteem
image
 Negative comments  To get fit
about my weight
 Other
______________________________________________________
What types of bodybuilding  Natural  Amateur  Professional

competitions do you competed in?
What category do you compete in? _______________________
How many competitions have you No. of Competitions: ________________________

competed in and what is your best
result? Best Result:________________________________
When did you last compete in a bodybuilding competition? ___________ months ago
250
Thank you!
Thank you for your participation in this study. Your answers are highly valued by the researchers
and we hope the data collected can provide us with some informative insight into the sport.
Do you wish to enter the draw to win a $100 Westfield gift voucher? If so, please provide your
contact details below. The winners will be randomly drawn and notified through the details
provided. Please note your personal details will be separated from your responses to ensure your
responses remain anonymous
Would you be interested in receiving a summary of the findings from this study? If so, please
provide your contact details below.
Would you be interested in participating in other bodybuilder research projects conducted by the
University of Sydney or the University of the Sunshine Coast?
If so, please provide your name and contact details below, and should a suitable project come up,
the research team will contact you:
Thank you once again for your participation in our study.
Kind regards,
251
The Research Team
252
Exclusion Page
Thank you for taking interest in the study. Unfortunately, you are outside of the targeted
population we wish to investigate. As we, the researchers, are only just beginning to explore the
world of bodybuilding, we may choose to investigate other areas and individuals in future
projects. In this case, we encourage you to keep an eye out for any studies that may suit you.
Kind regards,
The Research Team
253
Exit page
Thank you for taking interest in our study. If you have chosen not to participate in our study as you
require more information, please feel free to contact the researchers:

Kind regards,
The Research Team
Version 2
Date: 29/5/2015
254
B4. Advertisement flyer for the cross-sectional study
255
Appendix C: Supplementary Material for Chapter 5
APPENDIX C: SUPPLEMENTARY MATERIAL FOR CHAPTER 5
C1. Study protocol for the qualitative study
C2. Participant information sheet for the qualitative study
C3. Participant consent form for the qualitative study
C4. Interview script for the qualitative study
C5. Advertisement flyer for the cross-sectional study
C6. Consent form to advertise study for recruitment purposes
256
C1. Study protocol for the qualitative study
Do Bodybuilders Use Evidence Based Nutrition Strategies to

Manipulate Physique?
257
Method
A. Study Design
The Modern Bodybuilder: Nutrition and Training Strategies is a cross-sectional study
investigating nutrition, supplementation and training habits of experienced male, “natural”
bodybuilders during preparation for competition.
Data collection takes place during a one-off in-depth interview. Interviews occur either in
person, at the University of Sydney Cumberland Campus, or over the phone. Interviews typically
take 90 minutes to complete.
B. Participants
• Flyers posted on the ANB official Facebook page, and subsequently “shared” by
Facebook users.
• Flyers distributed to bodybuilders from previous studies
Inclusion criteria
• Male, aged 18 years or older
• Natural (drug free) bodybuilders, competing in the bodybuilding division of drug-tested
bodybuilding federations.
• Five or more years bodybuilding experience, with competition experience at either
national or international bodybuilding contests
Exclusion criteria
• Less than five years’ experience
• No national or international competition experience
• Fitness model division
C. Study Parameters
The interview is a semi-scripted interview, with questions asking for information about topics
relevant to bodybuilding preparation. The script has been designed to allow probing for further
information. The topics of questions include demographic information and bodybuilding
experience, training/exercise, dietary intake, dietary supplements, performance enhancing drugs,
and sources of bodybuilding information.
Participants are free to decline to answer any question or section of questions, and can finish the
interview at any time.
Participants taking part in the interview face to face are to present to the campus at the
designated time. The interview is to be conducted in H111. Participants taking part in the
interview over the phone are asked to dial in to the conference call using the number provided
(Optus ExecutiveMEET).
258
The interview will be recorded to produce an mp3 file. The interview recording will be uploaded
to a secure transcription service website (Way With Words) whose staff transcribe the
interviews. Transcribed interviews will be de-identified for name, and other identifying features,
and sent back to participants for verification and correction. Participants may make changes to
transcripts to correct transcriber error, replace what was said with the intended meaning, or
further de-identify themselves. Field notes will also be taken by the researcher to capture
information such as details not spoken (e.g. tone, body language) or comments/information
passed on outside of the recording. These documents will be included as data in the analysis.
Analysis of In-depth Interview
As categorisation and coding of data proceed, underlying contextual themes will emerge through
talk on the topics. The data will be analysed inductively. Identification of themes that recur
through and across interviews will be achieved by a process of reading, coding, code category
refinement, rereading and code checking, and analysis of developing concepts. To assist in
organising ideas from the unstructured data, pieces of data within the text of each interview will
be coded using specialised software (NVivo 10.0, QSR International Pty. Ltd., Doncaster,
Australia, 2012). Coding will be done in duplicate.
Storage of Data
Interview recordings will be stored on the secure, password protected laptop of the researcher.
Field notes taken during the interviews will be stored in a locked cabinet draw, in the locked
office of the researcher, located in H111.
259
Potential participant
contacts researcher -
study explanation, PIS
and requirements
discussed
Is the person interestesed

in taking part?
NO YES
Add details to database, cite

Conduct eligibility
reasons for declining,
screening. Does the person
document how they heard
meet all eligibility criteria?
about the study
YES NO
Add details to database, Subject is unable to participat

- do not proceed. Add details
Record how participant to database and cite reason for
learned about study ineligibility
Determine if interview will take

place in person, or over the
phone. Book interview date and
time. Send consent form.
Send interview reminder via

email or text 1 day before
interview
Receive signed consent

form. Conduct interview.
Figure C1. Flowchart of recruitment and study methods
260
D. Breakdown of Assessment Process

1. Pre-testing
1.1 Provide information to potential participants via phone or email. Document all enquiries in
the recruitment tracking sheet.
1.2 Screen participant, document outcomes in participant tracking sheet.
1.3 If eligible, book in interview time and date.
1.4 Send participation information statement if not done so during initial contact, via email or
post. Ask participant to read carefully and ask any questions before the interview begins.
1.5 If interview is to be conducted over the phone, also send a consent form to be signed by
participant.
1.6 Instruct the participant to present to the campus at the designated time if interview is to be
conducted in person. Provide participant with consent form to sign. Provide participant with
conference call number if interview is to be conducted over the phone.
2. Interview
2.1 Ensure signed consent form has been returned either via email, or signed in person.
2.2 Begin interview by reminding participant of study details, that they are free to decline to
answer any question or section of questions. Also remind participant that the interview is being
recorded.
2.3 Conduct interview by following script. Probe for further information as necessary.
E. Scripts
Initial email script
“Hello [insert name],
Thank you for expressing interest in taking part in our study, The Modern Bodybuilder: Nutrition
and Training Strategies. Our study will involve a one-off, in-depth interview, which can be
conducted in person on campus, or over the phone. The study aims to describe the nutrition,
supplement and training practices of male, competitive, natural bodybuilders. The interview will
take approximately 90 minutes to complete. Two researchers will be present for the interview.
The interview will be recorded and transcribed to then be analysed. I have attached an
information statement which gives a thorough run down of the study.
We would love to have you involved. If you would like further information or would like to
proceed with taking part, the next step is to conduct a brief telephone screen (2 minutes) to check
the eligibility criteria is met. If so, please let me know the best time and number to contact you
on, and I will give you a call. Alternatively please feel free to contact me at your convenience on
0431 363 027.
Kind regards,
261
Lachlan Mitchell”
F. Collection Forms
Pre assessment
• Participant consent form
• Consent to advertise study on website and Facebook page
Assessment
• Interview script
262
C2. Participant information sheet for the qualitative study

Exercise, Health and Performance
Research Group
Faculty of Health Science
ABN 15 211 513 464
Dr Helen O’Connor Room H106

SENIOR LECTURER, DISCIPLIINE OF C42 Cumberland Campus
EXERCISE & SPORT SCIENCE The University of Sydney
75 East St Lidcombe
NSW 2141 AUSTRALIA
Telephone: +61 2 9351 9625
Facsimile: +61 2 9351 9204
Email:
[email protected]
Web: http://sydney.edu.au/health-sciences/
THE MODERN BODYBUILDER: NUTRITION AND TRAINING

STRATEGIES

You are invited to participate in a study titled The Modern Bodybuilder: Nutrition and
Training Strategies. The overall aim of the study is to describe the nutrition, supplement
and training strategies used by natural bodybuilders in preparation for competition. We are
recruiting open division male and female bodybuilders with 5 or more years bodybuilding
experience who are willing to participate in the study.

The study is being conducted at The University of Sydney by the following researchers:
• Dr Helen O’Connor, Faculty of Health Sciences, The University of Sydney
• Dr Daniel Hackett, Faculty of Health Sciences, The University of Sydney
• Dr Stephen Cobley, Faculty of Health Sciences, The University of Sydney
• Dr Janelle Gifford, Faculty of Health Sciences, The University of Sydney
263
• Dr Gary Slater, Faculty of Science, Health, Education and Engineering, University

of Sunshine Coast
• Mr Lachlan Mitchell (Masters Student), Faculty of Health Science, The University
of Sydney
(3) What does the study involve?
If you agree to take part in this study you will be asked to sign the Participant Consent
Form. All participants will be invited to participate in a one on one interview, or over the
phone, interview with one of the researchers.
Interviews will take place in person or via a phone call. All face to face interviews will
take place at either University of Sydney, Cumberland Campus, 75 East Street Lidcombe,
NSW 2141; or University of Sydney, Faculty of Health Science Offices, Camperdown
Campus, Parramatta Rd, Camperdown, NSW 2006
The interview will gather information regarding the nutrition, supplementation and
exercise strategies used by natural bodybuilders during different stages of preparation for
bodybuilding contests. Participants will be free to decline to answer any question for which
they do not feel comfortable to respond. Interviews will be taped by researchers, and later
transcribed by a transcription service. Participant confidentiality will be maintained and all
interviews will be de-identified.
Information about nutrition, supplement and training strategies obtained during the
interviews may be used to help develop a second research project involving bodybuilders.
You will not be required to participate in this second project.
(4) How much time will the study take?
The interview will take approximately 60-90 minutes to complete.

264
Being in this study is completely voluntary – you are not under any obligation to consent
and, if you do consent, you can withdraw at any time without affecting your relationship
with The University of Sydney. Any data collected prior to your withdrawal will be
destroyed.
Participant confidentiality will be maintained by the assignment of a study ID number. This

will be used on all data collection sheets. Records from the study that identify participants
by name will be treated as strictly confidential and will be kept in a locked filing cabinet in
a locked office away from all other study data. Only staff directly involved in the study will
have access to participate records. If the results of this study lead to publication in a
research thesis, scientific journal or are represented at scientific meetings, individual
participants will not be identified by name.

Yes. At the conclusion of the interview a qualified dietitian will be available for up to 20
minutes for participants to ask questions concerning dietary practices.

Yes, if you know a male or female natural bodybuilder who has competed at, or is
intending to compete at, a bodybuilding contest please tell them about this study.
(9) What if I require further information about the study or my involvement?
If you require any further information, or have any queries you wish to be answered please
do not hesitate to contact Lachlan Mitchell (0431-363-027 or
[email protected])
265
Any person with concerns or complaints about the conduct of a research study can
contact The Manager, Human Ethics Administration, University of Sydney, on +61 2 8627
8176 (telephone); +61 2 8627 8177 (facsimile) or [email protected]
(email).
This information sheet is for you to keep
Version 3
Date: 4/3/2015
266
C3. Participant consent form for the qualitative study
Discipline of Exercise and Sport

Science
Exercise, Health and Performance
Research Group
ABN 15 211 513 464

SENIOR LECTURER, DISCIPLINE OF C42 Cumberland Campus
EXERCISE & SPORT SCIENCE
75 East St Lidcombe
NSW 2141 AUSTRALIA
Telephone: +61 2 9351 9625
Facsimile: +61 2 9351 9204
Email:
[email protected]
Web: http://sydney.edu.au/health-
sciences/
PARTICIPANT CONSENT FORM
I, ...........................................................................................[PRINT NAME], give consent to my

participation in the research project
TITLE:
THE MODERN BODYBUILDER: NUTRITION AND TRAINING STRATEGIES
In giving my consent I acknowledge that:
267
1. The procedures required for the project and the time involved have been explained to me
and any questions I have about the project have been answered to my satisfaction.
2. I have read the Participant Information Statement and have been given the opportunity to
discuss the information and my involvement in the project with the researcher/s.
3. I understand that being in this study is completely voluntary – I am not under any obligation
to consent.
4. I understand that my involvement is strictly confidential. I understand that any research

data gathered from the results of the study may be published however no information
about me will be used in any way that is identifiable.
5. I understand that I can withdraw from the study at any time, without affecting my
relationship with the researcher(s) or the University of Sydney now or in the future.
6. I understand that information I provide during the study may be used in future research
studies.
............................ ...................................................
Signature
............................ ....................................................
Please PRINT name
..................................................................................
Date
Version 1
Date: 10/11/2014
268
C4. Interview script for the qualitative study
Interview script
Hello, my name is (insert investigator name) from the University of Sydney. We are conducting a
study on nutrition in bodybuilders. As discussed with you, and as you have provided your
informed consent, we are now conducting this interview on the dietary strategies used by
bodybuilders. Your responses will be confidential to the research team.
I need to go through a few housekeeping items before we start.
• I just want to remind you that the interview is being recorded. Other members of the
research team may also listen to the recordings at a later date.
• You may decline to answer any question or section of questions, and can finish the
interview at any time.
This work being undertaken by the University of Sydney and is titled the ‘The Modern Body
Builder: Nutrition and Training Strategies”. The overall aim of the study is to develop an
understanding of dietary preparation of competitive, natural bodybuilders.
• Mention date and time.
269
Interview Guiding Questions
I would like to ask you about your diet preparation strategies for each phase of your preparation
for competition e.g. 12 months out, 6 weeks out, 1 week out and then the day of and immediately
post competition.
Demographic Information & Body Building Experience
Could you please tell me your age and state your gender
What initially attracted you to the sport of body building?
How long have you been body building for now?
Could you tell me about your history in competing?

when did you start competing
how many competitions have you entered over that time
how successful have you been (e.g. any place awards)?
what category of body building do you compete in now?
how much longer do you intend to compete for?
Tell me about your training…..

How often would you say you train in a given week?
How many hours a week would you train?
How much of that is weight training and how much is cardio training?
Other bodybuilders
I’m sure there is a lot of “comparing notes” amongst bodybuilders.

How do you think other bodybuilders train that might be different to what you do?
Diet Intake Questions
Can you tell be about your diet during each of the phases of your training?”
Why do you follow this specific diet during “x” phase?
Are there any kinds of foods or food groups you avoid in the different phases?
Do you have a specific percentage fat/protein/carbohydrate you aim for when creating
your meal plans?
270
Tell me about how strict you are with your diet over the different phases. (Do you have any
'cheat meals' you allow yourself, how regular are these?)
What do you do when you feel hungry/crave or long for certain foods that you are trying
to avoid?
What have you tried before that definitely works/definitely doesn’t work?
How much time do you spend preparing your food for the day/week?
How do you change your fluid intake during these phases?
How do you keep track of your fluid intake or hydration during these phases?
(possible prompts: Food diaries, dietary intake applications, weighing food)
What does your food/fluid intake look like on the day of competition?
How do you monitor your diet regime is working for you?

(possible prompts: weighing, physique monitoring, skinfolds - they do themselves or
have someone not qualified to do, measurements/girths etc)
Other bodybuilders
Do you think there is one type of diet that works for everyone?
What do you think other bodybuilders do differently to you in

approach to dietary preparation?
Social aspects
How does your diet impact on your social life/family life?
What role does your partner/family play in support of your dietary changes?
271
Diet Supplement Questions
What sort of dietary supplements do you use when you are training or preparing for a
competition?
(for each mentioned, ask the quantity they use, the frequency and why they use it ).
If the participant has indicated that they take supplements: Before I ask you
these next questions, I just want to remind you that your answers are confidential and
you don’t have to answer this one. Do you check the compliance of these supplements
with Australian Sports Anti-Doping Agency (ASADA) prohibited lists?
Have you ever taken a supplement on the ASADA prohibited list?
Tell me about any experiences you have had with drug testing as part of your body building
competition participation.
Other bodybuilders
What do you think other bodybuilders do with dietary supplements?
Learning about nutrition for bodybuilders
Now I just want to ask you some questions about how you learn about nutrition. To start with,
tell me how do you go about learning about nutrition for body building?
Which of these do you find most useful?
How much time a week would you spend in finding out nutrition information?
What area of nutrition knowledge do you feel is most lacking in ………?
Other bodybuilders
From what you have seen and experienced from being around other bodybuilders, how do they
learn about nutrition?
272
C5. Advertisement flyer for the cross-sectional study

Exercise, Health and Performance Research
Group
ABN 15 211 513 464

SENIOR LECTURER, DISCIPLINE OF EXERCISE & C42 Cumberland Campus
SPORT SCIENCE The University of Sydney
75 East St Lidcombe
NSW 2141 AUSTRALIA
Telephone: +61 2 9351 9625
Facsimile: +61 2 9351 9204
Bodybuilding Research Study

Are you a natural bodybuilder with 5 years’ experience training
and competing at a National level?
If YES, we are looking for male and female bodybuilders to be

involved in a research study for the purpose of investigating the
nutrition, supplement and training strategies of modern day natural
bodybuilders.
The research study involves taking part in a 60 minute interview with

questions relating to your nutrition, supplement and training strategies.
Participant identity will remain confidential at all times.
Testing for this research study will take place over the phone, or in person,
at University of Sydney, Cumberland campus, 75 East Street, Lidcombe, or
University of Sydney, Camperdown campus, Parramatta Road, Camperdown.
The interviews will be conducted by Accredited Practising Dietitians and

Accredited Sports Dietitians who will be available to answer any questions
you may have about nutrition and supplements at the completion of the
interview
273
So if you would like to express interest in participating in this study or would like
more information please contact
Lachlan Mitchell on 0431 363 027 or email [email protected],
or Dr Helen O’Connor on 02 9351 9625 or email: [email protected]
Version 3
Date: 4/3/2015
274
C6. Consent form to advertise study for recruitment purposes

Group
ABN 15 211 513 464

75 East St Lidcombe
NSW 2141 AUSTRALIA
Telephone: +61 2 9351 9625
Facsimile: +61 2 9351 9204
[RE: Permission Letter for advertising]

[date]
[Name and address of health club/gym/supplement store/website for requesting of

advertisement]
Dear [manager/president/etc],
We are in the process of recruiting participants for an exciting study titled ‘The modern
bodybuilder: Nutrition and Training Strategies.’ The overall aim of the study is to identify
and describe the nutrition, supplements, and training strategies of bodybuilders in
preparation for competition. We are recruiting bodybuilders who are willing to participate
in a 60-90 minute interview.
We are therefore seeking your permission for the placement and distribution of the attached
advertisement on the website, Facebook page of the [bodybuilding association] to help with
the recruitment for this study and would greatly appreciate your cooperation with this
study.
Please do not hesitate to contact Mr Lachlan Mitchell on 0431-363-027

([email protected]) should you have any further inquires.
275
Kind regards,
[signature]
Helen O’Connor
Version 1
Date: 10/11/2014
276
Appendix D: Supplementary Material for Chapters 6 and 7
APPENDIX D: SUPPLEMENTARY MATERIAL FOR CHAPTERS 6 AND 7
D1. Study protocol for the longitudinal study
D2. Participant information sheet for the longitudinal study
D3. Participant consent form for the longitudinal study
D4. Advertisement flyer for the longitudinal study
D5. Consent form to advertise study for recruitment purposes
277
D1. Study protocol for the longitudinal study
Physiological Implications of Preparing for a Natural Male

Bodybuilding Competition
278
Method
A. Study Design
The Modern Bodybuilder is a longitudinal study investigating changes in physiology,
psychology and body composition in adult males during the preparation and recovery from a
“natural” bodybuilding competition.
Data collection occurs on five different occasions, over the course of 20 weeks. Participants are
invited to attend the University of Sydney Cumberland Campus on each of the five testing points
for measurements, as well as being asked to perform further assessments off campus in their own
time over the following 7 days. Assessment on campus is expected to take 2-2.5 hours. After the
7 day assessments, participants are to return to the campus with study utensils to receive
feedback on assessment results.
The study timeline is centred around each participants’ bodybuilding contest. Three testing
occasions occur during the 16 weeks prior to the bodybuilding contest. The remaining two
testing occasions occur in the four weeks following the contest.
B. Participants
• Flyers in local gymnasiums
• Flyers in local supplement stores
• Flyers posted on the ANB official Facebook page, and subsequently “shared” by Facebook
users
• Flyer emailed to participants of previous study, “The Modern Bodybuilder: Nutrition and
Training Strategies”
• A stall will be set up at the ANB Nationals contest in October 2015 by the researchers to
distribute flyers to competitors, spectators and coaches
Inclusion Criteria:
• Male, aged 20 years and over
• Natural (drug free) bodybuilders, competing in the bodybuilding class at a contest of either
the Australasian Natural Bodybuilding or the International Natural Bodybuilding
Association.
Exclusion Criteria
• Not competing at a non-natural contest
• Under 20 years of age
• Competing in fitness model or swimwear class
• Performance enhancing drug use
C. Study Parameters
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Each collection includes measures of urine specific gravity, bioelectrical impedance, resting
metabolic rate, dual-energy x-ray absorptiometry, surface anthropometry, and blood collection,
all of which are performed at the University of Sydney Cumberland Campus. In addition to these
measures, the following assessments are completed by the participant in the 7 days following
these measures: 7-day food diary, 7-day training diary, energy expenditure via SenseWear
armbands, MDDI, BIG-O and EAT-26 online questionnaires, and collection of a stool sample.
Participants are to present to campus in the morning after a 12 hour fast from food, fluid and
exercise.
On Site Assessments
1. Urine Specific Gravity
Urine Specific Gravity will be measured upon presentation to the campus using the Atago UG-α
refractometer. The participant will be asked to provide a small sample of urine in a container.
The refractometer is calibrated by the researcher using distilled water, before a drop of the urine
provided by the participant is pipetted onto the prism top for analysis. Analysis is performed
twice, with the mean urine specific gravity recorded.
2. Body Composition
2.1 Bioelectrical Impedance Analysis
Body composition, total body water and intracellular and extracellular fluid will be measured
using bioelectrical impedance analysis using the tetra-polar surface electrode technique.
Participants’ weight and stretch stature will be measured and input into the Impedimed machine.
Participants will be asked to lie flat on a bed in preparation for the bioelectrical impedance
analysis. This will be performed by the researcher using an Impedimed SFB7 with dual tab
electrodes. Electrode site preparation consists of shaving any hair, and cleaning the site with a
70% ethanol swab. Electrodes are placed on the right side of the body. The proximal hand
electrode is placed on the midline of the ulnar styloid process, on the wrist, with the green line of
the electrode running along this midline. The distal electrode is subsequently placed toward the
fingers. The proximal foot electrode is placed between the medial and lateral malleolus bones, on
the ankle, with the green line of the electrode running between the malleoli. The distal electrode
is subsequently placed toward the toes. After lying still for 10 minutes, cords running from the
Impedimed BSF7 are attached to the electrodes using alligator clips. The yellow sense lead
attaches to the proximal hand electrode; the red current source lead attaches to the distal hand
lead; the blue sense lead attaches to the proximal foot lead; the black current sink lead attaches to
the distal foot lead. Three measures are taken. Results for each three measurements are averaged
for participant result.
2.2 Dual Energy X-Ray Absorptiometry

Body composition will also be assessed using dual energy x-ray absorptiometry (DXA).
Participants will be scanned using the Lunar Prodigy (GE Lunar Corp, Madison, WI) using a
280
total body scan. The participant is asked to strip to briefs or sports shorts, and remove all
jewellery, watches etc. Height and weight are collected, to the nearest 0.1kg, and 0.1cm,
respectively. The participant is to lie flat on the table. The technician uses the centreline on the
table as a reference to align the participant. The participant is to lie as still as possible for the
duration of the scan, taking approximately seven minutes. Tissue %fat, total mass, fat mass and
lean mass are documented. The radiation dose participants will be exposed to does not exceed
0.02 mSv and side effects are negligible. DXA measurements will be performed by a trained
technician.
2.3 Surface Anthropometry
Surface anthropometry will be used as another measure of body composition. An accredited
anthropometrist will mark and measure the participant using a Harpenden skinfold caliper,
Lufkin Executive steel tape measure, sliding caliper, and segmometer. Eight skinfold sites will
be measured, (triceps, subscapular, biceps, iliac crest, supraspinale, abdominal, front thigh,
medial calf); 12 girths will be measured (head, neck, arm relaxed, arm flexed and tensed,
forearm, wrist, chest, waist, hips, thigh 1 cm below gluteal fold, thigh mid trochanter-tibiale,
calf, ankle); 10 lengths will be measured (acromiale-radiale, radiale-stylion, midstylion-
dactylion, trochanter-tibiale laterale, tibiale med-sphyrion tib, foot length, sitting height,
iliospinale-box height, troch-box height, tibiale laterale-box height); 6 breadths will be measured
(biacromial, biiliocristale, transverse chest, AP chest depth, humerus, femur). All measures will
be taken in duplicate.
3. Physiological Parameters
3.1 Resting Metabolic Rate
Resting metabolic rate will be measured via indirect calorimetry using the COSMED Quark
CPET metabolic cart. The cart will be calibrated prior to gas collection according to
manufacturer instructions. Along with the 12 hour food and fluid fast, participants are asked to
abstain from exercise for 12 hours before testing, and to limit physical activity the morning of
the test. This includes walking, stair climbing, and house work. Testing will take place in a
small, quiet room, away from noisy machinery, with a comfortable room temperature. After
completion of BIA measurement, participants are fitted with a face mask and continue lying on a
bed in a comfortable position, for 30 minutes of gas collection. The final 15 minutes of sampling
is saved and used for analysis. VO2, VCO2, and energy expenditure are documented and
averaged. RMR is determined from this data. Room lights are dimmed for testing, and
participants are asked to remain still, to breathe normally and to remain awake.
3.2 Venepuncture
Blood will be collected by a trained venipuncturist. A total of 9 tubes will be collected, equating
to approximately 43 mL of whole blood. Blood will be collected from the antecubital vein with
the following criteria: 12 hour fast from food, no exercise or alcohol for 12 hours, and showing
no signs of infection or illness at the time of blood draw.
281
Blood parameters to be measured:

• Leptin
• Ghrelin
• Adiponectin
• Testosterone
• Insulin
• Electrolytes (sodium, potassium, calcium, magnesium)
• Albumin
• eGFR
• Glucose
• Cholesterol, HDL, LDL, triglycerides
• β-hydroxy butyrate
• Serum Osmolality
Blood will be collected into two precooled on ice 2 mL potassium oxalate/sodium fluoride tubes,
one precooled on ice 9 mL EDTA tube, and six 5mL SST tubes. The EDTA and potassium
oxalate/sodium fluoride tubes will immediately be plunged back into the ice water. Tubes will be
centrifuged at 2000 x g for 15 minutes at 4˚C, before plasma/serum is pipetted in 0.5mL volumes
into cryovial Eppendorf tubes and frozen at -80˚C. Blood processing will take place in the L204
laboratory, and serum/plasma storage will be in freezers in the H108 laboratory.
Off Site Assessments

The following measures are completed off campus by the participant in the 7 days following the
above measures.
4. Seven Day Food Diary
The participant will complete a seven day food diary, documenting all food, fluid, and
supplements consumed. Serving size (weighed if possible), meal preparation method and meal
timing is to be documented.
5. Seven Day Training Diary
The participant will complete a seven day training diary, documenting all exercise completed.
The participant will document the number of repetitions, the weight lifted, the effort required, the
speed of the movement, and the rest between every set of every resistance exercise. Details for
each variable are as follows:
Repetitions: the number of repetitions in a set
Weight lifted: The weight used for the set. This is presented in kg, lbs, body weight, or machine
weight
Effort: This will be presented using a scale of 1-10, where 1 is very easy, and 10 is maximal
effort.
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Speed: This is presented using four numbers, each representing a phase of the movement. The
phases are eccentric, a pause at the end of eccentric, concentric, and a pause at the end of
concentric. Results should appear as E.P.C.P e.g. 2.0.1.1
Rest: This is the recovery time, in minutes or seconds, between sets of the exercise.
Aerobic/Cardio/Anaerobic exercise will be documented in a similar fashion. The mode,
structure, duration, intensity, and details of all aerobic/ cardio/anaerobic exercise will be
documented. Details for each variable are as follows:
Mode/type: For example running, cycling, swimming
Structure: For example interval training, steady state exercise
Duration: The duration of session in minutes or hours is documented
Intensity: The intensity of the exercise can be provided in many different units, such as
%HRmax, HR, RPE/effort (1-10 scale)
Details: The detail of the session is to include as much information as possible. This would
include any information not documented in previous variables, such as interval duration,
distance, recovery time, power output.
6. SenseWear armbands
The SenseWear armband is a small band fitted around the upper arm used for calculating total
energy expenditure, active energy expenditure, resting energy expenditure, total number of steps,
physical activity duration, sleep duration, and lying down duration, based on measurement of
skin temperature, galvanic skin response, heat flux, and a 2-axis accelerometer. The participant is
to wear the band for three complete days of the seven day period. These days do not need to be
consecutive. These three days should consist of two training days and one non-training day. If
there are no non-training days in the participants schedule then the band should be worn for three
training days. The band is to be worn at all times, except during water activities (e.g. swimming,
showering). This includes training sessions. One day is constituted by an entire 24 hour period,
e.g. 9am to 9am. The band is placed on the right upper arm, so that the two sensors are in direct
contact with the skin over the triceps muscle. Skin should be clean and dry, with no moisturiser
or oil present. The sensor begins data collection within 10 minutes of placement, and is indicated
by a progression of tones.
7. Online psychology questionnaires
7.1 Muscle Dysmorphic Disorder Inventory
The Muscle Dysmorphic Disorder Inventory (MDDI) is a brief, 13 item questionnaire. The
MDDI uses a 5 point Likert-type scale for responses, ranging from “never” to “always”. The
questions are preceded by the statement, “Please respond to each of the following statements. For
each question, select the option that most closely describes how the statement applies to you
right now.” This questionnaire is completed by the participant online, on a training day. A link to
the questionnaire is sent to the participants email address. The questionnaire is hosted by the
server www.qualtrics.com. The participant is to respond to all questions before submitting.
7.2 Bodybuilder Image Grid-Original
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The Bodybuilder Image Grid-Original (BIG-O) is a 4 item questionnaire, which requires the
participant to respond to questions based on a grid of 30 body silhouettes. The questions and grid
are preceded by the statement, “For each of the following four questions, you will be asked to
choose which of these figures the male body asked about best represents. You will indicate for
each question the numerical value (from 1-30) that corresponds to the figure as requested.” This
questionnaire is completed by the participant online, on a training day. A link to the
questionnaire is sent to the participants email address. The questionnaire is hosted by the server
www.qualtrics.com. The participant is to respond to all questions before submitting.
7.3 Eating Attitude Test-26
The Eating Attitude Test-26 (EAT-26) is a 26 item questionnaire. The EAT-26 uses a 6-point
Likert-type scale for responses, ranging from “never” to “always”. The questions are preceded
by the statement, “Please respond to each of the following statements. For each question, select
the option that most closely describes how the statement applies to you right now.” This
questionnaire is completed by the participant online, on a training day. A link to the
questionnaire is sent to the participants email address. The questionnaire is hosted by the server
www.qualtrics.com. The participant is to respond to all questions before submitting.
8. Stool Sample
At each measurement point, participants will be provided with a stool collection kit, containing a
pair of latex gloves, a labelled sterile collection container with spoon on the inside of the lid, a
zip lock bag, and collection instructions. The faecal sample will be used to measure gut
microbiota colonies. Participants are instructed to pass a stool into a clean milk carton or onto a
newspaper, being sure to avoid any water or urine contacting the stool. After washing hands and
wearing the latex gloves, they will use the spoon on the inside of the container lid to scoop a
small portion, about the size of a ping pong ball, into the container and screw on the lid. Once
closed they will document the time and date of sample collection on the container label, then
lock inside the zip lock bag. The sample will immediately be placed into the participant’s
freezer. The sample will be returned to the university campus at the completion of the seven day
data collection period, and placed inside the -80˚C freezer. Participants are advised to leave the
sample in their personal freezer until just prior to travelling to the campus, to avoid the sample
thawing out.
At the conclusion of the seven day data collection period, each participant will return to campus
with their completed 7-day food diary, 7-day training diary, SenseWear band, and frozen stool
sample. At this point results from the on-campus measures can be provided to the participant,
minus the blood test results.
284
43 mL of blood drawn into 9 tubes labelled with participant ID, time and date of collection
5 mL SST tubes: Na, K, Ca, Mg, Albumin, eGFR, Glucose, Pre-cooled 2 mL Pre-cooled 9
Cholesterol, Triglycerides, LDL, HDL, Testosterone, Insulin, NaF/K oxalate mL EDTA:
tubes: β hydroxy Ghrelin

L ti Adi ti S O l lit
Invert 6 -10 times to allow blood to mix with separator Immediately plunge back into ice water.
fluid. Spin at 2000 x g for 15 minutes at 4˚C. Transfer Within 15 minutes of collection, spin at 2000
serum into pre-labelled Eppendorf tubes. Place tubes into x g for 15 minutes at 4˚C. Transfer serum
storage box. Freeze at -80˚C in H block into pre-labelled Eppendorf tubes. Place
Figure D1. Blood Draw and Processing Chart
285
Labelling and storage of bloods

Labelling of Eppendorf’s for freezer storage
Using a fine tip permanent marker label each Eppendorf with participant code, date, and type of collection tube e.g. SST, EDTA, NaF/K oxalate
Participant ID on lid
Participant ID
Time point of collection
Collection tube type e.g. SST, EDTA, NaF/K oxalate
Figure D2. Eppendorf labelling
After centrifuging, pipette approximately 0.5mL of plasma/serum into the appropriate Eppendorf tubes. Transport tubes in labelled freezer
boxes, then store in -80˚C freezer located in H block laboratory.
286
Potential participant contacts researcher -

study explanation, PIS and requirements
discussed
Is the person interested in

taking part?
NO Yes
Add details to database,

cite reasons for Conduct eligibility screening.
declining, document Does the person meet all
how they heard about eligibility criteria?
the study
YES NO
Add details to
database. Record Subject is unable to
how participant participate - do not
learned about study proceed. Add details to
database and cite reason
for ineligibilty
Book testing session and
send consent form
Send appointment reminder via

email or text message 1 day before
session
On site session 1 - use checklist to ensure

all assessments are completed. Provide off
site assessment tools
Off site assessments completed by

participant
1 week post assessments - participant

returns with completed diaries, stool
sample. Results provided. Follow up
testing date confirmed, including off
site diaries and questionnaires.
Participant completes online

questionnaires.
Repeat procedure for testing sessions 2-

6
Figure D3. Flowchart of recruitment and study methods
287
Timeline of Events
1. Timetable
Table D1. Schedule of recruitment and assessment
Parameter Pre -16 -12 -8 -4 -1 1 4
On site Off site On site Off site Off site On site Off site Off Site On site Off site On site Off site On site Off site
Recruitment
Screening X
Information pack X
Consent
Study consent
Hydration
USG X X X X X
Body composition
BIA X X X X X
DXA X X X X X
Anthropometry X X X X X
Physiology
RMR X X X X X
Biomarkers
Blood collection X X X X X
Stool collection X X X X X
Diaries
Food diary X X X X X
Training diary X X X X X
Questionnaires
MDDI X X X X X X X
BIG-O X X X X X X X
EAT-26 X X X X X X X
Energy Expenditure
SenseWear X X X X X
288
2. Breakdown of Testing Sessions
1. Pre-testing
1.1 Provide Information to potential participants via phone or email. Document all enquiries in
the recruitment tracking sheet.
1.2 Screen participant, document outcomes in participant tracking sheet.
1.3 If eligible, book in testing session.
1.4 Send participant information statement to participant via email or post. Ask participant to
read carefully and to ask any questions when they arrive for the first session.
1.5 Instruct the participant to present to the campus on the morning of their session fasted for 12
hours from food and fluid, and to avoid exercise for 12 hours before the session. To obtain an
accurate RMR measure, also advise them to be as inactive as possible the morning of the
session.
2. On Site (2.5 Hours)

2.1 Assign participant identification number.
2.2 Explain the structure and function of the study. Complete participant consent form.
2.3 Complete bodybuilding background information form.
2.4 Ask participant to void their bladder, and provide a urine sample. Complete USG test.
2.5 Measure weight and stretch stature.
2.6 Lie participant on bed for 10 minutes, and prepare them for BIA measurement. While lying
down, complete bodybuilding background form. After 10 minute lying, and placement of
electrodes, take three consecutive BIA measures.
2.7 With participant still on bed, fit the gas mask onto participant for RMR test. Instruct
participant to remain very still, and to breathe normally, then begin 30 minute expired gas
analysis. The room should be quiet, dimly lit, and at a comfortable temperature. The
participant should limit movement during the collection period, so advise them to find a
comfortable position to lie in before collection begins. It is important the participant does
not fall asleep, therefore if this begins to occur, gently nudge the participant.
2.8 Upon completion of RMR, remove mask from participant, and escort them to the DXA
machine. Ask participant to strip to briefs or light shorts for the DXA scan. Set the
participant up on the DXA table then begin the scan.
2.9 Escort participant back to H block testing room. Ask participant to strip to briefs or light
shorts to begin surface anthropometry. Palpate and mark the complete profile, then take the
8 skinfolds, 12 girths, 10 lengths, and 6 breadths, in duplicate. Duplicate skinfolds with
greater than 5% error are measured a third time, and duplicate girths, lengths and breadths
greater than 1% error are measured a third time.
2.10 Explain to participant the procedures for completing the food and training diaries, the
SenseWear arm band, the online questionnaires, and stool sample collection. Provide them
with the stool collection kit.
2.11 Prepare participant for blood collection. Have 9 tubes ready, with the 2 sodium
fluoride/potassium oxalate tubes and the EDTA tube precooled in ice water. Once each tube
has been filled, immediately place NaF and EDTA tubes back in ice water.
2.12 Use assessment checklist to ensure all measures have been taken.
289
2.13 Thank participant and book in the return visit for one week later, when off-site measures will
be returned, and result feedback given.
2.14 Process bloods.
2.15 Data entry.
2.16 Email the links to the online questionnaires to the participant.
3. Off Site
3.1 Participant is to complete the seven day food diary, documenting all food, fluid and
supplements consumed, the time they are consumed, and the preparation method used. If they
have the capacity to weigh their food this should be attempted.
3.2 Participant is to complete the seven day training diary, documenting all details of each
training session they complete.
3.3 Participant is to wear the SenseWear arm band for three complete days. The sensors should
be in direct contact with the skin over the triceps muscle on the right upper arm. The days worn
should be documented in the food diary.
3.4 The participant will receive a link to each of the online questionnaires via email. To
standardise the test conditions, these should all be completed in one sitting, on a training day.
Once each question has been answered, the participant can submit their completed questionnaire.
3.5 The participant will use the stool collection kit to collect a small sample of faeces passed.
With the provided latex gloves on, and after placing a clean milk carton or newspaper in the
toilet bowl, the participant is to pass a bowel movement, avoiding contact of water or urine on
the sample. Scoop a small amount (ping pong ball size) into the container using the spoon on the
underside of the container lid. Close the container, label with date and time, lock in zip lock bag,
and immediately place in home freezer.
4. Returning to campus
4.1 Seven days after the on campus tests, the participant is to return to campus with the
completed food diary, training diary, SenseWear band and frozen stool sample.
4.2 The stool sample should be left in the home freezer until travelling to the campus. Once the
participant has arrived, the researcher should immediately place the sample in the -80˚C freezer.
4.3 Researcher is to visually check the food and training diaries for completeness.
4.4 Connect SenseWear to computer and load data to confirm three complete days of data have
been collected. If not, ask participant to wear for the required days and return when done.
4.5 Provide participant with results of RMR, skinfolds, BIA assessments.
4.6 Thank participant for returning
4.7 Organise next visit for repeat testing.
4.8 Online questionnaires will be completed midway between current testing point and next
complete testing point – organise a reminder for this, and provide participant with online link.
5. Follow Up On Site Sessions (90 minutes)

5.1 Ask participant to void their bladder, and provide a urine sample. Complete USG test.
5.2 Lie participant on bed for 10 minutes, and prepare them for BIA measurement. After 10
minute rest, and placement of electrodes, take three consecutive BIA measures.
290
5.3 With participant still on bed, fit the gas mask onto participant for RMR test. Instruct
participant to remain very still, and to breathe normally, then begin 30 minute expired gas
analysis. The room should be quiet, dimly lit, and at a comfortable temperature. The participant
should limit movement during the collection period, so advise them to find a comfortable
position to lie in before collection begins. It is important the participant does not fall asleep,
therefore if this begins to occur, gently nudge the participant.
5.4 Upon completion of RMR, remove mask from participant, and escort them to the DXA
machine. Ask the participant to strip to briefs or light shorts for the DXA scan. Set the
participant up on the DXA table then begin the scan.
5.5 Escort the participant back to the H block testing room. Ask participant to strip to briefs or
light shorts to begin surface anthropometry. Palpate and mark the complete profile, then take the
8 skinfolds and 12 girths, in duplicate. Duplicate skinfolds with greater than 5% error measure a
third time, and duplicate girths greater than 1% error measure a third time. (Lengths and breadths
will not change between sessions therefore only measured on initial testing session).
5.6 Provide a repeat explanation to participant of the procedures for completing the food and
training diaries, the SenseWear arm band, and stool sample collection. Provide them with the
stool collection kit.
5.7 Prepare participant for blood collection. Have 9 tubes ready, with the 2 sodium
fluoride/potassium oxalate tubes and the EDTA tube precooled in ice water. Once each tube has
been filled, immediately place NaF and EDTA tubes back in ice water.
5.8 Use assessment checklist to ensure all measures have been taken.
5.9 Thank participant and book in the return visit for one week later, when off-site measures will
be returned, and result feedback given.
5.10 Process bloods.
5.11 Data entry.
5.12 Email the links to the online questionnaires to the participant.
6. Off Site
6.1 Participant is to complete the seven day food diary, documenting all food, fluid and
supplements consumed, the time they are consumed, and the preparation method used. If they
have the capacity to weigh their food this should be attempted.
6.2 Participant is to complete the seven day training diary, documenting all details of each
training session they complete.
6.3 Participant is to wear the SenseWear arm band for three complete days. The sensors should
be in direct contact with the skin over the triceps muscle on the right upper arm. The days worn
should be documented in the food diary.
6.4 The participant will receive a link to each of the online questionnaires via email. To
standardise the test conditions, these should all be completed in one sitting, on a training day.
Once each question has been answered, the participant can submit their completed questionnaire.
6.5 The participant will use the stool collection kit to collect a small sample of faeces passed.
With the provided latex gloves on, and after placing a clean milk carton or newspaper in the
toilet bowl, the participant is to pass a bowel movement, avoiding contact of water or urine on
the sample. Scoop a small amount (ping pong ball size) into the container using the spoon on the
underside of the container lid. Close the container, label with date and time, lock in zip lock bag,
and immediately place in home freezer.
291
7. Returning to campus
7.1 Seven days after the on campus tests, the participant is to return to campus with the
completed food diary, training diary, SenseWear band and frozen stool sample.
7.2 The stool sample should be left in the home freezer until travelling to the campus. Once the
participant has arrived, the researcher should immediately place the sample in the -80˚C freezer.
7.3 Researcher is to visually check the food and training diaries for completeness.
7.4 Connect SenseWear to computer and load data to confirm three complete days of data have
been collected. If not, ask participant to wear for the required days and return when done.
7.5 Provide participant with results of RMR, skinfolds, BIA assessments.
7.6 Thank participant for returning
7.7 Organise next visit for repeat testing. Online questionnaires will be completed midway
between current testing point and next complete testing point – organise a reminder for this, and
provide participant with online link.
Scripts
Initial email script
“Hi [Insert name],
Thank you for expressing interest in taking part in our study, The Modern Bodybuilder.
Our study will involve following participants as they prepare for the national bodybuilding titles,
taking measurements on 5 occasions over a 20 week time period. The measures will include
body composition - skinfolds, DXA scan, BIA; resting metabolic rate; blood tests including
appetite hormones; diet analysis, energy expenditure, some basic psychological assessments, and
gut microbiota. In a nutshell we will be measuring the changes in your metabolism as you
prepare and recover from the contest, and how this affects other systems of your body. I have
attached an information statement which gives a complete run down of our study.
The measures will be done at the University of Sydney Cumberland Campus, Lidcombe, and will
take 1.5-2.5 hours. Testing is done in the morning as we require you to present fasted.
We would love to have you involved. If you would like more information or would like to
proceed, the next step is to conduct a brief telephone screen (3 minutes) to check the eligibility
criteria is met. If so, let me know the best time and number to contact you on, and I will give
you a call. Alternatively please feel free to contact me at your convenience on 0431 363 027.
Kindest regards,
Lachlan Mitchell”
292
Invitation email to participants of The Modern Bodybuilder: Nutrition and training

strategies
“Dear [participant name],
Continuing on from our current research project, we are now in the process of recruiting
bodybuilders for a study titled “The Modern Bodybuilder: Physiology, psychology and body
composition changes in preparation for a bodybuilding competition. A longitudinal study.”
Please see the attached advertisement flyer for project information.
If you are interested in taking part in this exciting study, or would like more information, please
contact Lachlan Mitchell via email or phone:
[email protected]
0431363027
Kindest regards”
Collection Forms
Pre assessment
• Participant consent form
• Consent to advertise study in gymnasium, supplement store, Facebook page
On site assessment
• Bodybuilder history form
• BIA assessment form
• DXA results form (print off from DXA computer)
• Surface anthropometry form
• Assessment checklist
Off site assessment
• Food diary
• Training diary
Participant handouts
• Stool collection kit, including collection instruction handout
• Take home package: food diary, training diary, SenseWear armband
• SenseWear user guide
293
D2. Participant information sheet for the longitudinal study

Group
ABN 15 211 513 464

75 East St Lidcombe
NSW 2141 AUSTRALIA
Telephone: +61 2 9351 9625
Facsimile: +61 2 9351 9204
The Modern Bodybuilder: Physiology, psychology and body composition changes in

preparation for a bodybuilding competition. A longitudinal study.
1. What is the study about?
You are invited to participate in a study called “The Modern Bodybuilder: Physiology,
psychology and body composition changes in preparation for a bodybuilding competition.” The
overall aims are to assess and describe dietary, training, psychology, physiology and body
composition changes in competitive, natural bodybuilders, during a period of competition
preparation and recovery.
2. Why are we doing this study?

We are conducting this study to learn about the preparation of competitive bodybuilders and the
effect of diet, training and competition on their physical and psychological health.
3. Who is carrying out the study?

The study is being conducted at The University of Sydney (Faculty of Health Sciences,
Cumberland Campus, 75 East Street Lidcombe NSW 2141) by the following researchers:
Faculty of Health Sciences, University of Sydney
• Dr Helen O’Connor
• Dr Daniel Hackett
• Dr Stephen Cobley
294
• Dr Janelle Gifford
• Dr Nathan Johnson
• Mr Lachlan Mitchell (PhD Candidate)
• Dr Gary Slater, Faculty of Science, Health, Education and Engineering,
University of Sunshine Coast
• Dr Stuart Murray, Department of Psychiatry, University of California San Diego
4. What does the study involve?

The study involves a battery of assessments, which will be performed on 8 different occasions
over a 6 month period. If you agree to participate in this study you will be asked to sign the
Participant Consent Form, and present to the Cumberland Campus of the University of Sydney
(Lidcombe) on 6 occasions to be measured. These measurement sessions will take 1.5-2.5 hours.
Further to this you will be required to return to the Cumberland campus 6 more times to return
analysis equipment. You will also be asked to complete two further assessment points on the
internet, which do not require you to present to the University.
During the study you will undergo the following:
• Dual-energy X-ray Absorptiometry (DXA) scans

• Bioelectrical Impedance Analysis (BIA)
• Resting Metabolic Rate analysis
• Surface anthropometry (skinfolds and girth measurements)
• Blood tests
• Food diary
• Energy expenditure assessments
• Training record
• Eating pathology and body image assessments
• Gut bacteria analysis (stool sample collection)
All assessments are described in detail below.
Dual-energy X-ray Absorptiometry (DXA)
295
A DXA scan will be used to determine the amount of muscle, fat and bone in your body. The
DXA measure will require that you lay on a table whilst the images will be obtained. Each scan
will expose you to a very small dose of ionising radiation. The DXA scan is expected to take
between 10 and 15 minutes.
Bioelectrical Impedance Analysis (BIA)
A BIA will be used to measure the amount of water in your body. It will also provide a second
measure of the amount of muscle and fat in your body. The BIA will require you to lie on a table
while small electrodes are taped to your hand and foot and a small non-detectable electric current
will be passed through your body for a second. This test poses no risk or discomfort to you and
takes about 5 minutes to perform.
Resting Metabolic Rate (RMR) analysis
After resting on a bed for 30 minutes, you will wear a mask with an attached mouth piece so that
we can measure all the air you breathe in and out. This will take 20 minutes, and you will need to
lie still. The inspired and expired air you breathe will allow us to calculate you resting metabolic
rate.
Surface Anthropometry
Surface anthropometry will be assessed by measuring 8 skinfolds, 13 girths, 9 lengths and 8
breadths, located on the right side of the body. A trained and certified anthropometrist will locate
the anatomical landmarks and also take the measurements. Additionally, standing height and
weight will be recorded. Measurements will be carried out while standing with your elbows and
knees extended and relaxed, but you can sit down in-between measurements. Complete surface
anthropometry assessment is expected to take between 45-60 minutes on the first assessment.
Subsequent surface anthropometry assessments are expected to take 30-45 minutes.
Blood tests
Blood sampling will be performed to measure appetite hormones, body salts (electrolytes), blood
proteins and hormones (including testosterone), blood glucose, insulin, blood lipids (fats) and
body hydration (osmolarity) while you are fasted. Venous blood will be drawn by a certified
venepuncturist from a site on the arm. There may be slight discomfort associated with collecting
the blood sample, and a small risk of bruising at the site.
Food Diary
You will be required to keep a one week food diary (either using a booklet provided or a phone
application: Easy Diet Diary), recording all food, fluid and supplements consumed over a seven
day period on each of the 8 occasions of measurement. The seven days will be consecutive. At
the conclusion of the seven day recording you will be required to return the written diary to the
University, along with your Sense Wear armband, seven day training record and stool sample
(see below)
Energy Expenditure
296
You will be asked to wear a Sense Wear armband on your upper left arm over three days. The
three days will be consecutive and cover two training days and one non-training day. These three
days will be the first three days of the food diary collection. You will be provided with this arm
band, and you will be required to return this arm band to the University each time you complete
this measurement.
Training record
You will be asked to complete a training record during the same seven day period as the food
diary analysis. The training record requires you to document all planned exercise performed over
the seven days, including the exercises, number of sets, number of repetitions, the resistance
used, the rest period, the intensity of exercise, the session duration and the rate of perceived
exertion. You will be required to return your written training record with your food diary, Sense
Wear arm band and stool sample at the conclusion of each one week collection period.
Eating behaviour and body image assessments
You will be asked to complete three different online questionnaires. Two of these will assess
body image, and the third will assess eating behaviours and attitudes.
Gut bacteria analysis
Gut bacteria cultures will be measured through the analysis of a stool sample. In order to do this
you will be asked to provide a small faecal sample, by collecting and freezing a sample off site
on the final day of your seven day food diary period. You will then be asked to present this to the
researchers at the University of Sydney Cumberland campus with your food diary, training
record and Sense Wear armband. You will be provided with a small, sterile collection container,
sterile collection spoon, and non-latex gloves.
Risks
During the course of taking blood samples, mild pain and/or bruising may occur at the site of the
needle entry. The total amount of blood taken over the 6 month study is small and will not result
in any harm.
Radiation
This research study involves exposure to a very small amount of radiation from x-rays. The
effective dose of radiation from this study is about 0.2 millisieverts (mSv). For comparison,
everyone receives a dose of about 2 mSv each year from natural sources as part of everyday
living, so the study is equivalent to a few weeks of natural ‘background’ radiation. No harmful
effects have been demonstrated at this level and the risk is minimal.
Please inform our researchers if you have participated in any research study in the last five years
where you were exposed to radiations. If you volunteer for another research study in the next 5
years, you should take this statement with you and show it to the researchers.
297
Psychological distress
This research study involves assessment of body image and eating attitudes. As a result of these
assessments some psychological distress may be encountered. A clinical psychologist will screen
all questionnaire responses and provide lay feedback to participants when necessary. A referral
to an independent psychologist will be offered to participants whom are displaying significant
signs of psychological distress or a psychological condition.
5. How much time will the study take?

You will need to come to the University of Sydney, Cumberland Campus, on 12 different
occasions. Six occasions for measurements and a further six occasions to return assessment tools.
The initial visit will involve an introduction and baseline measurements, and is expected to last
2-2.5 hours. All measurements will be taken on this visit. Subsequent visits to the University are
expected to last 1.5 hours. DXA, BIA, RMR, surface anthropometry and blood collection will
take place at the University on these visits. You will be asked to complete the eating behaviour
and body image assessment tools online at these measurement points. In addition you will be
required to complete the food diary, training record, Sense Wear and a stool sample collection
during the seven days after these subsequent visits.
6. Will I be given a training program and diet to follow?

No. We will not be intervening into your competition preparation or recovery. We will not
provide you with any training or nutrition programs to follow. We want you to follow your
regular competition diet, supplement and training regimen, as our aim is to measure changes in
your body resulting from your dietary and training habits. After the study is finished we will be
able to review all of the measures (except for blood and stool which will take longer to analyse)
and provide feedback on your diet and training program.
7. Can I withdraw from the study?

During all study procedures, you will be monitored very closely by qualified and experienced
health professionals. Being in this study is completely voluntary – you are not under any
obligation to give your consent and, if you do not consent, you can withdraw at any time without
affecting your relationship with The University of Sydney. You may also be withdrawn from the
study by us, if we find that your participation may be unhealthy to you.
8. Will anyone else know the results?
298
All aspects of the study, including results, blood test findings etc. will be strictly confidential and
only the researchers will have access to information on participants, except as required by law. A
report of the study may be submitted for publication, but individual participants will not be
identifiable in such a report.
The data collected in this study may be used in future research studies by the research group. The
data will remain confidential, and only researchers will have access to the information.
9. Will the study benefit me?

Yes. You will receive relevant feedback to your competition preparation regarding your body
composition. You will be assessed using highly accurate tools by experienced, qualified health
professionals, which otherwise may not be available to you. The researchers will also be
available to provide feedback regarding your results. A lay summary will be given to you at the
conclusion of the study.
10. Can I tell other people about the study?

Yes, you can! If you know any other male natural bodybuilders competing at the national
contests please tell them about this study.
11. What if I require further information about the study or my involvement?

If you require further information about the study, or have any queries you wish to be answered,
please do not hesitate to contact Lachlan Mitchell ([email protected] or 0431-363-
027).
12. What if I have a complaint or any concerns?

Any person with concerns or complaints about the conduct of a research study can contact The
Manager, Human Ethics administration, University of Sydney, on +61 2 8627 8176 (telephone);
+61 2 8627 8177 (facsimile); or [email protected] (email).
This information sheet is for you to keep

Version 2
Date: 10/6/2015
299
D3. Participant consent form for the longitudinal study

Group
ABN 15 211 513 464

75 East St Lidcombe
NSW 2141 AUSTRALIA
Telephone: +61 2 9351 9625
Facsimile: +61 2 9351 9204
PARTICIPANT CONSENT FORM
I, ...........................................................................................[PRINT NAME], give consent to my

participation in the research project
TITLE:
THE MODERN BODYBUILDER: PHYSIOLOGY, PSYCHOLOGY AND
BODY COMPOSITION CHANGES IN PREPARATION FOR A
BODYBUILDING CONTEST. A LONGITUDINAL STUDY
In giving my consent I acknowledge that:
7. The procedures required for the project and the time involved have been explained to me and any
questions I have about the project have been answered to my satisfaction.
8. The procedures will take place both on site at the University of Sydney, Cumberland Campus, and
off site.
9. I have read the Participant Information Statement and have been given the opportunity to discuss
the information and my involvement in the project with the researcher/s.
10. I understand that being in this study is completely voluntary – I am not under any obligation to
consent.
300
11. I understand that my involvement is strictly confidential. I understand that any research data
gathered from the results of the study may be published however no information about me will be
used in any way that is identifiable.
12. I understand that I can withdraw from the study at any time, without affecting my relationship with
the researcher(s) or the University of Sydney now or in the future.
13. There is a very low risk of skin irritation and bruising at the site where blood is drawn from the
arm.
8. I understand I will be exposed to a very low dose of radiation associated with the DXA scan. No
harmful effects have been demonstrated at this level and the risk is minimal.
9. Information collected during this study may be used in future research carried out by the research
group.
................................... ...................................................
Signature
................................... ....................................................
Please PRINT name
..................................................................................
Date
Version 2
Date: 5/6/2015
301
D4. Advertisement flyer for the longitudinal study
Dr Helen O’Connor
Exercise, Health and Performance Research Group
C42 Cumberland Campus
75 East Street Lidcombe, NSW 2141
T: +61 2 9361 9625 E: [email protected]
W: www.sydney.edu.au/health-sciences/
PARTICIPANTS NEEDED
BODYBUILDING RESEARCH STUDY
Are you a natural bodybuilder competing at the INBA
Australian National Championships or the ANB Australian
Titles?
If YES you may be eligible to participate in an exciting study
We are seeking natural male bodybuilders aged 20 years and over to take part in a
research study measuring nutrition, exercise, body fat, muscle mass, metabolic
rate, appetite hormones, body image and gut bacteria during preparation and
recovery from a national bodybuilding contest.
Testing will occur on 8 occasions, over a 6 month period, and will take place at
University of Sydney, Cumberland Campus, 75 East St Lidcombe.
You will receive accurate feedback about your competition preparation from
highly experienced Accredited Practising Dietitians, Accredited Sports
Dietitians, and Exercise Physiologists.
So if you would like to express interest in participating in this study, or would like more
information, please contact
Mr Lachlan Mitchell on 0431 363 027 or email [email protected],
Or Dr Helen O’Connor on 02 9351 9625 or email [email protected]

Version 1
Date: 4/5/2015
302
D5. Consent form to advertise study for recruitment purposes

Group
ABN 15 211 513 464

75 East St Lidcombe
NSW 2141 AUSTRALIA
Telephone: +61 2 9351 9625
Facsimile: +61 2 9351 9204
[RE: Permission Letter for advertising]
[date]
[Name and address of health club/gym/supplement store/website for requesting of

advertisement]
Dear [manager/president/etc],
We are in the process of recruiting participants for an exciting study titled ‘The Modern
Bodybuilder: Physiology, psychology and body composition changes in preparation for a
bodybuilding competition.’ The overall aims of the study are to assess and describe the
diet, training and supplement practices, psychological traits and body composition changes
in competitive natural bodybuilders during a cycle of competition preparation and
recovery. As we aim to assess changes during competition preparation and recovery, we
are recruiting bodybuilders who are willing to participate in the study in the prior to, and
following, the ANB and INBA national contests.
We are therefore seeking your permission for the placement of the attached advertisement
at your [health club/gym/supplement store/website] to help with the recruitment for this
study and would greatly appreciate your assistance.
Please do not hesitate to contact Mr Lachlan Mitchell on 0431 363 027

([email protected]) should you have any further inquiries.
303
Kind regards,
[signature]
Dr Helen O’Connor
Chief Investigator
Version 1
Date: 25/8/2014
304
Appendix E: Published Manuscripts Related to this Thesis
APPENDIX E: PUBLISHED MANUSCRIPTS RELATED TO THIS THESIS
E1. Mitchell L, Murray SB, Cobley S, Hackett D, Gifford J, Capling L, O’Connor. Muscle
dysmorphia symptomatology and associated psychological features in bodybuilders and non-
bodybuilder resistance trainers. A systematic review and meta-analysis. Sports Med 2017; 47:
233-259. https://doi.org/10.1007/s40279-016-0564-3
E2. Mitchell L, Murray SB, Hoon M, Hackett D, Prvan T, O’Connor H. Correlates of Muscle
Dysmorphia Symptomatology in Natural Bodybuilders: Distinguishing factors in the Pursuit of
Hyper-Muscularity. Body Image 2017; 22: 1-5. http://dx.doi.org/10.1016/j.bodyim.2017.04.003
E3. Mitchell L, Hackett D, Gifford J, Estermann F, O’Connor H. Do Bodybuilders Use
Evidence Based Nutrition Strategies to Manipulate Physique? Sports 2017; 5(4): 76.
https://doi.org/10.3390/sports5040076
E4. Mitchell L, Slater G, Hackett D, Johnson N, O’Connor H. Physiological Implications of
Preparing for a Natural Male Bodybuilding Competition. Eur J Sport Sci 2018; In Press.
https://doi.org/10.1080/17461391.2018.1444095
305

The Modern Natural Bodybuilder: Dietary Intake, Supplement Usage, Training Demands, and Their Health Implications

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THE MODERN NATURAL BODYBUILDER: DIETARY

INTAKE, SUPPLEMENT USAGE, TRAINING DEMANDS,

AND THEIR HEALTH IMPLICATIONS

Lachlan James Mitchell

BAppSc (Ex&SpSci) / BSc (Nut&Diet) (Hons)

The University of Sydney, 2008

A thesis submitted in fulfilment of the requirements for the degree of

Doctor of Philosophy (PhD)

Discipline of Exercise and Sport Science

Faculty of Health Sciences

The University of Sydney

requirement for any higher degree.

Name ______Lachlan Mitchell___

and outside of the University.

Firstly, I must express my deepest gratitude to my primary supervisor Associate Professor

settings I remained in contact with you expressing my interest in undertaking postgraduate

an opportunity which will define my professional career – to begin my doctoral candidature.

an academic. I also enjoyed the relaxed nature of our teaching together!

provided the grant for which this research was conducted.

I have compiled in this thesis.

STATEMENT OF ORIGINALITY ...........................................................................................ii

ACKNOWLEDGEMENTS ..................................................................................................... iii

TABLE OF CONTENTS .......................................................................................................... vi

LIST OF ABBREVIATIONS .................................................................................................... x

LIST OF TABLES ...................................................................................................................xii

LIST OF FIGURES ................................................................................................................ xiv

PUBLICATIONS ARISING FROM THIS THESIS ............................................................. xxv

OTHER PUBLICATIONS DURING CANDIDATURE ..................................................... xxvi

CHAPTERS OF THIS THESIS PUBLISHED AS MANUSCRIPTS ................................xxvii

Specific Hypotheses .......................................................................... 5

Significance of this Research ............................................................ 5

Background Literature ........................................................................... 8

Literature Review .............................................................................. 9

Muscle Dysmorphia Symptomatology and Associated Psychological

Conflict of Interest .......................................................................... 98

Correlates of Muscle Dysmorphia Symptomatology in Natural

Abstract ......................................................................................... 100

Introduction ................................................................................... 101

Methods ......................................................................................... 103

Results ........................................................................................... 106

Discussion ..................................................................................... 108

Conclusion .................................................................................... 111

Acknowledgements ....................................................................... 112

Conflict of Interest ........................................................................ 112

CHAPTER 5. ......................................................................................................................... 113

Do Bodybuilders Use Evidence Based Nutrition Strategies to

Abstract ......................................................................................... 114

Introduction ................................................................................... 116

Methods ......................................................................................... 117

Results ........................................................................................... 120

Discussion ..................................................................................... 134

Conclusion .................................................................................... 139

Acknowledgements ....................................................................... 139

CHAPTER 6. ......................................................................................................................... 140

Physiological Implications of Preparing for a Natural Male

Abstract ......................................................................................... 141

Introduction ................................................................................... 142

Methods ......................................................................................... 144

Results ........................................................................................... 148

Discussion ..................................................................................... 159

Conclusion .................................................................................... 165

Acknowledgements ....................................................................... 165

Name ____Lachlan Mitchell_