ARTICLE
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Can Exercise Treat Eating Disorders?
Heather A. Hausenblas, Brian J. Cook, and Nickles I. Chittester
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University of Florida, Gainesville, FL, United States
HAUSENBLAS, H.A., B.J. COOK, and N.I. CHITTESTER. Can exercise treat eating disorders? Exerc. Sport Sci. Rev., Vol.
36, No. 1, pp. 43Y47, 2008. Exercise is not a standard intervention for patients with eating disorders. In this article, six studies are
reviewed that examined exercise interventions in populations with eating disorders. The key conclusion is that exercise may improve a
range of biopsychosocial outcomes in patients with eating disorders, but more research is needed. Key Words: physical activity,
anorexia nervosa, bulimia nervosa, eating pathology, exercise intervention
INTRODUCTION
Eating disorders (ED) are among the most common
psychiatric disorders for young women; and their persistent
course is marked by severe negative physical, psychological,
social, and financial consequences. The prevalence of ED
(2.4% of women; (14)), coupled with the expense and
limited availability of treatment, warrants developing
efficient and cost-effective treatment programs. We propose
that exercise may be an innovative, practical, and widely
disseminative treatment for patients with ED who have
received medical approval to participate. In this article, we
conduct a comprehensive and systematic review of the
evidence on the effects of exercise interventions for ED,
with a focus on our own research. A conceptual framework is
advanced that expands the current knowledge and challenges
traditional thinking regarding exercise and ED. We critically
examine the rationale for the lack of research examining
exercise as a treatment for patients with ED. Finally, we
recommend that intervention trials be performed to deter-
mine whether these associations are causal. The primary
hypothesis of our review is that exercise may have beneficial
effects on biopsychosocial outcomes for patients with ED.
PERSPECTIVES ON EXERCISE INTERVENTIONS FOR ED
Despite the health benefits of regular exercise in both
clinical and nonclinical populations, exercise is not an
established ED treatment. This is not surprising considering
Address for correspondence: Heather A. Hausenblas, Ph.D., Department of Applied
Physiology and Kinesiology, College of Health and Human Performance, University
of Florida, Gainesville, FL 32611 (E-mail: heatherh@hhp.ufl.edu).
Accepted for publication: September 26, 2007.
Associate Editor: Paul A. Estabrooks, Ph.D.
0091-6331/3601/43Y47
Exercise and Sport Sciences Reviews
Copyright * 2007 by the American College of Sports Medicine
43
Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
that the estimated prevalence of excessive exercise for people
with ED of 39% (20) has resulted in researchers focusing on
the effects of exercise for developing and maintaining ED
as opposed to its treatment potential. Addressing this
unhealthy level of exercise is a critical component of ED
treatment. However, the byproduct of the dominant view of
exercise as negative in the context of ED is a lack of
understanding of how exercise can be moderated (when
excessive) or promoted (when either low or nonexistent)
under appropriate conditions (e.g., stabilization of weight
and medical clearance from a physician). In this vein, at
least three reasons underlie the absence of research examin-
ing the effectiveness of exercise as a treatment for ED.
First, this research consists mostly of correlational, retro-
spective, and case history studies that have unvalidated self-
report measures and unidimensional operational definitions
of Bexcessive[ exercise which fail to do the following: (a)
exceed the guidelines for healthy exercise and (b) assess the
multidimensional nature of excessive exercise (2,18). Sec-
ond, research examining the multidimensional nature of
excessive exercise (i.e., exercise behavior and pathological
exercise motivation) has found that there may not be a
direct relationship between exercise behavior and ED
symptoms (12,17). Pinkston et al. (19) found that women
with ED do not differ from controls in physical activity
level, despite women with ED reporting a greater patho-
logical compulsion to exercise than controls. In further
support, Cook and Hausenblas (9) found that exercise
dependence served as a mediator (but not a moderator) for
the relationship between exercise behavior and eating
pathology. This unidirectional causal model suggests that
an individual’s pathological motivation to exercise (i.e.,
exercise dependence), and not exercise behavior per se, is
the critical component that plays the mediation role in the
context of ED. Thus, the psychological motivation for
exercise within ED populations, rather than exercise behav-
ior (i.e., exercise frequency, duration, type, and intensity),
may be the critical component within ED populations (13).
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Figure. Conceptual framework for the effects of exercise on ED.
Finally, the patient’s weight may be the reason exercise
has not been advanced for treating ED. Because anorexics
are by definition underweight, this may, in the view of some
clinicians, preclude participation in healthy amounts of
exercise. Although health care professionals may believe
that the caloric requirement for weight gain must be
increased for existing anorexia nervosa (AN), the caloric
requirement for weight gain during refeeding is not
predicted by the patient’s exercise behavior (4). A high
level of exercise is not necessarily an obstacle to weight
recovery in patients with ED because satisfactory levels of
weight gain are achieved, despite moderate levels of
exercise. Once patient with ED is medically cleared by a
physician, exercise may be a viable treatment.
CONCEPTUAL FRAMEWORK FOR EXERCISE
TREATMENT FOR ED
Although well-documented concerns exist about exercise
behavior for people with ED (20), there may be benefits for
using exercise, under medically approved conditions, as an
ED intervention. Regular exercise is associated with improve-
ments in several physiological, psychological, and social
benefits (Fig.) that are risk factors, maintenance factors,
outcomes, or diagnostic criteria for ED. For physiological
benefits, regular exercise results in reductions in chronic
pain, substance abuse, obesity, osteoporosis, and insomnia
(21,22). Psychologically, exercise results in improvements
in the malleable ED risk and maintenance factors of self-
44 Exercise and Sport Sciences Reviews
Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
esteem, anxiety, depression, negative mood, and body image
(11,15). Of significance, patients with ED often cite
controlling negative mood as a main reason for exercising
(16). Finally, exercise results in improved social bonds and
relations (8). Because patients with ED may have disturbed
social relations (e.g., isolated eating and reduced social
contact (3)), exercise may aid in improving social behaviors.
In short, theoretical justification suggests that by improving
physical fitness through regular healthy exercise, patients
with ED may experience improved self-esteem, body image,
and mood, as well as a reduction in the uncomfortable
sensations of bloating and distention during eating (10).
Additionally, exercise promotes self-regulation. Therefore,
exercise may reduce bodily tensions and negative mood and
increase tolerance to everyday stress, which are all triggers
for binging and purging (1).
Our conceptual framework illustrates how regular exercise
results in improvements in several malleable physiological,
psychological, and social risk and protective factors for ED.
More specifically, our framework is based on the fundamen-
tal principle that a reciprocal relationship occurs whereby
exercise results in improvements in well-being, and
improved well-being results in increased exercise. Similarly,
a reciprocal relationship occurs whereby improved well-
being results in decreased ED risk factors, maintenance
factors, and outcomes, which ultimately results in decreased
ED prevalence. Exercise also has the benefit of being self-
sustaining, socially acceptable, and highly accessible, as well
as having low cost and minimal side effects compared with
traditional treatments. Also of great importance, the
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 TABLE. Summary of exercise intervention studies in populations with Eating Disorders.
Control Exercise Outcome
Study (Country) Exercise Group Group Intervention Measures Results

Calogero and Pedrotty AN, BN, AN, BN, EDNOS Group exercise Obligatory Exercise Exercise group obligatory
(6) (United States) EDNOS (women) Questionnaire exercise scores decreased
(women) (n = 127) from preexercise to
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(n = 127) postexercise.
Calogero Wah and AN, BN, Women (Variable week) group Obligatory Exercise Exercise group showed
Pedrotty (5) EDNOS (n, unknown) exercise sessions Questionnaire reductions in obligatory
(United States) (women) exercise compared with
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(n, unknown) control group. Exercise

Sundgot-Borgen et al.
(24) (Norway)
Szabo and Green (25)
(South Africa)
Thien et al. (26) Canada
Tokumura et al. (27)
(Japan)
group gained more weight
than control group.
BN Nonclinical 16-wk combined Laxative use, Exercise group drive
(women) (women) aerobic/nonaerobic Diagnostic Survey for thinness, bulimic
(n = 58) (n = 13) for Eating Disorders symptoms, and body
dissatisfaction decreased
toward the level of
healthy controls compared
with cognitive behavioral
therapy group.
AN AN 8-wk resistance Beck Depression Both exercise and
(unknown) (unknown) training program Inventory, Eating nonexercise groups showed
(n = 7) (n = 7) Disorder Inventory improved Beck Depression
Inventory and Eating
Disorder Inventory scores.
Non-AN
(n = 7)
AN AN 3-mo combined Medical Outcomes Nonsignificant improvements
(women) (women and men) aerobic/nonaerobic SurveyY36 in quality of life scores
(n = 5) (n = 7) Quality of Life were seen in the exercise
Questionnaire group whereas the control
group showed a decrease
in quality of life scores.
AN AN Prescribed 30 min BMI, exercise capacity Exercise group BMI and
(women) (women) of stationary (endurance time, exercise capacity increased
(n = 9) (n = 8) bicycle 5 times V̇O2 at anaerobic compared with control
a wk (6Y12 mo) threshold, peak V̇O2 group. Exercise training
did not have adverse
effects on recovery of
menstruation or ED relapse.

AN indicates anorexia nervosa; BMI, body mass index; BN, bulimia nervosa; ED, eating disorders; EDNOS, eating disorder not otherwise specified.

exercise environment can be tailored to maximize overall
effectiveness and long-term adherence via cohesive group
exercise classes and can be fostered within a socially
enriched leadership environment.
EXPERIMENTAL STUDIES
We retrieved reports related to exercise as a treatment for
ED that were available by February 2007 by means of
multiple procedures. First, the key words of exercise,
physical activity, ED, AN, bulimia nervosa (BN), inter-
vention, and eating pathology were used to conduct
computer-based searches in the following databases: Dis-
sertation Abstracts International, PubMed, and PsycINFO.
Second, the reference list of review articles, books, book
chapters, and all located research studies were hand
searched. Third, the indexes of pertinent journals in the
field were hand searched. Fourth, to locate fugitive
literature, active researchers in the field were contacted to
retrieve either current or unpublished research.
To be included in our review, studies had to examine the
effects of an exercise intervention for an ED population (i.e.,
AN, BN, and ED not otherwise specified). Descriptive
studies and studies that examined exercise interventions with
nonclinical populations were excluded. Also, studies needed
to report outcome data for an ED symptom (e.g., body
satisfaction, self-esteem, and weight). We operationalized ED
symptom to represent risk and maintenance factors for ED as
well as diagnostic criteria (e.g., frequency of binges).
Although all these symptoms have not received consistent
support as predictors/maintainers of ED (21,23), it was
important to examine their effect to provide a more
comprehensive review and enable stronger recommendations

Volume 36 ●
Number 1 ●
January 2008 Exercise and Eating Disorders 45

Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 for future research. One study was excluded because,
although it described an exercise program for an ED
population, it reported no data (7). Overall, six studies
(5,6,24Y27) met our selection criteria (Table).
Of the six studies reviewed, the median year of publication
was 2002 (range, 2000Y2004). None of the studies reported
response rate, and only three studies reported attrition rates
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(median, 6 participants; range, 4Y26). Five studies used
random group assignment. Data collection was done on site
in all the studies, and only one was grant supported. Five
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studies included women only, and one study did not specify
the participants’ sex. One study reported the ethnicity and
socioeconomic status of its participants. Participants in four
studies were volunteers; one study used a target population,
and one study randomly selected participants.
The most frequently measured outcome was depression.
In addition, each of the following outcomes was used by at
least one study: obligatory exercise, binge frequency,
laxative use, body dissatisfaction, bulimic symptoms, drive
for thinness, social functioning, role functioning, vitality,
and overall quality of life. Three studies used an aerobic
exercise intervention, two studies used a combination of
aerobic and resistance exercise, and one study did not
include the characteristics of its exercise intervention.
Session duration varied across studies: three studies did not
specify the exercise duration, one study used 60-min
exercise sessions, one study used 30-min sessions, and one
study used a 60-min session for 1 d and 235-min sessions for
the remaining 2 d per week. One study held exercise
sessions 5 times per week, one study held sessions 4Y5 times
per week, one study held session 4 times per week, one study
had sessions 3 times per week, and two studies did not
specify how many sessions were held per week. Two studies
did not specify the exercise intensity of the program. None
of these exercise interventions met the guidelines for type,
duration, and frequency of exercise set forth by the
American College of Sports Medicine (2). In addition, no
studies quantified the participants’ previous exercise behav-
ior or fitness level.
Overall, these studies reveal that exercise interventions
for patients with ED have positive effects. In fact, four
studies showed statistically significant results in favor of the
hypothesis, despite small sample size. The physical benefits
included improved body composition. More specifically,
exercise did not affect weight gain in patients with AN, and
in patients with BN, it resulted in weight loss. These
preliminary results challenge the common wisdom that
underweight women should not engage in any additional
physical activity during treatment. This perspective is
guided by the belief that exercise is an obstacle for weight
gain because it is used solely for weight loss. The
psychological benefits of exercise included improved body
satisfaction, positive mood states, and quality of life. Results
of the reviewed studies are promising and suggest that
exercise during ED treatment may improve many biopsy-
chosocial outcomes. For example, Sundgot-Borgen et al.
(24) found that an exercise program resulted in reductions
of drive for thinness, bulimic symptoms, and body dissat-
isfaction, superior to improvements seen in a cognitive
behavioral therapy group and control group.
46 Exercise and Sport Sciences Reviews
Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
The few studies that assessed multiple outcomes did not
examine the interrelationships among the outcomes and
consequently can be considered either descriptive or
atheoretical. In such studies, it is not clear whether changes
in the physical mechanisms were responsible for changes in
the psychological outcomes. The primary methodological
limitations of the research are small convenient samples
that restrict generalizability of the findings, relatively short
exercise interventions, limited follow-up, variability of
control groups, nonrandom assignment, atheoretical inter-
vention designs; and lack of fitness assessments. Future
studies should adopt theoretical frameworks to determine
and improve the effects of exercise on ED treatment because
exercise interventions that are developed using a theoretical
framework tend to produce larger effects than interventions
that are not based on a theoretical framework.
FUTURE PERSPECTIVES
Despite the descriptive nature and methodological limita-
tions of the reviewed research, the major concern at this time
is the lack of research. Traditionally, research has focused both
on exercise as a precursor to ED and the use of exercise by
people with ED as a compensatory behavior. Especially as a
result of the former, many clinicians and researchers have
implied that exercise behavior is ill advised and that, at worst,
it may cause an ED. Our findings suggest that traditional
thought has overlooked the potential usefulness of healthy
exercise behavior as a potential treatment for patients with ED
while controlling pathological exercise motivation.
Future research should use psychometrically sound instru-
ments to measure both previous and present exercise
behavior. Also, interventions should adhere to exercise
guidelines, so that a standard program (that is based on a
theoretical framework) may be analyzed across studies. In
addition, future studies should use exercise as an intervention
in itself as opposed to an adjunctive component added to, for
example, a cognitive behavior therapy treatment (24) to
control for the effects of an exercise intervention on ED
outcomes. One salient lesson and a future priority is to
incorporate theory to reveal the intervention content and
mechanisms to modify physical activity behaviors, so that
future interventions are more efficacious and efficient.
SUMMARY AND CONCLUSIONS
Our review suggests that patients with ED can safely
engage in exercise programs during treatment, and such
participation can help attenuate treatment-related symp-
toms, difficulties, and distress. Adoption of a healthy
behavior such as exercise may give patients with ED an
increased sense of the self as healthy, whereas the improve-
ments in bodily strength and tone, along with potential
weight loss, might bring about beneficial changes in body
image. Because of the chronic course of ED, treatment is
expensive. Accordingly, there exists a need to identify
treatment modalities that are more cost effective. In addition,
the stigma that a person with an ED perceives may discourage
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 her/him from seeking treatment. It is our belief that an
exercise intervention may be a viable treatment for certain
patients with ED with these concerns. However, before
exercise interventions are considered mainstream, future
research should focus on establishing a dose-response rela-
tionship for exercise, identifying patients that would benefit
the most from such an intervention, and identifying the
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conditions (e.g., type/severity of ED, minimum weight level,
and exercise environment) under which an exercise inter-
vention may be undertaken. There are many questions to be
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answered concerning who would benefit from increasing
exercise, when exercise would be most beneficial, and how
much exercise would be optimal. Given the high level of
sedentariness in the population and the heavy burden that
ED creates for the individual and for society, the need for
well-designed randomized trials of exercise based on a
theoretical framework for patients with ED is an important
public health concern.
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