Addressing Eating Dysfunction and Disorder: ecSatter or IE?

by Ellyn Satter, MS, MSSW, Dietitian and Family Therapist

The Satter Eating Competence Model (ecSatter) and Intuitive Eating (IE) are similar in that they are both food- and weight-neutral and they are more (ecSatter) or less (IE) well-defined. After that, they part company.

How ecSatter and IE align

Interventions that heal eating attitudes and behaviors have this in common:

• Are food neutral: Give strong permission to eat preferred food, without in any way stipulating “healthy” or “unhealthy” food.
• Support internally regulated eating: Give strong permission to eat as much as desired based on hunger, appetite, and satiety.
• Are weight neutral: Give strong acceptance of constitutionally determined weight.

Consider discipline and structure

ecSatter is built around the productive tension between positive discipline and permission, otherwise described as “routine plus trust”¹ or, in the words of Becoming Eating Competent (sBEC): “Feed yourself faithfully and give yourself permission to eat.” While IE doesn’t encourage structure, discipline is embodied through continual monitoring of physical hunger and appetite and eating when hunger and appetite reach a certain level—“am I hungry? What am I hungry for?”—then being tuned in and self-aware while eating.²

ecSatter emphasizes structure; IE does not. ecSatter research contradicts the notion that structure breeds restraint. High scores on ecSI 2.0 (the inventory for ecSatter) correlate with low scores on cognitive restraint^3-5 and restrained feeding.⁵ Parents who score high on sDOR.2-6y, the validated inventory for the Satter Division of Responsibility in Feeding (sDOR)⁵ also score high on ecSI 2.0 and do particularly well with context.⁵ Consistent meals and snacks and feeding children in the family context and raising children to be eating competent (EatC) are the backbone of the Satter Feeding Dynamics Model and sDOR.⁶

Are ecSatter and IE models?

To convincingly support food- and weight-neutrality, an intervention has to be a model: It has to be grounded in research, be so concretely defined that someone else can reproduce it, and outcomes must be objectively tested. The use of validated instruments for before-and-after testing raises effectiveness evaluation from subjective (and possibly biased) clinical observation to objective assessment.

ecSatter is a model; IE loosely qualifies as being a model. ecSatter is supported by research and concretely described in in peer-reviewed literature,⁷ has a rubric to guide proper usage,⁸ has a validated inventory, ecSI 2.0, that has been tested for reliability (you can use it for before-and-after testing).⁹ ecSatter is supported by extensive research.¹⁰ The ecSatter-based, clinically tested “How to Eat” method,¹¹ is rigorously taught to other professionals.¹²

Intuitive Eating lays out general principles and practice in a self-help lay publication² and has a validated and reliability tested inventory, IES 2.0.¹³ You can track down IE training and research here: https://www.intuitiveeating.org/studies/.

Methods that are not models and that may or may have the three characteristics listed above as healing for distorted eating attitudes and behaviors include “non-dieting,” generic “intuitive eating,”¹⁴ HAES^®, nonspecific methods described as “weight-neutral,” mindfulness, non-dieting, size acceptance, and/or eclectic mixes of psychoeducation and persuasion.^15-18

Using ecSI 2.0 or IES 2.0

Here is what each inventory addresses:

ecSI 2.0: Measures ecSatter’s four components: context management, eating attitudes, internal regulation, and food acceptance.

IES 2.0: Measures unconditional permission to eat, eating for physical rather than emotional reasons, and relying on internal hunger/satiety cues.

ecSI 2.0 is available at no cost by applying for permission and satisfying training prerequisites. IES 2.0¹³ can be downloaded from a subscription-based journal.

Consider methods

How do ecSatter and IE educate and address uncomplicated eating issues? How do they treat established problems? ecSatter addresses uncomplicated eating issues with counseling guidance¹⁹ and published self-help information^{1, 20}. ecSatter does secondary intervention with complicated and established eating issues using the outcome-tested “How to Eat” method.¹¹ “How to Eat” restores positive eating attitudes and behaviors and neutralizes weight preoccupation by using a variety of evidence-based cognitive-behavioral techniques such as relaxation and desensitization training.

For education and primary intervention as well as treatment, IE utilizes flooding: encouraging access to unlimited amounts of “forbidden” foods until the foods’ fear potential is neutralized. IE utilizes in-session teaching, discussion, and persuasion to replace negative eating attitudes and behaviors with positive ones.²

Nutritional guidance

A key challenge in any food- and weight-neutral intervention is addressing nutrition and food selection without taking away permission to eat preferred food. Nutritional excellence is an integral component of ecSatter.^{7, 21} Working with ecSatter, food selection is addressed in the context of meal-building, giving strong permission to eat preferred foods. As described by the Satter Hierarchy of Food Needs,²² growing out of having enough to eat of personally preferred food, adults evolve variety and dietary quality. Subjects who score as EatC on ecSI 2.0 do well nutritionally. ^23-25

IE encourages “gentle nutrition:” “In matters of taste, consider nutrition; in matters of nutrition, consider taste.”² Generic methods tend to avoid addressing nutrition and food selection.

Emotional eating

From the ecSatter perspective, emotional eating is normal and legitimate. ecSatter gives permission to eat for emotional reasons and, in the context of the permission and discipline of EatC, emotional eating does not disrupt energy homeostasis. The IE perspective is that emotional eating causes weight gain and that identifying underlying issues and preventing emotional eating produces weight loss.

Parenthetically, EatC subjects have the same or lower BMI as the general population.^{3, 4} It appears the same holds true for those who test high on IES 2.0.²⁶

You can help further weight neutrality

Secondary intervention with ecSatter is “research-ready.” You can learn “How to Eat” in the Master Course, Treating the Dieting Casualty.¹² The course teaches you to take data on your patients. However, you don’t even have to go it alone with publication. ESI Faculty Member Cristen Harris is willing and ready to compile your data with that of other “How to Eat” practitioners and get your contribution into print, the way she helped Pam Harris and Peggy Crum.¹¹ Check out Dr. Harris’s excellent and accessible training on doing clinical research.²⁷