Measured physical activity in anorexia nervosa: features and treatment outcome

Momentary physiological indices related to eating disorders: A systematic and methodological review

Eating disorders (ED) are serious psychiatric illnesses, with no everyday support to intervene on the high rates of relapse. Understanding physiological indices that can be measured by wearable sensor technologies may provide new momentary interventions for individuals with ED. This systematic review, searching large databases, synthesises studies investigating peripheral physiological (PP) indices commonly included in wearable wristbands (heart rate [HR], heart rate variability [HRV], electrodermal activity [EDA], peripheral skin temperature [PST], and acceleration) in ED. Inclusion criteria included: (a) full peer-reviewed empirical articles in English; (b) human participants with active ED; and (c) containing one of five wearable physiological measures. Kmet risk of bias was assessed. Ninety-four studies were included (Anorexia nervosa [AN; N = 4418], bulimia nervosa [BN; N = 916], binge eating disorder [BED; N = 1604], other specified feeding and eating disorders [OSFED; N = 424], and transdiagnostic [N = 47]). Participants with AN displayed lower HR and EDA and higher HRV compared to healthy individuals. Those with BN showed higher HRV, and lower EDA and PST compared to healthy individuals. Other ED and Transdiagnostic samples showed mixed results. PP differences are indicated through various assessments in ED, which may suggest diagnostic associations, although more studies are needed to validate observed patterns. Results suggest important therapeutic potential for PP in ED, and larger studies including diverse participants and diagnostic groups are needed to fully uncover their role in ED.

Assessment and treatment of compulsive exercise in anorexia nervosa - A combined investigation of Compulsive Exercise Activity Therapy (LEAP) and Compulsive Exercise Test subscales

INTRODUCTION

Compulsive exercise is a transdiagnostic feature of eating disorders which adversely affects aspects of recovery, such as length of hospitalisation, risk of a chronic outcome, and risk of relapse. CompuLsive Exercise Activity TheraPy (LEAP) aims to reduce compulsive exercise through a cognitive behavioural approach. This study aims to investigate the effect of LEAP on compulsive exercise behaviour using subscales of the Compulsive Exercise Test (CET), a measure of exercise in individuals with eating disorders. Predictive validity of the CET's subscales and its ability to predict eating psychopathology are investigated.

METHOD

This study used data from a randomized controlled trial of LEAP (1). Linear mixed modelling was used to investigate the effect of LEAP on compulsive exercise behaviour, and the predictive ability of CET subscales on various outcomes. The CET was compared to other exercise measures to assess its superiority in predicting eating psychopathology.

RESULTS

LEAP was superior in reducing the scores of the CET's Avoidance and Rule Driven Behaviour and Exercise Rigidity subscales. All subscales made a contribution to the respective models. The CET was superior to other measures in predicting eating pathology.

CONCLUSION

The results lend credibility to LEAP's ability to reduce core parts of compulsive exercise. The CET has been found to target important aspects of compulsive exercise behaviour, and has was superior to other exercise measures in predicting eating psychopathology.

A systematic review and meta-analysis of intensive treatment options for adults with eating disorders

Eating disorders (EDs) are complex conditions with one of the highest mortality rates among psychiatric illnesses. While outpatient evidence-based treatments for EDs in adults exist, there is often utilisation of more intensive interventions as part of treatment. However, a comprehensive analysis of the impacts of intensive treatment (inpatient, residential and day program) on physical and psychosocial outcomes is lacking. Thus, the current systematic review and meta-analysis aimed to investigate the effectiveness of intensive treatments in adults with EDs for the outcomes of body mass index (BMI), disordered eating, depression, and quality of life, as well as a moderation analysis investigating a range of clinical characteristics. Overall, 62 studies were included in the meta-analysis. The results revealed that intensive treatment in adults yielded significant improvements in BMI (for underweight patients), disordered eating, depression, and quality of life. Treatment setting, length of stay and geographical region of the study all served as moderators for disordered eating and depression. Nevertheless, given the high heterogeneity in the meta- and moderation analyses, these results should be interpreted with caution. Future high-quality research is needed to determine the most beneficial elements of intensive treatment (compared to outpatient) in adults with EDs.

Similarities and differences regarding acute anorexia nervosa and semi-starvation: does behavioral thermoregulation play a central role?

Objective

To clarify the association between acute anorexia nervosa (AN) and semi-starvation (SS) by focusing on similarities and differences in physiology, mood, and behavior.

Method

A comparison of published literature between these two groups.

Results

Both groups show similar hormonal and metabolic changes in response to caloric restriction and extreme weight loss (~25%). Associated changes result in a reduced body temperature (Tcore-low). Maintenance of body temperature within a specific range is crucial to survival. However, both groups cannot activate autonomic strategies to maintain their Tcore-low, such as increasing metabolic rate, constricting skin blood vessels, or shivering. Furthermore, Tcore-low increases the individuals' "coldness sensations" throughout the body, hence the frequent reports from ANs and SSs of "feeling cold." To eliminate these uncomfortable "coldness sensations" and, importantly, to maintain Tcore-low, ANs, and SSs "select" different thermoregulatory behavioral strategies. It is proposed that the primary differences between AN and SS, based on genetics, now manifest due to the "selection" of different thermo-regulatory behaviors. AN patients (ANs) "select" hyperactive behavior (HyAc), which increases internal metabolic heat and thus assists with maintaining Tcore-low; in harmony with hyperactive behavior is a lively mood. Also related to this elevated arousal pattern, ANs experience disrupted sleep. In contrast, SS individuals "select" a passive thermo-behavioral strategy, "shallow torpor," which includes reduced activity, resulting in energy conservation. In addition, this inactivity aids in the retention of generated metabolic heat. Corresponding to this lethargic behavior, SS individuals display a listless mood and increased sleep.

Conclusion

Initial similarities between the two are attributable to physiological changes related to extreme weight loss. Differences are most likely attributable to genetically programmed "selection" of alternate thermoregulatory strategies, primarily to maintain Tcore-low. However, if acute AN is prolonged and evolves into a chronic condition, AN will more closely align with starvation and more precisely reflect SS symptomology.

Endocrinology of Underweight and Anorexia Nervosa

More than any other mental illness, the course, prognosis, and therapy of anorexia nervosa are shaped by the physical changes associated with being underweight. This article provides an overview of the endocrine changes associated with malnutrition and underweight. This overview serves as a basis for understanding the other articles in this special issue, which deal with the health risks associated with being underweight. In this context, the differences between underweight in anorexia nervosa and in constitutional thinness are of particular importance in assessing the impact of intentional weight loss. In this context, the regulation of hunger and satiety deserves special interest, as this is the area in which the intentional influence on body weight comes into play. Clinical consequences on, for example, fertility, bone metabolism, the homeostasis of, for example, serum glucose levels, or body temperature have been observed for a long time; nonetheless, the medical responses, apart from vitamin supplementations and advice to gain weight, are still limited. Therefore, emphasis was placed on the potential improvement of outcomes through the administration of central or peripheral hormones. Studies were identified on PubMed via a selection of relevant keywords; original texts that were cited in reviews were studied where it was advantageous. This review found some promising data on bone health and the administration of transdermal oestrogen, which is not yet widely used, as well as distinct hormonal markers to differentiate between CT and AN. We concluded that the continuous efforts to investigate the role of endocrinology in underweight and/or anorexia nervosa lead to outcome benefits and that more and higher-powered studies are needed.

Athletes with Eating Disorders: Analysis of Their Clinical Characteristics, Psychopathology and Response to Treatment

Eating disorders (ED) have frequently been described among athletes. However, their specific features and therapy responses are lacking in the literature. The aims of this article were to compare clinical, psychopathological and personality traits between ED patients who were professional athletes (ED-A) with those who were not (ED-NA) and to explore differences in response to treatment. The sample comprised n = 104 patients with ED (n = 52 ED-A and n = 52 matched ED-NA) diagnosed according to DSM-5 criteria. Evaluation consisted of a semi-structured face-to-face clinical interview conducted by expert clinicians and a psychometric battery. Treatment outcome was evaluated when the treatment program ended. ED-A patients showed less body dissatisfaction and psychological distress. No differences were found in treatment outcome among the groups. Within the ED-A group, those participants who performed individual sport activities and aesthetic sports presented higher eating psychopathology, more general psychopathology, differential personality traits and poor therapy outcome. Individual and aesthetic sports presented more severity and worse prognosis. Although usual treatment for ED might be similarly effective in ED-A and ED-NA, it might be important to develop preventive and early detection programs involving sports physicians and psychologists, coaches and family throughout the entire athletic career and afterwards.

Engagement of the brain orexin system in activity-based anorexia behaviour in mice

While excessive physical activity is common amongst anorexia nervosa (AN) patients, contributing to their low body weight, little is known about the underlying biology and effective treatments targeting the hyperactivity are lacking. Given the role of orexin in arousal, physical activity and energy expenditure, we sought to investigate i) the extent to which orexin neurons are activated during severe anorectic state in the activity-based anorexia (ABA) mouse model, and ii) if the dual orexin receptor antagonist suvorexant can reduce physical activity during ABA. The Fos-TRAP2 technique enable us to visually capture active neurons (Fos expressing) during severe anorectic state in the ABA mouse model, and by immunohistochemistry, determine the extent to which these active neurons are orexin positive. In addition, suvorexant was administered peripherally to ABA mice and running activity was monitored. We found that a large population of orexin neurons in the hypothalamus are activated by ABA and that peripheral administration of suvorexant decreases food anticipatory activity in these mice. We conclude that orexin may be a suitable target to treat hyperactivity in AN and recommend further studies to examine the efficacy of suvorexant in aiding AN patients to control their drive for hyperactivity.

A machine learning investigation into the temporal dynamics of physical activity-mediated emotional regulation in adolescents with anorexia nervosa and healthy controls

OBJECTIVE

Anorexia nervosa (AN) is commonly experienced alongside difficulties of emotion regulation (ER). Previous works identified physical activity (PA) as a mechanism for AN sufferers to achieve desired affective states, with evidence towards mitigation of negative affect. However, temporal associations of PA with specific emotional state outcomes are unknown.

METHOD

Using lag-ensemble machine learning and feature importance analyses, 888 affect-based ecological momentary assessments across N = 75 adolescents with AN (N = 44) and healthy controls (N = 31) were analysed to explore significance of past PA, measured through passively collected wrist-worn actigraphy, with subsequent self-report momentary affect change across 9 affect constructs.

RESULTS

Among AN adolescents, later lags (≥2.5 h) were important in predicting change across negative emotions (hostility, sadness, fear, guilt). AN-specific model performance on held-out test data revealed the holistic "negative affect" construct as significantly predictable. Only joviality and self-assurance, both positively-valenced constructs, were significantly predictable among healthy-control-specific models.

DISCUSSION

Results recapitulated previous findings regarding the importance of PA in negative ER for AN individuals. Moreover, PA was found to play a uniquely prominent role in predicting negative affect 4.5-6 h later among AN adolescents. Future research into the PA-ER dynamic will benefit from targeting specific negative emotions across greater temporal scales.

Measuring exercise in eating disorder patients: a Delphi study to aggregate clinical and research knowledge

BACKGROUND

Exercise is a prominent feature of most eating disorders, and has been shown to have a number of detrimental effects on treatment outcome. There is some disagreement in the literature regarding the construct of compulsive exercise, and assessment and treatment varies significantly. This study therefore aimed to aggregate expert clinicians' and researchers' views on how to define and measure compulsive exercise in eating disorder patients. The expert panel was also asked about questionnaire design, and possible problems when measuring compulsive exercise.

METHOD

This study used the Delphi method to establish consensus amongst an expert panel. Three successive rounds of questionnaires were distributed to the panel over a period of six months. The first round consisted of four open-ended questions regarding the definition and measurement of compulsive exercise in eating disorder patients. For Round 2, 70 statements were derived from the answers, and panelists were asked to rate each item on a Likert-based scale. An 85% consensus level was chosen. In Round 3, 44 statements were re-rated by the panel.

RESULTS

Seventeen of 24 participants completed all three rounds of the study. Consensus was achieved for 63% of the items, while 18.5% reached near consensus, and 18.5% did not reach consensus after Round 3. The panel agreed on a number of important aspects of compulsive exercise. Several suggestions regarding the format of a questionnaire assessing this behavior were also endorsed. The panel further identified common difficulties when assessing compulsive exercise in eating disorder patients, notably a lack of consensus still apparent in the literature.

CONCLUSION

The current findings constitute a further step towards a unified definition of compulsive exercise, and contribute important suggestions to the measurement of this behavior.

Restlessness and an Increased Urge to Move (Drive for Activity) in Anorexia Nervosa May Strengthen Personal Motivation to Maintain Caloric Restriction and May Augment Body Awareness and Proprioception: A Lesson From Leptin Administration in Anorexia Nervosa

Anorexia nervosa (AN), a disorder of voluntary food restriction leading to severe weight loss in female adolescents, remains an enigma. In particular, the appropriation of the starved thin body into the self-concept in AN is a process insufficiently researched and still poorly understood. Healthy humans undergoing starvation experience a slowing of movements and avoid voluntary exercise. By contrast, AN tends to be not infrequently associated with voluntary, sometimes excessive and/or compulsive exercise. Such deliberate exercise, not reported in starvation, seems to be facilitated by an increased urge for movement and physical restlessness, particular to AN. The increased urge to move would reflect spontaneous daily activity, the energy expended for everything that is not sleeping, eating, or voluntary exercise. Our hypothesis is that the starvation-induced increased urge to move and restlessness may promote the development of AN. Reversal of the fasting state, by either high caloric food or by leptin administration, would be expected to reduce restlessness and the increased urge to move along with improvement in other symptoms in AN. This review explores the idea that such restless activation in AN, in itself and through accelerating body weight loss, might foster the integration of the starving body into the self-concept by (1) enhancing the person’s sense of self-control and sense of achievement and (2) through invigorating proprioception and through intensifying the perception of the changing body shape. (3) Tentative evidence from studies piloting leptin administration in chronic AN patients which support this hypothesis is reviewed. The findings show that short term administration of high doses of leptin indeed mitigated depressive feelings, inner tension, intrusive thoughts of food, and the increased urge to be physically active, easing the way to recovery, yet had little influence on the patients’ personal commitment to remain at a low weight. Full recovery then requires resolution of the individuals’ personal unresolved psychological conflicts through psychotherapy and frequently needs specialized treatment approaches to address psychiatric co-morbidities. AN might be conceptualized as a hereditary form of starvation resistance, facilitated by the effects of starvation on fitness allowing for an exceptionally intense personal commitment to perpetuate food restriction.

Sensor technology in eating disorders research: A systematic review

OBJECTIVE

Sensor technologies offer exciting potential to objectively measure psychopathological correlates of eating pathology and eating disorder (ED) research utilizing sensors has rapidly proliferated in the past several years. The aims of the present review are: (1) characterize the types of sensors that have been utilized in ED research, (2) identify the psychopathological factors relevant to EDs that have been assessed using sensors, (3) describe the data supporting the validity and reliability of these sensors, (4) discuss limitations associated with these sensors, and (5) identify gaps that persist within the ED literature with regard to use of sensor technologies.

METHOD

A systematic search was conducted of PubMed, PsycINFO, Web of Science, ProQuest, and "gray" literature sources. Eligible publications were empirical studies that utilized sensors to measure at least one psychological variable among clinical ED populations.

RESULTS

Sensors have been utilized with ED samples to measure eating behaviors, physical activity, sleep, autonomic nervous system activity, eyeblink startle response, visual attention, and visual-haptic object integration. The reliability and validity of these sensors varies widely and there are a number of significant gaps that remain in the literature with regard to the types of sensors utilized, context in which sensors have been used, and populations studied.

DISCUSSION

The existing literature utilizing sensors within ED research largely support the feasibility and acceptability of these tools. Sensors should continue to be utilized within the field, with a specific focus on examining the reliability and validity of these tools within ED samples and increasing the diversity of samples studied.

PUBLIC SIGNIFICANCE STATEMENT

Sensor technologies, such as those included in modern smartwatches, offer new opportunities to measure factors that may maintain or contribute to symptoms of eating disorders. This article describes the types of sensors that have been used in eating disorders research, challenges that may arise in using these sensors, and discusses new applications of these sensors that may be pursued in future research.

Psychometric properties of the Compulsive Exercise Test in a large sample of female adolescent and adult inpatients with anorexia nervosa and bulimia nervosa

OBJECTIVE

The Compulsive Exercise Test (CET) was developed to assess compulsive exercise in patients with eating disorders (EDs), but originally validated in a nonclinical sample, and psychometric properties were only investigated in small clinical samples. Therefore, the aim of this study was to examine its psychometric properties in a large clinical sample of adolescent and adult inpatients with anorexia nervosa and bulimia nervosa.

METHOD

A sample of 2,535 German female inpatients with EDs completed the CET and other instruments at admission and discharge. Factor structure (confirmatory [CFA] and exploratory factor analyses [EFA]), internal consistency and construct validity, measurement invariance across age and diagnostic groups, group comparisons of means, as well as sensitivity to change during treatment were assessed.

RESULTS

The CET showed high internal consistency, very good construct validity, and sensitivity to change. CFA indicated a better fit of four-factor and three-factor solutions compared to the original five-factor model. However, subsequent EFA identified an optimum for a five-factor model. Only three subscales were satisfactorily invariant to measurement, but not the CET total score. Only small differences in scores between patient groups were observed.

DISCUSSION

Results support internal consistency, construct validity, and sensitivity to change, whereas factor structure remains inconclusive, questioning the theoretical basis of the CET. There is limited support for using the lack of enjoyment subscale, and only moderate support for using the rigidity subscale in patients with EDs. It is recommended to further explore and/or revise the original CET, including investigation in other samples, for example, male samples.

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).

Physical activity and sleep during the first week of anorexia nervosa inpatient care

BACKGROUND

Individuals with Anorexia Nervosa are often described as restless, hyperactive and having disturbed sleep. The result reproducibility and generalisability of these results are low due to the use of unreliable methods, different measurement methods and outcome measures. A reliable method to measure both physical activity and sleep is through accelerometry. The main purpose of the study was to quantify the physical activity and sleeping behaviour of anorexia nervosa patients. Another purpose was to increase result reproducibility and generalisability of the study.

MATERIAL AND METHODS

Accelerometer data were collected from the first week of treatment of anorexia nervosa at an inpatient ward. Raw data from the Axivity AX3© accelerometer was used with the open-source package GGIR for analysis, in the free statistical software R. Accelerometer measurements were transformed into euclidean norm minus one with negative values rounded to zero (ENMO). Physical activity measurements of interest were 24h average ENMO, daytime average ENMO, inactivity, light activity, moderate activity, and vigorous activity. Sleep parameters of interest were sleep duration, sleep efficiency, awakenings, and wake after sleep onset. The sleep duration of different age groups was compared to recommendations by the National Sleep Foundation using a Fisher's exact test.

RESULTS

Of 67 patients, due to data quality 58 (93% female) were included in the analysis. Average age of participants was 17.8 (±6.9) years and body mass index was 15.5 (±1.9) kg/m2. Daytime average ENMO was 17.4 (±5.1) mg. Participants spent 862.6 (±66.2) min per day inactive, 88.4 (±22.6) min with light activities, 25.8 (±16.7) min with moderate activities and 0.5 (±1.8) min with vigorous activities. Participants slept for 461.0 (±68.4) min, waking up 1.45 (±1.25) times per night for 54.6 (±35.8) min, having an average sleep quality of 0.88 (±0.10). 31% of participants met sleep recommendations, with a significantly higher number of 6-13 year old patients failing to reach recommendations compared to 14-25 year old patients.

CONCLUSION

The patient group spent most of their time inactive at the beginning of treatment. Most patients failed to reach sleep recommendations. The use of raw data and opensource software should ensure result reproducibility, enable comparison across points in treatment and comparison with healthy individuals.

Potential bioelectrical impedance analysis (BIA) parameters in prediction muscle strength in women with anorexia nervosa

OBJECTIVES

The role of physical activity in anorexia nervosa (AN) treatment has been investigated. Muscle strength (MS) reflects physical condition and can predict AN patients' response to this novel treatment approach. This study was intended to find bioelectrical impedance analysis (BIA) parameters that predict AN patients' MS.

METHODS

The study included 42 AN patients and 42 healthy ones in the control group. BIA parameters that predict MS were assessed by dividing AN patients into groups by their hand grip strength test score (higher/lower than 22.5 kg).

RESULTS

The highest accuracy for distinguishing AN subjects from the control group was achieved by cell membrane capacitance (AUC = 0.916), impedance at 200 kHz and 5 kHz ratio (AUC = 0.924), phase angle (PA) 5 kHz (AUC = 0.906) and PA 50 kHz (AUC = 0.919). The low MS group had significantly lower values of PA 50 kHz (mean: 4.03 ± 0.80° vs. 4.58 ± 0.65°; p = 0.032) and fat-free mass index (mean: 12.22 ± 1.41 kg/m² vs. 13.14 ± 0.94 kg/m²; p = 0.026). In the univariate model, PA 50 kHz ≥4.037° was associated with the lowest chance of muscle weakness (OR = 0.230; p = 0.005). In the multivariate analysis, PA 50 kHz was the only significant factor of MS (OR = 0.01; p = 0.027).

CONCLUSIONS

PA 50 kHz is the best BIA parameter to predict MS in AN patients. It could be useful for assessment before physical activity treatment application.

Physical activity behaviors and attitudes among women with an eating disorder: a qualitative study

BACKGROUND

Physical activity (PA) is an integral part of healthcare for the general population and individuals with psychiatric disorders. However, PA is significantly more complex for and related to both healthy (e.g., reduced anxiety and depressive symptoms) and unhealthy outcomes (e.g., intrusive, repetitive thoughts that lead to abnormally high levels of PA) among women with an eating disorder (ED). Consequently, many healthcare professionals recommend abstinence from PA during ED treatment. Despite this, women may remain engaged in PA during ED treatment or resume PA shortly thereafter. Little has been done to understand women's PA behaviors and attitudes and to explore how they integrate PA into their lives during and after ED treatment. Thus, this study sought to explore PA behaviors and attitudes among women with an ED.

METHODS

Nine women who self-reported receiving an ED diagnosis participated in semi-structured interviews, which were transcribed and analysed thematically.

RESULTS

Six interrelated themes were constructed to represent participants' PA experiences: PA as a lifestyle, PA can be beneficial, How I feel when I can't do PA, Being cautious about PA, Reactions to healthcare professionals' practice of recommending abstinence from PA during ED treatment, and PA programming thoughts.

CONCLUSIONS

Overcoming dysfunctional PA behaviors (e.g., engaging in abnormally high levels of PA) and attitudes (e.g., associating PA with caloric expenditure) can be a long and complicated journey for women with an ED. Nevertheless, women with an ED want PA to be integrated into their ED treatment protocol for two key reasons, namely to accrue the benefits associated with PA and to learn how to engage in PA in adaptive and healthy ways.

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.

Might Starvation-Induced Adaptations in Muscle Mass, Muscle Morphology and Muscle Function Contribute to the Increased Urge for Movement and to Spontaneous Physical Activity in Anorexia Nervosa?

Severely undernourished and underweight anorexia nervosa (AN) patients typically remain active and mobile. Might such persistent physical activity in AN be supported by specific adaptations in muscle tissue during long term undernutrition? To identify potential differences, studies examining the effects of undernutrition on skeletal muscle mass, muscle morphology and muscle function in healthy humans and in AN patients were reviewed. Adjustments in muscle morphology and function in AN did not differ in substance from those in healthy humans, undernourished people, or undergoing semi-starvation. Loss of muscle mass, changes in muscle contractility and atrophy of muscle fibers (predominantly type II fibers) characterized both groups. Muscle innervation was unaffected. Work capacity in men in semi-starvation experiments and in females with AN declined by about 70% and 50%, respectively. Perceptions of fatigue and effort distinguished the groups: signs of general weakness, tiring quickly and avoidance of physical activity that were recorded in semi-starvation were not reported for AN patients. The absence of distinctive starvation-related adjustments in skeletal muscle in AN suggests that new methods, such as muscle gene expression profiles in response to deficient nutrient intake, and better knowledge of the central regulatory circuitries contributing to motor urgency will be required to shed light on the persistent mobility in AN patients.

Psychological and nutritional correlates of objectively assessed physical activity in patients with anorexia nervosa

BACKGROUND

Physical activity (PA) plays a role in the course of anorexia nervosa (AN).

OBJECTIVE

To assess the association between PA, nutritional status and psychological parameters in patients with AN.

METHOD

Using a wearable activity monitor, PA was assessed in 60 female AN inpatients, by step count and time spent in 4 metabolic equivalent (MET)-intensity levels: sedentary behaviour, light, moderate and vigorous PA. In addition, BMI, psychological (patient-reported outcome questionnaires) and nutritional parameters (body fat, energy and macronutrient intake) were assessed.

RESULTS

The study population spent little time in vigorous PA. BMI on admission and discharge was higher when more time was spent in sedentary behaviour, and lower with more time spent in light PA. Relationships between PA and patient-reported outcomes were weak and limited to an association between vigorous PA and compulsiveness. Low fat mass was associated with more time spent in light PA, while subjects with higher step counts showed less intake of energy, carbohydrates and fat.

CONCLUSION

The relationship between inadequate food intake and increased PA in patients with AN requires further investigation.

Feasibility and effect of a Pilates program on the clinical, physical and sleep parameters of adolescents with anorexia nervosa

BACKGROUND AND PURPOSE

Anorexia nervosa (AN) becomes chronic, with high physical, psychological and social morbidity and high mortality without early and effective treatment. The impact of physical exercise as a coadjutant to conventional treatment in this clinical population has been studied with favorable results. Although a Pilates program could be beneficial for patients with AN, no study has analyzed its feasibility and effects in adolescents with AN. Therefore, this study evaluated the safety of a Pilates program and investigated the feasibility and effect in adolescents with AN.

MATERIALS AND METHODS

In this prospective quasi-experimental study, body composition, blood analysis, sedentary time, physical activity and time of sleep, and physical fitness were measured objectively before and after a 10-week Pilates supervised program.

RESULTS

Twelve female adolescents with AN (14.6 ± 1.7 years old) completed the program, with a session attendance rate of 96%, a persistence rate of 100%. There were significant increases in height, plasma calcium and sleep efficiency. Significant decreases in plasma follitropin, sleep duration and, duration and number of night perturbations were observed.

CONCLUSION

A Pilates program is safe and feasible in adolescents with AN when they have a controlled and stable weight, and such a program could be a viable alternative among treatment programs to achieve better sleep quality.

Assessment of Physical Activity Patterns in Adolescent Patients with Anorexia Nervosa and Their Effect on Weight Gain

(1) Background: Altered physical activity (PA) affects weight recovery in anorexia nervosa (AN) patients. The study aimed to objectively characterize PA patterns and their effect on weight trajectory in adolescent AN patients. (2) Methods: PA was assessed in 47 patients on admission to inpatient treatment, in n = 25 of these patients again 4 weeks after discharge (follow-up, FU), as well as in 20 adolescent healthy controls using the Sense Wear™ armband. The following PA categories were defined by metabolic equivalent (MET) ranges: sedentary behavior (SB), light (LPA), moderate (MPA), vigorous (VPA), and high-level PA (HLPA= MPA + VPA). (3) Results: LPA on admission was significantly higher in AN patients than in controls (103 vs. 55 min/d, p < 0.001), and LPA in AN decreased over time to 90 min/d (p = 0.006). Patients with higher admission LPA (n = 12) still had elevated LPA at FU (p = 0.003). High admission LPA was associated with a higher inpatient BMI percentage gain (ΔBMI%; 18.2% ± 10.0% vs. 12.0% ± 9.7%, p = 0.037) but with a loss of ΔBMI% at FU (-2.3% ± 3.6% vs. 0.8% ± 3.6%, p = 0.045). HLPA at baseline was associated with a lower inpatient ΔBMI% (p = 0.045). (4) Conclusion: Elevated LPA in AN patients decreased after inpatient treatment, and PA patterns had an impact on weight trajectory.

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.

Prevalence and correlates of self-reported disordered eating: A cross-sectional study among 90 592 middle-aged Norwegian women

Disordered eating (DE) is extensively studied among adolescents and young women. However, there is growing evidence that DE as well as the clinical eating disorders may occur at any age from childhood to advanced years. This study aimed to determine the prevalence and correlates of DE in a representative sample of middle-aged women from Norway. The study included 90 592 women (median age: 55 years) from the Norwegian Women and Cancer study who responded to a questionnaire between the years 2002–2005. Correlates of self-reported DE were assessed by logistic regression analyses. The overall period prevalence of DE between 2002–2005 was 0.28 (95% confidence interval 0.25–0.31) %, and was highest among women ≥ 66 years: 0.65 (0.60–0.70) %. DE was strongly associated with depression (Odds ratio [OR] 3.34 [95% confidence interval 2.53–4.41]), being unemployed (OR 1.78 [1.32–2.40]) and single (OR 1.66 [1.25–2.20]). Women with DE were more likely to report low energy intake (OR 1.41 [1.08–1.86]) and were less likely to be moderately physically active (OR 0.67 [0.47–0.95]). Using the largest study sample in the literature, the present findings confirm smaller studies showing that DE do occur in women in mid-life and older age as well. Our results contribute to address a somewhat under-communicated community health problem that needs attention in terms of age-specific treatment and prevention.

High-intensity exercise is associated with a better nutritional status in anorexia nervosa

OBJECTIVE

Our aim is to investigate the links between duration and intensity of exercise and the nutritional status in terms of body composition in acute anorexia nervosa (AN) patients.

METHOD

One hundred ninety-one hospitalized women suffering from AN were included. Exercise duration and intensity were assessed using a semistructured questionnaire. Body composition was measured using bioelectrical impedance. Linear multiple regression analyses were carried out using body mass index, fat-free mass index, and fat mass index as dependent variables and including systematically exercise duration, exercise intensity, and other confounding variables described in the literature that were significantly associated with each dependent variable in univariate analysis.

RESULTS

A lower BMI was linked to lower exercise intensity, AN restrictive type, and presence of amenorrhea. A lower FFMI was linked to lower exercise intensity, older age, AN restrictive type, and premenarchal AN. Duration of exercise was not linked to the nutritional status.

CONCLUSIONS

Exercising at higher intensity in AN is associated with a better nutritional status, thus, a better resistance to starvation. The impact of therapeutic physical activity sessions, adapted in terms of exercise intensity and patient's clinical status, should be evaluated during nutrition rehabilitation.

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.

The Role of Objectively Measured, Altered Physical Activity Patterns for Body Mass Index Change during Inpatient Treatment in Female Patients with Anorexia Nervosa

Increased physical activity (PA) affects outcomes in patients with anorexia nervosa (AN). To objectively assess PA patterns of hospitalized AN patients in comparison with healthy, outpatient controls (HC), and to analyze the effect of PA on Body Mass Index (BMI) change in patients with AN, we measured PA in 50 female patients with AN (median age = 25 years, range = 18–52 years; mean BMI = 14.4 ± 2.0 kg/m²) at the initiation of inpatient treatment and in 30 female healthy controls (median age = 26 years, range = 19–53 years; mean BMI = 21.3 ± 1.7 kg/m²) using the SenseWear™ armband. Duration of inpatient stay and weight at discharge were abstracted from medical records. Compared with controls, AN patients spent more time in very light-intensity physical activity (VLPA) (median VLPA = 647 vs. 566 min/day, p = 0.004) and light-intensity physical activity (LPA) (median LPA = 126 vs. 84 min/day, p < 0.001) and less time in moderate-intensity physical activity (MPA) (median MPA = 82 vs. 114 min/day, p = 0.022) and vigorous physical activity (VPA) (median VPA = 0 vs. 16 min/day, p < 0.001). PA and BMI increase were not associated in a linear model, and BMI increase was mostly explained by lower admission BMI and longer inpatient stay. In a non-linear model, an influence of PA on BMI increase seemed probable (jack knife validation, r² = 0.203; p < 0.001). No direct association was observed between physical inactivity and BMI increase in AN. An altered PA pattern exists in AN patients compared to controls, yet the origin and consequences thereof deserve further investigation.

Self-reported quantity, compulsiveness and motives of exercise in patients with eating disorders and healthy controls: differences and similarities

BACKGROUND

Compulsive exercise (CE) is a frequent symptom in patients with eating disorders (EDs). It includes, in addition to quantitatively excessive exercise behaviour, a driven aspect and specific motives of exercise. CE is generally associated with worse therapy outcomes. The aims of the study were to compare self-reported quantity of exercise, compulsiveness of exercise as well as motives for exercise between patients with anorexia nervosa (AN), bulimia nervosa (BN) and healthy controls (HC). Additionally, we wanted to explore predictors of compulsive exercise (CE) in each group.

METHODS

We investigated 335 female participants (n = 226 inpatients, n = 109 HC) and assessed self-reported quantity of exercise, compulsiveness of exercise (Compulsive Exercise Test), motives for exercise (Exercise Motivations Inventory-2), ED symptoms (Eating Disorder Inventory-2), obsessive-compulsiveness (Obsessive-Compulsive Inventory-Revised), general psychopathology (Brief Symptom Inventory-18) and depression (Beck Depression Inventory-2).

RESULTS

Both patients with AN and BN exercised significantly more hours per week and showed significantly higher CE than HC; no differences were found between patients with AN and BN. Patients with EDs and HC also partly varied in motives for exercise. Specific motives were enjoyment, challenge, recognition and weight management in patients with EDs in contrast to ill-health avoidance and affiliation in HC. Patients with AN and BN only differed in regard to exercise for appearance reasons in which patients with BN scored higher. The most relevant predictor of CE across groups was exercise for weight and shape reasons.

CONCLUSIONS

Exercise behaviours and motives differ between patients with EDs and HC. CE was pronounced in both patients with AN and BN. Therefore, future research should focus not only on CE in patients with AN, but also on CE in patients with BN. Similarities in CE in patients with AN and BN support a transdiagnostic approach during the development of interventions specifically targeting CE in patients with EDs.

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.

Characterization and correlates of exercise among adolescents with anorexia nervosa and bulimia nervosa

OBJECTIVE

To characterize exercise behaviors among adolescents with anorexia nervosa (AN), atypical AN, or bulimia nervosa (BN), and determine associations between exercise and medical risk.

STUDY DESIGN

Cross-sectional electronic medical records of all patients evaluated by the Eating Disorder Program at Stanford between January 1997 and February 2011 were retrospectively reviewed.

RESULTS

1,083 subjects (961 females, 122 males; mean age 15.6) met eligibility criteria. Most patients (89.7%) reported exercise (mean 7.0 h per week over mean 5.4 days per week) prior to presentation. Running (49.9%), calisthenics (40.7%), walking (23.4%), soccer (20.9%), and swimming (18.2%) were the most common exercises; a majority (60.6%) reported team sport participation. Males were less likely to report team exercise (p = .005). Bradycardia (heart rate <50) at presentation was associated with team sport participation (adjusted odds ratio [AOR] 1.66, 95% confidence interval [CI] 1.02-2.72) and hours of exercise per week (AOR 1.05, 95% CI 1.02-1.09), controlling for diagnosis, sex, age, duration of illness, rate of weight loss, and percent median body mass index (%mBMI).

DISCUSSION

Adolescents with AN, atypical AN, and BN reported high levels of exercise. Females reported more team sport participation. Greater exercise frequency and team sport participation were associated with bradycardia. Further studies assessing the relationship between exercise and bradycardia may help inform the medical management of adolescents with these eating disorders who are more physically active.

Leptin and Physical Activity in Adult Patients with Anorexia Nervosa: Failure to Demonstrate a Simple Linear Association

High physical activity (PA) in patients with anorexia nervosa (AN) is hypothesized to be, at least in part, a consequence of hypoleptinemia. However, most studies on the association of leptin and PA in AN were performed in adolescents or young adults, and PA was generally measured with subjective tools. We aimed to explore the association of leptin and PA in adults with AN using an objective technique to quantify PA. Using a cross-sectional, observational design, we analyzed body fat (bioelectrical impedance), PA (accelerometry, SenseWear™ armband) and plasma leptin (ELISA) in 61 women with AN (median age: 25 years, range: 18–52 years; median BMI: 14.8 ± 2.0 kg/m²) at the start of hospitalization. Results indicated a mean step count per day of 12,841 ± 6408 (range: 3956–37,750). Leptin was closely associated with BMI and body fat (ρ = 0.508 and ρ = 0.669, p < 0.001), but not with steps (ρ = 0.015, p = 0.908). Moreover, no significant association was observed between BMI and steps (ρ = 0.189, p = 0.146). In conclusion, there was no simple, linear association of leptin and PA, highlighting the need for more complex and non-linear models to analyze the association of leptin and PA in adults with AN in future studies.

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.

Measurement of fidgeting in patients with anorexia nervosa using a novel shoe-based monitor

OBJECTIVE

To objectively assess seated non-exercise physical activity in patients with anorexia nervosa (AN) relative to healthy controls (HCs) and examine the associations between this physical activity, eating disorder pathology, and levels of anxiety and depression.

METHOD

Eleven inpatients with AN and 10 HCs wore a shoe-based accelerometer (SmartShoe) at three time points: a) while eating lunch, b) filling out questionnaires, and c) watching television for 1h.

RESULTS

Across all three tasks, patients with AN were significantly more active than HCs, thereby engaging in a greater degree of restless or fidgeting behavior. Degree of physical activity was positively correlated with eating disorder psychopathology in the sample with AN, and a trend towards a positive association between physical activity and levels of depression and anxiety was also found in this sample. Among individuals with AN, physical activity was not significantly correlated with BMI, duration of illness, or number of days since hospital admission.

DISCUSSION

Use of a minimally invasive, shoe-based monitor revealed patients with AN engaged in a greater degree of fidgeting relative to HCs during quiet, seated tasks and this heightened activity was related to measures of pathology. Non-exercise physical activity, including fidgeting, may warrant further clinical attention in this patient population.

Physical activity, body weight, and resumption of menses in anorexia nervosa

Few data are available on long-term outcomes and increased physical activity at the end of inpatient treatment in patients with anorexia nervosa. Hence we assessed the association between physical activity, measured objectively by Sense Wear Armband (SWA), and body mass index (BMI; kg/m²) and menses resumption at one-year follow-up in 32 females with anorexia nervosa who had restored normal body weight by the end of a specialist inpatient treatment. Combined logistic regression models used to evaluate the relationship between variables at discharge, BMI and resumption of menses at one-year follow-up revealed no significant association between BMI at one-year follow-up and physical activity patterns at inpatient discharge. However, total daily steps at inpatient discharge were significantly lower in patients who had resumed menstruation, as confirmed by logistic regression analysis. A small reduction in daily steps at inpatient discharge (~1000 steps) was found to increase the probability of menses resumption at one-year follow-up by ~3%. These data provide preliminary indications as to the potential usefulness of assessing daily steps to predict the resumption of menses at one-year follow-up in patients with anorexia nervosa who restore body weight by the end of inpatient treatment, although confirmation on larger samples is urgently required.

Dimensions of Compulsive Exercise across Eating Disorder Diagnostic Subtypes and the Validation of the Spanish Version of the Compulsive Exercise Test

Objectives: Compulsive exercise in eating disorders has been traditionally considered as a behavior that serves the purpose of weight/shape control. More recently, it has been postulated that there may be other factors that drive the compulsive need to exercise. This has led to the development of the Compulsive Exercise Test (CET); a self-reported questionnaire that aims to explore the cognitive-behavioral underpinnings of compulsive exercise from a multi-faceted perspective. The objectives of this study were threefold: (1) to validate the Spanish version of the CET; (2) to compare eating disorder diagnostic subtypes and a healthy control group in terms of the factors that drive compulsive exercise as defined by the CET; (3) to explore how the dimensions evaluated in the CET are associated with eating disorder symptoms and general psychopathology.

Methods: The CET was administered to a total of 157 patients with an eating disorder [40 anorexia nervosa, 56 bulimia nervosa (BN), and 61 eating disorder not-otherwise-specified (EDNOS)] and 128 healthy weight/eating controls. Patients were assessed via a semi-structured interview to reach a DSM-IV-TR diagnosis. Additionally, all participants completed the Symptom Checklist-90-Revised (SCL-90R) and the Eating Disorders Inventory-2 (EDI-2).

Results: Confirmatory factor analysis demonstrated adequate goodness-of-fit to the original five-factor model of the CET. BN and EDNOS patients scored higher in the avoidance and rule-driven behavior, weight control, and total CET scales in comparison to the healthy controls, and higher across all scales apart from the exercise rigidity scale compared to the anorexia nervosa patients. Mean scores of the anorexia nervosa patients did not differ to those of the control participants, except for the mood improvement scale where the anorexia nervosa patients obtained a lower mean score. Mean scores between the BN and EDNOS patients were equivalent. The CET scales avoidance and rule-driven behavior, weight of control and total CET scores were positively correlated with the clinical assessment measures of the SCL-90R and EDI-2.

Conclusion: Compulsive exercise is a multidimensional construct and the factors driving compulsive exercise differ according to the eating disorder diagnostic subtype. This should be taken into account when addressing compulsive exercise during the treatment of eating disorders.

Management of Severe Rhabdomyolysis and Exercise-Associated Hyponatremia in a Female with Anorexia Nervosa and Excessive Compulsive Exercising

This case report describes the management of a 49-year-old female with restricting-type anorexia nervosa and excessive compulsive exercising associated with rhabdomyolysis, high levels of serum creatine kinase (CK) (3,238 U/L), and marked hyponatremia (Na⁺: 123 mEq/L) in the absence of purging behaviours or psychogenic polydipsia; it is the first case report to describe exercise-associated hyponatremia in a patient with anorexia nervosa. The patient, who presented with a body mass index (BMI) of 13.4 kg/m², was successfully treated by means of an adapted inpatient version of an enhanced form of cognitive behavioural therapy (CBT-E). Within a few days, careful water restriction, solute refeeding, and the specific cognitive behavioural strategies and procedures used to address the patient's excessive compulsive exercising and undereating produced a marked reduction in CK levels, which normalised within one week. Exercise-associated hyponatremia also gradually improved, with serum sodium levels returning to normal within two weeks. The patient thereby avoided severe complications such as cerebral or pulmonary oedema or acute renal failure and was discharged after 20 weeks of treatment with a BMI of 19.0 kg/m² and improved eating disorder psychopathology.

The reinforcing effect of exercise in anorexia nervosa: Clinical correlates and relationship to outcome

The purpose of the current study was to examine the relative reinforcing effect of exercise compared to a non-monetary alternative reinforcer (leisure activity), and to money, before and after weight restoration in an inpatient population with anorexia nervosa (AN). Sixty-two inpatients with AN completed a progressive ratio (PR) task to earn exercise, leisure activities, or cash at low weight and after weight restoration. Measures of pathology and motivation to exercise were completed and post-treatment discharge weights were collected. Patients worked harder for exercise at low weight than after weight restoration (df = 46, t = 5.50, p < .001). PR task performance was weakly associated with a measure of commitment to exercise (low weight: r = 0.31, weight restored: r = 0.36, p < .05), but not with other clinical measures or follow-up weights. Contrary to prior suggestions, measurement of the reinforcing value of exercise among individuals with AN via a PR task does not appear valuable in assessing clinical severity or outcome. Other, simpler, self-report measures of commitment to exercise may have greater value in assessing these outcomes.

Physical activity and post-treatment weight trajectory in anorexia nervosa

OBJECTIVE

This study compared an objective measurement of physical activity (PA) in individuals with anorexia nervosa (AN) at low-weight, weight-restored, and post-treatment time points, and also compared PA in AN with that of healthy controls (HC).

METHOD

Sixty-one female inpatients with AN wore a novel accelerometer (the IDEEA) which measured PA at three time points: a) low-weight, b) weight-restored, and c) one month post-hospital discharge. Twenty-four HCs wore the IDEEA at one time point.

RESULTS

Inpatients with AN became more physically active than they were at low-weight at weight restoration and following treatment discharge. Post-treatment patients with AN were more physically active than HCs during the day and less active at night, which was primarily accounted for by amount of time spent on feet, including standing and walking. Greater time spent on feet during the weight-restoration time point of inpatient treatment was associated with more rapid decrease in BMI over the 12 months following treatment discharge. Fidgeting did not differ between patients and controls, did not change with weight restoration, and did not predict post-treatment weight change.

DISCUSSION

Use of a novel accelerometer demonstrated greater PA in AN than in HC. PA following weight restoration in AN, particularly time spent in standing postures, may contribute to weight loss in the year following hospitalization. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:482-489).

Evaluation of the Compulsive Exercise Test (CET) in Adolescents with Eating Disorders: Factor Structure and Relation to Eating Disordered Psychopathology

OBJECTIVE

The aims of this study were to explore the factor structure of the Compulsive Exercise Test (CET) in a clinical sample of Swedish adolescents with eating disorders (ED) and to study the relationship of CET with ED cognitions, body weight and exercise frequency.

METHODS

The compulsive Exercise Test, the Eating Disorders Examination-Questionnaire, body mass index (BMI) and exercise frequency were available at assessment of 210 adolescents (age 14.4 ± 1.6 years) with ED.

RESULTS

Factor analysis generated four factors with close similarity to factors previously obtained in a community sample of adolescents samples and supported the use of the original version of CET. Exercise for weight control was strongly related to ED cognitions but less to exercise frequency and BMI. Exercise for regulation of mood was related to ED cognitions and exercise frequency but not to BMI.

DISCUSSION

In adolescents with ED, different aspects of exercise are related to ED cognitions. This needs addressing in the treatment of adolescents with ED. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

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.

Restricted temporal access to food and anorexia in mice: Microstructure of eating within feeding opportunities

Intake and body weight were recorded in a closed economy as male and female C57BL/6 mice progressed through either fixed interval (FI) or fixed unit price (FUP) schedules of cost for 20-mg food pellets. Access to food was constrained to four 40 min food opportunities (FOs) per day, spaced 4-h apart through the dark phase. Nose poke responses and pellet deliveries were collected at 10-s resolution to allow pellet-by-pellet analysis. In the FI protocol, mice maintained adequate food intake and body weight through the study, even though at the highest FI (50-s) they spent the entire 40-min FOs engaged in eating at or near the maximum rate allowed by the schedule. In the FUP protocol, mice greatly reduced their intake and lost weight at the highest FUP (50 responses/pellet). The analysis of response and pellet distributions showed these mice were not filling the FOs with responding and ate less at dusk (FO #1) and dawn (FO #4) than at FOs #2 and 3 in the middle of the night. The principal, and unexpected, sex difference was that females tended to eat more than males despite lower body weight, but behavioral changes as a function of feeding cost or schedule were qualitatively similar in both sexes. These results show that slow eating as imposed by an FI is not sufficient to produce hypophagia and, in the FUP protocol, hypophagia cannot be explained by slowed eating due to response requirements. We discuss the role of effort or time in FUP-induced anorexia, and suggest this murine model may emulate some aspects of human anorexia nervosa better than current activity-based protocols.

Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta-analysis

OBJECTIVE

Understanding the factors that predict a favourable outcome following specialist treatment for an eating disorder may assist in improving treatment efficacy, and in developing novel interventions. This review and meta-analysis examined predictors of treatment outcome and drop-out.

METHOD

A literature search was conducted to identify research investigating predictors of outcome in individuals treated for an eating disorder. We organized predictors first by statistical type (simple, meditational, and moderational), and then by category. Average weighted mean effect sizes (r) were calculated for each category of predictor.

RESULTS

The most robust predictor of outcome at both end of treatment (EoT) and follow-up was the meditational mechanism of greater symptom change early during treatment. Simple baseline predictors associated with better outcomes at both EoT and follow-up included higher BMI, fewer binge/purge behaviors, greater motivation to recover, lower depression, lower shape/weight concern, fewer comorbidities, better interpersonal functioning and fewer familial problems. Drop-out was predicted by more binge/purge behaviors and lower motivation to recover. For most predictors, there was large interstudy variability in effect sizes, and outcomes were operationalized in different ways. There were generally insufficient studies to allow analysis of predictors by eating disorder subtype or treatment type.

DISCUSSION

To ensure that this area continues to develop with robust and clinically relevant findings, future studies should adopt a consistent definition of outcome and continue to examine complex multivariate predictor models. Growth in this area will allow for stronger conclusions to be drawn about the prediction of outcome for specific diagnoses and treatment types.

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.

High Levels of Physical Activity in Anorexia Nervosa: A Systematic Review

High level physical activity is a frequent symptom in patients with anorexia nervosa (AN), influencing the development, maintenance, complications, treatment success, relapse rate and severity of the disease. Accelerometry is assumed to be an objective method to assess physical activity (PA) in AN. We aimed to review objectively measured levels of PA in AN and to give an overview for clinical practice and future research. Data were searched in PubMed and PsychINFO until April 2015 following the preferred reporting items for systematic reviews and meta-analyses statement. Twenty studies fulfilled the inclusion criteria. A notable heterogeneity of measurements, outcomes, participants and settings was found. Overall, HLPA is not adressed enough by current evidence. A common valid terminology of HLPA is not available, and accurate criteria of different levels of PA must be defined to create comparability of future studies. Further objective PA assessments are needed to improve treatment outcome and relapse rate.

Physical activity and the drive to exercise in anorexia nervosa

OBJECTIVES

To investigate physical activity (PA) and drive for exercise in anorexia nervosa (AN) in relation to eating disorder (ED) pathology and anxiety.

METHOD

Female participants were recruited into four groups: AN outpatients (n = 37), AN inpatients (n = 18), an anxiety group (n = 34), and healthy controls (HCs; n = 30). PA was measured by actigraphy and self-report together with drive/reasons for exercise, ED pathology, anxiety, depression, stress, BMI, and body composition.

RESULTS

ED psychopathology, general psychopathology, and physiological measures were consistent with diagnosis. All groups showed a wide range in activity, especially on self-report. No significant group differences were observed in objective PA levels, yet AN groups reported 57-92% higher total activity than HCs. Outpatients reported more walking and moderate exercise than HCs, and inpatients reported more walking but less moderate and vigorous activity than all other groups. AN groups had significantly higher drive to exercise and valued "improving tone" as important and health and enjoyment as less important reasons to exercise.

DISCUSSION

Self-perceived activity rather than objective data may partly explain the increased activity reported in AN. Drive to exercise in AN appears to be more related to ED pathology than to anxiety.