The contribution of anxiety and food restriction on physical activity levels in acute anorexia nervosa

The Relationship between Patient Self-Reported, Pre-Morbid Physical Activity and Clinical Outcomes of Inpatient Treatment in Youth with Anorexia Nervosa: A Pilot Study

Links between premorbid physical activity (PA) and disease onset/course in patients with anorexia nervosa (AN) remain unclear. The aim was to assess self-reported PA as a predictor of change in percent median BMI (%mBMI) and length of hospital stay (LOS). Five PA domains were assessed via semi-structured interview in adolescents with AN at hospitalization: premorbid PA in school grades 1-6 (PA1-6); PA before AN onset (PA-pre) and after AN onset (PA-post); new, pathological motivation for PA (PA-new); and high intensity PA (PA-high). Eating disorder psychopathology was measured via the Eating Disorder Examination Questionnaire (EDE-Q), and current PA (steps/day) with accelerometry. PA1-6 was also assessed in healthy controls (HCs). Using stepwise backward regression models, predictors of %mBMI change and LOS were examined. Compared with 22 HCs (age = 14.7 ± 1.3 years, %mBMI = 102.4 ± 12.1), 25 patients with AN (age = 15.1 ± 1.7 years, %mBMI = 74.8 ± 6.0) reported significantly higher PA1-6 (median, AN = 115 [interquartile range IQR = 75;200] min vs. HC = 68 [IQR = 29;105] min; p = 0.017). PA-post was 244 ± 323% higher than PA-pre. PA1-6 was directly associated with PA-pre (p = 0.001) but not with PA-post (p = 0.179) or change in PA-pre to PA-post (p = 0.735). Lower %mBMI gain was predicted by lower baseline %mBMI (p = 0.001) and more PA-high (p = 0.004; r2 = 0.604). Longer LOS was predicted by higher PA-pre (p = 0.003, r2 = 0.368). Self-reported PA may identify a subgroup of youth with AN at risk of less weight gain and prolonged LOS during inpatient treatment for AN.

Subtypes of exercise are differentially associated with baseline eating disorder pathology and treatment outcome among individuals with bulimia nervosa

OBJECTIVE

Individuals with bulimia nervosa (BN) engage in both maladaptive (i.e., compulsive and/or compensatory) and adaptive exercise (e.g., for enjoyment). No research has examined whether those who engage in adaptive, compulsive, and/or compensatory exercise exhibit differences in BN pathology or treatment outcome compared to those not engaging in exercise, limiting intervention efficacy.

METHOD

We examined associations of baseline exercise engagement with baseline and posttreatment BN pathology among 106 treatment-seeking adults (Mage  = 37.4, SDage  = 12.95, 87.74% female, 68.87% White) enrolled across four clinical trials of outpatient enhanced cognitive behavioral therapy for BN (range: 12-16 sessions). Analysis of covariances examined associations between baseline exercise type and baseline/posttreatment global eating pathology, dietary restraint, loss-of-control (LOC) eating, and purging frequency.

RESULTS

Those engaging in only adaptive exercise reported lower global eating pathology compared to those engaging in compulsive-only exercise (Est = -1.493, p = .014, Mdiff  = -.97) while those engaging in baseline compulsive exercise reported less LOC eating compared to those not engaging in exercise (Est = -22.42, p = .012, Mdiff  = -12.50). Baseline engagement in compulsive-only exercise was associated with lower posttreatment global eating pathology compared to baseline engagement in no exercise (Est = -.856, p = .023, Mdiff  = -.64) and both compulsive and compensatory exercise (Est = .895, p = .026, Mdiff  = -1.08).

DISCUSSION

Those engaging in compulsive, compensatory, adaptive, and no exercise exhibit different patterns and severity of BN pathology. Future research is needed to position treatments to intervene on maladaptive, while still promoting adaptive, exercise.

PUBLIC SIGNIFICANCE STATEMENT

No research to date has examined whether those who engage in adaptive, compulsive, and/or compensatory exercise exhibit differences in BN pathology or treatment outcome compared to those not engaging in exercise, limiting targeted intervention efforts. We found that those engaging in compulsive, compensatory, and adaptive exercise exhibit different patterns of BN pathology and that adaptive exercise engagement was related to lower cognitive eating disorder symptoms at baseline.

[Sports and Physical Exercise Therapy in the Treatment of Mental Health Issues in Children and Adolescents]

Sports and Physical Exercise Therapy in the Treatment of Mental Health Issues in Children and Adolescents Abstract: Mental disorders are among the most common chronic diseases in childhood and adolescence in Germany and worldwide. The health benefits of a physically active lifestyle during adolescence are well documented. Furthermore, a growing body of evidence suggests a positive impact of physical activity on mental health and emotional well-being. Longitudinal studies also show an association between physical activity and reduced risk of developing a mental disorder. Therefore, therapeutic exercise plays an important role in child and adolescent psychiatry. High-quality randomized-controlled trials are needed to substantiate the described effects.

Socialization, and its modulation by sex, on the development and recovery of activity-based anorexia in rats

The activity-based anorexia (ABA) animal model has been used in the laboratory to study the role of excessive physical activity in the manifestation of anorexia nervosa (AN) in humans. Factors of social context are crucial in human health and the emergence of many psychological disorders, which have also been observed in studies using different mammal species that, like human beings, set their lives in groups. In the present study, the animals' social condition was manipulated to observe the effect of socialization in ABA development, and the possible different influence of the variable sex on the phenomenon. Eighty Wistar Han rats were distributed into four male and four female groups with 10 subjects each, manipulating social conditions (group housing or social isolation) and physical activity (access or not to a running wheel). Throughout the procedure, all groups had food restricted to 1 h/day during the light period. Furthermore, ABA experimental groups with access to the running wheel had two periods of access to the wheel of 2 h each, one before and the other after the food period. In this experiment, socialized rats were less vulnerable to weight loss during the procedure, although there were no differences between the ABA groups. Moreover, social enrichment was shown to be an enabling variable of the animals' recovery after their withdrawal from the procedure, with this effect being more pronounced in females. The results in this study suggest the need to further in the analysis of the role of socialization in the development of ABA.

Protocol for a 2-year longitudinal study of eating disturbances, mental health problems and overuse injuries in rock climbers (CLIMB)

INTRODUCTION

Rock climbing is a rapidly growing sport in which performance may be affected by participant's weight and leanness, and there may be pressure on athletes with respect to their eating behaviour and body weight. However, there is sparse research performed on climbers, constituting a knowledge gap which the present study aims to fill. The primary outcomes of the study are to examine disordered eating and overuse injuries in rock climbers. Secondary variables are body image, indicators of relative energy deficiency, mental health problems, compulsive training, perfectionism, sleep quality and bone density.

METHOD AND ANALYSIS

This prospective longitudinal study aims to recruit Swedish competitive rock climbers (>13 years) via the Swedish Climbing Federation. A non-athlete control group will be recruited via social media (n=equal of the climbing group). Data will be collected using streamlined validated web-based questionnaires with three follow-ups over 2 years. Inclusion criteria for rock climbers will be a minimum advanced level according to International Rock-Climbing Research Association. The non-athlete control group is matched for age and gender. Exclusion criteria are having competed at an elite level in any sport as well as training more often than twice per week. Statistical analyses will include multinominal logistic regression, multivariate analysis of variance (MANOVA) and structural equation modelling (SEM). We will assess effect measure modification when relevant and conduct sensitivity analyses to assess the impact of lost to follow-up.

ETHICS AND DISSEMINATION

The Rock-Climbers' Longitudinal attitudes towards Injuries, Mental health and Body image study, CLIMB, was approved by the Swedish ethics authority (2021-05557-01). Results will be disseminated through peer-reviewed research papers, reports, research conferences, student theses and stakeholder communications.

TRIAL REGISTRATION NUMBER

NCT05587270.

Long-lasting BDNF signaling alterations in the amygdala of adolescent female rats exposed to the activity-based anorexia model

Introduction: Anorexia nervosa (AN) is a severe psychiatric disorder characterized by a pathological fear of gaining weight, excessive physical exercise, and emotional instability. Since the amygdala is a key region for emotion processing and BDNF has been shown to play a critical role in this process, we hypothesized that alteration in the amygdalar BDNF system might underline vulnerability traits typical of AN patients. Methods: To this end, adolescent female rats have been exposed to the Activity-Based Anorexia (ABA) protocol, characterized by the combination of caloric restriction and intense physical exercise. Results: The induction of the anorexic phenotype caused hyperactivity and body weight loss in ABA animals. These changes were paralleled by amygdalar hyperactivation, as measured by the up-regulation of cfos mRNA levels. In the acute phase of the pathology, we observed reduced Bdnf exon IX, exon IV, and exon VI gene expression, while mBDNF protein levels were enhanced, an increase that was, instead, uncoupled from its downstream signaling as the phosphorylation of TrkB, Akt, and S6 in ABA rats were reduced. Despite the body weight recovery observed 7 days later, the BDNF-mediated signaling was still downregulated at this time point. Discussion: Our findings indicate that the BDNF system is downregulated in the amygdala of adolescent female rats under these experimental conditions, which mimic the anorexic phenotype in humans, pointing to such dysregulation as a potential contributor to the altered emotional processing observed in AN patients. In addition, since the modulation of BDNF levels is observed in other psychiatric conditions, the persistent AN-induced changes of the BDNF system in the amygdala might contribute to explaining the onset of comorbid psychiatric disorders that persist in patients even beyond recovery from AN.

The Fitter I Am, the Larger I Feel-The Vicious Circle of Physical Exercise in Anorexia Nervosa

Introduction: Body image distortion is a core symptom of anorexia nervosa (AN), embodying dissatisfaction and overvaluation of body appearance and weight. Body image distortion is an important factor in the maintenance of weight loss behaviours such as compulsive physical exercise. Conversely, physical exercise seems to have an aggravating effect on body image in patients with AN, but the evidence is still poor. The aim of this study was to examine the relationship between body image distortion and physical exercise in AN in order to understand whether physical exercise may play a specific role in body image distortion beyond psychopathological severity. Methods: Forty patients with AN and 21 healthy controls were tested for body image distortion and different proxies of physical exercise. Univariate correlations tested the relationship between body image distortion and physical exercise in AN and control groups. Then, to experimentally assess the effect of exercise on body image distortion, participants were invited to rate their body image before and after a standardised effort test. Results: In the AN group, a correlation was found between physical activity and body image distortion (p < 0.01), which was still significant after controlling for psychopathological severity. No correlation was found in healthy controls. After a standardised effort, patients with AN had higher increases in body image distortion than healthy controls (almost 4 kg/m2 vs. 0.8 kg/m2) (p < 0.01). Discussion: Physical exercise may contribute to the distortion of body image in anorexia nervosa and explain the paradoxical augmentation of unhealthy exercise despite ongoing weight loss.

The role of hypoleptinemia in the psychological and behavioral adaptation to starvation: implications for anorexia nervosa

This narrative review aims to pinpoint mental and behavioral effects of starvation, which may be triggered by hypoleptinemia and as such may be amenable to treatment with leptin receptor agonists. The reduced leptin secretion results from the continuous loss of fat mass, thus initiating a graded triggering of diverse starvation related adaptive functions. In light of leptin receptors located in several peripheral tissues and many brain regions adaptations may extend beyond those of the hypothalamus-pituitary-end organ-axes. We focus on gastrointestinal tract and reward system as relevant examples of peripheral and central effects of leptin. Despite its association with extreme obesity, congenital leptin deficiency with its many parallels to a state of starvation allows the elucidation of mental symptoms amenable to treatment with exogenous leptin in both ob/ob mice and humans with this autosomal recessive disorder. For starvation induced behavioral changes with an intact leptin signaling we particularly focus on rodent models for which proof of concept has been provided for the causative role of hypoleptinemia. For humans, we highlight the major cognitive, emotional and behavioral findings of the Minnesota Starvation Experiment to contrast them with results obtained upon a lesser degree of caloric restriction. Evidence for hypoleptinemia induced mental changes also stems from findings obtained in lipodystrophies. In light of the recently reported beneficial cognitive, emotional and behavioral effects of metreleptin-administration in anorexia nervosa we discuss potential implications for the treatment of this eating disorder. We postulate that leptin has profound psychopharmacological effects in the state of starvation.

Morphing analysis of facial emotion recognition in anorexia nervosa: association with physical activity

PURPOSE

Anorexia Nervosa (AN) has been linked to emotion processing inefficiencies, social cognition difficulties and emotion dysregulation, but data on Facial Emotion Recognition (FER) are heterogenous and inconclusive. This study aims to explore FER in patients with AN using a dynamic and ecological evaluation, and its relationship with Physical Activity (PA), an important aspect of AN that could impact emotional processing.

METHODS

Sixty-six participants (33 patients with AN and 33 healthy controls) performed a morphed facial emotional recognition task and 49 of them wore an accelerometer during seven days to assess PA. Axis-I disorders and depressive symptoms have been assessed.

RESULTS

No difference was found regarding time to recognize facial emotions. However, patients with AN correctly recognize emotions more frequently than controls. This was specific to disgust, although there was also a tendency for sadness. Among patients, higher depressive scores are associated with a faster and more accurate recognition of disgust, while a higher level of PA is associated to decreased accuracy in recognizing sadness.

CONCLUSION

Patients with AN are capable of recognizing facial emotions as accurately as controls, but could have a higher sensitivity in recognizing negative emotions, especially disgust and sadness. PA has opposite effects and, thus, could be considered as an emotional regulation strategy against negative affect.

LEVEL OF EVIDENCE II

Controlled trial without randomization.

Clinical features of children and adolescents with anorexia nervosa and problematic physical activity

PURPOSE

Problematic physical activity (PPA) is a symptom commonly present in patients suffering from anorexia nervosa (AN). This study aims to refine the clinical description of children with early-onset AN and adolescents with standard-onset AN and associated PPA, in order to better understand their associated features, and to offer them adapted care and physical activity programs.

METHODS

107 participants treated at the Salvator University Hospital Centre of Marseille for AN were retrospectively evaluated by the Exercise Dependence Scale Revised concerning PPA. Other self-report questionnaires were used to evaluate eating disorder, anxiety and depressive symptoms, quality of life, emotions, sleep, and attention deficit disorder with or without hyperactivity.

RESULTS

In the entire sample, the presence of PPA was associated with significantly higher levels of eating disorder (EDI-2: p = 0.001) and body image concerns (p = 0.002), anxiety (STAI-Y-trait: p = 0.013) and depression (p = 0.006), as well as significantly lower psychological well-being (p < 0.001) and quality of life (p < 0.001) and impaired sleep (PSQI: p = 0.008). The early-onset group showed a lower prevalence of PPA than the standard-onset group (p < 0.05) but their clinical symptomatology, when this symptom was present, was significantly more severe (EDI-2: p < 0.01; BSQ: p < 0.05; CDI: p < 0.05; STAI-Y-trait: p < 0.05).

CONCLUSION

PPA appears to be associated with more severe features in patients with early-onset AN, which seems to differ from standard-onset. It seems necessary to refine our knowledge on the involvement of PPA in the severity of AN, especially in patients with early-onset AN who remain little studied so far.

LEVEL OF EVIDENCE

Level V, descriptive study (evaluation data retrospectively studied).

High levels of physical activity in female adolescents with anorexia nervosa: medical and psychopathological correlates

PURPOSE

While overexercise is commonly described in patients who experience anorexia nervosa (AN), it represents a condition still underestimated, especially in the paediatric population.

METHOD

The present study aims at assessing the possible associations between levels of physical activity (PA) and clinical features, endocrinological data and psychopathological traits in a sample of 244 female adolescents hospitalised for AN subdivided into two groups according to PA levels (high PA vs. no/low PA). The two groups were compared through multivariate analyses, while multiple regression analysis was conducted to determine whether physical activity predict specific outcomes.

RESULTS

No significant differences were found between the two groups in terms of last Body Mass Index (BMI) before illness, BMI at admission and disease duration, while a difference emerged in delta BMI(rapidity of weight loss), significantly higher in high-PA group (p = 0.021). Significant differences were observed in Free triiodothyronine- (p < 0.001), Free thyroxine (p = 0.046), Follicle-stimulating hormone (p = 0.019), Luteinising hormone (p = 0.002) levels, with values remarkably lower in high-PA group. Concerning psychopathological scales, the high-PA group showed worst Children's Global Assessment Scale (CGAS) scores (p = 0.035). Regression analyses revealed that higher PA predicts higher delta BMI (p = 0.021), presence of amenorrhea (p = 0.003), lower heart rate (p = 0.012), lower thyroid (Free triiodothyronine p < 0.001, Free thyroxine p = 0.029) and gynaecological hormones' levels (Follicle-stimulating hormone p = 0.023, Luteinising hormone p = 0.003, 17-Beta estradiol p = 0.041). Concerning psychiatric measures, HPA predicts worst scores at CGAS (p = 0.019), and at scales for evaluation of alexithymia (p = 0.028) and depression (p = 0.004).

CONCLUSIONS

Results suggest that high levels of physical activity in acute AN associate with worst clinical conditions at admission, especially in terms of endocrinological and medical features.

LEVEL OF EVIDENCE

Level III.

Rethinking the Approach to Preclinical Models of Anorexia Nervosa

PURPOSE OF REVIEW

The goal of this review is to describe how emerging technological developments in pre-clinical animal research can be harnessed to accelerate research in anorexia nervosa (AN).

RECENT FINDINGS

The activity-based anorexia (ABA) paradigm, the best characterized animal model of AN, combines restricted feeding, excessive exercise, and weight loss. A growing body of evidence supports the idea that pathophysiological weight loss in this model is due to cognitive inflexibility, a clinical feature of AN. Targeted manipulations that recapitulate brain changes reported in AN - hyperdopaminergia or hyperactivity of cortical inputs to the nucleus accumbens - exacerbate weight loss in the ABA paradigm, providing the first evidence of causality. The power of preclinical research lies in the ability to assess the consequences of targeted manipulations of neuronal circuits that have been implicated in clinical research. Additional paradigms are needed to capture other features of AN that are not seen in ABA.

Registered report: A pilot investigation of acute exercise response among girls and young women with and without eating disorders

OBJECTIVE

Driven exercise (DEx) is a serious and common feature of eating disorders (EDs), but current understanding of factors that give rise to and maintain DEx is limited. DEx may be reinforced through its effects on the threat reduction and reward systems. The current protocol is designed to evaluate acute psychobiological response to exercise among female participants (age 16-22) with and without EDs.

METHOD

Twenty medically-stable participants with restrictive-spectrum EDs and 20 healthy control (HC) participants will complete study screening and three task visits which will include two 30-minute bouts of aerobic exercise.

RESULTS

We aim to validate and demonstrate feasibility of two tasks capturing exercise response in this sample. Further, we will estimate the degree to which a bout of exercise impacts state body image, affect, and circulating concentrations of biological markers among participants, and we will examine whether the impact of exercise on psychological outcomes may differ across ED and HC groups.

DISCUSSION

Completion of this project will contribute to the conceptualization of DEx and how individuals' acute biological and affective responses to exercise contribute to risk for and maintenance of DEx.

Exploring the Mechanisms of Recovery in Anorexia Nervosa through a Translational Approach: From Original Ecological Measurements in Human to Brain Tissue Analyses in Mice

Anorexia nervosa (AN) is a severe eating disorder where caloric restriction, excessive physical activity and metabolic alterations lead to life-threatening situations. Despite weight restoration after treatment, a significant part of patients experience relapses. In this translational study, we combined clinical and preclinical approaches. We describe preliminary data about the effect of weight gain on the symptomatology of patients suffering from acute AN (n = 225) and partially recovered (n = 41). We measured more precisely physical activity with continuous cardiac monitoring in a sub-group (n = 68). Using a mouse model, we investigated whether a long-term food restriction followed by nutritional recovery associated or not with physical activity may differentially impact peripheral and central homeostatic regulation. We assessed the plasma concentration of acyl ghrelin, desacyl ghrelin and leptin and the mRNA expression of hypothalamic neuropeptides and their receptors. Our data show an effect of undernutrition history on the level of physical activity in AN. The preclinical model supports an important role of physical activity in the recovery process and points out the leptin system as one factor that can drive a reliable restoration of metabolic variables through the hypothalamic regulation of neuropeptides involved in feeding behavior.

Psychosocial etiology of maladaptive exercise and its role in eating disorders: A systematic review

OBJECTIVE

Although maladaptive exercise (ME) is widely recognized as a clinical feature in transdiagnostic eating disorders, less is known about psychosocial factors that give rise to and perpetuate this behavior. This systematic review aimed to examine the empirical status of this association.

METHOD

We reviewed 46 full text articles examining longitudinal associations between psychosocial variables and ME.

RESULTS

Eighteen studies met full inclusion criteria. Based on our qualitative synthesis, evidence suggests reasonably consistent associations between early concern with weight and shape, and negative affect on later development of ME.

DISCUSSION

Inconsistent and insufficient assessment of ME across a majority of studies underscores caution in interpretation of results, but guides important discussion for future clinical and research efforts.

Development and evaluation of an adapted physical activity program in anorexia nervosa inpatients: A pilot study

BACKGROUND AND CONTEXT

Problematic use of physical activity is frequent in subjects with anorexia nervosa (AN). Although it increases resistance to therapeutic treatment, paradoxically, physical activity in AN can also improve mental and physical health. Based on the literature review we hypothesized that adding an adapted physical activity (APA) program to treatment programs could be more beneficial than a total suppression of physical activities. We designed this open study to evaluate the outcome of AN inpatients after an APA program implementation as well as the perceived effect of APA.

METHOD

Forty-one women with AN (17.2 (±2.5) years old, BMI of 16.86 (±2.0)) were included. An eight-session (1 h30/session/week) standardized APA program was delivered and evaluated by structured questionnaires assessing exercise dependence, perceived physical activity, eating disorder (ED) symptoms, body mass index (BMI), along with an interview before and after the APA program.

RESULTS

Twenty-nine women complete the PA program and evaluation. BMI and perceived PA score significantly increased, ED and exercise dependence scores significantly decreased (p < .01). Participants appreciated the program.

DISCUSSION/CONCLUSION

The inpatient program which included APA program helped AN inpatients in decreasing their ED symptoms and their dependence to PA, without any deleterious effect on BMI. Furthermore, APA was appreciated by participants.

Does physical activity associated with chronic food restriction alleviate anxiety like behaviour, in female mice?

Anorexia nervosa (AN) is an eating disorder characterized by excessive weight loss, persistent food restriction and inappropriate physical activity relative to declining energy balance. The comorbidity with depression and/or anxiety disorders might contribute to the "chronicization" of the disease. We aimed here to question first the link between physical activity and anxiety from a clinical investigation of AN patients (n = 206). Then, using a rodent model mimicking numerous physiological and metabolic alterations commonly seen in AN patients, we examined whether 1) chronic food restriction increased anxiety-like behaviour and 2) physical activity plays a role in regulating anxiety levels. To this end, we exposed young female mice to a chronic food restriction (FR, n = 8) paradigm combined or not with access to a running wheel (FRW, n = 8) for two weeks. The mice were compared to a group of mice fed ad libitum without (AL, n = 6) or with running wheel access (ALW, n = 8). We explored anxiety-like behaviour of all mice in the following tests: hyponeophagia, marble burying, elevated plus maze, open field, and the light and dark box. On the last day, we used a restraint test of 30 min duration and measured their stress reactivity by assaying plasma corticosterone. In the open field and the elevated plus-maze, we found that FRW mice behaved similarly to AL and ALW mice whereas FR mice did not express anxiety-like behaviour. The FRW mice displayed the lowest latency to reach the food in the hyponeophagia test. Regarding stress reactivity, FRW mice exhibited corticosterone reactivity after acute stress that was similar to the control mice, while FR mice did not fully return to basal corticosterone at one hour after the restraint stress. Taken together, these data demonstrate a differential reactivity to acute stress in FR conditions and a beneficial effect of running wheel activity in ALW and FRW conditions. Moreover, we report the absence of a typical anxiety-like behaviour associated with the food restriction (FR and FRW groups). We conclude that this model (FR and FRW mice) did not express typical anxiety-like behaviour, but that physical activity linked to food restriction improved coping strategies in an anxiogenic context.

Dopaminergic activity and exercise behavior in anorexia nervosa

Driven exercise (i.e., the tendency to exercise in excess to influence weight/shape or regulate emotion) is difficult to manage in the context of anorexia nervosa, and is associated with poorer treatment outcomes, and psychological and medical severity. Driven exercise is observed in a considerable number of those diagnosed with anorexia nervosa; however, to date, this hallmark symptom remains poorly understood. Dopamine signaling is implicated in motivating and maintaining appetitive behavior among patients with eating disorders; but, much less is known about the role of dopamine signaling specific to the symptom of driven exercise. An improved understanding of this biobehavioral mechanism may inform the etiology of driven exercise in anorexia nervosa, with the potential to impact future research and treatment efforts. This review describes the role that dopamine serves in maintaining symptoms in the context of anorexia nervosa, and synthesizes current relevant evidence on exercise in AN and related dopaminergic activity. Throughout, theoretical implications are discussed, along with critical directions for future research.

Costs of exploratory behavior: the energy trade-off hypothesis and the allocation model tested under caloric restriction

In order to maintain the energy balance, animals often exhibit several physiological adjustments when subjected to a decrease in resource availability. Specifically, some rodents show increases in behavioral activity in response to food restriction; a response regarded as a paradox because it would imply an investment in locomotor activity, despite the lack of trophic resources. Here, we aim to explore the possible existence of trade-offs between metabolic variables and behavioral responses when rodents are faced to stochastic deprivation of food and caloric restriction. Adult BALB/c mice were acclimatized for four weeks to four food treatments: two caloric regimens (ad libitum and 60% restriction) and two periodicities (continuous and stochastic). In these mice, we analyzed: exploratory behavior and home-cage behavior, basal metabolic rate, citrate synthase and cytochrome oxidase c enzyme activity (in liver and skeletal muscle), body temperature and non-shivering thermogenesis. Our results support the model of allocation, which indicates commitments between metabolic rates and exploratory behavior, in a caloric restricted environment. Specifically, we identify the role of thermogenesis as a pivotal budget item, modulating the reallocation of energy between behavior and basal metabolic rate. We conclude that brown adipose tissue and liver play a key role in the development of paradoxical responses when facing decreased dietary availability.

Joining forces: the need to combine science and ethics to address problems of validity and translation in neuropsychiatry research using animal models

BACKGROUND

Current policies regulating the use of animals for scientific purposes are based on balancing between potential gain of knowledge and suffering of animals used in experimentation. The balancing process is complicated, on the one hand by plurality of views on our duties towards animals, and on the other hand by more recent discussions on uncertainty in the probability of reaching the final aim of the research and problems of translational failure.

METHODS

The study combines ethical analysis based on a literature review with neuropsychiatry-related preclinical research as a case study.

RESULTS

Based on the analysis and the case study we show that neuropsychiatry-related preclinical research is an especially interesting case from an ethical perspective. The 3R principles (Replacement, Reduction and Refinement) are used to minimize the negative consequences for the animals used in research. However, neuropsychiatric research is characterized by specific challenges in assessing the probability of success of reaching the final aim, due to our limited mechanistic knowledge of human neuropsychiatric illness. Consequently, the translational value of the currently used animal models may be difficult to prove, which undermines the validity of these models and complicated the ethical assessment.

CONCLUSIONS

We conclude that a combined approach that deals with both science and the ethical dimensions is necessary to address the problems of validity and translation in neuropsychiatry-related preclinical research. We suggest this approach to comprise first, improved experimental methods, e.g. by using systematic reviews, second, a more patients-based approach that leads to models that reflect interindividual variation better, and third, more interdisciplinary cooperation.

Physical Activity in Eating Disorders: A Systematic Review

Abnormally high levels of physical activity have been documented throughout the literature in patients with eating disorders (ED), especially those diagnosed with anorexia nervosa (AN). Yet no clear definition, conceptualization, or treatment of the problematic use of physical activity (PPA) in ED patients exists. The aim of this review is to propose a new classification of PPA, report the prevalence, triggers, predictors, maintainers and other related factors of PPA in ED patients, in addition to proposing a comprehensive model of the development of PPA in AN. A total of 47 articles, retrieved from Medline and Web of Science, met the inclusion criteria and were included in the analysis. As a result, the new approach of PPA was divided into two groups (group 1 and group 2) according to the dimension (quantitative vs qualitative approach) of physical activity that was evaluated. The prevalence of PPA in ED was reported in 20 out of 47 studies, the comparison of PPA between ED versus controls in 21 articles, and the links between PPA and psychological factors in ED in 26 articles, including depression (16/26), anxiety (13/26), obsessive–compulsiveness (9/26), self-esteem (4/26), addictiveness (1/26), regulation and verbal expression of emotions (1/26) and anhedonia (1/26). The links between PPA and ED symptomatology, PPA and weight, body mass index (BMI) and body composition in ED, PPA and age, onset, illness duration and lifetime activity status in ED, PPA and ED treatment outcome were reported in 18, 15, 7, 5 articles, respectively. All of the factors have been systematically clustered into group 1 and group 2. Results focused more on AN rather than BN due to the limited studies on the latter. Additionally, a model for the development of PPA in AN patients was proposed, encompassing five periods evolving into three clinical stages. Thus, two very opposite components of PPA in AN were suggested: voluntarily PPA increased in AN was viewed as a conscious strategy to maximize weight loss, while involuntarily PPA increased proportionally with weight-loss, indicating that exercise might be under the control of a subconscious biological drive and involuntary cognition.

The Freiburg sport therapy program for eating disorders: a randomized controlled trial

BACKGROUND

Unhealthy attitudes towards sport and problematic exercise behavior in eating disorders (ED) are common and associated with poorer treatment outcome and higher relapse rates. There is a need to develop and empirically test interventions that could complement standard treatment. The study aimed to assess the efficacy of the Freiburg sport therapy program for eating disorders (FSTP).

METHODS

Outpatients with ED were randomized either to a 3 month sport therapy program (sport therapy group: STG) or a waiting list control group (CG). Patients were assessed when starting the program and at the end of the intervention. The intervention group (STG) was followed up after 6 month. Main outcome criterion was a reduction in unhealthy exercise (Commitment to Exercise Scale, CES). Secondary outcomes encompassed eating pathology (Eating Disorder Examination, EDE), different dimensions of unhealthy exercise (Compulsive Exercise Test, CET subscales) and exercise quantity (accelerometer).

RESULTS

Recruitment was challenging. Fifteen patients were randomized to the STG and 11 were randomized to the CG condition. There was no statistically significant difference between groups according to the main outcome criterion. However, the STG showed a significantly stronger reduction in avoidance and rule driven behavior (CET subscale) when compared to the CG. Improvements (STG) were maintained at follow up.

CONCLUSIONS

There was no statistically significant difference in the reduction of unhealthy attitudes towards sport and problematic exercise behavior between the intervention and the group, as measured with the Commitment to Exercise Scale. Further findings may point to the effectiveness of the program, but have to be interpreted with caution and verified in further studies. A major limitation is the small sample size.

TRIAL REGISTRATION

Study register: ISRCTN 14776348 (registered 26 January, 2015.

Psychometric properties of instruments assessing exercise in patients with eating disorders: a systematic review

BACKGROUND

Research has identified factors specific to exercise in eating disorder patients such as affect regulation and compulsivity. Existing measures of exercise behaviour which were not originally designed for eating disorder patients may not adequately assess these factors. The aim of this systematic review is to identify and assess the psychometric properties of all self-report measures of exercise designed to be used with eating disorder patients.

METHOD

A systematic review was conducted following the PRISMA guidelines. MedLine, Scopus and PsycINFO were systematically searched. A total of 12 studies examining two measures, the Exercise and Eating Disorders and the Compulsive Exercise Test, met inclusion criteria.

RESULTS

Validation studies showed promising results for both tests and established internal consistency, concurrent and convergent validity, and construct validity. The factor structure of the Compulsive Exercise Test was not confirmed in the majority of the studies included in this review, while there are only two studies conducting factor analysis on the Exercise and Eating Disorders.

CONCLUSION

The two measures identified by this systematic review represent the current research on measures of compulsive exercise for eating disorder patients. Further research is needed to confirm a factor structure and validate both the Compulsive Exercise Test and the Exercise and Eating Disorders in more diverse clinical samples.

Changes of BMI, steroid metabolome and psychopathology in patients with anorexia nervosa during hospitalization

Anorexia nervosa (AN) is associated with various alterations including the dysfunction of the HPA axis and consequently the hypercortisolemia and deficit in sex hormones but the comprehensive evaluation of changes in circulating steroids during the hospitalization of AN patients is lacking. We investigated the effect of realimentation of women with AN during hospitalization on 45 circulating steroids, the relationships between BMI, its change during hospitalization and physical activity, on one side and initial levels and their changes for two adipokines, circulating steroids, anorexia-specific (hunger, appetite and satiety), and anorexia non-specific symptoms (anxiety, depression fatigue, sleep, and body pain) on the other side. We included 33 women with anorexia who were hospitalized for 38(35, 44) days (median with quartiles). The increase of BMI from the initial value 15.2 (13.2, 16.6) kg/m² was 1.69 (1.37, 2.66) kg/m². The patients with more severe anorexia showed higher activity in 7β-, and 16α-hydroxylation of androgen precursors, which declined during hospitalization. Otherwise, the 7α-hydroxylation activity is higher in AN patients with less severe malnutrition and the ratio of 5-androstene-3β,7α,17β-triol to 5-androstene-3β,7β,17β-triol increased during the realimentation. Our data allow to speculate that the intensive 7β-, and 16α- and possibly also the 7α-hydroxylation of C19 Δ⁵ steroids participate in the pathophysiology of anorexia by additional catabolism of substrates available for synthesis of active androgens and estrogens. However, the question remains whether the synthetic analogues of 7α/β- and 16α-hydroxy-steroids prevent the catabolism of the sex steroid precursors, or further activate the "energy wasting" mitochondrial thermogenic metabolism.

Compulsive exercise and weight suppression: Associations with eating pathology in distance runners

Some athletes, particularly those who participate in activities that emphasize leanness such as competitive running, are at greater risk for eating disorder (ED) pathology. Compulsive exercise (CE) is linked with ED pathology among female athletes, with evidence that CE for weight control is most strongly correlated with ED thoughts and behaviors. Weight suppression (WS), the discrepancy between highest adult weight and current weight, is also linked with ED symptoms. Taken together, runners with greater WS may be more likely to engage in CE to influence their weight or shape and may subsequently report other associated ED symptoms. As such, the current study investigated associations between CE and ED pathology in a mixed-gender sample of adult distance runners (N = 277, 51% female), and tested the impact of WS on this association. Results indicated that females reported greater CE and ED pathology, whereas males reported greater WS. A significant interaction effect for CE x WS, (p < .05) indicated that the relation between CE and ED scores was stronger among male runners who reported higher WS. In contrast, WS did not impact the association between CE and ED pathology for female runners. Results from the current study have important implications for the assessment and treatment of ED in athletes, specifically runners, and suggest that WS is an important factor to consider when working with male athletes.

Compulsive exercise or exercise dependence? Clarifying conceptualizations of exercise in the context of eating disorder pathology

OBJECTIVE

Maladaptive exercise relates to eating disorder (ED) pathology and impairment in clinical and non-clinical populations. At present, two different conceptualizations of maladaptive exercise are often studied in relation to ED pathology: compulsive exercise and exercise dependence. Compulsive exercise functions to avoid negative affect (e.g., guilt and anxiety) associated with not exercising, whereas exercise dependence is associated with tolerance to exercise benefits and avoidance of exercise withdrawal. At present, clinicians and researchers struggle to determine the most appropriate term for describing problematic exercise in individuals with ED pathology. This study aimed to directly compare these conceptualizations of maladaptive exercise in relation to severity of ED pathology.

DESIGN

This study examined cross-sectional data.

METHOD

Undergraduate participants (N =235, 78% female) with elevated ED pathology completed the Eating Disorder Examination Questionnaire (EDE-Q), Compulsive Exercise Test (CET), and Exercise Dependence Scale (EDS). Multiple linear regression analyses evaluated associations between EDE-Q and CET and EDS scores and dominance analysis determined which qualities of exercise were uniquely associated with EDE-Q scores.

RESULTS

Results suggest that compulsive qualities of exercise, including exercise to control shape and weight and to avoid negative affect are more strongly associated with severity of ED pathology than qualities of exercise dependence.

CONCLUSIONS

Clinicians and researchers working with ED populations can benefit from prioritizing assessments that capture compulsive qualities of exercise. Additionally, these results suggest that interventions that effectively target other compulsive behaviors (e.g., exposure and response prevention) may be promising treatment options for problematic exercise in the context of EDs.

Testing an emotion regulation model of physical activity in adolescents with anorexia nervosa: A pilot ecological momentary assessment

OBJECTIVE

Adolescents with anorexia nervosa (AN) often show increased levels of exercise and physical activity. Psychological models suggest that physical activity in AN might attenuate momentary negative affect. However, this has not been directly tested in adolescents with AN, and it remains unclear whether this is a distinct mechanism of physical activity in AN compared with healthy controls (HCs).

METHOD

In a 1-day ecological momentary assessment, 32 adolescent inpatients with AN and 30 HCs responded to hourly questions on momentary affect while wearing an actigraph to objectively assess physical activity.

RESULTS

Linear mixed models identified that adolescents with AN experienced more aversive tension, more negative affect, and less positive affect throughout the day than HCs. Preliminary evidence for a momentary association of higher levels of physical activity with positive affect were found for both groups, whereas higher levels of physical activity were associated with less negative affect in adolescents with AN only. When correcting for multiple testing, interactions did not hold statistical significance.

DISCUSSION

Our results indicate a down-regulation effect of physical activity on negative affect for AN and a more general up-regulation effect of positive affect. However, our sample size was small, and replication of our findings is needed.

Clinical Trials Required to Assess Potential Benefits and Side Effects of Treatment of Patients With Anorexia Nervosa With Recombinant Human Leptin

The core phenotype of anorexia nervosa (AN) comprises the age and stage dependent intertwining of both its primary and secondary (i.e., starvation induced) somatic and mental symptoms. Hypoleptinemia acts as a key trigger for the adaptation to starvation by affecting diverse brain regions including the reward system and by induction of alterations of the hypothalamus-pituitary-“target-organ” axes, e.g., resulting in amenorrhea as a characteristic symptom of AN. Particularly, the rat model activity-based anorexia (ABA) convincingly demonstrates the pivotal role of hypoleptinemia in the development of starvation-induced hyperactivity. STAT3 signaling in dopaminergic neurons in the ventral tegmental area (VTA) plays a crucial role in the transmission of the leptin signal in ABA. In patients with AN, an inverted U-shaped relationship has been observed between their serum leptin levels and physical activity. Albeit obese and therewith of a very different phenotype, humans diagnosed with rare congenital leptin deficiency have starvation like symptoms including hypothalamic amenorrhea in females. Over the past 20 years, such patients have been successfully treated with recombinant human (rh) leptin (metreleptin) within a compassionate use program. The extreme hunger of these patients subsides within hours upon initiation of treatment; substantial weight loss and menarche in females ensue after medium term treatment. In contrast, metreleptin had little effect in patients with multifactorial obesity. Small clinical trials have been conducted for hypothalamic amenorrhea and to increase bone mineral density, in which metreleptin proved beneficial. Up to now, metreleptin has not yet been used to treat patients with AN. Metreleptin has been approved by the FDA under strict regulations solely for the treatment of generalized lipodystrophy. The recent approval by the EMA may offer, for the first time, the possibility to treat extremely hyperactive patients with AN off-label. Furthermore, a potential dissection of hypoleptinemia-induced AN symptoms from the primary cognitions and behaviors of these patients could ensue. Accordingly, the aim of this article is to review the current state of the art of leptin in relation to AN to provide the theoretical basis for the initiation of clinical trials for treatment of this eating disorder.

A comparative network analysis of eating disorder psychopathology and co-occurring depression and anxiety symptoms before and after treatment

BACKGROUND

Network analysis is an emerging approach in the study of psychopathology, yet few applications have been seen in eating disorders (EDs). Furthermore, little research exists regarding changes in network strength after interventions. Therefore the present study examined the network structures of ED and co-occurring depression and anxiety symptoms before and after treatment for EDs.

METHOD

Participants from residential or partial hospital ED treatment programs (N = 446) completed assessments upon admission and discharge. Networks were estimated using regularized Graphical Gaussian Models using 38 items from the Eating Disorders Examination-Questionnaire, Quick Inventory of Depressive Symptomatology, and State-Trait Anxiety Inventory.

RESULTS

ED symptoms with high centrality indices included a desire to lose weight, guilt about eating, shape overvaluation, and wanting an empty stomach, while restlessness, self-esteem, lack of energy, and feeling overwhelmed bridged ED to depression and anxiety symptoms. Comparisons between admission and discharge networks indicated the global network strength did not change significantly, though symptom severity decreased. Participants with denser networks at admission evidenced less change in ED symptomatology during treatment.

CONCLUSIONS

Findings suggest that symptoms related to shape and weight concerns and guilt are central ED symptoms, while physical symptoms, self-esteem, and feeling overwhelmed are links that may underlie comorbidities in EDs. Results provided some support for the validity of network approaches, in that admission networks conveyed prognostic information. However, the lack of correspondence between symptom reduction and change in network strength indicates that future research is needed to examine network dynamics in the context of intervention and relapse prevention.

Body composition and resting energy expenditure in women with anorexia nervosa: Is hyperactivity a protecting factor?

BACKGROUND

In subjects with anorexia nervosa (AN) physical exercise may cause or even prevent weight loss, body composition alterations and adaptive thermogenesis. To investigate the influence of behavioral patterns on body composition and energy expenditure in women with AN, we conducted a retrospective analysis in 62 patients with AN referring to our outpatients' clinic.

MATERIALS AND METHODS

We assessed anthropometric measurement of weight, height, and BMI; body composition was assessed by bioelectrical impedance analysis; resting energy expenditure was measured through indirect calorimetry. Patients' characteristics were assessed at the time of first evaluation.

RESULTS

The subjects were both restricting type (ANR, n = 39) and binge-eating/purging type (ANBP, n = 23) according to DSM-5. We observed a lower reactance (58.63 (11.9) vs. 66.5 (15.5) Ohm, p < 0.05) and higher total body water in ANR subjects. No differences were found in phase angle, fat mass or fat-free mass, nor in REE measures. Within ANR subgroup, we identified two behavioral patterns, with or without physical hyperactivity. Compared to dieting and fasting subjects, hyperactive subjects showed higher phase angle [5.6 (0.7) vs. 4.8 (0.8), p < 0.05], lower fat-free mass [82.5 (6.8) vs. 89.9 (7.5)%, p < 0.05], greater proportion of fat mass [17.5 (6.8) vs. 10.1 (7.5)%, p < 0.05] and body cell mass [46.6 (5.1) vs. 42.5 (5.5)%, p < 0.05]. Finally, hyperactive subjects had greater BMI than dieting or fasting subjects [18.2 (1.7) vs. 15.8 (1.7), p < 0.005].

CONCLUSION

With limitations due to the small sample size, hyperactive subjects show body composition and energy metabolism features that seem protective in terms of prognosis.

Sex dependent impact of gestational stress on predisposition to eating disorders and metabolic disease

OBJECTIVE

Vulnerability to eating disorders (EDs) is broadly assumed to be associated with early life stress. However, a careful examination of the literature shows that susceptibility to EDs may depend on the type, severity and timing of the stressor and the sex of the individual. We aimed at exploring the link between chronic prenatal stress and predisposition to EDs and metabolic disease.

METHODS

We used a chronic variable stress protocol during gestation to explore the metabolic response of male and female offspring to food restriction (FR), activity-based anorexia (ABA), binge eating (BE) and exposure to high fat (HF) diet.

RESULTS

Contrary to controls, prenatally stressed (PNS) female offspring showed resistance to ABA and BE and displayed a lower metabolic rate leading to hyperadiposity and obesity on HF diet. Male PNS offspring showed healthy responses to FR and ABA, increased propensity to binge and improved coping with HF compared to controls. We found that long-lasting abnormal responses to metabolic challenge are linked to fetal programming and adult hypothalamic dysregulation in PNS females, resulting from sexually dimorphic adaptations in placental methylation and gene expression.

CONCLUSIONS

Our results show that maternal stress may have variable and even opposing effects on ED risk, depending on the ED and the sex of the offspring.

Exercise, diet, and the reinforcing value of food in an animal model of anorexia nervosa

Activity-based anorexia (ABA) develops when laboratory rats are subjected to a single meal per day and have access to an activity wheel for the remaining time. Here, we studied the contribution of exercise and diet to the reinforcing value of food during ABA development. Three groups of eight adult male Wistar rats were used: an ABA group with 21.5 hr (then 22 hr) of wheel access and 1 hr (then 30 min) of food access, a control group with the same time exposure to food but without exercise, and a yoked group to the ABA in terms of weight loss. Rats were daily tested on a progressive-ratio schedule to measure their motivation for food. ABA rats gradually reduced their body weight more than the food control group. Animals steadily increased their breaking points in parallel to losses in body weight, but no significant differences were found between groups. Adult rats can develop ABA, but their loss in weight neither resulted in a decrease of food intake nor in the motivation to obtain it.

Excessive physical activity in young girls with restrictive-type anorexia nervosa: its role on cardiac structure and performance

PURPOSE

The aim of this study was to investigate the influence of hyperactivity on left ventricular mass (LVM) in Anorexia Nervosa restricting-type (AN-R) and the correlation between LVM and auxologic parameters/circulating hormones.

METHODS

Echocardiography was performed in 44 AN-R girls, subgrouped in 24 hyperactive (ANH+) and 20 non-hyperactive (ANH-), and in 20 controls (HC). LVM indexed to Body Surface Area (LVMi) and LVM indexed to height (LVMh) were calculated.

RESULTS

LVMi and LVMh were significantly lower in the AN-R subjects compared to HC. Moreover, both LVMi and LVMh were higher in the ANH+ than in the ANH-. In the HC, LVMi was higher when compared to the ANH- subjects than to the ANH+. Stepwise analysis revealed that in the ANH+ group, fT4 was the only independent predictor of LVMh, while in the ANH- group, height was the only independent predictors of LVMi.

CONCLUSIONS

Despite its negative influence on disease severity and outcome, hyperactivity from the standpoint of cardiac function makes the LVM of AN-R young girls more similar to HC.

LEVEL OF EVIDENCE

Level III, case-control study.

Relationships between compulsive exercise, quality of life, psychological distress and motivation to change in adults with anorexia nervosa

BACKGROUND

For people with anorexia nervosa (AN), compulsive exercise is characterized by extreme concerns about the perceived negative consequences of stopping/reducing exercise, dysregulation of affect, and inflexible exercise routines. It is associated with increased eating disorder psychopathology and poor clinical outcome. However, its relationships with two important clinical issues, quality of life (QoL) and motivation to change, are currently unknown. This study aimed to assess the cross-sectional relationships between compulsive exercise, QoL, psychological distress (anxiety and depressive symptoms, and obsessive-compulsive traits) and motivation to change in patients with AN.

METHOD

A total of 78 adults with AN participated in this study, which was nested within a randomized controlled trial of psychological treatments for AN. At baseline (pre-treatment), participants completed questionnaires assessing compulsive exercise, eating disorder (ED) psychopathology, QoL, psychological distress and motivation to change.

RESULTS

Baseline correlational analyses demonstrated a moderate positive relationship between compulsive exercise and ED psychopathology, and a weak positive relationship between compulsive exercise and psychological distress. There was a moderate negative relationship between compulsive exercise and eating disorder QoL.

CONCLUSIONS

These results indicate compulsive exercise is moderately associated with poorer QoL and weakly associated with higher distress. Targeting compulsive exercise in the treatment of anorexia nervosa may help reduce the burden of illness and improve patients' engagement in treatment.

TRIAL REGISTRATION

ACTRN12610000585022. Taking a LEAP forward in the treatment of anorexia nervosa: a randomized controlled trial. NHMRC grant: 634922.

Specialized group intervention for compulsive exercise in inpatients with eating disorders: feasibility and preliminary outcomes

BACKGROUND

Patients with eating disorders (ED) often suffer from compulsive exercise behavior, which is associated with lower short-term response to treatment and poorer long-term outcome. Evidence-based interventions specifically targeting compulsive exercise behavior have been scarce so far. We developed a manualized group therapeutic approach integrating cognitive-behavioral therapy, exercise therapy and exposure with response management to promote healthy exercise behavior. Our objective was to examine the feasibility and acceptance of this new approach as add-on to regular inpatient treatment in a pilot study. Additionally, we wanted to estimate preliminary effect sizes.

METHODS

Thirty-two female, adolescent and adult eating disordered inpatients were recruited. According to the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), twenty-six patients met criteria for Anorexia nervosa (AN), two for Bulimia nervosa and four for eating disorder not otherwise specified. Semi-structured interviews were conducted for qualitative evaluation of feasibility and acceptance of the new intervention. Patients completed the Commitment to Exercise Scale (CES) and the Compulsive Exercise Test (CET) for assessment of compulsive exercise, the Eating Disorder Inventory-2 for assessment of eating disorder pathology, the Beck Depression Inventory-II and Brief Symptom Inventory for assessment of depressive and general psychopathology and the Emotion Regulation Skills Questionnaire for assessment of emotion regulation before the beginning and at the end of the group intervention. Additionally, weight gain was monitored.

RESULTS

Feasibility of our approach was confirmed. All patients reported a high satisfaction with both structure and content of the group. Between pre- and post-intervention, patients showed significant reductions in compulsive exercise (effect size CES: 1.44; effect size CET total: 0.93), drive for thinness (effect size: 0.48), depressive symptoms (effect size: 0.36), general psychopathology (effect size: 0.29) and acceptance of emotions (effect size: - 0.62). Patients with AN also showed significant mean weight gain during the intervention (effect size: - 0.44).

CONCLUSIONS

Results of our pilot study indicate that our integrative approach to compulsive exercise in ED patients might represent a promising new therapeutic option. Feasibility and acceptance of the intervention were confirmed. Preliminary effect sizes on most outcomes were promising. As improvements in Body-mass-index, eating disorder and general psychopathology are also to be expected by routine inpatient treatment, a large randomized trial is currently underway to evaluate the efficacy of this new intervention.

Running on empty - a nationwide large-scale examination of compulsive exercise in eating disorders

BACKGROUND

Compulsive exercise (CE) has been the neglected "Cinderella" among eating disorder (ED) symptoms, even though it seems to impact severity, treatment and outcome. This prompted a large-scale and systematic examination of the impact of CE in a representative ED sample.

METHODS

CE was examined in over 9000 female and male patients from a clinical ED database (covering out-patient, day and/or residential treatment) with respect to prevalence, ED diagnosis, ED symptoms, clinical features, patient characteristics, and outcome at 1-year follow-up. Relationships between changes in CE behavior and remission were also examined.

RESULTS

CE was a transdiagnostic symptom, present in nearly half of all patients (48%). It was associated with greater overall ED pathology, particularly dietary restraint, and negative perfectionism. Initial CE did not impact remission rate, but patients continuing or starting CE during treatment had considerably lower remission rates compared to patients who never engaged in, or ceased with, CE. Results were comparable for females and males.

CONCLUSIONS

At baseline, there were few differences between patients with and without CE, except a somewhat higher symptom load for patients with CE, and CE did not predict ED outcome. However, how CE developed during treatment to 1-year follow-up considerably impacted remission rates. We strongly recommend CE to be systematically assessed, addressed, and continuously evaluated in all ED patients seeking treatment.

Stress is associated with exercise differently among individuals with higher and lower eating disorder symptoms: An ecological momentary assessment study

OBJECTIVE

Stress is associated with the maintenance of eating disorders and exercise behaviors. However, it is unclear how stress is associated with exercise and vice-versa among individuals with higher levels of eating disorder symptoms in daily life. The current study tested the moderating effect of eating disorder symptoms on the relationships between (1) daily stress and later exercise behavior and (2) daily exercise behavior and later stress.

METHOD

Female college students [N = 129, mean age = 19.19 (SD = 1.40)] completed the Eating Disorder Inventory-2. Participants then completed measures of stress and exercise four times daily across seven days using an automated telephone ecological momentary assessment system. Data were analyzed using multilevel models.

RESULTS

Drive for thinness, bulimic symptoms, and body dissatisfaction significantly moderated the relationship between daily stress and later exercise (ps = .01-.05), such that higher daily stress predicted higher later exercise only in individuals who were low (but not average or high) in drive for thinness, bulimic symptoms, and body dissatisfaction symptoms.

DISCUSSION

Stress is associated with exercise differentially depending on individuals' eating disorder symptoms. Our findings suggest that only individuals with lower levels of eating disorder symptoms exercise when stressed.

Excessive exercise among adolescents with eating disorders: examination of psychological and demographic variables

Background While a large number of patients with eating disorders (EDs) engage in excessive exercise (EE), both for weight control and mood regulation, there has been minimal research evaluating the relationship between EE and demographic and psychological factors, especially in adolescent patients. Purpose The goals of this study were to identify the occurrence of EE compared to other ED behaviors and to develop a regression model examining psychological, behavioral and demographic predictors of EE among adolescents with EDs. Methods Demographic and clinical information was determined for 217 adolescent patients in several levels of care (126 outpatient, 61 day program, 28 inpatient) with diagnoses of anorexia nervosa (AN) (24.9%), bulimia nervosa (BN) (25.8%), and eating disorder not otherwise specified (EDNOS) (49.3%). These patients presented to a large ED program and completed a series of questionnaires on admission to the program. Descriptive statistics, t-tests, chi-square analyses and multiple logistic regression were utilized to describe the population of adolescent patients and develop the model for predicting EE. Results Forty-seven percent of patients indicated they participated in EE in the past 4 weeks, compared to 32% for binge eating, 35% for vomiting and 15% for laxative use; 42% of patients with anorexia nervosa participated in EE, compared to 54% with bulimia nervosa and 49% with EDNOS. The regression model that was developed to predict EE, which included factors of depression, anxiety, dietary restraint, age, body mass index (BMI), diagnosis and level of care, correctly classified EE in 71.5% of cases. Dietary restraint and BMI were the two factors found to be significantly associated with EE. Conclusions Forty-seven percent of adolescent patients presenting for treatment of an ED reported participating in EE. This was larger than the numbers of patients reporting other ED behaviors that are commonly assessed, indicating the need for psychoeducation for multidisciplinary treatment teams, assessment, prevention, and clinical treatment services for this problematic behavior. It is important that those who treat patients with ED assess for and monitor EE behaviors that can complicate the treatment.

Treatment of anorexia nervosa: a multimethod investigation translating experimental neuroscience into clinical practice

Background

Anorexia nervosa (AN) is a severe psychiatric condition and evidence on how to best treat it is limited.

Objectives

This programme consists of seven integrated work packages (WPs) and aims to develop and test disseminable and cost-effective treatments to optimise management for people with AN across all stages of illness.

Methods

WP1a used surveys, focus groups and a pre–post trial to develop and evaluate a training programme for school staff on eating disorders (EDs). WP1b used a randomised controlled trial (RCT) [International Standard Randomised Controlled Trial Number (ISRCTN) 42594993] to evaluate a prevention programme for EDs in schools. WP2a evaluated an inpatient treatment for AN using case reports, interviews and a quasi-experimental trial. WP2b used a RCT (ISRCTN67720902) to evaluate two outpatient psychological therapies for AN. WP3 used a RCT (ISRCTN06149665) to evaluate an intervention for carers of inpatients with AN. WP4 used actimetry, self-report and endocrine assessment to examine physical activity (PA) in AN. WP5 conducted a RCT (ISRCTN18274621) of an e-mail-guided relapse prevention programme for inpatients with AN. WP6 analysed cohort data to examine the effects of maternal EDs on fertility and their children’s diet and growth. WP7a examined clinical case notes to explore how access to specialist ED services affects care pathways and user experiences. Finally, WP7b used data from this programme and the British Cohort Study (1970) to identify the costs of services used by people with AN and to estimate annual costs of AN for England.

Results

WP1a: a brief training programme improved knowledge, attitudes and confidence of school staff in managing EDs in school. WP1b: a teacher-delivered intervention was feasible and improved risk factors for EDs in adolescent girls. WP2a: both psychological therapies improved outcomes in outpatients with AN similarly, but patients preferred one of the treatments. WP2b: the inpatient treatment (Cognitive Remediation and Emotional Skills Training) was acceptable with perceived benefits by patients, but showed no benefits compared with treatment as usual (TAU). WP3: compared with TAU, the carer intervention improved a range of patient and carer outcomes, including carer burden and patient ED symptomatology. WP4: drive to exercise is tied to ED pathology and a desire to improve mood in AN patients. PA was not increased in these patients. WP5: compared with TAU, the e-mail-guided relapse prevention programme resulted in higher body mass index and lower distress in patients at 12 months after discharge. WP6: women with an ED had impaired fertility and their children had altered dietary and growth patterns compared with the children of women without an ED. WP7a: direct access to specialist ED services was associated with higher referral rates, lower admission rates, greater consistency of care and user satisfaction. WP7b: the annual costs of AN in England are estimated at between £45M and £230M for 2011.

Conclusions

This programme has produced evidence to inform future intervention development and has developed interventions that can be disseminated to improve outcomes for individuals with AN. Directions for future research include RCTs with longer-term outcomes and sufficient power to examine mediators and moderators of change.

Trial registration

Current Controlled Trials ISRCTN42594993, ISRCTN67720902, ISRCTN06149665 and ISRCTN18274621.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 16. See the NIHR Journals Library website for further project information.

Activity-Based Anorexia Reduces Body Weight without Inducing a Separate Food Intake Microstructure or Activity Phenotype in Female Rats-Mediation via an Activation of Distinct Brain Nuclei

Anorexia nervosa (AN) is accompanied by severe somatic and psychosocial complications. However, the underlying pathogenesis is poorly understood, treatment is challenging and often hampered by high relapse. Therefore, more basic research is needed to better understand the disease. Since hyperactivity often plays a role in AN, we characterized an animal model to mimic AN using restricted feeding and hyperactivity. Female Sprague-Dawley rats were divided into four groups: no activity/ad libitum feeding (ad libitum, AL, n = 9), activity/ad libitum feeding (activity, AC, n = 9), no activity/restricted feeding (RF, n = 12) and activity/restricted feeding (activity-based anorexia, ABA, n = 11). During the first week all rats were fed ad libitum, ABA and AC had access to a running wheel for 24 h/day. From week two ABA and RF only had access to food from 9:00 to 10:30 a.m. Body weight was assessed daily, activity and food intake monitored electronically, brain activation assessed using Fos immunohistochemistry at the end of the experiment. While during the first week no body weight differences were observed (p > 0.05), after food restriction RF rats showed a body weight decrease: −13% vs. day eight (p < 0.001) and vs. AC (−22%, p < 0.001) and AL (−26%, p < 0.001) that gained body weight (+10% and +13%, respectively; p < 0.001). ABA showed an additional body weight loss (−9%) compared to RF (p < 0.001) reaching a body weight loss of −22% during the 2-week restricted feeding period (p < 0.001). Food intake was greatly reduced in RF (−38%) and ABA (−41%) compared to AL (p < 0.001). Interestingly, no difference in 1.5-h food intake microstructure was observed between RF and ABA (p > 0.05). Similarly, the daily physical activity was not different between AC and ABA (p > 0.05). The investigation of Fos expression in the brain showed neuronal activation in several brain nuclei such as the supraoptic nucleus, arcuate nucleus, locus coeruleus and nucleus of the solitary tract of ABA compared to AL rats. In conclusion, ABA combining physical activity and restricted feeding likely represents a suited animal model for AN to study pathophysiological alterations and pharmacological treatment options. Nonetheless, cautious interpretation of the data is necessary since rats do not voluntarily reduce their body weight as observed in human AN.

A clinical profile of compulsive exercise in adolescent inpatients with anorexia nervosa

BACKGROUND

The aim of the current study was to contribute to the development of a clinical profile of compulsive exercise in adolescents with Anorexia Nervosa (AN), by examining associations between compulsive exercise and eating and general psychopathology.

METHOD

A sample of 60 female adolescent inpatients with AN completed a self-report measure of compulsive exercise and a series of standardized self-report questionnaires assessing eating and general psychopathology.

RESULTS

Higher levels of compulsive exercise were associated with increased levels of eating disorder psychopathology and anxiety. Specifically, the avoidance aspect (negatively reinforced) of compulsive exercise was associated with elevated scores on measures of eating disorder, anxiety, depression, and obsessive compulsiveness psychopathology, as well as lower self-esteem scores. The mood improvement value (positively reinforced) of compulsive exercise, however, did not reflect such trends.

CONCLUSIONS

Compulsive exercise driven by avoidance of negative affect is associated with more severe psychological features in adolescent inpatients with AN. The current findings emphasize the need for research and clinical efforts in the development of treatments addressing avoidance of negative affect and compulsive exercise in adolescents with AN.

The Compulsive Exercise Test: confirmatory factor analysis and links with eating psychopathology among women with clinical eating disorders

BACKGROUND

This study aimed to determine the psychometric properties of the Compulsive Exercise Test (CET) among an adult sample of patients with eating disorders.

METHOD

Three hundred and fifty six patients and 360 non-clinical control women completed the CET and the Eating Disorders Examination questionnaire (EDE-Q).

RESULTS

A confirmatory factor analysis revealed that the clinical data showed a moderate fit to the previously published five factor model derived from a community sample (Taranis L, Touyz S, Meyer C, Eur Eat Disord Rev 19:256-268, 2011). The clinical group scored significantly higher than the non-clinical group on four of the five CET subscales, and logistic regression analysis revealed that the CET could successfully discriminate between the two groups. A Receiver Operating Curve analysis revealed that a cut-off score of 15 on the CET resulted in acceptable values of both sensitivity and specificity.

CONCLUSIONS

The CET appears to have a factor structure that is acceptable for use with an adult sample of patients with eating disorders. It can identify compulsive exercise among patients with eating disorders and a cut-off score of 15 is acceptable as indicating an appropriate cut-off point.

Problematic Exercise in Anorexia Nervosa: Testing Potential Risk Factors against Different Definitions

“Hyperactivity” has a wide prevalence range of 31% to 80% in the anorexia nervosa literature that could be partly due to the plethora of definitions provided by researchers in this field. The purpose of this study was two-fold: 1) To assess the variance across prevalence rates of problematic exercise encountered in patients with anorexia nervosa, in relation to seven different definitions found in the literature. 2) To examine how core eating disorder symptoms and the dimensions of emotional profile are associated with these different definitions and the impact of these definitions on the assessment of patients’ quality of life. Exercise was evaluated in terms of duration, intensity, type and compulsion using a semi-structured questionnaire administered to 180 women suffering from severe anorexia nervosa. Seven different definitions of problematic exercise were identified in the literature: three entailing a single dimension of problematic exercise (duration, compulsion or intensity) and four combining these different dimensions. Emotional profile scores, obsessive-compulsive symptoms, eating disorder symptomatology, worries and concerns about body shape, self-esteem and quality of life were assessed using several established questionnaires. The prevalence of problematic exercise varied considerably from, 5% to 54%, depending on the number of criteria used for its definition. The type and level of eating disorder symptomatology was found to be associated with several definitions of problematic exercise. Surprisingly, a better self-reported quality of life was found among problematic exercisers compared to non-problematic exercisers in three of the definitions. The different definitions of problematic exercise explain the broad prevalence ranges and the conflicting associations generally reported in the literature between problematic exercise and eating disorder-related psychological parameters. There is an urgent need for a valid consensus on the definition of problematic exercise in anorexia nervosa. This will support the development of further research on the etiology and treatment of problematic exercise.

Physical activity in anorexia nervosa: How relevant is it to therapy response?

OBJECTIVE

Elevated physical activity has been observed in some patients with anorexia nervosa (AN) despite their emaciated condition. However, its effects on treatment outcome remain unclear. This study aimed to examine objectively measured physical activity in this clinical population and how it might be related to a partial hospitalization therapy response, after considering potential confounders.

METHOD

The sample comprised 88 AN patients consecutively enrolled in a day hospital treatment program, and 116 healthy-weight controls. All participants were female and a baseline assessment took place using an accelerometer (Actiwatch AW7) to measure physical activity, the Eating Disorders Inventory-2 and the Depression subscale of the Symptom Checklist-Revised. Outcome was evaluated upon the termination of the treatment program by expert clinicians.

RESULTS

Although AN patients and controls did not differ in the average time spent in moderate-to-vigorous physical activity (MVPA) (P=.21), nor daytime physical activity (P=.34), fewer AN patients presented a high physical activity profile compared to the controls (37% vs. 61%, respectively; P=.014). Both lower levels of MVPA and greater eating disorder severity had a direct effect on a poor treatment outcome. Depression symptoms in the patients were associated with lower MVPA, as well as with an older age, a shorter duration of the disorder and greater eating disorder psychopathology.

CONCLUSIONS

There is a notable variation in the physical activity profile of AN patients, characterized by either low or very high patterns. Physical activity is a highly relevant issue in AN that must be taken into account during the treatment process.