Exercise in Eating Disorder Recovery: Yes or No?
First of all, I just want to start by saying that I am not a medical doctor and, especially if you are underweight or in recovery from an eating disorder, you should always follow the advice of your doctor and/or treatment team. Each individual person is different after all.
However, the following is based on both my own experience, as well as what I've learnt from doing a tonne of research, studying health and nutrition, and talking to many many other health professionals and those who have recovered or are in recovery from eating disorders.
Whilst exercise and moving your body is AMAZING for both physical and mental wellbeing, there are certain situations where exercise can in fact be more harmful than beneficial. In general, while recovering from and eating disorder, the general recommendations are NO exercise until full weight restoration has occurred, that is, until you are a healthy weight and most often also until you have maintained that healthy weight long enough to have a regular cycle (if you're female!).
Personally, having struggled with a serve eating disorder alongside exercise addition, I wholeheartedly agree with this recommendation - to a certain extent. As long as you are:
Struggling to eat enough
Have any physical signs of poor health, such as low blood pressure or heart palpitations
Have a negative relationship with exercise
Then physical activity should certainly be kept to a minimum.
Well, being underweight is just as harmful, if not more harmful, than being overweight and puts serious strain on the body, especially the heart. Any additional stress, which exercise is, puts you at serious risk of health consequences, such as a stroke. The absolute priority should be reaching a healthy weight and allowing the body to heal and grow stronger - so you can start exercising again, but in order to feel good, not punish your body!
Personally, and from my experience, I do think a small amount of physical activity, such as short walks, light yoga and stretching can do wonders for both the body and mind during recovery, as long as you have gotten the okay from your doctor that it is safe to do so AND it doesn't become an obsession or a must. Only if you genuinely enjoy it and feel like it, and can continue moving towards recovery at the same time.
Having been a competitive athlete throughout my teenage years, with a very high training load and genuine passion for training, stopping exercise was one of the hardest things about recovery for me. I had to give up training for just over 2 whole years because my body was physically just not capable of handling the extra stress from exercise, and needed the rest in order to heal and repair. Keep in mind, at a hospital or eating disorder treatment centre, you would be put on FULL BED REST until over a BMI of 15. That means not even being allowed to walk to the bathroom. It might sound extreme, but that is how serious being underweight is.
Incorporating some light strength and resistance training towards the end stages of recovery may also be very beneficial for rebuilding muscle and strengthening bone - but again this must be cleared by a doctor AND be done out of genuine enjoyment and not compulsion (something you will have to be very honest with yourself about) AND always with an even bigger focus on prioritising recovery ~ getting enough rest, sleep and of course, food/fuel/calories!
The Science Behind It
Stress on the body - Exercise is additional stress on the body that can potentially be harmful when you are underweight, which is already a huge stress on the body alone. Furthermore, stress increases cortisol levels which can lead to increased water retention, uneven weight distribution, muscle wasting, poor sleep and poor digestion - already common experiences in recovery without being exacerbated from added stressors. In order to heal and recover fully, stress should be kept to a minimum. That means plenty of rest, sleep and self care.
Metabolic adaptations - When your body isn’t receiving an adequate amount of energy (either from burning too much or not consuming enough or both!), it has to make metabolic adaptations in order to maintain homeostasis and, essentially, keep you alive. That means the body will hold onto every little bit of energy it receives, in fear that it is in a state of famine. Slowing down your metabolism, reducing digestive function, decreasing hormone production and energy levels, and more. It takes an extraordinary amount of energy (ie. extra energy) to build muscle, and this most definitely isn’t a priority in staying alive. Fact is, if you aren’t giving your body enough fuel, you will not be building muscle, recovering well or performing your best, while compromising metabolic function. Rest, exercise less, allow your body to trust you again and give it enough fuel and you’ll see much greater progress. Trust me!
Energy wasting - Let’s get real, gaining weight is already damn hard as it is. It takes a LOT of extra food to gain weight, and coming from an eating disorder, most likely not only are you used to small amount of food, but your digestion is compromised - yet to recover you will have to eat MORE than everyone else around you. That’s no easy thing to do, both physically and mentally. The more calories you burn doing physical activity, the more you will have to eat to continue supporting recovery, on top of all the extra that you already have to eat for weight gain and recovery without exercise.
Hormones - Exercise is a stress on the body. When we exercise, we are in fact breaking down our muscle tissue and making the body weaker…it’s during the rest and recovery that those muscles get rebuilt to make us stronger! The reason this is so important and relevant to hormones is because if the body is in a state of high stress, such as malnutrition, it shuts of processes that aren’t absolutely essential for survival, such as hormone production and the reproductive cycle, resulting in low hormone levels (especially oestrogen in females) and loss of your period. Very low oestrogen levels and not having a regular period is very serious, because oestrogen is essential for bone health. Without adequate oestrogen levels, bone resorption (breakdown) is greater than bone deposition (re-building), which results in significantly decreased bone density for every cycle that is missed. Brittle bones and osteoporosis is one of the most serious long term consequences of eating disorders, and restoring hormonal balance to regain a regular period and prevent bone loss is one of the biggest priorities in recovery. With the additional stress that exercise puts on the body (especially high intensity exercise and inadequate rest), this will only prolong the process of restoring normal hormone levels and menstruation.
Mindset - Are you exercising to compensate for the extra calories you are eating? Or are you exercising because you are determined to only ‘gain muscle not fat’? Then all the more reason to stop. This is an unhealthy relationship to both food and exercise, and still a very disordered way to think and behave. In order to recover, gaining weight, including some essential and healthy body fat is essential. And for that you need to eat more energy than you are burning. You need to face you fears and get comfortable with being very uncomfortable. Recovery is hard and scary and there is no way around but through. But it will make you stronger and healthier and so much happier and FREE in the long run. Trust the process.
Commonly Asked Questions
Q: How do I prevent exercise from becoming obsessive again?
A: Be REAL with yourself. You have to take responsibility for your own health and wellbeing and be completely honest with yourself if you want to recover and find peace with exercise and your body. Are you exercising because you want to, or because you feel like you should or have to? If you answered yes to the second part, then you need to take a break. Get comfortable with feeling uncomfortable. Break the addiction. Realise that nothing bad will happen when you take a break from exercise. Once you genuinely want to exercise again, by all means go ahead and slowly start again, with plenty of rest days too! But never stop checking in with yourself and your mindset towards exercise. There’s a fine line between passion and obsession and only YOU can tell that difference.
Q: What if exercise is genuinely a passion and not done out of punishment?
A: It’s your HEALTH we are talking about here. My parents and doctors always told me that if I was truly passionate about my sport, then I would put in the effort to eat enough, gain the weight and get healthy so I could get back to training and pursue that passion again. They were totally right, and so I did.
Use it as motivation to keep going and get your body to a healthy place as quickly as possible. I can promise your energy levels, strength and performance will only increase once you are properly fuelled and at a healthy weight, even with a few weeks or months off exercise. I can vouch for that personally!!
Q: How do you deal with the guilt of not exercising?
A: Do you mean the guilt of allowing your body to rest, heal and repair? Get healthy and stronger? You should NEVER feel guilty for that.
But I know it’s damn hard, and I’m not going to pretend it was easy for me and I didn’t feel the compulsion to exercise and guilt of not doing so. But it’s something you just have to push through and trust that it’s the right thing that you NEED right now. It also really helps to distract yourself and find things to do/hobbies that aren’t related to exercise - reading or writing, taking some sort of classes, photography, baking, playing an instrument, catching up with friends, DIY projects, art…there is so much more out there that can fill your days and bring you joy whilst also allowing you to heal your body and relationship with exercise!
Q: How much should you exercise if your weight is dangerously low?
A: You should not be exercising at all. You should be regaining to a healthy, stable weight and making recovery your absolute priority.
Q: Is it possible to get your period back while still exercising?
A: This is a bit controversial, but ultimately, yes it is. There is BUT though. Losing your period is as a result of the body being under stress which shuts off the reproductive process in order to conserve energy. If you have reached a healthy weight, yet haven’t gained your period back, it is not necessarily a bad thing to start doing some form of exercise again (after all, exercise is great for building strength, bone health, mental health and more!)…but you do have to be careful to still keep stress on the body to a minimum in order to restore hormone balance and get your period back.
That means avoiding too much cardio or very high intensity exercise (such as HIIT), making sure you are eating enough and still in a calorie surplus, and also making sure you are getting enough sleep, rest and relaxation. Keep in mind: Not having your period is MUCH much more unhealthy and detrimental to your health than taking a break from exercise, so it needs to remain a priority and I always recommend working with qualified health professionals (such as a Nutritionist, Naturopath, Dietitian and/or Doctor) to ensure you are on the right path to get your period back as soon as possible.
Q: When is it safe to start exercising again?
A: When you have been cleared to do so by a doctor AND feel strong enough to do so. That almost always means only once you have reached a minimum healthy weight for your body, have stable blood pressure and no abnormalities (electrolyte levels, heart rhythm, blood sugar etc), and are consistently eating enough food.
Q: But won’t weight training prevent osteoporosis?
A: Absolutely yes it will!! But you wanna know what has caused your low bone density in the first place? Being underweight, malnutrition and not having a period! So fix the cause and then you can introduce weight training to help build stronger bones!!
Being underweight and not having a period is much more devastating on bone density than not doing weight training, so work towards getting your body to a healthy weight and gaining back your period through giving your body the nutrition it requires, THEN you can look at things you can do to help further increase bone density and get stronger, such as weight training. You can’t skip the foundations!
Q: Should you wait until the doctor says it’s safe to exercise?
A: Yes you absolutely should. End of story!
Your doctor isn’t not allowing you to exercise ‘just because’, there’s a very well meaning and important reason behind their recommendations as a qualified health professional. Your doctor only wants you healthy, so take their advice and work towards health. They will be the first to congratulate you once they can give you the all clear to exercise again!!
Anorexia and Amenorrhea, 2018