A Healthy Exercise Prescription for ED Patients

reprinted courtesy of eating disorders review

In a keynote session, “Management and Therapeutic Use of Exercise in Eating Disorders Treatment,” Brian Cook, PhD, outlined an interdisciplinary approach to harness the power of exercise to heal the body amid the unique setting of eating disorders. With EDs, he said, the interdisciplinary approach includes psychology, physiology, and nutrition, which he described as a crucial part of successful treatment. Dr. Cook is Assistant Professor of Kinesiology at the California State University, Monterey Bay. [See “The Effects of Compulsive Exercise among Teens,” elsewhere in this issue.]

Compulsive Exercise

Two major questions concerning exercise in recovery include the appropriateness of exercise for clients and how to harness the healthful power of exercise to heal the body, he said. EDs are tough to handle, with the highest mortality rate of psychiatric illnesses, coupled with recidivism and secrecy, he added. However, he added, “We see a rising acceptance of exercise in certain eating disorders, especially binge-eating disorder, where the research, which is good, shows that exercise prevents relapse. The data for anorexia nervosa and bulimia nervosa are still emerging.”

Noting that there is so much push-back on including exercise as part of ED treatment protocols, Dr. Cook told the audience that ED professionals need to lay the groundwork for research, etiology, and therapy. Patients with eating disorders are often in a very bad state physiologically, and all too commonly linear thinking leads to excluding exercise in treatment, he said.

Last year Dr. Cook and colleagues performed a systematic literature review of guidelines for exercise in eating disorders treatment (Med Sci Sports Exerc. 2016; 48:1408). The group identified 11 core themes that have been successful when using exercise in ED treatment: (1) use of a team of relevant experts, (2) monitoring medical status, (3) screening for exercise-related psychopathology, (4) creating a written contract of how therapeutic exercise will be used, (5) including a psychoeducational component, (6) focusing on positive reinforcement, (7) creating a graded exercise program, (8) beginning with mild-intensity exercise, (9) tailoring the mode of exercise to the needs of the individual, (10) including a nutritional component, and (11) debriefing the patient after exercise sessions.

The Exercise Medicine Initiative

Dr. Cook also pointed to an important movement that can be used to better define the use of exercise among patients with eating disorders, the Exercise Medicine Initiative by the American College of Sports Medicine (ACSM). The group has established recommendations for pre-exercise health screening (Med Sci Sports Med. 2015; 48:579). The goal is to better identify individuals who need medical clearance before beginning an exercise program, including patients with clinically significant diseases (such as EDs) who would benefit from participating in a medically supervised exercise program.

Every day more technological devices make it more and more easy to sit and do nothing, he said, and the ACSM is working to help clinicians and patients understand exercise in an appropriate fashion, he said, adding that regularly assessing and treating exercise problems fits well with ED treatment. A team approach is a must for developing an exercise protocol, he said. The main thing is that clinicians can’t do this on their own, but instead need the help of other professionals. Professionals in physical therapy and nutrition, for example, have expertise that is essential to designing an appropriate exercise program. They can help determine if exercise is helping or hurting the patient and importantly when it is not useful for an individual with an eating disorder.

Some contraindications to exercise

Medical contraindications to exercise include dehydration, and other negative physiologic effects. However, he advised that, rather than concentrating on negatives, clinicians can help patients become aware of what their body is telling them, and that carefully designed exercise programs can be enjoyable and appropriate for ED patients.

Another point is to help patients imagine themselves as healthy, and to help them become aware of the signals the body is giving. For example, in many exercise programs, such as in yoga, an important aspect of the program is separating good pain from bad pain and improving body self-awareness. Identifying factors involved on overtraining is also important, and getting a patient to accept the negative effects of overtraining and to recognize warning signs of this are important. He recommends that a recovering ED patient start exercising at a slow pace. It is also helpful to draw attention to progress in other areas, such as improvement in body weight, and to tailor that to outcome.