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Oh H, Landré B, Yon DK, Frajerman A, Gyasi RM, Jacob L. Physical activity and suicidal behavior in medical students from the United States. J Affect Disord 2024; 367:658-667. [PMID: 39243821 DOI: 10.1016/j.jad.2024.08.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 08/24/2024] [Accepted: 08/31/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND There are little data on the relationship between physical activity and suicidal behavior in medical students. Therefore, this cross-sectional study aimed to investigate the association between physical activity and suicidal behavior and identify mediating factors involved in the association among medical students from the United States. METHODS Data from the Healthy Minds Study (2007-2023) were used. Physical activity and suicidal behavior (i.e., suicidal ideation, suicide plans, and suicide attempts) were self-reported. Control variables included age, gender, ethnicity/race, relationship status, citizenship, current financial stress, and academic year. Mediating factors were flourishing, generalized anxiety disorder symptoms, depressive symptoms, eating disorder symptoms, binge drinking, smoking, and drug use. RESULTS There were 6452 medical students included in the study (median [IQR] age 25.0 [3.0] years; 4032 [62.5 %] women). After adjusting for control variables, compared with <1 hour of physical activity per week, the odds of any suicidal behavior were significantly lower for 3-4 hours (OR = 0.57, 95 % CI = 0.41-0.79) and ≥5 hours of physical activity per week (OR = 0.52, 95 % CI = 0.39-0.70). The physical activity-any suicidal behavior relationship was partially explained by decreased depressive symptoms (39.4 %), increased flourishing (27.6 %), and decreased generalized anxiety disorder symptoms (18.7 %). LIMITATIONS Data are of a cross-sectional nature. CONCLUSIONS There was an inverse association between physical activity and suicidal behavior in medical students from the United States, while several variables were identified as mediating factors (i.e., depressive symptoms, flourishing, and general anxiety disorder symptoms). Further research is needed to corroborate these findings in other settings, while longitudinal data are urgently warranted.
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Affiliation(s)
- Hans Oh
- Suzanne Dworak Peck School of Social Work, University of Southern California, Los Angeles, CA, United States
| | - Benjamin Landré
- Université Paris Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases (EpiAgeing), Paris, France
| | - Dong Keon Yon
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul, South Korea; Department of Regulatory Science, Kyung Hee University, Seoul, South Korea; Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Ariel Frajerman
- Université Paris-Saclay, AP-HP, Service Hospitalo-Universitaire de Psychiatrie, Hôpital de Bicêtre, France; Équipe MOODS, Inserm U1178, CESP (Centre de Recherche en Épidémiologie et Santé des Populations), Le Kremlin-Bicêtre, France
| | - Razak M Gyasi
- African Population and Health Research Center, Nairobi, Kenya; National Centre for Naturopathic Medicine, Faculty of Health, Southern Cross University, Lismore, New South Wales, Australia
| | - Louis Jacob
- Université Paris Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases (EpiAgeing), Paris, France; AP-HP, Université Paris Cité, Lariboisière-Fernand Widal Hospital, Department of Physical Medicine and Rehabilitation, Paris, France; Research and Development Unit, Parc Sanitari Sant Joan de Déu, CIBERSAM, ISCIII, Dr. Antoni Pujadas, 42, Sant Boi de Llobregat, Barcelona, Spain.
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Camacho-Barcia L, Sánchez I, Ibáñez-Caparrós A, Ohsako N, Granero R, Artero C, Crespo JM, Paslakis G, Jiménez-Murcia S, Fernández-Aranda F. The Impact of High Levels of Compensatory Exercise on Treatment Outcomes in Threshold and Subthreshold Bulimia Nervosa. Nutrients 2024; 16:2337. [PMID: 39064779 PMCID: PMC11279786 DOI: 10.3390/nu16142337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 07/18/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024] Open
Abstract
Bulimia nervosa (BN) and other specific feeding or eating disorders with subthreshold BN symptoms (OSFED-BN) are characterized by recurrent binge eating episodes accompanied by compensatory behaviors, including excessive exercise. We aimed to examine the role of compensatory exercise on several clinical disorder-related variables and the treatment outcomes. The sample included 478 patients diagnosed with either BN or OSFED-BN admitted for a 16-week eating disorder-specific treatment program. A battery of questionnaires was administered to evaluate eating and general psychopathology, and personality traits. Other clinical disorder-related data, including levels of compensatory exercise, were assessed through a semi-structured clinical interview. Between-group comparisons of compensatory exercise levels were analyzed, as a predictive model of risk of poor treatment outcomes. Path analysis was conducted using structural equation models to estimate the direct and indirect effects between the main variables. Higher levels of self-reported compensatory exercise were associated with greater eating psychopathology, general psychopathology, and more dysfunctional personality traits and were a predictor of poor treatment outcomes. Additionally, these levels achieved a mediating role in several paths contributing to a higher likelihood of a poor outcome. Further research is required to determine how psychotherapeutic approaches can be optimized to adequately include adaptive exercise for these patients.
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Affiliation(s)
- Lucía Camacho-Barcia
- Clinical Psychology Department, Bellvitge University Hospital, 08907 Barcelona, Spain; (L.C.-B.); (I.S.); (C.A.); (S.J.-M.)
- Psychoneurobiology of Eating and Addictive Behaviours Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), 08908 Barcelona, Spain; (N.O.); (R.G.)
- Ciber Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 08908 Barcelona, Spain
| | - Isabel Sánchez
- Clinical Psychology Department, Bellvitge University Hospital, 08907 Barcelona, Spain; (L.C.-B.); (I.S.); (C.A.); (S.J.-M.)
- Psychoneurobiology of Eating and Addictive Behaviours Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), 08908 Barcelona, Spain; (N.O.); (R.G.)
- Ciber Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 08908 Barcelona, Spain
| | - Ana Ibáñez-Caparrós
- Department of Psychiatry, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain;
- Institut Recerca Germans Trias i Pujol (IGTP), 08916 Badalona, Spain
- Department of Psychiatrics and Legal Medicine, School of Medicine, Autonomous University of Barcelona, 08193 Barcelona, Spain
| | - Noriaki Ohsako
- Psychoneurobiology of Eating and Addictive Behaviours Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), 08908 Barcelona, Spain; (N.O.); (R.G.)
- Department of Psychiatry, Graduate School of Medicine, Chiba University, Chiba 263-8522, Japan
| | - Roser Granero
- Psychoneurobiology of Eating and Addictive Behaviours Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), 08908 Barcelona, Spain; (N.O.); (R.G.)
- Ciber Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 08908 Barcelona, Spain
- Departament de Psicobiologia i Metodologia de les Ciències de la Salut, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
| | - Cristina Artero
- Clinical Psychology Department, Bellvitge University Hospital, 08907 Barcelona, Spain; (L.C.-B.); (I.S.); (C.A.); (S.J.-M.)
- Psychoneurobiology of Eating and Addictive Behaviours Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), 08908 Barcelona, Spain; (N.O.); (R.G.)
| | - José Manuel Crespo
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), 28029 Madrid, Spain;
- Departament of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-Idibell, 08907 Barcelona, Spain
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Bellvitge Campus, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
- Psychiatry and Mental Health Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), 08908 Barcelona, Spain
| | - Georgios Paslakis
- University Clinic for Psychosomatic Medicine and Psychotherapy, Ruhr-University Bochum, Medical Faculty, Campus East-Westphalia, 32312 Luebbecke, Germany;
| | - Susana Jiménez-Murcia
- Clinical Psychology Department, Bellvitge University Hospital, 08907 Barcelona, Spain; (L.C.-B.); (I.S.); (C.A.); (S.J.-M.)
- Psychoneurobiology of Eating and Addictive Behaviours Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), 08908 Barcelona, Spain; (N.O.); (R.G.)
- Ciber Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 08908 Barcelona, Spain
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Bellvitge Campus, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
- Centre for Psychological Services, University of Barcelona (UB), 08035 Barcelona, Spain
| | - Fernando Fernández-Aranda
- Clinical Psychology Department, Bellvitge University Hospital, 08907 Barcelona, Spain; (L.C.-B.); (I.S.); (C.A.); (S.J.-M.)
- Psychoneurobiology of Eating and Addictive Behaviours Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), 08908 Barcelona, Spain; (N.O.); (R.G.)
- Ciber Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 08908 Barcelona, Spain
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Bellvitge Campus, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
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Anis N, Keski-Rahkonen A, Kaartinen S, Silén Y, Kaprio J, Aaltonen S. Adolescent leisure-time physical activity and eating disorders: a longitudinal population-based twin study. Eat Weight Disord 2024; 29:40. [PMID: 38850337 PMCID: PMC11162369 DOI: 10.1007/s40519-024-01670-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/26/2024] [Indexed: 06/10/2024] Open
Abstract
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.
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Affiliation(s)
- Nadja Anis
- Department of Public Health, University of Helsinki, P.O. Box 20, 00014, Helsinki, Finland.
| | - Anna Keski-Rahkonen
- Department of Public Health, University of Helsinki, P.O. Box 20, 00014, Helsinki, Finland
| | - Sara Kaartinen
- Department of Public Health, University of Helsinki, P.O. Box 20, 00014, Helsinki, Finland
- Department of Physical Medicine and Rehabilitation, HUS Hyvinkää Hospital, P.O. Box 585, 05850, Hyvinkää, Finland
| | - Yasmina Silén
- Department of Public Health, University of Helsinki, P.O. Box 20, 00014, Helsinki, Finland
| | - Jaakko Kaprio
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, P.O. Box 20, 00014, Helsinki, Finland
| | - Sari Aaltonen
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, P.O. Box 20, 00014, Helsinki, Finland
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Glass IV, Frankenburg FR, Zanarini MC. Longitudinal description and prediction of physical inactivity among patients with borderline personality disorder and personality-disordered comparison subjects. Borderline Personal Disord Emot Dysregul 2024; 11:11. [PMID: 38845011 PMCID: PMC11157732 DOI: 10.1186/s40479-024-00253-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/22/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND The physical and psychological benefits of physical activity are well-known, and physical activity has been proven to be a helpful adjunct to psychotherapeutic treatment for many symptomatic disorders, including mood and anxiety disorders. The current study explores physical inactivity levels in patients with borderline personality disorder (BPD). The first aim of this study is to describe the 12-year course of physical inactivity in patients with BPD. The second aim is to examine predictors of physical inactivity, including adversity experiences, comorbid symptomatic (formerly axis I) disorders, medical disorders, and demographic factors. METHODS Two hundred and forty-five patients with BPD were interviewed seven times over 12-years of prospective follow-up as part of the McLean Study of Adult Development (MSAD). Patients were categorized as ever-recovered (i.e., patient had experienced a symptomatic and psychosocial recovery from BPD) or never-recovered. At each follow-up, patients reported physical activity levels (minutes of exercise per week) via a semi-structured interview- the Medical History and Services Utilization Interview (MHSUI). Data was collected from June 1992 to December 2018. RESULTS Never-recovered patients with BPD were significantly more inactive than their ever-recovered counterparts (p < 0.001). These rates of inactivity remained stable over time for both groups. Two significant multivariate predictors of inactivity were found: obesity (p = 0.003) and PTSD (p < 0.001). CONCLUSIONS Non-recovered BPD patients are more likely to be inactive than patients who have recovered. Both clinical and medical factors appear to contribute to inactivity levels in patients with BPD.
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Affiliation(s)
- Isabel V Glass
- Laboratory for the Study of Adult Development, McLean Hospital, 115 Mill Street, Belmont, MA, 02478, USA
| | - Frances R Frankenburg
- Boston University School of Medicine, Boston, MA, USA
- Edith Nourse Rogers Veterans Administration Medical Center, Bedford, MA, USA
| | - Mary C Zanarini
- Laboratory for the Study of Adult Development, McLean Hospital, 115 Mill Street, Belmont, MA, 02478, USA.
- Harvard Medical School, Boston, MA, USA.
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Lampe EW, Hill NG, Schleyer B, Giannone A, Juarascio AS, Manasse SM. Subtypes of exercise are differentially associated with baseline eating disorder pathology and treatment outcome among individuals with bulimia nervosa. Int J Eat Disord 2024; 57:363-375. [PMID: 38065930 PMCID: PMC10922686 DOI: 10.1002/eat.24103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 02/10/2024]
Abstract
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.
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Affiliation(s)
- Elizabeth W Lampe
- Department of Psychological and Brain Sciences, Drexel University, Philadelphia, Pennsylvania, USA
- Center for Weight Eating and Lifestyle Sciences, Drexel University, Philadelphia, Pennsylvania, USA
| | - Naomi G Hill
- Department of Psychology, Ohio University, Athens, Ohio, USA
| | - Brooke Schleyer
- Department of Psychology and Neuroscience, Temple University, Philadelphia, Pennsylvania, USA
| | - Alyssa Giannone
- Department of Psychological and Brain Sciences, Drexel University, Philadelphia, Pennsylvania, USA
- Center for Weight Eating and Lifestyle Sciences, Drexel University, Philadelphia, Pennsylvania, USA
| | - Adrienne S Juarascio
- Department of Psychological and Brain Sciences, Drexel University, Philadelphia, Pennsylvania, USA
- Center for Weight Eating and Lifestyle Sciences, Drexel University, Philadelphia, Pennsylvania, USA
| | - Stephanie M Manasse
- Department of Psychological and Brain Sciences, Drexel University, Philadelphia, Pennsylvania, USA
- Center for Weight Eating and Lifestyle Sciences, Drexel University, Philadelphia, Pennsylvania, USA
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Wons O, Lampe E, Patarinski AG, Schaumberg K, Juarascio A. Change in adaptive and maladaptive exercise and objective physical activity throughout CBT for individuals with eating disorders. Eat Weight Disord 2023; 28:40. [PMID: 37079117 PMCID: PMC10115602 DOI: 10.1007/s40519-023-01566-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/23/2023] [Indexed: 04/21/2023] Open
Abstract
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.
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Affiliation(s)
- Olivia Wons
- Department of Psychological and Brain Sciences, Drexel University, Stratton Hall, 3141 Chestnut Street, Philadelphia, PA, 19104, USA.
- Center for Weight, Eating, and Lifestyle Science, Drexel University, Stratton Hall, 3141 Chestnut Street, Philadelphia, PA, 19104, USA.
| | - Elizabeth Lampe
- Department of Psychological and Brain Sciences, Drexel University, Stratton Hall, 3141 Chestnut Street, Philadelphia, PA, 19104, USA
- Center for Weight, Eating, and Lifestyle Science, Drexel University, Stratton Hall, 3141 Chestnut Street, Philadelphia, PA, 19104, USA
| | - Anna Gabrielle Patarinski
- Center for Weight, Eating, and Lifestyle Science, Drexel University, Stratton Hall, 3141 Chestnut Street, Philadelphia, PA, 19104, USA
| | - Katherine Schaumberg
- Department of Psychiatry, University of Wisconsin-Madison, 6001 Research Park Blvd, Madison, WI, 53719, USA
| | - Adrienne Juarascio
- Department of Psychological and Brain Sciences, Drexel University, Stratton Hall, 3141 Chestnut Street, Philadelphia, PA, 19104, USA
- Center for Weight, Eating, and Lifestyle Science, Drexel University, Stratton Hall, 3141 Chestnut Street, Philadelphia, PA, 19104, USA
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Arend AK, Kaiser T, Pannicke B, Reichenberger J, Naab S, Voderholzer U, Blechert J. Toward Individualized Prediction of Binge-Eating Episodes Based on Ecological Momentary Assessment Data: Item Development and Pilot Study in Patients With Bulimia Nervosa and Binge-Eating Disorder. JMIR Med Inform 2023; 11:e41513. [PMID: 36821359 PMCID: PMC9999257 DOI: 10.2196/41513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Prevention of binge eating through just-in-time mobile interventions requires the prediction of respective high-risk times, for example, through preceding affective states or associated contexts. However, these factors and states are highly idiographic; thus, prediction models based on averages across individuals often fail. OBJECTIVE We developed an idiographic, within-individual binge-eating prediction approach based on ecological momentary assessment (EMA) data. METHODS We first derived a novel EMA-item set that covers a broad set of potential idiographic binge-eating antecedents from literature and an eating disorder focus group (n=11). The final EMA-item set (6 prompts per day for 14 days) was assessed in female patients with bulimia nervosa or binge-eating disorder. We used a correlation-based machine learning approach (Best Items Scale that is Cross-validated, Unit-weighted, Informative, and Transparent) to select parsimonious, idiographic item subsets and predict binge-eating occurrence from EMA data (32 items assessing antecedent contextual and affective states and 12 time-derived predictors). RESULTS On average 67.3 (SD 13.4; range 43-84) EMA observations were analyzed within participants (n=13). The derived item subsets predicted binge-eating episodes with high accuracy on average (mean area under the curve 0.80, SD 0.15; mean 95% CI 0.63-0.95; mean specificity 0.87, SD 0.08; mean sensitivity 0.79, SD 0.19; mean maximum reliability of rD 0.40, SD 0.13; and mean rCV 0.13, SD 0.31). Across patients, highly heterogeneous predictor sets of varying sizes (mean 7.31, SD 1.49; range 5-9 predictors) were chosen for the respective best prediction models. CONCLUSIONS Predicting binge-eating episodes from psychological and contextual states seems feasible and accurate, but the predictor sets are highly idiographic. This has practical implications for mobile health and just-in-time adaptive interventions. Furthermore, current theories around binge eating need to account for this high between-person variability and broaden the scope of potential antecedent factors. Ultimately, a radical shift from purely nomothetic models to idiographic prediction models and theories is required.
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Affiliation(s)
- Ann-Kathrin Arend
- Department of Psychology, Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
| | - Tim Kaiser
- Department of Clinical Psychology, University of Greifswald, Greifswald, Germany
| | - Björn Pannicke
- Department of Psychology, Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
| | - Julia Reichenberger
- Department of Psychology, Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
| | - Silke Naab
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany
| | - Ulrich Voderholzer
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany.,Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany.,Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, Freiburg, Germany
| | - Jens Blechert
- Department of Psychology, Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
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Associations between average step counts, variability in step counts and nonhomeostatic eating. Eat Weight Disord 2022; 27:2165-2171. [PMID: 35107825 PMCID: PMC9288421 DOI: 10.1007/s40519-022-01362-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 01/08/2022] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Nonhomeostatic drives (e.g., reward and negative emotion) for eating are associated with weight gain over time. Higher average and lower intraindividual variability in physical activity (PA) levels are positively associated with health and weight outcomes, but have not been evaluated in relation to nonhomeostatic eating. The aim of this paper is to examine the associations between PA and nonhomeostatic drives for eating. The hypotheses were that average levels of and consistency in PA would be negatively correlated with nonhomeostatic eating. METHODS Adult participants (N = 432) were recruited online and asked to report objectively measured PA using commercially available PA monitors for the previous 7 days and to complete self-report measures of reward-driven and emotional eating. RESULTS Average daily steps (M = 6519.36) were negatively associated with emotional eating, but were not significantly related to reward-driven eating. Intraindividual variability in steps (M = 2209.85) was not associated with either type of nonhomeostatic eating. Adjusting for relevant covariates (e.g., age, BMI, gender), average daily step count was negatively associated with emotional eating (p = 0.01) but not reward-driven eating (p = 0.31) and variability in step counts was positively associated with reward-driven eating (p = 0.04) but not emotional eating (p = 0.52). CONCLUSION The results suggest that greater average levels and lower variability in PA are related to lower nonhomeostatic eating; thus, complex associations between PA and eating exist, and may impact weight and outcomes of treatment related to eating and weight. LEVEL OF EVIDENCE V, cross-sectional correlation study.
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Cena H, Vandoni M, Magenes VC, Di Napoli I, Marin L, Baldassarre P, Luzzi A, De Pasquale F, Zuccotti G, Calcaterra V. Benefits of Exercise in Multidisciplinary Treatment of Binge Eating Disorder in Adolescents with Obesity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:8300. [PMID: 35886152 PMCID: PMC9315465 DOI: 10.3390/ijerph19148300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 11/17/2022]
Abstract
Obesity in childhood and adolescence represents a serious health problem worldwide. Similarly, eating disorders (EDs) are complex diseases that affect adolescents with an increasing prevalence and are an alarming health concern to both physical and mental health. Traditionally, obesity and EDs, particularly binge eating disorder (BED), have been considered separate conditions, but there is emerging evidence such as etiology, comorbidities, risk factors, psychosocial impairment, and prevention approaches, highlighting important overlaps among these conditions. In youth, the two conditions share risk factors and consequences at both the physical and psychological levels, requiring special care. Exercise, useful as strategy to prevent and treat overweight conditions, may have beneficial effects on BED symptoms, suggesting that it may be considered as one of the key factors in the treatment of individuals affected by obesity with BED. The purpose of this narrative review is to examine the bidirectional impact of obesity and BED in adolescents, in terms of risk factors, etiology and comorbid conditions. Specifically, we focused on the benefits of physical activity (PA) in the multidisciplinary treatment of subjects affected by obesity with BED. Even though additional research is needed to reach conclusions about the role of exercise in the treatment of obesity and comorbid BED, especially in adolescents, promising results have already suggested that closely monitored exercise is safe and, paired with cognitive behavioral therapy, may provide multiple benefits on both the physical and psychological levels. Tailored and integrated treatments for weight management and eating disorders are important to promptly and effectively treat obese subjects that have BED.
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Affiliation(s)
- Hellas Cena
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (H.C.); (I.D.N.); (F.D.P.)
- Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, ICS Maugeri IRCCS, 27100 Pavia, Italy;
| | - Matteo Vandoni
- Laboratory of Adapted Motor Activity (LAMA), Department of Public Health, Experimental Medicine and Forensic Science, University of Pavia, 27100 Pavia, Italy;
| | - Vittoria Carlotta Magenes
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (V.C.M.); (P.B.); (G.Z.)
| | - Ilaria Di Napoli
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (H.C.); (I.D.N.); (F.D.P.)
| | - Luca Marin
- Research Department—LJA 2021, Asomi College of Sciences, 2080 Marsa, Malta;
- Department of Rehabilitation, Città di Pavia Hospital, 27100 Pavia, Italy
| | - Paola Baldassarre
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (V.C.M.); (P.B.); (G.Z.)
| | - Alessia Luzzi
- Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, ICS Maugeri IRCCS, 27100 Pavia, Italy;
- Post Graduate Course in Food Science and Human Nutrition, Università Statale di Milano, 20122 Milan, Italy
| | - Francesca De Pasquale
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (H.C.); (I.D.N.); (F.D.P.)
| | - Gianvincenzo Zuccotti
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (V.C.M.); (P.B.); (G.Z.)
- Department of Biomedical and Clinical Science, University of Milan, 20157 Milan, Italy
| | - Valeria Calcaterra
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (V.C.M.); (P.B.); (G.Z.)
- Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
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10
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Wyssen A, Munsch S. [Physical Activity in the Prevention and Treatment of Eating Disorders]. PRAXIS 2022; 111:327-332. [PMID: 35473329 DOI: 10.1024/1661-8157/a003840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Physical Activity in the Prevention and Treatment of Eating Disorders Abstract. On the one hand, excessive or insufficient physical activity is a phenomenological feature and an important etiological factor in eating disorders. On the other hand, healthy and adaptive physical activity has the potential to support the effectiveness of preventive and therapeutic interventions for eating disorders. Research findings confirm the usefulness of interventions focusing on physical activity as an add-on to psychotherapy. Professionally planned and accompanied interventions of this kind are not counterproductive or dangerous but can have a positive effect on the treatment outcome. The current state of research allows a preliminary formulation of guidelines to embed physical activity interventions into evidence-based treatment approaches. The focus of such interventions lies on the reduction of unhealthy, excessive physical activity and the promotion of flexible physical activity.
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Affiliation(s)
- Andrea Wyssen
- Universitätsklinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Bern, Bern, Schweiz
| | - Simone Munsch
- Klinische Psychologie und Psychotherapie, Departement für Psychologie, Universität Fribourg, Fribourg, Schweiz
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11
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Ouellet M, Monthuy-Blanc J. Quand bouger n’est plus synonyme de santé : une recension des traitements de l’exercice physique pathologique en troubles des conduites alimentaires. ANNALES MEDICO-PSYCHOLOGIQUES 2022. [DOI: 10.1016/j.amp.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Grilo CM, Kerrigan SG, Lydecker JA, White MA. Physical activity changes during behavioral weight loss treatment by Latinx patients with obesity with and without binge eating disorder. Obesity (Silver Spring) 2021; 29:2026-2034. [PMID: 34582624 PMCID: PMC8612949 DOI: 10.1002/oby.23278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/04/2021] [Accepted: 07/04/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE This secondary analysis examined physical activity (PA) changes and their prognostic significance among Latinx patients with obesity, with and without binge eating disorder (BED), who participated in a randomized, placebo-controlled trial testing the addition of orlistat to behavioral weight-loss (BWL) treatment in a "real-world" clinical setting. METHODS In this randomized controlled trial at a community mental health center serving economically disadvantaged Spanish-speaking-only Latinx patients, 79 patients with obesity (40 with BED and 39 without BED) received BWL treatment and were randomized to orlistat or placebo. PA, weight, depression, and binge eating were assessed at baseline, posttreatment (end of treatment [4 months]), and the 6-month follow-up (10 months after baseline). RESULTS PA was low at baseline (9.3% categorized as "active"), increased during treatment (32.9% categorized as "active" at posttreatment), and declined from posttreatment to the 6-month follow-up (28.2% classified as "active"). At baseline, PA was lower among patients with BED than those without BED. Changes in PA during and after treatment did not differ by BED status or medication condition. PA change was associated with reduced depression but not weight loss. CONCLUSIONS Latinx patients with obesity receiving BWL treatment achieved significant, albeit modest, increases in PA. Although PA changes were not associated with weight loss, they were associated with reduced depression. Identifying methods to increase PA further is necessary.
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Affiliation(s)
- Carlos M. Grilo
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | | | - Janet A. Lydecker
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Marney A. White
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Department of Social & Behavioral Sciences, Yale School Public Health, New Haven, CT, USA
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13
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Lydecker JA, Silverman JA, Grilo CM. Disentangling Associations of Children's Sports Participation and Compulsive Exercise With Parenting Practices and Child Disordered Eating Behavior. J Adolesc Health 2021; 68:178-183. [PMID: 32611508 PMCID: PMC7755740 DOI: 10.1016/j.jadohealth.2020.04.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 04/17/2020] [Accepted: 04/27/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Exercise can enhance health and well-being. Exercise can also, when it is highly driven and compulsive, reflect eating disorder psychopathology. The present study examined associations of compulsive exercise and youth athletics with child disordered eating behaviors (overeating, binge eating, and secretive eating) and with parenting practices related to eating and weight, including how parents talk to their children about weight. METHODS Participants were parents (N = 875) who completed an online cross-sectional survey. Parents reported whether their child was an athlete and how often their child exercised in a "driven" or "compulsive" way to control their weight. Four groups were compared: child athletes with compulsive exercise (Group AE: n = 34, 3.9%), athletes without compulsive exercise (Group A: n = 314, 35.9%), nonathletes with compulsive exercise (Group E: n = 40, 4.6%), and nonathletes without compulsive exercise (Group X: n = 487, 55.7%). RESULTS There was a significant, graded association of eating/weight-related parenting: parents of Group E children had the most negative eating/weight-related parenting, followed by parents of Group AE children, followed by both noncompulsive exercise groups (Group A and Group X). Parents reported significantly more "fat talk" in both compulsive exercise groups (Group AE and Group E) than noncompulsive exercise groups (Group A and Group X). Significantly more youth had regular disordered eating behaviors (overeating, binge eating, and secretive eating) in compulsive exercise groups (Group AE and Group E) compared with noncompulsive exercise groups (Group A and Group X). CONCLUSIONS Overall, relatively few youth were categorized as engaging in compulsive exercise. However, compulsive exercise, particularly among nonathletes, was consistently associated with both disordered eating behaviors and eating/weight-related parenting practices. Stronger associations emerged for compulsive exercise than child athletics.
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Affiliation(s)
- Janet A. Lydecker
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Jessica A. Silverman
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA,Department of Psychology, University of Hartford, Hartford, CT, USA
| | - Carlos M. Grilo
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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14
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Wons OB, Michael ML, Lin M, Juarascio AS. Characterizing rates of physical activity in individuals with binge eating disorder using wearable sensor technologies and clinical interviews. EUROPEAN EATING DISORDERS REVIEW 2020; 29:292-299. [PMID: 33247869 DOI: 10.1002/erv.2811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 10/19/2020] [Accepted: 11/13/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Research suggests physical activity (PA) improves behavioural, psychological and behavioural symptoms in individuals with binge eating disorder (BED), yet self-reported PA is notably low. Little remains known about objective rates of PA and subclinical levels of maladaptive PA (i.e., compensatory or driven PA), and few studies have attempted to understand the role that dissatisfaction and overvaluation with shape and weight plays in promoting PA in individuals with BED. We sought to characterize PA and investigate whether elevated rates of shape and weight concerns contribute to rates of PA in individuals with BED. METHOD Individuals meeting DSM-5 diagnosis of BED (N = 56) completed the Eating Disorder Examination and wore a Fitbit Flex 2 for 1 week. RESULTS On average, participants recorded 7621.12 (SD = 3034.20) daily steps and 194.30 (SD = 161.45) weekly moderate-to-vigorous PA minutes. About 21% of participants reported subclinical levels of maladaptive PA. Greater shape and weight overvaluation predicted lower duration of compensatory PA. CONCLUSION A small percentage of individuals with BED are engaging in subclinical levels of maladaptive PA, and there is a need to identify factors that influence rates of PA in individuals with BED.
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Affiliation(s)
- Olivia B Wons
- Center for Weight, Eating, and Lifestyle Sciences (WELL Center), Drexel University, Philadelphia, Pennsylvania, USA.,Department of Psychology & WELL Center, Drexel University, Philadelphia, Pennsylvania, USA
| | - Megan L Michael
- Center for Weight, Eating, and Lifestyle Sciences (WELL Center), Drexel University, Philadelphia, Pennsylvania, USA.,Department of Psychology & WELL Center, Drexel University, Philadelphia, Pennsylvania, USA
| | - Mandy Lin
- Center for Weight, Eating, and Lifestyle Sciences (WELL Center), Drexel University, Philadelphia, Pennsylvania, USA
| | - Adrienne S Juarascio
- Center for Weight, Eating, and Lifestyle Sciences (WELL Center), Drexel University, Philadelphia, Pennsylvania, USA.,Department of Psychology & WELL Center, Drexel University, Philadelphia, Pennsylvania, USA
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15
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Štefanová E, Bakalár P, Baška T. Eating-Disordered Behavior in Adolescents: Associations with Body Image, Body Composition and Physical Activity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17186665. [PMID: 32933145 PMCID: PMC7558562 DOI: 10.3390/ijerph17186665] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/02/2020] [Accepted: 09/10/2020] [Indexed: 01/18/2023]
Abstract
Eating disorders (EDs) represent a disparate group of mental health problems that significantly impair physical health or psychosocial functioning. The aim of this study was to present some evidence about the prevalence of eating-disordered behavior (EDB) in adolescents, and explore its associations with body image (BI), body composition (BC) and physical activity (PA) in this age group. Data from 780 adolescents participating in a health behavior in school-aged children (HBSC) study conducted in Slovakia in 2018 were used (mean age 13.5 ± 1.3; 56% boys). Differences in mean values of numerical indicators were evaluated using the independent samples t-test. Differences between nominal variables were assessed by the chi-square test. Pearson correlation was used to describe the associations between all the selected variables. EDB was positively screened in 26.7% (208/780) of adolescents, with a higher prevalence in girls (128/344, 37.2%) than in boys (80/436, 18.3%). Significantly higher means of BI, body weight (BW), body mass index (BMI), body fat mass (BFM), body fat percentage (BFP), body fat mass index (BFMI), fat free mass index (FFMI), and SCOFF questionnaire score (SCOFF QS) were found in those positively screened for EDB. Pearson correlation analysis revealed positive associations between EDB and BI, BW, BMI, BFM, BFP and BFMI. The prevalence of EDB is high in Slovak adolescents. Positive associations between EDB, BI, BMI and fat-related body composition parameters support the idea of a more integrated approach in EDs and obesity prevention and treatment. At the same time, gender differences suggest the need for considering gender-specific strategies aimed at girls and boys separately.
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Affiliation(s)
- Eliška Štefanová
- Department of Public Health, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 01 Martin, Slovakia; (E.Š.); (T.B.)
| | - Peter Bakalár
- Department of Sports Educology and Humanistics, Faculty of Sports, University of Presov, 080 01 Presov, Slovakia
- Correspondence:
| | - Tibor Baška
- Department of Public Health, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 01 Martin, Slovakia; (E.Š.); (T.B.)
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16
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Mathisen TF, Rosenvinge JH, Friborg O, Vrabel K, Bratland‐Sanda S, Pettersen G, Sundgot‐Borgen J. Is physical exercise and dietary therapy a feasible alternative to cognitive behavior therapy in treatment of eating disorders? A randomized controlled trial of two group therapies. Int J Eat Disord 2020; 53:574-585. [PMID: 31944339 PMCID: PMC7187559 DOI: 10.1002/eat.23228] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/06/2020] [Accepted: 01/06/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare effects of physical exercise and dietary therapy (PED-t) to cognitive behavioral therapy (CBT) in treatment of bulimia nervosa (BN) and binge-eating disorder (BED). METHOD The active sample (18-40 years of age) consisted of 76 women in the PED-t condition and 73 in the CBT condition. Participants who chose not to initiate treatment immediately (n = 23) were put on a waiting list. Outcome measures were the eating disorder examination questionnaire (EDE-Q), Clinical Impairment Assessment (CIA), Satisfaction with Life Scale (SWLS), Beck Depression Inventory (BDI), and numbers in remission at posttreatment, and at 6-, 12-, and 24-months follow-up. RESULTS Both treatment conditions produced medium to strong significant improvements on all outcomes with long-term effect. The PED-t produced a faster improvement in EDE-Q and CIA, but these differences vanished at follow-ups. Only PED-t provided improvements in BDI, still with no between-group difference. Totally, 30-50% of participants responded favorable to treatments, with no statistical between-group difference. DISCUSSION Both treatments shared a focus on normalizing eating patterns, correcting basic self-regulatory processes and reducing idealized aesthetic evaluations of self-worth. The results point to the PED-t as an alternative to CBT for BN and BED, although results are limited due to compliance and dropout rates. Replications are needed by independent research groups as well as in more clinical settings.
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Affiliation(s)
| | - Jan H. Rosenvinge
- UiT—The Arctic University of Norway, Department of PsychologyFaculty of Health SciencesTromsøNorway
| | - Oddgeir Friborg
- UiT—The Arctic University of Norway, Department of PsychologyFaculty of Health SciencesTromsøNorway
| | | | - Solfrid Bratland‐Sanda
- Department of Outdoor Studies, Sports and Physical EducationUniversity College of Southeast NorwayBøNorway
| | - Gunn Pettersen
- Department of Health and Caring Sciences, Faculty of Health SciencesUiT—The Arctic University of NorwayTromsøNorway
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