Monday, October 13, 2014

The Truth About Eating Disorders and Yoga

The Truth About Eating Disorders and Yoga
Catherine Cook-Cottone


The Truth About Eating Disorders and Yoga: that is the title of a recent piece in Yoga Journal. I have been researching eating disorders and yoga interventions for over 10 years (see my research page here http://gse.buffalo.edu/about/directory/faculty/cook-cottone). When I read, what I believe was a well-intentioned article; I was conflicted about it. I was very happy this important topic was brought to light. However, I was also somewhat confused by the content and disheartened (read the article here http://www.yogajournal.com/article/eating-disorders/truth-yoga-eating-disorders/).

I imagined what I might think as a parent of someone who was struggling with an eating disorder or a care provider trying to decide if patients should be encouraged to do yoga or not. From this perspective, I worry that the article might have been discouraging, framing yoga as a risk for patients. Most certainly, the highlighting of a tragic story of parents finding their daughter dead, in a yoga pose, was alarming and I would guess terrifying for parents with a child who is struggling.  For weeks, I have thought about it, reflected on it, and wondered if I should write about it. Many people have commented and blogged about this article. At this point there has been no voice, among the many, representing what is known in the research. I decided to write.

I have spent years in academic study pursuing the truth about yoga and eating disorders. I am careful, cautious, and in serious study. This line of inquiry matters to me for many reasons. I hope that someday we will get close to the truth. I know that finding truth will take years, perhaps decades, and likely careers to discover.

My take on the article by Chelsea Roff (read more about Chelsea Roff here http://www.eatbreathethrive.org/chelsea-roff.html) was that her intentions were good. I have watched her journey across media channels. She most certainly is an inspiration and is doing very important work. I applaud her breakthrough effort to bring attention to the risk some practitioners bring to yoga class. Also, I think her article, critically, calls attention to the importance of watching for practitioners who are struggling. In addition, I hope her article inspires the industry to integrate screening for risk into teaching/studio guidelines, teach a protocol for intervening during our training programs, and encourage studios to have policies related to those at risk. 

The TRUTH is…

My first concern is with the title. As an academic, I am part of a group of individuals who work decade after decade in pursuit of-- what use of the scientific method guides us cautiously toward-- “the truth.” Practice guiding conclusions are made only after a foundation of theory (i.e., theory papers and qualitative studies), exploration of ideas and experiences among individuals (i.e., clinical case studies), pilot studies, controlled trials, randomized controlled trials, replication-- and eventually-- works that aggregate many studies (e.g., systematic literature reviews and meta-analyses). Even then, we speak in terms of “the evidence suggests that___,” or “current research indicates that____,” etc. The word truth holds a scared place. Years of discovery and rediscovery have taught us that, perhaps, we only get glimmers of truths and-- most certainly-- it is only together that we get close. That is, we carefully read and review the work that has been done, honor and cite those who have done the work, and base our current assessments and cautious guidance on what is known- empirically known.

A More Careful Review of the Literature

Given that context, I would argue that we do not know the truth about yoga and eating disorders. Here is what we know- right now. Please note- we don’t know that much at this point.

Early studies were correlational. That means that participants were likely given a survey that asked a lot of questions about yoga, eating disordered behaviors, eating disorder risk factors, etc. Researchers then ran the data to see what went with what. For example, did yoga correlate with lower rates of eating disordered behavior and risk factors?

In an early study, Daubenmier (2005) found this:

  • Yoga practice is associated with greater awareness of and responsiveness to bodily sensations, lower self-objectification, greater body satisfaction, and fewer disordered eating attitudes.
  • As predicted, yoga practitioners reported more favorably on all measures. Body responsiveness, and, to some extent, body awareness significantly explained group differences in self-objectification, body satisfaction, and disordered eating attitudes.

Some of the research that Roff referred to in her article was done by Neumark‐Sztainer and colleagues. Here are findings from a study published in 2011. This was a survey study that combined yoga and Pilates in one category and analyzed data accordingly. This information is directly from the study:
  •  Among study participants, 17.6% (n = 221) of the young women and 5.2% (n = 53) of the young men reported an average of 30 min or more of yoga/Pilates per week.
  • Among yoga/Pilates participants, the average time spent in yoga or Pilates was 2.0 h/week (SD = 1.4) for young women and 2.2 h/week (SD= 1.7) for young men.
  • Young women who participated in yoga/Pilates were less likely to report body dissatisfaction than nonparticipants (36.1% vs. 51.4%, p < .001).
  • The proportions of young women reporting unhealthy weight-control behaviors, extreme weight-control behaviors, and binge eating did not differ significantly by yoga/Pilates participation.
  • Men participating in yoga/Pilates were more likely to use extreme weight control behaviors (18.6% vs. 6.8%, p=.006) and binge eating (11.6% vs. 4.2%, p=.023), and marginally more likely to use unhealthy weight control behaviors (49.1% vs. 34.5%; p=.053), than non-participants after adjusting for sociodemographics, weight status, and overall physical activity.

My team became very interested in yoga interventions and eating disorders. Note that the studies I listed above were surveys. In our review we looked at yoga used as an intervention with pre and posttests conducted to see if yoga interventions made things better, worse, or had no effect. [Survey, or correlations studies, do not assess pre and post test findings- so they can’t say if the yoga practice can help explain changes in eating disordered behavior or risk. They can only describe what seemed to go together]. 

Jessalyn Klein and I completed a systematic review and synthesis of the yoga literature. We searched databases for peer-reviewed articles about yoga practice and Eating Disorder symptoms and correlates.  Again- at this point there have been VERY FEW studies completed.


  • Of the 14 articles reviewed, 40% used cross-sectional designs to examine risk and protective factors for Eating Disorders among yoga practitioners, and 60% used longitudinal designs to assess the effectiveness of yoga interventions for preventing and treating Eating Disorders.
  •  Yoga practitioners were reported to be at decreased risk for Eating Disorders, and Eating Disorder risk and symptoms were reduced or unchanged after yoga interventions.
  •  Conclusions: More well-controlled studies are needed to understand whether the positive effects of yoga on ED symptoms and correlates are related to the type of yoga practiced, the amount/frequency of practice, and/or other variables.
  • See the article here: http://yogaclub.us/attachments/Yoga%20as%20Medicine%20-%20Effects%20of%20Yoga%20on%20Eating%20Disorders.pdf


Using Yoga Against Yourself

Perhaps, this is what was Chelsea Roff was talking about? I am very happy that her article brought attention to this often negected risk that is inherent in embodied practices. Like others before me (e.g., Dittmann, & Freedman, 2009), in my forthcoming book, “Mindfulness and Yoga for Embodied Self-Regulation: A Primer for Clinicians(see Springer Publishing, 2015) I address this issue.

I tell the story of Mathew Sanford (2006), author of the deeply moving and inspiring book “Waking: A Memoir of Trauma and Transcendence.” Sanford articulately describes the moment he had taken his self-destructive struggle onto his yoga mat. After a traumatic injury, yoga was Sanford’s pathway to healing. However, for a while, he used this healing tool against himself. He notes, “I know the moment my yoga practice passed over into the threshold into violence” (Sanford, 2006; p. 203). Practicing with a spinal chord injury that left him paralyzed, Mathew describes pushing and straining so hard in a pose that he broke his own leg. The injury was complicated as was his recovery from it. Sanford (2006) states, “Breaking my leg was the harshest lesson that I have ever experienced in yoga. For me, nonviolence is no longer an intellectual platitude within my practice. It is an energetic fact” (p. 213).  

I believe this turning of yoga into a self-destructive act is what Chelsea Roff was describing in her tragic story of a death of one yoga practitioner, who also apparently suffered from a clinical level eating disorder. Like any other practice, yoga can be misused and turned against the self. It is this notion that I think was the spirit of Roff’s piece.

I agree that this can happen and I am concerned that yoga teachers are often not prepared to identify, assess, set limits, and refer. Yes. We need to integrate warning signs, screening tools, and how to confront and refer someone who is struggling into yoga teacher training. However, it is my belief that this is the exception and not the rule. Research to date supports this contention. That is, although some people who are already struggling with clinical levels of risk or struggle may misuse yoga as a self-destructive tool, many may benefit from the practice. It also seems that for some, depending on various factors (dosage of yoga, style, etc..), yoga may have no effects. I also believe there are factors present in some yoga communities (note- not the yoga- the community) that trigger risk. Although, this has yet to be effectively researched.

So What is the Truth about Yoga and Eating Disorders?

I don’t think we know. It may be that some people who are struggling are drawn to the practice (see Neumark‐Sztainer et al., 2011). That makes sense to me. Those who have eating disorders find challenge in the mind body connection. Yoga lives in that connection.

Overall, it looks—somewhat—cautiously-- promising. That is, there is some evidence that yoga may help. We are not sure what about the yoga practice helps, what type of practice helps, and what aspects of the practice are important to include (e.g., breath work, asana, meditation). There is—honestly-- more that we don’t know, than we know.

I have seen tremendous growth in my own life and in the lives of others manifest through the practice of yoga. I have researched a yoga intervention as a prevention tool for eating disorders. I have done pilot work using a yoga intervention as an adjunct treatment for eating disorders. I continue this work today. I want to know if it works, why it works, how it works, and how might it work best. I most certainly want to know what might cause harm, who might be at-risk in yoga class, and what might place people at risk. I have seen yoga studio cultures that promote the thin-deal, encourage fasting, and hire and maintain dangerously thin teachers. Note- as I mentioned above-  these are yoga studio variables and not yoga. As the body of research grows, it is my hope and intention that studio features and variables will be de-coupled from the 8-limb practice of yoga. And that both will be the focus of research going forward.

So, yeah- for at least right now- I don’t think we quite know the truth about yoga.

So, what can you do now?

I have a short list here for guidance. Do these things for a healthy, body positive yoga; prevention of eating disorder risk; and referral for those who are struggling:

  1.  Let yoga be about yoga. The yoga scriptures do not speak about weight loss and body sculpting as a pathway to enlightenment. Teach yoga, not self-judgment. 
  2. Create and maintain a body positive culture. Teach yoga that brings awareness to the body and honors the body. All shapes, sizes, abilities, ages, ranges of flexibility, and levels of strength belong—as students and teachers—we all belong.
  3.  See http://www.nationaleatingdisorders.org/types-symptoms-eating-disorders  and http://www.eatingdisorderfoundation.org/EatingDisorders.htm for signs and symptoms of eating disorders.
  4.  If you see someone at risk and you do not know what to do, get help. Contact a local eating disorder specialist and ask for guidance.
  5.  See http://www.eat-26.com for an eating disorder screening tool.
  6. Eat well, maintain a healthy weight, and get help when you need help. A yoga teacher with an eating disorder (even if you are keeping it a secret) is creating risk in his or her community. Take a break from teaching and get help for yourself.
  7.  Be careful with food cleanses, fasting, juicing, and eating guidance. Work with a nutritionist who has familiarity with eating disorder behavior. Do not guide people on topics outside of your expertise.
  8.  Privately, consult with any students you believe may be at risk. If necessary, require a student who is presenting dangerous behavior or appears to be at-risk to get help before you allow them to continue to attend classes. See “How to Help Someone with an Eating Disorder” at http://anad.org/wp-content/uploads/2010/11/How-to-Help5.pdf
  9. Follow the research. We all have access to Google scholar. Use it. National and international eating disorder organizations also provide research updates- see links ANAD, NEDA, and Something Fishy. 
  10. Yoga training programs should include warning signs for mental health issues, risk assessment, guidelines for intervening, and practice in confronting struggling students safely and compassionately.






References and Additional Readings:

Dittmann, K. A., & Freedman, M. R. (2009). Body awareness, eating attitudes, and spiritual beliefs of women practicing yoga. Eating Disorders, 17(4), 273-292.

Douglass, L. (2009). Yoga as an intervention in the treatment of eating disorders: does it help?. Eating Disorders, 17(2), 126-139.

Daubenmier, J. J. (2005). The Relationship of Yoga, Body Awareness, and Body Responsiveness to SelfObjectification and Disordered Eating. Psychology of Women Quarterly, 29(2), 207-219.

Klein, J., & Cook-Cottone, C. (2013). The Effects of Yoga on Eating Disorder Symptoms and Correlates: A Review. International journal of yoga therapy, 2(2), 41-50.


Neumark‐Sztainer, D., Eisenberg, M. E., Wall, M., & Loth, K. A. (2011). Yoga and pilates: Associations with body image and disordered‐eating behaviors in a population‐based sample of young adults. International Journal of Eating Disorders, 44(3), 276-280.
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