When Can Diet and Exercise Be Unhealthy?

One day Sarah walked into my office. As an undergraduate kinesiology student, she was interested in conducting research on her fellow students’ knowledge of eating disorders. After some further chat on her research interest, Sarah told me that she is recovering from an eating disorder herself. When she was diagnosed, she was told not to exercise at all. As a former dancer, leaving exercise entirely was difficult for her, but how to control it was even more difficult. She now realized that there had been very little discussion of excessive exercise, disordered eating, and eating disorders during her studies that focused on combatting sedentary behavior, increasing exercise motivation, and promoting obesity prevention as desirable health behaviours. She felt very strongly that her fellow students, as future exercise and fitness professionals, should also know about the negative consequences of health behaviors gone too far. If exercise is medicine, similar to other medicines, there needs to be a suitable dose for optimal health benefits: too little is not enough, but too much can be harmful.

To justify Sarah’s proposed study, we wanted to find out how common eating disorders are in the fitness industry. In general, we discovered, the risk of eating disorders is higher in sport—particularly in aesthetic sports such as gymnastics or figure skating and in sports where low weight is considered an advantage such as distance running (Joy, Kussman, & Nattiv, 2016)—in dance, and in the fitness industry. Bratland-Sanda and Sundgot-Borgen report that up to 28% of female fitness center members have been found to have an eating disorder. While eating disorders are significantly more common among women, also men are increasingly affected. Joy, Kussman and Nattiv (2016) note that while 10 million women and 1 million men in the US suffer from eating disorders, eating disordered behavior is more common among male athletes than non-athletes. While female athletes represent 90% of those who seek help for an eating disorder, it has been estimated that 3% up to 42% of male athletes exhibit eating disordered behaviors and similar to women, the highest percentage is in aesthetic (‘antigravitational’) and endurance sports.

Some researchers have examined the prevalence of eating disorders among fitness instructors. Because not everyone who has serious trouble with food is necessarily diagnosed with an eating disorder (ED) such as anorexia nervosa or bulimia nervosa, many researchers now talk about disordered eating (DE) that in addition to similar behaviors to eating disorders also includes constantly restricted diet, compulsive eating, or irregular, chaotic eating patterns. Bratland-Sanda and Sundgot-Borgen (2015) describe DE as a continuum that starts with healthy dieting behavior progressing to chronic dieting, frequent weight fluctuation, fasting, purging, and ending with clinical ED. Bratland-Sanda, Nilsson, and Sundgot-Borgen (2015) add that excessive exercise is a core symptom throughout the wide spectrum of ED and DE behaviors. While definitions for excessive or compulsive exercise vary, it is usually considered a type of exercising beyond positive health benefits. This can range between more than 5 hours and up to 20 hours of exercise/week that is not required for sport or dance performance. While many fitness instructors teach up to 20 or more classes each week, they can also exercise in addition to their instructional requirements. So, how common is DE among fitness instructors?

In their recent study, Bratland-Sanda and her colleagues (2015) examined the prevalence of DE and self-reported ED in 152 male and 685 female group fitness instructors in Norway. Based on the Eating Disorders Inventory (EDI), 22% of the male instructors and 59% of the female instructors were classified with DE behavior. However, only 4% of the female instructors (and no male instructor) reported actually having ED. The instructors with DE had higher body mass index and more weight loss attempts than the instructors without DE. It is important to note that not all individuals with DE are necessarily willowy thin. There were no differences between instructors teaching different types of exercise classes.

The researchers added that the instructors with self-reported ED had not disclosed it to their managers at the fitness center. Some worried about being dismissed. As one instructor wrote: “I’m ashamed, I don’t want them to feel sorry for me, and I’m afraid to lose my job” (p. 7). Others felt that it was their private business: “It’s something I will not tell them. It is none of their business, and they cannot solve my eating disorder” (p. 7).

The researchers were concerned with the high number of fitness instructors with DE that can have a detrimental effect to their health. Similar to Sarah, they pointed out that the instructors are often role models to their participants who then may be inspired to adopt unhealthy eating behaviors.

In a follow up study, Bratland-Sanda and Sundgot Borgen (2015) examined what fitness instructors actually knew about ED. In a questionnaire sent to over 800 instructors, 29% reported having an eating disorder. Only 29% of the instructors, more women than men, were able to correctly identify symptoms for DE. However, 47% reported that they knew how to respond to concerns regarding a member with DE. It was not an accident that the prevalence of DE and the ability to identify their symptoms was similar: the researchers found that having a DE history, as well as a higher level of education, predicted an ability to recognize others with similar symptoms.

The authors further emphasized that while group fitness instructors are not licensed to diagnose DE behaviors, they can identify symptoms and then follow the appropriate guidelines at their fitness center. The assumption here is that each fitness center has established such guidelines. Some countries, such as Australia and the UK, have developed national guidelines for dealing with DE. For example, Fitness Australia published guidelines for identifying and managing members with DE in collaboration with the Center for Eating & Dieting Disorders in 2004. Bratland-Sanda and Sundgot Borgen (2015) have developed guidelines in Norway in collaboration with the Norwegian Association of Fitness Centers and an ED nongovernmental organization. It is important, however, that the instructors are aware of these guidelines.

Similar to Sarah, Bratland-Sanda and Sundgot Borgen (2015) emphasized the importance of increasing fitness instructors’ awareness of DE and ED symptoms, particularly excessive/compulsive exercise. It is equally important to clearly establish pathways through which instructors can report their concerns to a person responsible for providing information to help the clients and colleagues with possible symptoms. But how is it that some women and men in the fitness industry become motivated to engage in these types of behaviors?

Social psychologists Hesse-Biber and her colleagues (2006) contend that DE is not only a psychological problem, but also a social problem, particularly for women. They explain: “Eating Disorders and disorderly eating are also culturally-induced diseases promoted partly by economic and social institutions that profit from the ‘cult of thinness’” (p. 208). When ‘the ultra-thin’ feminine ideal is celebrated all around us, they clarify, it is difficult to detach one’s individual agency from the larger interests of such cultural industries as the diet, cosmetic, beauty, mass media, or fitness. They find these industries “allied with patriarchal interests” (p. 221) that “have convinced women that independence means women are responsible for maintaining the ultra-slender body ideal through self-improvement and self-control” (p. 221). As a result, Hesse-Biber and her colleagues (2006) conclude, “women spend an enormous amount of time, emotional energy, and money attempting to attain the ultra-slender ideal” instead of “other investments women might make, for example, political activity, education, and career advancement-activities that would promote empowerment” (p. 221). DE behaviors, they believe, are part of this complex cult of thinness.

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If DE behaviors have both social, cultural, and economic as well as individual psychological elements, what can an individual instructor do to combat the cultural messages of extreme thinness that can motivate DE behaviour? Hesse-Biber and her colleagues suggest three strategies:

1. Revisioning femininity

Hesse-Biber and her colleagues suggest that women should be able to determine their own identities to be empowered to challenge the thin body ideal. For example, fitness instructors can empower their participants by promoting other fitness goals such as bodily functionality and then design exercises that, instead of aimed only at thinness, help to improve women’s everyday lives. We can also carefully avoid trying to motivate our participants by promises of reduced ‘love handles,’ ‘bat wings,’ or ‘thunder thighs’ to emphasize instead, for example, postural benefits.

2. Media literacy

Hesse-Biber and her colleagues suggest increasing media literacy that aims to educate women “to critically analyze mass media and to develop new ways of putting one's own message into the multi-media network” (p. 219). We can then develop strategies to question how realistic the media images of the thin and toned fit feminine body are. Fitness instructors as well as fitness participants can actively share healthier images of fitness through social media networks. While an individual instructor or member cannot be responsible for fitness industry advertising or the fitness media, we can bring the possible connections between DE behaviors and the images of unrealistic ideal body to the attention of the management in our fitness centers.

3. Empowerment education

Finally, Hesse-Biber and her colleagues suggest “empowerment education” that “creates resilience towards ‘unhealthy’ media messages by teaching ‘critical thinking skills’” (p. 219). This is a more community-based approach through which we can involve the community of fitness participants, fitness instructors, and the fitness center management in eating disorder education by initiating, for example, creation of the DE guidelines. As one of our empowerment education initiatives, Sarah and I helped organize a fitness leader workshop about strategies of dealing with participants with possible signs of DE.

As demonstrated by Hesse-Bieber and her colleagues (2006), social and psychological elements are entangled in DE behavior. Such elements also differ across groups and individuals (across race, ethnicity, sexuality, gender, age). Eating disorders, with the highest mortality rate of any mental health condition (Joy, Kussman & Nattiv, 2016), are difficult to cure, but as they are relatively common in the fitness industry, there is a need to openly discuss the dangers related to them. However, as Sarah envisioned, further awareness and education regarding when exercise and dieting is no longer healthy can help to prevent and confront DE behavior in the fitness industry.