How to Screen and When to Refer: A Guide to Eating Disorders for Certified Personal Trainers

This information is for educational purposes only. It is not intended to be used to diagnose or treat an eating disorder or any other medical or mental health condition. 

As a registered dietitian and certified personal trainer working with clients/patients with eating disorders, I’m extremely passionate about providing personal trainers with the tools they need to to screen clients for potential eating disorders, disordered eating behaviors, and exercise addiction, and also giving them the confidence to refer to complementary professionals like dietitians and therapists when needed. Today, I’m excited to share a conversation between Matt Stranberg, a registered dietitian and certified strength and conditioning coach and myself about how to screen for an eating disorder and what to do if you suspect your client is struggling. Matt is the nutritionist and exercise science advisor for the GOALS program and Walden Behavioral Care, an eating disorder center here Massachusetts.

Check out the full conversation, and make sure to scroll down to read through the key takeaways. 

Here are some key takeaways from our conversation:

What should trainers look out for during an initial intake session with a client?

While there are a few things you can look out for during an initial session, Matt reminds us that the tools that we use are only as strong as our own mindset and perspective as a trainer. We have to be aware that eating disorders exist on a spectrum, and are often buried in shame and secrecy, so it’s important to develop a trusting relationship with your client before digging into an eating disorder assessment. Here are a couple of ways to build that relationship:

Start a conversation like you normally do!

Ask your client why they came in to see you and practice active listening. Look out for extreme or unrealistic goals like weight loss or extreme changes in body shape or size. While this is unfortunately completely normal in most personal training sessions, it’s important to keep in mind that the majority of clients seeking weight loss, are also struggling with disordered eating.

Ask WHY?

When a client tells you about their goals, ask why? Is it because they want to feel better? Feel less winded playing with their kids? Be able to bike to work? Listen for answers motivated by shame or fear, for example, “because I’m embarrassed of my arms” or “because I’m afraid of gaining weight”. These can be red flags for an eating disorder on the horizon.

Take a thorough past medical and health history

Ask about any current or past diagnoses, recent injuries, sleep patterns, stress, and of course, if there is any history of disordered eating. Asking for a detailed history shows that you’re interested in this person as a whole, and not just concerned about their fitness routine.

What are some of the warning signs?

It’s important to note that eating disorder symptoms might be physical, but more often than not they are behavioral and emotional. As Matt emphasizes, it’s important not to be blind to your biases, and remember that eating disorder present in bodies of all shapes and sizes. Significant weight loss in someone in a larger body is still significant weight loss, and could be a symptom of an eating disorder or exercise addiction. It’s also important to note that weight loss is only one symptom of an eating disorder, and many eating disorders don’t result in weight loss at all. Here are a few warning signs to look out for.

Physical symptoms

Rapid or significant weight loss, low blood pressure, dizziness or lightheadedness, lack of energy, gastrointestinal problems, electrolyte imbalances (dehydration), overuse injuries or stress fractures. You can check out the RED-S assessment guide to see a full list of physical symptoms. However, it’s important to note that this assessment is not adequate for males or for clients in larger bodies, who might not meet BMI requirements for a diagnosis.

Emotional symptoms

Preoccupied with food and dieting, constant body shame, inflexible thinking, depression, anxiety, obsessive thoughts or behaviors.

Behavioral symptoms

Skipping meals, compensatory exercise, excessive exercise, excessive food rituals or rules, obsession with weight loss or body appearance.

For a full summary of eating disorders and their physical, emotional, and behavioral symptoms, check out my blog post: Eating Disorders 101: A Guide for Personal Trainers and Group Exercise Instructors.

What should a personal trainer do if they suspect their client is struggling with an eating disorder?

As the trainer you are in a unique position to get your client the help they need if you suspect they are really struggling. Sometimes it might take a few conversations and a few attempts, but here are some simple steps you can take:

Approach with curiosity

Try not to point fingers or accuse your client of engaging in disordered behaviors. Instead, approach with curiosity and ask open ended questions.

  • It seems like you’ve had some trouble eating before our sessions, can you tell me more about that?
  • I’ve noticed that you’re spending another hour at the gym after our sessions, tell me a little bit about what you’re trying to accomplish…

Ask for permission to refer

Practice active listening and really listen to how your client responds to these questions. Sometimes you might be able to offer some simple education around eating frequent meals throughout the day, or how your body needs time to recover after a workout. Other times you might realize that their responses require help that is beyond your scope. In this case, it’s important to ask permission to refer out.

  • It sounds like your diet is preventing you from getting the fuel you need for our sessions, would it be ok if I referred you to a dietitian who can help make sure you’re eating adequately?
  • It sounds like you’re using exercise as an outlet to deal with stress and anxiety, would it be ok if I referred you to a therapist who specializes in this area?

Know when it’s time to press pause

Unfortunately, there are some clients who will be resistant to treatment, but eating disorders and exercise addiction is not something to be taken lightly. In our conversation Matt offers a really clear analogy: if a client had a broken ankle, you wouldn’t continue training them, because you know they were at an increased risk for further injury. The same applies to someone with an eating disorder. Let your client know that you are no longer able to train them, unless they are willing to speak to a dietitian or therapist, or seek a higher level of care to treat their eating disorder.  Bottom line: when in doubt, refer out!

This conversation was originally much longer, and Matt and I dug into details on how you can help ensure your clients are fueling adequately and how to tell the difference between habitual under fueling and disordered eating. If you’d like to reach out to Matt directly, you can email him at and make sure to download the guide he mentioned in this video, Eating Disorders in Sport: What Can Athletic Staff Do? for more insights from him!

And, if you’re looking for a more in-depth training on nutrition, body image, and eating disorders consider checking out (and joining!) my upcoming training for certified personal trainers: Nutrition & Body Image Coaching Skills for Personal Trainers. Here we’ll dive deeper into these topics, and also work through some more specific case studies. You’ll receive direct support from myself, and continuing education credits!