Growing up, exercise was what Equip Peer Mentor Jillian Yatso-Bukoski called “the centerpiece” of her life. She pursued competitive dance as a child, and ventured into competitive rock climbing as a young adult. “Both of these sports were my identity—the reason I got out of bed in the morning, my source of perceived worth,” she says. “But they were also my fuel for restrictive eating.” Exercise, of course, can be perfectly healthy for many (or even most) people, but as Yatsko-Bukoski's story illustrates, compulsive exercise and eating disorders often go hand-in-hand.

Leading up to her first international climbing competition, Yatso-Bukoski says she severely restricted her food intake while “training my body into the ground.” This culminated in a sobbing breakdown after her qualifying round in France, which left her “hungry, exhausted, and emotionally at one of my lowest points.” On the other side of the world, friends, family members, and sponsors woke up to the news of her making the finals and messages of praise began to roll in.

“My suffering for this sport felt invisible,” she says. “Starving and torturing yourself for ‘excellence’ looks an awful lot like dedication to those around us. You begin to veil your self-destruction as inspiring motivation.”

What the research says about eating disorders and exercise

Yatso-Bukoski’s experience is quite common, and not exclusive to athletes. While it’s tough to nail down an exact definition or even a single name for the phenomenon—over-exercise, compulsive exercise, overtraining, exercise addiction—this type of disordered relationship with movement often exists alongside disordered eating. Some experts use the term “addiction” to describe “excessive and obsessive” patterns of exercise, and estimate that anywhere from 3 to 9% of people are affected worldwide. Others take issue with the term “addiction,” and say characterizing the issue as “problematic” is perhaps more precise and less stigmatizing.

Regardless of how it’s described or categorized, research has consistently shown a strong relationship between excessive or compulsive exercise and eating disorders, and it’s often a major factor in maintaining the illness and predicting poor treatment outcomes. A recent study found that nearly half of those with eating disorders engage in excessive exercise, and the current prevalence is highest in people with anorexia (48%), followed by those with bulimia (45%), OSFED (38%), and binge eating disorder (BED) (11%). The lifetime prevalence of excessive exercise in all eating disorders is 63%.

How exercise shows up in eating disorders

According to Equip Lead Therapist and Clinical Supervisor Brittney Lauro, LCSW, exercise often shows up in the context of eating disorders as a rigid relationship with both routine and a “no days off” mindset. “People will often feel guilt or sadness for taking time off,” she says. “They may feel compelled to stay on exercise machines for a specific amount of time or complete a rigid requirement for an amount of reps with no flexibility to reduce.” This can mean that those who are struggling exercise when sick or injured, or in poor weather.

Lauro also notes that people with eating disorders may use exercise as a compensatory behavior—meaning they “have” to work out if they allow themselves to eat certain types or amounts of food. This mindset is unfortunately common in our society (which is heavily informed by diet culture), so it's an important reminder that food is a fundamental human need, not something that needs to be earned.

Underfueling for exercise is also a major issue among those with eating disorders. “People are often praised for spending early morning hours in the gym instead of sleeping adequately or eating breakfast with their children,” Yatso-Bukoski says. “Not only do we hide eating disorders under banners of health, but we’ve gone further to create a fitness niche called ‘fasted fitness’ where people are encouraged to exercise in a malnourished state because the shape of our bodies are more important than the wellness of our spirits. The most insidious part of this is that those who have gone the longest without eating prior to their exercise are praised as being the most committed to their ‘health and fitness.’”

How extreme exercise can lead to an eating disorder

Board-certified pediatrician, Katherine Hill, MD, says that compulsive exercise is something she’s become familiar with in her profession, but is also an issue she witnessed firsthand during her days as an NCAA Division I swimmer. “Problematic exercise is extremely common in people with eating disorders, and is often the primary behavior that sets off the eating disorder in the first place, almost always with great intentions,” she says.

Hill says the external validation so many individuals get when they apply a “more must be better” mentality to exercise only serves to reinforce problematic behavior—even for those in the throes of a life-threatening eating disorder. “The trickiest part about exercise is that it is not only socially acceptable to exercise, but also socially acceptable to exercise to the extreme,” she says. “Training for a marathon or ultramarathon, for instance, is often seen as more impressive and more ‘healthy’ than training for a 5K. Too often, exercise behaviors that started in moderation to improve health become compulsive, to the point where people are exercising when sick, injured, or fatigued without taking a day off.”

Former college football player and current mental health advocate Patrick Devenny, who once struggled with bulimia, says excessive exercise is the number one thing he emphasizes when speaking about eating disorders. “The reality is that ‘bro science’ and gym life affirm and glorify overexercise, and people have begun to associate overexercise and pushing yourself to burn calories as a badge of honor,” he says. “There is so much harm being done to the mind and body when this kind of gym culture exists.”

Compulsive exercise symptoms: how to know when it’s gone too far

Considering how celebrated exercise is in our society, it can be difficult, if not impossible to know how much is “too much.” According to Lauro, assessing whether exercise has become compulsive can be likened to assessing whether substance use has gone too far: “I think of this the same way I think of conversations surrounding substance use like alcohol or marijuana,” she says. “If someone can stop their exercise or skip days without feelings of guilt, anxiety, shame, or sadness, it is likely not a problem. If someone does experience these feelings, exercise is no longer serving a healthy purpose and has instead turned into a ‘maintaining mechanism’ or ‘compensatory behavior’ that contributes to an eating disorder.”

Of course, all of this can be complicated in the context of a society that considers thin bodies to be more desirable than other body types and praises hours-long, punishing workouts. With that in mind, here are a few telltale signs that someone’s relationship with exercise has gone too:

• Chronic fatigue
• Frequent or recurring injuries
• Frequent illness, or taking a long time to recover from illness
• Mood changes including increased irritability, agitation, anger, or confusion
• Symptoms of depression or anxiety
• Trouble concentrating
• Feeling guilty or anxious about missing a workout, or continuing to exercise despite injury or severe fatigue
• Changes in menstrual cycle, such as irregular periods or amenorrhea (loss of periods)

Compulsive exercise treatment options

Compulsive exercise is a disordered behavior with serious consequences that often co-occurs with eating disorders, and treatment typically involves a multidisciplinary approach that tackles both the physical and psychological aspects. The same evidence-based modalities we use at Equip to address eating-related behaviors can be effective for managing exercise-related symptoms and concerns.

In addition to family-based treatment (FBT), cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and other forms of therapy, treatment for compulsive exercise may also include structured exercise and safe, supported re-exposure to movement. This generally involves a gradual and planned reintroduction to moderate movement to help reduce rigidity, process urges, and build a non-compulsive relationship with physical activity. Sometimes, it’s important to take a complete break from exercise initially, especially if there are injuries or severe medical complications.

The role of exercise in eating disorder treatment

Understandably, there are a lot of varying opinions about the role movement should (or shouldn’t) have in eating disorder recovery. Some experts advocate for total abstinence from exercise, while others believe some form of physical movement is necessary for long-term healing. Hill says that she’s a big believer in moderate exercise done “for the right reasons,” and that learning to integrate movement into a healthy lifestyle can improve both physical and mental well-being. However, given the societal pressures around the “more is better” mentality, it can be challenging for those in recovery to strike a balanced relationship with movement.

“I tell patients that they need to be both medically and behaviorally cleared for exercise,” Hill says. “What this means is that they need to have stable vital signs and labs, but they also need to be completing meals and snacks and not engaging in compulsive exercise behaviors for the purposes of weight loss or modifying their body.”

Equip’s approach to exercise during recovery

Equip’s Staged Approach for Exercise Reintroduction (SAFER) Protocol is based on the Safe Exercise at Every Stage (SEES) guidelines, which were created by leading experts in eating disorders, sports nutrition, and psychology. These guidelines are intended to assist clinicians through the process of reintroducing activity across all stages of eating disorder treatment. Because of the growing body of evidence suggesting that closely monitored, nutritionally supported physical activity may improve eating disorder symptoms, treatment response, and long-term prognosis, Equip works with each patient and their support system to help them safely navigate recovery and their return to movement.

Hill adds that at Equip, the decision to allow exercise in recovery is made with input from the entire care team, including the patient and families. “I tell families that we all want the same thing: for the patient to be doing all the activity they want to do, but for it to be done in a safe way that supports recovery,” she says. “I’ve seen the addition of activity go both ways in recovery, and it can be very discouraging if we advance too quickly. Because of this, we typically start slow with lower intensity activities like yoga or walks before increasing in volume and intensity to set our patients up for success.”

Lauro agrees, noting that Equip takes a personalized approach that meets each patient where they are. “Our team can guide folks on which activities are safe at which time, and help patients work towards their exercise goals while removing the eating disorder from their relationship with exercise,” she says. “In some cases, we may take a harm reduction approach of gradually reducing exercise, and in other cases it might make sense to go ‘cold turkey’ for a period of time. In either of these situations, we can absolutely work with patients to return to a healthy exercise routine.”

For Yatso-Bukoski, repairing her relationship with exercise was one of the toughest parts of her recovery journey, but one she’s so grateful she had the opportunity to take on. “I have always been extremely competitive, and for so long I was told that I had to stifle that part of myself in order to enjoy athletics again. It was impossible with the constant triggers of diet culture always challenging us to be more driven, more dedicated, more disciplined. The light came on when I chose to lean into my competitiveness rather than try to stifle it. I challenged myself to find mindfulness during cycling instead of burning more calories than my last ride, to complete proper breathing cycles in yoga to calm my mind instead of holding my plank longer than the person next to me, and to challenge myself to get a good night’s sleep instead of attending a 5 a.m. workout class.”

Fostering a balanced relationship with exercise can be challenging in a culture that rewards compulsive attitudes toward fitness. But the pressure to push to the limit can lead to serious mental and physical consequences, regardless of whether others may mistake the effort for pure “healthy” dedication. If you find yourself experiencing guilt, anxiety, or distress when you miss a workout, or if you continue to exercise despite injury or fatigue, your relationship with movement may be problematic. If you or a loved one is struggling, schedule a call with an Equip team member to talk through your concerns.

FAQ

What is the relationship between eating disorders and exercise?

Compulsive or excessive exercise is a common and serious symptom across many eating disorders and may be driven by an unhealthy preoccupation with body weight or shape. For those with eating disorders, exercise is often used as a rigid or compensatory behavior (e.g., to 'burn off' calories or alleviate anxiety), rather than for health or enjoyment.

Is compulsive exercise an eating disorder?

Although compulsive exercise is not a formal standalone eating disorder diagnosis in the DSM-5, it is considered a serious and common symptom or feature of established eating disorders, including anorexia and bulimia, where it is used to control weight and body shape.

What is the treatment for compulsive exercise?

Treatment for compulsive exercise is typically integrated into the overall treatment plan for the underlying eating disorder and involves a multidisciplinary team. Key components of treatment usually include psychotherapy, education, and, if medically appropriate, a gradual, supervised re-introduction of movement.