REE was decreased in AN-patients compared with controls but not when adjusted for body surface area or lean body mass. Subgroup analyses showed that the percentage of high-level AN- exercisers was higher compared with controls. Anorexia nervosa AN is a serious illness associated with a chronic course and high mortality[ 1 ]. Physical activity is a metabolically expensive process.
Thus, hyperactivity might be one of the underlying problems in the process of weight restoration and maintenance. However, for clinicians it is difficult to assess physical activity due to rather accurate but time-expensive methodologies or underreporting in self-assessment instruments[ 5 , 6 ]. A simple tool for clinicians to estimate the degree of physical activity would be helpful to solve this problem.
The gold standard for assessing physical activity involves the use of the doubly labelled water technique[ 8 ] which measures the total daily energy expenditure TDEE. REE is generally reduced in emaciation due to the decreased body weight, lean body mass LBM and metabolic adaptations[ 10 — 12 ]. In contrast, TDEE, measured by doubly labelled water, is sometimes reported to be decreased in AN and sometimes to be similar to healthy controls[ 12 ].
Additionally, we have shown previously that energy metabolism is altered in the different stages of illness; for example, early refeeding of AN is accompanied with a paradoxically high DIT[ 13 , 14 ]. Interestingly, the former studies on energy expenditure in AN did not distinguish between patients with high-activity levels and patients with low-activity levels and did not combine these measurements with assessing psychological data.
Given the interindividual differences in activity of AN patients, we compared the energy metabolism, endocrine parameters as well as psychological data of AN patients with healthy controls and performed subgroup analysis by distinguishing between low-level and high-level exercisers.
AN patients with comorbid depression were not excluded. Participants were instructed to continue their usual activities during the period of participation in this study. All participants were in a nutritional rehabilitation program. Patients were asked to take part in the study not before an initial two weeks of stabilization. Initially they were encouraged to eat three meals and three snacks per day selected from a cafeteria situation and containing — kJ initially, increasing towards — kJ per day in the latter part of treatment.
Patients were fully ambulant but were required to rest on their beds for 30 minutes after breakfast and dinner and 60 minutes after lunch. Eating disorders, dietary restriction and over-exercise were excluded by means of a careful standardized DDE interview[ 16 ].
All participants gave informed consent to the procedure and parental consent was also obtained for subjects less than 18 years of age. After an overnight fast, all participants patients and controls were first interviewed, using a structured interview[ 16 ] for the assessment of an eating disorder, including a detailed history of the exercise behaviour. A fasting blood sample for the analysis of leptin, thyroid hormones and basal cortisol was collected. Body composition was assessed via skinfold thickness by a caliper at four sites of the body.
Subsequently, the body fat mass was derived from the equations of Durnin and Womersley[ 20 ]. LBM was calculated as the difference between body mass and body fat mass. Participants were asked to lie still and were permitted to read or listen to music via headphones. They were prevented from sleeping. TDEE was measured over 15 days by the doubly labelled water method and was applied as described in detail elsewhere[ 8 , 21 , 22 ].
The amounts of labelled water taken were scaled according to estimated total body water TBW : H 2 18 O, 0. All results are presented as mean and standard deviations SD. In case of skew distribution or inhomogeneous variance, Wilcoxon 2-sample-tests were computed. Data were adjusted for multiple testing using the Bonferroni correction.
Baseline demographic and physical characteristics of AN patients and controls are presented in Table 1. The daily amount of exercise did not statistically differ between the groups due to the great interindividual differences as assessed by structured interview DDE.
The amount of daily exercise in patients labeled as high-level exercisers was 3- to 4-fold higher compared with the controls and low-level exercisers, respectively. REE, determined by indirect calorimetry, was significantly decreased in patients with AN compared with healthy controls Table 2 , Figure 1. However, no significant differences in REE were found between patients and controls when adjusted for body surface area or lean body mass LBM. In contrast, the low-level AN exercisers had significantly decreased TDEE values compared to the high-level exerciser subgroup and the controls, respectively Figure 2.
The physical activity level PAL was 1. Next, we analyzed the plasma levels for a selected panel of hormones known to be involved in energy metabolism, including TSH, T 3 , T 4 , leptin and cortisol Table 3. Leptin, T 3 and T 4 plasma levels were significantly reduced in patients with AN compared to the controls.
A differential regulation was observed for T 4 , which was significantly reduced in high-level exercisers versus the controls. TSH and cortisol levels remained unchanged between the groups. For the subgroup analysis low- versus high-level AN exercisers , no significant differences were observed. This energy expenditure study provides new insights into the energy metabolism of patients with AN. Here we assessed, for the first time in low-level exercise and high-level exercise AN patients, compared with healthy controls 1 the differences in their energy expenditure by analyzing TDEE and REE by doubly labeled water and indirect calorimetry, respectively, 2 their hormonal status combined with 3 psychological data for depression, eating attitudes and eating disorder by established standardized questionnaires BDI, EAT, EDI-SC, EDI We found that the daily amount of exercise in AN patients and controls was similar despite a marked difference in weight and body composition.
In accordance, using the doubly labeled water method, we found no significant differences in mean TDEE between AN patients and controls. Applying the same technique, some other studies support our findings[ 24 — 26 ], whereas others report a reduced TDEE in AN patients[ 23 , 27 , 28 ].
Greater Psychological Distress Finally, compulsive exercise among adults with anorexia is directly associated with higher levels of psychological distress, including depression, anxiety, obsessive-compulsiveness, and chronic negative affect [9]. A risk profile of compulsive exercise in adolescents with an eating disorder: a systematic review.
Adv Eat Disord. Front Neurosci. Verywell Mind. Self-Starvation in the Rat: Running versus Eating. Sudden death in eating disorders. Vasc Health Risk Manag. S [7] JI. Hudson, E. Scott, S. Striegel-Moore, C. Tremblay, M. Fietz, S. Meyer, L. Anorexia athletica also known as Exercise Bulimia is a form of an eating disorder where an individual exercises to the point of malnourishment, injury and even death.
Anorexia athletica is an eating disorder characterized by excessive and compulsive exercising. Most common among athletes, anorexia athletica is a mental illness which gives those suffering from it a sense of having control over their body. Commonly, people with the disorder tend to feel they have no control over their lives other than their control of food and exercise. The anorexia definition highlighting the subtype anorexia athletica sports anorexia also referred to, as hypergymnasia is an eating disorder characterized by an obsession with exercise to lose weight or prevent oneself from gaining weight.
Although not formally recognized by the American Psychiatric Association APA or The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition DSM-5 as an official eating disorder, anorexia athletica is still recognized as a severe problem associated with eating disorders such as anorexia nervosa and bulimia nervosa. Anorexia athletica often accompanies anorexia nervosa or bulimia nervosa as a form of getting rid of calories after a binge.
Running eight miles on the treadmill followed by an hour on the elliptical and an hour of weight training is considered a typical workout for an individual with anorexia athletica.
Although there is no specific diagnostic criterion for anorexia athletica, the signs and symptoms are centered on excessive exercise and the obsession with weight and body image. Since this disorder is often associated with anorexia or bulimia nervosa, signs and symptoms usually correlate with the specific eating disorder anorexia athletica is associated with.
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