What Can You Do if a Coach is Uncomfortable Addressing Eating Disorders? (Q&A with Paula Quatromoni)

This is part of a Q&A series with the leading expert in eating disorders and sports, Paula Quatromoni. For more Q&As click here.

Q: There is suspicion that there are girls struggling with eating disorders on a high school sports team. The coach hasn’t addressed these issues even though he is concerned and is aware that it’s a problem. A mom, amongst a few other parents, brought this up and feels eating disorders/body image should be addressed. Should parents bring it to the attention of the athletic trainers next? Bring in the school counselor?

A: It sounds like this mom has a concern about the culture on this team in relation to body image and unsafe dieting practices, and she wants it addressed. That the coach is aware and reportedly concerned but is not taking action is a red flag to me. The coach sets the tone for team culture and, to a certain extent, is responsible for the safety and well-being of his athletes in relation to how he coaches, communicates, and interacts with them. By ignoring his concerns, he is silently (or maybe actively) condoning the culture that endorses, perpetuates and sustains unhealthy behaviors. This puts athletes at risk of injury and other physical and emotional consequences.

Don’t Accept Inaction

There are several possible scenarios, but none condone inaction. It could be that the coach is uneducated about the dangers of eating disorders and the risks of this culture to his athletes’ well-being. It could be that the coach actually holds and role models the common yet faulty belief system that thinness is the key to athletic performance. If the coach is giving his athletes advice about nutrition that includes weight loss, fad diets or restrictive eating, he is creating a potentially dangerous situation for his athletes. No matter how well-intentioned, the coach is not likely a trained nutrition professional qualified to give accurate and appropriate nutrition advice. Through his behaviors and/or his words, he could be setting expectations either overtly or covertly that are driving disordered eating behaviors in his athletes. It could also be that the coach simply has no idea how to address eating disorders, is afraid of doing the wrong thing, or believes it is not his “turf,” so he is opting not to intervene.

The coach’s level of reported concern appears not high enough to act. In choosing not to act, he is putting his athletes at risk by tolerating or condoning this culture on his team. It is his responsibility to address it and engage with professional colleagues who can assist.

Address Unhealthy Behaviors that Jeopardize Athlete Well-being

Substitute this behavior for any other – smoking pot, vaping, binge drinking on the weekend, drinking and driving – could/should/would a coach turn a blind eye to those behaviors on his team if he became aware? I don’t think so. I understand the difference being that some of the behaviors I listed are actually illegal for high-schoolers; but legality aside, no one would debate that each of these behaviors puts a high school athlete’s well-being and athletic performance in jeopardy. The same is true for eating disorders and the accompanying condition known as relative energy deficiency in sport (RED-S).

We have to ask, why is it that unsafe dieting, disordered eating, and self-induced vomiting are considered below the threshold to warrant action? And why is the contagious nature of athletes role modeling this behavior to teammates not deserving of intervention? Eating disorders in sport are considered “metabolic injuries.” They are injuries just like ACL tears, concussions, and stress fractures. Coaches intervene and refer athletes to treatment when they suffer traditional injuries in sport. Why are eating disorders handled differently and left unaddressed?

The research, the literature, and clinical practice tell us consistently that unhealthy dieting behaviors and body image disorders cannot be ignored; they are precursors to eating disorders; they can be addressed and treated because there are services, programs and providers who can educate and treat. We also know that eating disorders can be prevented with appropriate educational and intervention strategies that include developing healthy communication skills, a positive team culture, and strong role models in coaches, captains and upper class-men. Ignoring these concerning behaviors given this level of evidence is not best practices for a coach. To me, it is irresponsible, dangerous and unethical.

Bring Forward Facts

I would encourage this concerned parent and others who share her concern to document known facts and what they have collectively observed. Rather than taking their concerns to the coach, I would advise the concerned parents to go directly to the Athletic Trainer (AT). The AT is the sports medicine professional who is best equipped to handle a health-related concern. The AT can investigate the situation further, likely knows the team, the coach and the individual athletes well, and can decide the best course of action given the circumstances. The chain of command in the high school environment includes the Athletic Director (AD) and the Principal if administrators need to get involved. School counselors are other collegial resources who can guide and support the AT.

Continue the Conversation

If this is happening on this team, rest assured it could be happening on others. That is why it is important for the Athletic Trainer and possibly the Athletic Director to be informed and involved. It may not be sufficient to simply address the problem with this one team and this one coach. A school-level or programmatic response may be indicated. For example, the AD may need to commit resources for comprehensive educational programming to reach student-athletes across all athletic teams. Programming for athletes, parents and coaches would certainly be appropriate to educate on proper nutrition for sport, confront and dispel myths, and address risks for both sides of the RED-S syndrome: underfueling and overtraining.

So much education and awareness-building around nutrition and eating disorders in sport is needed, yet so little is available inside high school athletics where health education for students, coach education, and access to qualified nutrition professionals are limited. Those realities, in a nutshell, are at the core of this issue.

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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.

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