Could Your Client Have an Eating Disorder?

Eating disorders may be more common (and deadly) than you think: Learn the signs today so you can help clients address issues early—and seek outside help when needed.

by Jessi Haggerty, RD

As fitness professionals, we don’t receive much (if any) training when it comes to eating disorders and disordered eating. Yet, being that an estimated 30 million individuals in the United States (20 million women and 10 million men) will have a diagnosable eating disorder at some point in their lives, the likelihood that some of our clients are among them is extremely high (NEDA 2018a).

Because we interact with these clients 1–3 times per week, we are in a unique position to recognize an eating problem in the early stages and, perhaps, use our professional coaching skills to help prevent it from developing into a full-blown eating disorder.

Unfortunately, it can be difficult to find the line between what is “normal” and what is “disordered,” especially when working in an environment that can promote practices that mirror eating disorders, such as fairly strict adherence to new dietary or exercise regimens.

Further, the eating disorder “image” we often see portrayed in the media is a young, emaciated woman. The reality is that people with eating disorders come in all ages, weights and genders, and a disorder is more often marked by behavioral and emotional signs than by an “underweight” body mass index.

Why Fit Pros Need to Know More

What follows is a summary examination of eating disorders you may encounter in your career, beginning with the most common. (Interestingly, these are not anorexia nervosa and bulimia nervosa, though those are certainly the most well-known.) Included are the signs and symptoms that may be most easily noticed in the context of your professional relationship with a client, but much more information is available on each condition from the National Eating Disorders Association (NEDA) at nationaleatingdisorders.org. By becoming better informed about the signs and symptoms of these conditions, you can improve your ability to assist your clients in an even more holistic way.

Otherwise Specified Feeding or Eating Disorders

Most eating disorders that don’t meet the criteria for anorexia nervosa or bulimia nervosa are clinically referred to as otherwise specified feeding or eating disorders (OSFED). Signs and symptoms of OSFED can include, but are not limited to, the following:

  • dieting or inadequate energy intake
  • weight loss (regardless of size)
  • orthorexia (obsession with healthy or “clean” eating)
  • excessive or compensatory exercise
  • body dissatisfaction

Binge Eating Disorder

Aside from OSFED, binge eating disorder is the most common eating disorder among Americans (NEDA 2018b). BED presents with recurring episodes of excessive food consumption over a short period of time, often to the point of physical discomfort. This is usually accompanied by feelings of loss of control, shame and guilt.

It’s important to note that BED is not due to an inherent “addiction” to food; more often than not, bingeing is back-loaded by dieting or food restriction. So, while it may sound counterintuitive, the antidote to binge eating disorder is not food restriction.

Signs and symptoms of BED can include, but are not limited to, the following:

  1. weight cycling
  2. frequent dieting or “failed” diets
  3. strong body dissatisfaction
  4. intense stress and shame around eating
  5. feeling “out of control” around food

Anorexia Nervosa

Anorexia nervosa (AN) is marked by severe restriction of energy intake, which leads to significant weight loss at the expense of physical health. This is often accompanied by an intense fear of gaining weight. It’s important to note that AN is not necessarily marked by an “underweight” BMI. The disorder can affect people of all sizes; just because a client isn’t thin or underweight doesn’t mean he or she isn’t suffering from AN.

Here are some signs and symptoms to look out for:

  • dramatic weight loss (regardless of size)
  • extreme fatigue
  • joint pain or stress fractures
  • thinning and loss of hair
  • intense fear of gaining weight
  • covering up in layers
  • depression and/or anxiety
  • perfectionistic or competitive tendencies

Bulimia Nervosa

Bulimia nervosa (BN) is marked by recurring episodes of bingeing, followed by a compensatory behavior designed to minimize the impact of the binge. There are two types of BN: purge type, which is bingeing followed by episodes of vomiting, laxative use or diuretic use; and nonpurge type, which is bingeing followed by excessive exercise or fasting.

Individuals with BN will likely use language that indicates a lack of self-control around food. It’s also likely they will voice their feelings of guilt about bingeing. They may ask you to work them excessively hard to compensate for a binge, or they may talk about the extra time they put in at the gym to offset their excessive calorie intake.

Here are some signs and symptoms to look out for:

  • swelling of cheeks, mouth or jaw; mouth sores
  • dehydration or excessive fluid intake
  • fatigue
  • self-induced vomiting (calluses on backs of hands)
  • excessive or compensatory exercising
  • depression and anxiety
  • low self-esteem
  • strong body dissatisfaction
  • perfectionistic or competitive tendencies

The Challenges of Screening

The screening process is much more complex than just checking off a list of signs and symptoms and then sending your client to a treatment center. Someone with an eating disorder will likely not present with all of the symptoms listed here, or he or she may present with symptoms that are not listed. And, again, many of the signs and symptoms of OSFED, BED, AN and BN—such as fear of gaining weight, perfectionistic tendencies, or compensatory or excessive exercise—might be considered “normal” behaviors in a fitness or gym environment. These factors make eating disorder screening particularly difficult for fitness professionals, but all the more necessary.

Simple Screening Strategies

It’s important to be continuously on the lookout for warning signs and clues from your clients. Here are a few ways you can be more mindful of potential eating disorders when first getting to know a new client:

START A CONVERSATION

Keeping communication open and building trust will go a long way toward enabling you to spot potential problems. Ideally this starts the moment you meet a client, carries through the initial preparticipation fitness assessment and is reinforced at each follow-up session.

In particular, watch for overall goals that are extreme or unrealistic, such as dramatic weight loss (regardless of the client’s size) or an overambitious exercise regimen. While these mindsets can unfortunately seem normal in personal training sessions, it’s important to keep in mind that, for some clients, they may signal disordered eating.

ASK “WHY?”

When clients tell you about their goals, ask “Why?” Then, practice active listening. Do they want to lose weight to have more energy? To feel less winded playing with their kids? To be able to bike to work?

Listen for answers that are motivated by shame or fear. For example, “Because I’m embarrassed about my arms” or “Because I’m afraid of gaining weight.” These can be red flags signaling a possible eating disorder on the horizon.

REVIEW THEIR MEDICAL HISTORY

Part of your initial preparticipation screening should include having clients fill out the Physical Activity Readiness Questionnaire (PAR-Q) and provide you with a medical history (NASM 2018). Generally, this includes asking about surgeries, injuries and chronic conditions (including mental health diagnoses) as well as occupation, lifestyle and other factors that may affect their fitness routine.

Be sure to remain within your scope of practice at all times, and refrain from giving clients advice. With permission, consult with a client’s physician(s) about his or her health information and medications (NASM 2018). Ideally, the physician will alert you if there is any concern or history of disordered eating. Remember: Asking for a detailed history shows that you’re interested in this person as a whole—and not just concerned about his or her fitness routine.

BE CURIOUS!

If at any time your client says something that raises a red flag and you’re unsure of how to proceed, keep the conversation open by being curious. Also keep an eye out for extreme changes in diet, body shape or size. A simple “Tell me more about that” can go a long way.

WHEN IN DOUBT, REFER OUT

If it becomes evident that a client is suffering from an eating disorder—or you simply worry that this may be the case—don’t hesitate to refer the person to a registered dietitian, eating disorder specialist and/or therapist who deals specifically with disordered eating and eating disorders (see “Steps to Starting a Referral” below).

Be aware that you may have to stop training a client until he or she is in the recovery phase of treatment for an eating disorder. Make sure clients are cleared by their doctor before returning to the gym.

Don’t Underestimate the Importance

Eating disorders are the most fatal mental illness (Smink, van Hoeken & Hoek 2012). As a fitness professional, you can play a huge role in the health of your clients outside of the gym—and maybe even save a life. For more information, visit the National Eating Disorders Association website at nationaleatingdisorders.org.

REFERENCES

NASM. (National Academy of Sports Medicine). 2018. NASM Essentials of Personal Fitness Training (6th ed., pp. 110–11 and 114–15). Burlington, MA: Jones & Bartlett Learning.

NEDA (National Eating Disorders Association). 2018a. What are eating disorders? Accessed Oct. 3, 2018: nationaleatingdisorders.org/what-are-eating-disorders.

NEDA. 2018b. Binge eating disorder. Accessed Oct. 13, 2018: nationaleatingdisorders.org/learn/by-eating-disorder/bed.

Smink, F.R.E., van Hoeken, D., & Hoek, H.W. 2012. Epidemiology of eating disorders: Incidence, prevalence and mortality rates. Current Psychiatry Reports, 14 (4), 406–14.

Meet our experts

Author_JessiHaggerty_bw JESSI HAGGERTY , is a registered dietitian and an NASM-certified personal trainer who specializes in eating disorders. She runs an online course for personal trainers on eating disorders, nutrition and body image. Learn more at www.JessiHaggerty.com.

The information provided is without warranty or guarantee and NASM disclaims any liability for decisions you make based on the information. Learn more