Compulsive Exercise and Eating Disorders in Athletes

Compulsive exercise—also known as excessive exercise or obligatory exercise—is defined as being “characterized by a significant amount of physical activity combined with a compulsive need to do the activity.” (Bewell-Weiss & Carter, 2010) Compulsive exercise poses significant health complications, including joint injuries, stress fractures, muscle tears, tendonitis, fatigue and dehydration.

The connection between excessive exercise and eating disorders generally stems from food-, body- or weight-related issues that drive the excessive physical activity. In fact, a study by Brewerton found that nearly 40 percent of patients with Anorexia Nervosa engaged in compulsive exercise behaviors. (Brewerton et al, 1995)

Some individuals abuse exercise as a compensatory behavior following a bingeing session or to give themselves “permission” to eat. Others begin over-exercising behaviors during eating disorder recovery, not realizing that the frequency and volume of their exercise is not “healthy” and has taken the place of other eating disordered behaviors as anxiety management tool.

What is compulsive exercise?

Compulsive exercise is most often done to regulate mood and compensate for eating (making it a form of purging). Many compulsive exercisers believe that exercise is not occurring or worth doing if they are not hyperventilating (breathing heavy) and/or sweating significantly.

Compulsive exercise has a number of serious negative physical health outcomes, including:

• Anxiety
• Depression
• Guilt^[3]
• Decreased immune system response
• Increased resting heart rate
• Increased blood pressure
• Orthopedic overuse injuries
• Overreaching
• Overtraining syndrome

Many patients believe that if they are not having any physical consequences to their exercise then they cannot be compulsively exercising and this is absolutely not true!

Typical psychological symptoms of someone who compulsively exercises include the following:

• Exercise significantly interferes with important activities, occurs at inappropriate times or in inappropriate settings, or when the individual continues to exercise despite injury or other medical complications
• Intense anxiety, depression, irritability, feelings of guilt, and/or distress if unable to exercise
• Maintains excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury
• Discomfort with rest or inactivity
• Exercise used to manage emotions
• Exercise as a means of purging (needing to “get rid of” or “burn off” calories)
• Exercise as permission to eat
• Exercise that is secretive or hidden
• Feeling as though you are not good enough, fast enough or not pushing hard enough during a period of exercise; overtraining
• Withdrawal from friends and family^[4]

It is important to understand the difference between compulsive exercise (a form of purging) in someone with an eating disorder history and overtraining.

Why do people exercise excessively?

Excessive exercise often starts in a seemingly harmless way. People start to exercise excessively for many reasons.

Activity level

Some people exercise compulsively because they are hyperactive; their nature is to always be moving.

Mood

Some exercise to control their mood, particularly anxiety issues; intense activity calms them down. Exercise can also have an antidepressant effect.

Dependence or Addiction

Some people are even conditioned to a dopamine or endorphin “high” from exercise. Signaling in the pleasure/reward system is genetically wired to increase the likelihood of being physically active and sustaining an exercise program (Herring ’14).

Athletic goals

Some athletes exercise compulsively to reach a goal; they may achieve a great deal of success in sports and in athletic competitions.

Genetics

Starvation activates certain genes through epigenetics. When a certain weight is reached, the body becomes unfazed by starvation and commences searching for food as a survival technique in times of famine. A foraging behavior of sorts begins and is often accompanied by hoarding. (Baird ’06; Gusinger ’03, Kersting ’04).

Weight control or physical appearance

Commonly, especially in people with eating disorders, many people exercise excessively to lose weight, to maintain weight loss or prevent weight gain.

Common warning signs of compulsive exercise behaviors

• Exercising excessively “just because” (as opposed to intentional exercise in preparation for a competition)
• Refusal to miss a workout, regardless of weather or injury
• Exercise takes precedence over all other activities, including work, school and spending time with friends and family
• Heightened anxiety and/or agitation if unable to engage in exercise
• Elevated rigidity and perfectionism with regard to exercise behaviors
• You are underweight or severely underweight.
• You are frequently tired.
• Your exercise routine interferes with (or has replaced) your social life.
• You experience injuries and muscle soreness and still continue to exercise.
• You get sick frequently and have many respiratory tract infections.
• You experience GI symptoms (bloating, cramps, diarrhea).
• You notice hair loss or have pale skin.
• You notice an increasing number of medical complications including racing heart, dizziness, fainting, hypotension and others.
• You spend what most people agree is an excessive amount of time and energy doing physical activities.
• You have an inflexible exercise schedule; “I must work out today; nothing will stop me.”
• You experience withdrawal symptoms when exercise is stopped (insomnia, mood or appetite changes).
• You deny over-exercising or downplay your exercise routine when someone brings it up.
• Females: You notice changes in your menstrual cycles (or your periods stop completely).

Are you exercising too much?

Compulsive exercise is exercise that is done to the point that problems start to arise. When exercise makes you ignore friends and family, if it is affecting your schoolwork or career, or causing health problems, it may be time to take a look at your behaviors. If you are concerned that someone you love — male or female — may be exercising too much, consider the following:

• Has athletic performance actually decreased or are there signs of fatigue?
• Does a female athlete have irregular or absent periods?
• Does the athlete suffer from stress fractures or other injuries caused by overuse?

Parents, healthcare providers, coaches and trainers can play an active role in communicating concern to athletes that show signs of unhealthy exercise or eating behaviors.

Excessive or compulsive exercise is frequently a symptom of an eating disorder and can even promote the development of the illness. Physical activity, in this sense, can become too much of a good thing.

For individuals who are restricting their food intake (a potential warning sign of anorexia) — too much exercise could lead to serious medical complications or even death.

Electrolyte imbalances can occur even if the individual is drinking a lot of water since food is necessary for hydration.

In addition, many individuals seeking treatment for anorexia also have anxiety, depression or obsessive compulsive disorder. Studies have shown that the combination of food restriction and excessive exercise temporarily reduces these symptoms. It can become a form of self-medication and a pattern that some liken to an addiction.

Is compulsive exercise an eating disorder?

Some people are driven to perform extreme amounts of physical activity due to food, body, or weight-related concerns. In fact, there is a type of bulimia called exercise bulimia. People with bulimia may purge by means of vomiting or laxatives, while exercise bulimics purge through exercise. Exercise bulimia affects people who feel the need to exercise compulsively at a high level in order to burn fat or calories.

Signs of eating disorders in athletes

It can be difficult to spot warning signs of eating disorders in athletes. Athletes may be able to mask signs of disordered behaviors – or just not report them. Experts generally agree that certain athletes (gymnastics, dance, cheerleading, cross country, swimming and wrestling) face a higher risk for anorexia or bulimia.

Learn more about anorexia symptoms and bulimia symptoms in athletes.

Sports that require revealing clothing or uniforms (dance, swimming) may put participating athletes at risk for body dissatisfaction and competitive thinness. Interestingly, there is a temperament associated with athletes that closely mirrors the traits of those with eating disorders. These traits include:

• Perfectionists
• High-achievers
• People-pleasers

Research by Dr. Craig Johnson, Chief Science Officer and Director of the Family Institute at Eating Recovery Center, shows that at least one-third of female college athletes have some type of disordered eating behaviors. And, one study found that 40 percent of patients with anorexia nervosa engaged in compulsive exercise.

How do I know if I need help?

While exercise is a part of a healthy lifestyle, it is possible to have too much of a good thing. It may help to know the signs of compulsive exercise, listed below, and to seek help from a professional, if warranted:

1. Are you exercising excessively, above and beyond what is necessary to prepare for competition?
2. Do you prioritize exercise over work, school and time spent with family and friends?
3. Do you have perfectionistic tendencies or heightened strictness when it comes to your exercise regimen?
4. Does your anxiety increase if you can’t exercise?
5. Do you refuse to miss workouts, even if you are injured or the weather is bad?

While exercise is a healthy behavior, it can also be a slippery slope for patients that are in treatment for, or recovering from, an eating disorder.

If you’re wondering if you have a problem, check out the link to the Compulsive Exercise Test, shared below. As you read the test questions, be honest with yourself. Try not to minimize or downplay your exercise habits.

Take the Compulsive Exercise Test.

Have the courage to seek help

Many individuals claim that they don’t like to exercise – but these same people persist with workouts despite injuries or bad weather. This indicates that there could be a serious problem.
 
The question is: how can you get help for compulsive exercise?
 
My belief regarding excessive exercise and eating disorders is that it’s better to be safe than sorry. Maybe you don’t have a problem. But what if you do?

There is nothing wrong with meeting with a mental health professional to talk about concerns related to exercise, athletics, eating habits or body image.

If you suspect that you have an issue with excessive exercise, know that it’s always better to catch these types of issues early on. Don’t wait too long, thinking that you are going to get better. Compulsive exercise, particularly when coupled with an eating disorder, can lead to long-term changes that seriously damage the brain and body (Cook ’16; Powers ’08).

When is exercise a problem?

Compulsive exercise can be defined as a craving for physical training, resulting in uncontrollable excessive exercise behavior with harmful consequences, such as injuries and impaired social relations.^[1] Compulsive exercise is more commonly associated with anorexia nervosa and bulimia, but can also be seen in loss of control eating disorder patients.

Compulsive exercise, particularly when done by someone who has a history of eating disorder behaviors (restricting, purging, binge eating, or body image issues) can be a major health concern.
 
To be clear, the term “exercise” for most individuals who are compulsively exercising consists of:

• Moderate to vigorous cardiovascular exercise (individual cardiovascular exercise, group fitness, CrossFit, cardio boxing, cardio kickboxing, circuit classes, etc.).
• Resistance training (HIIT training, Tabata, Circuit training, etc.)

Unfortunately, no agreed upon definition exists regarding overtraining syndrome, but research done by Halson and Jeukendrup defines overtraining as: “An accumulation of training and/or non-training stress resulting in long-term decrement of performance capacity with or without related physiological and psychological signs and symptoms of overtraining in which restoration of performance capacity may take several weeks or months.”^[2]

Most people experiencing overtraining syndrome tend to be professional or amateur athletes. Put more simply, overtraining has some negative physical consequences — from lack of adequate recovery time between exercise/activity sessions. Overtraining may or may not also have psychological signs and symptoms.

What is overtraining syndrome?

The major difference between compulsive exercise and overtraining syndrome/overreaching is that compulsive exercise does NOT necessarily need a negative physical consequence to occur, whereas overtraining syndrome will always see some type of negative physical consequence.
 
Let’s define a few terms.

1. Overload: A planned, systematic, and progressive increase in training to improve performance.^[5]
2. Overreaching: Unplanned, excessive overload with inadequate rest. Poor performance is observed in training and competition. Successful recovery should result from a short term (a few days to a couple weeks) rest period. ^[6]
3. Overtraining Syndrome: Untreated overreaching that produces long-term decreased performance and impaired ability to train.^[7],[8]

Common Overtraining Physical Health/Medical Consequences

• Bone density loss (osteopenia or osteoporosis) 
• Loss of menstrual cycle (in women)
• Female Athlete Triad (in women)
• Relative Energy Deficiency in Sport (RED-S)
• Persistent muscle soreness
• Chronic bone & joint pain
• Increased incidence of injury (overuse injuries, stress fractures, etc.)
• Persistent fatigue and sluggishness
• Altered resting heart rate
• Increased frequency of illness & upper respiratory infections^[9]

Adults who are not professional or amateur athletes are rarely diagnosed with overtraining syndrome. The average person will most likely quit the activity or exercise they have begun before they get to the point of overtraining syndrome.

Are Elite Male Athletes at Increased Risk for Eating Disorders?

Thankfully, health and recovery from eating disorders are possible. Of course, it depends on a combination of factors including the support of coaches, teams, families, medical and mental health professionals. Learn more about the signs of compulsive exercise and eating disorders in athletes.

Many sports use short bursts of energy (think: sprinters), but endurance athletics requires longevity. Put simply, if you have to eat food to finish a race, it’s probably an endurance sport like distance running, cycling, and some triathlons.

To be an “elite” endurance athlete, you must rank within the top 10 to 15 percent of the competition. The next level of competition from here is competing at the world level.

Some elite endurance athletes say that this culture offers mixed messaging: Athletes should live healthy and normal lives — but they must also do what they have to, in order to win. Consider these quotes from some of the group’s most competitive athletes:

"You’re willing to do anything to lose time. Saving four to six seconds could make a difference of how you place, or if you win money.” Regarding the omission of food groups like gluten, dairy, and alcohol, “I don’t think it’s a disorder to not do those things, I think it’s smart and healthy.” Brett Rindt, age 34, Pro 1-2 level cyclist

“It’s a whole lot easier to change your weight than ^{[it is]} to change your power in order to climb hills. I would guess most elite endurance athletes have some form of an eating disorder. We weigh ourselves every day.” Kyle Thomas, age 33, Pro 1-2 level cyclist.

“I’m 6’3”, 195 lbs. I’d have to lose 20 to 30 pounds to be in the range of a world class Iron Man. I have no interest in doing that. For me, it’s about maintaining my weight and finishing.” Jon Slinger, age 35, triathlete.

Can a quest for winning become unhealthy?

Endurance athletic culture is centered upon discipline regarding training regimens, weight, sleep and food. For these men, their eating and weighing habits aren’t necessarily about a certain body image — rather, they are about performance. While eating disorder professionals have different criterion for “red flags”, the athletes shared the following turning points in which they noticed unhealthy habits:

• Over training
• An increase in injuries
• Continual food group restriction post-race day
• Continual focus on weight loss post-race day
• Feeling guilty about food choices
• Focusing so much on “healthy” food that it was limiting happiness

Endurance athletics: A risk for eating disorders

Male athletes develop eating disorders for the same reasons other male and female non-athletes do, and these behaviors are not caused by participation in a particular sport (Currie, 2010).

Participation in endurance sports is a risk factor, not a cause of, an eating disorder.

This risk factor for developing an eating disorder, particularly affects men with an underlying genetic predisposition influenced by biological, psychological and social factors (Thompson and Sherman, 2010).

Compare it to the genetic vulnerability a person may have when alcoholism runs in their family. Consuming alcohol creates a higher risk of developing the disorder, just as engaging in diet manipulation and intensive exercise is a risk factor for someone who is vulnerable to eating disorders.

Eating disorders often go unnoticed in sports; endurance athletics will continue to be a risk factor for many men

“To be elite or at world level — you have to have intense focus. Eating disorders for these athletes is often misguided focus — intense focus, detail, excellence and perfection. But when that becomes misdirected, ‘eating well’ doesn’t equal success — it equals disordered eating,” says Danny Gerow, age 25.

Gerow was an elite cyclist who competed at the world level in Belgium and went on to coach cycling at the collegiate level. Gerow saw athletes struggling with obsessive thoughts around food and training. These habits are fear-based — a fear of eating too much or too little, and a fear about how this might affect performance. Gerow urges the community to look beyond eating disordered behaviors to understand the function of the disorder:

“There’s a lot of people to be helped and freed… if the athlete has disordered eating, it’s the outward expression of something inward gone awry.”

How to Overcome Excessive Exercise in Eating Disorder Treatment

When an individual begins treatment at Eating Recovery Center, we do a thorough assessment of their relationship with exercise to determine whether or not it is a symptom of the eating disorder. The assessment includes the following:

• History of individual exercise activities
• When physical activity became out of control and possible reasons why
• Record of athletics, including types of sports and for how long
• Family history of excessive/compulsive exercise, eating disorders or related symptoms
• Personal history of stress, trauma or anxiety
• Feelings of shame or guilt when not exercising
• Using exercise as a form of self-punishment

Statements such as “I am going to get fat if I don’t exercise today,” “I’m worthless if I don’t run ten miles” or “my girlfriend won’t think I’m attractive if I don’t work out three hours a day” indicate an unhealthy relationship with exercise. These components are important to address and will be jointly considered in treatment, along with any other mental health and physical symptoms.

A treatment plan for excessive exercise

If it is determined that the individual’s relationship with exercise is disordered they could be asked to temporarily refrain from all forms of physical activity other than gentle yoga or movement therapy. This can be extremely challenging for the individual who has become physiologically and psychologically dependent on exercise.

In the early stages of treatment at our eating disorder clinic, an individual may struggle with decreasing their exercise. The combination of eating more and exercising less can increase anxiety, trigger phobias about weight gain and increase negative body image. The individual may experience increased depression or anxiety, irritability, and even a sense of a loss of identity.

The importance of being treated by a multi-disciplinary team of experts cannot be overemphasized. At ERC, the treatment team consists of a physician, psychiatrist, registered dietitian, therapist, psychiatrist, certified eating disorder specialists and movement therapists working together to support each patient’s individual needs during this very difficult phase of treatment.

Here’s what an individualized treatment plan at our eating disorder treatment center typically looks like:

• A thorough psychiatric assessment to determine if medicine may be necessary to treat anxiety or depression
• Therapy using ACT (Acceptance and Commitment Therapy), DBT (Dialectical Behavior Therapy) and CBT (Cognitive Behavioral Therapy) to increase awareness of the underlying causes of the behaviors and to introduce coping tools and strategies for managing symptoms such as guilt, shame, or intrusive thoughts about body image or weight
• Customized meal plans to help restore nutritional balance
• Yoga/movement therapy for relaxation and improving body image
• Recreational activities including gardening, crafts, music to help develop coping tools and alternatives to exercise

The good news is that individuals who follow the recommendations of the treatment team and stay the course can develop a healthier relationship with exercise. They learn to listen to their bodies while providing the fuel that they need to be active. They discover ways to incorporate exercise into their lives while maintaining relationships with friends and family. They often find that by putting excessive/compulsive exercise behind them, they find more enjoyment in physical activity and feel more connected with what they truly value in life.

How to Find Balance with Exercise in Eating Disorder Recovery

Let go of old beliefs

Many of us who have had an eating disorder associate exercise with weight loss and control. We have pushed ourselves to excessively exercise or refused to exercise at all —ever. Make peace by scratching everything you thought you knew about exercise and open your mind to building a new relationship with it. Whenever you mind goes to calories or time frames associated with ED, gently ask it to "let go."

Bring curiosity to exercise

Find balance with exercise by inviting curiosity in and trying new activities that are fun. You may be so used to associating exercise with "have to's" and “should’s” that you don't know what activities you truly find enjoyable. Be willing to try new things. Make a list of the things that you are curious about and try one new activity a week.

Listen to your body

Find balance with exercise by stopping when your body says it's tired. And, if you are still struggling with an eating disorder or are early on in your recovery, set a timer, but only if you have agreed on an amount of exercise with your treatment team. If you are not used to exercising, start with a slow, twenty-minute walk with a friend. Better yet, practice mindful walking out in nature.

Create a safety net

In ED recovery, our goal is to ultimately get to a place where we feel like we can honor eating when we are hungry and stopping when we are full — with little judgement towards ourselves. However, there has to be a build up to that. There has to be a structure. It's the same with exercise. If you have not incorporated a structure (aka. safety net) around your exercise, do so. Here’s an example: for the first year, I exercised 20 minutes a day, or no more than an hour three times per week. I stuck to this structure so that I did not have to think about it too much. Later in my recovery, I began to honor my body and it told me when to exercise and when not to.

"Allowing others in to help us in those early days of treatment is so challenging, but it's imperative - we cannot achieve recovery alone," says fellow ERC National Recovery Advocate, Jen Lombardi, MFT, CEDS.  "As a clinician, I impress the importance of always allowing your support system in, even once you are in recovery.  In my own recovery, exercise became a serious struggle after other behaviors subsided.  I know first-hand that you must consult with your treatment team first to determine if and when exercise is appropriate.  It's difficult to know what moderation is, and having guidance from experts is invaluable."

"We also live in a culture that values the punitive qualities of exercise," adds Lombardi.  "As a fitness instructor who is in recovery, I try to challenge this idea.  And without the support of my treatment team and family, I doubt I would have been able to bring exercise back into my life in a balanced and joyful way."

Be honest with yourself

Have you ever noticed that your relationship with exercise is identical to the relationship you have with food? At first it can be a struggle between your eating disorder’s way or your treatment team’s way. The key to finding balance with this struggle is being brutally honest with yourself and your intentions. If exercise is triggering you, speak to your treatment team and start small. Remember: Acting on your eating disorder’s demands is not wellness, it’s part of the illness.

How can you find balance and make peace with exercise?

Today, I love moderate exercise and the way it reduces my anxiety. When I opened my mind up to having a different relationship and experience with exercise, I found it to be so emotionally rewarding.

When we do anything in life that is extreme, the universe will seek balance. The pendulum of life swings back and forth until it can find its resting place smack bam in the middle. It takes time to find balance and, for many of us, it will also take the following:

• Practice
• Gentle reflection
• Making sure that our authentic self is triumphing over ED beliefs

When we are honest with ourselves and willing to invite curiosity in, we can rebuild our relationship with exercise and bring balance into our lives.

Sources

^[1] Lichtenstein MB, Hinze CJ, Emborg B, Thomsen F, Hemmingsen SD. Compulsive exercise: links, risks and challenges faced. Psychology Research and Behavior Management. 2017;10:85-95. doi:10.2147/PRBM.S113093.

^[2] Halson, SL, and Jeukendrup, AE. Does overtraining exist? An analysis of overreaching and overtraining research. Sports Medicine 34(14): 967-981, 2004

^[3] Hausenblas HA,Symons Downs D. Exercise dependence: A systematic review. Psychol Sport Exerc 2002; 3: 23–80

^[4] https://www.nationaleatingdisorders.org/learn/general-information/compulsive-exercise

^[5] McArdle, W. D., Katch, F. I., & Katch, V. L. (2015). Exercise physiology: Nutrition, energy, and human performance.

^[6] McArdle, W. D., Katch, F. I., & Katch, V. L. (2015). Exercise physiology: Nutrition, energy, and human performance.

^[7] McArdle, W. D., Katch, F. I., & Katch, V. L. (2015). Exercise physiology: Nutrition, energy, and human performance.

^[8] Raglin J, Bardukas A. Overtraining in athletes: the challenge of prevention. A consensus statement. ACSM’s Health Fitness J 1999;3(2):27.

^[9] https://www.nationaleatingdisorders.org/learn/general-information/compulsive-exercise