Seven reasons to reintroduce exercise in patients with eating disorders

“When they took away my exercise, I felt like I was being sentenced to jail. It was like having shackles. I perceived a kind of prison in my own body. As if I was pronounced dead in life,” admits Mónica, 20 years old. “I was diagnosed with anorexia, I was hospitalized, and after that physical activity disappeared from my routine, when it had always been present, since I was a child,” she adds.

Exercise is not an end in itself; it is a means to live better. Also for patients suffering from eating disorders. “When I began to coordinate the hospitalization program for patients suffering from eating disorders, I noticed a significant deficit in their physical approach. After three months of admission and carrying out the medical-nutritional recovery protocol, I realized that when the patients left the unit they got tired just by going up some stairs,” says Josep Pou Castillo, adult, child and adolescent psychiatrist at the Acute Hospitalization Unit of the Santa Caterina Hospital in Girona, Spain.

When she left the hospital, Monica could barely go for a walk with her friends. “I got tired and sad, even though I was at a healthy weight,” she recalls. Before being in the hospital, she used to exercise with a youtuber. “I just couldn’t stop doing it. It was my first priority, over everything. I didn’t even go out with my parents. I used to spend two or three hours a day in front of the screen,” she admits. When asked why she acted that way, she replies: “Because I wanted to get rid of my belly, and I don’t like my legs.”

According to the studies, up to 85% of people with eating disorders often exhibit maladaptive exercise behaviors. The research points to certain behaviors that indicate a relationship with problematic exercise: compensatory (burning calories after eating); compulsive (addictive); rigid (it must always be done at the same specific times) and used as a tool for physical change (often focused on an area like the abdomen, legs or buttocks).

The dilemma

Doctors usually recommend abstinence from exercise during treatment to prevent it from hindering the weight regain process. However, research has shown that stopping exercise or any type of physical activity completely during treatment is unrealistic and potentially harmful to long-term health outcomes. “The vast majority of mental health professionals continue to see exercise as problematic, when it is really a matter of each person’s relationship with it, just as it happens with food,” explains Pou, who is also the coordinator of the eating disorder hospitalization program at the Santa Caterina Hospital. “I wonder what is blocking what has already been proved in many studies regarding the benefits of strength exercise to deal with the severe muscle atrophy that these patients suffer. Not only at a structural level, but also neuromuscular dysfunction and postural disorders that end up causing clear difficulties when they have regained their weight and want to return to sports.”

The dilemma that patients and health professionals face despite the evidence is real: if food is reintroduced, why is exercise sometimes left aside within the comprehensive treatment of these disorders? Here’s seven reasons:

It reduces the risk of relapse

Chronically, according to research, the elimination of exercise can lead to higher rates of depression, an increased risk of relapse, a lengthier treatment and a longer-lasting disease.

Education

If physical activity is eliminated in patients who have shown a maladaptive relationship with exercise, the educational factor is eradicated. If a patient that is used to working out for hours with an app, YouTube videos or in the gym, is not educated in health by a physical activity professional, they will probably go back to the same problematic patterns, as that is what they know. When exercise is restricted, patients may not have the opportunity to learn how to engage in physical activity in a healthy, safe and moderate manner. In this case, it is crucial to have a specialized professional to educate patients about health.

Lower psychological distress

In hospitalized patients, being inactive as they start to eat again may prolong the physical and psychological distress associated with the reintroduction of nutrition.

Muscle mass

Research shows that people suffering from these disorders can present significant losses in strength, type II muscle fiber atrophy and loss of lean tissue that affects organ mass and function in patients with anorexia.

Antidepressant properties

Exercise can be as effective as antidepressants in mild cases, and a good complement to psychological therapies to treat some cases of depression. “It is also important to keep in mind that there is no such thing as happy anorexia. In cases of malnutrition there is a depressed mood, so if a lot of physical activity is introduced, with the resulting energy expenditure, malnutrition could be maintained or increased, as well as the lack of energy to do activities. The depressive state will improve in parallel if there are changes in diet and progressive exercise,” explains Manuel Antolín, specialized psychologist and director of the project Cómete el mundo (Eat the world).

Body image and body mass index

In disorders in which self-esteem depends so much on body perception, addressing them also from a bodily perspective can be especially effective. Different studies have shown that supervised exercise would not have a negative impact on the body mass index, something that concerns many healthcare professionals and is present in most research.

Constant supervision

It is important not to leave patients alone and having physical activity professionals in charge of prescribing exercise on an individual basis. A meta-analysis published in the journal Phycotherapy advocates promoting gradual and supervised healthy exercise in patients with anorexia.

Monica started exercising after receiving approval from her therapist and nutritionist. She began with very little, and supervised. She went from working out every day with a YouTube video to doing it two days a week for 45 minutes, accompanied by a physical activity professional. She now understands that exercise is a health tool that allows her “to live to go out with my friends, take trips with my parents, surf and ride a bike to college. I used to feel good, on one hand — I felt the burn and knew that my belly would change — and bad on the other. I compared myself to the girl in the video, I looked terrible, I suffered if I didn’t exercise one day. But I no longer look at anyone other than myself.” Life changes when you stop comparing yourself with others, when you see health as something flexible and exercise as a tool that goes beyond the (aesthetic) shape of our body. Working out allows our body to function properly. Don’t cancel it; change it.

From the theory to the practice

1. Supervision and interdisciplinary work. Patients need to be supported by a team (psychologist, psychiatrists, nurses, endocrinologists, nutritionists) that looks after their health and which includes a physical exercise professional. Communication between them is key for exercise to be reintroduced.
2. Don’t overdo it. Mobility exercises, a short walk or some work with elastic bands can be a way to help the patient reintroduce exercise as their dietary guidelines improve.
3. Strength training is key. This has been shown to improve body composition (muscle mass) without affecting the body mass index and increasing the patient’s quality of life.

The experts’ conclusion

Pou considers it necessary to incorporate coordination and muscle strength exercises from the beginning of the hospital treatment, if there is no hemodynamic instability that prevents it. “It is necessary to understand recovery as body recomposition, not so much focusing on weight as a goal to achieve.” At the same time, he alludes to the need to have professionals who know how to prescribe exercise and work closely with them to take into account the psychological moment they are living. “This also allows us to work on body awareness so that patients, who are completely disconnected from these sensations, can begin to tolerate it accompanied by our direct care teams,” he emphasizes.

Antolín makes a similar analysis. “In my work, I focus a lot on five basic pillars of health: nutrition, physical exercise, rest, emotional management and social relationships.” Just like we cannot tell someone not to eat, not to sleep, not to bond or not to feel, he reflects, “it also makes no sense to tell someone not to move.” But depending on the case, the activity will have to be adapted to the physical and mental situation of each person, to their tastes and preferences, always supervised by a trained physical activity professional and with constant communication with the other professionals in the treatment.

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