How Can a Coach Support an Athlete With Exercise Restrictions in Eating Disorder Treatment? Q&A With Dr. Paula Quatromoni
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.
The old-school approach is to restrict sports participation and exercise when someone is undergoing eating disorder treatment. More modern advice, informed by research and clinical practice outcomes, recognizes the important role that supervised and appropriately timed and tailored movement plays in eating disorder treatment, particularly when treating athletes. It is important to have these conversations with eating disorders specialists who are experts in the care of athletes to be sure that they are up-to-date on contemporary clinical practice guidelines when it comes to safe exercise prescriptions at every stage of eating disorders recovery for athletes.
I am not in any position to second-guess any of the team’s qualifications or decision-making, and neither should the coach. But the athlete and their family need to understand and (with the right providers on the case) trust and lean into the expertise of their treatment team. If they are working with providers who are not ED-informed specialists or up-to-date on the recent research concerning the role of exercise in the treatment of eating disorders, the athlete and their family might seek a second opinion from an eating disorders specialty clinic, preferably one that has an athlete specialization track. Another strategy is that the athlete or parents can bring their concerns to the existing treatment team and ask about the additional collaboration with an exercise science specialist and/or physical therapist who can add input to the case management. Depending on where they live and what programs, services, and providers are accessible to them, they may have fewer or more limited options.
It is very important for the coach to understand that it matters not what the origins of the athlete’s eating disorder is. It doesn’t matter if it is driven by performance goals or in pursuit of the perfect body. What matters is that the athlete has an active eating disorder and is in treatment. The athlete needs to follow the treatment recommendations of the expert care team managing their case, and the coach should respect and align with that reality.
What I hear in this story is the eating disorder talking to the coach right now. It is begging and pleading and trying to reason, to allow itself to survive and thrive. It is looking for an ally to buffer the distress caused by the treatment team. And the eating disorder is portraying itself as a victim being punished, threatened, and unfairly treated. The coach cannot respond in a way that undermines the treatment team or gives the eating disorder what it wants. The coach can help to put their athlete on a path to better health by empathizing with the athlete while fully endorsing the recommendations of the treatment team.
No Exercise, No Sports Plan
It is true that appropriate exercise in an appropriately nourished body has positive effects on one’s mental health and well-being. But in the case of an eating disorder in sport, the body is likely severely malnourished and the level of exercise likely far exceeds the nutritional inputs the body is receiving. That is the basis for exercise restriction in eating disorder treatment, to restore energy balance and to heal the damage malnutrition imposes on the body systems.
Only when an athlete is properly nourished and consistently compliant with their fueling plan will return to a supervised, modified program of physical activity be allowed. This starts as gentle movement, perhaps yoga or neighborhood walks, a few times a week for a specified (short) duration. Gradually with supervision, activity is increased over time before return to a modified training protocol is initiated. Clearance for sports participation is the eventual goal, but this takes time and is entirely dependent on the athlete’s behavioral compliance and how their body, physiology, and emotional resilience respond.
In the meantime, while exercise is curtailed and that specific coping strategy is inaccessible to the athlete, the goal of eating disorder treatment is to help the athlete develop other coping skills to provide the mental health outlet this athlete needs and deserves. Chasing perfectionism is an exhausting and chronic mental stressor. This, too, is the work to be done in therapy. Many people (athletes included) confuse exercise as a stress-reliever with compulsive over-exercise as a behavioral tool for managing a host of chronic, negative emotions like anxiety, depression, fear, low self-worth, or body dissatisfaction.
It is important for the treatment team to discern if a compulsive exercise disorder co-exists alongside the eating disorder, as it often does. If the exercise is compulsive in nature, it is working in service to the eating disorder. That is the connection that needs to be broken with the help of a skilled therapist, and the treatment goals will include replacing exercise with a variety of other coping skills and behaviors that will serve both physical and mental well-being while the athlete continues to practice renourishment.
Stand Firm in Alliance Against the Eating Disorder
As with any eating disorder presentation, there is a lot to consider and yet, the coach only sees what’s in front of them from their limited perspective, often informed exclusively by the person experiencing the eating disorder. This is a place where the coach has to have faith in the parents and trust in the treatment team guiding this athlete towards recovery; and to understand that the voice and the “story” they are hearing from their athlete may actually be the voice and the “story” of the eating disorder that is in control, begging to be left alone so that it can remain in control.
The coach’s role at this time is one of an important source of support, social and emotional connection, and strengthening character values. The best thing this coach can do is keep their door open, offer a listening ear, reinforce compliance with the treatment team’s plan, and be authentic with empathy. Check in often and keep this athlete on your radar screen. And offer plenty of understanding phrases like, “I know this is really hard. I see you working on this every day. You’ve got this! You can do hard things, and I’m proud of you.”
As the athlete moves through recovery, their voice will become stronger than the eating disorder voice and the coach will recognize in their recovered athlete the strength, resilience, emotional balance, and new self-care and coping skills that will serve them well to manage the demands of competitive sport.
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 in 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 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 served as a Senior Consultant until 2024. 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.
