Body comparisons often lead to a distorted body image and ultimately a drive to be thin or avoid gaining weight - sometimes through food restriction, sometimes through exercise.
"Exercise is often a part of the battle against excess weight during these stages," Markula said. "Many women with exercise dependence simply do not eat if they have not exercised. Exercise can become a way to control, to stay in control of one's eating."
Exercise addiction or excessive exercise is not yet its own disorder in the Diagnostic and Statistical Manual of Mental Disorders; it usually goes "hand-in-hand" with disordered eating or a full-blown eating disorder, according to Claire Mysko, chief executive of the National Eating Disorders Association. "Oftentimes, people with an unhealthy approach to exercise will use the exercise as a compensatory behaviour," Mysko said. "We often frame exercise as a form of purging. Someone with an unhealthy relationship to exercise is counting, 'How many calories have I burned off?' "
And it's an important element of this complex disorder to be aware of. "Eating disorders are notoriously difficult to 'cure', " said Susan Albers-Bowling, a psychologist at the Cleveland Clinic. "There is no medicine for these conditions, and eating disorders have the highest mortality rate of any psychiatric disorder."
Unfortunately, it's difficult to spot someone who is engaging in excessive exercise, for several reasons. First, Mysko said, those who have any sort of eating disorder "are very good at convincing other people they have it under control."
Second, because exercise and fit bodies are lauded in our culture, the dependence can hide in plain sight, or even be celebrated by those who see exercise as purely good. "Many who exercise excessively can admit they are addicted to exercise but can also perceive their addiction as healthy - unlike an eating disorder, which is unhealthy," Markula said. "In their minds, exercise makes them strong and confident" as well as thin.
Finally, a lot of women turn to exercise thinking it will help them recover from their eating disorder, much like Lovato did; it can be good for one's self-esteem and overall well-being to work out regularly.
There are some signs to watch out for if you or someone you love is an avid exerciser and you're afraid that training has reached an unhealthy level, Albers-Bowling said. But one is paramount: "Inflexibility is a huge red flag," she said.
Someone with exercise dependence might be sick with the flu or dealing with a nagging injury and go to the gym anyway. "I've seen clients who are exhausted or injured, and the drive to exercise overpowers their body sending them cues, literally screaming at them to stop," Albers-Bowling said. Another point of rigidity might centre on social outings; people with an exercise addiction may refuse to socialise unless they've done their workout.
Another sign is disruption to one's life. "We often will hear from people who must exercise or work out a certain number of times a day, or for many, many hours a day, to the point where they are disconnecting from life," Mysko said. "The drive to work out is the major focus throughout every day."
Also, a person's feelings about the exercise matter, Albers-Bowling said. "Demi said that working out was not fun," she explained. "Dreading working out, or not experiencing joy or pleasure from working out, is another sign that it has become a problem. If you are working out in secret, inflexible about your workout routine, isolating from friends or family, and feeling guilt or shame from working out - that it is never enough, that you do it even when your body does not feel like it - it's time to consult a professional."
If you notice a friend is exhibiting signs of exercise dependence or an eating disorder, it's important to approach them with compassion. "Give specific examples of your concern," Mysko said. "For instance, 'I am concerned that every time I invite you to hang out, you can't because you need to work out,' or, 'I see you working out through injury.' "
Mysko said persistence is key. "You can't force people to get help, but you can be persistent," she said. "It might not be the first time or the 10th time, but maybe the 11th time they'll be ready to receive that support."
Eric Storch, vice-chair of psychology at Baylor College of Medicine in Houston, said it's important to be prepared if a friend does finally say he or she wants to recover. "When they're ready, it may be helpful to point them toward available resources at National Eating Disorder Association, or even set an appointment at a local clinic or university clinic that has services for body image-related problems," he said. NEDA has a help line you can contact by phone, text or instant message.
While recovery from an exercise addiction "takes therapy and time," according to Markula, it's important to remember that it's very possible with the right support, including a health-care provider as well as a therapist, to ensure the exercise disorder hasn't affected your health. "Have your bloodwork checked out, as compulsive exercise can lead to bone loss, problems with your period, muscle or joint problems, fatigue and inflammation in the body." She also suggests working with a dietician or a trainer who helps set "realistic and reasonable" limits for exercise.
Other aspects of Lovato's recovery have involved not keeping track of weight and only wearing jeans that are comfortable for her. A dietician told her that practising body acceptance instead of body positivity might be a better approach to healing. For all the progress that's happened in our culture because of the body positivity movement, Mysko said, true positivity may feel "inaccessible" or "unrealistic" to someone struggling with an eating disorder.
Body acceptance is about appreciating your body for what it can do instead of how it looks, Mysko said.
"We think about acceptance in terms of what makes your body feel good, what makes you feel strong, what is your personal definition of health, because we have so many mixed, confusing messages about health and wellness today," she said. "For many in recovery, that concept compared to positivity is a little more accessible and more aligned with recovery."
Lovato explained how this looks in practice. "Now when I look in the mirror and I start to have a negative thought, I don't stop and say, 'No, you're beautiful, you're gorgeous, I love you, you're perfect the way you are,' because I don't believe that. So, what I say to myself is, 'No, you're healthy, and I accept you. And that's all I need to do is accept you.'"
