Exercise compulsion with an eating disorder — what can we learn from others?

Over-exercising, exercise compulsion, exercise addiction, dysfunctional exercise behaviours

It’s very common for people with an eating disorder to feel compelled to over-exercise.

It can come from a psychological drive to burn calories, or to get a ‘fit’ body. Or to cope with stress, or with guilt…. so many possible reasons, all worth exploring with the person.

There can also be a physiological driver for restlessness. It’s quite visible in some young children, for whom staying still, while malnourished, is agony.

Whatever the drivers, it’s heartbreaking to see a young person throwing themselves on the floor to do pushups, the instant a parent’s back is turned. Or to go running when a cardiologist has given strict instructions to rest. Or to renounce fun, sociable activities or rest, because they really must work out. Or to be unable to sit during a car journey.

It can also be medically dangerous.

What’s the treatment? And how can we parents help our child?

Where’s the science?

You may, like me, wish for scientific answers to the following:

• Should we enforce complete rest?
• Is some form of movement OK or even beneficial, if supervised?
• Are there recommendations for a progressive return to exercise?
• Can a person return to the precise sport that led to the eating disorder?
• Is it true that any form of exercise within x years will lead to relapse?
• How can a person learn a relaxed, balanced attitude to exercise?

To my knowledge there is no good body of scientific knowledge to answer these questions. And while we have specialist standards and guides for treating, say, anorexia, or bulimia, there’s very little on the exercise aspects.

For instance there’s no recommended methods in the NICE guideline for eating disorders. I can’t see any in official guidance from societies of psychiatrists or paediatricians.

Treatment manuals for eating disorders, like the FBT manual, don’t have much to say about exercise.

For adults, some outpatient and inpatient eating disorder treatment providers make use of the Loughborough Eating disorders Activity programme (LEAP), as it has some evidence to support it. LEAP includes an assessment (the Compulsive Exercise Test), and a cognitive behavioural intervention spanning several weeks. An adolescent inpatient unit has been trialling an adaptation of it, which they’ve called Newbridge Eating Disorder and Activity Treatment Group (NEAT). (Don’t confuse this LEAP with the LEAP communication method of Xavier Amador!)

Yes, there are many journal articles, and eating disorder societies publish recommendations, but my understanding is the whole field is in its infancy and full unknowns.

On training courses, I see clinicians who are keen to know, what’s the best advice to give on exercise? COVID lockdowns multiplied the number of people who combine an eating disorder with a serious exercise compulsion. And every gym will have people who consider themselves recovered from an eating disorder but .. pursue extreme muscularity to a miserable or dangerous degree.

What IS a balanced attitude to exercise, anyway?

If you’re in a world where sport and fitness are dominant, you may struggle to know what you’re aiming at for your child. It’s not obvious, in a society where the message is that more exercise is always better. Where exercise is linked to weight loss and to changing your looks.

Note also that the drive to move is one of the genetic factors that correlates with anorexia. Occasionally, when a parent tells me of their child’s extreme exercise compulsion, it’s interesting that one or both parent is extremely sporty — sometimes to a level that sounds rather excessive (e.g. running through injuries).

Exercise can be a useful stress reliever, but it would be better for your child to have a wider ranger of strategies. I list some here.

So what might be a healthy attitude to exercise? It may be companionable. It may give us a sense of belonging. It may bring us into nature. It may involve the delight of a skill, connect us to music, to art. It’s conducive to good health, of course, but not ‘health’ in the kind of way that is actually terrible for your health (not enough rest, injuries, heart trouble, use of steroids, restrictive diet, orthorexia). Exercise should not be punishment or compensation for eating. It should not be so regimented that it gets in the way of a social life, or a party. And it should not be about making your body shape fit into some ideal. Some experts prefer to talk about joyful ‘movement’ rather than ‘exercise’.

Learning from others’ experiences… and their opinions

With all that, when parents ask me what are the recommendations regarding exercise, I send them a miscellaneous bunch of resources. Some come from reasonably prestigious sources. Some come from a professional’s experience and opinion. Some are personal accounts, but I warn you: what helped one person may turn out to be bad for another.

I propose the best that parents can do is assess what makes sense to them, knowing their child. Hopefully they have great clinicians to guide them.

So here is what I tend to share with parents. I am sorry it’s all a bit random. And contradictory.

Great guidance from FBT therapist Lauren Muhlheim

In Return to Exercise and Eating Disorder Recovery in Teens During FBT, Lauren Muhlheim provides an excellent guide for different interventions at different stages.

SEES Guidelines – the only evidence-based thing out there currently?

Clinicians and researchers produced guidelines for Safe Exercise at Every Stage (SEES). Currently it’s for adults and athletes. I believe they’re working on guidelines for younger people too.

They argue that you get better recovery when you include attention to exercise, rather than just remove exercise.

The American Psychiatric Association Practice Guideline

The APA’s Practice Guideline (2023) summarises the situation well:

"An individual assessment of motivations, benefits, and risks of exercise should be done for each patient as part of treatment planning and be reassessed as renourishment proceeds.

Treatment planning should also consider whether compulsive or driven exercise was a part of the patient’s eating disorder–related behaviors. […]

Once a safe weight is achieved, the focus of an exercise program should be on gaining physical fitness as opposed to expending calories. The focus on fitness should be balanced with restoring patients’ positive relationship with their bodies—helping them take back control and get pleasure from physical activities rather than feeling compelled to engage in exercise.

Consequently, an exercise program should be developmentally appropriate and enjoyable and have endpoints that are not determined by time spent expending calories or by effects on weight and body shape.

Weight training to promote bone health and team sports such as soccer, basketball, volleyball, or tennis are preferable to solitary activities. For competitive athletes, decisions about an individual’s return to full participation in sports will require balancing health-related factors, risks of participation in the designated sport, and other factors that may influence decision-making about participation."

The American Psychiatric Association (APA) Practice Guideline 2023, page 36

AED guidebook for nutrition treatment of eating disorders

See pages 48 to 50 of the Academy for Eating Disorders (AED) guidebook for nutrition (2020) for advice based on the latest research.

In summary: have a plan, don’t allow anything but limited daily tasks for those in medical danger, and for others, go gradually.

A comprehensive and practical guide

NEDA’s  ‘Coach and Trainer toolkit‘. Although it’s aimed at school and team coaches, it’s useful reading for anyone, with good principles of both harmful and positive practices, and good case studies too.

Lots of resources for athletes and their supporters

Project RED-S has resources for athletes, for their supporters, and for specialists: articles, videos etc. Sections for the UK, and for the US.

The International Olympic Committee (IOC) produced a risk assesment tool, using red, amber, green traffic lights: Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT) It includes a ‘treatment contract’ and a ‘return to play’ model, but I would warn that there are surely many more considerations, in returning to the sport, than what’s in there. There’s also a section on eating disorders in Mental health in elite athletes: International Olympic Committe concensus statement

A webinar to give you clarity: Sarah Archer

Out of many webinars I’ve seen on exercise compulsion, my current favourite is Sarah Archer: ‘Mastering Movement: how to safely and effectively support your child with their return to exercise and sport‘. It’s part of a F.E.A.S.T. 2023 conference which will continue to be available for a while upon payment of the registration fee. I like this particular webinar for its practical know-how, based on a decade of work at the excellent UCSD’s eating disorder center.

Joyful movement: an ANAD webinar

This is a good YouTube from ANAD (National Association of Anorexia Nervosa and Associated Disorders). Amanda Schlitzer Tierney, MS, CSCS, CEDS speaks about the contrast between a balanced and joyful relationship to movement versus one driven by diet-culture.

Youth sports: another ANAD webinar

Another good YouTube from ANAD: ‘Off the Starting Blocks: Eating Disorder Prevention in Youth Sports‘ with Savannah Fernandez, PsyD.

Lots of good concepts on prevention, what is a good attitude, what is ‘well balanced’,  and I like how she suggests having conversations with ‘athletes’ – meaning any young person who’s a lot into their sport – for instance on their concerns when they have gained weight or when they are less performing.

Most learning starts at around 35 minutes but the whole thing is good. Bear in mind the focus is not on a family-based approach (FBT) and is for any age.

Fit or over-exercising?

If you’d describe your child as an athlete, or involved in competitive sports, be aware that they may be pushed to high levels of exertion even though they are malnourished. Their body is in real danger. Not every coach understands that, for example, a low heart rate may be a sign of malnutrition, not a fitness. And loss of periods in females is not normal.

The keyword for research in this field is Relative Energy Deficiency in Sport (RED-S). It replaces the defunct name ‘Female athlete triad‘ (defunct because the problem exists in males too). It can happen with or without weight loss. Lauren Muhlheim describes how this relates to eating disorders here. The AED guidebook for nutrition treatment of eating disorders (2020), a reputable source of guidance, suggests that treatment is like that for restrictive eating disorders and is focused on increased food intake and reduction or cessation of exercise.

Personal stories

The stories below show that people’s experiences can be quite contradictory. Some of these may serve as warnings — DON’T DO THIS!!!! — and some may give you good ideas.

Read Mamabear’s story of dealing with her daughter’s huge exercise compulsion. At first they tried to reduce the exercise, believing that some exercise would relieve their daughter’s anxiety. Then one day:

"‘we thought, "What in the hell are we doing? This is torture for her." So we stopped ALL exercise. She could not get the mail or even go upstairs unless essential. If we caught exercise she got a replacement of Ensure. We slept with her for over a year. Months later she told us how relieved she was. She told is her joints ached all of the time and how much she hated doing what the voice in her head made her do."

Whether or not you think Mamabear’s approach is for your child, there’s a universal message here: your child could be very tired, and longing for someone to stop them exercising.

See KyrasMom_US comment, where she shares a similar experience:

"I am certain that had we stopped the exercise compulsion behaviors sooner and not tried to find a controlled way for her to exercise as a "stress reliever," recovery would have come sooner"

Here’s an inspiring journey of transformation for a young person who was an elite tennis player, and had been planning to study on a tennis scholarship. The illness caused a reframe for the whole family (I have made minor edits as I quote Teecee’s post and my conversation with her):

My daughter played performance tennis nationally. Before being diagnosed with anorexia 5 years ago, tennis was intrinsically linked to our family and dominated every aspect.

Ask yourself, if continuing her sport was detrimental to your child’s recovery from cancer or even life threatening, would you allow it? The answer to that question made me reconsider what I hoped and dreamed for my daughter.

She tried to continue with her tennis in university, however she recognised it was not conducive to full recovery. Her Psychologist explained that having to balance the diet needed to perform would always leave her dangerously close to serious illness.

She’s recovered now and today we were talking about eating disorders in performance sports, and how her identity was so wrapped up in tennis. And that part of her journey has been detaching herself from that and finding she is good at other things.

The eating disorder made her learn about herself and what other things were out there to discover.  Who she really is and what she really likes.

Health is so precious and she still loves tennis, so chose to coach instead. She now believes competitive performance sports with kids is unhealthy due to the risk of eating disorders being high. She focuses on the fun aspect with the kids…removing any pressure.

More great personal accounts

Good discussion here of a pretty ordinary exercise compulsion and a parent’s fear of stopping the soccer:

And lots more of varied parent experiences on https://www.aroundthedinnertable.org/post/resume-athletics-11768848

And lots more of varied parent experiences on https://www.aroundthedinnertable.org/post/resume-athletics-11768848

Shirly Bachman: How her son kept relapsing while he continued his competitive diving. Ending the diving was hard, but effective: https://themighty.com/2018/02/no-sports-eating-disorder-recovery-parent/  

Contradicting the idea that people should not return to their old sport, the first few posts on https://www.feast-ed.org/forum/?p=post%2Fsuccess-stories-for-returning-athletes-10439866 describe positive experiences.

Perhaps useful to you: KLP on her son’s massive exercise compulsion, the use of Olanzapine to reduce his level of anxiety, and the need for NG tube feeding

Eloise Dulu, triathlete, tells her story of anorexia (I’m told she produces good inspirational instagrams): https://eloisedulu.wordpress.com/2015/09/29/from-black-to-gold-my-journey-from-the-dark-side-of-anorexia-to-claiming-the-podium/

And from Mina Leslie-Wujastyk, competitive climber, ‘Relative Energy Deficiency in Sport – A Cautionary Tale‘. She describes how she got caught up in Relative Energy Deficiency in Sport (RED-S). Careful (trigger warning): she gives figures for weight and BMI.

Dr Julie O’Toole is an eating disorder physician. Two articles are a bit old but possibly still instructive: ‘Tough calls parents have to make’, and ‘Exercise and the severely anorexic patient She warns that exercising could prolong deficiencies in growth, metabolism and cognitive development. She uses lab tests to assess a child’s readiness to resume exercise. (In the UK I don’t tend to hear of that being done).

I am concerned that according to the CBT-E manual (Cognitive Behavioural Therapy for eating disorders) by Fairburn, even underweight patients are encouraged to engage in ‘healthy exercise’.

Podcasts

Podcasts are ways to hear from the experiences and opinions of professionals. I’ve made a note of some of the ones that interested me:

‘Integration of physical fitness’ by Amanda Schlitzer  Tierney (already mentioned above). It’s only towards the end that points are made in the context of someone with anorexia, or someone who is underweight.

‘Eating Disorders, Exercise, and the Recovery Process’ with Dr Beth Hartman McGilley. I thought this was a good adjunct to the Tierney podcast. I was interested in the message that you can move, but you have to choose a new form of movement than the one that was associated with obessionality, that was ritualistic.

‘Ed on ED’: Athletes and eating disorders with Dr Tyson. A fascinating account of the biology of undernutrition while someone continues to over-exercise. It’s very extreme, and hopefully your own child is not at that level. So only listen if you’re interested in how someone in malnutrition might still be able to do so much.

Yoga

Eating disorder treatment centers often provide yoga. The idea is that it’s a gentle form of movement and restores a kind attitude to the body and its sensations. And it can reduce stress before a meal.

Be careful: there are so many forms of yoga! Some are all (covertly) about weight loss. Some are very energetic. Even the slow kind requires strength, and can make you sweaty and hungry afterwards.

Check out the yoga teacher. Do they suffer from an eating disorder? It happens. Is their website full of images showing off their ‘perfect’ body and their prowess? Not good, in my opinion. I would avoid any yoga teacher who likes pushing bodies into extreme flexibility. It promotes an attitude of harshness and disrespect for the body (and it’s probably not good for the body anyway). I would look for yoga that’s all about acceptance and kindness both in mind and body.

Professionals: therapists, physiotherapists, personal trainers

I don’t really want to recommend anyone until I’ve collected more feedback from users. But I also know how much you may want a few names to check out for yourself. So here goes (and really do check them out carefully, and come back to me with feedback!)

The eating disorder exercise clinic

I’ve heard from someone that physiotherapist Daniel Mansaray is experienced in eating disorder treatment settings, and that sessions so far are offering a lot of hope. The website seems to say all the right things. I got in touch with Daniel and he replied, "We work with people aged 14+ as long as we feel we can meet the individual’s needs. Yes we work virtually and so we can work with clients all over."

Free your Fitness: a gradual method

Watch this webinar from Maria Sorbara Mora of "Free Your Fitness". She’s also on IntegratedEating.com and on FreeUrFitness.com and on Instagram free.your.fitness

She has created a progressive method, called Sit-Stay-Heal, to rehabilitate individuals with chronic, obsessive and compulsive exercise issues.

Gyms and personal trainers

Be aware that gym equipment displays calories supposedly burned (even though this is pitifully inaccurate) and body composition (muscle, fat — again inaccurate) and that there are scales in the changing room — all this may reinforce someone’s obsessiveness. It could re-trigger someone who’s in recovery.

Personal trainers may have an eating disorder or an exercise disorder. Decades ago I attended an aerobics class where the trainer’s lips would go blue. I was gutted to learn later that she’d been hospitalised for anorexia and fractures.

I’ve also been shocked to discover that some personal trainers deliver detailed diet advice and meal plans. They may or may not have a ‘nutrition’ qualification, but as far as I’m concerned only registered dietitians can safely give nutrition advice, and even then I would only use one who uses a no-diet, intuitive eating, Health At Every Size approach. Many PTs and gyms use promises of weight loss to bring customers in. They may call it ‘changing your body composition‘: that means more muscle… and sadly, sometimes it also means reducing body fat to a dangerously low level.

There are some great fitness professionals out there, who may be an asset to your child. Sometimes a parent tells me about a personal trainer who has allowed their son or daughter to reign in an exercise compulsion. They may do this by setting a gradual progression of exercises. It’s great when this is combined with life-enhacing messages around food and around acceptance of all body shapes.

Where do you find these gems? I don’t know. There are no qualifications for this, and how could there be, when there is no science to set a curriculum? You’ll have to ask around, and monitor very carefully. Talking of which, this book intrigued me. At first, I thought it was all going to be very eating-disordered, and then I loved the message of inclusivity and acceptance: Stronger: Changing Everything I Knew About Women’s Strength by weightlifter Poorna Bell. Still, I worry about health effects when any sport gets to competitive level.

It’s hard to know whether to allow our children — more or less recovered from an eating disorder — to join a gym. I once posed the question on a forum and got a whole lot of answers. Some parents felt that a desire to join a gym was a sure sign of relapse. Some warn that their gym is a highly triggering environment, with incessant ‘fat talk’ among users, and calorie-counters and weight-loss messages everywhere. Some are confident their child can use the gym sensibly, and can just as easily not attend when there’s something better to do. Some, like me, think that our youngsters might benefit from the practice while they’re with us — so that could be a positive if your child is self-aware and able to reflect on the effect gym attendance has on them. Finally, some parents observe that the gym is just a social place, full of teenagers ‘standing around gossiping and eyeing up the boys’!

This is incomplete

This is a rather random collection and hopefully there will soon be a lot more certainty on what to advise. Meanwhile, I hope this is useful to you. Feel free to share your experiences in the comments below.

Onwards

* Chapter 6 of my book has a section on exercise, movement, even just sitting, while your child is very much in the grip of an eating disorder *

* Chapter 10 also has a section on exercise, for a later phase, when the aim is to phase in more movement and to promote a balanced attitude *