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A Professional Journal of The Renfrew Center Foundation Page 12

and anxiety about eating issues which, in • Duration of eating disorder. appropriately to these cues when they
turn, may blunt hunger and cause nausea. • Severity of malnutrition. arise. This also means developing the
Nutrition Rehabilitation. In the begin- • Intensity of anxiety and fear ability to distinguish between physical
ning of treatment, nutrition rehabilitation about eating. and emotional cues.
• Motivation for Recovery.
usually requires some sort of eating plan As a person’s hunger and fullness cues
• Medications (which can distort
(often under the direction of a nutrition resurface, it’s not unusual for fears and
therapist). This is similar to when a cast is distorted beliefs to arise in-tandem. For
needed to support the healing of a broken hunger and satiety cues). example, some patients distort and
arm. The cast provides structure and mislabel the sensation of fullness as
Phase 2: Identifying, Normalizing and
support, but it is not lifelong, nor the “proof ” of overeating. Consequently, they
Responding to Satiety Cues
destination in recovery. The cast is used may fear any fullness and label it as “bad”
until the bone is strong enough on its own. It is vital that satiety cues are normalized or “wrong.” Or, some patients might
Similarly, a meal plan serves as structure before further exploring Intuitive Eating. believe that achieving fullness means
and support, until there is biological The challenge lies beyond “hearing” the eating just until the hunger goes away, but
restoration. For a low-weight patient, this range of physical hunger and fullness cues. not a single bite more.
includes weight restoration. Patients need to learn how to respond In this stage it is helpful to explore the
Nourishment as Self-Care. The body
has been through nutritional trauma and How Intuitive Eating Principles Apply to Eating Disorders
needs consistent nourishment with Core Principle Anorexia Nervosa Bulimia Nervosa/
adequate calories. In this phase, nutrition Binge Eating Disorder

rehabilitation is a form of necessary self- Reject the Diet Mentality Restricting is a core issue and can Restricting does not work and triggers primal
care, regardless of the absence of hunger be deadly. hunger, which can lead to binge eating.

or the presence of early fullness. This Honor Your Hunger Weight Restoration is essential. The Eat regularly—this means 3 meals and 2 to 3
proscriptive eating phase is somewhat mind can not function and think properly. snacks. Eating regularly will help you get in
You are likely caught in an obsessional touch with gentle hunger, rather than the
mechanical because, in this early stage, a cycle of thinking and worrying about extremes that often occur with chaotic eating.
patient’s willingness alone is usually not food, and have difficulty making a deci- Ultimately, you will trust your own hunger signals
sion. Your body and brain need calories even if they deviate slightly from this plan.
enough to assure adequate intake. to function. Your nutrition therapist will
work with you to create a way of eating
that feels safe to you.
Boundaries: The Role of the
Schedule of Eating Make Peace with Food Taking risks, add new foods, when ready. Take risks, try “fear” foods, when ready and not
Do this gradually, take baby steps. vulnerable. Vulnerable includes over-hungry,
Creating a schedule of eating (with the overstressed, or experiencing some other feeling
patient) helps contain “eating anxiety”
by establishing a predictable expectation Challenge the Food Challenge the thoughts and beliefs about Challenge the thoughts and beliefs about food.
Police food. Take the morality and judgment Take the morality and judgment out of eating.
of when to eat. Eating regularly helps out of eating.
foster body rhythms, which include
Feel Your Fullness You can’t rely on your fullness signals A transition away from experiencing the extreme
hormonal patterns that help the body during the beginning phases of recovery fullness that is experienced with binge eating.
gear up for digestion. as your body likely feels prematurely full Once regular eating is established, gentle full-
due to slower digestion. ness will begin to resonate. Note: if you are
In an outpatient setting, I like to withdrawing purging, especially from laxatives,
establish a built-in flexibility of 30 minutes you may temporarily feel bloated which will
distort the feeling of fullness.
for each agreed upon eating time. For
example, if the patient agrees to eat lunch Discover the Frequently, there are fears or resistance If satisfying foods and eating experiences are
Satisfaction Factor to experiencing the pleasure from eating included regularly, there will be less impetus to
at 12:00, then eating between 11:30 and (as well as other pleasures of life). binge.
12:30 is acceptable. But if that 30 minutes
Cope with Emotions You may often feel emotionally shut Binge eating, purging, excessive exercise are
of flex-time is up, the patient needs to without Using Food down. Food restriction, food rituals and used as coping mechanisms. You can begin to
stop-and-drop (the other tasks at hand) obsessional thinking are the coping tools take a time out from these behaviors to start
of life. With re-nourishment, you will be experiencing and dealing with feelings.
and feed her body. This is an important more prepared to deal with feelings that
concept, because it helps the patient emerge.

establish her self-care (nourishment) as a Respect Your Body Heal the body image distortion. Respect the here and now body.
non-negotiable priority. For example, she
Exercise You will likely need to stop exercising. Over-exercising can be a purging behavior.
might need to tell her friends she must eat Learn to remove the rigidity of nutrition— Moderate exercise can help manage stress and
first, before shopping (rather than visa where there is a strict adherence to anxiety.
“nutritional principles”, regardless of their
versa). This often requires learning and source.
practicing assertiveness skills.
Honor Your Health Recognize that the body needs: Learn to remove the rigidity of nutrition. There is
During this phase, gentle hunger cues Essential fat a strict belief as to what constitutes healthy
begin to emerge. Keep in mind that the Carbohydrates eating, and if this belief is violated, purging
Energy consequences can ensue (if bulimic). Recognize
occurrence of regular hunger cues varies Variety of Foods that the body needs:
and is determined by many factors Essential fat
including: Energy
Variety of Foods

*from Tribole, E. & Resch, E. Intuitive Eating, 2nd ed (2003). New York: St. Martin’s Press.
Perspectives • Winter 2010 Page 13
patient’s understanding and beliefs around which may arise from ordinary life There is no right or wrong way to proceed.

• Recognize vulnerability—such as
hunger and fullness. What is the expecta- stressors? The challenge is to create more eating
tion around satiety cues? What might experiences that build self-trust. What does
“normal” cues feel like? What did these being too hungry, too tired, too the patient need in order to feel safe?
cues feel like before the eating disorder stressed and so forth? What types of foods and meals feel
developed? What fears arise for the patient satisfying and sustaining? What types
Intuitive Eating Trial. In the beginning, it
about the idea of responding appropriately of foods would provide more social
is best to explore a one or two-day
to hunger and fullness cues? It is also connectivity? For example, would the
Intuitive Eating trial to determine if the
important to emphasize that there is no ability to eat pizza without anxiety allow
patient is truly ready to eat on the basis of
single “correct” way to experience these more social interaction with her friends?
her biological cues. During this time, it is
biological cues. Exploring Unconditional Permission
helpful to explore these issues:
• Were you able to honor hunger/
Dealing with “False-Labeling” of Body to Eat. The ability to eat any food is an
Cue Experiences. In general, there is a important component of recovery and
fullness cues in a timely manner?
• How did you respond to hunger cues?
three-step process to normalizing satiety Intuitive Eating. Eating becomes
• How did you respond to
emotionally neutral—without moral
1. Develop ability to identify dilemma or shame—where the patient
physical cue. fullness cues?
• Was there a part of you that was
understands that one food, one meal, or
2. Normalize the physical cue— one day of eating does not make or break
confront the distortion (or fear) about thinking it was an opportunity for you health or weight. When guilt is removed
the physical cue. to eat less? And, more importantly, from eating, it is easier to be attuned to the
did you act on that thought? needs and experiences of the body.
• If you were scared about an upcoming
3. Respond appropriately to cue.
Furthermore, habituation studies show
Every eating experience is an opportunity to that the more a person is exposed to a
learn about the body. For example, if for event (such as eating dinner at a
restaurant), did you compensate by food, eating becomes less distressful
some reason the patient did not eat enough (Epstein, 2009).
food at a meal—did she get hungrier eating less?
A promising study from the University
sooner? (Usually, yes). Did she think about During this trial, a patient might discover of Notre Dame applied the Intuitive Eating
food more often? (Usually, yes). that she doesn’t feel ready, and she may principles to 30 women with diagnosed
Or, if she ate beyond comfortable opt to continue on her existing meal plan. binge eating disorder (Smitham, 2008).
fullness, did she feel satisfied and It’s important to emphasize that this is After eight, 90-minute, weekly sessions,
sustained for a longer period of time? not failure. Rather, it usually reflects a binge episodes decreased significantly—
(Usually, yes). Were there fewer thoughts patient’s desire to protect her recovery. 80% of the women no longer met the
about food? (Usually, yes). It is important to move at an emotionally diagnostic criteria for the disorder.
comfortable pace (assuming she is eating
Phase 3: Indicators of Readiness for adequate calories). Moreover, it is still The Model: Integrating Intuitive Eating
Intuitive Eating possible to move forward with other for Eating Disorder Recovery
While many patients would like to jump Intuitive Eating principles within this
framework—such as working on permis- Cook-Cottone (2006) developed the
into Intuitive Eating, it is best to look for Attunement Representation Model to
readiness indicators before proceeding. sion to eat any food. Patients often express
feeling safer trying new food challenges conceptualize the integration needed for
• Recognize that the eating disorder is
Is the patient able to: an individual’s recovery from an eating
within the framework of an eating plan.
disorder. This integration also aligns with
about something deeper—weight and
eating are symptoms?
• Tolerate risk? As a person begins
Figure 1: The Representational Self: Attunement and Expression

to heal both physically and

psychologically, she is able to take
and tolerate risks with eating.
• Tolerate being uncomfortable?
Trying new eating experiences can
be temporarily uncomfortable.
• Recognize (and manage) needs and
feelings? If an individual is not able
to identify her needs or cope with
feelings, she may continue to use
eating disorder behaviors such as
restricting food, over-exercise, or

• Value Self-Care? Is she willing to

binge eating as coping strategies.

feed herself in the absence of hunger,

A Professional Journal of The Renfrew Center Foundation Page 14
Intuitive Eating. This model defines • Enhances the mind–body connection Mathieu, J. (2009). What should you know
attunement as the dynamic integration of and coordination, and does not about mindful and intuitive eating? Journal
a person’s inner and external worlds. confuse or dysregulate it. of the American Dietetic Association, 109
A person with an eating disorder is skewed • Alleviates mental and physical stress, (12), 1982-1987.
or mis-attuned toward the expectations of not contribute to and exacerbate stress.
• Provides genuine enjoyment and
Scime, M., & Cook-Cottone, C.P. (2008).
others (such as cultural expectations of
Primary prevention of eating disorders: A
thinness). See figure 1. pleasure, not to provide pain and be constructivist integration of mind and body
Internal System. Ultimately, Intuitive punitive. strategies. International Journal of Eating
Eating is an individual’s attunement with
The pursuit of exercise is about feeling Disorders, 41, 134-142.
food, mind and body. The Intuitive Eating
principles fall primarily within the internal good, not about calories-burned or used as Smitham, L.A. (2008). Evaluating an
system of the attunement model, which a penance for eating. intuitive eating program for binge eating
consists of a person’s thoughts, feelings, Similarly, health can be honored with disorder: A bench-marking study
and physiology (biological sensations of gentle nutrition. For example, a family [dissertation]. South Bend, IN: University
the body). may desire to eat locally-grown foods with of Notre Dame.
a low carbon footprint. If a person is truly
Thoughts Tribole, E. (2009). Intuitive Eating: Can you
inner-attuned, she can integrate this value
Principle 1. Reject the Dieting be healthy and eat anything? Eating
without resorting to an eating disorder
Mentality Disorders Today. Winter: 10-11.
behavior or mind-set.
Principle 3. Make Peace with Food
A person recovered from an eating Tribole, E. & Resch, E. Intuitive Eating,
Principle 4. Challenge the Food Police
disorder can eat within this dietary 2nd ed. (2003). New York: St. Martin’s
Principle 8. Respect Your Body
framework, while paying attention to Press.
Feelings hunger, fullness, satisfaction and so forth.
Principle 7. Honor Your Feelings If, however, a person enters this realm too Tylka T. (2006). Intuitive Eating assessment
without Food soon, there is a risk for the new mindset to scale. Journal of Counseling Psychology,
be embraced as another rigid set of rules, 53, 226-240.
Physiology (Body)
fueling old eating disorder thinking and Tylka, T. & Wilcox, J. (2006). Are Intuitive
Principle 2. Honor Your Hunger
behavior. Timing and readiness are the keys. Eating and eating disorder symptomatology
Principle 5. Respect Your Fullness
Ultimately, when a person recovers opposite poles of the same construct?
Principle 6. Discover Satisfaction
from an eating disorder, she trusts her Journal of Counseling Psychology, 53 (4),
Principle 9. Exercise—
inner body wisdom. She is at peace with 474-485.
Feel the Difference
her mind and body, and finally, enjoys the
Principle 10. Honor Your Health
pleasures of eating without guilt or moral
with Gentle Nutrition
decree. Evelyn Tribole, MS, RD,
The External System consists of family, has written seven books
communities, and culture. These external and co-authored Intuitive
influences include food traditions, cultural References Eating. Ms. Tribole
beauty standards and public health Calogero, R. & Pedrotty, K. (2007). specializes in eating
guidelines. Daily practices for mindful exercise. disorders in Newport
The last two principles of Intuitive In L. L’Abate, D. Embry, & M. Baggett Beach, CA. She also
Eating pertaining to exercise and nutrition, (Eds.), Handbook of low-cost preventive teaches Intuitive Eating
are components of both the inner and interventions for physical and mental PRO skills to health professionals.
external systems and are excellent health: Theory, research, and practice For more information, visit
examples of the dynamic integration (pp.141-160). New York: Springer-Verlag.
needed to achieve authentic health.
For example, a person can integrate Cook-Cottone, C. (2006).The attuned repre-
exercise recommendations for health while sentation model for the primary prevention
being attuned to the experience of her of eating disorders: an overview for school
body. This type of physical activity is also psychologists. Psychology in the Schools,
called “mindful exercise” (Calogero & 43 (2), 223-230.

• Is used to rejuvenate the body,

Pedrotty, 2007) where exercise: Cook-Cottone, C.P., Beck, M., & Kane, L.
(2008). Manualized-group treatment of
not exhaust or deplete it. eating disorders: Attunement in mind, body,
and relationship (AMBR). Journal for
Specialists in Group Work, 33, 61-83.

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