Non-abstinence

This principle was central to our motivation to develop the SEES guideline. The clinical practice of recommending exercise abstinence for individuals with eating disorders is common and understandable considering the high rates of complex medical complications (Davies, 2015; Hechler et al., 2005; Thien et al., 2000; Zunker et al., 2011) . The safety of this recommendation is further supported by an absence of standard practice in managing dysfunctional exercise in ED treatment. However, we equate recommending exercise abstinence with simply encouraging an individual with AN to ‘just eat,’ without further intervention to guide the process of renourishing or supporting their return to a healthy relationship with food.

Exercise abstinence has been associated with an increased risk of relapse (Carter et al., 2004) , poorer treatment outcomes (Bratland-Sanda & Vrabel, 2018) , more severe psychopathologies, and worsened illness chronicity (Davis et al., 1994; Dalle Grave et al., 2008). Furthermore, promoting complete exercise abstinence before providing new and healthy ways to cope may remove a vital and significant coping mechanism for an individual and may also cause negative affect withdrawal symptoms (Geller, Cockell, & Goldner, 2000; Morris, Steinberg, Sykes, & Salmon, 1990) . Conversely, healthy exercise engagement and education during treatment has been associated with improved quality of life, body composition, central health markers of the illnesses (e.g., drive for thinness, weight and shape concerns and eating restraint), and improved comorbid physical and psychological symptomatology (e.g., anxiety, depression, muscle degradation, body esteem issues, sleep disturbances, perceived stress and osteoporosis) in those with an ED (Hausenblas et al., 2008; Ng et al., 2013; Moola et al., 2013; Vancampfort et al., 2014) .

Safe and Healthful

EDs (AN in particular) are associated with high morbidity and mortality rates (Bulik et al., 2005; Crow, 2014; Reel, 2013). Furthermore, individuals with an ED who engage in dysfunctional exercise are more likely to have a chronic ED, severe psychopathologies, and a higher risk of relapse (Dalle Grave et al., 2008). Considering these deleterious outcomes, it is crucial that exercise prescription in ED treatment promotes the safety of clients. Safe exercise prescription is currently limited; due, in part, to gaps in knowledge among health professionals (Quesnel et al., 2017). This limited knowledge has likely contributed to uncertainty and confusion related to the safety of clients engaging in any exercise during ED. The SEES guideline has subsequently been developed to provide a summary of the current evidence with the hope that this will address concerns related to safety and improve upon clinical knowledge of exercise engagement during ED treatment. Furthermore, the SEES guideline was developed to promote physical and psychological safety as paramount for any exercise intervention. We hope that by providing a safety-focused guideline, SEES may help alleviate both the lack of knowledge as well as concerns of health professionals regarding the prescription and management of exercise during ED treatment.

Holistic

The relationship with exercise is multifaceted; comprising physical, emotional, social, cognitive, and sociocultural components (Calogero & Pedrotty, 2007). Engagement in exercise, consequently, influences and is influenced by each of these individual components (Calogero & Pedrotty, 2003). While clinical management of exercise in ED treatment commonly considers the physical risk of exercise engagement, this can be at the cost of addressing the psychological relationship with exercise. As highlighted above, safe and healthful exercise has been paramount in developing the SEES guideline; however, we also further define this relationship with exercise to incorporate these socio-emotional aspects of exercise engagement. Addressing these dimensions through a holistic lens is integral to supporting individuals in developing a healthy relationship with exercise. Our prioritization of a holistic approach underpins the combination of medical, cognitive, emotional, and behavioural benchmarks in the SEES guideline. This decision-making process aims to guide clinicians in supporting their clients to begin and continue safe exercise engagement, contributing to this multifaceted construct of well-being.

Mindful and Intuitive Movement

A dysfunctional relationship with exercise is often characterised by rigid inflexibility, punitive attitudes, and guilt (Meyer, Taranis, Goodwin, & Haycraft, 2011). Clinicians supporting clients to reduce dysfunctional exercise must, consequently, address each of these mechanisms to promote a healthy relationship with exercise. Building skills in mindful and intuitive movement can be a key strategy to facilitate this transition. Mindful and intuitive movement is defined as, “movement that is done with attention, purpose, self-compassion, acceptance, awareness, and joy... focused on the process of becoming more connected, healthier, and stronger” (Calogero & Pedrotty, 2010 p.434). Clinicians can support their clients to begin mindful movement through providing opportunities to learn to listen to their physiological and psychological cues prior to, during, and after exercise engagement and use these internal signals to choose and adjust their own health-enhancing movement (Calogero and Pedrotty, 2007). This process aims to support individuals to foster trust in their bodies’ preferences and needs related to exercise contributing to the likelihood of positive, rather than destructive, health outcomes over time (Calogero & Pedrotty, 2003). According to Calogero and Pedrotty (2007, p.184), mindful and intuitive movement should:

1.     Rejuvenate the body, not exhaust or deplete it.

2.     Enhance mind–body connection, not allow or induce disconnection.

3.     Alleviate mental and physical stress, not produce more.

4.     Provide genuine enjoyment and pleasure, not pain and dread.

Collaborative

Developing a strong therapeutic alliance in treatment is a well-established predictor of positive treatment outcomes (Geller et al., 2003). Collaborative client-practitioner relationships have been identified as more likely to prevent dropout, reduce client ambivalence toward change, and increase treatment acceptability by both clients and clinicians (Geller et al., 2003). The SEES guideline has, consequently, been designed to promote collaboration between the individual, their loved ones, and a team of experienced eating disorder professionals to help guide safe exercise engagement at all stages of ED treatment and recovery. This approach differs from directive approaches in that it emphasises listening to the individual’s needs and preferences, addressing client motivation and ambivalence, and fostering client autonomy. It should be noted that collaborative approaches are not wholly client-directed. Rather, collaborative approaches view clients as an active member in clinical decision-making and, consequently, these decisions are still made within the context of clinicians prioritising the client’s engagement in safe and healthful exercise. We aim that this approach will facilitate open and honest conversations with clients about exercise, identifying their needs and concerns about exercise engagement.