Exercise Series, Part 2: The Role of Exercise in Eating Disorder Recovery

The role of exercise in eating disorder treatment is complicated and a topic of some debate within the recovery field. Whereas I used to feel strongly that clients who were operating in a calorie deficit due to restriction should never be allowed extra movement or exercise, I’ve shifted my thinking a bit. Now I think it’s best to avoid approaching the topic with a one-size-fits-all approach, and recommendations should be based on each individual client, weighing the potential pros and cons of exercise during recovery.

What are the pros and cons of exercise during eating disorder recovery?

Potential Benefits

For the general population, exercise has many known health benefits, both mentally as well as physically, including:

• Improving mood and ability to manage stress and emotions
• Improving mobility and helping prevent injuries
• Reducing risk for heart disease and reversing cardiac abnormalities
• Reducing risk of some cancers
• Strengthening muscles and increasing bone density
• Helping manage blood sugar and insulin levels
• Improving sleep

However, if an individual is not physically stable and properly nourished, exercise can actually worsen their physical condition. Which is a nice lead-in to the discussion about the drawbacks of exercise in recovery…

Potential Drawbacks

One of the most concerning issues for someone with an eating disorder exercising is that expending additional energy during a starvation state puts even more strain on an already stressed and weakened body. In other words, exercise exacerbates the physiological consequences of being malnourished. It can worsen hormonal dysfunctions, harm cardiovascular systems, and further decrease bone density. Injuries are more likely to happen (e.g. stress fractures are common).

I often hear clients say they are not working out to lose weight, and that it’s not wrapped up in their eating disorder. Common statements are “I want to exercise because….

I love it.”
It makes me feel good.”
It makes me feel strong and healthy.”

For now, let’s set aside the issue of whether these statements are actually true or whether the client is trying to maintain disordered behavior. That’s something to unpack with them a bit later. Initially, the foremost concern is that, as previously discussed, exercise can cause harm for those who are malnourished. So if a client talks about wanting to be healthy, then we have an opening with them to discuss how exercise at this point could be incredibly unhealthy for them. 

“Attempting to use the health argument to justify a behaviour that is contributing to energy deficit during starvation and thus helping perpetuate a life-threatening illness is classic eating-disorder logic.”
– Emily T. Troscianko, Ph.D.

So… to exercise or not to exercise?

In her book Sick Enough: A Guide to the Medical Complications of Eating Disorders, Dr. Jennifer Gaudiani makes a good argument that forbidding people in recovery from engaging in physical activity unintentionally reinforces the disordered idea that the main purpose of movement is to burn calories and prevent weight gain. She states that although “serious exercise is a privilege of full recovery… movement during weight restoration makes recovery sustainable.” Dr. Gaudiani supports physical movement as part of the recovery process for most patients. She has observed positive outcomes for patients who experience stronger, more independent bodies through a combination of rest, nutrition and expert physical and occupational therapy.

Once nutritional rehabilitation is achieved and caloric intake is sufficient, more serious exercise becomes safer. This means that good nutrition, weight restoration, and the return of normal hormonal and cardiac physiology are crucial to deciding when such exercise would be advisable.

However, we need to consider more than just the client’s physical condition. The mentality regarding exercise is equally important. Research has found that exercise is a predictor of relapse for approximately 30% of individuals after discharging from higher levels of treatment. Notably, the highest risk occurs between 4 and 17 months after discharge, but the risk of exercise contributing to relapse stays high for up to 2.5 years after treatment.

This is partially due to the fact that in our current culture, exercise is often tied to weight management. It can be tough for an average person to disconnect the two, so it’s understandable how difficult that is for a person recovering from an eating disorder. For many patients, exercise is interwoven into their disorder. The motivation for exercise can to serve many eating disorder functions for individuals, such as burning calories, attempting to control one’s body, managing anxiety about food, and even being a form of self-punishment.

The challenge, therefore, is developing a healthier relationship with exercise and reaping the benefits of it without triggering a relapse. I do think that Dr. Gaudiani’s approach can be helpful in repairing the disordered relationship with exercise, as well incorporating discussion of exercise into the therapy work.

Assessing your relationship with exercise

If you’re not sure whether a client’s (or your) relationship with exercise is healthy, check out my previous post, Is Your Relationship with Exercise Toxic?. Some of the red-flags to look for include:

• Feeling guilty, anxious or ashamed when a workout is missed or isn’t as long or intense as the individual thinks it should be
• Exercising even when they’re fatigued, injured, or ill
• Exercise is focused on getting or staying in a certain type of body
• “Earning” food through working out
• Not really enjoying your workouts but feeling compelled to do them anyway
• Working out causes stress instead of relieving it
• Needing to exercise displaces other important things in the person’s life
• Their identity/self-worth is wrapped up in working out

You can also check out these online assessments:

• The Compulsive Exercise Test (Meyer et al., 2016)
• The Exercise Addiction Inventory (Lichtenstein et al., 2014)

Other posts in the exercise series…

• Part 1: Is Your Relationship with Exercise Toxic?
• Part 3: Developing a Health Relationship with Exercise

Sources:

Bardone-Cone AM, Higgins MK, St George SM, et al. Behavioral and psychological aspects of exercise across stages of eating disorder recovery. Eat Disord. 2016;24(5):424-439. doi:10.1080/10640266.2016.1207452

Cook, B., Wonderlich, S. A., Mitchell, J., Thompson, R., Sherman, R., & McCallum, K. (2016). Exercise in Eating Disorders Treatment: Systematic Review and Proposal of Guidelines. Medicine and Science in Sports and Exercise, 48(7), 1408–1414. http://doi.org/10.1249/MSS.0000000000000912

https://www.psychologytoday.com/us/blog/hunger-artist/201812/should-you-exercise-during-recovery-anorexia-part-1

https://edinstitute.org/paper/2013/2/26/exercise-ii-insidious-activity

https://www.allianceforeatingdisorders.com/exercise-during-recovery/