Gymnastik- och idrottshögskolan, GIH

Objective: Maladaptive exercise is a common symptom of eating disorders (EDs). While several measures exist to assess current maladaptive exercise, there are no validated self-report tools to assess maladaptive exercise history—an important symptom domain among individuals with lifetime EDs. Method: Using data from a large sample of individuals with at least one lifetime ED diagnosis across four countries (N = 31,670), the current study aimed to validate and refine the Eating Disorders 100,000 Questionnaire—version 3 exercise items to create a brief measure of lifetime and current maladaptive exercise, suitable for large-scale epidemiological research and clinical screenings. Results: Five non-redundant operationalisations of maladaptive exercise were identified (‘Any Maladaptive Exercise’, ‘Regular Maladaptive Exercise’, ‘Compensatory Exercise’, ‘Excessive Exercise’, ‘Current Maladaptive Exercise’). Maladaptive exercise history was present across all lifetime ED presentations assessed, though endorsement levels varied based on scoring operationalisation. Individuals reporting a history of anorexia nervosa reported the highest levels of endorsement of most constructs, closely followed by bulimia nervosa. Compensatory exercise was endorsed most frequently among those reporting a history of bulimia nervosa relative to other diagnostic groups. Conclusions: Six key items were recommended as a brief screening assessment to capture maladaptive exercise history in EDs. Trial Registration: EDGI is a registered clinical trial (clinicaltrials.gov ID: NCT04378101). © 2026 The Author(s). European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd.

BACKGROUND: Compulsive exercise (CE) is commonly observed in eating disorders (ED) and is associated with a more severe clinical picture. Including 3105 participants from the Eating Disorders Genetics Initiative-Sweden, the aim of this cross-sectional study was to expand the knowledge of how CE relates to ED symptoms and other core psychological features.

METHODS: Through multiple linear regression analyses, we investigated simple and unique associations between CE, measured with the Compulsive Exercise Test (CET) including its subscales and ED symptoms, obsessive compulsive disorder (OCD) symptoms, anxiety, perfectionism, depression, and health-related quality of life.

RESULTS: Results suggested that ED symptoms, OCD symptoms, and perfectionism all have unique positive associations with CE, and depressive symptoms a negative association when controlling for the other constructs. Each CET subscale showed its own specific pattern of associations with the examined constructs.

CONCLUSIONS: Overall, results were consistent with previous research and the proposed cognitive-behavioral model of CE. Implications support the idea that CE may not be clinically relevant in the absence of ED symptoms, but an important symptom domain when they are present. Future research should focus on the directionality of associations between OCD symptoms, perfectionism, and CE, including samples without ED experience.

Objective

Maladaptive exercise (ME), problematic attitudes or behaviors related to physical activity, is often observed in eating disorders (EDs), but its prevalence, severity, and relationships with ED features remain incompletely characterized. This study aimed to describe lifetime and current ME across ED diagnoses, examine associations with ED symptoms, sociodemographic characteristics, and weight status, and compare ME phenotypes to identify those most strongly linked to ED features.

Methods

ME was assessed in 31,671 individuals with lifetime EDs (anorexia nervosa [AN], bulimia nervosa, and binge-eating disorder [BED]) recruited to sites in the United States, Australia, New Zealand, and Sweden as part of the Eating Disorders Genetics Initiative (NCT04378101). We examined one lifetime ME phenotype, capturing any occurrence of ME across the lifespan (derived from the ED100K), and five current ME phenotypes (any driven exercise [Eating Disorder Examination-Questionnaire, EDE-Q], frequency of driven exercise [EDE-Q], regular driven exercise [EDE-Q], compulsive exercise test [CET] total, and dichotomous compulsive exercise [CET]).

Results

Lifetime ME was highly prevalent across countries and ED diagnoses (pooled prevalence 88%). Current ME was also common (40% any driven exercise, 35% compulsive exercise, and 12% regular driven exercise), highest in AN and lowest, but notable, in BED. CET-based phenotypes showed the strongest association with ED symptoms, while EDE-Q-derived regular driven exercise was most strongly associated with underweight (BMI < 18.5). Younger generations exhibited a higher ME risk, likely reflecting societal shifts in body ideals and fitness culture.

Discussion

This large, multicountry study demonstrates that ME is highly prevalent across EDs, often emerges early, and can persist or recur for decades. Prevalence and severity vary considerably by assessment method. The ED100K, CET, and EDE-Q capture complementary aspects of ME, and incorporating all three may improve clinical care. We recommend that clinicians assess both current and lifetime ME in all patients with EDs. Routine, harmonized assessment will be essential to advancing research and improving patient outcomes.

Trial Registration

ClinicalTrials.gov identifier: NCT04378101

Maladaptive exercise is a common and serious symptom in eating disorders (EDs), yet often poorly addressed in treatment. This study examined clinicians' knowledge, practices, and access to structured guidance such as clinic-level practices/informal protocols related to maladaptive exercise, and whether these varied by profession, experience, or personal exercise habits. A cross-sectional survey was completed by 102 clinicians working in Swedish ED care. The survey assessed self-reported knowledge, clinical practices, and access to clinic-level practices/informal protocols. Differences by profession, years of ED work experience, and personal physical activity were analyzed using Fisher's exact test and Spearman correlations. Most clinicians viewed maladaptive exercise as an aggravating symptom but reported limited formal training and moderate confidence in managing it. Assessment was common, but structured interventions were rare and opinions about them varied by profession. Only 42% reported access to clinic-level practices/informal protocols, while 84% expressed a need for national guidance. Despite recognizing maladaptive exercise as clinically significant, ED clinicians report limited training and inconsistent guidance. Profession-specific differences and the strong demand for national guidelines underscore the need for structured, evidence-based approaches to both the assessment and treatment of maladaptive exercise, as well as adequate training for clinicians in their application.

OBJECTIVE: The COVID-19 pandemic caused millions of deaths worldwide and significantly impacted people with eating disorders, exacerbating symptoms and limiting access to care. This study examined the association between COVID-19 death-related loss-defined as the death of a family member, friend, or acquaintance due to COVID-19-and mental health among people with preexisting eating disorders in the United States (US), the Netherlands, and Sweden.

METHOD: Participants with a history of eating disorders completed a baseline survey early in the pandemic (US: N = 511; Netherlands: N = 510; Sweden: N = 982) and monthly (US, the Netherlands) or biannual (Sweden) follow-ups from April 2020 to May 2021. The surveys assessed pandemic impact on eating disorder-related behaviors and concerns, anxiety, depression, sleep disturbances, and COVID-19-related deaths. A matched nested case-control design was used to compare individuals experiencing a death-related loss with matched controls.

RESULTS: A substantial proportion experienced a COVID-19 death-related loss (US: 33%; Netherlands: 39%; Sweden: 17%). No significant differences were found between cases and controls on eating disorder, anxiety, depression, or sleep outcomes.

DISCUSSION: Despite the expected influence of COVID-19 death-related loss on mental health, our study found no significant association. Reactions to pandemics may be highly individual, and practitioners may want to consider broader losses-such as bereavement, missed educational experiences, relationship disruptions, financial instability, and employment challenges-when addressing patients' needs. Future research should continue to explore how death-related loss impacts eating disorder risk and progression.

OBJECTIVE: The Nine Item ARFID Scale (NIAS) is a widely used measure assessing symptoms of avoidant/restrictive food intake disorder (ARFID). Previous studies suggest that individuals with eating disorders driven by shape/weight concerns also have elevated scores on the NIAS. To further describe NIAS scores among individuals with diverse current and previous eating disorders, we characterized NIAS scores in a large sample of individuals with eating disorders and evaluated overlap in symptoms measured by the NIAS and the Eating Disorder Examination-Questionnaire (EDE-Q) version 6.0.

METHOD: Our sample comprised 9148 participants from the Eating Disorders Genetics Initiative Sweden (EDGI-SE), who completed surveys including NIAS and EDE-Q. NIAS scores were calculated and compared by eating disorder diagnostic group using descriptive statistics and linear models.

RESULTS: Participants with current anorexia nervosa demonstrated the highest mean NIAS scores and had the greatest proportion (57.0%) of individuals scoring above a clinical cutoff on at least one of the NIAS subscales. Individuals with bulimia nervosa, binge-eating disorder, and other specified feeding or eating disorder also demonstrated elevated NIAS scores compared to individuals with no lifetime history of an eating disorder (ps < 0.05). All subscales of the NIAS showed small to moderate correlations with all subscales of the EDE-Q (rs = 0.26-0.40).

DISCUSSION: Our results substantiate that individuals with eating disorders other than ARFID demonstrate elevated scores on the NIAS, suggesting that this tool is inadequate on its own for differentiating ARFID from shape/weight-motivated eating disorders. Further research is needed to inform clinical interventions addressing the co-occurrence of ARFID-related drivers and shape/weight-related motivation for dietary restriction.

BACKGROUND: Many patients with eating disorders report exercise as a central symptom of their illness-as a way to compensate for food intake, prevent weight-gain, and/or reduce negative affect. Previous findings show associations between maladaptive exercise and more severe eating disorder pathology, higher risk for relapse, other co-morbid symptoms, and worse treatment outcome.

METHODS: In this study, we included 8252 participants with eating disorders and investigated associations between maladaptive exercise (both lifetime and current) and ED pathology, illness duration, depression, anxiety, self-harm and suicidal ideation, and treatment seeking patterns in individuals with lifetime maladaptive exercise. Participants were included via the Swedish site of the large global study The Eating Disorders Genetics Initiative (EDGI) and completed measures of both lifetime and current symptomatology.

RESULTS: Results indicate that lifetime maladaptive exercise is associated with higher prevalence of lifetime depression and anxiety and with patients more often receiving treatment, although these results need to be investigated in future studies. Current maladaptive exercise was associated with more severe ED symptoms, and higher levels of depression, anxiety, obsessive-compulsive traits, and suicidal ideation.

CONCLUSIONS: Our findings point to the complexities of exercise as an eating disorder symptom and the need for clearly assessing and acknowledging this, as well as tailoring interventions to treat this symptom to achieve sustainable recovery.

BACKGROUND: Compulsive exercise is common in eating disorders (EDs), but a systematic treatment model is lacking. The CompuLsive Exercise Activity TheraPy (LEAP) is a cognitive behavioral therapy treatment for compulsive exercise in EDs, delivered by trained therapists in groups over four consecutive weeks (8 groupsessions and 1 individual session), aiming to promote healthy physical activity. LEAP is currently evaluated in a randomized efficacy trial. In parallel, it is crucial to learn more about how it is perceived by qualitatively investigating participants' subjective experiences.

METHODS: Nine patients with various EDs participating in the LEAP trial were interviewed about their experiences of taking part in LEAP and about compulsive exercise as an ED symptom using a semi-structured interview guide. The interview transcripts were analyzed according to thematic analysis.

RESULTS: The informants expressed that compulsive exercise had not been addressed in their standard ED treatment and that LEAP as such provided an important complement, spurring reflection, awareness, and changed feelings and behaviors in relation to compulsive exercise. Initially, increased PA was triggered for some, but this side effect was transitory. A wish for more treatment time, in terms of longer or additional sessions, was expressed.

CONCLUSIONS: Overall, LEAP seemed to fill an important treatment need and seemed both acceptable and feasible to patients. However, treatment time and the initial increase in PA may need further investigation and attention in order to optimize this treatment.

TRIAL REGISTRATION: The trial is registered with the ISRCTN registry (registration date 20200325), trial ID ISRCTN80711391.

Objective We assessed eating disorder (ED) illness status, symptomatology, treatment access, anxiety, and depression in the first year of the COVID-19 pandemic among individuals with a pre-existing ED in the United States (US), the Netherlands (NL), and Sweden (SE). Methods Participants completed online surveys in April-July 2020, at the early stage of the pandemic, and one year later. At one-year follow-up, we added questions addressing retrospective changes in ED symptoms, treatment, and anxiety/depression since the start of the COVID-19 pandemic. We present descriptive statistics and assess change in ED symptomatology, treatment, and anxiety/depression among those with an active or lingering ED. Results Participants (US n = 132; NL n = 219; SE n = 702) were mostly young and female with a history of anorexia nervosa (>60% in all three countries). Across countries, respondents reported impact of COVID-19 on ED symptoms at both time points, with improvement in US and NL at one-year follow-up, and stable but less impact on ED symptoms in SE. Furthermore, at one-year follow-up, roughly half of those in treatment reported reduced treatment access and quality, and the majority of the sample reported increased anxiety and depressive mood since the start of the pandemic. Discussion Our findings suggest that the self-perceived impact of COVID-19 changed over time but remained concerning even one year after the start of the pandemic. Clinicians, community organizations, and policy makers are encouraged to address potentially changing treatment needs in the face of public health emergency events. Public Significance Our findings suggest that the impact of COVID-19 on individuals with eating disorders decreased over time but remained concerning even one year after the start of the pandemic and that the impact differed across countries. Clinicians, community organizations, and policy makers are encouraged to incorporate this knowledge to address potentially changing treatment needs in the face of public health emergency events.

Atypical anorexia nervosa (AAN) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM5), is characterized by meeting all criteria for anorexia nervosa (AN) except for weight being within or above the "normal" range despite significant weight loss. The current definition is plagued by several problems, resulting in widely heterogeneous operationalizations in research and clinical practice. As such, the poorly defined diagnosis of AAN negatively impacts affected individuals and frustrates research attempts to better understand the syndrome. We consider conceptual flaws in the AAN description and contend that the undefined weight range and nature of weight loss renders these two factors functionally inapplicable in research and practice. They also represent a departure from the originally intended use of the AAN category, i.e., arresting a negative weight trajectory likely to result in AN, making the target population, and the application of the label, unclear. We propose revised criteria and a new name, restrictive eating disorder (RED), intended to reduce stigma and encompass a wide but better-defined range of presentations. The RED criteria focus on clinically significant restrictive behavior that disrupts normal living (i.e., impairment), and cognitive symptoms of overevaluation, disturbed experience, and lack of recognition of illness seriousness. We believe that RED may enable more appropriate clinical application, but also inspire coordinated research toward a more valid psychiatric nosology in the eating disorders field.