Anorexia nervosa is a serious mental health condition characterized by a distorted body image and an intense fear of gaining weight, leading to severe food restriction and, in many cases, excessive exercise. While exercise is often viewed as a healthy behavior, for individuals with anorexia, it can become a dangerous compulsion, exacerbating physical and psychological issues. However, when approached mindfully and under the guidance of a treatment team, exercise can be a valuable tool in the recovery process, promoting mental health and overall well-being rather than serving as a means of weight control.
The Complex Relationship Between Anorexia and Exercise
Anorexia nervosa is more than just restrictive eating habits or extreme weight loss; it is a multifaceted psychological disorder significantly impacting an individual’s mental and emotional well-being. People with anorexia experience an intense fear of gaining weight and a strong desire for control over their body image, often leading to severe food restrictions and/or excessive exercise. This intertwines physical behaviors with mental and emotional challenges.
It’s estimated that approximately 80% of patients with anorexia nervosa engage in unhealthy exercise patterns. This excessive exercise often stems from a desire to control weight and body shape, and can be a diagnostic criterion for bulimia nervosa as well. Unlike healthy exercise, which is encouraged for its physical and mental benefits, exercise in the context of anorexia becomes unhealthy due to its excessive and obsessive nature.
Dangers of Excessive Exercise in Anorexia
Excessive exercise can have numerous detrimental effects on individuals with anorexia:
- Physical Injuries: Exercising despite injuries can lead to permanent damage to ligaments, bones, muscles, or tendons.
- Weight Loss: Combined with restricted eating, excessive exercise can lead to unsafe levels of weight loss.
- Bone Loss: Osteoporosis can result from excessive exercise, leading to brittle bones.
- Dehydration: Higher risk of dehydration, which can cause severe complications.
- Social Isolation: Individuals may withdraw from social activities to exercise, leading to relationship problems.
- Heart Problems: A heart weakened by anorexia may not be able to handle the strain of intense workouts, leading to potentially fatal complications.
- Electrolyte Imbalances: These imbalances, already present due to eating habits, can worsen with excessive exercise, affecting cell communication and bodily functions.
- Poor Treatment Outcomes: Compulsive exercise is associated with poorer treatment outcomes in individuals with anorexia.
- Increased Psychological Distress: Can increase concerns about weight and shape, body dissatisfaction, perfectionism, and drive for thinness.
Reframing Exercise: A Shift Towards Mental Health
In recovery from anorexia, the focus of exercise must shift from weight control and body image to mental health and overall well-being. This involves a conscious effort to change the way exercise is perceived and approached.
Mindful Movement and Body Connection
Mindful movement is a key component in reframing exercise during anorexia recovery. It involves:
- Focusing on the present moment: Paying attention to how the body feels during movement, rather than fixating on calories burned or physical appearance.
- Connecting with the body: Rebuilding a positive relationship with the body by appreciating its capabilities and respecting its limits.
- Practicing self-compassion: Treating the body with kindness and understanding, rather than punishment or criticism.
Activities like yoga, Tai Chi, and gentle walking can be particularly beneficial for promoting mindful movement. These practices emphasize body awareness, relaxation, and stress reduction, helping individuals reconnect with their bodies in a positive way. Yoga, in particular, has shown to reduce depression and anxiety, and improve state of mind in young women with anorexia or other eating disorders.
Benefits of Exercise on Mental Well-being
When approached mindfully, exercise can offer significant benefits for mental health during anorexia recovery:
- Mood Enhancement: Exercise can boost mood and reduce symptoms of depression and anxiety.
- Improved Self-Esteem: Engaging in physical activity can improve self-image and self-esteem.
- Stress Reduction: Exercise can be a healthy way to manage stress and cope with difficult emotions.
- Better Body Perception: Exercise can improve body perception, positive mood and quality of life.
- Outlet for Inclinations: Exercise provides an outlet for the patient’s inclinations towards exercise.
- Improved Social Behaviour: Exercise can lead to improved social behavior.
Safe Exercise Guidelines During Anorexia Recovery
Introducing or re-introducing exercise during anorexia recovery requires a carefully planned and supervised approach. The following guidelines can help ensure safety and promote positive outcomes:
Consulting the Treatment Team
It is crucial to consult with a treatment team, including a therapist, dietitian, and physician, before starting any exercise program. The treatment team can assess the individual’s physical and mental health status, identify potential risks, and develop a personalized exercise plan that aligns with their recovery goals. The team’s guidance is essential to ensure that exercise does not interfere with weight restoration or exacerbate disordered thoughts and behaviors.
Gradual Progression
Exercise should be introduced gradually, starting with low-intensity activities and gradually increasing the duration and intensity as the individual progresses in recovery. Starting small and slow is important, and making a plan before beginning can be helpful. It might start with walking around the block once or twice a week. Going slow, listening to the body, and supporting oneself as best as possible is key.
Monitoring Physical and Psychological Signs
Close monitoring of physical and psychological signs is essential to prevent overexertion and identify potential warning signs of relapse. This includes tracking heart rate, energy levels, mood, and any changes in thoughts or behaviors related to food and body image.
Choosing Appropriate Activities
Activities that promote body awareness, relaxation, and enjoyment are generally preferred over those that focus on competition or calorie burning. Examples include:
- Yoga: Gentle forms of yoga can improve flexibility, strength, and body awareness.
- Tai Chi: This ancient Chinese practice combines slow, flowing movements with deep breathing and meditation.
- Walking: Walking in nature can be a relaxing and enjoyable way to increase physical activity.
- Swimming: Swimming can be a gentle form of exercise that is easier on the joints.
- Dancing: Group exercises are preferable to solitary exercising.
Avoiding Triggering Environments and Behaviors
It is important to avoid environments and behaviors that may trigger disordered thoughts and behaviors related to exercise. This includes:
- Gyms: Gyms can be triggering environments due to their focus on body image and competition.
- Fitness Trackers: These devices can promote obsessive tracking of calories and exercise metrics.
- Comparing oneself to others: Comparing one’s body or fitness level to others can lead to negative self-image and drive for thinness.
- Rigid exercise schedules: Creating rigid exercise schedules, calorie tracking or negative self-talk over missed workouts can be harmful.
The Safe Exercise at Every Stage (SEES) Guideline
The Safe Exercise at Every Stage (SEES) guideline was developed to support clinicians and exercise professionals in managing exercise during eating disorder treatment. It is a tool to help clinicians navigate this complex behavior and work with their patients to help them find life long fulfilling relationships with movement across their lives. It involves two key components:
- Risk assessment: Reviews key markers of psychological and physical health requiring assessment to facilitate safe exercise prescription.
- Exercise recommendations: Describes exercise interventions as related to the level of risk identified in the risk assessment.
The Role of Physical Therapy
Physical therapy plays an integral role in the rehabilitation of patients with anorexia nervosa once stretching and exercise are reintroduced. A healthcare provider with extensive knowledge of proper exercise guidelines and how to monitor physical signs of fatigue and vitals is needed to treat these patients. These skills are important to help the patient learn to monitor levels of fatigue and heart rate in order to prevent them from over exercising or exercising to the point of exhaustion.
Physiotherapy has a unique role to play in the treatment of eating disorders, as a member of the multidisciplinary team using physical therapeutic interventions and education to help patients overcome their symptoms and to accept their changing body shape as they restore weight.
BMI Related Guidance
- Below BMI 14: Exercise is not recommended because weight gain at this stage is the overriding priority.
- Between BMI 14 and 15: Following assessment it may be appropriate to recommend exercises in lying and sitting eg gentle Pilates, relaxation techniques and gentle stretches.
- BMI 15 to 17: Commence a gradual progression to moderate weight bearing activities. Pilates, Tai Chi and Yoga type exercises can be introduced. Sessions should still be carefully monitored and supervised and preferably done in a group setting.
- BMI 17 and above, towards a healthy weight: At this point patients are still on a weight-restoration programme and, therefore, any recommendations for exercise must not be allowed to compromise this. Sessions may become increasingly active eg swimming, walking, dancing. Group exercises are preferable to solitary exercising.
- At a healthy weight: Patients need to find a healthy balance between activity levels and nutritional intake.
Conclusion
Exercise can be a valuable tool in anorexia recovery when approached with a focus on mental health and overall well-being, rather than weight control. By reframing exercise as a means of self-care, stress reduction, and body connection, individuals can develop a healthier relationship with movement and their bodies. However, it is essential to consult with a treatment team, follow safe exercise guidelines, and monitor physical and psychological signs to ensure that exercise supports, rather than hinders, the recovery process. With mindful movement and a focus on mental health, individuals recovering from anorexia can find joy and empowerment in exercise, leading to lasting recovery and improved quality of life.
