In this Q&A series, Dr. Paula Quatromoni (DSc, RD) answers some of the biggest questions coaches and athletic staff have to better prevent 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&As right to your inbox.
Q: What do you do when parents are in denial about their athlete struggling with a possible eating disorder, even when the athletic trainer is in on that conversation?
This is a common question from coaches. With this context, we will take this question as being posed by a coach. Since there is an expectation of parental involvement, we will assume that this is an adolescent (middle- or high-school athlete) rather than an adult/collegiate athlete.
A: Presenting concern about a possible eating disorder to parents requires a lot of sensitivity, empathy, and professional competence and confidence. It should not be entered into lightly, and it should not be entered into without objective data, documented observations, an informed action plan, and a set of recommendations and referrals.
This is a context where the Athletic Trainer (AT) needs some specialized training as well as some policies and procedures in place with the support of Athletics Administration. The AT is the licensed health professional at the center of the athlete care team. In a high school setting, the AT constitutes the accessible core of sports medicine expertise available to athletes on a daily basis. In a collegiate setting, the AT staff have the back-up of the sports medicine physician(s) who may primarily be orthopedic specialists who attune to sports injuries. This means that if a sports medicine doctor is accessible, they may not be trained in recognizing or treating REDs (relative energy deficiency in sport), eating disorders, or the endocrine and hormonal disturbances that occur in the setting of a restrictive eating disorder. Also in the collegiate setting, there may be a sports dietitian, sport psychologist, and/or mental health counselor. These members of the multidisciplinary care team can support the actions of the AT when they work collaboratively as an eating concerns team. Rarely are these other health professionals available to athletes in the high school setting. Collaborating with the school counselor may, therefore, be appropriate in order to fully assess the situation and to help the AT prepare to communicate their concerns to the parents.
As posed in this question, it sounds like the coach and AT are on the same page about a possible eating concern in their athlete and they have discussed it. That is desirable when it occurs, because there may be cases where the AT is concerned about an athlete, but the coach is not open to any exploration of the risk or any intervention that may remove the athlete from training and competition.
My approach to this situation would involve seven important steps:
collect the objective data and document the observed behaviors of concern,
decide who will have the conversation with the parent(s),
schedule a call or appointment with the parent(s),
have the conversation,
communicate an action plan,
make recommendations and referrals,
follow-up and respond accordingly.
Collect data: If there is an established screening protocol in place to identify eating concerns, this equips the AT with essential information about self-disclosed behaviors, beliefs, and attitudes that put the athlete at risk. If scores from screening tools are not available, there may be other pieces of objective data like recent, acute, or significant weight loss. Weight loss is not necessary, however, to raise or pursue a concern. There may be other observed behaviors of concern like compulsive exercise or overtraining, decreased performance, a decreased training response, decreased cognitive focus including in ways that may undermine academic performance, negative body image, low self-esteem, observed food restriction (including food avoidance or refusal, extreme clean eating, dieting to lose weight or change body shape/size, intermittent fasting, overuse of vitamin/mineral supplements, etc), or increased fatigue, anxiety, psycho-social distress, interpersonal conflict, or self-isolation and withdrawal. There may be physical signs of dehydration, underfueling, disturbed vital signs (low blood pressure, low heart rate, fainting, etc), and recurrent injuries, specifically bone stress injury. Each of these factors needs to be documented, along with any conversations the AT, coach, or counselor has had with the athlete about these observations, recommended strategies to address what is observed, and the athlete’s willingness and ability to attune to the advice and remediate the areas of concern.
Decide who: Discuss and decide who is best-suited to have this conversation with the parents. As the health professional, the AT should take the lead role in the conversation with parents. The role of the coach in the conversation is less certain, and their involvement should be secondary to that of the AT. Whether or not the coach should be included in the parent- or athlete-facing communication depends to a great extent on the coach’s relationship with the athlete and parents. If the coach relationship is positive, empathetic, collaborative, and highly respected, the coach’s involvement may be appropriate alongside the AT. If the coach relationship is strained, difficult, contentious, or superficial, it would be best to remove the coach from these conversations.
Schedule: The AT should arrange a meeting or phone/zoom conversation with the parent(s). It should be done in a private setting and under calm circumstances. It would be ideal to communicate briefly the agenda for the meeting so that parents are not blindsided by the information they receive at the meeting. “I’d like to have a meeting with you to share some information that relates to your athlete’s well-being.” It should explicitly be stated that the athlete should not be present for this conversation. An honest and direct conversation with parents is needed.
Have the conversation: Here, the AT needs to introduce their concerns with empathy and sensitivity. Stick to the facts and present the data on what has been observed, measured, and documented. Include the input of other members of the care team (if coach and/or counselor input has added supporting data or observations). Refrain from sharing observations from teammates or captains, even if that is part of the data that has come to your attention. It is best to keep the input of other adolescents out of the conversation given the highly stigmatized nature of mental health concerns and the need to maintain privacy for the athlete and the family. Invite the parents to add their own observations from the home environment and to ask any questions about what you shared with them.
Communicate an action plan: Define clearly what is needed for next steps and the consequences of inaction. What do you need the parents to do in response to this information? What needs to happen to protect the athlete’s well-being in the meantime? What are you prepared to do if the parents do not take and act upon your recommendations and requirements that would be needed to allow the athlete to continue to train and compete? Who and how will this be communicated to the athlete?
Make recommendations and referrals: First and foremost, the athlete should be evaluated by their pediatrician/primary care doctor. The AT can require this and can modify or fully restrict the athlete’s participation in sport until clearance is provided by an MD. Full evaluation by a medical provider is necessary to make or to rule out an eating disorder diagnosis. Whether the eating concern is diagnosable as a clinical eating disorder or lower in severity, intervention is important in both scenarios to lower risks for worsening health and mental health outcomes. A referral to a registered dietitian nutritionist (RDN), preferably one with expertise in sports and/or eating disorders, would be appropriate. A referral to a therapist, counselor, or sport psychologist would be helpful to address psycho-social, emotional, or performance stressors, anxiety, depression, or perfectionism risk factors. Establishing referral networks to identify local professionals and eating disorder specialists is another way the AT can offer support to parents when they are processing this information and beginning the process of being open to seeking help.
Follow-up and respond: Do not expect that one conversation will be enough. Parents will experience a range of emotions and responses. Their readiness to accept this information and act on it can vary widely. They may need more education, and they may want a second opinion. The pediatrician is the perfect second opinion for them to seek! For more education, you can refer them to sources like National Eating Disorders Association (www.nationaleatingdisorders.org) or Rebecca McConville’s book, Finding your Sweet Spot: How to Avoid REDs (Relative Energy Deficiency in Sport).
Ongoing follow-up and monitoring is essential. If the parents do not meet the expectations of the AT to ensure the safety of the athlete to train and complete, the AT has the ability to remove the athlete from sport participation. This will require collaboration and the support of athletics administration and the coach. This bold but appropriate action if usually sufficient to urge the parents to respond to the ATs directive. If the athlete does enter eating disorder treatment, the AT can collaborate with the treatment team to prepare for when the athlete can return to sport. The AT and coach can define a modified training plan and can help to monitor treatment compliance in ways that inform the treatment team. It is not uncommon to enact a treatment contract that specifies what benchmarks the athlete needs to sustain in order to continue to train and compete. If an eating disorder is ruled out, the AT should continue to monitor the athlete’s data, behavior, and clinical presentation.
The presentation of signs and symptoms of an eating disorder are highly variable from one athlete to another. Some athletes deteriorate rapidly while others are more physiologically resilient in spite of significant psycho-social consequences which may be hard to detect, including by parents. This reality endorses screening activity and keeping eyes and ears open to notice and respond to any red flags of concern. Keeping an open dialog with athletes and parents facilitates these goals, and communication is built on trusted relationships with members of the sports family.
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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, and Chair of 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 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 serves as a Senior Consultant. 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.
