The Prevalence of Exercise Addiction Symptoms in a Sample of National Level Elite Athletes

Personality predictors of exercise addiction in competitive sport

Exercise addiction is increasingly recognized as a possible threat to athletes' well-being, especially in elite sports. However, research on underlying personality predictors predisposing athletes to exercise addiction remains limited. This study hypothesized several key personality attributes including athletic identity, sport motivation, perfectionism, and neuroticism as possible risk factors of exercise addiction in elite athletes and examined relationships between these personality attributes and symptoms of exercise addiction in 168 Czech elite athletes aged from 18 to 30 years. Results showed that 16.5% of athletes exhibited signs of exercise addiction, while 76.7% were at risk with low symptom severity. Multiple linear regression indicated that neuroticism, introjected regulation, and athletic identity significantly predicted exercise addiction (F(3, 164) = 32.63, p < .001, R2 = .36). These findings underscore the importance of psychological factors in understanding exercise addiction among athletes. The high prevalence suggests discrepancies in diagnosing exercise addiction and inconsistent use of diagnostic tools, necessitating cautious interpretation of the results.

The Prevalence of Excessive Exercise in Eating Disorders: A Systematic Review and Meta-Analysis

OBJECTIVE

Individuals with eating disorders (EDs) often present with maladaptive behaviours such as excessive exercise (EE). The consequences of EE include physical injuries, increased risk of anxiety and depression, and impaired social functioning. No systematic reviews have been conducted on the prevalence of EE in EDs. This study aimed to assess the prevalence of EE in EDs and by ED type.

METHOD

An electronic database search of the peer-reviewed literature was conducted from inception to October 2024. Review eligibility was restricted to research studies reporting prevalence data for EE in individuals diagnosed with EDs.

RESULTS

Fifty-six studies met the inclusion criteria (n = 21,518; mean age: 22.34 years). The current prevalence of EE in all EDs was 48%. Current prevalence was highest in AN (48%), followed by BN (45%), OSFED (38%), and BED (11%). The lifetime prevalence of EE in all EDs was 63%. Lifetime prevalence was highest in AN (72%), followed by BN (57%) and OSFED (21%).

CONCLUSIONS

Nearly half of individuals with an ED engage in EE. High heterogeneity across the included studies likely influenced the prevalence found in this study. Data suggest clinical screening and longitudinal monitoring of EE in those with EDs. Future research into early intervention and treatment for EE in those with EDs is recommended.

TRIAL REGISTRATION

PROSPERO: CRD42023464148; Open Science Framework: https://doi.org/10.17605/OSF.IO/MYVXW.

Hippocampal MCT4 as a key regulator in excessive exercise-induced cognitive impairment: involvement of neuroinflammation

BACKGROUND

As human life expectancy increases, maintaining a healthy lifestyle has become crucial. However, excessive exercise (EE) can lead to negative consequences such as muscle damage and exercise addiction. Recently, numerous reports have indicated that EE negatively impacts cognitive performance, although the exact mechanism remains unclear.

OBJECTIVE

This study aimed to investigate the specific mechanisms underlying cognitive alterations induced by EE.

METHODS

We conducted the Y-maze, Barnes maze, and Novel Object Recognition Test to assess both short-term and long-term memory, as well as object recognition ability. We then validated our findings using qRT-PCR to elucidate the underlying mechanisms. Additionally, Diclofenac (Dic), an anti-inflammatory drug, was administered to evaluate its effects on cognitive function and the results of the molecular experiments.

RESULTS

EE-induced mice exhibited cognitive impairments, along with elevated expression of inflammatory cytokines such as tumor necrosis factor-α, interleukin (IL) -6, and IL-1β, and downregulated monocarboxylate transporters (MCTs) like MCT4. However, animals pre-treated with Dic regained cognitive function, alongside restored levels of IL-6, IL-1β, and MCT4.

CONCLUSION

MCT4 plays may play a crucial role in EE-induced cognitive impairments.

Are Sub-elite Athletes at Higher Risk of Eating Disorders, Exercise Addiction, Depression, and Low Energy Availability Compared With Elite Athletes?

OBJECTIVE

The main objective of this study was to investigate the risk of eating disorders, exercise addiction, depression, and low energy availability (LEA) in Danish female and male elite compared with sub-elite athletes.

DESIGN

A cross-sectional study.

SETTING

An online survey.

PARTICIPANTS

A total of 410 elite athletes (mean age 20.1 years, 51% females) and 206 sub-elite athletes (mean age 21.3 years, 52% females) from 15 different sports.Assessment of Risk Factors: Eating Disorders, exercise addiction, depression, and LEA.

MAIN OUTCOME MEASURES

The Sick Control, One Stone (6.5 kg), Fat, Food, the Eating Disorder Examination-Questionnaire, the Exercise Addiction Inventory, the Major Depression Inventory, and the Low Energy Availability in Females Questionnaire or the Low Energy Availability in Males Questionnaire.

RESULTS

We found that more female sub-elite athletes compared with elite athletes had risk of eating disorders (EDs) (37.4% vs 23.4%; P < 0.012) and the same was found for males (23.2% vs 10.4%; P = 0.005). More athletes with risk of EDs had risk of exercise addiction (12.8 vs 5.4%, P = 0.006), depression (27.3 vs 4.2%, P < 0.001), and LEA (females 55.1 vs 40.7%, P = 0.024, and males 29.4 vs 13.7%, P = 0.036, respectively) compared with athletes without risk of EDs.

CONCLUSIONS

Sub-elite athletes have a higher risk of eating disorders compared with elite athletes. Regular screening of ED symptoms and associated conditions in elite and especially sub-elite athletes may ensure early identification.

Effect of Physical Activity Behaviors, Team Sports, and Sitting Time on Body Image and Exercise Dependence

This study aimed to evaluate whether the type and degree of physical activity commitment (i.e., team sport athletes, highly active individuals, sedentary behavior) influence body image and exercise behavior. A total of 96 participants (46 women and 50 men; age: 22.7 ± 2.7 years; height: 170 ± 8.6 cm; weight: 67.6 ± 10.8 kg) were divided in six groups: female volleyball and male football players (student athletes classified as Tier 2), highly physically active women and men, with high sitting time completed the Body Image Dimensional Assessment and the 21-item Exercise Dependence Scale to evaluate body dissatisfaction and level of dependency on exercise. The Body Image Dimensional Assessment is a silhouette-based scale, where three direct indices are derived from the participants' responses: body dissatisfaction, sexual body dissatisfaction, and comparative body dissatisfaction. The Exercise Dependence Scale is a six-point Likert scale that evaluates seven dimensions of exercise dependence (tolerance, withdrawal, intention effects, lack of control, time, reductions in other activities, and continuance) and provides an overall score. A multivariate analysis of variance was used to examine the effects of different levels of physical activity, team sport participation (volleyball and football), and sedentary behavior (i.e., high sitting time) on participants' body image indices and dimensions of exercise dependence according to sex. Volleyball players showed significantly higher body dissatisfaction than football players (d = 0.99) and the physically active men group (d = 2.31), who had lower values than sedentary women group (d = 1.68). Football players had lower comparative body dissatisfaction values than volleyball players (d = 1.70) and sedentary women (d = 1.69), who had higher values than sedentary men (d = 1.04). Sedentary women had a significantly lower exercise dependence scale score than volleyball players (d = 1.71), football players (d = 1.12), and physically active men (d = 1.21). The findings highlight the impact of regular physical activity on body dissatisfaction and the variance in body image perceptions between the sexes. Moreover, the high exercise dependence values found in volleyball and football players and physically active men suggest an effect of intense training and maladaptive exercise behaviors, underlining the need for comprehensive strategies to address exercise dependence.

A systematic review, meta-analysis, and meta-regression of the prevalence of self-reported disordered eating and associated factors among athletes worldwide

BACKGROUND

The purpose of this meta-analysis was to provide a pooled prevalence estimate of self-reported disordered eating (SRDE) in athletes based on the available literature, and to identify risk factors for their occurrence.

METHODS

Across ten academic databases, an electronic search was conducted from inception to 7th January 2024. The proportion of athletes scoring at or above predetermined cutoffs on validated self-reporting screening measures was used to identify disordered eating (DE). Subgroup analysis per country, per culture, and per research measure were also conducted. Age, body mass index (BMI), and sex were considered as associated/correlated factors.

RESULTS

The mean prevalence of SRDE among 70,957 athletes in 177 studies (132 publications) was 19.23% (17.04%; 21.62%), I2 = 97.4%, τ2 = 0.8990, Cochran's Q p value = 0. Australia had the highest percentage of SRDE athletes with a mean of 57.1% (36.0%-75.8%), while Iceland had the lowest, with a mean of 4.9% (1.2%-17.7%). The SRDE prevalence in Eastern countries was higher than in Western countries with 29.1% versus 18.5%. Anaerobic sports had almost double the prevalence of SRDE 37.9% (27.0%-50.2%) compared to aerobic sports 19.6% (15.2%-25%). Gymnastics sports had the highest SRDE prevalence rate, with 41.5% (30.4%-53.6%) while outdoor sports showed the lowest at 15.4% (11.6%-20.2%). Among various tools used to assess SRDE, the three-factor eating questionnaire yielded the highest SRDE rate 73.0% (60.1%-82.8%). Meta-regression analyses showed that female sex, older age, and higher BMI (all p < 0.01) are associated with higher prevalence rates of SRDE.

CONCLUSION

The outcome of this review suggests that factors specific to the sport affect eating behaviors throughout an athlete's life. As a result, one in five athletes run the risk of developing an eating disorder. Culture-specific and sport-specific diagnostic tools need to be developed and increased attention paid to nutritional deficiencies in athletes.

Short-term effects and long-term changes of FUEL-a digital sports nutrition intervention on REDs related symptoms in female athletes

Female endurance athletes are at high risk for developing Relative Energy Deficiency in Sport (REDs), resulting in symptoms such as menstrual dysfunction and gastrointestinal (GI) problems. The primary aim of this study was to investigate effects of the FUEL (Food and nUtrition for Endurance athletes-a Learning program) intervention consisting of weekly online lectures combined with individual athlete-centered nutrition counseling every other week for sixteen weeks on REDs related symptoms in female endurance athletes at risk of low energy availability [Low Energy Availability in Females Questionnaire (LEAF-Q) score ≥8]. Female endurance athletes from Norway (n = 60), Sweden (n = 84), Ireland (n = 17), and Germany (n = 47) were recruited. Fifty athletes with risk of REDs (LEAF-Q score ≥8) and with low risk of eating disorders [Eating Disorder Examination Questionnaire (EDE-Q) global score <2.5], with no use of hormonal contraceptives and no chronic diseases, were allocated to either the FUEL intervention (n = 32) (FUEL) or a sixteen-week control period (n = 18) (CON). All but one completed FUEL and n = 15 completed CON. While no evidence for difference in change in LEAF-Q total or subscale scores between groups was detected post-intervention (BFincl < 1), the 6- and 12-months follow-up revealed strong evidence for improved LEAF-Q total (BFincl = 123) and menstrual score (BFincl = 840) and weak evidence for improved GI-score (BFincl = 2.3) among FUEL athletes. In addition, differences in change between groups was found for EDE-Q global score post-intervention (BFincl = 1.9). The reduction in EDE-Q score remained at 6- and 12- months follow-up among FUEL athletes. Therefore, the FUEL intervention may improve REDs related symptoms in female endurance athletes.

Clinical Trial Registration

www.clinicaltrials.gov (NCT04959565).

Mental Health in Ultra-Endurance Runners: A Systematic Review

BACKGROUND

Among ultra-endurance runners (UER), the mental, behavioral, and physical demands of training/competition can result in maladaptive outcomes. Mental health issues are common in athletes and can impact psychology, physical health, and performance.

OBJECTIVE

To synthesize information regarding the incidence/prevalence and factors associated with mental health issues among UER.

METHODS

Systematic searches were performed in PubMed, SPORTDiscus, Scopus, Cochrane databases, CINAHL, Web of Science, and Medline Ovid using key terms related to UER (e.g., trail running, road running) and psychological issues (e.g., exercise addiction, depression). Inclusion criteria included original articles published in peer-reviewed journals in English, using qualitative or quantitative approaches. We considered papers reporting incidence/prevalence and associated factors with mental health outcomes in UER of both sexes, all ages, and levels of competition (e.g., elite, nonprofessional runners). The Joanna Briggs Institute Analytical Cross-Sectional Studies critical appraisal tool was used for quality assessment.

RESULTS

A total of 282 studies were identified, and 11 studies were included in the final selection. A total of 3670 UER were included in the studies. The prevalence of mental health issues among UER ranged between 32.0% and 62.5% for eating disorders, from 11.5% to 18.2% for exercise addiction, 18.6% for depressive symptoms, and 24.5% for sleep disturbance. Exercise addiction was not related to weekly volume, but a strong relationship with exercise in an unstructured space, age, and body mass index was shown.

CONCLUSION

Mental health issues among UER are common, especially eating disorders, exercise addiction, sleep disturbances, and depressive symptoms. Further high-quality studies are needed to examine underlying factors and find preventative strategies to protect UER.

REGISTRATION

The protocol of this systematic review was registered at the PROSPERO-CRD42022338743.

Mind-over-body beliefs in sport and exercise: A driving force for training volume and performance, but with risks for exercise addiction

We assume that athletic success is associated with certain beliefs that on the one hand promote performance-enhancing behavior (training volume), but on the other hand can also be detrimental to health (sports addiction). These beliefs are succinctly characterized by the title of the 9-item "Mind-over-Body" scale presented here. They are the three beliefs that 1) athletic performance requires a high level of effort, 2) that willpower plays an important role in athletic success, and 3) that athletic success requires pain tolerance. A total of six web-survey-based studies with a total of 1121 participants (approximately gender parity), including individuals with different levels of athletic performance (no competition; amateur sport; regional, national, or international competition), examined the psychometric network and construct and criterion validity of the MoB scale. Exploratory graph analyses, which included the studies with the largest sample sizes, showed that the three belief components (effort, willpower, pain) form separable communities within the MoB network and that the MoB items form communities distinct from self-control and self-efficacy. Meta-analyzed correlations across all six studies showed low positive correlations with self-control and self-efficacy. In terms of criterion validity, MoB beliefs were positively correlated with training volume and exercise addiction. We discuss MoBs as "on the edge of unhealthy" and place MOBs within a framework of related but distinct concepts.

Mediating Roles of Psychological Distress, Insomnia, and Body Image Concerns in the Association Between Exercise Addiction and Eating Disorders

PURPOSE

Exercising can promote good health. However, excessive exercising may have downsides. This study examined the association between exercise addiction and eating disorders and whether the identified association was mediated by psychological distress, insomnia (including sleep quality), and body image concern.

METHODS

A total of 2088 adolescents (mean age of 15.3 years) participated in this cross-sectional study by questions assessing exercise addiction, eating disorders, psychological distress, insomnia, sleep quality, and body image concern.

RESULTS

There were significantly positive relationships between the variables (r=0.12-0.54, p<0.01) with effect sizes from small to large. The four potential mediators (ie, insomnia, sleep quality, psychological distress, and body image concern), individually and in total, significantly mediated the association between exercise addiction and eating disorders.

CONCLUSION

The findings suggest that exercise addiction in adolescents may influence eating disorders through multiple pathways, such as insomnia, psychological distress, and body image concerns. Future research should examine these relationships longitudinally and use gathered information to inform intervention development. Clinicians and healthcare workers are encouraged to assess exercise addiction when treating individuals with eating disorders.

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.

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.

Behind the athletic body: a clinical interview study of identification of eating disorder symptoms and diagnoses in elite athletes

Eating disorders are more prevalent in athletes than in the general population and may have severe consequences for sports performance and health. Identifying symptoms can be difficult in athletes because restrictive eating and slim body images are often idealised in a sports setting. The Eating Disorders Examination Questionnaire (EDE-Q) and the SCOFF (Sick, Control, One stone, Fat and Food) questionnaire (SCOFF) are widely used generic instruments to identify symptoms of eating disorders. This study aimed to investigate the instruments’ validity and explore eating disorder symptoms in a sample of athletes.

A sample of 28 athletes (25 females) competing at a national level was interviewed based on the diagnostic criteria for eating disorders. We interviewed 18 athletes with a high score on EDE-Q and 10 with a low score. All interviews were transcribed and analysed from a general inductive approach. We identified 20 athletes with an eating disorder diagnosis, while 8 had no diagnosis. EDE-Q found 90% of the cases, while SCOFF found 94%. EDE-Q found no false-positive cases, while SCOFF found one.

The qualitative results showed that most athletes reported eating concerns, restrictive eating, eating control (counting calories), weight concerns, body dissatisfaction (feeling fat and non-athletic), excessive exercise and health problems (eg, pain, fatigue).

In conclusion, EDE-Q and SCOFF seem valid instruments to screen athletes’ samples but may fail to find 6%–10% cases with eating disorders. Despite athletic bodies and normal body mass index, many athletes report severe eating problems and dissatisfaction with weight and body appearance. Implementation of regular screening may identify these symptoms at an early stage.

Risk of Low Energy Availability, Disordered Eating, Exercise Addiction, and Food Intolerances in Female Endurance Athletes

Relative energy deficiency in sport (RED-S) is a complex syndrome describing health and performance consequences of low energy availability (LEA) and is common among female endurance athletes. Various underlying causes of LEA have been reported, including disordered eating behavior (DE), but studies investigating the association with exercise addiction and food intolerances are lacking. Therefore, the aim of this cross-sectional study was to investigate the association between DE, exercise addiction and food intolerances in athletes at risk of LEA compared to those with low risk. Female endurance athletes, 18-35 years, training ≥5 times/week were recruited in Norway, Sweden, Ireland, and Germany. Participants completed an online-survey comprising the LEA in Females Questionnaire (LEAF-Q), Exercise Addiction Inventory (EAI), Eating Disorder Examination Questionnaire (EDE-Q), and questions regarding food intolerances. Of the 202 participants who met the inclusion criteria and completed the online survey, 65% were at risk of LEA, 23% were at risk of exercise addiction, and 21% had DE. Athletes at risk of LEA had higher EDE-Q and EAI scores compared to athletes with low risk. EAI score remained higher in athletes with risk of LEA after excluding athletes with DE. Athletes at risk of LEA did not report more food intolerances (17 vs. 10%, P = 0.198), but were more frequently reported by athletes with DE (28 vs. 11%, P = 0.004). In conclusion, these athletes had a high risk of LEA, exercise addiction, and DE. Exercise addiction should be considered as an additional risk factor in the prevention, early detection, and targeted treatment of RED-S among female endurance athletes.

The Relationship between Alexithymia, Dysmorphic Concern, and Exercise Addiction: The Moderating Effect of Self-Esteem

As with other addictions, exercise addiction can severely impact individuals' lives and have significant psychophysical consequences. Consequently, the study of the mechanisms involved in this psychopathological condition has great clinical and practical relevance. Therefore, the goal of the present study was to explore the risk factors and protective factors for exercise addiction, with a particular focus on the roles of alexithymia, body image concerns, and self-esteem. A sample of 288 regular exercisers (mean age = 28.35 years, SD = 8.26; 72% females, 18% males) completed the Exercise Addiction Inventory, 20-Item Toronto Alexithymia Scale, Body Image Concern Inventory, and Rosenberg Self-Esteem Scale. Data were analyzed by implementing a moderated mediation model. Results showed a significant and positive association between alexithymia and exercise addiction, totally mediated by body image concerns. Furthermore, self-esteem showed a relevant moderating effect, such that at high levels of self-esteem the effect of alexithymia on body image concerns became insignificant. Such data have important implications, highlighting some core variables on which it might be useful to keep a focus in order to elaborate tailored interventions, from both preventive and treatment perspectives.

Validation of the Eating Disorder Examination Questionnaire in Danish Eating Disorder Patients and Athletes

The Eating Disorder Examination Questionnaire (EDE-Q) is a gold standard questionnaire to identify eating disorder symptoms but has not yet been validated in Danish. The scale consists of four theoretical constructs of disordered eating: Restraint eating, Eating concerns, Shape concerns and Weight concerns. However, the four-factor structure has been difficult to replicate across cultures. This study aimed to examine the factor structure and psychometric properties of the EDE-Q in Danish. The study consisted of four samples (aged 15–70): Patients with anorexia, bulimia and unspecified eating disorders (n = 101), patients with symptoms of binge-eating disorder (n = 300), recreational athletes (n = 404), and elite athletes (n = 526). Depending on the analysis performed, participants had to complete the EDE-Q, the SCOFF questionnaire for eating disorders or the Binge Eating Disorders Questionnaire. In accordance with international research, we found no evidence for a four-factor structure in the EDE-Q among patients or among athletes. But our results showed significant, positive associations between EDE-Q and SCOFF, BED-Q and MDI in all samples. We conclude that the internal structure of EDE-Q is low, while construct validity is high, making EDE-Q useful as an instrument to identify individuals with eating disorder symptoms, including recreational, and elite athletes.