Physical Activity, Exercise and Eating Disorders

If you have an eating disorder, exercise can become driven, rigid, and compulsive, with activity levels becoming excessive and unsafe. When this happens, exercise becomes more harmful to the body than helpful. An unhealthier relationship with exercise can develop, and that relationship can become a strong maintaining factor and/or coping strategy as part of an eating disorder.

It can be detrimental for someone with an eating disorder to follow general exercise guidance available to the general public, because it doesn’t consider individual mental and physical health.

Exercising as part of an eating disorder

The relationship between an eating disorder and exercise is often complex and unique to each individual. What may begin as a fun, enjoyable, and enriching activity can shift over time. As the eating disorder develops, exercise behaviours and rules may emerge. While the initial motivation might have been related to overall health or wellbeing, the focus can gradually shift toward controlling weight or shape, or using exercise as a way to manage difficult emotions.

Whatever the reason, exercise can become a very powerful tool in maintaining an eating disorder - developing into a strong compensatory behaviour and coping strategy and can subsequently result in an increase in exercise dependence, and negative emotions if exercise opportunities are reduced or not available.

It’s crucial to recognise that exercise can become detrimental if approached without careful consideration, particularly alongside an eating disorder. Considering your motivations for, and relationship with, exercise can help you to make informed decisions about what is right for you.

It’s important to remember that exercise challenges don’t only relate to structured or planned workouts. Physical activity can include a wide range of movements — not just things like gym sessions or exercise classes, but also activities like running, dancing, walking the dog, shopping, gardening, or doing housework. Some of these are structured and intentional, while others happen more naturally throughout the day. These unplanned movements are often referred to as incidental exercise.

When reflecting on your relationship with exercise, it’s helpful to consider all types of physical activity — both structured and incidental — and how they can add up over the course of a day or week. Awareness of the full picture can support a more balanced and compassionate understanding of how movement fits into your life.

The table below can help you to reflect on your own motivation and experience of exercise.

Simply tick the appropriate option for each statement.

If you find yourself selecting 'quite often' or 'very often' for multiple statements in this table, it can indicate that your relationship and engagement with exercise could be unhealthy for you, and likely having a negative impact on your physical and mental health.

What do we mean by unhealthy exercise?

When considering what an unhealthy approach or relationship with exercise is – it can be one that results in negative health consequences – physically, psychologically or a combination of both. If you experience any of the symptoms below, you may be exercising at a level, or with an approach that is not supportive of your health and wellbeing. The list provides examples of unhealthy exercise approaches, whilst it is recognised that everyone’s experience of exercise will be different.

• Overexercising (this consists of exercising to the point of creating an unbalance, and often harm, relating to oneself physically, emotionally, occupationally or vocationally, socially, as well as spiritually, or financially, even if the type and quantity of exercise does not appear to be excessive in frequency, duration or intensity).
• Solitary exercise, and often in secret
• Engaging in rigid/repetitive or punitive exercise
• Exercise that is directly related to the eating disorder (e.g., nutritional compensation, body image dissatisfaction) or to self-harm
• Exercise performed despite injury or illness
• Experiencing guilt, anxiety and low mood in relation to exercise
• Experiencing distorted exercise beliefs, often to the benefit of eating disorder rules or beliefs
• Exercise that interrupts daily life, or an overwhelming preoccupation with movement and exercise
• A feeling that it is not possible to change an exercise session or style/intensity, or introduce anything new, with exercise often feeling unnegotiable.

The following link will take you to a short film produced by Nottingham University highlighting how to spot the signs and symptoms of when a relationship with physical activity may become unhealthy, and tips to support people. https://youtu.be/jQV7EUnwVOk

Understanding your relationship with exercise

Establishing a balanced relationship with exercise is crucial for overall well-being. The following traffic light system can help you to better understand your relationship with exercise and help determine which ‘zone’ you may be in.

If you are in the green zone, you may think, for example:

• It's acceptable to me not to exercise and I enjoy time being restful.
• If I am active, it is within reasonable limits, enjoyable and flexible, and balanced with rest
• I do not experience any negative emotional effects of not exercising.

The orange zone represents, for example:

• The time when you are noticing that you want to exercise more than usual
• Feelings of guilt if you don’t exercise
• Feeling the need to exercise to compensate for binge-purge behaviours, or to manage your emotions

The red zone represents, for example:

• You are over-exercising and feel you need to, or should, exercise, rather than want to exercise
• The goals for your exercise have shifted from positive health related goals to more unhealthy and eating disorder driven goals
• You feel guilty if you don’t exercise
• You feel that you must exercise to compensate for binge-purge behaviours or in order to be able to cope
• Your activity and exercise levels are having a negative impact on your physical and/or mental health

If you're uncertain whether you're exercising excessively, or your exercise is negatively impacting on your health, consider how anxious you would feel if you were prevented from exercising. If the thought of not being able to exercise makes you very anxious, or that you are noticing that your relationship with exercise is shifting to a more unhealthy focus, it is possible that you're in the orange or red zone. Note that athletes have a high risk of over-exercising. If you are an athlete, do speak to your coach or healthcare professional for advice.

What to do if you are in the green zone

If you are in the green zone, then you may have a positive and healthy approach to exercise, where exercise could be about: (draft note link with intuitive movement principles)

• Maintaining good physical health.
• Enhancing your overall sense of well-being.
• Finding joy and fulfilment in physical activity.
• Cultivating social connections by exercising with friends and family.
• Enjoying the outdoors and spending time in nature while being active.

What to do if you are in the orange zone

• Establish clear boundaries with your exercise routine and discuss with your GP or eating disorders team to assess how much exercise you should engage in each week. It is important to recognise that individual needs may vary, and you may need to spend some time being less active in order to improve your health, and relationship with exercise.
• Identify if there are certain triggers to your exercise becoming more driven/unhealthy – are there other ways in which you could manage these?
• Are there warning signs that you or those around you may notice that show your exercise is becoming more unhealthy? Would you feel able to share these? Again linking with any other healthy and compassionate ways to manage these.

If you find yourself in the red zone:

• Gradually reduce the amount of exercise you're doing. You could start by cutting it down each session or throughout the week, and gradually reduce it over time. You may need to modify the type of exercise or activity that you are engaging in, in order to minimise harm from this engagement – this includes intensity, frequency, level of impact, duration. Remember, you do not need to be perfect with this process. The overall aim is to keep you safe and ensure that you can return to exercise when it is more appropriate to do so, in a healthier and more balanced way.
• Explore alternative activities and coping mechanisms. You could talk to others about how you're feeling, utilise distraction techniques such as journaling, or engage in other enjoyable activities that don't involve exercise. Seeking professional support can also be extremely effective in guiding you, for example, to identify other ways to manage your emotions.
• Try to gain insight into how you feel before, during and after exercising to help try to establish a better understanding of your emotions and motivations surrounding exercise.
• It may feel more beneficial for you to stop exercising while you focus on your recovery journey. This is ok too!

An individual’s willingness and readiness to work on managing a safer approach to exercise and physical activity may vary, and for some it may be hard to recognise that their exercise engagement is unhelpful or unsafe. It is therefore important to consider whether you feel able to work on your relationship with physical activity and exercise, and what level of support you may require.

If exercise engagement is deemed to be placing an individual at risk, or compromising health, and/or your health status is such that it is not safe and appropriate for you to be engaging in physical activity or exercise, then the advice must be that you stop, whether this can be immediate or a graded reduction/modification to your exercise that results in reduced risk. An approach that could be taken is ‘cold turkey’ in which an individual totally stops physical activity and exercise engagement. Whilst this can be very challenging for many, particularly if no other strategies for emotional regulation are in place, it has also been reported to provide a great sense of relief in giving permission that the individual no longer has to engage in exercise or activity they have not been wanting to engage in but felt compelled to do. It can often be helpful to describe this as a pause in exercise engagement, to support a period of rest and recovery and an opportunity to re-set the relationship with exercise.

When considering whether you feel ready to work on your exercise and if so, whether this be totally stopping/pausing, adapting the type of exercise to one which reduces physical/psychological demand, or practical steps to reducing overall exercise engagement - it is essential that this be done alongside support to help manage the risk of increased negative emotions or increase of alternative unhelpful copying strategies, that may arise from not exercising.

You may also find the following information helpful in exploring advice for developing a safer approach to exercise and activity, consider modifications and how this might work for you, with the aim of reducing the overall demand of the exercise or activity (including intensity, duration and frequency), and adopting a more intuitive and mindful approach to movement that supports overall wellbeing.

Education

• Are you putting your health at risk? For many with an eating disorder the risks far outweigh any benefits and if exercise or activity engagement is increasing medical, physical or psychological risk then it is vital to stop this type of exercise.
• Understand your reasons for exercising – if you use exercise to manage emotion can this be obtained through other strategies?
• Do not be led by national guidance or what others are doing – develop what’s right for you individually and specific to your health and recovery journey.

Keeping track of time

• Set an alarm for rests and finish
• Avoid solitary exercise/activity – being with others can help support keeping track of time and minimise risk of being led by ‘just another…’; ‘the more the better’

Letting go of external measures and data driven exercise

• Remove Smart watch trackers/Turn off or delete exercise apps/step counters, as for some these can increase exercise rigidity and compulsive behaviours around data/number driven exercise. It is important to listen to your body, and what is right for you, and not be led by numbers.
• Cover exercise equipment screens to avoid being data outcome driven or focusing on energy expenditure (the read outs are rarely accurate).
• Minimise use of social media and internet sites related to exercise, due to the risk that they increase a negative relationship with the body, perceived body ideal, and/or unrealistic exercise goals

Taking your mind off things – alternatives to exercise

• Listen to music.
• Listen to podcasts, lectures or audiobooks.
• Engage in self-care
• Use sensory or self-soothing techniques
• Mindfulness, relaxation and breathing exercises
• Distract, delay, decide technique – can you delay giving into the urges to be active? The urges may pass.

Changing things up

• Reduce or break the duration into bouts (e.g. 10minutes less today).
• Mix the types of movement within the session (e.g. integrate gentler, slower movement options).
• Change session layout (e.g. different work/rest intervals, body awareness and function movement – reduce higher intensity and higher impact exercise and reduce physical demand from exercise)
• Cancel Gym/Sports Centre membership to avoid feelings of ‘I have to go, I’ve paid for it’ ‘to get my monies worth’ and therefore feeling unable to miss sessions.

Develop alternative to coping strategies

• Consider using a different coping strategy than movement (e.g. call a friend, podcast, spend time with animals, gardening, art, write in diary, etc).
• Write down triggers that lead to exercising unhealthily. Plan for them in future.

Avoiding unhealthy movement

• Schedule a healthier movement session at the exact same time as the unhelpful one in order to reduce physical and psychological demand as well as maintain safety. Consider what went well, and challenges, to discuss in treatment.

Key messages of maintaining a healthy relationship with exercise during eating disorder recovery:

1. Recognise the relationship you currently have with exercise. Please remember that everyone’s relationship is different and yours will be individual to you and your own journey. Start to explore ways in which you can develop a healthy relationship with exercise, and what works for you in achieving this. Find new healthier, more compassionate coping strategies.
2. Remember, the goal is not to lose weight. You need to remain nourished and hydrated with your usual meals and snacks alongside any exercise you do, as well as on rest days.
3. Rest days– all the world’s athletes do this, and you should too!

Please use this information as a guide only, and to consider your own relationship with exercise. Attempts to reduce excessive exercise can elicit strong negative thoughts and high levels of anxiety. It is important to get professional help if you are struggling to reduce excessive exercise on your own. It is important to contact your GP or Health Professional if you have any concerns about your relationship with exercise and would like to discuss this further. You may also find it helpful to see a Physiotherapist who has experience working with eating disorders for safe exercise programming support.

Note: if you are medically unwell, have recently experienced any (including whilst being active or engaging in exercise) heart palpitations, chest pain, dizziness, fainting, light-headedness, or you are using compensatory methods to purge calories, it is important to consult your GP, Psychiatrist or other Health Professional prior to engaging in any form of exercise.

This resource has been adapted from the Centre for Clinical Interventions (CCI).

With thanks to the University of Nottingham, Alanah Dobinson, Accredited Exercise Physiologist, and the UK Professional Physiotherapy Eating Disorder Network Physiotherapy in Eating Disorders | Chartered Physiotherapists in Mental Health (csp.org.uk) for the resources that have been included in this webpage.