National Eating Disorders Association

The Importance of Including Exercise in Eating Disorders Treatment

Thank you to Alsana for sponsoring this blog post. 

Exercise is ubiquitous in modern society. We can’t drive by a strip mall without seeing a new store-front gym complete with a secret breakthrough diet that promises to supercharge aesthetically focused results, go on social media without being bombarded by ‘fitspo’ messages and incredibly persuasive testimonials of how exercise changed someone’s life, or even look at our newsfeeds on our phones without seeing a press release touting the latest great news about the health effects of exercise. 

The constant din is enough to confuse anyone.  Certainly, many individuals with good intentions make poor decisions about exercise. Consequentially, reports of increased injury rates associated with fad fitness centers are becoming increasingly more common. For example, a recent article in the New York Times reports that emergency room doctors are noticing an uptick in fitness-related injuries, including severe life-threatening conditions such as rhabdomyolysis.

What’s interesting is that many of these injuries are in people that are otherwise generally fit and have a history of being physically active. Seeing such reports immediately makes me wonder, if otherwise fit and healthy individuals are succumbing to the barrage of information and cultural factors about dangerous patterns of exercise, what is happening with an individual with an eating disorder or sub-clinical eating disorder when they experience these messages? 

The bottom line is we no longer live in a world where we can tell individuals with eating disorders that recovery means never exercising again. The constant salvo of exercise, fitness, and health related messages that are omnipresent are surely more enticing to an individual struggling with treatment or recovery than our well-intentioned advice. Simply put, we have a professional obligation to empower individuals with eating disorders with the tools necessary to navigate our risky environment that includes contrived ideals about the interaction of exercise, diet, health, and cultural conceptions of beauty.  

Including exercise in eating disorders treatment is not a new or novel concept. It has long been acknowledged that we need to do something about excessive and compulsive patterns of exercise in our clients/patients. To this end, initial approaches have attempted to modify exercise behaviors and amounts. Certainly, many eating disorders treatment centers now include yoga and walks as recommended forms of exercise or movement. Other more comprehensive centers even include modified versions of physical therapy or circuit training when clients are medically stable. Such efforts are to be commended and celebrated in their attempt at intervening on exercise as a contributing factor to eating disorders while also encouraging the well-established physical, mental, and social health benefits of regular exercise. Unfortunately, simply modifying behaviors alone does not adequately address the full array of factors that are implicated in the exercise and eating disorders relationship. Simply put, modifying types or forms of exercise behavior just scratches the itch, but fails to treat the underlying rash.

Our field has made some tremendous gains recently in understanding the very complicated nuances of exercise that are unique to individuals with eating disorders. The current state of this work suggests that to effect lasting change in exercise behaviors, we must intervene on the psychological factors that drive the behavior itself. In other words, changing or modifying exercise behavior doesn’t tell the whole story. Rather, efforts to change the way an individual approaches the exercise behavior have been documented to shift exercise patterns from pathological to health-promoting. 

The main techniques that have proven effective are a combination of addressing irrational beliefs about exercise and consequences of exercise, examining external and internal sources of motivation for exercise, re-educating individuals on basic facts about the physiology of exercise and the role of nutrition in supporting exercise, recognizing how emotions can cloud judgments about exercise and how those emotions may then be driving excessive exercise, and re-examining how exercise is related to an individual’s self-identity. Only once these antecedents of exercise are addressed can the modification of exercise behaviors impact the underlying pathology of exercise in eating disorders.

I’m encouraged by these advancements as we shift to a deeper appreciation of exercise in eating disorders and the potential to use exercise therapeutically. Continuing to learn more about these very complicated relationships will help us empathize with individuals with eating disorders and simultaneously satisfy our professional ethical obligation to improve our care. Persuasive, albeit maladaptive, messages that encourage pathological forms of exercise without regard to underlying medical conditions, nutritional concerns, or psychological states will continue to permeate culture.  This, perhaps more than any other singular factor, is the main challenge for treatment professionals, patient advocates, and individuals struggling with eating disorders alike. 

Encouragingly, contemporary approaches to exercise recognize abstinence only does not work and have been successful by intervening on the full scope of factors that precede exercise behavior, include exercise as a part of comprehensive treatment, and empower individuals with coping skills necessary to navigate our modern society supersaturated with mixed messages about exercise and health. This approach represents a sea change in eating disorders orthodoxy, but it may just be a needed change to keep pace with our rapidly changing modern society.  

Brian Cook is an internationally sought-after expert on eating disorders. He works as the National Director of Movement and Exercise at Alsana, working closely with other experts to develop Alsana's innovative movement program that changes the relationship with exercise from a compensatory behavior to one that functions equally with other components of health. Brian is currently an assistant professor at California State at Monterey Bay.