Abstract
Purpose
While overexercise is commonly described in patients who experience anorexia nervosa (AN), it represents a condition still underestimated, especially in the paediatric population.
Method
The present study aims at assessing the possible associations between levels of physical activity (PA) and clinical features, endocrinological data and psychopathological traits in a sample of 244 female adolescents hospitalised for AN subdivided into two groups according to PA levels (high PA vs. no/low PA). The two groups were compared through multivariate analyses, while multiple regression analysis was conducted to determine whether physical activity predict specific outcomes.
Results
No significant differences were found between the two groups in terms of last Body Mass Index (BMI) before illness, BMI at admission and disease duration, while a difference emerged in delta BMI(rapidity of weight loss), significantly higher in high-PA group (p = 0.021). Significant differences were observed in Free triiodothyronine- (p < 0.001), Free thyroxine (p = 0.046), Follicle-stimulating hormone (p = 0.019), Luteinising hormone (p = 0.002) levels, with values remarkably lower in high-PA group. Concerning psychopathological scales, the high-PA group showed worst Children’s Global Assessment Scale (CGAS) scores (p = 0.035). Regression analyses revealed that higher PA predicts higher delta BMI (p = 0.021), presence of amenorrhea (p = 0.003), lower heart rate (p = 0.012), lower thyroid (Free triiodothyronine p < 0.001, Free thyroxine p = 0.029) and gynaecological hormones’ levels (Follicle-stimulating hormone p = 0.023, Luteinising hormone p = 0.003, 17-Beta estradiol p = 0.041). Concerning psychiatric measures, HPA predicts worst scores at CGAS (p = 0.019), and at scales for evaluation of alexithymia (p = 0.028) and depression (p = 0.004).
Conclusions
Results suggest that high levels of physical activity in acute AN associate with worst clinical conditions at admission, especially in terms of endocrinological and medical features.
Level of evidence
Level III.
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References
Herpertz-Dahlmann B (2009) Adolescent eating disorders: definitions, symptomatology, epidemiology and comorbidity. Child Adolescent Psychiatric Clin North America 18(1):31–47. https://doi.org/10.1016/j.chc.2008.07.005
Moskowitz L, Weiselberg E (2017) Anorexia nervosa/atypical anorexia nervosa. Current Problems Pediatric Adolescent Health Care 47(4):70–84. https://doi.org/10.1016/j.cppeds.2017.02.003
Herpertz-Dahlmann B (2015) Adolescent eating disorders: update on definitions, symptomatology, epidemiology, and comorbidity. Child Adolescent Psychiatric Clin North America 24(1):177–196. https://doi.org/10.1016/j.chc.2014.08.003
Shufelt CL, Torbati T, Dutra E (2017) Hypothalamic amenorrhea and the long-term health consequences. Seminars Reproductive Med 35(3): 256–262. https://doi.org/https://doi.org/10.1055/s-0037-1603581. Solenberger SE (2001) Exercise and eating disorders: a 3-year inpatient hospital record analysis. Eating Behav 2(2): 151–168. https://doi.org/10.1016/s1471-0153(01)00026-5
Shroff H, Reba L, Thornton LM, Tozzi F, Klump KL, Berrettini WH, Brandt H, Crawford S, Crow S, Fichter MM, Goldman D, Halmi KA, Johnson C, Kaplan AS, Keel P, LaVia M, Mitchell J, Rotondo A, Strober M, Treasure J et al (2006) Features associated with excessive exercise in women with eating disorders. Int J Eating Disord 39(6):454–461. https://doi.org/10.1002/eat.20247
Treasure J, Zipfel S, Micali N, Wade T, Stice E, Claudino A, Schmidt U, Frank GK, Bulik CM, Wentz E (2015) Anorexia nervosa. Nat Rev Dis Primers 26(1):15074. https://doi.org/10.1038/nrdp.2015.74 (PMID: 27189821)
Gull WW (1997) Anorexia nervosa (apepsia hysterica, anorexia hysterica). 1868. Obesity Res 5(5):498–502. https://doi.org/10.1002/j.1550-8528.1997.tb00677.x
Solenberger SE (2001) Exercise and eating disorders: a 3-year inpatient hospital record analysis. Eat Behav 2(2):151–168. https://doi.org/10.1016/s1471-0153(01)00026-5
Taranis L, Meyer C (2011) Associations between specific components of compulsive exercise and eating-disordered cognitions and behaviors among young women. Int J Eating Disord 44(5):452–458. https://doi.org/10.1002/eat.20838
Ng LW, Ng DP, Wong WP (2013) Is supervised exercise training safe in patients with anorexia nervosa? A meta-analysis. Physiotherapy 99(1):1–11. https://doi.org/10.1016/j.physio.2012.05.006
Strober M, Freeman R, Morrell W (1997) The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10–15 years in a prospective study. Int J Eating Disord 22(4):339–360
Rizk M, Mattar L, Kern L, Berthoz S, Duclos J, Viltart O, Godart N (2020) Physical activity in eating disorders: a systematic review. Nutrients 12(1):183. https://doi.org/10.3390/nu12010183
Peñas-Lledó E, Vaz Leal FJ, Waller G (2002) Excessive exercise in anorexia nervosa and bulimia nervosa: relation to eating characteristics and general psychopathology. Int J Eating Disord 31(4):370–375. https://doi.org/10.1002/eat.10042
Holtkamp K, Hebebrand J, Herpertz-Dahlmann B (2004) The contribution of anxiety and food restriction on physical activity levels in acute anorexia nervosa. Int J Eating Disord 36(2):163–171. https://doi.org/10.1002/eat.20035
Keyes A, Woerwag-Mehta S, Bartholdy S, Koskina A, Middleton B, Connan F, Webster P, Schmidt U, Campbell IC (2015) Physical activity and the drive to exercise in anorexia nervosa. Int J Eating Disord 48(1):46–54. https://doi.org/10.1002/eat.22354
Davis C, Katzman DK, Kirsh C (1999) Compulsive physical activity in adolescents with anorexia nervosa: a psychobehavioral spiral of pathology. J Nerval Mental Disord 187:336–342
Holtkamp K, Herpertz-Dahlmann B, Hebebrand K, Mika C, Kratzsch J, Hebebrand J (2006) Physical activity and restlessness correlate with leptin levels in patients with adolescent anorexia nervosa. Biol Psychiat 60(3):311–313
Kostrzewa E, van Elburg AA, Sanders N, Sternheim L, Adan RA, Kas MJ (2013) Longitudinal changes in the physical activity of adolescents with anorexia nervosa and their influence on body composition and leptin serum levels after recovery. PLoS ONE 8(10):e78251. https://doi.org/10.1371/journal.pone.0078251
Duclos M, Ouerdani A, Mormède P, Konsman JP (2013) Food restriction-induced hyperactivity: addiction or adaptation to famine? Psychoneuroendocrinology 38(6):884–897. https://doi.org/10.1016/j.psyneuen.2012.09.012
Grosser J, Hofmann T, Stengel A, Zeeck A, Winter S, Correll CU, Haas V (2020) Psychological and nutritional correlates of objectively assessed physical activity in patients with anorexia nervosa. Eur Eating Disord Rev: J Eating Disord Assoc 28(5):559–570. https://doi.org/10.1002/erv.2756
Davis C, Blackmore E, Katzman D, Fox J (2005) Female adolescents with anorexia nervosa and their parents: a case-control study of exercise attitudes and behaviours. Psychol Med 35(3):377–386. https://doi.org/10.1017/S0033291704003447
Falk JR, Halmi KA, Tryon WW (1985) Activity measures in anorexia nervosa. Arch Gen Psychiatry 42(8):811–814. https://doi.org/10.1001/archpsyc.1985.01790310073010
Lehmann CS, Hofmann T, Elbelt U, Rose M, Correll CU, Stengel A, Haas V (2018) The role of objectively measured, altered physical activity patterns for body mass index change during inpatient treatment in female patients with anorexia nervosa. J Clin Med 7(9):289. https://doi.org/10.3390/jcm7090289
Casper RC, Schoeller DA, Kushner R, Hnilicka J, Gold ST (1991) Total daily energy expenditure and activity level in anorexia nervosa. Am J Clin Nutr 53(5):1143–1150. https://doi.org/10.1093/ajcn/53.5.1143
Bouten CV, van Marken Lichtenbelt WD, Westerterp KR (1996) Body mass index and daily physical activity in anorexia nervosa. Med Sci Sports Exerc 28(8):967–973. https://doi.org/10.1097/00005768-199608000-00005
Sauchelli S, Arcelus J, Sánchez I, Riesco N, Jiménez-Murcia S, Granero R, Gunnard K, Baños R, Botella C, de la Torre R, Fernández-García JC, Fernández-Real JM, Frühbeck G, Gómez-Ambrosi J, Tinahones FJ, Casanueva FF, Menchón JM, Fernandez-Aranda F (2015) Physical activity in anorexia nervosa: How relevant is it to therapy response? Eur Psychiatry: J Assoc Eur Psychiatrists 30(8):924–931. https://doi.org/10.1016/j.eurpsy.2015.09.008
El Ghoch M, Calugi S, Pellegrini M, Chignola E, Dalle Grave R (2016) Physical activity, body weight, and resumption of menses in anorexia nervosa. Psychiatry Res 246:507–511. https://doi.org/10.1016/j.psychres.2016.10.043
Steinglass JE, Sysko R, Glasofer D, Albano AM, Simpson HB, Walsh BT (2011) Rationale for the application of exposure and response prevention to the treatment of anorexia nervosa. Int J Eating Disord 44(2):134–141. https://doi.org/10.1002/eat.20784
Meyer C, Plateau CR, Taranis L, Brewin N, Wales J, Arcelus J (2016) The Compulsive Exercise Test: confirmatory factor analysis and links with eating psychopathology among women with clinical eating disorders. J Eating Disord 4:22. https://doi.org/10.1186/s40337-016-0113-3
Nagata JM, Carlson JL, Kao JM, Golden NH, Murray SB, Peebles R (2017) Characterization and correlates of exercise among adolescents with anorexia nervosa and bulimia nervosa. Int J Eating Disord 50(12):1394–1403. https://doi.org/10.1002/eat.22796
Giannini M, Pannocchia L, Dalle Grave R, Muratori F (2008) Italian version of the Eating Disorder Inventory-3. Edizioni O. S. Giunti, Florence
Clausen L, Rosenvinge JH, Friborg O, Rokkedal K (2011) Validating the eating disorder inventory-3 (EDI-3): a comparison between 561 female eating disorders patients and 878 females from the general population. J Psychopathol Behav Assessment 33(1):101–110. https://doi.org/10.1007/s10862-010-9207-4
Prunas A, Sarno I, Preti E, Madeddu F, Perugini M (2012) Psychometric properties of the Italian version of the SCL-90-R: a study on a large community sample. Eur Psychiatry: J Assoc Eur Psychiatrists 27(8):591–597. https://doi.org/10.1016/j.eurpsy.2010.12.006
Bagby RM, Parker JD, Taylor GJ (1994) The twenty-item Toronto Alexithymia Scale–I. Item selection and cross-va15lidation of the factor structure. J Psychosomatic Res 38(1):23–32. https://doi.org/10.1016/0022-3999(94)90005-1
Kovacs M (1985) The children’s depression, inventory (CDI). Psychopharmacol Bull 21(4):995–998
Camuffo M, Cerutti R, Lucarelli L, Mayer R (1988) IL CDI (Children’s Depression Inventory) nella scuola media: indagine psicometrica. Bollettino di Psicologia Applicata, 185: 37–46, ISSN: 0006-6761
Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, Aluwahlia S (1983) A children’s global assessment scale (CGAS). Arch Gen Psychiatry 40(11):1228–1231. https://doi.org/10.1001/archpsyc.1983.01790100074010
Frigerio A, Vanzin L, Pastore V, Nobile M, Giorda R, Marino C, Molteni M, Rucci P, Ammaniti M, Lucarelli L, Lenti C, Walder M, Martinuzzi A, Carlet O, Muratori F, Milone A, Zuddas A, Cavolina P, Nardocci F, Tullini A et al (2006) The Italian preadolescent mental health project (PrISMA): rationale and methods. Int J Methods Psychiatric Res 15(1):22–35. https://doi.org/10.1002/mpr.25
Fichter MM, Herpertz S, Quadflieg N, Herpertz-Dahlmann B (1998) Structured interview for anorexic and bulimic disorders for DSM-IV and ICD-10: updated (third) revision. Int J Eating Disord 24(3):227–249. https://doi.org/10.1002/(sici)1098-108x(199811)24:3%3c227::aid-eat1%3e3.0.co;2-o
Holtkamp K, Herpertz-Dahlmann B, Mika C, Heer M, Heussen N, Fichter M, Herpertz S, Senf W, Blum WF, Schweiger U, Warnke A, Ballauff A, Remschmidt H, Hebebrand J (2003) Elevated physical activity and low leptin levels co-occur in patients with anorexia nervosa. J Clin Endocrinol Metab 88(11):5169–5174. https://doi.org/10.1210/jc.2003-030569
Leggero C, Viglione V, Maestro S, Carissimo R, Apicella F, Bruonori E, Montalto C, Muratori F (2006) Hyperactivity in adolescents with anorexia nervosa: a misunderstood symptom. Gior Neuropsich Età Evol 26:190–202
Billeci L, Brunori E, Scardigli S, Curzio O, Calderoni S, Maestro S, Morales MA (2018) Excessive physical activity in young girls with restrictive-type anorexia nervosa: its role on cardiac structure and performance. Eating Weight Disord: EWD 23(5):653–663. https://doi.org/10.1007/s40519-017-0447-0
Gümmer R, Giel KE, Schag K, Resmark G, Junne FP, Becker S, Zipfel S, Teufel M (2015) High levels of physical activity in anorexia nervosa: a systematic review. Eur Eating Disord Rev: J Eating Disord Assoc 23(5):333–344. https://doi.org/10.1002/erv.2377
Belak L, Gianini L, Klein DA, Sazonov E, Keegan K, Neustadt E, Walsh BT, Attia E (2017) Measurement of fidgeting in patients with anorexia nervosa using a novel shoe-based monitor. Eat Behav 24:45–48. https://doi.org/10.1016/j.eatbeh.2016.11.005
Pirke KM, Trimborn P, Platte P, Fichter M (1991) Average total energy expenditure in anorexia nervosa, bulimia nervosa, and healthy young women. Biol Psychiat 30(7):711–718. https://doi.org/10.1016/0006-3223(91)90016-f
Carrera O, Adan RA, Gutierrez E, Danner UN, Hoek HW, van Elburg AA, Kas MJ (2012) Hyperactivity in anorexia nervosa: warming up not just burning-off calories. PLoS ONE 7(7):e41851. https://doi.org/10.1371/journal.pone.0041851
Gianini LM, Klein DA, Call C, Walsh BT, Wang Y, Wu P, Attia E (2016) Physical activity and post-treatment weight trajectory in anorexia nervosa. Int J Eating Disord 49(5):482–489. https://doi.org/10.1002/eat.22495
Casiero D, Frishman WH (2006) Cardiovascular complications of eating disorders. Cardiol Rev 14(5):227–231. https://doi.org/10.1097/01.crd.0000216745.96062.7c
Bomba M, Tremolizzo L, Corbetta F, Nicosia F, Lanfranconi F, Poggioli G, Goulene K, Stramba-Badiale M, Conti E, Neri F, Nacinovich R (2018) QT interval and dispersion in drug-free anorexia nervosa adolescents: a case control study. Eur Child Adolesc Psychiatry 27(7):861–866. https://doi.org/10.1007/s00787-017-1080-1
Spaulding-Barclay MA, Stern J, Mehler PS (2016) Cardiac changes in anorexia nervosa. Cardiol Young 26(4):623–628. https://doi.org/10.1017/S104795111500267X
Misra M, Klibanski A (2016) Anorexia nervosa and its associated endocrinopathy in young people. Hormone Res Paediatrics 85(3):147–157. https://doi.org/10.1159/000443735
Warren MP (2011) Endocrine manifestations of eating disorders. J Clin Endocrinol Metab 96(2):333–343. https://doi.org/10.1210/jc.2009-2304
Maestro S, Scardigli S, Brunori E, Calderoni S, Curzio O, Denoth F, Lorenzoni V, Molinaro S, Morales M, Muratori F (2014) Anoressia nervosa e iperattività in adolescenza: correlati psichiatrici e internistici [Anorexia nervosa and hyperactivity in adolescence: psychiatric and internal medicine features]. Minerva Pediatr 66(4):237–248
Klein DA, Mayer LE, Schebendach JE, Walsh BT (2007) Physical activity and cortisol in anorexia nervosa. Psychoneuroendocrinology 32(5):539–547. https://doi.org/10.1016/j.psyneuen.2007.03.007
Davis C, Kaptein S (2006) Anorexia nervosa with excessive exercise: a phenotype with close links to obsessive-compulsive disorder. Psychiatry Res 142(2–3):209–217. https://doi.org/10.1016/j.psychres.2005.11.006
Zipfel S, Mack I, Baur LA, Hebebrand J, Touyz S, Herzog W, Abraham S, Davies PS, Russell J (2013) Impact of exercise on energy metabolism in anorexia nervosa. J Eating Disord 1(1):37. https://doi.org/10.1186/2050-2974-1-37
Błachno M, Bryńska A, Tomaszewicz-Libudzic C, Jagielska G, Srebnicki T, Wiśniewski A, Wolańczyk T (2016) Obsessive-compulsive symptoms and physical activity in patients with anorexia nervosa possible relationships. Psychiatr Pol 50(1):55–64. https://doi.org/10.12740/PP/34810
Davis C, Kennedy SH, Ralevski E, Dionne M, Brewer H, Neitzert C, Ratusny D (1995) Obsessive compulsiveness and physical activity in anorexia nervosa and high-level exercising. J Psychosom Res 39(8):967–976. https://doi.org/10.1016/0022-3999(95)00064-x
Noetel M, Dawson L, Hay P, Touyz S (2017) The assessment and treatment of unhealthy exercise in adolescents with anorexia nervosa: a Delphi study to synthesize clinical knowledge. Int J Eating Disord 50(4):378–388. https://doi.org/10.1002/eat.22657
Thornton LM, Dellava JE, Root TL, Lichtenstein P, Bulik CM (2011) Anorexia nervosa and generalized anxiety disorder: further explorations of the relation between anxiety and body mass index. J Anxiety Disord 25(5):727–730. https://doi.org/10.1016/j.janxdis.2011.03.010
Bewell-Weiss CV, Carter JC (2010) Predictors of excessive exercise in anorexia nervosa. Compr Psychiatry 51(6):566–571. https://doi.org/10.1016/j.comppsych.2010.03.002
Kohl M, Foulon C, Guelfi JD (2004) Aspects comportementaux et biologiques de l’hyperactivité dans l’anorexie mentale [Hyperactivity and anorexia nervosa: behavioural and biological perspective]. L’Encephale 30(5):492–499. https://doi.org/10.1016/s0013-7006(04)95463-2
Noetel M, Miskovic-Wheatley J, Crosby RD, Hay P, Madden S, Touyz S (2016) A clinical profile of compulsive exercise in adolescent inpatients with anorexia nervosa. J Eating Disord 4:1. https://doi.org/10.1186/s40337-016-0090-6
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Riva, A., Falbo, M., Passoni, P. et al. High levels of physical activity in female adolescents with anorexia nervosa: medical and psychopathological correlates. Eat Weight Disord 27, 151–162 (2022). https://doi.org/10.1007/s40519-021-01126-3
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DOI: https://doi.org/10.1007/s40519-021-01126-3