- To outline basic classifications and the characteristics of eating and exercise related disorders.
- To effectively manage the needs of clients with eating and exercise related disorders.
- To avoid potentially harmful expressions to this population.
- To communicate effectively with clients with eating and exercise related disorders.
This article is intended to provide practical information for trainers to use within their scope of practice to serve clients displaying eating and exercise disorder behavior. It is not to serve as an advisory on curing or treating eating disorders, nor is the guidance in this article meant to serve in place of a specially qualified mental health professional.
Every day, fitness pros work, often unknowingly, with a silent and gravely at-risk population. Eating and exercise related disorders disrupt the lives and influence the choices of millions of people. According to eating disorder specialist and dietician, Christina Scribner, research has shown that the genetic risk for Anorexia alone “is thought to be as high as 76% and 83% for Bulimia, with greater prevalence among adolescent or young adult females” (C. Scribner, personal communication, January, 2013). However, these eating and exercise related disorders are not just for girls. According to a 10 year longitudinal study, Project EAT-III, one third of boys were found to be using unhealthy ways to control their weight (Neumark-Sztainer, Wall, Larson, Eisenberg, & Loth, 2011). This is not even counting what has become the “catch all” category of EDNOS (Eating Disorder Not Otherwise Specified).
What this has to do with the Fitness Professional
The ACE Health Coach Manual devotes several pages to eating and exercise disorders. It advises readers, “While diagnosing and treating eating disorders falls outside of a health coach’s scope of practice, health coaches are often among the first to discuss the topic with individuals who are at risk or are already coping with eating disorders…”
Table of Terms:
The World of Eating Disorders (ED)
Given how EDNOS is becoming a more vague and catch-all clinical category for the time being, Eating Disorder specialist, Camilla Mager, Psy.D., uses four primary categories to describe the disorder spectrum (C. Mager, PsyD., personal communication, January, 2013). In any of the items below, BDD (distorted body image) may be present:
- Binge Eating
- Anorexia Nervosa (AN)
- Refusal to maintain bodyweight within the normal range for age and height (> 85% norm).
- Intense fear of and obsession with gaining weight
- Distorted perception of body weight and/or image
- Denial of being extremely underweight
In postmenarcheal women (not yet experienced menopause), the disorder is marked by the absence of one's period at least three months in a row.
- Bulimia Nervosa (BN)
- Recurrent episodes of binge eating (uncontrollable, compulsive, excessive eating, usually in secret) combined with recurrent inappropriate compensatory behavior (e.g., self-induced vomiting, misuse of laxatives and/or diuretics, extended periods of time on the toilet to void meals, fasting or excessive exercise)
- Excessive exercise is used more than purging as a compensatory measure
- Binge Eating
- Recurrent episodes of uncontrollably consuming large quantities of food in the absence of the regular use of compensatory measures
- Dysfunctional patterns of food restriction, such as not eating adequately during the day, leading to subsequent binge behavior
- Unhealthy obsession with eating only healthy food
- Exemplified by severely limited diets in the name of healthy eating and purity
- Consumed with overall "health benefits" of food (e.g., how the food was processed, prepared, etc.) in the same way an anorexic or bulimic person's thoughts are consumed with calories, volume of food, grams of fat, etc.
Nutritionist and eating disorder specialist, Sondra Kronberg, states that when the thoughts, actions, beliefs and consequences around eating and/or exercise take up space in a person’s mind and interfere with the quality of his/her life, it is a red flag (S. Kronberg, personal communication, January 21, 2013).
Although definitive criteria has yet to be established, other potential red flags for eating disorder behavior include:
- engaging in compensatory measures for consuming food or drink,
- determination to burn a certain number of calories regardless of immediate condition, and
- designating little time for friends, family or other recreation; limiting their hours to work and exercise.
The same red flags that apply to eating disorders apply to exercise related disorders (DEX) as well. The prevalence of exercise related disorders is becoming more widely recognized among the athletic and non-athletic communities and is often connected to ED. According to Eating Disorders in Sport, excessive exercise is thought to affect between 33-80% of athletes and is one of the last symptoms to improve in treatment (Thompson & Sherman, 2010).
The criteria for excessive exercise is still widely debated. However, two points largely agreed on:
Meyer et al., 2011
- The client feels “intense guilt” if exercise is missed (Bryant, Green, & Newton-Merrill, 2013).
- Excessive exercise, ‘‘significantly interferes with important activities, occurs at inappropriate times or in inappropriate settings, or continues despite injury or other medical complications’’(American Psychiatric Association [APA], 2000).
DEX Up Close
Clients may obsess about particular exercises and avoid others to prevent “bulkiness” or to maintain slender arms, etc., regardless of whether or not it makes sense to the trainer. Their relationship with exercise can be a tortured one. A person suffering from DEX often uses exercise as a form of punishment or retribution for extra calories consumed, while continuing a workout until the point of physical exhaustion, which serves as the sign to end exercise. Any changes to exercise, including missing a workout, may trigger anxiety and bring about a sense of loss of control.
This obsessive behavior may worsen after experiencing injuries. Physical therapy protocol can exacerbate the compulsion for perfection and fear that the prescribed exercises will change the shape of their body.
Ask yourself, "Where does response crossover from healthy self care into compulsion and disorder?" It’s a fine line sometimes. Training ED clients is extremely tricky as none of the findings are conclusive enough yet for a standard definitive criterion to be established.
“Irrespective of the volume or frequency of exercise activity, the quality of the exercise—or the exercise mindset—is what links DEX to eating related pathology” (Calogero & Pedrotty-Stump, 2010).
Whether a person is wrestling with ED, or DEX alone, can be nearly impossible to discern. These disorders are often interrelated and can easily present in some sort of combination with each other. Consequently, warning signs, red flags and triggers can apply for multiple disorders.
The Physical Red Flags
The following are several physical changes, or red flags, which may be observed by trainers or mentioned to them by clients and could indicate that one or more disorders is present:
- Lanugo – fine hair on face and trunk
- Brittle hair
- Dry skin
- Cyanosis (bluing) of the hands and feet
- Muscle weakness
- Loss of Concentration
- Memory loss
- Postural Hypotension
- GI atrophy: digestive issues such as constipation and Irritable Bowel Syndrome (IBS)
- Ammenorrhea (cessation of menstrual cycle)
- Osteopenia or osteoporosis (Bryant, Green, & Newton-Merrill, 2013)
It is important to recognize that even though a client may appear to be within a healthy weight range, this does not mean that they should be engaging in such intense activities if they are displaying “red flag” behavior or physical symptoms. It is our responsibility as fitness professionals to encourage a balanced approach towards food, physical activity and emotional wellbeing.
Clarifying a Red Flag
Picking up on red flags can be a challenge for those outside the mental health profession. Much like a PAR-Q, the mental health field has guides and forms to help screen for disordered relationships with eating and exercise. Several screens are available online (see links below for selections) or consult your local mental health professional or clinic.
Raising the Issue
How you broach this subject with your client can impact the potential to productively work together, as clients often perceive their trainer as part expert, role model, and confidante. Being respectful and professional is crucial to helping your client. Therefore, the trainer should avoid being accusatory, judgmental, or confrontational.
The Question of Involving Others
While the trainer might be uniquely positioned to spot potential danger, the client may or may not be open to discussing it. Mager summed up the crux of this ethical dilemma very simply, "If a client is clearly at risk, refusing to take care of their emotional and physical wellbeing, the question you must ask yourself is whether you are helping or hurting by continuing to train them" (C. Mager, PsyD., personal communication, January, 2013).
Discerning whether training them will help or hurt can be difficult for the trainer to assess without care from the client’s treating medical professional. Whenever possible, share with your clients first that as normal routine you will reach out to their medical professional (contact the mental health pro first if they have one) to touch base. This way, you will demonstrate transparency and trustworthiness to your clients. If there is an issue, conversations without their knowledge will only drive a wedge of secrecy and distrust into the relationship. If your client seems resistant to discussing whether there is an issue, express your concerns to the treating medical professional as a start. Request their recommendations, cooperation and confidentiality.
Working in Tandem with Client’s Multidisciplinary Team
Requiring a medical release to contact the client’s physician, for all clients or at-risk clients (American College of Sports Medicine [ACSM], 2010), alleviates any confrontation with your client and allows you to strategize with the physician/therapist how best to support your shared patient/client while he or she refuses to face the issue. It is ideal to gain permission to confer with the client’s medical team at the outset.
Working together provides your client with a consistent approach across the board.
- Acquire the contact information of your client's multidisciplinary team (therapists, nutritionists, doctors, etc.)
- Gain permission to reach out to them as standard practice to begin or continue sessions with you
- Revise your intake as needed to include this information
- Confer with providers at the start of relationship
- Tailor the program to those approaches and goals
A flexible approach with your client and the treatment team is to your client’s benefit. Later, when your client slips into resistance or even denial, you can reach out to the appropriate medical professional and express your concern. If your state or country prohibits acquiring this information from clients, you may have to create a permission letter or other measure.
The Question of Contracts and Other Structures
In addition to boundaries for the session as a whole (e.g., not training or training intensely on days where there has been no food intake for over X amount of hours), implementing tools and conditions depend upon the client and the issues that drive their disorder. For some, signing a contract will feel like another constraint against which they need to rebel. For others, a contract will feel like you are joining them on their path. Consult with your client's therapist to help determine if and what kinds of limits or structures would be most beneficial.
The importance of losing body fat and rewarding weight loss are conflicting messages for at-risk clients. Common social and marketing practices of glamorizing thinness, being lean, small, or buff/ripped/cut, suggest an unrealistic end goal of “no visible body fat” in the eye of the at-risk client. The popular "go hard or go home" approach only fuels the tendency to deny themselves and drive their bodies to their physical limit.
Using appropriate/gentle language/approach will help your at-risk client feel safe, develop trust, and view the situation with more balance. Refer to the chart below for the preferred language or approach for each action listed.
What You Say and What They Hear
Our clients experience the world through their own eyes. What is seen and heard can affect them in unpredictable ways. Mager explains, "Imagine only being able to see the outside world through a dirty screen door - nothing would look quite as it is, you would see blobs and shapes. The only tools you would have to interpret what those blobs and shapes are would come from your frame of reference of what is inside the door. You would be unable to identify a tree, or a swing, or a car" (C. Mager, PsyD., personal communication, January, 2013).
The same goes for what is said, messages are convoluted, distorted by the filter/lens of their disorder. The client sees the world while psychologically trapped behind the ”dirty screen door.” As a result, the comments of others not only have undue influence, but also get filtered through that lens. Be aware of your client’s insecurities so that you don’t help escalate the compulsion for excessive exercise, obsessive thoughts or behavior.
Common comments and potential negative responses
How to Effectively Support your Client
- Be Patient. Working with someone with an eating disorder "can be profoundly frustrating and even enraging at times - when your best intentions have been misunderstood or manipulated to reinforce a state of illness rather than health," says Mager. Being patient will help you get a step further to a healthier client - they also sense it and will tend to trust you more and hopefully confide in you.
- Research. Mager stresses the importance of doing your own research on the specific disorder with which your client is struggling: understand some of the pitfalls, obsessions, fears and the very real, potentially deadly health risks involved. Also be aware of specific scenarios or language that will trigger an unfavorable response.
- Release Your Ego. Maintain a separation between client's progress and your own sense of accomplishment. Your client’s progress is not a measure of your competence, knowledge, or level of expertise. Your client is battling with issues of control, so avoid power struggles in this case.
- Practice Non-judgment. Suspend judgment of client behavior, logic and choices as this will erode the trust and transparency of a client. Be gentle and resist the urge to bombard your client with confrontational questions.
- Be Reassuring and Create a Safe Place for Your Client. When your client admits to engaging in destructive thoughts or habits, reassure them that they have your support and that you are glad they confided in you. Continually ask them what other options they can see for themselves and what choices they might like to make now, for their wellbeing. This will empower them to take ownership of their thoughts and subsequent actions.
- Provide Moderation and Balance. Slowly introduce alternative exercises, while avoiding too many changes that will create instability for your client. Don’t make them feel like you are taking something away from them. They look to you for some sort of stability, so be that for them.
- Reinforce Accountability. When a client raises many objections to particular exercises or has strong parameters about what type of exercise is acceptable to them, transcend the power struggle. The common goal is wellbeing. Give clients specific choices and let them assume responsibility. There will be moments of fear and discomfort for the client –provide patience and support. Each person takes this/her own time to move through change.
- Use Humor. Humor creates a safe environment for your client who is always in their head, and it gives them a mental break from the intensity and the need to “be perfect.” It can open the door to accepting oneself and lifting the spirit. Both the acceptance and the elevation of mindset are key to healing.
- Be Empathetic. Putting yourself in their shoes helps you manage your own response when your client seems to resist new thoughts and new habits. Avoid taking it personally and be conscious of what is going on in their mind and the emotions attached to it.
- Have Realistic Expectations for Recovery. Recovery is incremental and not necessarily linear. Acknowledge each achievement as a significant success, and allow for the reality that they may take one step forward and two steps back.
It would be negligent to omit disclosing that every one of the experts consulted for this article voiced their concern for the prevalence of eating and exercise disorders within the fitness profession. Under the guise of being fit or even being healthy, a great deal of distortion and obsession occurs. If fitness professionals wish to make the greatest impact in the lives of our clients with eating disorders, it stands that we too must look at our own attitudes, beliefs and behavior around food and exercise. The outcome would revolutionize how we approach exercise, our clients, the gym atmosphere, marketing, and overall health and wellness.
- Thompson, R.A., & Sherman, R.T. (2010). Eating Disorders in Sport. New York, NY: Taylor & Francis.
- Neumark-Sztainer, D., Wall, M., Larson, N.I., Eisenberg, M.E., Loth, K. (2011). Dieting and disordered eating behaviors from adolescence to young adulthood. J Am Diet Assoc, 111, 1004–1011.
- Mond, J.M., Hay, P.J., Rodgers, B., & Owen, C. (2006). An update on the definition of “excessive exercise” in eating disorders research. IJED, 39(2), 147-153.
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.
- Bryant, C., Green, D., Newton-Merrill, S. (2013). ACE Health Coach Manual: The Ultimate Guide to Wellness, Fitness, and Lifestyle Change (pp 243-251). American Council on Exercise.
- American College of Sports Medicine. (2010). ACSM Testing Guidelines (8th ed.). Lippincott Williams and Wilkins, WoltersKluwer Health.
- Calogero, R., & Pedrotty-Stump, K. (2010). Incorporating exercise into eating disorder treatment and recovery. In Maine, McGilley & Bunnell (Eds.), Treatment of Eating Disorders: Bridging the research-practice gap (pp. 425-441). NY: Elsevier, Inc.