Adolescent and Young Adult Use of Muscle-Building Dietary Supplements: Guidance for Assessment and Harm Reduction Approaches to Mitigate Risks

Muscle-building dietary supplements (muscle-building supplements hereafter) are a broad category of products intended to supplement the diet, with purported benefits of building muscle and strength, reducing fatigue and muscle wasting, and improving recovery and performance [1Ganson K.T. Sinicropi E. Nagata J.M. Assessing Canadian regulation of muscle-building supplements: Identifying gaps and recommendations for improvement to protect the health and well-being of young people.Perform Enhanc Health. 2023; 11100255Crossref PubMed Scopus (6) Google Scholar,2LaBotz M. Griesemer B.A. Use of performance-enhancing substances.Pediatrics. 2016; 138e20161300Crossref PubMed Scopus (54) Google Scholar]. Use of muscle-building supplements is ubiquitous among adolescents and young adults, particularly boys and young men. For example, lifetime and 12-month prevalence estimates of protein supplement use range from 55%–83% for boys and young men, and creatine use ranges from 19%–50% [3Ganson K.T. Hallward L. Cunningham M.L. et al.Use of legal appearance- and performance- enhancing drugs and substances: Findings from the Canadian study of adolescent health behaviors use of legal appearance- and performance-enhancing drugs health behaviors.Subst Use Misuse. 2022; 58: 289-297Crossref PubMed Scopus (10) Google Scholar,4Nagata J.M. Hazzard V.M. Ganson K.T. et al.Muscle-building behaviors from adolescence to emerging adulthood: A prospective cohort study.Prev Med Rep. 2022; 27101778PubMed Google Scholar]. Indeed, the high use of muscle-building supplements among boys and young men is driven by pressures to adhere to the muscular and lean body ideal [5Murray S.B. Nagata J.M. Griffiths S. et al.The enigma of male eating disorders: A critical review and synthesis.Clin Psychol Rev. 2017; 57: 1-11Crossref PubMed Scopus (0) Google Scholar]. Despite the common use of muscle-building supplements, there remains little guidance for health and mental health–care professionals (health-care professionals hereafter) on how to best assess and support adolescents and young adults using muscle-building supplements, and how to determine whether its use is problematic. Generally, the use of muscle-building supplements is believed to be largely benign with minimal risks given the availability, and little government regulation and oversight, of these products [1Ganson K.T. Sinicropi E. Nagata J.M. Assessing Canadian regulation of muscle-building supplements: Identifying gaps and recommendations for improvement to protect the health and well-being of young people.Perform Enhanc Health. 2023; 11100255Crossref PubMed Scopus (6) Google Scholar]. For many, this is the case, and their use of muscle-building supplements is without adverse effects related to their physical, psychological, and social health and functioning. However, for others, the use of muscle-building supplements can lead to potential adverse consequences, including disability and death [6Or F. Kim Y. Simms J. Austin S.B. Taking stock of dietary supplements’ harmful effects on children, adolescents, and young adults.J Adolesc Health. 2019; : 1-7Google Scholar]. In this commentary, we provide guidance to health-care professionals who are assessing muscle-building supplement use among adolescent and young adult clients, including whether use is potentially problematic, and how to intervene to mitigate risks from use. In general, health-care professionals can consider taking a harm reduction approach when assessing and intervening with adolescent and young adult use of muscle-building supplements. Harm reduction emphasizes multiple principles and practices that are intended to reduce negative effects associated with risky behaviors, including substance use (i.e., muscle-building supplement use) [7Ramprashad A. Burnett G.M. Welsh C. Harm reduction.Psychiatr Clin North Am. 2022; 45: 529-546Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar,8Winer J.M. Yule A.M. Hadland S.E. Bagley S.M. Addressing adolescent substance use with a public health prevention framework: The case for harm reduction.Ann Med. 2022; 54: 2123-2136Crossref PubMed Scopus (21) Google Scholar]. This approach also communicates to adolescents and young adults an understanding that the use of muscle-building supplements may be common in their sport or among their social community, and thus, abstinence may be an unrealistic possibility or goal. Foundational components of the harm reduction approach include open communication, understanding motivations, psychoeducation, providing ongoing monitoring and treatment, and mitigating effects [8Winer J.M. Yule A.M. Hadland S.E. Bagley S.M. Addressing adolescent substance use with a public health prevention framework: The case for harm reduction.Ann Med. 2022; 54: 2123-2136Crossref PubMed Scopus (21) Google Scholar]. Table 1 provides guidance in the key areas of assessment, specific details describing each assessment area, and harm reduction approaches that may be utilized to engage adolescents and young adults regarding muscle-building supplement use. The areas of assessment provide health-care professionals with guidance when assessing (1) whether the client is using muscle-building supplements, their pattern of use, and motivations and (2) whether their use is potentially problematic (i.e., having a detrimental effect on their physical, psychological, and social health and functioning).Table 1Guidance for assessment and harm reduction interventions to mitigate risks associated with muscle-building supplement use among adolescents and young adultsArea of assessmentDetailsHarm reduction considerationsIs the client using muscle-building supplements?Use of muscle-building supplements is common among adolescents and young adults. There is a plethora of types of muscle-building supplements with various purported benefits, including increasing muscle mass, increasing strength, improving recovery time, enhancing athletic performance, and sharpening cognitive functioning. These various benefits increase the appeal of using muscle-building supplements.•Assess which muscle-building supplements are being used, including the number of muscle-building supplements, frequency, dose, and methods of use.•Assess the client's motivations and goals for muscle-building supplement use, focusing specifically on body and muscle dissatisfaction, performance, and strength.•Assess their level of knowledge on the muscle-building supplements they are using and where they receive information about muscle-building supplements.•Assess influences of use, including whether others in their social network also use muscle-building supplements.•Consider the involvement of parents (adolescents) or family members (young adults) to provide education on muscle-building supplements and support for the client.Is the current level of consumption of muscle-building dietary supplements superfluous considering the client's current food intake?The client may already be consuming sufficient protein, carbohydrates, fats, calories, and vitamins and minerals to support their growth and development (adolescents) or maintain their current physiological health and functioning (young adults). Alternatively, the client may be able to make minor changes to their diet to meet their nutritional needs. Therefore, their use of muscle-building supplements to support their diet may not be needed.•Assess for potential deficiencies (e.g., iron, B12, vitamin D) through laboratory blood tests.•Assess dietary intake, including consumption of protein, carbohydrates, fats, calories, and vitamins and minerals.•Provide education on current food intake meeting nutritional needs (if indicated).•Provide referral to a registered dietician for further nutrition assessment and support.•Assess the client's access (including financial means) to various foods relevant to their culture, needs, and preferences, including fresh fruits and vegetables, and unprocessed foods.Is the client engaging in any other behaviors intended to change their appearance, weight, shape, strength, and/or performance?Many clients who use muscle-building supplements also engage in behaviors intended to change their appearance, weight, shape, strength, and/or performance. These behaviors may include excessive exercise and weight training, elimination dieting/dieting, calorie and macronutrient counting, bulking and cutting cycles, cheat meals, and intermittent fasting, among others.•Provide education on potential harms of body change behaviors.•Assess body image and current body/muscle dissatisfaction.•Assess for an eating disorder, body dysmorphic disorder, and muscle dysmorphia.•Provide referral(s) to a mental health professional, registered dietician, and/or trainer/physiotherapist for further assessment and treatment.Is the current level of consumption of muscle-building dietary supplements having a negative effect on the client's current psychological, emotional, and/or social health and/or functioning?Some clients may experience mental health and substance use problems and engage in risky behaviors (e.g., sexually risky behaviors, criminal offending), which may impact their functioning.•Assess for engagement in risky behaviors and determine the role of muscle-building supplements in their engagement.•Assess for co-occurring mental health (e.g., eating disorders, body dysmorphic disorder, muscle dysmorphia) and substance use (e.g., polysubstance use) problems.•Assess body image and current body/muscle dissatisfaction.•Discuss the role of muscle-building supplement use on risky behaviors and mental health and substance use problems. Assess insight related to this connection.•Provide referral(s) to a mental health and/or substance use professional for further assessment and treatment.Is the current level of consumption of muscle-building dietary supplements having a negative effect on the client's physical health and/or growth and development?Some clients will experience various acute and chronic physical health problems related to their use of muscle-building supplements, particularly excessive use. This may include problems across systems of the body, such as gastrointestinal (e.g., diarrhea, nausea) and musculoskeletal (e.g., injury, muscle cramps) problems, as well as issues with kidney and liver functioning, among others. For adolescents, assessing whether muscle-building supplement use is negatively impacting their growth and development may be warranted.•Provide physical assessment of reported health effects across systems of the body (e.g., gastrointestinal, musculoskeletal, renal).•Provide treatment and guidance to mitigate physical health effects.•Provide ongoing monitoring of physical health functioning during use of muscle-building supplements to identify new onset problems.•Report adverse events and physical health problems to government reporting agencies.•Discuss the potential role of muscle-building supplements use on physical health problems and assess insight related to this connection.•Utilize motivational interviewing techniques to identify change talk and encourage change behaviors to address physical health effects due to muscle-building supplement use.Is the client considering using, currently using, or have they previously used anabolic-androgenic steroids (without a medical prescription)?Use of muscle-building supplements is predictive of future use of anabolic-androgenic steroids. Additionally, many social contexts (e.g., gyms, sports teams) that support the use of muscle-building supplements are also where anabolic-androgenic steroid use occurs (and may be recommended). Many people who use muscle-building supplements recognize the limits to these products while also know the effectiveness of anabolic-androgenic steroids at increasing muscle mass and strength, fostering consideration of use. There is a significant amount of informal information sources online and on social media, which may increase risky use of anabolic-androgenic steroids. While there are many harms associated with anabolic-androgenic steroid use, harm reduction approaches can mitigate these negative effects.Client is considering anabolic-androgenic steroid use or has reported past use:•Order blood tests to establish a baseline for lipids, liver function, hemoglobin, hematocrit, and total testosterone.•Provide information on potential biopsychosocial harms from use.•Assess the likelihood of using in the future.•Provide information on how to use safely (e.g., single-use needles, needle exchanges, cycling with postcycle therapy).Client is currently using anabolic-androgenic steroids:•Continually assess motivations for use and utilize motivational interviewing to listen for change talk and encourage change behaviors.•Provide ongoing medical monitoring with intermittent blood tests to monitor physiological functioning.•Continue to provide information on potential biopsychosocial harms from use.•Reiterate information on how to reduce risks from anabolic-androgenic steroid use (e.g., single-use needles, needle exchanges, cycling with postcycle therapy) and monitor for safe use.•Assess for symptoms of dependence (e.g., difficulty stopping, using more than intended or longer than intended).•Assess their social community who can reinforce harm reduction approaches or who adversely perpetuates use.•Provide referral(s) for mental health and/or substance use assessment and treatment. Open table in a new tab First, for the harm reduction approach to be effective, and given the high prevalence of muscle-building supplement use, health-care professionals may consider asking about use with all of their adolescent and young adult clients in clinical practice. Without this critical information, there is little foundation for engagement and harm reduction interventions. Once it has been identified that the client is using muscle-building supplements, health-care professionals should inquire about the patterns of use, including the number of muscle-building supplements used, and the frequency, dose, and method of use. Health-care professionals should assess current dietary intake. Understanding the current dietary intake of the client provides information as to whether they are consuming appropriate calories and macronutrients to grow and develop (for adolescents) and maintain health and well-being (for young adults), and thus, the use of muscle-building supplements may not be needed. Given the connection between muscle-building supplement use and body image issues [2LaBotz M. Griesemer B.A. Use of performance-enhancing substances.Pediatrics. 2016; 138e20161300Crossref PubMed Scopus (54) Google Scholar], assessing other behaviors the client is engaging in that are intended to alter their weight, shape, and performance may be considered. This information will guide further assessment related to a potential eating disorder, body dysmorphic disorder, or muscle dysmorphia diagnosis. As previously noted, the aim of the areas of assessment is to determine whether use is problematic and having an adverse effect on the client's physical, psychological, and social health and functioning. Therefore, health-care professionals should conduct a thorough biopsychosocial assessment of the client to determine the status of their health and functioning within the context of their use of muscle-building supplements. Adverse physical side effects from use, changes in growth and development (for adolescents), mental health and substance use problems, social engagement (e.g., connectedness, functioning), and risky behaviors should be noted. Finally, given the connection between muscle-building dietary supplement use and anabolic-androgenic steroid (AAS) use [9Nagata J.M. Ganson K.T. Gorrell S. et al.Association between legal performance-enhancing substances and use of anabolic-androgenic steroids in young adults.JAMA Pediatr. 2020; 174: 992-993Crossref PubMed Scopus (26) Google Scholar], health-care professionals should assess the client for potential and current or past use of AAS. Many individuals who use AAS are hesitant to disclose their use to health-care professionals [10Bonnecaze A.K. O’Connor T. Aloi J.A. Characteristics and attitudes of men using anabolic androgenic steroids (AAS): A Survey of 2385 men.Am J Men’s Health. 2020; 141557988320966536Crossref PubMed Scopus (53) Google Scholar]. Therefore, health-care professionals should be prepared to inquire about the use of AAS among adolescents and young adults, particularly those who are using muscle-building supplements, from a non-judgemental stance and with sensitivity to potential reluctance to disclose. In conclusion, this commentary underscores the importance of health-care professionals addressing the use of muscle-building supplements among adolescent and young adult clients. It highlights the widespread prevalence of such usage, particularly among adolescent boys and young men, emphasizing proactive assessment regardless of overt warning signs. While many clients may not experience adverse effects from use, recognizing the potential risks associated with using muscle-building supplements is warranted. A harm reduction approach is advocated, prioritizing the mitigation of risks when absolute abstinence is not considered a viable option by the client. Finally, we recommend a formal evidence-based review be conducted by an appropriate task force that can inform the development of evidence-based clinical practice guidelines on muscle-building supplement use among adolescents and young adults.

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