Compulsive exercise and eating disorders

Adolescent leisure-time physical activity and eating disorders: a longitudinal population-based twin study

PURPOSE

High levels of physical activity have been documented in eating disorder patients. Our aim was to examine whether adolescent leisure-time physical activity is prospectively associated with eating disorders in adolescence and young adulthood.

METHODS

Finnish twins born in 1983-1987 reported their physical activity frequency at ages 12, 14, and 17. A subsample of participants underwent structured, retrospective interviews for eating disorders at the mean age of 22.4 years. Associations between female twins' physical activity and future eating disorders (571-683 twins/wave) were investigated with the Cox proportional hazards model. To illustrate the physical activity similarity of the co-twins in a twin pair, we used cross-tabulation of eating disorder-discordant twin pairs (13-24 pairs/wave).

RESULTS

After adjusting for several covariates, we found no statistically significant longitudinal association between physical activity and eating disorders. This applied when all eating disorders were combined but also when assessed separately as restrictive and non-restrictive eating disorders. Co-twins' physical activity in adolescence tended to be similar irrespective of their future eating disorder, supporting the results of the regression analysis.

CONCLUSION

We observed no evidence of adolescent physical activity frequency being prospectively associated with eating disorders in female twins. Further longitudinal studies with larger sample sizes and more detailed physical activity data are needed.

LEVEL OF EVIDENCE

III, evidence obtained from cohort or case-control analytic studies.

Examining compulsive exercise as a risk factor for eating disorder symptoms in first-year college students using a latent change score modeling approach

OBJECTIVE

Research suggests that both compulsive exercise and eating disordered behaviors increase during college. Despite strong cross-sectional associations between compulsive exercise and eating disorders, it is unknown if compulsive exercise is a variable risk factor for eating disorders or simply a correlate. It was hypothesized that increases in compulsive exercise would significantly and prospectively predict increases in overall number of eating disorder symptoms over the study period.

METHOD

A total of 265 first year college students who did not meet criteria for a full or subthreshold eating disorder diagnosis at Time 1 (age M = 18.15; SD = 0.42; 122 female [46%] at Time 1) completed reports of compulsive exercise and eating disorder symptoms via online questionnaires at four timepoints over the 9-month 2021-2022 academic year (76% retention rate). Hypotheses were tested using a bivariate latent change score model.

RESULTS

Hypotheses were not supported. Change in compulsive exercise did not predict change in number of eating disorder symptoms. Change in number of eating disorder symptoms also did not predict change in compulsive exercise.

CONCLUSIONS

Compulsive exercise did not emerge as a variable risk factor for the development of eating disorder symptoms among first year college students. The relationship between these behaviors should be investigated at different developmental timepoints, such as early adolescence, and potential third variables that may explain the observed co-occurrence should be explored.

PUBLIC SIGNIFICANCE

This study investigated whether increases in compulsive exercise predicted increases in number of eating disorder symptoms among first year college students. Compulsive exercise did not significantly predict number of eating disorder symptoms. Additional research is warranted to clarify the relationship between compulsive exercise and eating disorder symptoms.

First international consensus statement on sports psychiatry

Sports psychiatry is a young field of medicine and psychiatry that focuses on mental health among athletes, and sports and exercise within psychiatry and mental disorders. However, the development of sports psychiatry and its fields of activity vary from region to region and are not uniform yet. Sports psychiatry and the role of sports psychiatrists have also already been discussed in the field of sports and exercise medicine, and within medical teams in competitive and elite sports. A uniform definition on sports psychiatry, its fields of activity, sports psychiatrist, and the essential knowledge, skills, and abilities (plus attitudes, eKSA+A) of the sports psychiatrist were developed as part of an International Society for Sports Psychiatry (ISSP) Summit, as well as First International Consensus Statement on Sports Psychiatry. Three fields of activity can be distinguished within sports psychiatry: (i) mental health and disorders in competitive and elite sports, (ii) sports and exercise in prevention of and treatment for mental disorders, and (iii) mental health and sport-specific mental disorders in recreational sports. Each of these fields have its own eKSA+A. The definitions on sports psychiatry and sports psychiatrists, as well as the framework of eKSA+A in the different fields of activity of sports psychiatrists will help to unify and standardize the future development of sports psychiatry, establish a standard of service within sports psychiatry and together with the neighboring disciplines, and should be included into current, and future sports psychiatry education and training.

Direct, indirect, and reciprocal associations between perfectionism, compulsive exercise and eating disorder pathology in adolescents with eating disorders

BACKGROUND

There is a strong association between perfectionism and eating disorders. In a cognitive-behavioural model of compulsive exercise it has been suggested there are reciprocal associations between perfectionism, eating disorder pathology, and compulsive exercise. No study has examined if there is an indirect association between perfectionism and compulsive exercise through eating disorder pathology, which would inform a preliminary understanding of the cognitive-behavioural model of compulsive exercise.

METHODS

The sample included 301 adolescent females diagnosed with eating disorders (age M = 14.89, SD = 0.85, range 13-17). We tested models of direct and indirect associations of compulsive exercise in the relationship between perfectionism and eating disorder pathology, and direct and indirect associations of eating disorder pathology in the relationship between compulsive exercise and perfectionism.

RESULTS

Perfectionism was directly associated with eating disorder pathology and compulsive exercise. Perfectionism was indirectly associated with eating disorder pathology through compulsive exercise. Perfectionism also had an indirect association with compulsive exercise through eating disorder pathology.

DISCUSSION

The findings suggest it would be useful for future prospective research to examine the cognitive-behavioural model of compulsive exercise in adolescents with eating disorders. Compulsive exercise and perfectionism may be useful targets for future research to improve eating disorder treatment. Level of evidence Level V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Working out measurement overlap in the assessment of maladaptive exercise

OBJECTIVE

Although exercise is generally considered healthy, many individuals engage in maladaptive exercise (e.g., compulsive in nature). Several definitions of maladaptive exercise exist, leading to multiple, varied assessment tools; assuming homogeneity across these assessments contributes to low consensus in etiological models.

METHOD

We used a Jaccard Index to quantify content overlap among 15 commonly-used self-report instruments measuring maladaptive exercise, with 31 features identified across 224 items.

RESULTS

The most common features were exercise to control weight/shape and to avoid negative affect (both included in 9/15 instruments), or compensate for calories consumed (8/15 instruments). Overlap among instruments was low (.206) and no features were common across all instruments.

CONCLUSIONS

Findings generally support theoretical models of exercise in eating pathology. However, instruments most commonly used to assess maladaptive exercise measure heterogenous content. Careful consideration should be taken when comparing findings derived from differing instruments, when synthesizing literature on maladaptive exercise, and when selecting instruments to measure specific maladaptive exercise features.

PUBLIC SIGNIFICANCE

Many, varied, tools exist for the assessment of maladaptive exercise (e.g., compulsive or compensatory) in the context of eating disorders. Assuming homogeneity across tools contributes to low consensus in the field. We used a Jaccard Index to quantify content overlap among 15 self-report instruments measuring maladaptive exercise. The most commonly used instruments measure heterogenous content. Careful consideration should be taken when synthesizing literature and selecting instruments to use in research.

The impact of socioeconomic status on health practices via health lifestyles: Results of qualitative interviews with Americans from diverse socioeconomic backgrounds

We performed 55 qualitative interviews with Americans from diverse socioeconomic backgrounds from a small city in the Northeast to better understand the complex process through which socioeconomic status (SES) influences the health practices persons carry out. We argue that SES not only influences health practices directly, but also via shaping interviewees' health lifestyles. We describe four connected ways that SES shapes interviewees' health lifestyles: (a) the impact of physical and mental illness on how much time, energy, and resources can be devoted to health; (b) the impact of social connections on opportunities to engage in healthy practices; (c) variation in interviewees' sense of control over health and health practices; and (d) how intentional and planned out interviewees' health lifestyles are. Although explored previously, the aim of this study is to examine how these elements come together to form into distinct styles of health shaped by the socioeconomic background of our respondents.

New understandings meet old treatments: putting a contemporary face on established protocols

In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.

Effects of inpatient treatment on compulsive exercise in adults with longstanding eating disorders: Secondary analysis from a randomized controlled trial with 12-month follow-up

PURPOSE

This study aimed to examine changes in compulsive exercise among adults with eating disorders (ED) admitted for inpatient treatment in a randomized controlled trial comparing cognitive behavioral therapy (CBT) and compassion-focused therapy (CFT) and whether such changes were influenced by treatment condition, childhood trauma, or level of compulsive exercise.

METHOD

A total of 130 adults admitted to inpatient treatment for EDs mean (SD) age 30.9 (9.7) years, mean illness duration 14.2 (8.9) years, were randomized to receive CBT or CFT and analyzed using multilevel modeling. Assessments included Eating Disorders Examination - Interview, Compulsive Exercise Test and Childhood Trauma Questionnaire.

RESULTS

Mean total CET score at baseline was 14.7 (4.0) with no difference between the treatment groups. A total of 63 (48.5%) had CET score ≥ 15, indicating clinical levels. There was an overall time effect on reduction in CET total and all CET subscale scores except Lack of enjoyment, and CFT provided greater reduction compared to CBT on the CET subscale Mood improvements. Patients with clinical CET score levels showed greater reduction on CET total and the subscales Avoidance, Weight, and Rigidity across time compared to persons with non-clinical CET score. Childhood trauma did not predict changes in CET total or subscale scores.

DISCUSSION

Both CBT and CFT improve overall compulsive exercise. The greater effect of CFT than CBT on exercise as a maladaptive mood regulator calls for further research on how affective oriented psychotherapies can not only reduce compulsive exercise but also promote functional exercise among persons with EDs.

PUBLIC SIGNIFICANCE STATEMENT

Understanding and addressing compulsive exercise in adults with eating disorders is crucial. This study comparing cognitive-behavioral therapy and compassion-focused therapy shows both improve compulsive exercise. Importantly, compassion-focused therapy has a greater impact as an emotion-focused regulator. This emphasizes the need for further exploration into how emotion-focused therapies can reduce compulsive exercise and promote healthier, functional physical activity for individuals with eating disorders.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

PUBLIC SIGNIFICANCE STATEMENT

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

Key-in-session identity negotiations in a first line treatment for adult anorexia nervosa

BACKGROUND

Exploration of client identity negotiations during treatment for Anorexia Nervosa (AN) is a relatively new area of research. Research suggests that difficulties with identity negotiations may present as a barrier to treatment. This study sought to explore individuals' identity negotiations during therapy sessions using Compulsive Exercise Activity Therapy (LEAP) combined with Cognitive Behaviour Therapy for Anorexia Nervosa (CBT-AN). Analysis focused on moments in therapy where individuals' identities were dominated or defined by AN and where alternative identities could be generated.

METHOD

40 in-session transcripts from sessions at early, mid and end points of the CBT-AN (with LEAP) treatment were qualitatively analysed for nine of the 78 participants in the original randomised control trial. Through a constructivist framework, thematic analysis was used to identify surface and latent meanings and discursive material participants used to negotiate their identities in the context of therapy sessions.

RESULTS

Analysis of in-therapy transcripts generated two themes pertaining to identity negotiations: (1) troubled identities and (2) rebuilding identities and lives outside of AN. Early therapy sessions explored fragmented and AN dominated identities, including how AN was troubling to participants' sense of self, contributed to conflicted identities, positioned them outside of normality, and was associated with isolated and othering identities. Within therapy sessions, participants engaged in a recursive process of shifting relationships with AN and themselves and building identities and lives outside of the AN identity. This included generating hopes for recovery and the future more frequently in mid- to late- therapy sessions.

CONCLUSION

Identity negotiations evident in the therapeutic conversations aligned with the key components of the CBT-AN intervention, including addressing (1) the characterisation of oneself as 'an anorexic' and (2) the diversification of roles and activities to broaden and enhance self-concepts. Future developments of therapeutic interventions for AN would benefit from greater consideration of ways to assist individuals to more comprehensively address problematic identities, including uncovering identities hidden by the AN identity and generating preferred identities.

TRIAL REGISTRATION

Ethics approval was obtained at the time of the initial study and for this embedded research by the HREC at the Western Sydney University (HR777332).

A transdiagnostic and translational framework for delineating the neuronal mechanisms of compulsive exercise in anorexia nervosa

OBJECTIVE

The development of novel treatments for anorexia nervosa (AN) requires a detailed understanding of the biological underpinnings of specific, commonly occurring symptoms, including compulsive exercise. There is considerable bio-behavioral overlap between AN and obsessive-compulsive disorder (OCD), therefore it is plausible that similar mechanisms underlie compulsive behavior in both populations. While the association between these conditions is widely acknowledged, defining the shared mechanisms for compulsive behavior in AN and OCD requires a novel approach.

METHODS

We present an argument that a better understanding of the neurobiological mechanisms that underpin compulsive exercise in AN can be achieved in two critical ways. First, by applying a framework of the neuronal control of OCD to exercise behavior in AN, and second, by taking better advantage of the activity-based anorexia (ABA) rodent model to directly test this framework in the context of feeding pathology.

RESULTS

A cross-disciplinary approach that spans preclinical, neuroimaging, and clinical research as well as compulsive neurocircuitry and behavior can advance our understanding of when, why, and how compulsive exercise develops in the context of AN and provide targets for novel treatment strategies.

DISCUSSION

In this article, we (i) link the expression of compulsive behavior in AN and OCD via a transition between goal-directed and habitual behavior, (ii) present disrupted cortico-striatal circuitry as a key substrate for the development of compulsive behavior in both conditions, and (iii) highlight the utility of the ABA rodent model to better understand the mechanisms of compulsive behavior relevant to AN.

PUBLIC SIGNIFICANCE

Individuals with AN who exercise compulsively are at risk of worse health outcomes and have poorer responses to standard treatments. However, when, why, and how compulsive exercise develops in AN remains inadequately understood. Identifying whether the neural circuitry underlying compulsive behavior in OCD also controls hyperactivity in the activity-based anorexia model will aid in the development of novel eating disorder treatment strategies for this high-risk population.

Validation and measurement invariance of the Compulsive Exercise Test among Brazilian and American young adults

PURPOSE

To evaluate compulsive exercise, researchers often rely on the widely used Compulsive Exercise Test (CET). However, the measure has shown unstable factor structure in several validation studies and is not available in Portuguese for use in Brazil. We aimed to describe the translation and cultural adaptation of the CET to Brazilian Portuguese, to test several factor structures among Brazilian and US samples of men and women, to test measurement invariance across countries, and to evaluate its internal consistency. Furthermore, we sought to evaluate convergent validity, correlating the CET with a measure of eating disorder symptoms, and to compare compulsive exercise symptoms between countries.

METHODS

Four models of the latent structure of the CET were tested using confirmatory factor analyses (CFAs), three-factor structure with 15 items, three-factor structure with 18 items, four-factor structure with 21 items, and the original five-factor structure with 24 items, in a sample of 1,531 young adults (601 Brazilians and 930 Americans), aged 18-35 years.

RESULTS

A series of CFAs demonstrated that the three-factor structure with 15 items showed a better fit to the data. This model demonstrated good convergent validity and internal consistency. Results from the CET multigroup CFA showed evidence for the invariance at the configural, metric, and scalar levels across Brazilians and Americans. Furthermore, significant differences were found between Brazilians and Americans, with Brazilians demonstrating higher scores on the Avoidance and rule-driven behavior and Mood improvement subscales, whereas US participants scored higher on the Weight control exercise subscale.

CONCLUSIONS

Results support the three-factor structure with 15 items to be used as a measure of compulsive exercise among Brazilians and Americans, allowing cross-cultural comparisons between these countries.

LEVEL OF EVIDENCE

Level V, Cross-sectional, Psychometric study.

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.

The impact of trauma-related symptoms and neuroticism on compensatory behaviors in a sample of adults with eating disorders

INTRODUCTION

Inappropriate compensatory behaviors (ICBs), including purging, restricting, and excessive exercising, are key symptoms of several eating disorders (EDs). Studies have found positive associations between trauma and ICBs, although few studies have explored mechanisms that may explain these relationships. Emotion dysregulation has been posited as a mechanism that explains associations among ICBs and trauma. Given that individuals with high neuroticism may be particularly likely to use ICBs to regulate emotions following a trauma, the purpose of this study was to test whether neuroticism moderated the relationship between trauma-related symptoms and each type of ICB (purging, restricting, and excessive exercise).

METHOD

A community sample of adults with a DSM-5 ED (N = 263; 83.7 % female) completed measures of trauma-related symptoms, ED psychopathology, and personality.

RESULTS

Zero-inflated negative binomial models revealed that trauma-related symptoms alone predicted restricting and purging behavior. In addition, we found that neuroticism alone predicted the presence of excessive exercise. We found no significant interaction between trauma-symptoms and neuroticism.

CONCLUSION

Although past research has documented high rates of co-occurring ED and PTSD, the connections between trauma-related symptoms and ICBs are complex and may be unique to each type of ICB. Given that neuroticism may not influence the relationship between trauma-related symptoms and ICBs, more research should be done to establish an understanding of factors that could explain the relationship between ICBs and trauma-related symptoms. Novel interventions that simultaneously target restricting, purging, and trauma-related symptoms could be beneficial to explore.

Affective profiles of exercise episodes are associated with maladaptive and adaptive motivations for exercise

OBJECTIVE

Maladaptive exercise (i.e., driven and/or compensatory exercise) is common in binge-spectrum eating disorders (EDs; e.g., bulimia nervosa, binge ED) and associated with adverse treatment outcomes. Alternatively, individuals with EDs are often also engaging in adaptive exercise (e.g., for enjoyment or health improvement), and increasing adaptive exercise may decrease ED symptoms. The current study aimed to understand which exercise episodes are likely to be maladaptive/adaptive so that interventions can appropriately decrease/increase maladaptive and adaptive exercise.

METHOD

We used latent profile analysis (LPA) to identify pre-exercise affective profiles of 661 exercise episodes among 84 individuals with binge-spectrum EDs and examined associations between LPA-identified profiles and subsequent exercise motivations using ecological momentary assessment.

RESULTS

A two-profile solution best fit our data: Profile 1 (n = 174), 'positive affectivity,' and Profile 2 (n = 487), 'negative affectivity.' Episodes in the 'negative affectivity' profile were more likely to be endorsed as both driven and intended to influence body shape/weight. Episodes in the 'positive affectivity' profile were more likely to be endorsed as exercising for enjoyment.

CONCLUSIONS

Results support two phenotypes of exercise episodes, and differential associations of these phenotypes with adaptive and maladaptive motivations for exercise.

How to address physical activity and exercise during treatment from eating disorders: a scoping review

PURPOSE OF REVIEW

This scoping review aimed to provide a recent update on how to address dysfunctional physical activity and exercise (DEx), and on effects and experiences from including supervised and adapted physical activity or exercise (PAE), during treatment of eating disorders.

RECENT FINDINGS

A systematic search for peer-reviewed publications in the period 2021-2023 generated 10 original studies and 6 reviews, including one meta-analysis (reporting according to PRISMA and SWiM). Findings showed that DEx was effectively managed by use of psychoeducation and/or PAE. Inclusion of PAE as part of treatment showed low-to-moderate impact on health and positive or neutral effects on eating disorder psychopathology. There were no reports of adverse events. For individuals with anorexia nervosa, PAE improved physical fitness with no influence on body weight or body composition unless progressive resistance training was conducted. For individuals with bulimia nervosa, DEx was reduced simultaneously with increased functional exercise and successful implementation of physical activity recommendations during treatment. Experiences by individuals with eating disorders and clinicians, including accredited exercise physiologists, pointed to positive benefits by including PAE in treatment.

SUMMARY

Lack of consensus about DEx and of recommendations for PAE in official treatment guidelines hinder adequate approaches to these issues in eating disorder treatment.

Classifying excessive exercise: Examining the relationship between compulsive exercise with obsessive-compulsive disorder symptoms and disordered eating symptoms

OBJECTIVE

There remains a lack of consensus around nosology for compulsive exercise (CE). Although widely observed in eating disorders (ED), CE shares theoretical overlap with obsessive-compulsive disorder (OCD), where exercise compulsions occur in response to obsessions. Yet, there is limited and mixed evidence of a relationship between CE with OCD. This study aims to explore the appropriate diagnostic classification of CE through examination of CE in relation to OCD, obsessional thinking, and ED symptoms.

METHOD

Two hundred and eighty one adults with mental health symptoms, dieting, and exercise behaviour completed measures of OCD, CE, and disordered eating symptoms. Regression and Receiver Operating Characteristic analyses examined relationships between dimensions of CE with OCD and ED symptoms, and the predictive ability of CE assessment for detecting threshold OCD and ED symptoms.

RESULTS

CE assessment was poor at predicting threshold OCD symptoms, probable Anorexia Nervosa, and Binge Eating Disorder and moderate at detecting probable disordered eating and Bulimia Nervosa. Associations between CE and OCD symptoms were not significant after adjustment for ED symptoms. Obsessional thinking was associated only with lack of exercise enjoyment.

CONCLUSIONS

Results indicate that excessive exercise might represent a distinct disorder, with some shared traits across CE, OCD and ED symptoms. Findings question the utility of adaptation of OCD diagnostic criteria for CE. Assessment and treatment implications are considered.

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

Objective

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

Method

A comparison of published literature between these two groups.

Results

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

Conclusion

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

The State Urge to be Physically Active-Questionnaire (SUPA-Q): Development and validation of a state measure of activity urges in patients with eating disorders

OBJECTIVE

Many people, including patients with eating disorders (EDs), experience an increased urge for physical activity. "Trait"-like activity in patients with EDs is assessed by existing questionnaires, but there are few clinically validated assessments of a "state" urge to be physically active. Here, we developed and validated the State Urge to be Physically Active-Questionnaire (SUPA-Q).

METHODS

After developing and piloting the items, N = 126 patients with EDs (mostly anorexia nervosa and bulimia nervosa) took part in our mixed-longitudinal validation study with one primary assessment for all patients and a secondary assessment for a subsample of patients. Cronbach's α and split-half-methods served as measures of consistency and reliability. Correlations with other questionnaires were used to determine convergent and divergent validity, and confirmatory factor analysis was used for investigating factorial validity. We used paired-samples t-tests for repeated assessments to investigate change sensitivity.

RESULTS

We found the SUPA-Q to be highly consistent, and reliable and to demonstrate convergent, divergent, and factorial validity. The comparison of SUPA-Q scores from repeated assessments within a subsample of patients demonstrated the questionnaire's change sensitivity, Cohen's d = 0.48. Moreover, an increase in SUPA-Q scores was associated with a less positive mood, more anxiety, more body dissatisfaction, more tenseness, less feelings of control, and more stress.

DISCUSSION

The newly developed SUPA-Q may help to accentuate the necessity to evaluate and address the acute urge to engage in physical activity in patients with EDs in clinical practice and ultimately support tailoring treatments to patients' unique symptom patterns. The questionnaire is available at https://doi.org/10.17605/OSF.IO/G2YBC.

Prevalence and Association of Exercise Dependence and Eating Disorder Risk in Collegiate Student-Athletes

CONTEXT

Exercise dependence (EXD) is a compulsive and addictive behavior that can negatively affect physical and mental health, leading to significant impairment or distress. Exercise dependence has been associated with symptoms of eating disorders (EDs). Student-athletes are an at-risk population for EXD and EDs given the physical and psychological demands of competitive sports.

OBJECTIVE

To examine the EXD and ED risks in student-athletes across sex and sport category and to determine the association between EXD and ED.

DESIGN

Cross-sectional study.

SETTING

Collegiate athletics.

PATIENTS OR OTHER PARTICIPANTS

National Collegiate Athletic Association Division I and II student-athletes (n = 1885; age = 19.8 ± 1.4 years; females = 69.6%, n = 1312; males = 30.4%, n = 573).

MAIN OUTCOME MEASURE(S)

A web-based survey including demographics, the Exercise Dependence Scale-21, the Eating Attitudes Test-26, and questions about pathogenic behaviors.

RESULTS

Overall, 4.9% (n = 92) of the student-athletes were categorized as at risk for EXD (females = 4.8%, n = 63/1312; males = 5.1%, n = 29/573), with differences across sex and sport categories (all: χ28,1885 = 99.1, P < .001). The ED risk in student-athletes (Eating Attitudes Test-2, pathogenic behavior use, or both) was 22.7% (n = 428; females = 25.5%, n = 334/1312; males = 16.4%, n = 94/573), with differences by sex (χ24,1885 = 10.1, P = .039). Multiple logistic regressions indicated a significant association between the risks of EXD and ED for all student-athletes; athletes at risk for EXD were also at greater risk for EDs (odds ratio = 5.104; 95% CI = 3.237, 8.046) than nondependent-asymptomatic athletes (odds ratio = 2.4068; 95% CI = 1.5618, 3.7089).

CONCLUSIONS

Although physical activity has become a public health intervention to improve overall health in populations, EXD can be considered a problem related to physical activity. Exercise dependence can negatively affect physical and mental health, whereas EDs may be psychiatric disorders influenced by EXD, as exercise can be a compensatory behavior to achieve weight loss. To minimize the overall risk of EDs in student-athletes, additional education and awareness are needed. Special attention should be given to any student-athletes, in particular females, who display signs of EXD.

Measuring cognitions during exercise: Associations between thoughts and eating disorder behaviors over a 3-week ecological momentary assessment study

OBJECTIVE

Previous work has outlined cognitive beliefs about exercise in general, but very little is known about momentary cognitions while engaging in pathological exercise. The primary aim of this study was to explore thought content during exercise and to test whether these thoughts predicted later engagement in eating disorder behaviors. We also tested associations between thoughts and specific exercise activity.

METHOD

We monitored 31 women with clinically significant eating psychopathology for 3 weeks via ecological momentary assessment as they reported on their exercise and eating disorder behaviors, and thoughts about shape, weight, or calories during exercise. Thoughts were self-reported upon cessation of each exercise session.

RESULTS

Thinking about weight loss during exercise predicted later engagement in body-checking behaviors. Weight-bearing exercise was associated with a decreased likelihood of thinking about calories but an increased likelihood of thinking about shape during exercise.

DISCUSSION

These findings show that shape and weight thoughts are present during exercise and that their influence on eating disorder behaviors may exist on a much briefer time scale (i.e., within a day) than previous studies show. Clinically, future studies may seek to test interventions aimed at changing or restructuring cognitions during exercise to help shape adaptive exercise behavior during and after treatment.

PUBLIC SIGNIFICANCE

This is the first study measuring thoughts during pathological exercise in real-time among those with eating disorder psychopathology. The results show that thinking about weight loss during exercise might increase the likelihood of engaging in body-checking behaviors. Findings will inform the development of treatment approaches to help those in recovery from eating disorders re-engage with exercise.

Impact of virtual adjunctive cognitive remediation therapy on cognitive flexibility and treatment outcomes in comorbid anorexia nervosa and exercise dependence as quantified using novel biomarkers: A stage 1 registered report

OBJECTIVE

Anorexia nervosa (AN) is associated with significant individual mental and physical suffering and public health burden and fewer than half of patients recover fully with current treatments. Comorbid exercise dependence (ExD) is common in AN and associated with significantly worse symptom severity and treatment outcomes. Research points to cognitive inflexibility as a prominent executive function inefficiency and transdiagnostic etiologic and maintaining mechanism linking AN and ExD. This study will evaluate the initial efficacy of adjunctive Cognitive Remediation Therapy (CRT), which has been shown to produce cognitive improvements in adults with AN, in targeting cognitive inflexibility in individuals with comorbid AN and ExD. As an exploratory aim, this study also addresses the current lack of quick and cost-effective assessments of cognitive flexibility by establishing the utility of two proposed biomarkers, heart rate variability and salivary oxytocin.

METHOD

We will conduct a single-group, within-subjects trial of an established CRT protocol delivered remotely as an adjunct to inpatient or intensive outpatient treatment as usual (TAU) to adult patients (n = 42) with comorbid AN and ExD. Assessments, including self-report, neuropsychological, and biomarker measurements, will occur at three time points.

RESULTS

We expect CRT to increase cognitive flexibility transdiagnostically and consequently, along with TAU, positively impact AN and ExD compulsivity and symptom severity, including weight gain.

DISCUSSION

Findings will inform the development of more effective integrative interventions for AN and ExD targeting shared mechanisms and facilitate the routine assessment of cognitive flexibility as a transdiagnostic risk and maintaining factor across psychopathologies in clinical and research settings.

PUBLIC SIGNIFICANCE

Patients with anorexia nervosa often engage in excessive exercise, leading to harmful outcomes, including increased suicidal behavior. This study examines the preliminary efficacy of an intervention that fosters flexible and holistic thinking in patients with problematic eating and exercise to, along with routine treatment, decrease harmful exercise symptoms. This study also examines new biological markers of the inflexible thinking style thought to be characteristic of anorexia nervosa and exercise dependence.

Effects of Mindfulness on Obligatory Exercise During the Return of Injured Athletes to Sports: The Mediating Roles of Self-Criticism and Competitive State Anxiety

Purpose

Despite the Advances in sports training methods and medicine, they have not reduced the recurrence rate of athletes' injuries significantly, and obligatory exercise may be an important reason for their re-injury. The purpose of this study was to investigate the effects of mindfulness on obligatory exercise behavior, self-criticism, and competitive state anxiety in athletes recovering from injury, and explain their interactions.

Patients and Methods

The study adopted the snowball and convenience sampling methods. From November to December 2022, a total of 265 high-level sports players in South China were selected, and ultimately, 208 valid data samples were obtained. Maximum likelihood estimation was used to analyze the data and test the hypotheses proposed using 5000 bootstrap samples to test the mediating effects of the structural equation model.

Results

The results demonstrated that there were positive correlations between self-criticism and obligatory exercise (standardized coefficients = 0.38, p < 0.001), as well as competitive state anxiety and self-criticism (standardized coefficients = 0.45, p < 0.001). Mindfulness and obligatory exercise were correlated negatively (standardized coefficients = -0.31, p < 0.001), but there was no significant relation between competitive state anxiety and obligatory exercise (standardized coefficients = 0.05, p > 0.01). Self-criticism and competitive state anxiety mediated mindfulness's positive effects on obligatory exercise in part (standardized indirect effect = -0.16, p < 0.01), and this explanatory power was higher than in any previous study (R2 = 0.37).

Conclusion

The irrational beliefs in Activating events-Beliefs-Consequence (ABC) theory play an important role in explaining athletes' obligatory exercise, and mindfulness has a positive effect on reducing obligatory exercise behavior.

Compulsive exercise and its relationship with mental health and psychosocial wellbeing in recreational exercisers and athletes

OBJECTIVES

Better understanding of compulsive exercise is needed in sports medicine. Whilst compulsive exercise may impact mental health, the limited research exploring the relationship between compulsive exercise and psychosocial outcomes is equivocal. The majority of studies have examined eating disorder populations where the eating disorder pathology might account for distress. This study explores relationships between compulsive exercise and mental health.

DESIGN

Cross-sectional observational study.

METHODS

Australian recreational exercisers and athletes (N = 1157; M_age 36.4, standard deviation = 12.9, 77 % female) recruited through sporting organisations, clubs, and gyms, completed measures of compulsive exercise, depression, anxiety, stress, life satisfaction, social physique anxiety, and self-esteem. Regression analyses examined relationships between dimensions of compulsive exercise and wellbeing.

RESULTS

After adjustment for eating disorder symptoms and sporting level, compulsive exercise was associated with increased risk of clinically-significant anxiety, depression, and stress symptoms. Compulsive exercise was also associated with lower life satisfaction and self-esteem, and higher social physique anxiety. Notably, different dimensions of compulsive exercise had varying relationships with outcomes, and avoidance and rule-driven behaviour and lack of exercise enjoyment were associated with poorer mental health and wellbeing.

CONCLUSIONS

Results suggest that compulsive exercise is uniquely associated with a range of psychosocial and mental health outcomes. Results support the need to improve identification and treatment of compulsive exercise in sport and exercise settings. Results highlight that mental health intervention is an important component of treatment, and treatments targeting symptoms related to avoidance and rule-driven behaviour, and anhedonia may be valuable treatment components for those with compulsive exercise.

Anxiety, body dissatisfaction, and exercise identity: Differentiating between adaptive and compulsive exercise

OBJECTIVE

Little is known about psychosocial variables that may be differentially associated with compulsive exercise versus adaptive exercise. The current study simultaneously examined associations of exercise identity, anxiety, and body dissatisfaction with both compulsive and adaptive exercise behaviors and investigated which construct may account for the most unique variance in compulsive and adaptive exercise. Hypotheses were that: 1) body dissatisfaction, anxiety, and exercise identity would be significantly associated with compulsive exercise and 2) exercise identity would be significantly associated with adaptive exercise.

METHOD

A total of 446 individuals (50.2 % female) completed reports of compulsive exercise, adaptive exercise, body dissatisfaction, exercise identity, and anxiety via an online survey. Multiple linear regression and dominance analyses were used to test hypotheses.

RESULTS

Exercise identity, body dissatisfaction, and anxiety were all significantly associated with compulsive exercise. Only exercise identity and anxiety were significantly associated with adaptive exercise. Dominance analyses suggested that exercise identity accounted for the largest proportion of variance in compulsive (Dominance R² = 0.27) and adaptive exercise (Dominance R² = 0.45).

CONCLUSION

Exercise identity emerged as the strongest predictor of both compulsive and adaptive exercise. The simultaneous presence of exercise identity, body dissatisfaction, and anxiety may contribute to high risk for engagement in compulsive exercise. Incorporating exercise identity into established eating disorder preventions and treatments may contribute to the reduction of compulsive exercise behaviors.

The association between sport type and eating/body image concerns in high school students: a cross-sectional observational study

PURPOSE

Disordered eating and body image concerns are increasingly common among adolescents, possibly representing the underpinning of eating disorders (EDs). This cross-sectional observational study aimed at investigating the relationship between various patterns of sports involvement or inactivity, and the abovementioned psychopathological dimensions.

METHODS

All adolescents attending their 3rd-5th Italian grade in a single high school reported their sociodemographic and anthropometric data, their weekly sports involvement, and filled the Eating Disorders Examination Questionnaire 6.0 (EDE-Q), the Body Uneasiness Test, and the Muscle Dysmorphia Disorder Inventory (for boys). Comparisons were performed considering sex, weekly hours of activity, and different sports type (none, individual, or team sports).

RESULTS

Of 744 enrolled students, 522 (70.2%) completed the survey. Girls showed higher underweight rates, preference for inactivity or individual sports, and higher psychometric scores compared to boys. Among girls, no differences were found based on time spent exercising or sports type. Inactive boys displayed worse weight- and shape-based psychopathology, higher body uneasiness, and higher appearance intolerance compared to those who devoted more time to exercise. Among boys, individual and team sports were associated with lower EDE-Q scores compared to inactivity, whereas body uneasiness and appearance intolerance were lower only in team sports.

CONCLUSIONS

The study confirms the presence of remarkable sex differences in eating and body concerns of adolescents. Among boys, sports involvement is tied to lower ED psychopathology, and preference for team sports may be associated with reduced concerns. Wider longitudinal studies on will clarify the direction and specificity of these findings.

LEVEL OF EVIDENCE

Level V-Cross-sectional observational study.

The Expanded Exercise Addiction Inventory (EAI-3): Towards Reliable and International Screening of Exercise-Related Dysfunction

Exercise addiction (EA) refers to excessive exercise, lack of control, and health risks. The Exercise Addiction Inventory (EAI) is one of the most widely used tools in its assessment. However, the cross-cultural psychometric properties of the EAI could be improved because it misses three pathological patterns, including guilt, exercise despite injury, and experienced harm. Therefore, the present study tested the psychometric properties of the expanded EAI (EAI-3) in a large international sample. The EAI-3 was administered to 1931 physically active adult exercisers speaking five languages (Chinese, German, Italian, Japanese, and Turkish) and other measures for obsessive-compulsive behavior, eating disorders, and personality traits. The assessment structure and reliability of the EAI-3 were tested with factorial analyses and through measurement invariance across languages and sex. Finally, a cutoff point for dysfunction-proneness was calculated. The EAI-3 comprised two factors, reflecting the positive and pathological sides of exercise. The structure had excellent reliability and goodness-of-fit indices and configural and metric invariances of the scale were supported. However, three items caused violations in scalar invariance. The results of partial measurement invariance testing suggested an adequate fit for the data. Following sensitivity and specificity analysis, the EAI-3's cutoff score was 34 out of a maximum score of 48. This preliminary study suggests that the EAI-3 is a promising tool for screening EA in an international sample, with a robust and reliable structure comparable across languages and sex. In addition, the proposed cutoff could pave the way toward a consensus on a threshold to screen for EA.

Gender differences in compulsive exercise facets and their associations with eating disorder symptoms

Compulsive exercise (CE) is a core symptom of eating disorders (EDs) that is common in undergraduate men and women. Importantly, CE is a multidimensional construct, and certain facets of CE (i.e., exercise to control weight or to avoid negative affect associated with missed exercise) are more strongly associated with ED symptoms in undergraduate women than others. However, less is known about how CE facets relate to ED symptoms in men. This study examined: 1) gender differences in levels of CE facets, assessed using the Compulsive Exercise Test (CET); 2) whether specific CE facets independently relate to ED symptoms; and 3) whether gender moderates these relationships. Five hundred and ninety-one university students (58.5 % men) completed the CET and Eating Pathology Symptoms Inventory. Women reported significantly greater weight control exercise, exercise for mood improvement, lack of exercise enjoyment, body dissatisfaction, and purging than men, while men reported more muscle building than women. CE motivated by avoidance of negative emotions and performed in a rule-driven manner and weight control CE were associated with the greatest number of ED symptoms. Further, rigid exercise routines were associated with greater muscle building. Women with greater weight control CE experienced more body dissatisfaction, and women with more CE motivated by avoidance of negative emotions experienced more restriction, compared to men. Overall, specific CE facets relate to ED symptoms in men and women. Findings highlight the importance of interventions designed to target unhealthy exercise motivations and of cultivating healthy attitudes towards exercise across genders.

Divergent trajectories of positive affect following maladaptive and non-maladaptive exercise among individuals with binge-spectrum eating disorders

OBJECTIVE

Individuals with eating disorders (EDs) often engage in maladaptive exercise (e.g., feeling driven, or to "compensate" for eating) which maintains eating pathology. Maladaptive exercise has been theorized to help individuals with EDs regulate emotions by enhancing positive affect (PA) and reducing negative affect (NA) associated with binge episodes and poor body image. However, no research has considered the presence of non-maladaptive exercise or evaluated this theory in binge-spectrum EDs.

METHODS

This study evaluated affective trajectories pre- and post-exercise and examined exercise type (maladaptive or non-maladaptive) as a moderator. We recruited adults with binge-spectrum EDs (N = 107; n = 84 endorsed exercise) to complete a 7- to 14-day ecological momentary assessment protocol assessing NA (anxiety, guilt, and sadness), PA (excitement and cheerfulness), and exercise.

RESULTS

There was a significant quadratic trajectory of PA pre-exercise, suggesting that the upward trajectory of PA leveled out as it moved closer to an exercise episode. Exercise type significantly moderated the cubic trajectory of PA post-exercise, such that the upward trajectory of PA accelerated in the hours following non-maladaptive exercise episodes while the downward trajectory of PA accelerated in the hours following maladaptive exercise episodes. No trajectories of NA demonstrated significant effects.

CONCLUSIONS

Pre-exercise trajectories of PA may reflect positive expectancies around exercise. Post-exercise trajectories of PA suggest that non-maladaptive exercise promotes increased PA. Future research should evaluate when, and for whom, exercise serves to regulate affect and examine other momentary risk factors of exercise in EDs.

PUBLIC SIGNIFICANCE

Individuals with EDs often engage in maladaptive exercise (e.g., feeling driven, or to "compensate" for eating). Maladaptive exercise has been theorized to help individuals with EDs regulate emotions. This study evaluated affective trajectories pre- and post-exercise and examined whether exercise type (maladaptive or non-maladaptive) changed these trajectories. Pre-exercise trajectories of PA may reflect positive expectancies around exercise. Post-exercise trajectories of PA suggest that non-maladaptive exercise promotes increased PA.

Change in adaptive and maladaptive exercise and objective physical activity throughout CBT for individuals with eating disorders

Maladaptive exercise (i.e., exercise that compensates for binge eating or is used to avoid negative consequences of not exercising-like weight gain) is a common eating disorder (ED) behavior, yet, some individuals with EDs only engage in adaptive exercise. CBT for EDs targets reducing maladaptive exercise but does not address adaptive exercise. Thus, research is limited on how adaptive and maladaptive exercise are impacted during CBT for EDs. The current study examined how assessor-rated adaptive and maladaptive exercise and objectively measured physical activity changed over a 12-week CBT treatment among adults with transdiagnostic binge eating and restrictive eating that did and did not engage in maladaptive exercise at the start of treatment (n = 13 non-maladaptive exercise group, n = 17 maladaptive exercise group). The overall amount of adaptive and maladaptive exercise was measured via the Eating Disorder Examination Interview and objectively measured physical activity (e.g., step count, minutes of moderate-to-vigorous physical activity [MVPA]) was measured via a wrist-worn fitness tracker. Throughout treatment, the overall amount of adaptive exercise did not significantly change for both groups, but the overall amount of maladaptive exercise significantly decreased in the maladaptive exercise group. Step count did not significantly change for both groups, but minutes of MVPA significantly increased over treatment for the non-maladaptive exercise group. Increases in step count and minutes of MVPA were not associated with ED symptom changes in either group. These results enhance an understanding of exercise changes during transdiagnostic CBT-based ED treatment for individuals with varying baseline exercise profiles.Level of evidence: Level 1, randomized controlled trial.

U.S. health professionals' perspectives on orthorexia nervosa: clinical utility, measurement and diagnosis, and perceived influence of sociocultural factors

PURPOSE

This study examined U.S. health professionals' perspectives on the clinical utility, measurement, and etiology of orthorexia nervosa (ON).

METHODS

Participants (n = 100) were U.S. health professionals with experience working clinically with eating disorders, including trainees, Ph.D. psychologists, social workers/mental health counselors, and medical health professionals. After reviewing the proposed ON criteria, participants responded to questions regarding the clinical utility, diagnosis, and measurement of ON, and sociocultural influence on the emergence of ON. Views of ON as a useful diagnostic category were examined as a function of participants' current involvement in clinical versus research activities.

RESULTS

Participants mostly (71.9%) agreed that ON should be a distinct clinical diagnosis. Participants who endorsed ON as a valid diagnosis spent more time on clinical work and less time engaged in research compared to participants who disagreed (both ps < 0.05). Approximately 27% of participants believed additional components should be added to the proposed ON diagnostic criteria. Participants indicated that sociocultural factors have considerable influence on the development of ON, namely the diet and weight loss industry, and the perceptions that biological/organic/vegan and low fat/low carb/gluten free food are the healthiest.

CONCLUSION

Professionals who spent more time working clinically with eating disorders were more likely to endorse ON as a unique disorder, and professionals who spent more time on research were more likely to disagree. To the extent that professionals who spend more time on research may shape the narrative around ON more visibly, this study underscores the importance of listening to practitioners' experiences in applied settings.

LEVEL OF EVIDENCE

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

The role of intolerance of uncertainty and anxiety on compulsive exercise in adolescents

BACKGROUND AND OBJECTIVES

The role of anxiety as a risk factor for compulsive exercise elements among adolescents is unclear. Intolerance of uncertainty (IU), which is a risk feature for anxiety and eating disorders, may be an important, unexplored risk factor for compulsive exercise dimensions. This study aimed to examine the role of IU dimensions and anxiety on compulsive exercise elements. Given previous evidence indicating gender differences in compulsive exercise and IU levels, gender was included as a moderator.

DESIGN/METHODS

A total of 201 adolescent girls and 207 adolescent boys completed the following questionnaires: Eating Disorder Inventory-3, Intolerance of Uncertainty Scale-12 (IUS-12), a brief version of the State-Trait Anxiety Inventory and the Compulsive Exercise Test (CET).

RESULTS

The hierarchical regression analyses showed that the interaction between IUS-Prospective and gender emerged as a significant predictor of CET-Avoidance and CET-Weight control exercise beyond symptoms of eating disorders and anxiety. Post hoc analysis revealed that the IUS-Prospective was a significant predictor of CET-Avoidance and CET-Weight Control among boys, but not among girls.

CONCLUSIONS

These findings suggest that prospective IU may contribute towards obsessive-compulsive attitudes towards exercise among adolescent population, specifically among boys.

Medical and physiological complications of exercise for individuals with an eating disorder: A narrative review

Individuals with eating disorders (ED) experience prolonged malnutrition, binge episodes, and compensatory behaviours that affect every organ system. Psychological and physiological symptoms are worsened with comorbid dysfunctional exercise, seen in up to 80% of those with an ED. Although return to exercise is an important component of treatment and recovery, little is known about the contraindications and risks of exercise engagement specific to those with an ED. This paper provides a comprehensive narrative review of the medical and physiological complications of engaging in exercise during ED treatment and outlines when exercise may be contraindicated or used in modified or cautionary ways. We conducted a literature search on MEDLINE, PubMed, and PsychArticles to identify relevant articles, which yielded six categories of medical and physiological complications of ED that may be exacerbated by exercise: energy availability, cardiovascular health, electrolyte abnormalities, biomedical function markers, sex hormones, and body composition. We summarize the evidence for these complications for readers and offer an initial set of recommendations for incorporating exercise during ED treatment based on our findings. This review may serve as a resource for members of ED treatment teams to help evaluate more readily and confidently whether exercise is safe for individual patients and when modifications and caution may be warranted.

Sociocultural predictors of obligatory exercise in young men: A Polish-Chinese comparison

Background

Obligatory exercise has been shown to have negative physical and mental effects on exercisers and is more prevalent among young people. However, there is limited research on obligatory exercise among young men. Social comparison theory offers a novel perspective to explore the relationship between sociocultural factors and obligatory exercise among young men, which offers an opportunity to understand potential factors contributing to obligatory exercise among young men across different cultures.

Method

We recruited a purposive sample of young people aged 18-30 from Poland (n=79) and China (n=194). Participants completed self-report measures including the Sociocultural Attitudes Toward Appearance Questionnaire3, Inventory of Physical Activity Objectives, and Obligatory Exercise Questionnaire. In the data analysis stage, we examined the strength of the relationships between the independent variables and the dependent variable through multiple regression analysis, and tested the role of the mediating variables.

Results

The main analyses revealed that Internalization-Athlete was a common direct predictor of obligatory exercise for both Polish and Chinese young men; that there were direct sociocultural predictors of obligatory exercise that were only used in relation to Polish or Chinese young men; and that social adaptation goals for motivation for physical activity mediated the development of obligatory exercise for Polish and Chinese young men, and that there were cross-cultural differences.

Conclusion

Attention should be paid to their attitudes towards the idea of a muscular and athletic body and socially adapted physical activity motivations when understanding young men's obligatory exercise, while also considering cross-cultural differences.

Weight-related Self-monitoring App Use Among Emerging Adults is Cross-sectionally Associated With Amount and Type of Physical Activity and Screen Time

Weight-related self-monitoring (WRSM) apps are often used by emerging adults to assist in behavior change. However, little is known about the relationship between WRSM among the general population of emerging adults and various physical activity and screen time behaviors. This paper examines associations between WRSM app use and various forms of physical activity and screen time among a population-based sample of emerging adults. Data come from EAT 2018 (N = 1,568, mean age = 22.0 ± 2.0 years), a population-based sample of emerging adults from Minneapolis/St. Paul, Minnesota. Participants reported on the types of WRSM apps used (physical activity and/or dietary focused), in addition to how much time they spent doing physical activity, whether they practiced yoga, compulsive exercise, recreational screen time, social media use, and whether they viewed dieting/weight loss materials. Linear and logistic regressions were used to assess adjusted means and prevalences of outcomes. We found that physical activity-focused WRSM app users engaged in more hours of total (8.7 vs 7.2, P < .001), and moderate-to-vigorous (5.1 vs 4.3, P = .002) physical activity compared to non-users. Similar results were found for dietary WRSM app users compared to non-users. However, WRSM app users had higher levels of compulsive exercise and were more likely to view dieting/weight loss materials (Ps < .001). Findings suggest that although physical activity is higher among WRSM users, the types of physical activity and screen time behaviors WRSM users are engaging in may be harmful.

Compulsive exercise in eating disorders: Validation of the Italian scale and evaluation of its relationships with body image concerns and quality of life

BACKGROUND

Compulsive exercise (CE) has been proposed as one of the maladaptive elements that might concur to developing and maintaining an eating disorder (ED), even if no conclusive consensus is yet available. This study evaluates the psychometric properties of the Compulsive Exercise Test (CET), the questionnaire most frequently discussed in the literature. Our second aim is to evaluate the relationships between CE, quality of life, and different body concerns in a group of individuals.

METHODS

Two different studies are performed. In the first study, we evaluate the psychometric properties of the Italian CET with a sample of 272 individuals (157 with different diagnoses of ED). In the second study, a group of 75 ED patients is compared to 68 of their peers looking for specific differences and relationships between CE, quality of life, and body concerns.

RESULTS

The CET shows optimal psychometric proprieties, and a five-factors structure. CE is linked to more severe specific psychopathology in ED patients, including increased thoughts of restraint and concerns about weight and shape. Moreover, weight phobia and quality of life are predictors of CE in patients.

CONCLUSION

The specific role of CE is discussed according to its connections with a core psychopathological element like weight phobia. Specific profiles of CE emerged for each clinical subgroup, and they corroborate the presence of different cognitive/physical approach to exercise. The CE showed to be a dysfunctional element with a disruptive role in patients' quality of life. Future directions and possible applications of the CET are also discussed.

The impact of critical comments from teammates on athletes' eating and exercise psychopathology

Critical comments from parents or coaches about weight or shape have been associated with athletes' body dissatisfaction and disordered eating. However, research is yet to explore how critical comments from an athlete's teammates may impact on eating and exercise psychopathology. This study aimed to (1) explore whether athletes who reported receiving a teammate critical comment have higher eating/exercise psychopathology and poorer psychological wellbeing versus matched athletes who have not, (2) determine whether gender differences exist in the perceived severity of critical comments and (3) evaluate the moderating role of gender when establishing the relative importance of explicit teammate critical comments versus implicit teammate influences (e.g., modelling) on eating/exercise psychopathology. Athletes (N = 646, Mage=23 years, n = 391 female) completed a survey exploring explicit/implicit teammate influences, psychological wellbeing (self-esteem, anxiety, depression) and eating/exercise psychopathology. Athletes receiving a teammate critical comment (n = 323) had significantly higher eating/exercise psychopathology, anxiety, and lower self-esteem compared to those who had not (n = 323). Females (n = 196) perceived the severity of the comment to be significantly worse than males (n = 127). Explicit critical comments had a greater influence on athletes' eating/exercise psychopathology versus implicit teammate influences. Disordered eating/compulsive exercise prevention efforts with athlete populations should highlight the detrimental impact that athletes' comments can have on teammates' wellbeing and body satisfaction.

Development and validation of a scale for the tendency to exercise in response to mood, eating, and body image cues: the Reactive Exercise Scale (RES)

PURPOSE

Earlier work on engaging in physical exercise when experiencing negative affect demonstrated robust associations with eating disorder (ED) behaviors and attitudes; however, measurement of the behavior was primitive, relying on one yes/no question that cannot capture much variability. We report on the development of a self-report measure, the Reactive Exercise Scale (RES), that disentangles the tendency to engage in exercise in response to negative mood cues from the tendency to engage in exercise in response to eating and body image cues, which themselves may be associated with negative mood. The measure also assesses exercising in response to positive mood cues.

METHODS

Exploratory factor analysis (EFA) guided item and factor selection. Confirmatory factor analysis (CFA) in an independent sample tested a 3-factor solution-exercising in response to negative mood cues, eating and body image cues, and positive mood cues. Correlations with exercise attitudes, eating disorder and body image attitudes, mood, and personality were used to evaluate construct validity.

RESULTS

Results supported the 3-factor structure and indicated that exercising in response to negative mood cues may not uniquely relate to most aspects of ED psychopathology when accounting for eating and body image cues, which themselves are associated with negative mood.

CONCLUSION

The RES captures the tendency to exercise in response to negative mood, positive mood, and eating and body image cues. Together, these constructs allow researchers to examine the unique relations of negative mood cued exercise with ED constructs, while accounting for appearance-related motives for which exercise may also be used.

LEVEL OF EVIDENCE

Level III: evidence obtained from well-designed cohort or case-control analytic studies.

The role of compulsive exercise in the relationship between perfectionism and eating disorder pathology in underweight adolescents with eating disorders

Perfectionism has a strong association with eating disorders. Research in non-clinical adults has suggested that perfectionism has both direct and indirect effects on eating disorder symptoms, and that compulsive exercise is a potential mediator. The aim of this study was to understand whether perfectionism is associated with eating disorder symptoms, both directly and indirectly through compulsive exercise in underweight adolescents with eating disorders. Participants were 149 female adolescents (M = 14.90 years, age range 13-17) with eating disorders from the Helping to Outline Paediatric Eating Disorders (HOPE) Project, an ongoing, registry study of individuals consecutively referred individuals to a statewide eating disorder service. The majority had a diagnosis of anorexia nervosa restricting type (66 %), followed by unspecified feeding or eating disorder (21 %), and anorexia nervosa binge-eating purging type (13 %). To test the model, path analyses with bootstrapping were conducted. All paths were statistically significant, including the indirect effect from perfectionism to eating disorder pathology via the mediator of compulsive exercise, and the direct effect of perfectionism on eating disorder pathology. Overall, this research provides further evidence that compulsive exercise may be one factor that can explain the relationship between perfectionism and eating disorder symptoms. Future research should seek to determine the relative efficacy of approaches for the treatment of eating disorders in adolescents which target perfectionism and compulsive exercise.

Compulsive Exercise, Exercise Identity, and Coping Styles

Abstract. Compulsive exercise occurs among the general exercise population and is associated with adverse mental and physical health outcomes. The current study explored compulsive exercise behavior regarding coping styles and its relationship to identity to improve our understanding of compulsive exercise among the general exercise population. A community sample of 1,209 adults (aged 18 – 89) with varied exercise levels completed an online survey. We examined the relationships between engagement and disengagement coping styles (as assessed by the Coping Strategy Inventory) and exercise identity (Exercise Identity Scale) with compulsive exercise (Compulsive Exercise Test) using correlation, regression, and moderation analyses. Emotion-focused engagement (β = .075, p < .01) and emotion-focused disengagement (β = .212, p < .001) coping styles significantly predicted compulsive exercise, as did exercise identity (β = .514, p < .001). Coping styles did not moderate the relationship between exercise identity and compulsive exercise behaviors. The results indicate that both adaptive and maladaptive emotion-based coping styles are associated with greater compulsive exercise behavior.

Relationships between personality traits and disordered eating among Chinese female exercisers: the role of symptoms of exercise dependence and obsessive-compulsiveness

BACKGROUND

Although numerous studies have examined associations between personality traits and eating disorders in females, few studies have been conducted on female exercisers. Given the high risk of disordered eating in female exercisers, this study investigated the associations between the Big Five personality traits and disordered eating in female exercisers, and further explored the potential mediators, namely exercise dependence symptoms, and obsessive-compulsive symptoms underlying this association.

METHODS

A total of 295 female exercisers aged between 18 to 67 years (M =  22.11, SD =  6.65) participated in this study.

RESULTS

Negative and statistically significant correlations between conscientiousness (r = - 0.17, p < 0.01), emotional stability (r = - 0.27, p < 0.001) and agreeableness (r = - 0.18, p < 0.01) and disordered eating were observed in our sample of female exercisers. The multiple mediation analyses revealed that exercise dependence symptoms and obsessive-compulsive symptoms mediate the relationship between conscientiousness (β = 0.016, CI = [0.003, 0.031]), emotional stability (β = -0.012, CI = [- 0.028, - 0.002]), and disordered eating in female exercisers, whereas obsessive-compulsive symptoms (β = - 0.041, CI = [- 0.088, - 0.001]) but not exercise dependence symptoms are a mediator of the relationship between agreeableness and disordered eating.

CONCLUSIONS

Our findings can be used to improve the screening procedures for eating disorders in female exercisers as they contribute to a better understanding of the psychological mechanisms that underlie the associations between the Big Five personality traits and disordered eating.

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

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

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.

Body image and compulsive exercise: are there associations with depression among university students?

PURPOSE

Mental health problems among university students have been reported to be significantly increasing and suggested to be associated with college drop-out. Body dissatisfaction and compulsive exercise are both constructs relevant for mental health problems in general and eating disorders in particular. This study examined associations between body dissatisfaction, compulsive exercise and self-reported symptoms of depression among Swedish university students.

METHODS

Participants (n = 4262) are students in an ongoing cohort study, and data from the baseline assessment were used. Four linear regression models were built to explore the associations between body dissatisfaction, compulsive weight control exercise and depressive symptoms.

RESULTS

Our findings showed that females reported higher levels of body dissatisfaction than males. Body dissatisfaction and compulsive exercise were associated with self-reported symptoms of depression in this non-clinical population. Results showed that compulsive exercise was negatively associated with reported symptoms of depression, while body dissatisfaction was positively associated with symptoms of depression.

CONCLUSION

In line with previous research, there was a gender difference in body dissatisfaction where females displayed higher levels of dissatisfaction than males.  Body dissatisfaction was  positively associated with reported symptoms of depression, suggesting support of previous research indicating body dissatisfaction to increase mental health problems. Compulsive exercise was negatively associated with symptoms of depression suggesting a behavior negatively reinforced, supporting both constructs to be of interest for reported symptoms of depression in a non-clinical population of Swedish university students.

LEVEL OF EVIDENCE

III, cohort study.

TRIAL REGISTRATION

http://clinicaltrials.gov/ID : NCT04465435.

Characterizing changes in obsessive-compulsive symptoms over the course of treatment for adolescent bulimia nervosa

OBJECTIVE

Data suggest that obsessive-compulsive (OC) symptoms are commonly observed in adolescents with eating disorders and predict poorer treatment response. Further, emerging data among adults suggest that changes in OC symptoms relate to changes in eating disorder symptoms across treatment. Given evidence that early invention decreases risk for protracted illness, evaluating processes that may relate to treatment response will be useful in increasing the effectiveness of existing interventions. Therefore, the current investigation explored changes in general and eating disorder-specific OC symptoms throughout family-based treatment (FBT) and cognitive behavioral therapy (CBT) for bulimia nervosa (BN), as well as associations among these changes and eating disorder outcomes at follow-up.

METHOD

Participants (N = 110) received 18 sessions of FBT or CBT and completed measurements of general and eating disorder-specific OC symptoms at baseline, end-of-treatment, and 6- and 12-month follow-up.

RESULTS

Multilevel models indicated that across both treatments, there was no change in general OC symptoms, whereas all eating disorder-related OC symptoms decreased over treatment and follow-up. Exploratory analyses indicated that lower severity in discharge eating-disorder-specific OC symptoms contributed to lower eating pathology at follow-up.

DISCUSSION

Together, findings support the efficacy of both FBT and CBT in helping to reduce eating disorder-specific OC symptoms and suggest that adjunctive intervention may be required for ameliorating general OC symptoms in this population.

PUBLIC SIGNIFICANCE

BN is associated with significant increases in mortality and societal cost, and there is a pressing need for innovations within available treatments for young people with this disorder. In the current study, we explore the extent to which existing evidence-based treatments for adolescent BN are effective in targeting obsessive-compulsive symptoms, a known predictor of treatment response and common co-morbidity in this population.

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.

Preliminary evaluation of the online course "I Care" targeting eating disorder knowledge and attitudes among sports coaches and fitness instructors

BACKGROUND

Fitness instructors, coaches and trainers are often looked up to and seen as role-models within their sporting community. Since problematic exercise is a common symptom of eating disorders, they are also highly likely to meet individuals at risk for developing eating disorders within their profession. Thus, educating coaches about how to promote healthy ideals within their sports/training context and equipping them with knowledge to be able to detect and approach individuals at risk, is of great importance.

METHOD

We studied the pre-to-post effects of the I Care online psychoeducational intervention in 150 coaches, trainers, and fitness instructors. Variables included the Compulsive Exercise Test, as well as knowledge of eating disorders, and confidence and awareness regarding approaching, talking to, and referring individuals whose observed behavior raised concerns.

RESULTS

Results showed significant and large improvements in coaches' confidence and knowledge regarding warning signs and how to approach an at-risk person, and a decrease in their perceived ability to recognize eating disorders by sight, e.g., insight about EDs not being recognizable just by looking at a person. Also, significant positive change in attitudes about their own rule-driven exercise behavior and lack of enjoyment of exercise was observed.

CONCLUSIONS

Although the lack of a control group compels caution, the study suggests that I Care may have positive effects in terms of a "declaration of intent" toward more positive role-modeling and interactions with clients.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

The 'not-so-healthy' appearance pursuit? Disentangling unique associations of female drive for toned muscularity with disordered eating and compulsive exercise

Today, many women are driven to subscribe to a more athletically oriented appearance ideal hallmarked by muscle tone (referred to as athletic- or fit-looking). However, the constellation of unhealthy eating and exercise behaviors that may accompany the pursuit of toned muscularity among women is not yet well characterized. To address this knowledge gap, our study evaluated the associations among the female drive for toned muscularity and both thinness-oriented disordered eating behaviors (e.g., dietary restriction) and muscularity-oriented disordered eating behaviors (e.g., excessive scrutiny of macro-nutrient values of food), as well as dimensions of compulsive exercise. Participants were 388 Australian undergraduate women who completed an online questionnaire including self-report measures of said constructs. Hierarchical regression models were used to determine whether the drive for toned muscularity accounted for unique variance in eating and exercise behaviors after adjusting for theoretically relevant covariates. Results indicated independent relationships between the drive for toned muscularity and several facets of thinness- and muscularity-oriented disordered eating, as well as compulsive exercise (e.g., exercise rigidity). Our findings further contribute to an emerging literature illustrating that women driven to attain a toned appearance may be vulnerable to engaging in a wide range of maladaptive eating and exercise practices.