Returning to Exercise After Eating Disorder Treatment

By Beth Riley, MSW, LISW-CP, CEDS

In a previous blog post, I discussed excessive and compulsive exercise habits in people with anorexia and bulimia. Today, I’d like to discuss how to help patients in treatment for anorexia or in treatment for bulimia integrate movement back into their lives.

First, I’d like to state that some patients are allowed to maintain a controlled amount of moderate activity during treatment if they do not have a history of excessive exercise and they have been cleared by the treatment team. These individuals will need to be monitored closely during and after treatment for any significant changes in their attitude or behaviors related to exercise (i.e. exercising to compensate for increased food intake or exercising to cope with anxiety about changes in their body).

Preventing excess exercise after eating disorder treatment

We take a different approach with those who with a history of excessive exercise. Those individuals are given a detailed exercise plan during treatment at our eating disorder clinic.

This exercise reintroduction process is highly individualized and depends on a number of factors, including:

• Progress in recovery
• Medical status
• Exercise history
• Attitude, thoughts and feelings about exercise
• Rationale behind decision to return to exercise

During this process, the team at our eating disorder clinic will work closely with the patient, support persons and outpatient providers to develop a reasonable plan that can be maintained after treatment ends. Patients can and should be involved in this decision-making process. Exercise physiologists and recreation therapists can also be helpful in developing this plan.

Starting with gentle movement 

If it seems appropriate to reintegrate physical activity back into the daily routine, a mindful and gradual approach is recommended.

Consider starting the movement program in a social setting; we find a social or group setting to be very therapeutic for patients, particularly because many of them have exercised in isolation in the past. Also, a group or social setting actively encourages the patient to branch out beyond their typical isolative habits, creating a new mindset regarding movement.

The type of movement will also be important to consider. We recommend integrating one of the following types of movements first:

• Gentle yoga in a group setting
• Tai Chi
• Mindful nature walks in a group setting

Additionally, we encourage the patient to use mindfulness as they move: focusing on their breath and being present in the moment. These skills work to replace what they may have been focusing on in the past: the length of time they are exercising, the intensity of the exercise, the number of calories burned or even negative self-talk. An example of a mindful walk might include noticing your surroundings (birds, trees, clouds in the sky).

Types of movement and situations to avoid

While mindful group movement works for some of our patients in recovery, there are some types of movement and triggering situations that we caution our patients and families against. I list some of these examples below:

Power yoga

While yoga can foster mindfulness and emotional healing, we find certain yoga classes (power yoga, hot yoga and other types of yoga that require great physical exertion) to be very triggering to patients. Instead, we encourage patients to start yoga in a non-competitive environment that is not focused on strength-building, calorie-burning or weight loss.

Running

Instead of fast-paced power walking or jogging, we encourage patients to try gentle walking with family and friends.

Focusing on numbers

We try not to use numbers as we talk about re-introducing exercise back into a patient’s routine. These numbers can be triggering. Instead of focusing on the numbers, we encourage our patients to begin by walking “at a gentle, slow pace” for “a short amount of time.”

Using technology to track exercise

We also educate our patients about the concerns of using technology in regards to physical activity. Technical gadgets that count and keep track of exercise have become a very significant factor for those who exercise excessively. This is especially true for perfectionists and over-achievers. We advise patients to avoid Fitbits and turn off any health tracking settings on their iPhones. Family members should also avoid using Fitbits and watch what they say around the patient.

Triggers from friends and loved ones

Family members and loved ones play a critical role in recovery and can help by monitoring the patient at home. Some patients will hide their exercise behaviors at home: waking up very early to run or exercising in their bedroom or bathroom. To support your loved one in recovery, do not talk about exercise and do not invite your loved one to go to the gym, participate in a 5K or attend an exercise class other than gentle yoga. Families that focus on physical activity frequently, such as those that run marathons or play soccer together, can try other activities to connect, such as festivals, dining out, plays and movies.

Places where nutrition, supplements and weight are discussed

Avoid other places and situations that can be triggering. For example, patients can avoid attending classes in locations that promote weight loss, nutrition/supplements or places that have scales easily accessible. Be careful about attending health classes or gym classes in schools or universities that promote calorie counting, weighing and exercise tracking.

It’s important that the outpatient team (alumni support, dietitian, therapist and MD) work together to keep each patient’s best needs in mind. As movement is added back in, patients should be encouraged to stay in outpatient therapy.

Returning to exercise after an eating disorder

In treatment, we ask our patients to look at movement as something that is to be enjoyed. We ask our patients a number of questions to help them through this process.

• What movement did you enjoy as a child?
• Did you enjoy being out in nature or in classes with others?
• Did you enjoy biking in the neighborhood with friends?
• Do you find pleasure in exercise?
• Can you make it a social event?

Physical movement shouldn’t make you feel worn out and depleted; instead, it can be fun and enjoyable and make you feel good. Instead of living a life that is structured around exercise, balance and moderation will be key.

In the long term, many patients will be able to resume regular activity and may even be able to compete in sports or visit a gym again. I estimate that it takes one to seven years in recovery to get to this place, and it really depends on the individual.

A special note regarding athletes: When it comes to resuming athletic or competitive activities, timing is very important. There must be a thoughtful and structured plan created in conjunction with the treatment team. In some cases, it is best that the patient first return as a team manager or as a non-active participant. Also, it is important that coaches, trainers, and team doctors have been educated about the patient’s history of excessive exercise, eating disorders and warning signs of relapse. Monitoring of the patient will be critical.

Beth Riley, MSW, LISW-CP, CEDS