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. Author manuscript; available in PMC: 2022 Nov 1.
Published in final edited form as: Int J Eat Disord. 2021 Jul 29;54(11):2057–2065. doi: 10.1002/eat.23587

Registered Report: A pilot investigation of acute exercise response among girls and young women with and without eating disorders

Katherine Schaumberg 1, Danielle Peters 1, Rachel Ahrenholtz 1, Kevin M Crombie 1, Ruisu Zhang 1, Sasha Gorrell 2
PMCID: PMC8595629  NIHMSID: NIHMS1726110  PMID: 34323294

Abstract

Driven exercise (DEx) is a serious and common feature of eating disorders (EDs), but current understanding of factors that give rise to and maintain DEx is limited. DEx may be reinforced through its effects on the threat reduction and reward systems. The current protocol is designed to evaluate acute psychobiological response to exercise among female participants (age 16–22) with and without EDs. Twenty medically-stable participants with restrictive-spectrum EDs and 20 healthy control (HC) participants will complete study screening and three task visits which will include two 30-minute bouts of aerobic exercise. We aim to validate and demonstrate feasibility of two tasks capturing exercise response in this sample. Further, we will estimate the degree to which a bout of exercise impacts state body image, affect, and circulating concentrations of biological markers among participants, and we will examine whether the impact of exercise on psychological outcomes may differ across ED and HC groups. Completion of this project will contribute to the conceptualization of DEx and how individuals’ acute biological and affective responses to exercise contribute to risk for and maintenance of DEx.

Keywords: Feeding and Eating Disorders, Compulsive Exercise, Exercise, Biomarkers, Reward

Introduction

Driven exercise (DEx) (i.e., exercise performed compulsively to control weight or shape and/or regulate affect), is a serious and understudied feature of eating disorders (EDs) (Fietz, Touyz, & Hay, 2014; Monell, Levallius, Forsén Mantilla, & Birgegård, 2018). DEx is a common feature of restrictive-spectrum EDs (Cook et al., 2014; Davis et al., 1997; Davis & Kaptein, 2006; Shroff et al., 2006), occurring in over half of outpatient adolescents with anorexia nervosa (AN) or atypical AN (Sawyer, Whitelaw, Le Grange, Yeo, & Hughes, 2016), and is associated with: risk for suicidal behavior; poor treatment outcome, disorder prognosis, and quality of life; obsessive-compulsive traits; anxiety, perfectionism, body dissatisfaction, reward dependence, dietary restraint; anhedonia, and hypoleptinemia (Brewerton, Stellefson, Hibbs, Hodges, & Cochrane, 1995; Dalle Grave, Calugi, & Marchesini, 2008; Davis & Kaptein, 2006; Davis & Woodside, 2002; Holtkamp, Hebebrand, & Herpertz-Dahlmann, 2004; Holtkamp et al., 2006, 2003; Shroff et al., 2006; Smith et al., 2013). At present, we have inadequate knowledge of factors that contribute to the substantial variability in exercise engagement among those with EDs (including DEx), and poor understanding of mechanisms that maintain this behavior. Barriers to studying exercise in EDs include historical lack of consensus on how to navigate safety concerns and blanket recommendations of exercise abstinence for those in ED recovery (Cook & Leininger, 2017; Kolar & Gorrell, 2021; Mond & Gorrell, 2021), though several recent calls for research aim to challenge these perceived barriers and expand research on this ED feature (Kolar & Gorrell, 2021; Touyz, Hay, & Noetel, 2017).

Existing psychosocial theories contend that DEx is reinforced by threat reduction (i.e., reductions in negative affect; negative reinforcement) and/or by rewarding experiences (i.e., increases in positive affect; positive reinforcement) (Adams, 2009; Adams & Kirkby, 2002; Bamber et al., 2003; Bratland-Sanda et al., 2011; Cassioli et al., 2020; Cook et al., 2014; Davis & Claridge, 1998; Davis & Kaptein, 2006; Guarda et al., 2015; Herring et al., 2014; Lichtenstein et al., 2017) (see Supplemental Table 1 for review of hypothesized mechanisms; Kolar & Gorrell, 2021 for further discussion of proposed mechanisms promoting DEx). While exercise may engage both threat- and reward-related mechanisms that may give rise to DEx, limited empirical research has examined acute response to exercise in ED samples. To further understand mechanisms predisposing and perpetuating DEx, and to characterize how and for whom this behavior may be reinforcing, research investigating biobehavioral response to acute exercise among individuals with EDs is critically needed (Kolar & Gorrell, 2021).

Development of exercise-specific tasks.

Although multiple eating-related tasks have discriminated between individuals with EDs and healthy populations, there are currently no validated tasks that assess sensitivity and responsivity to exercise in ED samples. Further, no behavioral tasks exist that capture potential threat-reduction functions of exercise among those with EDs, including those specific to a core ED fear: fear of weight gain (American Psychiatric Association, 2013; Levinson et al., 2019; Murray et al., 2016). Fear of weight gain may both engage and be a product of threat-related systems present in EDs (Hildebrandt, Bacow, Markella, & Loeb, 2012), and can perpetuate ritualistic behaviors (e.g., restriction, purging, exercise) that serve to alleviate negative affect (Cederlöf et al., 2015; Crane, Roberts, & Treasure, 2007; Mazure, Halmi, Sunday, Romano, & Einhorn, 1994). Development of exercise-based tasks that clarify reinforcers of exercise (e.g., threat and reward) and capture responsivity to exercise among those with EDs will provide the foundation for critical research that can advance knowledge of DEx risk and maintenance.

Current Study

The current study aims to provide initial validation for assessment of acute psychobiological response to exercise among girls and young women with and without EDs. We will characterize exercise-related behavior and response using two exercise paradigms. One task will capture willingness to work for exercise along with psychobiological responses to prescribed exercise. A second, self-paced exercise task will capture disorder-relevant threat-reduction aspects of exercise after drinking a calorically-dense milkshake. We hypothesize that these tasks will be feasible to administer among girls and young women with EDs in an outpatient setting. We will characterize psychobiological response (shifts in affect, body image, biomarkers) to exercise along with preferred-intensity exercise choices across groups. Within the ED group, we will further estimate correlations between psychobiological response to exercise, preferred-intensity exercise, and ED and DEx severity.

Method

Study methods are pre-registered through the Open Science Framework at osf.io/f28zw. The study has been approved by the University’s Institutional Review Board.

2.2. Participants

We will recruit 20 adolescent girls and young adult women (age 16–22) with restrictive-spectrum EDs through targeted advertisements in outpatient health care settings (e.g., flyers in adolescent medicine, psychiatry, and university clinics) and 20 healthy control female participants within the same age range through community-based advertising. Inclusion and exclusion criteria are outlined in Supplementary Table 2.

2.3. Measures and materials

Assessments are detailed in Table 1. Constructs to be evaluated include ED severity, compulsive exercise, functions of exercise, anthropometry, psychological diagnoses, reinforcing value of exercise, reinforcing value of money, perceived exertion, state body image, state affect, compensatory urges, exercise self-pacing, and exercise-related biomarkers.

Table 1.

Study Measures

Construct Assessment Description Timepoint
Eating Disorder Severity Eating Disorder Examination (EDE; Cooper & Fairburn, 1987) A semi-structured interview assessing ED symptoms. The EDE includes subscales for dietary restraint, weight concern, shape concern, and eating concern, along with items assessing the frequency of ED behaviors over the past 28 days. Baseline
Compulsive Exercise Compulsive Exercise Test (CET; Taranis et al., 2011) 24-item, self-report measure assessing five core factors: avoidance and rule-driven behavior, weight control exercise, mood improvement, lack of exercise enjoyment, and exercise rigidity. The CET has demonstrated high internal consistency (α = .85; Taranis et al., 2011). Baseline
Functions of Exercise Questions adapted from the Functional Assessment of Maladaptive Behaviors (Wedig & Nock, 2010) Functions of exercise will be assessed via self-report using four subscales, items assess the degree to which people exercise to decrease negative emotion (automatic-negative reinforcement), increase positive emotion (automatic-positive reinforcement), get help or attention from others (social-positive reinforcement), and escape from social interactions (social-negative reinforcement). Baseline
Anthropometry Height (to the nearest cm) and weight (blinded, and to the nearest .1kg, in light clothes without shoes) Objectively measured with a Tanita-WB 3000 scale Measurements will be taken in duplicate and then averaged. Baseline
Psychological Diagnoses The DIAMOND interview for DSM-5 (Tolin et al., 2016) Semi-structured interview used to determine DSM-5 diagnoses and to measure distress and impairment associated with psychiatric disorders Baseline
Reinforcing value of exercise/money A computer-based behavioral-economic reward measure adapted from Klein et al. (2010) Participants will complete up to 10 trials in which they must repeatedly press a key on the keyboard in order to earn increments of exercise time (3 min) or money ($3). Each subsequent trial will require an increasing number of key presses in order to earn more of the reinforcer Day A (Money); Day B (Exercise)
Perceived Exertion Borg Rating of Perceived Exertion Scale (RPE) (Borg, 1998) RPE ranges from 6 (no exertion) to 20 (maximal exertion) and standard instructions will be provided (e.g., ratings should be made based on fatigue in your exercising muscles, feelings of breathlessness or aches in the chest) During exercise (5-minute intervals)
State Body Image Body Image States Scale (BISS; Cash et al., 2002) a 6-item self-report evaluation of state-level physical appearance. The BISS is sensitive to state changes in body image depending on the situational context, and has demonstrated acceptable internal consistency (α = .77–.90; Cash et al., 2002). During exercise (5-minute intervals)
State Affect Physical Activity Affect Scale (Lox, Jackson, Tuholski, Wasley, & Treasure, 2000) Four items from different subscales reflect the extent to which a participant feels enthusiastic (positive affect), crummy (negative affect), fatigued (fatigue), and calm (tranquility) on a scale from 0 (do not feel) to 40 (feel very strongly). During exercise (5-minute intervals)
Compensatory Urges Intense Desire to Eat subscale of the Food Cravings Questionnaire – State (FCQ-S; Meule, 2020). Three items evaluating desire to eat Prior to and after exercise
Exercise Self-pacing Variability in exercise parameters (e.g., exercise intensity [average % maximum heart rate (MHR), average HR beats per minute], speed [revolutions per minute], power [wattage], and time spent exercising [seconds]) Output of the cycle ergometer; Polar OH1 Optical Heart Rate Sensor (Polar, Lake Success, New York) worn on the upper arm. The Polar OH1 records at 1-s intervals using 6 LED sensors. The Polar OH1 is a validated method of measuring HR during moderate-vigorous exercise (Schubert, Clark, & Rosa, 2018). During exercise (continuous)
Exercise-related biomarkers Circulating concentrations of several biological and neuromodulatory systems (eCBs: N-arachidonylethanolamine (anandamide, AEA), 2-arachidonoyglycerol (2-AG), oleoylethanolamide [OEA] and palmitoylethanolamide [PEA]; homovanillic acid (HVA; a dopamine metabolite associated with central levels), BDNF, 5-HT (serotonin precursor), cortisol, and leptin) Serum and plasma assays Prior to and after exercise
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2.4. Procedure

Participant flow through the study and an overview of procedures are outlined in Figure 1.

Figure 1.

Figure 1.

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Describes participant flow through the study. Participants will attend in-person study visits Day A-C in a randomized order. Day A includes the rest condition of the Prescribed Exercise Task and the exercise condition of the Self-Paced Exercise Task. Day B includes half of the self-report measures and the exercise condition of the Prescribed Exercise Task. Day C includes the other half of the self-report measures and the rest condition of the Self-Paced Exercise Task.

The study will consist of online screening, screening interview, and three task visits. The online screening will assess inclusion and exclusion criteria (e.g., medical disorders; difficulty engaging in moderate-intensity aerobic exercise). The screening interview will further establish inclusion/exclusion criteria (Supplementary Table 2). Eligible participants will complete three task visits (Days A-C; Figure 1). Day order will be randomized, and visits will occur within one week of one another sequentially, spaced 6–8 days apart. To provide consistency and minimize potential confounds related to daily and monthly hormonal fluctuation, task days will be scheduled at 4pm. Among those who are menstruating, Task Day B will be scheduled during the follicular phase to control for possible menstrual phase effects on the biological response to exercise. Menstrual phase will be further clarified and controlled by quantifying estradiol levels on Day B. To control for blood monoamine levels and levels of fullness, participants will be asked to refrain from eating after 1pm and will be asked to eat a provided nutritional supplement snack (i.e., nutritional bar) upon attending study visits at 4pm. Participants will be compensated at three different timepoints: $30 after completion of the study screening, $140 after completion of all study visits (Days A-C), and a potential bonus up to $30 after completing the work for money task on Day A. Total compensation for completing all study material is up to $200.

Prescribed Exercise.

Individuals will complete a series of measures before, during, and after 30 min of rest (Day A; rest condition) and 30 min of prescribed, moderate-intensity aerobic exercise (Day B; exercise condition). Participants will be asked to rest for 30 min (rest condition) or ride a stationary cycle ergometer (Lode Corival cpet, Lode BV, Gronigen, The Netherlands) for 30 min (after a 5-minute warm-up) at a moderate-intensity range (i.e., 70–75% age-adjusted maximum heart rate [MHR]), followed by a 2-min cool-down (exercise condition). This intensity was selected based on prior work (Brellenthin, Crombie, Hillard, & Koltyn, 2017; Crombie, Brellenthin, Hillard, & Koltyn, 2018) demonstrating that a bout of moderate-intensity aerobic exercise increases circulating concentrations of our biomarkers of interest. Additionally, the American College of Sports Medicine (ACSM) Guidelines for Exercise Testing and Prescription (11th edition) indicate our selected exercise intensity is within the moderate-intensity range, thus, our exercise stimulus will be safe and feasible for participants to complete. Research staff will verbally ask participants to adjust their cycling speed if their revolutions per minute fall outside of the 60–70 range, and, with consent, will manually adjust wattage on the cycle ergometer if HR falls outside of the 70–75% MHR range. Participants will be able to view speed and power for the purposes of titrating effort to prescribed range. Participants will not view distance or calories burned. In both conditions, participants will verbally self-report state body image and affect at 5-min intervals throughout the session, as well as rate of perceived exertion (RPE) during the exercise session. Prompts for these measures will be on posters on the wall in front of participants. Participants will complete baseline self-report measures of state body image, affect, and compensatory behavior urges, along with the Work for Money (rest condition) or Work for Exercise (exercise condition) behavioral measure prior to rest/exercise. Participants will complete a final, post-rest or post-exercise session measure of state body image, affect, and compensatory urges after rest/exercise. Blood samples will be obtained prior to and following the rest and exercise sessions.

Self-Paced Exercise Task.

This task captures self-paced exercise and associations with body image and affect in response to an ED-related challenge. Individuals will report baseline state body image, affect and urges to engage in compensatory behaviors at the beginning of the task. Participants will then be asked to ingest a calorically-dense (~500kcal; 12-ounce) milkshake to elicit moderate levels of anxiety and distress related to fear of weight gain. After finishing the milkshake, individuals will again report state affect, urges to engage in a range of compensatory behaviors (e.g., fasting, purging, exercise), and associated expectancies. Participants will then complete either 30 min rest (rest condition; Day C) or will have the opportunity to exercise for up to 30 min on a stationary cycle ergometer at a self-paced intensity and speed, up to 80% MHR (exercise condition; Day A). In the event that an individual surpasses the threshold of 80% HRmax or reports a rating of perceived exertion over 17 during the exercise session, research staff will verbally ask the participant to reduce the wattage on the stationary cycle ergometer. If the participant does not comply, research staff will manually reduce the wattage on the stationary cycle ergometer until the participant’s heart rate is below the 80% MHR limit. Participants may choose to stop exercise at any time and rest for the duration of the task. Similar to the Prescribed Exercise Task, participants will verbally self-report state body image, affect, and RPE at 5-min intervals throughout the exercise and rest sessions. At the end of the session, participants will report the proportion of milkshake calories they believe they burned during the exercise task. They will also repeat self-report of state body image, affect, and compensatory urges.

2.5. Data Analysis

Sample Description

We will provide sample descriptive statistics for both ED and HC groups on variables of interest (e.g., age, ED diagnosis, BMI, compulsive exercise, Eating Disorder Examination [EDE] subscales). Comparison of affect ratings before and after milkshake ingestion will also serve as a manipulation check to clarify the degree to which negative affect (specifically anxiety) increased as a result of this challenge.

Aim 1: Confirm feasibility of paradigms evaluating acute response to exercise among outpatient individuals with EDs.

We will confirm feasibility of our exercise-based tasks via a) study dropout at all timepoints, b) adverse events, c) completion rates of exercise task on Day B, d) completion rates of milkshake task across ED and HC participants. Over the course of the study, we expect both ED and HC groups to meet thresholds of < 20% dropout, zero adverse events, and > 80% task completion.

Aim 2: Characterize variability in biobehavioral response to in-lab exercise.

We will characterize changes during exercise in state body image, mood, and biological markers in both ED and HC groups; we will specifically characterize mean levels of, and variability in, biobehavioral response to exercise across the ED and HC groups.

We will evaluate changes in self-report ratings of body image and affect before, during (every 5 min), and immediately following exercise for both tasks using a multilevel modeling approach (see Supplement 3 for additional details). Overall, we expect swifter, greater reductions in anxiety and body dissatisfaction in the exercise condition of both tasks. Further, we expect these exercise effects to be more pronounced in the ED group vs. HCs.

We will evaluate exercise-induced changes in DA, 5-HT, BDNF, leptin, and eCB biomarkers for the Prescribed Exercise Task. Shifts in affect and biomarkers will be evaluated descriptively with measures of central tendency, skew, and variance. We will further characterize shifts in biomarkers through linear mixed effect models. For affect and body image variables, we will specify a model that includes the following fixed effects: Intercept, Age, Group (ED vs. HC), BMI × Condition, Time × Condition, and a Time × Group × Condition interaction term. The model will include a random intercept and random time effect within condition, within participant. For biomarkers, we will specify a model that includes the following fixed effects: Intercept, Age, Group (ED vs HC), BMI × Condition, and Time × Condition. The model will include a random intercept and random time effect within condition, within participant. We will compute this model in the full sample, and a similar model removing the effect of group within the ED condition.

The primary goal of Aim 2 is preliminary effect size estimation which we will characterize using regression coefficients with 95% confidence intervals. Existing studies using similar exercise paradigms demonstrate significant (p < .05) exercise-induced changes in biomarkers among women with depression and women with posttraumatic stress disorder in modest sample sizes (n ~20–40), with medium-sized effects (Cohen’s d ~0.5) (Brellenthin, Crombie, Hillard, & Koltyn, 2017; Crombie, Cisler, Hillard, & Koltyn, 2020; Crombie, Leitzelar, Brellenthin, Hillard, & Koltyn, 2019; Meyer, Crombie, Cook, Hillard, & Koltyn, 2019). While null hypothesis significance testing is not the primary goal of this study, power was estimated to be adequate (> 0.95) for detecting Time × Condition × Group interactions of moderate effect among DVs assessed during the exercise session (e.g., affect, state body image). Power to detect Time × Condition biomarker interactions of small-to-moderate effect (Cohen’s d = 0.35) was also determined to be adequate (> 0.95). We will not be well-powered to detect small or moderate 3-way Time × Condition × Group biomarker interactions.

Aim 3: Define preliminary estimates of associations between task-based measures of acute exercise response, self-reported functions of exercise, DEx, and ED severity among the ED group.

Within the ED group, we will calculate correlations between acute exercise parameters/response and ED-related measures.

We will conduct a linear regression:

Y=α+β(time)+ϵ

to obtain slope estimates for affect and body image shifts for each individual, within exercise condition. We will also conduct a linear regression estimating post biomarker scores across all individuals with EDs in the exercise condition, saving residuals:

Biomarkerpost=α+β(Biomarkerpre)+ϵ

We will quantify Pearson correlations with 95% confidence intervals between these slope estimates, biomarker residuals, Self-Paced Task exercise parameters (e.g., average bike speed, HR), functions of exercise subscales, self-report of compulsive exercise, and EDE global scores. We will estimate Pearson correlations and 95% confidence intervals for these correlations. Power calculations indicate that only moderate-to-large true correlations (e.g., | r | > 0.6) will be reliably detected (power > 0.8; α = 0.05).

Limitations

Methodological limitations of the study include a modest sample size which precludes determining the significance and potential detection of small effects. Future adequately powered work will also benefit from including other ED diagnoses where DEx is a common feature (e.g., bulimia nervosa). Further, while drinking a milkshake in the Self-paced Exercise Task will provide a disorder-relevant experience of distress (i.e., fear of weight gain) and existing evidence suggests that exercise to manage weight concern demonstrates prominent and consistent associations with ED psychopathology (Mond & Calogero, 2009; Mond, Hay, Rodgers, & Owen, 2006; Scharmer, Gorrell, Schaumberg, & Anderson, 2020), not all individuals report that negative reinforcement properties of DEx are weight-specific. Variations of the task that focus on broader experiences of negative affect may be relevant to consider in future work.

Conclusion

Currently, little is known about response to acute exercise among individuals with EDs, and how exercise-related response may associate with the symptom of DEx. Distinguishing the biological and affective changes that underlie exercise’s role in threat reduction and reward will further our conceptualization of DEx and how this behavior is reinforced. Detailed explication of acute exercise effects among individuals with EDs will (i) improve assessment of DEx risk and function among those with EDs, (ii) elucidate a testable model of DEx risk, and (iii) suggest targets for mechanistically-informed DEx intervention. The methods validated in this study will lay the groundwork for larger-scale clinical research which clarifies optimal targets for DEx in ED treatment.

Data availability statement:

Once collected, the data that support the findings of this study will be available from the corresponding author upon reasonable request.

Supplementary Material

tS1
tS2
supinfo

Acknowledgements:

This study is supported by grants from the National Institute of Health (K01MH123914; Schaumberg and K23MH126201; Gorrell) and the Virginia Horne Henry Fund for Women’s Physical Education and Movement (Schaumberg).

Footnotes

Conflict of interest statement: The authors have no conflict to declare.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

tS1
NIHMS1726110-supplement-tS1.docx (41.8KB, docx)
tS2
NIHMS1726110-supplement-tS2.docx (19.2KB, docx)
supinfo
NIHMS1726110-supplement-supinfo.docx (17.9KB, docx)

Data Availability Statement

Once collected, the data that support the findings of this study will be available from the corresponding author upon reasonable request.

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