Is Intuitive Eating for Everyone?

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I want to say “yes!” because I’m an advocate, I see so much value in it, and have been using Intuitive Eating in nutrition counselling for many years. However, it is not a simple answer.

Intuitive Eating is not a weight loss method but a nutrition philosophy that is actually an anti-diet approach to reconnecting with your body and healing your relationship with food. Intuitive Eating has many excellent principles that are of value to everyone including: rejecting the dieting mentality, coping with emotions, respecting your body, etc. (for more information see www.intuitiveeating.org)

What I don’t see discussed very often are situations and factors that may make Intuitive Eating challenging for some people. I want to touch on one possible limitation of Intuitive Eating and that is the presence of having trustable internal cues or identifiable hunger/fullness cues. This may be temporary because many people can regain their internal cues or learn to identify and trust them but we have no evidence that everyone can. For some people these cues are not even present and for others they are not reliable for a variety of reasons (short or long-term).

Here are some factors to take into consideration that may make internal cues less reliable: 

  1. Sleep deprivation: When you are sleep deprived the hormones ghrelin and leptin are affected. Ghrelin (stimulates appetite) levels increase and leptin (suppresses appetite) levels decrease.
  1. Chronic stress: Initially short-term stress may cause appetite to decrease but prolonged or chronic stress can increase the hormone cortisol that may increase appetite.
  1. Medications: (a few examples that can affect appetite)
  • Corticosteroids ie. prednisone, dexamethasone
  • Insulin, sulfonylureas (for diabetes)
  • Vyvanse (for ADHD)
  • Some antidepressants: ie. Fluoxetine (Prozac)
  • Morphine
  • Levothyroxine (Synthroid) for hypothyroidism
  1. Intense training/exercise: Prolonged intense endurance training is known to suppress appetite.Therefore these athletes may need to eat beyond their hunger cues to adequately fuel themselves and for optimal recovery.
  1. Illness: When we become sick (for example the flu), we often lose our appetite. There is a physiological reason for this as cytokine production is increased when we become ill. Cytokines can reduce appetite by acting directly on neurons that regulate appetite in our brains.    
  1. Eating disorders: People struggling with eating disorders always have very individual needs, challenges, and different journeys to recovery. There are so many factors both physical and psychological that can affect their hunger and fullness cues (or lack of). For example, for someone working on increasing their food intake after prolonged restriction they may experience early satiety (because of gastroparesis). Or someone who binges may not experience or recognize fullness cues because they have been eating well beyond them for years. A person affected by an eating disorder may need to be nourished, achieve medical stability and have psychological supports and counselling first. Even then it may take a great deal of time before they are ready to trust and identify their internal cues. In my experience if the concept is introduced too early it can cause unnecessary “mental noise”, confusion, or anxiety.  

My on-going learning:

With all the hype of Intuitive Eating in recent years, I have seen and heard amazing stories of how it has changed people’s lives and relationship with food. On the other end, I have seen people struggle with some of the principles and application of it. Or they never could rely on their internal cues for various reasons.

In my professional opinion, all aspects of Intuitive Eating are not for everyone but there are Intuitive Eating principles that can be helpful for anyone.  Intuitive eating is a journey of learning and timing is important. As a Dietitian I need to be prepared, willing and open to supporting people in a variety of ways, always individualizing care. There is never going to be one single approach that works for everyone.

Dear Doctor, commenting on my weight is damaging…

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…please don’t make comments about my weight without me expressing concern about it or not knowing anything about my lifestyle or behaviour. It is not helpful and in fact is damaging.

This is meant to be more of a plea on behalf of my clients rather than a critique as I know many great doctors. I know most doctors also have great intentions. However, I have clients and people I know continually telling me stories of negative experiences in the doctor’s office (and with other health professionals) that have affected them deeply. Most of them caused by a few words: you need to lose weight, you should try this diet, etc. without any other conversation on what is going on in the patient’s life.

Let me give you a few examples directly from my clients on how this is damaging:

  1. “I have had doctors congratulate me on weight loss (in a way reinforcing my eating disorder, because often my weight loss is a result of unhealthy behaviours)”
  2. “I went in for a full physical exam and without any conversation on what I was doing for exercise or any other lifestyle behaviours, the doctor weighed me and said “ooh you used to be ___Kg…we need to keep an eye on your weight”. Little did the doctor know that I was feeling really good about my health because for the first time in a while I was in a regular exercise routine and had gained muscle mass and strength with guidance of a trainer.  (To make matters worse ~10 years ago, the same situation had occurred where I gained weight with building muscle and I ended up quitting solely because of the weight gain despite the health benefits)”
  3. “I’ve had doctors make diet suggestions (i.e. keto) for weight loss when in reality I was suffering from anorexia and was already severely restricting my intake. This was obviously triggering.”
  4. “I had a doctor directly tell me that I was overweight with recommendations to “eat less, exercise more” without first asking me what I was doing.”
  5. “When I’ve shared that I have an eating disorder, I’ve had several doctors assume that I binge eat or overeat based on my weight and they’ve provided weight loss suggestions without first assessing what my eating disorder behaviours are.”
  6. “I went to see my doctor for cold/flu symptoms and she started lecturing me about how I should work on losing weight. I felt embarrassed and it has made me reluctant to see any doctor for any issue in the future.”
  7. “I’ve had doctors minimize my eating disorder because I am not underweight.”
  8. “I have had comments about my BMI (body mass index), like “are you aware that you’re in the overweight range?” Thanks for pointing that out when I already hate my body. Not helpful.”

What to do?

Ideally ending weight bias/stigma and a shift in focus to promoting health behaviours vs the number on the scale are important for doctors and any health professional. However, just as essential is the need for a patient-centered approach in terms of really listening and understanding what is going on in the patient’s life (and yes that includes addressing weight concerns if that is the patient’s concern) and then individualizing care plans.

No matter what our job title, area we specialize in or our personal beliefs (General Practitioner, Dietitian, eating disorder expert, weight-inclusive, weight neutral, Health at Every Size® practitioner, obesity specialist, certified bariatric educator, weight management practitioner, etc.), we need to address and listen to our patient or client’s experiences and concerns, not our own agenda. Otherwise we are missing the point of patient-centered care. Also, in order for patient-centered care to be evidence-based practice we must integrate the best available research evidence, clinical judgement and expertise, and client preferences and values.  We cannot let our pronounced views, title, network, paradigm or guidelines prevent us from openly listening to the people we are supposed to be supporting.

In the end, imposing conversations on weight can be just as damaging as avoiding conversations on weight. Both can make people feel unheard and unsupported. Lets do a better job at listening to the concerns of our patients.

If you or someone you know has been impacted by a health professional commenting on your weight please comment below. 

Avoidant/Restrictive Food Intake Disorder (ARFID): How does it differ from other eating disorders?  

As a Registered Dietitian that specializes in disordered eating, I see a wide variety of clients (both male and female and of varying ages) that struggle with food. While you have likely heard of anorexia, bulimia and binge eating disorder, how much do you know about ARFID?

What is ARFID?

ARFID stands for Avoidant/Restrictive Food Intake Disorder (See DSM-5 for diagnostic criteria).  Individuals diagnosed with ARFID have developed a problem with eating or feeding which affects their ability to eat enough to meet their nutritional needs.  Food intake may be restricted based on the food’s taste, texture, smell, colour or past negative experience with the food.

As a result, children or teens may lose weight or not gain weight during growth or may not grow in height as expected. Adults may lose weight and/or not eat enough to maintain basic body functions. ARFID can cause social issues because individuals may have extreme anxiety with eating around other people and/or isolate themselves to avoid social situations that involve food.  Ie. At school or work lunches, holidays with family or gatherings with friends.

Examples of possible ways ARFID may present itself (with no other medical explanation):

  • A child/teen is an extremely picky eater since childhood + not gaining weight or growing.
  • Child/teen/adult had a negative past experience with choking or vomiting followed by a fear of eating solid foods.
  • Child/teen has abdominal pain that prevents them from eating enough + height has dropped or stopped on their growth curve.
  • Client is unnecessarily avoiding a long list of foods that they claim to be triggers for digestive symptoms, are very rigid and fearful of the restricted food/symptoms + losing weight.

What is not ARFID?

People with ARFID don’t typically fear weight gain and don’t have a distorted body image which are characteristics of other eating disorders.  (However, if left untreated ARFID can develop into anorexia or bulimia nervosa.)  Also, if inadequate food intake is better explained by a medical condition or limited access to food then this is not an ARFID diagnosis.

Don’t confuse ARFID with Obsessive Compulsive Disorder (OCD).  For example, an individual with OCD may not eat any raw food for fear of contamination. However, OCD and ARFID can co-occur together.

Remember ARFID is not the same as picky eating.  ARFID and eating disorders are a mental illness.  Ellyn Satter, Family therapist and Registered Dietitian says “Most problems with eating and feeding are not psychiatric disorders. They are problems, and, as such, they can be addressed by education or brief intervention conducted knowledgeably.” Therefore if you are unsure it is important to seek the advice of a health professional with good experience in the area of family feeding (for children), disordered eating and eating disorders.

Is a diagnosis needed before seeking support?

Knowing a diagnosis can be very helpful but it is not necessary nor the solution to recovery.  For example, a diagnosis can help guide which type of psychotherapy to use (ie. Cognitive behavioral therapy, dialectical behavior therapy, etc.) using evidence based guidelines for effectiveness.  However, often behaviors and symptoms are “grey” in terms of whether it is an eating disorder, type of eating disorder and/or whether other mental illness is a factor (ie. OCD, depression, ADHD, etc.).  This is why collaborating and referring to other experienced health professionals is crucial.  However, you can still successfully support someone with healthy change with or without an official diagnosis or while they are seeking out other supports and assessments.  Most important is supporting the individual and creating a plan specific to their needs and situation because even two people with the same diagnosis can have very different struggles, fears, behaviors, etc.

Treatment for ARFID:

Because ARFID is a relatively new diagnosis, the most effective treatment is still being studied.  Treatment must address any nutritional deficiencies, inadequate growth, weight loss and psychological concerns.  Some programs use nutrition counseling, cognitive behavioral therapy, exposure therapy and/or family counseling for children/teens (and many other therapies are being explored).  Also treatment of other underlying conditions is important. Ie. anxiety disorder, OCD, ADHD, and autism are common.  This is why having a medical doctor, Eating Disorder Dietitian, and Psychotherapist (experienced in eating disorders) are all important professionals on a  support team.

Specifically when it comes to nutrition support, here are a few things I have found helpful for my clients with any eating issue including ARFID:

  1. Meet the client where they’re at. Every client is different even if they have the same diagnosis so you need to ask questions, be a good listener and individualize treatment plans with every client.
  2. Explore the home food environment and feeding relationship between the parent/caregiver and child. (Even if the client is an adult it is important to get their childhood food and feeding history.)
  3. Involve and educate the client’s supports (ie. parents, caregivers, spouses or other loved ones) in terms of eating and feeding no matter what age the client is.