Page 38 - Today's Dietitian (March 2020)

for moderate to vigorous physical activity at baseline, stable, it’s unnecessary to wait for weight restoration
yet some of those patients also scored above the cutoff before starting activity. “I think what has happened
point on a self-report assessment of compulsive exer- in our field is progressive movement, starting with
cise. This suggests that while many patients may have no movement then yoga then maybe walking by the
dysfunctional attitudes towards exercise, these atti- end,” Beasley says. “We’re trying to move away from
tudes don’t always translate to action. that, instead including movement as a part of life.” She
This is consistent with results of a 2006 study that says that using metabolic equivalents, or METs, dieti-
found that, among women with eating disorders, more tians easily can calculate how many calories, say, a
than 45% of those with the purging (no binging) subtype 15-minute walk will use. “As long as that fuel has been
of anorexia were sedentary or had “normal” exercise consumed in their plan for the day, they know that
patterns. That number jumps to almost 60% for women movement will be covered.”
with the restrictive subtype and is even higher among Exercise does need to be tailored to each patient,
women with bulimia or the binging/purging subtype of including creating a graded exercise program that
4
anorexia. Cook emphasizes that, while eating disorders begins with short bursts of low-intensity exercise. Cook
have been around since the beginning of human history, points out that exercise doesn’t have to be intense to
the science of eating disorders is fairly young. “It’s only have benefits. A 2019 meta-analysis found no difference
in the last 45 years or so that we have a formal study in the health benefits from accumulated low-intensity
of eating disorders.” Surprisingly, in some ways, the vs continuous exercise. Other research suggests that
7
research on exercise also is relatively young. “It really people are more likely to stick with low-intensity activ-
wasn’t until recently that we had an understanding ity because it’s more enjoyable.
8
of exercise and what it does physiologically as well as The patient-provider team also has to agree how
psychologically with the mind-body connection,” he says. exercise will be used—including rules, goals, outcomes,
“That’s changing pretty rapidly.” and expectations—with permission to exercise contin-
gent on treatment compliance (positive reinforcement).
What Does Therapeutic Exercise Look Like? However, Beasley says revoking permission is best
Indeed, more evidence is demonstrating that exercise framed as a natural consequence rather than a punish-
is both safe and beneficial for eating disorder patients. ment. For example, saying “You’re not going to be able
This means the question is more nuanced than to join the group walk today because your body doesn’t
whether to recommend exercise. It’s how to make sure have the fuel it needs for energy and repair,” instead
that exercise is supporting health rather than support- of “You can’t go on the walk today because you didn’t
ing the eating disorder. follow your meal plan.” In other words, not making exer-
A 2016 review coauthored by Cook looked at cise the carrot at the end of the stick.
research from different fields on the role of exercise in Debriefing sessions also are important to dis-
eating disorder treatment and suggested guidelines for cuss the sensations, thoughts, and emotions experi-
6
using exercise therapeutically. They include involving enced during exercise. “Our biggest goal is not just
a multidisciplinary team of experts in exercise, mental to address the behavior, but what goes in and what
health, medicine, physical therapy, and nutrition—spe- comes out. This includes processing before, during,
cifically, a dietitian with expertise in eating disorder and after,” Beasley says. “Including exercise in treat-
refeeding and weight restoration. This may make ther- ment allows them to practice in a safe space; it allows
apeutic exercise more practical in hospital-based or them to deal with the stuff that comes up around exer-
residential treatment. cise with support.” For example, if a patient feels that
Tammy Beasley, RDN, CEDRD, vice present of clini- a 15-minute walk on the beach wasn’t enough, and
cal nutrition services for Alsana, says that even with that they needed to walk for another hour, the pro-
patients who had been severely restricting, once blood vider could explore why 15 minutes “wasn’t enough,”
pressure, blood glucose, and other biometrics are ask them whether they enjoyed it, and explain why

“ There is a huge misconception that exercise influences

weight loss, but exercise is not an efficient way of

purging calories. Exercise triggers the body to use fuel

in a way that’s more productive.”

— Brian Cook, PhD

38 TODAY’S DIETITIAN • MARCH 2020