By Riley Nickols, PhD, CEDS
What is the Role of the Coach?
As a coach, you play a significant role in the physical and psychological health of your athletes. You are a key person in creating training environments conducive to successful athletic performance as well as emotionally rewarding sport experiences.
Coaches are uniquely positioned to notice physical changes or concerning shifts in an athlete’s emotional state, attitudes and behaviors.
If you think an athlete might be at risk for disordered eating or is in the midst of an eating disorder, you are in an important position to help. Remember to involve the athlete’s family members whenever appropriate. It is important to take warning signs and eating-disordered behaviors seriously as timely, targeted treatment is needed to provide healing and minimize the risk of an athlete’s physical and emotional state to further deteriorate. Eating disorders can have serious health consequences and be fatal as cardiac arrest and suicide are the leading causes of death among people with eating disorders.1 It is important that sport providers recognize the risks of eating disorders and how athletes might exhibit eating disorder symptoms.
What should you do if you are concerned about an athlete?
Don’t try to manage the situation alone! Here are some people and resources to involve:
Considerations for Adult Athletes (over 18 years-old):
Sports Medicine or Student Health Services can help by:
▪ Connecting the athlete with a physician for a comprehensive examination.
▪ Monitoring the athlete’s medical stability, labs, weight, and vital signs.
▪ Facilitating athlete weigh-ins and communicating this information to the athlete’s treatment team.
▪ Providing referrals to eating disorder informed medical specialists as needed.
▪ Communicate with the athlete’s parents/guardian as appropriate and only with the athlete’s consent.
Sport-Informed Mental Health Providers/Mental Health Services can help by:
▪ Connecting the athlete with a mental health provider specializing in eating disorders.
▪ Providing treatment to address psychological, internal, and behavioral factors contributing to the development and sustainment of the athlete’s eating disorder.
▪ Being a resource to provide presentations and/or facilitate discussions specific to athlete mental health, disordered eating/eating disorders, and the importance of cultivating a supportive environment within an athletic team.
▪ Reminding you of the athletic department’s, sport organization’s, or sport governing body’s policy on eating disorder treatment.
▪ Assist in instances where athletes refuse to seek treatment or address the problem.
▪ Communicate with the athlete’s parents/guardian as appropriate and only with the athlete’s consent.
Sports Dietitians can help by:
▪ Assessing an athlete’s energy needs and providing nutritional recommendations thereafter.
▪ Provide education and suggestions to ensure that nutrition and hydration needs of athletes are supported before, during, and after practices and games.
▪ Identifying a provider to conduct weigh-ins and determine the framework of an athlete’s weigh-ins (i.e., scheduled vs. random, blind vs non-blind weigh-ins).
▪ Talking to the team about optimal eating behaviors that support health and sport performance.
▪ Identify an individualized goal weight range, and provide supportive nutritional interventions, for athletes with the primary goal of optimizing an athlete’s physical and psychological health.
▪ Communicate with the athlete’s parents/guardian as appropriate and only with the athlete’s consent.
Athletic Trainers can help by:
▪ Early identification if/when disordered eating or eating disorder behaviors and symptoms arise on a team.
▪ Developing rapport with athletes to express concern and access the support of other providers when needed.
▪ Oversee implementing training recommendations made by the athlete’s multidisciplinary treatment team.
▪ Supporting an athlete’s treatment recommendations and engaging in consistent communication with the treatment team.
▪ Assisting with monitoring the athlete’s medical stability by obtaining an athlete’s weight and vital signs as directed by the treatment team.
▪ Communicate with the athlete’s parents/guardian as appropriate and only with the athlete’s consent.
Considerations for Adolescent Athletes (under 18 years-old):
School Nurse or School Medical Provider can help by:
▪ Connecting the athlete with a physician for a comprehensive examination.
▪ Assisting with monitoring the athlete’s medical stability by obtaining an athlete’s weight and vital signs as directed by the treatment team.
▪ Facilitating athlete weigh-ins and communicating this information to the athlete’s treatment team.
▪ Providing referrals to eating disorder informed medical specialists as needed.
▪ Communicate with the athlete’s parents/guardian as needed.
School Mental Health Provider can help by:
▪ Connecting the athlete with a mental health provider specializing in eating disorders to provide treatment to address psychological, internal, and behavioral factors contributing to the development and sustainment of the athlete’s eating disorder.
▪ Connecting the athlete with a sports dietitian with eating disorder expertise.
▪ Being a resource to provide presentations and/or facilitate discussions specific to athlete mental health, disordered eating/eating disorders, and the importance of cultivating a supportive environment within an athletic team.
▪ Reminding you of the school’s policy on eating disorder treatment.
▪ Assist in instances where athletes refuse to seek treatment or address the problem.
▪ Communicate with the athlete’s parents/guardian as needed.
Athletic Trainers can help by:
▪ Early identification if/when disordered eating or eating disorder behaviors and symptoms arise on a team.
▪ Developing rapport with athletes to express concern and access the support of other providers when needed.
▪ Oversee implementing training recommendations made by the athlete’s multidisciplinary treatment team.
▪ Supporting an athlete’s treatment recommendations and engaging in consistent communication with the treatment team.
▪ Assisting with monitoring the athlete’s medical stability by obtaining an athlete’s weight and vital signs as directed by the treatment team.
▪ Communicate with the athlete’s parents/guardian as needed.
Tips on How to Positively Intervene:
▪ Consult with a mental health provider to discuss considerations for how to compassionately intervene with your athlete and to be reminded of the school or sport organization’s eating disorder policy.
▪ Approach your athlete sensitively and in private, while being as direct and straightforward as possible; cite the evidence you see for disordered eating, the impact that such behaviors can have on the individual’s and team’s performance, while also expressing your concern for the athlete’s health and well-being.
▪ Do not judge or criticize your athlete. The goal is to help the athlete inform important, supportive people (i.e., their parent/caregiver) about the disordered eating, if they have not already done so.
▪ Seek help as soon as possible. Make a prompt and appropriate referral to a healthcare specialist familiar with treating eating disorders (e.g., physician, therapist, eating disorder specialist, or dietitian). Voice your concerns to a designated family member or caregiver, the school’s student assistance program, and/or health services. If the athlete is an adult, they must provide consent for you to communicate with family members about your concerns. Early detection and treatment increases the likelihood of successful treatment, in addition to decreasing the likelihood of serious or long-term medical and psychological consequences; left untreated, a problem that begins as disordered eating may progress to an eating disorder.
▪ Encourage your athlete to immediately seek treatment. An athlete can stay involved in sport while seeking treatment; however, when physical or mental health is at risk, encourage the athlete to abstain from participation until a physician gives clearance to resume sport participation. Consider the whole person when making decisions about an athlete’s sport participation: physical, physiological, and emotional/mental health.
▪ If your athlete is not able or willing to comply with treatment recommendations, consult with the athlete’s treatment team to discuss suspending participation to prioritize the athlete’s health. Such a response conveys that health is more important than sport. Reassure the athlete their position on the team will not be jeopardized by seeking treatment.
▪ Be open and cooperative with the treatment team. The most effective treatment for an eating disorder is to utilize a collaborative treatment approach consisting of a team of health professionals (e.g., physician, therapist, dietician, etc.). As a coach, your support of, trust in, and cooperation with the team’s treatment plan will be critical to your athlete’s successful recovery.
▪ As a coach, your involvement and positive communications are very important for your athletes. Be a source of support by maintaining open lines of communication with athletes struggling with eating issues and support them in their treatment. It is often helpful to ask an athlete how you can be helpful in their treatment.
Sample conversation with an athlete you are concerned about:
“Sarah, I really value you as a team member and appreciate x, y, and z about you. I am concerned because I have noticed you are having a hard time focusing, you aren’t as social with your teammates, and I’m worried that you are becoming overly restrictive in your eating and are training to the point of diminishing returns. I think you could really benefit from seeing a physician, a mental health provider, and a dietitian for an evaluation to determine if there is a problem. Would you be willing to explore this idea with me?”
Make it clear to the athlete that you are concerned, that the conversation will continue, and that you will be following up further with your concerns. The athlete may acknowledge or deny there is a problem. If they deny there is a problem, continue to encourage the athlete to be evaluated by an appropriate healthcare professional. An evaluation should also include a decision regarding whether training and competition can continue without increasing the risk to the athlete. Such a decision is made by the multidisciplinary treatment team and can be adjusted as necessary as the athlete’s treatment progresses. Should the evaluation indicate a problem, communicate the importance and urgency in seeking treatment. If an athlete continues to deny a problem and refuses to get help, consult with a designated mental health provider to guide you through the next steps.
Ultimately, it is important for you, the athlete, the athlete’s family, and the treatment team to realize that there are resources and support networks to help.
Tips on How to Cultivate a Sport Environment Conducive to Recovery:
▪ Provide athletes with resources (i.e., providers who can offer direct individual services to athletes or team presentations, handouts, articles, websites etc.) that communicate specific ways they can balance training and nutritional needs to support their health and athletic performance. Additionally, identified resources can address common myths about eating disorders and inform athletes about specific ways to enhance their physical and emotional health.
▪ If you have access to a sports dietitian who specializes in treating eating disorders, consider asking them to help your athletes optimize health, enjoyment of food, and sport performance. Many athletes underestimate their energy needs and how much/frequently they need to support these energy needs. A qualified sports dietitian can provide general recommendations in a team presentation and more specific feedback and suggestions during individual sessions with athletes.
▪ Make use of your school’s mental health services, if available, or seek consultation from a qualified mental health provider within the community. They can help by connecting your athlete with a mental health provider; assigning a specialist to talk to the team; informing you of the athletic department and school’s policy on eating disorders, and aiding in handling athletes who refuse to seek treatment.
▪ Identify and utilize local health professionals with expertise in eating disorders and athletes who can provide education and treatment to your athletes. Consider collaborating with other sport personnel to develop a referral list of vetted, qualified individual providers and treatment centers locally, regionally, and nationally where athletes can seek help. Keep this referral list available for you to use when discussing the need for evaluation and treatment with an athlete. An athlete is more apt to follow through with a referral to a specific provider that you have recommended.
▪ Identify and cease any negative messages your sport communicates about weight/size/appearance and dieting to your athletes. Such messages are not conducive in supporting any athlete, heighten the vulnerabilities of some athletes, and are not aligned with helpful camaraderie within the team.
▪ Emphasize the health risks of low energy availability (not consuming enough energy for the body to optimally function) and/or low weight in your athletes. Should you be made aware of menstrual irregularities or female athletes who have stopped having periods completely, refer these athletes for medical evaluation and assistance.
▪ Although all sports are susceptible for the development of eating disorders, be especially vigilant if your sport is considered high-risk (e.g., weight class sports, aesthetic and judged sports, endurance sports). You will need to be particularly vigilant and committed to countering harmful messages that are, at times, normalized in the context of sport.
▪ Be aware of possible discomfort from athletes regarding their uniforms. Some sports attire, particularly in female sports, is revealing, either in terms of how sport clothing attire fits and/or in the amount of skin exposed in athletic attire. Such uniforms may increase body consciousness and body dissatisfaction in addition to facilitating body comparisons.
▪ Be mindful of your own comments and behaviors about value judgements specific to food and body size/shape, as well as such comments from your athletes. Identify and eliminate derogatory comments or behaviors about weight—no matter how subtle or “in good fun” they seem. Understand your role in promoting positive self-image and self-esteem in your athletes.
▪ Coaches should de-emphasize focusing on weight (i.e., encouraging athletes to weigh, obtain body fat measurements, diet, and/or complete additional workouts) for the purpose of enhancing sport performance. Such misguided comments can be a catalyst for an athlete to begin, or intensify, destructive compensatory behaviors. Sport performance should never come at the expense of the athlete’s health.
▪ In sports where weigh-ins are required (i.e., wrestling, crew, boxing) they should be done in an open and transparent manner in private, rather than in front of others (e.g., teammates). Weigh-ins should occur in a supportive environment where athletes are provided appropriate, and ongoing, nutrition and eating disorders prevention education. Careful consideration should be given as to whether or not blind weigh-ins (athlete is not informed of their weight) or non-blind weigh-ins (athlete is informed of their weight) are most appropriate to support the athlete’s health and well-being. Athletes should understand that engaging in eating-disordered behavior is not supported or encouraged.
▪ Discourage dieting, which is the primary precursor to disordered eating. Being stuck in a pattern of disordered eating can create mental and emotional turmoil. This can not only increase health risks, but can easily offset any potential performance enhancement in sport that might be achieved through a reduction in body weight or body fat.
▪ Emphasize methods of enhancing performance that do not focus on weight such as mental skills, sleep, adequate nutrition and hydration, strength training, and physical skills training.
▪ Enlist the help of athletic trainers, who often have good rapport with athletes and may be the best person to initially express concern to an athlete. Qualified athletic trainers may also be able to talk to athletes about the importance of appropriate rest and recovery to support health and sport performance.
▪ Avoid comparing athletes’ bodies to one another as doing so is never appropriate or supportive.
Issues of Confidentiality
Issues of confidentiality can be challenging when an athlete is seeking treatment for disordered eating or an eating disorder. You may desire to seek information about the health and well-being of your athlete and find you are not allowed to access such information without the athlete’s consent. A useful resource for coaches who have an athlete with an eating disorder is the International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs).2
Here are some tips on how to fulfill your job as coach while honoring confidentiality:
▪ Familiarize yourself with HIPAA (the 1996 Health Insurance Portability and Accountability Act), which protects the privacy of insured patients. Healthcare professionals are not at liberty to talk with you about an athlete’s condition because they are legally and ethically bound to protect an athlete’s confidentiality. Confidentiality is important because it allows the athlete to be honest with their treatment team, knowing that a provider can only release information to others with the written consent of the athlete.
▪ It is likely that an athlete prefers to keep their treatment/recovery private and doing so may be important to their recovery. Athletes might be more willing to share general treatment progress with their coaches, but could be less open to sharing information related to more personal issues.
▪ Communicate your thoughts and observations to the treatment team even if you are not formally included in the treatment planning. You may be able to provide important information for the treatment team pertaining to the health of your athlete. Even though the healthcare professionals treating the athlete may be unable to discuss with you about their condition or treatment, they can listen to what you have to report.
▪ Be accepting and understanding of the complexities and challenges of treating an eating disorder. Encourage and support appropriate treatment.
Sources
[1] Hambleton, A., Pepin, G., Le, A., Maloney, D., National Eating Disorder Research Consortium, Touyz, S., & Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. Journal of eating disorders, 10(1), 132. https://doi.org/10.1186/s40337-022-00654-2
[2] Mountjoy, M., Ackerman, K. E., Bailey, D. M., Burke, L. M., Constantini, N., Hackney, A. C., Heikura, I. A., Melin, A., Pensgaard, A. M., Stellingwerff, T., Sundgot-Borgen, J. K., Torstveit, M. K., Jacobsen, A. U., Verhagen, E., Budgett, R., Engebretsen, L., & Erdener, U. (2023). 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). British journal of sports medicine, 57(17), 1073–1097. https://doi.org/10.1136/bjsports-2023-106994