Exercise Caution: Physical Activity and Eating Disorder Recovery

Compulsive exercise is often a symptom of eating disorders. It is common for a child who is developing an eating disorder to take a sudden interest in running and other vigorous forms of exercise. Given that exercise is a symptom which is directly related to the energy imbalance that triggers and maintains a restrictive eating disorder, it is important for clinicians and caregivers to monitor and manage patients’ exercise during treatment and recovery.

When a patient has an active eating disorder, it is generally ineffective to use exercise or sports as an “incentive” to get him to eat more or gain weight. Even the patient who absolutely loves soccer, and says he would do anything to keep playing, probably won’t be able to eat enough to make that happen. The malnourished anorexic brain is just not capable of overriding symptoms, no matter how alluring the reward may be.

For people with eating disorders, exercise poses numerous medical risks including stress fractures, osteoporosis, muscle wasting, and heart arrhythmia. Further, exercise can be counterproductive to treatment goals when a patient needs to restore weight. For these reasons, I recommend that patients with Anorexia Nervosa or Bulimia Nervosa abstain from all physical activity until they meet the following criteria:

a.) Complete weight restoration
b.) Complete abstinence from binge/purge behaviors for at least two weeks
c.) Consistently eating complete, balanced meals with little resistance
d.) Sufficient hydration
e.) Willingness and ability to increase nutrition and hydration to compensate for activity
f.) Medically cleared to exercise by physician

Explaining the dangers of exercise to the eating disordered patient is important but rarely sufficient to curb the compulsion. Patients with exercise compulsion need an authoritative source to tell them directly, in no uncertain terms, that all exercise must be stopped until the above criteria are met. In my practice, the hiatus from exercise typically lasts for several months, but this varies widely based upon the patient’s severity of illness and response to treatment.

Abstaining from all physical activity means stopping sports, dance classes, martial arts, and any other extracurricular activity that involves movement. It also means no PE at school, no bike riding, no home workouts, no yoga, and no long-distance walking.

Parents can do a number of things to help prevent their ill child from exercising. They can obtain a doctor’s note to except him from PE class, they can call the coach to inform him that the child will not be able to play for the rest of the season, they can give him a break from his usual chore of walking the dog.

When the exercise compulsion is strong, more serious measures must be taken. Some parents may need to get rid of home exercise equipment, terminate their child’s gym membership, or hide her running shoes. Parents must be extremely vigilant in protecting their child from secretly exercising.

Any time spent behind closed doors presents an opportunity for the patient to succumb to the exercise compulsion. It is not unusual for anorexic patients to exercise in the middle of the night, to sneak out of the house to go running, or to do calisthenics on the bathroom floor. Sometimes it is necessary for parents to sleep in the same room with their child and provide round-the-clock supervision for weeks or months at a time in order to break the exercise compulsion.

Full nutrition and weight restoration often help tremendously in lessening the compulsion to exercise. Many recovering kids will lose interest in exercise once the compulsion has faded. These are often the kids who first began exercising in the context of their eating disorder, but never really enjoyed their activity. Once recovered, these kids will often return to lives that are not particularly active, and decide to pursue other interests instead, such as music, art, or a very busy social life.

For some children, exercise has been a part of their lives since they were very young, but took on a new intensity when the eating disorder arrived. For example, a 12-year-old girl who loves to dance and has taken ballet since preschool may suddenly start taking eight dance classes a week instead of her usual four. As another example, a teenage basketball player may begin rising at 4:00 AM to go jogging in addition to afternoon practices with his team. These kids suffer tremendously as the activities they love become tools for their eating disorder to use against them.

In my experience, these patients are often able to return to the sports and activities they previously enjoyed without compromising their recovery, so long as they are physically and mentally ready to do so, and so long as their activity is monitored and limited. The young dancer described above may return to her studio, once weight-restored and back in school, for three or four classes per week. The recovering teenage basketball player may be permitted to practice with his team, but would not be allowed to exercise outside of scheduled practices.

While it’s rarely effective to use sports as an incentive for a sick patient to get well, sports can be a great incentive for a recovered patient to stay well. Many patients, once physically and psychologically recovered, feel motivated to do whatever it takes to maintain their exciting new life. I have found that exercise contracts work well for these patients.

For example, my former patient, whom I will call Andy, played on a competitive year-round traveling soccer team. When Andy developed Anorexia Nervosa at age 14, his parents and I agreed that he would need to take five months off from soccer to restore his weight and focus on his recovery. Once he was feeling better, Andy became excited to rejoin his team.

Andy’s family and I supported his return to soccer so long as it did not interfere with his recovery. We developed a written contract which stated that Andy may participate in club soccer so long as he maintained his weight, ate all of his meals and snacks, drank 8 glasses of water per day, abstained from exercise outside of team practices, and attended monthly therapy sessions. We also agreed that he would drink a smoothie after each soccer practice and that one of his parents would travel with him to all tournaments to ensure that he ate enough to fuel his activity.

Certain solo long-distance endurance activities, such as cross country running and competitive swimming, pose particular risks for patients predisposed to eating disorders. This is in part due to their very high energy requirements, in part due to their solitary nature, and in part due to the extreme rigor of the activity which demands a high level of dedication. Not only do these factors attract young people who are competitive, driven, and dedicated (read: predisposed to eating disorders); they also create the perfect formula for triggering and perpetuating an eating disorder.

If a recovered person who had been a runner or a swimmer prior to getting sick expresses a desire to return to athletics, it may be preferable for him to choose a different sport. Team sports such as volleyball or basketball may be more conducive to sustained remission.

Activities with an artistic or aesthetic element, such as gymnastics, dance, figure skating, and diving, can pose a risk for those in recovery from eating disorders, particularly if body dissatisfaction and drive for thinness were major symptoms of the patient’s illness. If a former dancer/gymnast/athlete wishes to return to these activities, certain factors must be considered. In addition to the criteria for resuming exercise that I listed above, these young people should attain a certain level of body acceptance prior to returning to their activity. They need to feel at least somewhat comfortable in a leotard, and they must be strong enough to challenge or ignore any negative body thoughts that may arise. If a young person experiences a noticeable increase in eating disordered thoughts or behaviors upon returning to her activity, this is an indication that she likely needs more time off to recover before she can safely return.

It is important for dancers and athletes to return to a nurturing environment that does not encourage food restriction, weight loss, or winning at all costs. It is helpful for parents to speak with coaches and trainers to alert them of their child’s vulnerability and ensure that the atmosphere is conducive to health and well-being. There are dance teachers and coaches who encourage full nutrition, healthy body image, self-care, and a balanced approach to life. These adults can be positive forces in helping a young dancer or athlete sustain remission.

It is of utmost importance that family members and treatment professionals convey, through their words and their actions, that the patient’s physical and mental health are the number one priority. Participation in activities that jeopardize health or fuel emotional distress should be avoided. Participation in activities that bring joy and enhance well-being should be encouraged.

14 Replies to “Exercise Caution: Physical Activity and Eating Disorder Recovery”

  1. I would die if I was told I couldn’t work out. I’m not a child, I’m in my mid 30s, but sports and working out have always been a part of my life. I hear what you’re saying in that post, but there’s no way I could not work out. I live in NYC and walk every where too. I played two division 1 sports (quite successfully) with my ED. I’m not saying that that’s a good thing, but I did it. No one knew that I wasn’t eating enough.

    If I was your pt right now, I would be restricted from working out. As bad as this will sound, I guess I’m glad that I’m not your patient.

    I do work out a LOT less than I use to.

  2. PTC,

    Your statement, “I would die if I was told I couldn’t work out” is concerning and suggests an unhealthy dependence on exercise. A hiatus from exercise not only allows your body to heal and strengthen, but also serves as a form of exposure therapy, challenging your belief that you cannot go without exercise.

    Given that you are a former elite athlete, I’m sure you are aware that over-training and exercising in the context of low energy availability have a negative impact on strength, endurance, and athletic performance.

    Many of my patients are devastated when they are told that they must take a break from exercise. But the hiatus does a world of good. The period of rest, in combination with recovery from the eating disorder, helps them experience joy and passion for sports once again. The sport becomes something they WANT to do, not something they HAVE to do.

  3. I never lost my joy and passion for sports. I still play to this day and love every second that I’m out on the field. I miss, more than I can explain, playing at the collegiate level so much. Being and athlete was such a part of who I was. Going to the gym, however, is not as joyful as playing field hockey. If I could play field hockey everyday instead of going to the gym, I would. Fitness is a big part of my life, in fact, I teach fitness classes, so while it’s a part of my ED, it’s also a huge part of who I am as a person.

    1. This is an interesting study. However, it is important to note that participants were not randomly assigned to the exercise program vs no exercise program. Therefore, we are limited in the conclusions we can draw from this study.

      It is important to note that these participants were in residential treatment, so their medical status, food intake, and overall activity level could be closely monitored and controlled. An exercise program for outpatients might pose more risks. I’d love to see more research on this topic.

  4. I’m really glad how you highlighted that activity can be an important part of recovery. I was pretty much as unathletic as you could get. I enjoyed swimming, but quit lessons when they made us dive off the high board (heights give me vertigo).

    When I developed my ED, I became attached to the gym. I worked out for the sake of working out. It was a tool to manage my anxiety and burn calories- there was no joy, passion, or love there. Eventually, I had to take several months off of exercise to do weight restoration, and I began activity again with short walks outside with my mom (I wasn’t weight restored but she had bad knees and needed to go, and she concluded it was better for me to go with her than run laps around the house by myself).

    I maintain a high level of physical activity today, but it took me a long time to get there. Exercise is a crucial part of my recovery BUT I almost never go to the gym. I take dance classes (also known as Adventures in Learning How to Suck at Something), and I do a lot of cycling, both by myself, with my fiance and with a group. But I’m not fixated on numbers and though I get really super disappointed when the weather sucks for months on end and I’m stuck inside all the damn time, I can live. I can do some yoga. I can take walks. Etc. I’m not exercising just to exercise. I’m doing it to socialize, to enjoy the outdoors (that one is HUGE for me), to spend time with people, to relax.

    Exercise was a major part of my disorder, but finding something that I loved to do and had no association with the ED was a major part of my recovery. It makes me feel good about my body, good about myself, and it’s a great tool to help with sleep and anxiety. The difference is that it’s not my life.

  5. It is true the participants in the study were not randomly assigned to either the exercise program or the no-exercise program. The patients were given the choice to join one group or the other. However, it is generally believed that AN sufferers who want to exercise are generally more ill than those who don’t. Consequently, it’s not unreasonable to assume the exercise group was actually more ill to begin with than the no-exercise group. The fact that the exercise group gained more weight duing treatment, and at the end of the treatment had less compulsion to exercise, is therefore all that much more significant.

    The exercise group didn’t run marathons or engage in other high-intensity exercise. The sufferers in that group mostly had yoga, pilates, and other kinds of moderate exercise. It’s hard to argue this was harmful to their recovery.

    There have been additional scientific studies on the role of exercise in recovery from anorexia nervosa. The results are inconclusive. Go to http://www.pubmed.gov for some of the studies.

    In FBT it is parents who establish and enforce rules relating to physical activity for their teenager who suffers from AN. The role of the professional therapist is to serve as a consultant to the parents, not to necessarily make recommendations, lay down the rules, or preempt the role of the parents.

    My daughter gave up lightweight rowing when she developed anorexia nervosa because she was required to weight less than 130 pounds in order to qualify for the lightweight division under the rules of US Rowing and the International Olympic Committee. Since her height was 5’10”, inorder to stay below 130 pounds she was required to maintain a BMI under 18.5, which is generally considered in the anorexic range. It was definitely an unhealthy weight, with serious medical and psychological consequences. It would have been impossible for her to stay in lightweight rowing and recover, because recovery requires the restoration of a healthy weight. We didn’t require that she be sedentary during recovery, but we, the parents, set strict limits on the nature and duration of exercise and we strictly enforced the limits even though she was not in an inpatient or residential setting. The approach worked well. She gradually lost the desire for high-intensity exercise, gave up competitive athletics in favor of other activities in life, and has been completely recovered now for about seven years.

    The best available evidence is that recovery from anorexia nervosa is possible — and likely — if the parents are willing to take control over the illness, by insisting on weight restoration and helping the teenager re-establish normal patterns of eating. How exercise plays into this equation will vary from family to family. One size does not fit all.

    1. Chris,

      Thank you for sharing this story which beautifully illustrates how the role of exercise in recovery will vary from family to family. I have worked with some families in which the teenager continued with limited, supervised exercise throughout treatment and recovered quite successfully. You are correct that one size does not fit all. As long as the exercise doesn’t put the patient at medical risk, or interfere with weight restoration, it can be successfully integrated into recovery from AN in some cases. In FBT, the role of exercise will depend a lot on the parents’ level of comfort with their child exercising.

  6. Great article. I teach piano lessons and have a lot of young students. I notice that especially the girls often talk about wanting to exercise to stay thin. It shocks me, because I never thought about this stuff when I was their age. Thanks for this.

  7. Hi! Dr. Ravin,

    Thank you for writing this post to clarify the confusion among the parents with ED kids about the sports. My wife and I read your posts very often and learned a lot from you.

    Actually I called you in March, 2012 and invited you to be my daughter’s therapist. Unfortunately you were not available at that time. I wish you could be my daughter’s therapist because you are one of few qualified FBT therapist in this country.

    We found another FBT therapist in different city at that time, however we only consulted with her for 6 times. It didn’t work very well because it was not effective talking through between me and the therapist, not my daughter and therapist.

    Then we decided to be our daughter’s therapists (I agree with what Chris said). It turned out that was the best decision we had ever made. My wife and I had high education and we are quick learners. It is not very difficult for us to learn the principles. The difficult part is how to apply those principles in practice.

    To make the story short, my daughter’s weight has been restore in June, 2012 after 3 months refeeding. We gradually allowed my daughter back to sports. First, PE, then recreational sports, finally competitive sports. Currently she has been maintaining her weight for almost 20 months and is enjoying her sports.

    No signs of exercise compulsion. The journey was not smooth, we have been gone through a lot of obstacles: lying on food, weight and activities. What we did is that if we found a loophole and we fixed one. Always define a contract before D joins a new sports.

    We have seen many examples that the kids go back to sports when they are not ready and are not tested.

    I totally agree that the AN kids can’t go back to sports before WR. Even after WR, the kids can’t join the sports if they are found to have exercise compulsion. Based on our experience, the parents should guide the kids back to sports slowly. The key is that the parents should always have the control. If the thing is out of control, the parents should take the control back. Gradually if the kids show more better signs, the parents will give more freedom.

    We are looking forward to hearing more about sports from you.

    My daughter (15 years old now)’s weight is in the expected (normal) range, however her period has been stopped for more than 3 months. She had the period before after WR. Do we need to stop her sports?

    Thanks in advance!

    1. David,

      Congratulations on helping your daughter recover from AN. It is fantastic that, under your guidance, she has been able to enjoy sports while maintaining her remission. In my practice, many kids who enjoyed sports before developing AN are able to return to sports successfully when they recover.

      If your daughter had been menstruating previously but has missed her period for 3 months in a row, this is a problem. You are wise to be concerned about your daughter’s amenorrhea, as it can lead to numerous health problems if left untreated.

      I cannot really answer your question about her continued participation in sports without first knowing the context. First, it is important to determine the reason for her amenorrhea and to correct it. I would recommend taking your daughter to her physician for a complete physical exam including blood tests. Dr. O’Toole of the Kartini Clinic has written a blog post recently on this topic. I would highly recommend reading it.

      In an adolescent with a history of AN, the most obvious possible reason for missing periods is that she may not be at her optimal body weight. It is possible that your daughter is “normal weight” by population standards but “underweight” by her individual growth curve. Pediatricians generally consider any weight between 5th and 85th percentile to be “normal.” From an eating disorder perspective, this makes no sense. If a child has always tracked in the 75th percentile for weight, but then drops to the 50th percentile for weight, her she would be below her ideal body weight even though she would be in the “normal range.” I would recommend checking her historic growth charts to ensure that her current height and weight percentiles are similar to where they have been in the past when she was healthy.

      If your daughter is right on track in terms of maintaining her historic height and weight percentiles, it is still possible that her body could be in an energy deficit. An energy deficit occurs when someone is consuming fewer calories than her body needs to maintain normal functioning. Energy deficits often, but not always, result in weight loss. It is possible that your daughter is taking in enough calories to maintain her weight, but not quite enough calories to menstruate. The female body requires extra energy to ovulate and menstruate, and when a body is deficient in calories, menstruation often ceases as the body tries to conserve precious calories. It is relatively easy for a teenage athlete to fall into an energy deficit because teenage athletes have very high caloric needs. It is possible that your daughter needs more calories to offset the energy deficit. In addition to having enough calories, it is also important that she is consuming enough dietary fat.

      I agree that you, as a well-informed parent, are in the best position to make decisions about your daughter’s treatment, including exercise and sports. In my opinion, the deciding factor would be whether your daughter is able to consume enough calories to resume menses while also playing sports. If your daughter loves sports and is motivated to continue playing, she may be able to increase her calories with your guidance and support. However, if she cannot manage to consume enough calories to fuel athletic activity and menstruation simultaneously, then it would be best for her to take a break from sports and focus on resuming her periods.

      On the other hand, it is also possible that the reason for her amenorrhea is not directly related to her eating disorder. Other conditions, such as polycystic ovarian syndrome (PCOS), pregnancy, tumors or diseases of the hypothalamous or pituitary gland, or hypothyroidism, can cause amenorrhea. Your daughter’s physician can conduct tests to rule out these conditions.

  8. Hi! Dr. Ravin,

    Thank you so much for your quick reply. We have taken our daughter to do the physical exam early this week.

    So far our daughter’s weight and state are pretty good. She can focus on her study and her academic performance is very good. At the same time, she enjoys her sports and the art as well. She also have many close friends like her. Nobody in school knows that she had ED before. She looks and behaves like a normal teenage. We like to keep this way.

    However, we still control the breakfast, dinner and night snacks. She eats lunch and afternoon snack by herself. We are trying to give the control back to her gradually. This is not easy. We have done several experiments, not very successful.

    I will appreciate it if you can write some posts about how to give the control back to the kids in the future. Our goal is very clear: eventually she can eat and maintain her weight independently.

    Thanks again!


  9. David,

    I have written previously about the challenging process of handing back control of food to the adolescent. I’d recommend that you read my blog post entitled Navigating Phase II:

    Helping a teenager with AN learn to eat independently and maintain her weight is often a process of trial and error. If your experiments with independence have not gone well, this is an indication that your daughter is not yet ready for that level of independence. For a lot of kids, it just takes time, consistent nutrition, and maturity.

    It sounds as though your daughter is living a happy, healthy, relatively normal teenage life. She can manage lunch and afternoon snack on her own, which is really all she needs to be able to do in order to attend school, play sports, and have a social life. Most teens eat breakfast and dinner with their families anyway, so this is not unusual even for a teen who has never been ill.

    It sounds like there is no need for your daughter to gain more independence in her eating at this time. She is only 15, so she will have at least 2 or 3 more years of living at home with you. In my opinion, there is no need to push for more independence in eating until your daughter is a senior in high school and preparing to live independently.

  10. The FBT manual says: “Much of the focus in the early part of Phase II is on experiments with transitioning control over eating and exercise back to the adolescent child safely. Parents think through this process during the sessions and decide on a course of action based on discussions with the therapist and patient about what is reasonable to attempt. Some families transition control back quickly; others take a step-by-step approach. There is no correct way to do this, but feedback in terms of patient behavior and weight provide important checks on the process.” Treatment Manual for Anorexia Nervosa; A Family-Based Approach, p. 179.

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