|Year : 2020 | Volume
| Issue : 2 | Page : 130-135
Body image dissatisfaction in young Indian Men: Prevalence, psychosocial correlates, and the impact of sociocultural pressure
Geeta Soohinda, Harshavardhan Sampath, Divyanti Mishra, Sanjiba Dutta
Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, Sikkim, India
|Date of Submission||15-Apr-2019|
|Date of Decision||22-Oct-2019|
|Date of Acceptance||09-Dec-2019|
|Date of Web Publication||27-Jun-2020|
Dr. Harshavardhan Sampath
Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, Sikkim
Source of Support: None, Conflict of Interest: None
Background: Body image dissatisfaction (BID) is the negative perception of the weight and shape of one's body. It is a prominent risk factor for conditions ranging from eating disorders, body dysmorphic disorder, depression, anxiety, and substance use disorders. BID evolves from a complex interaction between psychological (personality, self-esteem), physical (body mass index), and cultural factors (social expectations and media messages). Once restricted to adolescent Caucasian females, BID has been increasing among men in developing Asian cultures. This study aimed to address the scarcity of research on BID and its correlates among young Indian men. Materials and Methods: A cross-sectional, quantitative, observational, questionnaire-based research design was chosen to address the objectives in a sample of male college students aged 18–25 years. The body shape questionnaire (BSQ-8c), sociocultural attitudes toward appearance questionnaire-4, Rosenberg's self-esteem scale and the mini-International personality item pool (MINI-IPIP) personality scale were used to measure BID, sociocultural pressures, self-esteem, and personality traits, respectively. Results: Of the 511 males, 34.44% (n = 176) had moderate to marked BID. Underweight men had greater BID than those who were obese. However, the differences in BSQ-8c scores across various BMI categories were not statistically significant (Kruskal–Wallis H = 6.07, df = 3, P = 0.108). BID significantly correlated with levels of neuroticism (rs = 0.093, P = 0.0360). Sociocultural pressure from the family, peers, and media significantly correlated with the internalization of thin and muscular body image ideals (all P < 0.001, highly significant). Conclusion: BID is a significant concern among young Indian men, especially those with high levels of neuroticism. This is compounded by the internalization of social pressures from the family, peers, and media.
Keywords: Body image, male, media, personality, self-esteem, sociocultural factors
|How to cite this article:|
Soohinda G, Sampath H, Mishra D, Dutta S. Body image dissatisfaction in young Indian Men: Prevalence, psychosocial correlates, and the impact of sociocultural pressure. Indian J Soc Psychiatry 2020;36:130-5
|How to cite this URL:|
Soohinda G, Sampath H, Mishra D, Dutta S. Body image dissatisfaction in young Indian Men: Prevalence, psychosocial correlates, and the impact of sociocultural pressure. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Dec 1];36:130-5. Available from: https://www.indjsp.org/text.asp?2020/36/2/130/288108
| Introduction|| |
Body image dissatisfaction (BID) refers to a negative subjective evaluation of one's physical appearance due to the discrepancy between the person's evaluation of their physical appearance and their concept of an ideal body image. Increasingly, BID has been reported as a significant risk factor for the development and maintenance of many disorders, including eating disorders, body dysmorpophobia, exercise addiction, and poor psychological functioning.,, Previously believed to be uncommon in Asian cultures, body dissatisfaction and eating disorders are increasingly reported in India. With growing exposure to Western media, this generation is equating Caucasian standards of physical appearance with beauty and trying to imitate their role models. Conventionally, women have been the focus of research on BID. However, in recent years, men are also increasingly reporting dissatisfaction with their body. This has been attributed to an increasingly unattainable and unrealistic lean muscular body image ideal (“six-pack abs”) being portrayed by the media, including mainstream Bollywood films.
BID can be conceptualized as a multifactorial disorder with an interplay between physical, psychological, and sociocultural factors. Social pressures from the family, peers, and the media influence self-image by making one constantly compare his/her appearance to images in the media and internalize the ideal standards that they represent. However, this internalization has not been observed universally, even across Western cultures. With its unique sociocultural environment, it would be interesting to observe whether an association between BID and sociocultural factors exists in the Indian context.
Bodyweight, reflected in the body mass index (BMI), is an important physical determinant of BID. In men, BID shows a curvilinear association with BMI, with low (underweight) and high (overweight and obese) BMI scores associated with greater body dissatisfaction. Although males tend to progressively idealize higher BMI as long as it is lean, cross-cultural differences have been observed. Given these findings, the effect of BMI on body dissatisfaction in Indian men needs to be investigated.
The importance of psychological determinants of BID cannot be overstated. Self-esteem and personality play a significant role in influencing the internalization of socio-cultural pressure on BID. Self-esteem buffers the negative effects of many psychological variables and imparts resilience. Studies have shown that high self-esteem is associated with lower psychological distress and eating disorders in people with BID., Personality traits influence the perception of body image irrespective of actual body proportions. Individuals with high levels of neuroticism tend to be more self-conscious about their appearance and sensitive to rejection, placing them at high risk for BID. Similarly, trait agreeableness is associated with an endorsement of traditional values, which might predispose individuals to assign greater importance to acceptable physical appearance, putting them at a greater risk for negative body image perception. On the contrary, people who score high on extraversion are less sensitive to social pressures and consequently less susceptible to sociocultural factors that contribute to a negative body image. Likewise, people with high levels of openness tend to be more acceptable of diversity and thus more likely to be open to different body image ideals, placing them at a lower risk for BID. Conscientiousness, however, is associated with both an endorsement of social conventions (like agreeableness) and high levels of confidence (like extraversion) and thus its association with BID is unclear, although some evidence suggests that it is associated with a healthier body image. One limitation of evidence of personality and BID is that it is focused mostly on women. In contrast to the drive for thinness among women, men tend to endorse simultaneous drives to reduce body fat and to increase muscle mass (the mesomorphic body ideal); and thus, it would be interesting to see what psychological factors are associated with BID in Indian men.
Studies in India on eating disorders and body dissatisfaction are limited and focused mostly on adolescent or young women.,,, Considering the potential consequences of BID in men in the form of excessive anabolic steroid and stimulant abuse, low self-esteem, and poor psychological functioning, the factors contributing to it deserves special attention.
From this review, it is clear; thus, literature regarding BID in young Indian men is scant. We aimed to explore BID in this population with the objective of measuring its prevalence and analyzing the physical (BMI) and psychological factors (self-esteem and personality traits) that contribute to it. We also wanted to find if social pressure contributed to the internalization of body image ideals in young Indian men.
| Materials and Methods|| |
We used a cross-sectional survey design with a convenience sampling technique to address the objectives of our study. The target population consisted of young men aged 18–25 years pursuing their graduation or postgraduation in Arts, Science, Commerce, or Management in colleges under the University of Kanpur, Uttar Pradesh. Over 3 months, questionnaires in English were distributed to 600 consenting students and the filled forms were collected by the investigator. Ethical clearance was obtained from the institutional ethics committee.
The following questionnaires were used:
- Socio-demographic pro forma that included details such as age, weight, and height
- The body shape questionnaire (BSQ-8c) is a widely used self-report questionnaire to assess dissatisfaction with body shape. It consists of 8 questions assessing BID over the past 4 weeks rated on a 6-point Likert scale. Higher scores are indicative of greater BID. The scale has been shown to possess good reliability, internal consistency, and convergent validity for the Indian population
- The family, peers, and media pressures subscale of the sociocultural attitudes towards appearance questionnaire version-4 (SATAQ-4) was used to measure appearance-related pressures from different social sources. Each sub-scale has four items rated on a 5-point Likert scale ranging from 1 (definitely disagree) to 5 (definitely agree). Higher scores indicate greater appearance-related pressures. The scale demonstrates good internal consistency and reliability
- The thin/low body fat internalization and the muscularity/athletic internalization subscales of the SATAQ-4 questionnaire were used to assess internalization of thin and muscular appearance ideals, respectively. Each ideal is measured by five items scored on a 5-point Likert scale ranging from 1 (definitely disagree) to 5 (definitely agree). Higher scores are indicative of greater internalization of the respective appearance ideals. The scale demonstrates good reliability and convergent validity with measures of body image, eating disturbance, and self-esteem
- Rosenberg's self-esteem scale was used to measure the construct of self-esteem. It is a 10-item questionnaire rated on a 4-point Likert scale with responses ranging from “Strongly agree” to “Strongly disagree.” The scale demonstrates excellent internal consistency, test-retest reliability, and stability
- The MINI-IPIP was used to measure of the big five personality traits of extraversion, agreeableness, conscientiousness, neuroticism, and imagination. It consists of 20 items, each describing a unique behavior rated by the respondent depending on the accuracy to which it reflects them on a 5-point Likert type scale. The scale demonstrates consistent and acceptable internal consistency, test-retest reliability, a comparable pattern of convergent, discriminant, and criterion-related validity.
Statistical analysis was done using MINITAB 17 statistical software (Minitab LLC, State college, Pennsylvania, USA). Mean, standard deviation (SD), and percentages were used to display the distribution of variables. Spearman's rank correlation was used to analyze the correlation between (a) BSQ-8c scores, BMI, self-esteem, and personality traits and (b) sociocultural pressure and internalization of thin and muscular body image ideals. Multiple regression analysis was employed to quantify the relationship between the variables.
| Results|| |
Of the 600 questionnaires distributed, 538 completed questionnaires were returned. Of these, 27 questionnaires could not be included due to missing data. Thus, the data from 511 students were used in the final analysis. The mean age of the sample was 20.7 years (SD 1.88). The median BSQ-8c score was 23 (minimum score = 8, maximum score = 48, mode = 24). 34.44% (n = 176) of men had moderate-marked body dissatisfaction [Table 1]. The mean BMI was 22.66 (SD 3.88). 12.52% were underweight (n = 64), 28.77% were overweight (n = 147) while 4.89% were obese (n = 25). BSQ-8c scores were higher for underweight (mean 24.19, SD 8.0) and obese men (mean 22.64, SD 8.28) than those within the normal (mean 21.67, SD 6.71) or overweight BMI categories (mean 21.69, SD 7.68). A greater number of underweight men (BMI <18.5) expressed moderate or marked concern (17.06%) over their body shape compared to obese (BMI >30) men (5.11%) [Figure 1].
|Table 1: Distribution of body image dissatisfaction among young men (n=511) based on body shape questionnaire-8c scores|
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|Figure 1: Interval plot illustrating body image dissatisfaction scores (BSQ-8c) across different body mass index categories|
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Kruskal–Wallis test was used as the BSQ-8c scores were not normally distributed (SD = 7.28, Anderson Darling normality test P < 0.005). The differences in BSQ-8c scores were not statistically significant across the BMI categories (Kruskal–Wallis H = 6.07, df = 3, P = 0.108). The mean Rosenberg self-esteem score was 16.72 (SD 3.51). Spearman's rank correlation was performed to find the correlation between BID and the biopsychosocial variables (non-normal data distribution). Only the personality trait of neuroticism (rs= 0.093, P = 0.036) significantly correlated with BID [Table 2].
|Table 2: Correlation between body image dissatisfaction (body shape questionnaire-8c scores) and psychobiological factors|
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The impact of social pressure on the internalization of a thin and muscular body image ideals are depicted in [Table 3]. Pressure from family, peers, and media significantly correlated with the internalization of both the thin and muscular body image ideals (all P < 0.001, highly significant).
|Table 3: Correlation between appearance-related social pressures and the internalization of body image ideals|
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Multiple regression analysis was performed to quantify the relative contribution of these sociocultural pressures on the internalization of body image ideals of thinness and muscularity. Sociocultural pressures significantly explained 30.07% (Adj R-sq = 29.66%) variance in the internalization of a thin body ideal among young men [Table 4]. All three sources of pressure (family, peers, and media) significantly affected the internalization of a thin body image (P < 0.001, highly significant).
|Table 4: ANOVA of internalization of the thin body ideal and appearance-related social pressures|
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Regarding internalization of a muscular body image ideal, social pressure explained 20.49% (R-sq (adj) = 20.02%) of the variance [Table 5]. Only family and media pressure significantly predicted the internalization of a muscular body ideal (P < 0.001, highly significant).
|Table 5: ANOVA of internalization of muscular body ideal and appearance-related social pressures|
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| Discussion|| |
A decade ago, BID was unheard of in India, especially among men. This was because BID and eating disorders were thought to be culture-bound syndromes of Westernized societies. However, a cultural shift in body image ideals has occurred in this part of the world owing to Western global influences and changing societal and gender norms. Our results indicate that nearly one-third of young men (34.44%) being moderately or markedly dissatisfied with their body shape. While other Indian studies have reported rates ranging from 10% to 33% in females, this is the first Indian study to report the extent of BID in young men.,,, This is indeed surprising, as men are generally stereotyped to be less conscious of their bodies. More research on BID and young Indian men needs to be done to replicate our findings.
We found that physical factors such as age and BMI did not correlate significantly with BID. Given the narrow age range of our sample, it is not surprising that we could not find such an association. However, the fact that BMI did not correlate significantly with BID is unusual, given the fact that one's body weight is generally construed to contribute to how one perceives oneself. This finding reiterates the observation by clinicians that rather than one's actual weight, it is how one perceives his body shape (dysfunctional metacognitive processes) that influences BID. Furthermore, a meta-analysis by Weinberger et al. concluded that the severity of BID was greater in obese women than in men illustrating the point that men and women perceive their body shape differently. Interestingly, we found underweight men to have the highest levels of BID even more than men who were obese. This is because, for young men, muscularity is more important than being thin or slender. Grogan, in her seminal work on body image, observes that men aspire to a muscular mesomorphic shape characterized by average build with well-developed muscles on the chest, arms, and shoulders, and slim waist and hips, rather than an ectomorphic (thin) or endomorphic (fat) build. The author also observes that women aspire for a different body image ideal characterized by a thin and slender physique.
Among the psychological factors, only the personality trait of neuroticism significantly correlated with BID. People who score high on neuroticism may be more sensitive to appearance evaluation and rejection and are more likely to experience negative emotional states, increasing their susceptibility to BID, especially if they are unable to attain their internalized body image ideal., Interestingly, self-esteem did not correlate significantly with BID in our study. Although many studies have reported high self-esteem as a protective factor for BID; some researchers have claimed that male self-esteem was not affected by body dissatisfaction.,
Sociocultural pressures from family, peers, and media messages correlated with the internalization of both thinness and muscularity in Indian men. While this has been replicated in women, this is the first study to observe such an association in Indian men. Sociocultural theory suggests that the ideal beauty standards are determined by the culture that is internalized leading to self-objectification. In a predominantly patriarchal societal structure, success, and power are attributed to a strong masculine appearance. Thus, the Darwinian struggle to achieve this ideal body image is reinforced by the family, and failure to do so may contribute to BID. Weight or shape related criticism by family members and peers has also been significantly related to BID body dissatisfaction. Similarly, peer pressure in the form of dieting behavior of classmates, weight, and shape teasing have been proposed as risk factors for body dissatisfaction. Curiously, even though peer pressure correlated with the internalization of a muscular ideal, the results were not statistically significant (P = 0.134). This is in contrast to Western literature which indicates that peer discussions on appearance results in body image concerns, especially among men as a way of asserting masculinity and peer status. Probably, Indian men instead of engaging in peer comparison as their Western counterparts, idolize their film stars who perpetuate and glorify a muscular and athletic male body ideal. Indeed, exposure to media images (magazines, posters, movies, etc.,) of men with idealized bodies has been shown to increase insecurity and body image concerns among men. Thus, the media portrayal of idealized male physiques can influence the minds of young men who engage uncritically with media imagery, using it to guide their body image ideal.
The strengths of our study lie in its exploration of BID in Indian men, a demographic that has been ignored for long. The sample size of over 500 is the largest till date on men aged 18–25 years. We explored the various biopsychosocial correlates of BID, namely, BMI, self-esteem, and personality traits. The contribution of sociocultural pressures from family, media, and peers in internalizing body image ideals was studied in the Indian context. Our study is not without its limitations. BID is a multidimensional and complex concept might not have been adequately captured by the BSQ-8c. Being cross-sectional in design, this study can infer association and not causation. Also, in a questionnaire-based study, one cannot rule out a self-report bias.
| Conclusion|| |
This study reiterates our concern about Indian men being vulnerable to body image problems. With wide assess to Western media and exposure to family and peer pressure, men are more prone to engage in altering their physical appearance. Resorting to physically and psychologically damaging quick fixes such as anabolic steroids, crash diets, and fat burners have been documented in American men who are willing to go to any lengths to conform to the sociocultural standards of masculinity., It would be worrying if this trend catches up among young Indian men. Awareness and psychoeducation programs need to be conducted on college campuses to promote a healthy body image.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Grogan S. Body Image: Understanding Body Dissatisfaction in Men, Women and Children. 3rd
ed. Georgetown, NY: Taylor and Francis; 2016.
Stice E, Shaw HE. Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings. J Psychosom Res 2002;53:985-93.
Moulton SJ, Gullyas C, Hogg FJ, Power KG. Psychosocial predictors of body image dissatisfaction in patients referred for NHS aesthetic surgery. J Plast Reconstr Aesthet Surg 2018;71:149-54.
Bell HS, Donovan CL, Ramme R. Is athletic really ideal? An examination of the mediating role of body dissatisfaction in predicting disordered eating and compulsive exercise. Eat Behav 2016;21:24-9.
Ganesan S, Ravishankar SL, Ramalingam S. Are body image issues affecting our adolescents? A cross-sectional study among college going adolescent girls. Indian J Community Med 2018;43:S42-6.
Leit RA, Gray JJ, Pope HG Jr., The media's representation of the ideal male body: A cause for muscle dysmorphia? Int J Eat Disord 2002;31:334-8.
Thompson JK, Heinberg LJ, Altabe M, Tantleff-Dunn S. Exacting Beauty: Theory, Assessment, and Treatment Of body Image Disturbance. Washington, DC: American Psychological Association; 1999.
Franko DL, Fuller-Tyszkiewicz M, Rodgers RF, Holmqvist Gattario K, Frisén A, Diedrichs PC, et al
. Internalization as a mediator of the relationship between conformity to masculine norms and body image attitudes and behaviors among young men in Sweden, US, UK, and Australia. Body Image 2015;15:54-60.
Duchesne AP, Dion J, Lalande D, Bégin C, Émond C, Lalande G, et al
. Body dissatisfaction and psychological distress in adolescents: Is self-esteem a mediator? J Health Psychol 2017;22:1563-9.
Brechan I, Kvalem IL. Relationship between body dissatisfaction and disordered eating: Mediating role of self-esteem and depression. Eat Behav 2015;17:49-58.
Swami V, Tran US, Brooks LH, Kanaan L, Luesse EM, Nader IW, et al
. Body image and personality: Associations between the big five personality factors, actual-ideal weight discrepancy, and body appreciation. Scand J Psychol 2013;54:146-51.
Benford K, Swami V. Body image and personality among British men: Associations between the big five personality domains, drive for muscularity, and body appreciation. Body Image 2014;11:454-7.
Allen MS, Walter EE. Personality and body image: A systematic review. Body Image 2016;19:79-88.
Wilt J, Revelle W. Extraversion. In: Leary MR, Hoyle RH, editors, Handbook of Individual Differences in Social Behavior. New York: Guilford; 2008. p. 27-45.
Swami V, Buchanan T, Furnham A, Tovée MJ. Five-factor personality correlates of perceptions of women's body sizes. Pers Indiv Differ 2008;45:697-9.
Arbour KP, Martin Ginis KA. Effects of exposure to muscular and hypermuscular media images on young men's muscularity dissatisfaction and body dissatisfaction. Body Image 2006;3:153-61.
Chandra PS, Abbas S, Palmer R. Are eating disorders a significant clinical issue in urban India? A survey among psychiatrists in Bangalore. Int J Eat Disord 2012;45:443-6.
Balhara YP, Mathur S, Kataria DK. Body shape and eating attitudes among female nursing students in India. East Asian Arch Psychiatry 2012;22:70-4.
Stigler MH, Arora M, Dhavan P, Shrivastav R, Reddy KS, Perry CL. Weight-related concerns and weight-control behaviors among overweight adolescents in Delhi, India: A cross-sectional study. Int J Behav Nutr Phys Act 2011;8:9.
Talukdar J. Thin but not skinny: Women negotiating the “never too thin” body ideal in urban India. Women Stud Int Forum 2012;35:109-18.
Kanayama G, Pope HG Jr., Hudson JI. “Body image” drugs: A growing psychosomatic problem. Psychother Psychosom 2001;70:61-5.
Evans C, Dolan B. Body Shape Questionnaire: Derivation of shortened “alternate forms”. Int J Eat Disord 1993;13:315-21.
Gupta N, Bhargava R, Chavan BS, Sharan P. Eating attitudes and body shape concerns among medical students in Chandigarh. Indian J Soc Psychiatry 2017;33:219-24. [Full text]
Schaefer LM, Burke NL, Thompson JK, Dedrick RF, Heinberg LJ, Calogero RM, et al
. Development and validation of the Sociocultural Attitudes Towards Appearance Questionnaire-4 (SATAQ-4). Psychol Assess 2015;27:54-67.
Rosenberg M. Society and the Adolescent Self-Image. Princeton, NJ: Princeton University Press; 2015.
Donnellan MB, Oswald FL, Baird BM, Lucas RE. The mini-IPIP scales: Tiny-yet-effective measures of the Big Five factors of personality. Psychol Assess 2006;18:192-203.
Taylor MJ. The Nature and Significance of Body Image Disturbance (Dissertation). University of Cambridge; 1987.
Goswami S, Sachdeva S, Sachdeva R. Body image satisfaction among female college students. Ind Psychiatry J 2012;21:168-72.
] [Full text]
Cavale J, Singh DC. Current status of body image research in India. Indian J Psychol Sci 2014;5:124-31.
Priya D, Prasanna KS, Sucharitha S, Vaz NC. Body image perception and attempts to change weight among female medical students at Mangalore. Indian J Community Med 2010;35:316-20.
] [Full text]
Rashmi BM, Patil SS, Angadi MM, Pattankar TP. A cross-sectional study of the pattern of body image perception among female students of BBM college in Vijayapur, North Karnataka. J Clin Diagn Res 2016;10:LC05-9.
Atkinson MJ, Wade TD. Impact of metacognitive acceptance on body dissatisfaction and negative affect: Engagement and efficacy. J Consult Clin Psychol 2012;80:416-25.
Weinberger NA, Kersting A, Riedel-Heller SG, Luck-Sikorski C. Body dissatisfaction in individuals with obesity compared to normal-weight individuals: A systematic review and meta-analysis. Obes Facts 2016;9:424-41.
Tylka TL, Bergeron D, Schwartz JP. Development and psychometric evaluation of the Male Body Attitudes Scale (MBAS). Body Image 2005;2:161-75.
Furnham A, Badmin N, Sneade I. Body image dissatisfaction: Gender differences in eating attitudes, self-esteem, and reasons for exercise. J Psychol 2002;136:581-96.
Schwartz DJ, Phares V, Tantleff-Dunn S, Thompson JK. Body image, psychological functioning, and parental feedback regarding physical appearance. Int J Eat Disord 1999;25:339-43.
Eisenberg ME, Neumark-Sztainer D, Story M. Associations of weight-based teasing and emotional well-being among adolescents. Arch Pediatr Adolesc Med 2003;157:733-8.
Jones DC, Vigfusdottir TH, Lee Y. Body image and the appearance culture among adolescent girls and boys: An examination of friend conversations, peer criticism, appearance magazines, and the internalization of appearance ideals. J Adolescent Res 2004;19:323-39.
Grogan S, Richards H. Body image: Focus groups with boys and men. Men Masc 2002;4:219-32.
Abell SC, Richards MH. The relationship between body shape satisfaction and self-esteem: An investigation of gender and class differences. J Youth Adolescence 1996;25:691-703.
Kanayama G, Brower KJ, Wood RI, Hudson JI, Pope HG Jr., Anabolic-androgenic steroid dependence: An emerging disorder. Addiction 2009;104:1966-78.
Blanck HM, Serdula MK, Gillespie C, Galuska DA, Sharpe PA, Conway JM, et al
. Use of nonprescription dietary supplements for weight loss is common among Americans. J Am Diet Assoc 2007;107:441-7.
Henderson J. Promoting Healthy body Image in College Men: An Evaluation of A Psychoeducation Program (Dissertation). University of Nebraska-Lincoln; 2012.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]