Table of Contents
Table of Contents
List of Figures
List of Abbreviations
2 Theoretical Background
3 Material and Methods
3.1 Search Strategy
3.2 Description of the Included Studies
3.2.1 Inclusion Criteria
3.2.2 Exclusion Criteria
3.3 study Selection
4.1 Cohort and Intervention Characteristics
4.2 Outcome Measurement
4.2.1 Physical Health Outcomes
4.2.2 Mental Health Outcomes
5.1 General Overview
5.2 Limitations in the Studies
Theoretical Background: Patients with Anorexia Nervosa (AN) often practice physical activity to influence their weight and shape or they partake in sporting exercise in a compulsive manner. It is generally known that physical activity may have negative consequences for patients with AN, if it is conducted excessively or used as a method to control weight, otherwise, sport can be used as a therapy to find a way to mitigate the medical condition or even cure it by influencing physiological and psychological condition of the patient and improving their fitness and self-esteem. The primary objective isto find out if and to what extent sports-therapy or physical activity can have a positive influence on sufferers of an Eating Disorder (ED). This elaboration is a systematic review that summarizes studies, which show the effect of physical activity in correlation with Anorexia Nervosa (AN). To give the reader an overview of the topic of ED, it is essential to clarify the causes of AN, its risk factors, as well as the consequences for the patient’ health that result from it. Method: Use of comparable studies, taken from the medical meta-database PubMed that analyzed a range of non- athletic adolescents, who were diagnosed with AN and underwent a schedule of low-intensity physical activity for a limited period. Target group: This thesis sets out to summarize the results of existing studies on this topic. Its objective is to prove any coherence in the results of these studies, and as a consequence proved information to therapists, or patients, suffering from AN, if and which kind of physical interventions could have a positive or negative influence on the ED. Results: Overall, seven studies were found that met the inclusion criteria. The results prove that only two of these studies show a significant improvement in physical conditions compared to the control group, while five of them reported better psychological condition. In summary, all participants identified small improvements, and none of the studies showed indications of deterioration. Conclusion: Given the suitable intensity and extensive duration of the therapy program, physical intervention in the form of anaerobic or resistance training can possibly lead to beneficial and significant outcomes in physiological strength, fitness and the psychological well-being in anorexic outpatients.
List of Figures
Fig. 1 Causes of Anorexia Nervosa
Fig. 2 Targets of body centered therapy for women with ED (cf. Alexandridis et al.)
Fig. 3 Flow chart of article retrieval process
Table 1 study Characteristics
Table 2 Training Program
Table 3 Training Program Continued
Table 4 Training Program Continued
Table 5 Training Program Continued
Table 6 Outcome Measurements
List of Abbreviations
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Eating disorders (ED) can be described as mental illnesses that are characterized by weight loss and which have effects on the physical composition of the body. In many cases the consequences are underestimated because it is often assumed to be a sort of a fashion phenomenon or a lifestyle choice, and not as a serious illness. Often, there are psychological problems associated with ED, such as depression, anxiety, personality disorder and physiological issues such as substance abuse, osteoporosis or bone fragility. (National Eating Disorder Collaboration, 2014, p.7)
Furthermore, correlations have been found between ED and sports. Exercise or physical activity can usually not be recommended for patients, because of the belief that it could lead to an exacerbation of the disorder. Many studies suspect that eating disorder patients have a higher urge to exercise excessively than average in effect to burn more calories, regulate their weight and control their body composition. (Meyer & Taranis, 2011, p. 171) Such hyperactivity performed by people with lower BMI, can lead to serious physical damage or produce detrimental results, and is not viewed as a beneficial form of treatment. However, surprisingly, excessive exercise can lead to higher scores in self-reported quality of life (QOL). (Rizk et al., 2015, p. 12)
Therefore, it can be assumed that sports could also have a positive influence on patients with ED like Anorexia Nervosa (AN). (Calogero & Pedrotty, 2004) Physical activity can influence how individuals perceive their body and it could be helpful in reducing risks of anxiety, depression, body dissatisfaction, feelings of self-consciousness and acceptance of one’s own body, and have an influence on body composition image issues. Moreover, it could lead to an improvement in social behavior. (National Eating Disorder Collaboration, 2014, p. 11 ) But not only psychological conditions might emend. Individualized physical treatment under medically approved conditions could improve muscle building and reduce physiological risks like substance abuse, chronic pain and bone fragility. (Peñas-Lledó, Vaz Leal, & Waller, 2002, p. 44)
The primar question is, how to identify what kind of sport constitutes healthy treatment. Obviously, overly intensive training, especially if aerobic, for example running or swimming would be unsuitable due to its high-energy expenditure, which might lead to even greater weight loss or carry other risks. The exercise should lead to improvement in, or at least maintain, physical fitness or health. Illustrative proposals for various sport therapy treatments can be found in different studies. Most commonly, low intervention training methods, such as resistance training, or movement exercises such as yoga or physical therapy have been used. The objective of this paper is the examination of different studies that concern the respective sporting exercise, as described above, in the context of ED, with a view to see, if and to what extent, it is possible for sport influences to patient’ health.
To begin with, a definition will be given and some theoretical basics of AN discussed. After that, the method of the systematic review will be explained more precisely. In the Results section, the methodological and contextual aspects of the selected studies for this review will be explained with the help of tables that summarize the exercises that the participants of the studies had to conduct. And finally, the methodical as well as substantive strengths and weaknesses of the studies is critically analyzed, and recommendations for further research and possibilities for the practical implementation of any conclusions are offered.
2 Theoretical Background
Definitions of Eating Disorders
Translated, the medical expression Anorexia means as much as nerve-conditioned loss of appetite. A person with this serious mental illness does not eat, or eats too little, with resulting in dangerous weight loss, malnutrition, and in some cases, it even leads to death. Anorexia is most commonly seen in adolescence girls or women between the age of eleven and forty. The cause is suspected to lie in a body composition disorder. Usually, sufferers have a distorted body image which leads to an underestimation of their body circumference even if extremely malnourished. Because of their fixation on thinness, patients commonly start extreme diets, counting every calorie and feeling guilty each time they eat something. (Attia & Walsh, 2007, p. 1806)
Currently, scientists categorize eating disorders into five different types. According to the National Eating Disorder Association (NEDA), AN is the most commonly known ED. It can be described as a restriction of energy intake and a significantly low body weight in relation to age, gender, developmental trajectory and physical health due to the fear of weight gain or becoming fat, even though weight is significantly low. Furthermore, there is a disturbance in the perception of body weight and of its shape, as well as a lack of appreciation of the current low body weight. The illness can be subdivided into a restricting type and a binge eating/ purging type.
On the other hand, Bulimia Nervosa (BN) describes a set of behavior, in which a person eats a larger amount of food than most people would do. They lose control of the amount of food ingested and are not able to stop. In a compensatory response to avoid weight gain, they engage in self-induced vomiting, fasting or excessive exercise. This compensatory behavior occurs at least once a week for three months.
Binge Eating Disorder (BED) has nearly the same characteristics as BN, except no compensatory behavior such as vomiting is displayed.
Avoidance Restrictive Food Intake Disorder (ARFID) is a specific type of ED, where people dispay a disturbance in eating or their diet characterized by a failure to meet their nutritional or energy needs resulting in significant weight loss or nutritional deficiency, or even dependence on enteral feeding.
Finally, there is a term used by the American Psychiatric Association’s Diagnostic and statistical Manual of Mental Disorders called Eating Disorder Not otherwise Specified (EDNOS). It does not fulfill all criteria of any of the above-described EDs but shows dietary or eating behaviors that can cause clinically significant distress and impairment in areas of functioning. For example, atypical AN is a form of eating disorder meeting all criteria of AN, except for significant emaciation, or weight loss. (National Eating Disorder Association, 20.0. p. 6)
This work is going to focus on AN because not only is it the most frequent of all illnesses, but also shows the most psychological and physiological changes in sufferers, which makes it all the more interesting to determine whether sport therapy treatment can be helpful.
This section provides a small insight of how commonly AN occurs in our population.
Floek et al. carried out a prevalence study to evaluate literature on the incidence and prev- alenee of ED. Results showed that 0. 3% of all young females suffer from AN. It has an incidence of 8 cases per 100,000 population per year and has been increasing markedly over the last 50 years. Furthermore, the study confiremd that, compared to people with BN and BED, AN is the most frequent illness among all EDs. The highest prevalence is noted among females in the age group of 15 to 19, while males only constitute an incidence less than 1 case per 100,000 population per year. (Floek & van Floeken, 2003, p. 385) This age group also has a ten times higher risk of dying compared to peers in the same age range. Rates of mortality vary between 0% and 25%. (National Eating Disorder Association, 2010) Meanwhile, the chances of full recovery are very low, almost 25% of all individuals remaining ill. Mostly, this occurs because individuals with AN usually deny their illness and are only seen for treatment if either their lives are in imminent danger, or if they have people around them who are concerned for their lives. (Zandian, Bergh & Södersten, 2007, p. 283)
Causes of AN
The factors that contribute to the development of ED are still unclear. There is a huge variety of literature that attempts to explain the different causes of ED. Usually they range trom individual psychological aspects to biological and cultural factors like tamily and social intluences. (Zeeck & Schlegel, 2012) Presumably it is a combination of those factors that lead to the illness. In order to provide a full overview, this chapter specifies these factors more precisely as belonging to three different groups.
Individual influences and psychological factors
In many cases the trigger is tound in an experience that contributes to the eating disorder. This can be in form of a stressful, burdening situation or a trauma.
Moreover, there are also certain personality traits that can be identitied more often in people with AN than in unaffected people. For example, they show a heightened sense of guilt, low self-esteem, or suppressed anger. These negative teelings about the self are channeled into dissatistaction with their body, pertectionism and obsessive thoughts that lead to ED. (Polivy & Herman, 2002, pp. 197 & 200)
Sociocultural contributors and familial influences
In today’s society there is widespread promulgation of the desire to possess an ideal body. Social media makes US think that having a perfect body improves self-worth, and leads to greater success and social acceptance. On the other hand, AN can be developed through different kinds of interpersonal difficulties, for example in the form of troubled personal relationships, a history of being bullied, or of physical or sexual abuse. Especially tamilies can have a decisive intluence on the individual. Perpetuation and even development of ED has been associated with tamilial, maternal invasion of privacy, jealousy, criticism, competition or paternal seductiveness. (Polivy & Herman, 2002, p. 203)
Biological and genetic influences
It is assumed by scientists that there is a biochemical or biological basis to the condition in the form of an imbalance between certain chemicals in the brain that control hunger, appetite and digestion. The underlying reason for this could possibly be a primary dysfunction of the hypothalamus, where appetite originates. Furthermore, tests show that hormonal functioning and aberrations are prevalent in AN. However, research concerning both matters is still at an early stage.
Another influence was proved with the help of twin and family studies that provided evidence of genetic transmission of ED. (Polivy & Herman, 2002, pp. 201 & 202) In the studies that have been researched, a majority of the participants are female adolescents aged between 15 and 24, who suffer from the illness. Males only represent 25% of individuals with AN, and they often carry a higher risk of dying. The reasons for the relative youth of AN individuals can be explained by biological, physical as well as psychic changes that occur in puberty. At this age, young people feel more insecure, self-conscious and are more susceptible to social pressure. (National Eating Disorder Association, 2010)
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According to Attia and Walsh, four different criteria must be met to be diagnosed with AN. The first of these is when individuals refuse to maintain their body weight and restrict their energy intake, which leads to significantly low body weight in relation to age, sex, developmental trajectory and physical health. The second is the fear of weight gain or becoming fat, even though the subject is underweight. The third is when individuals have a disturbed experience of their body weight or shape, try to influence it, or deny the abnormal body weight they have. And finally, the biological consequence of the illness is the absence of at least three consecutive menstrual cycles, also known as amenorrhea. (Attia & Walsh, 2007, p.1806)
Consequences of AN
Without treatment, the process of not eating and starvation leads to irreparable psychological and physiological damage to people with AN. In extreme cases, important organs start to fail and the patient dies.
For many people, weight loss is the most obvious and visible consequence of AN. But there are lots of other negative side effects caused by the illness that are not only physiological but also psychological. In the following sections, these will be discussed more precisely. Most of the effects displayed over the course of the disease will be cured as soon as the patient recovers, but some consequences will never completely heal, and can only be partly treated with methods of therapy. (Gendall & Bulik, 2005, p. 93)
Health and physiological risk factors
Typical physiological consequences are bone fragility, substance abuse and osteoporosis because of a decrease in bone mineral density. This leads to an increased risk of fractures, even after the illness has been treated successfully. (Meczekalski, Podfigurna-Stopa, & Katulski, 2013, p.215) Because of the low-calorie intake, the body breaks down and consequently muscles like the heart weaken. The heart is less able to pump blood and there are fewer blood cells to circulate. Consequently, not enough energy provided to the organs, which leads to cardiovascular risks like an abnormally slow heart rate and lower blood pressure. This means that the risk of heart failure rises. (Mitchell & Crow, 2006, p. 440).
Affected individuals will have a hard time completing daily tasks. Due to drastic muscle loss, they teel weak or fatigued, and are otten teel overwhelmed and become prone to fainting. The brain needs up to one fifth ot our calorie intake, and the lowered provision ot energy during dieting will lead to difficulties concentrating. Generally, there are also visible signs ot AN, such as dry hair and skin or loss ot hair. In some cases, sutferers will experience growth ot a downy layer ot hair, called lanugo, all over the body to keep it warm. (National Eating Disorder Association, 2010, p.16)
In some cases, AN can cause birth complications. For example, tor women who have suffered trom AN otten bear children ot low birth weight. Usually, atfected women have fertility problems, and birth control becomes more difficult because lowered estrogen and thyroid levels can cause menstruation to be delayed , become irregular, or stop completely. Furthermore, there are more complications during the pregnancy. There is a higher rate ot Hyperemesis Gravidarum and obstetric complications, which means the tetus also suffers from the illness and can be impaired in its development. (Meczekalski, Podtigurna-Stopa, & Katulski, 2013, p. 217)
Psychological risk factors
People suffering from AN frequently withdraw trom their friends and environment. This makes it difficult to understand their behavior, get close to them or influence them. As eating causes a redistribution ot dopamine/ serotonin, which makes people teel happier and content, many people with AN suffer from negative moods and depression due to their lack ot food. This can, however, also be caused by their never-ending dissatisfaction with their body image. (Hausenblas, Cook, & Chittester, 2008, p. 44)
Intense sensations ot hunger at bedtime, also causes poor sleep quality and insomnia tor AN sufferers, which among other things leads to tatigue and difficulties in concentration.
Prevention and treatment
Some basic prerequisites, tor example stable selt-esteem and healthy selt confidence, are necessary to prevent AN developing among predisposed subjects. Especially teenagers and young adults have difficulties developing these capacities to an adequate degree and need to be supported. Parents can encourage their children by tocusing on their abilities and characteristics, and should talk with them about feelings and experiences. Moreover, children should have enough access to sporting activities to gain a healthy sense of their bodies. Another important point is the function of parents as role models. Hence, they should always be aware of their own food intake.
When starting treatment, the focus lies on reactivating and strengthening these basic requirements.
Therapy methods vary, but almost all of them focus on stabilizing the eating behavior of patients with the help of psychotherapy. In some critical cases AN patients must be hospitalized and undergo a strict diet or parenteral nutrition.
Other therapy methods are family therapies, in the case of problematic familial interaction that could have been a trigger or sustaining factor. Cognitive behavioral therapies are also often used to influence the patient’s distorted physical awareness of themselves, and to improve their attitude towards eating. Alexandris presumed that intensive therapy combined with physical intervention could improve not only the patient’s willingness to partake in physical activity and improve their physical endurance, but also lead to a higher body acceptance and a more realistic body perception in patients with ED. Results of a study on patients with BN indeed have already shown small improvements in body acceptance, thanks to body oriented therapies . (Alexandridis, Schüle, Ehrig, & Fichter, 2007, p. 50) Especially physical activities like yoga or physiotherapy have been adapted over the last few years as a new method of physical therapy for individuals with ED. Indeed, the mind-body therapy strategy promotes stronger self-acceptance, a healthier body experience, as well as the ability to tolerate discomfort. (Neumark-Sztainer, 2014, p. 137)