The ethics of exercise in eating disorders: Can an ethical principles approach guide the next generation of research and clinical practice?

Eating disorders (ED) are the most common psychiatric disorders afflicting young women1 and contribute to great detriments in psychological, social, and physical health.2, 3 Unfortunately, ED treatments tend to be long lasting, intensive, and expensive.4 Additionally, individuals with ED seeking treatment use healthcare services more frequently than non-ED individuals, thereby placing an added burden on the healthcare system.5 The severe nature of ED, high cost of treatment, and added healthcare burden provide rational support for examining efficacious, easily disseminated, innovative, and cost-effective ED interventions that may improve treatment outcomes. The multidimensional etiology of ED suggests that optimal interventions must also be multifaceted.6, 7 Therefore, it may be more effective to identify treatment strategies that impact both psychological and physiological processes and consequently impact the progression of multiple factors that contribute to the development and maintenance of ED. Accordingly, the comprehensive health benefits provided by exercise have led researchers to consider exercise as an ED treatment. It should be noted that exercise refers to a form of physical activity undertaken with intent to obtain a specific objective or desired outcome.8 Thus, distinguishing whether that objective is to facilitate symptoms of an ED (i.e., compensatory exercise) or to obtain a health outcome (i.e., therapeutic exercise) is paramount in individuals with ED. Several literature reviews of studies that used exercise in ED treatment have concluded that therapeutic exercise is a safe9 and potentially effective adjunct to ED treatment.10, 11, 12, 13, 14, 15 Moreover, a recent meta-analysis of studies that have examined exercise in the treatment of anorexia nervosa (i.e., underweight individuals for whom exercise has been previously restricted) found that nutritionally supported exercise resulted in no detrimental effects, distorted feelings about food and exercise were reduced, cardiovascular fitness improved, and there was no decrease in weight or other detrimental anthropometric outcomes.9 However, there is an ethical concern that any form of exercise may cause harm in individuals with ED, which has led many clinicians and researchers to recommend avoiding exercise in ED at all costs. For example, 97% of clinicians surveyed in the US, Canada, Europe, Asia, Australia, and New Zealand reported they believe that exercise is related to ED.16 Not surprisingly, a different study of how ED treatment centers approach physical activity found that exercise was generally considered harmful in ED, approximately one third of treatment centers did not assess exercise or physical activity, and that incorporating exercise into treatment was much less common in ED than treatment approaches for other mental health conditions.17 This lack of clarity may be due to ambiguous clinical recommendations in treatment manuals to address physical activity attitudes while also restricting physical activity.18 One possibility as to why therapeutic exercise has been overlooked in ED treatment may be the potential for unsupervised, compensatory exercise performed during times of severe nutritional deficiency to exacerbate ED pathology. This overly cautious view is not supported by the emerging literature on the therapeutic potential of exercise in ED treatment and further alienates individuals with ED from taking control of their own health. Moreover, it minimizes the role and will of individuals with ED in their recovery by ignoring the potential for exercise to be used as part of living a healthy lifestyle that matches socially determined norms. Simply stated, restricting all forms of exercise is an ethical issue because doing so eliminates autonomy, respect, empathy, and dignity19 for individuals with ED by preventing them from partaking in socially acceptable healthy lifestyle behaviors and take control of their recovery. Clinical and research efforts guided by the ethical principles of nonmaleficence, beneficence, respect for autonomy, and justice20 may be a better approach to empowering individuals with ED as they work toward recovery. Therefore, the purpose of this paper is to present an ethical perspective for clinicians and researchers to consider for the use of exercise as a potential treatment modality for ED. Allowing such a view may provide opportunity to re-evaluate previously misunderstood or ignored aspects of the relationships among exercise, mental health, and physical health of individuals with ED.