Physical exercise is an important element of healthy human life. However, exercise can also have unhealthy consequences when engaged in excessively and without proper recovery [1]. For example, individuals with eating disorders may exercise in order to lose weight, or purge calories consumed. Individuals may also exercise excessively (beyond the requirements for general health or athletic adaptation) and find themselves unable to control or reduce the exercise volume [2].
It is well established that exercise is used as a weight control method by individuals with eating disorders, particularly anorexia nervosa and bulimia nervosa [3, 4]. Excessive exercise has not yet been classified as a behavioral addiction, compulsive disorder, or other form of psychiatric disorder [5]; however, the existing body of evidence suggests that there are individuals who exercise to a degree that causes them psychiatric distress, but they feel unable to stop (due to a sense of guilt at not completing planned sessions, or fear of severe withdrawal symptoms) [6]. It has been suggested that excessive exercise only occurs as a symptom of eating disorders [7]; however, numerous case studies indicate that there appear to be individuals who exercise to excess, but are not primarily, or perhaps at all, motivated by weight or body image [8,9,10]. Indeed, some researchers have posited a distinction between “primary” and “secondary” exercise addiction, with the primary form characterized by exercise itself as a rewarding experience to be pursued, while in the secondary form, another goal, such as weight loss or relief of anxiety is desired [11]. Due to the lack of clarity around the nature of excessive exercise, we treat this as a separate condition in this manuscript, but refrain from using terms such as “exercise addiction” or “exercise dependence”.
Certain eating disorders [12] and excessive exercise [13] involve a number of signs and behaviors that can be recognized by observers (although these are certainly not sufficient for a conclusive diagnosis). When these behaviors are carried out in a fitness center, it is therefore possible that the employees of that center are in a position to observe these signs [14]. Anorexia nervosa, particularly in an advanced stage, is likely to leave the sufferer at a very low body weight [15]; lanugo may also be visible [16]. Bulimia nervosa may be accompanied by the presence of Russel’s sign on the hand [17]; however, these latter two symptoms are unlikely to be recognized without specific training. Other forms of disordered eating, such as binge eating disorder or orthorexia, may involve no clear physical signs [18]. Indeed, signs such as overweight, in the case of binge eating disorder, may not be interpreted as symptomatic of an eating disorder at all. For this reason, although anorexia nervosa is not the most prevalent eating disorder [19], it may be the most widely recognized based on physical characteristics alone; so-called “weight bias”, the negative attitude towards overweight and obesity, and a corresponding tendency to overlook eating disorders which result in overweight, may also be relevant here [20].
Excessive exercise involves prolonged and regular bouts of physical exercise, a behavior which is potentially apparent to an observer, but which may be seen as healthy and laudable, or the preparation of a high-level athlete [21]. This can be distinguished from compulsive exercise, characterized by an extreme urge to exercise [3]; excessive exercisers may be motivated by this urge, but motivation is not inherent to the definition. There is evidence that individuals who exercise excessively are supported by their friends and family in this behavior [22]. There is also evidence that this behavior is carried out, at least to some extent, in fitness centers. Estimates of between 8% [23] and 43% [24] of “exercise dependence prevalence” have been reported, with Stapleton and colleagues [25] reporting at least a single occurrence in 43% of their male gym-using sample.
While studies for the prevalence of disordered eating amongst fitness center clients are scarce, it is estimated that between 20 and 50% of females with eating disorders engage in excessive exercise [3, 11]. There is also evidence that prevalence of eating disorders among such exercisers is higher than among competitive and organized sports participants [26]. Muller and colleagues reported that 10.9% of their sample of fitness center clients fulfilled the criteria for an eating disorder, as assessed by the Eating Disorders Examination-Questionnaire [23]. Stapleton and colleagues [25] reported at least one occurrence of binge eating or dietary restraint in 35 and 15%, respectively, of male fitness center clients. While exercise in any setting can be a means to lose weight, at least one study of 60 female aerobic exercisers has reported that exercise in the fitness center setting is associated with higher levels of self-objectification, which in turn was related to disordered eating habits [27]. Finally, Lejoyeux and colleagues [24] also reported that 57% of their sample of fitness center clients fulfilled Diagnostic and Statistical Manual of Mental Disorders (DSM) IV criteria for bulimia.
In summary, sufferers of both eating disorders and excessive exercise may display signs and behaviors of their disorders which could arouse suspicion in observers. It is likely that at least some sufferers of these disorders carry out some of their exercise in fitness centers. The majority of fitness centers employ staff and personal trainers who are responsible, among other duties, for ensuring that their equipment is used safely. It is likely that certain individuals suffering from exercise-related psychiatric disturbances and disorders will spend some time in fitness centers, and they may display symptoms that an attentive observer could pick up on. Fitness center employees are well placed to observe these symptoms.
In line with this notion, in a study of 143 Canadian fitness center employees, 62% reported having observed a client that they believed suffered from anorexia nervosa [28]. However, only just over 25% have been trained on how to deal with such a situation. Bratland-Sanda and Sundgot-Borgen [12], in their study of 837 Norwegian fitness instructors, reported that while 89% of instructors self-reported knowledge about eating disorders, only 29% were found to have adequate knowledge. While the authors do not speculate on the causes of this discrepancy, it may be a further example of the role of weight bias, with employees believing that physical appearance is a key indicator, rather than other signs and behaviors. Similarly, Manley, O’Brien and Samuels [29] reported that 32% of fitness instructors, compared with 88% of pediatricians, were accurately able to identify a case of anorexia nervosa presented in a case study. In their study of eating disorder characteristic recognition, Worsfold and Sheffield [30] reported that 80% of fitness instructors failed to recognize that a case study involved symptoms of an eating disorder. By contrast, only 40% psychologists failed to identify this. The authors also note that 36.7% of fitness instructors suggested that the behavior of the individual presented in the case study was desirable in achieving weight loss goals.
To date, no study has examined whether fitness center employees suspect that certain clients may be exercising excessively. As this behavior is still not an established psychiatric condition [5], it is also unclear whether fitness center employees are aware of it, or if they differentiate between excessive exercise and exercise related to an eating disorder. As the debate about the definition and categorization of excessive exercise habits is ongoing [31], fitness center employees represent an important source of information about the possible behaviors and indicators which may be observed in excessive exercisers. Crucially, they may also provide insight into whether these behaviors appear to differ from those shown by individuals who they suspect of eating disorders.
The aim of this study is therefore to determine whether fitness center employees in Switzerland believe they have observed clients who they suspect had an eating disorder, or were training excessively. While a small number of studies have examined employee responses to suspected eating disorders, none have to date addressed excessive exercise. Consequently, our study not only provides further insight into current approaches to two distinct conditions, but allows an understanding of how fitness professionals view the differences between the two, for instance by asking whether they have suspicions regarding the motivations of those they observe. Our study is the first to assess both disorders in a single questionnaire. By including excessive exercise, we hope to target the perspective of fitness professionals and gain valuable insight into a condition that is frequently only addressed from the psychiatric perspective.
This study does not aim to establish causal relationships between fitness center attendance and exercise-related disorders. We do not make statements about the degree of responsibility that fitness center employees have with regards to psychiatric conditions. This study is intended to be an exploration of the current behavior and concerns of fitness center employees.