How Can a Coach Support an Athlete With Exercise Restrictions in Eating Disorder Treatment? Q&A With Dr. Paula Quatromoni

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In this Q&A series, Dr. Paula Quatromoni (DSc, RD) answers questions about common situations athletics staff or athletes face in sports involving eating disorders. Sign up for our email list to get the next link to the newest Q&A right to your inbox.

Q: You have a year-round competitive athlete who has been diagnosed with an eating disorder. The athlete’s treatment team says the athlete needs to discontinue training and physical activity for a period of time, including missing out on an upcoming sports season. The athlete comes to you in distress and tells you they need the physical activity—not because they want to lose weight by exercising, but because it is a mental health outlet. On the other hand, the athlete admits that they are seeking perfection in their body image and acknowledges that this (rather than performance pursuits) is what is driving their eating disorder. How can a coach support an athlete in this situation?

A (Dr. Paula Quatromoni):

The most direct answer is that the best way for the coach to help their athlete who is in treatment for an eating disorder is to support the guidelines established by the treatment team, to endorse the “no exercise, no sports participation” plan, and to stand firm in alliance against the eating disorder.

Support the Treatment Team Guidelines

I assume this is an adolescent/high school athlete and, in that case, the parents must be involved in the treatment plan and its execution. But we don’t know much more, including where the athlete is in terms of treatment compliance, in relation to their goal weight, or what level of care they are being treated at (in the outpatient setting, or in an eating disorder specialty clinic in an intensive outpatient (IOP) or partial hospitalization (PHP) program). The coach likely does not have access to that information, either. Yet all of those factors influence the decision about return to sport.

We also don’t know if the providers are eating disorders specialists and/or how informed they are in working with athletes. Not all doctors/pediatricians, therapists, and dietitians are eating disorder experts and/or know how to safely prescribe and monitor partial training plans (ie. modified training and exercise prescriptions that are in between “no exercise at all” and “full participation in sport”). There is tremendous variation out there in terms of provider training and expertise.

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The Eating Disorder Tainted Happy Events

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7 years ago our Aquinas women’s cross country team placed 7th at the NAIA national championships—our highest finish ever at that point. When our coach announced the news just beyond the finish line, the nine of us women had our arms around each other’s shoulders and tears in our eyes. We looked around in awe and triumph, proud of how far we had come that season. And I was thrilled to be a part of it.

However, the eating disorder I had been struggling with for two years leading up to that point crept in as the day went on. I couldn’t help but think, How could we have finished if I had been “lighter?” How would things have ended up if I had never binged and gained weight?

Knowing that I had placed much higher individually my freshman year–when I had been at my fastest, but also struggling with the beginning of my eating disorder–didn’t help.

An Invisible Injury

A lot had happened since that freshman year. I redshirted my second cross country season as I struggled with a knee injury, even more intense food restriction, and then the bingeing. Now, instead of seeing how far I had come and seeing the eating disorder as another “invisible” injury, I only saw what I “should’ve known” or where I could have “tried harder” with food. The eating disorder voice was always there, ready to rear its head even during what should have been a happy time.

Attending the All-American awards ceremony that afternoon was where I vowed to “do better.” I vowed to turn things around with food. Sick of the binge eating, and wanting to lose the weight I had gained, I told myself that I had to drop at least a little bit of weight to get back to the top. With the focus on the next nationals meet already, I emotionally and socially shut down.

When our team ate at a steak restaurant that evening, I calculated my calories while everyone bonded over the new Snapchat app they had on their phones. And later that night I stepped away from the celebration my teammates hosted in one of their hotel rooms. I sat holed away in front of my hotel room mini fridge, shoving peanut butter-laden vegetables into my mouth with a vengeance. The hunger I had experienced up until that point–the raging, unending hunger–had returned.

The cycle of restriction and bingeing continued, and I felt powerless to stop it.

Long Term Effects

Even with two years left to compete, I never made it back to the national meet. Just less than one year later, my kneecap broke while running.

The sacrifice I believed I needed to put in with food had never been worth it. It just destroyed my physical and mental health.

I know now that many other athletes experience or have experienced similar struggles. I know that the mental battles I had were part of an eating disorder, and that athletes at any body weight, shape, or size can struggle in silence. Many others often think that if they just did this or that with food, that everything would be “better.” The eating disorder robbed me of what could have been an even more exciting experience with my teammates, and the day is still tainted with what my mindset had been at the time.

I’m thankful for my team. I’m proud of what we accomplished. Looking back, we did everything we could. And even though I didn’t believe it then, I know now that I did everything I could at that time, too. I did more than enough. There was nothing more I was “supposed” to do with food, except to allow myself to eat it without shame, guilt, or fear.

My body and performance that day didn’t need to change. My eating disorder did.

Reflecting on Failure

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This September I spoke at an event called Failure Lab. Seven speakers talked about a time they’ve failed to “pave the way for change by crushing the isolation and stigma around failure.” We had to share our stories of failure, and leave it at that—no lesson learned, and we could not talk about how we made it out.

Preparing for, speaking at, and reflecting on this event made me think about many of my failures–one, in particular.

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Why Don’t You Lose 5 Pounds: Eating Disorder and Sports Documentary

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In a recent trip to St. Louis, MO for the Eating Disorders in Sports Conference through McCallum’s Place Victory Program, I was able to talk with and be interviewed by Chris Blunk, producer of the upcoming documentary Why Don’t You Lose 5 Pounds? And after a few days at the conference connecting with eating disorder therapists, dietitians, and athletic trainers focused on eating disorders in athletes/sports, I was even more excited for what Chris (and Nancy Kerrigan, Executive Producer!) have in store for us with this documentary. Chris Blunk has more background on the documentary below, but be sure to also follow the Why Don’t You Lose 5 Pounds website and social media pages for updates!

How long have you been in film?

I started making films my senior year of high school and went to the University of Kansas for a film degree. I graduated in 2004 and started working professional in film right after that.

What inspired you to start making a documentary for eating disorders in sports?

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National Eating Disorders Awareness Week

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February 23-March 1 is National Eating Disorders Awareness Week.

Eating disorder awareness is great, but the most important part of this is that people become aware of how hidden and prevalent it really is. The key to my own recovery was recognizing it within myself. This was difficult to do since I was never extremely underweight. And there are people out there with a BMI under 18 who don’t have eating disorders, too.

Therefore, we must emphasize how much of a psychological problem this is–that it is how we approach food and our habits around food that make an eating disorder what it really is.

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Hungry to Speak

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You ask me why I eat in secret.

I wish you couldn’t see me eat. I wonder how much you think about what I eat. I decide what I will eat next to make it look like I am not eating too much. I wait until it is noisy enough in the room so that you may not notice how much I am eating when I grab more food.

I sit there acting like nothing is wrong because I don’t want you to notice I am screaming inside. I don’t want you to know how embarrassing this is for me.

You ask why I can’t have more self-control. I tell you, it is because I used to have all the control in the world.

You ask me why I take food out of the trash. I tell you, it is because I used to spit my food into it.

You ask me why you find food wrappers, empty cans of vegetables in strange places around the house. I tell you, it is because I pushed food away for so long–and now there is a shaking, anxious girl inside of me that is terrified she will never have enough.

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If Dieting is Detrimental to Athletes, Why Did I Keep Doing It?

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Q: Even though running was your primary goal, when it became evident that the diet was detrimental to running it still pulled you back in. Why do you think it still gripped you even when you knew it wasn’t the direction you wanted to go?

One word: Fear.

When I noticed any detrimental effects on the raw food diet (especially the fruit-focused diet), I felt that I “just wasn’t it doing it right.” I was deeply invested in what I had learned about raw food and its connection to weight loss. I believed that “just eating normally” again would be to ignore “science” and gain weight.

Little did I know how much misinformation I had absorbed. I was following many fruitarians who claimed that the food pyramid was government propaganda and that the fantastic results I was seeing from a select few fruitarians mattered more than working with a registered dietitian. I felt that the world of raw food was something new and exciting I had uncovered and that this alone held the truth to health and success.

I also thought that cooked food would only cause me to binge more. I was afraid of my own appetite, afraid of how “out-of-control” I would feel if I ate any cooked food. And after months of reading from what I thought to be credible sources that protein would “leach the calcium from your bones,” and that eating “cow pus” and “animal carcass” was supposedly “immoral,” I was scared to stop being vegan.

I thought I was meant for this raw food diet. I thought I had more discipline than anyone else, that this was something my competitors could not and would not ever do (I guess I was partly right, haha–very few people would want to do this). After years of toiling away at running, after working so hard, and watching other athletes make it to the top without me, I became frustrated. Why wasn’t my body doing what I wanted it to do? Why, after all the discipline, strength training, high mileage, and eating healthy (or what I thought was healthy), why wasn’t it working?

Restriction–and raw food, at that–was what I believed (at the time) would help me to achieve success at last.

Once I realized that fruit probably wasn’t everything I had thought it to be, it still took weeks for me to “allow” myself to eat cooked food. I can’t pinpoint exactly what it was that made it so long and difficult to make this change, especially since I was bingeing on the very foods I was scared to incorporate into a regular diet. But even when I did make the change back to cooked food, it was a long, slow process (to be detailed in the Running in Silence book). If I thought raw food was the bulk of the journey, I was mistaken.

I was now facing my fear head-on. Yes, I was dealing with an eating disorder. Yes, I would be eating cooked food again. Yes, I had to learn to overcome the bingeing, learn how to eat properly again, learn to be okay with eating (tasty) cooked food.

I had fallen so fast and hard into the raw food eating disorder that I forgot how and what to eat anymore, and I had to act fast–with three or more meals a day and all the running and racing I was doing for my team, I had to learn to eat to fuel my body properly. I had to do things I never would have thought I would ever do again. I had to fight against every rule I had ingrained in my brain for the past few years, grit my teeth, and move past them.

If I wanted a good relationship with food again, I had to face my fears.

Update: Original title was The Power of Fear

Do I Really Have An Eating Disorder?

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I remember going into my sophomore year of college thinking about how I “had” to lose some weight to run faster than my freshman year. I had gotten to the point where I thought only weight loss would keep me at the top.

Although I was at my thinnest, I was not just skin and bones. I didn’t starve for days-on-end. I never fainted or ended up in the hospital. In fact, I began gaining weight that sophomore year. Because I was gaining weight while struggling with food, I felt it was not “that bad” of an eating disorder, if an eating disorder at all.

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I need YOU

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Okay, so I can’t abandon this blog.

I need your help; I’m trying to take this to the next level. What are your biggest questions about eating disorders or diets in general? Do you have specific questions about what you have read so far on this website?

I want to keep you all connected as I put my project together and I want to keep you updated without giving too much away. Please post any suggestions, comments, etc, and maybe we can dive into these topics and my perspective for a few posts here and there. What are your input or thoughts?

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Where Are the Next Posts?

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As of right now, I will not be posting any more journal entries. This was a difficult decision to make. There are more journal entries to reveal, but I need to take action and make something more of these than just a blog. I never planned on doing this; in fact, I anticipated sharing the entire journey on this website. However, after a lot of thinking and professional writing advice, I have decided I want to work on these posts more and create something bigger.

You will be able to read the rest of the posts eventually—however, I can’t tell you when since I don’t even know myself. All I do know is that this is the next step I have to take and I don’t want to risk self-publishing all of my work on this site if my gut feeling is to do something bigger.

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