See

discussions, stats, and author profiles for this publication at:

http://www.researchgate.net/publication/15307592

The role of physical activity in the

development and maintenance of eating
disorders. Psychological Medicine, 957-
967

ARTICLE in PSYCHOLOGICAL MEDICINE · DECEMBER 1994

Impact Factor: 5.43 · DOI: 10.1017/S0033291700029044 · Source: PubMed

CITATIONS

170

4 AUTHORS, INCLUDING:

Caroline Davis Sidney H Kennedy

York University University of Toronto
142 PUBLICATIONS 4,350 CITATIONS 414 PUBLICATIONS 15,186 CITATIONS

SEE PROFILE SEE PROFILE

Available from: Sidney H Kennedy

Retrieved on: 28 August 2015
Psychological Medicine, 1994, 24, 957-967. Copyright © 1994 Cambridge University Press

The role of physical activity in the development

and maintenance of eating disorders
C. DAVIS,* S. H. KENNEDY, E. RAVELSKI AND M. DIONNE
From the Departments of Psychiatry and Psychology, The Toronto Hospital, Toronto, Ontario, Canada

SYNOPSIS This study was intended to establish the pathogenic significance of sport and exercise
in the development of eating disorders. Hospitalized eating disordered patients and an age-matched
control group were assessed. Historical and current physical activity data were collected. An in-
depth interview was also conducted to ascertain the age of onset of the diagnostic symptoms for
eating disorders, and to determine whether: (/) exercising predated dieting; (//) patients had been
involved in competitive athletics; (Hi) exercise was excessive; and (iv) weight loss was inversely
related to level of exercise. The results indicated that patients were more physically active than
controls from adolescence onwards, and prior to the onset of the primary diagnostic criteria for
anorexia nervosa. A content analysis of the interview data indicated that 78 % of patients engaged
in excessive exercise, 60% were competitive athletes prior to the onset of their disorder, 60%
reported that sport or exercise pre-dated dieting, and 75% claimed that physical activity levels
steadily increased during the period when food intake and weight loss decreased the most. Together
our results suggest that overactivity should not be routinely viewed as a secondary symptom in
anorexia nervosa, equivalent to other behaviours. For a number of anorexic women, sport/exercise
is an integral part of the pathogenesis and progression of self-starvation.

DSM-III-R (APA, 1987) expressly states that

INTRODUCTION
Most would agree that the state of starvation
seems biologically incompatible with high levels
of physical activity, calling to mind the lethargy
that is typically observed among famine victims
and emaciated political prisoners. Nevertheless,
the coexistence of excessive calorie restriction
and hyperactivity among anorexia nervosa
patients has been reported consistently by
clinicians and researchers, both historically
(Gull, 1874; Inches, 1895) and more recently
(e.g. Bruch, 1965; Crisp, 1967; Dally, 1969;
Feighner et al. 1972; Yates, 1991). It may well be
the counterintuitive nature of this association
that has convinced many authorities (e.g. Garner
et al. 1985; Garfinkel & Goldbloom, 1988) that
overactivity is simply a deliberate and wilful
method of calorie expenditure for those who are
preoccupied with the pursuit of thinness. Indeed,
* Address for correspondence: Dr Caroline Davis, 343 Bethune
College, York University, 4700 Keele Street, North York, Ontario,
M3J 1P3, Canada.
957
the weight loss in anorexia nervosa is 'often
[accomplished] with extensive exercise' (p. 65).
Despite the prevalence of this particular
viewpoint, a number of other theories have been
proposed concerning the role of physical activity
in the development and maintenance of eating
disorders. For example, a small but compelling
body of clinical evidence has led some re-
searchers to conclude that physical activity may
occupy a more central role in the development
of eating disorders. In one study, retrospective
data were collected from the hospital records of
33 anorexic patients, and in some cases, from
follow-up interviews. It was found that 21 of
these patients were described as extremely
physically active well before they ever dieted or
lost weight (Kron et al. 1978). Katz (1986) also
provided case reports about two patients for
whom long distance running clearly preceded
the appearance of anorexia nervosa, and ap-
peared to play a significant role in its onset.
Based on the apparent psychological simi-
larities between those described as excessive
958 C. Davis and others
exercisers and those with eating disorders, Yates
and her colleagues have claimed that dieting and
exercise are 'sister activities' with respect to
aetiology, and that a serious investment in one is
likely to be accompanied by a preoccupation
with the other (Yates, 1991; Yates et al. 1992).
Sacks (1987) argues that while the two be-
haviours may exist independently, they both
share a 'central narcissistic dynamic' and are
motivated by a strong element of perfectionism;
for the exerciser this is manifested in the pursuit
of physical effectiveness; for the anorexic, in the
pursuit of physical attractiveness.
On the basis of extensive clinical observations,
Crisp (1967) concluded that starvation facili-
tates generalized compulsive behaviour so that
exercising, like various other activities, can
involuntarily become stereotyped, ritualized
and excessive, simply as a consequence of the
disorder. He noted that the need for ceaseless
exercise tends to diminish when patients are
re-fed. At a biological level, recent research has
implicated serotonin dysregulation (also a
frequent consequence of malnutrition) in the
development of compulsive behaviours (see
Holden, 1990; Barr et al. 1992; Kaye et al.
1993).
Perhaps the most provocative hypothesis
concerning the relationship between physical
activity and starvation has been that proposed
by Epling & Pierce (1988, 1992). They claim that
for many patients, anorexia is not a nervosa, but
a physiologically mediated outcome that is likely
to affect those who simultaneously subject
themselves to a marked reduction in food intake
and high levels of energy expenditure (see Lowe,
1993). Under-eating and over-exercise become
mutually reinforcing behaviours that are self-
perpetuating and resistant to change. They argue
that sociocultural exigencies can initiate a state
of food restriction (e.g. dieting to lose weight),
which can then cause an increase in physical
activity if the opportunity to exercise is available.
Deprivation-induced activity will further sup-
press appetite, and so the weight-loss cycle
begins. The strength of their argument rests on
the assumption that the relationship between
activity and appetite is reciprocal. Specifically,
they maintain that food intake is reduced
following exercise, and that in the face of food
restriction, physical activity increases.
The impetus behind much of their thinking
about exercise and dieting has come from a body
of well-controlled animal research that has
consistently demonstrated the development of
excessive exercising induced by food restriction
and mediated by endogenous opioid peptides
(EOPs) (Epling et al. 1983; Epling & Pierce,
1984; Russell, et al. 1987). About 90% of
adolescent rats and 70% of mature rats with
voluntary access to an activity wheel begin to
run when their food supply is restricted to
60-90 min/day. They exhibit decompensated
eating behaviour within one week with an
exponential increase in running and decrease in
food intake. In the original experiments the
animals literally ran themselves to death. On the
other hand, control rats, with no access to an
exercise wheel, learn to eat sufficient food in the
restricted time frame to remain in energy
balance.
To date, there is little empirical or scientific
evidence to support the notion of activity-
induced anorexia in the human condition except
for a handful of case reports drawn from a
variety of sources, and presented as illustration
by Epling & Pierce (1992). Despite the obvious
simplicity of their model-in particular, the
absence of any recognition of the mediating role
of individual differences and psychological vul-
nerabilities in the development and progression
of the disorder - its relevance to the under-
standing of anorexia nervosa should not be
underestimated, especially in the light of current
attitudes to body image and health issues.
Over the past decade or so, the idealized
female body shape has become even more slender
than in previous years, at least in Western
cultures (Wiseman et al. 1992). At the same
time, the physiological, and indeed psycho-
logical, benefits of regular physical activity,
weight control and low-fat diets have been well-
studied and clearly established (see Bouchard et
al. 1993). As a consequence, health-related
lifestyle changes are now strongly promoted,
and have become a focus of public attention and
government spending - some would even argue,
a national obsession. Not surprisingly, there has
been a steady increase in the number of articles
in popular women's magazines advocating diet-
ing and exercise for the putative purpose of
weight loss. In fact, over the past 10 years, the
percentage of articles promoting dieting on its
own has decreased, as those promoting dieting
 Exercise and eating disorders
in combination with exercise have increased,
and have surpassed the former (Wiseman et al.
1992). Frequently, however, there is an insidious
message in the health-promotion propaganda
presented by the media - that is, that ' physical
attractiveness' is synonymous with 'physical
fitness', and that both qualities are personified
in the young and ultra-slender female body.
In the context of these issues, the two studies
described here were designed to investigate
systematically, and in-depth, the inter-related
dynamics of exercise and starvation. The specific
purpose of Study 1 was to test the reliability of
historical physical activity data collected retro-
spectively. It was also intended to obtain an
estimate of the degree of physical activity typical
of a non-clinical sample of college-aged Cana-
dian women during childhood and early adult-
hood.
In Study 2 it was our intention: (/) to obtain
a lifetime sport and exercise profile for a group
of hospitalized eating disordered patients in
order to ascertain whether physical activity
participation is a significant factor in the patho-
genesis of the disorder; (;7) to compare the pre-
morbid and morbid levels of physical activity
between these patients and a group of age and
sex-matched peers; (Hi) to establish the relative
frequency with which exercising predated dieting
and weight loss among patients; and (iv) to test
the hypothesis of Epling & Pierce (1988; 1992)
that in many cases, weight loss and exercise are
mutually reinforcing and positively related with
respect to intensity and degree.
STUDY 1
Physical activity assessment
When the aim of the investigation is to determine
the association of physical activity with illness,
disease or other health outcomes, a number of
issues must be considered that relate specifically
to the methods used to assess and quantify
physical activity (see Caspersen, 1989 for a
review). Previously, when work weeks were
longer and leisure time tended to be relatively
restful and inactive, the assessment of job-
related activity patterns was particularly relevant
to some epidemiological research. At present,
few jobs require sustained exercise and therefore,
assessment of leisure-time physical activity is of
primary importance. The type of physical-
959
activity measurements that are made are largely
dependent on the degree of precision required by
the investigation. For example, although ca-
lorimetry provides very detailed information
about metabolism and energy expenditure, this
type of assessment has little utility for large scale
studies and does not provide information about
the types of activity performed. It is generally
agreed (see Durnin, 1990), that self-report
methods are the most practical means of testing
a large sample. They also can provide con-
siderable detail about frequency, duration and
intensity of each type of activity, as well as
information concerning individual's attitudes
towards the activity. Self-report methods can
take the form of prospective diaries or retro-
spective recall. Diary procedures have the
disadvantage of being unsuitable for the as-
sessment of a long time-frame, and they may
actually influence the participants' activity pat-
terns during the period being monitored. On the
other hand, recall surveys have been used for
assessing periods of 1 day to 1 year, and in a few
cases (e.g. Kriska et al. 1988) for lifetime activity.
Clearly, when the research questions require
investigation of time periods that extend well
into the past, retrospective reports provide the
only reasonable option.
Memory aids
The question of reliability is especially important
when the study involves the collection of
retrospective data because this method relies
entirely on recall and memory, and therefore,
information can be easily forgotten, misdated or
misinterpreted. Inaccuracies of recall can also be
compounded if respondents are experiencing
psychological distress, e.g. depression, or if they
perceive an association between the events being
investigated and their illness.
Much of the research designed to improve the
accuracy of retrospective reporting has been
conducted in the area of 'life events' and
psychiatric disorders. However, the general ideas
appear to be adaptable to a wide variety of
survey domains, including the collection of
physical activity recall data. Paykel (1983)
reviewed a number of studies of recent life
events and illness, and found that the test-retest
reliability of self-report questionnaires was poor
compared to recall data collected by interview
techniques. He concluded that a semi-structured
960 C. Davis and others

interview that permits the opportunity to probe indicate those in which they had participated
answers in order to establish detail, is the regularly, either for sport or for exercise. They
preferred and most reliable method. were then asked to specify, within the relevant
Some investigators have tested the effects of time frame, the number of weeks of participation
memory aids in reducing the problems of errors per year, the average frequency of that activity
of recall. Loftus and Marburger (1983) used a per week, the average duration of each session
temporal anchor to provide some ' surrounding in minutes (1-30, 31-60, 61-90, 90 + ) and the
context' for the time period being recalled. By intensity (high, moderate, low). Physical activity
providing respondents with a 'landmark' event was quantified by multiplying weeks per year
that was salient to them, they were able to x frequency per week x duration per session
improve substantially the accuracy of temporal in half-hour units (1, 2, 3, 4 consecutively)
judgements. In a recent study, the question of x intensity (1, 2, 3) for each activity, and
whether memory aids would reduce errors in summing across all activities.
reports of life events during a 1-year time frame
was investigated (Sobell et al. 1990). A signifi- Procedure
cantly higher test-retest reliability for life events
Subjects were tested on two occasions, one
was reported by the group who received memory month apart. At the onset, the interviewer
aids. This group also recalled a greater number indicated to the subjects that the purpose of the
of events. study was to collect historical physical activity
data in order to determine the level of partici-
Method pation typical of young women during childhood
Subjects and early adulthood. Prior to the first data
Fifty-one female subjects between the ages of 18 collection, each subject in the memory-aids
and 27 were randomly assigned to one of three condition was given a calendar, which listed the
experimental conditions. All subjects were re- years between 1972 and 1990. With the help of
cruited from advertisements posted at the uni- the interviewer, dates were marked on this
versity asking for volunteers to participate in a calendar to match ages with school grades.
'lifestyle study'.1! None of the subjects had a Other important events in the subject's life (e.g.
history of anorexia or bulimia nervosa. In the graduation, moving house, marriage, family
first condition (TV = 15, mean age = 21-3, S.D. = births or deaths, etc.) were also marked on the
2-4) memory aids were used at both testing calendar. These landmark dates were intended
sessions. In the second condition (N = 17, mean to serve as temporal anchors to help the subject
age = 21 -5, S.D. = 159), memory aids were used recall more accurately the time period targeted
at one testing session but not the other, and for each assessment. In order to provide another
order of presentation was counterbalanced means of assisting recall, the interviewer pre-
across subjects. In the control condition (N = sented a list of three or four major news events
19, mean age = 21-2, S.D. = 1-4), memory aids for the year of each targeted age (e.g. 1984 was
were not used at either session. the year that Michael Jackson released his
album, Thriller).
Measurements Subjects were told that the second meeting
Using a structured interview format, retrospec- would be similar to the first, but no specific
tive leisure-time physical activity data were details were given. At the beginning of the
collected for five separate time frames - when second meeting subjects were asked not to try
the subjects were 8, 13, 18 and 23 (when and remember what they had said during the
applicable) years old, and for the 12 months first meeting but rather to think about each
immediately preceding the first testing session. question as if it were being asked for the first
For each target age, the interviewer described a time.
number of physical activities (e.g. jogging/
running, swimming, cycling, home exercises, Results
dance classes, etc.) and subjects were asked to Table 1 presents a list of means, standard
deviations and minima and maxima for all
t The notes will be found on p. 966. physical activity variables, listed separately by
 Exercise and eating disorders 961

Table 1. Means, standard deviations, minima and maxima for physical activity data listed by
experimental condition
Variable Mean Minimum Maximum

Memory-aids group (JV = 17)

8 years
A 590-8 485-6 0 1520
B 461-7 462-5 0 1536
13 years
A 9480 750-9 0 2536
B 828-7 6251 0 1660
18 years
A 699-5 623-5 0 1730
B 570-9 584-4 0 1980
Current
A 990-3 680-7 12 2076
B 799-3 645-1 0 2484

Mixed group (/V= 17)

8 years
A 464-4 429-9 0 1338
B 3391 302-4 0 1152
13 years
A 10430 859-8 48 2748
B 828-7 625-1 192 2016
18 years
A 11721 1021-4 0 3660
B 589-5 675-7 0 2160
Current
A 12511 1036-7 88 3476
B 799-3 789-6 48 2832

Control group (/V = 19)

8 years
A 487-3 5151 0 2176
B 357-2 463-8 0 1984
13 years
A 909-5 846-8 0 2640
B 826-0 741-2 16 2740
18 years
A 1178-4 1043-3 0 3632
B 930-3 8470 0 2964

Current
A 647-3 613-7 0 2510
B 5701 579-4 0 2626

experimental group. A 3 x 2 x 4 repeated meas- that subjects participated in significantly less

ures Analysis of Variance was conducted with 1
between-subjects factor (Experimental Group)
and 2 within-subjects factors (Session and Recall
Age2). There was no main effect for Group.
There was, however, a significant effect of
Session (FliS = 21-93, P<(K>001) indicating
that across all Groups and Recall Ages, subjects
consistently reported greater physical activity at
the first session than at the second session. There
was also a significant effect of Recall Age (F3 144
= 7-84, P< 00001). A series of Bonferroni-
corrected paired / tests (a = 00167) indicated
activity at age 8 than at the other three ages, but
that there were no differences among 13, 18 or
current age. Neither the 2-way or 3-way inter-
actions were statistically significant.
STUDY 2
Method
Subjects
Forty-five consecutive female patients under the
age of 35 who were admitted to the in-patient
unit of the Programme for Eating Disorders at
962 C. Davis and others

competitive athletics, the chronology of her

Table 2. Eating disorder symptom checklist with
dieting and exercise behaviours, and her per-
mean age of onset and standard deviation in
ceptions concerning any causal associations
parentheses
between the two behaviours. The patient was
1 When did you first experience a strong fear of putting on encouraged to be as detailed as possible with her
weight, even a pound or two? (170, 3-3 yr) responses.
2 When did you first experience persistent feelings of being fat
even when others remarked on you being too thin? (181,
3. Symptom checklist Patients were presented
3-6 yr) with a list of symptoms associated with eating
3 When did you first notice that the way you valued yourself was disorders and were asked to indicate, on a chart
strongly related to how much you weighed or whether or not
you were thin? ( 1 8 1 , 4 0 y r )
provided, the age at which they first experienced
4 When did you first start to diet as a regular activity? (160, that particular feeling or engaged in that
3-0 yr) behaviour. The exact wording of these questions
5 When did you first lose a lot of weight from dieting ( > 10-15
pounds)? (17-4, 30yr)
is listed in Table 2.
6 When did you achieve your lowest weight by dieting? (20-6,
3-8 yr) Procedure
7 When did menstruation stop possibly as a result of weight loss
or dieting (19-1, 3 0 y r ) Each patient was tested by two female re-
searchers ( C D . and E.R.) on two separate
occasions. Assessments were scheduled within
the first week of admission to the psychiatric
The Toronto Hospital, from the autumn of 1991 unit and again 4 weeks later. In all cases, the
to the autumn of 1993, were included in the tape-recorded interview was conducted by C D .
study (mean age = 24-6, S.D. = 4-84). Patients after the second session, and later transcribed by
represented a broad range of ethnic and socio- a research assistant. Physical activity data and
economic backgrounds. Diagnoses of anorexia symptom onset data were collected separately
nervosa and/or bulimia nervosa were made on both occasions by different interviews. Order-
according to DSM-III-R criteria. At the time of of-interviewer and order-of-interview-schedule
admission 32 of these were diagnosed with were counterbalanced across testing sessions.
anorexia nervosa (AN), and 13 with bulimia
nervosa (BN), of whom 10 had met criteria for Results
AN at a previous time (i.e. their weight had been Table 3 lists means, standard deviations and
less than 85 % of average weight for age and minima and maxima for all physical activity
height, and they had experienced amenorrhoea). variables.
The other three had all experienced a period
weight loss equally approximately 90 % of their Quantitative analyses
normal weight although there was no evidence 1. A 2 x 4 repeated measures Analysis of Vari-
of amenorrhoea. Therefore, none of the sample ance with two within-subjects factors (Session
were continuously 'normal weight' or 'stat- and Recall Age) was conducted on the physical
istically obese' bulimics. activity data. 4 There were main effects for
Session (F1 36 = 4-74, P = 00361) and for Recall
Measurements A
ge CE>,io8 = 9 ' 90 > ^ < 00001) indicating that
1. Quantitative physical activity The data were patients, similar to control subjects, reported
collected in the manner described in Study 1, significantly more activity at Session 1 than at
except that memory aids were used at both Session 2.5 Using the same Bonferroni-corrected
testing sessions for all subjects.3 alpha level as Study 1, a series of paired t tests
2. Semi-structured interview At the end of the indicated that patients were also less active at
second testing session, a tape-recorded interview age 8 than at the other ages, however, there were
was conducted with each patient during which a no differences among ages 13, 18 or current age.
number of topics concerning dieting and exercise 2. Since the results of both studies indicated a
were introduced. For example, the interviewer significantly higher degree of reporting at Session
questioned her participation in, and commitment 1 than at Session 2, it was decided to average the
to, sport and physical activity from childhood physical activity scores for the two sessions at
onwards, whether or not she was involved in each age of recall in order to improve the
 Exercise and eating disorders 963

Table 3. Means, standard deviations, minima and maxima for physical activity for eating
disordered patients
Variable Mean* Minimum Maximum

8 years
A 603-3 977-9 0 4500
B 3800 589-2 0 2224
13 years
A 1695-4 2161-8 0 10141
B 1467-2 1762-5 0 6280
18 years
A 2511-8 27691 0 11964
B 2117-9 2490-3 0 10272
Current
A 1791-6 2068-7 0 9660
B 1537-9 24711 0 12528

* All the B values are based on a sample size of 38 reflecting missing data for the seven patients who terminated the programme early.

2500 18 (Fx 99 = 15-40, P = 00002), and at current

2000
Patients
1500
a IOOO
a Controls
x: 500
0.
Current
13 18
Age (years)
FIG. 1. Physical activity participation levels for eating disordered
patients and normal controls from age 8 to current age.
validity of the estimate. In the seven cases where
Session 2 data were missing for the patient
sample, Session 1 data were used on their own.
Following this, a 2 x 4 repeated measures Analy-
sis of Variance with 1 between-subjects factor
(Group) and 1 within-subjects factor (Age of
Recall) compared physical activity levels be-
tween patients and the control subjects from
Study 1. There were significant Group (Fx 99 =
12-40, P = 0-0006) and Recall Age (F3 297 =
21-46, P < 00001) main effects. There was also a
significant Group x Recall Age interaction
(^3.207 = 6 ' 85 > p = 0-0002). A test of the simple
effects indicated that there were no Group
differences at age 8, but differences were signifi-
cant at age 13 (F1 100 = 6-59, P = 0-0118), age
age6 (F l i l 0 0 = 6-80, P < = 00105).' Fig. 1 pre-
sents a graphical representation of these results.
3. For consistency with the physical activity
data, Session 1 and Session 2 ages were averaged
for each patient to create the raw score. In the
event that Session 2 data were missing, Section
1 data were used on their own. For this sample,
it can be seen that ages 16-20 represent the
average range within which patients report the
onset of symptoms associated with the DSM-
III-R criteria for anorexia nervosa. The mean
age and the standard deviation of onset are
listed in parentheses following each of the
questions in Table 2.
Qualitative analyses
A content analysis of the interview data was
carried out. Based on the topics and questions
that were introduced, the following themes
emerged, and are described below. In each
category, the percentage of cases which were
coded positively is presented in parentheses (see
below). All transcripts were read and coded by
the first author. Following this, six transcripts
(representing 15 % of the data) were coded by an
independent judge who was unfamiliar with the
research hypotheses and who was simply given a
written description of each theme or category.
An agreement rate of over 90 % was achieved
across the six categories and the six subjects.
1. Childhood physical activity Whether the
patient was more physically active than her
peers during childhood and at a time before she
started to diet or begin to lose weight (70%).
964 C. Davis and others

2. Competitive athletics Whether the patient are at greater than normal risk of developing
was involved in competitive athletics beyond in- eating disorders (see Burckes-Miller & Black,
tramural school competitions. An affirmative in 1991; Davis, 1992). Clearly there are a number
this category was also coded for those who were of sports like gymnastics and dance where
involved in dance beyond the recreational level, success is not only determined by technical
and in one case, for a patient who was a certified prowess but by grace and physical appeal, and
aerobics instructor and operated her own fitness therefore, an ultra-slender form confers an
centre (60%). important performance advantage. However, in
3. Excessive exercising Whether the degree and most sports, weight greater than a healthy
frequency of exercising was beyond what would minimum limits speed, endurance and agility,
be considered the normal range for women of an and contributes to increase in fatigue (Smith,
equivalent age (78 %). 1980). Thinner is faster, up to a point! As a
4. Obsessive and ritualized activity Whether the consequence, the typical female athlete confronts
patient perceived her need to be physically active body image pressures at a number of levels,
as 'out of control' — that is, her exercise routine from those performance-related pressures rein-
had become compulsive and/or stereotyped and forced by coaches and trainers, to those inherent
ritualized (93 %). in the judging criteria which give physically
5. Degree of weight loss related to degree of attractive athletes 'the winning edge'.
exercising Whether, during the period of great- Despite some evidence that female athletes
est weight loss, her level of physical activity was show greater weight concerns and problems
increasing steadily as her weight and food intake with eating and body image than one would
decreased in the same manner (75 % ) . 8 9 expect among age-matched non-athletes, defini-
6. Chronology of dieting and exercise onset tive large-scale prevalence studies have not yet
Whether sport or exercising participation pre- been done (Brownell & Rodin, 1992). Never-
ceded regular dieting, or whether the two theless, our finding that approximately 60 % of
activities began simultaneously (60 % and 13 % the patient sample had been involved in com-
respectively). petitive athletics or dance before the onset of
their disorder suggests that prevalence rates may
DISCUSSION actually be quite high. Of particular interest in
this regard is the fact that a number of the
The combined results of this study strongly athlete patients in our study developed the
support the hypothesis that sport and assiduous clinical disorder only after terminating partici-
exercise participation can play a pathogenic role pation in their sport. For these women, a
in the onset and maintenance of eating disorders, repetitive narrative emerged: when the patient
at least among seriously ill patients requiring stopped training, usually as a result of injury or
intense hospital treatment. For example, the conflicting scholastic pressures, she developed a
finding (/) that more than half the patients were strong fear of weight gain. Reasoning that few
involved in regular sport or exercise partici- calories should go in if little energy was being
pation before they ever began to diet, and (ii) expended, she then began seriously to restrict
that, on average, patients were more physically her food intake. Regrettably, it seems that the
active than control subjects from early ado- institutionalized preoccupation with body
lescence onwards, and prior to the onset of weight and slenderness that characterizes most
anorexia nervosa, are factors that mitigate female sports has consequences that reach
against the notion that the hyperactivity ob- beyond the competitive arena.
served among eating disordered women is merely Another social influence that exerts consider-
a behaviour initiated in response to a patho- able force on women is the current fitness craze.
logical drive for thinness and fear of weight gain. Not only is there evidence that the media
Two dominant subcultures, competitive athletics promotion of physical activity has increased
and the fitness movement, provide a psycho- over the last decade (Wiseman el al. 1992), but
social backdrop and framework within which to it appears that middle-class North Americans
view these results. have also increased their participation in aerobic
Some have already argued that female athletes and strengthening exercise activities during the
 Exercise and eating disorders
same period (Rodin & Larsen, 1992). Mean-
while, the marketing of so-called 'active living'
and 'healthy lifestyle' has systematically down-
played the importance of physical activity for
physiological fitness and psychological well-
being. Instead it has placed an over-emphasis on
body aesthetics and fostered a narcissistic in-
vestment in the pursuit of physical perfection as
the pre-eminent manifestation of sexual attrac-
tiveness.
It was also our intention to test the model of
activity-induced anorexia proposed by Epling &
Pierce (1988, 1992) for a group of hospitalized
eating-disordered women. In this regard, we
found a remarkable coincidence between the
frequency with which food-deprived experimen-
tal animals developed the weight decrease-
activity-increase cycle, and the frequency with
which the same behavioural dynamics iwere
reported by the patient group. On average,
about 80 % of food-deprived rats become anor-
exic when exposed to the experimental pro-
cedures, while 75 % of our patients reported a
similar inverse relationship between activity and
food intake. Comments such as 'the more I
restricted the more I exercised'; 'all I was doing
was exercising'; and 'the lower my weight got
the more energy I had' were pervasive themes. It
is especially important to take account of the
large proportion of patients (in excess of 90%)
for whom exercising had become a compulsive
and ritualized behaviour - who described their
need to be physically active as 'beyond my
control', 'driven to exercise' and 'nothing
would prevent me from exercising'. The reports
of these women left no doubt that their
hyperactivity and restlessness was not entirely
determined by voluntary cognitive choice.
Epling & Pierce (1992) argue that the inverse
relationship between degree of food intake and
physical activity is regulated by specific physio-
logical processes, and believe that beta endor-
phins, and perhaps other brain opiates, mediate
this relationship. Buck & Marrazzi (1987) point
out that atypical responses (viz. anorexia and
hyperactivity) can occur in response to stimu-
lation of the opioid system. Several factors may
account for the uncoupling of the usual be-
haviour responses including the type or the
amount of endogenous opioids released. The
fact that morphine injections reduce food intake
when animals are food deprived or when their
965
exercise is intensive (Epling & Pierce, 1992), and
also that strenuous physical activity and food
deprivation independently release endogenous
opioids in the brain (Marrazzi et al. 1990)
suggest that if wilful dieting is combined with
excessive exercise, a biochemical uncoupling
and behavioural reversal may occur. In other
words, starvation and overactivity, in concert,
potentiate one another.
However, it is unlikely that such complex
patterns of behaviour would be mediated
through a simple neuropeptide pathway. There
is also evidence that corticotropin releasing
factor (CRF), which is released during strenuous
exercise and has been recognized as a potent
neuropeptide in anorexia (Rivest & Richard,
1990) may mediate the activity induced star-
vation effect. Further support for this argument
comes from reports of elevated cerebrospinal
fluid levels of CRF in anorexia nervosa patients
(Kaye et al. 1987). There is also evidence that
both serotonin and dopamine function may be
increased in the presence of obsessive compulsive
behaviour (Barr et al., 1992; Marazziti et al.
1992), a finding that is relevant in the light of the
obsessive, ritualized and stereotyped nature of
the eating and exercise behaviours reported by a
large proportion of patients in our study.
In summary, we conclude that a serious
commitment to sport or exercise has significance,
not only for its potential to create a psychological
predisposition to an eating disorder, but as a
contributing factor in its progression. In the first
instance, it can create a heightened focus on
physical appearance, an increased awareness of
the relationship between weight and maximal
performance, and a preoccupation with the
interdependence of diet and exercise for weight
control, and other health and appearance-related
benefits. Secondly, there appears to be a power-
ful behavioural synergy and potentiation that
occurs when starvation is combined with strenu-
ous physical activity. We suggest that for a large
number of anorexic and bulimic women, over-
activity is not merely the benign adjunct to
pathological calorie restriction that many have
believed it to be. Rather it is an integral part of
the pathogenesis and the maintenance of the
disorder.
The authors wish to thank Dr Muriel Egerton,
Research Officer, Nuffield College, Oxford University,
966 C. Davis and others
for her invaluable assistance with the content analysis
of the interview data in Study 2, and Martha McCain
for her help with the transcription of the interview
tapes.
This research was funded by a grant from the
Canadian Fitness and Lifestyle Research Institute
project number 1064-2068-2007.
NOTES
1
Although no socio-economic status data were
collected from subjects, it is assumed that they
represented a broad range of backgrounds. The
university from which subjects were recruited is
one of the largest in Canada. As such, it attracts
students from a broad range of social, ethnic and
economic backgrounds. Therefore, it would be
highly unlikely, by chance, that a group of
research volunteers would not reflect the socio-
economic diversity found in the student popu-
lation as a whole.
2
Since there were only four subjects in the sample
who were 24-years-old or older, the physical ac-
tivity data for age 23 were not included in the
analysis.
3 DC.
Although the results of Study 1 showed no clear
effect of memory aids in assisting recall, other
research has reported benefits. For this reason,
and since the patient sample represented a
different population from the non-clinical sample,
it was decided to keep memory aids in the
protocol. Clearly they conferred no negative
effect.
4
One patient was 17-years-old, and seven other
patients were discharged, or left the hospital
against medical advice before the time scheduled
for the second data collection. As a result, their
data were dropped from this particular analysis.
5
We are at a loss to explain thesefindings.The fact
that the same results were found among the
control subjects and the patient group, argues
strongly against dismissing them as Type I errors.
One can only offer speculation. Due to the fact
that sport and exercise are highly socially desirable
activities, it may be that subjects, in a flush of
enthusiasm, tended, at the onset, to over-report
their degree of physical activity participation,
while later and after some reflection, they modified
their responses.
6
In considering this difference it is important to
take account of the fact that at least half the
patients had been hospitalized for some period of
time during the 12 months that immediately
preceded their admission to this institution, or
they had had to curtail their normal amount of
exercise because of acute physical weakness or
injury.
7
Given that Session 1 physical activity scores were
significantly higher than those for Session 2, it
could be argued that the use of Session 1 data for
the seven subjects for whom Session 2 scores were
unavailable, artificially inflates the group dif-
ferences in these analyses. Therefore, these analy-
ses were redone excluding these seven subjects. It
was found that the magnitude and the statistical
significance of the results were not meaningfully
altered.
8
Due to ambiguous information, four records
could not be coded in this category.
9
In the context of this question, patients were
asked to draw a paper-and-pencil line graph to
indicate the degree of calorie restriction and of
exercise during the period of their maximum
weight loss. Patients who were coded affirmative
in this category consistently drew two cross-over
lines indicating a steady decrease in food intake
and a concomitant increase in activity.
REFERENCES
American Psychiatric Association (1987). Diagnostic and Statistical
Manual for Mental Disorders, 3rd edn. Revised. APA: Washington,
Barr, L. C , Goodman, W. K., Price, L. H., McDougle, C. J. &
Charney, D. S. (1992). The serotonin hypothesis of obsessive
compulsive disorder: Implications of pharmacologic challenge
studies. Journal of Clinical Psychiatry 53, 17-28.
Bouchard, C , Shephard, R. J. & Stephens, T. (1993). Physical
Activity, Fitness and Health Consensus Statement. Human Kinetics
Publishers: Champaign, IL.
Brownell, K. D. & Rodin, J. (1992). Prevalence of eating disorders in
athletes. In Eating, Body Weight and Performance in Athletes (ed.
K. D. Brownell, J. Rodin and J. Wilmore), pp. 128-145. Lea &
Febiger: Philadelphia.
Bruch, H. (1965). Anorexia nervosa-Its differential diagnosis.
Journal of Mental and Nervous Disorders 141, 555-566.
Buck, M. & Marrazzi, M. A. (1987). Atypical responses to morphine
in mice: a possible relationship to anorexia nervosa? Life Sciences
41, 765-773.
Burckes-Miller, M. & Black, D. (1991). College athletes and eating
disorders: a theoretical context. In Eating Disorders Among
Athletes: Theories, Issues, and Research (ed. D. Black), pp. 11-26.
American Alliance for Health, Physical Education, Recreation &
Dance: Reston, VA.
Casperson, C. (1989). Physical activity epidemiology: Concepts,
methods, and application to exercise science. Exercise and Sport
Sciences Reviews: Volume 17 (ed. K. B. Pandolf), pp. 423-473.
Williams & Wilkins: Baltimore.
Crisp, A. H. (1967). The possible significance of some behavioral
correlates of weight and carbohydrate intake. Journal of Psycho-
somatic Research 11, 117-131.
Dally, P. J. (1969). Anorexia Nervosa. Grune & Stratton: New York.
Davis, C. (1992). Body image, dieting behaviours, and personality
factors: a study of high-performance female athletes. International
Journal of Sport Psychology 23, 179-192.
Durnin, J. V. G. A. (1990). Assessment of physical activity during
leisure and work. In Exercise, Fitness, and Health (ed. C. Bouchard,
R. J. Shephard, T. Stephens, J. R. Sutton and B. D. McPherson),
pp. 63-70. Human Kinetics Publishers: Champaign, IL.
 Exercise and eating disorders
Epling, W. F. & Pierce, W. D. (1984). Activity-based anorexia in rats
as a function of opportunity to run on an activity wheel. Nutrition
and Behavior 2, 37—49.
Epling, W. F. & Pierce, W. D. (1988). Activity-based anorexia: A
biobchavioral perspective. International Journal of Eating Disorders
7, 475-485.
Epling, W. F. & Pierce, W. D. (1992). Solving the Anorexia Puzzle.
Hogrefe & Huber Publishers: Toronto.
Epling, W. F., Pierce, W. D. & Stefan, L. (1983). A theory of activity-
based anorexia. International Journal of Eating Disorders 3, 27—43.
Feighner, J. P., Robins, E., Guze, S. B., Woodruff, R. A., Winokur,
G. & Munoz, R. (1972). Diagnostic criteria for use in psychiatric
research. Archives of General Psychiatry 26, 57-63.
Garfinkel, P. E. & Goldbloom, D. M. (1988). Anorexia nervosa and
bulimia nervosa (chapter 1.). Anorexia Nervosa and Bulimia
Nervosa: Current Update. Toronto: Eating Disorders Group.
Department of Psychiatry, Toronto General Hospital.
Garner, D. M., Rockert, W., Olmsted, M. P., Johnson, C. & Coscina,
D. V. (1985). Psychoeducational principles in the treatment of
bulimia and anorexia nervosa. In Handbook of Psychotherapy for
Anorexia Nervosa and Bulimia (ed.D. M. Garner andP. Garfinkel),
pp. 513-572. The Guilford Press: New York.
Gull, W. W. (1874). Anorexia nervosa. Transactions of the Clinical
Society (London) 7, 22-28. (Cited by Warah, A. (1993). In
Overactivity and boundary setting in anorexia nervosa: an
existential perspective. Journal of Adolescence 16, 93-100.)
Holden, N. L. (1990). Is anorexia nervosa an obsessive-compulsive
disorder? British Journal of Psychiatry 157, 1-5.
Inches, P. (1895). Anorexia nervosa. Maritime Medical News 7,
73-75.
Katz, J. L. (1986). Long-distance running, anorexia nervosa, and
bulimia: a report of two cases. Comprehensive Psychiatry 27,
74-78.
Kaye, W. H.. Gwirtsman, H. E., George, D. T., Ebert, M. H.,
Jimerson, D. C , Tomai, T. P., Chrousos, G. P. & Gold, P. W.
(1987). Elevated cerebrospinal fluid levels of immunoreactive
corticotropin-releasing hormone in anorexia nervosa: relation to
state of nutrition, adrenal function, and intensity of depression.
Journal of Clinical Endocrinology and Metabolism 64, 203-208.
Kaye, W. H.. Weltzin, T. & Hsu, L. K. G. (1993). Relationship
between anorexia nervosa and obsessive compulsive behaviors.
Psychiatric Annals 23, 365-373.
Kriska, A. M.. Sandier, R. B., Cauley, J. A., LaPorte, R. E., Horn,
D. L. & Pambianco, G. (1988). The assessment of historical
967
physical activity and its relation to adult bone parameter. American
Journal of Epidemiology 127, 1053-1063.
Kron, L., Katz, J. L., Gorzynski, G. & Weiner, W. (1978).
Hyperactivity in anorexia nervosa: A fundamental clinical feature.
Comprehensive Psychiatry 19, 433-439.
Loftus, E. F. & Marburger, W. (1983). Since the eruption of Mt. St.
Helens, has anyone beaten you up? Improving the accuracy of
retrospective reports with landmark events. Memory and Cognition
11, 114-120.
Lowe, M. R. (1993). Anorexics aren't neurotic. Contemporary
Psychology 38, 42-43.
Marrazzi, M. A., Mullings-Brown, J., Stack, L., Powers, R. J.,
Lawhorn, J., Graham, U., Eccles, T. & Gunter, S. (1990). Atypical
endogenous opioid systems in mice in relation to an auto-addiction
opioid model of anorexia nervosa. Life Sciences 47, 1427-1435.
Marazziti, D., Hollander, E., Lensi, P., Ravagli, S. & Cassano, G. B.
(1992). Peripheral markers of serotonin and dopamine function in
obsessive-compulsive disorder. Psychiatry Research 42, 41-51.
Paykel, E. (1983). Methodological aspects of life events research.
Journal of Psychosomatic Research 27, 341—352.
Rivest, S. & Richard, D. (1990). Involvement of corticotropin-
releasing factor in the anorexia induced by exercise. Brain Research
Bulletin 25, 169-172.
Rodin, J. & Larsen, L. (1992). Social factors and the ideal body
shape. In Eating, Body Weight and Performance in Athletes (ed. K.
Brownell, J.Rodin and J. H. Wilmore), pp. 146-158. Lea &
Febiger: Philadelphia.
Russell, J. C , Epling, W. F., Pierce, W. D., Amy, R. M. & Boer,
D. P. (1987). Induction of voluntary prolonged running in rats.
Journal of Applied Physiology 63, 2549-2553.
Sacks, M. H. (1987). Eating disorders and long-distance running.
Integraiive Psychiatry 5, 201-211.
Smith, N. J. (1980). Excessive weight loss and food aversion
simulating anorexia nervosa. Pediatrics 66, 139-142.
Sobell, L. C , Toneatto, T., Sobell, M. B., Schuller, R. & Maxwell,
M. (1990). A procedure for reducing errors in reports of life events.
Journal of Psychosomatic Research 34, 163-170.
Wiseman, C. V., Gray, J. J., Mosimann, J. E. & Ahrens, A. H.
(1992). Cultural expectations of thinness in women: an update.
International Journal of Eating Disorders 11, 85-89.
Yates, A. (1991). Compulsive Exercise and the Eating Disorders.
Brunner/Mazel: New York.
Yates, A., Shisslak, C. M., Allender, J., Crago, M. & Leehey, K.
(1992). Comparing obligatory and nonobligatory runners. Psycho-
somatics 33, 180-189.