How Can a Coach Support an Athlete With an Eating Disorder? Paula Quatromoni Q&A

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 (Anonymous): I’m a coach with an athlete who told me she is struggling with an eating disorder and is getting treatment. She asked me to keep her accountable. How can I do this? Should I monitor her weight and food?


A (Paula Quatromoni, DSc, MS, RD, LDN): I would ask the athlete, “What do you mean by “keep me accountable?” Can you say more about specifically what you are asking of me?” I would not make any assumptions about what the athlete means. It is very important to set some boundaries and clear expectations about what the coach can and cannot do related to appropriate kinds of support for an athlete with an eating disorder. Leaving expectations vague leaves room for misunderstanding, misinterpretation and misplaced responsibility. Clear expectations and ground rules are best!

Experts Needed

First, let’s be clear about this: it is not the coach’s responsibility or within the scope of a coach’s training and expertise to monitor an athlete’s weight or food intake. This is particularly dangerous in the case of an athlete with an eating disorder because it could delay timely diagnosis and proper intervention. Anything that delays timely diagnosis and treatment of an eating disorder escalates the health risks for the athlete, increases risk of injury, and lowers the likelihood of recovery.

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Bringing Mental Health Education to Coaches and Athletes in Michigan

As many of you might know, I coach high school cross country and track in Michigan and I’m required to take trainings on the sports rules and how to spot concussions. These trainings are run by the MHSAA, which is also a member of the National Federation of State High School Associations. Of course, with my eye for mental health and eating disorders, I noticed that there were no required trainings on how to identify mental health issues in our athletes (something I’ve already witnessed in the few years of coaching).

But when I went to the Stomp Out Stigma walk a few weeks ago, I spoke with Christy Buck, CEO of the Mental Health Foundation of West Michigan, who shared the great news that there would now be an Action Plan implemented by the MHSAA to educate coaches on how to spot possible mental health issues in their athletes. It’s my greatest hope that we can get more trainings like this in all athletic/coaching programs, and I’m so thankful the MHSAA took this on, that I had to learn more and share:

Representing the Michigan Eating Disorders Alliance with Director Gail Hall just before Christy Buck told us about the Action Plan for the MHSAA

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Coaches in the Dark: What Can Athletic Staff Do in Eating Disorder Situations?

Having had an eating disorder as an athlete, I’ve been hyper-aware of the signs to look for in the athletes I coach. I knew, from my eating disorder experience, that if I suspected an athlete was struggling, it was my responsibility to refer them to a mental health professional and/or a dietitian for a proper evaluation. I even started doing homework to look for available resources in our area.

But I still felt like I was in the dark. Was I following all the right steps? How did other coaches know what to do in these situations? It wasn’t until a year ago that I realized that athletic trainers—staff right within the school—have formal education and training to recognize, screen and triage signs and symptoms of eating disorders in sport. In fact, most use an eating disorder protocol to begin the evaluation process, make referrals for intervention, and guide decisions about whether and when it is safe to participate in sport.

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Conversations with Coach: The Rollercoaster of Running with an Eating Disorder

It was fall 2012, and I had bonked at one of the most important races of the cross country season. Days later, Coach Woj asked me to meet him in his office.

“It tore my heart to read your running log,” Woj said. “You’re a smart girl. How can Rachael, who does everything right, not eat breakfast before her race?”

My heart dropped. Yes, in my online running log I had admitted to skipping breakfast. But it wasn’t until this moment that I realized how foolish it had been, how warped my mind had become with food in that past year.

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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.

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It’s Not Just Overbearing Coaches and Division I Programs

Post updated April 12, 2021, to improve clarity.

When we think of eating disorders in athletics, we often point to overbearing coaches in large, competitive sports programs. We bring up an athlete’s desire to please a demanding coach or mention the comments tossed around about restricting food and losing weight.

This often leaves people to think that eating disorders rarely happen in smaller programs, or amongst gentler coaches. And if a coach is not saying anything that would trigger an eating disorder, would an athlete develop it on their own?

Secrecy and Shame

I went to a smaller college. My level of competition equated to NCAA Division II or III.

I had an eating disorder.

My eating disorder thrived when signs were missed by those around me. It thrived when I harbored misconceptions about eating disorders and had no knowledge of its prevalence in sports. My eating disorder rolled its eyes any time my coach would tell the team, “Make sure to replenish with plenty of calories tonight,” because I was restricting my calories and running the fastest. My eating disorder thrived in a mind that thought what she was dealing with “wasn’t bad enough.”

I convinced myself that it was simply the discipline and willpower of a high-performance runner.

No One Talks About This

Athletic programs did not bring up nutrition or eating disorders. We didn’t have a dietitian come in and talk about these issues.

When a coach approached me about my weight a week before my final high school track meet, it was a comment about how much weight I had lost. Not about how sad, tired, and exhausted I looked and behaved.

When a sports physician said she’d follow up with me about my period loss, she never did.

Photo: Peter Draugalis

When I started a raw food diet, was repeatedly injured, depressed, and had drastic weight fluctuations, I was not approached about my mental health.

During my junior year of college, I took the initiative to open up to my team about my own struggle with an eating disorder. And I suggested that we talk about these issues each year as a team. Because the more I talked about it, it seemed more athletes were willing to speak up as well.

When it was finally out in the open, we were better able to see there was a problem and do something about it.

We were talking.

Shame, Fear, and Denial

I say all of this not to blame coaches, but to point out the missing piece in our system. Athletes everywhere–from every program/division–are struggling silently due to a lack of knowledge and openness, and shame, fear, and denial. Coaches are often left in the dark with how to follow up with someone who has an eating disorder. They have little knowledge of what it entails beyond appearance.

There is currently no training required for coaches to learn how to identify eating disorders and to help athletes get the professional help they need sooner. We do, however, have resources. Part of the Running in Silence mission is to spread awareness so that athletic staff knows how important it is to read these resources.

Whether it’s from the pressure of an intense coach, or the inner voice that tells an athlete they need to achieve more through weight loss, eating disorders affect all athletes, at any level of competition.

Coaches can show athletes that to get help and recover is not to give up their sport or run slower, but to find joy in the sport and in their lives. Because the best (and longest) athletic careers often come from having a voice, the power to change for the better, and the people to support them.

Mistreatment and Body-Shaming in Coaching

I recently returned from the empowering Strong Runner Chicks (SRC) retreat in the wake of an NCAA coach allegedly body-shaming his athletes—something that is not the sole “cause” of eating disorders, but it sure can trigger them.

I went to the SRC retreat knowing that many of us runners had very similar stories with eating disorders, body image, amenorrhea, and injuries. And it broke my heart to hear about the comments made by coaches that triggered the destructive relationships with food in many of these young women.

It breaks my heart, because many of the runners were still dealing with the physical and emotional consequences of under-fueling. Some voiced their struggle with understanding how to eat again as we talked about intuitive eating. Others shared their lost hopes and dreams and asked how to make a comeback in a sport they love.

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When a Coach Suggests Athletes “Drop a Few Pounds”: 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.

A coach of an adult, co-ed triathlon team sent out a training guide offering athletes advice on “top 5 ways to become a faster cyclist.” One of the “lessons”:

Lesson B: Dropping a few pounds
When it comes to biking, we can all stand to lose a few pounds.

Q: How can athletes advocate for themselves and their teammates to tell a coach they are uncomfortable with recommendations being put forth to the team about weight loss?

A (Paula Quatromoni): For several reasons, this is a dangerous message for coaches to deliver to athletes, and it is a dangerous way in which to deliver it.

First, this advice endorses the “thinner is faster” mentality. Bodyweight is not the best indicator of athletic performance, so this advice overemphasizes dieting and weight loss as solutions and oversimplifies the many factors that influence performance.

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What Coaches Can Do to Prevent Eating Disorders: 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: What can coaches do to build a healthy culture and prevent eating disorders?

A: First, I’d recommend education. There is a lot that coaches can do to educate themselves and increase awareness on the topic of eating disorders in sport. They can turn to Walden GOALS materialsRunning in Silence and Running in Silence blog posts, Nancy Clark’s Sports Nutrition Guidebook, and credible websites like NEDA, etc. They can also attend lectures, events, and coaching conferences to engage in continuing education on the topic. Armed with this information, coaches can address concerns that they see on their teams in a one-on-one conversation and a referral to the AT like we were talking about in that last Q&A.

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For Coaches, Approaching an Athlete with an Eating Disorder: Q&A with Dr. Paula 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: How do you recommend approaching an athlete you think might have an eating disorder?

A (Paula Quatromoni): 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.

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