Morbid exercise behaviour and eating disorders: A meta-analysis

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.

Exercise addiction in team sports: A systematic literature review

While regular exercise should be part of the contemporary lifestyle, many people overindulge in it to the point of losing control over their behavior. This condition is known as exercise addiction (EA). Although addiction is an individual phenomenon, and most of the over 1,000 published studies on EA look at individual exercisers, there are studies on team sports athletes, too. Theoretically, these athletes should not manifest exercise addiction, but some studies are projecting the contrary. Therefore, in this literature review, we analyze EA in team athletes. Based on four databases (PsycINFO, SPORTDiscus, Web of Science, and Google Scholar), we located 22 articles conforming to inclusion criteria. These studies suggest a high risk of exercise addiction among team sports participants. While the figures are lower than for individual exercisers, they are in discord with the concept of addiction as a dysfunction, and the lack of a single case of exercise addiction reported (to date) in team sports athletes in the academic literature. In agreement with a recent position paper, we conclude that there are substantial conceptual and measurement errors in exercise addiction research.

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.

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

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

Social physical anxiety and eating disorders: A systematic review and meta-analysis

The present study's aim was to summarize existing quantitative evidence linking social physique anxiety (SPA) and eating disorders (ED). Eligible studies were searched for up to June 2, 2022 in six databases: MEDLINE, Current Contents Connect, PsycINFO, Web of Science, SciELO, and Dissertations & Theses Global. Studies were considered eligible if they included information derived from self-report instruments that allowed for computing the relationship between SPA and ED. Pooled effect sizes (r) were computed using three-level meta-analytic models. Potential sources of heterogeneity were examined using univariable and multivariable meta-regressions. Influence analyses and a three-parameter selection model (3PSM) were used for the purpose of examining the robustness of the results and publication bias, respectively. Results summarizing 170 effect sizes from 69 studies (N = 41,257) showed two main groups of findings. Firstly, that SPA and ED were very largely related (i.e., r = .51). Secondly, that this relationship was stronger (i) among individuals from Western countries, and (ii) when ED scores concerned the diagnostic feature of bulimia/anorexia nervosa involving body image disturbances. The present study adds to the current understanding of ED by suggesting that SPA is a maladaptive emotion with a potential role in the onset and maintenance of these group of pathologies.

Exercise addiction: A narrative overview of research issues

This narrative overview summarises the work on exercise addiction (EA) over the past 12 years and exposes critical conceptual and methodological issues. More than 1000 articles exist on EA, conceptualised as uncontrolled training harming the individual. Still, EA has no clinical diagnosis criteria at this time. Research is increasing continuously, but it is stale in advancing knowledge. Scalar measurement and lack of differentiation between addictive and instrumental exercise could be reasons for insufficient progress. Exercise addiction fits in the framework of behavioural addictions, but excessive exercise patterns also co-occur with other morbidities, including eating or body-image disorders. In these cases, exercise is instrumental; it functions to achieve a non-exercise-related goal. Therefore, it is essential to separate primary from secondary EA. Based on the interactional model, significant stress and capacity-exceeding ambitions fuel primary EA, while chief motives behind secondary EA embed body image dissatisfaction and eating disorders. Few reports exist on EA's brain mechanisms, which could delay its classification as a distinct psychiatric dysfunction. Treatment of EA involves cognitive-behavioural approaches, but we know little about their effectiveness. Conceptually focussed psychophysiological research and in-depth interviews, complementing scalar data, could answer several open questions in this widely studied but relatively stagnant scholastic field.

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.

Relationship between college lifestyle variables, eating disorder education, and eating disorder risk

Objective: This study examined relationships between eating disorder risk (EDR), lifestyle variables (e.g., exposure to healthy eating media), and differences among male and female college students. Participants: College students (N = 323) completed survey questionnaires (Fall, 2016). Fifty-three participants retook the survey at a later time. Methods: Participants completed a survey measuring EDR using EDI-3 subscales and 10 college lifestyle variables. Female and male EDR and Time 1 and Time 2 EDR were compared. Relationships between EDR and college life-style variables were examined. Results: Exercise, fewer daily meals, less face-to-face interactions, more digital interactions, less exposure to healthy eating media, and having conversations about body image were associated with EDR risk. Male college students showed an increase in EDR over time. Conclusions: Several lifestyle factors predicted EDR in college females and males. These lifestyle factors are modifiable and may be addressed by colleges during orientation and within the campus environment.

Management of eating disorders for people with higher weight: clinical practice guideline

INTRODUCTION

The prevalence of eating disorders is high in people with higher weight. However, despite this, eating disorders experienced by people with higher weight have been consistently under-recognised and under-treated, and there is little to guide clinicians in the management of eating disorders in this population.

AIM

The aim of this guideline is to synthesise the current best practice approaches to the management of eating disorders in people with higher weight and make evidence-based clinical practice recommendations.

METHODS

The National Eating Disorders Collaboration Steering Committee auspiced a Development Group for a Clinical Practice Guideline for the treatment of eating disorders for people with higher weight. The Development Group followed the 'Guidelines for Guidelines' process outlined by the National Health and Medical Research Council and aim to meet their Standards to be: 1. relevant and useful for decision making; 2. transparent; 3. overseen by a guideline development group; 4. identifying and managing conflicts of interest; 5. focused on health and related outcomes; 6. evidence informed; 7. making actionable recommendations; 8. up-to-date; and, 9. accessible. The development group included people with clinical and/or academic expertise and/or lived experience. The guideline has undergone extensive peer review and consultation over an 18-month period involving reviews by key stakeholders, including experts and organisations with clinical academic and/or lived experience.

RECOMMENDATIONS

Twenty-one clinical recommendations are made and graded according to the National Health and Medical Research Council evidence levels. Strong recommendations were supported for psychological treatment as a first-line treatment approach adults (with bulimia nervosa or binge-eating disorder), adolescents and children. Clinical considerations such as weight stigma, interprofessional collaborative practice and cultural considerations are also discussed.

CONCLUSIONS

This guideline will fill an important gap in the need to better understand and care for people experiencing eating disorders who also have higher weight. This guideline acknowledges deficits in knowledge and consequently the reliance on consensus and lower levels of evidence for many recommendations, and the need for research particularly evaluating weight-neutral and other more recent approaches in this field.

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

Background and aims

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

Methods

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

Results

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

Discussion

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

A Review of the Components of Problematic Exercise in Psychometric Assessment Instruments

Backgrounds

The range of theoretical conceptualizations of problematic exercise in psychometric assessment instruments makes it difficult to identify the components that define this phenomenon. A better understanding of the underlying components of problematic exercise may contribute to progress toward providing scientific evidence that allows for deciding whether problematic exercise should be considered a substantive mental health disorder. The objective of the present review was to examine and compare, through a content analysis of their items, the components of problematic exercise in psychometric assessment instruments identified in a recent systematic review.

Methods

A total of 33 components of problematic exercise were identified in the 17 assessment instruments included in the present review.

Results

The results show that, despite the lack of consensus in the operational definition of their factors and the variety of ways of wording their items, the instruments reflect some common components that might indicate core criteria (i.e., salience, withdrawal, and mood modification) or candidate components (i.e., conflict, and continuance despite problems) of problematic exercise. However, other components of different nature were shown to be specific to some of the problematic exercise conceptualizations on which the assessment instruments are based.

Conclusion

In the interest of reaching a consensus that allows to advance in this research field, further studies are needed to resolve which components are inherently problematic.

Exercise Dependence and Body Image Concerns Amongst Group Fitness Instructors: A Self-Determination Theory Approach

Introduction

Despite the fact that group fitness instructors serve as significant role models with potentially great impact on class participants' motivation for exercise, they are a very under-researched group. The aim of this study was therefore to examine group fitness instructors' motivational regulations for exercise, and how these motivational regulations can predict symptoms of exercise dependence and body image concerns.

Methods

Group fitness instructors from the largest fitness companies in Norway (n = 837, response rate: 57%) completed an online survey with reference to the Situational Motivation Scale (SIMS), the Exercise Dependence Scale (EDS), the Eating Disorders Inventory subscales drive for thinness (EDI-DT) and body dissatisfaction (EDI-BD), and their weekly amount of exercise and instruction.

Results

The instructors scored high on identified regulation and intrinsic regulation for exercise. EDS total score was positively correlated with all SIMS subscales and weekly instruction was positively correlated with Intrinsic regulation. Multiple hierarchical regression analyses found that both self-determined motivational regulations as well as external regulation positively predicted their EDS score. External regulation positively predicted EDI-DT, and EDI-BD.

Conclusion

Group fitness instructors seem highly intrinsically motivated for exercise, which is hypothesized to have a positive impact on group fitness class participants. High self-determined exercise behavior does not seem to buffer against symptoms of exercise dependence within this specific population. There is a need for awareness of group fitness instructors who show high exercise dependency scores due to the link to body image concerns, amotivation and external regulated motivation.

Characterizing reasons for exercise in binge-spectrum eating disorders

Although 40-60% of individuals with eating disorders (EDs) report engaging in maladaptive exercise, self-reported reasons for engaging in exercise vary. Further, no studies have examined momentary reasons for exercise and whether reasons for exercising could be both adaptive and maladaptive for any episode. Examining reasons for exercise can inform interventions which more effectively target maladaptive exercise. The current study recruited adults with binge-spectrum EDs (N = 58, 89.2% Female) and assessed self-reported reasons for exercise using ecological momentary assessment over 7-14 days. Exercise episodes were categorized as maladaptive if the participant endorsed exercising to compensate for eating or feeling driven to exercise. On average, participants reported exercising 8 times (SD = 8) over the 7-14 days. On average, 73% of exercise episodes were maladaptive. Participants most frequently stated exercising to control shape or weight (67.2% of episodes), feeling driven (62.9%), and exercising as part of a routine (52.9%). Participants least endorsed exercising so that they could eat more later (9.8%). Participants reported a mean of 3.6 reasons for exercising at each episode (SD = 1.85, mode = 1.0). As hypothesized, individuals with EDs were exercising for several reasons at each exercise episode. Further, the extent to which each exercise episode is maladaptive varied between participants and even within a single participant's exercise episodes. These findings underscore the importance of research evaluating when, and for whom, exercise becomes maladaptive, as well as research examining other characteristic features of maladaptive and adaptive exercise in EDs.

Protective and Risk Factors in Exercise Addiction: A Series of Moderated Mediation Analyses

For a minority of individuals, exercise may become excessive and lead to an addictive behaviour. To better understand the processes by which exercise could become an addiction, the present study examined the risk and protective factors of exercise addiction among regular exercisers, by investigating the role of drive for thinness, bulimia, body dissatisfaction, body image concerns, and self-esteem. A sample of 319 Italian regular exercisers (M_age = 30.78 years, SD = 11.98) completed the Italian versions of the Exercise Addiction Inventory, Eating Disorder Inventory-3 Referral Form, Body Image Concern Inventory, and Rosenberg Self-Esteem Scale. Data were analyzed by implementing a series of moderated mediations. Drive for thinness, bulimia, and body dissatisfaction were positively associated with exercise addiction. An indirect path was found in each of these relationships, which included the mediation of body image concerns, as well as a significant moderation of self-esteem in the associations between drive for thinness, bulimia, body dissatisfaction, and the mediator. High self-esteem appeared to be a protective factor. The higher the level of self-esteem, the less indirect the effects of thinness drive, bulimia, body dissatisfaction, and body image concerns were on exercise addiction. Such findings contribute to a better understanding concerning the risk and protective factors of excessive exercise, and may have important practical implications in structuring interventions to reduce risk of developing exercise addiction, as well as orienting future research.

Theoretical conceptualisations of problematic exercise in psychometric assessment instruments: A systematic review

BACKGROUND AND AIMS

The aim of the present systematic review was to identify psychometric tools developed to assess problematic exercise in order to identify and compare their theoretical conceptualisations on which they are based.

METHODS

A systematic literature search was conducted in the electronic databases Web of Science, Scielo, PsychINFO, PsycTEST and SCOPUS from their inception to January 2020.

RESULTS

Seventeen assessment instruments met the eligibility criteria to be included in the present review. The instruments were classified according to their conceptualisation into five groups: (i) problematic exercise as an end of an exercise continuum, (ii) problematic exercise as a means of regulating body size and weight, (iii) problematic exercise as dependence, (iv) problematic exercise as a behavioural addiction and (v) no clear conceptualisation.

DISCUSSION

The results suggest that the conceptualisations of the assessment instruments have resulted in a strong dichotomy in relation to the primary or secondary character of the problematic exercise that might be limiting the capacity of the instruments to adequately capture the multidimensionality of this construct.

CONCLUSIONS

Given the interest in understanding the complexity surrounding the problematic exercise, future research should develop more comprehensive definitions of this construct. This would allow a greater conceptual consensus to be reached that would allow progress to be made in the study of the problematic exercise.

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

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