How Can Coaches Help Underweight Athletes Gain Weight? Q&A with Dr. Quatromoni

This is part of a Q&A series with leading expert in eating disorders and sports, Paula Quatromoni. For more Q&As click here.

Q: I’m a high school coach. I have an elite runner who needs to gain weight/body fat. She is not intentionally losing weight but is very active with either running or other workouts like core and strength work. She never really slows down and on top of that just doesn’t eat enough to offset her exercise. She has seen a dietitian, but they haven’t really given her a strategy. She knows what needs to happen and her parents are working on it as well. My immediate thoughts are that she needs to record her intake and maybe that shows her just how much it is and shows ways to increase it. It could also show me how much she can run so as not to create a deficit each day.

A (Paula Quatromoni, DSc, MS, RD, LDN): It sounds to me like maybe she hasn’t seen the right dietitian who truly understands sport and the importance of a fueling strategy for an elite runner, because she reportedly came away from that interaction (was it only one session?) without one. I am betting that the RD (Registered Dietitian) she saw was not credentialed and experienced as a sports dietitian; not all registered dietitians have the additional training or qualifications to work in sports nutrition or eating disorder treatment. She needs an expert capable of designing a fueling strategy for an elite athlete. She should look for someone with the CSSD credential (Certified Specialist in Sports Dietetics) on top of the RD credential; or at least an RD who states on her practice website or is known to the local sports community as experienced working with and customizing nutrition plans for athletes.

This runner may also very well be “over-training” per the coach’s comments. I would recommend that she be fully evaluated by a certified strength and conditioning coach and evaluated by the Athletic Trainer (AT) or sports medicine doctor to be sure there is not a history of stress fractures, amenorrhea, or other things the coach may not be aware of.

In short, I would not focus solely on the nutrition side of the equation and ignore the risks associated with over-training or over-exercising (refusing to take a rest day is a big red flag, for example). Both situations need to be addressed.

And while she is “not intentionally losing weight,” if she is chronically underfueling and over-exercising in an attempt to maintain her low weight status through this regimen, that too is a big red flag. If she were to cut back on training and increase her intake, she would see her weight increase a bit. It could be that the fear and anxiety associated with that reality is what is keeping her fixed in her training routine, not with the intention of losing more weight, but to maintain her low weight and a low body fat percentage.

As far as evaluating the athlete’s food records, that crosses a boundary that I would not endorse to a coach. A coach should not be monitoring an athlete’s weight or food intake. Let the coach focus on her mileage, training plans and performance outcomes. A nutrition professional is the appropriate person to monitor food intake and nutritional adequacy, not a coach. They need to find the right, well-qualified nutrition professional to assess, plan and monitor the athlete’s nutritional needs and nutritional status; this is not a role that the coach should step into. That is altogether inappropriate for several reasons. It gives a false sense of assurance that the coach is trained and qualified to do this, which he/she most likely is not if the initials R.D. do not appear after the coach’s name. If something goes wrong, a coach would not want that liability on his/her shoulders. That is why professionals carry malpractice insurance; but they also have years of education and training behind them (in nutrition, metabolism, physiology and medical nutrition therapy) that coaches do not.

Finally, it sounds like this athlete is in high school since her parents are involved? The statement “she knows what needs to happen” suggests to me that there is some obstacle that is preventing the knowledge to be translated into behaviors to support her training demands. This would be appropriate to explore to rule out disordered thoughts, beliefs, and eating habits. A qualified sports RD would be able to tease this apart, if the client (and her parents, if appropriate) saw her for more than one initial appointment. It takes an ongoing working relationship to evaluate whether recommendations are being put into action and to identify potential barriers that are getting in the way. It also takes practice on behalf of the client and it takes back-and-forth discussions through several counseling sessions to see what works, what isn’t working, and to collaboratively fine tune and tweak the fueling strategy. Several sessions with the RD will be needed to uncover obstacles to putting a fueling strategy into practice; and the RD will work with the client to identify priorities, set goals, guide behavior change, and creatively problem solve around the challenges. To be effective, this work requires a full assessment of the situation that may not be obvious to the coach’s eye or to an RD who only sees a client for a brief interaction without follow up sessions where the collaborative working relationship develops.

If everyone is invested in building this athlete to stand the test of time through a high school and a collegiate career, investing in building a relationship with a sports RD is a wise investment. It takes a time commitment, some resources, and a whole lot of buy-in. The coach, athlete and parents all need to buy-into this advice and to prioritize the work with the nutritionist right alongside the training regimen. This is a working relationship that needs to be cultivated to support the athlete over time and through these transitions in sport, school, injury, transition to college, etc. It is not a “one-and-done, go see the RD once and you’re good to go” kind of situation.

The best way this coach can support this athlete is to clearly and consistently articulate concern, make the recommendation to work with a qualified sports RD, understand and endorse the need for a follow-up plan managed by the RD, and maintain the boundaries that define the scope of work of the coach vs. the nutritionist.


Paula Quatromoni, DSc, MS, RD is a registered dietitian, academic researcher, and one of the country’s leading experts in the prevention and treatment of eating disorders in athletes. Dr. Quatromoni is a tenured associate professor of Nutrition and Epidemiology, and Chair of the Department of Health Sciences at Boston University where she maintains an active program of research. She publishes widely on topics including clinical treatment outcomes and the lived experiences of athletes and others with and recovering from eating disorders. In 2004, she pioneered the sports nutrition consult service for student-athletes at Boston University, and in 2016, she led the creation of the GOALS Program, an athlete-specific intensive outpatient eating disorders treatment program at Walden Behavioral Care where she serves as a Senior Consultant. Dr. Quatromoni is an award-winning educator. 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.