Conceptualizing primary and secondary pathological exercise using available measures of excessive exercise

Going deeper into eating and body image pathology in males: Prevalence of muscle dysmorphia and eating disorders in a university representative sample

Disorders associated with body dissatisfaction such eating disorders (ED) and muscle dysmorphia (MD) in males are understudied and surrounded by controversy regarding their nosological aspects. The current study examined the prevalence rates of clinical cases of ED and MD through a two-phase study with gold standard clinical interview in a representative sample of 850 Spanish undergraduate men, of whom 141 were interviewed. Levels of body dissatisfaction, compulsive exercise, anxious-depressive symptoms and the amount of physical activity were also explored. A prevalence rate for ED of 1.4% and 1.3% for MD was found. No differences were observed between the clinical groups on scales related to body image, supporting the current perspective that MD as well as ED and Body Dysmorphic Disorder could be clustered in a new spectrum of body image disorders, where the behaviours performed to achieve body change could range from restriction or muscularity-oriented eating alterations to pathological exercise or cosmetic surgery. The usefulness of the cut-off points of the screening questionnaires in MD and ED in males are discussed.

Does Exercise Addiction Exist Among Individuals Engaged in Team-Based Exercise? A Position Paper

Exercise addiction is a term used to describe dysfunctional exercise behavior characterized by the classic symptoms of addictions, which eventually result in physical, psychological, or social harm to the affected individual. While well over 1000 peer-reviewed papers on problematic exercise have been published, very few studies have explored the conceptual differences between team-based and individual-based exercise, and no previous study has critically addressed this issue. The rationale for this distinction is that team-based exercise is typically organized and scheduled by others with little or no control over its timing by the individual team member. On the contrary, individual-based exercise can be self-scheduled. Consequently, more (total) control over its timing facilitates the satisfaction of craving-induced urges characterized by an addiction. It is posited that exercise addicts, in general, are “lone wolves” in the context of their addiction. Therefore, being addicted to exercise in team sports is only possible if the individual resorts to additional individually-controlled exercise above and beyond team-based training. To support this position, the present paper briefly reviews the few studies conducted in this area and examines how their results match the diagnostic interpretation of “addiction.” The present position paper highlights that “control” over the addictive behavior, in this case, exercise, is an important marker in the potential for the risk of exercise addiction. Therefore, future studies should consider that team-based exercise assigns little control to the individual. However, the extent to which additional individual-based exercise occurs and poses a risk of addiction within team exercises merits further research attention.

Identity Formation, Body Image, and Body-Related Symptoms: Developmental Trajectories and Associations Throughout Adolescence

Emerging evidence highlights the intricate link between identity and one's body, however, integrative longitudinal research on this identity-body interplay is lacking. The current study used three-wave longitudinal data (Time 1: N = 403; 52.1% female; M_age = 14.85, SD = 0.89, range = 13-19 years) spanning two years (2019-2021; T1 and T2 being pre-pandemic, T3 peri-pandemic) to identify identity trajectory classes and examine their co-development with negative and positive body image and various body-related variables (i.e., sociocultural pressures, internalization of appearance ideals, self-objectification, appearance comparison, and eating disorder symptoms). First, four identity classes emerged using latent class growth analysis (achievement, moratorium, carefree diffusion, and troubled diffusion). Second, using multigroup latent growth curve modeling, adolescents in less adaptive identity trajectory classes (i.e., engaging less in pro-active processes and more in ruminative processes) displayed higher levels of negative body image and body-related symptoms. The current study testified to the clinically meaningful associations linking identity formation to adolescents' body image and other body-related symptoms.

Psychological well-being and exercise addiction: The treatment effects of an REBT intervention for females

Whilst there is growing research on the benefits of Rational Emotive Behaviour Therapy (REBT) for athletic performance and wellbeing, there has been little attention on the effectiveness of REBT for the exercising population. Recent evidence suggests that REBT may be helpful for males who show signs of exercise addiction, but the effects for females are currently unknown. The current study aims to build on the extant research by adopting a single-case research design to examine the effects of REBT on irrational beliefs, exercise addiction symptomology, psychological distress, and unconditional self-acceptance (USA) of three female exercisers. Self-report data were collected at pre-, during, and post-REBT timepoints. Visual analyses revealed reductions in irrational beliefs and psychological distress, and increases in USA, maintained two-weeks post-REBT. Exercise addiction symptomology also reduced during the intervention, and this was maintained for two out of the three exercisers post-REBT. Social validation data supported these findings. The study adds weight to the efficacy of REBT in improving exercise addiction and its comorbidities.

Brain default mode network mediates the association between negative perfectionism and exercise dependence

BACKGROUND AND AIMS

Perfectionism is correlated with the occurrence of exercise dependence. We aim to reveal the role of functional connectivity (FC) between gray matter (GM) and white matter (WM) networks in the association between perfectionism and exercise dependence.

METHODS

In this cross-sectional study, one hundred ten participants with exercise dependence underwent behavioral evaluation and resting-state functional magnetic resonance imaging. Perfectionism and exercise dependence were quantified using the Frost Multidimensional Perfectionism Scale (FMPS) and Exercise Dependence Scale (EDS). We used a K-means clustering algorithm to identify functional GM and WM networks and obtained the FCs of the GM-GM, GM-WM, and WM-WM networks. Partial correlation and mediation analyses were performed to explore the relationships among FCs, FMPS, and EDS.

RESULTS

We identified ten stable GM networks and nine WM networks. Of these, FCs existed between the corona radiata network (WM1) and default mode network (DMN, GM8), WM1 network and WM DMN (WM4), WM1 network and midbrain WM network (WM7), and WM4 network and inferior longitudinal fasciculus network (WM9). The WM1-GM8 and WM1-WM4 FCs were positively correlated with the EDS and negative FMPS. The mediating effects of the WM1-GM8 and WM1-WM4 FCs were established in the association between the negative dimensional FMPS and EDS.

DISCUSSION AND CONCLUSIONS

The WM1 network anatomically linked the subregions within the GM8 and WM4 networks, and WM1-GM8 and WM1-WM4 FCs mediated the association between negative dimensional FMPS and EDS. These findings indicated that DMN function might be involved in the increased risks of exercise dependence promoted by negative perfectionism.

Alexithymia, reward sensitivity and excessive exercise in non-binge-eaters versus severe binge eaters: Implications for primary and secondary exercise dependence

A distinction has been made between primary and secondary exercise dependence, with the latter defined as excessive exercise secondary to disordered eating and weight concerns. Based on theoretical considerations from research on the roles of trait factors in addictions, the present study used validated scales to assess alexithymia, sensitivity to reward and punishment, emotion regulation and interoception in relation to exercise dependence symptoms in Australian male and female non-binge eaters (n = 228) and severe binge eaters (n = 126) aged 18-30 yr. In both groups, exercise dependence symptoms were significantly positively associated with reward sensitivity and interoceptive awareness, with the latter two variables predicting exercise dependence symptoms in hierarchical regression models; punishment sensitivity was significantly negatively related to such symptoms. Alexithymia was significantly associated with exercise dependence symptoms only in non-binge eaters; in severe binge eaters, alexithymia explained 0% of unique variance. Male sex was associated with more exercise dependence symptoms in severe binge eaters only. Participants in the severe binge group scored significantly higher on measures of exercise dependence, alexithymia, risky alcohol use, and sensitivity to reward and punishment, and significantly lower on emotion regulation, compared to those in the non-binge group. Hierarchical regression models explained 25% of variance in exercise dependence symptoms in non-binge-eaters and 43% in severe binge eaters. Findings are discussed in terms of the distinction between primary and secondary exercise dependence, the role of alexithymia, study limitations including data collection during the COVID-19 pandemic in Australia, and suggestions for future research.

Associations between aerobic exercise and dopamine-related reward-processing: Informing a model of human exercise engagement

Endurance or aerobic exercise has many physical and mental health benefits, but less is known about the specific impact that cardiovascular activity may have on dopamine-associated brain circuits involved in reward processing and mood regulation in humans. Understanding such effects will help to explain individual differences in both exercise uptake and maintenance. This study evaluated neural response to a classical taste-conditioning reward prediction error task with the use of functional magnetic resonance imaging, along with data on self-reported aerobic exercise among healthy young adult females (N = 111). Results indicated positive associations between reported aerobic exercise and regional brain response that remained significant after multiple comparison correction for the right medial orbital frontal cortex response to unexpected sucrose receipt (r = 0.315, p = .0008). The medial orbitofrontal cortex is implicated in reward and outcome value computation and the results suggest that aerobic exercise may strengthen this circuitry, or reciprocally, higher orbitofrontal cortical activity may reinforce exercise behavior. The findings aid in developing a model of how exercise engagement can modify reward-circuit function and could be used therapeutically in conditions associated with altered brain salience response.

Examining the reliability of the scores of self-report instruments assessing problematic exercise: A systematic review and meta-analysis

Background and aims

Problematic exercise (PE) has mainly been assessed with self-report instruments. However, summarized evidence on the reliability of the scores derived from such instruments has yet to be provided. The present study reports a reliability generalization meta-analysis of six well-known self-report measures of PE (Commitment to Exercise Scale, Compulsive Exercise Test, Exercise Addiction Inventory, Exercise Dependence Questionnaire, Exercise Dependence Scale, and Obligatory Exercise Questionnaire).

Methods

Pooled effect sizes were computed using a random-effect model employing a restricted maximum likelihood estimation method. Univariable and multivariable meta-regressions analyses were employed for testing moderator variables.

Results

Data retrieved from 255 studies (741 independent samples, N = 254,174) identified three main groups of findings: (i) pooled alpha values that, ranging from 0.768 to 0.930 for global scores and from 0.615 to 0.907 for subscale scores, were found to be sensitive to sociodemographic and methodological characteristics; (ii) reliability induction rates of 47.58%; and (iii) the virtually non-existent testing of the assumptions required for the proper applicability of alpha. Data unavailability prevented the provision of summarized reliability estimates in terms of temporal stability.

Discussion

These findings highlight the need to improve reliability reporting of the scores of self-reported instruments of PE in primary studies. This implies providing both prior justification for the appropriateness of the index employed and reliability data for all the subpopulation of interest. The values presented could be used as a reference both for comparisons with those obtained in future primary studies and for correcting measurement-related artefacts in quantitative meta-analytic research concerning PE.

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.

Concerns and recommendations for using Amazon MTurk for eating disorder research

OBJECTIVE

Our original aim was to validate and norm common eating disorder (ED) symptom measures in a large, representative community sample of transgender adults in the United States. We recruited via Amazon Mechanical Turk (MTurk), a popular online recruitment and data collection platform both within and outside of the ED field. We present an overview of our experience using MTurk.

METHOD

Recruitment began in Spring 2020; our original target N was 2,250 transgender adults stratified evenly across the United States. Measures included a demographics questionnaire, the Eating Disorder Examination-Questionnaire, and the Eating Attitudes Test-26. Consistent with current literature recommendations, we implemented a comprehensive set of attention and validity measures to reduce and identify bot responding, data farming, and participant misrepresentation.

RESULTS

Recommended validity and attention checks failed to identify the majority of likely invalid responses. Our collection of two similar ED measures, thorough weight history assessment, and gender identity experiences allowed us to examine response concordance and identify impossible and improbable responses, which revealed glaring discrepancies and invalid data. Furthermore, qualitative data (e.g., emails received from MTurk workers) raised concerns about economic conditions facing MTurk workers that could compel misrepresentation.

DISCUSSION

Our results strongly suggest most of our data were invalid, and call into question results of recently published MTurk studies. We assert that caution and rigor must be applied when using MTurk as a recruitment tool for ED research, and offer several suggestions for ED researchers to mitigate and identify invalid data.

Individuals at Risk of Exercise Addiction Have Higher Scores for Depression, ADHD, and Childhood Trauma

Background

Exercise addiction is increasingly being recognized as a psychologically and physically burdensome set of symptoms. However, little is known about the psychiatric profiles of individuals who are at risk. It is well-established that individuals affected by substance use disorders frequently suffer from depression, attention deficit hyperactivity disorder (ADHD), and experiences of childhood trauma. The aim of this study is to determine whether this pattern of psychiatric disturbance is also present in individuals at risk for exercise addiction.

Methods

Individuals exercising for 10+ h/week were divided into those at risk and not at risk for exercise addiction based on their scores on the Exercise Dependence Scale (EDS). Demographic data and scores on the Beck Depression Inventory (BDI), a measure for ADHD in adults and the Childhood Trauma Questionnaire (CTQ) were also gathered.

Results

One hundred and twenty-three individuals agreed to participate in the study, and completed the questionnaires. Twenty-nine (23.6%) of these individuals were classed as at risk for exercise addiction. There was a statistically significant difference between the at-risk and not at-risk groups on the combined dependent variable after controlling for hours of exercise per week, F_{(3, 95)}= 10.198, p = 0.00, Wilk's Λ = 0.756, partial η2 = 0.244. Compared to those not at risk, individuals at risk for exercise addiction had significantly higher scores for symptoms of depression [t₍₁₂₁₎ = 4.944, p = 0.000], ADHD [t₍₁₂₁₎ = 2.915, p = 0.004], and childhood trauma [t₍₁₂₁₎ = 2.297, p = 0.024].

Conclusion

Our results suggest that exercise addiction may be accompanied by a disturbed psychiatric profile consistent with other addictive disorders. Clinical interviewing in individuals at risk for exercise addiction is a valuable and worthwhile next step in characterizing this phenomenon.

Exercise Addiction in the Sports Context: What Is Known and What Is Yet to Be Known

Exercise addiction (EA) involves excessive concerns for exercise routines, an abusive practice, and the inability to control one’s own behavior, as well as the presence of psychological processes that are typical of behavioral addictions such as abstinence. EA is further associated with an alteration of the individual’s personal, social, and professional functioning and a higher risk for several pathologies, including physical injury, psychological distress, and eating disorders. The present work presents a narrative scoping review of the state of the art and the main findings of the research on EA, with a focus in the athletic population. The prevalence of EA risk, between 1 and 52% and up to 80% when co-occurring with eating disturbances, is also reviewed. Additionally, some of the explanatory models proposed to date and their power and limitations in terms of their capacity for a consensual operationalization and characterization of EA, and thus for the optimal exploration and management of this condition, are discussed. Finally, some deficiencies in the research on EA are noted which are to be addressed to successfully respond to the intervention and prevention needs that occur both in the general context of exercise-sports practice and the specific context of competitive athletes.

A Systematic Review on Exercise Addiction and the Disordered Eating-Eating Disorders Continuum in the Competitive Sport Context

Exercise addiction (EA) affects a considerable number of individuals who regularly perform exercise-sport activities. The co-occurrence of EA manifestations and the continuum of disordered eating-eating disorders (EDs) is so common in sports that a deeper understanding of them as comorbidities is warranted. The aim of this review is to provide an up-to-date overview and synthesis of the research on the relationship between maladaptive exercise and dysfunctional eating in the sport context. A systematic review was conducted following the PRISMA guidelines. A total of 22 empirical studies (23 articles) with young and adult female and male athletes from several sports and competition levels was included. EA in conjunction with eating disturbances is frequent among athletes, yet the prevalence rates are inconsistent. Existing evidence suggests that EA is a relevant outcome of ED pathology among athletes, supporting the classical secondary type of EA. However, research also reveals that excessive exercising plays a central role in the psychopathology of disordered eating. There is a need for further quantitative research addressing the features and correlates of the EA-EDs dyad, qualitative research on the subjective experiences of athletes with disordered exercise and eating, longitudinal and experimental research to establish possible causal paths and attempts to develop comprehensive conceptual models of EA and its co-occurrence with EDs, in order to improve the identification, prevention, and management of this dyadic condition in the sport context.

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.

Examining the Relationship between Exercise Dependence, Disordered Eating, and Low Energy Availability

Both dietary and exercise behaviors need to be considered when examining underlying causes of low energy availability (LEA). The study assessed if exercise dependence is independently related to the risk of LEA with consideration of disordered eating and athlete calibre. Via survey response, female (n = 642) and male (n = 257) athletes were categorized by risk of: disordered eating, exercise dependence, disordered eating and exercise dependence, or if not presenting with disordered eating or exercise dependence as controls. Compared to female controls, the likelihood of being at risk of LEA was 2.5 times for female athletes with disordered eating and >5.5 times with combined disordered eating and exercise dependence. Male athletes with disordered eating, with or without exercise dependence, were more likely to report signs and symptoms compared to male controls-including suppression of morning erections (OR = 3.4; p < 0.0001), increased gas and bloating (OR = 4.0-5.2; p < 0.002) and were more likely to report a previous bone stress fracture (OR = 2.4; p = 0.01) and ≥22 missed training days due to overload injuries (OR = 5.7; p = 0.02). For both males and females, in the absence of disordered eating, athletes with exercise dependence were not at an increased risk of LEA or associated health outcomes. Compared to recreational athletes, female and male international caliber and male national calibre athletes were less likely to be classified with disordered eating.

Physical Activity and Female Sexual Dysfunction: A Lot Helps, But Not Too Much

BACKGROUND

Research on the relationship between physical activity (PA) and female sexual dysfunction (FSD) is lacking.

AIM

To investigate the clinical, psychological, and sexual correlates of PA in women with FSD.

METHODS

A non-selected series of n = 322 pre- and post-menopausal patients consulting for FSD was retrospectively studied. Regular involvement in PA and its frequency (<1 hour/week: sedentary, 1-3 hours/week: active, 4-6 hours/week: very active, >6 hours/week: extremely active) were investigated with a specific question.

OUTCOMES

FSDs, including HSDD (Hypoactive sexual desire disorder) and FGAD (Female genital arousal disorder), were diagnosed according to a structured and clinical interview. Participants underwent a physical examination and a clitoral Doppler ultrasound, and were asked to complete the Female Sexual Function Index, Female Sexual Distress Scale-Revised, Body Uneasiness Test, and Middlesex Hospital Questionnaire.

RESULTS

At multivariate analysis, women engaging in PA (67.4%, n = 217) scored significantly higher in several Female Sexual Function Index domains - including desire, arousal and lubrication - and showed lower sexual distress and lower resistance of clitoral arteries, as compared to sedentary women. A significant, inverse association between PA and HSDD was observed. Mediation analysis demonstrated that the negative association between PA and HSDD was partly mediated by body image concerns (Body Uneasiness Test Global severity index), psychopathological symptoms (Middlesex Hospital Questionnaire total score) and sexual distress (Female Sexual Distress Scale-Revised score). These latter 2 factors also partly mediated the association between PA and a reduced risk of FGAD, whilst a lower BMI was a full mediator in the relationship between PA and FGAD. Finally, extreme PA was associated with significantly worse scores in several psychosexual parameters (i,e, sexual satisfaction and histrionic/hysterical symptoms), even compared to a sedentary lifestyle.

CLINICAL IMPLICATIONS

Women consulting for FSD may gain benefits on desire, arousal, lubrication and sex-related distress from regular PA; however, physicians should remain alert to the downsides of excessive exercise.

STRENGTHS & LIMITATIONS

The main strength lies in the novelty of the findings. The main limitations are the cross-sectional nature, the clinical setting, the small sample size of the different PA groups, and the use of self-reported instruments for the evaluation of PA.

CONCLUSION

In women with FSD, PA was associated with better sexual function and clitoral vascularization, lower sexual distress and reduced odds of HSDD and FGAD; the benefits of PA on sexuality were mediated by both psychological and organic determinants; excessive PA was related with a poor overall sexual function and with a low sexual satisfaction. Maseroli E, Rastrelli G, Di Stasi V, et al. Physical Activity and Female Sexual Dysfunction: A Lot Helps, But Not Too Much. J Sex Med 2021;18:1217-1229.

Using Self-Determination Theory to Define Pathological Exercise

Pathological exercise behavior is pervasive in eating disorder psychopathology, yet minimal treatment guidance exists for extinguishing it as little is known about how to differentiate pathological from healthy exercise. The purpose of this study was to characterize pathological exercise in terms of motivation to increase the specificity with which both pathological and healthy exercise is described and to inform treatment interventions. Latent profile analysis characterized homogenous groups based on exercise motivation in two samples: college women (n = 200) and women with eating psychopathology (n = 211). These profiles were compared on levels of eating and general psychopathology and emotion dysregulation. Three profiles emerged describing sedentary, pathological exercise, and athlete groups in the first sample, and five profiles describing neutral, sedentary, weight loss, athlete, and pathological exercise groups emerged in the second sample. Findings indicate that motivation style is salient in defining pathological exercise and may, therefore, be a clinically useful treatment target.

A Systematic Review and Meta-Analysis on the Relationship between Body Dissatisfaction and Morbid Exercise Behaviour

Background: The present study aimed to quantify the relationship between body dissatisfaction and morbid exercise behaviour (MEB). Methods: The electronic databases MEDLINE, PsycINFO, Web of Science, SciELO, and Dissertations & Theses Global were searched from inception to September 2020. Pooled effect sizes corrected for sampling errors (r⁺) were computed using a bare-bones meta-analysis. The robustness of the results was examined by influence analyses. The presence of moderators was examined by inspection of the variance in r⁺ attributable to sampling errors and 80% credibility intervals, followed by subgroup analysis and univariable/multivariable meta-regressions. Publication bias was examined by visual inspection of funnel plot symmetry, cumulative meta-analysis, and Egger’s test. Results: A total of 41 effect sizes from 33 studies (n = 8747) were retrieved. Results showed a significant and near to moderate effect size (r⁺ = 0.267, 95% CI = 0.226 to 0.307), and this did not differ by gender, BMI, age, percentage of Whites, study quality, or MEB measure. Conversely, effect sizes were found to be stronger in published and more recently conducted studies. Conclusion: The findings indicate that body dissatisfaction is one of the likely causes underlying MEB. This suggests the need for further longitudinal research aimed at confirming the potential causal nature of this relationship.

Disentangling Associations of Children's Sports Participation and Compulsive Exercise With Parenting Practices and Child Disordered Eating Behavior

PURPOSE

Exercise can enhance health and well-being. Exercise can also, when it is highly driven and compulsive, reflect eating disorder psychopathology. The present study examined associations of compulsive exercise and youth athletics with child disordered eating behaviors (overeating, binge eating, and secretive eating) and with parenting practices related to eating and weight, including how parents talk to their children about weight.

METHODS

Participants were parents (N = 875) who completed an online cross-sectional survey. Parents reported whether their child was an athlete and how often their child exercised in a "driven" or "compulsive" way to control their weight. Four groups were compared: child athletes with compulsive exercise (Group AE: n = 34, 3.9%), athletes without compulsive exercise (Group A: n = 314, 35.9%), nonathletes with compulsive exercise (Group E: n = 40, 4.6%), and nonathletes without compulsive exercise (Group X: n = 487, 55.7%).

RESULTS

There was a significant, graded association of eating/weight-related parenting: parents of Group E children had the most negative eating/weight-related parenting, followed by parents of Group AE children, followed by both noncompulsive exercise groups (Group A and Group X). Parents reported significantly more "fat talk" in both compulsive exercise groups (Group AE and Group E) than noncompulsive exercise groups (Group A and Group X). Significantly more youth had regular disordered eating behaviors (overeating, binge eating, and secretive eating) in compulsive exercise groups (Group AE and Group E) compared with noncompulsive exercise groups (Group A and Group X).

CONCLUSIONS

Overall, relatively few youth were categorized as engaging in compulsive exercise. However, compulsive exercise, particularly among nonathletes, was consistently associated with both disordered eating behaviors and eating/weight-related parenting practices. Stronger associations emerged for compulsive exercise than child athletics.

Mental Disorders in Individuals With Exercise Addiction-A Cross-Sectional Study

Background and Aims: Exercise addiction has not yet been designated as an addictive disorder in the DSM-5 due to a lack of detailed research. In particular, associations with other psychiatric diagnoses have received little attention. In this study, individuals with a possible exercise addiction are clinically assessed, in order to establish a profile of co-occurring psychiatric disorders in individuals with exercise addiction. Methods: One hundred and fifty-six individuals who reported exercising more than 10 h a week, and continued to do so despite illness or injury, were recruited for the study. Those who met the cut-off of the Exercise Dependence Scale (n = 32) were invited to participate in a screening with the Structured Clinical Interview for DSM-5 (SCID-5-CV) and personality disorders (SCID-5-PD). Additionally, an interview based on the DSM-5 criteria of non-substance-related addictive disorders was conducted to explore the severity of exercise addiction symptoms. Results: 75% of participants fulfilled the criteria for at least one psychiatric disorder. Depressive disorders (56.3%), personality disorders (46.9%) and obsessive-compulsive disorders (31.3%) were the most common disorders. Moreover, there was a significant positive correlation between the number of psychiatric disorders and the severity of exercise addiction (r = 0.549, p = 0.002). Discussion: The results showed a variety of mental disorders in individuals with exercise addiction and a correlation between the co-occurrence of mental disorders and the severity of exercise addiction. Exercise addiction differs from other addictive und substance use disorders, as obsessive-compulsive (Cluster C), rather than impulsive (Cluster B) personality traits were most commonly identified. Conclusions: Our results underscore the importance of clinical diagnostics, and indicate that treatment options for individuals with exercise addiction are required. However, the natural history and specific challenges of exercise addiction must be studied in more detail.

The relationship between food addiction and patterns of disordered eating with exercise dependence: in amateur endurance athletes

PURPOSE

Examine the prevalence and potential relationships among food addiction (FA)-as measured by Yale Food Addiction Scale 2.0 (YFAS 2.0), eating disorders (ED)-as measured by Eating Disorder Diagnostic Scale (EDDS)-and exercise dependence (EXD)-as measured by Questionnaire to Diagnose Exercise Dependence in Endurance Sports (FESA), for the first time worldwide, in amateur endurance athletes.

METHODS

A total of 1022 German-speaking endurance athletes (44% male, Ø 36 years, Ø BMI 23 kg/m²) replied to an online questionnaire consisting of demographics, related parameters, and the German versions of YFAS 2.0, EDDS, and FESA.

RESULTS

Prevalence of FA, ED, and EXD was 6.2, 6.5, and 30.5%. The probability for FA increases with BMI, thoughts about food and EXD score, and decreases with age and when an ED is present. People with FA and people with ED vs. people with both, FA&ED, differed significantly in this cohort. Strong significant relationships were found between FA and EXD (X² (1) = 15.117, p < 0.001, n = 1022).

CONCLUSIONS

A considerable number of amateur endurance athletes may suffer from FA. The association between FA and EXD is stronger than between ED and EXD, indicating FA as a potentially more relevant subject-than ED-for prevention or therapy in people with EXD. Further studies are needed to investigate parameters and relationships between the possibly involved types of ED, FA, and EXD.

LEVEL OF EVIDENCE

Level III, well-designed cohort analytic study.

Dimensions of unhealthy exercise and their associations with restrictive eating and binge eating

Unhealthy exercise is a core symptom of eating disorders that predicts greater chronicity and risk of relapse. A detailed conceptualization of unhealthy exercise in the context of eating disorders is only beginning to emerge, and associations between specific dimensions of unhealthy exercise and eating disorder symptoms have received little attention. The aim of the current study was to examine associations between three key dimensions of unhealthy exercise - compulsive exercise (i.e., rule-driven exercise to avoid negative affect), exercise to control weight/shape, and exercise to compensate for recent food intake - with restrictive eating and binge eating. Participants were 239 women drawn from two separate studies of emotions and eating behavior; 126 (52.7%) endorsed restrictive eating and/or objective binge eating episodes in the past three months. Unhealthy exercise dimensions were measured using the Compulsive Exercise Test and investigator-designed items, and eating disorder symptoms were assessed using the Eating Pathology Symptoms Inventory. Restrictive eating was only associated with avoidance and rule-driven exercise, whereas binge eating was significantly correlated with all unhealthy exercise variables. Multiple regression results revealed that only compensatory exercise was uniquely associated with binge eating. Unhealthy exercise consists of partially distinct dimensions with differential relations to core eating disorder symptoms. Future research should examine unhealthy exercise dimensions in patients with eating disorder diagnoses and consider whether treatments for specific unhealthy exercise forms might be beneficial.

Community-Based Prevention Programs for Disordered Eating and Obesity: Updates and Current Limitations

PURPOSE OF REVIEW

To review the status of community-based disordered eating and obesity prevention programs from 2014 to 2019.

RECENT FINDINGS

In the last 5 years, prevention programs have found success in intervening with children and parental figures in wellness centers, physical activity centers, childcare centers, workplaces, online, and over-the-phone through directly reducing disordered eating and obesity or by targeting risk factors of disordered eating and obesity. Community-based prevention programs for disordered eating and programs targeting both disordered eating and obesity were scarce, highlighting the critical need for the development of these programs. Qualities of the most effective programs were those in which parents and children were educated on physical activity and nutrition via multiple group-based sessions. Limitations of current prevention programs include few programs targeting high-risk populations, a dearth of trained community members serving as facilitators, inconsistent reporting of adherence rates, and few direct measurements of disordered eating and obesity, as well as few long-term follow-ups, precluding the evaluation of sustained effectiveness.

Morbid exercise behaviour and eating disorders: A meta-analysis

BACKGROUND AND AIMS

This study examined the relationship between self-reported symptoms of morbid exercise behaviour (MEB) and eating disorders (ED) using meta-analytic techniques.

METHODS

We systematically searched MEDLINE, PsycINFO, Web of Science, SciELO and Scopus. Random effects models were used to compute pooled effect sizes estimates (r). The robustness of the summarized estimates was examined through sensitivity analyses by removing studies one at a time.

RESULTS

Sixty-six studies comprising 135 effect-sizes (N = 21,816) were included. The results revealed: (a) small-sized relationship in the case of bulimic symptoms (r = 0.19), (b) small- (r = 0.28) to medium-sized relationships (r = 0.41) in the case of body/eating concerns, and (c) medium-sized relationships in the case of overall ED symptoms (r = 0.35) and dietary restraint (r = 0.42). Larger effect sizes were observed in the case of overall ED symptoms in clinical, younger, and thinner populations, as well as when employing a continuously-scored instrument for assessing ED or the Compulsive Exercise Test for assessing MEB. Larger effect sizes were also found in female samples when the ED outcome was dietary restraint.

CONCLUSIONS

The identified gaps in the literature suggest that future research on the topic may benefit from: (a) considering a range of clinical (in terms of diagnosed ED) and non-clinical populations from diverse exercise modalities, (b) addressing a wide range of ED symptomatology, and (c) employing longitudinal designs that clarify the temporal direction of the relationship under consideration.

Fitness-Related Self-Conscious Emotions and Risk for Exercise Addiction: Examining the Mediating Role of Passion

Fitness-related self-conscious emotions (SCEs) have been proposed as antecedents of exercise addiction (EA). However, the potential mechanisms underlying such a relationship remain unexplored. The present study examined the relationship between fitness-related SCEs and risk of EA, as well as the mediating role of passion for exercise. A total of 296 male runners (M = 40.35 years, SD = 10.69) completed a survey assessing weekly exercise frequency/hours, fitness-related SCEs, passion for exercise, and the risk of EA. The relationships between the study variables were examined using structural equation modeling. After controlling for age and weekly exercise frequency/hours, fitness-related SCEs of shame, guilt, and hubristic pride were positively associated with risk of EA. However, while guilt had direct effects on risk of EA, shame and hubristic pride showed indirect effects via obsessive passion. The results of the study are discussed, and some practical implications and future research directions are presented.

Prevalence of Risk for Exercise Dependence: A Systematic Review

BACKGROUND

Exercise dependence (EXD) can be considered an addictive behaviour because it presents signs typical of other addictive behaviours. Despite possible health problems related to EXD, the prevalence of risk for EXD has never been systematically reviewed.

OBJECTIVE

This article aimed to systematically review the prevalence of risk for EXD.

METHODS

Studies were identified from searches in the ERIC, PsycINFO, PubMed, Scopus, SPORTDiscus, and Web of Science electronic databases up to June 2018. Empirical studies were selected if (1) they included the outcomes of the prevalence of EXD; (2) participants were regular exercisers; and (3) they were published in either the English, French, Portuguese, or Spanish languages. A total of 34 articles met the inclusion criteria.

RESULTS

The prevalence of risk for EXD was estimated to be between 3 and 7% of regular exercisers and the university student population, and between 6 and 9% of the athlete population.

CONCLUSION

The results of this review indicated that the prevalence of risk for EXD varies with the characteristics of the exerciser, but an overall prevalence of 3-9% is estimated. Risk for EXD is a cause for concern and, from a public health point of view, is a problem that has to be addressed.

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.

Excessive Exercise-A Meta-Review

Background and Aims: While a number of studies have reported on individuals who exercise excessively, and feel unable to stop despite negative consequences, there is still insufficient evidence to categorize exercise as an addictive disorder. The aim of this meta-review is to summarize the published articles and to compile a list of symptoms reported in the qualitative literature in conjunction with excessive exercise. This list is compared with the DSM-5 criteria for gambling disorder, and initial diagnostic criteria for exercise addiction are suggested. Methods: The databases MEDLINE, Web of Science and PsycInfo were searched for qualitative studies or case reports, in which excessive exercise was the main focus. All symptoms reported in conjunction with excessive exercise were extracted from each study and documented. Symptoms were also compared to the diagnostic criteria for gambling disorder. Results: Seventeen studies were included in the review, yielding 56 distinct symptoms. The Critical Appraisal Skills Program tool showed that the majority of the studies were of acceptable quality. Exercise-related symptoms corresponded with seven of the nine DSM-5 criteria for gambling disorder. The ten suggested criteria for exercise addiction are: increasing volume, negative affect, inability to reduce, preoccupation, exercise as coping, continuation despite illness/injury, minimization, jeopardized relationships, continuation despite recognizing consequences, guilt when exercise is missed. Discussion: Our results suggest that excessive exercise may constitute a behavioral addiction, based on the criteria of the DSM-5. Conclusions: Subsequent studies should aim to systematically classify symptoms of excessive exercise; in addition, it should be noted that basic questionnaires may be need to be supplemented with detailed clinical examinations.

Responses of fitness center employees to cases of suspected eating disorders or excessive exercise

BACKGROUND

While exercise and physical activity are important parts of a healthy life, there is evidence that some individuals exercise to a degree which may jeopardize their health. These individuals may in some cases be exercising to lose weight or compensate binge eating episodes as part of an eating disorder. Others may experience an addiction-like relationship with exercise. Fitness center employees are ideally placed to observe these forms of unhealthy behavior, and are responsible for ensuring that clients do not put themselves at undue risk; however, to date, no study has addressed both eating disorders and excessive exercise. Therefore, the aim of our study is to determine whether these employees report incidences of these issues, and if they believe they can differentiate between them.

METHODS

One-hundred-and-forty fitness centers in the German-speaking regions of Switzerland were contacted. Of these, 99 employees (60 men, 39 women, M_age = 33.33 years, SD = 12.02) responded to an online questionnaire. The questionnaire briefly described the two issues of interest (eating disorders and excessive exercise), and then invited respondents to complete a number of questions detailing whether they had experience with these issues, and how they dealt with them.

RESULTS

Approximately 75% of the employees had suspected a client of having an eating disorder or exercising excessively, and 65% of these respondents confronted the client at least once. Interestingly, respondents reported clearly that they felt able to differentiate between the two types of disorder. Older respondents were significantly more likely to have suspicions and act on them. However, less than half of the respondents were aware of guidelines addressing this issue, and the majority desired more information about how to identify and address both disorders.

CONCLUSIONS

Swiss fitness center employees frequently encounter individuals who they suspect of exercising excessively, or suffering from an eating disorder. While they often confront these individuals, they would like more detailed information about how to manage this process. Given that both disorders can potentially lead to severe health consequences, a detailed description of symptoms, management techniques and resources should be a feature in all Swiss fitness center guidelines.

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.

Do It, Don't Feel It, and Be Invincible: A Prolog of Exercise Addiction in Endurance Sports

The social relevance of endurance sports has increased people's motivation to engage in these particular physical activities, associating their practice with a particular lifestyle (e.g., feeling victorious and a feeling of self-improvement). Therefore, the dark personality traits (not because they are negative but because they are more hidden), understood as a personal and adaptive response to the psychosocial relationships that athletes establish while practicing these sports. Following these arguments, Grit has been used to trace the response of athletes in their quest to improve performance and endurance in the face of common setbacks suffered as a result of long hours of training. Empirical studies should help to discover how these personality traits can pose real challenges to their adaptation, and what the impact of their psychological response may be in a functional or dysfunctional way [e.g., exercise addiction (EA)], in order to classify them as risk or protective factors. Through transversal design, the present study sought to explore the relationship between Grit and Dark Traits of Personality regarding the appearance of EA in a sample (N = 241) of amateur endurance sport athletes (M age = 31.80; SD = 9.87). The results show that men not only score higher for addiction levels but also for narcissism (grandiosity feelings) and psychopathy (coldness) factors. If signs of narcissism and Machiavellianism increase, perseverance efforts grow too, and the likelihood of EA increases considerably. The conclusions drawn on the basis of the results allow us to place consistency of interest as a protective factor for the EA, whereas Dark Traits of personality - especially Machiavellianism - constitute a risk factor.

Examining the relationship between fitness-related self-conscious emotions, disordered eating symptoms, and morbid exercise behavior: An exploratory study

BACKGROUND AND AIMS

Theoretical models of morbid exercise behavior (MEB) suggest that it may emerge as a result of complex interactions between a range of psychosocial factors. However, in spite of fitness-related self-conscious emotions involving such factors, their relationship with the risk of MEB has never been investigated. Consequently, this study had two objectives. First, to explore the relationship that fitness-related self-conscious emotions have with (a) symptoms reflecting MEB as assessed by the Exercise Addiction Inventory (EAI) and the Exercise Dependence Scale-Revised (EDS-R) and (b) exercise frequency. Second, to examine whether these relationships might vary according to disordered eating symptoms.

METHODS

A sample of 646 undergraduate students (59% males; M_age = 21.25; SD_age = 2.94) completed a self-reported questionnaire.

RESULTS

After controlling for age, sex, and disordered eating symptoms, it was found that shame, hubristic pride, and authentic pride positively explained MEB; for their part, guilt (negatively) and authentic pride (positively) explained exercise frequency. The positive relationships between pride and MEB were weaker (in the case of the hubristic facet) or stronger (in the case of the authentic facet) under higher levels of disordered eating symptoms. The independent variables explained 29% (EAI), 28% (EDS-R), and 27% (exercise frequency) of the variance in dependent variables.

DISCUSSION

Tempering fitness-related emotions of shame, guilt, hubristic pride, and authentic pride may contribute to healthier exercise behavior.

Body image and weight management among Hispanic American adolescents: Differences by sport type

BACKGROUND

Adolescents' body image concerns vary by sex, ages, and participation in different types of sports. Little is known about variability of body image and weight management behaviors by sport type in Hispanic American adolescents. This study examined whether body image distortion and dissatisfaction are associated with weight management behaviors by sex and sport type in Hispanic adolescents.

METHODS

A sample of 728 Hispanic participants from the United States (61.6% female, Mage = 12.36 ± 2.35) completed the Stunkard Figural Stimuli, reported weight management behaviors and sport participation. Sports were classified as non-aesthetic (such as soccer), aesthetic (such as cheerleading), or non-sport participation. Separate multiple linear regression and multinomial logistic regression models were conducted to test adjusted associations between body image dissatisfaction and distortion, and sport type with weight management behaviors.

RESULTS AND CONCLUSIONS

Participants in non-aesthetic sports (51.2% male) were more dissatisfied with their body image (want to be bigger; B = -0.17; p = .01) and were 1.5 times more likely to use exercise to lose weight than non-sport participants. Greater body image dissatisfaction increased the likelihood of weight management behaviors. As year in school increased, participants perceived themselves as smaller than their actual BMI and wanted to be smaller. Hispanic females exhibited similar trends to other ethnicities. However, Hispanic males may have interpreted a desire to be "smaller" as a more lean, muscular physique. Subsequent studies should focus on reasons for weight management, and whether those behaviors are healthy.

Which sports are more at risk of physical exercise addiction: A systematic review

INTRODUCTION

Excessive physical exercise may evolve into physical exercise addiction, a recently identified entity with many yet unclear aspects, such as global prevalence and variability according to different types of physical exercise.

METHODS

We systematically reviewed the current literature up to June 2018 to collect all studies screening exercise addiction with two of the most frequently used screening scales: the Exercise Addiction Inventory (EAI) and the Exercise Dependence Scale (EDS).

RESULTS

We detected forty-eight studies (20 using the EAI, 26 the EDS, and 2 both scales) reporting variable point prevalence of exercise addiction risk, depending on the target population and the investigated sport. The EAI identifies a higher proportion of people at risk for physical exercise addiction among endurance athletes (14,2%) followed by ball games (10,4%), fitness centre attendees (8,2%) and power disciplines (6,4%), while a frequency of 3,0% was reported in the general population. Studies using the EDS found discrepant results.

DISCUSSION

This systematic review suggests that sport disciplines are associated with different vulnerability for physical exercise addiction. Besides the different addictive potential of each sport, the heterogeneity of results may be also due to socio-demographic and cultural characteristics of the target populations. The EAI and the EDS identify different proportions of individuals at risk for exercise addiction both in general population and in specific sport categories. As the EAI screens a higher proportion of subjects at risk, especially in endurance disciplines, it could be more appropriate for early detection of at-risk subjects and/or disciplines.

CONCLUSION

Tailored prevention strategies for each discipline could help better preserving benefits of sports. More precision in research methods and the use of the most appropriate scale are required to allow a better comparability of prevalence among physical exercise disciplines and in general population.

Are Adolescent Body Image Concerns Associated with Health-Compromising Physical Activity Behaviours?

The present study aimed to assess the-prevalence of health-compromising eating and physical activity behaviours, and to test their associations with physical activity, internalisation of sociocultural attitudes towards appearance, and body image in a sample of adolescents of both genders. A total sample of 736 adolescents (437 or 59.4% were girls) participated in the study. The participants ranged in age from 16 to 19 years (x = 17.2, SD = 0.6). The sample completed a questionnaire measuring body mass index, the risk of eating disorders, body image, internalisation of sociocultural ideals of appearance, health-compromising eating behaviours (HCEB), and health-compromising weight control related to physical activity behaviours (HCPAB). Logistic regressions were used to assess the associations between the study variables and predictors of HCEB and HCPAB. The results of the study showed a relatively high prevalence of HCEB with a significantly higher prevalence in girls and participants with a higher BMI. The study also demonstrated that the prevalence of adolescent HCPAB was higher than HCEB. The internalisation of sociocultural attitudes towards appearance and body image concerns were higher in the HCEB and HCPAB groups. Female gender (OR = 1.88; 95% PI = 1.10⁻3.18), HCPAB (OR = 1.19; 95% PI = 1.10⁻1.28), a preoccupation with being overweight (OR = 3.43; 95% PI = 2.52⁻4.66), and body weight evaluation as too high (OR = 2.40; 95% PI = 1.57⁻3.68) were significant predictors of HCEB. More frequent physical activity (OR = 3.02; 95% PI = 1.76⁻5.17), HCEB (OR = 1.22; 95% PI = 1.11⁻1.32), and perceived pressures to conform to popular beauty ideals (OR = 1.51; 95% PI = 1.12⁻2.03) predicted higher HCPAB. HCPAB is an important variable associated with adolescents' body image, physical activity, and weight control. The results of the present study are important for health promotion and education programs addressing adolescents' healthy lifestyle, weight control, and body image concerns.

Defining compulsive exercise in eating disorders: acknowledging the exercise paradox and exercise obsessions

Recently Dittmer et al. (JED 6:1-9, 2018). suggested a transdiagnostic definition and a clinical assessment for compulsive exercise in adolescents and adults with eating disorders. In this letter to the editor, we extend the transdiagnostic bridge to the DSM-5-criteria for obsessive-compulsive disorders and hence raise the issue of exercise obsession without compulsive exercise actions. We argue that, at least among persons with bulimia nervosa or binge eating disorders, a belief in the need to exercise to control food, weight and shape, does not necessarily imply that the actual exercise behaviour is excessive in nature. In our opinion, the high scores displayed on compulsive exercise screening instruments is therefore an exercise paradox. This paradox may call attention to the fact that because such obsessions can impair quality of life, they need to be addressed in the clinical evaluation and treatment. Therefore, we suggest adding "exercise obsession" as a fourth subtype of compulsive exercise.

Validation of the exercise and eating disorder questionnaire in males with and without eating disorders

OBJECTIVE

The need to consider gender when studying exercise in eating disorder (ED) has been underscored. The study aimed to test the psychometric properties and factor structure of the exercise and eating disorder (EED) questionnaire for males with and without ED, to highlight gender differences, and to explore issues relevant for a male version of the EED questionnaire.

METHOD

This cross sectional study included 258 male participants: 55 ED patients (inpatients and outpatients) and 203 student controls. The patient group consisted of 54.5% (n = 30) with AN, 18.2% (n = 10) with BN, 27.2% (n = 15) with unspecified ED. The ED sample was treated as transdiagnostic in all analyses. t Tests, chi-square test, correlations analyses, and a principal component analysis were conducted.

RESULTS

The analyses confirmed that the EED questionnaire had adequate psychometric properties, and a four-factor solution: (a) compulsive exercise, (b) positive and healthy exercise, (c) awareness of bodily signals, and (d) weight and shape exercise. The questionnaire discriminated significantly (p < .01- < .001) between patients and controls on the global score, subscales, and 16 out of 18 individual items. Convergent validity was demonstrated by high correlations between the EED questionnaire and the eating disorder examination questionnaire (r = .65).

DISCUSSION

The results indicated that the EED questionnaire is a valid and reliable tool for males. It is a clinically derived, self-report questionnaire to assess compulsive exercise among ED patients, regarding attitudes and thoughts toward compulsive exercise and identification of treatment targets and priorities.

Driven exercise in the absence of binge eating: Implications for purging disorder

OBJECTIVE

Purging disorder (PD) is characterized by recurrent purging without objectively large binge-eating episodes. PD has received relatively little attention, and questions remain about the clinical significance of "purging" by exercise that is driven or compulsive (i.e., as extreme compensatory or weight-control behavior). The little available research suggests that individuals who use exercise as a compensatory behavior might have less eating-disorder psychopathology than those who purge by vomiting or laxatives, but those studies have had smaller sample sizes, defined PD using low-frequency thresholds, and defined exercise without weight-compensatory or driven elements.

METHOD

Participants (N = 2,017) completed a web-based survey with established measures of eating-disorder psychopathology, depression, and physical activity. Participants were categorized (regular compensatory driven exercise, PD-E, n = 297; regular compensatory vomiting/laxatives, PD-VL, n = 59; broadly defined anorexia nervosa, AN, n = 20; and no eating-disordered behaviors, NED, n = 1,658) and compared.

RESULTS

PD-E, PD-VL, and AN had higher eating-disorder psychopathology and physical activity than NED but did not significantly differ from each other on most domains. PD-VL and AN had higher depression than PD-E, which was higher than NED.

DISCUSSION

Findings suggest that among participants with regularly compensatory behaviors without binge eating, those who use exercise alone have similar levels of associated eating-disorder psychopathology as those who use vomiting/laxatives, although they have lower depression levels and overall frequency of purging. Findings provide further support for the clinical significance of PD. Clinicians and researchers should recognize the severity of driven exercise as a compensatory behavior, and the need for further epidemiological and treatment research.

Orthorexic eating behaviors related to exercise addiction and internal motivations in a sample of university students

PURPOSE

This research explored the exercise tendencies and motivations of individuals varying in orthorexia symptomatology.

METHOD

Participants were 411 university students, who completed the Eating Habits Questionnaire alongside measures of exercise activity and addiction in Study 1 (a modified version of the Leisure-Time Exercise Questionnaire, the Exercise Addiction Inventory, and the Compulsive Exercise Test) and various exercise motivations in Study 2 (the Behavioural Regulations in Exercise Questionnaire and the Exercise Motivations Inventory-2).

RESULTS

Orthorexia symptomatology was positively correlated with aerobic and strength-training exercise levels; all measures of exercise addiction; all measures of internal exercise motivation; and nearly all measures of exercise motivation for the purposes of psychological, social, health, and body improvement. Symptomatology was not significantly related to either measure that specifically assessed external motivation to exercise.

CONCLUSION

Individuals high in orthorexia symptomatology are internally driven to exercise for the purposes of improving their physical and mental health, but these strong motivations also lead to exercise addiction characterized by a compulsive need to follow a rigid schedule of intensive exercise even in the face of injury, illness, or other problems.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Compulsive exercise in eating disorders: proposal for a definition and a clinical assessment

BACKGROUND

Compulsive exercise has been recognized as a highly prevalent symptom in eating disorders (ED) for over 100 years and is associated with poor short-term and long-term treatment outcome. Progress in understanding and treatment of compulsive exercise will remain limited as long as no consensus framework for definition and assessment of compulsive exercise exists, as results cannot be compared across clinical studies.Based on existing literature, it was our aim to propose a transdiagnostic definition and a clinical assessment for compulsive exercise, that can be applied to adolescent and adult patients with ED.

METHOD

During a series of meetings of experienced clinicians at a highly specialized hospital for eating disorders, we elaborated a transdiagnostic definition of compulsive exercise in ED. Additionally, we derived a clinical interview for the assessment of compulsive exercise and its different subtypes.

RESULTS

The core criterion when defining and assessing compulsive exercise is a pathologically increased exercise pattern characterized by 1) excessive exercise that a patient feels driven to perform in response to an obsession or according to rules that must be applied rigidly, and 2) exercise that is aimed at preventing or reducing distress or at preventing some dreaded consequence. A second necessary criterion is the physical or psychological burden caused by compulsive exercise, i.e., that it is time-consuming, significantly interferes with the patient's daily routine, occupational functioning or social relationships or is continued despite medical injury, illness, or lack of enjoyment. Insight that compulsive exercise is excessive or unreasonable was added as an optional criterion.Compulsive exercise manifests itself in three different subtypes: 1) vigorous exercise, 2) marked increase in daily movement, or 3) motor restlessness.The above criteria must be met during the past 6 months, together with one of the three subtypes of compulsive exercise.

CONCLUSIONS

The proposed criteria aim to foster the discussion around definition and assessment of compulsive exercise with the goal of reaching an international consensus in the near future.Providing a consistent framework for researchers and clinicians would considerably advance understanding and treatment of compulsive exercise in ED patients.

Physical Fitness Levels Do Not Affect Stress Levels in a Sample of Norwegian Adolescents

Physical inactivity, low physical fitness, and perceived stress during adolescence are presumed to be risk factors for various disorders and subjective health complaints. On the other hand, physical activity and physical fitness, as well as mindfulness qualities, are regarded as prerequisites for health and well-being in children and adolescent, possibly by moderating the negative effects of stress and protecting against stress-related health complaints. Previous studies have suggested gender differences in the relationship between physical activity/physical fitness and psychological variables. The main objective in this study was to evaluate how physical fitness, along with mindfulness qualities (MAAS-A), pain, and BMI, relate to stress (PSQ) in adolescents. Secondary objectives were to explore the relationship between physical fitness, mindfulness (MAAS-A), and BMI more explicitly in the study sample, as well as to evaluate possible gender differences. The cross-sectional sample included 102 Norwegian pupils in 10th grade (15 or 16 years). Study measurements were four items from the Test of Physical Fitness (TPF), the Norwegian version of the four-factor Perceived Stress Questionnaire (PSQ), the Norwegian version of the Mindful Attention Awareness Scale-Adolescent (MAAS-A), and BMI (recorded in terms of self-reported height and weight). Additionally, pain was measured in terms of localization, number of pain sites, duration, and intensity (Visual analogue scale; VAS). According to the regression analyses, physical fitness could not explain any variation in stress among the adolescents. Nevertheless, there were some negative associations between one stress factor (lack of joy) and components of physical fitness at a group level, possibly influenced by conditions not measured in this study. As opposed to physical fitness, mindfulness qualities, and to some degree gender, seemed to explain variation in stress among the adolescents. None of the physical fitness components were associated to mindfulness (MAAS-A), but some components seemed negatively related to BMI, particularly among the males. Among the females, higher physical fitness (in terms of endurance) seemed related to reduced number of pain sites. Of note, the cross-sectional design did not allow us to determine any causal direction among the variables.

Validity of Exercise Measures in Adults with Anorexia Nervosa: The EDE, Compulsive Exercise Test and Other Self-Report Scales

OBJECTIVE

Compulsive exercise is a prominent feature for the majority of patients with Anorexia Nervosa (AN), but there is a dearth of research evaluating assessment instruments. This study assessed the concurrent validity of the exercise items of the Eating Disorder Examination (EDE) and Eating Disorder Examination-Questionnaire (EDE-Q), with the Compulsive Exercise Test (CET) and other self-report exercise measures in patients with AN. We also aimed to perform validation of the CET in an adult clinical sample.

METHODS

The sample consisted of 78 adults with AN, recruited for the randomized controlled trial "Taking a LEAP forward in the treatment of anorexia nervosa." At baseline, participants completed the EDE, EDE-Q, CET, Reasons for Exercise Inventory (REI), Commitment to Exercise Scale (CES) and Exercise Beliefs Questionnaire (EBQ). Correlational and regression analyses were performed.

RESULTS

EDE exercise days and exercise time per day were positively correlated with each other and with all CET subscales (except Lack of exercise enjoyment), CES mean, EBQ total and REI total. Exercise time per day was associated with a higher EDE global score. The CET demonstrated good concurrent validity with the CES, the REI and the EBQ. Of the self-reports, the CET explained the greatest variance in eating disorder psychopathology and demonstrated good to excellent reliability in this sample.

DISCUSSION

The EDE and EDE-Q demonstrated good concurrent validity with the CET. Further research is required to evaluate the CET's factor structure in a large clinical sample. However, the CET has demonstrated strong clinical utility in adult patients with AN. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:533-541).

Compulsive exercise: links, risks and challenges faced

Compulsive exercise is a condition described since 1970s. It is characterized by a craving for physical training, resulting in uncontrollable excessive exercise behavior with harmful consequences, such as injuries and impaired social relations. It has not been accepted as a mental disorder in either International Classification of Diseases or Diagnostic and Statistical Manual of Mental Disorders. The aim of this literature review was to critically examine the research on links (comorbidity), risks (negative consequences), and challenges faced (problems in a treatment context). This review found that compulsive exercise is associated with eating disorder pathology, perfectionism, neuroticism, narcissism, and obsessive compulsive traits. The most prominent negative consequences were injuries, social impairment, and depression, but more research is needed to uncover the potential dysfunction resulting from compulsive exercise. As the condition is not recognized as a psychiatric disorder, studies on treatment interventions are sparse. Problems with compliance have been reported; therefore, motivational interviewing has been proposed as a treatment approach, in combination with cognitive behavioral therapy. This review summarizes and discusses findings on links/comorbidity, risks/negative consequences, and treatment challenges. We suggest that future studies should pay attention to both prevention and counseling in sports settings, where compulsive exercise appears, as the condition may be associated with harmful consequences.

Body dissatisfaction, excessive exercise, and weight change strategies used by first-year undergraduate students: comparing health and physical education and other education students

BACKGROUND

Health and Physical Education (HPE) teachers are known to be under social-, personal-, and employment-related pressure to be and appear physically fit, and to use dangerous dieting and weight control practices. This is problematic due to the influence this may have on their own health and the potential to model these attitudes and behaviours to their future students.

METHODS

In this paper, we compare the body image, dieting, disordered eating, and exercise behaviours of first year, HPE, and non-HPE, teacher education students. Participants were 596 first-year university student pre-service teachers (n = 249 HPE and n = 347 non-HPE) from three universities in Australia who completed self-report questionnaires. Analysis of covariance and logistic regression analyses were used to determine differences in attitudes and behaviours between these two groups for males and females separately.

RESULTS

We found that male HPE participants had significantly higher levels of drive for muscularity and obligatory exercise, and were more likely to be classified as having an exercise disorder, dieting, and using steroids than non-HPE students were. Female HPE students were more likely to engage in self-reported excessive exercise, to have higher scores on the Obligatory Exercise Questionnaire, and be classified as having an exercise disorder.

CONCLUSION

These findings are important as they confirm the presence of dieting and disordered eating attitudes and behaviours among all teacher education students, and highlight male HPE teachers as a potentially vulnerable group. These results may inform the implementation of intervention programs for teacher education students to ensure their personal wellbeing and professional capacity in promoting positive body image, nutrition, and physical activity among young people.