January 18, 2016

Discovering the Role of Yoga in Eating Disorder Treatment

Reprinted with permission from SCAN’S PULSE, Winter 2016, Vol 35, No 1, official publication of Sports, Cardiovascular, and Wellness Nutrition (SCAN), Academy of Nutrition and Dietetics, Chicago, IL.

The popularity and accessibility of yoga has grown exponentially in the past decade. According to a study by Yoga Journal, approximately 20 million Americans older than 18 years practiced yoga in 2012, constituting 8.7% of the adult population.¹ An industry report by IBIS World estimates there are more than 30,000 yoga and Pilates studios in the United States.² Many of the 170+ eating disorder (ED) treatment facilities in the U.S. offer yoga or other mind-body based activities as a component of treatment.³ A 2006 study of 18 residential ED treatment programs in the nation found that two-thirds of the programs offered yoga.⁴

Twenty million women and 10 million men in the U.S. suffer from an ED (all diagnosis considered) at some point in life.⁵ Some research indicates that 97% of patients admitted to inpatient ED treatment facilities also meet diagnostic criteria for greater than or equal to one comorbid disorder.⁵ Of those patients, 94% evidenced comorbid mood disorders (largely depression) and 56% evidenced anxiety disorders.⁶

Preliminary research demonstrates the positive effects that yoga may have on the management of anxiety and depression symptoms, including improved body awareness and responsiveness, self-acceptance, emotion regulation, and increased mindfulness.⁷ Given these findings, yoga may have a role as an adjunctive therapy when incorporated into ED treatment. Fortunately, with the growing popularity and accessibly of yoga (via studios, podcasts, Internet videos, DVDs, written materials), it can more easily be incorporated into daily living for ongoing recovery support.

What Is Yoga?

The definition of yoga comes from the Sanskrit root meaning “to join.” Traditionally, yoga seeks to join several parts of an individual’s life into a coherent whole.⁸ Perhaps when traditional yoga is incorporated into ED treatment, it has the potential of helping clients rediscover and reconnect their mind and body in a healthful way.

Traditional yoga is integration: integration of mind, body, breath, and spirit/soul. Yoga is a practice of specific postures (asanas) linked with breath while incorporating a focused intention of moving inward for self-exploration and/or reflection. This practice provides an opportunity to begin learning how one’s mind and body may react to an array of life experiences, thus creating an awareness of behavioral and emotional patterns.⁸ Once yoga is learned on the mat, positive change or a change in unhelpful behavior patterns can begin.

How Yoga Differs From Exercise or Stretching

Yoga differs from exercise in its intentional and mindful movement using particular poses and breathing techniques to support an inward and reflective focus as well as physical benefits. When exercising, someone may not be fully present in mind and body. An example would be watching TV while running on the treadmill. The body and mind are engaged in different ways. Yoga takes the physical and adds the component of listening to the body, self-acceptance, forming the pose to the student not the student to the pose, moving inward, and cultivating both mind and body with the power of the breath. In yoga, the mind is not separate from the body nor is the body separate from the mind. When yoga is practiced with traditional methods, it is a practice of wholeness.

How Is Yoga Useful in Treating Eating Disorders?

How does yoga relate to ED treatment? An ED can serve as a distraction from unwanted feelings, experiences, and stressors. The needs of the body are ignored to a great degree and the numbing of uncomfortable sensations can occur through a variety of maladaptive coping mechanisms. Of course, these coping skills are highly dangerous and not sustainable. In order to live in recovery, one needs to learn how to cope with intense situations, life stressors, and emotions in a healthier way. Learning about the patterns of the mind and body, awareness of personal triggers, and early signs of urges or dysregulation could prevent, delay, or lessen ED symptoms.

Because yoga embodies the connection between body, mind, and breath and provides a canvas of sorts to explore internal reactions in a non-judgmental way, it can serve, for many, as a non-threatening tool to begin healing the emotional and physical body. Bridging the gap between body and mind in this way can aid in developing a nonreactive and curious stance in the face of otherwise harmful thoughts, emotions, and behaviors.⁹ The practice of yoga through mindful movement, meditation, and breathing can serve as a “pause” button creating space to choose how to respond to stress or unhelpful coping mechanisms. At the heart of yoga is acceptance and care for the body, which may ultimately be determined to be helpful in the recovery process. This focus on body appreciation could be helpful in the recovery journey.^7,9

Another avenue by which yoga could be useful in ED treatment involves regulation of the nervous system. The prevalence of anxiety and depression in those with an eating disorder is significant6 and the seemingly positive effect yoga may have on stress, anxiety, and depression could help people with EDs to manage these symptoms. There is evidence that practices such as yoga can stimulate an underactive parasympathetic nervous system and “increase the inhibitory action of a hypoactive GABA (gamma-aminobutyric acid) system in the brain pathways and structures that are critical for threat perception, emotional regulation, and stress reactivity.”¹⁰ One study further suggests that such practices as vagal nerve stimulation in yoga, which activates the parasympathetic nervous system, could impact stress responses.¹¹ By stimulating the vagal nerve via chanting or specific postures (inversions), yoga may help decrease heart rate and lower blood pressure. These are effective indicators of improved stress response. The practice of yoga improves resting vagal tone, which may help those with depression cope more effectively.¹² Results from a recent pilot study on the effects of a vinyasa yoga class, taken twice weekly for 8 weeks, on affect and stress among college students, suggested that yoga practice was associated with acute improvements in this population; positive affect scores (measured by the Positive and Negative Affect Schedule) increased significantly (P<.05) and negative affect decreased significantly from pre- to post-yoga (P<.05).¹¹ Further research and stronger study designs regarding the role of yoga in anxiety and stress management is needed.¹³ With adequate funding to allow access to strong measurements and study designs, these studies could shed light on prescriptive yoga approaches that could target these common comorbid conditions in ED and potentially help alleviate symptoms that impair ED recovery.

Yoga in ED Treatment: Anecdotes from Professional Experience

Prior to becoming a registered yoga teacher, I practiced as a dietitian specializing in ED treatment for The Emily Program. I learned much about recovery from our clients and had the privilege to witness their experiences firsthand. Seven years ago, I began teaching yoga in ED treatment at The Emily Program. Even at that time, with only two weekly yoga classes offered by the agency, I saw the impact yoga was having at mealtime, group process, and individual sessions. What I observed profoundly shaped my vision for yoga in ED treatment. Some anecdotal examples of the changes clients exhibited include the following:

Renegotiation of trauma
Use of positive coping skills to calm down during high anxiety events (grocery shopping, meals, symptom succession)
Decreased manifestation of anxiety at mealtimes
Increased awareness of internal hunger and fullness cues
Enhanced ability to challenge negative body image, checking, and behaviors
Reclaiming positive movement (from over-exercising to under-exercising)
Appreciation of what the body is capable of versus appearance
Facing fears and challenging old beliefs of self
Having fun, laughter, joy, feeling hopeful
Decreased isolation
Increased awareness of and decreased engagement in comparison (body and food)
Increased awareness of and decreased engagement in negative self-talk
Increase in deep breathing and grounding techniques at mealtime
Utilization of yoga to aid in digestion

Case Examples of Yoga Supporting ED Recovery

While shopping one day, a client noticed her anxiety level increasing as she navigated the grocery store. She inconspicuously moved into a Forward Fold (Uttanasana). This inversion slowed her heart rate and she experienced feeling more calm and centered. She continued grocery shopping with success.

Another client struggled with the Downward Facing Dog pose (Adho Mukha Svanasana). Typically she would experience disgust for her legs when she was in this posture. After several weeks of practice, she moved into the pose and appreciated the strength of her legs and their ability to support her inverted practice, and she didn’t experience the usual judgmental thoughts.

At The Emily Program, yoga is integrated into all levels of treatment. An average week contains more than 40 yoga classes led and facilitated by 16 registered yoga teachers across all locations. Yoga teachers are registered at the 200-hour level or higher and undergo extensive ED-sensitive yoga training. Over the past 6 years, The Emily Program has developed yoga in ED training for clinicians (yoga instructors, therapists, dietitians) practicing in ED treatment. Because of the comorbid conditions in the client population (anxiety, depression, personality disorders, trauma, and more), careful consideration, thoughtful technique, specific language, trauma-sensitive options, and creating a safe environment are required of all of our teachers. The poses are adapted to meet the student, not the student to the poses. Individuals of any level of experience, mobility, and body size can participate fully. Eating disorders do not discriminate and neither does yoga. Systematic research is needed to comprehensively test the efficacy of yoga in this population.

Practical Application: Tips for Incorporation

Only those who are formally trained and registered should teach yoga. However, if you are a clinician working in ED treatment, showing your client a few grounding and centering yogic techniques could provide helpful tools to add to the recovery toolbox. Your client should be fully aware and willing to participate.

Following are postures and purported benefits for consideration:

Mountain Pose (standing or seated) – for grounding and centering
Downward-facing Dog (traditional, chair or wall) – activates parasympathetic vagal response
Alternate Nostril Breathing – balances the autonomic nervous system
Legs up the Wall – calming, decreases swelling
Wind-Relieving Pose – for relief of constipation and gas discomfort
Supine Twist – for relief of constipation and gas discomfort
Heart Openers (on bolster) – counterbalance for withdrawal
Crescent Moon Pose – stretches intercostal muscles, increasing capacity for deeper breathing

Consider incorporating simple breathing techniques (alternate nostril breathing; noticing the breath; deepening the breath) into or before sessions and at mealtimes. Some clients have increased anxiety during the initial phases of breath integration, so always guide with curiosity and a reminder that these are only suggestions, not requirements.

Be curious and ask your client about their yoga practice:

Why is the client practicing yoga? What is his/her intention?
Is he/she taking a class that best meets his/her current needs?
What does the client notice prior, during, and after a practice?
Does the client have a helpful intention, mantra, or quote?
Can a yoga experience relate to an experience with food, body, shape, exercise, emotion?
What is the client’s hydration before, during, and after a class?
Is the client adapting postures as needed, or ignoring his/her body?
Does the studio have mirrors? How is this affecting the client’s body image and perception?
What types of messages are being integrated into the class (weight-focused, appearance, competition vs. acceptance, adaptation, modification)?
Can the client or you discuss concerns or needs with the yoga teacher?

Careful Considerations

Although the healing benefits of yoga are promising, yoga should be incorporated and taught in a thoughtful and skillful way. If incorporated carelessly, it could be traumatizing to the client.

Clear communication of needs and outcomes between the yoga teacher, client, and treatment team is a must to provide a safe experience.

The Future of Research

Studies are showing that yoga has the potential for producing positive effects on mental health, although in a 2013 review of studies on the effectiveness of yoga on EDs, Neumark-Sztainer suggests that more research with stronger designs are needed to prove yoga’s effectiveness as a supportive treatment and prevention modality for people with EDs.¹⁴ Another review on the effects of yoga on ED symptoms support the need for additional research that is of higher quality and provides specifics on technique and effects of postures and amounts.¹⁵

At The Emily Program, in collaboration with the University of Minnesota’s Division of Epidemiology and Community Health, in the School of Public Health, two research studies furthering the exploration of the impact of yoga on EDs are in the data analysis phase. One study involves the evaluation of The Emily Program’s popular yoga and body image groups. This is a mixed-methods (quantitative and qualitative) study evaluating the effects of these interventions on different aspects of participants’ body image. The second study is a small randomized, control trial examining the effects of yoga on mealtime anxiety among clients in residential treatment at The Emily Program’s Anna Westin House. Findings from both of these studies will contribute to the limited empirical evidence regarding the role of yoga in ED treatment.

Summary

The popularity and health benefits of yoga, together with the principles of ED-sensitive teaching, shed favorable light on the potential advantages of incorporating yoga into ED treatment. Through yoga postures and breathing techniques that focus on autonomic nervous system regulation, neuromuscular re-patterning, observation, choice, behavior modification, distress tolerance, and a lessened or nonreactive response to stressors, shifts in ED thoughts and activities have the opportunity to take place.

References

1. Yoga in America Market Study. Available at: http://www.yogajournal.com/article/press-releases/yoga-journal-releases-2012-yoga-in-america-market-study/. Accessed May 18, 2015.

2. Pilates & Yoga Studios in the US: Market Research Report. Available at: https://www.ibisworld.com/industry/pilates-yoga-studios.html. Accessed May 18, 2015.

3. Treatment Center Finder. Available at: http://www.edreferral.com/treatmentframe.htm. Accessed May 18, 2015.

4. Frisch MJ, Herzog DB, Franko DL. Residential treatment for eating disorders. Int J Eat Disord. 2006;39: 434-442.

5. Wade T, Keski-Rahkonen A, Hudson J. Epidemiology of eating disorders. In: Tsuang M, Thohen M. Textbook in Psychiatric Epidemiology. New York, NY: Wiley; 2011:343-360.

6. Blinder BJ, Cumella EJ, Sanathara VA. Psychiatric comorbidities of female in patients with eating disorders. Psychosom Med. 2006; 68:454-462.

7. Daubenmier JJ. The relationship of yoga, body awareness, and body responsiveness to self-objectification and disordered eating. Psychology of Women Quarterly. 2005;29:207-219.

8. Kraftsow G. Nourishing the physical. In: Kraftsow G. Yoga for Transformation. New York, NY: Penguin Encompass; 2002:45-60.

9. Dittmann KA, Freedman MR. Body awareness, eating attitudes and spiritual beliefs of women practicing yoga. J Treat Prev. 2009;4,273-292.

10. Streeter CC, Gerbarg PL, Saper RB, et al. Effects of yoga on the autonomic nervous system, gamma-aminobutryric acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Med Hypoth. 2012;78:571-579.

11. Gaskins R, Jennings E, Thind H, et al. Acute and cumulative effects of Vinyasa yoga on affect and stress among college students participating in an eight-week yoga program: a pilot study. Int J Yoga Ther. 2014;24:63-70.

12. Shapiro D, Cooke I, Davydov, D, et al. Yoga as a complementary treatment of depression: effects of traits and moods on treatment outcome. Evid Based Complem Alt Med. 2007;4:493-502.

13. Li A, Goldsmith CA. The effects of yoga on anxiety and stress. Alt Med Rev. 2012 17:21-35.

14. Neumark-Sztainer D. Yoga and eating disorders: is there a place for yoga in the prevention and treatment of eating disorders and disordered eating behaviors? Adv Eat Disord. 2014;2:136-145.

15. Klein BA, Cook-Cottone C. The effects of yoga on eating disorder symptoms and correlates: a review. Int J Yoga Ther. 2013;23:41-50.