Until recently, exercise has been seen as a symptom of eating disorders. Can it be a part of recovery as well?

“Really rampant.” That’s how Claire Mysko, CEO of the National Eating Disorders Association (NEDA), describes the state of eating disorders on college campuses.

Data from one college that participated in the organization’s Collegiate Survey Project showed that between 1995 and 2008, total eating disorders increased from 23 to 32 percent among females and 7.9 to 25 percent among males.

College campuses create, in many cases, the ideal conditions for disordered eating. Adjusting to new lifestyles and responsibilities can be stressful, particularly in a highly competitive environment. Many students are living away from home for the first time, away from their family support system. Starting a new social circle means that friends don’t know one another’s baselines, making it difficult to know when a fellow student’s “usual” self is slipping away. The combination of increased pressure and a new environment can lead to feeling a loss of control. And even good habits, such as diligent exercise, can go too far in the quest for regaining control.

Eating disorders often arise as a way to feel control in stressful situations. For students who have already experimented with dieting, college is often when those behaviors progress to a dangerous and unhealthy level. Negative body talk and dieting are generally accepted in American culture, but are especially pervasive among college students. On campus, it’s socially acceptable to complain about thunder thighs or casually compete for who has gone the longest without carbs, allowing eating disorder pathologies to continue without social repercussions.

Nationally, an estimated thirty million people struggle with an eating disorder, according to NEDA. And yet many do so invisibly, because they don’t fit the stock photo image of a severely underweight woman.

“That picture of a young white woman dying to be thin is reinforced in the media,” Mysko said. “With that, unfortunately, comes a lot of judgment and misunderstanding.” Obese people struggle with eating disorders. Athletes struggle with eating disorders. And men struggle with eating disorders, as evidenced by the rapidly growing statistics.

The eating disorders themselves take different forms and are not always well understood. Anorexia is characterized by an obsession with thinness that leads to a rigid routine of self-starvation. Bulimia and binge eating both involve eating large quantities of food to reduce stress; bulimics then take a compensatory purging action, such as self-induced vomiting or taking laxatives. “Other Specified Feeding or Eating Disorder” includes any other unhealthy eating that causes stress or impairment but doesn’t fit into the checklists the Diagnostic Statistical Manual uses to define the other three categories.

Usually, exercise is categorized as a symptom of an eating disorder or an indicator that one could develop, but new research suggests that it could also be a powerful tool for treatment. Physical activity leads to a wide range of benefits, from reducing the risk of heart attacks to improving mental health. Regular exercise can reduce chronic pain, substance abuse, insomnia, and obesity, all established risk factors for eating disorders.

But exercise is often absent from prevention programs and treatment plans because of its association with the development or maintenance of an eating disorder.

In 2006, then-President of Tufts University, Lawrence Bacow, was frustrated with previous tactics to curb students’ risky behaviors.

“Instead,” he said, “I challenged the student body to do something aggressively healthy.”

That “something” was running the Boston Marathon. Bacow secured bibs for Tufts runners for 12 years through a deal with John Hancock Financial Services, the Marathon’s main sponsor.

Student Tara Vance wanted to claim one of the Tufts Marathon Team bibs. But in order to participate, all students needed clearance from the school’s health services. Vance had struggled with an eating disorder in high school, and health services was concerned that the training would cause the disorder to resurface. Before granting approval, they required her to sit down with Don Megerle, the marathon team coach.

After a long and tearful conversation, she was approved to run. Her training and racing went successfully without any sign of her previous disorder, and when she ran again two years later, she was one of the top 100 female finishers in the marathon.

“I feel as if I dug some place that I didn't even know existed within me, and I know you helped me find it,” she emailed Megerle after the race.

Every year, Megerle watches the process of training for the marathon improve the students’ self-esteem and shoot their confidence through the roof. “They become different people,” he said.

The science backs him up. Exercise releases chemicals in the brain similar to dopamine, which improves mood while reducing the immune system chemicals that can cause depression.

But the Tufts Health Services was also right to be cautious: for students coping with or at risk for developing an eating disorder, exercise has the potential take on an addictive quality.

For bulimics, exercise can be a compensatory action, seen as a way to get rid of the calories. Most people hospitalized for anorexia exercised obsessively and excessively somewhere along the trajectory of their disorder. Even before hospitalization, students with an eating disorder can develop an addictive relationship to exercise.

However, Heather Hausenblas, a kinesiology professor at Jacksonville University, argues that most previous studies have started with the assumption that the relationship between eating disorders and exercise is negative, leading to a body of research detailing the various ways that exercise exacerbates an eating disorder and limited knowledge of how it could serve as a remedy.

“The byproduct of the dominant view of exercise as negative in the context of eating disorders is a lack of understanding of how exercise can be moderated (when excessive) or promoted (when either low or nonexistent) under appropriate conditions,” she wrote in her paper “Can Exercise Treat Eating Disorders?”

Her research has highlighted the physical, psychological, and social benefits of exercise in relation to eating disorders. She also developed the Exercise Dependence Scale, based on the criteria for substance dependence, to determine when exercise becomes a compulsion.

“It’s like any addiction,” said Nancy Zucker, director of the Duke Center for Eating Disorders. “The question is: Is abstinence the best model? Or do you learn to incorporate it in ways that are moderate and positive?”

Zucker is currently collaborating with Duke’s Recreation and Physical Education department to determine if strength training programs can help students with eating disorders. The study will track participating students’ eating disorder symptoms and their motivation to exercise.

Examining the relationship between exercise and mental health aims to help determine when a fitness regimen is beneficial, and when it is harmful. The program hopes to retrain the students’ motivation for exercise by emphasizing what the body is capable of, rather than the calories burned. Removing body image from the equation is a necessary first step if exercise is going to be a part of the treatment.

Both eating disorders and exercise exist on physical and mental planes. The physical is the action, the what. The mental is the motivation, the why.

Although actions such as restricting food intake or purging after binge eating are the symptoms of an eating disorder, anorexia, bulimia, and binge eating are all rooted in psychological motivations. Students with an eating disorder may be driven to exercise because they want to burn a certain number of calories or clock a certain amount of time on the treadmill. The motivation is weight control and how the body looks, and it creates a rigid structure that can lead to exercising to the point of exhaustion or illness.

Researchers hope that by shifting the motivation to exercise away from body image and toward capability, exercise can become a way for students to gain body confidence and, ultimately, maintain a more healthy relationship with food. If exercise is driven by how the body feels and the health benefits it provides, the action becomes more positive.

“The relationship can be very different, person to person,” Zucker said, “but rather than taking a punitive action like restricting gym access, we should make the message about working as a team with your body.”

“It has to be a highly individualized process to determine what would be appropriate,” Mysko said. “It depends on where they are in their recovery and what their relationship to exercise is. The same behavior can be helpful for one individual and not helpful for another, given circumstances and context.” The key, experts say, is knowing what to look for and when to intervene. Colleges and universities may be target zones for eating disorders, but as communities, they are uniquely able to reach students where they eat, sleep and work out. They have the potential to provide systemic support for their students coping with an eating disorder, and the campus fitness center is a critical part of that support structure.

“I really believe that fitness professionals—coaches, trainers—are part of that category that I’d call the ‘front line,’” Mysko said. “They are the ones who can recognize problematic behavior and direct people to help.”

But despite their front-line status, only a small percentage of college athletic and fitness professionals are trained to detect and respond to a person with an eating disorder. Nearly all students surveyed by NEDA (91 percent) thought that training opportunities for fitness instructors and dieticians was important in supporting students with eating disorders, yet fewer than one quarter of schools (22 percent) said that their campuses provided this training for their employees.

There are still gaps between the resources universities offer and what students need. Students who suffer from eating disorders can recover and go on to lead healthy lives, and the campus setting can become a part of that solution.