This is Part 2 of a Q&A with leading specialist in eating disorders and sports, Paula Quatromoni. Read Part 1 here.
Q: How do you recommend approaching an athlete you think might have an eating disorder?
A: Set up a private meeting with the athlete to discuss your concerns. Never, ever, ever do this in public and do not do it without some purposeful thought and advance preparation. In other words, do not have this conversation off the cuff or in the heat of a moment when you are having any kind of emotionally charged interaction with the athlete, like after a bad sport performance or when they suffer an injury.
It is important that you know the signs and symptoms of an eating disorder and that you have objective data and personal observations that align with those warning signs. Do not act on hearsay or second-hand information that could be false or inaccurate. Make notes about your observations and your concerns so that you can stay focused on the facts when you have this conversation.
Discuss your concerns with the Athletic Trainer. If your school does not have an AT, consult the school nurse or a guidance counselor. The AT or school nurse or counselor can help to validate your concerns, ask insightful questions for clarification, share additional observations, provide clinical input, and help you decide who should have this difficult conversation depending on the relationship dynamics you each have established with the athlete. The AT is a trained sports medicine professional. The coach is in a different position of power and authority which can influence how this sensitive message is received by the athlete.
Invite the athlete to sit down with you and have a conversation. Establish rapport by asking the athlete how he/she is doing and how things are going for them. This opens the floor for the athlete to confide in you. But don’t be surprised if they don’t. You may get “just fine!” as a response. It is not likely that they will open up willingly, even if they are aware there is a problem or want help.
Start by expressing your concern for the athlete. Then tell them what you’ve observed. Stick to the facts; things like, “I noticed you didn’t eat anything at team dinner last night. What’s going on?” or “You looked really fatigued at practice this afternoon, and your energy level seems low. Is there something bringing you down?”
Expect short and dismissive answers. Expect resistance. Anticipate that the athlete is afraid to say too much, so be as neutral and non-judgemental as possible. You don’t even have to use the words “eating disorder” in this conversation. In fact, you probably want to avoid that phrase altogether in this initial conversation. It is not your job to make a diagnosis of any kind! If the athlete uses that phrase, posing a question (“Are you asking me if I have an eating disorder?”) or in a statement of denial (“I don’t have an eating disorder, if that’s what you think!”), tell them, “I am not in any position to determine that. I’m a coach, not a doctor. I am just telling you what I’ve observed and that I am concerned about your health and well-being. I’d like to try to help. And I can only help you if I know what you’re going through.”
Try to “normalize” the situation and avoid blaming the athlete by saying things like, “Athletes who train as hard as you do in sport sometimes need help to be sure they are taking the best care of themselves and are getting enough nutrition. I’m concerned that maybe you’re not giving your body what it needs. Would you be open to talking to someone about it?” Or in the case of an injured athlete, “I’m concerned that you’re not getting proper nutrition to heal from your surgery.” Or in the athlete who is compulsively exercising, “I am concerned that you are not taking rest days and are over-training.”
The athlete trusts you, so if you tell them that in your opinion you believe this other professional would help them be the best athlete they can be, they will take your advice and go. Remind the athlete that you believe in them and in their potential to be a great contributor to your team. Make sure you acknowledge how much you value them as an athlete and care about them as an individual. Tell them that you are as invested in their health and wellness as you are in their athletic performance. These are very important points to communicate! Tell them that you understand what they are up against and that you want to help.
Refer them to the Athletic Trainer. The AT can do a more thorough assessment of the situation and can ask more clinical questions. The AT can determine what appropriate next steps should be taken and can follow up with a recommendation to the parents, in the case of an adolescent athlete. Options include making a referral to a nutrition professional (preferably one with expertise in sports nutrition), referral to the athletes’ pediatrician/physician for a medical evaluation, referral to a counselor or therapist to address anxiety, depression or other sources of stress and, if needed, referral for an eating disorder evaluation.
Conclude the meeting by restating your concern for the athlete and your commitment to being a source of support for them. Make a plan to follow up in a couple of days to set the expectation that you are holding them accountable to follow through, see the AT, and report back to you an action plan. Remain open, supportive, positive, and confidential with your ongoing interactions with the athlete while he/she works with qualified professionals who will manage their needs.
Q: What do you do if an athlete denies having an eating disorder, but the coach (or anyone else) really feels that something is wrong?
You should fully expect denial and you should prepare for it. The tips suggested above are the keys to the conversation: state your concerns, stick to the facts, rely on your own observations, and make your referral to talk to an expert. When the athlete denies and refuses, simply return the conversation with authority and confidence to what it is you recommend, a conversation with the AT. Let the AT do the rest of the work by fully assessing the situation. The AT has access to screening tools that can help discern the scope of the problem and bring awareness to the athlete and to the parents. ATs are trained to assess, treat, and refer athletes for appropriate interventions. This is their job.
The piece about “everyone else feels like something is wrong” is tricky. You don’t want to make the athlete feel ganged up on, as if everyone is talking about him/her and “everyone knows!” Imagine the humiliation that would induce. It would only make the athlete feel more isolated and desperate than they already are. For this reason, refrain from talking about rumors, things you’ve heard from teammates or other teachers, or things the AT confided in you. Do not pile on second-hand information that will feel like a truckload of accusations to the athlete. This will cause more damage than good and may actually increase despair and contribute to resistance to coming forward for help.
For more on What an Athletic Staff Can Do, please download this PDF. This resource guide was created by Dr. Quatromoni and her colleagues in the Walden GOALS program at Walden Behavioral Care, serving the greater Boston area.
Paula Quatromoni, DSc, MS, RD, LDN
Dr. Quatromoni is a senior consultant for Walden Behavioral Care, and one of the nation’s top minds on the intersection of sports nutrition and eating disorders. As a registered dietitian, she has more than a dozen years of experience working with athletes with disordered eating and has published several papers on both clinical experiences and qualitative research on recovery experiences of athletes. Dr. Quatromoni is the Department Chair of Health Sciences and a tenured associate professor of Nutrition and Epidemiology at Boston University where she maintains an active, funded research program. In 2004, she pioneered the sports nutrition consult service for student athletes at Boston University. Dr. Quatromoni was named a 2016 Outstanding Dietetics Educator from the Nutrition and Dietetic Educators and Preceptors (NDEP) Council. She earned her B.S. and M.S. degrees in Nutrition from the University of Maine at Orono and her Doctorate in Epidemiology from the Boston University School of Public Health.