Dr. Gabrielle Fundaro, PhD, CISSN, CHC @vitaminphd
	Shannon Beer, MNU-Certified Flex Success Coach, LLB @shannonbeer_

SYNOPSIS:  In the past year or so, a chasm has formed between some groups in the health industry. Many people have strong opinions about Health at Every Size (HAES), Intuitive Eating, weight neutrality, anti-diet culture, and body positivity, often despite having read none of the books or literature. Let me be clear: I have seen misinformed, extremist voices yelling from both sides of this divide. I also have respected colleagues and friends in both camps. While I'm sure that we as practitioners have good intentions, we also need to provide good information and content. We need to operate from a place of awareness and understanding for the context and nuanced ideals of these paradigms. We serve no one but ourselves when we dig our heels in and refuse to acknowledge that both sides make relevant points. We certainly aren't doing any favors when we form opinions without adequate evidence to support them. It is my hope that this series of articles, written in collaboration with Shannon Beer, will serve to improve the dialogue and the industry as a whole by bridging the divide with shared meaning and a deeper understanding of weight-neutral approaches to health. In this first installment, I will first explain the Intuitive Eating framework and skill subset of mindful eating to establish clear definitions and meaning. I'll clarify some of the common concerns and misconceptions around weight-neutral approaches to health. In order to illustrate the commonalities between Intuitive Eating, mindfulness and athletic endeavors, I'll explain the ways we as athletes and coaches implement intuition and interoceptive sensitivity (recognition of internal physical cues) to enhance the efficacy of training. The subsequent series of articles will serve to contextualize Intuitive Eating processes in the fitness industry, bringing light to oft-neglected risk of dieting, and how we might best set clients up for long-term success through more conscientious approaches to coaching.

 
"Seek first to understand, then be understood." –Covey

INTUITIVE EATING: NOT JUST ANTI-DIET DIETING

Overview of Intuitive Eating

Although Intuitive Eating (IE) is promoted in the media as the ‘anti-diet diet,' this is a significant misnomer with a myopic view of the paradigm. Intuitive Eating is a framework of self-care principles, including:

• Improving relationships with food

• Removing moral judgments around food

• Building awareness of hunger / fullness cues

• Emphasizing emotional and physical wellness over pursuit of lower weight or smaller size 

• Advocating for removal of weight stigma

It is aligned with Health at Every Size (HAES), which promotes the concepts of:

• Weight inclusivity

• Health enhancement

• Respectful care

• Eating for well-being

• Life-enhancing movement 

Contrary to popular belief, HAES does not state that health is present at every size; rather, the central tenant of the paradigm is simply that a person's size should not prevent them from engaging in health-seeking behavior. They accurately assert that weight is not predictive of health status and focus on health-seeking behaviors rather than outcomes (such as weight loss). Both HAES and IE are weight-neutral, which is not synonymous with anti-weight-loss. Indeed, weight loss—or gain, or stability—may occur as a result of engaging in health-seeking behaviors. However, intentional weight loss is not the goal; rather, weight loss could be one of the many outcomes of a lifestyle change that focuses on mental, emotional, and physical self-care. HAES establishes the need to focus on the "How" instead of the "What" for patient-centered care. Informing a client or patient that they need to lose weight is just as ineffective as informing them that they need to reduce their blood pressure. The oft-maligned statistics about long-term diet success are, arguably, misrepresented by both camps. In reality, both weight-loss-focused and weight-neutral programs result in very little weight loss after 6-9 months of intervention. However, both realize positive health outcomes such as improvements in cardiometabolic risk factors, and weight-neutral approaches also boast improvements in psychological health outcomes. This isn't to say that weight loss isn't beneficial; clearly, evidence illustrates that it can be. But the "how" is, arguably, more important than the "what". And, if we can help our clients achieve better health with less harm, isn't that something worth exploring?

Also contrary to popular belief: IE is not simply a break from dieting. It is a non-linear process and collection of principles intended to break cycles of harmful eating behaviors and challenge the beliefs that precipitate them. It addresses cognitive distortions that lead to negative self-perception and chronic dieting, and it is indeed and evidence-based practice with an extensive body of literature on individuals with overweight, obesity, and binge eating disorder. Emerging literature is examining its use in a variety of other populations, as well, and the results are promising. IE describes the cycle of chronic dieting as phases of deprivation, rebellion, and rebound weight gain, resulting in subsequent deprivation. A diet, in this context, refers to a way of eating for the intention of reducing body weight (a definition that serves as a major point of contention which will be addressed later). Many individuals may assume that IE simply a phase of uninhibited eating, and reduce it to the internet memes of eating cookies and "pink donuts" (as one of the paradigm's authors, Evelyn Tribole, chuckles about in her recent podcast appearance on Dan Harris's 10% Happier show). Unfortunately, the combination of ingrained diet culture and misunderstanding leads people to fear and vilify the entire paradigm at the thought of weight gain and eating "without rules or reason". A deeper dive into the underlying principles illustrates that any individual embarking on this journey will be doing far more internal work than the internet might have you believe. The principles of IE emphasize satisfaction as the focal point during mealtimes, enjoyable physical activity, rejection of the diet mentality, using nutrition information without judgment, and respecting one's body even in the presence of negative feelings about how it might look. It is a dynamic, integrative process that appreciates the connections between our thoughts, feelings, and behaviors around nutrition and physical activity in order to facilitate positive, productive relationships with our food, physical activity, and selves.

The book "Intuitive Eating: A Revolutionary Program That Works" was first authored by dietitians Evelyn Tribole, MS, RDN and Elyse Resch, MS, RDN, CEDRD-S, FIAEDP, FADA, FAND in 1995, and has since undergone several modifications, with a fourth edition to include weight stigma and diet culture due out in June 2020. It covers ten main principles of self-care around food, physical activity, and mental health. They are briefly summarized as follows:

1. Reject the Diet Mentality

• The false hope of losing weight quickly, easily and permanently

• The lie that weight regain is failure

• The promise that there's a new or better diet that will work for you

2. Honor Your Hunger

• Remain biologically fed through adequate energy intake to prevent excessive hunger that may lead to overeating and counter your intentions to eat moderately and consciously

• Learn to respond to biological hunger to rebuild your trust in self around food

• Eating when hungry, rather than in response to a specific set of rules

3. Make Peace with Food

• Unconditional permission to eat prevents feelings of deprivation and subsequent binging (also known as the abstinence violation effect)

• habituation through regular exposure dilutes the alluring quality of forbidden foods whereas rigid rules trigger rebellion

• Eating without obligatory penance

4. Challenge the Food Police

• Reject the idea of "good or bad" foods (also known as binary thinking) and food morality to reduce guilt after eating

• Ignore inappropriate comments from others and liberate yourself from justifying food choices to others (or yourself)

5. Feel Your Fullness

• Listen for signals that tell you you're no longer hungry

• Pause mid-meal to reassess your enjoyment and fullness

• Practice conscious (mindful) eating

6. Discover the Satisfaction Factor

• Eat what you really want, in an inviting environment, and focus on the pleasure of the meal in concert with your biological cues

• Savor your meal so you aren't left seeking other foods to "hit the spot"

7. Cope with Your Emotions Without Using Food

• Truly assess and meet your emotional and mental needs without food 

• Food can't fulfill emotional or mental needs; applying it this way may only add the discomfort of overeating to those difficult emotions, leaving one with the discomfort of those original emotions, and the added discomfort of overeating

8. Respect Your Body

• Recognize and accept your genetic blueprint and predispositions 

• It is difficult to reject the diet mentality if you are overly critical of your body shape and unrealistic about your expectations

• Respecting your body means taking care of your health, treating it with dignity and meeting its basic needs

9. Exercise (Feel the Difference)

• Replace militant exercise with enjoyable physical activity

• Focus on the benefits of movement rather than the calorie burn

• Focusing on your enjoyment of the opportunity to move—rather than an external motivator like weight loss—will be a stronger motivator in the moment

10. Honor Your Health with Gentle Nutrition

• Make food choices that honor your health, taste buds, and digestive comfort so they feel good

• You don't have to eat a "perfect" diet to be healthy; no single food is inherently going to make or break a healthy lifestyle

• Emphasize moderation, balance, and a variety of fruits and vegetables, nutrient-dense foods, protein-rich foods, quality fats, and whole foods; processed foods are generally less nutrient-dense

• Balance is something to be achieved over a period of time, and it does not have to be reached at each meal; focus on consistency and progress

• At times it is appropriate to prioritize the nutritional qualities of foods and eat intuitively

Tribole and Resch also characterize potential types of "dieters" based on common beliefs and habits. The Careful Eater is militant and diligent, enforcing strict rules that, when broken, lead to binging behaviors. The Professional Eater may have more content knowledge than the Careful Eater, but applies it for the purposes of weight loss, and may rapidly shift from one diet to the next. An Unconscious Eater is a multitasker, eating without awareness of hunger or satiety cues, often cleaning the plate or perhaps eating emotionally. The Intuitive Eater eats in response to biological cues, making choices without guilt and enjoys the pleasure of eating while respecting their fullness.

The transition from cyclic, chronic dieting to a normal eating pattern that responds to physiological hunger without the structure of specific dietary guidelines is (understandably) daunting for many. The book outlines some common experiences which likely resonate with many individuals. Importantly, the "Exploration" phase seems to create the most confusion and controversy, as it's often the only one that people imagine experiencing. However, the authors clarify that the commonly-held belief, "I can eat whatever I want, as much as I want, whenever I feel like it," distorts the premise of IE, as doing so can lead to physical discomfort and is not satisfying. The stages, while not necessarily linear, do lend themselves to a processional flow as one might reach complete diet burnout before embarking upon IE. 

1. Hitting Diet Bottom

• Feelings of failure, frustration, discouragement, and being "stuck"

• Negative body image 

• Unintentional weight gain

• Lost touch with physical cues of hunger and fullness (aka "interoceptive awareness")

• Strict food rules and emotion dictate food choices

• Weary of dieting but terrified of eating

• Cycles of restriction and counterregulatory eating (the "Last Supper" phenomenon leads to excessive intake of "off-limits" food due to perceived past and future restriction)

2. Exploration

• Conscious learning and pursuit of pleasure

• Hyperconsciousness and awareness of mind and body cues

• Experimentation with new foods; with permission comes choice

• Reconnecting with physical cues

• May be difficult to respect fullness due to old thoughts of deprivation and difficulty recognizing appropriate level of fullness

• Not indicative of lifetime habits, but a period of time learning

3. Crystallization

• Feeling ready for solid behavior change

• Thoughts are no longer obsessive

• Easier to identify and respond to physical cues

• More established trust in self

4. The Intuitive Eater Awakens

• Comfortable and free-flowing

• Consistently and easily choosing the foods you want when biologically hungry and stopping when full, so food is more satisfying

• Healthier foods are chosen because they feel better rather than any moral value

• You have found alternative outlets for emotions, so they no longer dictate your food choices

5. Treasure the Pleasure

• Feeling empowered, regularly practicing positive self-talk and trust

• Nutrition and exercise are paths to health and feeling good

• This lifestyle is enjoyable and enticing

The benefits of IE and other HAES-aligned weight-neutral approaches to health are documented in literature, and span both physical and psychological outcomes. While weight-focused programs do result in greater weight loss at 6 or 9-month follow-ups, long-term studies illustrate higher attrition rates in dieting groups and little or no significant difference in net weight lost. A recent meta-analysis reported that, after 4-5 years, individuals in structured weight loss programs maintained a 3.2% reduction in bodyweight, which was only 2.9% more than those on the weight-neutral program. Obviously, unsustainable diets produce unsustainable results, and with such a magnified focus on weight loss as an outcome, the process of obtaining it is often overlooked. More importantly, dieting behaviors predict later development of disordered eating—a phenomenon that isn't currently identified in WN approaches. 

One question that challenges practitioners—and that you may be wondering as well—is the question of metabolically healthy obesity (MHO). Is it factual? A recent meta-analysis found that the prevalence of metabolically-healthy obesity is about 35% in individuals with obesity, though they do have an 80% increased relative risk of developing a metabolic abnormality within 3-10 years, and about ½ of them will no longer be considered metabolically healthy over time. The facts about metabolic disease risk factors can be used to inform, but shouldn't be used to stigmatize. We must acknowledge that MHO is as real as weight stigma, and approach the conversation conscientiously.

Physical Outcomes of Weight-Neutral Approaches

Weight-neutral (WN) approaches such as eating in response to biological hunger and the use of fasting blood glucose measurement has been shown to improve insulin sensitivity and lead to weight loss in individuals receiving diabetes education. Contrary to popular belief, high scores on the Intuitive Eating Scale don't correlate with an increase in unhealthy food or BMI; in fact, a study on members of the US Army illustrated correlations between normal BMI, intuitive eating scores, and eating in response to biological hunger. The phenomenon of greater reliance on hunger signals is consistent across the literature in overweight and obese individuals as well. This is an intriguing finding, in light of the fact that some studies have illustrated that individuals with overweight, obesity, or anorexia nervosa exhibit attenuated hunger and satiety signals, resulting in an level of food intake that may not match energy needs. When comparing cardiometabolic markers such as blood lipids and blood pressure, long-term studies illustrate no differences in improvements between WN and WL programs. Compared to WL approaches, WN approaches significantly reduce episodes of binge eating and bulimia scores. This could be due, in part, to the habituation response to repeated food exposure which leads to reduced food novelty, making it less tempting. In concert with conscious (mindful) eating, this can reduce distracted, counterregulatory eating which may lead to eating past fullness (a phenomenon commonly seen during chronic dieting cycles). Importantly, because WN approaches focus on behaviors, individuals participating in these programs increase their physical activity levels and dietary quality. Healthy habits such as consuming fruits and vegetables, exercising, limiting alcohol intake, and refraining from smoking can improve health independent of BMI. In fact, low cardiorespiratory fitness is a stronger predictor of all-cause mortality risk than BMI. 

Mental Outcomes of Weight-Neutral Approaches

Participation in WN programs significantly reduces body dissatisfaction, dieting attempts, eating disorder symptoms, and depressive symptoms. Multiple studies in males and females have found associations between IE scores and positive body image, unconditional self-regard, and a focus on body function rather than appearance, among many other beneficial psychological variables. While these are correlational in nature, and not all studies can discern directionality between IE and psychological outcomes, longitudinal studies have identified IE as a predictor for reduced risk of developing low self-esteem and engaging in unhealthy weight loss behaviors. Interestingly, positive self-talk and encouragement (specifically after weight regain) was recently identified as a key behavior in individuals successfully maintaining weight long-term. In contrast, restrained eating (a dieting behavior) can precipitate binge/purge cycles and increase the risk of developing an eating disorder. Given the risk of developing disordered eating as a result of engaging in diet behaviors and the elevated prevalence of eating disorders in the athletic population, these results should not be overlooked.  

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MINDFULNESS IN EATING AND TRAINING

Mindful Eating

A skill set within the framework of—but not exclusive to—IE is that of mindful eating (ME). In 1995, Tribole and Resch used the term "conscious eating" to describe remaining aware while eating. Several years later, this was reframed as "mindful eating." Michelle May, M.D., author of "Eat What You Love, Love What You Eat" (2009) and the "Am I Hungry?™" series, describes mindful eating as, "eating with attention and intention." The Center for Mindful Eating provides the following principles:

• Becoming aware of positive and nurturing opportunities available through food preparation and consumption

• Respecting one's inner wisdom around food selection

• Choosing to eat food that is nourishing and pleasing

• Using all senses to explore food

• Awareness and use of physical hunger and satiety signals to guide the beginning and end of a meal

Mindfulness is commonly perceived as a trait someone might possess, but it is more likely a skill that arises as both a function of an individual's capacity for self-regulation and their motivation to enact that self-regulation. Motivation to allocate these mental resources depends on an individual's belief in the value of mindfulness and their ability to allocate mental resources to remaining mindful. Mindfulness requires attention, reflection, and practice. It is arguably one of the more valuable but overlooked skills we can encourage clients or patients to practice. By establishing a strong inner framework and intentionality behind our actions, we can make choices aligned with our goals and values regardless of the external environment.

May's Mindful Eating Cycle encourages the readers to ask themselves probing questions about why they want to eat, when they want to eat, how they usually eat, what they eat, how much they eat, and where they invest their energy from eating. While these seem simple on the surface, they are actually asking readers to think about whether or not they're eating for biological hunger, how often they're thinking about food, how mindfully they're consuming their food, what dictates their food choices and intake, and whether their current relationship with food might be overruling their ability to be fully present in their lives. 

Similar to the phases covered in Intuitive Eating, May describes specific types of eaters: Instinctive, Overeating, and Restrictive. Instinctive Eaters fuel their bodies in response to biological hunger with an awareness of nutrition but no emotional attachment to the food, and they consume meals with intentionality, purpose, and focus so they can direct their energy to living an active life. Overeaters and Restrictive eaters may eat based on rules, triggers, or emotions, and their meals may be consumed mindlessly, rigidly, or even in secret. Unlike Instinctive Eaters, they often find themselves reinvesting their (sometimes scarce) energy back into the dieting cycle, or simply storing the excess fuel that isn't used. 

Mindful eating cultivates non-judgment and self-acceptance, and though this is aimed at mealtimes, it can be applied to all facets of life. While it may lead to weight loss, the focus is still placed on other health-based outcomes. 

Mindful Training

As a counter to "unhealthy exercise," or exercise practices indicating exercise dependence, researchers Calogero and Pedrotty (2007) conceptualized Mindful Exercise. It includes the following four principles, encouraging attention to bodily sensations before, during, and after exercise for indications of fatigue, pain, and when to stop. The intentions of Mindful Exercise include:

• Enhancing the mind-body connection and coordination

• Alleviating mental and physical stress

• Providing enjoyment and pleasure (not used punitively)

• Use for rejuvenation, not exhaustion or depletion

Disordered exercise habits are often concurrent with disordered eating habits, though they can be difficult to identify, especially in an athletic population. Perhaps unsurprisingly, chronic dieting and chronic training ultimately result in similar signs and manifestations of burnout, the latter of which is referred to as overtraining syndrome. When energy intake is chronically insufficient, relative energy deficiency syndrome (RED-S) may result in suppressed metabolic and immune function, reduced bone health and protein synthesis, and diminished performance with increased injury risk. 

Diet "Burnout"

1. Reduced energy expenditure

2. Fatigue

3. Reliance on caffeine

4. Appetite dysregulation

5. Lack of adherence

6. Social withdrawal

7. Feeling need to "earn" food

8. Food cravings

9. Net weight gain

10. Disordered eating habits

Overtraining 

1. >2 month performance decrement

2. Sleep disturbance

3. Loss of motivation

4. Mood disruption

Perhaps, then, hitting "training rock bottom" might mirror both diet burnout and overtraining syndrome, and certain behaviors—like training to failure every time, failing to heed internal cues, and impatiently plan-jumping—might precipitate a similar lack of results with increased injury risk. Fortunately, in the same way that IE and ME can facilitate a normal eating pattern that, among other benefits, provides adequate energy intake for optimal health, training can be adjusted to provide an adequate stimulus for optimal adaptations and improvements. You may be surprised to learn that both approaches rely on the same skill: interoceptive awareness and sensitivity. 

Autoregulated Training

Autoregulation is based on decades-old methods of determining progression rates for physiotherapy and rehabilitation coupled with a more recent method to determine subjective levels of exertion. Today, these scales have been modified and applied to progressive resistance training programs, and many of us know them as "RPE (rate of perceived exertion)" or "RIR (reps in reserve)." They're based on the phenomena of interoceptive awareness—an individual's sense of the physical condition of the body—and interoceptive sensitivity to accurately identify the sensation. Individuals are capable of utilizing internal cues to determine level of fatigue and training readiness, thereby allowing them to modify their training accordingly. An individual may decide to modify their rep ranges, reps in reserve, RPE limits, or rest periods based on the physical sensations they're experiencing before and during training. 

In 2017, Dr. Eric Helms's Stronger by Science article on the science of autoregulation provided substantial evidence that the subjective information used to autoregulate can beat out valid, reliable objective training tools that measure alterations of physiological variables. Helms specifically addressed the utility of Tuchscherer's RPE, a quantitative tool for rating RPE based on reps in reserve. Menno Henselmans describes the approach of implementing a reactive deloading as a short-term, unplanned adjustment based on lack of predicted progression in a single training session. In other words, it is necessary to make on-the-spot adjustments when interoceptive awareness allows us to determine that the predicted, prescribed volume would not be appropriate for the training bout given our current physical status. Dr. Mike Israetel is arguably one of the most prolific authors in sport science, and covers the science of hypertrophy extensively. His exercise selection and progression considerations emphasize the importance of interoceptive awareness, as well. Attunement to RIR/RPE, pump, soreness (versus pain), muscle tension, and the mind-muscle connection can be applied to optimize exercise selection and appropriate volume accumulation over time. 

Use of these subjective measures allows for the individualization of programming, and it needs to be stressed that subjective is not synonymous with qualitative (though, the latter is still a valid form of data). This isn't emotion-based training, but you might say it is somewhat… intuitive.

BRIDGING THE GAP: INTUITIVE TRAINING AND COACHING

Intuitive is synonymous with instinctive; we feel something is true without conscious reasoning. This word—along with many others in the industry—seems to ruffle feathers and cause undue controversy. Intuition isn't synonymous with a lack of reason; it's simply a lack of reason that we perceive. Mike Tuscherer has clarified that his RPE scale is, indeed, a performance metric, and it's not based on emotional feeling. RPE-based training still includes goals, but utilizes "course-corrections" and a process-oriented approach to adjust plans based on emerging information. Of course, emotions can impact our performance—for better or worse—along with a host of other factors. Ignoring these factors doesn't preclude them from affecting our clients' or our own training. Determining RPE is a skill that requires practice, but it can be honed over time. Determining the type of correction to make requires extensive knowledge of the client or self—along with some level of intuition. Despite early criticisms that "training by feel" would result in suboptimal performance outcomes, autoregulation has emerged as a cornerstone in modern program design. It seems that the industry largely agrees that individuals who train are capable of discerning their interoceptive signals and responding to them accordingly.

Perhaps because we perceive eating habits as more complex and emotionally-charged than exercise habits, a sea of doubt is still cast over individuals' abilities to apply interoceptive awareness at mealtimes. The doubt and criticism surrounding IE and HAES likely also stem from misunderstanding and the resulting fear of that which we do not understand. Intuitive eating is not synonymous with eating without rational thought, or eating based on emotion, or eating as much as one possibly can of everything they might want (though all of these practices might be enacted as part of IE… but are often also enacted in absence of it). Just as applying the principles of autoregulation to a training plan can enhance health and performance while reducing injury risk, applying the principles of intuitive eating facilitates the disruption of harmful eating patterns and cycles. Intuitive eating is not a diet, any more than autoregulation is a training plan. They are each a foundation of principles creating a collective approach to modifying behavior for a more beneficial outcome. Obviously, IE is about much more than eating, but it is in this arena that we can begin to build a shared understanding and improve the dialogue around all aspects of IE and HAES.

We might start by considering that biological cues can regulate food intake, and that everyone would benefit by not needing to rationalize a food choice based on external influence.

We might also be able to agree that mindful eating is a skill set, and a form of autoregulation in eating.

Perhaps we can also agree that awareness, adaptation, and flexibility in our approach to eating, training, and coaching ultimately lead to better outcomes. 

Most of all, I hope we can agree that our vigilant focus on the external environment and factors that drive behavior has led to neglecting the internal environment—the one that is truly within our capacity to change and fortify. By investing in our  internal environments and those of our clients, we prepare ourselves to respond more effectively to external factors that are outside of our control.

We have already seen a paradigm shift away from rigid attempts to control long-term outcomes, instead remaining flexible and in charge of the current situation in order to remain on a generally positive trajectory. Those of us who are passionately invested in training and eating for long-term success would do well to embrace this shift, on our plates, at our gyms, and, most crucially, in our perceptions.   

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