Motivation and emotion/Book/2020/Intuitive eating

Overview
Intuitive eating is the practice of self-care through being in-tune with your biological and psychological needs to satisfy hunger and thirst. This has been shown to benefit both physical and mental health by developing an eating style which integrates instinct and rational thought. This approach was created by two dietitians in 1995, and since then numerous research, studies and assessment have taken place to show the potential benefits from adopting this approach (Tribole, 2019).

Psychological traits, including both affective and cognitive components, can impact one's eating habits and overall health outcomes (Camilleri et al., 2016).

For example:
 * Some people are likely to overeat in response to negative emotions such as sadness, anxiety and loneliness
 * Restrictive and restraining eating habits are likely to result in binge eating and form unhealthy relationships with eating and food (Camilleri et al., 2016)

This creates an absence of a healthy relationship with food and ruins one's ability to follow their own cues for satiety and hunger.

The goal of using intuitive eating practices in your daily routine is to build a connection with physiological cues for hunger and satiety. Intuitive eating also focuses on establishing body acceptance, rejecting diet models and restrictive eating, and recognising emotional triggers that may cause you to eat for reasons other than hunger (Augustus-Horvath & Tylka, 2011).

Principles of intuitive eating
Intuitive eating is summarised into 10 main points that can be used as guidelines for how to adopt an approach towards intuitive eating.

Table 1.

10 principles of intuitive eating:

These principles can help develop an awareness of the physical sensations that arise in the body and remove obstacles to this awareness, which usually come from the mind in the form of beliefs, attitudes and rules (Resch & Tribole, 2019).

Origin of intuitive eating
The term intuitive eating was first used by two dietitians, Evelyn Tribole and Elyse Resch in 1995. It was created by adopting a psychological approach to eating, helping to change individuals attitudes and beliefs around eating in order to gain a healthy relationship with food and themselves (Tribole, 2019).


 * Elyse Resch is a nutritional therapist working in a private practice in Beverly Hills. She specializes in eating disorders, intuitive eating, and Health at Every Size. She has a masters degree in science and is a registered dietitian. Her philosophy embraces the goal of developing body positivity and reconnecting with one’s internal wisdom about eating (Resch, 2020).
 * Evelyn Tribole is a registered dietitian with a nutrition counselling practice in California. She specializes in eating disorders, celiac disease, digestive health and intuitive eating. She is a public speaker, runs workshops in her specialised areas and is a author of nine books about intuitive eating, cooking, nutrition and health (Tribole, 2019).

Geenan Roth
Geenan Roth had earlier ideas based around the same principles of intuitive eating, without using the term. She suggested that compulsive eating and constant dieting was linked with deeply personal and spiritual issues. Her books indicated that our relationship to food is a reflection of our deeply held beliefs about ourselves. She put forward a similar set of guidelines around building a holistically healthy attitude towards eating and food. Her guidelines are:


 * Eat when you are hungry
 * Eat without distractions. Distractions include radio, television, newspapers, books, intense or anxiety-producing conversations or music
 * Eat what your body wants
 * Eat until you are satisfied
 * Eat (with the intention of being) in full view of others
 * Eat with enjoyment, gusto and pleasure (Roth, 2011)

Thelma Wayler
Thelma Wayler founded Green Mountain at Fox Run in 1975 after working as a nutritionist specialising in working with diabetic patients and was a nationally recognised diabetes educator for the US public health sector (Green Mountain, 2020). She founded the idea of the non-diet movements, claiming that from her extensive work with patients she realised a need for a change in the way we view lifestyle changes and overall health (Green Mountain, 2020). Thelma often said her greatest achievement was helping women give themselves permission to eat, empowering them to take greater responsibility for their health. Green Mountain is a retreat exclusively for women and aims to help women by adopting an integrated health approach incorporating fitness, nutrition, and behavioural/emotional health. In regards to intuitive eating, Green Mountain aims to help develop a healthy relationship with food by focusing on:

This is done by incorporating aspects of mindfulness, cognitive behavioural therapy, dialectical behavioural therapy and Acceptance and Commitment Therapy (Green Mountain, 2020).
 * Identifying the reasons they emotionally eat
 * Establishing a regular eating pattern, which prevents overeating
 * Thinking differently about food, stop thinking of some foods as 'good' and 'bad'.
 * Eliminating approaches that include dieting

Ellyn Satter Institute
Ellyn Satter is a dietitian who created the Satter Eating Competence Model because as she found during her time as a practitioner that dieting was not a reliable or necessarily a healthy way lose weight or obtain optimal health outcomes. When she began helping patients who struggled with their weight and health she was determined to find a way to help them. After time she realised not many patients were able to keep the weight off, with only 5% being able to diet, successfully lose weight and keep it off in the long-term. She soon realised the diet approach to weight loss and overall health was not sustainable or the ideal options for patients health long-term (Satter, 2019)

The aim of the model is to teach individuals to eat intuitively, build a healthy relationship with food and therefore be more relaxed around food. She believes that your attitudes about eating leave most people feeling anxious or ambivalent.

Interoceptive awareness


Interoceptive awareness is defined as the ability to detect internal bodily cues and the way in which we respond to these cues. This relates to the three sub-scales of intuitive eating: 'unconditional permission to eat', 'reliance on internal hunger and satiety cues' and 'eating for physical rather than emotional reasons' (Oswald et al., 2016). Several studies have suggested that intuitive eaters have higher interoceptive awareness, as body awareness is a key component in adopting the intuitive mind state of eating (Tribole, 2017). By responding to these bodily sensations directly by consuming food when one is hungry, biological states are satisfied and building a trusting and respectful relationship with oneself is fostered.

Mindful eating
Mindful eating is often used interchangeably with intuitive eating. They are both popular terms in research when exploring the conscious experience around eating and the relationship individuals have with food (Warren et al., 2017). The term mindful eating was first used by Jon Kobat-Zinn in his book 'full catastrophe living', where he describes mindful eating as 'paying attention to our food, on purpose, moment by moment' (Nelson, 2017).

One of the founders of intuitive eating, Tribole stated that while mindful eating is a part of intuitive eating, she consider intuitive eating to be a broader philosophy which also encompasses physical activity that one enjoys, using nutrition information without judgement, rejecting the dieting mentality and respecting your body at any shape or size (Tribole, 2010).

 {What percentage of individuals can lose weight and successfully keep it off?}


 * type=""}

+ 5% - 15% - 30% - 20%

How are the effects of intuitive eating measured?
Tykla et al. (2013) clustered the 10 principles of intuitive eating into three domains and developed a 21-item scale called the intuitive eating scale (IES).

The three domains are:
 * 1) Unconditional permission to eat
 * 2) Reliance on hunger and satiety cues
 * 3) Eating for physical rather than emotional reasons (Tylka et al., 2013).

These scales have shown reliability and validity when used to assess disordered eating symptoms and psychological wellbeing measures (Tylka et al., 2013).

Overview of HAES
The Health at Every Size® (HAES®) paradigm is a non-diet approach that incorporates aspects of intuitive eating along with shifting the focus from from weight to health. It emphasises following the principles of intuitive eating by listening to internal cues of hunger and fullness as well as focusing on body acceptance (Humphrey et al., 2015). This paradigm emerged as the amount of obese and overweight individuals increased, and new diets became more restrictive and proved not sustainable or successful in the long-term (Carbonneau et al., 2016). By focusing less on weight loss, it approaches health on a holistic level encompassing physical activity, intuitive eating, self-acceptance and overall well-being. The intuitive eating aspect helps guide individuals to eating in response to bodily cues and respecting physical body cues to determine when, how and what to eat (Carbonneau et al., 2016). Other aspects of the program include nutritional information and self-reflection on food intakes and eating behaviours. This creates a more natural learning environment to foster individuals mentality and behaviour of choosing food to nourish and energise their body (Carbonneau et al., 2016).

Aspects of program


A summary of what is included in the HAES®


 * Evaluating food intake through food diary documenting emotions, mood hunger and satiety
 * Evaluating energy intake through learning about energy needs and balance
 * Physical activity and the importance of body movement
 * Dimensions of eating including listening to bodily cues
 * Exploring body image through beauty standards around the world
 * Realising others influence on self
 * Examining motivation towards weight loss
 * Being critical about diets
 * Defining personal action plan
 * Evaluating own process

Lectures and information provided is delivered by trained health professionals such as dietitians, psychologists, social workers and physiotherapists (Carbonneau et al., 2016).

Research on HAES
Research has evaluated the outcomes HAES programs have provided, some studies include:

 Humphrey et al. (2015) conducted research with a sample of college students in California. Participants were required to complete a pre-intervention and post-intervention survey to assess the changes in individuals after participating in the curriculum. Surveys included an intuitive eating scale, containing four subscales 'unconditional permission to eat', 'eating for physical rather than emotional reasons', 'reliance on internal hunger and satiety cues' and 'body-food choice congruence' were completed both pre-intervention and post-intervention. Results showed that students in the HAES program experienced improvements in intuitive eating scores which suggests that students were motivated by and adopted the information provided in the curriculum. A significant decrease in anti-fat attitudes and a significant increase in body esteem were found indicating that the compassion and anti-prejudice teachings in class directly affecting participants compassionate feelings towards themselves and others facing weight stigmas. Although, limitations include a small sample size and low generalisability of results as two thirds of participants were Caucasian. This research would also have benefitted from a follow up to access the longitudinal effects of the HAES program.

 {Which one of the following is NOT a part of the HAES program?}


 * type=""}

- In depth learning about body image and history of beauty standards - Exploring why weight loss is a goal - Exploring what influences the self + Consuming only nutritious foods

What are the effects of intuitive eating on well-being?
Richard et al. (2017) stated that some psychologists and medical practitioners believe that intuitive eating is a more holistic and realistic approach to health than conventional diet and exercise programs. This view has been supported by research showing that intuitive eating is associated with a lower body mass index (BMI) (Hawks et al. (2005), improved management and alleviation of eating disorders (Anderson et al., 2016), healthier routines and mentalities postpartum (Leahy et al., 2017) and weight loss/ weight management (Camilleri et al., 2016).

Effects on mental health
Intuitive eating has been linked to better emotional regulation, decreased body image discrepancy, and less anxiety over food choices and the overall experience of eating (Richards et al., 2017).

Self-compassion has been positively associated with intuitive eating. This association has been explained by body image acceptance (Shoenefeld and Webb, 2013). Adopting a self-compassionate approach towards internal experiences related to the body may enable individuals to eat more intuitively.

Eating disorders
An eating disorder is defined and diagnosed by the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) and is characterised by eating, exercise, and body weight/shape becoming an unhealthy preoccupation in someone's life (Eating Disorders, 2020). The most common types of eating disorders are:


 * Anorexia nervosa: Low body weight and body image distortion with an obsessive fear of gaining weight.
 * Bulimia nervosa: Recurrent binge eating episodes followed by induced vomiting, fasting or over-exercising.
 * Binge eating disorder: Frequently eating excess amounts of food, often when not hungry (Eating Disorders, 2020).

Traits and personality types that are common in those with eating disorders are low self-esteem, perfectionism, restraint, and a distorted view of body image. There is evidence to suggest that intuitive eating may improve emotional and physical outcomes for individuals suffering from eating disorders (Anderson et al., 2015). Intuitive eating is used as an intervention strategy to help those struggling with disordered eating patterns to challenge maladaptive dietary restraint behaviours (Anderson et al., 2015). Using intuitive eating as an intervention strategy has been found to be useful because, by adopting an approach that incorporates an internal awareness for bodily cues such hunger and satiety, it promotes acceptance and helps to build the foundation for a strong connection to oneself (Anderson et al., 2015). Anderson et al. (2015) found that intuitive eating was significantly negatively correlated with restraint, suggesting that intuitive eating is at one end of the spectrum, while restraint is at the other. Therefore, by adopting an intuitive eating approach to eating, it can help those struggling with restraint, which is a characteristic of eating disorders. The principles focusing on body respect, approaching emotions with kindness and making peace with food promote emotional resilience and help in the development of a healthy attitude of oneself (Richards et al., 2017).

 Richards et al. (2017) conducted a two year pilot study to explore whether it was possible to teach intuitive eating principles to inpatients with anorexia nervosa, bulimia, and disordered eating at the Centre for Change (CFC). These principles were taught alongside other health interventions such as weight stabilisation, medication, dietary intake, and symptom management. Intuitive eating principles were incorporated into the program at the CFC by each patient having a one on one meeting with a registered dietitian each week, and helping the patients develop autonomy by practicing intuitive eating when they exhibited a clear readiness to do so. Results showed preliminary evidence that there are benefits to incorporating the intuitive eating principles into a residential eating disorder treatment program. Patients with anorexia nervosa were found to develop intuitive eating skills. This is an important finding as it has been questioned in the past whether patients with anorexia nervosa are able to learn the ability to eat intuitively. Patients with bulimia nervosa showed rapid progress in their ability to intuitively eat, which resulted in less episodes of binge eating. Overall, a reduction in depression, anxiety, social conflict, eating disorder symptoms, spiritual-wellbeing and body image acceptance.

Pregnancy, postpartum and raising children
Intuitive eating may also be a useful approach for families. Mothers are often concerned with their weight during pregnancy and postpartum because of societal pressures, developing anxiety that it may be difficult to lose the weight they put on during pregnancy. Pregnancy is a stage in the life cycle which dramatic changes in a woman's body shape and weight occur (Lee et al., 2018). While these bodily changes are mostly accepted in society as the new changes in body shape and size show support for developing new life, once postpartum the weight is no longer attributed to supporting a baby and creates body dissatisfaction for many women (Lee et al., 2018). These anxieties and concerns about body weight can affect children as well as families concerned with their children's weight and health. Healthy eating habits and attitudes towards eating are important for oneself but also crucial when raising children. Mothers may pass on their own concerns about eating habits onto their children by engaging in restrictive feeding practices in their young children as well as themselves. Mothers who restrict their child's food intake are more likely to see behaviours such as emotional eating, overeating and increased food seeking behaviour in their children (Tylka et al., 2015).

Obesity is on the rise in many countries worldwide, so if the wealth of information regarding the prevention and adverse health effects of being obese. While this information is important, the manner in which it is portrayed can have detrimental effects on the public. The news and media often dramatizes and exaggerates information about childhood obesity, blaming families but failing to provide appropriate information on the subject. This can lead families to alter their feeding practices and often partake in restrictive feeding (Tylka et al., 2015).

Intuitive eating is a useful intervention to use with mothers and families when approaching the health and wellbeing of themselves but also their children. By adopting an approach to intuitive eating it can help mothers build a healthier relationship with food, eating practices, feeding practices and gain a sense of body acceptance (Leahy et al., 2017).

 Lee et al., (2018) examined intuitive eating styles in postpartum women and relationships between eating attitudes, body image satisfaction and depressive symptomology. This study revealed that common thoughts shared by postpartum women are self deprivation, weight-cycling, food preoccupation, and binge eating. The intuitive eating scale was used alongside other scales of measurements such as body image satisfaction, eating attitudes and depressive symptomologies. The women who rated high in intuitive eating were found to be less likely to engage in restrictive eating, dieting or have body dissatisfaction. Post partum women are often unprepared for weight and shape changes that continue after childbirth. This can further affect self-esteem, body dissatisfaction. This is why intuitive eating principles as well as other interventions are beneficial for mothers during pregnancy and postpartum. These results support previous research by Denny et al. (2013) who found that women with intuitive eating styles had lower chances of reporting maladaptive eating attitudes than those who did not intuitively eat. It was also found that postpartum women often find that additional pressures and responsibilities of caring for a new-born child impacts personal eating habits and can result in the adoption of unhealthy and disordered eating patterns.

Further study
The majority of research that has been published regarding the effects of intuitive eating on individuals has been conducted with Caucasian populations. Research on intuitive eating would benefit from exploring these ideas cross-culturally to see if they apply to diverse cultural populations.

Most research has been completed with female populations. While females are more likely to suffer from eating disorders and body image negativity, males also suffer from eating disorders, most commonly binge eating disorder (Eating disorders, 2020). Societal pressures of beauty standards for males also exist, with a focus being on muscular males as being ideal in society. Research focusing on the effects of intuitive eating programs with male participants would be beneficial to see if this approach can also help the male population.

Conclusion
This chapter explained intuitive eating and the effects it has on emotion and overall health. Intuitive eating has been shown to be a useful intervention to use with those who suffer from disordered eating, restrictive eating practices, body image dissatisfaction, anxiety over food choices and difficulties managing weight. Intuitive eating can be measured using the intuitive eating scale (IES) and used alongside other scales in studies to assess how intuitive eating correlates with mental and physical health outcomes. The term intuitive eating was first used by Resch and Tribole in 1995, but the idea of a non-diet approach to eating has been around for many years and incorporated into many different programs, retreats and therapies. Ten statements make up the principles of intuitive eating and focus on learning signs of hunger and fullness, learning to cope with emotions, rejecting diet mentalities and building a healthy relationship with oneself. The intuitive eating movement offers an important step towards teaching others that diets generally do not work and that restrictive eating has detrimental effects on mental health and overall wellbeing. Greater health outcomes are possible with a more holistic approach to health and weight management encompassing compassion, acceptance and flexibility.