This was without doubt the most controversial aspect of our recovery programme for Helen as exercise is regarded as the anorexic’s ally owing to the fact that it helps the obsessed out of control dieter to shed even more weight than would otherwise be possible. However, exercise also promotes mental well-being and helps to counteract depression - and after the episode in the kitchen, Helen had fallen into a deep suicidal depression. Having discovered in my own life that a one hour period of rigorous exercise each day helps me to maintain my equilibrium, particularly at times of crisis, I was determined to offer the same opportunity to Helen. And Helen was eager to take up that opportunity because it made her feel safer about eating - and she realised that she had no choice but to eat owing to the ever-present threat of hospitalisation.
During the two week school holiday at Easter, April 2003, I took Helen swimming almost every day. We would both swim for about 70 minutes which would enable me to swim two miles and Helen to swim a mile and a quarter. Both Helen’s dietician and psychiatrist were very concerned about this owing to the number of calories Helen would be burning off during a swim of this length - approximately 400. In order to estimate this number of calories, I used the book referred to which contained a chart detailing the “Number of Calories burned in 30 minutes of activity in relation to body weight”. The chart only went down to a body mass of 50 kg but I was able to arrive at a reasonable estimate of Helen’s calorie usage by examining the pattern of the decreasing number of calories burnt in proportion to the decreasing body weight as shown in the chart. Fiona and I would then add the 400 calories onto the 1600 Helen’s dietician had already decided was to be the base line, thus making a total of 2000 in all for that day. At this point, I feel it is important to stress that this baseline of 1600 calories was deemed appropriate for Helen as a result of her low body weight. It was made clear to us that as Helen began to put weight back on, her metabolic rate would increase and, therefore, that baseline would need to rise, eventually climbing to a more normal figure of approximately 2000 calories per day.
As mentioned earlier , our system initially appeared to be unsuccessful owing to the fact that Helen was making no progress in regaining weight. But the main difficulty was with the yardstick that we were using of one pound per week. Once we changed the yardstick to 3 to 4 pounds per month, and therefore, were able to boost Helen’s calorie baseline to a much higher figure on particular weeks, weight gain ceased to be an issue. However, before we could reach this point, Helen lost the 7 ounces mentioned earlier and Helen’s psychiatrist called the emergency meeting.
So as to retain control of the situation, at this meeting we had to compromise and agreed to cease taking Helen swimming until her bodyweight had reached 6 stone. But rather than abandon the exercise programme, we simply replaced 70 minutes swimming with an hour’s rigorous walking - and I mean rigorous. I had difficulty keeping up with Helen despite my much longer legs. Helen’s walking equalled about 200 calories but still had a wonderfully calming effect on her mood, thus making it much easier for us to persuade her to eat. Regardless of the weather, we would venture out on one of our routes. As with the swimming, it made eating feel safer.
A second vitally important aspect of the exercise regime was that we were able to use it to counter Helen’s paranoia about becoming fat were she to resume healthy eating. We were able to convince her that any food she consumed, as a result of the exercise, would turn to muscle rather than fat and Helen soon became proud of the firmness of the muscles in her legs owing to the walking.
Thirdly, the exercise became so important to Helen that it made eating meals at home in her house with her parents and her little brother, Jack, much more preferable to being force fed in a passive hospital environment where she would have enforced bed rest. A fourth advantage was that it enabled us, by and large, to regulate exercise to something rational as opposed to the madness that Helen had initially exhibited. When we first set out on the dietician’s programme of a 1600 calorie a day baseline, Helen would very reluctantly eat the small meals and snacks that this was translated into - as she did not want to go into hospital - but she would then manically run up and down the stairs for anything up to 15 minutes until she believed that she had burnt off the calories that she had just consumed. The rigorous exercise regime that we instituted (as well as Helen’s increased understanding of how calories work) put an end to this. Our exercise schedule was tiring and left her with much less nervous energy.
However, there was still secret exercising going on which we did not detect for a number of months. Helen would set her alarm for 6.00 am and do up to a 1000 sit-ups on her bed. We suspected that there was an unplugged calorie leak somewhere because we had to keep raising the calorie baseline from 1600. However, shifting the weight measurement yardstick to between 3 and 4 pounds per month gave us the confidence to demand that Helen meet the higher targets. And the weight did start to go back on at a steady but controlled pace. Eventually, Helen confessed about the secret sit-ups, possibly because they were proving to be ineffective in keeping off the weight and so were becoming a real chore to her.
To reward her honesty, we agreed to lower the calorie intake by the approximate number of calories she would have burnt up by doing so many sit-ups - a reduction of about 200 calories per day - but we still allowed her to do a supervised 200 sit-ups per day. Of course, she could have cheated but it would soon have been detected via our official weekly weigh-ins and we would simply have raised the calorie baseline again. Helen was much more rational by this time. The slow increase in weight gain, and her growing confidence in her ability to control her weight through calorie counting, helped to weaken the grip that the anorexia had on her. Many of the demons that it had created within her imagination to control her had been destroyed or weakened and so she was much more willing to listen to reason. Thus, we took her for a one hour session with a female personal trainer who worked out an all over body exercise regime for Helen which involved light weights and the use of her own body weight on activities such as press ups and squats. The personal trainer also showed Helen exercise techniques for stomach muscle strengthening which were much more demanding than sit-ups and a hundred of those really made Helen feel good about her stomach, thus also contributing to the termination of the secret regime of 1,000 sit-ups per day.
One of Helen’s psychiatrist’s main worries about our exercise programme - apart from the obvious calorie burning aspects of it - was that exercise would become an unhealthy obsession in itself. I was aware of this possibility and had even cut out an article from a women’s magazine about a lady body builder whose life fell apart because of such an obsession. She would exercise for up to 5 hours per day and lost sight of all other aspects of her life apart from diet and exercise. However, I was convinced that exercise was simply a means to an end. If Helen wanted to exercise on a daily basis at the sensible level that we were establishing to replace the manic exercising generated by the anorexia, then that could only be a good thing. However, I did suspect that as Helen psychologically recovered and learnt to stabilise her weight through sensible eating, the desire to exercise would gradually dissipate - and this is exactly what has happened.
This stage of our strategy did, however, come with a major health warning. Thanks to Fiona’s vigilance, Helen was just verging on the emaciated when she was diagnosed and so, as a variety of medical tests confirmed, no real damage had been done to her body. Therefore, she was still fit enough to undertake the kind of intense exercise programme that I have outlined here. However, had the weight loss been more severe, she would most likely have been incapable of sustaining such levels of physical activity and may have suffered severe and permanent injury as a result.