Muscle function and body composition profile in adolescents with restrictive anorexia nervosa: does resistance training help?

The Impact of Anorexia Nervosa and the Basis for Non-Pharmacological Interventions

Anorexia nervosa is a psychiatric disorder with an unknown etiology that is characterized by an individual's preoccupation with their weight and body structure while denying the severity of their low body weight. Due to the fact that anorexia nervosa is multifaceted and may indicate the coexistence of genetic, social, hormonal, and psychiatric disorders, a description of non-pharmacological interventions can be used to ameliorate or reduce the symptoms of this condition. Consequently, the purpose of the present narrative review is to describe the profile's context in the anorexic person as well as the support they would require from their family and environment. In addition, it is aimed at examining preventative and non-pharmacological interventions, such as nutritional interventions, physical activity interventions, psychological interventions, psychosocial interventions, and physical therapy interventions. To reach the narrative review aims, a critical review was conducted utilizing both primary sources, such as scientific publications, and secondary sources, such as bibliographic indexes, web pages, and databases. Nutritional interventions include nutritional education and an individualized treatment for each patient, physical activity interventions include allowing patients to perform controlled physical activity, psychological interventions include family therapy and evaluation of the existence of other psychological disorders, psychosocial interventions include management of the relationship between the patient and social media and physical therapy interventions include relaxation massages and exercises to relieve pain. All these non-pharmacological interventions need to be individualized based on each patient's needs.

Physical Therapy Interventions in Patients with Anorexia Nervosa: A Systematic Review

OBJECTIVE

Assess the effectiveness of physical therapy, including supervised physical exercise for body mass index (BMI) restoration; improving muscle strength and the psychological, behavioural, cognitive symptoms and quality of life in patients with anorexia nervosa (AN).

METHODS

A Systematic Review (SR) was conducted in the following scientific databases: Medline, PubMed, PEDro, PsychInfo, Cochrane Library plus, Nursing and Allied Health database, Scopus and Web of Science databases, from inception until November 2021. An assessment of the risk of bias and the certainty of evidence across studies was conducted. Articles were eligible if they followed randomized and non-randomized control trial designs with treatments based on physical therapy or exercise or physical activity in AN patients.

RESULTS

496 records were screened, and after eligibility assessment, 6 studies from 8 articles were finally analysed. The studies, involving 176 AN patient (85.02% of patients), reported improvements in muscle strength, eating behaviour, eating attitude, mood and quality of life. Three studies included nutritional co-interventions and four studies included psychological therapy. None of the studies reported adverse effects.

CONCLUSIONS

In two of the RCTs included in this SR, strength training and high intensity resistance improved the muscle strength of patients with AN. In addition, in two RCTs, improvements were observed in patients' attitudes towards their bodies after basic body awareness therapy or after full body massage and instruction to relax. In addition, quality of life improved in two studies, with stretching, isometrics, endurance cardiovascular and muscular exercising.

Inpatient Rehabilitation during Intensive Refeeding in Severe Anorexia Nervosa

Severe forms of anorexia nervosa are responsible for weight loss and life-threatening consequences. Refeeding represents a real psychiatric and somatic challenge. Physical activities are usually not recommended during intensive refeeding in order to avoid energy expenditure. This study assessed the interest in an early return to controlled physical activities, during a hospitalization in a Physical Medicine and Rehabilitation (PMR) department, including continuous nasogastric refeeding and psychiatric care. A total of 37 subjects aged 32 ± 11 years old performed inpatient physical activities during nasogastric refeeding initiated after intensive care. The physical activity program was adapted according to the hyperactivity of the patients. Evaluation parameters were weight, body mass index (BMI), body composition (fat, lean, and bone masses), and function (strength, balance, walking, ventilation). Patient satisfaction, re-hospitalizations, and physical activities continuation were assessed at 12 months of follow-up. Weight, BMI, and body fat increased significantly (+2.7 ± 1.7 kg; +1.0 ± 0.6 kg/m²; +1.7 ± 2.5 kg, respectively). Muscle strength increased even if the lean mass did not. Walking distance, balance, and respiratory function were significantly improved. Weight and fat mass gains did not differ according to the presence or absence of hyperactivity. At 12 months, 46% of the patients continued to be physically active, but 21% of the patients had been re-hospitalized. The early return to controlled physical activities in PMR hospitalization does not compromise the efficiency of intensive refeeding in severe anorexia nervosa patients.

Physical Fitness-Not Physical Activity Levels-Influence Quality of Life in Anorexia Nervosa

Background: Incorporating physical activity (PA) has been a challenge for health care professionals working with anorexia nervosa (AN) patients. This has contributed to partial physical fitness (PFit) recovery that persists after weight restoration. Objective: This cross-sectional study aimed to examine the relationships between PA, sedentary behaviors, PFit, and quality of life (QoL) in a group of adolescents after hospitalization. Methods: QoL, PA, and sedentary behaviors were measured using the Health-Questionnaire Short-Form 36 (SF-36) and accelerometers, while PFit was assessed through cardiorespiratory fitness, body composition (anthropometry), and strength (six repetition maximum) tests in a total of 63 patients. Results: Light-PA (LPA), moderate-PA (MPA), moderate-to-vigorous-PA (MVPA), and relative sedentary time (%ST) did not meet the recommendations (p < 0.001). Only 22% of the patients met MVPA criteria, and ~82% exceeded %ST. SF-36 scores were lower than normative values except the physical component scale. Absolute cardiorespiratory fitness was reduced (p < 0.001) in 84% of the patients, and was positively associated to body weight, body mass index (BMI), circumferences, and muscle areas. Additional positive significant relationships were found between QoL, muscular strength, and body composition, and negative associations between vigorous-to-very vigorous PA and BMI, skinfolds, and percent body fat. Regression analyses revealed lower body strength as an explanatory factor for improved QoL (OR 1.03, 95%CI 1.00−1.07). Conclusions: PFit and QoL scores are poor after hospitalization. LPA, MPA, and MVPA do not meet recommendations. PFit management—with emphasis on improving muscular fitness—may be a valuable strategy for QoL improvement in AN after hospitalization.

Exercise therapy in the treatment of anorexia nervosa: Its effects depending on the type of physical exercise-A systematic review

BACKGROUND AND PURPOSE

Clinical research focusing on the effectiveness of exercise therapy (ET) in patients with anorexia nervosa (AN) shows increasing interest in the last decade. The aim of this systematic review was to provide an overview of quantitative studies that have examined the impact of ET in AN patients and to examine its specific effects on physical and mental health according to the type of physical exercise (PE) practiced.

METHODS

The review was carried out based on the PRISMA 2020. Electronic databases PubMed, Web of Science, Embase, and Wiley were searched from inception to December 2021. Quantitative studies assessing the effects of ET interventions on AN patients were included and study quality was assessed using the PEDro scale.

RESULTS

A total of 27 studies were selected, including 13 randomized controlled trials. Regarding outcomes measured, results showed that aerobic and resistance exercise improved muscle strength, that mind-body PE decreased main symptoms of AN and mental health, and that combined PE reduced dysfunctional exercise and improved weight gain.

CONCLUSION

The findings suggest that ET intervention can induce benefits and has no deleterious effects on patients. In addition, specific effects on anorexia symptoms and physical and mental health have been observed according to the type of PE. However, this review reported several methodological weaknesses, including a lack of control group or randomization and statistical misconduct. Finally, ET intervention parameters were heterogeneous, and ET intervention generally lacked details, making reproducibility and comparability difficult. All these limitations underscore the need for a more rigorous methodology for further research.

Canadian practice guidelines for the treatment of children and adolescents with eating disorders

OBJECTIVES

Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline.

METHODS

Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders.

RESULTS

Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed.

CONCLUSIONS

Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.

What is the evidence for using bed rest as part of hospital treatment of severe anorexia nervosa?

Bed rest is commonly used on medical and paediatric wards as part of nursing management of the physically compromised patient with severe anorexia nervosa. The aim of this study was to review the evidence base of bed rest as an intervention in the management of severe anorexia nervosa. We searched MEDLINE, PubMed, Embase, PsychInfo, CINAHL, HMIC, AMED, HBE, BNI and guidelines written in English until April 2018 using the following terms: bed rest and anorexia nervosa. After exclusion of duplicates, three guidelines and eight articles were included. The papers were methodologically heterogeneous, and therefore, quantitative summary was not possible. There have been no randomised controlled trials to compare the benefits and harms of bed rest as the focus of intervention in the treatment of anorexia nervosa. Several papers showed that patients have a strong preference for less restrictive approaches. These are also less intensive in nursing time. Negative physical consequences were described in a number of studies: these included lower heart rate, impaired bone turn over and increased risk of infection. We found no evidence to support bed rest in hospital treatment of anorexia nervosa. The risks associated with bed rest are significant and include both physical and psychological harm, and these can be avoided by early mobilisation. Given the established complications of bed rest in other critically ill patient populations, it is difficult to recommend the enforcement of bed rest for patients with anorexia nervosa. Future research should focus on safe early mobilisation, which would reduce complications and improve patient satisfaction.

Novel approaches for the assessment of relative body weight and body fat in diagnosis and treatment of anorexia nervosa: A cross-sectional study

BACKGROUND & AIMS

Anorexia nervosa (AN) is a severe psychosomatic disease that seriously affects nutritional status. Therapeutic approaches primarily aim for rapid weight restoration by high caloric diets and activity restriction. This often promotes abdominal body fat gain, which potentially negatively influences the patient's compliance and increases the risk of relapse. This study focused on the evaluation of body weight and subcutaneous adipose tissue (SAT) in AN patients by novel approaches.

METHODS

The SAT of AN patients (n = 18, body mass index (BMI) 15.3 ± 1.3 kg/m²) was determined by a highly accurate and reliable ultrasound method. The sum of SAT thicknesses of eight sites (D_INCL) was calculated. Individual metabolic profiles were analyzed. The mass index (MI), which considers body proportions, was used in addition to BMI. Additional to the standard laboratory diagnostics, dermal carotenoids measured by resonance Raman spectroscopy, leptin, and oxidative stress indicators were determined.

RESULTS

The mean MI was 15.7 ± 1.4 kg/m². The D_INCL considerably differed between individuals with the same BMI. Half of the patients (Group 1) had low D_INCL: 1.3-28.4 mm, and Group 2 showed values up to 58.2 mm (corresponding to approximately 6 kg SAT mass). The two group means differed by more than 300% (P < 0.001). Accordingly, leptin levels significantly differed (P < 0.001). Mean SAT thicknesses were significantly higher in Group 2 at all eight sites. The groups also significantly differed in two oxidative stress parameters: total antioxidative capacity, malondialdehyde-modified low density lipoprotein immunoglobulin M (MDA-LDL IgM), and in the carotenoid level.

CONCLUSION

Half of the patients had sufficiently high fat mass, despite very low BMI. Consequently, their muscle (and other organ) masses must have been extremely low. Diagnostic criteria and treatment protocols for AN should consider each patient's body composition. In addition to dietary treatments, muscle training at low energy turnover rates may be essential for avoiding unnecessary body fat gain, better treatment results, and long-term recovery.

Maximal Strength Training as a Therapeutic Approach in Long-Standing Anorexia Nervosa: A Case Study of a Woman With Osteopenia, Menstrual Dysfunction, and Compulsive Exercise

In persons with anorexia nervosa (AN), compulsive exercise and osteopenia are common symptoms. Although treatment of osteopenia besides weight regain is lacking, maximal strength training (MST) has been found to be effective in other populations. Such training has not been prescribed to those with AN due to uncertainty of tolerance. We therefore examined use of MST in a woman with long-standing AN, osteopenia, menstrual dysfunction, and compulsive exercise. The MST intervention consisted of four exercises: three sets of five repetitions maximum (RM), 3 times per week for 16 weeks. We examined muscle strength, bone mineral density (BMD), AN psychopathology, and compulsive exercise at baseline, posttest, and 6-month follow-up. Attendance rate was 100%. The subject improved muscle strength by 20% to 40%. BMD in lumbar spine improved by 4% to posttest, and by 8% from baseline to 6-month follow-up. The BMD T-scores shifted from values classified as osteopenic to normal values throughout the course of the intervention, despite continuance of menstrual dysfunction and lack of weight gain. No changes in AN psychopathology or levels of compulsive exercise were detected. Perceived psychological benefits including new bodily experiences were self-reported by the subject, emphasizing the importance of close follow-up by competent instructors.