A few months ago, while attempting my new morning exercise routine at the local gym, I noticed a young woman in her mid-twenties. Let's call her Amy. I don't go to the gym as regularly as I should, but each time I do, Amy is there too. While I'm trying to wake up on the treadmill, Amy is coming out of the early morning aerobics class, having finished an hour-long workout. While the others head to the showers, Amy heads to the bicycles. Often she is still there by the time I leave.
I have no doubt that Amy has an eating disorder. This view is based not only on her exercise habits, but also the eating behaviours I have witnessed and her incredibly thin frame. Having shared several concerned glances with fellow gym members, I suspect I'm not the only one feeling worried.
As a researcher working in the field of ethics and adolescent health, I can't help but wonder what constitutes appropriate action by my gym manager in Amy's case. Should something be done? If so, what? Do gyms have obligations when it comes to the well-being of their members? What is their role in the delicate and sensitive battle against eating disorders?
There are a number of arguments in favour of gyms taking action with people like Amy. Firstly, it is an opportunity for intervention. The lifetime prevalence of eating disorders among Australian women has been estimated at up to 15 per cent. We also know that only a minority of people with eating disorders are treated in mental healthcare settings. This means that the majority of people with severe eating disorders do not receive adequate treatment. Gyms are well placed to identify individuals with such disorders, thereby increasing the chances of early diagnosis and treatment.
Secondly, many formal weight loss organisations refuse to take on clients who are not above a specific body mass index, therefore reinforcing healthy messages about body image. If gyms intervened with members who may have an eating disorder, they would act as advocates for a realistic and healthy body image.
Finally, when gyms fail to intervene with members who are below a healthy body weight, they risk becoming complicit in the delusions held by these individuals, strengthening the perception that more exercise and weight loss is needed. Not only does this harm the person with the eating disorder, it has the potential to harm other members of the gym who may begin to see the person's behaviour as normal or even exemplary.
Of course, taking an active role has potential for problems. Depending on the approach taken by the gym, the person with the eating disorder may feel embarrassed, angry, offended, humiliated, or ashamed. It is also possible that the person won't return to the gym, which may increase isolation and break important social links. Gym employees are not counsellors or doctors and have not necessarily been trained in the skills required for successful intervention.
A variety of other businesses actively influence the health of their customers but are not required to monitor outcomes. Fast food chains, for example, are not required to refrain from serving obese customers. Alcoholics are not refused service in bars. Gambling addicts are free to enter casinos. It could be argued that requiring gyms to intervene over people with eating disorders falls outside their ethical remit. At the end of the day, gyms are independent, profit driven organisations.
Furthermore, we simply don't know if intervening will actually improve outcomes. There is no evidence to suggest that a private conversation has the capacity to change exercise habits. Telling people they are underweight and alerting them to avenues for help may not result in them accessing treatment. And banning people from gyms will certainly not prevent them from exercising. In the absence of evidence of benefit, it may be that refraining from intervention is the safest option—the least likely to cause harm.
This morning I asked my gym instructor about Amy. She said I wasn't the first to ask and that it was a very difficult issue. She mentioned that the gym was following appropriate guidelines. The guidelines, which I've seen, are impressive. They recommend a detailed step by step process that begins with a private conversation, can entail a request to see a GP, and, eventually, may entail suspension of membership.
I wonder, then, what has happened in the case of Amy, who has been attending my gym for at least a year now? Is the current approach working? Is it sufficient? I'm not an expert in eating disorders and I'm sure the situation is more complicated than I know, but every time I see Amy my unease increases. It is time to address this issue and establish industry-wide standards for gyms.
Eating Disorders Helpline number (Victoria): 1300 550 236
Dr Rony Duncan is a Postdoctoral Research Fellow specialising in adolescent health and ethics at the Murdoch Childrens Research Institute, Victoria.