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Black box warning: when exercise is not medicine
  1. Dusty Marie Narducci
  1. Department of Family Medicine and Department of Sports Medicine, University of South Florida, Tampa, Florida, USA
  1. Correspondence to Dr Dusty Marie Narducci, USF Health Morsani College of Medicine, Tampa, FL 33612, USA; dustymarienarducci{at}

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Is it possible for exercise to become excessive and unhealthy, and if so, when? Is this threshold different in athletes versus non-athletes? Is it customary for an athlete to track caloric intake and workouts in a manner as habitual as brushing one’s teeth yet fail to have sufficient energy availability for healthy function? Indeed, the adverse psychological and physiological effects endured by athletes who far exceed exercise guidelines in an unhealthy fashion may go undetected if these behaviours are considered normal or permissible. The aim of this editorial is to illustrate how even the well-trained sports and exercise medicine (SEM) clinician can overlook an athlete engaging in unhealthy exercise and eating behaviours, and how the field of SEM can better support this unrecognised population of athletes.

A missed opportunity

Eating disorder specialists care for a patient population including athletes where excessive exercise can become harmful and sometimes even fatal. Behaviours such as self-induced vomiting and caloric restriction causing emaciation are notoriously concerning, yet a confirmed case of unhealthy exercise or malnourishment without obvious health consequences is unlikely to be recognised as problematic.

Given that SEM clinicians routinely use exercise and nutrition to prevent and treat chronic illnesses, the threshold for defining unsafe activity and inadequate nourishment may be unclear. Athletes may have complicated incentives steering them towards pathological exercise, often feeling obligated to undergo high levels of training to meet scholarship, income, personal goals and athletic commitments. Therefore, individuals who …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.