Montuori et al.

BMC Sports Science, Medicine and Rehabilitation (2021) 13:147

https://doi.org/10.1186/s13102-021-00378-x

RESEARCH Open Access

Bodybuilding, dietary supplements

and hormones use: behaviour and determinant
analysis in young bodybuilders
Paolo Montuori†, Ilaria Loperto*†, Carmine Paolo, Davide Castrianni, Raffaele Nubi, Elvira De Rosa,
Raffaele Palladino and Maria Triassi

Abstract
Background: Among athletes, bodybuilders are more predisposed to the use of dietary supplements (DS) and hor-
mones (H) to increase in adaptations to physical training and performance. The purpose of the study was to identify
social, psychological, and organisational factors that are associated with the use of food supplements and hormones
in young bodybuilders of the metropolitan area of Naples.
Methods: 107 athletes, practicing bodybuilding, were consecutively recruited in 30 gyms, randomly selected in the
metropolitan area of Naples. Athletes were administered an anonymous questionnaire. The questionnaire consists
of 5 sections (socio-demographic, frequency and reasons for bodybuilding, knowledge, attitudes and behaviours).
Descriptive statistics were performed using T-test and Chi-square statistics. A score was created for knowledge, atti-
tudes, behaviours. Multivariable logistic regression models were employed to assess association between each score
and the use of DS and H. Statistical analyses were carried out using STATA 15.
Results: 81.31% of the subjects reported to use DS while 35.51% H. Females are less likely to practise bodybuilding
frequently than males (OR 0.18 (95% CI 0.05–0.69), p = 0.01). Subjects who have attended high school or university
have a lower probability of taking DS (OR 0.17 (95% CI 0.04–0.65), p = 0.01). H users also use supplements more
frequently (OR 61.21 (95% CI 3.99–939.31), p < 0.001). Those who scored higher on knowledge scores are more likely
to take DS (OR 1.53 (95% CI 1.11–2.12), p < 0.001). Attitudes are correlated with the use of DS; those who scored higher
were less likely to use DS (OR 0.77 (95% CI 0.30–0.98), p = 0.03). People who use DS are 30 times more likely to use
H at the same time (OR 30.25 (95% CI 2.51–365.24), p < 0.001). Subjects who have a higher score for knowledge and
attitudes are less likely to use H (OR 0.68 (95% CI 0.54–0.87), p < 0.001, OR 0.75 (95% CI 0.62–0.90), p < 0.001).
Conclusions: Prevalence of H and DS’ use, although lower than reported in the literature, is a worrying public health
problem. Better knowledge can lead to an informed use. Gym instructors should be trained to provide accurate and
scientifically sound information. Health professionals should combine their expertise to provide more comprehensive
guidance to the exercisers.
Keywords: Dietary supplements, Bodybuilding, Athletes, Diet, Gyms

Background
Bodybuilding is a sport in which the athlete is judged on
*Correspondence: [email protected]
muscular appearance. Proper preparation for a body-
†
Paolo Montuori and Ilaria Loperto these two authors contributed equally building contest generally involves years of strength
Department of Public Health, University of Naples “Federico II”, Via S. training followed by a phase in which the athlete focuses
Pansini, 5, 80131 Naples, Italy

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Montuori et al. BMC Sports Science, Medicine and Rehabilitation (2021) 13:147 Page 2 of 11

on drastically reducing body fat to improve muscle [19]. At the present time, DS that have as ingredients the
appearance [1, 2].. Bodybuilding’s training programs are substances allowed by the legislation can be placed on
characterized by a separation of training into four dis- the market. If this condition does not occur, it is neces-
tinct periods: off-season, pre-contest, peak week, and sary to request an ad hoc authorization, based solely on
post-contest. Each period has a specific spectrum of the demonstration of safety of use, as governed by EU
intensity load, total training volume, and exercise type Regulation 2015/2283 on novel foods [20].
(multi- or single-joint) [3]. The bodybuilders’ goal is to At the same time, it should be emphasized that for the
develop muscular hypertrophy and to obtain low fat placing on the market of a substance such as DS and/or
levels based on a balanced body shape [2]. Since energy ingredient of a DS, no proof of efficacy is required.
restriction prior to competition has a negative effect About 50% of the general population and up to 100% of
on anabolic hormones, it can result in a reduction in athletes in some sports have reported taking dietary sup-
serum concentrations of hormones such as testosterone, plement [11, 21]. In a recent study on spanish bodybuild-
insulin-like growth factor-1 (IGF-1) and insulin [4]. So ers, 100% of subjects reported consuming DS [4].
among athletes, bodybuilders are more predisposed to Although many mechanisms of action in improving
the use of dietary supplements (DS) and hormones (H) performance have been proposed for DS, there are few
as compared to other sportsmen [4]. The aim of the con- studies that demonstrate real efficacy. For example, very
sumption of these substances is the increase in adapta- high intakes of arginine may increase exercise-induced
tions to physical training and physical performance. In Human growth hormone (HGH) release, but this does
addition to friends and family, advertisements through not correspond to an objective increase in sports perfor-
media were the main source of information on supple- mance; carnitine should improve skeletal muscle func-
ment use; very few obtained information/advice from tion but there is no evidence that carnitine improves
their physicians [5]. The most common DS currently physical performance in healthy subjects [22]. Also, cre-
used are vitamins, minerals, protein powders/liquid, atine is a popular supplement for elevating energy during
and amino acids [6]. The use of DS is also a risk factor short, high-intensity exercises [23].
for illicit substance use and may cause so-called inadvert- Several studies have indicated adverse effects of dietary
ent doping due to the contamination of their ingredients supplements consumption, including cardiovascular,
with, for example, oxilofrine, β-methylphenethylamine hematological, metabolic, and neurological problems [14,
(BMPEA) and N,β-dimethylphenethylamine (NBDM- 22]. Despite the availability of wide information about
PEA), the stimulant 4-methylhexan-2-amine (methylhex- supplement utilization from different parts of the world,
aneamine, 1,3-dimethylamylamine, DMAA), the anabolic limited data is available from Italy.
steroids boldione (1,4-androstadiene-3,17-dione) and Sometimes bodybuilders use banned substances such
5-androstene-3β,17α-diol (17α-AED), the beta-2 agonist as diuretics, stimulants, or anabolic substances, included
higenamine and the beta-blocker bisoprolol [7, 8]. in the list of prohibited methods and substances pub-
However, the exact health benefits DS are still not well lished by the World Anti-Doping Agency (WADA) [24].
established [9, 10]. Moreover, various possible hazards Previous reports that have analyzed the prevalence of
were described when used inappropriately or without use of anabolic steroids suggest polypharmacy and high
medical consultation [11]. doses of injectable agents [25]. Nandrolone decanoate
In Italy, a medical prescription is not required for natu- and Sustanon, a combination product of 4 testosterone
ral health products so DS are easily available for self-care esters, were the most commonly reportedly used agents
and self-selection. [25]. The use of prohibited substances is estimated to be
The main EU rules concerning food supplements is 1–5% in the general population, reaching up to 50% in
Directive 2002/46/EC [12]. Since an excessive intake can some sports [26, 27].
cause undesirable effects [13–17], the directive provides The use of doping agents has become a public health
for the establishment of maximum amounts of vitamins problem as it also affects young and non-professional
and minerals to be added to food supplements. In Italy, athletes [28]. However, there are objective health risks
in addition to the transposition of these directives (Leg- including cardiovascular illnesses, diabetes, cancer, men-
islative Decree no. 169 of 21 May 2004 and subsequent tal health problems, virilization in women and the sup-
amendments [18]), in order to ensure an adequate level pression of the androgens produced naturally in men
of quality and safety of dietary supplements, the Ministry [26].
of Health published in November 2018 the “Recommen- Given that bodybuilders are an high risk category of DS
dations on the good manufacturing practices of food sup- and H consumption and that studies carried out in Italy
plements”, aimed at providing technical indications that in this population are lacking, our purpose was to iden-
meet the specific needs of the manufacturing industries tify the social, psychological, and organisational factors

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Montuori et al. BMC Sports Science, Medicine and Rehabilitation (2021) 13:147 Page 3 of 11

that are associated with the use of food supplements and practice less than 3 workouts a week and to the "fre-
hormones in young bodybuilders of the metropolitan quently" group all the others. The questionnaire (see
area of Naples. Additional file 1), which was mirrored on existing ques-
tionnaires and adapted [31–33], consists of 58 questions
Methods focusing on bodybuilding, supplements and hormones.
Study design and setting The questionnaire consists of 5 sections. The first Sect. (6
A cross-sectional analysis of data from 107 athletes, prac- questions) asks socio-demographic information while
ticing bodybuilding, recruited from 30 gyms, randomly the second one (5 questions) asks information about fre-
selected in the metropolitan area of Naples, has been quency and reasons for bodybuilding. The third Sect. (11
performed. Inclusion criteria for the gyms were to be questions), concerning knowledge, and the fourth (16
located in Naples provinces and have at least one body- questions), concerning attitudes, were assessed on a
building course held by a bodybuilding instructor with three-point Likert scale (agree, uncertain and disagree)
a technical card recognized by CONI (Italian National while the fifth Sect. (20 questions), concerning behav-
Olympic Committee). For each gym, all subjects enrolled iours, is based on a 4-degree scale (yes, often, sometimes,
in bodybuilding courses, aged over 18 years and able to never). For each section, using a Likert scale, a score
understand every item of the questionnaire were eligible, ranging from 1 to 3 or from 1 to 4 was created. For the
with no regard to sex, skin color, class, or social group. "knowledge" and "behaviours" sections, the highest score
In Italy, the FIPE (Italian weightlifting federation) Federal was attributed to the correct answer or to the healthier
Council decided to assimilate the contents of resolution behaviour, while for the "attitudes" the higher score was
no.1568 of 14 February 2017 of the National Council of attributed to the attitude that could lead to healthier
CONI about the authentic interpretation of the definition behavior. The questionnaire underwent an internal vali-
of "Activities with overloads and resistances aimed at fit- dation, was pre-tested and modifications were been made
ness and physical well-being" specified below: “Physical to improve validity of responses. Specifically, the ques-
Culture (bodybuilding) includes all those activities that tionnaire was administered to 20 public health trainees
use any form of load (or resistance) to achieve the goal based at the Department of Public Health to discuss clar-
in terms of sports (competitive and non-competitive), ity of the questions.
conditioning (fitness) also aimed at competitive perfor- The following information from the survey was
mance, well-being (wellness) and recovery of physical included in the following study: age, sex, weight, height,
efficiency” [29]. For this reason, both professional and education attainment, employment status, reasons for
non-professional athletes, both competing bodybuilders bodybuilding, frequency of bodybuilding, duration of
and amateur bodybuilders have been enrolled. No sample practice, use of supplements, use of hormones, smoke
size calculation was performed because data on the total habits, knowledge, attitude and behaviour’s scores. As
number of athletes practicing bodybuilders in the area regards education attainment, the Italian school system
was not possible to retrieve. However, our study popula- is structured in three cycles of education: primary edu-
tion size is comparable to study populations from previ- cation, which includes primary school, lasting five years;
ous studies on the topic conducted in similar settings [4, secondary education, which includes a three-year lower
30]. Informed consent was obtained from each partici- secondary school, and a five-year high school.
pant, the project was approved by the Ethics Committee
of Medical School of the University “Federico II” and all Statistical analysis
methods were carried out in accordance with relevant Descriptive statistics of the study variables were per-
guidelines and regulations. formed using T-test, Chi-square and Fisher’s exact test
statistics, as appropriate. For the multivariable analyses, a
Study population and study variables score was created for each section (knowledge, attitudes,
Athletes were administered an anonymous paper ques- behaviours). Multivariable logistic regression models
tionnaire. Each participant was instructed on how to were employed to assess the association between each
fill in the questionnaire, providing a list of the most score and the use of supplements and hormones.
frequently used DS and H with the commercial name Four binary outcome variables were selected: body-
and defining some variables. In particular, it was speci- building frequency (seldomly, frequently), bodybuilding
fied that for the “Reason for Bodybuilding” variable, reasons (other reasons, improve body look), use of sup-
the answer "Other reasons" included "Improve health", plements, use of hormones. Models were adjusted for
"Lose weight", "Increase strength", "Participate in com- age, gender, BMI, education attainment, employment,
petitions"; while for the "Bodybuilding Frequency" vari- smoking and the remaining outcome variables.
able, the "seldomly" response included the subjects who Statistical analyses were carried out using STATA 15.

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Montuori et al. BMC Sports Science, Medicine and Rehabilitation (2021) 13:147 Page 4 of 11

Results For the "bodybuilding reason" outcome variable, no

Of the 107 participants, 68% are male and 32% are variable considered was associated in any of the con-
female. 81.31% of the subjects reported to use sup- structed models (Table 3).
plements while 35.51% hormones. Table 1 shows the As shown in Table 4, compared to those with a mid-
characteristics of the patients divided by use of supple- dle school diploma, subjects who have attended high
ments, hormones, and by gender. school or university have a lower probability of tak-
81.31% of the athletes declared to use supplements. ing supplements (Fully adjusted model—OR 0.17 (95%
65.52% of the subjects who use supplements are male CI 0.04–0.65), p = 0.01). Hormone users also use sup-
while only the 34.48% are female. The majority of sub- plements more frequently (Fully adjusted model—OR
jects who use supplements (55.17%) completed the high 61.21 (95% CI 3.99–939.31), p < 0.001). In addition, those
school while the percentages regarding employment who scored higher on knowledge scores are more likely
status are very similar: 32.18% are unemployed, 36.78% to take supplements (Fully adjusted model—OR 1.53
are employed, 31.03% are self-employed. 63.22% of the (95% CI 1.11–2.12), p < 0.001). Only in the fully adjusted
subjects who use supplements practice bodybuilding model, attitudes are correlated with the use of supple-
for aesthetic reasons, 75.86% declare to practice it fre- ments; those who scored higher were less likely to use
quently while 51.72% declare that they have been train- supplements (Fully adjusted model—OR 0.77 (95% CI
ing for less than 5 years. For these variables, there is no 0.30–0.98), p = 0.03).
difference between the group that uses supplements Finally, Table 5 shows the associations between hor-
and the one that does not use them (p > 0.05). The aver- mone intake and the other variables taken into consid-
age age of those who use supplements is lower than eration. People who use supplements are 30 times more
those who do not use them (31.13 vs 34.45, p = 0.048). likely to use hormones at the same time (Fully adjusted
The 42.53% of subjects who use supplements say they model—OR 30.25 (95% CI 2.51–365.24), p < 0.001). Sub-
also use hormones (p = 0.002). jects who have a higher score for knowledge and attitudes
35.51% of the interviewed subjects declared to use are less likely to use hormones (Fully adjusted model—
hormones. Of these, 71.05% are male and only 28.05% OR 0.68 (95% CI 0.54–0.87), p < 0.001, OR 0.75 (95% CI
are female. The average age of hormone users is 32.42 0.62–0.90), p < 0.001).
and there is no difference with that of non-users (31.37, As far as the source of information is concerned, it is
p = ns). As for supplements, even in the case of hor- interesting to note that for DS 83.18% of subjects declare
mones, those who use them have more frequently a to inquire at the gym, 71.03% on the internet and 64.49%
high school diploma (50.00%), while as regards employ- from their doctor/nutritionist. For H, on the other hand,
ment status, the distribution is very similar in the three 42.45% of subjects declare to obtain information in the
groups (unemployed: 31.58%; employed: 36.84%; self- gym, 25.23% on the internet, 38.22% from their doctor/
employed: 31.58%, p = ns). Most people who use hor- nutritionist (data not shown).
mones practice bodybuilding to improve body look
(57.89%), 76.32% train frequently and 47.37% declare to Discussion
practice bodybuilding for more than 5 years. The hypotheses tested in the present research concern
For the use of hormones, there is no difference in the the possibility that the basic knowledge of bodybuilders
two groups for any variable (p > 0.05). influences the use of DS and H. If this is true in profes-
It is interesting to note that those who use hormones sional bodybuilders, it is interesting to know whether in
also tend to use supplements at the same time (97.37%, a mixed population of professional and non-professional
p = 0.002). bodybuilders, this phenomenon occurs. If this were the
On average, females have a higher level of education case, in fact, the phenomenon could be conditioned with
than males (p = 0.045), while males tend to train more health education interventions.
frequently (p = 0.029). For the other variables consid- In the present study, 81.31% of the subjects reported to
ered, there is no statistically significant difference. use supplements while 35.51% hormones. Subjects who
As shown in Table 2, female subjects are less likely have attended high school or university have a lower
to practise bodybuilding frequently than male subjects probability of taking supplements, while hormone users
(Fully adjusted model—OR 0.18 (95% CI 0.05–0.69), also use supplements more frequently. In addition, those
p = 0.01). For the "bodybuilding frequency" outcome who scored higher on knowledge scores are more likely
variable, no other statistically significant association to take supplements; instead, those who scored higher on
was found. attitude scores were less likely to use supplements.
Finally, people who use supplements are 30 times more
likely to use hormones at the same time and subjects who

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 Table 1 Patient characteristics by supplements use, hormone use and sex
Supplements use Hormones use Sex
NO YES P NO YES P M F p

N (%) 20 (18.69) 87 (81.31) 69 (64.49) 38 (35.51) 73 (68.22) 34 (31.78)

Sex, n (%)
Male 16 (80.00) 57 (65.52) 0.210§ 46 (66.67) 27 (71.05) 0.641§
Female 4 (20.00) 30 (34.48) 23 (33.33) 11 (28.95)
AGE, mean (SD) 34.45 (10.22) 31.13 (7.40) 0.048* 31.37 (8.65) 32.42 (6.90) 0.738* 32.09 (7.82) 31 (8.62) 0.26*
Education attainment, n (%)
Up to secondary school 1 (5.00) 24 (27.59) 0.096§ 14 (20.29) 11 (28.95) 0.449§ 19 (26.03) 6 (17.65) 0.045§
High-school 14 (70.00) 48 (55.17) 43 (62.32) 19 (50.00) 45 (61.64) 17 (50.00)
Bachelor degree and above 5 (25.00) 15 (17.24) 12 (17.39) 8 (21.05) 9 (12.33) 11 (32.35)
Montuori et al. BMC Sports Science, Medicine and Rehabilitation

Employment status, n (%)

Unemployed/others 4 (20.00) 28 (32.18) 0.464§ 20 (28.99) 12 (31.58) 0.926§ 18 (24.66) 14 (41.18) 0.220§
Employed 10 (50.00) 32 (36.78) 28 (40.58) 14 (36.84) 31 (42.47) 11 (32.35)
Self-employed 6 (30.00) 27 (31.03) 21 (30.43) 12 (31.58) 24 (32.88) 9 (26.47)
(2021) 13:147

Reason for bodybuilding, n (%)

Other reason 10 (50.00) 32 (36.78) 0.275§ 26 (37.68) 16 (42.11) 0.654§ 26 (53.62) 16 (47.06) 0.259§
Improve body look 10 (50.00) 55 (63.22) 43 (62.32) 22 (57.89) 47 (64.38) 18 (52.94)
Frequency of bodybuilding, n (%)
Seldomly 3 (15.00) 21 (24.14) 0.377§ 15 (21.74) 9 (23.68) 0.817§ 12 (16.44) 12 (35.29) 0.029§
Frequently 17 (85.00) 66 (75.86) 54 (78.26) 29 (76.32) 61 (83.56) 22 (64.71)
Duration of Bodybuilding, n (%)
Less than a year 2 (10.00) 10 (11.49) 0.793§ 8 (11.59) 4 (10.53) 0.350§ 5 (6.85) 7 (20.59) 0.106§
Less than five years 9 (45.00) 45 (51.72) 38 (55.07) 16 (42.11) 38 (52.05) 16 (47.06)
More than five years 9 (45.00) 32 (36.78) 23 (33.33) 18 (47.37) 30 (41.10) 11 (32.35)
Hormones, n (%) 1 (5.00) 37 (42.53) 0.002§ 27 (36.99) 11 (32.35) 0.641§
Supplements, n (%) 50 (72.46) 37 (97.37) 0.002§ 57 (78.08) 30 (88.24) 0.210§
Statistically significant p values (<0.05) are in bold

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*
T Test
§
Chi square Test/ Fisher’s exact Test
Page 5 of 11
 Table 2 Association between knowledge, attitudes, and behaviour and bodybuilding frequency (X, Y)
Partially adjusted model 1 Partially adjusted model 2 Partially adjusted model 3 Partially adjusted model 4 Fully adjusted model
OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p

Age 1.08 1.01 1.17 0.04 1.07 0.99 1.15 0.06 1.07 0.99 1.15 0.07 1.07 1.00 1.16 0.06 1.07 0.99 1.15 0.09
Montuori et al. BMC Sports Science, Medicine and Rehabilitation

Sex (F) 0.22 0.07 0.95 0.04 0.23 0.07 0.80 0.02 0.17 0.05 0.65 0.01 0.22 0.06 0.75 0.02 0.18 0.05 0.68 0.01
BMI 0.88 0.71 1.08 0.22 0.85 0.70 1.05 0.13 0.82 0.66 1.01 0.07 0.85 0.69 1.04 0.12 0.82 0.66 1.02 0.08
Education attainment 1.13 0.52 2.46 0.32 1.11 0.51 2.43 0.79 1.28 0.57 2.84 0.60 1.14 0.52 2.47 0.74 1.24 0.55 2.78 0.61
Employment status 1.15 0.61 2.17 0.42 1.10 0.58 2.11 0.77 1.18 0.62 2.27 0.61 1.14 0.60 2.17 0.68 1.15 0.59 2.24 0.68
(2021) 13:147

Smoke 0.81 0.43 1.49 0.49 0.80 0.43 1.51 0.50 0.81 0.43 1.51 0.50 0.80 0.43 1.49 0.49 0.80 0.42 1.52 0.50
Supplements’ use 0.82 0.18 3.61 0.79 0.76 0.17 3.42 0.72 0.65 0.14 3.01 0.58 0.83 0.19 3.66 0.80 0.57 0.12 2.71 0.48
Hormones’ use 0.92 0.31 2.70 0.90 1.06 0.32 3.44 0.92 0.59 0.18 1.94 0.38 0.91 0.30 2.74 0.87 0.70 0.19 2.52 0.58
Knowledge 1.06 0.87 1.29 0.55 1.08 0.88 1.32 0.48
Attitudes 0.86 0.73 1.01 0.06 0.85 0.72 1.01 0.05
Behaviours 1.00 0.92 1.08 0.95 1.02 0.93 1.11 0.70
Statistically significant p values (<0.05) are in bold
Estimates were derived from multivariable logistic regression models adjusted for age, gender, BMI, education attainment, employment, smoking and the remaining outcome variables

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Page 6 of 11
Montuori et al. BMC Sports Science, Medicine and Rehabilitation (2021) 13:147 Page 7 of 11

Table 3 Association between knowledge, attitudes, and behaviour and bodybuilding reasons (X, Y)
Partially adjusted Partially adjusted Partially adjusted Partially adjusted Fully adjusted model
model 1 model 2 model 3 model 4
OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p

Age 0.97 0.93 1.03 0.38 0.97 0.92 1.03 0.38 0.97 0.92 1.03 0.44 0.97 0.93 1.03 0.40 0.97 0.92 1.03 0.46
Sex (F) 0.48 0.17 1.36 0.17 0.48 0.17 1.36 0.17 0.50 0.18 1.41 0.19 0.47 0.17 1.33 0.15 0.48 0.16 1.39 0.18
BMI 0.94 0.80 1.11 0.49 0.94 0.80 1.11 0.49 0.95 0.81 1.12 0.54 0.93 0.80 1.10 0.45 0.94 0.80 1.11 0.50
Education attainment 0.93 0.49 1.79 0.66 0.93 0.48 1.79 0.83 0.91 0.47 1.75 0.78 0.91 0.47 1.76 0.78 0.90 0.47 1.75 0.76
Employment status 1.32 0.77 2.26 0.31 1.32 0.76 2.28 0.32 1.30 0.76 2.23 0.33 1.34 0.78 2.30 0.29 1.32 0.76 2.31 0.32
Smoke 1.39 0.82 2.35 0.22 1.39 0.82 2.35 0.22 1.40 0.82 2.37 0.22 1.40 0.83 2.38 0.21 1.41 0.83 2.39 0.21
Supplements’ use 1.98 0.64 6.11 0.24 1.97 0.61 6.32 0.25 2.11 0.67 6.66 0.20 1.89 0.60 5.91 0.27 2.06 0.62 6.90 0.24
Hormones’ use 0.75 0.30 1.85 0.53 0.75 0.28 2.06 0.58 0.88 0.32 2.40 0.81 0.79 0.31 2.01 0.62 0.87 0.30 2.57 0.81
Knowledge 1.00 0.85 1.17 0.98 0.99 0.84 1.17 0.90
Attitudes 1.05 0.92 1.19 0.45 1.04 0.91 1.19 0.54
Behaviours 1.02 0.95 1.09 0.56 1.01 0.94 1.09 0.69
Statistically significant p values (<0.05) are in bold
Estimates were derived from multivariable logistic regression models adjusted for age, gender, BMI, education attainment, employment, smoking and the remaining
outcome variables

have a higher score for knowledge and attitudes are less men, although not statistically significant. Even though
likely to use hormones. the role of gender as a determinant of use is not clearly
Gym trainees constitute an important target for dietary established, our result is consistent with previous studies
supplement markets and professional bodybuilders fre- [5, 35, 38, 39].
quently consume banned substances and hormones in The associated use of supplements and hormones is
large dosages [4, 33, 34]. The chosen population, there- consistent with what is already present in literature, con-
fore, being made up of professional and non-professional firming the trend towards polypharmacotherapy [25].
bodybuilders, should place itself between the two popu- To our knowledge, the scoring method used for ana-
lations indicated above. Nevertheless, the prevalence of lysing questionnaires has never been used to investigate
dietary supplements use we found (81.31%) is higher than the relationships between use of supplements and hor-
described in most recent studies in gym users (36.8– mones and risk factors. Moreover, in literature there are
43.8%) [5, 34–36], but it is closer to what is reported by several articles that associate the frequency or reasons
Morrison et al. (2004) in USA gym trainees (84.7%) [37]. of exercise with the use of substances, characterizing
It is interesting to note that in international athletes and them as factors of considerable influence in the athlete’s
professional bodybuilders the prevalence of the use of decision-making process [36, 40]. Therefore, we decided
supplements is 82.2% and 100%, respectively [4, 32]. The to choose 4 outcome variables that characterized the
prevalence of steroid hormones’ use among bodybuilders entire decision-making process of the athletes to evaluate
reported in the literature is between 83.3 and 72.9% [4, which associations were with modifiable and non-modi-
25]. In the present study, only 35.51% of subjects report fiable factors. In particular, from the multinomial logistic
using hormones. This discrepancy would be attributable analysis, it emerges that female subjects tend to prac-
to the belonging of the subjects to the non-professional tice bodybuilding less frequently. This attitude is likely
category. to reflect specific cultural characteristics. Gwizdek et al.
However, the discrepancies in the reported prevalence reported that gender did not have any significant influ-
rates of supplements and hormones use may be related to ence on exercise dependence [41].
sociodemographic and cultural characteristics, the type The data of considerable interest that emerged from
of gyms included or methodologic aspects, namely what multivariable models is the role of knowledge in the
was considered to be a supplement or hormone and the choice of the substances used. It seems, in fact, that sub-
method of data acquisition. However, research indicates jects with higher education attainment, and with a higher
that direct questioning of sensitive information, such as score in the knowledge section, are able to discriminate
the use of performance enhancing drugs, is character- between supplements and hormones, know the differ-
ized by underreporting [28]. We found that supplement ences and seem able to choose the substance that harms
and hormones consumption was more prevalent among them less to health. Alhomoud et al. suggest that there

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 Table 4 Association between knowledge, attitudes, and behaviour and use of supplements (X, Y)
Partially adjusted model 1 Partially adjusted model 2 Partially adjusted model 3 Partially adjusted model 4 Fully adjusted model
OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p

Age 0.94 0.88 1.01 0.09 0.92 0.85 0.99 0.03 0.94 0.87 1.00 0.06 0.95 0.89 1.02 0.19 0.92 0.84 0.99 0.05
Montuori et al. BMC Sports Science, Medicine and Rehabilitation

Sex (F) 3.22 0.55 18.93 0.19 4.80 0.79 29.05 0.09 2.65 0.42 16.78 0.30 2.60 0.43 15.62 0.30 2.60 0.39 17.29 0.32
BMI 0.91 0.72 1.15 0.43 0.97 0.76 1.23 0.79 0.92 0.72 1.17 0.49 0.86 0.68 1.10 0.24 0.94 0.73 1.23 0.69
Education Attainment 0.28 0.10 0.84 0.02 0.19 0.05 0.67 0.01 0.30 0.10 0.92 0.04 0.23 0.07 0.75 0.01 0.17 0.04 0.65 0.01
Employment Status 1.07 0.49 2.35 0.86 0.89 0.39 2.04 0.79 1.18 0.52 2.68 0.69 1.07 0.47 2.43 0.87 1.08 0.43 2.67 0.83
(2021) 13:147

Smoke 1.23 0.56 2.71 0.61 1.51 0.61 3.75 0.37 1.29 0.58 2.88 0.53 1.25 0.56 2.78 0.59 1.86 0.65 4.99 0.22
Frequencies 0.83 0.17 3.95 0.82 0.84 0.16 4.40 0.84 0.60 0.11 3.16 0.55 0.95 0.20 4.44 0.94 0.61 0.11 3.38 0.57
Hormones’ use 23.02 2.63 201.57 0.00 87.93 6.32 1223.7 0.00 13.52 1.42 128.33 0.02 33.12 3.29 333.60 0.00 61.21 3.99 939.31 0.00
Knowledge 1.47 1.12 1.93 0.00 1.53 1.11 2.12 0.00
Attitudes 0.85 0.69 1.05 0.14 0.77 0.60 0.98 0.03
Behaviours 1.09 0.98 1.22 0.09 1.11 0.98 1.25 0.07
Statistically significant p values (<0.05) are in bold
Estimates were derived from multivariable logistic regression models adjusted for age, gender, BMI, education attainment, employment, smoking and the remaining outcome variables

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Page 8 of 11
 Table 5 Association between knowledge, attitudes, and behaviour and use of hormones (X, Y)
Partially adjusted model 1 Partially adjusted model 2 Partially adjusted model 3 Partially adjusted model 4 Fully adjusted model
OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p
Montuori et al. BMC Sports Science, Medicine and Rehabilitation

Age 1.03 0.97 1.10 0.26 1.05 0.98 1.31 0.13 1.03 0.96 1.09 0.41 1.03 0.97 1.10 0.29 1.04 0.97 1.11 0.26
Sex (F) 1.03 0.34 3.14 0.95 0.67 0.19 2.40 0.54 0.73 0.21 2.57 0.62 1.12 0.36 3.46 0.85 0.47 0.12 1.93 0.30
BMI 1.18 0.99 1.40 0.06 1.16 0.95 1.42 0.15 1.11 0.90 1.36 0.32 1.19 1.00 1.42 0.05 1.08 0.86 1.36 0.49
Education attainment 1.11 0.56 1.20 0.76 1.38 0.64 2.95 0.41 1.36 0.63 2.94 0.42 1.25 0.61 2.56 0.54 1.56 0.68 3.59 0.30
Employment status 0.88 0.50 1.56 0.67 1.24 0.63 2.42 0.53 1.02 0.54 1.92 0.95 0.86 0.48 1.53 0.61 1.27 0.62 2.61 0.51
(2021) 13:147

Smoke 0.79 0.45 1.39 0.42 0.99 0.52 1.88 0.98 0.77 0.40 1.45 0.41 0.78 0.43 1.38 0.39 0.94 0.47 1.88 0.86
Frequencies 0.86 0.29 2.48 0.78 1.10 0.31 3.89 0.89 0.57 0.17 1.95 0.37 0.90 0.29 2.73 0.85 0.72 0.17 2.96 0.65
Supplements’ use 21.07 2.47 179.66 0.00 47.04 4.78 463.20 0.00 11.21 1.24 101.27 0.03 24.29 2.80 210.70 0.00 30.25 2.51 365.24 0.00
Knowledge 0.65 0.52 0.81 0.00 0.68 0.54 0.87 0.00
Attitudes 0.71 0.60 0.84 0.00 0.75 0.62 0.90 0.00
Behaviours 0.93 0.86 1.00 0.05 1.00 0.91 1.09 0.99
Statistically significant p values (<0.05) are in bold
Estimates were derived from multivariable logistic regression models adjusted for age, gender, BMI, education attainment, employment, smoking and the remaining outcome variables

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 9 of 11
Montuori et al. BMC Sports Science, Medicine and Rehabilitation (2021) 13:147 Page 10 of 11

are significant differences in the knowledge of health sci- Health professionals, including physicians, dietitians,
ences and non-health sciences students pertaining to the and pharmacists, should combine their expertise with
health benefits and safety of these supplements, what that of coaches and athletic trainers in order to provide
they are and the source of information and help which more comprehensive guidance to the exercisers. Specific
should be sought when using them [33]. To the best of and multidisciplinary health education programs could
our knowledge, there are no specific studies conducted be created involving prevention departments and local
on the population of amateur bodybuilders. health authorities.
The present study is one of the few that investigates the
use of supplements and hormones among amateur body-
Abbreviations
builders by integrating the data with that of ad hoc scores DS: Dietary supplements; H: Hormones; N: Number; SD: Standard deviation; F:
on knowledge, attitudes and behaviours. This approach Female; M: Male; BMI: Body mass index.
allows us to understand which factors can be used to
change behaviours and gain health. The present study, Supplementary Information
however, has some limitations. First of all, a complete list The online version contains supplementary material available at https://​doi.​
of substances considered supplements or hormones has org/​10.​1186/​s13102-​021-​00378-x.
not been provided and the result could be strongly influ-
enced by the subject’s personal culture. Hence, the ability Additional file 1. Anonymous questionnaire on knowledge, attitudes and
behaviors regarding the use of food supplements in body builders. The
to act without conditioning may have overestimated the questionnaire mirrored on existing questionnaires and adapted, consists
use of supplements and underestimated the use of hor- of questions focusing on bodybuilding, supplements and hormones.
mones. The results obtained, however, compared with lit-
erature, lead us to believe that they are not too far from Acknowledgements
reality. Secondly, the main source of information was not Not applicable.
requested in a specific question. However, 6 questions in
Authors’ contributions
the behavior section concern the main sources of infor- PM, IL, RP, MT designed the study; IL, RN, DC, CP, EDR collected data. IL, RP, and
mation (gym, internet, doctor/nutritionist) and can offer MT analysed data. PM, IL, RP drafted a preliminary version of this manuscript.
an overview, albeit not exhaustive, of the issue. In retro- All authors read and approved the final manuscript.

spect, we realized that it could be useful to know where Funding

the correct information was coming from. In addition, a No funding has been received for this work.
question on whether use was based on medical advice or
Availability of data and materials
not was not included in the tool and it is difficult to gen- The questionnaire used during the current study is included in this published
eralize the results because the study was carried out in article and its supplementary information files.
province of Naples only. Finally, we suspect the variable
scoring system likely did not capture all differences to be Declarations
identified, although, to better identify the role of the sin-
Ethics approval and consent to participate
gle scores and their association with the other outcome Informed consent was obtained from each participant, the project was
variables, it was decided to use partially adjusted models approved by the Ethics Committee of Medical School of the University
and a fully adjusted model. “Federico II” and all methods were carried out in accordance with relevant
guidelines and regulations.

Consent for publication

Conclusions Not applicable.
The high prevalence of dietary supplement use among
Naples bodybuilders reflects a public health concern as, Competing interests
The authors declare that they have no competing interests.
although there are supplements that appear to be effec-
tive, indiscriminate use can be correlated with serious Received: 3 February 2021 Accepted: 5 November 2021
health risks. The prevalence of hormone use, although
lower than reported in the literature, is similarly a wor-
rying public health problem. The two problems appear
related as evidenced by frequent combined use. Better References
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