Undergraduate perspective on Sports & Exercise Medicine – a BJSM blog series

By Daniel Taylor-Sweet (@dtaylorsweet)

We all know exercise is probably the single best activity to do if you want to keep healthy. On a daily basis we encourage patients to exercise more, persuade ourselves to go to the gym and read the innumerable public health campaigns aiming to increase our societies exercise levels. But as with any good thing, too much exercise can become detrimental.

Exercise addiction is an issue that is rarely talked about in medicine – the main reason for this revolves around the misconception that being ‘addicted’ to something that is so inherently healthy is not in fact a problem at all. Some high-level professional coaching staff would probably argue that in order to succeed at the highest levels an athlete must be addicted. However, when you begin to dive into the problems that surround exercise addiction it becomes apparent that SEM should focus more attention here.

Exercise Addiction Definition

Exercise addiction can be described as having a persistent craving for leisure-time physical activity, resulting in uncontrollable excessive exercise behaviour that manifests in physiological (e.g. tolerance or withdrawal) and/or psychological (e.g. anxiety, depression) symptoms.[i] (1)

Epidemiology of Exercise Addiction

Most studies estimate the prevalence of individuals addicted to exercise to be between 3-3.7% of the exercising population, with some having estimates as high as 10%. Several studies have placed the rates of addiction within professional athletes to be much higher than this.

Evidence currently suggests that there is an equal risk of exercise addiction within both sexes.

Symptoms of Exercise Addiction

The signs and symptoms to look out for in an athlete or patient with exercise addiction are:

• Exercise becomes the most important element of a person’s life
• The athlete may comment on increased levels of (social) conflict in their life
• Mood swings and alteration of mood
• Increased tolerance to usual exercise regimes
• Withdrawal symptoms (anxiety, pain, sleep disturbance & depression are common)
• A sensation of loss of control over their life

These become harder to distinguish in a professional athlete due to the nature their schedule and training frequency but they are still vital signs to attempt to identify.

Complications of Exercise Addiction

Exercise addiction is associated with both psychiatric and physical complications.

Individuals who are addicted to exercise are more likely to suffer from depression and anxiety as well as having an increased risk of addiction to other activities and substances such as gambling and alcohol[ii] (2). Physically, one of the most significant issues that occurs in exercise addiction is overtraining. Overtraining is a well-documented phenomenon and is a great cause of morbidity and lost training hours in professional athletes[iii] (3).

Importantly, exercise addiction has been shown to have a close relationship with eating disorders. It is estimated that between 39-48% of patients with an eating disorder will also have an addiction to exercise[iv] (4) and thus is an important factor to consider in an athlete presenting with addiction to exercise.

Identification of Individuals at Risk of Addiction

Alongside a clear consultation, the use of the fully validated ‘Exercise Addiction Inventory’ (or EAI) questionnaire by doctors is a very quick and accurate method of identifying those at risk[v] (5). It is 6-question 5-point Likert scale for patients/ athletes to complete (see below). A score of 24 or above out of 30 indicates a risk of exercise addiction and warrants further investigation, support and counselling.

Support of Addicted Individuals

A multi-disciplinary team approach is best used when caring for an athlete or patient with an addiction to exercise[vii] (7):

• Nutritional optimisation with the help of a dietician
• Complete medical assessment for any comorbidities and subsequent management
• Cognitive behavioural therapy (CBT) has been shown to be effective in addicted individuals[viii] (8)
• Group therapy sessions can be useful for some patients
• A phased, re-entry to safe training supervised by coaches and physiotherapists
• Completion of learning modules aiming to re-educate athletes about safe training and healthy levels of exercise

Conclusion

Exercise addiction is a hidden burden on many professional and recreational athletes alike. It can lead to the development of many psychiatric and physical illnesses while putting the athlete in question at risk of damaging his or her sporting career. It is a condition that needs greater public recognition, as the consequences can be huge and the solutions are generally simple and relatively cheap to implement. As an SEM doctor or allied health professional it is vital to recognise the signs and symptoms of exercise addiction in your patients, as these individuals are unlikely to present for help with their addiction and are able to be helped.

References

1. Hausenblas, H. A., & Symons Downs, D. (2002). How much is too much? The development and validation of the Exercise Dependence Scale. Psychology & Health, 17, 387-404.
2. Aidman EV, Woollard S. The influence of self-reported exercise addiction on acute emotional and physiological responses to brief exercise deprivation. Psychol. Sport Exerc. 2003;4:225–236.
3. Whyte, Gregory; Harries, Mark; Williams, Clyde (2005). ABC of sports and exercise medicine. Blackwell Publishing. pp. pages=46–49.
4. Hausenblas HA, Downs DS. How much is too much? The development and validation of the Exercise Addiction scale. Psychology and Health. 2002;17:387–404.
5. M Griffiths, A Szabo, and A Terry . The exercise addiction inventory: a quick and easy screening tool for health practitioners. Br J Sports Med. 2005 Jun; 39(6): e30.
6. M Griffiths, A Szabo, and A Terry . The exercise addiction inventory: a quick and easy screening tool for health practitioners. Br J Sports Med. 2005 Jun; 39(6): e30.
7. Cumella, Edward (September 2005). “The heavy weight of exercise addiction”. Behavioral Health Management 25 (5): 26–31.
8. Freimuth, Moniz, and Kim. Clarifying Exercise Addiction: Differential Diagnosis, Co-occurring Disorders, and Phases of Addiction. Int J Environ Res Public Health. 2011 Oct; 8(10): 4069–4081.

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Daniel Taylor-Sweet is fifth year medical student at Glasgow University. He is keen on all things Sports & Exercise Medicine related and is interested in pursuing a career within the field.

Dr. Liam West (@Liam_West) coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.