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Keywords:

  • Adolescents;
  • fitness;
  • overweight;
  • eating disorder risk

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflict of interest statement
  9. Acknowledgements
  10. Contributors’ statement
  11. References
  12. Supporting Information
What is already known about this subject
  • Eating disorders are among the public health issues facing adolescents.
  • An excess of body fat has been associated with an increased risk of these disorders.
  • The association of physical fitness with eating disorders has not yet been analysed in adolescents.
What this study adds
  • This study confirms that the overweight and obesity increase the risk of developing eating disorders.
  • The present study shows that there is an inverse association between physical fitness levels and the risk of eating disorders.
  • This study suggests that physical fitness might attenuate the influence of overweight on the development of eating disorders in adolescents.

Background

Eating disorders together with the overweight and obesity are important health concerns in adolescents.

Objective

To analyse the individual and combined influence of overweight and physical fitness on the risk of developing eating disorders in Spanish adolescents.

Methods

The sample consisted of 3571 adolescents (1864 females), aged 13 to 18.5 years, from Spain who participated in the AVENA and AFINOS studies. The risk of eating disorders was evaluated using the SCOFF questionnaire. Body mass index was calculated and the adolescents were classified into two groups: overweight (including obesity) and non-overweight according to Cole's cut-off points. Cardiorespiratory fitness in the AVENA Study was assessed by the 20-m shuttle-run test and the overall physical fitness level was self-reported in the AFINOS Study.

Results

Overweight adolescents had a higher risk of developing eating disorders than non-overweight adolescents (odds ratio [OR] = 4.91, 95% confidence interval [CI]: 3.63–6.61 in the AVENA Study and OR = 2.45, 95% CI: 1.83–3.22 in the AFINOS Study). Also, adolescents with medium and low levels of physical fitness had a higher risk of developing eating disorders (OR = 1.51, 95% CI: 1.05–2.16, and OR = 2.25, 95% CI: 1.60–3.19, respectively, in the AVENA Study, and OR = 1.73, 95% CI: 1.37–2.17, and OR = 4.11 95% CI: 2.98–5.65, respectively, in the AFINOS Study) than adolescents with high levels of physical fitness. In both studies, the combined influence of overweight and physical fitness showed that adolescents with lower levels of physical fitness had an increased risk of developing eating disorders in both non-overweight and overweight groups.

Conclusions

Physical fitness might attenuate the influence of overweight on the development of eating disorders in adolescents.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflict of interest statement
  9. Acknowledgements
  10. Contributors’ statement
  11. References
  12. Supporting Information

Eating disorders are currently a public health concern in developed countries since their prevalence in young people have remarkably increased in the last decade [1]. For example, European and US surveillance studies have found that between 10% and 25% of adolescents scored above the limit for being at risk for developing an eating disorder [2]. Eating disorders constitute the third cause of illness after obesity and asthma in young population. In addition, they present a chronic course, and have an elevated morbidity and mortality ranging from 6% to 15%, respectively [3]. Importantly, a variety of biological and psychological factors may play a key role in the development of eating disorders [3].

Eating disorders and obesity are part of a range of weight-related problems, and they are usually seen as opposite pathologies but in fact they share many similarities. Evidence from cross-sectional studies suggests that these disorders can occur simultaneously in the same individual [4]. An excess of body fat has been associated with a later increased risk of developing eating disorders such as anorexia, bulimia nervosa, self-induced vomiting and binge eating in both children [4-6] and adults [7]. Today's society idealizes thinness and stigmatizes fatness, yet high-calorie foods are widely available and heavily advertised. The mass media, family and peers may be sending children and adolescents mixed messages about food and weight that encourage disordered eating [8].

On the other hand, physical fitness, defined as the capacity to perform physical activity, is a powerful marker of health [9]. Most studies have found inverse associations among obesity, physical activity [10] and fitness [11], and there is strong evidence that high physical fitness attenuates the negative effect of obesity on cardiovascular diseases [12]. However, little is known about the influence of physical fitness on the risk of developing eating disorders. In spite of this, some studies have shown that higher levels of fitness might have a positive influence on depression, anxiety, mood status and self-esteem in young people [9]. This fact is important since adolescents who are at risk of developing eating disorders are also likely to develop other mental health disorders [13, 14]. Therefore, the present study aims to examine the individual and combined association of overweight and physical fitness with the risk of developing eating disorders in Spanish adolescents. This research question was tested in two separate studies conducted in Spanish adolescents.

Patients and methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflict of interest statement
  9. Acknowledgements
  10. Contributors’ statement
  11. References
  12. Supporting Information

Study design and participants

The present study involves data from two different research projects: the AVENA (Food and Assessment of the Nutritional Status of Adolescents) [15] Study and the AFINOS (Physical Activity as a Preventive Measure of the Development of Overweight, Obesity, Allergies, Infections, and Cardiovascular Risk Factors in Adolescents) [16] Study. The AVENA and AFINOS are cross-sectional studies performed in Spain from November 2000 to June 2002, and from November 2007 to February 2008, respectively. The AVENA Study was designed to assess the health and nutritional status of a national representative sample (n = 2859) of Spanish adolescents [15]. Participants in this study were recruited in five Spanish cities (Madrid, Murcia, Granada, Santander and Zaragoza). The AFINOS Study was designed to determine the relationship between physical activity and the incidence of overweight, infections and allergies in a representative sample of adolescents (n = 2116) from the Madrid region [16]. The final sample used for the current study comprised 3571 adolescents (1864 girls) aged from 13 to 18.5 years with valid data for the analysed variables. Specifically, a total of 1554 adolescents (828 girls) belonged to the AVENA Study, and 2017 adolescents (1036 girls) to the AFINOS Study.

A comprehensive verbal description of the nature and purpose of these studies was given to the adolescents and their parents, and a written consent to participate was requested from both parents and adolescents. The AVENA Study protocol was approved by the Review Committee for Research Involving Human Subjects of the Hospital Universitario Marqués de Valdecilla (Santander), and the AFINOS Study protocol was approved by the Ethics Committee of Puerta de Hierro Hospital (Madrid) and the Bioethics Committee from Spanish National Research Council [15, 16].

Measurement of the risk of eating disorders

In both studies, the risk of eating disorders was assessed using the SCOFF questionnaire [17]. This questionnaire is a screening instrument originally designed to be routinely used in all individuals considered at risk of such disorders, and it has been validated in Spanish adolescents [18]. The SCOFF questionnaire consists of five eating-related questions asking about intentional vomiting, loss of control over eating, weight loss, body dissatisfaction and food intrusive thoughts. Answering positively two or more items of SCOFF questionnaire has been suggested as the threshold for a suspicion of a probable eating disorder case [17].

Anthropometric measures

In the AVENA Study, two anthropometrists in each city performed all measurements [19]. Body weight and height were measured to 0.05 kg and 0.1 cm using a beam balance including a stadiometer (SECA 861, SECA, Hamburg, Germany). In the AFINOS Study, body weight and height were self-reported by the adolescents. In both studies, body mass index (BMI) was calculated as weight/height squared (kg m−2). The International Obesity Task Force-proposed gender- and age-adjusted cut-off points were used to classify adolescents according to their weight status in underweight, normal-weight, overweight and obesity [20, 21].

Measurements of physical fitness

Cardiorespiratory fitness (CRF) in the AVENA Study was assessed by the 20-m shuttle-run test [22]. The 20-m shuttle-run test is one of the most widely used field tests to assess CRF in youth (http://www.fitnessgram.net). Adolescents ran as long as possible, back and forth, across a 20-m space at a specific sound protocol that became 0.5 km h−1 faster each minute or period from a starting speed of 8.5 km h−1.

The test finished when the participant failed to reach the end lines concurrent with the audio signals on two consecutive occasions. Adolescents were instructed to abstain from strenuous exercises within the 48 h preceding the test. Last lap completed was the individual score for each participant. Maximal oxygen consumption (VO2max, mL kg−1 min−1) was estimated by the Leger equation [23]. In the AVENA Study, adolescents were classified according to their CRF levels based on sex- and age-specific tertiles [24].

In the AFINOS Study, the participants completed a questionnaire that assessed their health status and lifestyle based on previous questionnaires used in several national and international health surveys [15]. A question about their physical fitness level was incorporated into the questionnaire: how is your physical fitness? The response options were scored from 1 = poor to 5 = excellent. The use of self-reported overall physical fitness has been shown to be useful, reliable and valid in adolescents [25]. In the AFINOS Study, participants were classified into low, medium and high fitness levels according to their response to this question as follows: low (categories 1 and 2), medium (category 3) and high (categories 4 and 5).

Data analysis

Characteristics of the sample and output results of the study are described as mean ± SD or percentage. The Kolmogorov–Smirnov test was used to test the normality of all continuous variables. Statistical differences by sex in the samples were analysed using the chi-squared test for qualitative variables and by one-way analysis of variance for continuous variables.

In both studies, underweight and normal-weight adolescents reported a similar (0.5 vs. 0.6, P = 1 in the AVENA Study) or slightly lower (0.6 vs. 0.9, P = 0.04 in the AFINOS Study) number of positive responses in the SCOFF questionnaire than normal-weight adolescents, whereas obese adolescents reported a higher number of positive responses in such questionnaire than overweight adolescents (1.5 vs. 1.2, P = 0.049 in the AVENA Study, and 2.0 vs. 1.2, P < 0.001 in the AFINOS Study). Consequently and for more robust analysis, overweight and obese adolescents were combined in the same group (hereafter called overweight adolescents), whereas underweight and normal-weight adolescents (hereafter called non-overweight adolescents) were also merged.

Logistic regression analysis was performed to examine individual and combined association of weight status (non-overweight and overweight) and levels of fitness (low, middle and high) with the risk of eating disorders development in each study. To analyse the combined association of weight status and fitness level subjects in each study, samples were stratified into six groups (two groups according to BMI status × three groups according to fitness levels) and the non-overweight/high fitness adolescents were used as reference group. All logistic regression analyses were sex- and age-adjusted. For all analyses, the error was fixed at 0.05. All analyses were performed using the SPSS statistical software package (v.17.0) (IBM, Armonk, NY, USA) for windows XP.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflict of interest statement
  9. Acknowledgements
  10. Contributors’ statement
  11. References
  12. Supporting Information

The descriptive characteristics for the adolescents of the AVENA and AFINOS Studies are shown in Table 1. In general, both studies showed that boys had higher levels of body fat and physical fitness than girls, whereas girls reported higher levels of eating disorders than boys. On the other hand, the prevalence of obesity was 4.6% (3.3% in girls, P = 0.001) in the AVENA Study and 2.1% (1.0% in girls, P < 0.001) in the AFINOS Study. The prevalence of underweight adolescents was 4.8% (4.7% in girls, P = 0.923) in the AVENA Study and 5.3% (6.7% in girls, P = 0.005) in the AFINOS Study.

Table 1. Descriptive characteristics of the study samples
 AVENA Study (2000–2002)PAFINOS Study (2007,2008)P
All BoysGirlsAll BoysGirls
n = 1554n = 726n = 828n = 2017n = 981n = 1036
  1. Values are expressed as mean ± SD or percentage (%).

  2. a

    Including obesity.

  3. b

    A score of ≥2 in the SCOFF questionnaire indicates a likely case of eating disorders.

  4. c

    A question about self-report of fitness levels was considered a measure of overall fitness.

  5. d

    Cardiorespiratory fitness measured by the 20-m shuttle-run test.

Age (years)15.4 ± 1.315.4 ± 1.315.4 ± 1.30.84514.8 ± 1.314.8 ± 1.314.8 ± 1.30.823
Weight (kg)60.4 ± 12.164.5 ± 12.856.3 ± 9.8<0.00158.3 ± 11.162.4 ± 12.054.3 ± 8.4<0.001
Height (cm)166.5 ± 8.8171.4 ± 8.2161.7 ± 6.2<0.001166.5 ± 9.2170.4 ± 9.7162.7 ± 6.90.001
Body mass index (kg m−2)21.7 ± 3.521.9 ± 3.621.5 ± 3.40.04720.9 ± 2.921.5 ± 3.120.5 ± 2.6<0.001
Overweighta22.225.918.50.00117.625.010.5<0.001
Fitness levels        
Low33.334.432.4 10.38.012.5 
Medium33.329.536.70.00636.129.442.60.001
High33.336.130.9 53.662.744.9 
SCOFF positive responses        
Q1: Deliberate vomiting34.330.038.6<0.00137.931.943.6<0.001
Q2: Loss of control over eating11.59.813.20.04215.812.618.8<0.001
Q3: Weight loss4.74.94.40.7289.19.98.30.215
Q4: Body image distortion17.69.026.3<0.00120.111.728.2<0.001
Q5: Impact of food on life5.14.16.10.06011.88.913.00.008
At risk for eating disorderb17.712.522.9<0.00125.217.632.3<0.001
Self-reported physical fitness (score)c 3.5 ± 0.93.7 ± 0.93.4 ± 0.9<0.001
Measured physical fitness (VO2max, mL kg−1 min−1)d45.7 ± 9.549.6 ± 9.941.8 ± 7.2<0.001 

Tables S1 and S2 (supporting information) show the proportions of positive responses in the SCOFF questionnaire and the risk of developing eating disorders by weight status and fitness levels. Overall, overweight adolescents and those who had low fitness levels had a greater proportion of positive responses in almost all the questions, as well as a higher risk of developing eating disorders. The associations of weight status and physical fitness levels with the risk of developing eating disorders for each study are shown in Table 2. In both studies, the results of the binary logistic regression analysis showed that the adolescents classified as overweight had a higher risk of developing eating disorders (both P < 0.001) than those classified as non-overweight. Also, adolescents who had low or middle level of physical fitness were more likely to develop eating disorders than those with high physical fitness (all P < 0.001).

Table 2. Odds ratios (OR) and 95% confidence intervals (CI) for risk of developing eating disorders in adolescents with different weight status and physical fitness levels
 AVENA StudybAFINOS Studyc
nOR95% CInOR95% CI
  1. Analyses were sex- and age-adjusted.

  2. a

    Including obesity.

  3. b

    Weight status and physical fitness variables were measured.

  4. c

    Weight status and physical fitness variables were self-reported.

Weight status      
Non-overweight12111Ref.16631Ref.
Overweighta3434.913.63-6.613542.451.83-3.22
Fitness levels      
High5181Ref.10811Ref.
Medium5181.511.05-2.167291.731.37-2.17
Low5182.251.60-3.192074.112.98-5.65

The combined associations of weight status and physical fitness with the risk of eating disorders for each study are shown in Fig. 1. In the AVENA Study, (A) among non-overweight adolescents only those with low fitness were at an increased risk of developing eating disorders compared with the high fitness group (odds ratio [OR]: 1.65, 95% confidence interval [CI]:1.07–2.55). Among overweight adolescents, the ORs (95% CI) of eating disorders for groups with low, medium and high fitness compared with non-overweight adolescents with high fitness were 3.34 (1.77–6.31), 5.78 (3.46–9.66) and 6.23 (4.00–9.70), respectively.

figure

Figure 1. Odds ratios and 95% confidence intervals (error bars) to assess the risk of developing eating disorders according to weight status and physical fitness levels. A = AVENA Study (measured variables). B = AFINOS Study (self-reported variables).a Including obesity.

Download figure to PowerPoint

In the AFINOS Study, (B) the ORs (95% CI) in the non-overweight group were 1.85 (1.44–2.37) and 4.50 (3.06–6.63) according to middle and low fitness groups, respectively, compared with the non-overweight group with high fitness levels. In the overweight group, the ORs (95% CIs) for eating disorders for groups with low, medium and high fitness compared with non-overweight adolescents with high fitness were 1.62 (1.03–2.57), 2.64 (1.84–3.80) and 5.12 (3.20–8.19), respectively.

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflict of interest statement
  9. Acknowledgements
  10. Contributors’ statement
  11. References
  12. Supporting Information

In the present study, we analysed the associations of physical fitness and overweight with the risk of developing eating disorders in two large samples of Spanish adolescents. The main findings of this study indicate that there is an inverse association between physical fitness levels and the risk of eating disorders in adolescents, independently of weight status. We also found that overweight adolescents had a higher risk of developing eating disorders than non-overweight adolescents. However, overweight adolescents with high levels of physical fitness had a lower risk of eating disorders than overweight adolescents with low levels of physical fitness. To the best of our knowledge, this is the first study suggesting that physical fitness might attenuate the negative influence of body fat on risk for eating disorder in adolescents.

Eating disorders are serious, potentially life-threatening conditions that can lead to very serious physical health problems. The origin of eating disorders is very complex. Individual and familial, biological and psychological characteristics contribute. In addition, a large number of previous research projects have concluded that the period with the greatest prevalence of eating disorders is the adolescence and early youth [26]. In Spain, only one previous study involving 841 students, aged 12–19 years, determined the risk of developing eating disorders using the SCOFF questionnaire [27]. The results of that study showed that 21% of the subjects had significant scores in the questionnaire. This rate is similar to and between the rates found in the AVENA (18%) Study and the AFINOS (25%) Study.

The number of investigations examining the association of physical fitness on health outcomes in youth and adults has increased substantially in recent years. High fitness levels have been consistently associated with physical unhealthy outcomes such as obesity, hypertension, type 2 diabetes, metabolic syndrome, cancer and skeletal health problems[12]. However, the scientific literature focused on the relationship between physical fitness and mental disorders is scarce.

Nowadays, the available information suggests that improvements in physical fitness have short-term and long-term positive effects on depression, anxiety, mood status and self-esteem in young people. For example, a school-based controlled trial involving 198 students aged 15 years from Chile showed that improving physical fitness was beneficial for mental well-being. At the end of the program, anxiety score decreased 13.7% in the intervention group versus 2.8% in the control group, and self-esteem score increased 1.3% in the intervention group and decreased 0.1% in the control group [28]. Another study performed in 66 Hispanic children showed that children included in an aerobic intensity program significantly improved their fitness and reported significantly (P < 0.05) less depression after 6 weeks [29]. In a sample of 4888 adult participants examined in 1988–1997, weak but significant correlations were found between CRF and positive and negative emotion [30]. Our findings extend these previous results because we have found a novel link between physical fitness and the risk of developing eating disorders.

Indeed, high physical fitness seems to protect against the risk of such disorders in overweight adolescents regardless of the methodology used to assess physical fitness since in the AVENA Study physical fitness was assessed by a field test [15], while in the AFINOS Study it was assessed using a self-reported question [16, 31-33]. The idea of fat but fit was proposed in 1995 by Blair and colleagues, who showed that within a fatness category, aerobic fitness attenuates the risk of disease [34, 35]. Although there is limited evidence, similar fat but fit findings have been observed in youth related to physical health outcomes [36] but, to date, there is no evidence regarding the fat but fit theory on mental health outcomes in youth.

Another finding in the current study was that the association of physical fitness with eating disorders was unclear in the group of non-overweight adolescents. In the AFINOS Study, where the measure of physical fitness was subjective, physical fitness levels were negatively associated with the risk of eating disorders (P < 0.001). However, in the AVENA Study, where the measure of physical fitness was objective, the association between physical fitness and eating disorders was notably attenuated (P = 0.078). Likewise, the association between physical fitness and eating disorders was stronger using self-reported fitness than measured fitness. Self-reported physical fitness may be influenced not only by real physical fitness (i.e. physical health) but also by other health dimensions (e.g. mental health, intellectual health, social health and spiritual health) that might be independent of adolescents’ weight status [37]. Whether other dimensions of health affects the answer on self-reported physical fitness is unknown. And the other way round, whether self-reported physical fitness could be considered a proximate estimate of overall health is also to be elucidated. This fact might explain the differences observed in our study using different procedures to measure physical fitness [38]. Taken together, these results suggest that improvements on physical fitness should be developed using a multifactorial approach based on multiple dimensions of health to more effectively prevent eating disorders in adolescents.

The main limitation of our study is its cross-sectional design, which cannot establish causal relationships. However, the use of two large and heterogeneous samples means that these results can be generalized. Likewise, the results found with the AFINOS Study must be interpreted with caution because we only had self-reported measurements of fatness and fitness. Consequently, our results in the AVENA Study could be more valuable for public health purposes.

Since physical fitness seems to be related to the different health outcomes, physical activity programs should be designed to improve the levels of fitness. Reinforcing the need to include physical fitness testing could also be interesting in health monitoring systems. Longitudinal studies and randomized control trials are still needed in this field to understand the nature and relative importance of alternative determinants of physical fitness during adolescence, and to verify the usefulness of alternative promotion strategies and recommendations.

Conclusion

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflict of interest statement
  9. Acknowledgements
  10. Contributors’ statement
  11. References
  12. Supporting Information

The present findings support the role of physical fitness in preventing the development of eating disorders in adolescents, especially in overweight or obese adolescents. Hence, it would be important and necessary to develop educational and public health strategies to identify, prevent and treat these health problems considering physical fitness as a relevant measure for prevention.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflict of interest statement
  9. Acknowledgements
  10. Contributors’ statement
  11. References
  12. Supporting Information

The authors gratefully acknowledge the adolescents and their parents who participated in this study. The AVENA Study was supported by the Spanish Ministry of Health, FIS (00/0015) and grants from Panrico S.A., Madaus S.A. and Procter & Gamble S.A. The AFINOS Study was supported by grant DEP2006-56184-C03-01-02-03/PREV from the Spanish Ministry of Education and Science and co-funded by FEDER funds from European Union. DMG was supported by a scholarship from the Spanish Ministry of Education and Science AP2006-02464. FBO was supported by grants from the Spanish Ministry of Education (EX-2008-0641) and the Swedish Heart-Lung Foundation (20090635).

Contributors’ statement

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflict of interest statement
  9. Acknowledgements
  10. Contributors’ statement
  11. References
  12. Supporting Information

Ana M Veses and David Martinez-Gomez wrote the paper and analysed the data. Sonia Gomez-Martinez wrote the paper and conducted the research. Germán Vicente-Rodriguez, Ruth Castillo and Francisco B Ortega provided essential reagents and other materials. María E Calle designed the research. Marcela Gonzalez-Gross and Oscar L Veiga designed and conducted the research, and Ascensión Marcos designed the research and had primary responsibility for final content. All authors read and approved the final manuscript.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflict of interest statement
  9. Acknowledgements
  10. Contributors’ statement
  11. References
  12. Supporting Information
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Supporting Information

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflict of interest statement
  9. Acknowledgements
  10. Contributors’ statement
  11. References
  12. Supporting Information
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ijpo138-sup-0001-si.pdf76K

Table S1. Proportion of adolescents with positive answers in the SCOFF questions and at risk of developing eating disorders by weight status.

Table S2. Proportion of adolescents with positive answers in the SCOFF questions and at risk of developing eating disorders by fitness levels.

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