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Welcome back to Food Psych Weekly, the newsletter where I answer your questions about intuitive eating, Health At Every Size, disordered-eating recovery, and other anti-diet topics.

This newsletter is made possible by subscribers like you. To help keep it running, you can forward it to someone who’d like it, buy my book, or join one of my courses. (Got this as a forward? Subscribe here for weekly anti-diet support!)

This week’s question is from a reader named Alexandra, who writes:

I am a relatively new listener/reader. I have already learned a great deal, although I know I have only dipped my toe in to the subjects you have covered in hundreds of articles, podcasts, and Q and As.

However, one thing jumps out at me almost every time I spend time with Food Psych and you. You use the wording "disordered eating," "recovery from disordered eating," and several other similarly worded phrases. Can you please tell me why the phrase "eating disorder" is not your usual choice of words? As someone "diagnosed with an eating disorder" I am not sure if you are including me in your thinking and writing since I don't hear you talking about "eating disorders." I feel sure you have a thoughtful reason for your choice of words. I would be interested to know what that is.

Thank you for all your work on behalf of those of us who struggle with food thoughts and choices.

Thanks for your question, Alexandra, and before I answer, here’s my standard disclaimer:

These answers are for informational and educational purposes only, aren’t a substitute for individual medical or mental health advice, and don’t constitute a provider-patient relationship.

I’m glad you asked this question, because I realize the terminology might be confusing! The short answer is that I typically use “disordered eating” in order to be inclusive of everyone along what I call the disordered-eating spectrum—people with diagnosed eating disorders, as well as those who don’t have a diagnosis but struggle with harmful thoughts and behaviors related to food. So yes, it very much includes you as someone with a diagnosis, while also including a far broader range of people than the term “eating disorders” (EDs) alone.

First of all, there are many, many people who don’t meet the diagnostic criteria for EDs but who nevertheless struggle with painfully disordered thoughts and behaviors around food. As I wrote in my book Anti-Diet, fasting, chronic restrained eating, restricting major food groups, and bulimic behaviors are all forms of disordered eating, as is bingeing, which many people do as a result of dieting/restrictive eating. ED diagnostic criteria are largely a matter of degree: engaging in X disordered-eating behavior at least Y times a week, for at least Z months (along with other diagnosis-specific criteria). But people who engage in those behaviors less frequently or consistently still have a problem in their relationship with food, and they still deserve help and support. The same is true for those who obsessively think about and hold disordered beliefs about food, even if they don’t always act on them. And millions of people experience some version of disordered eating despite not having a diagnosed ED. A 2008 survey (Content Warning: weight and calorie numbers, detailed descriptions of disordered-eating behaviors) by researchers at the University of North Carolina at Chapel Hill in conjunction with SELF magazine found that 65 percent of American women between the ages of 25 and 45 have some form of disordered eating, and that another 10 percent would meet the criteria for eating disorders (although far fewer are actually diagnosed—more on that shortly). Clinicians specializing in eating and body image report that these issues are on the rise in men as well, and transgender people are actually more likely than cisgender folks to have both diagnosed eating disorders and general disordered-eating behaviors. We don’t have great estimates for many other populations, but judging by the data we do have, I think it’s safe to say that “subclinical” disordered eating is a rampant problem in many communities that’s far more common than diagnosed EDs.

There are also many people who do meet the criteria for full-blown EDs but are never diagnosed, often because of various forms of bias. Even though the diagnostic criteria are now somewhat less focused on weight than they were in the past, in practice many clinicians who diagnose EDs still use weight in making their assessments, overlooking people with significantly restrictive behaviors because their bodies are supposedly “too large” to indicate an ED. Similarly, although it’s now becoming more widely known that people across the spectrums of race, gender, age, and socioeconomic status struggle with EDs, longstanding stereotypes of eating disorders as a disease of affluent, white, teenage girls can prevent people of different identities from getting the proper diagnosis. There are many providers in the ED field working in various ways to dismantle these stereotypes and improve care for marginalized populations, but at this point it’s still challenging for many people with EDs to access the support they need because of pervasive bias among clinicians.

Another barrier to diagnosis for many people is the inaccessibility of good mental-health care. In the U.S., where I’m based (and I believe in many other English-speaking countries as well), psychologists/psychotherapists are the main providers who can make an official ED diagnosis. (In some cases medical doctors technically would be allowed to make the diagnosis, but in practice they often don’t.) In the American private-payer healthcare system, if you don’t have insurance and can’t afford to pay out of pocket, you likely won’t be able to see a psychotherapist in the first place. And in public healthcare systems, waiting lists and referral requirements can be prohibitive, even if the cost itself is not. What’s more, EDs are a specialized field, and many psychotherapists don’t have the training to be able to recognize an ED when they see one (though of course there are also some great general-practice therapists out there who do have that awareness). I say this both from professional experience working alongside therapists as well as personal experience trying to get help for my own ED nearly two decades ago; I went through several therapists who didn’t identify that I had a problem and made me feel like my issues with food were minimized or dismissed, before finally finding a great therapist who helped me tremendously (even though at that point I no longer met the criteria for a full-blown ED). In one case I even experienced weight bias when trying to get help for my ED, despite always having been smaller-bodied—unfortunately sometimes even relatively thin people are deemed “not thin enough” to have an ED based on ridiculous stereotypes about what these disorders supposedly “look like.”

Meanwhile, even when larger-bodied people do manage to get an ED diagnosis, they can face many issues getting the care they need and deserve. Larger-bodied clients are sometimes labeled as having Binge Eating Disorder even though they don’t binge—simply because of the size of their bodies. They also unfortunately sometimes receive harmful weight-loss advice in ED treatment that worsens their disordered behaviors rather than helping. (I talked about these issues with Binge Eating Disorder specialist Amy Pershing in the Food Psych episode that’s re-airing this week, as well as with Erin Harrop and Rachel Millner in their episodes.)

So to recap: many people don’t meet the criteria for EDs, and getting an ED diagnosis isn’t an equal-opportunity experience. That’s certainly not to say that people who have managed to get an ED diagnosis and high-quality care did anything wrong—just that everyone should have the same opportunities, and we’re not there yet. That’s why, to me, using the term “eating disorders” in my work for the general public feels too narrow, and why I prefer to use the phrase “disordered eating” to help people all along the disordered-eating spectrum feel included.

Granted, there are some cases in which the treatment recommendations for people with diagnosed EDs will likely be different than for those with other forms of disordered eating, such as chronic dieting. There are no hard-and-fast rules here because of how difficult it can be to get an ED diagnosis (meaning that some folks who identify as chronic dieters actually may have experiences that are more similar to those with diagnosed EDs), but sometimes making these distinctions can be important for treatment. For example, with intuitive eating, there are some principles that might not be immediately accessible or helpful to focus on when you’re in the throes of a full-blown eating disorder, such as honoring hunger (which might feel totally absent because of the ED) or feeling fullness (because some folks with EDs experience early fullness that doesn’t accurately represent the body’s needs). These are fairly nuanced points, so if you’re interested in learning more I’d recommend checking out this article I wrote for SELF or joining my Intro to Intuitive Eating course, as well as working with an individual ED treatment team, if it’s available to you.

Still, although there are some situations in which those distinctions may be useful, in my experience (again both professional and personal) the similarities between diagnosed/diagnosable EDs and other forms of disordered eating are often greater than the differences. Of course that’s not to say that everyone’s experience of disordered eating is exactly the same—far from it—but just that there are similar themes and issues that tend to crop up across the disordered-eating spectrum. Those include diet culture’s pressures to be thin and eat “perfectly,” which are a main focus of my work, because I believe that exploring and challenging those pressures is important for pretty much everyone who struggles with disordered eating—regardless of where they fall along that spectrum.

So Alexandra, I hope all of that helps you feel reassured that my work is definitely meant to include folks like you with diagnosed EDs, and thanks again for the great question!

​Ask your own question for a chance to have it answered in an upcoming edition of the newsletter.

Podcast Archives

In Episode 149 of Food Psych, anti-diet therapist and Binge Eating Disorder specialist Amy Pershing joined me to discuss how our fat-stigmatizing culture hinders eating disorder recovery, how diet culture steals our personal power, the healing that can be found in getting angry, the role of restriction and trauma in binge eating, and so much more.

Plus, I answered a listener question about quick ways for primary-care providers to talk to patients about intuitive eating and HAES.

​Check it out right here, and be sure to subscribe to the pod so that you get (VERY) occasional bonus episodes while we’re on hiatus, and a brand new season of the show when we return.

Thanks so much for reading! This newsletter is made possible by subscribers like you. To show your support, you can forward it to someone who’d like it, make a donation, buy my book, or join one of my courses.

Got this as a forward? Subscribe here for weekly anti-diet support!

Here’s to healing for everyone on the disordered-eating spectrum,

Christy