Maladaptive exercise: the hidden role of physical activity and sport professionals in the early detection of eating disorders

Abstract

Eating disorders (EDs) are a significant public health concern, particularly among adolescents and young adults. While physical activity (PA) is generally health-promoting, maladaptive exercise, characterized by compulsive and excessive activity linked to weight control, is often a core feature of ED pathology. Despite the high prevalence of these conditions, early identification remains a critical challenge, as most cases are detected only after severe organic or psychiatric complications. PA and sport professionals, such as personal trainers and coaches, are uniquely positioned to observe early warning signs due to their frequent direct contact with at-risk individuals. This Comment, developed within the European ERASMUS+ Sport project “My Fit Friend”, proposes a practical framework for equipping PA and sport professionals with tools for early detection in youths aged 11–18 years, including a structured observational diary and simulation-based training using avatar interactions. These tools allow those professionals to act as “informed sentinels”, identifying fractures in global functioning and facilitating timely referrals while maintaining clear professional boundaries. We argued that integrating standardized educational interventions and observational tools into European sport policy is pivotal to bridge the gap between the gym floor and clinical intervention, transforming recreational settings into protective environments for youth mental health.

Key points

• Maladaptive exercise may serve as an early indicator of emerging eating disorders within physical activity (PA) contexts.

• PA and sport professionals can act as informed sentinels, identifying early behavioral and functional changes associated with ED risk.

• Integrating structured training and digital tools into PA training policies could turn recreational settings into protective environments for youth mental health.

The clinical burden of EDs and the role of PA and sport professionals

Eating disorders (EDs) represent an increasing public health concern worldwide, with their point prevalence in the general population more than doubling over the past two decades (from 3.5% in 2000–2006 to 7.8% in 2013–2018), and affecting an estimated 20 million people in Europe alone [1–4]. This alarming trend has been observed globally across children and adolescents, becoming particularly evident during and after the COVID‑19 pandemic [1]. While these conditions can affect people of any age, gender, and social background, the highest incidence rate is reported in young women aged 15–19 years, with a peak at 16 [5]. Alarmingly, clinicians are increasingly observing these phenomena in even younger adolescents and children [1, 6]. Within this vulnerable demographic, athletes represent an exceptionally high-risk population compared to non-athletes, with the risk escalating significantly among those participating in aesthetic, endurance, and weight-class sports [7].

Although physical activity (PA) is a key element in pursuing and preserving health and providing physical and psychological benefits, excessive PA is strongly associated with EDs, especially anorexia nervosa, bulimia nervosa, and muscle dysmorphia [8, 9]. Maladaptive exercise, characterized by excessive, compulsive, and driven PA for weight or shape control, has a lifetime prevalence of 88% across people living with EDs and point prevalence of 48% [5, 8, 9].

Despite this significant burden, the majority of cases of EDs are identified only after substantial health deterioration has already occurred [10, 11]. Early identification and treatment of maladaptive exercise remain challenging, especially in preventing the onset of more severe organic and psychiatric comorbidities, including cardiovascular, renal, and musculoskeletal complications, and higher risk of suicide [12, 13].

In this landscape, PA and sport professionals occupy a unique and critical position. Across European countries, this heterogeneous workforce includes kinesiologists, personal trainers, and fitness coaches in sport settings, physical education teachers in school settings, and sport medicine physicians. Despite their diverse educational backgrounds and professional scopes, these professionals share a common characteristic: a regular, intimate contact with at-risk individuals during vulnerable moments in their natural training environment.

In 2020, the Australian Institute of Sport issued a position statement on EDs in high-performance sport, calling for coaches and support staff to participate in early identification [14]. The following year, the American Academy of Pediatrics published recommendations urging teachers, coaches, and athletic trainers to promote healthy approaches to nutrition and exercise, raise awareness of the detrimental effects of weight stigmatization, and recognize the warning signs of EDs [15].

At the same time, the American Academy of Pediatrics has highlighted concerns about the limited expertise of these professional groups across the domains of correct nutrition, weight management, and communication. This tension between the opportunity for early detection and the risk of iatrogenic harm from inadequately trained professionals continues to shape the central debate surrounding the role of non-medical professionals in the identification of EDs [16]. Iatrogenic harm in sports settings often stems from well-intentioned but misguided practices. This includes inappropriate comments regarding weight or body shape, the prescription of non–evidence-based nutritional plans, the minimization of clinical red flags, and the inadvertent reinforcement of compulsive training patterns [14, 16].

The 2023 International Olympic Committee Consensus Statement on Relative Energy Deficiency in Sport (REDs) further emphasized a multifaceted approach that engages athletes, their team, and broader entourage (e.g., coaches, parents, and managers) to foster a supportive environment, identify early signs of REDs, and prioritize education over an emphasis on body weight [17].

However, a critical gap emerges: these recommendations were primarily developed for elite athletes with direct access to multidisciplinary medical teams, sports dietitians, and mental health specialists. In contrast, epidemiological data indicate that the vast majority of individuals engaging in maladaptive exercise are recreational exercisers and amateur athletes training in commercial fitness centers, community sports clubs, or school programs [18, 19]. These grassroots environments inherently lack internal specialized medical or psychological support structures, leaving early signs of pathology undetected until severe clinical deterioration occurs.

To date, no European consensus statement has specifically addressed the role of exercise and sport professionals in identifying EDs among non-elite populations.

In Europe, only a study by Martinsen and colleagues (2015) in Norway has addressed this issue, showing that a one-year educational intervention significantly improved coaches’ knowledge of EDs [20]. This proof-of-concept demonstrates that structured training can effectively prepare non-medical professionals for early identification, yet it remains an isolated case and has not been incorporated into broader European policy or educational standards. Moreover, increased knowledge about EDs among coaches does not necessarily translate into earlier identification of affected athletes in everyday practice. This limitation indicates that educational interventions should aim not only to improve knowledge, but also to reduce the barriers that prevent recognition and referral in sport environments.

This gap is compounded by the fragmentation of exercise professional qualifications across Europe and the absence of unified educational standards, which limits the consistent implementation of evidence-based screening practices across the continent. Our Comment proposes a practical framework to address this gap, targeting the full spectrum of exercise and sport professionals involved in recreational and youth sport settings.

The “My Fit Friend” project: a European framework for early detection

In recent years, Italy has witnessed a concerning and rapid increase in ED cases, representing a major national health priority [21, 22]. In response to this escalating crisis, Sapienza University of Rome has taken the scientific lead within this framework through the “My Fit Friend” project. Supported by the Erasmus+ Sport Programme and co-funded by the European Union (Project n.101184114), this project serves as an innovative initiative to adapt evidence-based recommendations from elite sport to the everyday realities of recreational and youth sports across Europe. With the coordination role of Italy, and through a collaborative effort involving different European partners from Portugal, Spain, and Turkey, it aims to equip PA and sport professionals with knowledge and tools to identify early warning signs of EDs in young athletes and gym-goers aged 11–18, while remaining within their non-medical role.

The initiative rests on two complementary pillars: (1) structured education on observable warning signs and red flags that professionals may encounter in daily practice, and (2) a practical observational diary to facilitate systematic documentation of concerning behaviors over time. This dual approach acknowledges that early identification requires both the ability to recognize warning signs and a structured method to track patterns that might otherwise go unnoticed.

Structured education provided a minimum of 6 h of in-person training, with optional online participation, delivered by physicians specialized in sports medicine and child and adolescent neuropsychiatry. Interactive participation was mandatory and included contributions from PA and sport professionals, who shared their experiences and discussed suspected cases from their practice. The training program covered physiology of nutrition and PA, the epidemiology and clinical features of EDs and body dysmorphic concerns, practical guidance on approaching suspected cases, and project-specific procedures, and each session included pre- and post-training questionnaires and satisfaction surveys. During the training, particular attention was given to communication skills, in particular to the use of non-judgmental language and open questions when exploring sensitive topics. Coaches and PA professionals were encouraged to focus on empathy, active listening and clarity about their role, in order to create a safe context and reduce blaming and stigmatization.

To maximize the impact of this intervention, the project heavily invested in a “train-the-trainer” model. By dedicating significant human, temporal, and economic resources to training “master trainers”, the project ensured that knowledge is not just delivered but sustainably disseminated across the sport ecosystem. This cascading mechanism allows for a scalable educational impact, transforming senior coaches and managers into internal educators who can maintain high standards of ED awareness within their own organizations.

Subsequently, we proposed the “My Fit Friend” diary, a tool including eight key domains to consider in such an assessment: training frequency, patterns, and setting, psychological dimensions of training, food habits, self-perception and body image, social engagement, and social media influence (Table 1).

Table 1.

A structured tool designed for exercise and sport professionals to systematically collect information on an individual’s physical activity behaviors and attitudes

The “My Fit Friend” diary: coach’s behavioral observations
Features	Observed behaviors	Questions
Workout	Frequency, intensity, rigidity/stiffness	- How many times per week and hours per day does the individual train? - Do they mainly do cardio, resistance, or flexibility training? - How intense is the session? - Where and in what context do they train (e.g., alone, with a coach, or in a group, indoors or outdoors)? - How strictly does the individual follow their training routine? - Do they have ritualistic training behaviors?
Language	Negative comments about their body	- How do they react to changes in their body? - Are they overly self-critical? - Do they seek reassurance about their body?
Diet	Rigidity, restriction, avoidance	- How strictly does the individual follow their diet? - Do they limit certain foods or avoid specific situations related to food?
Emotions	Irritability, perfectionism	- Are they open to dialogue or do they tend to withdraw into themselves? - How do they feel when missing a session?
Social Media (SM)	Exposure to extreme or dysmorphic content	- What type of content do they view most often on SM? - Is it related to fitness, diet, or body image? - How often do they engage with fitness or food-related content?

The “My Fit Friend” diary was developed on the basis of a systematic review of the literature on EDs, integrated with a detailed analysis of ED‑related content on social media, in order to align the questions with a colloquial and easily understandable language. The questionnaire and educational materials were subsequently refined through expert consensus involving physicians specialized in sports medicine and child and adolescent neuropsychiatry. These materials are currently delivered to PA and sport professionals through theoretical lessons and workshops, both in person and online, with supervision offered to all participants and strongly recommended when suspect ED cases are detected.

The My Fit Friend diary was presented as an observational and practical tool to help coaches and PA professionals identify and record suspicious behaviors over time, rather than as a diagnostic instrument. Some of the information listed in the diary may not always be directly accessible, such as additional training performed elsewhere, social media content or eating patterns outside sport settings, unless explicitly disclosed by the individual or reported by others. During the project, trained participants reported using the diary mainly on their own, especially when they noticed something of concern, in order to document relevant details and avoid forgetting specific aspects over time.

Simulation-based training: the role of avatar interactions

Recent evidence shows that avatar-based interventions and immersive virtual reality are a promising frontier in ED management [23, 24] and can effectively train healthcare professionals to assess mental health disorders, with outcomes comparable to or better than traditional methods [25]. Australian elite sport coaches report preferring interactive, in-person training, emphasizing the value of experiential learning for discussing body image and responding to denial [26].

The ‘My Fit Friend’ framework used avatar‑based simulations as an educational tool to expose PA and sport professionals to common scenarios in recreational settings, thus enhancing their training. One featured an adolescent female with early-onset ED behaviors such as dietary restriction and excessive training, while the other depicted a young adult male with body dysmorphic concerns focused on muscularity. These simulations consisted of real‑time, online interactions between participants and an avatar operated by trained medical personnel, based on live question‑and‑answer exchanges around two prototypical cases. Each one‑hour session included a facilitated debriefing and provided a safe environment for practicing risk recognition and communication. The implementation of this approach requires dedicated technical support and clinical expertise but relies on standard videoconferencing technology, making adaptation to other recreational sport settings feasible at relatively contained costs.

Research highlights that avatar-based training reduces communication barriers, encourages exploration of challenging situations, and lets facilitators control learning stimuli [27]. Participants can make mistakes and receive feedback without risk to real individuals. Guided debriefings foster understanding of appropriate professional roles: observation, documentation, and referral rather than diagnosis or intervention, while the immersive, realistic format increases engagement and motivation.

In parallel, in settings where avatar technology is not available, traditional in‑person role‑play may achieve similar educational goals and represents a valid alternative. However, this strategy is more exposed to interpersonal dynamics and awareness of the counterpart’s identity, which may heighten evaluation anxiety, concerns about personal judgment, and ultimately limit the exploration of more challenging communication scenarios [27, 28].

Identifying maladaptive patterns: red flags and observational cues

Changes in training behavior suggestive of maladaptive exercise have been described since the earliest reports of Eds [29].

PA and sport professionals may notice a progressive increase in load through duration, intensity, or frequency, accompanied by reduced flexibility in scheduling. Distress when workouts are missed, insistence on exercising despite illness or injury, and performing “extra” or “secret” sessions beyond prescribed plans signal compulsive patterns rather than goal-oriented commitment [30].

Notably, the emergence of compulsive exercise, characterized by an obsessive need to train that transcends physical health or performance goals, serves as a primary indicator of underlying pathology. This pattern is often accompanied by heightened anxiety, depressive symptoms, and diminished well-being, particularly when the individual is unable to adhere to their rigid exercise routine [30].

Environmental and social context provides additional cues. A move from group to solitary training, avoidance of situations where the body may be visible, or exercising at unusual times to avoid observation may indicate body image concerns or concealment behaviors [19].

While exercise professionals should not conduct nutritional assessments, they could observe food-related behaviors, such as avoiding team meals, strict dietary rules beyond sport nutrition, or preoccupation with food timing, composition, or calories [10]. Social media may exacerbate these pressures, with individuals frequently checking fitness or body-related content, comparing themselves to influencers, or expressing distress over online contents [31–33].

Indicators of body image issues include preoccupation with weight or shape, frequent body-checking, wearing baggy clothing to conceal the body, and persistent dissatisfaction despite objective evidence. In male athletes, concerns often focus on muscularity and leanness, with rigid routines or “bulk and cut” cycles resembling binge-purge patterns [34]. Signs include reassurance-seeking, distress over normal bodily changes, or beliefs about the body inconsistent with reality.

Coaches and PA professionals are encouraged to refer when multiple warning signs are observed and persist over time, whereas ambiguous or borderline situations are first monitored before any referral is attempted. In situations judged to be clearly severe, they are encouraged to advise prompt medical evaluation, in line with local health care pathways, rather than relying on a stepped referral process. The core principles are consistent across settings, but the specific referral destinations (e.g., primary care physicians, school-based or community mental health services) inevitably vary depending on local resources and organizational structures.

Finally, each coach and PA professional received a written guidance document summarizing the topics discussed during training and outlining the suggested actions. For individuals under 18, this guidance also highlights the need to liaise with parents or legal guardians when concerns arise.

Defining the boundaries

Defining the limits of the non-clinical role of PA and sport professionals is essential to prevent iatrogenic harm, including inappropriate comments about weight or body image, non‑evidence‑based nutritional advice and inadvertent reinforcement of maladaptive behaviors. Otherwise, their role is to act as an informed “sentinel”. This position is uniquely powerful because it is built on trust and role-modeling rather than clinical authority. For younger athletes, the coach often represents a non-judgmental figure to whom they can relate more easily than a medical professional. For children, adolescents and young adults, PA and sport professionals frequently act as trusted figures outside the family context, perceived as approachable and relatively non-judgmental. Moreover, they may be current or former athletes and display a highly trained physique. Therefore, their attitudes toward training and eating habits, as well as their discipline and commitment to sport, are often interpreted as behavioral standards, thereby strengthening their role‑modelling influence.

Within this framework, their goal in real life is to monitor a “fracture” in global functioning, such as a shift from exercise as enjoyment to a rigid, compulsive obligation and to serve as a bridge for communication. Emerging concerns should be addressed in accordance with the target population’s age and maturity. A supportive and non‑judgmental approach should be used, seeking their consent to involve family members and/or clinical services. In cases of denial, PA and sport professionals are advised to maintain close monitoring and to prioritize health and safety by activating referral pathways when clear red flags or significant health risks are observed. In younger athletes, especially children, concerns may need to be communicated directly to parents or legal guardians.

Implications for European training and policy

The current fragmentation of professional qualifications in Europe represents a significant vulnerability for public health, since PA and sport professionals’ education often ranges from brief course certificates to university degrees in fields such as sport and exercise science or physiotherapy across countries.

Most PA/sport training curricula focus heavily on biomechanics, physiology and sport performance development, with limited emphasis on mental health content and on communication skills related to recognizing and referring to individuals with psychological difficulties. These aspects contribute to a substantial gap in mental health literacy among PA and sport professionals.

To address this, we propose that ED awareness and systematic observation tools, like the “My Fit Friend” diary, become mandatory components of European professional certifications. Furthermore, European sport policy should foster “fast-track” referral pathways between community fitness centers and local mental health services. Integrating these standards across the continent would ensure that the training facility becomes a protective environment, catching the earliest signs of distress before they might evolve into chronic illness.

It is important to acknowledge that, despite its conceptual appeal, this theoretical model might present several practical limitations. Implementing ‘fast-track’ referral pathways between community fitness centers and local mental health services would inevitably need to be adapted to the heterogeneous and fragmented landscape of European health systems, which differ in their overall organization and funding. Moreover, mental health services represent a critical area of care, characterized by marked heterogeneity in organization, coverage and accessibility across and within countries, which further complicates the implementation of uniform referral models at European level. In countries where PA and sport professionals are mostly employed in the private sector, such pathways would likely require formal agreements between private providers and public mental health services, for example by designating contact persons and standard referral procedures. In publicly funded settings, such as institutional or municipal sport centers, closer integration with existing mental health services might be more feasible, although sustainable funding remains a major constraint. In this context, awareness-raising campaigns and targeted pilot projects, supported by national health systems or European funding schemes, such as the My Fit Friend initiative, could be a pragmatic first step towards improving community awareness and access for at-risk individuals.

Abbreviations

EDs

Eating disorders

PA

Physical activity

REDs

Relative energy deficiency

SM

Social media

Author contributions

All authors made substantial contributions to the study and have read and approved the final version of the manuscript.Conceptualization: VZ and FP; Methodology: VZ, FP, MI and DF; Writing - original draft preparation: VZ and FP; Writing - review and editing: RP, MI and DF; Funding acquisition: MI, DF, IA and FPi; Supervision: IA and FPi.

Funding

This work was supported by the Erasmus+ Sport Programme, co-funded by the European Union (Project No. 101184114). Valerio Zaccaria, Fabiola Panvino, Roberto Paparella, Maura Ilardi, Dolores Forgione, Ignazio Ardizzone, and Francesco Pisani have no relevant financial or non-financial interests to disclose.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.