For Coaches, How to Help Athletes with Eating Disorders (Q&A with Paula Quatromoni Part 1)

Ever since meeting Paula Quatromoni at the Eating Disorders in Sport Conference last August, we have been in constant communication. Paula even had me come speak at Boston University to talk about my eating disorder experience, recovery process, and the book Running in Silence, which she endorses as a great resource for athletes and coaches, along with the information she provides below (including a downloadable PDF guide).

Paula has been especially helpful for me since I am not an expert/professional in the area of treating eating disorders. So as one of the leading experts in this field, it is a privilege and an honor to have Paula answer a few questions to help coaches better work with athletes who may have eating/weight struggles. Stay tuned for another Q&A with Paula in the near future!

Q: What can coaches/parents/sports programs do if an athlete is resistant to going to an eating disorder therapist or dietitian, but very clearly struggling with an eating disorder?

A: There are guidelines for this in the literature now, thanks to the RED-S model (Relative Energy Deficiency in Sport). A 2016 publication from this expert group included a sample “contract” that an athletic trainer (AT) or a coach can use to require an athlete to engage in treatment for an eating disorder in order to continue to participate in sport. The RED-S clinical assessment tool allows a sports medicine professional to determine whether or not the athlete is healthy enough to train and/or compete while engaged in treatment or if sports participation needs to be suspended. The “return-to-play” guidelines inform decisions about when it is safe for the athlete to return to sport. In the case of a collegiate athlete, there is more control over the situation with NCAA eligibility and medical clearance to participate in sport managed by a team of sports medicine professionals (MD, AT, Nutritionist, etc) who really should be the ones doing this work and making these decisions, not the coach.

At the high school level, the proper action for the coach is to express his/her concerns to the athletic trainer and to let the AT follow proper channels of communication with the parents as a sports medicine professional. The AT should inform the parents about the observed behaviors and measurable concerns that validate their clinical judgement that their child needs to be evaluated by their pediatrician for an ED risk. The athlete needs a full work up and evaluation by their primary care doctor if an eating disorder concern is identified. If the parents refuse, the AT has the right to say, “Your child will not be cleared to participate in sports until we have clearance from the pediatrician.” The student should be off the team until their MD has evaluated the situation and provides medical clearance for sports participation. If a contract is used in this setting, parents need to be aware and involved, and the contract should be managed by the medical professionals (the AT and/or the pediatrician), not the coach.

Q: Should coaches weigh their athletes to make sure their weight doesn’t get too low?

A: Coaches should NOT be weighing athletes.

If necessary for concern about an eating disorder, weight should only be monitored by a sports medicine professional (MD, AT or Nutritionist) – not the coach. An athlete that a coach is concerned about their weight dropping too low needs medical evaluation and supervision, and most likely they need intervention and treatment as well. All of these tasks are beyond the scope of the coach’s expertise, making it clear that monitoring weight is not the coach’s responsibility.

In the case of a high school athlete with an ED concern, the pediatrician and the school’s AT need to be on the case; NOT the coach monitoring weights. If a coach monitors an athlete’s weight because he/she is concerned about the athlete’s weight dipping too low, he/she is providing a false sense of assurance that someone is watching the situation, but the person monitoring it is not trained to do so or to recognize the medical risks. This is not appropriate and is opening up liability that I would imagine a coach would not want if something went wrong. By trying to manage it him/herself and by not calling it out as a problem of concern to the AT, the coach is condoning the ED behavior that the athlete is displaying and is missing the opportunity to send the right message to the athlete and the parents that there is a problem here of serious concern that requires full medical evaluation if this student is going to be allowed to participate in sport. In this situation, the coach would be delaying a potential diagnosis, delaying treatment interventions, and worsening the health outcomes for this athlete. The coach would also be sending a message to other athletes on the team that ED behaviors are acceptable within the culture of the team, because observable behaviors do not go unnoticed by teammates. Eating disordered behaviors are role modeled by teammates and become contagious if not addressed.

In collegiate settings, weight (if required or justified for a weight-class sport like crew or wrestling) should be monitored by a nutrition professional, sports medicine doctor, athletic trainer, or perhaps a strength and conditioning coach. Since not all collegiate athletic departments employ registered dietitians, the practices are highly variable. But most sports medicine professionals agree that, particularly outside of these weight-class sports, to avoid contributing to weight bias, stigma, body image concerns, dieting or disordered eating or exercise behaviors, coaches should not have access to specific information about athletes’ weights.

Q: Can coaches tell athletes to lose weight?

A: Weight concerns should be managed by a qualified nutrition professional, not a coach. So if a coach has a concern about an athlete’s weight, he/she should express that concern to the nutrition professional (not to the athlete) and let the nutritionist assess the athlete, determine whether weight change is appropriate, and initiate a proper plan of nutrition intervention. The work between the nutritionist and the athlete should remain private and confidential, with the coach placing full trust that the nutritionist is managing the case and monitoring the athlete’s progress towards goals. This allows the coach to focus interactions with the athlete on skill, technique and training, not on weight.

A coach who tells an athlete to lose weight may be very well-intentioned and caring, yet he/she risks inducing a lot of collateral damage. First, the power of a head coach who determines who earns a spot in the starting line-up and who gets how much playing time makes messages about body shape and size very much tied to those highly coveted sports outcomes in the minds of student-athletes. Weight should not be used to make decisions about playing time and starting line-ups; those coaching decisions should be based on performance, fitness, skill and other indicators of readiness to play, not weight. No matter how carefully the coach tries to deliver a message about weight loss, the athlete is likely to hear it as a criticism or a judgment. This can be internalized by the athlete as, “I’m not good enough” because of their weight, shape or size, threatening the athlete identity and undermining self-confidence.

Second, if a coach says, “drop 5 pounds,” the average athlete, so determined to please, will drop 10. One who is vulnerable to an eating disorder won’t stop there. Disordered thoughts and behaviors quickly become ingrained and the dieting and the weight loss become the sole focus, even overshadowing performance because the number on the scale becomes the most important indicator of success.

Third, it could be humiliating or devastating for an athlete to be told to lose weight by their coach, a trusted and highly respected authority figure, inducing tremendous psychosocial distress and damaging self-esteem.

Finally, and most importantly, if a coach tells an athlete to lose weight without connecting them to a qualified nutrition professional to help the athlete understand their unique nutritional needs and manage their weight (even if changes in body composition truly are indicated to benefit sport performance), they are contributing to potential problems. Adolescents and young adults do not, on their own, have ready access to nutritionists to guide them in these pursuits. In a desperate attempt to do what the coach mandated, they will set off on their own, be vulnerable to restrictive eating habits and fad diets, over-train and turn to a variety of other disordered behaviors including laxative abuse and self-induced vomiting as a means of achieving a weight goal with no understanding of their nutritional needs for growth, development or fueling for sport. This strategy ultimately sabotages athletic performance and both emotional and physical well-being. Research shows that it predisposes athletes to eating disorders.

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For more on What an Athletic Staff Can Do for eating disorders in athletes, please download this PDF. This resource guide was created by Paula Quatromoni and her colleagues in the Walden GOALS program at Walden Behavioral Care, serving the greater Boston area.

Paula endorses books like Running in Silence, the blog posts on this website, and Nancy Clark’s Sports Nutrition Guidebook as helpful resources for coaches and athletes.

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.

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  1. […] A few of the women approached me after the presentation about concerns with themselves or with a friend or teammates. I offered advice based on what I’ve learned through my own experience, and from experts like Dr. Paula Quatromoni. […]

  2. […] Q&A with leading specialist in eating disorders and sports, Paula Quatromoni. You can also read Part 1 and Part 2 of this […]

  3. […] This is Part 2 of a Q&A with leading specialist in eating disorders and sports, Paula Quatromoni. Read Part 1 here. […]

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