Epidemiologic Reviews
Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2015. This work is written
by (a) US Government employee(s) and is in the public domain in the US.
Vol. 37, 2015
DOI: 10.1093/epirev/mxu011
Advance Access publication:
January 16, 2015
Post-Traumatic Stress Disorder, Physical Activity, and Eating Behaviors
Katherine S. Hall*, Katherine D. Hoerster, and William S. Yancy, Jr.
* Correspondence to Dr. Katherine S. Hall, Geriatric Research, Education, and Clinical Center (GRECC 182), Veterans Affairs Medical Center,
508 Fulton Street, Durham, NC 27705 (e-mail: [email protected]).
Accepted for publication October 13, 2014.
Post-traumatic stress disorder (PTSD), a prevalent and costly psychiatric disorder, is associated with high rates
of obesity and cardiometabolic diseases. Many studies have examined PTSD and risky behaviors (e.g., smoking,
alcohol/substance abuse); far fewer have examined the relationship between PTSD and health-promoting behaviors. Physical activity and eating behaviors are 2 lifestyle factors that impact cardiometabolic risk and long-term
health. This comprehensive review of the literature (1980–2014) examined studies that reported physical activity
and eating behaviors in adults with PTSD or PTSD symptoms. A systematic search of electronic databases identified 15 articles on PTSD–physical activity and 10 articles on PTSD–eating behaviors in adults. These studies suggest that there may be a negative association among PTSD, physical activity, and eating behaviors. Preliminary
evidence from 3 pilot intervention studies suggests that changes in physical activity or diet may have beneficial effects on PTSD symptoms. There was considerable heterogeneity in the study designs and sample populations, and
many of the studies had methodological and reporting limitations. More evidence in representative samples, using
multivariable analytical techniques, is needed to identify a definitive relationship between PTSD and these health
behaviors. Intervention studies for PTSD that examine secondary effects on physical activity/eating behaviors, as
well as interventions to change physical activity/eating behaviors that examine change in PTSD, are also of interest.
binge eating; diet; exercise; health outcomes; health promotion; nutrition; prevention; PTSD
Abbreviations: CBT, cognitive behavioral therapy; PTSD, post-traumatic stress disorder.
physical functioning and comorbid psychological conditions
such as depression (9–12).
Physical inactivity and poor eating behaviors (particularly
binge eating and binge eating disorder) are important established predictors of morbidity and mortality, including diabetes, cardiovascular disease, hypertension and hyperlipidemia,
and obesity (13–15). Physical activity and diet have demonstrated efficacy as secondary prevention strategies, promoting
weight loss/maintenance and glucose control, attenuating
functional decline, and improving mood and anxiety symptoms (16–18). Individuals with PTSD may be less likely to
exercise and more likely to have poor dietary habits because
of fear of bodily arousal symptoms (e.g., increased heart rate,
shortness of breath) or comorbid depression, which is common in PTSD and undermines motivation to exercise and
eat healthily (11). People with PTSD also engage in other unhealthy behaviors, such as smoking and alcohol use, which
may make it more difficult for someone with PTSD to start an
exercise program or to consume a well-balanced diet (19, 20).
Recent evidence suggests that hyperarousal symptoms of
INTRODUCTION
Post-traumatic stress disorder (PTSD) is a psychological
condition triggered by a traumatic event. Although not everyone who experiences trauma develops PTSD, a significant
minority of individuals go on to experience chronic PTSD
symptoms that can last years and even decades after the traumatic event (1). PTSD is prevalent among military veterans
and civilians alike. A recent study by the Department of Veterans Affairs reports that nearly 30% of Iraq and Afghanistan
veterans seen at its facilities have PTSD (2), and PTSD rates
among Vietnam-era military veterans are estimated at well
over the half-million mark (3, 4). Among civilian populations, the prevalence of PTSD is lower but still significant,
affecting approximately 8% of the US adult population (5).
There is substantial evidence suggesting that chronic PTSD
is associated with cardiovascular and metabolic risk factors,
with studies reporting higher rates of obesity, dyslipidemia,
hypertension, diabetes, and cardiovascular disease (6–8).
PTSD is also associated with significant impairments in
103
Epidemiol Rev 2015;37:103–115
104 Hall et al.
PTSD are most strongly associated with inactivity and that a
heightened concern for safety, which is common in PTSD,
may interfere with exercise (21). Use of food to cope with
negative affect and stress may also explain why PTSD is associated with unhealthy diet and overweight/obesity (22).
Finally, sleep disturbance, a prominent PTSD symptom,
is a barrier to physical activity (23, 24) and healthy diet
(25). In addition to these behavioral indices, research has
shown that poor social support (26) and low self-efficacy
(27)—psychosocial factors that are critical facilitators of
physical activity and healthy diet (28–33)—are common
in PTSD.
A comprehensive review of the literature examining PTSD
and health-promoting behaviors is needed, given the central
role of physical activity and diet in the prevention of overweight/obesity and related cardiometabolic sequelae and
the high prevalence of these health conditions among individuals with PTSD. Previous reviews of the link between
PTSD and health that include health behaviors have focused
largely on adverse health behaviors such as tobacco use,
alcohol/substance abuse, or eating disorders such as anorexia
nervosa and bulimia nervosa, and few have included or focused on military veterans. The aim of this paper is to provide
a narrative review of the existing published data regarding
PTSD, physical activity, and eating behaviors. This review
will discuss the gaps in the existing literature and identify
areas for future research.
METHODS
We conducted a search of the published literature (including PubMed, PsycINFO, and Cochrane) for original research
articles published in English between January 1980 and July
2014 using a text search. A text search identifies studies that
have any part of the word or string of words in the search
fields, casting a relatively wide net. The search terms used
for this search included the following: posttraumatic stress
disorder, post-traumatic stress disorder, or PTSD with physical activity, exercise, sedentary, inactivity, or sitting; and
diet, nutrition, eating disorder, disordered eating, or binge
eating. We also utilized references of empirical and review
articles to identify additional studies. This literature search
was initially restricted to studies conducted in military service members and veterans; however, this yielded a very
small number of studies. We subsequently conducted another
literature search inclusive of all adult samples (regardless of
military/veteran status) that yielded sufficient results for this
review. We consulted a medical librarian regarding our search
procedures and confirmed that we had obtained an accurate
and comprehensive list of articles that meet our study objectives using these search approaches.
Studies that provided information on the associations between PTSD and physical activity or eating behaviors in
adults were included. Given our interest in health behaviors
related to obesity and cardiometabolic health, we did not consider studies that did not separate binge eating from other eating disorders (e.g., anorexia nervosa or bulimia nervosa).
Finally, studies that did not directly assess PTSD status or
symptoms (e.g., only assessed trauma exposure) were not
considered. Methodological rigor was considered during
the inclusion and exclusion process, such that articles that
had a sample size of less than 25 were excluded, as were studies that did not statistically examine between-group differences. Data collected from each study included the study
design, number of individuals who had a diagnosis of or
symptoms consistent with PTSD, study location, primary
outcome of the study, the measure utilized to assess PTSD,
physical activity and/or eating behaviors, and statistical associations of PTSD with physical activity and eating behavior.
All papers were reviewed independently by 2 researchers
(K. S. H, K. D. H.). Any disagreements between reviewers
were discussed until consensus was reached.
RESULTS
A meta-analysis approach was not feasible given the large
heterogeneity of the study designs and methodologies. Also,
the outcome of PTSD was not measured consistently across
studies, because different instruments were used and the way
in which the outcome was examined (dichotomous vs. continuous) varied greatly. The same is true of the physical activity and dietary outcomes. Therefore, a comprehensive and
descriptive review of the literature was conducted.
Search results
Figures 1 and 2 show the article selection process for the
PTSD–physical activity and PTSD–eating behavior literature
searches. Although a large number of articles on PTSD and
health have been published in the last decade, few focused on
the association between PTSD and health-promoting behaviors such as physical activity and eating behaviors. Fifteen
studies of PTSD and physical activity were identified. Ten
studies of PTSD and eating behaviors were identified.
Studies were commonly conducted among community
samples of adults, with a few studies examining these associations in military or veteran samples (n = 6). Studies in the
literature utilized survey instruments (n = 11), medical record
codes (n = 2), and/or clinical interviews (n = 12) for diagnosing PTSD and binge eating disorder. Few studies (n = 4)
reported using previously validated measures of physical activity or eating behaviors.
The identified studies were categorized by behavior (e.g.,
physical activity or eating behavior), sample population, and
study design. Details of these studies are summarized in
Tables 1 and 2.
PTSD and physical activity
PTSD as a correlate or predictor of physical activity. There
were 10 published observational studies that reported the associations between PTSD and physical activity (21, 34–43),
all of which were conducted between 2010 and 2014.
Six of the 10 studies examined the associations between
PTSD status (yes/no) and physical activity (34, 36, 38, 39,
41, 43). These studies can be further divided by those that examined physical activity versus inactivity as the primary outcome. Among those studies that examined physical activity,
2 reported that adults with PTSD were significantly less
likely to engage in regular physical activity compared with
Epidemiol Rev 2015;37:103–115
PTSD, Exercise, and Eating Behaviors 105
Search Terms Used to Identify Articles
“Posttraumatic stress disorder” OR “posttraumatic stress disorder” OR “PTSD”
AND
“Physical activity” OR “exercise” OR
“sedentary” OR “inactivity” OR “sitting”
(N = 201)
Excluded During Title Review
(n = 107)
Excluded During Abstract
Review
(n = 50)
PA or PTSD Not Included as
Unique Outcome
(n = 16)
Unique Articles
(n = 44)
PTSD Symptoms Not
Assessed
(n = 6)
Did Not Analyze PTSD or PA
Associations
(n = 3)
Insufficient Empirical or
Statistical Rigor
(n = 4)
Final Articles Included in Review
(n = 15)
Figure 1.
disorder.
Scheme for physical activity article selection process, January 1980–July 2014. PA, physical activity; PTSD, post-traumatic stress
those without PTSD (36, 38), and 2 reported no differences
in physical activity by PTSD status (39, 43). The results for
inactivity by PTSD status are also mixed, with 1 reporting
no differences in inactivity by PTSD status (41) and 2 reporting that individuals with PTSD are significantly more
likely to be inactive (34, 43). One of these studies reported
that, compared with veterans with other psychiatric diagnoses, veterans with PTSD had the highest odds of no regular exercise (odds ratio = 1.09, 95% confidence interval:
1.06, 1.12) (34).
The other 5 observational studies identified in this review
examined the associations between PTSD symptoms and
physical activity (21, 35, 37, 40, 42). Two studies, both conducted in young adult samples (mean age, <25 years), reported that, as PTSD symptoms increased, physical activity
levels decreased (21, 42). One of these studies reported that
only hyperarousal symptoms were significantly and negaEpidemiol Rev 2015;37:103–115
tively associated with exercise (42). The remaining 3 studies
reported no significant associations between PTSD symptoms and physical activity (35, 37, 40).
Preventive effects of exercise on developing PTSD.
There were 2 published prospective cohort studies that examined the relationships between exercise and risk of PTSD
(44, 45). The first study examined the relationship between
changes in exercise over time (increase in exercise, no change
in exercise, decrease in exercise) and probable PTSD among
trauma-exposed firefighters (45). This study reported that a
decrease in exercise over time is related to delayed onset of
PTSD ( present at follow-up but not enrollment) and is associated with a lower likelihood of recovery from PTSD. The
other prospective cohort study examined the associations between physical activity (measured at follow-up) and prospectively assessed PTSD symptoms (measured at baseline and
follow-up) among 38,883 US service members enrolled in
106 Hall et al.
Search Terms Used to Identify Articles
“Posttraumatic stress disorder” OR “posttraumatic stress disorder” OR “PTSD”
AND
“Diet” OR “nutrition” OR “eating disorder”
OR “disordered eating” OR “binge eating”
(N = 187)
Excluded During Title Review
(n = 77)
Excluded During Abstract
Review
(n = 55)
EB or PTSD Not Included as
Unique Outcome
(n = 22)
PTSD Not Assessed (Trauma)
(n = 5)
Unique Articles
(n = 55)
BED Not Isolated
(n = 14)
Did Not Analyze PTSD or EB
Associations
(n = 1)
Insufficient Empirical or
Statistical Rigor
(n = 3)
Final Articles Included in Review
(n = 10)
Figure 2. Scheme for eating behaviors article selection process, January 1980–July 2014. BED, binge eating disorder; EB, eating behavior;
PTSD, post-traumatic stress disorder.
the Millennium Cohort Study (44). The most consistent results were reported for vigorous physical activity, such that
those who reported increased engagement in vigorous physical activity were at significantly reduced odds of having
new-onset symptoms and/or persistent PTSD symptoms.
Those individuals who reported “cannot physically do”
strength training or vigorous physical activity had significantly higher odds of new-onset PTSD symptoms. No significant effects for any of the other activity intensities were
observed.
Exercise as an intervention for PTSD symptoms. Two
intervention studies utilized physical activity as a treatment
for PTSD symptoms, and both reported beneficial effects
(46, 47). The first study from 2005 was a small, single-arm,
community-based study of physical activity for PTSD symptoms (47). Nine adults with PTSD completed the 10-week exercise regimen and demonstrated significant before and after
reductions in PTSD symptoms.
The second intervention study from 2014 examined the
effects of a 2-week aerobic exercise program on PTSD symptoms (46). Thirty-three participants with PTSD were randomly
assigned to 3 exercise conditions: Group 1 (prompted attention
to somatic arousal during exercise); Group 2 (distraction from
somatic arousal during exercise); and Group 3 (exercise with
no distractions or interoceptive prompts). Results of this study
showed that exercise, with and without distraction, significantly reduced PTSD symptoms. Interestingly, when specific
PTSD symptoms were examined, significant group × time
Epidemiol Rev 2015;37:103–115
PTSD, Exercise, and Eating Behaviors 107
interactions were found, such that those randomized to Group
1 experienced significantly less reduction in hyperarousal
symptoms than did the other 2 groups.
PTSD and eating behaviors
PTSD as a correlate or predictor of eating behaviors.
There were 9 published observational studies that reported the
associations between PTSD and eating behaviors (36, 48–55),
all of which were conducted between 1997 and 2014. These
studies can be further divided into 2 categories based on primary outcome: disordered eating behaviors (n = 7) and dietary
content (n = 2).
Six of the 9 studies examined the associations between
PTSD and binge eating disorder and reported conflicting
results (48–50, 52–55). Three of these studies reported no
significant differences in the prevalence of PTSD between
patients with and without binge eating disorder (49, 50, 55),
while 2 studies reported significant associations between
PTSD and binge eating disorder (52, 56). Only 1 study explored the association between PTSD symptoms and binge
eating behaviors (48). This study was completed in a sample
of treatment-seeking women with substance use disorder and
PTSD. Women who engaged in binge eating had significantly more PTSD symptoms than did those who do not binge
eat. These between-group differences were not observed for
the Clinician-Administered PTSD Scale (CAPS) (57) clinical
interview.
One study took a slightly different approach to examining the associations between PTSD and disordered eating,
focusing instead on the subclinical indicator of “emotional
eating” as assessed by self-report (54). Participants with
PTSD exhibited significantly more emotional eating than
did participants without PTSD. PTSD symptom severity was
also significantly associated with increased emotional eating,
explaining a significant proportion of the variance in adjusted
models.
Two studies examined the association between PTSD and
dietary quality (36, 51). One study of young women reported that PTSD symptoms were associated with an increased frequency of fast food and soda consumption (51).
Another study reported that participants with PTSD eat significantly fewer servings of fruit per day compared with persons without PTSD (36). No differences in consumption of
vegetables, soda, caffeine, or fast food by PTSD status were
observed.
Preventive effects of eating behaviors on PTSD. No prospective studies of PTSD and dietary behaviors were identified in this review.
Eating behavior interventions for PTSD symptoms. Only
1 dietary intervention study for PTSD was identified (58).
This study examined the efficacy of 12-week fish oil supplementation in trauma-exposed Japanese Disaster Medical Assistance team workers. This single-blind, randomized
parallel-group trial reported no significant effects for fish oil
supplementation on PTSD symptoms. However, there was a
significant gender effect, such that women in the fish oil group
reported significantly greater improvements in PTSD symptoms compared with women in the psychoeducation only
group, whereas no differences were noted in men.
Epidemiol Rev 2015;37:103–115
Summary of results
In summary, 15 studies of PTSD and physical activity and
10 studies of PTSD and eating behaviors in adults from 24
unique study populations were included in this review. Regarding the PTSD and physical activity literature, physical
activity was identified as a primary outcome in only 6 of these
studies. The methods of assessing PTSD and physical activity, study design, and sample characteristics varied widely
across these 15 studies. Results from the observational studies are split, with half of the studies reporting a significant
negative association between PTSD and physical activity
and the other half reporting no significant associations between PTSD and physical activity. Studies that examined
specific PTSD symptoms reported significant associations
for PTSD-hyperarousal only. Results of the 2 pilot intervention studies, however, suggest a positive effect of physical activity intervention on PTSD symptoms.
Regarding the PTSD and eating behaviors literature, binge
eating disorder was the primary outcome in 5 of these studies.
Four studies examined dietary quality and subclinical eating
behaviors. Results from the observational studies were split,
with 3 studies reporting no association between PTSD and
binge eating disorder and 4 studies reporting high rates of
binge eating disorder among adults with PTSD. The studies
examining dietary content are also inconclusive, though suggestive of an association between PTSD and eating fewer
servings of fruit and consuming more fast food. Only 1 intervention study was identified and reported significant effects
of fish oil supplementation on PTSD symptoms only among
women.
DISCUSSION
Studies have consistently shown that habitual physical activity and a healthy diet are associated with better physical
and mental health (59–62). As the evidence continues to grow
showing increased risk of cardiometabolic diseases among
individuals with PTSD, so too does the recognition among
the clinical community that PTSD is more than “just” a mental illness. However, as Levine et al. cogently note, “Current
management of PTSD focuses on the psychiatric parameters
of this condition with little emphasis on addressing the comorbid cardiometabolic risk factors that impair overall longterm health outcomes” (8, p. 1). Even less attention is paid to
health-promoting behaviors in this at-risk population; instead,
the focus of clinical research has been on adverse health behaviors such as tobacco use, alcohol/substance abuse, and eating
disorders such as anorexia nervosa and bulimia nervosa.
While these adverse behaviors clearly play a critical role
in disease risk, it is important to recognize that optimal health
is achieved by minimizing adverse health behaviors and
promoting healthy behaviors. Years of research on PTSD and
tobacco use in veterans have resulted in numerous evidencebased smoking cessation interventions for veterans with
PTSD (63–65). It appears that the time is ripe to establish a
similar scientific basis to inform health promotion interventions targeting physical activity and diet in adults with PTSD.
An important and necessary first step in guiding research
in this area is to evaluate existing models of PTSD and health
Sample
First Author, Year
(Reference No.)
Study Design
Population
Godfrey,
2013 (36)
Cross-sectional
Nonveteran (88%)
and veteran
adults
Kozaric-Kovacic,
2009 (38)
Cross-sectional
Male Croatian
veterans
Kukihara,
2014 (39)
Cross-sectional
Zen, 2012 (43)
Mean Age,
Years
39.9
Setting
Primary Outcome
Analytical
Methods
Results
PA Measure
PTSD
Measure
Limitations
Epidemiol Rev 2015;37:103–115
Total No.
No. with
PTSD
80a
25
San Diego VA and
university
health-care
facilities
Diet and exercise Multivariate
Participants with PTSD
ANOVA (not
reported significantly
adjusted)
less vigorous PA. No
other differences across
PA were observed.
269
University hospital
BMI and PTSD
Government survey
Trauma,
t tests
depression,
and resilience
No significant differences in Measure not reported
exercise habits were
reported for respondents
with vs. without PTSD.
IES-R
PA measure not
(yes/no)
reported and does
not include
multivariable
results
Clinical
Association
between
PTSD and
health
behaviors in
patients with
CVD
Multivariate
logistic
regression
models
(adjusted)
Patients with PTSD were
Questionnaire
more likely to be inactive
developed by
vs. those with no PTSD.
authors
No differences were
(dichotomized as
observed for
inactive vs. active)
self-reported frequency
of moderate or heavy
exercise.
Adjustment for
depression significantly
impacted these
associations.
CDIS
PA measure of
(yes/no)
unknown validity
and CVD patients
(generalizability)
1999 Large Health
Survey of
Veteran
Enrollees
Obesity and
health
behaviors
Multivariate
logistic
regression
67.5% of patients with
Single item: “How often ICD-9
Single item:
PTSD reported no
do you engage in
criteria
unvalidated PA
weekly exercise.
regular activities
(yes/no)
measure and no
Veterans with PTSD
(e.g., brisk walking,
assessment of
have the highest odds of
jogging, bicycling)
PTSD symptoms
no regular exercise
long enough to work
(adjusted model) vs.
up a sweat?” (“any
those with other
regular exercise” vs.
psychiatric diagnoses.
“none”)
University
PTSD,
depression,
and health
status
Bivariate
correlations
and linear
regression
Significant, negative
Single item from the
association reported
Health Risk
between PTSD symptom
Appraisal
severity and exercise.
questionnaire
PTSD-hyperarousal was
the only significant
predictor of exercise in
regression analyses.
PCL-C
Government
PTSD and
low-grade
inflammation
χ2 test
No significant differences in Inactivity defined as
physical inactivity (%)
performing sports
were reported between
for less than 1 hour
those with vs. those
per week
without PTSD.
SCID
PA measure of
(yes/no)
unknown validity,
only sports were
assessed, and
does not include
multivariable
results
University
Smoking status,
exercise, and
PTSD
symptoms
Hierarchical
multiple
regression
analyses
Significant main effect of
exercise on
PDS-hyperarousal
symptoms only
Exercise Habits
QuestionnaireRevised (METs)
SCID, PDS Low mean levels of
PTSD symptoms
VA 90-day
residential
rehabilitation
program for
PTSD
Suicide risk
Zero-order
correlations
On average, reported very
infrequent PA.
PTSD symptoms not
significantly associated
with exercise
Single item at intake:
PCL-M
“Over the past
month, how often
have you engaged
in regular activities
long enough to work
up a sweat?”
30–61b
478
Earthquake,
tsunami, and
nuclear disaster
survivors in
Japan
58.0
241
Cross-sectional
Outpatients with
documented
cardiovascular
disease
64
1,022
95
Chwastiak,
2011 (34)
Epidemiologic
Veterans
64
501,161
31,072
Rutter,
2013 (21)
Cross-sectional
Undergraduate
psychology
students
18
200
Spitzer,
2010 (41)
Cross-sectional
community
survey and
medical
examination
Communitydwelling adults
54.2
Vujanovic,
2013 (42)
Cross-sectional
survey
Community sample
of traumaexposed adults
24.3
Davidson,
2013 (35)
Cross-sectional
Inpatient veterans
with PTSD
45
3,049
55
86a
346
χ2 test
Significantly fewer veterans
with PTSD engaged in
weekly PA compared
with veterans without
PTSD.
Short form of the IPAQ CIDI (yes/
no)
Weekly PA (yes/no).
Item wording not
provided
Does not include
multivariable
results and small
sample of PTSD
ICD-10
PA measure not
criteria
provided and does
(yes/no)
not include
multivariable
results
Does not include
multivariable
results, student
sample (limited
generalizability),
and PTSD
frequency not
reported
Inpatient sample,
single item,
unvalidated PA
measure, does not
include
multivariable
results, and no
comparison group
Table continues
108 Hall et al.
Table 1. Summary of Published Studies on Physical Activity and PTSD, 1980–2014
Epidemiol Rev 2015;37:103–115
Table 1. Continued
Sample
First Author, Year
(Reference No.)
Study Design
Population
Mean Age,
Years
Total No.
No. with
PTSD
Setting
Primary Outcome
Analytical
Methods
Results
PA Measure
PTSD
Measure
Limitations
Hoerster,
2012 (37)
Cross-sectional
Iraq and
Afghanistan
veterans
29.8
266
Veterans assessed
at intake to
VAMC
postdeployment
health clinic
PA correlates
t test and
multivariate
models
No significant association
Short Form of the
between PTSD
IPAQ. Categorized
symptoms and likelihood
as meeting PA
of meeting/not meeting
recommendations
PA recommendation
(≥150 vs. <150
(150 minutes/week of
minutes/week of
moderate-intensity
moderate-vigorous
activity).
PA).
PCL-M
Medina,
2011 (40)
Cross-sectional
Participants with
trauma
exposure and
reported alcohol
consumption
22.3
114
University
Alcohol use for
coping with
trauma
Zero-order
correlations
No significant association
Exercise Habits
between PTSD symptom
Questionnaireseverity and exercise
Revised
SCID, PDS Does not include
multivariable
results
LeardMann,
2011 (44)
Prospective
cohort
US service
members
Millennium Cohort
Study
PA and
prospectively
assessed
PTSD
Multivariable
logistic
regression
(adjusted)
Vigorous PA is associated
Self-reported minutes/ PCL-C
with decreased odds of
week were
both new-onset and
measured across 3
persistent PTSD
categories of
symptoms.
activity: strength
Those with PTSD
training, vigorous
symptoms at follow-up
PA, and light/
were proportionately less
moderate PA. Then
active than those without
they were classified
symptoms at follow-up.
into 1 of 5
categories for each
type of activity (from
“cannot do” to “very
active”).
Soo, 2011 (45)
Prospective
cohort
Firefighters
exposed to
World Trade
Center disaster
Clinical
Trends in
probable
PTSD
Cox regression Reporting a decrease in
Change in exercise
models
exercise associated with
since last
lower likelihood of
questionnaire
recovery from probable
(measure not
PTSD.
reported)
Reporting a decrease in
exercise associated with
delayed onset of
probable PTSD
Manger,
2005 (47)
Single-arm,
10-week
exercise trial
Adults with PTSD
from the
community
Community/YMCA
PTSD symptoms Paired-sample
t tests
Significant reductions in
PTSD symptoms
Fetzner,
2014 (46)
RCT (2-week
Adults with PTSD
exercise with
or without
distraction)
University
PTSD symptoms Hierarchical
linear
model
Exercise, with and without
6 sessions of aerobic
PCL-C
distraction,
exercise (Group 1:
demonstrated decreases
PA plus cognitive
in PTSD symptoms.
distraction; Group 2:
PA plus
interoceptive
prompts; Group 3:
PA alone)
38,883a
39.5
1,401
11,006
36.9
33a
Adherence to
intervention
PA measure of
unknown validity,
PA categorization
scheme not
readily
interpretable, and
age of sample not
reported
PCL-C
PA measure of
unknown validity
and does not
include results
adjusted for
depression
PDS,
CAPS
No comparison
group, small
sample, and
demographic
characteristics not
reported
Lacking “no-exercise”
control group and
small sample
Abbreviations: ANOVA, analysis of variance; BMI, body mass index; CAPS, Clinician Administered Post-Traumatic Stress Disorder Scale; CDIS, Computerized Diagnostic Interview Schedule; CIDI, Composite International Diagnostic Interview; CVD,
cardiovascular disease; ICD-9, International Classification of Diseases, Ninth Revision; ICD-10, International Classification of Diseases, Tenth Revision; IES-R, Impact of Event Scale-Revised; IPAQ, International Physical Activity Questionnaire; MET,
metabolic equivalent; PA, physical activity; PCL-C, Post-Traumatic Stress Disorder Checklist-Civilian Version; PCL-M, Post-Traumatic Stress Disorder Checklist-Military Version; PDS, Posttraumatic Diagnostic Scale; PTSD, post-traumatic stress
disorder; RCT, randomized controlled trial; SCID, Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders; VA, Veterans Affairs; VAMC, Veterans Affairs Medical Center; YMCA, Young Men’s Christian Association.
a
For Godfrey et al. (36), 45% female; for Vujanovic et al. (42), 58.1% female; for LeardMann et al. (44), 22.3% female; for Fetzner and Asmundson (46), 76% women.
b
Range of years.
PTSD, Exercise, and Eating Behaviors 109
26 (9
adherent,
used for
analyses)
PTSD prevalence not
reported
Sample
First Author, Year
(Reference No.)
Study Design
Population
Mean Age,
Years
Total No.
No. with
PTSD
Setting
Primary Outcome
Analytical
Methods
PTSD Measure
Limitations
Epidemiol Rev 2015;37:103–115
Relationship
χ2 test
between eating
disorders and
PTSD
No differences in
Binge eating
PTSD among those
disorder
with vs. those
screening
without binge eating
questions
disorder
National Women’s
Study PTSD
module (yes/no)
Does not include
multivariable
results
Clinical
Associations
ANOVA/
between binge
ANCOVA
eating disorder
and PTSD
Patients with binge
SCID, eating
eating disorder plus
disorder
PTSD did not have
examination
a greater frequency
of binge eating
compared with
binge eating
disorder without
PTSD
SCID (yes/no)
Sample limited to
obese plus binge
eating disorder
patients
Prevalence of PTSD
did not differ by
binge eating
disorder status
CIDI, ICD-10 (yes/no)
Does not include
multivariable
results and
treatmentseeking patients
with eating
disorders
PTSD symptom
SCID
severity
significantly
associated with
lifetime but not
current binge eating
disorder severity
CAPS
Cross-sectional
design
PTSD and obesity Multivariate
logistic
regression
(adjusted)
Significant association CIDI (yes/no)
of past year PTSD
with past year binge
eating disorder
CIDI (yes/no)
Cross-sectional
design and small
sample of PTSD
Community
substance
treatment
program
Eating disorder
symptoms
t tests
PTSD symptoms
significantly higher
among those with
vs. those without
binge eating
The Eating Disorder CAPS, PTSD
Examination
Symptom Scale
self-report
Questionnaire
Treatment-seeking
women with
substance use
disorder
University
Emotional eating
Univariate
ANCOVA
and linear
regression
(adjusted)
PTSD participants
exhibited
significantly more
emotional eating
than participants
without PTSD.
More severe PTSD
is associated with
increased
emotional eating.
PTSD severity
explained a
significant
proportion of
variance in eating
behavior.
Dutch Eating
Behavior
Questionnaire
CAPS, SCID
Cross-sectional
Clinical
Association
Ordinal and
between PTSD
binary
and dietary
logistic
behaviors
regression
models
PTSD symptoms
positively
associated with
frequency of fast
food consumption
and frequency of
soda consumption
Questions
generated for
this study
PDSQ (altered)
Unvalidated eating
behavior
measure and
sample limited to
young women
Cross-sectional
Participants in the
National
Women’s
Study
46.1
3,006
376
Grilo,
2012 (50)
Cross-sectional
Obese patients
with binge
eating disorder
42.7
105
25
von Lojewski,
2012 (55)
Cross-sectional
Patients receiving
treatment for
eating
disorders
20.9
226
Clinical,
Psychiatric
inpatient and
comorbidity in
outpatient
eating
disorders
Litwack,
2014 (52)
Cross-sectional
US military
veterans
51.9
499
Clinical
Symptom severity General linear
of bulimia
models
nervosa, binge
(adjusted)
eating
disorder, and
comorbidities
in veterans
Pagoto,
2012 (56)
Cross-sectional/
epidemiologic
US adults
44.9
20,013
CPES
Cohen,
2010 (48)
Cross-sectional
(secondary analysis
of baseline data)
Women with
substance use
disorder and
PTSD
38
Talbot,
2013 (54)
Cross-sectional
Communitydwelling adults
and veterans
30.2
93
44
Hirth,
2011 (51)
Cross-sectional
Women who
visited select
reproductive
clinics in Texas
20.8
3,154
1,203
122
Eating Behavior
Measure
Telephone
interviews
Dansky,
1997 (49)
1,341
Results
t test
CIDI, ICD-10 (yes/
no)
Table continues
110 Hall et al.
Table 2. Summary of Published Studies on Eating Behaviors and PTSD, 1980–2014
RCT (fish oil plus
Japanese
psychoeducation vs.
Disaster
psychoeducation);
Medical
12 weeks,
Assistance
single-blind study
Team workers
deployed to
disaster areas
Nishi,
2012 (58)
Epidemiol Rev 2015;37:103–115
Abbreviations: ANCOVA, analysis of covariance; ANOVA, analysis of variance; CAPS, Clinician Administered Post-Traumatic Stress Disorder Scale; CIDI, Composite International Diagnostic Interview; CPES, Collaborative Psychiatric Epidemiology
Surveys; ICD-10, International Classification of Diseases, Tenth Revision; ITT, intention to treat; PDSQ, Psychiatric Diagnostic Screening Questionnaire; PTSD, post-traumatic stress disorder; RCT, randomized controlled trial; SCID, Structured Clinical
Interview for the Diagnostic and Statistical Manual of Mental Disorders; VA, Veterans Affairs.
a
For Godfrey et al., 2013 (36), 45% female.
Single-blind study
and
demographic
characteristics
not reported
No significant
Fish oil
Impact of Event
differences in PTSD
supplementation
Scale-Revised
changes between
the 2 groups.
In women,
significantly greater
reductions in PTSD
symptoms in the
fish oil group
ANCOVA with
ITT analysis
(adjusted)
172
Clinical
PTSD symptoms
Unvalidated eating
behavior
measure
PTSD associated with Self-report measure CIDI (yes/no)
eating fewer fruits/
created for this
day vs. without
study
PTSD.
No group
differences in
consumption of
vegetables, soda,
caffeine, or fast food
Multivariate
ANOVA (not
adjusted)
25
80a
Cross-sectional
Godfrey,
2013 (36)
Nonveteran (88%)
and veteran
sample
39.9
No. with
PTSD
Total No.
Mean Age,
Years
First Author, Year
(Reference No.)
Table 2. Continued
Study Design
Population
Sample
Setting
San Diego
VA and
university
health-care
facilities
Primary Outcome
Diet and exercise
Analytical
Methods
Results
Eating Behavior
Measure
PTSD Measure
Limitations
PTSD, Exercise, and Eating Behaviors 111
provided in the literature. Current theoretical models relating
PTSD to physical health outcomes emphasize risky behaviors (6, 66, 67). The evidence synthesized in this review
suggests that health-promoting behaviors such as physical
activity and healthy eating behavior should be included as
mediating variables along the PTSD–health pathway. There
is also reason to consider including sedentary behavior and
binge eating alongside tobacco use and substance abuse as
risky behaviors in these models. Sedentary behavior has been
shown to be a distinct risk factor, independent of amounts of
physical activity, for poor health outcomes including cardiometabolic and inflammatory biomarkers, obesity, functional
decline, and depression (68–71). Binge eating and binge eating disorder demonstrate many of these same associations
(72–75).
In an effort to inform future research in this area, limitations in the existing literature and considerations for future
work are discussed here. Specifically, issues related to sample
characteristics, study design, methodology, and study outcomes are presented.
Sample characteristics
The studies included various samples ranging from
treatment-seeking to non–treatment-seeking clinical populations, community- and population-based samples, and military service members and veterans. Although a strength in
terms of generalizability, the heterogeneous sample characteristics make it difficult to summarize these results in a
meaningful way. Many of these studies are limited by underrepresentation of ethnic minorities and women (the latter in
studies of military service members and veterans). Elevated
rates of chronic PTSD have been reported among black and
Hispanic military veterans compared with white veterans, attributed in part to their greater rates of combat exposure (76).
Women, both civilian and military, have high rates of exposure to trauma (77). Female veterans are a growing (∼10%
of US military veterans are female) (78) and understudied
group. A greater effort must be made to include representative
samples of ethnic minorities and females in studies of PTSD
and these health behaviors. Finally, a notable limitation of
many of these studies is a focus on young and middle-aged
adults, with very little representation of older adults (>65
years of age). Both the civilian and the veteran populations
are experiencing a graying effect, with nearly 40% of male
veterans being over the age of 65 (78).
Study design
The literature to date is limited largely to observational
studies, with only 2 longitudinal and 3 intervention studies
of PTSD and physical activity or eating behavior identified.
The lack of longitudinal and intervention studies points to future research in this area. Both cross-sectional studies in
larger and more diverse populations and longitudinal studies
are needed to 1) elucidate the effects of changes in PTSD
symptom severity and changes in health behaviors, 2) examine the impact of aging with chronic PTSD on health and
physical function, and 3) explore barriers and facilitators
to an active lifestyle and healthy eating behaviors in adults
112 Hall et al.
with PTSD. It is recommended that future studies also measure and evaluate mediating and moderating factors, which
may provide a more nuanced understanding of the relationships between PTSD and physical activity and eating behaviors. Such factors may include functional status, psychosocial
factors, socioeconomic status, environmental characteristics,
and somatic symptoms. Perhaps the most notable of these
factors is depression. PTSD and depression are highly comorbid in national surveys and in military samples. Depression has also been linked to physical inactivity and poor
eating behaviors (79, 80). Although some of the studies included in this review examined these associations with multivariable models including depression, others did not adjust
for depression and/or examined only univariate associations
(Tables 1 and 2). Unfortunately, many of these studies were
underpowered to examine the mediating or moderating effects of depression; however, this is an important question
for future studies in larger samples. The only study that examined the independent effects of PTSD and depression in
a stepwise fashion reported that the association between
PTSD and physical inactivity was explained, in part, by depression (43).
Feasibility studies of physical activity and eating behavior
change are also needed in veterans with PTSD, which will inform subsequent larger efficacy trials. As persons with PTSD
engage in multiple unhealthy lifestyle behaviors, future studies
designed to promote multiple health behavior change (e.g., increased exercise, decreased tobacco use, healthier diet) would
be particularly informative. The scientific foundation generated by these future research efforts will be instrumental to informing more integrated clinical care models that integrate
preventive therapies (e.g., exercise, diet, pharmacological modalities) with psychiatric intervention to treat PTSD and associated cardiometabolic disease risk factors.
Measurement
Another important consideration among these studies is
the validity of PTSD, physical activity, and eating behavior
assessments. The studies approached the construct of PTSD
in 3 ways: 1) coding PTSD status as yes/no using diagnostic
codes, 2) coding PTSD yes/no using clinical interview, or
3) assessing PTSD symptoms based on self-report. Of those
studies that did assess PTSD via interview, different clinical
instruments, with different measurement properties and sensitivities, were used. Consistency in assessing and reporting
PTSD status and symptoms would greatly strengthen this
body of work. The Clinician Administered PTSD Scale is
widely considered the “gold standard” of PTSD assessment,
and it provides both a categorical diagnosis and a scale of
symptom severity. However, the Clinician-Administered
PTSD Scale requires a great deal of time and trained personnel to administer the interview. When possible, clinical
interviews or validated self-report assessments of PTSD are
preferred over the use of diagnostic codes, as the latter do not
indicate current symptomology. Of note, only 2 of these studies measured or explored specific PTSD symptoms (i.e., hyperarousal, reexperiencing, avoidance) and their associations
with physical activity or eating behavior, highlighting another area for further research efforts.
The studies also varied widely in their approach to assessing physical activity and eating behavior. A critical limitation
of the current literature is the utilization of self-report tools of
unknown reliability and validity to assess physical activity.
Several of the studies provided no information on how physical activity was assessed or used a single-item measure of
unknown validity. Only 4 studies used a validated physical
activity questionnaire. Studies of eating behaviors used clinical interview or diagnostic codes to determine binge eating
disorder, but the assessment validity of subclinical eating behaviors and dietary habits was unclear.
Future studies building on the data reported here should
use validated, multiitem physical activity and dietary assessment instruments. Other assessment methods such as activity
monitors, food diaries, and ecological momentary assessment technology to capture “real-time” physical activity
and eating behaviors are needed so that we can better understand why it is that PTSD is associated with activity and eating behavior. Finally, population-based studies that examine
physical activity and sedentary behavior in adults with PTSD
are now feasible with the availability of objective activity
monitors (e.g., pedometers, accelerometers).
In closing, there is a paucity of research examining the
associations among PTSD, physical activity, and eating
behaviors in civilian and military populations. Although
preliminary, the results of these studies suggest that PTSD
may be negatively associated with physical activity and unhealthy eating behaviors. However, the results of these studies are mixed, pointing to the need for future research in
representative samples of adults including veterans, which
utilize validated outcome measures, appropriate comparison groups, and multivariable analytical techniques. Such
studies are needed to inform future intervention studies. Intervention studies for PTSD that examine secondary effects
on physical activity and eating behaviors, as well as interventions to change physical activity and eating behaviors
that test change in PTSD symptoms, are potential areas
for future research.
ACKNOWLEDGMENTS
Author affiliations: Geriatric Research, Education, and
Clinical Center, Veterans Affairs Medical Center, Durham,
North Carolina (Katherine S. Hall); Department of Medicine,
Duke University Medical Center, Durham, North Carolina
(Katherine S. Hall, William S. Yancy); VA Puget Sound
Healthcare System, Seattle Division, Mental Health Service,
Seattle, Washington (Katherine D. Hoerster); Department of
Psychiatry and Behavioral Sciences, University of Washington,
Seattle, Washington (Katherine D. Hoerster); and Center for
Health Services Research in Primary Care, Department of
Veterans Affairs Medical Center, Durham, North Carolina
(William S. Yancy).
Dr. Katherine S. Hall is supported by Career Development
Award RRD-E782MM from the Department of Veterans
Affairs.
We thank Megan Van Noord for her thoughtful comments
on the literature search process used in this article.
Epidemiol Rev 2015;37:103–115
PTSD, Exercise, and Eating Behaviors 113
The views expressed by the authors do not necessarily reflect the views of the Department of Veterans Affairs.
Conflict of interest: none declared.
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