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: My daughter started running and quickly developed a highly restrictive diet. She tries to eat no carbs. She has lost so much weight, but it’s never enough for her. She enjoys running, but I’m afraid she is using it as a punishment and has to do “workouts” in the morning and before bed. I am very worried about her, but she doesn’t want to talk about eating as a problem, because anything that helps her lose weight is a “good thing”. What can I do?
A (Paula Quatromoni, DSc, MS, RD, LDN): You are right to be concerned. This is a place where you have to trust your intuition and continue to observe the warning signs: restrictive eating, food rules (no carbs), substantial weight loss with a continued, strong, driven mission to lose more, and what could be compulsive exercise. This young woman is dieting and exercising, yet is not fueling properly to meet her nutritional demands. This creates a condition called “relative energy deficiency in sport” (RED-S). The consequences of RED-S are far-reaching and put her physical health, her emotional well-being, and her sports performance at risk. The fact that she “doesn’t want to talk about eating” is a hallmark of the denial that anything could possibly be of concern.
My best advice to you is not to ignore or dismiss what you see. Without knowing her age or whether or not she is a competitive athlete, on a team, or simply exercising on her own, it is hard to give specific advice. For example, if she is not on a high school or collegiate team, there may be no coach or athletic trainer involved. If she is an adolescent, insisting on a visit to her pediatrician “just to get checked out to verify that her health is not being compromised” by what she is doing is certainly within the realm of a parental or grandparental directive. If she is an adult, it can be more complicated; but endorsing a visit to her primary care physician is a wise action on your part.
You need to approach this difficult conversation with confidence and conviction that you are doing the right thing and that you are steadfast in your concern based on what you’ve observed. Prepare yourself by getting information that will validate your concerns. The NEDA website is full of useful information to equip yourself with knowledge and resources.
Plan the right time to have this conversation, in a private location, at a time when you can sit and talk openly without time pressure or distraction.
Start by expressing your concern for your daughter’s wellness and state objectively what you have observed. Be as neutral and non-judgmental as possible. Do not diagnose her or pretend that you understand all that is going on for her. But tell her that you are concerned and that you’d like to help. Ask her if she’d be willing to accept your help.
Next, make your recommendation that she be evaluated first by her doctor for a full medical evaluation to be sure that what she is doing is not jeopardizing her health. In response to denial and refusals, just continue to calmly restate these facts: “I am concerned about you. I am seeing signs that reinforce my concerns. I want to help you.” You do not have to defend or reiterate the signs you are observing. Stay convicted that you know what you are seeing, the concerns are real, the signs are visible, the health consequences warrant evaluation now, and that she deserves professional assessment and timely care.
You are right to expect continued denial, refusal, and perhaps even anger directed at you. But you have now planted the seed for the next honest conversation when the time is right, when you’ve observed additional signs and symptoms, and when she may be more open to the conversation. It may take several attempts, but don’t give up and don’t let too much time go by before you address your observations again.
A Turning Point
Research shows that these kinds of conversations, initiated by important people in the lives of athletes, are very often the turning points that help the athlete consider and enter treatment. In contrast, some athletes struggle for years waiting for someone that they love to notice that they are suffering and to “care enough” to speak up and express their concern.
When coaches, family members, friends, and teammates hold back and don’t say anything, not only does it condone the disordered behaviors, it perpetuates feelings of low self-worth and despair in the athlete who believes they are “not worthy” of others’ care and compassion. Your ability to express and role model concern and compassion can open the door to the athlete’s willingness and ability to care for themselves and seek professional help.
Dr. Quatromoni is a senior consultant for Walden Behavioral Care, and one of the nation’s top minds on the intersection of sports nutrition and eating disorders. As a registered dietitian, she has more than a decade of experience working with athletes with disordered eating and has published several papers on both clinical experiences and qualitative research on recovery experiences of athletes. Dr. Quatromoni is the Department Chair of Health Sciences and a tenured associate professor of Nutrition and Epidemiology at Boston University where she maintains an active, funded research program. In 2004, she pioneered the sports nutrition consult service for student athletes at Boston University. Dr. Quatromoni was recently named a 2016 Outstanding Dietetics Educator from the Nutrition and Dietetic Educators and Preceptors (NDEP) Council. 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.