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!
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.
In this case, the athlete is already diagnosed and is in treatment. That constitutes best practice. Treatment for an eating disorder in sport involves a multi-disciplinary team of experts trained in medicine, nutrition, exercise science and mental health to monitor the client and adjust the treatment plan over time. Monitoring weight and food intake represents just the tip of the iceberg. As well, weight does not tell the full story of eating disorder severity. There are many athletes who appear to be subjectively at an acceptable weight from a coach’s perspective who are extremely sick from their eating disorder. Vital signs (heart rate and blood pressure, for example), physiologic and metabolic indicators, nutritional biomarkers, bone health, depression/anxiety/distress tolerance, suicide risk, medication needs, and other parameters including the athlete’s capacity to train and recover from training sessions must be monitored. All of this is far beyond the grasp of the coach and requires the expertise of a comprehensive treatment team.
If a coach were to act as the monitor of the athlete’s weight and food, several undesirable outcomes could occur that might interfere with proper treatment. For these reasons, it is not advised.
First, the coach’s feedback or reaction to the athlete’s weight and food intake might not be consistent with the feedback of the treatment team. This could undermine treatment efforts and the athlete’s perception of the credibility of the treatment team if, for example, the athlete overvalues the coach’s input and/or simply prefers the coach’s opinion. The coach has to be careful not to collude with the eating disorder by inadvertently telling the athlete what she wants to hear.
Second, a coach who accepts the responsibility of being a monitor of an athlete’s eating disorder-related behaviors runs the risk of shifting the dynamic of his relationship with his athlete in ways that could undercut an otherwise trusting coach-athlete relationship. In trying to hold the athlete accountable, the coach risks losing his status as a trusted supporter and instead becoming a target of the athlete’s anger and frustration if or when the situation worsens.
Given the cyclical nature of eating disorders and treatment, the journey is long, obstacles are large, and relapse is common. This reality sets the coach up for an inevitable confrontation if he is serving as the monitor of treatment compliance and behavioral progress. It is best when a coach remains squarely in the position of coaching the athlete on her skills, tactics, leadership and character in sport while encouraging, empowering and supporting her to stay in treatment and do the emotional, physical and nutritional rehabilitation work with her treatment team in order to recover and return to sport.
Finally, the coach could be giving a false sense of security that a qualified professional is monitoring the situation. This is particularly risky for an athlete who is not in treatment or who has taken a break from treatment, experiences a relapse, and needs guidance to recognize when to re-enter treatment. Relative energy deficiency in sport (RED-S) is a serious situation with consequences to mental health, physical health, metabolic health and athletic performance. As explained, many of these consequences are invisible to a coach’s eye and extend far beyond weight and observed or self-reported food intake. For all these reasons, the coach should not accept this responsibility and risk being mistaken as a substitute for or an extension of the treatment team. The stakes are simply too high.
It is absolutely appropriate and strongly recommended that the coach have weekly or bi-monthly check-ins with the athlete to ask how she is doing and express care and concern. These interactions should be scheduled, private and purposeful to generate honest and meaningful dialog. Scheduled meetings serve the function of ongoing accountability to check in emotionally with the athlete. At the same time, the coach can reinforce the importance of adhering to treatment recommendations. This strategy keeps communication open between the athlete and the coach and it keeps the athlete connected to the team. The athlete can share whatever she wants about her progress or her challenges; or she can simply experience the coach’s empathic concern for her well-being. In this way, the coach remains actively engaged in supporting the athlete’s hard work in treatment and validating her experience.
Finally, it is the responsibility of the coach and the Athletic Trainer to be sure that they are following protocol, informed by the physician and the eating disorder treatment team, for whether or not the athlete is allowed to train and compete or if an exercise restriction has been imposed until weight restoration or other parameters are met (like return of menses, ability to use appropriate coping skills, diminished frequency or intensity of eating disorder thoughts and behaviors, or demonstrated compliance with adequate food intake and/or with counseling attendance). This is where the RED-S Clinical Assessment Tool comes in handy – to determine if and when it is appropriate for the athlete to return to sport. This comprehensive decision-making is the responsibility of the eating disorder treatment team, not the coach, and it considers far more than weight and food intake.