Prevalence of Muscle dysmorphia and associated health activities in male medical students in Karachi, Pakistan.

Azza Sarfraz1, Ali Faisal Sultan1, Mirza Zain Baig1, Moheudin Khan1,Noayna Arshad1, Rijah Chappra1, Sarosh Madhani1, Muhammad Owais Abdul Ghani1, Hassan Bin Khalid1, Imtiaz Jehan2.

  1. Students 4th Year MBBS, Aga Khan University, Karachi, Pakistan.
  2. Associate Professor, Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.

Corresponding Author: Dr Imtiaz Jehan, Associate Professor, Department of Community Health Sciences, Aga Khan University Stadium Road Karachi 74800. Contact Author.
Submission: Oct 15, 2019
Acceptance: Jan 22, 2020
Publication: Feb 1, 2020

Copyright © 2020 Pakistan Journal of Surgery & Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 License, which permits unrestricted use, distribution & reproduction in any medium provided that original work is cited properly.

Article Citation:  Sarfraz A, Sultan AF, Baig MZ, Khan M, Arshad N, Chhapra R, Madhani SI, Ghani MOA, Khalid HB and Jehan I. Prevalence of muscle dysmorphia and associated health activities in male medical students in Karachi, Pakistan. Pak J Surg Med. 2020;1(1):10-17. doi: 10.5281/zenodo.3595081

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Abstract

Background: Muscle Dysmorphia (MD) is a subtype of body dysmorphic disorder (BDD) and is currently classified under anxiety disorders (subheading: Obsessive-compulsive disorder) in DSM 5. MD is hypothesized to affect the self-esteem and social outlook of the younger generation. MD shows a higher rate in males and may influence their self-confidence rendering them more prone towards using steroids, supplementary proteins and other drugs to alter their physical outlooks as shown in previous studies. This problem has been on the rise lately due to revolutionary advancement in the media and film industry and the abrupt changes about the standards of physical good looks and body shapes. With the lack of studies done in our population, our study will be helpful to consider the prevalence of the disease in our setting and increase awareness in the general public and clinicians. We hope to help clinicians/ therapists find better options in managing the disease.
Materials: We performed a cross-sectional study with a sample size of 246 medical school students in Karachi to collect data through self-administered questionnaires. We used the DSM 5 criteria for the diagnosis of BDD and additional questions on the presence of MD. Nutritional habits, exercise routines, use of supplements and drugs were also obtained for exploratory analysis.  
Results: Our study predicted the prevalence of MD to be 25%. Other main findings included statistical significant associations between MD and the thoughts and practice of steroid use for muscularity.
Conclusion: MD is an underdiagnosed and often unrecognized disease that we believe has significant consequences for the young male population. Further work is needed on this in our part of the world. Our research, we believe, can be a stepping stone for further studies that would incorporate wider populations.
Keywords: Muscle dysmorphia (MD), DSM 5, medical students, male, body dysmorphia disorder (BDD)

Introduction

Muscle dysmorphia (MD) is a DSM 5 disease characterized by feelings of inadequacy with regards to muscle size in people with an average build. There is an excessive drive for muscularity in patients with MD, which is significantly out of proportion to any need.[1, 2] It is a subtype of body dysmorphic disorder (BDD) and is currently classified under anxiety disorders (subheading: Obsessive-compulsive disorder) in DSM 5. MD has been the centre of much debate in the past. It was originally classified under somatoform illnesses under DSM 4. However, current insights and more recent data have shown similar features to OCD.[2-4] The basis for this study rests in the hypothesis that MD can have lasting effects on the self-esteem and social outlook of a population of young men.[5, 6] We also hypothesized that the prevalence of the disease is particularly high in young male adults; hence, the study was tailored towards a sample of male medical students. This was well supported by previous literature as it is reported that women have a higher prevalence of eating disorders while men demonstrate higher rates of MD. Previous literature has also shown a much higher rate of substance and steroid abuse in patients with MD.[7] Additionally, patients with MD are seen to consume well over their daily requirements of dietary protein.[8] Furthermore, there is a greater reliance on dietary supplements to obtain extra protein content.[9] 

Rationale for this article

Tod D (2016) reviewed the current insights on MD and found that it continues to be a poorly understood disease, and there is a lack of robust studies done on the topic.[3] Hence, to add to the limited literature on MD, the authors feel the need to explore the prevalence and potential health concerns that it may cause.

Methodology 

We used a cross-sectional study design to assess the prevalence of Muscle Dysmorphia in male medical students aged 19-24 years of age and enrolled in the Aga Khan University and Sindh Medical College. Along with calculating prevalence, we evaluated the use of performance-enhancing drugs/steroids and dietary supplements in the study participants, along with their awareness of protein consumption. These variables were explored in correlation with muscle dysmorphia in the final results discussed below. The study spanned over a period of 5 weeks from March till April 2017.
Data Collection:
DSM 5 criteria along with queries about thoughts regarding the use or use of steroids, protein supplements and the time spent exercising. Subjects were approached in their respective medical college campuses and courtyards during academic hours. Prior permission had been obtained from both the institutions. Prior to the administration of the questionnaire, consent from the subjects was obtained, and a brief introduction of the study was concurrently given. The questionnaires were then collected in a questionnaire box to ensure anonymity. The approximate time taken to fill in the questionnaire was ten minutes. All participants had a chance to refuse or leave midway filling of the questionnaire. However, no such problems were faced. Convenience sampling method was used.
Sample Size:
The sample size was calculated to be 246 on OpenEpi Software, using the estimate of population size to be 100,000 male medical students due to lack of data on the exact number of male medical students aged 19-24 in Karachi. The predicted hypothesis of the outcome factor is 20%, Confidence Interval is 95%, and the accepted margin of error is 5%.
Questionnaire:
In keeping with the objectives of the study, we drafted a questionnaire. The questionnaire was divided into three sections⎯

  • Section 1: This section focused on the subject’s demographics, including age, name of institution and area of study.
  • Section 2: This section included the DSM 5 scoring criteria for body dysmorphic disorder. The DSM 5 scoring criteria consist of 5 parts with each part rated on a five-point scale. This was then used to calculate a total score and an average score for each subject. The average score was then interpreted as⎯
    0= None, 1= Mild, 2= Moderate, 3= Severe and 4= Extreme
  • Section 3: This section included general questions related to the subject’s usage of steroids, protein supplements and hours spent in physical training.

Data entry and quality assurance check
Each researcher was allocated a set of serial numbers, and the filled questionnaires were then manually entered into a questionnaire document on EpiData. Data were analyzed using the data entry program SPSS 21. Data collected from the questionnaires were entered and edited manually. Methods used to prevent data entry errors included double entry and validation following data entry and data analysis screening for outliers during data analysis. Checks were applied on OpenEpi software. Data were cleaned by running frequencies and was then double-checked and entries, peer-reviewed. 
Informed consent 
The informed consent included a brief description of the research topic, along with its objectives to establish informed consent. To further increase the comfort of the subject during filling of the form, anonymity was maintained by keeping the disclosure of identities optional. The responses were secured immediately after collection without being viewed to maintain confidentiality. 
Ethical consideration
The study was approved by Aga Khan University ethical review committee in April, 2017.

Results

Our study population consisted of 252 male medical students between the ages of 19-24. Mean age was 21.67, with the most frequent age being 21 (23.8%), as indicated in table 1.

AgeFrequency (n=252)Percentage (N= 100%)
192911.5 %
20249.5 %
216023.8 %
225421.4 %
235722.6 %
242811.1 %

Table 1⎯ Background characteristics of study participants

Tables 2-5 show the findings of DSM 5 criteria used in our questionnaire. The individual scores of each of these components were used to calculate an average score for all the study participants. Table 2 demonstrates findings for hours occupied per day with thoughts of muscle underdevelopment. 152 (60.3%) respondents were not occupied with thoughts of muscle underdevelopment throughout the day. 71 (28.2%) respondents spent less than 1 hour per day thinking about muscle underdevelopment, classified as mild. Only 2 (0.8 %) respondents were pre-occupied with the thought of muscle underdevelopment spending between 3 till 8 hours per day, classified as severe. No respondents spent more than 8 hours per day, classified as extreme.

Table 2⎯ Frequency of average amount of time occupied with thoughts of muscle underdevelopment amongst subjects

Table 3 presents findings for the difficulty faced in controlling thoughts of muscle underdevelopment, 154 (61.1%) respondents were in complete control of their thought or behaviour, 60 (23.8%) were usually able to control their thoughts or behaviour, categorized as grade 1, 29 (11.5%) respondents were able to moderately control their thoughts or behaviours, categorized as grade 2 and 7 (2.8%) respondents had little control over their thoughts or behaviours, categorized as grade 3. No respondents lost control over their thoughts or behaviours, classified as extreme.

Table 3⎯ Frequency of degree of distress caused by thoughts of muscle underdevelopment amongst subjects

Table 4 demonstrates findings for the degree as to which thoughts of muscle development cause subjects to avoid anything, going anywhere or being with anyone; 167 (66.3 %) respondents reported no avoidance pertaining to thoughts of muscle underdevelopment, 59 (23.4 %) were mildly caught with thoughts of muscle under development, leading to occasional avoidance, classified as grade 1, 19 (7.5 %) respondents were moderately thinking about muscle underdevelopment, causing regular avoidance and categorized as grade 2 and 7 (2.8 %) respondents were frequently and extensively avoiding anything, going anywhere or being with anyone, categorized as severe or grade 3. No respondents selected near-complete avoidance of being housebound due to thoughts of muscle underdevelopment.

Table 4⎯ Frequency of degree to which thoughts of muscle underdevelopment cause subjects to avoid anything, going anywhere or being with anyone

Table 5 demonstrates findings for the degree to which thoughts of muscle development interferes with school, work, social or family life amongst study participants; 175 (69.4 %) respondents reported no avoidance pertaining to thought interference with school, social, work or family life, 56 (22.2 %) reported being mildly caught with thoughts of muscle under development, leading to slight interference, categorized as grade 1, 17 (6.7 %) respondents were moderately thinking about muscle underdevelopment, causing definite interference with functionality but manageable, categorized as grade 2 and only 4 (1.6 %) respondents reported facing substantial interference, categorized as severe or grade 3. No respondents responded with grade 4 or near-total interference leading to incapacitation.

Table 5⎯ Frequency of degree to which thoughts of muscle development interferes with school, work, social or family life amongst subjects

The average score is summarized in table 6. One hundred and fifty five (61.5%) respondents had an average score of 0, 69 (27.4) respondents had an average score of 1, 27 (10.7%) respondents had 2 and only 1 (0.4%) respondent had an average score of 3. No subject in our study sample had a calculated total score of 4. Average scores were calculated for each subject individually based on the DSM 5 criteria demonstrated in tables 2-5.

Average scoreFrequency (n= 252)Percentage (N= 100 %)
0 (None) 155 61.5 %
1 (Mild) 69 27.4 %
2 (Moderate) 27 10.7 %
3 (Severe) 1 0.4 %
4 (Extreme) 0 0 %

Table 6⎯ Average score frequency amongst subjects

The average scores, presented in table 6, were incorporated with part three of our questionnaire, which asked whether the subjects had thoughts of muscle inadequacy. Muscle Dysmorphia was then diagnosed in those subjects who had an average score of 1 and above as well as a positive response to the above question. The findings are summarized in table 7, 63 subjects (25 %) were diagnosed with Muscle dysmorphia using the above-mentioned protocol.

Table 7⎯ Prevalence of muscle dysmorphia amongst subjects

Table 8 shows the frequency of all study subjects and their healthy activities, 37 (14.7 %) respondents had thought of using steroids or performance-enhancing drugs, while 17 (6.7 %) respondents admitted to having personally used them, 90 (35.7 %) respondents claimed to use dietary supplements, while 99 (39.3 %) respondents were aware of their protein intake.

Table 8⎯ Frequency of health activities amongst subjects

Table 9 divides the subject population by the absence or presence of MD. It then looks at the frequency of each health activity. As shown by the table, 23 (36.5 %) subjects diagnosed with MD admitted to thoughts of using steroids or performance-enhancing drugs. While only 14 (7.4 %) subjects who did not have MD admitted to the same thoughts. 12 (19 %) MD-positive subjects used steroids and performance-enhancing drugs, while only 5 (2.6 %) MD-negative subjects admitted to doing the same. Both these differences in the thoughts and use of steroids between the two groups was statistically significant when the Chi-square test was run (p-values<0.05). 27 (42.9 %) of MD-positive subjects and 63 (33.3 %) MD-negative subjects admitted using dietary supplements. 30 (47.6 %) MD positive and 69 (36.5 %) of MD-negative respondents were aware of their total dietary protein. However, when the differences in these two variables between the MD-positive and -negative groups were evaluated, they were found to be statistically insignificant as the Chi-square test yielded a p-value higher than 0.05.

Table 9⎯ Frequency of health activities based on presence or absence of muscle dysmorphia amongst subjects

Table 10 compares the number of hours a week spent in the gym between the two groups. In both groups, most subjects spent more than 4 hours in the gym per week. Those with MD spent more hours in the gym in this subcategory however in all other subcategories the subjects without MD were spending more time in the gym.

Table 10⎯ Hours spent exercising per week based on presence or absence of muscle dysmorphia amongst subjects

Discussion

Twenty-five percent of our sample population was found to have muscle dysmorphia. Majority of the positive cases were found to be mild. More specifically, 25% of subjects described the distress caused by this disease as slightly disturbing, 23.8 % admitted that they were usually able to control their thoughts of muscle underdevelopment, 23.4% avoided doing anything only occasionally, and 22.2% of subjects admitted that it slightly interfered with their school, work, social or family life. Therefore, it can be concluded that the majority of those labelled positive for muscle dysmorphia only exhibited a rather mild form of the disease. This can be backed by the average score frequency, which a score of 1 (mild) had the second-highest frequency (27.4%) following 0 (none). The prevalence of MD in our study comes out to be higher than what other studies have suggested.
Compte et al.[10] reported a prevalence of 6.99% in their sample of male medical students in Buenos Aires. Similarly, Campagna [11] reports a prevalence of 12.7% in males and 4.2% in females. We hypothesize that the relatively high level of prevalence in our population might be due to the severe lack of mental health facilities in our part of the world. Studies show the role of media in changing the ideals of what a young male considers to be the target goal with regards to physical appearance.[12] The desire to be lean and slim has changed to that of being larger and stronger in adolescents.[13] There is also a loose link between anthropometric measurements of subjects and the presence of MD. Obesity correlates positively with MD, as does mesomorphy.[14] The body dysmorphia disorder questionnaire has also been critically analyzed and is found to be an effective screening tool.[15, 16] However, there is an absence of a widely accepted diagnostic tool.
Our study explored other variables that included thoughts of steroid use, usage of steroids, usage of supplements and awareness regarding daily protein consumption. Statistically significant associations were found for both thoughts of and usage of steroid use. When we talk about dietary supplementation and protein consumption awareness, we saw higher rate among subjects with the disease, but neither was statistically significant. Subjects with MD also on average spent more time in the gym and in physical activity. Our results show a lot of interesting data with possible implications. Our prevalence value of 25 % contrasts with previous studies which showed it to be in the range of 7 to 13 %. Additionally, it shows a higher prevalence in a younger, more at-risk population. There are statistically significant associations with both thoughts and actual usage of steroids. Both showed very high rates, and this highlights the future implications of the disease. Such high values cannot be ignored and hope to serve as a platform for both future research and societal and clinical awareness.
Although no statistically significant associations were found for other variables in the study, we found baseline rates of dietary supplementation and awareness of protein consumption to be high even in the general population. This may mask our data from showing the trend in our positive cases. The study hopes to highlight MD as a growing health concern and one that affects the young health of our population in specific. Mass media consumption and societal paradigm shifts had left the medical and overall community with a disease more prevalent than ever before which was once thought to be negligible.

Strengths and Weaknesses

The strengths of our study include a good sample size and response rate. Our definition of MD was robust and served to make sure there was no over-reporting of the disease. Additional questions were included to make our criteria even stronger. The study is the first of its kind in our population. Additionally, our results are meaningful and have implications for our population. Lastly, our topic is a current day issue.
Weaknesses of this study include limited population. The validity to be extended to the general population is not profound. Our population is also focused on a specific socio-economic class. Although the authors hope to strengthen further the definition of MD used by other studies, it is a new definition and not one widely used. Lastly, our study does not take into consideration any confounders.

Conclusion

MD is an under-diagnosed and under-reported disease. The authors sought out to highlight and mainstream the disease in an effort to show the increasing prevalence and possible health implications. We found the value to be within 5 % of our expected outcome of 20 % and found statistically significant associations with MD and steroid abuse. The long-term outcomes of our data are vast and should be explored through further studies. We hope our data will serve as a pilot for future research. 

Acknowledgement

The authors would like to acknowledge the efforts of Dr. Imtiaz Jehan, who as the student project supervisor provided the research oversight and technical guidance from Health Sciences (CHS). The students and faculty contributed in the study are listed as authors.

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