European Eating Disorders Review

Eur. Eat. Disorders Rev. 16, 334–340 (2008)

The Inpatient Management ofPhysical Activity in Young Peoplewith Anorexia Nervosa

*Correspondence to: Tony Jaffa, The PhoDarwin, Fulbourn, Cambridge CB2101223-884314. Fax: 01223-884313.E-mail: tony.jaffa@cambsmh.nhs.uk

Copyright # 2007 John Wiley & Sons, Ltd a

Published online 5 December 2007 in Wiley In

Sarah Davies1, Komal Parekh2, Kaisa Etelapaa2,David Wood2 and Tony Jaffa1*1The Phoenix Centre, Cambridge, UK2The Ellern Mede Centre, London, UK

This study investigates the management of physical activity inyoung inpatients with anorexia nervosa. Through telephone inter-views and postal surveys inpatient units across the UK were askedabout written documents regarding physical activity management,how they viewed healthy exercise, how they assessed physicalfitness to engage in activity, the management approaches taken,provision of education and support around this issue and range ofactivities provided. Results indicated that a variety of approacheswere taken, with little consensus between units, although themajority of approaches did involve some form of restriction, fre-quently determined by weight criteria. There were few substantialwritten documents to guide practice and a range of interpretationsof healthy exercise. The findings are discussed and suggestionsmade for research to explore this area further and to inform thedevelopment of effective interventions. Copyright # 2007 JohnWiley & Sons, Ltd and Eating Disorders Association.

Keywords: adolescent; anorexia nervosa; inpatient; management; physical activity

INTRODUCTION

Over-activity is common among individuals witheating disorders, and in particular individuals witha diagnosis of anorexia nervosa (AN) (Touyz,Beumont, & Hoek, 1987). Forty to 80% of patientsadmitted for the treatment of AN have an urge toover-exercise (Davis et al., 1997). Physical activitymay be used as a means of weight control (Mond,Hay, Rodgers, Owen, & Beumont, 2004) or as a wayof regulating and managing disturbing affects(Long, Smith, Midgley, & Cassidy, 1993).Over-activity appears to be a particular issue for

individuals who have been athletes, dancers or

enix Centre, Ida5EE, UK. Tel:

nd Eating Disorders

terScience (www.inte

gymnasts (Calogero and Pedrotty, 2004) or whohave high pre-morbid activity levels (Davis et al.,1997). Animal experimentation has demonstratedthat excessive physical activity and caloric restric-tion can potentiate each other in the development ofsevere weight loss, so that over time the twobehaviours can become self-perpetuating andresistant to change (Pirk, Brooks, Wilckens, Mar-quard, & Schweiger, 1993). Excessive physicalactivity appears to be one of the strongest predictorsof poor outcome of AN with Strober, Freeman, andMorrell (1997) finding that compulsion to exercise athospital discharge was associated with earlierrelapse. A pattern of longer hospitalisation andearlier relapse in those with high exercise levels wasalso described by Solenberger (2001).There has been little research exploring the

assessment of physical activity and consequentmanagement strategies in the treatment of patients

Association.

rscience.wiley.com) DOI: 10.1002/erv.847

Physical Activity Management in Adolescent Anorexia Nervosa 335

with AN. A variety of approaches have beendescribed as helpful though none has been ade-quately researched. Beumont, Arthur, Russell, andTouyz (1994) describe a behavioural approachwhere activity was used as a reward for treatmentcompliance and weight gain. The authors reportedanecdotal benefits. In contrast, Calogero andPedrotty’s (2004) exercise programme for inpatientsavoided a reward-punishment model, emphasisinginstead safety and incorporating facilitated proces-sing of experiences. Their study of 254 cases showedreduced obligatory attitudes toward exercise and nointerference with weight gain. A third approach, agraded exercise programme where activity levelprogressed through incremental stages dependenton weight and body fat also had no adverse impacton weight gain and some improvement in quality oflife was reported, although this did not reachsignificance (Thien, Thomas, Markin, & Birming-ham, 2000). Long and Smith’s (1990) post-inpatienttreatment programme combined a wide range ofapproaches: educational, motivational and cogniti-ve-behavioural, derived from techniques used withcompulsive exercise in non-AN patients. Positiveoutcomes were cited for 5 of the 7 cases reported(Long and Hollin, 1995).It should be noted that none of the above pro-

grammes were specifically focused on adolescents.It is likely that the use of formalised approaches tothe management of exercise and activity in routineclinical practice remains relatively rare (Hechler,Beumont, Marks, & Touyz, 2005).The aims of this current UK national study are to

explore (1) whether there is any consensus in units’approaches to the management of physical activity,(2) whether units have policies, guidelines orprotocols for the management of physical activityand (3) in the absence of written documentation,what informal approaches the units have taken tothe management of physical activity.

METHOD

Design and Participants

Initially, it was hoped that it would be possible tocollect all data through written documentation.However, a pilot study revealed that this would notbe feasible, as many units did not have thisavailable. The study design was therefore modifiedsuch that a senior nurse on each unit was contactedby telephone to conduct a 10–15min semi-structured interview. Units were also offered the

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders A

option of responding via a postal questionnaire.Where units did not respond, follow-up phone callswere made and up to two reminder letters sent untilthe end of the data collection period.The inclusion criteria for this study were inpatient

units that treat young people (up to age 18) with aformal diagnosis of AN. A list of such units wascompiled from the Inpatient CAMHS Directory(Farr andO’Herlihy, 2004) and the Quality Networkfor Inpatient Child and Adolescent Psychiatry(QNIC) Members List. All 66 units, which wereconsidered potentially eligible, were approached.Forty-three (65%) responded and were included inthe study. All were initially contacted by telephone.Twenty-three (53%) of these then took part instructured telephone interviews whilst 20 (47%)responded in questionnaire format.Thirty (70%) of the units were generic units and 12

(28%) identified themselves as specialist eatingdisorder units. One questionnaire respondent didnot provide this information about their unit.Twenty-nine (67%) were National Health Service(NHS) units, 13 (30%) were run by independentproviders and there was 1 case of missing data.Units varied in the age range of their patients. Of the43 units, 4 (9%) treated both children and adoles-cents (up to age 18), 32 (74%) were adolescent-onlyunits (ages 11–18) and 6 (14%) treated adolescentsand adults. One unit did not report age range.

Measures

The interview and questionnaire, designed by theresearchers, sought information on whether eachunit had any written documents regarding themanagement of physical activity with this patientgroup; whether they had a written definition forhealthy exercise and if not, how they would defineit; whether they carried out an assessment ofphysical health in relation to ability to engage inphysical activity; whether programmes involvedstages of increasing activity, for example, linked toweight; which activities were offered; whether unitsadapted their approach with patients who wereathletes or dancers; whether they provided edu-cation or support around physical activity; whetherthe patients went on home leave and if so, whetherguidelines were provided for managing physicalactivity during leave. In addition, descriptiveinformation was sought (name, address and tele-phone number of service; type of service; age rangeof patients; provider of service; number of beds;name and position of person interviewed).

ssociation. Eur. Eat. Disorders Rev. 16, 334–340 (2008)

DOI: 10.1002/erv

Table 1. Documents supplied

Type of document Frequency

List of activities allowed at specific weights 4Outline of assessment/treatment stages incorporating increasing activity levels 3Care plan 2Treatment protocol making passing reference to activity 1List of incentives (including activity) to promote weight gain 1Protocol for management of activity on unit 1Psycho-educational information on exercise and activity 1Unit guidelines for exercise 1

336 S. Davies et al.

RESULTS

Written Documents

Twenty-two units (51% of those that responded)reported having written documents for themanage-ment of physical activity and 13 units suppliedcopies of these (see Table 1).

Definition

Only 4 (9%) units reported having a writtendefinition of healthy exercise. Table 2 shows themost common themes of these combined with the‘ad hoc’ definitions given during interviews and onquestionnaires.

Assessment

Units reported using a range of measures to assesswhether patients were well enough to engage inphysical activity including weight, electrocardio-gram (ECG), temperature, pulse, blood pressureand blood tests plus mental state assessments. Mostunits used several of these assessment measures,particularly emphasising medical monitoringthrough physical observations and weights.

Table 2. Themes of definitions of healthy exercise

Themes Frequency

Individually defined 10Reasonable given dietary intake 9Related to some measure of weight 9Not excessive in time, duration nor amount 9Not harmful to the patient’s physical health 8Enjoyable 5Part of normal daily or weekly routine 4Not driven by weight loss or calorie burning 4Should promote health 4

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders A

Standardised Criteria

Thirty-seven (86%) units reported using standar-dised stages, weight thresholds or other criteria todetermine appropriate activity levels, whereas sixsaid that they did not have these but made decisionson an individual case basis. Of the 37 that did havestandardised criteria, 26 had set figures for theamount and type of activity allowed according toweight-based criteria. See Tables 3 and 4 forsummaries of the information supplied. It shouldbe noted that as healthy Body Mass Index (BMI)varies with age, reports of the former (as shown inTable 3) are of less use in an adolescent age range.Percentage expected weight for height and age (seeTable 4), on the other hand, includes an adjustmentfor age in its calculation. Nine units did not baseactivity on weight but used criteria includingcombined assessment of physical and psychologicalreadiness and engagement in therapeutic work.

Athletes and Dancers

Ten (23%) units reported taking different approa-ches to physical activity management for patientswho were athletes or dancers. Some felt a higheractivity level was normal for athletes and shouldtherefore be expected. They also viewed activity as astrong motivating factor for these patients. Specialmeasures included individual sessions with aphysical activities manager or constructed careplans encompassing training programmes. Thir-ty-two units reported no difference in their manage-ment of these patients justified on the grounds thatexercise tends to be problematic in AN patientsregardless of pre-morbid activity levels.

Education and Support

Thirty-eight (88%) units said they provided edu-cation or support around physical activity. Sourcesof education or support included key workers

ssociation. Eur. Eat. Disorders Rev. 16, 334–340 (2008)

DOI: 10.1002/erv

Tab

le3.

Activitiesallowed

—BMI

BMI

Activityallowed

Unit1

Unit2

Unit3

Unit4

Unit5

Unit6

13.5

1houtofroom

twiceper

day

13.7

2hsoutofroom

twiceper

day

<14

Noexercise

14Outofroom,

seden

tary

activities

14.5

Lightexercise

14–1

6Stretch

‘n’tone,

10min

walk

15Allunitactivities

Weekly

exercise

group

15.2

Can

goto

hosp

ital

shop

15.4

Can

playpool

15.6

May

goonunittrips

<16

Noexercise

16Physicalactivity

commen

ces

16þ

Fun‘n’fitness,

trips

offunit,sw

imming,

football,bad

minton,

orien

teeringetc.

16.2

Can

gointo

town

16.6

Can

gosw

imming

16–1

8.5

Someactivity

17Gam

esW

eekly

exercise

groupþ

1sp

orting

activityin

community

17.8

Offrest

18.2

Stretch

andtone

18.5þ

Norm

alactivity

20W

eekly

exercise

groupþ

2sp

orting

activitiesin

community

20þ

Upto

3activitiesper

week

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 16, 334–340 (200

DOI: 10.1002/e

Physical Activity Management in Adolescent Anorexia Nervosa 337

8)

rv

Tab

le4.

Activitiesallowed

—%

weightexpectedforheightan

dag

e

%W

eight

forheight

Activityallowed

Unit7

Unit8

Unit9

Unit10

Unit11

<60

Bed

rest

60Bed

orch

airrest,wheelchair

tran

sport,restricted

toroom

includingformeals,no

therap

yored

ucation

60–6

5Couch

rest

<65

Offtheunitsu

pervised

butnophysical

activityincluding

walkingaround

65Chairrest,wheelchair

tran

sport,outofroom

only

for1meal,beg

intherap

y65

–70

Restrictedwalking

duringvisitsoffunit

aslongas

supervised

Chairrest

<70

Able

tojoin

activities/

groupsifphysicallywell

enough,noother

exercise

70Chairrest,canwalkaround

unitbutwheelchairoff

unit,

inroom

forbreak

fast

only

70–7

5Gen

tleactivities,

e.g.

poolortable

tennis

forsp

ecified

,sh

ort

periodsoftime

70–8

0W

alksortripsout,

supervisiondiscretionary

71–8

0Moderateexercise,low

impact,sw

imming,

bad

mintonetc.

(30min)

75Lim

ited

physicalactivity

butcanattendschool,

therap

ygroupsan

dexternal

activitiesbutbodily

rest

dep

enden

tonactivitylevels

Yogaclassesonunit

75–8

0Gen

tleactivitiesoff

unit,e.g.relaxation,

swim

ming,stretches,

short

walketc.

80Bodilyrest

ifap

propriate

80þ

Unsu

pervised

physical

activities

Commen

ceexercise

80–8

5Gen

tleactivitiesoff

unit,e.g.schooltrip,

short

daily

walk

85–9

0Gen

tleactivitiesoff

unit,e.g.peerwalk,

PE,sw

immingetc.

90þ

Moderateactivities,

e.g.sw

imming,gam

esetc.

Target

weight

Fullrangeofactivities

338 S. Davies et al.

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 16, 334–340 (2008

DOI: 10.1002/erv

)

Physical Activity Management in Adolescent Anorexia Nervosa 339

(n¼ 12), physiotherapists (n¼ 11), psycho-education(n¼ 5), therapeutic groups (n¼ 5) and dieticians(n¼ 4) amongst others.

Leave

All units reported their patients went on periods ofhome leave. Thirty-seven (88%) units said they hadguidelines for the management of physical activityduring leave and these mostly involved discussingappropriate activity levels with families.

Activities

The activities most frequently provided includedwalks (n¼ 35), swimming (n¼ 19), table tennis(n¼ 15), yoga (n¼ 13) and the use of gym equip-ment (n¼ 12). Pool and various ball gameswere alsowidely available. Classes such as pilates, tai chi anddance and movement were reported, plus moreunusual activities including ice-skating, horse-riding, bowling, rock-climbing, water aerobics,skiing, sailing and trampolining. Some units hadphysiotherapy or occupational therapy-run activi-ties.

DISCUSSION

This study provides an overview of current practicein the management of physical activity with UKadolescent AN inpatients. Given the clinicalimportance of this area, the lack of consistentapproach found in this study is of concern. Anillustration of this is in the use of weight-basedcriteria to determine acceptable levels of activity.Although most treatment regimes adopted such anapproach the figures used to set what activity couldbe allowed at which BMI or % weight expected forheight and age varied enormously and werepresumably rather arbitrary. For example, normalactivities would be resumed in one unit at a BMI of15 whereas in another this did not happen until aBMI of 18.5 was reached.Perhaps inevitably the approaches described by

units bear some resemblance to aspects of thoseoutlined in the literature. For example most unitsincorporated education (Long and Smith, 1990) andstage or weight-related activity restriction (Thienet al., 2000) and some used activity as a reward orincentive for weight gain (Beumont et al., 1994).However, no units reported following these pub-lished approaches directly and none of the pub-lished literature was mentioned to the interviewers.

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders A

It may be that there is some work to be done in unitseducating staff concerning the relevant literature,sparse as this is.The difficulty in reaching a rational and satisfac-

tory approach to physical activity may be partlyrelated to how activity and over-activity areunderstood. If one sees activity as an obstacle toweight gain and that a central task of inpatienttreatment is weight restoration, then this may leadto the conclusion that activity should be restricted soas to facilitate the gaining of weight. If instead onefocuses on the patient’s struggle to deal withdifficult emotions including the anxiety of weightgain, then this might lead to an approach morebased on recognition and management of emotions,development of alternative strategies and so on.There is therefore somewhat of a tension betweenthe need to control so as to facilitate weight gainversus the need to help the patient improve theirown ability to manage difficult emotions andanxieties, including those about weight gain andtherefore to make changes which might be sus-tained beyond the admission. This balance can beseen as the art of clinical practice and referencemade to the complicated interplay of patient, familyand staff variables. Alternatively this appeal tocomplexity and the need to work with theindividual characteristics of patient, family andunit might be seen as an avoidance of the need totake a more rigorous approach to standardising andevaluating treatment regimes.Although this was not universal, there was a

tendency amongst the units surveyed not to treatathletes and dancers differently from other patients.Perhaps what is important is not so much whetherthe patient is an athlete, but what is the place ofexercise and activity in their normal healthy life.The authors are aware of patients who werepreviously athletes and dancers but who, throughtreatment, came to the conclusion that returning tothis was not in their interest but also others forwhom the desire to achieve in their chosen sportwas a major positive motivating factor.Although inevitably a higher response rate would

have been desirable information was obtained fromapproximately two-thirds of the relevant units intheUK.Allowing the use of both questionnaires andinterviews probably improved the response rate butdid introduce more opportunity for missing data,for variation in level of detail in answers andmisinterpretation of questions. A more structuredinterview may have reduced these differences.Another limitation of the study is that the

researchers only spoke to one member of staff from

ssociation. Eur. Eat. Disorders Rev. 16, 334–340 (2008)

DOI: 10.1002/erv

340 S. Davies et al.

each unit. The current survey captured the under-standing and management of physical activity fromprimarily a nursing point of view. Although nursestend to be central in the management of activity andexercise, gaining information from other disciplinesand from the patient’s perspective, would havebeen helpful.

CONCLUSION

Excessive physical activity in patients with AN is aclinically important area. The lack of consistency inthe way this is approached by child and adolescentinpatient units across the UK is cause for concernand indicates a need for the development andevaluation of clinical management protocols in thisarea.

ACKNOWLEDGEMENTS

The authors thank members of the child and ado-lescent eating disorders research consortium fortheir support and advice throughout this study.For more information about the consortium contactTony Jaffa.

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ssociation. Eur. Eat. Disorders Rev. 16, 334–340 (2008)

DOI: 10.1002/erv