In 2011, when Emily Fonnesbeck, then the nutrition director of the Biggest Loser Resort in Fitness Ridge, Utah, began accepting private clients on the side, she knew she had to screen them carefully. "I was not in a place to take on eating disordered clients, because I was actually in the middle of my own."
Fonnesbeck didn’t have long-standing food issues; her eating disorder had emerged a few years before, when the weight she gained during her first pregnancy didn’t magically vanish after she gave birth. Thanks to her job at the Ranch, where she had worked since getting her degree in 2006, she knew how to drop the additional pounds. She exercised compulsively and cut out any foods that weren’t nutritionally dense. When she began to have digestive issues, she eliminated more foods. Soon, though, she was eating only five foods total. Her joints ached, she was having regular migraines, and she fractured her pelvis.
She knew that she had a problem and that she didn’t want to bring it into her fledgling practice. At the Ranch, which she left in 2012 to focus on private clients full-time, she had seen firsthand the toll extreme dieting and all-day workouts had on clients. "I remember the guests were hobbling in so much pain. And over time I started thinking, Is this really what health looks like? Can't walk at the end of the day? Preoccupied with food?”
And yet she found herself advising her private clients to eliminate sugar and dairy from their diets, just like she had. “Cut this out and you’ll feel better,” she remembers telling them, even though there is still no good data showing that people without diabetes or a severe dairy allergy need to eliminate either. “It wasn't really evidence-based practice,'' she says now. “It was coming out of my own fear.”
One of the clients Fonnesbeck treated at that time was struggling with disordered eating and thus particularly vulnerable to putting Fonnesbeck’s restrictive recommendations into practice. The dietitian was so deep in her own eating disorder that she didn’t recognize that her client was in trouble. What’s striking for Fonnesbeck now, in recovery, is that she didn’t even realize she wasn’t giving sound advice. “I really felt like I was.”
If you've seen a nutritionist in private practice, you may already suspect that Fonnesbeck is not the only dietitian to have practiced with an active eating disorder. You sit across from a probably slender, probably white woman who extols the energy and clarity you’ll have when you follow the meal plan she recommends. She tells you not to worry if it seems like not that much food. “Detoxing” from gluten, dairy, sugar, and processed food will curb your cravings for them, and you can always fill up on Scandinavian fiber crackers with the consistency of pressed mulch. As you leave to pursue the nearest cheeseburger, you may catch yourself thinking (uncharitably, because looming starvation makes you petty): Like she even eats.
But it is widely known among nutritionists and the most powerful body in American dietetics that many dietitians actually do struggle to feed themselves, potentially putting unsuspecting clients at risk. “It’s the elephant in the room,” one dietitian says, even though it’s not all that surprising. After all, how do you avoid obsessing about food when thinking about it is literally your job? And more than a decade into our current, juice-slicked quest for wellness, what’s the difference between eating that harms and eating that — allegedly — heals?
Eating disorder behaviors have been observed in dietetics students since at least 1985, but the only study of how prevalent they are among practicing U.S. dietitians is a published master’s thesis by dietitian Kaylee Tremelling, who is also now in private practice in Utah. When Tremelling began her graduate degree in clinical nutrition at University of Texas Southwestern Medical Center in Dallas in 2014, she had been caught in a cycle of bingeing and restricting for years. Like many dietetics students, she majored in nutrition as an undergrad partly in the hopes of figuring out what was wrong with her eating — and thereby managing her weight. “It was definitely coming from, How do I fix this? What's the secret magic formula that I should be trying to use? ... I knew I was struggling." In grad school, her disordered eating morphed into orthorexia, a preoccupation with eating only “healthy” food that nutrition training seemed to support. “Because I was going to be a dietician, I felt pressure to act a certain way and eat a certain way."
Noticing a similar mindset among her classmates, Tremelling designed a survey to detect the prevalence of eating disorders generally, and orthorexia specifically, among practicing registered dietitians nationwide. Almost half of the 636 respondents included scored as high risk for orthorexia. Thirteen percent scored as high risk for anorexia, bulimia, binge eating disorder, or another type of disordered eating. Eight percent reported that they had been treated for an eating disorder in the past.
Tremelling’s faculty advisers weren’t exactly surprised by the results. “Maybe they wanted to be like, ‘No way, that's not real,’ but inside, they knew this is common,” she says. “Eating disorders bring people into the dietetic[s] field.”
It’s easy to see why: One common eating disorder symptom is frequent and obsessive thinking about food.
Other dietitians say their eating disorders were triggered by dietetics training itself, and the culture around it. "I did not have an eating disorder until I started studying nutrition," says Jessica Serdikoff Romola, a registered dietitian in New Jersey who traces her orthorexia back to her first semester as a dietetics major. When she learned that trans fats are highly associated with heart disease, she tried to avoid foods containing them and felt anxiety when she did eat them. “The statistics that they teach you are so alarming, you go, ‘I feel like I can't eat them at all.’ Then, it just became one thing after another that I would cut out of my diet in order to be healthier,” she says.
In her first job out of college, she worked as an in-store nutritionist for a supermarket chain, performing food demos and providing individual and group nutrition counseling to customers. She estimates that she practiced for three years before she began to recognize and address her disordered eating.
To be accredited by the Academy of Nutrition and Dietetics, undergraduate and graduate nutrition programs must offer courses in a long list of subject areas, from organic chemistry and research methodology to medical nutrition therapy (nutrition support related to a specific illness, such as diabetes or renal failure) and clinical workflow. Course materials generally encourage moderate, sensible eating and instruct students not to eliminate any food from a client’s diet unless there is a food allergy. “All foods fit” is an often repeated tenet. However, dietitians say there is a disconnect between this message of moderation and the parts of the curriculum that are dominated by obesity prevention.
“The assumption is that this is this core issue with public health, so much of the curriculum ends up being focused on that,” says Kimmie Singh, an eating disorder dietitian in New York City who entered the field after recovering from her own eating disorder.
Former students remember being required to track what they ate for three days, then analyze their choices based on any change in their body size. Others recall being paired with another student to perform skin fold analyses on each other in class to measure percent body fat. Tremelling, who surveyed the prevalence of eating disorders among U.S. dietitians for her graduate thesis, says she had to weigh herself and measure her waist circumference in front of classmates in an undergraduate class. Most courses don’t mention body diversity, or the long-established research indicating that most people cannot intentionally lose weight and keep it off. “Even a dietitian that promotes weight loss should know that,” says Singh. “Why are you not at least aware of the research?”
On top of the curriculum, there is a classroom and social atmosphere that Singh describes as “diet culture on steroids.” Serdikoff Romola has clear memories of this. “One professor asked us in class to raise our hands if we eat salad every day. I didn't raise my hand because I didn't. And they asked anyone who wasn't raising [their] hand how they expected to get all of their vegetables in,” she recalls. Another time, as part of her involvement with the dietetics student organization, “I wanted to plan a cupcake-decorating party as a team building exercise, and I got a good amount of pushback” from fellow students. They told her it was unethical for a dietetic association to be promoting dessert. Singh remembers students being embarrassed about the snacks they brought to school. “Once in class a student opened a bag of Flaming Hot Cheetos, and she tried to hide them and apologized for eating them.”
Sometimes faculty members in Singh’s program openly made fun of fat people or habits they ascribed to fat people. “In my first nutrition class, the professor, who has since retired, started making fat jokes right at the start of class. I remember him saying, I miss the days you could just call people fat. The fatphobia was very explicit,” says Singh, a self-described fat dietitian. “You see I'm a fat person sitting right here,” she remembers thinking. “It was really, really f*cking weird.”
Dietitians describe understanding as students that succeeding in the field meant maintaining a low weight. Kylie Mitchell, 32, a Houston-based registered dietitian who specializes in treating eating disorders, sums up the mentality: “If you’re a dietitian, you’re thin.” Rather than worrying about disordered eating, she says, students are more likely to be haunted by the question, “What if I end up a fat dietitian?”
Meanwhile, undergraduate dietetics programs are not required to teach future dietitians about eating disorders, and most of the dietitians interviewed for this story recalled fewer than three class meetings mentioning them. "It was always talked about as this really rare thing that you'll never see," Mitchell says. (The worldwide prevalence of eating disorders more than doubled between 2000 and 2018, from an average of 3.5% between 2000 and 2006 to 7.8% between 2013 and 2018.) Students who are interested can pursue additional certification after graduation.
A nutritionist practicing in the grip of an untreated eating disorder can harm clients, experts say. The most obvious concern is one of basic functioning: “Are they malnourished? Is it affecting their cognitive function?” Singh says. “Similar to why you shouldn't see clients while you're drunk — you want to be of sound mind.” If the dietitian is medically stable but not in treatment, she might pass on disordered ideas as fact. In Singh’s first sessions with new clients, they often recall their eating disorder gaining fuel from a specific instance when a dietitian came to speak to their class about “healthy eating.” “Dietitians are seen as the food and body authority,” Singh says. “So if they're given that position of power, and then they don't know what's appropriate to say because their eating disorder is driving the car, it can be really harmful for all the passengers.”
Despite the evidence that nutritionists and clients are struggling, the field has taken little official action to help them. Whitney Linsenmeyer, a registered dietitian and a spokesperson for the Academy of Nutrition and Dietetics, the governing authority in U.S. dietetics, said in an interview that the academy has long been aware of the prevalence of eating disorders among dietitians and the ethical dilemmas it presents. When asked what support or education has been offered in response, she said, “To my knowledge there is not movement at the national level or from the academy to specifically address this issue.”
The academy also emailed a statement:
The issue has been discussed in papers published in the Journal of the Academy of Nutrition and Dietetics and in blog posts by members of the Academy’s Behavioral Health Nutrition dietetic practice group.
The Academy of Nutrition and Dietetics and the Accreditation Council for Education in Nutrition and Dietetics do not track or screen RDNs or dietetic students for eating disorders due to privacy concerns.
Registered dietitian nutritionists, like all people, experience the full range of health issues. RDNs or dietetic students with eating disorders are encouraged to seek the help of RDNs who specialize in treating clients with eating disorders.
Dietitians in recovery from eating disorders point out that colleagues who are struggling may be reluctant to see another member of the field about their eating issues. When Fonnesbeck entered recovery, she saw a therapist and a medical doctor, but she wouldn’t see a dietitian. She remembers thinking, “I'm a dietician. I should have food figured out.”
What’s difficult about addressing disordered eating in anyone, including dietitians, is that disordered eating and healthy eating often look a lot alike. Is going gluten-free a proactive effort to reduce inflammation or an acceptable rebranding of the low-carb diets of the late ‘90s and early aughts? Is cutting out sugar a gateway to years of binge-restrict hell or the only sensible option if you want to prevent diabetes?
According to eating disorder nutritionists, the difference actually has nothing to do with food. “It's impossible to say that someone who doesn't eat sugar is orthorexic,” Fonnesbeck says. “It has to do with the intention around those behaviors, how those behaviors are affecting quality of life. One person could be choosing to eat a certain way because they feel really good about it, and … someone could be eating the very same way and have it be pathological and dysfunctional.”
Fonnesbeck screens new clients in part by asking what percentage of their day they spend thinking about food or their body. “Someone who's struggling is going to be 50% or higher,” she says. It’s an even bigger red flag when they defend their preoccupation as “I’m just interested in health.” For nutritionists and clients alike, Singh says, “The more anxiety it gives you to not eat healthy, the more disordered your eating probably is.”
If you’re a prospective client looking for a nutritionist, the best way to guard against potentially harmful advice is to see a dietitian who takes a non-diet approach, meaning they won’t focus on your weight, ask you to count calories, encourage you to eat less, or ban any food. Any guidelines offered should be flexible and accommodate your budget, schedule, ethnic background, and circumstances. Above all, a dietitian should encourage variety. The human body works by acquiring the nutrients it needs from many different sources, Fonnesbeck says. “If someone is cutting out foods over and over again, [that] restriction puts them at risk for inadequate nourishment.”
Dietitians say they do see more of this advice trickling into the profession, thanks in part to individual practitioners’ willingness to go public about their own struggles. Serdikoff, who now counsels other dietitians on burnout and “the pressures of being a dietician — looking, acting, eating a certain way” — says the whole field is shifting to be more honest and supportive about the difficulties both clinicians and clients have with food. She describes colleagues becoming more sensitive to their clients' struggles after confronting their own eating issues. “It's an amazing time to be a dietician,” she says.
In the depths of her eating disorder, Fonnesbeck promised herself, “If I ever can find a way out of this, I promise to be part of the solution, not a part of the problem.” When she recovered, she posted a public apology on her blog. She also made individual amends to the clients she worked with, including the client she treated when she first went into practice, who she later realized had an eating disorder. In 2019, that person became her client again. This time around, all foods fit.