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Tribole.IntuitiveEatingResearchUpdate.SCAN.2017

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Abstract

This article presents a brief summary of Intuitive Eating research and implications. Key Words: Interoceptive Awareness, Heath at Every Size, Intuitive Eating
Summer 2017, Vol. 36, No. 3
CONTENTS
1
Intuitive Eating: Research Update
3
From the Editor
6
CPE article:
The Significance of Essential Amino
Acid Density to Protein Quality: Con-
siderations for Building Healthy Eat-
ing Patterns
9
Can Dairy Products Play a Role in
Cardiometabolic Health?
13
From the Chair
14
Conference Highlights
18
Reviews
18
Research Digest
20
SCAN Notables
22
Of Further Interest
24
Upcoming Events
In 1995, Elyse Resch and I developed
the Intuitive Eating (IE) model to help
move consumers away from the haz-
ards of dieting.1Our model was in-
formed by both evidence-based
studies and our clinical experience
working with patients. While the haz-
ards of dieting had been well-docu-
mented at that time, a body of
research continues to show the pro-
fundity of harm associated with diet-
ing, including increased risk of eating
disorders (EDs), binge eating, weight
gain, food preoccupation, body dis-
satisfaction, and weight stigma, as
well as poor psychological health,
such as depression and anxiety.2
Today there is robust research on IE,
with more than 70 published studies
showing benefits and providing
growing recognition that IE is a
healthy adaptive eating style that
may aid in positive psychological and
physical well-being.3This article pres-
ents a brief summary of the research
and implications.
What Is Intuitive Eating?
Intuitive Eating, an evidence-based
model, is a dynamic integration be-
tween mind and body via 10 princi-
ples (Table 1, page 4) that work by
either cultivating or removing obsta-
cles to body awareness, known as in-
teroceptive awareness.
S C A N ’ S
Pu l s e
Intuitive Eating: Research Update
by Evelyn Tribole, MS, RDN
Interoceptive awareness is the ability
to perceive physical sensations that
arise from within the body; this
awareness is a direct experience me-
diated by the right brain.4Indeed,
several studies show that Intuitive
Eaters have higher interoceptive
awareness.5However, body aware-
ness itself is only one part of the
process. The way in which an individ-
ual values and responds to these
body sensations is known as intero-
ceptive responsiveness.6This respon-
siveness, or attunement, to physical
body sensations provides a person
with a powerful portal to tap into for
identifying his or her needs, includ-
ing:
Emotional feelings.Every emotion
has a physical sensation.
States. States such as sleepiness or
having a full bladder have a physical
sensation.
Biological eating cues. Cues such as
hunger and fullness have unique
physical sensations.
Ultimately, IE is a personal process of
honoring health by listening and re-
sponding to the direct messages of
the body in order to meet physical
and psychological needs. The chal-
lenge in today’s dieting, clean eating,
culture is that many people do not
value, let alone trust, their body’s sen-
sations. Instead, they eat based on
Benefits of Intuitive Eating
A recent meta-analysis review of 24
studies published between 2006 and
2015 found that IE was associated
with the following benefits:12
Greater body appreciation and sat-
isfaction
Positive emotional functioning
Greater life satisfaction
Unconditional self-regard and
optimism
Psychological hardiness
Greater motivation to exercise
when focus is on enjoyment rather
than guilt or appearance
Furthermore, IE was inversely related
to disordered eating, dieting, poor in-
teroceptive awareness, and internal-
ization of thin ideal. Most of the
research to date has been cross-sec-
tional in nature and mostly limited to
college-aged women. Prospective in-
tervention studies are needed to ver-
ify the beneficial associations.
Another scholarly review evaluated
the relationship between IE and
health indicators, and found that IE
was associated with improved blood
pressure, blood lipids, and dietary in-
take.13 It is noteworthy that one of
the earliest studies evaluated the
health-related properties of Intuitive
Eaters’ food choices.14 People scoring
high on Hawk’s Intuitive Eating scale
ate a more varied diet. It is important
to note that Hawk’s scale is different
from the Tylka scale. Hawk’s scale has
four components: intrinsic eating (re-
flects eating based on inner body
cues), extrinsic eating (reflects exter-
nal triggers for eating such as mood
and food availability), anti-dieting,
and self-care (reflects taking care of
the body).
Intuitive Eating and Recent
Research
Eating Disorders
A recent study from Germany looked
specifically at the relationship be-
tween IE and individuals who had a
range of EDs.9The results provided
the first evidence of reduced IE
2|SCAN’S PULSE Summer 2017, Vol. 36, No. 3
externality—i.e., eating according to
rules and diet plans, which ultimately
create confusion between mind and
body.
Key Characteristics of
Intuitive Eaters
In 2006, Tylka published a four-part
seminal study on IE that evaluated
health benefits in 1,260 female col-
lege students, and created and vali-
dated the Intuitive Eating Scale (IES).7
IES scores were negatively related to
ED symptoms, body dissatisfaction,
poor interoceptive awareness, pres-
sure for thinness, and internalization
of the thin ideal. High IES scores were
associated with several indexes of
well-being, including proactive cop-
ing, higher body satisfaction, and
general life satisfaction. This scale was
updated in 2013 and validated to in-
clude both men and women (2,600
college students); it has also been val-
idated in other countries and in ado-
lescents.7-11 The most current IES is
composed of four subscales. It is
based on the 10 principles of Intu-
itive Eating, and ultimately reflects
four key characteristics of Intuitive
Eaters:8
1. Eating for physical rather than emo-
tional reasons. Eating is based on sat-
isfying hunger, rather than under-
taken to escape emotions or self-
soothe.
2. Presence of unconditional permis-
sion to eat. This reflects the ability to
eat foods desired when hungry, as
well as refusal to label foods as for-
bidden or bad. (Note that attunement
is a vital aspect, as sometimes people
mistakenly perceive this as an au-
thorization to overeat.)
3. Reliance on hunger and satiety cues.
Eating is based on internal hunger
and satiety cues, and these cues are
trusted to guide eating behavior.
4. Body-food choice congruence. This
reflects the extent to which a person
matches his or her food choices with
the needs of the body.
Academy of Nutrition and Dietetics
Dietetic Practice Group of Sports,
Cardiovascular, and Wellness Nutrition (SCAN)
SCAN Website: www.scandpg.org
SCAN Office
230 Washington Ave. Ext., Suite 101
Albany, NY 12203
Phone: 518/254-6730; 800/249-2875
info@scandpg.org
Executive Director: Thomas J. Coté, MBA, CAE
SCAN Executive Committee
Chair
Cheryl Toner, MS, RDN
Chair-Elect
Lindzi Sara Howder, MPH, MS, RDN, CSSD
Past Chair
Karen Collins, MS, RDN, CDN, FAND
Treasurer
Jon Vredenburg, RDN, CSSD, CDE
Secretary
Sherri Stastny, PhD, RD, CSSD
Director, Sports Dietetics—USA Subunit
Elizabeth Abbey, PhD, RDN, CDN
Co-Directors, Wellness/Cardiovascular
RDs Subunit
Amanda Clark, MA, RD, CHES
Judith Hinderliter, MPH, RD, CPT
Director, Disordered Eating & Eating
Disorders Subunit
Sarah Gleason, RD, CEDRD
Director of Events
Enette Larson-Meyer, PhD, RD, CSSD, FACSM
Director of Communications
Heather Mangieri, MS, RD, CSSD
Director of Member Services
Karen Reznik Dolins, EdD, RD, CSSD, CDN
Director of Volunteer Coordination
Noaa Bujanover, MS, RD, CSSD
SCAN Delegate to House of Delegates
Jean Storlie, MS, RD
____________________________
Editor-in-Chief, SCAN’S PULSE
Mark Kern, PhD, RD, CSSD
DPG Relations Manager
Mya Wilson, MPH, MBA
To contact an individual listed above, go to
www.scandpg.org/executive-committee/
SCAN’S PULSE Summer 2017, Vol. 36, No. 3 | 3
scores in individuals with EDs and
suggest that the IES could be a useful
tool in monitoring recovery progress.
This is consistent with other studies,
which indicate promise for using IE in
the prevention and treatment of
EDs.7,8,15-18 Similarly, a new study on
retired athletes indicates that IE may
help reduce disordered eating and
help athletes to relearn how to trust
their bodies’ signals about hunger
and satiety once they leave their
sport.19
Diabetes
Emerging research suggests that IE
programs could be a valuable tool to
improve glycemic control.20.21 In chil-
dren and adolescents with type 1 dia-
betes mellitus, there was an inverse
relationship between hemoglobin
A1c and IE scores.20 Intuitive Eating
may have even more saliency for
people with diabetes. This is because
people with diabetes are at higher
risk of developing EDs, and IE is asso-
ciated with decreased risk of prob-
lematic eating.
Intervention Studies
There are limited intervention stud-
ies, but the results are promising. A
recent short-term study used a com-
bination of IE with Acceptance and
Commitment Therapy (ACT).22 ACT is
a validated counseling process that
cultivates psychological flexibility via
mindfulness, based on a person’s
value system. Women who com-
pleted the 3-month intervention im-
proved in the areas of binge eating,
general mental health, psychological
flexibility, and IE.
A 10-week worksite wellness inter-
vention program combined IE and
mindfulness to address problematic
eating behaviors, which is an unin-
tended consequence of many tradi-
tional worksite wellness programs.23
The intervention group had improve-
ments in body appreciation, IE, and
problematic eating behaviors com-
pared with the control group. No-
tably, weight and body mass index
(BMI) were not used as indicators of
success, because focus on these may
trigger problematic eating.
Body Mass Index
The body mass index is fraught with
problems because it does not accu-
rately reflect health status.24-26 How-
ever, it is noteworthy that the
majority of studies that have evalu-
ated the relationship between BMI
and IE have found a negative associa-
tion.3, 27-31 This is relevant for health
practitioners who are concerned that
letting people eat whatever food
they desire (unconditional permis-
sion to eat) would lead to weight
gain. It is important to remember that
attunement is a vital part of this prin-
ciple.
For some people, there may be a side
effect of weight loss as a conse-
quence of implementing the IE prin-
ciples. However, given that IE is an
internal-based process, the promo-
The Spice of Life
by Mark Kern, PhD, RD, Editor-in-Chief
From the title, you probably think the theme of this article is about zesty flavor, but actually it’s about the variety of topics
we’ve provided for you to read. I’m not sure why I’m always surprised when an issue covers such an assortment of subjects, but
I am. It goes to show just how diverse and interdisciplinary SCAN and the fields of nutrition and dietetics are.
On the cover you’ll find an excellent article by Evelyn Tribole, MS, RD that describes the current state of research on Intuitive
Eating, which she helped to pioneer. Our free CPE article, written by Nancy Rodriguez, PhD, RD, CSSD, FACSM, discusses the im-
portance of protein quality within dietary patterns of athletes. Later in these pages you will find a review from Sara Llamas-
Moya, M.Sc., PhD on the roles of dairy products in affecting risk factors for cardiometabolic diseases. Finally, we have included
extensive coverage of the recent Annual SCAN Symposium in “Conference Highlights,” thanks to the hard work of our excep-
tional Highlights editor Nancy Clark, MS, RD and an assist from our very own Karen Wetherall, RD.
The array of information doesn’t stop there, though. We also have a wide range of information in our “SCAN Notables,”
“Research Digest,” “Reviews,” and “Of Further Interest” sections. And since variety is considered the spice of life, I’m sure you’ll
feel like a seasoned professional after you’ve read this issue cover to cover.
FromThe Editor
policy, there has been an uninten-
tional consequence of weight stigma,
which in and of itself is a risk factor
for diminished health.2,17,26 For these
reasons, a growing number of scien-
tists and health professionals are call-
ing for a weight inclusive or HAES
approach, which advocates for
IE.2,26,28,32 Rather than focus on
weight, the focus of IE is on cultivat-
ing healthy behaviors, period. Body
weight is not a behavior.
Conclusion
A body of research indicates that IE is
a promising and comprehensive ap-
proach to healthy eating with physi-
cal and psychological health benefits.
For the health practitioner, it is a grat-
ifying way to collaborate with pa-
tients to achieve sustainable healthy
behaviors, while helping them be-
come the expert of their own bodies.
However, there are gaps in the re-
search. In particular, there is a need
for intervention studies in a variety of
age groups and across socio-eco-
nomic backgrounds and gender.
4|SCAN’S PULSE Summer 2017, Vol. 36, No. 3
tion of IE for weight loss may under-
mine and interfere with the process,
because weight loss is external-
based. A recent 3-year prospective
study illustrates this problem. Women
who were trying to lose weight had a
reduction in their IES score at year 3
compared with baseline scores.31
Furthermore, these women had in-
creased episodes of binge eating,
which is consistent with a body of re-
search linking dieting to binge eating
behaviors.23,28
Health at Every Size (HAES)
A plethora of research shows that fo-
cusing on body weight and weight
loss is linked to diminished physical
and psychological health.26 Particu-
larly problematic is weight cycling, a
byproduct of repetitive dieting,
where weight is lost and regained—
and is associated with increased mor-
tality and morbidity, some forms of
cancer, loss of muscle tissue, chronic
inflammation, hypertension, and os-
teoporotic fractures.26 With the push
for “healthy weights” in public health
Evelyn Tribole, MS, RDN divides her pro-
fessional time between a private coun-
seling practice in Newport Beach, CA
and training/certifying health profes-
sionals in the Intuitive Eating process
via teleseminars and workshops. Her
newest book (co-author), The Intuitive
Eating Workbook, was recently re-
leased. For more resources, visit
www.IntuitiveEating.org.
References
1.Tribole E, Resch E. Intuitive Eating,
3rd ed. New York, NY: St. Martin’s
Press; 2012.
2. Bacon L, Aphramor L. Weight sci-
ence: evaluating the evidence for a
paradigm shift. Nutr J. 2011;10:9.
3. Tribole E, Resch E. The Intuitive Eat-
ing Workbook: Ten Principles for Nour-
ishing a Healthy Relationship with
Food. Oakland, CA: New Harbinger
Publications; 2017.
4. Mehling W, Price C, Daubenmier J,
et al. The multidimensional assess-
ment of interoceptive awareness.
PLOS One. 2012;7: e48230. Available at
http://dx.doi.org/10.1371/journal.po
ne.0048230. Accessed December 7,
2016.
5. Herbert B, Blechert J, Hautzinger M,
et al. Intuitive eating is associated
with interoceptive sensitivity. Effects
on body mass index. Appetite.
2013;70:22-30.
6. Oswald A, Chapman J, Wilson, C. Do
interoceptive awareness and intero-
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relationship between body apprecia-
tion and intuitive eating in young
women? Appetite. 2017;109:66-72.
7. Tylka T. Development and psycho-
metric evaluation of a measure of in-
tuitive eating. J Counsel Psych.
2006;53:226-240.
8. Tylka T, Kroon Van Diest A. The Intu-
itive Eating Scale–2: item refinement
and psychometric evaluation with
college women and men. J Counsel
Psych. 2013;60:137-153.
Table 1. Intuitive Eating Principles and
Interoceptive Awareness
Improves Interoceptive Awareness
Honor your hunger. Eat when you are biologically hungry.
Respect your fullness. Stop eating when comfortably full—not too little and
not too much.
Discover the satisfaction factor. Aim for satisfaction when eating meals and
snacks.
Exercise—feel the difference. Discover enjoyable ways to move the body.
Removes Obstacles to Interoceptive Awareness
Reject the diet mentality. Stop all forms of dieting, behaviorally and mentally.
Make peace with food. No food is forbidden. Eat the foods you desire, based
on attunement to hunger and fullness cues.
Challenge the food police. Challenge the food rules, the root of which may
originate from personal, family, and cultural mores and beliefs.
Honor your feelings without using food. Cope with your emotions without
using food.
Respect your body. Your body deserves to be treated with dignity and
respect, regardless of shape or size.
Honor your health with gentle nutrition. Select foods that taste good, while
making you feel well.
SCAN’S PULSE Summer 2017, Vol. 36, No. 3 | 5
9. Van Dyck A, Herbert B, Happ C, et al.
German version of the Intuitive Eat-
ing Scale: psychometric evaluation
and application to an eating disor-
dered population. Appetite. 2016;
105:798-807.
10. Carbonneau E, Carbonneau N,
Lamarche B, et al. Validation of a
French-Canadian adaptation of the
Intuitive Eating Scale-2 for the adult
population. Appetite. 2016;105:37-45.
11. Dockendorff S, Petrie T, Greenleaf
C, et al. Intuitive Eating Scale: an ex-
amination among early adolescents.
J Counsel Psych. 2012;59:604-611.
12. Bruce L, Ricciardelli L. A systematic
review of the psychosocial correlates
of intuitive eating among adult
women. Appetite. 2016; 96:454-472.
13. Van Dyke N, Drinkwater E. Rela-
tionships between intuitive eating
and health indicators: literature re-
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1766.
14. Smith T, Hawks S. Intuitive eating,
diet composition, and the meaning of
food in healthy weight promotion.
Am J Health Educ. 2006;(May/June):
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15. Anderson L, Reilly E, Schaumberg
K, et al. Contributions of mindful eat-
ing, intuitive eating, and restraint to
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sumption in college students. Eating
Weight Dis. 2016;21:83-90.
16. Tylka T, Wilcox J. Are Intuitive Eat-
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tology opposite poles of the same
construct? J Counsel Psych. 2006;53:
474-485.
17. Webb J, Hardin A. An integrative
affect regulation process model of in-
ternalized weight bias and Intuitive
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2016;102:60-69.
18. Spoor K, Madanat H. Relationship
between body image discrepancy
and Intuitive Eating. Intern Quart
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19. Plateau CR, Petrie TA, Papathomas
A. Learning to eat again: Intuitive Eat-
ing practices among retired female
collegiate athletes. Eating Disorders.
2016;Aug 12:1-7.
20. Wheeler B, Lawrence J, Chae M, et
al. Intuitive Eating is associated with
glycaemic control in adolescents with
type I diabetes mellitus. Appetite.
2016;96:160-165.
21. Willig AL, Richardson BS, Agne A,
et al. Intuitive Eating practices among
African-American women living with
type 2 diabetes: a qualitative study.
J Acad Nutr Diet. 2014;114:889-896.
22. Boucher S, Edwards O, Gray A, et
al.Teaching Intuitive Eating and Ac-
ceptance and Commitment Therapy
skills via a web-based intervention: a
pilot single-arm intervention study.
JMIR Res Protoc. 2016;5:e180.
23. Bush H, Rossy L, Mintz L. et al. Eat
for Life: a work site feasibility study of
a novel mindfulness-based Intuitive
Eating intervention. Am J Health
Prom. 2014;28:380-388.
24.Tomiyama A, Hunger J, Nguyen-
Cuu J, et al. Misclassification of car-
diometabolic health when using
body mass index categories in
NHANES 2005-2012. Inter J Obes.
2016;40:883-886.
25. Bacon L, Aphramor L. Weight sci-
ence: evaluating the evidence for a
paradigm shift. Nutr J. 2011;10:9.
26. Tylka T, Annunziato R, Burgard D,
et al. The weight-inclusive versus
weight-normative approach to
health: evaluating the evidence for
prioritizing well-being over weight
loss. J Obes. 2014; 2014:983495.
27. Camilleri G, Méjea C, Bellisle F, et
al. Intuitive eating is inversely associ-
ated with body weight status in the
general population-based NutriNet-
Santé study. Obesity. 2016;24:1154-
1161.
28. Denny K, Loth K, Eisenberg M, et
al. Intuitive Eating in young adults.
Who is doing it, and how is it related
to disordered eating behaviors?
Appetite. 2013;60:13-19.
29. Cole R, Clark H, Heileson J, et al.
Normal weight status in military serv-
ice members was associated with In-
tuitive Eating characteristic. Military
Med. 2016;181:589-595.
30. Madden C, Leong S, Gray A, et al.
Eating in response to hunger and
satiety signals is related to BMI in a
nationwide sample of 1601 mid-age
New Zealand women. Pub Health
Nutr. 2012; Mar:1-8.
31. Leong S, Gray A, Haszard J, et al.
Weight-control methods, 3-year
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based interventions to help kids
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Publication of the Sports,
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ISSN: 1528-5707.
Editor-in-Chief
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Intuitive eating is an adaptive eating style based on the reliance on physiological cues to determine when, what, and how much to eat. The Intuitive Eating Scale-2 (IES-2) is a validated four subscale tool measuring the degree of adherence to intuitive eating principles. The present series of studies aimed at evaluating the psychometric properties of a French-Canadian adaptation of the IES-2 for the adult population. The factor structure, the reliability (internal consistency and test-retest), the construct validity, and the discriminant validity were evaluated in 334 women and 75 men from the Province of Québec, Canada, across two studies. A confirmatory factor analysis upheld that the four-factor structure of the original IES-2 was adequate for the present sample of French-Canadians. The scale demonstrated adequate internal consistency and test-retest reliability. Construct validity evidence was obtained with the significant associations between intuitive eating and psychological and eating-related variables. Intuitive eating was negatively associated with eating disorder symptomatology and with food- and weight-preoccupation, and positively associated with body-esteem and well-being. The French-Canadian IES-2 was also able to discriminate between genders and body mass index categories. The properties of this new version of the IES-2 are demonstrative of a reliable and valid tool to assess intuitive eating in the French-Canadian adult population of the Province of Québec.
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Background: The effectiveness of women's weight-control methods and the influences of dieting on eating behaviors remain unclear. Objectives: Our aim was to determine the association of various weight-control methods at baseline with weight change to 3 years, and examine the association between baseline weight-control status (trying to lose weight, trying to prevent weight gain or no weight-control attempts) and changes in intuitive eating and binge eating at 3 years. Design: A nationally representative sample of 1,601 New Zealand women (40 to 50 years) was recruited and completed a self-administered questionnaire at baseline regarding use of variety of weight-control methods. Information on demographic characteristics, weight, height, food habits, binge eating, and intuitive eating were collected at baseline and 3 years. Statistical analyses: Linear and logistic regression models examined associations between both weight status and weight-control methods at baseline and weight change to 3 years; and baseline weight-control status and change in intuitive eating from baseline to 3 years and binge eating at 3 years. χ(2) tests were used to cross-sectionally compare food habits across the weight status categories at both baseline and 3 years. Results: Trying to lose weight and the use of weight-control methods at baseline were not associated with change in body weight to 3 years. There were a few differences in the frequency of consumption of high-energy-density foods between those trying to lose or maintain weight and those not attempting weight control. Trying to lose weight at baseline was associated with a 2.0-unit (95% CI 0.7 to 3.4, P=0.003) reduction in intuitive eating scores by 3 years (potential range=21 to 105), and 224% (odds ratio=3.24; 95% CI 1.69 to 6.20; P<0.001) higher odds of binge eating at 3 years. Conclusions: The apparent ineffectiveness of dieting and weight-control behaviors may reflect misconceptions about what constitutes healthy eating or energy-dense foods. Dieting may reduce women's ability to recognize hunger and satiety cues and place women at increased risk of binge eating.
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Objective: To examine the relationship between intuitive eating (IE), which includes eating in response to hunger and satiety cues rather than emotional cues and without having forbidden foods, and weight status in a large sample of adults. Methods: A total of 11,774 men and 40,389 women aged ≥18 years participating in the NutriNet-Santé cohort were included in this cross-sectional analysis. Self-reported weight and height were collected as well as IE levels using the validated French version of the Intuitive Eating Scale-2. The association between IE and weight status was assessed using multinomial logistic regression models. Results: A higher IE score was strongly associated with lower odds of overweight or obesity in both men and women. The strongest associations were observed in women for both overweight [quartile 4 vs. 1 of IE: odds ratio, 95% confidence interval: (0.19, 0.17-0.20)] and obesity (0.09, 0.08-0.10). Associations in men were as follows: for overweight (0.43, 0.38-0.48) and obesity (0.14, 0.11-0.18). Conclusions: IE is inversely associated with overweight and obesity which supports its importance. Although no causality can be inferred from the reported associations, these data suggest that IE might be relevant for obesity prevention and treatment.