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November 2011

The Tough Stuff: Confronting Clients About Body Image–related Health Concerns


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 way too much weight, the spinning class participant who takes two or three cardio classes each day and always seems exhausted, or the client who flat-out tells you he takes steroids to bulk up.

As a front-line wellness 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 the type of client conversations you hope to never have.

Identifying Issues
Unless you are a doctor or psychologist, it is absolutely not your job 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, Ph.D., 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 fitness 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 25 years and president of award-winning fitness studio Reality Fitness in Naperville, Ill. Becoming familiar with the visible symptoms 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 the fitness professional 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, M.D., M.P.H., R.D., a pediatrics resident and an ACE spokesperson based in Los Angeles, Calif. Consequently, they often appear to be of normal weight or to be very fit, despite their binge/overtraining cycles.

Symptoms you may see: 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:

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 to bulk up even though everyone else reasonably thinks he is “ripped,” says Muth.

Symptoms you may see: 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:

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 HCG (human chorionic gonadotropin) or ephedrine.

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.

Symptoms you may see: “Substance abuse is hard to detect, especially if you do not know the fitness enthusiast well,” counsels Haley Perlus, M.S., Ph.D., a sports psychologist, ACE-certified Fitness Professional and author of The Ultimate Achievement Journal, who divides her time between Toronto, Canada, and Colorado. While visible 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, “Bring it Up at the Beginning.”

Bring it Up at the Beginning

While you cannot control a client’s choices, you can set behavioral boundaries early on in your personal-training relationships. “It is the fitness professional’s job to ask the client about medication use at the initial interview and to express concerns if a client practices unsafe weight-loss practices,” notes physician Natalie Digate Muth. Be willing to turn down business if you don’t agree with a client’s approach to nutrition, training or supplements. “If any of my clients take any type of supplements I tell them I am not familiar with the way the drugs interact with their body and I’m not willing to risk any type of reaction while they’re taking it,” says trainer Nicki Anderson. Thus, she has refused to take on many clients taking dietary supplements unless they have had a prior medical clearance.

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.

Symptoms you may see: 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 or the client’s personal trainer, 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.

Sample Scripts

Exactly what words should you use to confront a client about a health issue? Veteran trainer Nicki Anderson and sports psychologist Haley Perlus weigh in:

Anderson: “Sam, you’ve been coming to my classes for a long time. I’m so amazed at your dedication. However, I have noticed a severe drop in weight and perhaps it’s none of my business, but I care about all of my clients. I just want to make sure everything is okay.”

Perlus:  “Kelly, I have been looking over your training log and performance accomplishments. In my professional opinion, the amount of time and level of intensity of your training sessions may be a bit excessive…I am concerned that you have developed certain behaviors that are hindering your performance and maybe even other areas of your life. With your permission, I would like to offer you the name and number of a professional who could help you rediscover a healthy sense of balance so that you can continue to achieve the goals we have set and truly enjoy this experience.”

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 are anorexic or have 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 or savior, 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 an RD or a program that can help, remember that it is the primary physician’s role (not yours) to refer troubled individuals to other specialists who can help.

Referring a client to their doctor 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 bodies,” 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 okay, then you have to make the critical choice of whether or not to require a doctor’s approval before continuing to work with them, explains Anderson. “I would tell them 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, non-judgmental 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 no doubt 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].”



Megan Senger is a writer, speaker and fitness sales consultant based in Southern California. Active in the exercise industry since 1995, she holds a bachelor’s degree in kinesiology and English. When not writing on health and lifestyle trends, techniques and business opportunities for leading trade magazines, she can be found in ardha uttanasana becoming reacquainted with her toes. She can be reached at

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