Lisa M. joined a gym as soon as she started college at Bridgewater State University, determined not to pack on an extra 15 pounds freshman year like her older sister.
"In my head there was that picture of my sister," Lisa said in an interview. "I didn't want that to happen to me."
For the next six years, Lisa says, she never missed a day at the gym unless it was preplanned and she could make it up later. In order to fulfill her self-imposed exercise requirements, Lisa skipped Christmas Eve gatherings, birthdays, weddings and dates with someone she loved and "very likely lost" because of her illness, she says.
"Every aspect of my life was dictated by exercise and food and the need to control it all," says Lisa, who asked that her last name not be used because she is still in treatment.
"Every aspect of my life was dictated by exercise and food and the need to control it all."Lisa M.
The thought of missing even one daily workout triggered massive anxiety, she says. And as her exercise obsession deepened, she began restricting her food intake too, mostly to salads and vegetables. She had "fear foods" she'd avoid: no cake, brownies or cookies, of course, but also, no cheese or pasta. Thoughts about food and exercise consumed her: "Any extra energy I had would go to...thinking about my next meal, my next snack, what I'd be able to eat next. I'd plan meals a week ahead."
Her weight dropped to 112 pounds on a 5-foot-6 frame. She hasn't had a period in six years. Now, as a result, Lisa, who is 25, has osteoporosis in her lower spine and hip.
"I worked so hard to be healthy, but I'm not," she says. "And I did this to myself."
Masquerading Behind Fitness
It's hard to quantify precisely how many people struggle with exercise addiction, also known as exercise bulimia, exercise anorexia or driven exercise. It's not new, but experts say the disorder may be on the rise — fueled, in part, by a selfie culture that privileges extreme healthy living, our near-worshipful embrace of the carb-and-gluten-free lifestyle and reverence for a virtuous diet and fit body.
"You're applauded when you go to the gym and your arms look great in a sun dress," says Paula Quatromoni, a registered dietitian, sports nutritionist and chair of the department of health sciences at Boston University. "But there's a slippery slope between commitment to a healthy lifestyle and obsession."
Quatromoni says compulsive exercise is "more and more common and happening at rates that are alarming if people paid attention." Unlike vomiting or taking laxatives — telltales signs of an eating disorder — exercise addiction "masquerades behind these well-intended, noble endeavors — 'I'm getting fit going to the gym,' " so it can remain secret for some time, she says.
"[Compulsive exercise is] more and more common and happening at rates that are alarming if people paid attention."Paula Quatromoni, sports nutritionist
Exercise, it goes without saying, can clearly offer tremendous benefits: a pathway to both physical and mental health. It can ease anxiety, make your body stronger and keep disease at bay.
The devil, as usual, is in the dosage, and in how you perceive it. Two women can look the same, for instance, work out the same amount and eat comparably, yet one might have a disorder based on her beliefs about exercise, and guilt over not doing it, while the other may pleasurably engage in exercise without a problem, therapists say.
That's why diagnosing and treating exercise addiction can be tricky. Even determining prevalence is elusive. A spokesperson for the National Eating Disorders Association says there are "virtually no hard numbers" on excessive exercise but sent over a statement from the group's CEO, Claire Mysko:
...for those predisposed to eating disorders, excessive exercise behaviors can quickly lead to dangerous results. When a person starts developing rigid habits, puts an over-emphasis on weight and/or body shape and feels compelled to ‘burn off’ calories, it's time to seek the help of a professional to see if there's something deeper going on. Eating disorders, such as exercise bulimia, are life-threatening illnesses, but recovery is possible, especially with early intervention.
A published review from 2012 estimated that about 2.5 to 3.5 percent of the general exercising public may be affected by exercise addiction.
A 2015 study found that "driven exercise" is a "common compensatory behavior in adolescents with bulimia and anorexia" and is associated with greater eating disorder severity and depressive symptoms. In other words, exercise addiction can make a dangerous eating disorder worse. The same study found that about 66 percent of adolescents with bulimia and 23 percent of those with anorexia also reported driven exercise.
"If you think about it like, 'Oh my god, I ate this and now I have to do 45 minutes of cardio to counteract what I ate,' that's a problem. It's basically an eating disorder that uses exercise as a purging method," says Beth Mayer, a clinical social worker and executive director of the Multi-Service Eating Disorders Association, in Newton, Massachusetts. Mayer says about 20 to 30 percent of her patients have some kind of exercise obsession as part of their illness.
And while eating disorders in general and exercise addiction in particular are thought to afflict more women than men, it's becoming clear that more men suffer with the disorders than previously acknowledged. They are simply not reporting their symptoms due to stigma and shame, experts say.
Punishing And Sneaky
The hallmark of the condition — generally considered one part of the constellation of problems related to eating disorders — usually involves exercising to punishing lengths.
But again, perception is key. If you feel driven to work out daily, for instance, for long periods of time — and do it even through illness and injury — that could signal a problem. And if you feel guilty, anxious or out of control when you miss a day's workout, that should be another clue. Also, if your motive in exercising is simply to purge calories, you've probably crossed a line.
"It's compulsive, it's punishment, it's sneaky," is how 39-year-old Leanne describes her exercise addiction, which is one component of an eating disorder she's struggled with for two decades. At one point, she was eating only between 200 to 300 calories a day, she said, and would sneak out of her Boston-area condo to the gym at night so her friends and neighbors wouldn't ask questions or worry.
Now, even though she's been working with a team of eating disorder specialists for several years, Leanne -- who also asked for confidentiality because her work colleagues don't know about her illness -- says: "I would say I'm not recovered. I don't eat three meals a day, for example. I'm better right this minute and making my way into more normal intake, but unfortunately, it's very much like a roller coaster. It becomes about compensatory behavior: I had a full meal, panic, gotta go to the gym and run. I would probably say I have a long way to go."
Genevieve, 23, calls the illness "mentally tormenting" because she was so driven to exercise, even when she was sick or visiting family on a school break. "I didn't have a gym membership at home," she says. "So I would end up spending my whole break coordinating which gyms I could go to to get a free trial, and patch it together. I couldn't get myself to take the week off." On her first Valentine's Day with a boyfriend, she left him after five minutes to go to the gym.
Passing Out After 20 Miles
Athletes are particularly at risk, says Quatromoni, who started BU's sports nutrition consult service for student athletes back in 2004. Now, she says, there's greater awareness that many athletes suffer from eating disorders and use their sports training in unhealthy ways. Indeed, she says, athletes are two to three times more likely to develop an eating disorder, compared to the general public. "There's the pressure to perform, their own expectations — and we have sports that are weight based and others where you are judged on how how you look and there are scholarship dollars tied to this," she says.
College seems to be a particularly vulnerable time, she says, with 18- and 19-year-olds on their own for the first time, and not always sure of where to turn for help.
Quatromoni and one of her patients, an elite student runner named David Proctor, wrote a paper together last year that tracked his eating disorder and five-year recovery. Proctor, who at 18 had moved to the U.S. from the U.K to compete as a Division 1 scholarship athlete, began fixating on his weight after a coach told him to lose a few pounds. In response, "David began restricting his energy intake significantly, dropping more than 10 pounds in about two weeks, and weighing himself multiple times daily," according to the paper. He became fixated on becoming lighter, which he believed would make him run faster. Here's more about Proctor from the case study:
The real eye-opener came a few days after that first Christmas when I decided I would “make up” for the amount I had eaten on Christmas Day by eating absolutely nothing for two days, and then setting off for a 20-mile run on the third day. As anyone would expect, I did not feel well during this run and I ended up passing out at the side of the road, collapsing onto the pavement.
Rachel Monroe used to wake up routinely at 4 a.m. to exercise, "and stay on the treadmill long enough to burn the calories to justify what I'd eat that day.”
But after years of counseling and healing, Monroe, now a licensed mental health counselor specializing in eating disorders at the Multi-Service Eating Disorders Association, says she gets joy from moving her body in very different ways:: doing yoga, for instance, or walking her dog, Rosie.
"Right now, we are in a societal crisis with the craze about health and exercise — like you're a good person only if you exercise and if you're healthy," Monroe says. "It's not a moral obligation to work out. So many people who live in larger bodies are told they have to work out, and they are shamed if they don't."
Signs Of An Unhealthy Habit
So how do you know if your daily exercise routine has crossed into obsession? Monroe offered these signs of an unhealthy exercise habit:
- Training even when injured or tired
- Working out several times a day
- Obsessing about training details
- Feeling angry or threatened when routine is interrupted
- Canceling or avoiding social activities and other responsibilities in order to exercise
- Creating a daily schedule around working out
- Repeated comments about being or feeling fat
- Feeling anxiety and guilt when unable to exercise
- Happiness reliant on productivity of workout
And here are Monroe's tips to check where you are on the "exercise dependence scale":
- Tolerance: Needing more and more of the activity to achieve its initial effects.
- Withdrawal: Increased agitation, fatigue and tension when not exercising.
- “Intention Effect”: Exercising for longer than intended on most trips to the gym.
- Lack Of control: Difficulty scaling back the duration and intensity of exercise.
- “Time Spent”: Funneling exorbitant chunks of our day and night toward fitness-related activities.
- Reduction Of Other Pursuits: Avoidance of social engagements that don’t involve exercise, canceling plans or showing up late for work in order to exercise longer.
- Continuance Despite Injury: Not taking enough time off to heal despite your doctor repeatedly raising judgmental eyebrows.
'It Feels Really Good To Feel'
The good news is that exercise addiction is very treatable, experts say.
Psychotherapy to address the eating disorder and exercise obsession (or really the underlying emotions and psychology driving the behavior) is standard; and patients report it can be helpful to work with a multidisciplinary team of providers, including a psychotherapist, nutritionist or dietitian, primary care doctor and, in some cases, a certified fitness expert.
Cognitive behavioral therapy and similar approaches can help people reframe their thinking around exercise, and eventually, gain more moderation and balance in their fitness pursuits. It can be frightening, overwhelming and anxiety-producing to break the cycle, therapists say, but the goal is to try to help people feel more at home and at peace in their bodies instead of seeing their bodies as something to perfect, manage or fight against.
Lori Lieberman -- a registered dietitian and nutrition consultant based in Weymouth and Sharon, Massachusetts, who treats patients with eating disorders — emphasizes that treatment needs to be tailored to the individual.
"Exercise is not an issue — unless it's an issue," she says. "In other words, it's the mindset, not necessarily the amount of exercise. It's also essential that food intake supports their activity."
In the midst of the illness, patients often continue to believe that working out is good for them.
"And while I understand the merits of exercise, it's important to convey how counterproductive it is for them," she says. "If you think you're becoming more fit, think again. In some people, their metabolic rate goes down, muscle mass decreases, the risk of injury and osteoporosis increases."
When patients are trying to recover, Lieberman says, they may feel compelled to keep moving, but should, at the very least, switch to something more gentle, like yoga or walking.
"People are often relieved to be told that they have to reduce or cut out exercise, they can't give themselves permission to stop — it's scary and overwhelming."
For Lisa M., who is in treatment with Lieberman, life has changed in some striking ways.
"The big thing being that I feel," she says. "I feel happy, I feel overwhelmed, I feel heartbreak, I feel sadness, I feel hopeful that I can get better. But I had felt void of it all for so long, and although I do not love the feelings all the time, it feels really good to feel. And the womanly curves coming back feel pretty great too."