Over Exercise: How Should the Recreation Facility Respond?

July 04, 2011

Karen S. Miller
Registered Dietitian/Nutrition Educator
Edited by Christopher Dulak, Dr. Janet Crawford, Katie James
University of Nebraska-Lincoln

Introduction
Imagine you are walking by a sauna and you see a woman doing steps on the benches; or you see a male participant who has moved an exercise bike into a sauna to exercise. Imagine you are seeing a middle aged women exercising on a treadmill, her body emaciated to the point of having no muscle tone. Or you see a “normal” weight participant who has been working out in the building for three hours. What is your response, what action is appropriate?

You may ask: “So what?” What “should” we do? What is appropriate? We know it’s an issue, but what action do we take?”

Occasionally there will be a story of over-exercise to bring the subject to the headlines. People Magazine reported on Peach Friedman in “Exercise Almost Killed Her” (Souter, et al, 2006). In a side bar segment they also mentioned actress Jamie-Lynn Sigler and her bout with “exercise bulimia.” Today’s Dietitian reported: “Exercise Abuse: Too Much of A Good Thing” (Jackson, 2005). And Fitness Magazine carried: “I Am an Exercise Addict” (Schein & Copeland, 1994).

In a society that idealizes and promotes the perfect body; with role models like The Biggest Loser (at least 4-5 hours of exercise daily) and with the pursuit of rock hard abs and tight butts, how much exercise is too much? When is it time for the fitness profession to step in and say ENOUGH IS ENOUGH!?
What is Healthy Exercise?
According to the 2007 combined recommendations of American College of Sports Medicine (ACSM) and the American Heart Association (AHA) (Haskell, et al, 2007), adults age 18-50** healthy exercise should include:

• At least 30 minutes of moderate-intensity aerobic activity five days a week or
• At least 20 minutes of vigorous-intensity aerobic activity three days a week
• A mix of the two intensities and/or short bursts of exercise for 10 minutes each will be adequate
• Recommendations are also made for at least two days a week of strength training using 8-10 exercises involving major muscle groups for 8-12 repetitions.

**additional recommendations are made for healthy individuals over the age of 65 and over the age of 50 with chronic diseases.

The United States Department of Health and Human Services recommends 150 minutes of moderate intensity exercise a week and muscle strengthening exercise two days a week.

What is Over Exercise?
When is exercise “too much”? And, how can something so “healthy” be considered excessive? Exercise may be considered to be excessive when it significantly interferes with important activities, when it occurs at inappropriate times or in inappropriate settings, or when the individual continues to exercise despite injury or other medical complications (American Psychiatric Association DSM-IV, 1994). Others have asked whether quantity of exercise is actually the problem.

Thompson (2005) suggests exercise could be discussed in terms of excessive, compulsive and/or obligatory. Excessive exercise may refer to quantity of exercise. One example of excessive exercise is the student who does 500 sit-ups three times a day, every day. Compulsive exercise according to Thompson is related to the “need” to exercise. An individual who is a compulsive exerciser “must” exercise to relieve the anxiety related to not exercising. In obligatory exercise, exercise is not a choice. The individual will exercise in spite of injury, illness, social engagements, and/or interference with relationships. Compulsive and obligatory exercise may or may not be related to quantity, frequency, duration or intensity (Thomson, 2005). More simply, exercise becomes a problem when it interferes with, instead of enhances, a person’s quality of life.

Regardless of the definition we use for excessive exercise, determining if an individual’s exercise routine is excessive or “not healthy” is difficult (Powers & Thompson, 2008).

Are there Health Risks of Over-Exercise?
The compulsion to over-exercise may go hand-in-hand with an eating disorder (Herrin, M & Matsumoto, N, 2007). It is estimated that 33%-80% of eating disorder patients struggle with excessive exercise (Ktaz, J.L., 1996). Health risks range from becoming over-tired to sudden death. Specific health risks associated with over exercise include: a decrease in sex hormone levels; impaired bone health; musculoskeletal abnormalities, reduced immunity, and cardiovascular abnormalities including sudden cardiac death (Powers and Thompson, 2008). One sometimes overlooked consequence of over exercise is the diminished quality of life.

Why Should We Care?
Health consequences of someone who is over-exercising AND struggling with an eating disorder are a clear concern to any recreation facility. Over-exercising without an eating disorder also presents issues of concern due to the potential for over-use injuries. As a recreation facility the question becomes where does personal choice of the participant end and the recreation facilities liability begin?

What Should We Do?
The National Intramural-Recreational Sports Association (NIRSA) list-serve was surveyed in fall 2009 about the issue of over-exercise policies. The questions asked were:

We are looking into what other campuses are doing related to known participants who are over-exercising or have severe eating disorders. Please answer the following questions:

1. Are you doing anything about these issues?
2. Do you know of best practices relating to these issues?

Seventeen schools responded with four schools sending fairly comprehensive policies. Five schools reported general guidelines and eight schools indicated an interest in the subject, trying to formulate policies and/or have had a policy but no longer have a policy. All respondents reported that it is an important issue that needs to be considered and worked on. Best practice and bench marking is difficult as over-exercise is not a new issue but is a new issue being addressed by recreation facilities.

Several schools indicated they were looking at policies related to high risk behavior (i.e. hours on fitness equipment, hours in the gym) as opposed to eating disorders. It is much easier to identify participants who are exercising “too much” than it is to identify participants with eating disorders. However, identifying a participant who over-exercises in terms of time does not necessarily identify the compulsive or obligatory exerciser, or exerciser that also has an eating disorder.

Other schools are taking action. Some are monitoring the amount of time participants are on machines; some have written policies that state staff will report suspected over-exercise behavior to health services; and schools have suspended membership of participants who show signs of over-exercise. There are schools that previously had policies and decided to suspend them by adopting a more “don’t ask, don’t report, don’t tell” philosophy.

What should we do? Professional Input
Amy Gleason (McGough, 2004) states that there is a liability to the fitness facility from participants are over-exercising. Whether a participant has an eating disorder or not, over-exercise can cause harm. However an individual who suffers from over-exercise and also have an eating disorder poses a larger risk. Eating disorders can result in dehydration, heart abnormalities, hypoglycemia, electrolyte imbalances and other physical ailments. These are all concerns if a person is not exercising; when a person is exercising excessively and has an eating disorder, any of these things could cause an exerciser to pass out and result in injury. This is a safety issue as well as a liability issue.

For an individual to make changes the “person must first be aware of the behavior that needs to be changed” (Powers and Thompson, 2008). This is the issue in a fitness facility. The participant may or may not be aware that their exercise is excessive or of concern to others. The first step with intervention is identifying the person and then approaching the person. Adrienne Ressler, M.A., C.S.W. training director for the Renfrew Center (an eating disorder treatment facility), suggests that the person with the best relationship with the participant be the one to approach him/her and express concern. She suggests starting with the least intrusive intervention, i.e. a conversation. Document each conversation a staff person has. Ressler suggests that there may become a time when the facility can no longer accept liability for the over-exercising participant. However, restricting access to the facility should be a last resort. Start a conversation, express concern, discuss healthy activity, and possibly ask for a doctors exercise release before denying access (Heaner, 2003).

Carolyn Costin, Director of the Monte Nido Residential Treatment Facility in Mailbu, California used information first directed toward female athletes (Rosen, 1986) and adapted it to be used for intervention guidelines for individuals who are over-exercising who are not athletes (Costin, 1996). These guidelines include:

1. Identify an individual within the facility staff that has good rapport with the participant.
2. Remain nonjudgmental and identify specific behavioral concerns, i.e. “I’m concerned that I see you in the facility three hours a day”. “I’m concerned that I’ve seen you exercise when you appear injured.”
3. Allow the participant to respond, but do not argue with the participant.
4. Let the participant know that you are not there to revoke exercise privileges, but sometimes that is the natural consequence through injury or increased physical risk.
5. Assess the participant’s reaction.
6. You may need to speak with the person again. Often one intervention is not enough.
7. If the participant continues to exercise at what you would judge to be an unsafe way, consult other professionals on campus that can help with an intervention.
8. Be sensitive. It’s not as easy as a person just being able to stop.
9. Document, document, document. Be specific in your documentation. What did you say? What was the person’s response?
10. Repeat from the top. If you are genuinely concerned for the health and safety of the participant, it is time to work with others in your facility and/or on campus to assure the safety of your participant and reduce the liability of the facility.

Tracy Noonan a physical therapist in Boston Massachusetts says: “be non-confrontational, but do address the topic” (McGough, 2004). Amy Gleason suggests the staff express concern and discuss basic healthy exercise guidelines. She also suggests having resources available to offer to the participant (McGough, 2004).

Are There Consequences of Intervention?
Even if there is an intervention, and recreation memberships are put on hold, true over-exercisers may find other avenues to exercise, if they do not get the appropriate help. One student from DuPage College stated that when her mother cancelled her membership to a gym, she would get up in the middle of the night and exercise at home in her room (Souter, 2006). Other students may have more than one gym membership or will exercise several times in one day exercising in different locations. Alayna Yates (1991) asks the question “Should people be allowed to abuse their bodies in ways which invite permanent damage?” Her response is “unless they are causing substantial, life-threatening damage to the body, adults cannot, and should not be forced to treatment.” Treatment is different than having an intervention that reduces the liability of the facility the individual is exercising in. We care about our participants, and at the same time we want to reduce our liability.

The issue of discrimination must also be considered when intervention with over-exercisers is discussed. Tracy Noonan a physical therapist in Boston (McGough, 2004) reports that eating disorders are classified as a disability. Therefore the facility must stay within the Americans with Disabilities Act. Noonan suggests the best way to do this is for the facility to have guidelines in place for participants to have medical clearance for all facility users prior to beginning exercise (McGough, 2004).

Now what?
At the very least, education is important. Develop a relationship with Health Services providers, both medical and counseling providers. They may actually be the first to recognize that a student is over exercising and may be in the best position to intervene. Educate athletic training staff in your facility to recognize over-use injuries.

Often when the subject of intervention with over exercising participants is discussed more questions than answers occur. Questions like what will happen if we do approach the client? Are we more liable if we confront? Is the “don’t ask, don’t tell” approach better and leaves us with less liability? What is our liability? Will we be sued for discrimination? These questions and concerns are all valid. However, what is the liability of the facility if there is concern expressed about a participant and nothing is done to intervene. Think of the swimmer who is going to dive into the three-foot end of your facility pool. If you don’t intervene, there very well could be a lawsuit. Over-exercise is like diving into a three-foot pool, the difference is an over exerciser may be able to continue the behavior for a long time before there are consequences. But, will the facility be liable when those over exercise consequences occur?

If you choose to write a policy, have the support of your campus. Work with your campus dietitian, counseling staff, eating disorder treatment team, medical practitioner, dean of student affairs, judicial affairs, risk management and legal counsel. Campus climate regarding these issues vary from place to place in the country. Be aware that there are many on campus that may have opinions related to how you handle the over-exercising participant.

Ultimately the best interests of the participant are served by our concern. The goal of the fitness industry should be to increase safety of the participant and decrease liability to the facility. While there are no clear-cut answers, making safety and reduced liability a priority will ensure the development of optimal procedures for your facility.

Resources
American Psychiatric Association (APA). 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed (p. 546) Washington D.C.

Costin, C. (1996). Activity disorder: too much/little of a good thing. The Eating Disorder Sourcebook. pp. 37-52. Los Angeles, CA: Lowell House.

Haskell, W.L., Lee, I-M., Pate, R., Powell, K.E., Blair, S.N., Franklin, B.A., Macera, C.A., Heath, G.W., Thompson, P.D., Bauman, A. (2007). Physical activity and public health: updates recommendation for adults from the American college of sports medicine and the American heart association. Medicine & Science in Sports & Exercise 39:8, pp 1423-1434

Heaner, M. (2003). The quest for the perfect body. Reebok Alliance News. 24, pp 1-4.

Herrin, M. (2003). Nutrition Counseling in the Treatment of Eating Disorders. New York, NY:Brunner-routledge.

Herrin, M. & Matsumoto, N (2007). The Parents Guide to Eating Disorders, 2nd edition. Carlsbad CA: Gurze Books.

Jackson, K. (2005). Exercise abuse: too much of a good thing. Today’s Dietitian. March 2005, pp.52-55

Katz, J.L.(1996). Clinical observations on the physical activity of anorexia nervosa. In W.F. Eplin & W.D. Pierce (Eds.) , Activity Anorexia: Theory, Research and Treatment (pp. 199-207). Mahwah, NH: Lawrence Erlbaum Associates, Inc.

McGough, S. (2004). http://www.mclean.harvard.edu/pdf/news/fitnessmanage0704.pdf

Nelson, M.E., Rejecski, J., Blair, S., Duncan, P.W., Judge, J.O., King, A.C., Macera, C.A., Castaneda-Sceppa, C. (2010). Physical Activity and Public Health.

Powers, P. and Thompson, R (2008). The Exercise Balance (pp 41-60). Carlsbad CA: Gurze Books.

Rosen LW, McKeag DB, Hough DO, Curley V Pathogenic weight-control behavior in female athletes. Phys Sportsmed. 1986; 14:79-84

Schein, P. and Copeland, J (1994) I am an exercise addict. Fitness Magazine. March/April 1994, pp. 67-69.

Souter, E., Wong, M., Zawel, M., Mascia, K., Harmel, K. Breuer, H., Atlas, D., Grout, P. (2006). Exercise almost killed her. People. May 15, 2006, pp. 165-170.

Thompson, R. (2005). Excessive Exercise: Quantity, quality and more. Perspective: A Professional Journal of the Renfrew Center (pp 1, 7-9). Winter 2005.

U.S. Department of Health and Human Services (2008). 2008 Physical Activity Guidelines for Americans, pp 21. http://www.health.gov/paguidelines/.

Yates, A. (1991). Compulsive Exercise and the Eating Disorders. New York, NY: Brunner/Mazel, pp. 198-199.