Expectations of a new eating disorder treatment and its delivery: Perspectives of patients and new therapists.

BACKGROUND: A significant number of people with bulimia nervosa (BN) or binge-eating disorder (BED) do not seek professional help. Important reasons include limited knowledge of eating disorders (EDs), feelings of shame, treatment costs, and restricted access to specialized healthcare. In this study, we explored if a novel therapy delivered in a primary care setting could overcome these barriers. We investigated factors such as motivation and expectations and included the patients' and newly trained therapists' perspectives. METHOD: We interviewed 10 women with BN (n = 2) or BED (n = 8), enrolled in the Physical Exercise and Dietary therapy (PED-t) program, in a Healthy Life Center (HLC) located in a primary healthcare facility. Interview topics discussed were motivations for and expectations of therapy, and the treatment location. In addition, 10 therapists from HLC's were interviewed on their experiences with the PED-t training program and expectations of running PED-t within their service. The semi-structured interviews were analyzed using reflexive thematic analysis. RESULTS: Most patients had limited knowledge about EDs and first realized the need for professional help after learning about PED-t. Patients exhibited strong motivations for treatment and a positive perception of both the PED-t, the new treatment setting, and the therapists' competencies. The therapists, following a brief training program, felt confident in their abilities to treat EDs and provide PED-t. With minor operational adjustments, PED-t can seamlessly be integrated into national HLC service locations. CONCLUSION: PED-t is an accessible therapeutic service that can be delivered in a primary care environment in a stepped-care therapy model. PUBLIC SIGNIFICANCE: This study investigates the views and experiences of patients and newly trained therapists of PED-t (Physical Exercise and Dietary therapy), a new program-led primary care therapy for binge-eating spectrum eating disorders. The treatment and the locations for the intervention, that is, local health care centers, were found to be highly acceptable to both patients and therapists, thus PED-t could easily be integrated as a first step into a step-care delivery model.

The "Young Athlete Body Project"-A pilot study evaluating the acceptability of and results from an eating disorder prevention program for adolescent athletes.

BACKGROUND: The high frequency of eating disorders (EDs) in sports speaks of a need for early-stage preventive measures. OBJECTIVES: This study evaluated the acceptability of an age, sex, and sports adapted version of the "Body Project" and changes in mental health symptoms. METHODS: This noncontrolled pilot study included a class of athletes from 18 sports (N = 73, 13-14 years) at a sport-specialized junior high school in six small-group workshops. We interviewed 34 athletes on program acceptability, and all athletes responded to questionnaires at pretest, posttest, and 6-month follow-up including the Body Appreciation Scale 2-Children, Social Attitudes towards Appearance Questionnaire-4 revised, Eating Disorder Examination Questionnaire Short form-12 modified, and questions about body appearance pressure (BAP). RESULTS: Athletes found the program acceptable and beneficial, but some missed physically oriented activities or did not identify with the focus, particularly boys. There were acceptable levels in mental health constructs before the workshops. There were temporary changes in the percentage of boys experiencing "BAP in society" by -14.8% points (95% CI: -.6 to .0, p = .04), % in total group experiencing "BAP at school" by +11% points (95% CI: .0-.2, p = .05), thinness idealization by girls (g = .6, p = .002) and total group (g = .4, p = .006), and muscularity idealization by boys (g = .3, p = .05) and total group (g = .23, p = .04). DISCUSSION: Athletes experienced benefits from the Young Athlete Body Project. Seeing stabilization in outcomes may mean a dampening of the otherwise expected worsening in body appreciation and ED symptoms over time. PUBLIC SIGNIFICANCE: Adolescent athletes are at risk for developing EDs. Due to lack of prevention programs for this group, we adapted and evaluated a well-documented effective program, the Body Project, to fit male and female athletes <15 years. The athletes accepted the program and experienced participation benefits, with stronger acceptance among girls. Our promising findings encourage larger scaled randomized controlled trials to further evaluate a refined version this program among very young athletes.

Best practice recommendations for body composition considerations in sport to reduce health and performance risks: a critical review, original survey and expert opinion by a subgroup of the IOC consensus on Relative Energy Deficiency in Sport (REDs).

BACKGROUND: The assessment of body composition (BC) in sport raises concern for athlete health, especially where an overfocus on being lighter or leaner increases the risk of Relative Energy Deficiency in Sport (REDs) and disordered eating. METHODS: We undertook a critical review of the effect of BC on performance (29 longitudinal, prospective or intervention studies) and explored current practice related to BC considerations via a follow-up to a 2013 internationally distributed survey. RESULTS: The review found that a higher level of body fat was negatively associated with endurance performance, while a gain in muscle mass resulted in performance benefits across sports. BC did not contribute to early talent identification, and no unique cut-off to signify a performance advantage for BC was identified. BC appears to be one of an array of variables impacting performance, and its influence should not be overstated. The survey (125 practitioners, 61 sports and 26 countries) showed subtle changes in BC considerations over time, such as an increased role for sport dietitian/nutrition practitioners as BC measurers (2013: 54%, 2022: 78%); less emphasis on reporting of body fat percentage (2013: 68%, 2022: 46%) and reduced frequency of BC assessment if ≥every fourth week (2013: 18%, 2022: 5%). Respondents remained concerned about a problematic focus on BC (2013: 69%, 2022: 78%). To address these findings, we provide detailed recommendations for BC considerations, including an overview of preferable BC methodology. CONCLUSIONS: The 'best practice' guidelines stress the importance of a multidisciplinary athlete health and performance team, and the treatment of BC data as confidential medical information. The guidelines provide a health focus around BC, aiming to reduce the associated burden of disordered eating, problematic low energy availability and REDs.

How to address physical activity and exercise during treatment from eating disorders: a scoping review.

PURPOSE OF REVIEW: This scoping review aimed to provide a recent update on how to address dysfunctional physical activity and exercise (DEx), and on effects and experiences from including supervised and adapted physical activity or exercise (PAE), during treatment of eating disorders. RECENT FINDINGS: A systematic search for peer-reviewed publications in the period 2021-2023 generated 10 original studies and 6 reviews, including one meta-analysis (reporting according to PRISMA and SWiM). Findings showed that DEx was effectively managed by use of psychoeducation and/or PAE. Inclusion of PAE as part of treatment showed low-to-moderate impact on health and positive or neutral effects on eating disorder psychopathology. There were no reports of adverse events. For individuals with anorexia nervosa, PAE improved physical fitness with no influence on body weight or body composition unless progressive resistance training was conducted. For individuals with bulimia nervosa, DEx was reduced simultaneously with increased functional exercise and successful implementation of physical activity recommendations during treatment. Experiences by individuals with eating disorders and clinicians, including accredited exercise physiologists, pointed to positive benefits by including PAE in treatment. SUMMARY: Lack of consensus about DEx and of recommendations for PAE in official treatment guidelines hinder adequate approaches to these issues in eating disorder treatment.

Effectiveness and acceptability of the physical exercise and dietary therapy in a healthy life center.

OBJECTIVE: The high burden of eating disorders (EDs) and limited availability of treatment speaks of a need to explore new avenues for treatment delivery. To understand if new treatment avenues are helpful and acceptable to patients, we investigated the effectiveness of Physical Exercise and Dietary Therapy (PED-t) in participants with bulimia nervosa or binge-eating disorder, and acceptability when the PED-t was implemented in a Healthy Life Center in a municipal primary healthcare service. METHOD: Exercise physiologists and one dietitian were trained in ED literacy and to run PED-t, before screening women for eligibility. Effectiveness (n = 16) of PED-t and participants' experiences (n = 8) were evaluated by a mixed methods study design. Results were analyzed by relevant statistics and reflexive thematic analysis. RESULTS: Of 19 eligible participants, 16 completed treatment. At post-treatment, the Eating Disorder Examination Questionnaire global score, binge-eating frequency, and symptoms of depression were lower, and nine (56% of completers) were in remission. Participants' treatment experiences were classified into two overarching themes: "competence" and "emotional support." Participants reported high acceptance for PED-t, the local venue and group format, and felt that PED-t provided them with coping tools and increased mental strength. However, many also spoke of an unmet need to address emotional eating. DISCUSSION: Findings point to a potential for making an effective ED therapy more accessible, and that participants find the local low-threshold delivery within a group-format helpful. With small adjustments, the PED-t could emerge as a promising first-line treatment for bulimic EDs. PUBLIC SIGNIFICANCE STATEMENT: Limited access to treatment for EDs, patients' high barriers to help-seeking, and the high rates of limited efficacy from psychotherapy speak of a need to explore new therapies and avenues for delivery. In this study, we build on findings from a controlled ED treatment trial and replicate the beneficial effects and find a high patient acceptance of "physical exercise and diet therapy" implemented in a real, non-clinical setting.

Metabolic profile in women with bulimia nervosa or binge-eating disorder before and after treatment: secondary analysis from the randomized PED-t trial.

PURPOSE: Chaotic eating and purging behavior pose a risk to the metabolic health of women with bulimia nervosa (BN) and binge-eating disorder (BED). This study reports on one-year changes in blood markers of metabolic health and thyroid hormones in women with BN or BED attending two different treatments. METHODS: These are secondary analyses from a randomized controlled trial of 16-week group treatment of either physical exercise and dietary therapy (PED-t) or cognitive behavior therapy (CBT). Blood samples collected at pre-treatment, week eight, post-treatment, and at 6- and 12-month follow-ups were analyzed for glucose, lipids (triglycerides (TG), total cholesterol (TC), LDL cholesterol (LDL-c), HDL cholesterol (HDL-c), apolipoprotein A (ApoA) and apolipoprotein B (ApoB) lipoproteins), and thyroid hormones (thyroxine (T4), thyroid stimulating hormone (TSH), and thyroperoxidase antibodies). RESULT: The average levels of blood glucose, lipids and thyroid hormones were within the recommended range, but clinical levels of TC and LDL-c were detected in 32.5% and 39.1%, respectively. More women with BED compared with BN had low HDL-c, and a larger increase over time in TC and TSH. No significant differences occurred between PED-t and CBT at any measurement. Exploratory moderator analyses indicated a more unfavorable metabolic response at follow-up among treatment non-responders. CONCLUSION: The proportion of women with impaired lipid profiles and unfavorable lipid changes, suggests active monitoring with necessary management of the metabolic health of women with BN or BED, as recommended by metabolic health guidelines. LEVEL OF EVIDENCE: Level I: Evidence obtained from a randomized, experimental trial. TRIAL REGISTRATION NUMBER: This trial was prospectively registered in the Norwegian Regional Committee for Medical and Health Research Ethics on December 16, 2013, with the identifier number 2013/1871, and in Clinical Trials on February 17, 2014, with the identifier number NCT02079935.

Intervention in professional dance students to increase mental health- and nutrition literacy: A controlled trial with follow up.

Introduction: There is a need to change the culture within the art of dance, as it has been associated with injuries and mental health consequences. This study evaluates an intervention designed to increase mental health literacy, enhance nutritional knowledge, reduce symptoms and effects of low energy availability, and strengthen understanding of sports nutrition and recovery strategies, in dance students of mixed genders. Material and methods: A total of 125 dance students received three workshops, with 39 arts and crafts students serving as references. The results were evaluated by the Eating Disorder Examination questionnaire, the Low Energy Availability in Females questionnaire, the Hopkins Symptom Check List, and questions on mental health literacy, sports nutrition, and recovery knowledge. Results: Dance students achieved sustained improvements in mental health and nutrition knowledge and temporary improvements in driven exercise (i.e., performing exercise because of a compulsive drive). No other benefits were identified from the intervention. Conclusion: Our findings indicate the need for an ongoing education program to reduce the occurrence and development of negative mental health outcomes and low energy availability in professional dance students. Such approaches may not only improve the mental health of dance students but also potentially prevent the high frequency of injuries.

The Impact of Smartphone Apps Designed to Reduce Food Waste on Improving Healthy Eating, Financial Expenses and Personal Food Waste: Crossover Pilot Intervention Trial Studying Students' User Experiences.

BACKGROUND: Global sustainability and individual health need coordinated attention. While individuals are recommended a healthy diet to reduce the burden of noncommunicable diseases, global attention to natural resource conservation is also needed. The latter specifically means effective measures to reduce food waste. OBJECTIVE: This pilot study evaluates the experiences of students and effect from using smartphone apps designed to reduce food waste on personal healthy eating, financial expenses, and food waste. METHODS: A total of 6 students from different study programs (mean age 24.7, SD 2.9) were recruited to evaluate 2 different apps designed to reduce food waste and to register food consumption, food waste, and financial food expenses before and after the app trials. The apps evaluated were the commercially available TotalCtrl Home and Too-Good-To-Go. Results were analyzed by mixed methods, comprising statistical analyses for quantifiable data and thematic analyses for qualitative data. The apps were used separately in random order, each for 1 month. Primary outcome was user expectations to and experiences from the use of the apps, which were obtained by semistructured interviews. Secondary outcomes were changes in food waste volume, financial food expenses, and healthy eating. While information on food waste and food expenses was obtained by weighing food waste and registering food costs for 2 weeks before and after app trials, scores for consuming healthy diets were calculated from registered food records by scoring criteria matched to national recommendations for healthy eating. RESULTS: Awareness on food waste increased after app trials, but experiences with apps pointed toward several potential for technical and content improvements. The students reported that there were too many manual operations in the apps to induce permanent use (TotalCtrl Home), that services seemed more concerned about the producers' interests than the individual's needs (Too-Good-To-Go), and that they missed a composite app that included functions to promote healthy eating and overview of budget and expenses as well as of food waste (both apps). Use of apps designed to reduce food waste and personal costs and to improve healthy eating did not result in any measurable effects, that is, no change in food waste (mean change 0.81, SD 1.5 kg; P=.13), healthy eating (mean change -0.24, SD 0.43; P=.24), or personal food expenses (mean change 47.5 NOK or US $4.8, SD 416.9 NOK or US $42.5; P=.39). CONCLUSIONS: Apps may aid in increased awareness of food waste at the producer and consumer levels. Large-scale studies with longer duration are needed to see if apps may induce measurable changes in food waste, healthy eating, and financial expenses.

The Healthy Body Image Intervention and Reduction in Eating Disorder Symptomatology and Muscle Building Supplement Use in High School Students: A Study of Mediating Factors.

Background: Mediation analysis is important to test the theoretical framework underpinning an intervention. We therefore aimed to investigate if the healthy body image (HBI) intervention's effect on eating disorder (ED) symptomatology and use of muscle building supplements was mediated by the change in risk and protective factors for ED development and muscle building supplement use. Methods: This study used data from the HBI intervention: a cluster randomized controlled universal intervention aiming to promote positive body image and embodiment and reduce the risk for ED development including 30 schools in Norway. A total of 1,713 (37% boys) participants were included in the analyses. Conditional latent growth curve analyses were performed to test for indirect effects on ED symptomatology and weekly frequency of protein and creatine supplement use measured at the 12-month follow-up via change in the proposed mediators. Results: In girls, the reduction in ED symptomatology was mediated by positive changes in protective factors (self-esteem and body image flexibility) and reductions in risk factor scores (perceived media pressure and thin appearance internalization). Comparable changes in protective and risk factors among boys played no mediating role. Conclusion: Interventions aiming to reduce the risk of ED development in girls may benefit from aiming to enhance self-esteem and body image flexibility and reduce perceived media pressure and thin appearance internalization. Future studies should investigate the casual relationship between muscle building supplement use and risk and protective factors for ED development in both girls and boys.

Empowered, Yet Vulnerable: Motives for Sport Participation, Health Correlates, and Experience of Sexual Harassment in Female Combat-Sport Athletes.

Background: To explore motives for combat sport participation, weight regulation practices, symptoms of low energy availability (LEA), disordered eating (DE) or eating disorders (ED), and any experiences with sexual harassment (SH) among female combat-sport athletes. Methods: In total, 29 athletes were recruited by social media and in clubs. Participants responded to a questionnaire on health behavior and mental health and completed diet registration and a DXA-scan. Results: Most athletes started combat sports to feel empowered and experienced an inclusive milieu, but the frequency of health issues was high. A total of 21−67% had symptoms of ED, suffered from injuries, had low site-specific BMD, and/or symptoms of LEA. Athletes had insufficient intake of energy and nutrients, and <50% received any dietary information or guidance from their clubs. Most athletes complied with favorable weight-loss strategies; still, >20% used unfavorable methods and rapid weight-loss periods. A total of 70% of the athletes had experienced SH, of which 41% experienced SH within the combat-sport context. Conclusion: Combat sport offers an inclusive milieu, which may increase women's health and confidence; still, our results indicates a need for actions to safeguard female combat-sport athletes' mental and physical health, implying a cultural change within the community of combat sport and a need for increased health and nutrition literacy.

Explanations for use of dietary- and muscle enhancing dietary supplements among university students: a national cross-sectional study.

BACKGROUND: Use of dietary supplements (DS) and muscle enhancing dietary supplements (MEDS) is frequent among students despite the lack of evidence of effects and health risks related to consumption. We need to increase our understanding of students' motivation, examine potential gender differences, and explore explanatory factors, to address preventive measures related to use. Therefore, this study aimed to explore the frequency of, and the reasons for, DS use among university students, as well as explanatory factors for use of MEDS. METHOD: Male and female students from nine Norwegian universities participated in this cross-sectional study. Participants responded to questions about demographics, DS and MEDS use, internalization of body ideals, physical activity- and exercise level, motives for exercise, and exercise context. Independent t-test, Chi-square test, Pearson's correlation, and logistic regression were used to investigate between group differences, associations, and explanatory factors for use, respectively. P-values ≤ 0.05 were defined as significant. RESULTS: A total of 1001 males (34%) and females, with a mean(sd) age of 24.21(4.76) years, participated. The frequency of DS use was 42% and 40% (p = .414) in males and females, respectively, in which more males than females used DS to improve physical or mental performance (p = < .001), increase muscle mass (p = < .001) and weight for health (p = .014), and improve appearance (p = < .001). In males and females, respectively, 25% and 10% used MEDS (p = < .001). In males, being a fitness center member (OR:3.80), exercising to improve muscle mass (OR:1.96), and a higher physical activity level (OR:1.09) positively explained MEDS use, while exercising to increase endurance (OR:0.49) and being an exercise science student (OR:0.47) negatively explained MEDS use. In females, internalizing the athletic body ideal (OR:1.78) and exercising to improve muscle mass (OR:1.74) positively explained MEDS use. CONCLUSIONS: Our main findings indicate that a surprisingly high percentage of male and female Norwegian students use DS and MEDS, and that reasons for use, and variables explaining the variability in frequency of use, differ between genders. Longitudinal studies to investigate direction of associations are needed in future research.

Protein, Creatine, and Dieting Supplements Among Adolescents: Use and Associations With Eating Disorder Risk Factors, Exercise-, and Sports Participation, and Immigrant Status.

Objective: This study aimed to estimate the number of weekly users of protein, creatine, and dieting supplements and to explore whether weekly use was related to eating disorder (ED) risk factors, exercise, sports participation, and immigrant status. Methods: In total, 629 and 1,060 high school boys and girls, respectively, self-reported weekly frequency of protein, creatine, and dieting supplement use, and weight and shape concerns, appearance internalization and pressure, self-esteem, mental distress, physical activity level, exercise context, and the type and weekly frequency of sport played. Multiple hierarchical regression analyses were performed to investigate explanatory factors for supplement use. Results: More boys than girls used protein and creatine supplements. Immigrant boys had more frequent use of all supplements than non-immigrant boys, and immigrant girls used creatine supplements more frequently than non-immigrant girls. In total, 23-40 and 5-6% of the variation in the weekly frequency of supplement use in boys and girls, respectively, was explained by immigrant status, ED risk factors, and exercise and sports participation. More frequent use of protein, creatine and dieting supplements in boys was significantly explained by more weight and shape concerns, fitness center exercise, and weight-sensitive sports participation. Depending on the type of supplement, more frequent use of supplements in girls was significantly explained by lower self-esteem, more engagement in weight-sensitive sports, and less engagement in general sport and exercise activities. Conclusion: Weekly supplement use was common and more frequent among boys than girls. The weekly use of protein, creatine, and dieting supplements was related to ED risk factors, exercise and sports participation, and immigrant status in boys but not in girls.

Sexual Harassment in Fitness Instructors: Prevalence, Perpetrators, and Mental Health Correlates.

Introduction: This paper explores frequency of experiences of sexual harassment (SH) among fitness instructors, outlines the typical perpetrator, and explores associated mental health symptoms. Design: Cross-sectional survey. Materials and Methods: A total of 270 Norwegian fitness instructors, recruited in social media, responded to an electronic questionnaire in 2019/2020 on experiences of body appearance pressure, SH, and mental health symptoms. Outcomes included in this publication are experiences of SH, and symptoms of mental health issues based on the Hopkins symptom checklist, SCL-10; Beck Depression Inventory, BDI-1a; and Eating Disorder Examination Questionnaire, EDE-q. Results: The frequencies of SH experiences were 30% among 211 women and 22% among 59 men, respectively, with customers being the most frequent source of such approaches and personal trainers (PTs) more often reporting such experiences compared to group instructors (GIs) and to those operating as both PT and GI. Women having experienced SH had significantly higher scores in symptoms of depression, anxiety, and eating disorders compared to women with no such experience. Conclusion: The high frequency of SH experiences among fitness instructors, with customers emerging as perpetrators and typically in the context of personal training, necessitates increased awareness of SH in the fitness industry. To reduce the occurrence of SH, the fitness centers need to communicate countermeasures with high level of compliance.

Compulsive exercise and mental health challenges in fitness instructors; presence and interactions.

BACKGROUND: Some physically active people exercise compulsively, which can be associated with several mental health challenges. Fitness instructors are considered important role models for an active, healthy lifestyle; yet little is known about their exercise motives and mental health. The aim of this study was to examine the presence of compulsive exercise and mental health challenges, and their interaction, in fitness instructors. METHODS: A total of 270 fitness instructors from Norwegian fitness clubs were recruited for this cross-sectional study. Inclusion criteria were operating as instructors within the current year and understanding Norwegian language. Data were collected by an electronic questionnaire and included demographic information, hours of classes instructed and of personal physical activity, Compulsive Exercise Test (CET), Symptom Check List - 10 (SCL-10), Beck Depression Inventory (BDI), and Eating Disorder Examination Questionnaire (EDE-Q)). RESULTS: Females had higher CET scores than males, and 9% of all respondents had CET score above clinical cutoff. Respondents with clinical CET score had higher SCL-10, BDI and EDE-Q global- and subscale scores compared with their counterparts. Although CET was positively and significantly associated with BDI, SCL-10, and EDE-Q, only the latter explained the CET score (ß = 1.23, 99% CI = 0.87, 1.59). CONCLUSION: About one out of eleven instructors were above clinical CET cut-off, revealing symptoms of compulsive exercise. EDE-Q significantly contributed in a model explaining 43% of the variation of compulsive exercise.

For some people, physical activity may be driven by compulsive thoughts, which can be associated with mental health issues and psychosocial impairment. This makes it important to understand the underpinnings to compulsive exercise (CE). Fitness instructors are considered important facilitators for a healthy and physically active lifestyle, but there is little knowledge on the occurrence of CE among these role models. Previous findings report on a significant frequency of symptoms of eating disorders in fitness instructors, and as such it is reasonable to assume that CE is present. By concurrently obtaining information on symptoms of depression, anxiety and eating disorders, this study was able to explore explanations to the variance in occurrence of CE. Our main findings were a moderately elevated frequency of symptoms of depression and anxiety, and that 9% of 270 male and female fitness instructors demonstrated CE behavior. Participants demonstrating CE had higher levels of symptoms of depression, anxiety, and eating disorders compared with those without CE. Nevertheless, only symptoms of eating disorders explained the variation in CE severity. Other than increasing our understanding of CE, the main implication from these findings is a need to increase mental health literacy in fitness instructors.

The neurostructural and neurocognitive effects of physical activity: A potential benefit to promote eating disorder recovery.

Accumulating evidence suggests that supervised and adapted physical activity provides cognitive benefits for individuals with eating disorders (EDs). The mechanisms underlying the benefits of physical activity are poorly understood. Addressing this knowledge gap may inform the appropriate integration of structured physical activity into eating disorders treatment and recovery. We draw attention to recent findings in the study of the impact of physical activity on the brain, and we describe the neurostructural and neurocognitive changes associated with physical activity observed in various clinical and nonclinical populations. Considering the identified impairment in brain volume- and/or neurocognitive function in various EDs, we propose that positive effects of physical activity may play a meaningful role in successful ED treatment. Accordingly, we outline research steps for closing the knowledge gap on how physical activity may aid in ED recovery, and emphasize the need to combine measures of cognitive and behavioral responses to physical activity, with technology capable of measuring changes in brain structure and/or function.

Body appreciation and body appearance pressure in Norwegian university students comparing exercise science students and other students.

BACKGROUND: Body image is considered a core issue for public health and associates with university students' overall health. Due to positive associations between exercise and body image, it has been suggested that students within an exercise science program might be more body appreciative compared to other students. On the other hand, the strong societal idealization of the athletic body may expose them to a pressure of having a specific body appearance, which may result in unfavorable health consequences. Nevertheless, studies investigating these hypotheses are lacking. We therefore aimed to explore the level and associations of body appreciation, body appearance pressure, body image related mental health constructs, physical activity, and exercise, in Norwegian university exercise science and non-health reference students. METHOD: Male and female exercise science students (n = 517) and reference students (n = 476), from nine large universities in Norway took part in this cross-sectional study. Participants responded to the Body appreciation scale-2, a self-developed questionnaire on body appearance pressure, Physical Appearance Comparison Scale-Revised, Sociocultural attitudes towards appearance questionnaire-4R, Rosenberg Self-Esteem Scale, Satisfaction with Life Scale, and questions about physical activity and exercise. Between group differences were analyzed using student independent t-test and ANCOVA for parametric data and Chi-square test for categorical data, and associations were evaluated by Person's correlation. P-values ≤0.05 were defined as significant. RESULTS: Female exercise science students had higher scores on body appreciation compared to reference students. No group difference was found in males. A high percentage of students reported experiencing body appearance pressure, with 69 and 85% among male and female exercise science students, and 57 and 83% among male and female reference students. Fitness centers were the settings where most respondents experienced body appearance pressure. Body appreciation was strongly associated with favorable scores on body image related mental health constructs, while personally experienced body appearance pressure associated with destructive scores on the same constructs. CONCLUSION: Body appearance pressure is an issue among university students regardless of study program. Actions to promote body appreciation and prevent body appearance pressure may include an implementation of media literacy, body functionality, and exercise as topics within the education program to safeguard students' health and well-being. CLINICAL TRIAL REGISTRY: No. NCT04256967 .