an inTeRlink feature
July 23, 2001
The Recreational Therapist Role in Prescribing
Exercise to the Eating Disorder Patient
Jon Mitchell, CTRS, CLC
University of Iowa Hospitals and Clinics
Anorexia nervosa and bulimia are psychiatric disorders
that often lead to serious medical complications. Anorexia nervosa is primarily
a disorder, which involves restriction of food intake to the point of starvation
and weight loss. Bulimia is a syndrome of binge eating, usually followed by
some form of purging, which may be self-induced vomiting, laxative use, or associated
behaviors such as diuretic use, diet pill use, or excessive exercise. Morbidity
and mortality rates among patients with eating disorders are among the highest
recorded for psychiatric disturbances. Using the specific recreational therapy
intervention for eating disordered clients, exercise prescription, this intervention
will assist in the role modeling of healthy levels of exercise, balance of lifestyle
choices, and improve the client's physical and psychological health. The distinctive
feature of recreational therapy, that makes it different from other therapies,
is the use of recreation activities as a mode of treatment. The recreational
therapist has a unique perspective regarding the leisure and social needs of
a client with an eating disorder. Recreational therapy can assist eating disordered
clients in assuming greater control over their leisure lifestyle, and is a useful
and effective addition to the treatment of the eating disordered client.
There are generic principles that are common to every training program, when
these principles are applied to a particular individual, the principles are
said to be the person's exercise prescription. Perhaps the best way to prescribe
exercise to patients with an eating disorder is to first redefine what exercise
is. Common definitions describe exercise as an activity for training or developing
the body or mind. The average person with Anorexia or Bulimia Nervosa may interpret
exercise as a way to cope with stressors or burn calories to help reduce weight.
This sounds fine and may closely resemble what the rest of society has come
to believe, but looking closely at what this really means to the person with
an eating disorder, we see this distorted. Their intense fear of gaining weight,
refusal to maintain a minimally normal body weight, and significant disturbance
in the perception of the shape or size of his or her body drives these patients
to over exercise. To these people exercise becomes an obsession. The client
becomes obsessive in thought and compulsive in deed. Since society accepts exercise
as a means of improving health, to persons with an eating disorder, it represents
their freedom to engage in self-degrading behaviors under the guise of a socially
accepted vehicle for improved wellness. A preoccupation with appearance may
grow out of a preoccupation with health. This is one of many negative feedback
cycles eating disordered patients face that yields stressed out, fatigued, and
isolated individuals with low self-esteem.
Exercise becomes a perceived need and is often
a determining factor for allowing them to feel like a success or failure. If
their busy day didn't allow them to get their exercise done, they state an increase
in stress and don't feel productive. Persons with Anorexia or Bulimia may feel
they need to exercise, especially after eating. This perceived need also ties
into the belief that their worthiness depends on how productive they are and
since exercise is generally accepted as productive, the more of it the better.
The person repeatedly exercises beyond the requirements for good health. Cardiovascular
health requires that 2,000 to 3,500 calories be burned each week in aerobic
exercise. After 3,500 calories are burned per week, the health benefits decrease,
and the risk of injury increases. It should also be identified that many persons
with an eating disorder also suffer from OCD or OCD traits, which further complicates
these exercisers ability to regulate appropriate frequency, intensity, and time
during their regime. The client may keep detailed records, scrupously observe
a rigid diet, and constantly focus on an unattainable goal. Many times exercise
becomes part of their daily rituals, in which they feel compelled to complete
a specific number of repetitions, minutes, or miles depending on the activity.
There are a number of ways that the Recreational
Therapist plays a distinct role in prescribing appropriate exercises and actually
establishing a prescription. Of course, we must mention incorporating fun and
play into the routine. The client focuses on challenge, and forgets that physical
activity can be fun. Eating disorder clients' exercises of choice tend to be
walking, running, and a multitude of house chores accompanied by vast quantities
of sit-ups. These venues are usually pursued alone, to a high intensity, follow
a rigid pattern, are a means for suppressing feelings, and allow few opportunities
for breaks. This isn't a particularly healthy form of exercise, nor is it as
fun as being in a group or with a partner.
As inherently social beings, we benefit significantly
from participating in exercises with friends or any other people. Not only is
exercising with others safer it yields opportunities for growth, emotional support,
and healthy competition. Especially beneficial to exercising with friends is
a potential sounding board for sorting out problems, rather than avoiding them
and literally running away from them, as the typical over exerciser would do.
Sociologists say we live in an age of narcissism, or self-absorption in our
bodies and ourselves. Both men and women are expected to achieve perfect or
near-perfect bodies: slim, toned, strong, agile, and aesthetically appealing.
The closer people get to the cultural ideal, the more they notice the flaws
that remain. They define self-worth in terms of performance. We all have at
times experienced having ourselves being our worst enemy. This can especially
be true when your standards are as high as those of the typical eating disorder.
There is constant competition involved during the exercise routine for these
people. Unfortunately, it is usually against themselves and unaccompanied by
any joy or praise for successes. In this way, we see patients with eating disorders
exercises as self esteem vacuums, where they are working hard, failing to meet
expected (but unattainable) goals for themselves and therefore not deserving
of external praise. This is justified in their mind as helping them to be thinner,
more attractive, and therefore deserving of attention from others. The problem
with this can be summed up in the adage, "you cannot, by doing something
external, solve a problem that is internal". It isn't hard to see how this
isolative, high-energy demanding, indirect approach to coping with problems
is ineffective and tiring, thereby lowering self-esteem.
The Recreational Therapist working closely with
persons having an eating disorder will also be able to assist them in encouraging
that their exercise activities are properly motivated. These people will tell
you outright that many times when they exercise or have exercised, it was primarily
to burn calories and fat, deal with guilt from eating, or to avoid feelings.
This is a form of purging and should not be called exercise. They will even
say that they "need" to exercise rather than they "want"
to exercise. If the exercise is motivated by eating disorder driven guilt, perceived
"need", obsessive urge, or solely to burn fat (for below minimum target
weight individuals) it needs to be called something other than exercise. To
me, a better word for activities driven this way would be punishment. When you
discuss this with eating disorder patients, they can relate and are usually
surprised by the accuracy of this concept. This is a core concept for our exercise
education groups and has helped eating disorder patients closely look at their
use of the word exercise as a distortion of the true behaviors
and self-punishment. Teaching these persons that they are deserving of praise
and are productive even in the absence of exercise and busy work is a challenging
but necessary aspect of their treatment. Dr. Arnold E. Andersen, an internationally
renown physician who heads the program at the University of Iowa Hospitals and
Clinics, likes to tell our patients that they are human beings, not human-doings.
Another significant concept to assist prescribing
exercise to persons with Anorexia or Bulimia Nervosa is the idea of considering
total daily physical activity. Many of our subjects are students, workaholics,
or not in work or school at all, but are active most of the day. Even though
they may have walked to work or school, remained on their feet, participated
in P.E. and after school sports, and fulfilled compulsive chores, they haven't
"exercised" until they have visited the gym for at least 60 minutes
of increased intense cardiovascular work. It should be mentioned here that a
contributory factor to this belief is the health related media, in a nation
dominated by predominantly obese and sedentary individuals. For many of us,
our jobs may entail sitting at a desk or in front of a computer for eight hours
per day, sitting in traffic jams, and then finally collapsing into a vegetative
state at the TV or computer. This working majority of us could be said to "need"
exercise in order to prevent or combat obesity, low energy, low cardio respiratory
functioning, and many other associated concerns. Eating disorder patients however,
have expended significant calories throughout their day and maintained a heart
rate and respirations above resting rate, thereby eliminating the "need"
Recreational Therapists play a significant role as ambassadors to promote stress
management indirectly or directly to our clients. This topic warrants its own
article, but can be touched on with regards to utilizing physical exercises
as techniques many of us do use exercise to lower stress or to cope with stressors
in our lives. To many persons with an eating disorder, relaxation or passive
self-nurturing activities have disappeared from their lives. Replacing these
means of reducing stress are active and seemingly "productive" asocial
activities, devoid of pleasure or fun. In order to cope with their problems,
we often see our clients avoid their situations, "stuff" their emotions,
and attempt to externally control their internal struggles by exercising, restricting
food intake, or purging. As any good stress management programs will emphasize,
in order to relieve perceived stress, clients must tune into these problems,
instead of stuffing their feelings or running away from the problem. These problems
are in a sense "sent to the back burner", and as the pressure from
these unresolved issues fester, stress boils to an overflow, leaving the person
feeling overwhelmed. This stress "boil" can often be the driving force
for excessive exercise. It may present itself as misplaced anger, guilt, disappointment,
We have to bear in mind the compromised physical
and mental capacities of persons with an eating disorder. Many have exercised
and restricted to the point of exhausting their necessary stores of body fat.
This prompts their body to break down muscle, organ, and tissues to provide
the body with energy. The compromised heart and skeletal muscles reduces the
functional capacity for the person's body to perform at, and recover from, an
optimal level of physical activity. A decrease in cardiac chamber size, cardiac
wall thickness, myocardial oxygen uptake, bradycardia, and hypotension are all
possible associated secondary conditions to the clients' eating disorder. These
secondary conditions can inhibit the exercise prescription, and could potentially
be a life-threatening situation. The ability of anorectic patients to exercise
at the level they do is surprising in view of their decreased cardiac capacity
to respond to exercise demand. Most of these secondary conditions are reversible
with weight gain.
There is much debate and uncertainty to the degree
of which cognitive functioning and decision-making skills are compromised. We
regularly observe eating disorder patients demonstrate a limited capacity to
chose appropriate exercises, self-regulate obsessive-compulsive behaviors, and
maintain a safe regime. The restricted mood and flat affect often displayed
by persons with eating disorders, combined with frequent preoccupation with
thoughts, can give the impression that there is a decrease in mental capacity.
These patients' minds are actually very busy with their preoccupied thoughts
calories, keeping mental food logs, worrying, and focusing on their dissatisfaction
with performance or physical appearance. Theodore Reothke once said, "A
mind too active is no mind at all".
Exercise prescription can also help restore another common medical problem of
eating disorder clients, bone density. Decreased bone density very often to
the degree of osteoporosis and osteopenia has been noted in women with chronic
anorexia nervosa. Fractures or the vertebrae, sternum, and long bones are common
complications among the eating disorder patients.
Digressing to the basic physiology of exercise,
it is important to remind the client with an eating disorder what is happening
to their body during exercise. When the muscles are strained, they are broken
down. Over the following 48 hrs or so, the body, utilizing ingested food and
periods of rest, rebuilds the lost tissues. The alarming combination of over
exercising and restricting food intake renders the body helpless against the
process of tearing the body down faster than it can rebuild.
Conforming to the concept of keeping energy input approximate to energy output,
we prescribe an exercise with low F.I.T. (Frequency, Intensity, and Time) for
the period in which they are restoring weight and until after at least 6 months
of attaining their goal weight. It should be understood that at no time do we
discuss the number of calories being burned or the client's weight, other than
the general guideline of balancing energy input to energy output. We start the
patient off with a frequency of only two to three times per week, have limits
on intensity that don't allow their heart rate to exceed 55 - 60% of their maximal
heart rate, and have a 20 minute limit on continual physical activity. We do
also allow a five to ten minute warm-up and a five to ten minute warm-down on
the front and back end of the exercise.
Upon admission to UIHC, patients with an eating
disorder are required to remain relatively sedentary to interrupt their focus
on physical activities as a primary segment of their day. This allows the patient
having an eating disorder to focus on thought distortion, family problems, body
image, self esteem, and many other core issues that often sprout the compulsive
urges to over exercise or exercise for the wrong reasons. Equally important,
this initial period of exercising at a reduced F.I.T. will allow the body tissues
to restore and replenish. These factors will yield a mind and body more able
to handle stress of exercise and responsibility of initiating and performing
Specific types of exercise we prescribe are low
impact, low intensity, and have a small risk of falling or collisions. This
prevents significant jarring of bones, damage to joints, tendons, and muscles
that are made weak from these persons' poor nutrition. The exercises are to
be performed with a partner or in a group as often as possible. Especially beneficial
are modalities such as weight lifting, walking, and stationary cycling. These
can be easily structured to start with lighter workloads and slowly progress
to higher ones. This conditions the clients' bone density and lean tissue to
progress accordingly. Building and maintaining muscle and bone mass requires
weight-bearing exercise. Individual requirements vary depending on age and level
of fitness. Overdoing weight-bearing exercise can tear down muscle tissue instead
of building it, and also damage bones, joints, cartilage, tendons, and ligaments.
Our prescription centers around the idea that their degraded body tissues and
loss of weight need time to recover, so they will begin with a light work load
and gradually progress to a more moderate one. The patients are able to restore
lost weight and participate in physical activities during their stay, which
greatly reduces anxiety from being sedentary and feel like all they are gaining
is fat tissue.
Successful treatment of patients with eating disorders relies on the joint efforts
of a variety of professions in the human services field. The most effective
approach has been to follow a cognitive behavioral model and utilize a multidisciplinary
team. Integral players in this team are physicians, nurses, dieticians, psychiatrists,
occupational therapists, recreational therapists and social workers. The recreational
therapist has a unique opportunity to allow patients to practice appropriate
physical activities and teach exercises within the parameters of the prescription.
Many of the professionals on our team have frequent discussion groups to address
problems and concerns our patients focus on. The Recreational Therapist provides
hands-on participation in guided activities to stimulate the patient to function
in a similar fashion to that which they would do outside of the hospitalized
setting. We are able to process through emotional struggles and catch inappropriate
behaviors as they arise and even before they would happen, rather than significantly
later than the stress inducing trigger took place.
Throughout our exercise sessions, we process how
patients can be working on high self-esteem, body image, social skills, coping
skills, and stress management. One of our best exercise groups to address all
of these areas is aquatic therapy. We require the patient to wear a swimming
suit, take them to an area surrounded by fitness equipment and full-length mirrors,
and allow them to experience fun exercises in the water. Participants are able
to improve not only a very safe modality of exercise, but directly requires
the patient to address body image concerns and overcome fears of looking in
the mirror. This has proven to be one of the most rewarding experiences for
our patients as the high degree of initial anxiety yields a high degree of self-satisfaction
upon completion of the activity.
Exercise prescription is one of the many ways in
which the Recreational Therapist can intervene to foster improved rate of recovery
for eating disorder patients. Our efforts in close conjunction with the multidisciplinary
team, are paving the way for eating disorder patients to enjoy an active and
healthy lifestyle in an appropriate balance with their nutrition and social
lives. These individuals are more emotionally stable, more able to physically
function closer to functional capacity, and demonstrate sounder cognitive skills
than prior to beginning treatment. Most enjoyably, these persons are able to
derive more fun out of their daily lives and can better balance the amount of
work with play.
Andersen, Arnold E. Medical consequences and complications
of the eating disorders. Directions in Psychiatry, Vol. 8, Lesson 10. Brotman,
Andrew W., Herzog, David B., & Rigotti, Nancy. (May/June) 1985.
Medical Complications of eating disorders: outpatient
evaluation and management. Comprehensive Psychiatry, Vol. 26, No. 3, 258-272.
Career Information. American Therapeutic Recreation
Association. [Online]. Wed. July 18, 2001. Available HTTP: http://www.atra-tr.org/careerinfo.htm.
Definitions. ANRED, Anorexia Nervosa and Related
Eating Disorders, Inc. [Online]. Available HTTP: http://www.anred.com.
Exercise prescription. ANRED, Anorexia Nervosa
and Related Eating Disorders, Inc. [Online]. Available HTTP: http://www.anred.com.
Jake, Laurie. Promoting recovery from eating disorders
through a healthy leisure lifestyle. Connections, Vol. 1, Issue 5, 12.
Male and female obligatory exercise. ANRED, Anorexia
Nervosa and Related Eating Disorders, Inc. [Online]. Available HTTP: http://www.anred.com.
Neiman, David C. Fitness and Sports Medicine. Copyright 1990. Bull Publishing
Prevention of eating disorders. ANRED, Anorexia
Nervosa and Related Eating Disorders, Inc. [Online]. Available HTTP: http://www.anred.com
Shangold, Mona M. Beyond the exercise prescription:
making exercise a way of life. The Physician and Sportsmedicine, Vol. 26, No.
11. (November) 1998. Available HTTP: http://www.physsportsmed.com/issues/1998/11nov/shangold.htm.
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