Could Exercise Be a Tool in Eating Disorder Recovery?

Traditionally, eating disorder (ED) treatment stipulates that people refrain from exercising based on the assumption that patients will misuse workout practices to compensate for enhanced food intake. Over-exercising and purging through exercise are common features across all EDs, and they're extremely unhealthy practices that are often some of the last symptoms to subside during recovery¹. The degree of over-exercise, as well as body image dissatisfaction, also predicts whether a person will relapse, an occurrence that happens in up to 52% of people who have initially recovered from an ED^2,3. From that perspective, it makes sense that ED treatment involves no access to exercise.

There are, however, two major problems with prohibiting or significantly restricting exercise during ED treatment. First, by not exercising during recovery, weight restored ED patients are often uncertain and even scared of how to reintroduce physical movement into their daily lives. This can lead to prolonged abstinence from exercising which aggravates their body image dissatisfaction and fuels future relapses into disordered eating.

“It was really scary to be allowed to exercise again. I wasn’t sure where to start or how to even exercise again without it being an eating disorder trigger.” —DB, age 34, lives in Colorado, USA

Second, scientific research is demonstrating that exercising during ED recovery improves treatment outcomes physically and mentally.

In this post, I dive into the science of how exercise benefits ED recovery, and recount how two leading ED treatment centers stand out by incorporating exercise as a standard part of therapy.

The results from research are in: Exercise benefits eating disorder recovery

Surprising to many, there are several scientific studies reporting how exercise supports ED recovery. One research group tested whether an exercise program consisting of four weekly classes improved the recovery of 127 women who received residential treatment for an ED¹. Compared to the control group (which also consisted of women receiving residential treatment but without the exercise classes), the women in the exercise program had a significant reduction in compulsive thoughts around working out, and, more impressively, the women who had anorexia gained 40% more weight than the anorexic women in the control group. In other words, exercising during ED recovery boosted both their psychological and physical recovery.

We know that exercising is great for our brains and bodies. Both during and after exercise our brains produce more endorphins and increase the signaling of the neurotransmitter dopamine, both of which are well-known to increase well-being. Exercise also improves cognitive performance and even changes structures of our brain that shape the way we think⁴. Changing the way we think is likely one of the major ways in which exercise benefits ED recovery. In fact, the exercise program implemented as a part of the study had dedicated time periods of reflection, which compelled the participants to notice their bodies in a new and different way¹.

Let’s dig into some of the components that may underlie this process of cognitive change and how it can contribute to more successful ED recovery.

Physical movement attunes our minds to our bodies

A major challenge for people with EDs is their reduced sense of interoception. Interoception is the ability to sense your internal cues, such as hunger, thirst and heartbeat, which shape how we feel and behave. People with EDs are less capable of sensing their body accurately, and this makes it more difficult for them to notice when their body is, for example, hungry. Exercising has the potential to enhance their interoceptive awareness⁵, thereby improving their ability to notice when they feel hunger and fatigue, which supports behavioral change (such as eating and resting).

But exercise can only increase interoceptive awareness if it is done mindfully. Mindful exercise involves paying attention to how your body moves and observing how you feel before, during and after the movement⁶. A critical component of the above-mentioned study was the continuous effort to facilitate reflections during and after the exercise. In this process, people become not just better at noticing internal cues but also reflecting on the meaning and purpose of these cues. This is a critical step in reconnecting with your body and stepping away from and questioning the ED behavior.

Exercising can help us say goodbye to maladaptive coping mechanisms

“We hold the belief… that the incorporation of movement in the recovery process (once someone is medically stable) works to dismantle the potential eating disordered belief that movement's sole purpose is for burning calories or body manipulation” —Dr. Jennifer Gaudiani, founder and medical director of the Gaudiani Clinic.

Exercise is abused by many people with EDs because it serves as a coping mechanism. In the face of emotional distress and uncertainty, people with EDs often turn to exercise to control the only thing that seems available to them: their body. A major component of recovery is therefore to dissociate exercise from their ED behavior, and find new coping mechanisms that are healthier and more effective (for example, mindfulness and journaling). This process is a part of therapy sessions, but could, according to scientists, be further improved by incorporating movement into the treatment program^1,6.

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Dr. Nicole Garber, the CMO of Alsana, an eating disorder treatment program and recovery community, told me that “what sets [Alsana] apart is that we incorporate movement into treatment. Many facilities exclude movement which is a disservice to patients. The patients have to learn how to move and at the same time find new coping mechanisms”. Notably, Alsana has a higher recovery rate than standard ED treatment centers (see the report here). One of the reasons for their success may be that their patients have learned to not abuse their bodies by over-exercising when a new stressor inevitably occurs during and after recovery.

Incorporating exercise gives people autonomy

You only need to watch the documentary Thin by Lauren Greenfield, to understand how ED treatment often equals complete loss of autonomy, which ultimately can push people farther into denial of their disease or simply make them refuse treatment. However, research demonstrates that when patients have a sense of autonomy in their recovery plan it increases their motivation to adhere to their treatment⁷ — this state of mind is also referred to as “active participation”. By giving access to exercise — in a structured and guided manner — patients are invited to see the treatment as something that works for them and not against them. Active participation in setting treatment goals and building a more trusting relationship between the healthcare professional and patient are known to improve treatment outcomes^8,9, and one study found that letting ED patients actively participate in their treatment plan reduced drop-out rates¹⁰.

“...if movement is an enjoyable or helpful self-care tool and is connected to a personal value of a patient, we want to find ways to honor its incorporation into life in a non-disordered manner.” —Dr. Jennifer Gaudiani, founder and medical director of the Gaudiani Clinic.

Providing patients with choice and autonomy requires that the treatment team sees the patient as a capable person who can recover under the right conditions. Unfortunately, this is often not the prevailing mindset among healthcare professionals, and ED patients are frequently told that they will never recover, nor are they allowed to provide any meaningful input to their treatment plan. Again and again, this dismissive approach stalls patients’ intrinsic motivation for receiving and adhering to recovery.

“I’m not sure I have ever met a professional who believed in full recovery from ED. It has been incredibly discouraging.” —DB, age 34, lives in Colorado, USA.

Exercise could make a difference for many ED patients, but we need to be cautious

Based on the scientific evidence and low cost, exercise programs have enormous potential in supporting a healthy recovery from ED, and that’s important to consider these days. During the pandemic, the number of people with EDs exploded, but despite research efforts, it is still less than 50% of people that recover, many of whom will relapse. Currently, two evidence-based treatments for EDs exist: cognitive behavioral therapy for adults and family based therapy for children and adolescents. Yet, many patients do not receive these evidence-based treatment methods, either because they cannot access treatment at all or because the treatment they receive comes from professionals without a specialty in EDs. From this perspective, it is tempting to think of exercise as a new accessible panacea for ED treatments. However, it is critical that we take caution to ensure that the implementation is done right. This necessitates proper education of healthcare professionals, which, according to Dr. James Lock, a researcher and psychiatrist at Stanford University, is currently lacking: “When it comes to eating disorders, most therapists are not trained in using evidence-based therapy methods. They end up relying on their own [professional] beliefs, which is not proven to help”. This challenge further underscores the importance of incorporating mindful exercise programs that are led by specialized professionals who can ascertain when movement can benefit an ED patient.

For recovery to start, people with EDs have to rethink why they exercise. During the disease, exercise is a way to exert control. During the recovery, it can start being a part of a healthy and fun lifestyle. This mental transition is much easier said than done, and requires enormous support from healthcare professionals, family members and friends.