The Runner Who Eats an Apple
You teach 10th-grade health at a 1,500-student high school. A 15-year-old cross-country runner has come to class without lunch three days this week; you have seen her eat only an apple and drink water. She wears a baggy hoodie in 80°F weather, has lost noticeable weight since August, and told a friend she 'needs to lean out for districts.' The nurse has seen her twice for dizziness and once for a resting heart rate of 48. Today she asks you to keep a secret: she is running 6 miles after practice and using an app to track every calorie, and she says her coach told the team that lighter runners are faster. She begs you not to tell her parents, who she says will 'overreact.'
1. Which eating disorder content knowledge is relevant, and what can and cannot you conclude from these observations?
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Relevant content:
- Anorexia nervosa features restriction, intense fear of weight gain, body image disturbance, and often excessive exercise.
- Bulimia nervosa and binge eating disorder are also possible; not all eating disorders involve low weight.
- Relative energy deficiency in sport (RED-S) explains the athletic picture: low energy availability can impair menstrual function, bone health, immunity, mood, and performance.
- Warning signs include marked weight change, secretive eating, calorie tracking, compulsive exercise, cold intolerance, dizziness, and social withdrawal.
What I cannot conclude:
- A resting heart rate of 48 may be normal in a trained endurance athlete, so it is not diagnostic by itself.
- I cannot diagnose anorexia, bulimia, or RED-S from these observations; diagnosis requires a medical and mental health evaluation.
- I should not comment on her body, weigh her, or prescribe a diet.
Reasoning: The pattern is concerning enough to require referral, but the teacher's role is recognition and connection to care, not diagnosis or treatment.
2. What are your next steps within 24 hours, given her request for confidentiality?
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First, be honest about limits: Thank her for trusting you, and say you cannot keep a secret when her health or safety may be at risk. Do not promise confidentiality you cannot keep.
Then act on safety:
- Warm handoff to the school nurse for a medical assessment-not a public weigh-in or a lecture.
- Refer to the school counselor or social worker the same day; coordinate so she is not retelling her story to five adults.
- Follow district protocol and state law on self-harm risk and child protection. An eating disorder alone may not be reportable, but suspected abuse or neglect must be reported; consult an administrator if unsure.
- Contact parents or guardians unless doing so would create a safety risk; frame it as concern about health and athletic performance, not accusation.
- Document objectively: what you saw, what she said, whom you notified.
Reasoning: Her request for secrecy is a test of trust, but safety overrides it. A coordinated, warm referral is more likely to keep her engaged than a cascade of separate disclosures. Avoid body comments and food rules; those can reinforce the disorder.
3. How would you address the coach's 'lean out' comment and the team environment?
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Address the environment, not just the individual.
Steps:
- Private conversation with the coach. Use performance framing: 'You want faster runners; RED-S research shows underfueling causes performance decline, injury, and bone stress.' Share a one-page resource rather than accusing.
- Involve the athletic director if the coach dismisses it, because a 'lighter is faster' message is a known risk factor and conflicts with safe sport policy.
- Ask for specific changes: no public body talk, no weigh-ins, no 'lean out' language, and a team norm that fueling is part of training.
- Offer a brief staff professional learning session on RED-S and eating disorder warning signs for coaches and health teachers.
- Protect the student from retaliation and keep her care team informed.
Reasoning: The coach's comment is a modifiable environmental influence. Changing team norms reaches more students than correcting one athlete, and it aligns with the health education principle that behavior is shaped by social and environmental factors.