Exercise
Abuse —Too Much of a Good Thing
Today’s Dietitan
By Kate Jackson
Vol. 7, No. 3, p. 51
Know when your client has tipped the scales from
healthy fitness to obsession.
Imagine a client who’s diligent about exercise
and walks every day for one hour. Sounds healthy, right? What if
she never misses a day and exercises rain or shine, even after spraining
an ankle or when she has the flu? As the picture becomes more complex,
the client’s behavior begins to sound less healthy and more
obsessive and compulsive.
Excessive exercise—sometimes called exercise
abuse or addiction—is defined as activity that has a deleterious
effect on physical and psychological well-being, says Kelly Pedrotty,
MA, exercise coordinator and program coordinator at the Renfrew
Center of Philadelphia, a residential treatment center for individuals
with eating disorders. “People who have a healthy view of
exercise,” she explains, “exercise because they enjoy
it.”
Those who exercise excessively have negative feelings
about their workouts and may consider it painful. It’s often
difficult to discern, say experts, but the key difference between
moderate and pathological exercise is that the latter is compulsive.
The individuals have to do it all the time—every day—or
they become anxious. “This need to engage in a behavior, such
as exercise every day or repeatedly, is a sign of compulsion,”
says Elizabeth Carll, PhD, a psychologist and eating disorders specialist
in private practice in Long Island, N.Y.
Rigorous activity by all means isn’t always
pathological. “Goals such as training for an athletic event
or weight loss that is medically necessary are appropriate, and
once those goals are reached, people cut back on the level of exercise
intensity,” explains Carll. “Exercise is compulsive
and considered a disorder, however, when it is in response to free-floating
anxiety, an obsessive need to improve the way one looks, or chronic
dissatisfaction with one’s appearance. The key difference
is that those who have an addiction or compulsion can’t stop.”
Although men, women, and children can abuse exercise,
it appears to be more common in women and is often linked with other
psychological disorders such as depression or obsessive compulsive
disorder. Compulsive patterns of exercise often go hand in hand
with eating disorders, particularly anorexia nervosa.
“Many girls with anorexia also exercise compulsively
in addition to restricting their intake of food in order to lose
weight,” says Carll. For these individuals, she explains,
exercise and eating are linked, so that every time they eat, they
feel they must exercise. They engage in activity, says Pedrotty,
solely to compensate for eating.
Excessive exercise is also frequently associated
with bulimia nervosa, says Christian Lemmon, PhD, department of
psychiatry and health behavior, MCG Health Systems in Atlanta, a
psychologist who specializes in treating people with eating disorders.
In patients with bulimia, excessive exercise is another form of
compensation for eating, such as inducing vomiting or taking laxatives
or diuretics. It exists independently of eating disorders as well,
most commonly in men, but appears to be more common in individuals
who struggle with food-related issues.
Typically viewed as merely exercising too much,
exercise abuse can be manifested in other behaviors, explains Pedrotty,
especially when eating disorders are involved. Bulimic women in
particular may exhibit what she calls all-or-nothing patterns of
exercise: “They’ll engage in a period of intense exercise,
and then they’ll avoid it. Perhaps they’ll train hard
for a month and then back off for three months because they feel
burned out. Or their approach may vary from day to day. They may
wake up one day and feel like they ate too much the day before and
therefore they exercise like crazy and then take a week off.”
Another associated behavior is obsessing about exercise but never
actually working out, says Pedrotty.
At the Root
Exercise abuse may have a gradual or quick onset and typically begins
as a healthy pattern that goes wrong, often in people with propensity
for compulsivity. Molly Kimball, sports and lifestyle nutritionist
at Ochsner Clinic’s Elmwood Fitness Center in New Orleans,
notes that it can arise easily among perfectionists. “Usually
it occurs in very driven people—those who are overachievers
and people who get great grades in school, excel at work, are well
liked, and tend to do things for the approval of others.”
Individuals who have eating disorders and who abuse
exercise often do so out of a lack of self-esteem and in an effort
to punish themselves. “A lot of our patients use it as a form
of self-harm, believing that they can’t stop until they’ve
experienced pain, until their heart rate reaches the maximum, until
they’re dripping with sweat, or until their bodies burn,”
says Pedrotty. They may feel they’re not worthy of eating
and that they must abuse their body. Many people derive a lot of
self-esteem from their ability to maintain a certain kind of exercise
regimen, agrees Lemmon, and it’s difficult for them to see
other reasons to feel good about themselves.
It’s also highly likely to arise in people
who by nature or circumstance have a need to control. Observes Kimball,
“When other things feel out of control, exercise may become
a control issue because it’s one thing they can master. No
one makes them do it and they don’t let anyone or anything
interfere.” A person might have been a recreational exerciser
for years, she says, but something happens to trigger the obsession,
such as a divorce or death of a parent. It might even be a less
drastic milestone—a move, a new job, or the start of college—that
erodes control and causes exercise to become an excessive focus.
Carll suggests that the root of overzealous exercise
is an obsession—along the lines of an anxiety disorder—with
one’s appearance, used as a way of reducing weight and changing
shape. “Frequently, individuals are both anxious and depressed
and display behaviors similar to those seen in people with obsessive
compulsive disorder, which is an anxiety disorder.” Exercise,
she explains, is a way of coping with the anxious feelings and taking
control of one’s body, much like anorexia. Most clients she
sees with anorexia started out by dieting, but the diets got out
of control. These girls and women kept losing weight, thinking that
eventually they’d reach their ideal weights and goals. “They
never do,” she says. “It’s always 5 pounds more.
The same thing happens with exercise addiction.”
Exercise abuse may also develop out of a habit that’s
widely promoted and generally considered healthy: working out to
ward off stress. But once again, in vulnerable individuals, there’s
a tendency to turn a plus into a minus. According to Juliet Zuercher,
RD, director of nutrition at Remuda Ranch, a treatment center for
women and girls with eating disorders and related issues such as
exercise addiction, “A client may dabble with exercise as
a means of stress release, and it feels good, so they think more
will be better.” Then they get into higher intensity exercise,
she explains, and are essentially self-medicating with endorphins.
“If they were depressed or stressed, they exercise and they
feel better. That’s positive reinforcement that goes to the
extreme and until the activity becomes compulsive and the person
thinks he or she will be depressed if they don’t run 10 miles
every day.”
Physicians and psychotherapists often recommend
exercise as a means to keep depression and stress at bay, but it
must be both moderate and balanced by proper nutrition. “I
feel great when I exercise,” says Lemmon, “but too much
of anything isn’t good for you.” Exercise abusers, he
says, also use negative reinforcement for their behaviors. “They
engage in excessive exercise to avoid a noxious set of stimuli—the
anxiety that comes from not exercising,” he explains.
Lemmon observes that many teens’ parents worry
that their kids may sneak out of the house at night and engage in
sexual or drug-related behaviors. Young people with exercise disorders,
however, may tiptoe out to engage in exercise surreptitiously. He
recalls one patient who waited until her parents were asleep to
go out and run five miles each night and another who got up every
day at 5 am to ride on a stationary bike for 25 minutes, run on
a treadmill for 45 minutes, and then do hundreds of crunches.
In all these cases, a good thing has gone too far.
“It’s an extremist way of thinking. If a certain amount
is good, then a lot more is better,” explains Carll. “These
individuals think that if it’s great to exercise three or
four times a week, imagine how much better shape they could be in
and how much healthier they’d be if they exercised all the
time.”
“Healthy” Symptoms
Regular exercise is healthy, but compulsive exercise becomes pathological.
It’s more often than not a hidden problem, and the line that
divides healthy from obsessive activity is seldom clear. One of
the reasons the problem goes unnoticed and and that many eating
disorders programs don’t have exercise abuse components, says
Pedrotty, is that exercise is the only symptom of an eating disorder
that’s actually healthy. “It’s never healthy to
binge-purge or use laxatives, but exercise is healthy when used
in moderation and when there’s a healthy mind-set motivating
it, so it’s challenging to find the balance.”
It’s important that healthcare professionals
know how to assess for excessive exercise, says Lemmon, who acknowledges
that it’s a hard set of behaviors to define. “If someone
says he or she exercises seven days a week, that’s almost
culturally sanctioned. We would all envy a person who can work out
seven days a week, not only because they’d be in good health
but because we’d wish we had the time to do the same. So problems
such as exercise addiction are actually reinforced by our society.”
For these reasons, professionals in the field suggest
that dietitians ask all clients—men or women, young or mature,
thin or obese—about exercise. By asking about it routinely,
RDs can begin to see beyond the camouflage exercise abusers wear.
Even in the ordinary course of practice with all clients, dietitians
need to know about daily input and output of energy since they can’t
determine recommended dietary allowances without knowing how much
energy a person is burning, says Lemmon. It’s an opportunity
to expand the conversation, he suggests, and dig a bit deeper.
Zuercher says that since excessive exercise is a
problem that can easily be missed, it makes sense for RDs to question
all clients about their feelings about exercise in the initial intake
or interview. It’s not necessary to go into great depth with
all clients, but when responses to simple questions about activity
levels and exercise patterns suggest a problem, further probing
is warranted.
“Clients who exercise a lot may appear to
have a healthy attitude. It’s only after you ask specific
questions to assess the degree of exercise that it may become apparent
that it’s no longer healthy,” explains Carll. In our
very health-oriented culture, exercise is seen as positive, so most
people might not pursue an avenue of questions about it. Dietitians,
she adds, should ask specific questions to determine what kind of
exercise their clients engage in and how much time they spend exercising.
It’s especially important, adds Pedrotty,
to probe clients with eating disorders about their activity. “Their
exercise patterns may seem to be healthy and normal, but you really
have to get in there and figure out their mind-sets.” The
crux of the program she codesigned with Rachel Calogero, MA, at
the Renfrew Center, she says, is geared toward getting at the thoughts
and feelings clients have about exercise.
Lemmon says he’d begin simply by asking clients
to tell him about their physical activity. “If she tells me
that she does aerobics six days a week, would I worry about that?
Not necessarily, but I’ll begin to ask more questions. I’ll
want to know if she has a tendency to exercise more on or after
days when she feels as if she’s eaten too much, or if she
eats less on a day when she didn’t get a chance to work out.
If she says yes to those kinds of questions, warning signals go
off in my head and I’m going to ask more questions.”
He’ll then want to explore whether clients’ exercise
regimens get in the way of their ability to function otherwise—if
the behaviors disrupt their ability to function occupationally,
academically, interpersonally, or socially. Many exercises abusers,
especially those with eating disorders, he notes, make exercise
their top priority. “They start limiting themselves socially
because their social obligations can’t fit into the structure
to which their eating disorder symptoms bind them.”
How to Help
Dietitians can help by discussing with clients the basics of energy
balance, says Lemmon, explaining the need for a proper diet to compensate
for exercise rather than the need for exercise to compensate for
diet. They can also make a difference by educating clients to recognize
unhealthy patterns and attitudes and understand the limits of healthy
exercise.
For people in healthy body weight range, says Zuercher,
“we suggest exercising for an hour at a time, three to five
times a week—an amount based upon recommendations to the American
College of Sports Medicine.” She stresses the importance of
taking one or two days off per week and advises people with weight
issues to increase the cardio segment of each day’s hour of
exercise or increase exercise to six days per week rather than attempting
to do more exercise each day. Anywhere from 30 to 60 minutes per
day from three to six times per week—mostly cardiovascular
exercise—is in the range of normal, suggests Kimball.
Ultimately, the healthy amount is different from
person to person, says Pedrotty. Olympic athletes may exercise six
days per week for eight hours per day, but that’s not necessarily
unhealthy because they fuel themselves appropriately, they enjoy
what they’re doing, and they take care of their bodies. “It’s
not the amount of exercise, it’s the mind-set.”
The simplest way dietitians can transform their
clients’ unhealthy attitudes about exercise is by being good
role models, says Pedrotty. “They should have healthy views
about exercise, know how much is enough and how much is too much,
and understand and communicate that the sole purpose of exercise
is not weight loss but rather that there are many purposes: to rejuvenate
the body, to create a connection between the mind and body, to have
fun, and to relieve stress.” In the end, she says, make sure
to promote the idea that we eat to exercise. We don’t exercise
to eat.” Then follow up by providing healthy eating and exercising
strategies.
Referring Clients
That said, more often than not, clients with exercise issues will
need more help than you alone can provide. It’s important
to keep in mind that an eating or exercise disorder is a psychological
illness, says Carll, so it’s necessary to refer patients to
mental health professionals who specialize in treating people with
compulsive behaviors. These types of issues, she adds, have typically
existed for some time and are not likely to change without therapeutic
intervention. And the consequences of continuing these behaviors
can be extremely serious. “Exercise by anorexic individuals
with low body weight and low blood pressure can result in cardiac
problems, including heart failure,” says Carll.
In most cases, she says, people who exercise compulsively
may not recognize that they have a problem because their behaviors
give them a false sense of control. Your clients may not be receptive
to the recommendation that they seek the care of a mental health
professional, says Carll, who advises that it’s still helpful
to make the suggestion.
“If you see someone who has a very low body
fat percentage and you discover that their intake isn’t appropriate
or their amount of exercise seems far in excess of what it needs
to be, ask questions,” says Lemmon, who stresses above all
the need to be sensitive. “Communicate concern but also understanding,
and recognize that if your clients are truly addicted to exercise,
they’re probably going to be a little bit skittish about seeking
treatment and may even get downright angry or upset with you.”
In a very loving, kind, empathic way, he urges,
tell them your concerns and offer to help them find someone with
whom they can talk about their issues. Then, ideally, he says, dietitians
would continue to be part of an interdisciplinary team that includes
physicians and psychotherapists working together to help clients
with exercise addiction.
— Kate Jackson is a staff writer for Today’s
Dietitian.
Sidebar
Don’t Go Gung-Ho
Juliet Zuercher, RD, director of nutrition at Remuda Ranch, cautions
dietitians that gung-ho attitudes about healthful eating and regular
exercise can be misinterpreted by individuals with exercise addiction
or eating disorders. “Dietitians tend to be health-conscious
and knowledgeable about exercise,” she says, “and sometimes
those who are not as adept or really experienced with eating disordered
clients can almost feed into what might be a brewing exercise addiction.”
All in the name of health, she says, dietitians
not experienced in eating disorders may affirm, support, and unknowingly
encourage what may sound like a healthy exercise pattern, not recognizing
the extreme nature of the client’s thinking. A dietitian,
she warns, can unwittingly feed into distorted thought patterns
by emphasizing low-fat foods, fewer calories, or extremely healthy
foods—all good ideas for normal clients, but easily misconstrued
by those with compulsive tendencies.
— KJ
Sidebar
Telltale Signs: Spying the Hidden Problem
Since exercise abusers, like those with eating disorders, are typically
skillful dissemblers, simple and straightforward questions may not
always cut through their disguises. Nutrition and exercise professionals
offer the following telltale signs of excessive exercise:
• using exercise merely as a way to lose weight,
especially by an individual with an
eating disorder;
• a strong emotional commitment to exercise;
• a sense of duty or obligation about exercise
manifested by an inability to take a day
off or anxiety when exercise is not possible;
• a strong relationship between intake and
output—having to exercise after eating;
• talking about exercise in a regimented way,
not having a relaxed attitude about exercise, and not expressing
enjoyment about activity;
• exercising through illness or injury, in
inclement weather, or in severe times of stress;
• using exercise as the only means of stress
control or mental health;
• exercising at the expense of one’s
social life or responsibilities;
• expressing guilt about not exercising;
• spot training—picking a particular
part of the body and focusing excessively on it
(eg, doing 1,500 crunches per day);
• being inflexible about exercise schedules
or having rigid patterns (eg, having to use
the same equipment at the same time in the same amount);
• always talking about exercise;
• exercising secretively—hiding or lying
about exercise;
• visiting the gym more than once per day;
• having all-or-nothing exercise patterns—going
from extremes of no exercise to constant exercise; and
• having a preoccupation with health food,
weight loss, or performance supplements
and products.
— KJ
The Toll of Exercise Abuse
In addition to the psychological toll of excessive exercise, a host
of physical complaints may arise, including the following:
• bone and muscle injuries
• inflamed joints, tendons, and ligaments
• decreased bone density
• disruption of the menstrual cycle
• infertility
• overuse injuries
• stress fracture
• plantar fasciatis
— KJ
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