Accessible Unlicensed Requires Authentication Published online by De Gruyter June 5, 2020

Prevalence and correlates of muscle-enhancing behaviors among adolescents and young adults in the United States

Jason M. Nagata ORCID logo, Kyle T. Ganson, Scott Griffiths, Deborah Mitchison, Andrea K. Garber, Eric Vittinghoff, Kirsten Bibbins-Domingo and Stuart B. Murray



To determine the prevalence of muscle-enhancing behaviors in adolescents and young adults using a nationally representative sample in the USA and to examine differences by sex, race/ethnicity, age, socioeconomic status, body mass index, and participation in team sports.


Prospective cohort data from the National Longitudinal Study of Adolescent to Adult Health, Waves I through III (1994–2002) were analyzed. Engagement in muscle-enhancing behaviors including dietary changes, exercise and weightlifting, supplement use, performance-enhancing substances, and anabolic androgenic steroids were recorded. Multiple logistic regression models using generalized estimating equations, incorporating robust standard errors with clustering by school and within persons, and using national sample weighting, were used to determine associations with muscle-enhancing behaviors across three data collection waves.


Of the 18,924 adolescents at baseline, 29.2% of males and 7.0% of females reported weight gain attempts, while 25.2% of males and 3.8% of females reported any muscle-enhancing behavior. All muscle-enhancing behaviors were more common in males compared to females (p<0.001). Among young men 18–26 years old, 15.6% reported using legal performance enhancing substances and 2.7% reported using androgenic anabolic steroids. Factors that were associated with muscle-enhancing behaviors in males across three data collection waves included Black or Hispanic/Latino race/ethnicity, age over 14 years, higher parental education, lower body mass index, and participation in team sports.


Muscle-enhancing behaviors ranging from dietary changes to supplement and androgenic anabolic steroid use are common among adolescent and young adult males. Clinicians should consider screening for muscle-enhancing behaviors in these populations.

Corresponding author: Jason M. Nagata, MD, MSc, 550 16th Street, 4th Floor, Box 0110, Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, 94158, USA, Phone: +1 (415) 476 3610, E-mail:

Funding source: American Academy of Pediatrics

Funding source: American Pediatric Society

Funding source: American Heart Association

Award Identifier / Grant number: CDA34760281

Funding source: National Institutes of Health

Award Identifier / Grant number: K23 MH115184

Award Identifier / Grant number: R01HD082166-02

Award Identifier / Grant number: K12HD00085033

Funding source: National Health and Medical Research Council

Award Identifier / Grant number: 1121538

Funding source: University of Melbourne

Award Identifier / Grant number: 603758

Funding source: Eunice Kennedy Shriver National Institute of Child Health and Human Development

Award Identifier / Grant number: P01-HD31921


J.M.N. is a participant in the Pediatric Scientist Development Program (K12HD00085033), funded by the American Academy of Pediatrics and the American Pediatric Society, and a recipient of the American Heart Association Career Development Award (CDA34760281). S.B.M. was supported by the National Institutes of Health (K23 MH115184). A.K.G. was supported by the National Institutes of Health (R01HD082166-02). S.G. is supported by a National Health and Medical Research Council Early Career Fellowship (grant number: 1121538) and a University of Melbourne Early Career Grant (grant number: 603758). Special thanks to Rebecca Schauer for assistance with the analyses and John Boscardin for biostatistical advice. This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill, and funded by grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Information on how to obtain the Add Health data files is available on the Add Health website ( No direct support was received from grant P01-HD31921 for this analysis.

  1. Author contributions: Dr. Nagata conceptualized and designed the study, completed the statistical analysis, drafted the initial manuscript, and reviewed and revised the manuscript. Dr. Ganson collaboratively conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. Dr. Vittinghoff completed the statistical analysis, and reviewed and revised the mansuscript. Dr. Mitchison, Dr. Murray, Dr. Griffiths, Dr. Garber, and Dr. Bibbins-Domingo critically reviewed the manuscript for important intellectual content and appropriate statistical analysis, as well as provided manuscript edits. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

  2. Ethical approval: The University of North Carolina Institutional Review Board approved all Add Health study procedures.

  3. Conflicts of interest: The authors have no conflicts of interest to report.


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Received: 2020-01-03
Accepted: 2020-02-16
Published Online: 2020-06-05

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