HEALTH & WELLBEING
INTUITIVE EATING This article will outline the history of intuitive eating (IE), its development and the evidence base, with an overview of the potential for application of IE in clinical nutrition and dietetics. IE has become increasingly popular in recent years, forming a bit of a buzz word in the health and wellbeing sector. With research having shown links between rigid dietary control and lower levels of psychological wellbeing and disordered eating,1 IE was developed in order to address problematic relationships with food, physical activity and body image that may be brought on, or exacerbated by, dieting. In 1995, dietitians Evelyn Tribole and Elyse Resch outlined IE as an evidencebased approach to health (although there were some similar earlier iterations), focusing on improving health behaviours by paying more attention to signals of hunger and fullness from your own body rather than external indicators. IE includes approaches to help with developing more positive body image and does not focus on weight as a primary outcome measure or indicator of health. There has been some confusion around the application of the principles of IE in general and also when applied to clinical nutrition. IE is defined by Tracy Tylka, a prominent IE researcher, as, ‘a flexible style of eating in which you largely follow your internal sensations of hunger and satiety to gauge when to eat, what to eat, and when to stop eating.’2 This contrasts with the traditional rules of dieting for weight loss, which may
rely on external cues, like meal plan timing and macronutrient adjustment to guide eating patterns and foods. There are no set rules to follow so it’s not possible to do it ‘wrong’. Instead, there are 10 principles which outline the theory and provide tools and activities for developing this attunement (see Table 1). The principles are designed to provide some insight into any obstacles to this interoceptive awareness, such as the development of long-held beliefs about food (eg, having to eat everything on our plates), any moral attribution to foods (eg, foods being inherently ‘good’ or ‘bad’) and the importance of finding enjoyment and satisfaction in food and movement where possible. There is also an emphasis on developing a ‘toolkit’ for handling our emotions without just using food. The importance of self-care in overall health is highlighted, as poor sleep and general lack of self-care will likely affect our eating and activity patterns.
Jessica English RD Freelance Dietitian, founder at Level Up Nutrition Jess runs Level Up Nutrition, working with individuals on a one-to-one basis in Brighton and online UK-wide. Jess has a special interest in health communications and global public health nutrition.
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DEVELOPMENT OF TOOLS FOR IE RESEARCH
Following the development of the IE principles, a 21-item scale was created and refined by Tylka in 2006, in order to assess levels of IE in research and within the population: the IES.3
Table 1: The 10 principles of intuitive eating 1 Reject the diet mentality
6 Discover the satisfaction factor
2 Honour your hunger
7 Honour your feelings without using food
3 Make peace with food
8 Respect your body
4 Challenge the food police
9 Exercise – feel the difference
5 Respect your fullness
10 Honour your health – gentle nutrition www.NHDmag.com May 2019 - Issue 144
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YOUR ESSENTIAL RESOURCE
HEALTH & WELLBEING Research by Tylka published in 2013 is the largest study to date on IE, (n= 2600), updating and validating the original IE assessment scale, which now has 23 items (IE-2). An additional category was added to address body-food choice congruence in order to assess aspects of ‘gentle nutrition’.4 This validated and refined scale has been used in much of the IE research to date as a tool to assess how intuitively participants eat. Modified versions have been developed in order to assess effectiveness in participants from different cultural backgrounds.5 NUTRITION, HEALTH AND IE
There has been some debate over the IE approach to nutrition; with many presenting it as an opportunity to ‘eat what you want, whenever you want – no matter the consequences’. However, with IE having been developed by dietitians, nutrition is understandably an important part of it, with Tribole and Resch advocating an approach they refer to as ‘gentle nutrition’. This gentle approach involves all of the standard (non-weight focused) nutrition guidelines, presented as an approach more akin to self-care, as opposed to focusing on food restriction. Research has shown that focusing on improving health behaviours independent of weight can have positive health outcomes with or without weight loss.6 Higher levels of IE have also been associated with improved outcome measures for health, regardless of weight changes.7 All foods (unless medically advised otherwise, or excluded for ethical, taste or moral reasons) are included and there is a focus on the healthpromoting properties of the more nutritionally dense foods, with less nutritionally dense foods enjoyed mindfully where possible, but not completely excluded. Variety and moderation are encouraged – again echoing standard nutrition guidelines. IE IN CLINICAL NUTRITION
There is some debate over where IE fits with clinical nutrition, as prescriptive diet plans for many medical conditions wouldn’t necessarily align with the intuitive aspects. Using clinical judgement, it is understandably not appropriate to attempt such an approach in a 10 or 15 minute slot in an acute setting. A clinical setting and acute illness will likely also prevent a patient from being able to eat intuitively.
IE is not intended to replace any part of clinical nutrition and instead may be used as an adjunct approach alongside traditional medical models. It is likely more suited to an outpatient or community setting, where more time can be spent working on some of the principles to address longer-term health goals. Other aspects of IE could be applied, with support, for those managing chronic conditions in the community, such as rejecting the dieting mentality in favour of balance and moderation and attunement to hunger/fullness signals. IE IN WEIGHT MANAGEMENT
It is generally accepted that traditional methods of dietary restriction for weight management, although potentially effective in the short term, are ineffective for the majority of dieters over the longer term. It appears that dieting specifically to reduce weight may even be associated with weight gain in the longer term.8 Tribole and Resch advise against using IE as an approach for weight loss, as the focus on weight and appearance may interfere with attunement and overrides any basis for intuition. Though not intended for the purpose of weight loss, there have been many studies into the effectiveness of IE as a tool for weight management. Higher levels of IE have been associated with lower BMI3,9,10 and certain aspects of IE, such as more attuned and mindful eating (though mindful and intuitive eating are different, there are many mindful aspects to IE) and the ‘hunger scale’, have been used elsewhere in weight management programmes including NHS programmes.11,12 Research is ongoing into whether this would mean that IE would be an effective weight management tool. It is difficult to ascertain causality from the available research at this time in order to establish whether those who eat more intuitively are more likely to have a lower BMI, or whether IE can be used as a tool for weight management. IE IN DIABETES
There have been a number of studies into IE and diabetes, including research from 2016 which showed a link between IE and improved glycaemic control in teenagers with Type 1 diabetes (T1DM)13 . There was a strong inverse www.NHDmag.com May 2019 - Issue 144
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HEALTH & WELLBEING statistical association between eating for physical rather than emotional reasons and HBa1c. In general, those with T1DM had a lower overall IE score than a control group. This may be expected, as those with T1DM may have been required to override their natural hunger/fullness in order to manage their blood glucose levels. The researchers highlight the potential to use this research to screen for emotional eating behaviours in those with T1DM in order to improve HBa1c outcomes. In Type 2 diabetes (T2DM), IE has been linked with enhanced glycaemic control in AfricanAmerican women with T2DM.14 This research also highlighted some confusion around dietary interventions in T2DM and the effects of stigma in healthcare. EATING DISORDERS
As chronic dieting and disordered eating can affect the ability to acknowledge innate hunger and fullness cues, there has been much interest in the application of IE in the treatment of eating disorders (ED). IE has been shown to be linked for positive outcomes for ED patients, including anorexia nervosa and bulimia nervosa.15 A mixed-sex study has also shown that although IE is again inversely associated with BMI in both reported sexes, it is also inversely associated with binge eating and other disordered eating behaviours: ‘Males and females who reported trusting their body to tell them how much to eat had lower odds of utilising disordered eating behaviours compared with those who did not have this trust.’16 There is also some promising evidence that IE interventions may be useful in preventing the development of disordered eating, though, again, it may be difficult to apply these results to a wider population. OTHER OUTCOMES FROM IE
Those who participate in IE studies report better psychological wellbeing, self-esteem, body appreciation and, in general, attrition rates are lower than with traditional dietary interventions.17,18 Women who show higher levels of IE have also been shown to be less likely to display disordered eating patterns and have better body image,19 although the majority of these studies have been cross-sectional and carried out at universities in 38
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the United States. Further prospective studies in a wider population are needed. LIMITATIONS
The efficacy of IE public health interventions is unclear, largely due to the difficulties of applying and assessing the principles in public health settings. There is also only limited application of the principles in those with low incomes and reduced food choices, as food scarcity and the need to eat for survival overrides the likelihood or need to eat intuitively. This does present limitations to the application of IE when compared with other interventions, though some aspects of IE may potentially be applied in some circumstances, ie, addressing food rules and body acceptance. Guidance when following the principles of IE is recommended for those with any medical condition, or with a history of disordered eating. SUMMARY
There is mounting evidence that being a more intuitive eater is associated with a host of holistic benefits, including improved psychological outcomes, reductions in binge eating and disordered eating, self-compassion and body acceptance. There is some evidence to support the use of IE in improving HbA1c in those with diabetes (T1DM and T2DM) - though further research is needed. Although IE is not intended to be a primary outcome measure for an ED intervention, it may be a useful tool in developing long-term behaviour changes around food and activity that could attenuate further weight gain and bring health benefits independent of any weight changes. Further research is needed into the effectiveness of IE as an intervention or assessment tool in a number of chronic conditions where eating is limited and rates of disordered eating may be high, such as with coeliac disease and inflammatory bowel disease. Overall, IE appears not to be harmful for those who undertake it, though supervision and guidance is advised for those with any medical condition, or for those with a history of or potential susceptibility to disordered eating. The approach doesn’t seek to replace traditional clinical thinking, but, instead, focuses on improving potentially disordered relationships with food.