What Do You Do if You Don’t Have an Athletic Trainer? 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.
Q: How does a coach support an athlete who may have an eating disorder when there is no athletic trainer on staff at their high school?
A: A coach who has a concern about an eating disorder in their athlete should trust their gut and act on their concerns. They should not ignore their observations, and they should act sooner rather than later. Watchful waiting risks more harm than good, for a whole host of reasons. We know that the keys to successful treatment and recovery from an eating disorder are early recognition and timely intervention. Especially in the case of an adolescent where growth, development (of the body and brain), and puberty are physiologic priorities, the urgency to act is heightened. Coach must first recognize that eating disorders are serious, life-threatening conditions that are mental health crises. They are not to be dismissed and coaches are not in any position to manage this themselves.
Collaboration
In the absence of an Athletic Trainer (AT), the Athletics Director (AD) and coach can collaborate with the school nurse and school counselor who serve as the on-site health and mental health professionals. These four professionals should meet to discuss the concerns, behavioral observations, and any relevant data concerning the athlete (including a pattern of recurrent injuries, significant changes in weight or performance). Next, it should be decided who is in the best position to speak with the athlete’s parents.
A Conversation With Parents
Getting guidance on how to have these difficult conversations with parents is imperative. This is why including the school counselor is essential – they are trained to facilitate these conversations with neutral, non-judgmental language and solutions-focused action planning to guide parents and athletes towards referral, assessment, and proper intervention. For guidance on how to have this conversation with parents, read our prior post.
Full Assessment and Treatment
First and foremost, a full assessment is needed to fully explore the eating concerns, evaluate the athlete’s growth, development, and nutritional status, and to make or rule out the diagnosis of an eating disorder. The best referral here is to the Pediatrician or Primary Care Provider (PCP).
If an eating disorder is diagnosed, a multi-disciplinary treatment team is put in place consisting of an MD, therapist, and registered dietitian nutritionist (RDN). Other professionals may be involved as needed, including a psychiatrist, exercise science specialist, physical therapist, or occupational therapist. A treatment strategy is decided, whether that involves outpatient treatment, family-based treatment (FBT), or treatment that necessitates a higher level of care (inpatient, residential, partial hospitalization, or intensive outpatient care). The treatment team will decide if the athlete needs to be restricted in their physical activity or removed from training and participation in sport.
As treatment progresses and the athlete moves into recovery, the treatment team will decide when the athlete can be cleared to resume activity or a modified training plan. With ongoing treatment compliance and improvement in health and mental health indicators, the athlete can return to full sports participation and competition.
Other Support Services
If an eating disorder is ruled out, there may still be need for support services for the student-athlete. For example, while not disordered, their eating patterns may be inadequate to support their level of sports participation. This often results from low sports nutrition knowledge, low skill in independently managing the increased need for fuel in relation to the energy costs of training and competition, and/or from intentional but misguided attempts to diet, lose weight, drop body fat, or “eat clean” in pursuit of peak performance. These circumstances, in the context of the high physiologic demands of sport, creates a situation of low energy availability that predisposes to relative energy deficiency in sport (REDS). When this becomes a chronic state of affairs, the athlete is at risk for a host of physical, physiological, and mental health consequences that predispose them to injury and poor health.
Athletes in this situation would benefit from a full work-up from an MD to evaluate the body systems that are negatively affected by REDS, including bone health, hormonal function, puberty, growth and developmental milestones, GI function, and cardiovascular function. A referral to a sports RDN is absolutely warranted to provide nutrition education and behavioral counseling to define and implement an optimal, personalized fueling strategy. Because REDS has both mental health precursors and consequences, a referral to a therapist is also recommended.
Returning to Competition
When the athlete returns to sport, it’s important to continue to monitor the situation. An adolescent athlete’s clinical condition can change quickly, and the pediatrician is not likely to catch subtle or overt changes in between routine health check-ups. The school nurse can make independent observations and communicate data, concerns, or alternate recommendations back to the pediatrician and parents as time goes on based on objective signs and symptoms. It would be wise for the nurse to collaborate with the coach and school counselor to monitor behavioral and emotional symptoms. Open communication will facilitate the teamwork and collaboration necessary to most fully support the athlete.
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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 at Boston University. She publishes widely on topics including clinical treatment outcomes and the lived experiences of athletes and others with and recovering from 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 2025. 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.
