The effect of exercise, cognitive therapy, and nutritional counseling in treating bulimia nervosa JORUNN SUNDGOT-BORGEN, JAN H. ROSENVINGE, ROALD BAHR, and LAILA SUNDGOT SCHNEIDER The Norwegian University of Sport and Physical Education, Oslo, NORWAY; and Department of Psychology, University of Tromsø, Tromsø, NORWAY ABSTRACT SUNDGOT-BORGEN, J., J. H. ROSENVINGE, R. BAHR, and L. SUNDGOT SCHNEIDER. The effect of exercise, cognitive therapy and nutritional counseling in treating bulimia nervosa. Med. Sci. Sports Exerc., Vol. 34, No. 2, pp. 190 –195, 2002. Objective: The aim of this treatment study on bulimia nervosa was (i) to examine the effect of physical exercise as an experimental treatment condition against the well-documented effect of cognitive-behavioral therapy (CBT), and (ii) to compare the effect of CBT versus the effect of nutritional advice as one single treatment component of CBT. Method: Normal weight female bulimic patients aged 18 –29 yr were randomly assigned to a physical exercise program (N  15), CBT (N  16), nutritional advice (N  17), or a waiting list control group (N  16). Seventeen healthy female control subjects were also included. Treatment effects were determined by the frequency of binge eating and purging, scores on the Eating Disorder Inventory subscales “Drive for thinness,” “Bulimia,” and “Body dissatisfaction” and by a clinical interview to measure symptom severity. Assessments were made before and after treatment and at 6- and 18-month follow-up after the end of treatment. Results: Nutritional counseling did not prove more effective than CBT. Physical exercise appeared more effective than CBT in reducing pursuit of thinness; change in body composition; aerobic fitness; and frequency of bingeing, purging, and laxative abuse. Conclusion: Physical exercise is important in the treatment of normal weight bulimic patients. Further studies should address possible additive effects of CBT and physical exercise. Key Words: EATING DISORDERS, TREATMENT, ACTIVITY E mpirical research has shown that cognitive behav- ioral therapy (CBT) is the treatment of choice for bulimia nervosa (BN) (7,8,13,19,20). CBT aims to identify events and emotions preceding bulimic binges, and to modify underlying dysfunctional core beliefs. Also, by using behavioral techniques and nutritional counseling, one aims at improving chaotic eating behaviors and, hence, the risk for semistarvation or malnutrition. Hence, CBT contains two behavior control methods: 1) psychoeducation on sound and regular eating and eating patterns, 2) psychotherapy. One line of research has focused on identifying whether CBT effects might be related to the package of approaches as a whole or to specific elements of CBT. For instance, several studies (1,2,12) have focused on the effects of CBT when adding antidepressants or behavior therapy ap- proaches such as response prevention. However, the specific effects of nutritional counseling have not been evaluated in previous research. Another line of research is to compare CBT with other treatment approaches. For instance, previous controlled studies (7,9) have reported on the proximal and distal effects of CBT versus behavioral therapy and interpersonal therapy. Another relevant comparison might, however, be between CBT and physical exercise (PE). Apart from being effective in the treatment of depression and anxiety disorders (18,23), physical exercise reduces overeating or bulimic binge eating in obese patients (16). Both aerobic and anaerobic exercise have been consistently related to improved self-esteem or self-concept (12). One may suggest that by improving phys- ical fitness, normal weight bulimic patients may experience improved self-concept, less body dissatisfaction, and less binge eating, and thus a reduction of the uncomfortable internal sensations of bloating and distention during eating. To our knowledge, the effects of PE versus CBT have not, however, been investigated in previous studies with bulimic patients. The first aim of this study was to compare the effects of CBT versus nutritional counseling alone. We suggest that this component of CBT would be less effective than the core CBT elements (cognitive restructuring and behavioral tech- niques) to accomplish reduced symptom load. The second aim of the study was to compare the effects of PE and CBT, suggesting that these approaches would produce equal symptom load reductions. METHODS Subjects Following the written consent from the Regional Ethical Committee for Medical Research and from the Data Inspec- 0195-9131/02/3402-0190/$3.00/0 MEDICINE & SCIENCE IN SPORTS & EXERCISE ® Copyright © 2002 by the American College of Sports Medicine Submitted for publication December 2000. Accepted for publication May 2001. 190