Eating Disorder Education for Athletic Staff With Limited Funds? Q&A With Dr. Paula Quatromoni

Coach: We want to bring more eating disorder education into our athletic programs for coaches, parents, and athletes, but I was told by my Athletic Director that the funding is lacking for bringing in speakers. They went on to express that if we only address eating disorders, we are missing out on many other topics that could also be addressed. Even the education and support for coaches is sorely lacking. It’s also been reported by our Athletic Trainer (AT) that even when parents are confronted about a possible eating disorder in their child, there is often denial and little if any response. What do we do?

PQ: What you are describing and experiencing is sadly, not uncommon. And this is why the problem persists and only gets worse when left unattended without resources committed to health and nutrition education for athletes. Eating disorder prevention work does not happen organically; it requires the right expertise and that requires effort and resources to make it happen. And it doesn’t happen in a silo. ED prevention addresses a host of other important health promoting topics including proper fueling for sport and peak performance, injury prevention, hydration and nutritional needs for growing bodies, eating competence, body image, social media literacy to offset pervasive diet culture, and help-seeking for related mental-health concerns including anxiety and depression.

Given the well-established links between eating disorders and suicidality, ED prevention work is a worthwhile pursuit with high return on investment. Yet the reality is, eating disorders are poorly understood, underappreciated, and rarely prioritized for targeted health education resources.

Parental Denial

Then there’s the parental denial. There are so many layers to this complex issue.

The reaction of the AD and the AT is telling me that however they are approaching and “handling” eating concerns, it is not being done well. If it were being done properly with qualified, trained sports medicine professionals involved, believing in what they are doing, and knowing full well the risks and consequences of NOT attending to eating disorder (ED) risk or RED-S (relative energy deficiency in sport), they would be able to effectively manage the parental denial.

A trained professional would know that denial is expected, and they would support the parents to take in their objective assessment of the situation (including data from an eating disorder screening tool, for example, if one were consistently used as part of pre-participation physicals). They would make a referral to connect the parents to a qualified provider for a full evaluation (a pediatrician, a mental health professional, or a Registered Dietitian Nutritionist (RDN)). The AT, if trained, would not be willing to accept the denial and would not back down from a mental health concern that may have documented physical manifestations. They would know the way to an action plan to protect the well-being of the athlete even in the face of parental denial.

In the face of denial, we cannot just accept it, ignore risk, disregard our clinical concerns, and simply “wait and see what happens.” Case in point – one can deny the severity of a concussion, and yet, we have protocols that we enact to hold athletes accountable to recovery efforts before they are cleared to return to sport, preventing denial from allowing an athlete to return sooner than the AT approves. Anyone can deny anything they want (like using opioids), but it doesn’t make it any less serious of a threat to the athlete’s well-being…

Until we start putting mental health on par with physical health, and until we buy into the fact that RED-S and EDs in sport are metabolic “injuries” that deserve prevention, screening, evaluation, treatment, and clearance protocols like any other sports-related injury, we will be stuck in the position of simply responding to bad outcomes that sideline our athletes rather than preventing bad outcomes that may or will eventually sideline our athletes if left unattended.

Limited Resources

Unfortunately, many athletic departments do not consider RED-S and EDs in sport a top priority area worthy of their time, their coach’s time, or their finite resources. Yes, resources are limited and still, athletic departments have the power to decide where to allocate their limited resources.

To offset costs, the athletic director (or the AT or a coach) could write a grant to the school coalition (or whatever it is that funds teachers’ initiatives) or they could fundraise for this specific purpose. Someone has to be the champion and raise or find the money. If it’s important enough, believe me, it is affordable.

Comparatively speaking, RDNs who provide health education programming are quite affordable and are not going to break the bank. We are used to working with athletics programs that have constrained funding. Not having the money is a convenient and overused excuse. There are many creative solutions, including partnering with a graduate program at a local college or university where graduate students could work under faculty mentorship (at no cost to you!) to create an educational session to bring to your school at a low cost; maybe even for free if they are earning college credit under the faculty’s mentorship! You have to be resourceful and find options that are affordable given your constraints. The answer is never to do nothing.

Coach Education

As for coach education, while there are some good one-pagers and infographics out there (including verbiage for coaches – what to say and what not to say to athletes on topics of food and body), these are only really useful when accompanied by education. They are great take-aways but don’t stand a chance at hitting the mark that a good educational session provides with the opportunity to ask questions of the expert in the room.

Another great resource is the Coaches and Trainers Toolkit provided by NEDA (the National Eating Disorders Association), but this requires a highly motivated coach to implement these resources on their own without upstream leadership and accountability.

In the end, if we cut corners on our education and training, we cut corners on the services we provide to our athletes. If an AD is unwilling to mandate education for coaches to protect the well-being of their athletes, they are sending the message that they just are not that invested in addressing the concern. So if the AD isn’t invested, why should the coaches be? Top-down leadership with some resources to back it up will make a difference in the culture of an athletics program, and that culture has important trickle-down effects for athlete well-being.

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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.