A large longitudinal study targeted younger patients with EDs.
Information about the benefits of exercise abounds, including the many ways regular exercise can improve our health and life. Compulsive exercise, however, is a completely different matter, particularly for people with eating disorders. Approximately one in four teens with eating disorders uses compulsive exercise to lose weight or to improve appearance. A Swedish group recently examined whether teens show the same associations between compulsive exercise and problematic behaviors as do adults. In a second study, a British group analyzed a test for identifying compulsive exercise.
Does compulsive exercise differ in teens vs older groups?
Drs. Johanna Levallius, Christina Collin, and Andreas Birgegård, of Stockholm’s Karolinska Institute, evaluated how compulsive exercise relates to eating disorders diagnoses, symptoms, and outcome among teens. The authors hypothesized that patterns of compulsive exercise would be similar in teens and adults and also that such exercise would be associated with earlier onset of an ED, more symptoms, the presence of suicidality, negative perfectionism, hyperactivity, and overall poorer prognosis (J Eat Disord. 2017; 5:9 doi 10.1.1186/s40337-016-0129-8).
Using the Stepwise database, a nationwide Swedish clinical database of ED patients seeking treatment at specialized treatment centers, the authors identified 3,255 patients between 13 and 17 years of age, 95.7% of whom were girls. Age at onset of disease was defined from the patient’s own account of the first appearance of symptoms, and other data were collected from numerous questionnaires. This is the largest longitudinal study thus far to investigate the effect of compulsive exercise on adolescents with EDs.
The Eating Disorder Examination Questionnaire (EDEQ, adolescent version) provided information about denial of illness, and 31% of AN patients fell into this category. More than a third of the patients regularly used compulsive exercise (mean: 4 times a week) to moderate their weight. Patients with bulimia nervosa (BN) used compulsive exercise most often. Patients who compulsively exercised differed significantly from those who did not on several measures: restraint (as measured on the EDEQ), negative perfectionism, emotional distress, hyperactivity, and self-esteem. When “disease deniers” were taken out of the equation, the groups of non-compulsive and compulsive exercisers were much more similar. Compulsive exercise was not linked to increased risk of suicide.
At follow-up, the authors noted a degree of cross-over, so that most patients (69%) stopped using compulsive exercise as compensatory behavior. However, 17% of those who hadn’t used compulsive exercise before had now adopted the practice. Patients who stopped using compulsive exercise had a greater likelihood of remission compared to those who continued exercising compulsively.
Teenage boys: 1 in 3 used compulsive exercise
There were some data for teenage boys, too. Twenty-nine percent of the boys reported using compulsive exercise and did so for a mean of 4.1 times a week. As in the case of the girls, boys who compulsively exercised had significantly higher global EDEQ and restraint scores, and also reported more negative perfectionism, emotional distress, and hyperactivity than did the other boys. Depression affected 28% of the boys, and the prevalence was 41% among boys who used compulsive exercise. At the one-year follow-up point, 58% of the boys were in remission, and their initial use of compulsive exercise did not affect their prognosis.
For the girls, compulsive exercise was more common among those with BN and eating disorders not otherwise specified (EDNOS) than among those with AN. This was the same pattern seen in earlier studies of adult women (Int J Eat Disord. 2006; 39:45, Behav Res Ther. 2011; 49:85). Compared to studies of adults, adolescents who engaged in compulsive exercise did not have a worse prognosis than those who did not. At the one-year follow-up point, two-thirds of the teens who originally used compulsive exercise were no longer doing so, and the remission rate was similar for them as for teens who did not compulsively exercise (59% vs 56%, respectively).
The authors also cautioned against instructing ED patients to stop exercising–except during the acute phase of treatment. Instead, they suggested concentrating on teaching patients to eat and exercise for the right reasons.
Testing for compulsive exercise
Dr. Levallius and colleagues noted that while tests for CE have been largely lacking, British researchers have recently provided psychometric data on such a test, The Compulsive Exercise Test, among a group of 356 adult patients with EDs and 360 non-clinical controls (women 16 to 60 years of age). Patients and controls took the test and also completed the EDE-Q (J Eat Disord. 2016;4:22). Caroline Meyer, MD, and colleagues at the University of Warwick, Coventry, UK, noted that up to 85% of patients with disordered eating use compulsive exercise, and are unable to stop the practice despite understanding the possible consequences.
The Compulsive Exercise Test contains 24 self-report items designed to assess the cognitive, behavioral, and emotional features of compulsive exercise. A previous factor analysis yielded five subscales: avoidance and rule-driven behavior, weight control exercise, mood improvement, lack of exercise enjoyment, and exercise rigidity (Taronis et al, 2011). The current paper described efforts to confirm this factor structure and to look at the relationship of scores to ED psychopathology.
Among the study group, 25.9% of patients had AN, 31% had BN, 38% were diagnosed with EDNOS, and 5% had diagnoses of BED. The control group was recruited from a university campus, workplaces, and a sports club. Elite or sub-elite athletes were excluded. The authors reported that the clinical group scored significantly higher than the non-clinical group on 4 of the 5 main subscales and had significantly higher global scores. However, the mood improvement subscale scores did not differ, and there were no significant differences by age.
Dr. Meyer and colleagues note that while much more research on the CET is needed, the fact that excessive or driven exercise often predates the onset of an eating disorder suggests the CET might be a way to identify individuals at risk of developing an eating disorder.
Defining Compulsive Exercise
Compulsive exercise (also termed problematic exercise) describes a condition of weight and shape concern and a persistent continuation of exercise in order to: (a) mitigate guilt/negative affect if not exercising, and (b) to avoid perceived negative consequences of ‘stopping’ exercise (Eur Eat Disord Rev. 2011; 19:174).