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Unpacking the Bulk: The Need to Contextualize Weight Gain Attempts Among Adolescent Boys

      See Related Article on p. 450
      As a developmental psychologist who researches gender and sexual orientation health disparities in disordered eating, I am often asked by health providers and researchers about how they should interact with male patients and research participants and what are the best questions and instruments to include. The preponderance of research on health risks associated with body image ideals across the lifespan has focused on thin-ideal internalization among girls and women. However, as evidence grows on gender differences in the phenomenology and risk factors for body image concerns, researchers and clinicians such as Nagata et al. [
      • Nagata J.M.
      • Bibbins-Domingo K.
      • Garber A.K.
      • et al.
      Boys, bulk, and body ideals: Sex differences in weight-gain attempts among adolescents in the United States.
      ] are appropriately framing research questions that are better aligned with the experiences of specific gender groups. This approach is consistent with gender-based analysis (GBA), an approach that recognizes that gender intersects with multiple forms of diversity (e.g., race and ethnicity, sexual orientation, weight, and culture) to shape lived experiences and health in myriad ways [
      • Springer K.W.
      • Mager Stellman J.
      • Jordan-Young R.M.
      Beyond a catalogue of differences: A theoretical frame and good practice guidelines for researching sex/gender in human health.
      ,
      • Krieger N.
      Genders, sexes, and health: What are the connections--and why does it matter?.
      ]. As a tool for promoting health equity, GBA can also guide critical, systematic inquiry, and identify what can (and cannot) be known about health and health disparities based on the availability of data and measures [
      • Haworth-Brockman M.
      • Isfeld H.
      Prairie Women's Health Centre of Excellence
      Guidelines for gender-based analysis of health data for decision making.
      ].
      The ideal body type for many boys and men in the U.S. is muscular; thus, a focus on weight gain attempts as an outcome in the Nagata et al.'s study, which predominantly focuses on adolescent boys, is appropriate [
      • Nagata J.M.
      • Bibbins-Domingo K.
      • Garber A.K.
      • et al.
      Boys, bulk, and body ideals: Sex differences in weight-gain attempts among adolescents in the United States.
      ,
      • Murray S.B.
      • Nagata J.M.
      • Griffiths S.
      • et al.
      The enigma of male eating disorders: A critical review and synthesis.
      ]. However, the use of a single item to assess weight change behavior (“Which of the following are you trying to do about your weight?”) is also a point of critique. The single measure does not provide sufficient information to draw conclusions about the motivations for weight gain (desire to gain weight in general vs. desire to gain muscle mass) or the actual behaviors that go into “weight gain attempts” (which could include weightlifting, dietary modifications, supplement and drug use, etc.). Because prior research has explored the overall weight gain attempts in boys and various forms of weight gain behaviors (e.g., consuming large quantities of food vs. steroid use) likely have different sequelae (e.g., steroid use and risk for cardiovascular disease), greater specificity in measurement matters in order for the field to progress [
      • Calzo J.P.
      • Corliss H.L.
      • Blood E.A.
      • et al.
      Development of muscularity and weight concerns in heterosexual and sexual minority males.
      ,
      • Kelly C.
      • Fitzgerald A.
      • Sentenac M.
      • et al.
      Weight concerns among adolescent boys.
      ]. Based on the measure available to Nagata et al. [
      • Nagata J.M.
      • Bibbins-Domingo K.
      • Garber A.K.
      • et al.
      Boys, bulk, and body ideals: Sex differences in weight-gain attempts among adolescents in the United States.
      ] in the Youth Risk Behavior Survey (YRBS), it is difficult to know whether boys reporting a weight gain attempt are doing so specifically to gain muscle, as the authors themselves note in the limitations. However, the authors could have leveraged other variables within the 2015 YRBS (e.g., sports involvement, weightlifting, nonprescription steroid use) to further clarify whether those attempting to gain weight were doing so alongside other muscularity-oriented behaviors. Health providers screening for weight gain attempts in patients should probe for specific weight gain motivations and weight change behaviors to better contextualize and understand weight gain attempts and their broader health implications. In addition, researchers can use validated instruments that assess drive for muscularity, muscle building behaviors, and other forms of associated eating pathology in greater depth [
      • McCreary D.R.
      • Saucier D.M.
      • Courtenay W.H.
      The drive for muscularity and masculinity: Testing the associations among gender-role traits, behaviors, attitudes, and conflict.
      ,
      • Forbush K.T.
      • Wildes J.E.
      • Hunt T.K.
      Gender norms, psychometric properties, and validity for the eating pathology symptoms inventory.
      ].
      Although Nagata et al. [
      • Nagata J.M.
      • Bibbins-Domingo K.
      • Garber A.K.
      • et al.
      Boys, bulk, and body ideals: Sex differences in weight-gain attempts among adolescents in the United States.
      ] found that nearly 30% of U.S. adolescent boys reported attempts to gain weight, they also found that black/African American boys reporting more weight gain attempts than white boys, and bisexual boys reporting fewer weight gain attempts than heterosexual boys. The results help direct targeted research and public health efforts by demonstrating that not all adolescent males are seeking to gain weight to the same degree. Considerably greater attention was paid to analyzing and attempting to contextualize how weight gain attempts vary across weight status groups. Nearly 40% of boys who were classified as “normal weight by BMI” reported attempts to gain weight (as did 13% and 11% of boys classified as overweight and obese, respectively). In addition, the authors noted several forms of weight misperception, with 24% of boys classified as normal weight perceiving themselves as underweight, and 54% of boys classified as overweight perceiving themselves as “about the right weight.” The authors used the weight status variable to further interpret the majority of weight gain attempts as “medically unnecessary” (as has been done in prior research [
      • Calzo J.P.
      • Corliss H.L.
      • Blood E.A.
      • et al.
      Development of muscularity and weight concerns in heterosexual and sexual minority males.
      ]) and noted the tendency for American boys to perceive themselves as “smaller than objective measures (of weight).”
      Although examining the distribution of weight gain attempts by weight status is consistent with the prioritization of obesity prevention in clinical practice and public health, an unintended negative consequence of this narrative is the promotion and perpetuation of weight bias (i.e., discrimination and stereotyping based on weight) [
      • Penney T.L.
      • Kirk S.F.L.
      The health at every size paradigm and obesity: Missing empirical evidence may help push the reframing obesity debate forward.
      ]. From a health equity standpoint, the lack of context and detail afforded in the single-item measures of weight gain attempts and weight perception, as well as the limitations around BMI assessment (e.g., inability to distinguish between fat and muscle; overestimation of height among boys in self-report), require researchers to be cautious in interpreting results and describing implications [
      • Pérez A.
      • Gabriel K.P.
      • Nehme E.K.
      • et al.
      Measuring the bias, precision, accuracy, and validity of self-reported height and weight in assessing overweight and obesity status among adolescents using a surveillance system.
      ]. The automatic interpretation of weight gain attempts (and by extension, overweight, and obesity) as negative or portraying weight gain attempts as being acceptable only under specific circumstances (e.g., if a boy is classified as underweight) has the potential to promote weight bias. Experiencing weight bias has been shown to be associated with increased risk for maladaptive eating, lower levels of physical activity, adverse mental health, and physiological stress [
      • Puhl R.
      • Suh Y.
      Health consequences of weight stigma: Implications for obesity prevention and treatment.
      ]. Of particular concern, recent research on secular trends in various forms of bias over the past 20 years in the U.S. has found that weight bias has not improved, and it may in fact be worsening [
      • Charlesworth T.E.S.
      • Banaji M.R.
      Patterns of implicit and explicit attitudes: I. Long-term change and stability from 2007 to 2016.
      ].
      Drawing a connection between self-reported weight gain attempts and obesity risk requires more research, as well as a critical review of the measurement instruments used to assess participants' lived experiences concerning weight. Focusing on the YRBS measures, for example, it is possible that the “weight perception” responses can be interpreted by the respondents and researchers in multiple ways, which calls into question whether research terminology sometimes problematizes experiences. For example, “misperceiving” oneself as being “about the right weight” (when one is classified as overweight or obese) could indicate “inaccurate perception of weight” or “body acceptance.”
      Although acknowledging the strengths of Nagata et al.'s study [
      • Nagata J.M.
      • Bibbins-Domingo K.
      • Garber A.K.
      • et al.
      Boys, bulk, and body ideals: Sex differences in weight-gain attempts among adolescents in the United States.
      ], interpreting it (and by extension the YRBS measures) through a GBA lens provides an opportunity to reflect on how measurement and data interpretations can be refined to further advance research, clinical practice, and health equity. Understanding the context, phenomenology of weight gain attempts, and potential consequences require more rigorous measurement of the constructs and exploration via in-depth quantitative and qualitative inquiry. In particular, mixed method approaches can help unpack how weight gain attempt experiences vary across diverse youth, including those of different racial and ethnic backgrounds, sexual orientations, and body sizes. The results from Nagata et al.'s study [
      • Nagata J.M.
      • Bibbins-Domingo K.
      • Garber A.K.
      • et al.
      Boys, bulk, and body ideals: Sex differences in weight-gain attempts among adolescents in the United States.
      ] should encourage clinicians to diversify the types of body image concerns they screen for beyond thinness concerns and traditionally assessed forms of disordered eating (e.g., purging). In addition, the findings are a call to health providers and researchers to tackle the challenge of understanding what is actually meant by “weight gain attempts” and how these diverse behaviors (and efforts to study and intervene on them) potentially intersect with weight bias.

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