Eating Disorders: Compulsive Exercising Among Anorexic Patients

Compulsive exercising is cited as a common behavior among patients with anorexia nervosa. Most therapists interpret this behavior as a compulsion triggered by the obsession with thinness or weight loss, or due to a phobia of obesity. The exercise is viewed as excessive because the patient is often severely malnourished as well.

The Female Athlete Triad

A significant proportion of female athletes develop a syndrome known as the female athlete triad, which involves loss of menses, disordered eating, and osteoporosis. Loss of menses is normally attributed to a drop in estrogen levels due to strenuous exercise and resulting low percentages of body fat. Low estrogen levels play a role in the drop in bone density in such individuals. Caloric restriction can also contribute to the syndrome.

The female athlete triad is not recognized as a psychiatric disorder, since it is a normal physiological adaptive response to an intense exercise regimen. Sports that require a high strength-to-weight ratio such as running, gymnastics, rock climbing, or ballet dancing are often dominated by petite or very thin women. This is because a smaller, lighter body structure is more energy efficient, since there is less mass to accelerate, lift, move, or rotate. Many of the world's top women athletes in these sports appear very thin indeed, and often are at risk of developing the triad.

Having run middle distance competitively for many years, I know what effect a rigorous training schedule can have on digestion and eating habits. Most runners have to be very careful when and how much they eat, and usually have to schedule meals around their training regimen. Any athlete will tell you it's not a good idea to eat a big meal before a training session, or race, since you'll suffer dire consequences as a result. Diarrhea and nausea are common ailments before a race or competition, since most athletes get nervous or anxious before and during competition. I recall one fellow athlete who used to vomit before every race. I myself would have to visit the washroom several times before each race, due to butterflies and diarrhea.

Any athlete that has experienced diarrhea or cramps during a 20 mile road race will soon learn that they need to carefully watch their food intake. Since top level athletes train almost every day, this becomes a daily routine. This does not represent any sort of psychiatric disorder; it is the price athletes pay to excel at their sport. It does come with health risks, which should be managed by a competent sports medicine physician.

Some therapists who do not understand the physiological response to intense exercise may misinterpret the triad as a manifestation of anorexia nervosa. Indeed, many elements of the syndrome fulfill the diagnostic criteria for AN (see page on diagnostic criteria).

Athletes and Anorexia

The higher prevalence of anorexia nervosa diagnosed among female athletes is to be expected, since an athlete's body has become optimized for the particular sport being engaged in. Successful athletes not only have optimized body structure, but also possess the mental attitudes necessary to compete successfully. They are used to pushing themselves to the limit of their endurance and beyond.

An appropriate analogy here would be an Indy race car. It is a machine that is operated to the limits of it's performance potential. If even a slight problem develops in the machinery, such as a sticky lifter or broken v-belt, total failure of the machine may ensue very quickly. For a vehicle being driven at low speeds, such as your car, you may drive for quite a while before you notice a problem. In fact, you might be able to drive it for many years with a small mechanical problem, because it does not cause catastrophic failure.

In a similar scenario, let's say a female distance runner is in top shape, training 6 to 7 days a week, several hours a day. She has very low body fat. Let's say she travels to the Pan Am games in Central Amercia and picks up a parasite while there. She feels very sick for a few weeks and experiences nausea, vomiting, and diarrhea. She loses 10 lbs. on her already skinny frame. She returns from the competition, and gradually gets her strength back. She is eager to get back to her normal training regimen.

Her physician, without doing any diagnostic tests, says she just had the flu, and she should be able to start training again. She is not aware that the parasitic infection has become chronic and has affected her intestine's ability to absorb nurtients. She starts training as soon as she can, because she does not want to lose the fitness level she has attained. She begins training again, but can't seem to reach the performance levels she once did. She also starts to lose even more weight, since she doesn't really feel very hungry. She thinks she has to push herself harder to get her performance up. The doctor says she must be stressed out, and that maybe she should take a break from training. Eventually she ends up in an eating disorder program where she told that her weight loss is a psychological problem. No tests were done to look for the underlying disorder.

In a non-athlete, such a parasite may cause only mild discomfort, and since caloric requirements are low, may go largely unnoticed. If the psychiatrist can convince the athlete to give up on all her goals and dreams, she may be able to gain weight by stopping all her training and thereby reducing her caloric requirements. This would be similar to telling a world-class pianist that they can no longer play, or a top level figure skater that they can no longer skate. It would be a tough pill to swallow; and since chronic medical illness is not even mentioned as a possibility, the anorexic athlete is left with no choice but to give up their goals and dreams.

Extensive diagnostic testing would likely have revealed the underlying disorder, and with appropriate treatment, allowed the athlete to resume her training regimen. The costs of these test would have been far less than the cost of psychotherapy, but most importantly, it may have allowed a young, ambitious, high achiever to once again chase her dreams.

Excessive Exercise and Anorexia Nervosa

Many anorexic patients who do not compete athletically also engage in strenuous exercise, despite being malnourished. Not all patients exercise excessively (excessively is a very subjective term, and each therapist will have their own definition), yet most are not able to gain weight.

Most nutritionists and therapists seem to take a very simplistic view of human digestion, assuming that everybody can absorb all the calories consumed. Patients are normally placed on a rigid meal plan, with caloric intake calculated to effect predictable weight gain. If the patient fails to gain weight, the patient is assumed to be purging, exercising, or using diuretics or laxatives secretly. Few will suspect a digestive disorder that may be affecting absorption of nutrients.

Defining Excessive

How much does a person have to exercise before it becomes excessive? Certainly, the exercises most anorexic patients engage in are only a fraction of what a healthy, world class athlete does. Yet these are viewed as excessive, mainly because the patient is usually malnourished as well.

To gain a perspective on just what is excessive, let's look at some world records of common exercises that anorexic patients engage in. It is important to remember that the records listed below were not established by athletes with any sort of psychiatric disorder, or obsessive compulsive personality disorders. They were achieved by healthy, fit, self-disciplined individuals. It is unlikely that any of these individuals suffered from a chronic medical illness, since they would not have been able to achieve these incredible levels of performance.

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