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

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.

Intrinsic and extrinsic motivations as moderators of the association between exercise frequency and exercise behavior

PURPOSE

Motivations underlying exercise may contribute to the extent to which exercise is maladaptive, independent of exercise frequency. Extrinsic and intrinsic exercise motivation may independently moderate associations between exercise frequency and 1) compulsive and 2) healthy exercise. It was expected that among individuals with high extrinsic motivation, greater exercise frequency would be associated with more compulsive exercise, whereas among individuals with high intrinsic motivation, greater exercise frequency would be associated with more healthy exercise.

METHODS

A total of 446 university students (50.9% female; 67.0% White) completed measures of intrinsic and extrinsic exercise motivations, exercise frequency, compulsive exercise, and healthy exercise. Intrinsic and extrinsic motivations for exercise were entered as simultaneous independent moderators of the associations between exercise frequency and 1) compulsive exercise and 2) healthy exercise in multiple linear regressions.

RESULTS

Moderation effects of exercise motivation were not supported for compulsive exercise. Only main effects of frequency (b = 0.04, p < 0.01) and extrinsic motivation (b = 0.27, p < 0.01) were observed. Intrinsic motivation moderated the association between frequency and healthy exercise (b = -0.02, p = 0.03). Among individuals with lower intrinsic motivation, greater frequency was related to more healthy exercise. This association was significantly weaker among individuals with high intrinsic motivation.

CONCLUSION

Consistent with theory and extant work, extrinsic motivation was associated with compulsive exercise, while intrinsic motivation was associated with healthy exercise. Clinically, assessing the extent to which exercise is intrinsically or extrinsically motivated may help identify whether individuals may be more likely to engage in compulsive versus healthy exercise. Results support the importance of exploring the exercise motivations as predictors of compulsive and healthy exercise.

LEVEL OF EVIDENCE

Level V, Descriptive Cross-Sectional Study.

Investigating engagement in maladaptive and adaptive exercise behaviors before and during COVID-19

PURPOSE

Evidence suggests that the coronavirus (COVID-19) pandemic has resulted in increased mental health concerns (e.g., anxiety) and there is ample discussion of how the pandemic has resulted in increases in weight control strategies (e.g., maladaptive exercise behaviors). It remains unclear, however, if maladaptive exercise behaviors are on the rise among non-clinical samples. The objective of this study was to examine college students' engagement in exercise behaviors (both adaptive and maladaptive) before and during COVID-19.

METHOD

This study compared reports of compulsive exercise, weight and shape exercise, and positive and healthy exercise in two separate samples recruited from a large southeastern university. Sample 1 was collected pre-COVID-19 (August 2019-February 2020) and Sample 2 was collected during COVID-19 (August 2020-April 2021). Case-control matched samples were generated for this study (N = 144; 52.1% male). Three separate analysis of covariance models tested the differences between (1) adaptive exercise; (2) compulsive exercise; and (3) weight and shape exercise in pre- and during COVID-19 samples, controlling for sex.

RESULTS

Individuals in the during COVID-19 sample reported significantly more compulsive exercise (p < .001), weight and shape exercise (p < .001), and adaptive exercise (p < .001) compared to individuals in the pre-COVID-19 sample. Effects were of medium to large sizes.

CONCLUSION

Consistent with reports from the research literature and popular press, the current study observed that both adaptive and maladaptive exercise were higher among college students during COVID-19 compared to pre-COVID-19.

LEVEL OF EVIDENCE

Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

A systematic review of treatment approaches for compulsive exercise among individuals with eating disorders

Individuals with eating disorders often experience compulsive exercise which, if left untreated, can lead to longer treatment and worsened symptoms. Compulsive exercise must be addressed within eating disorder treatment to help individuals establish a healthy relationship with exercise. However, there are currently no standardized guidelines for treating compulsive exercise or a consensus on which forms of treatment are most effective. Therefore, the purpose of this review was to examine interventions that address compulsive exercise and their impact on treating compulsive exercise among individuals with eating disorders. A systematic review of the literature was conducted. Eleven studies testing treatments for compulsive exercise were included in this review. Participants were diagnosed with anorexia nervosa, bulimia nervosa, or EDNOS, and a small portion had BED. Improvements in compulsive exercise and eating psychopathology were observed across all studies. The interventions focused on exercise psychoeducation and often incorporated exercise sessions. The findings highlight the positive impact of treating compulsive exercise, suggesting it should be a standard component of eating disorder treatment. Future studies should examine differences in treatment approaches and outcomes specific to each eating disorder, and specific to males. More consistency across studies in the conceptualization and measurement of compulsive exercises is also needed.

Emotion Dysregulation as a Mediator of the Relationship between Anxiety, Compulsive Exercise and Eating Disorder Symptoms in Adolescents

Anxiety has been suggested to be a key contributing factor for compulsive exercise, however, existing literature has demonstrated contradictory relationships between anxiety and compulsive exercise among adolescents. According to the Emotional Cascade Model (ECM), factors such as rumination and emotional suppression may mediate the association between affect and exercise. The current study therefore aimed to investigate whether rumination and emotional suppression mediate the relationship between anxiety and compulsive exercise in predicting ED symptoms in adolescents. Questionnaires assessing compulsive exercise, anxiety, depressive rumination, emotional suppression, and ED symptoms were completed by 212 adolescent males (Mage = 13.39, SD = 1.22) and 189 adolescent females (Mage = 13.64, SD = 1.29). The structural equation model showed indirect effects between anxiety and compulsive exercise through rumination and emotional suppression in males but not in females. Moreover, anxiety had an indirect effect on eating disorder symptoms through rumination, emotional suppression and compulsive exercise in both males and females. In line with ECM, the results suggest that rumination and emotional suppression may have a key role in the association between anxiety, compulsive exercise and eating disorder symptoms in adolescents. These findings suggest that compulsive exercise may be used as a dysfunctional coping mechanism to escape from a negative emotional cascade generated by the interaction of anxiety, rumination and emotional suppression. Future longitudinal studies to test the role of compulsive exercise as a dysfunctional behaviour in the ECM are needed.

What role can accredited exercise physiologists play in the treatment of eating disorders? A descriptive study

Including exercise alongside other therapeutic approaches may help to address dysfunctional exercise use and improve eating disorder treatment outcomes. However, traditional treatment teams often lack the expertise needed to safely prescribe exercise. The aims of this study were to explore the perceptions and experiences of Accredited Exercise Physiologists (AEPs) relating to working with clients diagnosed with eating disorders to identify the role they play in the treatment of eating disorders and identify future training needs. Individual semi-structured telephone interviews were conducted with 12 (n = 9 females) AEPs working in the eating disorders field. Thematic analysis was conducted to extract major themes from the interview transcripts. Five major themes were identified: (1) The role of AEPs in the treatment of individuals with eating disorders is comprehensive; (2) Treatment is more effective when all components are addressed; (3) The absence of therapeutic exercise within standard treatment protocols reflects limitations of traditional scope of practice and knowledge about the role of AEPs; (4) Methods of acquiring further knowledge are insufficient for those in current practice; and (5) Accredited comprehensive training is currently unavailable but needed. This qualitative study showed that AEPs believe they can play a major role in the treatment of eating disorders and that treatment outcomes for individuals are likely to be greatly enhanced when dysfunctional exercise is addressed. Multidisciplinary training is needed.

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.

Body image and body change behaviors associated with orthorexia symptoms in males

In recent years, Orthorexia Nervosa has received increasing attention as a form of restrictive disordered eating driven by concerns related to "healthy eating" as opposed to weight and shape concerns. To date, however, data on the correlates of orthorexia in men are lacking, particularly pertaining to the relationship between orthorexia and muscularity-related dimensions. A sample of 103 (M_age = 19.84) male college students completed an online questionnaire reporting on orthorexia symptoms, eating pathology, drive for muscularity, exercise dependence, and internalization of the thin and athletic ideals. Correlational analyses and linear regression models were used to explore relationships between orthorexia and variables of interest. Findings revealed positive relationships between high levels of orthorexia symptoms and eating pathology, exercise dependence, thin and athletic internalization, and behavioral dimensions of drive for muscularity. The results of this study extend our understanding of the correlates of orthorexia symptoms among young men and highlight their association with other dimensions of eating pathology as well as dysfunctional exercise. In addition, concerns related to healthiness may overlap with muscularity-related concerns, perhaps due to the conflation between health and muscular appearance in social constructions of male body ideals.

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.

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.

How to integrate physical activity and exercise approaches into inpatient treatment for eating disorders: fifteen years of clinical experience and research

BACKGROUND

The importance of physical activity and exercise among patients with eating disorders (EDs) is acknowledged among clinicians and researchers. The lack of clinical guidelines, the differing attitudes towards exercise approaches in treatment, and the lack of specialized competence all influence the management of ED symptoms in specialist ED treatment units. The purpose of the study was to examine 15 years of clinical experience with exercise approaches as an integrated part our inpatients treatment program.

METHODS

From January 2003 to December 2017, 244 patients were admitted to a specialist ED unit in Norway. The treatment program at the ED unit is multidisciplinary. It is based on psychodynamic theory, and designed to enhance patients' recovery and to enable them to adopt a lifestyle that is as healthy as possible. The authors describe the clinical management of patients with reference to practical examples and a case example.

RECOMMENDATIONS AND EXPERIENCE

The treatment for exercise is not manualized, but adjusted to the specific symptoms and needs of individual ED patients. The treatment approaches to exercise are part of the body-oriented treatment at the Specialist eating disorder unit (Regionalt kompetansesenter for spiseforstyrrelser (RKSF)), and the therapy addresses the entire body and the relation between the body, emotions, and the patient's social situation. It covers a chain of approaches from admission to discharge, from rest and relaxation to regular exercise groups.

CONCLUSIONS

Our experience and recommendations support earlier proposals for treatment approaches to exercise and exercise-related issues as a beneficial supplement to the treatment of ED inpatients. We have not experienced any adverse influences on patients' recovery processes, such as their rate of weight gain. Our intention is that this paper will be a contribution to the field of ED, the integration of exercise approaches in the inpatient treatment of ED and development of clinical guidelines.