What Do You Do if Parents Switch to a New Doctor After an Eating Disorder is Suspected? Q&A With Dr. Quatromoni
In this Q&A series, Dr. Paula Quatromoni (DSc, RD) answers some of the biggest questions coaches and athletic staff have to help prevent or address eating disorders in athletes and assist athletes who may be struggling. Sign up for our email list to get the next link to the newest Q&A right to your inbox. If you have a question to submit to Dr. Quatromoni, please reach out at our contact page here: https://runninginsilence.org/contact/
Q: A multi-sport athlete gets diagnosed with a bone stress injury and their doctor suspects there is an underlying eating disorder. What do you do if parents refute this suggestion and instead, switch to a new doctor whose second opinion dismisses the eating concerns and allows the athlete to continue to train and compete, going against the best judgement of the coach?
A (Dr. Paula Quatromoni): First, it’s important to set the context for this situation.
Most medical doctors (MDs) do not have sufficient training in nutrition, sports medicine, or eating disorders to diagnose an eating disorder or recognize relative energy deficiency in sport (REDS), both of which contribute to poor bone health and recurrent bone stress injuries in athletes. There is, unfortunately, a large degree of variability across MDs and other health professionals with regards to competence in these areas. This is one of several contributing factors to the reality that eating disorders and REDS are under-diagnosed and under-attended to, including among athletes where the risk is substantially higher than in the general population. This leaves our athletes highly vulnerable to emotional and physical suffering, and oftentimes athletes are “on their own” to identify qualified providers and seek help.
In the case of an adolescent athlete, we need parents to collaborate and be solutions-focused when problems or injuries arise; but that is sometimes easier said than done. In contrast to physical injuries where evidence of an ACL tear or a fractured bone is indisputable, when it comes to eating disorders, layers of stigma and stereotypes often get in the way of seeing, acknowledging, or accessing care for this mental health condition. Even if parents cannot recognize the behavioral (i.e. restrictive eating) or physiological (i.e. compromised bone health leading to stress fractures) red flags themselves, we expect parents to be able to hear, process, and act on concerns articulated by a coach or a health professional. This turns out to be particularly challenging for some parents.
Most athletes and parents are far less educated than health professionals are about eating disorders, warning signs, risk factors, consequences to mental health, physical health and sport performance, or action steps for proper assessment, referral and treatment. Add to that the stigma, stereotypes, fear, and denial that accompany eating disorders and you have the perfect storm for eating disorders to stay in the shadows and worsen without intervention. These parents’ disbelief of a potential eating concern, choice to not return to the original doctor, and unconditional belief in a second doctor whose advice is more consistent with what they want to hear (i.e. clearance to return to sport) is, sadly, not uncommon. This, unfortunately, reduces timely identification and intervention, two known keys to recovery from an eating disorder and for preventing disordered eating or REDS from developing into a clinically diagnosable eating disorder.
In this case, both Doctor #2 and the parents are dismissing the concern, missing the red flag signs and symptoms, and choosing not to investigate any further by conducting a full clinical assessment which may include a referral to a specialist or colleague in a related discipline like nutrition, mental health, or sports medicine. This behavior communicates to the athlete, coach, and parents that the individual is “not sick enough” to be taken seriously or warrant a full work-up. Instead of acting on concern expressed by the coach and Doctor #1, the green light of clearance is given to allow full participation in sport.
In my professional opinion, this is a series of unfortunate events that could and should be handled differently from both treatment and prevention standpoints.
The MD can clear the athlete for sport participation, and that puts the responsibility to monitor the situation daily on the school’s Athletic Trainer (AT).
This adds burden to the AT’s already excessive workload. Plus, not all schools have ATs on staff, a reality that would put this athlete’s well-being at risk. It also risks the spread of problematic behaviors (under-fueling, overtraining, training while injured, etc.) across other members of the team who are watching the affected athlete train and compete from a depleted and injured state. While the affected athlete and parents may be oblivious to the red flags, they are likely not going unnoticed by others.
This kind of sport culture where injuries and health concerns are not taken seriously sends strong messages to teammates. The athlete is putting their teammates at risk because role modeling of disordered eating behaviors leaves teammates increasingly vulnerable to eating disorder risks. This culture also undermines the authority and competence of the coach in the eyes of athletes and other parents. The Athletic Director needs urgent education on the widespread dangers of these circumstances so that he/she can better navigate this situation with the parents of the affected athlete, for it is within the AD’s realm of responsibility to ensure the safety and well-being of all athletes under their jurisdiction.
When educated and empowered, coaches, ATs, school nurses, and athletics administrators can be more proactive.
In fact, it may only be a matter of time before parents of other athletes bring their concerns forward. Action will likely be required sooner or later, so why not act sooner? We know from clinical experience and from research how untreated eating disorders in sport play out, and it is not a recipe for success. Why leave athletes vulnerable when we know, see, and understand the factors contributing to their vulnerability? Why not intervene now? The school-based team has the right to set expectations for sports participation in its own community. Those expectations, intended to keep individuals and the entire school community safe, may be different from the expectations of an MD set for an individual athlete. So, what can Coach do?
Honest, informed, and direct conversations with the parents of the affected athlete are certainly appropriate.
For guidance on this, read our prior post. In summary, it would be prudent to involve several school officials in this meeting: coach, AT, athletics director, school counselor/psychologist, school nurse. If the school had an eating concerns team in place, that team would provide the context for this dialogue and would normalize these actions for the entire school community. That would help parents and athletes feel less singled-out or ganged up on if this team were in place and its existence, policies, and procedures were transparently communicated to parents from the outset of their athlete’s participation in sport and consistently enacted across the board when concerns arise.
Expressing care and concern for an athlete’s well-being is never a bad thing and should not be discouraged.
In this instance, the coach sees an injured, multi-sport athlete under a lot of pressure and fears a bad outcome if the larger context is not addressed. Coach should trust their gut and share their concerns. Risk for eating disorders to develop or worsen is heightened when an athlete suffers an injury. Research shows that care and concern expressed by an “important other” in an athlete’s life (like a coach or AT) is what often ignites a willingness to seek and accept help for an eating disorder; and the lack of an expression of care and concern is incredibly invalidating of the athlete’s lived experience, leaving them to suffer in silence, feel unworthy of intervention, remain unconnected to help, and sink further into their eating disorder. These outcomes are not acceptable. We can and need to do better.
My advice to the Coach is to be patient yet persistent; keep this athlete on the radar screen of a school’s health professional, and continue to act on new signs, symptoms, and concerns. Do not take the MD’s assessment as a blanket clearance and dismiss your concerns as a coach. It is only a matter of time before more risk factors become evident, and new concerns should be articulated and acted upon to continue to build the case for intervention. The sad reality is that the athlete is at risk of ongoing suffering, often in silence, while the doctor and parents allow them to continue training. This is unfortunately at the parents’ discretion if they choose not to act on the collective wisdom of experts.
Remember that an eating disorder diagnosis is not necessarily needed to drive solutions and guide an athlete and their family in a direction that can improve their well-being and lower risks.
First, the coach can reduce the athlete’s training load and put firm parameters around the amount of exercise, mileage, strength training, and recreational activity they do. Removing the risk of overtraining is priority #1. The AT and/or school nurse or counselor can require a specific pattern of monitoring for the athlete to check in and be screened for risk factors on a weekly basis.
A referral to a registered dietitian nutritionist (RDN) should be made if there is evidence of undernutrition or under-fueling. Even without an eating disorder diagnosis, this recommendation can simply be presented to the athlete and parents as a strong endorsement with the goal of helping the athlete identify where and how to improve their nutritional intake to heal (and prevent future) bone stress injuries and achieve the performance goals they are pursuing. Many parents and athletes will readily buy into this kind of performance-enhancing advice. Similarly, a referral to a sport psychologist might be well-received, acknowledging the stress on an injured, multi-sport athlete who may be trying to pursue a collegiate career. Building a list of local providers with sport and eating disorder expertise equips you with an arsenal of referrals for families. This action puts more eyes on the athlete, meaning that the power of the MD’s and parents’ voices will be diluted as more and more health providers, including experts outside of the school environment, weigh in on the concerns they each see from their respective areas of expertise.
In the meantime and even without an eating disorder diagnosis, these providers can do really great work with the athlete to build up adaptive life skills like proper nutrition for adolescent wellness, fueling for sport, injury recovery/prevention, eating competence, body respect, and emotional coping skills. The provider relationships built under the umbrella of prevention set the stage for deeper work when readiness to address eating disorder concerns is achieved, and this facilitates effective help-seeking.
Finally, consequences can be specified for if or when the modified training plan is violated.
An injured athlete who is truly committed to injury recovery and nutritional restoration will follow the individualized guidance of the coach and sport professionals. An athlete with an eating and/or exercise disorder will not. Noncompliance with the reduced training load and/or an improved fueling plan provides more evidence to refute the MD’s clearance and re-open the dialogue about investigating a possible eating concern. Participation in sport can be restricted and assessments by other health professionals, including mental health and nutrition, can be required in order for the athlete to return to full participation. A coach will need the AD and a school health professional to back them up and enforce these mandates. This case offers the perfect illustration of how and why an eating concerns teams can best serve the interests of all members of the sports community. For more on this, see The Professionals to Bring in for Student-Athletes With Eating Disorders
~
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.
