Paula Quatromoni is a senior consultant for Walden Behavioral Care, a registered dietitian, and one of the leading experts for eating disorders in athletes. She 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.
In this Q&A series, Paula will be answering some of the biggest questions coaches and athletic staff have to better prevent and assist athletes who may be struggling with eating disorders.
What can coaches do to prevent eating disorders?
First, coaches need to get educated about eating disorders in sport from credible professional sources like the National Eating Disorders Association (www.nationaleatingdisorders.org/sites/default/files/Toolkits/CoachandTrainerToolkit.pdf). Coaches and athletics administrators can also bring professionals in to educate athletes and support staff about eating disorders in sport.
Eating disorders are poorly understood, probably more so inside sport than in the general public. There are stereotypes and sources of stigma that perpetuate faulty beliefs about who is at risk and what an eating disorder “looks like.” Coaches, strength coaches, athletic trainers (ATs), doctors, parents and athletes all need education about eating disorders in sport, the unique sport-specific risk factors, the negative impact on health and sport performance, and the diverse ways in which eating disorders present. There is no one universal sign or symptom of an eating disorder. Eating disorders do not discriminate; they occur in males and females, in individuals in smaller bodies and larger bodies, and in all sports.
The book, Finding Your Sweet Spot by Rebecca McConville, MS, RD, CSSD, CEDRD is an excellent resource to help coaches, athletes and parents understand the dangerous consequences to physical health, mental health and athletic performance caused by relative energy deficiency in sport (RED-S) that occurs as a result of disordered eating, under-fueling, and/or overtraining. This education is essential to help recognize eating disorder risk sooner rather than later and respond in a timely fashion with appropriate interventions. Delayed recognition and delayed intervention contribute to poor outcomes for affected individuals, a higher likelihood of removal from training and competition, and a lower likelihood of a return to full athletic participation and competition. Delayed intervention also risks the spread of disordered eating behaviors to other teammates given the behavioral role modeling that occurs and the cultural messages endorsed.
Second, coaches have a large responsibility and influential role in setting team culture. Coach behavior and coach communications on topics of nutrition and weight send strong messages to athletes that can be positive and empowering, or negative and hurtful.
Coaches need to be aware that an athlete’s self-esteem, self-worth and body image are points of vulnerability, so locker-room talk or even well-intentioned comments about food choices, dietary habits or athletes’ bodies, sometimes used in hopes of motivating an athlete to achieve a goal or perform better, can contribute to a culture that endorses dieting and restrictive eating. A proactive approach to achieve a healthy team culture would involve coaches explicitly denouncing diet culture and embracing body diversity.
Coaches who communicate their guidelines with their athletes (and parents, in the case of youth/adolescent athletes) can hold captains and upper-classmen accountable for helping to reinforce zero tolerance for body shaming or food shaming interactions. When a coach remains silent or inactive against a culture that endorses disordered behaviors and/or body-shaming commentary, or if a coach perpetuates that culture through their own actions, the coach risks condoning the behavior and causing widespread harm to their athletes.
Finally, coaches need to set protocols for mandatory screening. Annual screening for eating disorder risk is recommended as a part of the pre-participation exam (PPE), yet this is not necessarily done inside most athletics departments or by most doctors/pediatricians using anything more than an assessment of weight (using BMI criteria) and the presence of amenorrhea in female athletes. This practice results in a heavily biased and stereotyped assessment of eating disorder risk and runs the risk of missing most eating disorders that occur in sport, including sub-clinical disordered eating behaviors that are just as dangerous and in need of intervention.
Often in collegiate settings, only freshmen are screened comprehensively– leaving athletes vulnerable beyond that freshman screen. Any time an athlete comes to attention for displaying restrictive eating behaviors, increased emotional distress, visible signs, or clinical symptoms of an eating disorder or compulsive over-training, a full assessment should be done. Included in this at-risk category are athletes who suffer an injury.
One rather simple assessment tool that is sometimes used in pre-participation physical exams to screen for eating disorder risk is the SCOFF (https://www.psychtools.info/scoff/). This brief 5 question screener is quick and easy to administer, making it suitable for an AT to administer annually at the PPE or any time an athlete appears to be “at risk” based on observed behavioral concerns. It is recommended that any athlete who answers “yes” to two or more of the screening questions should be referred for a full assessment for a possible eating disorder, however given higher risk profiles in athletes including other disordered thoughts and behaviors that the SCOFF does not assess, it would be prudent to make a referral if any one question is affirmed by an athlete. That referral is best made to a Registered Dietitian, doctor/pediatrician, or a licensed therapist.
For more, visit a previous question on this here: https://runninginsilence.org/what-coaches-can-do-to-prevent-eating-disorders-qa-with-paula-quatromoni-part-3/