InsideOut Institute has teamed up with Fitness Australia to release new national recommendations for the identification and support of people with eating disorders in the fitness industry.

Recommendation One: Support a Healthy, Inclusive Environment

The health and safety of clientele is the priority. Exercise professionals and fitness businesses should adopt a positive approach to promoting physical activity instead of one that focuses on guilt and shame around weight and shape. A preventive approach to eating and excessive exercise disorders includes pre-exercise screening, appropriate referrals and exercise prescription to avoid adverse events. Creating a holistic, inclusive environment that focuses on health rather than weight will facilitate an environment that supports positive body image.

Guidelines for marketing and advertising messages that encourage physical activity, without encouraging disordered eating and exercise

• Messages should focus on health, not weight, and be delivered from a holistic perspective with equal consideration given to social, emotional and physical health
• Weight is not a behaviour and therefore not an appropriate target for behaviour modification; services should focus only on modifiable behaviours (e.g. physical activity, eating habits, time spent watching TV)
• People of all sizes deserve a nurturing environment and will benefit from a healthy lifestyle and positive self-image
• The ideal client support is integrated, addresses risk factors for the spectrum of weight-related problems, and promotes protective behaviours
• Client services should honour the role of families and carers and support them to model healthy behaviours at home without overemphasising weight
• Community members should be included in the planning process to ensure that facilities and services are sensitive to diverse norms, cultural traditions and practices
• It is important that specific intervention programs are evaluated by qualified health care providers and/or researchers, who are familiar with the research on risk factors for eating disorders

Modified from: National Eating Disorders Collaboration, (2015). Eating Disorders in Sport and Fitness: Prevention, Early Identification and Response, 2nd Edition, NSW. Australia.

Recommendation Two Recognise Warning Signs and Refer Appropriately

There are a broad range of physiological, behavioural and social warning signs associated with eating and/or exercise disorders. These may be observed when undertaking pre-exercise screening, throughout training sessions or in general interaction with a member or client

Behavioural Warning Signs

• Dieting behaviours (e.g. fasting, counting calories/kilojoules, avoidance of food groups or types)
• Evidence of binge eating (e.g. disappearance or hoarding of food)
• Evidence of vomiting or laxative use (e.g. taking trips to the bathroom during or immediately after meals)
• Excessive, obsessive or ritualistic exercise patterns (e.g. exercising when injured or in bad weather, feeling compelled to perform a certain number of repetitions of exercises or experiencing distress if unable to exercise)
• Changes in food preferences (e.g. refusing to eat certain ‘fatty’ or ‘bad’ foods, cutting out whole food groups such as meat or dairy, claiming to dislike foods previously enjoyed, a sudden concern with ‘healthy eating’, or replacing meals with fluids)
• Development of rigid patterns around food selection, preparation and eating (e.g. cutting food into small pieces or eating very slowly)
• Avoidance of eating meals, especially when in a social setting (e.g. skipping meals by claiming they have already eaten or have an intolerance/allergy to particular foods)
• Lying about amount or type of food consumed or evading questions about eating and weight
• Behaviours focused on food (e.g. planning, buying, preparing and cooking meals for others but not actually consuming; interest in cookbooks, recipes and nutrition)
• Behaviours focused on body shape and weight (e.g. interest in weight-loss websites, books and magazines, or images of thin people)
• Development of repetitive or obsessive behaviours relating to body shape and weight (e.g. bodychecking such as pinching waist or wrists, repeated weighing of self, excessive time spent looking in mirrors)
• Social withdrawal or avoidance of previously enjoyed activities

Source: Mental Health First Aid Australia Eating Disorders: First Aid Guidelines. Melbourne: Mental Health First Aid Australia; 2008.

The physical complications associated with experiencing a rapid and significant weight loss (even when above or at a normal weight) and/or being underweight or carrying low percentage body fat (particularly the potential for cardiac problems) mean that it is essential that clients who are thought to have an eating disorder, or symptoms of an eating disorder should be appropriately referred to and managed by a medical professional (i.e. GP, paediatrician).

Psychological Warning Signs [2] –

• Pre-occupation with food, body shape and weight
• Extreme body dissatisfaction
• Distorted body image (e.g. complaining of being/ feeling/looking fat when a healthy weight or underweight)
• Sensitivity to comments or criticism about exercise, food, body shape or weight
• Heightened anxiety around meal times
• Depression, anxiety or irritability
• Low self-esteem (e.g. negative opinions of self, feelings of shame, guilt or self-loathing)

Physical Warning Signs [2] –

• Weight loss or weight fluctuations
• Sensitivity to the cold or feeling cold most of the time, even in warm temperatures
• Changes in or loss of menstrual patterns
• Swelling around the cheeks or jaw, calluses on knuckles, or damage to teeth from vomiting
• Fainting

This includes individuals with a Body Mass Index (BMI) lower than 14kg/m2 and clients whose BMI falls between 14 and 18 who are thought to be at risk of losing weight. Individuals with eating disorders may experience weight gain over time and as such weight gain should also be considered as a potential warning sign. They too should be referred to see a medical or health professional. [3-5] If exercise professionals identify or observe any of the warning signs in their clients, professional judgement should be applied with respect to exercise prescription or the necessity to obtain medical guidance. Whilst some of the warning signs may not be initially considered to be of major concern, help from an appropriate health or medical professional should be considered. A delay in seeking treatment can lead to serious long-term consequences for the person’s physical and mental health. For most people, the earlier help is sought for their unhealthy eating and exercise behaviours, the easier it will be to overcome the problem and the more likely they are to make a full recovery. It should be noted that eating disorders carry a high mortality rate so best practice for any professional delivering services to this group is to ensure the involvement of a medical professional.

Recommendation Three Identify Suitable Referral Processes for Higher Risk Clients

Exercise professionals must work within their Scope of Practice and appropriately refer clients identified as at higher risk (i.e. those with a lower BMI or who experience rapid weight loss) to a medical professional for assessment and guidance. Fitness Australia’s Exercise Referral Kit provides resources to support fitness business and exercise professionals to ensure that they are referring clients in a professional manner and meeting recognised standards for client referral communication.

Recommendation Four Identify clients with extreme forms of dieting, binge eating, self-inducing vomiting and misuse of laxatives, diuretics, diet pills or performance and image enhancing drugs (PIEDs) and implement appropriate actions

There are many physical and mental adverse effects associated with disordered eating and compensatory behaviours such as self-induced vomiting, misuse of laxatives, diuretics, diet pills or performance and image enhancing drugs (PIEDs). If you identify this behaviour or clients confide that they are engaging in any of these behaviours, their exercise activity should be reviewed by an appropriate medical professional. The client may be feeling anxious, upset, angry or defensive about being approached and therefore it is important that the exercise professional maintains a non-threatening and empathic approach. Using professional judgement, exercise professionals should approach the client with initial concern for their health and well-being. If exercise professionals don’t feel equipped to do so then they should first seek guidance from senior management or one of the services listed on the InsideOut treatment services database (https://insideoutinstitute.org.au/treatment-services). Exercise professionals and fitness businesses must comply with illicit drug laws and enforce a ‘zero tolerance’ drug and alcohol policy and procedure (Fitness Industry Code of Practice).

Recommendation Five Support Recovery in Collaboration and Maintain Best Practice

Evidence-based interventions are required in the treatment and recovery of clients with eating and/or exercise disorders. The treatment and recovery journey for clients experiencing an eating or exercise disorder often requires treatment from a multi-disciplinary team of medical or health professionals including a GP, mental health practitioner and/or dietitian. Individuals can and do make a full recovery with good collaborative treatment. Ongoing collaboration between this multidisciplinary team, the exercise professional, and the client will assist in the recovery process. Within the discussions, guidance should be given with regards to the clients’ prescribed physical activity levels or whether in the interest of the clients’ health that training sessions or memberships should be withdrawn or suspended, or access to the fitness facility may be limited. If every reasonable and practical effort has been made to assist higher risk clients to appropriately modify their exercise regime has failed to yield change, and/or the clients’ failed to adhere to medical guidance then they should be advised to cease all physical activity. Memberships or training sessions should be withdrawn or suspended until further appropriate guidance from a medical professional has been formally received. Members or clients should be advised appropriately of any associated businesses policies.