Disordered eating (DE) is the newest buzzword in my social media echo chamber. Social media is rife with individuals discussing disordered eating, and it is great to see a more open dialogue around this topic, which has previously been deemed taboo in the industry. However, like anything in the fitness sphere, once something becomes popular, the charlatans come along to capitalise on the unsuspecting public. I’ve seen coaches claim they can “cure” DE, banish binge-eating forever and diagnose everyone with disordered eating. We will of course break down these abhorrent practices in due time, dear reader.

In the interim, we’re going to run through the basics of disordered eating, what the science says and what we as practitioners can do about it, whilst staying within our scope of practice.

What Exactly Is Disordered Eating?

Well, this is where we encounter the first hurdle. Reba-Harrelson et al.⁽¹⁾ define disordered eating as “endorsing unhealthy eating behaviours, without meeting the criteria for an eating disorder”. Eating disorders are medical conditions with specific diagnostic criteria, and are diagnosed and treated by clinicians ⁽²⁾. These disorders typically encompass binge-eating disorder, anorexia nervosa, night-eating syndrome and eating disorder not otherwise specified⁽³⁾. Working with individuals with eating disorders, or even suspected eating disorders is for trained professionals (clinicians, dietitians etc) only. Not online coaches that ordered their nutrition certificate off Google.

If you suspect that your client has an eating disorder, it is extremely unethical and dangerous for you to act outside of your scope of practice and offer them nutrition coaching, no matter how well-intentioned. Stay in your lane, babes.

My beef with the fitness industry aside, disordered eating is a little more nuanced. We know from the previous paragraph that there is no defined threshold for disordered eating. This is challenging in itself, and has led to the advent of this era of “anti-diet culture” influencers label anything outside of the iNtUiTiVe EaTiNg sphere as disordered.

In addition to being highly annoying, this is actually quite misleading. Disordered eating exists on a spectrum, and must be treated as such.

How Disordered Eating Presents

Disordered eating is an umbrella term, that isn’t solely limited to nutritional practices. Disordered eating presents as behaviours or cognitions. Disordered eating cognitions refer to unhealthy perspectives and beliefs around nutrition and training⁽⁴⁾. These beliefs can centre around poor body image – through dissatisfaction with one’s physique, overemphasis on achieving a body ideal (read: Instagram model)⁽⁵⁾. These cognitions may also extend to nutrition and training, and typically encompass a rigorous, or “dichotomous” mindset to diet/exercise⁽⁶⁾. Consider individuals who exclusively “clean”, or are either “on/off” plan with their training.

Disordered eating behaviours (DEB) centre around unhealthy diet and exercising habits, and are the actions an individual carries out as a result of their cognitions. These behaviours are extensive and vary in both presentation and severity. DEBs include (but are not limited to): binge-eating, purging/compensatory behaviour (not necessarily vomiting – but exercising compulsively to “burn off” calories [overexercising]), excessive dietary restriction and removing food groups entirely from the diet^(7,8).

It is super important to note here that DEBs are a component of clinical eating disorders⁽³⁾, but this relationship is not bi-directional. You can have disordered eating habits and beliefs, and not have an eating disorder. The reverse of this is not true. If you have a clinically diagnosed eating disorder, you will exhibit some form of disordered eating^(3,8).

Challenges with Disordered Eating Presentation

Disordered eating needs to be considered on an individual basis, based on the severity, frequency and impact of these behaviours/beliefs on the quality of life of the individual. As disordered eating exists on a spectrum, it also affects each of us differently⁽⁹⁾.

Of course, there are certain behaviours at the far end of the spectrum, such as vomiting after eating, consuming laxatives after eating and repeated bouts of binge eating that are indisputably disordered and concerning. Things get a little “hairier” as we enter the middle to lower end of the spectrum of disordered eating.

This is where the “anti-diet” brigade love to blanket ascribe the word “disordered” to a whole host of behaviours, based off their n=1 experience. A prime example of this is tracking calories. According to the anti-diet brigade, if you track calories or weigh anything ever, you’re now a disordered eater. Need to weigh out flour for those cookies you’re making? Think again.  Disordered eating can actually enter your skin through osmosis from contact with the weighing scales. Best just eyeball it and make foul-tasting cookies babe. Can’t take the chance.

My dramaticism aside, of course we cannot ignore the research that links tracking calories and macros with higher disordered eating behaviours^(10,11). It is not that MyFitnessPal is the sole driver of these habits, nor is it fair to ascribe full blame to an app. Rather, it is the individuals’ dichotomous attitude to tracking – either they hit perfect targets or don’t – that fosters these negative impacts on individuals.

Again, this is where we see how important it is to consider these “disordered” behaviours on an individual basis. If I am starting off learning about nutrition and fuelling my body and I am tracking my calories to make sure I am eating enough of certain foods, that is not disordered. However, if I am tracking calories because if I don’t have everything planned to the gram I get super anxious and binge-eat, that is most certainly disordered.

Similarly, consider vegetarianism. We can point to systematic reviews that have identified a link between vegetarianism and eating disorders⁽¹²⁾. Does that mean forgoing meat is disordered? Of course not, and this research clearly states that. Again, it just further exemplifies a need to consider the motivations behind an individual’s actions. Going veggie for ethical/environmental reasons is not disordered. Going veggie because excluding food groups helps you to keep calories down is probably a little more iffy.

These are just two scenarios that highlight the challenges with blanket labelling behaviours “disordered”, and the importance of assessing individuals on a case-by-case basis. Not from your n=1 experience.

So, Can I Coach My Client with Disordered Eating?

As the great W.B. Yeats said, tread softly because you tread on my dreams.

Good old Yeatsy evidently made this point in reference to questionable practices of online nutrition coaches. Now obviously the fitness industry trampled on my dreams of widespread ethically sound practices long ago, but a gal can still dream.

We know by now that disordered eating exists on a spectrum, and there is definitely a higher end of the scale that is better left to more specifically trained professionals.

However, I haven’t written this to say that as a coach you should never coach anyone with disordered eating habits. You would legitimately have zero clients then! Everyone has a little bit of disordered eating in them, and given how subjective it is, this can exist to varying degrees. As a coach, you have an incredible opportunity to help coach people out of disordered eating, and give them their life back. That is incredibly rewarding. I know from my own coaching practice, nothing gives me a buzz than seeing clients report that they are happier with their body and overeating less after being a prisoner to it for so long. Similarly, I have experienced myself first-hand just how transformative good nutritional coaching can be. I’ve worked with Dr Emilia Thompson for roughly 2 years now, and she has been incredible in challenging my previously held body and food beliefs.

Rather, I have written this so that you consider your client as an individual and meet them where they are, in a capacity that you can. Hopefully after reading this, you have an appreciation of the basics of disordered eating, how it differs from clinical eating disorders and the importance of staying within your scope of practice.

If you are concerned that you, or your clients are at risk for clinical eating disorder or high-risk disordered eating behaviours you can contact your GP.

For further information on eating disorders/disordered eating support, contact Bodywhys or BEAT if you’re in the UK.

The next article will cover the risk factors for DE, and what you should look out for in yourself and your clients. Any feedback, comments or questions, please do let me know.

References

1. Reba-Harrelson L, Van Holle A, Hamer RM et al. (2013) Patterns and Prevalence of Disordered Eating and Weight Control Behaviors in Women Ages 25-45. Eat Weight Disord 14, 190-198.
2. Sim LA, McAlpine, DE, Grothe KB et al. (2010) Identification and Treatment of Eating Disorders in the Primary Care Setting. Mayo Clin Proc 85(8), 746-751.
3. American Psychological Association (2013) The Diagnostic and Statistical Manual of Mental Disorders, 5^th ed. Arlington, VA: American Psychiatric Association.
4. Hill ML, Masuda A, Latzman RD (2013) Body image flexibility as a protective factor against disordered eating behavior for women with lower body mass index. Eating Behav 14, 336-341.
5. Diehl, NS, Johnson, CE, Rogers, RL et al. (1998) Social physique anxiety and disordered eating: what’s the connection? Add Behav 23(1), 1-6.
6. Westenhoefer J, Engel D, Holst C et al. (2013) Cognitive and weight-related correlates of flexible and rigid restrained eating behaviour. Eat Behav 14(1), 69-72.
7. Pereira RF, Alvarenga M (2007) Disordered Eating: Identifying, Treating, Preventing and Differentiating It From Eating Disorders. Diabetes Spectr 20.
8. Tanofsky-Kraff M, Yanovski SZ (2004) Eating Disorder or Disordered Eating? Non-normative Eating Patterns in Obese Individuals. Obesity 12, 1361-1366.
9. Kärkkäinen U, Mustelin L, Raevuori A et al. (2017) Do Disordered Eating Behaviours Have Long-term Health-Related Consequences? Eur Eat Dis Rev.
10.  Messer M, McClure Z, Norton B et al. (2021) Using an app to count calories: Motives, perceptions, and connections to thinness- and muscularity-oriented disordered eating. Eat Behav 43.
11.  Simpson CC, Mazzeo SE (2017) Calorie couting and fitness tracking technology: Associations with eating disorder symptomology. Eat Behav 26, 89-92.
12. Sergentanis TN, Chelmi ME, Liampas A et al. (2020) Vegetarian Diets and Eating Disorders in Adolescents and Young Adults: A Systematic Review. Children, 8(1), 12.