Have you ever suspected that one of your clients has an eating disorder, takes questionable supplements for weight loss or gain or dangerously overtrains? Perhaps it’s the client who has lost too much weight, the indoor cycling class participant who takes two or three cardio classes each day and always seems exhausted or the client who tells you he takes steroids to bulk up.

As a front-line health and exercise professional, you must now decide whether or not to begin an important and tremendously delicate client health conversation. What should you say to the troubled trainee—if anything? Read on to learn the signs of some specific body image–related health concerns that may be especially evident in an exercise environment, and for advice on how to handle these types of client conversations.

Identifying Issues

Unless you are a doctor or psychologist, it is not within your scope of practice to diagnose or treat mental health issues. Nevertheless, “people coming into the gym may have some body-image issues, which tend to be along a continuum, [from] mild to moderate to severe,” says Divya Kakaiya, PhD, a psychologist, certified eating-disorder specialist, and founder of the Healthy Within treatment program in San Diego, Calif.

Because many health warning signs can be uniquely apparent in the gym, it is important for health and exercise professionals to have a general understanding of what might underlie symptoms like ongoing fatigue or weight loss. And in your gut, “you know when something is not right and a client or student is raising a red flag,” says Nicki Anderson, a trainer for more than 30 years and founder of Reality Fitness in Naperville, Ill. Becoming familiar with the visible signs of such concerns will help you recognize when a client may be in need of extra assistance.

Eating Disorders

These potentially life-threatening conditions include anorexia, bulimia and severe overeating. Anorexia typically manifests as self-starvation and rapid weight loss, whereas bulimia is characterized by compulsive overeating followed by compensatory behaviors, such as laxative abuse or self-induced vomiting.

Of particular interest to health and exercise professionals is a lesser-known disorder called exercise bulimia. Sufferers may spend hours each day exercising "to compensate for binge eating episodes,” says Natalie Digate Muth, MD, MPH, RD, a pediatrician and nutritionist based in Carlsbad, Calif. Consequently, they often appear to be of normal weight or to be very fit, despite their binge/overtraining cycles.

Signs and symptoms to be aware of: Although the signs of eating disorders will vary, watch out for unhealthy amounts of weight loss, excessive exercise, fatigue, dizziness, fainting and negative self-talk concerning body image.

More information: www.nationaleatingdisorders.org

Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is characterized by a belief that there is an ugly abnormality or flaw in one’s appearance. While BDD may manifest as an obsession with a particular body part (such as one’s nose), it also may present itself as an obsession with muscular size and shape. For example, you may have a client who thinks he needs more muscular definition even though everyone else reasonably thinks he is “ripped,” says Muth.

Signs and symptoms you may observe: Excessive grooming, preoccupation with, or avoidance of, one’s image in mirrors, negative self-talk about body image, an ongoing belief that one’s body mass is too big or too small, and the need for reassurance from others

More information: www.bddcentral.com

Performance-enhancing Drugs and Weight-loss Pills

In an effort to gain muscle, a fitness enthusiast may turn to performance-enhancing drugs such as anabolic steroids, human growth hormone or other hormonally based “doping” methods. Likewise, to lose weight he or she may try diet supplements, such as products containing diuretics or high amounts of caffeine or other stimulants.

Unfortunately, over-the-counter weight-loss products are not subject to the same safety standards as prescription pills and may be of questionable safety. Plus, performance-enhancing drugs can present varying degrees of health risks, depending on the type and quantity used.

Signs and symptoms you may observe: “Substance abuse is hard to detect, especially if you do not know the fitness enthusiast well,” counsels Haley Perlus, PhD, MS, an Ontario, Canada−based sports psychologist, ACE Certified Group Fitness Instructor and author of The Ultimate Achievement Journal. While visible signs and symptoms may not always accompany the use of diet pills, in the case of performance-enhancing drugs, “look out for unusual increases in performance (strength, speed, etc.), aggressive behavior and the ability to train hard without taking rest,” says Perlus.

More information: See the sidebar below, “Bring It Up at the Beginning.”

Overtraining

Performing excessive workouts with insufficient recovery can lead to overtraining syndrome—a chronic physical and mental fatigue that becomes detrimental to ongoing exercise efforts. Overtraining can be a problem in and of itself (perhaps stemming from a simple lack of understanding of the importance of rest) or may be a single symptom of a more serious mental-health concern.

For example, “while people with anorexia and sometimes bulimia engage in excessive amounts of exercise in an effort to lose weight, people with body dysmorphic disorder engage in excessive amounts of resistance training in an effort to be muscular,” notes Muth.

Signs and symptoms you may observe: Watch for “declines in endurance, strength and/or flexibility, low energy levels, prolonged muscle soreness or fatigue, higher than normal heart rates, and slower recovery times [between] training sessions,” explains Perlus.

More information: ACE Fit Fact: Too Much of a Good Thing

Confronting Your Client

If you suspect your client has one of these ongoing health issues, should you mention your concern—or just mind your own business? “It is definitely not best to do nothing,” answers Muth.

However, if you do choose to act, be sure that your involvement will be enough to make a difference, notes Perlus. “Do not do it just to make yourself feel better. Do it to make a difference in the life of the fitness enthusiast,” she says.

If you do not have a relationship with the troubled client, you can defer challenging conversations to your manager, adds Perlus. However, if you know the client well, you may decide to bring up the concern yourself. To do so, observe the following steps:

Recognize your own issues. “First and foremost, the trainer needs to be aware of his or her own body-image issues, [which may] play a huge role in how he or she may interact with a client,” advises Kakaiya. Also consider how your own issues and clothing choices can affect a client's self-image, she adds.

Stick to the facts. Bring up the “logical instead of the emotional,” advises Perlus, so that the client can focus on the facts—instead of the perception of being attacked and labeled. For example, Anderson recommends discussing something you can clearly see (e.g., “You’ve lost 14 pounds since our weigh-in together last month”) versus something you just think (e.g., “Maybe you have an eating disorder”). Check out the sidebar, “Sample Scripts,” for tips on how to convey your concerns to a client.

Avoid assumptions. Although you suspect your client has a serious health concern, you could also be completely wrong. For example, just because a client works out a lot or loses weight does not mean they have anorexia or BDD. “Be careful not to accuse anyone of [having a condition such as] an eating disorder before you have all of the facts,” agrees Kakaiya.

Don’t diagnose. It’s beyond your scope of practice to diagnose any physical or mental health issues, says Anderson. Above all, “act with caution and never label someone with a disorder,” advises Perlus.

Don’t try to fix the problem. Beyond bringing up your concerns, don’t try to solve any of your client’s health issues. Don’t give advice about how to stop the behaviors, and don’t become the person’s therapist, emphasizes Kakaiya.

Refer to a professional. Refer clients to their primary doctor, advises Muth, or potentially to a registered dietitian who specializes in eating disorders. If you are uncertain about finding a registered dietitian or a program that can help, remember that it is the primary physician’s role (not yours) to refer patients to other specialists who can help.

Referring a client to his or her physician instead of a mental health professional may make your message easier to receive, adds Anderson. “You can’t really [refer to] a psychologist because then you’re insinuating that the client has mental issues, which is very, very personal,” she cautions.

Handling the Response

Before you begin the client conversation, prepare yourself for the possible outcome. In the best-case scenario, he or she will agree with your referral suggestion. But be ready for the alternatives:

The client is upset. “The individual may become angry or feel offended, but this often is the disorder lashing back, not the individual,” explains Kakaiya. In this case, think of your discussion as a “seed that gets planted in their mind regarding what they are doing to their body,” she says.

The client denies that there is a problem. Denial is common among individuals with eating disorders. Furthermore, notes Kakaiya, “addiction to diet pills and performance-enhancing drugs is one of the worst addictions to confront and [only] after multiple confrontations will the denial crack. Don’t have expectations that the client will agree or want help right away.”

If the client says everything is O.K., then you have to make the critical choice of whether or not to require a doctor’s approval before continuing to work with him or her, explains Anderson. “I would tell the client I need a medical clearance just to make sure everything is fine,” she says.

Managing Your Expectations

Keep in mind that, ultimately, the decision to get help belongs to your client, advises Perlus. “You can only control that which is controllable (i.e., you can only do so much). Say what you need to say. Do what you need to do, and then move on.”

If you have concerns about a client’s health, don’t be afraid to address the facts in a non-emotional, nonjudgmental way. “The worst that can happen is that the person will get offended and not come [to your workout facility or class] for a few days,” says Perlus.

At some point in your career, you will undoubtedly encounter a client with a health issue related to body image. When you do, remember Kakaiya’s advice: “We are very quick to jump on individuals for weight loss to aid in their health, so we should be just as quick to [respond to healthy behaviors that are taken too far].”