Eating disorders and disordered eating behaviours, such as unhealthy weight control practices and binge eating, are of public health concern given their high prevalence and serious health consequences (Eaton et al., 2012; Hoek & van Hoeken, 2003; Johnson, Cohen, Kasen, & Brook, 2002; Neumark-Sztainer, 2012; Neumark-Sztainer, Story, Hannan, Perry, & Irving, 2002; Neumark-Sztainer, Wall, Story, & Standish, 2012; Patton, Selzer, Coffey, Carlin, & Wolfe, 1999; Paxton & Heinicke, 2008; Stice, Presnell, Shaw, & Rohde, 2005). It is crucial to identify strategies that can help in the prevention and treatment of these problems. Strategies that are particularly desirable are those that are widely accessible to populations at greatest risk for these problems, acceptable to participants, and relatively low in cost.

The practice of yoga, which is based in ancient Eastern teachings, has grown in popularity over the past few decades within Westernised societies, particularly among women. Yoga, which incorporates physical postures (i.e. asanas) with mindfulness and meditation, offers promise to the field of eating disorders as a mind–body therapy that can promote a stronger connection with, and a greater acceptance of, oneself and one's body (Boudette, 2006; Dittmann & Freedman, 2009; Douglass, 2009, 2011; Mehling et al., 2011; Neumark-Sztainer, 2012). Yoga is used as an adjunct component to eating disorders treatment within many treatment programmes. A 2006 study on therapies offered within 18 residential eating disorder treatment programmes in the USA found that two-thirds of the programmes (66.7%) offered yoga (Frisch, Herzog, & Franko, 2006). Emerging evidence suggests that yoga has benefits for mental health, although a 2013 review of randomised, controlled trials examining the effects of yoga on neuropsychiatric disorders found that the evidence for a beneficial effect of yoga on eating disorders was inconclusive (Balasubramaniam, Telles, & Doraiswamy, 2012). There were only two studies that met inclusion criteria (i.e. were randomised, controlled trials) and these studies had inconsistent findings (McIver, O'Halloran, & McGartland, 2009; Mitchell, Mazzeo, Rausch, & Cooke, 2007). Given that the basic tenets of yoga seem to offer potential for the prevention and treatment of eating disorders, and yoga is being utilised within treatment programmes, it is worthwhile to explore its potential utility and consider necessary steps for future research.

The aim of this paper is to consider the potential benefits of yoga in the prevention and treatment of eating disorders and related disordered eating behaviours. Specific questions to be addressed include the following: what can the practice of yoga offer the field of eating disorders in terms of prevention? How strong is the evidence that yoga can help in the treatment of eating disorders? And what are the next steps needed to more fully determine the potential value of the practice of yoga for the field of eating disorders?

What can yoga offer the field of eating disorders in terms of prevention?

Given the high prevalence of eating disorders and disordered eating behaviours and the challenges and costs associated with treatment, it is crucial to work towards their prevention. One option for utilising yoga to help prevent eating disorders is to make use of ongoing yoga classes as a setting for eating disorder prevention by incorporating language, messages, and activities aimed at eating disorder prevention and early identification of problems. A second option is to incorporate yoga into eating disorder prevention interventions. Both of these options are considered here.

Can yoga help in the treatment of eating disorders?

Yoga is often used as a complement to eating disorder treatment. For example, The Emily Programme, a large facility in the Minneapolis/St Paul area, offers approximately 30 yoga classes a week for clients at different levels of treatment (Diers, personal communication, 15 May 2013). At the Monte Nido Residential treatment programme, yoga is a regular component of treatment (Wyer, 2001). Thus, an important question to consider is whether the inclusion of yoga enhances programme effectiveness. Two randomised, controlled trials, conducted in very different populations for different types of eating disorders, were found in the published scientific literature (Carei, Fyfe-Johnson, Breuner, & Brown, 2010; McIver et al., 2009). As described below, these trials, in conjunction with valuable but somewhat smaller and less rigorous studies (Cook-Cottone, Beck, & Kane, 2008; Dale et al., 2009) and some of the studies already described in this paper, provide preliminary evidence for the utility of yoga in eating disorders treatment.

Carei et al. (2010) conducted a randomised, controlled pilot study to assess the impact of individualised yoga treatment on adolescents receiving outpatient care for anorexia nervosa, bulimia nervosa, or eating disorders not otherwise specified. Participants included 50 girls and 5 boys, 11–21 years of age. Participants in the control group received ‘standardised’ care (i.e. meeting with a physician and a dietician every other week), while those in the intervention group additionally received individualised yoga instruction (1:1) twice a week for eight weeks. A standardised yoga treatment protocol was employed. This study is of particular interest in that it is the only study located that taught yoga on an individualised basis, which is the manner in which it was originally taught in the Viniyoga tradition (Desikachar, 1999; Kraftsow, 1999). Results showed improvements in various measures in both study arms, but the group receiving yoga had significantly lower global scores on the Eating Disorder Examination at follow-up (four weeks following completion of the intervention) as compared to the standard treatment group. A food preoccupation assessment, given to the yoga participants before and after each of the 16 yoga sessions, showed pre–post differences, such that participants indicated less food preoccupation after their yoga practice.

McIver et al. (2009) conducted a randomised, controlled trial to assess the impact of yoga on binge eating behaviours among a community-based sample of adult women in Australia. The final analysis included 25 women in the intervention group and 25 women in the wait-list control group. Participants were recruited via newspaper and radio announcements; inclusion criteria included a body mass index greater than 25 and a score higher than 20 on the Binge Eating Scale (Gormally, Black, Daston, & Rardin, 1982). The yoga intervention included 12 60-minute weekly group sessions that included movement and stillness, breath awareness, and meditation. Additionally, participants were strongly encouraged to engage in a 30-minute daily home practice and were provided with a CD and an illustrated manual. Mindful eating was also an important component of the programme; participants were invited to become aware of their eating habits and to try to eat in the absence of other distractions (e.g. television). Feedback forms suggested that the majority of participants practiced five days a week. Results were very encouraging; statistically significant and meaningful improvements were seen in binge eating behaviours in the intervention group as compared to the control group. Specifically, from baseline to post-test, binge eating scores decreased from 29.9 to 14.5 among women receiving the yoga intervention as compared to a decrease from 28.6 to 27.2 in the control condition; differences remained statistically significant at three-month follow-up. Additional benefits included an increase in physical activity and a small, but statistically significant, decrease in body mass index among those in the yoga intervention. The authors also conducted a qualitative analysis based upon personal journals from 20 of the participants receiving yoga, which provided rich data on the experience of the participants as a result of the practice (McIver, McGartland, & O'Halloran, 2009). Emerging themes showed a greater connection over time both with one's body (i.e. went from feeling estranged to empowered) and one's food consumption (i.e. went from being full and feeling empty to feeling satiation). Findings from this study provide preliminary evidence that combining a yoga practice with work on mindful eating may have benefits for the treatment of binge eating disorder. Findings suggest that research with larger populations and a longer follow-up period is warranted.

What are the next steps needed?

The first question addressed in this paper is: what can the practice of yoga offer the field of eating disorders in terms of prevention? Further research is clearly needed to determine the potential for yoga to contribute to eating disorder prevention. Preliminary findings suggest that a regular and fairly intensive yoga practice is associated with factors that may protect individuals from eating disorders and disordered eating behaviours, such as greater body awareness and responsiveness (Daubenmier, 2005) and an overall sense of well-being (Impett et al., 2006). Furthermore, a programme specifically designed to prevent risk factors for eating disorders, which incorporated yoga alongside other interactive activities, showed some positive effects (Scime & Cook-Cottone, 2008). However, in a randomised, controlled trial, a brief yoga intervention did not infer benefits and was found to be less effective than a more focused dissonance-based approach (Mitchell et al., 2007). These preliminary findings showing that yoga may have some benefits for risk factors for eating disorders, in conjunction with the underlying philosophy of yoga that supports greater self-awareness, a non-judgemental stance towards oneself, and the integration of mind and body, suggest that it is certainly worthwhile to move forward with more rigorously designed studies. Some questions that arise as worthy of study include: how much yoga is needed to reduce risk factors and enhance protective factors for eating disorders? What types of yoga might infer the greatest benefits and the lowest risk of harm? Should yoga be combined with other approaches that address risk factors in order to be most effective and if so, how should this be done?

Given the popularity of yoga and that many participants in group classes may be at risk for body image concerns and disordered eating behaviours, it is worthwhile to explore how to utilise ongoing yoga classes as settings for prevention. Some possible ideas for utilising yoga classes to decrease risk factors and enhance protective factors for eating disorders include the following: using language that helps students appreciate their bodies; a focus on noticing what one's body is saying and not pushing beyond that point; avoidance of any language that might promote comparison among students; and avoidance of language promoting a certain body type (e.g. six-packs). Care should also be taken in discussing eating patterns such as cleansings, detoxification, and, of course, dieting. Yoga teacher training programmes can offer sessions to help future, or current, yoga teachers incorporate appropriate language. Additionally, teachers should be trained to recognise signs that may indicate increased risk for eating disorders. Teachers should also be taught what to do if concerned about students (e.g. students doing excessive numbers of intensive classes), while recognising that in most cases, students with body image concerns and those engaging in disordered eating behaviours will not be recognisable. Finally, studios can take steps to help individuals with body image issues feel more comfortable such as employing teachers of different shapes and sizes, having mirror-free studios, offering classes suitable for people of different sizes and abilities, and, if merchandise is sold, making sure to have a variety of sizes. Evaluation is important to determine the acceptability of these activities to yoga students and teachers and their effectiveness in modifying relevant attitudes and behaviours. Challenges in implementing such research are likely to be encountered given that there may be objections to utilising modern Western research methods to examine long-standing practices based on Eastern traditions. Thus, it seems particularly important to tread carefully, with great respect for traditional practices that may differ to those viewed as ‘evidenced-based’.

It is also worthwhile to build on the work done by Scime and Cook-Cottone (2008) by integrating yoga into eating disorder prevention interventions that utilise other strategies aimed at enhancing media literacy, mindful eating, and self-esteem and decreasing body dissatisfaction and disordered eating behaviours. As previously noted, this research team has published a detailed curriculum (Cook-Cottone et al., 2013) that provides a model for how to integrate different intervention components and use yoga to reinforce messages from the other components. It seems as though their approach, which was implemented with elementary school children, could be modified to meet the needs of older populations and different settings. In order to truly assess the added value of the yoga on targeted outcomes, a three-arm study is recommended in which participants are randomised into ‘standard’ intervention, intervention plus yoga, and a control condition.

The second question addressed in this paper is: how strong is the evidence that yoga can help in the treatment of eating disorders? Research on the use of yoga within eating disorder treatment programmes is also in its early stages, with preliminary findings suggesting that yoga may help in the treatment of eating disorders. The two randomised, controlled trials that have been conducted and are described in this paper used different approaches (individualised vs. group and clinic-based vs. community-based) and worked with different age groups (adolescents vs. adults) with different types of eating disorders (primarily anorexia nervosa vs. binge eating disorder) (Carei et al., 2010; McIver et al., 2009). The positive results achieved from these studies, and other smaller studies that did not utilise randomised, controlled study designs (Cook-Cottone et al., 2008; Dale et al., 2009), suggest the potential for yoga, taught in different ways, to aid in the treatment of a variety of eating disorders. Furthermore, it is noteworthy that individuals practicing yoga perceive numerous mental and physical health benefits associated with the practice (Ross, Friedmann, Bevans, & Thomas, 2013).

Given the challenges and costs associated with eating disorders treatment and these preliminary promising findings, it is certainly worthwhile to move forward in exploring the value of yoga as a complement to eating disorder treatment, with more rigorous study designs. Both the acceptance of yoga by participants and its effectiveness should be explored. Best practices in terms of how yoga should be practiced and taught should be explored. An interesting question is whether yoga should be taught in manner that focuses on eating disorders or whether a more global approach should be utilised. For example, should the teacher takes concepts commonly taught in yoga, such as noticing what is going on in one's body, and discuss them in relation to noticing signs of hunger and satiety outside of class? It is also important to explore the mechanisms by which yoga may be contributing to recover from eating disorders, for example, is yoga leading to decreases in anxiety, improvements in body image and self-esteem, and/or increased recognition and responsiveness to hunger and satiety cues?

There is clearly a need for further research to address the question as to whether and how yoga can best help in the prevention and treatment of eating disorders, disordered eating, and body dissatisfaction. A list of suggested recommendations for further research is given in Table 1. More rigorous research is strongly needed. The state of research in this area is very preliminary and as such tends to have study design weaknesses. It is noteworthy that many of the studies on yoga and its effectiveness with regard to eating disorders have been conducted as student research projects. The dedication of time and resources to the study of yoga and eating disorders is strongly recommended in order to assess effectiveness, best practices, and mechanisms by which yoga may be working.

In closing, it should be noted that it is not the author's opinion that yoga is the ‘be-all-and-end-all’ to the prevention and treatment of eating disorders. It is, however, the author's opinion that yoga provides another tool in the toolbox that may be suitable for some individuals. Given the popularity of yoga, its seemingly high level of acceptability among individuals at risk for disordered eating and eating disorders, and its potential for both benefits (if done correctly) and harm (if not), an exploration of its value in the prevention and treatment of eating disorders, disordered eating behaviours, and body dissatisfaction seems timely.