Bulimia involves bingeing and purging and often conjures up the image of a woman consuming huge quantities of food followed by vomiting to eliminate the unwanted calories. This image is often accurate. But bulimics do not always purge through vomiting. Certain individuals elect to purge through extreme exercise (compulsive exercising). Some are simply incapable of inducing vomiting. Others find vomiting aversive. Still others choose exercise because it is more socially acceptable.

Bingeing embraces a host of negative medical complications. The ingestion of a large volume of food at one time places a tremendous burden on the digestive system. This may result in rupture of the esophagus or stomach or, in rare cases, intestinal blockage. Spontaneous regurgitation may occur due to sheer overload. Most complications of bingeing are long term; the greatest is weight gain. A binge can last for hours. Regardless of how the calories are purged, some calories will be absorbed and lead to weight gain. Above-normal weight can result in myriad medical complications, such as hypertension, elevated cholesterol and triglycerides, and type 2 diabetes.

Purging through exercise may keep weight down, but this is not always the case. If an individual binges twice a week and exercises compulsively every day, weight may remain unchanged. Reverse the frequencies of these behaviors, however, and the individual will become overweight.

The most significant dangers of extreme exercise are overuse syndromes such as stress fractures, heart arrhythmias where metabolism has been altered, and amenorrhea.

Stress fractures are micro-fractures of the bone, typically in weight-bearing areas such as feet and lower legs. Stress fractures develop from repetitive, high-impact, weight-bearing aerobic activity. Eating disorder patients, because they often have bone loss from osteopenia or osteoporosis, are particularly susceptible to stress fractures. Often stress fractures do not show up on x-rays but require a bone scan or MRI. Stress fractures limit a woman's ability to exercise, lead to pain during exercise and long-term pain if not allowed to heal, and increase the risk of major bone fractures which may ultimately promote curvature of the spine. Treatment includes resting the extremity, use of assistive devices if it is painful to walk, and avoidance of the repetitive activity that caused the fracture. In eating disorder patients with malnutrition, treatment also includes calcium and vitamin D supplementation, weight restoration, and resumption of normal menstruation.

Heart arrhythmias result from reverse metabolism. In response to rapid weight loss, the body protects itself from further loss by slowing the metabolism. A woman will experience reduced body temperature and resting heart rate. She may incorrectly perceive her lowered heart rate as positive heart health due to exercise, but the heart has slowed in an effort to expend as few calories as possible. The long-term implications of reduced heart rate are the potential for arrhythmias and the prolonging of the heart's electrical conduction with possible sudden death.

Amenorrhea results from significant and rapid weight loss and leads to osteopenia and osteoporosis-dangerous losses of bone density that may result in other more serious complications.

Excessive exercise also offers another built-in reinforcement: it increases endorphin levels, providing the individual with a sense of well-being. The endorphin levels remain high even though the individual is seriously, and perhaps permanently, compromising her own health. Studies are currently being conducted to ascertain and better understand the addictive nature of exercise.

In trying to evaluate whether exercise levels have gone from reasonable to excessive, the following questions might be asked:

Do you feel guilty if you miss your workout?

Do you still exercise when you are sick or hurt?

Would you miss going out with friends just to ensure you got your workout in?

Do you freak out if you miss a workout?

Do you calculate how much to exercise based on how much you eat?

6. Do you have trouble sitting still because you're not burning calories?

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