May 2019 Issue
Yoga & Mindfulness Therapies for Eating Disorders
By Caroline L. Young, MS, RD, LD, RYT
Today’s Dietitian
Vol. 21, No. 5, P. 40
An Overview of the Current Research Plus Counseling Strategies for Dietitians
Whether you encounter clients or patients with binge eating disorder, anorexia nervosa, bulimia nervosa (BN), or orthorexia, it’s important for dietitians to keep in mind that an eating disorder is a mental illness that affects all aspects of the individual—mind, body, and spirit. While highly destructive and sometimes deadly, eating disorders are used as coping mechanisms and ways to avoid or suppress uncomfortable or painful thoughts, feelings, and emotions.
As a result, regardless of a person’s eating disorder diagnosis, he or she experiences extreme mental, physical, and emotional imbalances, and an overall disconnection from the body and its needs.1
According to Susanne Draper, MS, LPC, a yoga nidra instructor and clinical manager at the Denver-based Eating Recovery Center (ERC), embodiment is “when you’re able to connect to your experience within your body.” Discomfort in one’s own skin and lack of embodiment are both present in patients with eating disorders.
Yoga, Yoga Nidra, and Yoga Therapy
Dating back more than 5,000 years in India, yoga is a physical, mental, emotional, and spiritual practice that aims to heal the whole person. There are a variety of physical yoga practices, from gentle and restorative, requiring little movement and more rest, to power and heated yoga, involving more energy and exertion—comparable to a workout.
Benefits of physical yoga range from reduced stress, depression, and anxiety to improved physical strength, balance, and bone density—all of which can aid in one’s mental and physical recovery from an eating disorder.2,3
“I always thought something was missing in eating disorder treatment,” says Beverly Price, MA, RD, E-RYT 200, C-IAYT, CEDRD-S, who now leads mindfulness-based trainings for eating disorder professionals. “I realized yoga was the missing link.”
Yoga emphasizes mindfulness, defined as “the practice of maintaining a nonjudgmental state of heightened or complete awareness of one’s thoughts, emotions, or experiences, on a moment-to-moment basis.”4 In the eating disorder population, cultivating awareness of and space from the distorted thoughts around food and body, and being able to identify emotions and be present in the body, are important in the recovery process.
Yoga nidra, a form of yoga also known as “sleep with awareness,” is another ancient practice intended to cause full-body relaxation and deep meditative states.5 At ERC, Draper guides patients with eating disorders through yoga nidra practices regularly. As she teaches, she begins with body scans, where she has patients bring awareness to different body parts and then leads them into deeper layers of consciousness, using their breath and guided imagery. “It reduces anxiety,” Draper says. “They have a very difficult time being still and being quiet … it gives them the experience of allowing their bodies to fully relax.”
While yoga and yoga nidra practices typically take place in studios or group settings, yoga therapy usually is conducted in one-on-one sessions with focus on healing the client’s specific condition. Yoga therapists create practices personalized for their clients, which works well for those who need extra attention, as long as the yoga therapist is trained and informed in working with this population.6
Other Mindfulness Techniques
Aside from physical postures, there are several facets of yoga, including meditation and breathing, both of which are mindfulness practices beneficial to the eating disorder population.
In fact, acceptance and commitment therapy (ACT), which ERC and many eating disorder therapists and RDs implement in their counseling work, is a mindfulness-based therapy. One facet of ACT is cognitive defusion, which involves observing thoughts and feelings and where they’re felt in the body, separating oneself from irrational thoughts, and eventually becoming less reactive to them. Mindfulness tools such as meditation and breathing exercises can help patients practice cognitive defusion by grounding them in reality and creating space between themselves and their thoughts.7
Why Are Complementary Treatments Effective?
These techniques are healthful coping skills that support the reconnection to mind and body necessary in eating disorder recovery. “They may not need the [eating disorder] anymore if they start welcoming their body back into their life. … Yoga helps them to reconnect the head back to the body,” says Sandee Nebel, MS, LMHC, CEDS-S, E-RYT 200, who counsels and teaches yoga to the eating disorder population. Nebel places an emphasis on body image in her classes and believes yoga also can help improve body acceptance and body appreciation. “It’s really about reconnecting people to their bodies in a way that’s joyful, pleasant, and full of compassion.”
Yoga and mindfulness techniques also help reduce anxiety and obsessive thinking, which are ever-present in those with eating disorders. “Yoga wants you to slow down thought processes, and the eating disorder thought process is just constant. Yoga teaches us to just be still and to find some sort of peace and quiet,” says Megan Kniskern, MS, RD, CEDRD-S, LD/N, who has worked with the eating disorder population for more than 10 years and incorporates yoga and mindfulness into her work. “[Eating disorders] have a focus on the external body, and yoga shows us how to connect internally. It helps you to just close your eyes and ask what your body is telling you right now.”
Price says yoga and mindfulness tools can be especially helpful for patients who resonate less with talk therapy. “It gives individuals an experience. They can tap into areas they may not be able to tap into just talking. It gives people access to healing in different ways.”
For example, Price says she had a patient who was resistant to feeling any emotion. However, once she guided her through some yoga postures, her patient began to cry. “From there, she was able to start feeling and go deeper.”
What Current Research Says
Evidence continues to emerge around the efficacy and benefits of yoga and mindfulness therapies in eating disorder treatment.
In one single-blinded, randomized controlled trial of 30 females diagnosed with BN or eating disorder not otherwise specified (EDNOS) published in the International Journal of Yoga, each participant in the intervention group was randomly assigned to an 11-week yoga intervention group. The yoga classes consisted of two 90-minute classes per week. The classes were nonheated physical practices that also integrated mindfulness techniques such as meditation and breathing practices. The control group participants were offered two classes on nutrition, exercise, and eating disorders and were instructed not to participate in yoga for the 11-week intervention and the study’s six-month follow-up period.
The study’s results showed reduced eating disorder psychopathology after the yoga intervention and at the six-month follow-up. Specifically, the results showed a larger decline over time in Eating Disorder Examination (EDE) Questionnaire scores, including the global score and subscores of eating restraint and eating concerns in the intervention group compared with the control group.
Despite the study’s strengths as a randomized trial using a gold standard assessment (ie, the EDE), the study had its limitations in that it had a small sample size and relatively high dropout rate at the postintervention test and six-month follow-up period.8
Another randomized controlled trial, published in the Journal of Adolescent Health, assessed the effects of individualized yoga treatment in 50 girls and four boys between the ages of 11 and 21 in outpatient treatment for anorexia nervosa, BN, or EDNOS. The intervention group received eight-week standard eating disorder care with yoga, and the control group received eight-week standard eating disorder care without yoga. The results showed the yoga group had a greater decrease in eating disorder symptoms than the control group. Food preoccupation also was measured before and after yoga sessions, and it dropped significantly over time. The study also showed yoga therapy didn’t negatively affect participants’ BMIs. While the study was a randomized trial using the EDE, it had the limitation of using a relatively small sample size.9
More research is necessary in the area of yoga and mindfulness therapies as treatments for eating disorders.
Areas of Caution
While yoga has shown itself to be an effective adjunct to eating disorder therapy in some research, dietitians need to be mindful of the following caveats:
• Intensity level: Intensity levels of yoga practices depend on a patient’s level of care (eg, inpatient, partial hospitalization, or outpatient) and where they are in the recovery process. However, for the majority of the eating disorder population, slow and gentle practices in unheated rooms often are the best choice. “Everyone should start out with gentle or restorative yoga regardless of their [eating disorder] diagnosis, and [the practice] should really emphasize connection to body and slowing of the mind,” Kniskern says. “It’s more about this connection than it is about the movement.” She says that stronger practices may be appropriate later in a person’s recovery to start rebuilding strength and balance.
• Osteoporosis and osteopenia: Physical practices in the eating disorder population should be osteoporosis and osteopenia friendly, which means there should be no flexion of the spine or hunching over, says Nebel, who recommends patients with eating disorders get bone density tests before participating in yoga. Typical transitions between yoga poses should be limited or eliminated. “Rolling down, rolling up, and some twisting should be restricted, and dropping the chin toward the chest,” she says. In addition, balancing poses should be limited for anyone with a high fall risk.
• Past trauma: Yoga teachers and therapists must be aware of clients’ and patients’ trauma histories, as it’s common for those with EDs to also have history of sexual, physical, and/or emotional trauma, and certain postures can be triggering. For example, some poses on the back, such as happy baby, can feel too vulnerable for someone with a sexual trauma history.
Draper advises against hands-on adjustments in yoga with patients, as it can bring more attention to the body and make patients more self-conscious.
• Exercise obsession: Clients with eating disorders often have an unhealthful relationship with exercise and can use yoga as a compensatory mechanism. RDs can help clients set exercise boundaries and separate their yoga practice from the eating disorder to help them approach it in a nondisordered and nourishing way. “Until clients can use inner wisdom, we have to help them with setting those boundaries,” Nebel says.
Tools RDs Can Integrate
If dietitians don’t have experience providing nutrition counseling to patients with eating disorders, they can implement the following mindfulness tools simply and safely:
• Encourage engagement of the senses at the beginning of sessions and during meals and snacks. Kniskern suggests having clients close their eyes and take a “mindful moment” before meals. “The slowing and connecting piece [of mindfulness] integrates easily into the nutrition aspect of eating disorder care.”
• Practice deep breathing and/or basic stretching with clients and patients to help them be more present and at ease during sessions and provide them with tools to use outside of sessions.
• Guide clients and patients through short meditations, and/or recommend meditation apps, such as Insight Timer or Headspace. “Anything to help more and more with relaxation and coming back to body can only help an RD’s work be easier,” Nebel says.
• Research and visit local yoga studios and teachers to find the most appropriate yoga classes for your clients and patients. “Look for key words like ‘gentle’ or ‘restorative’ or ‘yoga nidra,’” Kniskern says. “Create your own reference list.”
If dietitians are interested in integrating yoga and mindfulness tools further into their work, visit Price’s Professionals page (https://beverlysprice.com/index.php/mindfulness-based-yoga-therapy-training). And to learn more about yoga therapy, visit the International Association of Yoga Therapists (www.iayt.org/page/Publications_of_IAYT) and Phoenix Rising Yoga Therapy (https://pryt.com).
— Caroline L. Young, MS, RD, LD, RYT, specializes in eating disorders and disordered eating and counsels clients virtually and in an outpatient private practice in the Atlanta area. She co-leads weekly groups and weekend retreats with the goal of helping people develop nourishing relationships with food and their bodies. Young writes nutrition-focused articles on a freelance basis and blogs at TheWholeYogiRD.com.
References
1. Health consequences. National Eating Disorders Association website. https://www.nationaleatingdisorders.org/health-consequences. Accessed March 1, 2019.
2. Yoga for health. US National Library of Medicine, Medline Plus website. https://medlineplus.gov/ency/patientinstructions/000876.htm. Updated August 3, 2018. Accessed Mach 1, 2019.
3. Yoga: another way to prevent osteoporosis? Harvard Health Publishing website. https://www.health.harvard.edu/womens-health/yoga-another-way-to-prevent-osteoporosis. Published May 2016. Accessed March 1, 2019.
4. Mindfulness. Merriam-Webster website. https://www.merriam-webster.com/dictionary/mindfulness. Accessed March 1, 2019.
5. Levin-Gervasi S. Find full-body relaxation in yoga nidra. Yoga Journal website. https://www.yogajournal.com/lifestyle/in-need-of-yoga-nidra. Published August 28, 2007. Accessed March 1, 2019.
6. McCall T. Yoga therapy: need to know. Yoga Journal website. https://www.yogajournal.com/yoga-101/yoga-vs-yoga-therapy. Published August 28, 2007. Accessed March 1, 2019.
7. Serani D. An introduction to acceptance and commitment therapy. Psychology Today website. https://www.psychologytoday.com/us/blog/two-takes-depression/201102/introduction-acceptance-and-commitment-therapy. Published February 22, 2011. Access March 1, 2019.
8. Karlsen KE, Vrabel K, Bratland-Sanda S, Ulleberg P, Benum K. Effect of yoga in the treatment of eating disorders: a single-blinded randomized controlled trial with 6-months follow-up. Int J Yoga. 2018;11(2):166-169.
9. Carei TR, Fyfe-Johnson AL, Breuner CC, Brown MA. Randomized controlled clinical trial of yoga in the treatment of eating disorders. J Adolesc Health. 2009;46(4):346-351.