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Guidelines for the Use of Exercise in Eating Disorders Treatment

Guidelines for the Use of Exercise in Eating Disorders Treatment

Brian Cook, PhD

A rapidly growing body of evidence suggests that exercise may be manageable in some, but not all, people with an eating disorder (ED). Accordingly, several recent narrative and meta-analytic reviews have concluded that when nutritional needs are satisfied, exercise appears to be a safe option in ED treatment (see Cook et al., 2016 for review). These preliminary results are encouraging and suggest that under close supervision and in the absence of medical or nutritional contraindications, exercise may be an efficacious adjunct to standard ED treatments. Moreover, these reviews suggest that one key to reversing exercise from being a compensatory behavior to that of a healthy behavior may be to change a person’s pathological attitudes and thoughts about exercise itself. This may change the fundamental function of exercise from that of a compensatory behavior to part of a comprehensive approach to managing health and ED recovery. Therefore, the goals of therapeutic exercise should include altering pathological exercise attitudes and beliefs, learning how one’s body feels when one engages in healthy amounts and types of exercise, and (most important) recognizing the need to properly support exercise with adequate nutrition. Exercise may then be introduced at low intensity and small amounts to support physiological and psychological healing and recovery. A recent study published in Medicine & Science in Sports & Exercise has consolidated various techniques and considerations that influence how exercise has been successfully used as part of ED treatment programs (Cook et al., 2016). From the extant literature, the following 11 guidelines for the therapeutic use of exercise in ED treatment were proposed.

  1. Adopt a Team Approach

Including an exercise program in the treatment of ED requires specific knowledge related to exercise prescription, physiology, and nutrition, in addition to medical and psychological factors relevant to ED treatment. Simply stated, exercise is a complex behavior that requires specialized expertise to distinguish maladaptive use of exercise from the health-promoting potential for specific patterns of exercise. This includes a necessary nuanced understanding of specific motives, attitudes, physiology, nutrition, medical considerations, and the interaction of these and other factors as they relate to ED. Therefore, a multidisciplinary team of experts in exercise, nutrition, mental health, physical therapy, and medicine should work collaboratively to develop individually tailored exercise programs with participation contingent upon adherence to ED therapy and should closely monitor ED patients to ensure safety. Clinicians and/or individuals with ED should not take a “go it alone” approach when introducing exercise as part of ED treatment.

  1. Continuously Monitor Medical Concerns/Contraindications

Safety is the primary concern when adding exercise to ED therapy, and all precautions must be taken to prevent harm. Beginning an exercise routine generally presents minimal health risks in nonclinical populations; however, ED patients present additional physiological and psychological concerns beyond that of an individual without an ED. Therefore, in addition to a standard physical activity readiness screening, such as the Physical Activity Readiness Questionnaire (Adams, 1999), a comprehensive medical screening for complications related to ED and nutritional deficiencies should be undertaken prior to engaging in any exercise. A non-comprehensive list of suggested factors to screen may include heart rate, electrolyte levels, glycogen stores, body mass index, bone density/osteoporosis risk, body temperature, blood pressure, orthostatic changes in pulse or blood pressure, hydration, and previous injury history.

  1. Screen for Exercise-Related Psychopathology or Pathological Attitudes, Cognitions, or Expectations for Exercise

Psychological variables (e.g., exercise pathology) are a positive predictor of negative eating attitudes and behaviors (Adkins & Keel, 2005); appear to mediate the relationship between exercise and ED (Cook & Hausenblas, 2008, 2011; Cook et al., 2011, 2015); and are associated with detriments in ED-specific health-related quality of life (Cook, Engel, et al., 2014). Moreover, a prospective study found that reductions in exercise pathology scores (e.g., exercise dependence) are correlated with reductions in ED symptoms (Bratland-Sanda et al., 2010). Therefore, identifying individuals who endorse pathological attitudes and behaviors toward exercise may indicate when unsupervised exercise will exacerbate ED symptoms (Hausenblas, Cook, & Chittester, 2008). In addition, identifying pathological exercise attitudes and behaviors may indicate targets for intervention (e.g., exercise attitudes and beliefs) that can be addressed while exercise is performed safely under closer supervision during treatment. Several exercise pathology screening measures exist and are all highly correlated in ED samples (Cunningham et al., 2016). For example, the Compulsive Exercise Test (Taranis, Touyz, & Meyer, 2011), Exercise Dependence Scale, (Hausenblas & Symons Downs, 2002), and Obligatory Exercise Questionnaire (Ackard et al., 2002) have all been used extensively in individuals with ED.

  1. Create a Written Contract

A written contract that details program rules, goals, outcomes, expectations, and contingencies for progression, regression, and cessation of exercise activity should be agreed upon by all members of the treatment team and the patient to foster an inclusive and collaborative exercise program that complements standard ED treatment. This contract can be tailored to the specific needs of each individual. For example, Bonci and colleagues (2008) provide an example of a contract that includes treatment and exercise goals for athletes with ED.

  1. Include a Psychoeducational Component

Psychoeducation is a main component of cognitive behavioral therapy and has been described as a key component of most ED-specific exercise programs. Moreover, clinicians commonly report that ED patients presenting with exercise problems have distorted beliefs and cognitions about exercise. For example, in ED patients, excessive or compulsive exercise may be driven by strong endorsements of athletic identity (Gapin & Petruzzello, 2011; Lu et al., 2012) or may reflect poor understanding of the role and appropriate use of exercise for health. Therefore, a psychoeducational component that is administered throughout the exercise program is needed to address misinformation and inaccurate beliefs that may be driving unhealthy patterns of exercise. Suggestions for content that may be emphasized include:

  1. The appropriate use of exercise for health benefits (Garber et al., 2011)
  2. How to recognize when exercise is becoming problematic
  3. Developing healthy attitudes and exercise behaviors
  4. Body awareness (i.e., understanding physiological states, injury, and pain)
  5. Enjoyment of exercise and exercising for fun rather than as a behavior that may serve a functional role in maintaining an ED
  6. Exercise identity
  7. Identifying factors related to overtraining or burnout (Hackney et al., 1990)
  8. Focus on Positive Reinforcement

The functional role of exercise in ED remains unclear. Recent ecological momentary assessment research suggests that exercise intensity is related to affect regulation in anorexia nervosa (Cook, Wonderlich, et al., 2014). Other studies have also concluded that exercise is a highly reinforcing activity for some individuals (Klein et al., 2010). Thus, the functional role of exercise in ED may be that it is simply another behavior used to manage affect regulation. Therefore, emphasis should be placed on using exercise to enhance treatment compliance (Thien et al., 2000) and success, rather than leaving exercise unmonitored and up to the ED individual to control.

  1. Create a Graded Program

A psychoeducational component that emphasizes the appropriate use of exercise, understanding bodily responses to exercise, and listening to one’s body when physiological resources are being exhausted must be used in conjunction with a graded exercise program (Thien et al., 2000). Thus, beginning with small amounts of low-intensity exercise should be emphasized: for example, starting with stretching or a quarter-mile (e.g., one lap around a track) walk at a slow pace. Exercise amount and intensity can be very gradually increased as the patient demonstrates progress with standard ED treatment, weight restoration, and any other predetermined therapeutic outcomes. Such a protocol matches recommendations for the use of exercise as an adjunct to treatment for other mental-health conditions (Garber et al., 2011). A graded program should outline incremental steps that reflect the specific treatment goals for each individual. Therefore, a generic example of what to include at each grade or level is not appropriate. While no ceiling or upper limit for exercise amount has been established in the exercise science literature, understanding upper limits of frequency, time, intensity, and exertion must be emphasized in ED treatment as the exercise progresses from mild (e.g., walking) to moderate (e.g., jogging) and vigorous (e.g., running) levels of intensity. In addition, scheduling an appropriate amount of rest between each exercise session is paramount to allow for refueling any nutrients used during exercise, physiological recovery, and psychologically processing the physical and emotional feelings related to the exercise session.

  1. Start with Mild Intensity and Slowly Build to Moderate

Often, individuals can convince themselves and others that they are able to do greater amounts and/or higher intensities of exercise despite a lack of the physiological resources or conditioning required to perform such activities. This is frequently the case with ED individuals and reflects the terms compulsive, obligatory, and driven, which are commonly used by those individuals to describe exercise. Therefore, a primary goal must be to initially limit individuals with ED to begin with short bouts of mild-intensity activities that will allow the gradual conditioning of physiological systems. Slow and gradual increases in exercise amount, intensity, and frequency will allow the individual to strengthen muscle groups and condition the cardiorespiratory system at a safe pace. In addition, emphasis should be placed on understanding biofeedback, bodily states, how to distinguish appropriate feelings of muscular exertion from pain and/or injury, heart and breathing rates, recovery, rest, and body acceptance. To these ends, additional time beyond that which is needed to obtain physical conditioning should be spent at each level of exercise.

  1. Tailor the Mode of Exercise

Maximum health effects resulting from regular exercise are experienced through a combination of cardiorespiratory (e.g., aerobic), resistance (e.g., strength), and flexibility (e.g., stretching) training. Moreover, amounts of aerobic and resistance exercises included in an exercise program should be tailored to the individual physiological and psychological needs of each client. For example, programs that have included resistance training for individuals with anorexia nervosa have demonstrated safety while increasing muscle mass and strength, and assisting in weight restoration (see Cook et al., 2016 for review). Similarly, programs focused on treatment of bulimia nervosa have reported weight loss, and reductions in drive for thinness, bulimic symptoms, and body dissatisfaction (Sundgot-Borgen et al., 2002).

9(a) Cardiorespiratory Training

Exercise amounts should not exceed current American College of Sports Medicine recommendations (Garber et al., 2011) of 150 minutes weekly of moderate-intensity cardiorespiratory exercise performed through a daily accumulated total of 30 to 60 minutes of moderate-intensity exercise (five days per week) or 20 to 60 minutes of vigorous-intensity exercise (three days per week). These amounts can be met through engaging in one continuous exercise session or accumulating several bouts of 10 minutes in duration until the aforementioned totals have been reached. With regard to maximum effort, a reasonable upper limit may be 30 to 40 minutes at 70 to 80 percent of maximum effort. For example, this could include activities like running, lap swimming, biking, or rowing. Machine-assisted activities, such as using elliptical machines or Nautilus-style resistance-training machines, can be adjusted to provide more or less resistance or support of body weight and, therefore, may be used to gradually increase intensity.

9(b) Resistance Training

Benefits of strength training that are relevant for ED, particularly anorexia nervosa, are improved cardiovascular profiles; fewer cardiovascular disease events; improvements in body composition, blood glucose, insulin sensitivity, and strength; the prevention and reverse of bone loss; improved thermogenesis regulation; and increases in basal metabolic rate (see Garber et al., 2011 for review). These effects have been observed in individuals with ED (Fernandez-del-Valle et al., 2014). Therefore, resistance training should focus on large muscle groups (i.e., pectoralis, latissimus dorsi and rhomboids, gluteus, quadriceps, trapezius, etc.). Resistance training should be performed two to three days per week each week, beginning at very light intensity. Exercises targeting large muscle groups should be performed in two to four sets of 10 to 15 repetitions each. It’s important that a full 48 hours of rest be taken between resistance-training sessions (Garber et al., 2011).

9(c) Flexibility Training

Range of motion can be increased through two to three days of flexibility training per week. Stretches held for 10 to 30 seconds to the point of tightness or slight discomfort, repeated two to four times, accumulating 60 seconds per stretch, are recommended (Garber et al., 2011).

  1. Make Sure the Nutritional Component Accounts for Physiological Needs of Exercise and Recovery

Dietitians with expertise in ED refeeding and weight restoration must be a part of the comprehensive treatment team. Introducing any exercise to a treatment protocol will inherently affect the caloric balance, and therefore, intake should be adjusted accordingly. Moreover, exercise should not be attempted until the individual with an ED has made sufficient progress in caloric and nutritional consumption to support the activities chosen. Because of the increased risk of cardiac complications and death, addressing deficiencies is especially important with regard to micronutrients, minerals, and electrolytes that play a role in cardiovascular function. Moreover, minerals and electrolytes play a key role in muscle contraction, normal heart rhythm, nerve impulse conduction, oxygen transportation, oxidative phosphorylation, enzyme activation, immune function, antioxidant activity, bone health, acid-based balance of blood, and maintenance of body water supplies (Williams, 2010). Thus, when nutritional needs are inadequate, catabolism of adipose tissue, calcium from bone mass, and/or protein from lean muscle mass are common mechanisms to supply nutrients needed for increased physical activity. Accordingly, nutritional restoration is paramount to provide adequate fuel for the anabolic effects of exercise (e.g., building muscle mass), which may assist in overall weight restoration. Simply put, energy is needed to sustain physiological functions required for exercise. Thus, the body must be adequately fueled to perform any activity resulting in a substantial increase over resting energy expenditure. Without an adequate exogenous energy source, the body will draw from endogenous sources, thereby causing damage.

  1. Incorporate Debriefing

Preferably during the exercise session, but certainly afterward, the individual should be “debriefed” regarding sensations, emotions, and thoughts evoked by exercising. Queries might inquire about bodily sensations such as pain or tiredness/fatigue. Debriefing can be used to assess psychological aspects of exercise, such as difficulty following the protocol, difficulty stopping exercising, and/or experiencing a “high.” Debriefing allows the patient to develop body awareness that differs from that experienced during previous symptomatic activity, while allowing treatment providers to obtain valuable information regarding how the person physically and psychologically experiences the activity. That information can then be shared with the treatment team and used as necessary.


The multidimensional etiology of ED suggests that optimal interventions must also be multifaceted. Therefore, it may be more effective to identify treatment strategies that have an impact on both psychological and physiological processes and, consequently, have an impact on the progression of multiple factors that contribute to the development and maintenance of ED. Accordingly, the comprehensive health benefits provided by exercise have led researchers and clinicians alike to consider exercise as part of a comprehensive approach to ED treatment. It should be noted that exercise refers to a form of physical activity undertaken with intent to obtain a specific objective or desired outcome (Garber et al., 2011). Therefore, the use of exercise as an adjunct to ED treatment reflects the functional intent of body movement to positively influence physical and mental health. The word exercise neither implies nor specifically suggests high levels or amounts of athletic behavior, involvement in strenuous activities or sports, or vigorous/high-intensity/hard exercise. In fact, it implies the exact opposite. The general goals of an exercise program as an adjunct to ED treatment should be developed “from the ground up” by reeducating patients about proper methods to perform exercise, attitudes related to motivation, and transparency regarding the health benefits and potential detriments of increased exercise. Thus, distinguishing whether the objective of engaging in exercise is to facilitate symptoms of an ED (i.e., compensatory exercise) or to obtain a health outcome (i.e., therapeutic exercise) is paramount in individuals with ED.

It is also important to note that there will be times when exercise needs to be prevented or seriously modified, given a patient’s clinical status. Therapeutic exercise programs are ideally conducted with ED patients under close monitoring and supervision by a multidisciplinary treatment team. If a patient’s medical or psychological status deteriorates, adjustments in the exercise program may be necessary. Furthermore, if a particular patient uses an exercise program in a fashion that is maladaptive, clinicians will need to modify treatment recommendations. Simply put, therapeutic exercise, like all effective components of ED treatment, must be carefully monitored, and sound clinical judgment must be employed in such oversight.

About the author:

Dr Cook has developed and maintained an original line of research focused on examining the etiological role, management, and therapeutic potential of exercise in eating disorders. His education at the University of Rhode Island, University of Florida, and a National Institute of Mental Health funded post-doctoral fellowship at the Neuropsychiatric Research Institute in Fargo, ND has allowed him to train under leading experts in the eating disorders field. This has resulted in consistently presenting research and invited talks at national and international level conferences (e.g., Eating Disorders Research Society, the Academy for Eating Disorders, etc.), chairing conference paper sessions focused on eating disorders and associated psychiatric illnesses at international level conferences (e.g., International Conference on Behavioral Addictions), several publications in leading journals (e.g., International Journal of Eating Disorders, etc.) and invited book chapters, and delivering an invited keynote address at the International Association of Eating Disorders Professionals Foundation’s 2017 Symposium. These accomplishments are commendable at this stage of Dr Cook’s career and provide strong evidence of his passion for improving the lives of individuals with eating disorders and his potential to continue to impact the fields of eating disorders research and treatment.


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