American Fitness Professionals & Associates

By: Ann-See Yeoh FitPro, Apr/May 98

 

This article addresses how you can recognise people suffering from these illnesses, offers guidelines for their recovery but most importantly, suggests ways that you, the exercise professional, can help prevent these illnesses in your class members and clients by helping them to develop a healthy body image.

Identifying anorexia nervosa

Anorexia nervosa is not difficult for others to recognise. The physical symptoms and signs usually reflect the effects of caloric restriction and subsequent weight loss . However, given Western society’s current emphasis on thinness, many patients, and even their families and friends, may not appreciate the serious implication of the weight loss. Certainly the perception of the body image by the fitness industry acts only to reinforce the value of being slim. The cornerstone of diagnosis lies in determining that the person has a body image disturbance. Nevertheless, those with anorexia nervosa may present physical complaints such as headaches and fatigue, both of which are very common. Others may report feeling anxious or agitated, and a history of excess exercise is common. Many will note an intolerance to cold, and although most females with established anorexia nervosa have amenorrhea, few will present with this complaint.

On physical examination, signs of anorexia nervosa are often quite obvious. Marked weight loss is apparent despite the fact that they usually attempt to disguise their weight loss by wearing loose fitting or oversized clothing. Vital signs are characteristically abnormal; blood pressure is often low because of their dehydrated state; bradycardia is common, with pulse rates of 30 to 50 beats per minute. Fine, downy hair, called lanugo hair, may be present on the face. Yellow discoloration of the skin may occur.

Males with anorexia nervosa are characterised by lower testosterone levels causing decreased sexual drive and performance, with changes occurring in a gradual manner rather than the more abrupt changes seen in females in the form of sudden cessation of menses.

Identifying bulimia nervosa

As previously mentioned, people with bulimia nervosa often appear healthy and may have few obvious signs or symptoms of illness. The diagnostic criteria for bulimia nervosa is gender independent. More often than not, these people will be quite secretive about these behaviours. They may, however, complain of depression, fatigue, or headaches. Physical symptoms can be attributed to the effects of associated diuretic, laxative, or diet pill use. If diuretic or laxative abuse results in significant electrolyte abnormalities, they may notice fatigue, weakness, or cardiac palpitations.

Physical signs or bulimia nervosa may be difficult to detect; many have entirely normal physical examinations. The classical sign of bulimia nervosa is Russell’s sign, which is the presence of bruises or calluses on the thumb or hand, secondary to trauma from self-induced vomiting. Erosion of dental enamel on the posterior surfaces of the teeth, as a result of damage by acidic gastric contents during recurrent vomiting, is characteristic in bulimia nervosa.

Recovery and prevention

The first step towards recovery is recognition of the problem by the person involved, and the realisation that they need help. Following that, treatment options are normally discussed following a thorough assessment of the symptoms and underlying causes, and the ways in which the person’s life is affected by their eating disorder. It is possible to be treated as an out-patient on an individual or group basis but for some, treatment as an in-patient will be necessary. As the causes of eating disorders are multiple, an effective treatment for one person may not be effective for another. Ideally though, prevention is always preferred to treatment and we, as exercise professionals, are in no position to diagnose and/or treat any eating disorder.

In looking to prevention, one of the primary issues that we need to address is that of body image. It is only when we are happy with our own image that we can hope to influence others.

Developing a healthy body image

1. Self-acceptance is the first step and as with any first step, it is often the hardest. Think about taking “baby steps”.

2. Look at the ‘whole’ and not the ‘parts’. When looking at yourself in the mirror, look at YOU instead of scathingly at your abdomen, your buttocks, your thighs, etc.

3. Take stock of the people around you within your social circle. Seek out those who are positive and non-judgemental about their own appearance or the appearance of others.

4. Aim to develop a calm mind and a healthy body. Explore the connection of mind and body.

5. Look after yourself - you have but one body.

6. Develop an appreciation of who you are, where you are at in your life journey, and where you are heading. Life is not just about your final destination but the experience of the journey itself.

A helping hand

How do I deal with the client I suspect might have an eating disorder? Confronting the client will work best if you have a well conceived plan of action.

How do I confront the client? First and foremost, you must consult with your manager if you have one, as it could be that there is an established protocol for this situation. If you do decide to confront the client, it is usually best if you already have an established relationship/rapport with the client. If not, try asking a colleague who does have a relationship with the client to do the talking.

Prior to the confrontation, it would help to discuss your method of approach with another health professional. Try contacting the local eating disorders hotline or the Eating Disorders Association (listed at the end of this article).

How should I structure my approach?

* Approach the client in a relaxed and private manner.

* Go by yourself rather than in a group.

* Always structure the approach from your point of view, e.g. “I am concerned about your well-being ….”, or “I feel that ….”.
The client will find it hard to argue with your feelings and say you are wrong, as you are simply stating how you feel.

* Use terms like “well-being” rather than “disorder”.

* Avoid terms such as “bingeing”, “fasting”, or “purging”, as these may make the client defensive.

* Ask them if they need your help

* Offer your support whenever they need it. Give them your time and listen. They may just need you to be there when things are hard to cope with.

* Try not to give advice but encourage them to seek help. You should not take responsibility for their problems.

What if they don’t accept there is a problem? You may need to accept that your client is not ready to tackle their eating disorder. But let them know how you are feeling. Tell them that they can come back to you later. Get further information about eating problems so you can help when your client is ready to accept that there is a problem. Perhaps follow up in a week to see if the client is ready to talk. Discuss your actions with your manager and allow them to decide the next step.

Should I encourage my client to eat? No. Everyone needs to decide for themselves what to eat. Your client is responsible for their own needs.

Should I inform their family? Tell them only if you really feel they should know, but first let your client know that you are going to inform someone. You may have to face the fact that they may not like what you have done, even if you did it for the best, but in time they will probably appreciate your decision.

In conclusion, it is important to remember that your goal, as a fitness professional, is to successfully give the client a referral. Ensure that you have the phone number of an eating disorders professional to hand.

Further information

Eating Disorders Association Sackville Place 44 Magdalen Street Norwich NR3 1JU Tel 01603-621414

There is usually a local eating disorders group in most areas.

Common Symptoms of Eating Disorders

* Marked weight loss

* Denial of complaints, including concern about low body weight

* Fatigue, decreased energy

* Anxious energy

* Sleep disturbances

* Irritability, depression, personality changes

* Headaches

* Abdominal pain, constipation

* Cold intolerance

* Amenorrhea

* Secrecy about disordered eating, bingeing, and purging

* Fatigue, decreased energy

* Depression

* Headaches

* Abdominal pain, bloating

* Recurrent vomiting

* Heartburn

* Constipation

* Irregular menses

* Swelling of hands, feet

Note. From Thompson, J.K. (1996). Body Image, Eating disorders, and Obesity.

Common Physical Examination Signs of Eating Disorders

* Bradycardia

* Low blood pressure

* Low body temperature

* Dry skin

* Brittle hair, hair loss on scalp

* Lanugo hair

* Brittle nails

* Yellow skin, especially palms

* Often appear healthy

* Russell’s sign

* Erosion of dental enamel

* Periodontal disease, dental cavities

* Absent gag reflex

* Peripheral oedema

Note. From Thompson, J.K. (1996). Body Image, Eating disorders, and Obesity.

Treatment for Eating Disorders

* Counselling and psychotherapy: Counselling and psychotherapy aim to address the underlying emotional and psychological issues, rather than concentrating on weight gain, and may be needed for a only few sessions or long-term over several years.

* Cognitive behaviour therapy: Cognitive behaviour therapy helps people look at the specific beliefs that underlie their behaviour, to challenge these beliefs and consequently alter behaviour. It is particularly effective for people with bulimia nervosa and normally lasts for 10-20 sessions over 4 to 5 months.

* Life skills: Anxiety management, relaxation, communication skills and assertiveness training can be helpful.

* Creative therapies: Psychodrama, art, drama and music therapy can help people recognise and express painful feelings that may be blocked by the eating disorder. Dance movement therapy is particularly useful for working with body-image issues.

* Family therapy and family counselling: This involves assessing how family members communicate and manage conflict, exploring how this might affect the person with the disorder. Helping the family system to make changes allows the person with the eating disorder to make positive changes towards recovery.

* Nutritional counselling: Dietary intervention is essential for all patients with eating disorders. Dieticians, as part of a multi-disciplinary team, can provide information and help to produce and eating programme that takes into account patients’ individual requirements.

* Drugs: Anti-depressants can be given to help with depression and may enable people with bulimia nervosa to reduce bingeing and purging, though relapse is common and drugs are not usually effective in the long term. Caution is needed in prescribing drugs for low weight individuals or children.

* Self-help programmes: Self-help programmes can be managed with the support and supervision of a GP or counsellor. The Eating Disorders Association has developed a self-help programme for people with bulimia nervosa that can be managed by the general practice.

Ann-See Yeoh MmedSci is a lecturer in Sport and Exercise Science at the University of Luton. She is an established instructor trainer, mind-body practitioner and is co-director of ‘Chi-Ragga Fitness. Ann-See has recently been appointed as the spokesperson for Team Puma.