The role of physiotherapy for people with eating disorders
Many who are close to me know that, as a physical activity researcher and physiotherapist, I am passionate about supporting people to become physically active. I enjoy being physically active myself and do something active every day simply because it makes me feel good, like a warm bed on a cold night (well, maybe not that good).
I am also a co-convenor of Physiotherapists for Physical Activity (P4PA), which is an Australia-wide group (with some international members too!) of physiotherapists and physical activity researchers who are passionate about increasing the capability of physiotherapists to change physical activity behaviours of all Australians. Our ultimate goal is to see each and every Australian participate in some kind of physical activity that suits their abilities, all the way from moving their legs in bed if they are bed-ridden to participating in their first fun run if they are more independent, and empowering physiotherapists to make this possible.
My involvement with P4PA has led me to take on the role of finding interesting research on physical activity and translating it for physiotherapists so they can use it in their clinical practice. Over the last couple of years of doing this I have noticed that the majority of research I translate is about helping conventional “at risk” populations, such as overweight and obese people at risk of heart attack, to become more active. But what about the less conventional populations?
I have decided to write a series of posts on the role of physiotherapy and physical activity in less conventional populations. Today, I will start by writing about the role of physiotherapy and physical activity for people with eating disorders, such as anorexia nervosa.
Why people with eating disorders?
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| Image 1: Which of these people have an eating disorder and which need some physical activity advice? (credit: RACGP) |
When you walk down the street, what do you see? You typically see a range of different people, all of different shapes and sizes. Some big, some small. Some tall, some short. We typically categorise these people based on our own experiences and knowledge. This categorisation might lead to judgemental thoughts (and even, unfortunately, vocalisations) such as:
“Oh, that person is overweight, they must eat poorly and not exercise. They should go to the gym and eat healthier food”
“That person is so thin, they must eat very little or exercise too much. They should stop exercising and eat a burger”
Conventionally, people think of people with eating disorders as young, underweight, unhealthy, white and female. But have you considered that anyone in Image 1 could have an eating disorder? That any of them could have anorexia? Bulimia? Well, it’s true. Understanding this might lead to more accurate thoughts such as:
“Oh, that person is overweight, they might eat poorly and not exercise…or they might really restrict what they eat and they exercise too much, which has led them to lose 30kg in three months, which is unsafe”
“That person is so thin, they must eat very little or exercise too much…or they might just be a slender person and might benefit from participating in some physical activity to improve their strength and preserve their general health”
This means that physiotherapists could come across a patient with an eating disorder at any time and not know it based on appearances only. It is important that we, as physiotherapists, know what we can do for people with eating disorders, especially when we might not know when these patients will present to us.
What is an eating disorder?
"An eating disorder is a complex mental illness characterised by disturbed eating behaviours, distorted beliefs, and extreme concerns about food, eating and body size, shape or weight" (SANE.org, 2020)
Video 1: Eating Disorders 101 (credit: NEDC Australia)
Watch video 1 to get an understanding of what eating disorders are and are not.
The potential harms of physical activity for people with eating disorders
Promoting physical activity, or encouraging people with eating disorders to exercise, is a very controversial topic.
Some health professionals strongly believe that people with eating disorders should not be encouraged to exercise because they often have unhealthy attitudes to exercise and use it for unhealthy weight control. In fact, excessive exercise beyond that recommended in the physical activity guidelines has been linked to impaired recovery for people with anorexia, increasing injury risk and risk of relapse. Exercise activates the reward system in the brain, making the person not want to reduce it or give it up, which limits the ability for the person’s body composition/weight to recover because their energy needs are greater than the amount of energy they are consuming.
People with an eating disorder might also have an exercise addiction. Exercise addiction is 3.5x more likely in people with eating disorders compared to those without. Furthermore, up to 85% of people with eating disorders compulsively participate in exercise and have likely exercised excessively long before being officially diagnosed with an eating disorder. These are unhealthy exercise behaviours and must be screened for before promoting physical activity to this group (e.g. by using the Compulsive Exercise Test [CET]).
The potential benefits of physical activity for people with eating disorders
Exercise can be beneficial for people with eating disorders provided it does not exacerbate their condition or interfere with treatment, meaning it is not being used for weight control (i.e. no weight is lost). Instead, people are supported to develop a healthier attitude to exercise where it is used simply for enjoyment instead. So, it’s the attitude towards exercise and the way it is used that can be harmful in this population, not necessarily the exercise itself.
Exercise is safe for people with anorexia and can lead to strength and cardiorespiratory fitness improvements without weight loss. Physical activity in people with anorexia can actually help with weight gain, specifically functional weight gain (e.g. by building muscle, which is often lost along with fat mass especially if the person is purging, consuming inadequate protein and not doing any strength activity). So, it can be safely and effectively incorporated into treatment programs provided weight changes are monitored.
Exercise can also be a helpful adjunct to treatment programs because it can lead to positive mental health benefits by improving psychological wellbeing, body image and self-esteem. High intensity activity has been linked to better nutritional status and resistance to starvation in people with anorexia compared to low intensity activity. Including resistance training in programs is not just beneficial for muscle strength, but can also be protective against osteoporosis.
The role of physiotherapy in treating people with eating disorders
People with anorexia who accept and understand that anorexia is an unhealthy condition can change their relationship with exercise from being unhealthy to healthy, where exercise is used for happiness and enjoyment rather than weight control or improving body image. Physiotherapists have the responsibility of facilitating this acceptance and understanding, and hence changing the attitudes of people with eating disorders. They are charged with helping people to change from having an unhealthy approach to exercise, where it is used for punishment or weight control, to using exercise for happiness and pleasure. This requires considerable skill in attitude and behaviour change, with the ability to personally tailor each program to the individual at various stages of their recovery.
Physiotherapy for people with anorexia should provide the following to address distorted body perceptions and excessive exercise behaviours:
- Support to reduce the distorted body perceptions people with anorexia have by focusing on accurate body perception (e.g. by using relaxation, mindfulness and awareness exercises like yoga), and healthy attitudes and behaviours (e.g. exercise with a focus on injury prevention through safe techniques, adequate preparation and recovery, and promotion of resistance training); and
- Help to reduce the compulsive and excessive engagement in exercise that is common for people with anorexia (i.e. focusing on low intensity activities and resistance training, not exercise to burn calories) and helping them to deal with the negative emotions that might lead to excessive exercise.
Despite there being no consensus or agreed guidelines on how physical activity should be prescribed to people with eating disorders, as well as the provision of professional training in this area drastically lacking, there are some established evidence-based strategies physiotherapists can use to safely prescribe physical activity to people with eating disorders.
How should physiotherapists prescribe physical activity to people with eating disorders?
All treatment programs for people with eating disorders should involve several relevant health professionals, such as the person’s doctor, psychologist, nutritionist, dietician, exercise physiologist and any other relevant professionals (e.g. if the person has a personal trainer). Having this multimodal approach is important to ensure the patient is receiving evidence-based and holistic care throughout their entire recovery journey.
It is imperative that all physical activity programs are tailored to the individual and do not interfere with treatment (i.e. exercise shouldn’t counteract weight regain). Physical activity should instead complement treatment by supporting behaviour change from unhealthy use to healthy use of exercise.
Physical activity prescription can be guided by activity risk, which can be determined using vital sign stability, how close the person is to achieving their ideal body weight and their results on the CET.
Activity risk can be categorised into three stages:
Activity risk can be categorised into three stages:
- High risk: person has vital sign instability, their ideal body weight is <80% and they have a high compulsive exercise score using the CET.
- Moderate risk: person has no vital sign instability, their ideal body weight is 80-90% with consistent weight restoration and they have a moderate compulsive exercise score.
- Low risk: person has no vital sign instability, their ideal body weight is 90-100% with consistent weight maintenance and they have a low compulsive exercise score.
Various levels of PA are recommended for each stage, from bed rest for people at high risk through to individualised program modification for people at low risk (which can include independent or supervised activity, depending on the person’s preferences and your clinical judgement). People with moderate activity risk are encouraged to exercise with supervision. These criteria have been tested in adolescents but could also be used in adults.
Programmed physical activity can occur in group or one-on-one exercise settings and should be graded, starting with low intensity activities, and include cardiorespiratory, resistance and flexibility training. Again, it’s all about tailoring the program to the individual, but the frequency and intensity of activities should not exceed the physical activity guidelines. Although social interaction can be helpful for people with anorexia during their recovery, some people with eating disorders can experience social anxiety, so it’s important to consider this when prescribing group or individual physical activity programs. For example, will your patient enjoy attending a group class or will they prefer to exercise alone?
It is important to closely monitor people with eating disorders while they participate in physical activity for several reasons. Consistent monitoring is needed during and after exercise sessions to ensure excessive exercise, and the negative effects of said exercise, isn’t occurring (e.g. impaired weight regain). However, be weary of using fitness trackers to monitor things like heart rate and exercise frequency as they might exacerbate eating disorder symptoms. Consider using a written contract to outline expectations for the following factors, such as exercise frequency per week (see Table 10 in this paper).
Some factors to monitor include:
- Exercise intensity
- Exercise frequency
- Attitudes to exercise and reasons for exercise
- Heart rate
- Irregular heart rhythm
- Blood pressure
- Hydration
- Electrolyte levels
- Glycogen stores
- Adherence to other aspects of treatment (e.g. nutrition plan)
- Weight changes (e.g. BMI)
- Bone density
- Fracture and other types of injury
- General wellbeing
Referral of the person to their medical team is necessary if any of these factors appear unusual or out of the normal range.
Where can I go for more information?
- Current guidelines for prescribing exercise for people with eating disorders
- The literature review that informed the above guidelines
- Recommendations for prescribing exercise for people with anorexia based on clinical experience
- Some questions to ask when determining if your patient is a compulsive exerciser
- International Olympic Committee consensus statement on relative energy deficiency in sport (RED-S): 2018 update
- Supervised Exercise in Anorexia Nervosa Treatment: Directions for Research and Recovery
- National Eating Disorders Collaboration: Health Professional Resources
- Centre for Eating and Dieting Disorders
- The Butterfly Foundation
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