The Medical Risks of Compulsive Exercise and Eating Disorders

Compulsive exercise — sometimes referred to as anorexia athletica — affects up to 80% of people with anorexia nervosa and 55% with bulimia nervosa. In this piece, I explain how excessive exercise, especially when combined with eating disorders, can cause serious health complications. Evidence-based treatments like physical therapy, psychoeducation and counseling can interrupt these patterns, leading to a full recovery.

What is Compulsive Exercise?

Compulsive exercise – also referred to as anorexia athletica – is an unhealthy obsession with exercise and fitness that can result in long-term harm. While exercise offers a range of physical and emotional benefits that are often seen as healthy, it can become dangerous when used as a method of weight control — or when unrealistic performance goals are set.

Alongside purging, compulsive exercising is a common compensatory method for individuals suffering from eating disorders. Up to 80% of those with anorexia nervosa and up to 55% of those with bulimia nervosa engage in compulsive exercise.¹ The relationship between compulsive exercise and eating disorders is reciprocal, with about 48% of those who overexercise also at risk for developing an eating disorder.²

Understanding the root of compulsive exercise

Compulsive exercise is a type of behavioral addiction. “When most people think of addiction, they often think of substance use. However, behavioral addictions don't involve consuming substances like drugs or alcohol to induce a high; instead, they are addictions to activities such as gambling, shopping, or even the internet,” describes Cheryl Lundberg, PsyD, CEDS, Psychology Team Lead at ACUTE.

Behavioral addictions have six core components:³

• Salience (seen as the most important activity in the person’s life)
• Mood modification (feeling of being “high” or “numbing” or is an “escape”)
• Tolerance (needing an increasing amount of the activity)
• Withdrawal (moodiness, irritability or shakes when the activity is stopped)
• Interpersonal and intrapersonal conflicts with others because of these behaviors
• Relapse

Behavioral addictions significantly interfere with daily life and negatively impact relationships and a person’s wellbeing.

Medical Risks of Compulsive Exercise

Serious medical consequences can occur in those who exercise compulsively. With early recognition and intervention, it is possible to prevent the following health risks from escalating.

Malnutrition

When combined with food restriction, excessive exercise can lead to malnutrition and its associated complications, including:

• Cardiac complications
• Endocrine dysfunction
• Gastrointestinal issues

Overuse injuries

Compulsive and excessive exercise can cause overuse injuries. These injuries happen when someone suddenly increases the intensity, duration, or frequency of their activity. They can also happen when a person is returning to a sport or activity after an injury and tries to make up for lost time, which can lead to injury.

Repetitive stress to the tendons, bones and joints can cause overuse injuries like:

• Tennis elbow
• Swimmer’s shoulder
• Pitcher’s elbow
• Achilles tendinitis
• Shin splints
• Stress fractures

Bone loss, osteoporosis & osteopenia

While exercise typically benefits bone health, it can cause osteoporosis or osteopenia when someone is malnourished or amenorrheic (lack of menstrual cycle).^4,5 Alongside low weight, hormonal changes and loss of lean muscle mass, excessive exercise can exacerbate bone density loss in those with anorexia.

Exercise-induced rhabdomyolysis

Intense, prolonged physical activity can cause exercise-induced rhabdomyolysis, which is the breakdown of muscle caused by unfamiliar or excessive exercise. Rhabdomyolysis results in the release of myoglobin and creatine kinase into the bloodstream, which can lead to kidney damage.

Rhabdomyolysis is becoming more common as physical activity and exercise have increased in popularity.⁶

Atrial fibrillation

Atrial fibrillation (AF), an irregular and very rapid heart rhythm, is the most common type of cardiac arrhythmia. While atrial fibrillation is typically associated with a sedentary lifestyle, recent evidence suggests that extreme and prolonged exercise is a risk factor.^7,8

Recent studies have shown that up to 10% of athletes have atrial fibrillation, with endurance athletes having a 5x greater risk than non-athletes.⁸ Sports associated with an increased risk of AF are:

• Cycling
• Long-distance running
• Cross-country skiing

While research on exercise-induced atrial fibrillation is still emerging, some studies suggest that the following mechanisms may contribute:⁷

• Increased atrial dilation with exercise
• High atrial wall stress during exercise
• Prolonged p-wave duration
• Systemic inflammation
• Bradycardia and increased vagal tone

Dehydration & low sodium

Intense and prolonged exercise, especially when already malnourished, leads to the loss of water and electrolytes, including:⁹

• Hyponatremia (low sodium)
• Hypernatremia (high sodium)
• Hypokalemia (low potassium)
• Hyperkalemia (high potassium)

How to Identify Compulsive Exercise

Recognizing the signs of compulsive exercise — such as slow recovery, declining athletic performance, and mood changes — is essential for early intervention. This is especially important for athletes who may be praised for behaviors that are causing harm.

The Compulsive Exercise Test

The Compulsive Exercise Test (CET) is a self-report questionnaire specific to exercise in eating disorders. It has five subscales:

• Avoidance and rule-driven behavior
• Weight control exercise
• Mood improvement
• Lack of exercise enjoyment
• Exercise rigidity

Know the signs of compulsive exercise

It can be hard for athletes, teammates, coaches and parents to recognize the signs of compulsive and excessive exercise. Often, supporters encourage more training to help athletes reach their goals, unaware of the risks related to compulsive exercise. From the outside, someone might even be praised for being motivated or passionate. 

Alongside medical complications, signs of compulsive exercise include:

• Declining athletic performance
• Difficulty recovering
• Anxiety or depression
• Mood swings or irritability
• Trouble sleeping
• Fatigue
• Amenorrhea

Why Do People Exercise Compulsively?

Compulsive exercise is often driven by perfectionism, challenges with emotion regulation, and the pressure to perform, as I explain below. Note: these traits are all common among athletes. When combined with disordered eating behaviors, the anorexia athletica cycle can be difficult to break without professional help.

Pressure to perform

Athletes often face pressure to perform, which can come from external sources like coaches, teammates or parents, or from internal motivation to keep improving. They might also feel pressure to reach specific athletic goals, such as breaking a record or personal best, making varsity or qualifying for college sports.

This pressure can cause athletes to ignore their body and:

• Train more intensely or longer
• Train more frequently
• Overlook injuries or signs of fatigue
• Restrict food or water intake to hit weight goals

Perfectionism

Perfectionist personality traits are a major contributor to compulsive exercise. Perfectionism is associated with higher eating disorder, anxiety, depression and obsessive-compulsive symptoms. A low toleranc e for flaws, rigid exercise routines that cause anxiety when disrupted and relying on exercise to cope with difficult emotions all work in tandem to maintain an individual’s exercise excessive exercise.^10-12

Alcohol use disorder

Compulsive exercising is also linked to alcohol use. Some people with eating disorders perform compensatory behaviors like excessive exercise to compensate for alcohol-related calories. Among college students, exercise and unhealthy weight management strategies often predict binge drinking.

One explanation for the link between compulsive exercise and alcohol use is the shared trait of impulsivity, which is common among patients who binge and purge.¹³ In particular, negative urgency and sensation seeking are linked to increased compulsive exercise.¹³

Struggles with emotion regulation

Those who exercise compulsively have lower emotional regulation and quality of life, as well as higher levels of anxiety, depression, and disordered eating behaviors than those who don't. This suggests that overexercising might be used for emotional regulation.^11,14

Coping with feelings of body dissatisfaction is one way this might show up. Body dissatisfaction is a risk factor for several psychiatric conditions, including eating disorders, depression and suicide.¹⁵ Patients might exercise compulsively when struggling with certain emotions, such as those caused by body dissatisfaction.

As they lose weight – especially if they receive praise for their efforts – those with eating disorders often use their progress as motivation to keep going, which reinforces a cycle of excessive exercise.

Treatment for Compulsive Exercise

Compulsive exercise is one of the strongest predictors of poor outcomes in patients with eating disorders.¹⁴ This emphasizes how important it is to understand and treat the reliance on excessive exercise along with the medical complications. Evidence-based treatment includes a comprehensive approach, as outlined below. Treatment must address the whole person, including disordered eating behaviors, feelings of shame and perfectionist ideals.

Physical therapy

Physical therapy is an essential part of treating severe eating disorders. During treatment, physical therapists can carefully reintroduce exercise and movement in a supportive setting to help manage acute and chronic pain, support recovery and enhance body awareness.

Under the guidance of a physical therapist, patients with eating disorders can discover ways to lead active lifestyles without overexercising. For many, healthy movement can be beneficial in their recovery by helping to:^16-18

• Improve weight restoration
• Reduce eating disorder symptoms
• Decrease negative exercise behaviors
• Improve treatment compliance
• Improve therapeutic relationship
• Lower food preoccupation

Learn more about physical therapy

Compulsive exercise activity therapy

CompuLsive Exercise Activity theraPy (LEAP) provides psychoeducation about healthy exercise, using strategies from cognitive behavioral therapy to challenge unhelpful thoughts about exercise and modify compulsive exercise behaviors.

Studies have shown that compulsive exercise activity therapy can help reduce core aspects of compulsive exercise, including avoidance and rule-driven behavior, and exercise rigidity.¹²

Compassion-focused therapy

Compassion-focused therapy (CFT) has proven effective in reducing compulsive exercise in adults with eating disorders, especially those with perfectionist traits or excessive exercise habits.¹¹ CFT helps patients develop self-compassion, particularly for those that struggle with shame and self-criticism.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is often used in substance use treatment and can be especially helpful for those with a behavioral addiction like compulsive exercise or a dual diagnosis. CBT assists individuals in recognizing the links between their thoughts, feelings and behaviors, and increases their understanding of how these factors affect their lives.

Find Help for Compulsive Exercise

If you or someone you care about is experiencing life-threatening health issues related to compulsive exercise or an eating disorder, know that compassionate, expert care is available.

References

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