Excessive exercise and anorexia
Updated: Nov 30, 2022
Please note: Information presented in this article may be triggering for some people.
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Exercise is promoted as a positive and seen only as a positive thing; Indeed, For most people, exercise does confer significant physical and mental health benefits.
But for those of us with eating disorders, excessive exercise is a common symptom and can play a role both in the development and maintenance of the disorder. In one study 37 percent to 54 percent of patients with anorexia nervosa (depending on subtype) engaged in excessive exercise.
Sufferers also frequently underreport the amount of time that they engage in physical activity, making it hard for caregivers and treatment professionals to fully assess. The so-called 'war on obesity' and diet culture can mean that excessive exercise as a symptom of an eating disorder can frequently be missed completely, not recognised as the problem it is or even lauded.
In this article I will look at excessive exercise as it has been studied by eating disorder researchers, and then review how excessive exercise manifests itself in eating disorders, the risks of over exercising, and what to do if you think you (or a loved one) are engaging in too much exercise.
Whereas most people understand self-induced vomiting or laxative abuse to be negative eating disorder behaviours, they may generally not think the same of exercise. Those of us who exercise excessively can be praised for our focus, motivation and self-discipline. But it can have serious consequences.
In one of the largest studies on excessive exercise in eating disorders, 'excessive exercise' was defined as any of the following:
Exercise that interfered with important activities
Exercise that exceeded three hours per day and caused distress if the individual were unable to exercise
Frequent exercise at inappropriate times and places and little or no attempt to suppress the behaviour
Exercising despite serious injury, illness or medical complication
Link to Eating Disorders
Excessive, driven or compulsive exercise is a common component of different types of eating disorders. It may be found among patients with anorexia nervosa (AN), bulimia nervosa (AN), and muscle dysmorphia, as well as other specified feeding and eating disorder (OSFED) and subclinical presentations. In the case of restrictive eating disorders, including anorexia, there is even some evidence that increased exercise may be a fundamental biological reaction.(compulsive exercise, links, risks and challenges faced, MB Lichtenstein et al, 2017)
Activity-Based Anorexia in Rats.
Animal studies have demonstrated that eating disorders can give rise to excessive exercise behaviour, by inducing what is called “Activity-Based Anorexia” in rats.
When researchers restricted rats’ food intake while giving them unlimited access to a wheel, many of the rats became hyperactive and ran more than they did prior to the food-restriction. Paradoxically, these rats opted to continue running rather than eat during the short intervals of time food is made available to them. If allowed, they will literally run themselves to death. (Anorexia Reduces Body Weight without Inducing a Separate Food Intake Microstructure or Activity Phenotype in Female Rats-Mediation via an Activation of Distinct Brain Nuclei. Front Neurosci. 2016).
These rats display the puzzling behaviour found in the self-starvation exhibited in anorexia . The assumption would usually be that rats (and humans) who are starving would become less, rather than more, active. Yet in young children who develop anorexia nervosa, restricted intake is usually accompanied by increased activity. Children with anorexia often present as hyperactive—they won’t sit still, they fidget, and they often run around aimlessly: this is particularly significant because they don't express a conscious attempt to burn calories in order to control weight and shape the way older adolescents and adults do. The excessive activity or exercise then would seem to be a more basic drive that gets turned on by the energy imbalance of restricted intake.
Exercise in Anorexia Nervosa.
Hyperactivity is a counter intuitive but common and well-documented symptom of anorexia nervosa, (Carrera O, Adan RA, Gutierrez E, et al. Hyperactivity in anorexia nervosa: warming up not just burning-off calories.)
noted as early as 1873 by the French physician Ernest-Charles Lasègue, one of the earliest writers about the disorder (read more about the early history of our understanding of anorexia here). Lasègue observed that patients with anorexia exhibited high levels of activity seemingly incompatible with their impoverished nutrition.
Another fact Lesegue notes is, that so far from muscular power being diminished, this abstinence tends to increase the aptitude for movement. The patient feels more light and active, rides on horseback [the French text also mentions: ‘long walking-tours'], receives and pays visits, and is able to pursue a fatiguing life in the world without perceiving the lassitudes he would at other times have complained of. (Lasègue, 1873, p.266)
In one study, up to 54 percent of patients with anorexia nervosa (depending on subtype) engaged in excessive exercise. People frequently underreport the amount of time that they engage in physical activity, making it hard for professionals and caregivers to see the full extent of the problem.
Exercise in anorexia nervosa is commonly described by patients as driven or compulsive. Physical signs of fatigue are ignored as patients continue to run or walk despite being physically ill or injured, exhausted, low in energy, and desperately wanting to stop.
People struggling with excessive/compulsive exercise will commonly walk or run for hours and, outside of these times, still feel compelled to pace, stand whilst eating and engage in unnecessary household activities.
One patient in a study about exercise reported:
"Before I attended treatment, I only sat down during meal times, or else I felt I did not deserve to sit still. I was incredibly restless, so it was difficult to relax…I feel like I am being compelled to exercise…" (Kolnes LJ. 'Feelings stronger than reason': conflicting experiences of exercise in women with anorexia nervosa. J Eat Disord. 2016)
After many years of engaging with ED and excessive exercise, it can become deeply entrenched and a distinct treatment for OCD treatment alongside ED treatment can be successful.
Excessive exercise in anorexia nervosa tends to be associated with younger age and higher rates of anxious/obsessional and perfectionistic traits.
Exercise in Bulimia Nervosa.
Excessive exercise has been included in the diagnostic criteria for bulimia nervosa (BN) since the publication of DSM-III-R in 1987.
The current diagnostic criteria (DSM-5) for BN specify that there is compensatory behaviour for binge eating which can include self-induced vomiting, but also intermittent fasting, laxative use, diuretics, and excessive exercise.
Exercise as a Compensatory Behaviour in Eating Disorders
Excessive exercise is a common compensatory behaviour in individuals with BN
In one study, 20 percent to 24 percent of patients with BN engaged in excessive exercise.
Among patients with BN, excessive exercise is associated with greater baseline eating disorder severity as well as poorer outcomes.
Exercise in Muscle Dysmorphia
Excessive exercise is a common symptom of muscle dysmorphia, a condition that sometimes affects bodybuilders.
Some researchers believe it to be a variation of anorexia nervosa characteristics of patients with a more traditional masculine gender identity. It is sometimes known as "reverse anorexia." Currently, this disorder is classified diagnostically as a type of body dysmorphic disorder versus an eating disorder.
Muscle dysmorphia is characterized by the persistent belief that one is not muscular enough and associated behaviours related to increasing musculature including an extreme exercise programme and dietary intake designed to build bulk (usually with a focus on protein).
Supplements and steroids are sometimes used in the pursuit of muscle.
Among men with muscle dysmorphia, approximately 71 percent lift weights excessively and 64 percent exercise excessively.
Excessive Exercise in OSFED and Subclinical Disordered Eating.
There is little research on excessive exercise in OSFED.
In subclinical samples, the relationship between compulsive exercise and elevated scores on measures of eating psychopathology is well established.
Behaviours such as dieting and exercise often coexist and reinforce one another. It is also the case that excessive exercise in the absence of disordered eating or disordered eating attitudes is believed to be less clinically significant and less impairing.
Exercise in patients with eating disorders and disordered eating can be dangerous. Patients may exercise and not fuel properly, putting themselves at risk for a variety of serious medical complications. These complications can include electrolyte imbalances, heart problems, muscle wasting, injuries, and sudden death.
Patients with anorexia often have weak bones and so may generally be more likely to experience fractures; the physical strain associated with over-exercising exacerbates this risk.
The presence of excessive exercise among patients with anorexia nervosa is associated with longer inpatient treatment duration and a shorter time to relapse .
Excessive exercise increases loneliness, isolation and challenges of building a 'normal' life with healthy connections. This is part of the reason excessive exercise among individuals with disordered eating is also associated with a greater risk of suicidality.
Excessive exercise immediately following hospital discharge is a strong predictor of relapse. Exercise can both maintain the beliefs that keep one caught in an eating disorder and be physically counterproductive when weight gain is a goal of treatment.
For this and other reasons, it is common for us as treatment professionals to work towards cessation of exercise in individuals with eating disorders until they are stable in recovery.
The idea of allowing someone in recovery to continue to participate in a sport or training as motivation to recover can be tempting but can seriously backfire.
Signs and Symptoms
Excessive exercise may be difficult to distinguish, especially considering the current culture.
The key feature that determines whether the exercise is problematic lies less in the quantity of activity than it does in the motivations and attitudes behind it: which include feeling exercise as a compulsion; exercising primarily to influence shape and weight; and feelings of guilt after missing an exercise session.
An athlete may engage in more total time exercising than a person with an eating disorder, but we could define the eating disorder person’s exercise as excessive while the elite athlete might not have the attitudes about exercise that would qualify it as excessive or problematic.
It should also be noted that the prevalence of eating disorders is higher among athletes, especially those in sports that emphasize leanness than it is in the general population. Thus, athletes who are exhibiting signs of an eating disorder should be assessed.
If one or more of the following statements are true to you (or a loved one), consider whether you may benefit from seeking help:
My exercise interferes with important activities such as work or socializing.
I exceed three hours of exercise per day.
I experience stress or guilt when I am unable to exercise.
I exercise at inappropriate times and places and cannot suppress the behaviour.
I continue to exercise despite injury, illness, or medical complications
If you or someone you know is exhibiting signs of excessive exercise and/or an eating disorder, eating disorder treatment, including therapy, cbte or recovery coaching, can help address both the eating disorder and exercise obsession. Cognitive-behavioural therapy, which helps to modify behaviours as well as underlying beliefs about exercise, can help individuals to develop moderation and balance
If you are a parent of a child in treatment, it may be beneficial for you to help limit or restrict their exercise.
If you are having suicidal thoughts:
Information:Childline – for children and young people under 19 Call 0800 1111 – the number will not show up on your phone bill