Should You Exercise During Recovery From Anorexia? Part 2

Practical guidelines for optimizing exercise and rest during and after recovery.

Posted Dec 23, 2018

By Karen Photiou and Emily Troscianko

This post follows on from an overview of the physical and psychological pros and cons of exercising during recovery from anorexia. Like the first post, it’s co-authored by me, Emily, and paediatrician Karen Photiou, who has generously contributed both professional and personal expertise to our discussion.

From our discussion in Part I, our conclusions are as follows.

1. If your menstrual cycle stopped as a result of your eating disorder, you should rest until it resumes and is regular. Waiting until you have had at least three consecutive cycles is a good indicator of hormonal balance.

2. If you are aware of any other physical factors that make exercise dangerous for you (electrolyte imbalance, hypoglycemia, bone density loss, heart muscle wastage, etc.), you should rest until they are resolved — or, in the case of bone density, until your hormonal functioning is normalized, and you are weight-restored. 

3. If you are underweight, weight restoration is a priority, and you should avoid strenuous activity until this has been achieved.

4. If your menstrual cycle is normal (or you’re pre/post-menopausal or male), and you don’t think you have any other physical risk factors, you should bear in mind that you may have physical problems of which you are unaware. 

5. In all cases, you should carefully assess all the psychological risk factors which we discussed in Part I and explore in more depth here before deciding whether it’s safe for you to be exercising. 

In the rest of our discussion, these five points will be taken as read. If (1), (2), or (3) is true for you, that should override any counter-indication that exercise is not a problem for you (e.g., no addictive relationship with it). You may find our suggestions about how to rest helpful, but make sure you keep resting until none of (1-3) is true, even if any psychological problems with exercise have been addressed. 

Total rest from demanding exercise is a crucial protection from significant physical dangers, including further bone damage, but no-exercise-ever is not a meaningful rule for your entire life after recovery (Calogero and Pedrotty-Stump, 2010). Developing a genuinely healthy personal model for physical activity everywhere on the spectrum, from everyday movement to organized sports will be crucial to whether and how you recover from anorexia and stay recovered. This post makes a set of practical suggestions for how to: 1) prevent exercise from compromising recovery and 2) help exercise be a life-enhancing pleasure for the future (if you want it to be).

Ways to assess the problem

First off, do you have a problem? Are you exercising in a way that’s doing you harm? If you’re doing any demanding exercise while underweight, amenorrheic thanks to eating inadequately, or with any other physical risk factors in place, the answer is yes. Beyond that, the lines are blurrier. One simple diagnostic question is: If I had to give up structured exercise for a week, how much of a problem would it be? Various tools are also available to assess the extent to which and the ways in which exercise is problematic for you. For example:

  • The Compulsive Exercise Test (Meyer et al., 2016; and reproduced on Jenni Schaefer’s website here), designed for eating disorder populations
  • The Exercise Addiction Inventory (Lichtenstein et al., 2014; reproduced on Gwyneth Olwyn’s Your Eatopia site here) designed for an athletic population and adapted by Olwyn into the Exercise for Restriction Inventory (here)

You may find questionnaires like this helpful as a way of identifying what exactly the problem is for you right now, on dimensions including saliencemood modificationtolerance, withdrawal symptomsconflict, and relapse.

You may also find it interesting to reflect on how your relationship with exercise has changed since you became ill. Before your anorexia began, did you enjoy exercise or sport of any kind? If so, did those pleasures gradually get distorted by your illness? If not, did you take up something pleasureless to serve the eating disorder? 

Why everyone should have a complete rest at some point in recovery

Whether you know, suspect, or doubt that your exercise habits are doing you psychological or physical harm, we recommend that a period of total rest from structured exercise be part of your recovery.

This will have the following effects:

  • Make sure that food for you isn’t something that has to be earned by anything more than being alive. Neither "burning off the calories" nor any kind of self-punishment is what makes it OK to eat; eating is necessary and hence legitimate to "merely" support life, whatever activities that life does or doesn’t involve. 
  • Get rid of any existing calculations about energy in and energy out.
  • Confirm that you can get through the discomfort, and that the world doesn’t end if you don’t do your daily 52 minutes on the spin bike.
  • Accept that recovery must take its course, and that trying to ensure a certain body size, shape, or composition (e.g., of the "I’m happy to gain weight if it’s muscle, but not fat" variety) through exercise, or indeed by any other means, makes full recovery impossible 

How to rest: Deciding on duration

Of course, many people in recovery, especially the relatively early stages of weight restoration, are simply exhausted. You sleep a lot, even basic daily activities are tiring, and anything more brings aches and pains and greater weariness. If this is you, listen to your body’s plea for rest, and wait for this phase to pass, as it will. This is your body saving you the trouble of having to systematically decide on rest, by making anything else just too hard. Be grateful for the helping hand, and enjoy the knowledge that rest means recuperation.

If you need to make an effort to let the exercise go, however, first decide how long you’re going to be without it until you take stock again. Our own experiences and what we know of many other people’s suggest that the minimum useful time to commit to in the first instance is a week: this is long enough for some of the early anguish to work itself out, and for a new kind of normality to start to assert itself. However, a week is extremely unlikely to be enough to kick the habit entirely, and we recommend a month as an ideal first stint if you can bring yourself to commit to it. In what follows we propose an iterative formula by which to gauge whether your time without has been enough or whether you need to do another block.

If a week seems beyond the realm of possibility, and all you can bring yourself to do right now is a day, do that. The arc of a waking day followed by the resetting of sleep is a powerful natural rhythm, and spending all of it without exercising will teach you something. But bear in mind that having to recommit to seven separate days is a lot more tiring than committing once to a week without, so choose your starting goal wisely. Likewise, whittling down the duration or intensity of your exercise little by little before you even get to a single day without may ultimately exact a higher cost in mental fatigue and dissipated motivation than you anticipate – and so risk compromising the entire recovery effort. Nonetheless, if this really is the only way you think you can work your way down to zero, do it that way. Just remember that what the anorexia tries to dress up as a great idea is often the opposite of a great idea.

Of course, it’s perfectly possible for exercise to be both compulsive and excessive without happening every day. If you have to go to the gym (or run, or swim, or whatever) three or four times a week, for example, and feel unable to miss a planned session, that is still a problem and is still driven by and helping sustain your eating disorder. If this is you, deciding on one new rest day may result in three consecutive exercise-free days, and it’s important to resist the urge you may feel to shift the session you’ve skipped to the following day.

If you have a job that involves demanding physical activity, at some point you may have to choose between your job and your recovery. You may be able to negotiate a temporary exchange of duties with colleagues, or to take a good chunk of annual leave in one go, or of course to claim sick leave during recovery. But if none of these is possible, for example because you work freelance, you may have to make a difficult decision about your future: about how both your work and your illness have shaped your life, about what you want the rest of your life to be, and how, in practical terms, you can achieve that.

How to rest: Avoiding pitfalls

However long an exercise-free phase you’ve decided on, it will probably be very hard at times – probably especially near the beginning, when your first normal exercise slot approaches and ticks by. One common response is to want to compensate for the reduced exercise by eating less. Acting on this instinct would completely defeat all the purposes of the time off: it would leave the conditions for eating, the energy in/out calculations, and the attempt to exert control over your body shape or size, untouched, and would also encourage your erroneous belief that you can’t get through the discomfort of resting without enlisting disordered strategies to help you neutralise the pain. So don’t do it. Eat every meal and snack as you would have done otherwise. Know that the combination of food and rest is precisely what your body has been longing for.

As for the difficulty of sticking to what you’ve resolved and just not exercising – here are some tactics that may help you stick to your intention to rest during the time you’ve decided to:

  • Take practical steps to remove yourself from the temptations of your old exercise habits. Whether it’s cancelling your gym membership (see our next point), removing exercise equipment from your home, telling your exercise buddies you’re taking a break, planning the bus route to replace your over-long walk to work, changing the way you walk to the shops to avoid passing the gym – whatever little environmental cues will make doing this thing harder, eliminate them.
  • If you have gym membership that you’re tied into for a long contract, or that has a fixed notice period, you may simply need to try doubly hard to resist the temptation to keep going, and reconcile yourself to losing the money. Remember, as far as costs of recovery go, this is not the greatest, and it will be repaid a million times over by getting fully better. However, many contracts include a clause allowing for cancellation in case of changed circumstances, like injury or illness. If yours does, then a doctor’s note may well be all you need to provide. If you’re in the UK, Citizens Advice and Which? offer further advice on cancellation, and Which? include a letter template you could consider adapting.
  • Decide on things to do at the times you’d normally have been exercising. Whether it’s cancelling your alarm and letting yourself sleep instead of getting up to exercise, planning something nice to look forward to in the slot you’d normally have filled with exercise, getting something useful done to free up time elsewhere in your day, or (especially early on) making sure you have company to distract you or cheer you up, don’t leave a vacuum that the old habit will find it easy to sneak up and refill.
  • Write yourself a list of reasons why you’re doing this: anything we raised in the previous post that resonates especially strongly with you; any ways in which you’ve realised that the way you exercise is supporting the survival of your eating disorder; any desires you have for a life in which exercise no longer plays this role. Turn to this list in times when you feel the urge to return to the old ways, to remind yourself why this matters and why the rest of the world’s rules and anxieties about exercise do not.
  • Remind yourself that you knew all these horrible painful emotions and sensations would arise, and that you don’t need to be dragged down by them. As Tabitha Farrar puts it:

You do not have to participate in your emotions. You don’t have to get involved. Emotions, like urges, come and go, and they only stay if you step into them and empower them. If you step out of the way, emotions will pass by. […] One of the most powerful things I ever learned was that my emotions are optional. I don’t have to step in. I don’t have to get involved. I get to make a choice. 

You almost certainly will feel some anxiety, guilt, panic, restlessness, or other kinds of misery. That doesn’t mean you need to act on them. Choose not to, and they will pass.

  • Deconstruct the thought process that may creep up on you at any time during this period of rest and try to convince you that this is stupid. If you find yourself worrying about gaining fat instead of muscle, remind yourself of the importance of fat as a reservoir for maintaining hormonal and metabolic balance. If you realise you’re thinking of yourself as lazy, remind yourself how much harder it has long been for you to rest than to exercise. If you question whether you’re just kidding yourself that resting is hard and it’s really way too easy because you are in fact just plain old lazy, remind yourself that this is classic unfalsifiable anorexic logic and it will dissipate only if you continue to act (or rather, not act) despite it. 
  • Keep an eye out for compensatory kinds of exercise creeping in, like (as Tabitha Farrar describes in the same post) walking unnecessarily, finding reasons to shop or do housework you wouldn’t have otherwise, finding excuses to stand not sit, or fidgeting as you sit. This defeats the purpose of the rest period just as much as eating less would.

Assessing and iterating

And then, once the rest period you decided on is over, take stock. 

  • How did it go? 
  • How much better or worse or different was it compared to your expectations? 
  • What benefits have come from doing it?
  • How do you now feel about exercise? Are you longing to get back to your previous routines, to make up for lost time, to get your body more toned again?

Ask yourself not just how you felt during your rest period, but what you can learn from how you felt: how you can turn any difficult parts of the experience into sources of insight. If you felt intense and undiminished anxiety at not exercising, for example, that signals clearly that you have a strong dependency on exercise which can be broken only by further abstinence.

And if you feel even a little of this kind of longing to get back to how things were, you need more time without. So decide on another exercise-free period: maybe two weeks this time, or another month, or whatever feels both doable and worthwhile. And ask yourself the same questions. 

Has anything changed? 

It may require many iterations, and of course there’s a danger of dragging this whole process out for so long that you lose all momentum and belief in the possibility of profound change. It’s the exercise equivalent of thinking you can make weight restoration happen by adding in an extra banana a day. Some progress may happen, but it’ll be so slow that it’ll take you years to see any real improvements. It’s also a bit like spending an inordinate amount of time dipping your toes in and gradually creeping deeper into the cold pool – inflicting far greater and more prolonged discomfort on yourself than just plunging right in and getting it done. So be sensible. If you’ve done a series of single days, or even a few weeks, and nothing much has changed, it’s time to brace yourself for something more substantial. Your ultimate aim is to have a decent break. the quicker you can get to that, the quicker you will be well again and able to move your body with freedom and delight again.

Opening out beyond rest

At some point, you’ll get to the end of an exercise-free period and realise you don’t care that it’s come to an end. Or maybe you’ll even find you’d forgotten when it was meant to end. Your life has grown meanwhile in richness and in other interests, and the exercise-shaped hole you once had to try to fill with other things, or ignore, or persuade yourself shouldn’t exist, has closed up of its own accord. 

In this case, you may not want to change anything when the time comes to an end. You may be happy to let life continue in the shapes it’s gradually acquired, to let physical activity be what it’s been for most of human history: the activity required to keep life ticking over. Or you may decide at this point to open yourself to opportunities to try physical activities or sports you’ve never tried before: things that friends enjoy, for example, or that you’ve read about and are curious about. You may or may not find they’re for you, but as part of the general process of opening yourself to life’s many possibilities beyond self-starvation, sports and physical activities of many kinds may well be valuable things to try out.

For Emily this new openness took the form of starting to wonder why her new boyfriend liked lifting so much, and overcoming her long-held disdain for gyms enough to go with him one day and give strength training a try. This changed the course of her recovery and post-recovery in ways described more fully in this post, and which were, as far as she can tell, wholly positive. But starting lifting any sooner would almost certainly have been problematic, both physically and psychologically. For Karen it involved allowing herself to stop overthinking the potential problems and pitfalls of new types of exercise, and trying something completely different from the obsessive cardiovascular pursuits that characterised her anorexia. For her, there was also an immediate physical incentive to start lifting: she developed osteoporosis in her thirties, and has suffered several fragility fractures including a broken arm. The Watson et al. (2017) study offered hope that by lifting as well as eating well, the damage will now start to be reversed.

Or maybe the success of your rest period will take a slightly more ambiguous form than carefree indifference or curiosity. Maybe you’ll have no desire to go back to your old exercise routines but you will be aware of wanting to be physically active for other reasons: wanting the feeling of using your muscles in varied ways, wanting the fun of playing on a team of other skilled people, wanting the joy of being active in the open air somewhere beautiful… These pleasures may be things you remember and miss from your life before anorexia, or things you’ve never experienced but would like to be part of your future. In this case, ask yourself carefully whether this is really what your desire for exercise is made of, or whether these positive desires may be cloaking some residual anxiety or compulsion. A little magic-wand question may help here in distinguishing between healthy and unhealthy instincts: if someone could wave a magic wand and your weight or body composition would never change, would you still be doing this? And, if not, what form of movement would you choose instead? 

If you conclude that your reasons for wanting to be active are still suspect: commit to another period of abstinence, and find ways of satisfying these desires in other ways (gentle stretching, a social group of another kind, trips to pretty places). If you’re confident they aren’t: experiment, explore, and enjoy.

If you’ve lost significant bone density during your illness, you may also want to give some consideration to how exercise could help you repair that damage post-recovery. The lifting protocol we mentioned in Part I (Watson et al., 2017), which demonstrated reversal of bone density loss in women with osteoporosis, included squat, deadlift, and overhead press for loading the entire kinetic chain in different orientations, plus jump chin-ups for impact loading. If you’re going to try something along these lines, make sure you take advice on developing and maintaining strict technique from a personal trainer or someone else who really knows what they’re doing (see the factsheet on Emily’s website, here, for some tips on getting into lifting). And avoid high-impact sports like jumping, running, contact sports, and horse riding, plus anything likely to result in falling, like ice skating, until you know that your bone health has improved.

Staying safe

So, you’ve had a significant period of time without structured exercise, you’ve started some new kind of sport and are enjoying it, and you want to make sure the danger of any new kind of compulsion creeping back in is as small as it can be. What do you do?

  • To begin with, stay away from the types of exercise that were part of your illness. You may one day be able to return to them with a new attitude and capacity for true appreciation, or you may never be able to. Either is OK. If your life never has another treadmill in it again, it’ll be all the richer for it.
Beat, Facebook
Source: Beat, Facebook
  • Especially early on, privilege skills-focused over endurance-focused sports and social activity over solitary exercise. It’s much harder to get obsessive about how many goals your team scores than about how fast you ran 800 metres. Exercise addiction is common in endurance sports like distance running (Nogueira et al., 2018) (which makes Beat’s habit of doing fundraisers in the form of endurance running and cycling events fairly disturbing), with the addictive qualities often being ascribed in part to the endorphin-driven ‘runner’s high’. Yoga has also been found to have positive effects on various body-related dimensions of wellbeing, and even on eating disorder pathology, without compromising weight restoration or maintenance (for an overview, see Calogero and Pedrotty-Stump, 2010, pp. 435-436). So, be sensible. If you have a history of compulsive endurance cardio, it will probably be much easier for you to take uncomplicated joy in walking with a friend with a picnic break and plenty of stops to admire the views than in walking alone – though you can work towards being able to grant yourself the same gentle pleasures alone as in company.
  • Guard against numerical proxies for the pleasures of exercise: so stay away from step counters, Fitbits, etc., and treat any instinct to quantify what you’re doing (counting minutes spent moving, for example) with caution. Never use any kind of calories-burned calculator – they’re always unreliable, and they will never again be relevant to you. Where numerical measures of individual performance are fundamental to your sport, as they are to many – weight in powerlifting, height in high jump, distance in javelin, etc. – check in with your attitudes to your progress. Are you enjoying adding weight or height to the bar because doing so is an objective indicator of your growing strength and skill or because it means you’re defeating weakness? (The difference is subtle but significant.) Are you happy about throwing further because you love the exhilaration and the proof of growing mastery of a skill, or because you’re burning more calories or pushing yourself harder? 
  • From time to time, ask yourself a few key questions: 

Is this activity serving the outdated values and aims of the eating disorder, however sneakily? 

Is my life being constrained rather than enhanced by this activity? 

Is this activity a compulsion more than a choice? 

Would this activity be hard to give up for a week? 

Is this activity a condition I am placing on my eating, my recovery, or my life? 

Are any rules growing up around this activity?

If the answer to any of these questions is ever yes, take careful note and change something. Maybe take the week off. Maybe do something else differently and see whether it helps. In early 2016, Emily realised (and described here) that her attempts to lose water weight for a powerlifting qualifier (by over- and then dehydrating), and her annoyance at her body for valiantly resisting those attempts, were just silly: she was ending up resenting her body for being resilient to stressors that there was no good reason to be imposing on it. She hasn’t competed since, and although she may do again one day, really the role of lifting in her life is as a flexible, sociable, skill-focused, meditative punctuation to the work of writing and coaching and all the other interests and pleasures life holds. She recently had a three-week break from lifting and enjoyed both having the break and getting back undert the bar afterwards, and was happy that both were true.

James Anderson, used with permission
Source: James Anderson, used with permission

With reflection and growing wisdom, you may want to adapt or add to this list of questions and check in with yourself or with someone close to you at intervals, to review how things are going. Karen is currently cultivating her own set of questions along these lines, and is enjoying giving herself permission to try new activities and feel her body grow stronger and physically skilful once again.

In conclusion

James Anderson, used with permission
Source: James Anderson, used with permission

Remember that eating disorders can be consummate shape-shifters, insinuating themselves back into your life in forms subtler than you could ever have expected: Karen’s running morphed from a positive pro-recovery activity to replace physical weakness with fitness to another manifestation of eating-disordered behaviour without her even noticing. But remember too that full solid robust recovery is possible, and that at some point the shape-shifting just stops happening: for Emily, lifting weights was never co-opted by any disordered instincts, and it has cultivated in her attitudes which are quite the opposite. For Karen, too, lifting has recently started to be a reliable force for good. For Emily (as described in this post), being able to ski again with strength and energy and enthusiasm and gradually growing skill has been one of the most exceptional embodied joys of her recovered life. Neither of us knows what sports or other forms of physical movement will come and go in our futures, but it would be sad to be scared away from an entire realm of potential enjoyment because of a single wrong turn long ago. 

The boundaries between healthy and unhealthy are rarely clear-cut when it comes to anything food- or exercise-related. So perhaps the best we can do is learn from each experience, and do our best to assess carefully the degree of likely risk versus reward, always with an eye to the gap between your best interests and the eating disorder’s. And inevitably we get it wrong sometimes, but by then hopefully we know enough to identify the error before it does too much damage. 

James Anderson, used with permission
Source: James Anderson, used with permission

References

Calogero, R. M., & Pedrotty-Stump, K. N. (2010). Incorporating exercise into eating disorder treatment and recovery: Cultivating a mindful approach. In M. Maine, B. Hartman McGilley, & D.W. Bunnell (Eds), Treatment of eating disorders (pp. 425-441). Elsevier. Full-text PDF here.

Lichtenstein, M. B., Larsen, K. S., Christiansen, E., Støving, R. K., & Bredahl, T. V. G. (2014). Exercise addiction in team sport and individual sport: prevalences and validation of the exercise addiction inventory. Addiction Research & Theory22(5), 431-437. Open-access full text here.

Meyer, C., Plateau, C. R., Taranis, L., Brewin, N., Wales, J., & Arcelus, J. (2016). The Compulsive Exercise Test: Confirmatory factor analysis and links with eating psychopathology among women with clinical eating disorders. Journal of Eating Disorders4(1), 22. Open-access full text here.

Nogueira, A., Molinero, O., Salguero, A., & Márquez, S. (2018). Exercise addiction in practitioners of endurance sports: A literature review. Frontiers in Psychology, 9, 1484. Open-access full text here.

Watson, S. L., Weeks, B. K., Weis, L. J., Harding, A. T., Horan, S. A., & Beck, B. R. (2018). High‐intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: The LIFTMOR randomized controlled trial. Journal of Bone and Mineral Research33(2), 211-220. Full-text PDF here.