Adding Exercise to Treatment

11 guidelines include a team approach, patient safety, and reasonable limits.

Reprinted from Eating Disorders Review
May/June Volume 27, Number 3
©2016 IAEDP

The pros and cons of adding exercise to treatment for people with EDs are still being debated. Should exercise be a regular part of treatment for an eating disorder? Or, does this perpetuate a dangerous cycle? After an extensive review of the ED literature, a group of eating disorders experts has developed a set of guidelines for adding exercise to treatment regimens. 

Brian Cook, PhD, and colleagues identified 11 core themes and techniques that have been successful in establishing therapeutic exercise programs for people with EDs (Med Sci Sports Exer. 2016; published ahead of print). The authors noted that the 11 guidelines can be applied to some, but not all, ED patients by “empowering individuals to use exercise as a tool for healthy living.” The authors point to previous research suggesting exercise may actually be helpful for people with EDs, mainly by reducing the drive for thinness and bulimic symptoms. Exercise can also decrease body dissatisfaction, help anorexic patients gain weight, and improve overall quality of life for many ED patients.

A team approach that weighs contraindications, screens for psychopathology

Adding an exercise program requires a spectrum of knowledge about exercise, physiology, and nutrition, as well as skill in tailoring the program to medical and psychological factors, according to the authors. Because of this, a multidisciplinary team with expertise in exercise physiology, nutrition, and mental health needs to be involved in tailoring exercise to the individual. Monitoring is needed both for physical safety as well as for driven or pathological exercise. The authors note that these criteria are mostly likely to be met in inpatient settings.

Tools include a written contract, psycho-education, and positive reinforcement

The authors suggest using a written contract that lays out program rules, goals, anticipated outcome, expectations and contingencies. The exercise program should also include psycho-education, key to most ED-specific programs. Availability of exercise should be contingent on compliance with other parts of the treatment program.

Dr. Cook and his colleagues also recommend the careful, incremental use of exercise starting with small amounts of low-intensity exercise. The researchers noted that the type of exercise is important: some successful programs for weight restoration in AN patients include resistance training vs. aerobic exercise for patients with BN. A reasonable upper limit for exercise, following American College of Sports Medicine recommendations, might be 30 to 40 minutes of exercise at 70% to 80% of maximum effort. 

Finally, it is key to include nutritionists with ED knowledge in the activity program. Weight stabilization must precede introduction of exercise, and the nutritional intake must account for activity level. Each patient can benefit from a debriefing, either during the exercise session or afterward. This enables the therapist and patient to evaluate sensations, emotions, and thoughts evoked by the exercise session.

The authors stressed that “safety is the ultimate concern” when an exercise program is being developed for people with EDs and that adding an exercise component to treatment is not appropriate for all ED patients. And, it does seem likely that most people who exercised before ED treatment reintroduce exercise after treatment. Doing so in a healthy fashion while in structured treatment may reduce long-term risks.