Skip to main content
SpringerLink
Log in

Cardiopulmonary exercise testing for patients with anorexia nervosa: a case–control study

  • Original Article
  • Published:
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity Aims and scope Submit manuscript

Abstract

Purpose

Patients with anorexia nervosa (AN) require appropriate nutrient therapy and physical activity management. Eating disorder treatment guidelines do not include safe, evidence-based intensity criteria for exercise. This study used cardiopulmonary exercise testing (CPX) to evaluate the exercise tolerance of patients with AN.

Methods

CPX was performed with 14 female patients with AN admitted to a specialized eating disorder unit between 2015 and 2019. Their anaerobic threshold (AT) was determined by assessing their exercise tolerance using CPX and compared with 14 healthy controls (HC). The metabolic equivalents (AT-METS) were compared when AT was reached. We examined factors related to AT (AN-AT) in the AN group, including age, body mass index (BMI), previous lowest weight, minimum BMI, past duration of BMI < 15, exercise history, and ΔHR (heart rate at the AT—resting heart rate).

Results

The AT of the AN group (BMI: 15.7 [Mean] ± 1.8 standard deviation [SD]) was significantly lower than that of the HC group (BMI: 19.7 ± 1.8) (AN: 10.0 ± 1.8 vs. HC: 15.2 ± 3.0 ml/kg/min, P < 0.001). AT-METS was also significantly lower in the AN group than in the HC group (AN: 2.9 ± 0.52 vs. HC: 4.4 ± 0.91, P < 0.001). AN-AT was highly influenced by ΔHR.

Conclusions

This study showed that AT and AT-METS were lower in patients with AN than in HC. Patients with AN should be prescribed light-intensity aerobic exercise, and the current findings may help develop future physical management guidelines for patients with AN.

Level of evidence

III: Evidence obtained from case–control analytic studies.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Availability of data and materials

The data sets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Code availability

Not applicable.

References

  1. Mitchell JE, Peterson CB (2020) Anorexia nervosa. N Engl J Med 382:1343–1351. https://doi.org/10.1056/NEJMcp1803175

    Article  Google Scholar 

  2. Fayssoil A, Melchior JC, Hanachi M (2021) Heart and anorexia nervosa. Heart Fail Rev 26:65–70. https://doi.org/10.1007/s10741-019-09911-0

    Article  Google Scholar 

  3. Westmoreland P, Krantz MJ, Mehler PS (2016) Medical complications of anorexia nervosa and bulimia. Am J Med 129:30–37. https://doi.org/10.1016/j.amjmed.2015.06.031

    Article  Google Scholar 

  4. Voderholzer U, Haas V, Correll CU, Korner T (2020) Medical management of eating disorders: an update. Curr Opin Psychiatry 33:542–553. https://doi.org/10.1097/YCO.0000000000000653

    Article  Google Scholar 

  5. Bargiacchi A, Clarke J, Paulsen A, Leger J (2019) Refeeding in anorexia nervosa. Eur J Pediatr 178:413–422. https://doi.org/10.1007/s00431-018-3295-7

    Article  Google Scholar 

  6. Godier LR, Park RJ (2014) Compulsivity in anorexia nervosa: a transdiagnostic concept. Front Psychol. https://doi.org/10.3389/fpsyg.2014.00778

    Article  Google Scholar 

  7. Zunker C, Mitchell JE, Wonderlich SA (2011) Exercise interventions for women with anorexia nervosa: a review of the literature. Int J Eat Disord 44:579–584. https://doi.org/10.1002/eat.20862

    Article  Google Scholar 

  8. Achamrah N, Coeffier M, Dechelotte P (2016) Physical activity in patients with anorexia nervosa. Nutr Rev 74:301–311. https://doi.org/10.1093/nutrit/nuw001

    Article  Google Scholar 

  9. Couturier J, Isserlin L, Norris M, Spettigue W, Brouwers M, Kimber M, McVey G, Webb C, Findlay S, Bhatnagar N, Snelgrove N, Ritsma A, Preskow W, Miller C, Coelho J, Boachie A, Steinegger C, Loewen R, Loewen T, Waite E, Ford C, Bourret K, Gusella J, Geller J, LaFrance A, LeClerc A, Scarborough J, Grewal S, Jericho M, Dimitropoulos G, Pilon D (2020) Canadian practice guidelines for the treatment of children and adolescents with eating disorders. J Eat Disord 8:4. https://doi.org/10.1186/s40337-020-0277-8

    Article  Google Scholar 

  10. National Guideline Alliance (UK) (2017) Eating disorders: recognition and treatment. National Institute for Health and Care Excellence (UK), London

  11. Danish Health Authority (2016) National clinical guideline for the treatment of anorexia nervosa. Quick guide

  12. Harrington BC, Jimerson M, Haxton C, Jimerson DC (2015) Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. Am Fam Physician 91:46–52

    Google Scholar 

  13. Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, Touyz S, Ward W, Australian R, College NZ, of Psychiatrists, (2014) Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry 48:977–1008. https://doi.org/10.1177/0004867414555814

    Article  Google Scholar 

  14. Cook BJ, Wonderlich SA, Mitchell JE, Thompson R, Sherman R, McCallum K (2016) Exercise in eating disorders treatment: systematic review and proposal of guidelines. Med Sci Sports Exerc 48:1408–1414. https://doi.org/10.1249/MSS.0000000000000912

    Article  Google Scholar 

  15. Wasserman K, Whipp BJ, Koyl SN, Beaver WL (1973) Anaerobic threshold and respiratory gas exchange during exercise. J Appl Physiol 35:236–243. https://doi.org/10.1152/jappl.1973.35.2.236

    Article  CAS  Google Scholar 

  16. Wasserman K, Whipp BJ (1975) Exercise physiology in health and disease. Am Rev Respir Dis 112:219–249. https://doi.org/10.1164/arrd.1975.112.2.219

    Article  CAS  Google Scholar 

  17. Fisher JP, Young CN, Fadel PJ (2015) Autonomic adjustments to exercise in humans. Compr Physiol 5:475–512. https://doi.org/10.1002/cphy.c140022

    Article  Google Scholar 

  18. Franklin BA, Brinks J, Berra K, Lavie CJ, Gordon NF, Sperling LS (2018) Using metabolic equivalents in clinical practice. Am J Cardiol 121:382–387. https://doi.org/10.1016/j.amjcard.2017.10.033

    Article  Google Scholar 

  19. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th edn. APA Publishing, Washington DC

    Book  Google Scholar 

  20. Albouaini K, Egred M, Alahmar A, Wright DJ (2007) Cardiopulmonary exercise testing and its application. Postgrad Med J 83:675–682. https://doi.org/10.1136/hrt.2007.121558

    Article  Google Scholar 

  21. Whipp BJ, Davis JA, Torres F, Wasserman K (1981) A test to determine parameters of aerobic function during exercise. J Appl Physiol Respir Environ Exerc Physiol 50:217–221. https://doi.org/10.1152/jappl.1981.50.1.217

    Article  CAS  Google Scholar 

  22. Biadi O, Rossini R, Musumeci G, Frediani L, Masullo M, Ramacciotti CE, Dell’Osso L, Paoli R, Mariotti R, Cassano GB, Mariani M (2001) Cardiopulmonary exercise test in young women affected by anorexia nervosa. Ital Heart J 2:462–467

    CAS  Google Scholar 

  23. Weber KT, Janicki JS (1985) Cardiopulmonary exercise testing for evaluation of chronic cardiac failure. Am J Cardiol 55:22A-31A

    Article  CAS  Google Scholar 

  24. Hebebrand J, Himmelmann GW, Herzog W, Herpertz-Dahlmann BM, Steinhausen HC, Amstein M, Seidel R, Deter HC, Remschmidt H, Schäfer H (1997) Prediction of low body weight at long-term follow-up in acute anorexia nervosa by low body weight at referral. Am J Psychiatry 154:566–569. https://doi.org/10.1176/ajp.154.4.566

    Article  CAS  Google Scholar 

  25. Yamashita S, Kawai K, Yamanaka T, Takehiro I, Yokoyama H, Morita C, Takii M, Kubo C (2010) BMI, body composition, and the energy requirement for body weight gain in patients with anorexia nervosa. Int J Eat Disord 43:365–371. https://doi.org/10.1002/eat.20700

    Article  Google Scholar 

  26. Kawai K, Yamashita S, Yamanaka T, Gondo M, Morita C, Nozaki T, Takakura S, Hata T, Yamada Y, Matsubayashi S, Takii M, Kubo C, Sudo N (2011) The longitudinal BMI pattern and body composition of patients with anorexia nervosa who require urgent hospitalization: a case control study. Biopsychosoc Med 5:14. https://doi.org/10.1186/1751-0759-5-14

    Article  Google Scholar 

  27. Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR Jr, Tudor-Locke C, Greer JL, Vezina J, Whitt-Glover MC, Leon AS (2011) 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc 43:1575–1581. https://doi.org/10.1016/0002-9149(85)90792-1

    Article  Google Scholar 

  28. Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, O’Brien WL, Bassett DR Jr, Schmitz KH, Emplaincourt PO, Jacobs DR Jr, Leon AS (2000) Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc 32:S498-504. https://doi.org/10.1097/00005768-200009001-00009

    Article  CAS  Google Scholar 

  29. Roche F, Barthelemy JC, Garet M, Costes F, Pichot V, Duverney D, Kadem M, Millot L, Estour B (2004) Chronotropic incompetence to exercise separates low body weight from established anorexia nervosa. Clin Physiol Funct Imaging 24:270–275. https://doi.org/10.1111/j.1475-97X.2004.00561.x

    Article  Google Scholar 

  30. Brubaker PH, Kitzman DW (2011) Chronotropic incompetence: causes, consequences, and management. Circulation 123:1010–1020

    Article  Google Scholar 

  31. Yoshida Y, Maeda J, Fukushima H, Tokita N, Yamagishi H, Tokumura M (2019) Chronotropic incompetence to exercise in anorexia nervosa patients during the body-weight recovery phase as an index of insufficient treatment. Heart Vessels 34:711–715. https://doi.org/10.1007/s00380-018-1282-6

    Article  Google Scholar 

  32. Escudero CA, Potts JE, Lam PY, De Souza AM, Duff K, Mugford GJ, Sandor GGS (2019) Echocardiographic assessment of ventricular function during exercise in adolescent female patients with anorexia nervosa. J Am Soc Echocardiogr 32:394-403.e3. https://doi.org/10.1016/j.echo.2018.10.014

    Article  Google Scholar 

  33. Fuller A, Okwose N, Scragg J, Eggett C, Luke P, Bandali A, Velicki R, Greaves L, MacGowan GA, Jakovljevic DG (2021) The effect of age on mechanisms of exercise tolerance: reduced arteriovenous oxygen difference causes lower oxygen consumption in older people. Exp Gerontol 149:111340. https://doi.org/10.1016/j.exger.2021.111340

    Article  CAS  Google Scholar 

  34. Fleg JL, Morrell CH, Bos AG, Brant LJ, Talbot LA, Wright JG, Lakatta EG (2005) Accelerated longitudinal decline of aerobic capacity in healthy older adults. Circulation 112:674–682. https://doi.org/10.1161/CIRCULATIONAHA.105.545459

    Article  Google Scholar 

  35. Tamai M, Kubota M, Ikeda M, Nagao K, Irikura N, Sugiyama M, Yoshikawa H, Kawamori R, Kamada T (1993) Usefulness of anaerobic threshold for evaluating daily life activity and prescribing exercise to the healthy participants and patients. J Med Syst 17:219–225. https://doi.org/10.1007/BF00996949

    Article  CAS  Google Scholar 

  36. Ibrahim A, Cutinha D, Ayton A (2019) What is the evidence for using bed rest as part of hospital treatment of severe anorexia nervosa? Evid Based Ment Health 22:77–82. https://doi.org/10.1136/ebmental-2018-300064

    Article  Google Scholar 

  37. Kolnes LJ (2017) Exercise and physical therapy help restore body and self in clients with severe anorexia nervosa. J Bodyw Mov Ther 21:481–494. https://doi.org/10.1016/j.jbmt.2016.09.005

    Article  Google Scholar 

  38. Moola FJ, Gairdner SE, Amara CE (2013) Exercise in the care of patients with anorexia nervosa: a systematic review of the literature. Ment Health Phys Act 6:59–68

    Article  Google Scholar 

  39. Zipfel S, Giel KE, Bulik CM, Hay P, Schmidt U (2015) Anorexia nervosa: aetiology, assessment, and treatment. Lancet Psychiatry 2:1099–1111. https://doi.org/10.1016/S2215-0366(15)00356-9

    Article  Google Scholar 

  40. Davies S, Parekh K, Etelapaa K, Wood D, Jaffa T (2008) The inpatient management of physical activity in young people with anorexia nervosa. Eur Eat Disord Rev 16:334–340. https://doi.org/10.1002/erv.847

    Article  Google Scholar 

Download references

Acknowledgements

We would like to acknowledge Mr. Tsurumaru for his advice and technical support regarding CPX.

We would also like to acknowledge all study participants as well as the anonymous reviewers who commented on the draft.

Funding

This study was supported by JSPS KAKENHI Grant Number JP17K09340. This work was supported in part by Grants-in-Aid for Research from the National Center for Global Health and Medicine (20A 3001) and Grants-in-Aid for Scientific Research from the Japanese Ministry of Health, Labor, and Welfare (17K09340).

Author information

Authors and Affiliations

  1. Department of Psychosomatic Medicine, Kyushu University Hospital, Fukuoka, Japan

    Makoto Yamashita, Keisuke Kawai, Kenta Toda, Tomokazu Hata, Shu Takakura & Nobuyuki Sudo

  2. Department of Psychosomatic Medicine, Kohnodai Hospital, National Center for Global Health Medicine, Chiba, Japan

    Keisuke Kawai

  3. Department of Psychosomatic Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

    Kenta Toda, Chie Aso, Takafumi Suematsu, Hiroaki Yokoyama & Nobuyuki Sudo

Authors
  1. Makoto Yamashita
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Keisuke Kawai
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kenta Toda
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Chie Aso
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Takafumi Suematsu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Hiroaki Yokoyama
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Tomokazu Hata
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Shu Takakura
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Nobuyuki Sudo
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

KK and NS contributed to the study conception and design. Material preparation and data collection were performed by MY, KT, CA, TS, HY, TH, and ST. Analysis was performed by MY and KK. The first draft of the manuscript was written by MY. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Keisuke Kawai.

Ethics declarations

Conflicts of interest

The authors have no conflicts of interest or competing interests to declare. The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

This study was approved by the Ethics Committee of Kyushu University (Ethical Approval Number 26–191) and the National Center for Global Health and Medicine (Ethical Approval Number NGM-G-003071–00).

Consent to participate

All participants provided written informed consent prior to participation in the study.

Consent for publication

All authors have given their consent for submission of the manuscript.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yamashita, M., Kawai, K., Toda, K. et al. Cardiopulmonary exercise testing for patients with anorexia nervosa: a case–control study. Eat Weight Disord 27, 3553–3560 (2022). https://doi.org/10.1007/s40519-022-01492-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40519-022-01492-6

Keywords

Search

Navigation