Exercise is often celebrated for its positive impact on health, encompassing benefits such as improved cardiovascular function, reduced risk of chronic diseases, enhanced mood, and increased longevity.

Yet, there exists a less-explored dimension to exercise that is equally important to understand: the side-effects of exercise on health and wellbeing. By recognising and mitigating these risks, individuals can foster a more sustainable and balanced approach to physical activity.

Overtraining Syndrome

OTS arises from excessive and prolonged exercise without adequate recovery. Pushing the body beyond its limits can lead to physical and mental repercussions. OTS manifests with symptoms of fatigue, decreased performance, mood disturbances, and compromised immune function. Recognising the signs of OTS and incorporating sufficient rest and recovery into one's exercise regimen is crucial for preventing it.

Psychological stress

While exercise is commonly touted as a stress reliever, it can paradoxically become a source of psychological stress for some individuals. Overwhelming pressure to achieve certain fitness goals can lead to anxiety, depression, or obsessive-compulsive tendencies. Practising mindfulness, setting realistic goals, and seeking professional support when needed can all help mitigate these stressors.

Exercise addiction

Exercise addiction, also known as "exercise dependence" or "compulsive exercise", is a condition characterised by an obsessive and uncontrollable need to exercise. It can lead to negative consequences, including physical injuries, social isolation and a distorted self-image. Factors contributing to exercise addiction may include genetics (a tendency for addictive behaviours), personality traits and societal pressures.

Exercise-related injuries

Exercise is associated with an inherent risk of injury, especially when performed without a proper routine or under excessive loads. Injuries range from acute issues like sprains and strains to chronic conditions such as tendinopathy and stress fractures.

Risk factors include improper warm-up, inadequate cool-down, overuse of same musculoskeletal groups, and inadequate flexibility.

Social isolation

Excessive dedication to exercise can lead to social isolation as individuals prioritise their workouts over social interactions. This isolation can impact relationships and mental wellbeing.

Body dysmorphia

In the pursuit of an ideal physique, some individuals may develop body dysmorphic disorder, a mental health condition characterised by a fixated preoccupation with perceived flaws or imperfections in their physical appearance. Exercise can exacerbate BDD, as individuals may engage in extreme training or dietary practices to attain an unrealistic body image.

Nutritional imbalances

Engaging in rigorous exercise routines can sometimes lead to nutritional imbalances. Athletes may be at risk of inadequate calorie intake, micronutrient deficiencies, or disordered eating patterns like anorexia and bulimia. Conditions such as “orthorexia”, where individuals obsessively focus on eating only "healthy" foods, can also develop.

Exercise and accelerated ageing

Excess exercise can accelerate joint degeneration, leading to premature arthritis in some people and the need for joints replacement at a higher rate or an earlier age than others. In addition, when working out in the sun, like running, swimming or sailing for extended periods of time, a faster skin ageing process, known as dermatoheliosis can develop, along with the risk of potential skin cancers.

Exercise and risk of atrial fibrillation

Atrial fibrillation is a common heart rhythm disorder characterised by irregular and often rapid heartbeats. Studies have suggested that long-term, high-intensity endurance exercise, such as marathon running or long-distance cycling, has been associated with a mildly to moderately elevated risk of atrial fibrillation. The exact mechanisms behind this association are not fully understood, but it is thought that prolonged, strenuous exercise may lead to structural and electrical changes in the upper heart chambers known as atria, leading to atrial fibrillation.

Exercise and sudden death risk

There is a small but noteworthy risk of sudden death associated with vigorous physical activity, especially in specific populations and situations. This is a vast – and at times controversial – medical topic, but suffice to mention that sudden death during exercise is most often attributed to cardiac events, such as arrhythmias or a heart attack. These events tend to occur in individuals with underlying heart conditions, even if they are unaware of them. Such conditions include coronary artery disease, cardiomyopathy, primary electrical diseases and congenital heart defects.

It's crucial to recognise the warning signs that may precede exercise-related cardiac events, such as chest pain, shortness of breath, dizziness, palpitations or unexplained fainting. Individuals experiencing these symptoms during exercise should seek immediate medical attention.

In addition, but rarely so, a life-threatening condition called “comotio cordis” can take place when there is a sudden blow or impact to the chest, causing a disruption in the heart's electrical system and immediate collapse/sudden death. It is most commonly seen in contact sports like martial arts, or in activities where high-velocity projectiles are involved, such as baseball, hockey or lacrosse. The risk is highest in children and adolescents, whose chest walls are more flexible and less protective.

Exercise and menstrual changes in young women

Intense and prolonged exercise, particularly in sports that emphasise leanness, can lead to “amenorrhoea”. This refers to the absence of menstruation for three or more consecutive menstrual cycles. Hormonal imbalance from low body fat levels and energy deficits are thought to play a role in this condition.

Even in the absence of amenorrhoea, some female athletes may experience irregular menstrual cycles. This can manifest as changes in cycle length, missed periods or alterations in menstrual flow.

In addition, in younger female athletes, intense exercise can potentially delay the onset of puberty. These exercise-related menstrual changes can also have potential implications for bone health as prolonged periods of low oestrogen levels seen in these settings, could increase the risk of bone density loss, potentially leading to osteopenia or osteoporosis.

The “female athlete triad” is a term used to describe the interrelated conditions of amenorrhoea, disordered eating and low bone density.

While these “dark sides” highlight the potential risks associated with exercise, it's essential to emphasise that exercise, when approached mindfully and in moderation, remains a critical component of a healthy lifestyle. Individuals should strive for a balanced and informed approach to exercise, prioritise their wellbeing, and seek professional guidance when needed.

• Joe Yammine, MD is a consultant cardiologist at the Bermuda Hospitals Board. The information here is not intended as medical advice or as a substitute for professional medical opinion. Always seek the advice of your physician