Recovery Trajectories in Adolescent Girls with Anorexia Nervosa

Background: This study aimed to document recovery trajectories among adolescents with anorexia nervosa (AN) based on three markers of remission, namely changes in body weight, food restriction, and excessive exercise, and to identify predictors of these trajectories. Methods: One hundred twenty-six adolescent girls (14.7 ± 1.3 years) were recruited during initial assessment visits at specialized eating disorder (ED) programs in five University Health Centers across the province of Quebec, Canada. z-BMI and AN symptom severity (food restriction and excessive exercise) were assessed at initial assessment visits and subsequently reassessed at each quarterly follow-up over a 12-month period to identify recovery trajectories. Results: Considering the three markers of remission, three distinct trajectories emerged: Group 1, rapid responders; Group 2, gradual responders; and Group 3, unstable responders. At initial visits, a difference between groups was found regarding the type of treatment (p = 0.01) and weight suppression (p = 0.02). Group 1 had a higher number of youths hospitalized than Group 2 and Group 3, and a greater weight suppression than Group 3. Furthermore, individuals with atypical AN were more likely to belong to Group 2 than to Group 1 and Group 3 (p < 0.0001). Conclusions: This study contributes to a better understanding of the heterogeneity of recovery trajectories in adolescent girls with AN.

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

CONTEXT

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

OBJECTIVE

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

DESIGN

Cross-sectional study.

SETTING

Collegiate athletics.

PATIENTS OR OTHER PARTICIPANTS

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

MAIN OUTCOME MEASURE(S)

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

RESULTS

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

CONCLUSIONS

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

Training and Competition Loads in Women's Rugby Sevens Athletes: Are There Implications for Cardiovascular Health?

National- and international-level rugby sevens athletes are exposed to high training and competition loads over the course of a competitive season. Research on load monitoring and body-system responses is widespread; however, the primary focus has been on optimizing performance rather than investigating or improving cardiovascular health. There is a degree of cardiovascular remodeling, as well as local and systemic inflammation, in response to excessive exercise. These responses are moderated by many factors including previous exercise exposure, current exercise intensity and duration, age, race, and gender, as well as sport-specific physiology. For these reasons, high-performing female rugby sevens athletes may have a unique cardiovascular risk profile different from males and other rugby codes. This review aimed to characterize the training and competition loads, as well as the anthropometric and physiological profiles, of female rugby sevens athletes; discuss the potential impacts these may have on the cardiovascular system; and provide recommendations on future research regarding the relationship between rugby sevens training and competition loads and cardiovascular health. Movement demands, competition formatting, and training routines could all contribute to adverse cardiovascular adaptations. Anthropometric data and physiological characteristics may also increase the risk of cardiovascular disease. Future research needs to adopt measures of cardiovascular health to obtain a greater understanding of cardiovascular profiles and risk factors in female rugby sevens athletes.

Exercise Addiction - Status, Identification and Treatment

The term "exercise addiction" has been used in the scientific literature since the late 1970s. It is used to refer to persistent excessive exercise despite negative physical, psychological and social consequences, with unsuccessful attempts to reduce or stop the behavior. In this article, the evidence for exercise addiction as a behavioral addiction is presented. Symptoms and psychiatric comorbidities are explained, and recommendations for identification and treatment of exercise addiction are presented.

Dysregulation of the Hypothalamic-Pituitary-Testicular Axis due to Energy Deficit

CONTEXT

Although gonadal axis dysregulation from energy deficit is well recognized in women, the effects of energy deficit on the male gonadal axis have received much less attention.

EVIDENCE ACQUISITION

To identify relevant articles, we conducted PubMed searches from inception to May 2021.

EVIDENCE SYNTHESIS

Case series and mechanistic studies demonstrate that energy deficit (both acutely over days or chronically over months) either from inadequate energy intake and/or excessive energy expenditure can lower serum testosterone concentration as a result of hypothalamic-pituitary-testicular (HPT) axis dysregulation in men. The extent to which this has clinical consequences that can be disentangled from the effects of nutritional insufficiency, concomitant endocrine dysregulation (eg, adrenal and thyroid axis), and coexisting comorbidities (eg, depression and substance abuse) is uncertain. HPT axis dysfunction is primarily the result of loss of GnRH pulsatility resulting from a failure of leptin to induce kisspeptin signaling. The roles of neuroendocrine consequences of depression, hypothalamic-pituitary-adrenal axis activation, proinflammatory cytokines, Ghrelin, and genetic susceptibility remain unclear. In contrast to hypogonadism from organic pathology of the HPT axis, energy deficit-associated HPT dysregulation is functional, and generally reversible by restoring energy balance.

CONCLUSIONS

The clinical management of such men should aim to restore adequate nutrition and achieve and maintain a healthy body weight. Psychosocial comorbidities must be identified and addressed. There is no evidence that testosterone treatment is beneficial. Many knowledge gaps regarding epidemiology, pathophysiology, and treatment remain and we highlight several areas that require future research.

Identification of Potentially Related Genes and Mechanisms Involved in Skeletal Muscle Atrophy Induced by Excessive Exercise in Zebrafish

Long-term imbalance between fatigue and recovery may eventually lead to muscle weakness or even atrophy. We previously reported that excessive exercise induces pathological cardiac hypertrophy. However, the effect of excessive exercise on the skeletal muscles remains unclear. In the present study, we successfully established an excessive-exercise-induced skeletal muscle atrophy zebrafish model, with decreased muscle fiber size, critical swimming speed, and maximal oxygen consumption. High-throughput RNA-seq analysis identified differentially expressed genes in the model system compared with control zebrafish. Gene ontology and KEGG enrichment analysis revealed that the upregulated genes were enriched in autophagy, homeostasis, circadian rhythm, response to oxidative stress, apoptosis, the p53 signaling pathway, and the FoxO signaling pathway. Protein-protein interaction network analysis identified several hub genes, including keap1b, per3, ulk1b, socs2, esrp1, bcl2l1, hsp70, igf2r, mdm2, rab18a, col1a1a, fn1a, ppih, tpx2, uba5, nhlrc2, mcm4, tac1, b3gat3, and ddost, that correlate with the pathogenesis of skeletal muscle atrophy induced by excessive exercise. The underlying regulatory pathways and muscle-pressure-response-related genes identified in the present study will provide valuable insights for prescribing safe and accurate exercise programs for athletes and the supervision and clinical treatment of muscle atrophy induced by excessive exercise.

Exploring the Relationship Between Mental Well-Being, Exercise Routines, and the Intake of Image and Performance Enhancing Drugs During the Coronavirus Disease 2019 Pandemic: A Comparison Across Sport Disciplines

Introduction: Physical distancing under the coronavirus disease 2019 (COVID-19) pandemic had a significant impact on lifestyles, including exercise routines. In this study, we examined the relationship between mental health and addictive behaviors, such as excessive exercise and the use of image and performance enhancing drugs (IPEDs) across 12 sport disciplines. Materials and methods: A large cross-sectional sample of the adult population (N = 2,295) was surveyed. The mean age was 33.09 (SD = 11.40). The number of male participants was 668 (30.0%). The use of IPEDs was assessed in conjunction with psychometric measures such as the Exercise Addiction Inventory (EAI) and the Appearance Anxiety Inventory (AAI). The participants were grouped into activity group (AG) and non-activity group (NAG) according to the presence or absence of their exercise habits. The results were compared between these groups, as well as across sport disciplines, while taking into account the relationship between different psychological measures and IPEDs consumption. Results: The frequency of IPEDs use was higher among AG (34.6%) than NAG (14.6%), although AG participants reported less history of addictions (7.1%) than NAG (11.8%). The logistic regression analysis revealed that scores equal to or above cutoff points, in both the EAI and AAI, predicted the IPEDs use. Regarding the differences across the various sport disciplines, those who were involved in practicing Weight Lifting and Cross Fit were found to be more at risk of excessive exercising and more inclined to use a wide range of IPEDs. Conclusions: Although exercise could help to increase well-being and prevent addictions during the COVID-19 pandemic, our results show that those in the AG are particularly vulnerable to excessive IPEDs use. Sport disciplines associated with higher EAI and AAI scores have also shown a higher tendency to excessive IPEDs use. Furthermore, the factor of having above the cutoff scores in EAI or AAI in each sport could indicate larger IPEDs consumption regardless of the discipline. In light of the current findings, it is necessary to better define the "non-excessive" levels of exercise in various sport disciplines and an adequate intake of IPEDs to ensure the safety and well-being of people during a pandemic.

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.

Mapping features of pathological exercise using hierarchical-dimensional modeling

OBJECTIVE

Pathological exercise is common among those with eating disorders and has typically been characterized as excessive, compulsive, or compensatory in nature. Little is known about how pathological exercise is associated with other eating disorder behaviors or personality traits, or whether these associations differ between men and women.

METHOD

We used hierarchical dimensional modeling in three samples, including college women (N = 205), women with eating psychopathology (N = 268), and college men (N = 235), to examine latent associations between pathological exercise and eating disorder psychopathology, namely compulsivity, emotion regulation, and body dissatisfaction.

RESULTS

Using Goldberg's (2006) "bass-ackwards" method, we identified separate 10-factor solutions (women) or an 11-factor solution (men). A distinct muscle building factor arose in the three-factor solution for men, and it also notably arose in the six- and eight-factor solutions for community and college women, respectively, highlighting an important understudied motivation factor in both healthy and pathological exercise. Each solution accounted for 64.8% (college women), 51.9% (women with eating psychopathology), and 43.9% (college men) of the variance in excessive exercise, respectively.

DISCUSSION

Findings indicate that pathological exercise is associated with different psychological traits (e.g., poor emotion regulation, compulsivity) across populations, and such differences may necessitate unique treatment approaches tailored accordingly.

Eating-disorder psychopathology and driven exercise change models: A latent change score analysis

OBJECTIVE

Approximately 50% of people with eating disorders (EDs) engage in driven exercise to influence their weight or shape and/or to compensate for loss-of-control eating. When present, driven exercise is associated with a lower quality-of-life, longer hospital stays, and faster rates-of-relapse. Despite the seriousness of driven exercise, most treatments for EDs do not target maladaptive exercise behaviors directly. Given the large proportion of patients with an ED who engage in driven exercise and its effect on treatment outcomes, it is critical to understand what predicts change in driven exercise. The purpose of this study was to test whether ED symptoms prospectively predicted change in driven exercise and vice versa.

METHOD

Participants were Recovery Record (RR) users (N = 4,568; 86.8% female) seeking treatment for an ED. Participants completed the Eating Pathology Symptoms Inventory (EPSI) monthly for 3 months.

RESULTS

In the full sample, dynamic bivariate latent change score analyses indicated that high levels of dietary restraint and restricting prospectively predicted reductions in driven exercise. Among persons with anorexia nervosa (AN), high levels of binge eating predicted increased driven exercise. Among persons with bulimia nervosa (BN), high levels of body dissatisfaction predicted increased driven exercise. Among persons with binge-eating disorder (BED), high levels of binge eating, purging, and restricting predicted reductions in driven exercise.

DISCUSSION

Results highlight changes that may predict increased or decreased driven exercise relative to other ED symptoms for AN, BN, and BED groups. These preliminary findings could inform future research on ED treatment efforts to manage driven exercise.

Identification of Potentially Relevant Genes for Excessive Exercise-Induced Pathological Cardiac Hypertrophy in Zebrafish

Exercise-induced cardiac remodeling has aroused public concern for some time, as sudden cardiac death is known to occur in athletes; however, little is known about the underlying mechanism of exercise-induced cardiac injury. In the present study, we established an excessive exercise-induced pathologic cardiac hypertrophy model in zebrafish with increased myocardial fibrosis, myofibril disassembly, mitochondrial degradation, upregulated expression of the pathological hypertrophy marker genes in the heart, contractile impairment, and cardiopulmonary function impairment. High-throughput RNA-seq analysis revealed that the differentially expressed genes were enriched in the regulation of autophagy, protein folding, and degradation, myofibril development, angiogenesis, metabolic reprogramming, and insulin and FoxO signaling pathways. FOXO proteins may be the core mediator of the regulatory network needed to promote the pathological response. Further, PPI network analysis showed that pik3c3, gapdh, fbox32, fzr1, ubox5, lmo7a, kctd7, fbxo9, lonrf1l, fbxl4, nhpb2l1b, nhp2, fbl, hsp90aa1.1, snrpd3l, dhx15, mrto4, ruvbl1, hspa8b, and faub are the hub genes that correlate with the pathogenesis of pathological cardiac hypertrophy. The underlying regulatory pathways and cardiac pressure-responsive molecules identified in the present study will provide valuable insights for the supervision and clinical treatment of pathological cardiac hypertrophy induced by excessive exercise.

Are Adolescent Body Image Concerns Associated with Health-Compromising Physical Activity Behaviours?

The present study aimed to assess the-prevalence of health-compromising eating and physical activity behaviours, and to test their associations with physical activity, internalisation of sociocultural attitudes towards appearance, and body image in a sample of adolescents of both genders. A total sample of 736 adolescents (437 or 59.4% were girls) participated in the study. The participants ranged in age from 16 to 19 years (x = 17.2, SD = 0.6). The sample completed a questionnaire measuring body mass index, the risk of eating disorders, body image, internalisation of sociocultural ideals of appearance, health-compromising eating behaviours (HCEB), and health-compromising weight control related to physical activity behaviours (HCPAB). Logistic regressions were used to assess the associations between the study variables and predictors of HCEB and HCPAB. The results of the study showed a relatively high prevalence of HCEB with a significantly higher prevalence in girls and participants with a higher BMI. The study also demonstrated that the prevalence of adolescent HCPAB was higher than HCEB. The internalisation of sociocultural attitudes towards appearance and body image concerns were higher in the HCEB and HCPAB groups. Female gender (OR = 1.88; 95% PI = 1.10–3.18), HCPAB (OR = 1.19; 95% PI = 1.10–1.28), a preoccupation with being overweight (OR = 3.43; 95% PI = 2.52–4.66), and body weight evaluation as too high (OR = 2.40; 95% PI = 1.57–3.68) were significant predictors of HCEB. More frequent physical activity (OR = 3.02; 95% PI = 1.76–5.17), HCEB (OR = 1.22; 95% PI = 1.11–1.32), and perceived pressures to conform to popular beauty ideals (OR = 1.51; 95% PI = 1.12–2.03) predicted higher HCPAB. HCPAB is an important variable associated with adolescents’ body image, physical activity, and weight control. The results of the present study are important for health promotion and education programs addressing adolescents’ healthy lifestyle, weight control, and body image concerns.

The Athletes' Relationships with Training scale (ART): A self-report measure of unhealthy training behaviors associated with eating disorders

OBJECTIVE

Several studies indicate that eating-disorder (ED) psychopathology is elevated in athletes compared to non-athletes. The assessment of excessive exercise among athletes is a challenge because, compared to non-athletes, athletes are required to train at higher intensities and for longer periods of time. However, individuals participating in competitive sports are still susceptible to unhealthy physical-activity patterns. Most ED assessments were developed and normed in non-athlete samples and, therefore, do not capture the nuances of athletes' training experiences. The purpose of the current study was to develop and validate a clinically useful, self-report measure of unhealthy training behaviors and beliefs in athletes, the Athletes' Relationships with Training Scale (ART).

METHOD

The initial item pool was administered to N = 267 women collegiate athletes who were participating in an ED prevention program study and N = 65 women athletes who were in ED treatment.

RESULTS

Factor analyses indicated the ART had a four-factor structure. Factorial and construct validity of the ART were demonstrated. ART scores significantly predicted health care utilization and differed between athletes with an ED versus athletes without an ED. For athletes in ED treatment, ART scores significantly decreased from treatment admission to discharge.

DISCUSSION

The ART showed evidence of strong psychometric properties and clinical utility. The ART could be helpful for clinicians and athletic trainers to help gauge whether athletes are engaging in unhealthy training practices that may warrant clinical attention and for tracking clinical outcomes in athletes with EDs who are receiving treatment.

Force properties of skinned cardiac muscle following increasing volumes of aerobic exercise in rats

The positive effects of chronic endurance exercise training on health and performance have been well documented. These positive effects have been evaluated primarily at the structural level, and work has begun to evaluate mechanical adaptations of the myocardium. However, it remains poorly understood how the volume of exercise training affects cardiac adaptation. To gain some understanding, we subjected 3-mo-old Sprague-Dawley rats ( n = 23) to treadmill running for 11 wk at one of three exercise volumes (moderate, high, and extra high). Following training, hearts were excised and mechanical testing was completed on skinned trabecular fiber bundles. Performance on a maximal fitness test was dose dependent on training volume, where greater levels of training led to greater performance. No differences were observed between animals from any group for maximal active stress and passive stress at a sarcomere length of 2.2 µm. Heart mass and passive stress at sarcomere lengths beyond 2.4 µm increased in a dose-dependent manner for animals in the control and moderate- and high-duration groups. However, hearts from animals in the extra high-duration group presented with inhibited responses for heart mass and passive stress, despite performing greatest on a graded treadmill fitness test. These results suggest that heart mass and passive stress adapt in a dose-dependent manner, until exercise becomes excessive and adaptation is inhibited. Our findings are in agreement with the beneficial role exercise has in cardiac adaptation. However, excessive exercise comes with risks of maladaptation, which must be weighed against the desire to increase performance. NEW & NOTEWORTHY For the first time, we present findings on cardiac trabecular muscle passive stiffness and show the effect of excessive exercise on the heart. We demonstrated that heart mass increases with exercise until a maximum, after which greater exercise volume results in inhibited adaptation. At paraphysiological lengths, passive stiffness increases with exercise but to a lesser degree with excessive training. Despite greater performance on graded exercise tests, animals in the highest trained group exhibited possible maladaptation.

Functions of mHealth applications: A user's perspective

The usage of mobile health (mHealth) applications is rapidly increasing. This research has been aimed mostly at reviewing existing mHealth apps and their functionality. However, studies from users' perspectives are rather scarce. This exploratory study addresses that gap and, using cross-sectional survey data, seeks to reveal the socio-demographic and individual characteristics of users who utilize specific functions of mHealth apps. The data were collected via an online survey through websites oriented toward eating habits, exercising, dieting, and weight loss. From the original sample (1002 users; M = 24.8, standard deviation = 6.9; 81.6% females), the final sub-sample of 406 participants aged from 13 to 39 years (M = 23.8, standard deviation = 5.3, 86.9% females) who reported usage of mHealth apps was examined. The analyses revealed demographic and individual differences in predicting usage of various functions of mHealth apps. The drive for thinness was associated with functions for weight monitoring and planning functions. Excessive exercise was associated with weight monitoring, socializing functions, and functions for planning and monitoring goals. These findings imply that mHealth apps should be individually tailored to incorporate components such as risk-specific warnings or the provision of information related to seeking professional help for at-risk audiences.

Pneumothorax in a young man with anorexia nervosa

Primary spontaneous pneumothorax (PSP) is defined as a pneumothorax that occurs in the absence of an external cause in an individual without underlying generalized lung disease. A number of factors are important and should be carefully considered in the pathogenesis of PSP. This is the first case report of a PSP in a severely malnourished adolescent male with anorexia nervosa (AN) who was involved in excessive physical activity. Clinicians caring for adolescents with AN and vigorous exercise need to be aware of the risk factors associated with the development of a PSP. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:895-898).

Orthorexia nervosa: An integrative literature review of a lifestyle syndrome

Bratman first proposed orthorexia nervosa in the late 1990s, defining it an obsession with eating healthy food to achieve, for instance, improved health. Today, in the Swedish media, excessive exercising plays a central role in relation to orthorexia. A few review articles on orthorexia have been conducted; however, these have not focused on aspects of food and eating, sport, exercise, or a societal perspective. The overall aim of this study was to provide an overview and synthesis of what philosophies of science approaches form the current academic framework of orthorexia. Key questions were: What aspects of food and eating are related to orthorexia? What role do exercise and sports play in relation to orthorexia? In what ways are orthorexia contextualized? Consequently, the concept of healthism was used to discuss and contextualize orthorexia. The method used was an integrative literature review; the material covered 19 empirical and theoretical articles published in peer-reviewed journals. This review demonstrates a multifaceted nature of orthorexia research; this field has been examined from four different philosophies of science approaches (i.e., empirical-atomistic, empirical-atomistic with elements of empirical-holistic, empirical-holistic, and rational-holistic) on individual, social, and societal levels. The majority of the articles followed an empirical-atomistic approach that focused on orthorexia as an individual issue, which was discussed using healthism. Our analysis indicates a need for (a) more empirical-holistic research that applies interpretive qualitative methods and uses a social perspective of health, e.g., healthism and (b) examining the role of sports and exercise in relation to orthorexia that takes the problematizing of “orthorexic behaviours” within the sports context into account.