Exercise is an often misunderstood, and sometimes overlooked, part of ED treatment. We lack well-studied, evidence-based protocols, and even among clinicians there is a lack of consensus about the best approach.
Health Benefits of Exercise
No doubt there are health benefits of exercise. For instance, exercise improves cardiopulmonary functioning, improves insulin sensitivity and blood glucose management, reduces risk factors for heart disease, reduces the risk of some cancers, improves brain functioning and mood, strengthens muscles and bones, and so on. It really is powerful stuff. Hence, we have adopted the ever-so-typical American attitude of "if some is good, then more must be better!" And we tend to see people at the extremes with exercise – doing none at all or doing a ton of it.
Exercise and Eating Disorders
While exercise can be a health-enhancing behavior, it can also be an eating disorder behavior. This is where it gets tricky. It's hard to tell someone not to exercise when we know they are getting legitimate physical health benefits, but we have to weigh that with the cost of the eating disorder and the psychological detriment. There are times when individuals are so medically compromised from their ED that it's a no brainer to tell them they can't work out, but even in a starved state some people just can't stop.
Research suggests that ED-related exercise occurs in 84% of patients with AN/BN (Taranis and Meyer, 2011). It can be used as a form of purging, and return to disordered exercise is a known predictor of relapse (Zunker et al., 2011). Not to mention that ongoing disordered exercise is associated with poor treatment outcomes (Taranis and Meyer, 2011).
Athletes have an increased risk of eating disorders (APA, 2006), particularly those in weight/appearance focused sports such as gymnastics, figure skating, dance, distance running, body building, wrestling. Common for people with ED’s to exercise with pain/injury, even stress fractures, especially in the world of competitive athletics where these things are normalized and the attitude is "no pain, no gain." It is estimated at at least 1/3 female collegiate athletes has the Female Athlete Triad, which is now being called REDS (relative energy deficiency syndrome) and is being recognized in males too.
A common misconception is that exercise always increases bone density. This is NOT true when someone is underweight. Without enough body fat to menstruate, there also isn't enough circulating estrogen to protect the bones and they start to demineralize. Therefore, high-impact exercise actually causes bone loss with anorexia. Weight increase is the only effective treatment for anorexia-induced osteopenia/osteoporosis. No amount of birth control pills or calcium supplements will fix this without weight restoration. Bone loss can occur in as little as 6 months after onset of the ED, and can be irreversible if full osteoporosis develops.
With bulimia patients sometimes use exercise as a form of purging, which unfortunately has become normalized by our culture. I often hear the general public making statements like, "I ate pizza so now I need to work out. " Or exercising before eating to "earn" their food.
People with binge eating disorder tend to have an on/off relationship with exercise. When they are on the dieting bandwagon they exercise, and when they fall off and are in the bingeing pattern they often stop exercising. Like so many things with ED's, it is black and white, all or none.
Exercise and ED Treatment
So what do we do? There are no concrete answers. Research has shown that exercise doesn't compromise weight restoration for patients who are underweight. Yet it is still common for treatment providers to tell patients that they have to reach a certain weight in order to be able to exercise. How are we supposed to sever the psychological bond between weight and exercise if we make the right to exercise based on a goal weight?
We do know that food deprivation increases activity – it's called "starvation-induced hyperactivity" and it is thought to be a survival mechanism. If no food is available, we need to seek out food which requires movement. In fact, when put on calorie-restricted diets rats will run until they die (Exner et al., 2000). Thus, it is important that a person is fueling appropriately for exercise.
It is the "why" more so than the "what" or "how much" exercise a patient does that makes it disordered. Modest exercise is sufficient for health, which equates to about 20-60min, 3-5 days/wk. If exceeding the limits recommended by the treatment team, exercise may need to be put on hold, as the psychopathology of exercise and the ED needs to be further addressed. Recovered patients often report feeling relieved then they were required to “take a break” from exercise, otherwise they feel obliged to exercise compulsively.
“Research examining the multidimensional nature of exercise has found that there may not be a direct relationship between exercise behavior and ED sx…The individual’s pathological motivation to exercise (i.e. exercise dependence), and not the exercise behavior per se (i.e. frequency, duration, type, intensity), is the critical component that plays the mediation role in the context of ED” (p.43)
(Hausenblas et al., 2007)
Setting limits with exercise:
- Can be a powerful motivation tool
- Treatment appointments should not be missed to train or compete
- No exercise if not complying with meal plan, not medically stable, excessive when exercises
For patients who have the all/none approach to exercise, we need to work with them on how to incorporate movement into their life in a way that is not only sustainable, but is also life-enhancing. These individuals already know that exercise would be good for their health, what they need is a reason to want to keep doing it and enjoy it. It is helpful to have them focus on their energy levels, mood, ability to focus, creativity, anxiety, and other ways they feel different after moving their bodies.
Recovering Amidst a Cultural Obsession
Ultimately, like the relationship with food, the relationship with exercise needs to be explored and redefined during the treatment process. This process needs to be highly individualized based on the needs of each client. Since we don't have clearly defined treatment protocols when it comes to exercise, clinicians have to rely on clinical intuition and trial and error.
It is difficult to reach a place of peace with exercise in a world that is so obsessed with it in a very toxic way. Social media is filled with posts about "fitspiration" and it's not uncommon for people to post about their workouts, and to then receive the positive accolades from followers for doing so. Culturally we tend to think of exercise as a way to burn calories and control weight. (As if there are no other reasons to work out.) Gyms are full of weight loss products and programs. We have apps on our phones that track our calories burned and watches to wear that do the same. And as if marathons aren't enough, now we have to have ultramarathons and ever more extreme versions of working out like boot camps that are all about disconnecting from your body and disobeying its signals to slow down or stop. I'm not saying that any of these activities are bad or wrong, in fact I am a marathon runner myself; but what I am saying is that we keep taking it to extremes. I cannot even count how many people have told me that yoga and walking "don't count" as exercise because they're not vigorous enough.
For those with ED's it is hard to see through the haze of these distorted attitudes. Recovery means returning to the wisdom of their own bodies and listening when the body speaks.