intuitive eating

Anorexia Recovery: The problem with “intuitive eating” 12


I’ll preface this blog post with this: this post is about intuitive eating and Anorexia recovery. If you don’t have Anorexia, go ahead and do all the intuitive eating that your intuition asks you to do —this post is not about you. I agree that intuitive eating may be a fantastic approach for a person without a mental illness that disrupts hunger cues and tries to make one starve oneself to death.

This post is not a general slur on intuitive eating, well, other than this first part 😉


Intuitive eating … I have to confess that writing that term makes me cringe. It is so … ugh. It’s not a far cry from “clean eating” and I’ll tell you why: There are no memes of intuitive eating that show a happy and healthy woman sitting in Five Guys with a double cheeseburger. (That was me yesterday — and yes I was happy)

This is the Tabitha Farrar Anorexia Recovery version of intuitive eating courtesy of Five Guys

 

Intuitive eating says “trust your body so long as your body wants to eat salad and not cheeseburgers.”

I know that intuitive eating fans will be shouting “no no, it’s not that!” But you have to see my point here? And if intuitive eating wasn’t originally meant to be that fine, but this is what it has turned into. And yes it may well have been hijacked along the way, but in this diet-obsessed, heath-obsessed, thin-obsessed world, what did you expect?

Intuitive eating is now no more than another label to aspire to. What was once supposed to be used to describe a natural way of eating has been turned into a fashionable category to place oneself in. Another way to be in the clean eating clique without actually saying clean eating anymore — as clean eating is no longer in vogue.

Okay, enough of my cranky opinion. Let’s have a look at the more logical reasons that intuitive eating should stay out of Anorexia recovery. Here’s the first line describing intuitive eating on an intuitive eating website I found:

“The basic idea of intuitive eating is learning how to recognize and respond to your inner hunger cues.”

Anorexia messes with hunger cues. Case closed.


Anorexia will disguise itself as intuition

Anorexia is a chameleon and it will slither its way into just about anything. Anorexia will tell you that intuitively you want the salad not the burger.  You cannot take the risk of even accidentally making the Anorexia-driven choice, so you need a default you can trust. The burger in this case.

intuitive eating

A very wonderful friend drew this. She is spot on.

In discussions I have had with adults in Anorexia recovery who have worked with dietitians who insisted on intuitive eating, it seems to be often the default response given by people who don’t really know what else to say, or want to express judgement but need a polite way of doing so. Maybe that is me being cynical. Possibly they are so smitten with the concept of intuitive eating that they honestly believe that it is the answer for all people, including people in recovery from a hunger-cue destroying illness such as Anorexia.

AN person: I don’t feel hungry

Dietician: Use your intuition to guide you as to your levels of hunger

AN person: How much do I need to eat?

Dietician: Use your intuition to guide you to knowing when you are full

AN person: I can’t decide if I want a second helping of dinner 

Dietician: Use your intuition to guide you to knowing if you should eat more

AN person: I don’t have any bloody intuition

Dietician: Use your intuition to guide your intuition


Here’s a discussion that an adult (let’s call her Jane, but that is not her real name) in the weight restoration phase of Anorexia recovery told me about last week:

Jane: I ate 3 scoops of ice cream last night and feel bad about it. Anorexia is screaming at me that I should have eaten less. Do you think that was too much?

Jane’s RD: Do you think that you were listening to your body? Maybe if you had been eating mindfully you would not have eaten so much as to make you feel guilty about it now.

Basically Jane’s RD just confirmed what Jane’s Anorexia wanted her to say. What Jane’s RD said translates to “you ate too much” in Anorexia speak. This person, Jane, is very underweight and fiercely battling a very entrenched eating disorder. Would it have killed her RD to drop the intuitive eating hat just for two seconds and have said: “No Jane, there is no such thing as too much food in Anorexia recovery.” ?

 

Anorexia distorts food perception 

When you tell a person in recovery from Anorexia to use intuitive eating, you are telling a person who possibly almost died of self-starvation to use their judgement about what size portion they should have. You are telling a person who once thought that half a sandwich was enough to feed her for a week, that she should trust her inner judgement on how much to put on her plate. You are telling a person who has a mental illness that distorts his hunger cues to “eat when hungry and stop when full.”

I’ve heard the “when we start off as babies we naturally know how to eat intuitively” story a million times and I don’t buy it for people with Anorexia. I mean, whoopie for babies and all that, but when I was a baby I didn’t have active Anorexia. It is not comparing like with like.

If a person has Anorexia, we cannot compare their eating goals to a person who doesn’t have Anorexia. Let’s not ignore the freaking mental illness and pretend it is not there! I find that slightly insulting actually. Being told I should eat intuitively like everyone else should regardless of the illness that could kill me if I were to even accidentally lose weight. Insulting because it belittles the seriousness of this illness. Unfair because I’m not on a level playing field when it comes to food.

I understand that the idea is that intuitive eating is supposed to remove all the food judgements and rules and reject the diet mentality and that I do like about it, but the whole build self trust with your body part puts this relationship on a pedestal. For those of us with mental illnesses such as Anorexia, it is wholly inappropriate. We need to learn to stay alive first. I’ll save bonding with my hunger cues for another life. In this one I’ll focus on not dying.

 

Intuitive eating relies on hunger cues

That should be all I have to say. But apparently it is not, because dietitians all over the world working with individuals in recovery from Anorexia are still telling them to eat when hungry and not eat when not hungry. As I explained in the recent podcast I did on hunger, people with Anorexia cannot trust hunger cues. We are often not physically hungry when we should be. We are often still mentally hungry when we are physically full. We often only actually experience hunger cues after having eaten.

Hunger cues are not reliable for people with Anorexia

I will repeat this one as it is important: we are often not hungry. There is an absence of hunger cues. While it may be argued that as a person moves forward in recovery that they have a return of their natural hunger cues, even this can be dodgy and unreliable at time for some of us.

Normally, when you average Joe begins to starve, neurochemical signals of hunger are elevated and signals for satiety and activity are lowered (G. H. Anderson & Kennedy, 1992; Leibowitz, 1992; Prentice et al., 1992). However, researchers have found that for people with Anorexia, most neuromodulators and hormones influencing hunger, satiety, and activity are present in unusual concentrations that are opposite to those found in normal starvation. In other words, people with Anorexia have funky happenings afoot with regards to hunger. 

These findings are all consistent with adaptations to turn off eating and turn on traveling — the theory that certain humans would have survived better in times of famine if they were able to direct energy to their limbs and walk to pastures new. They are also consistent with AN patients’ descriptions of their subjective experience of finding it very difficult to eat and feeling restless and driven to exercise.

 

Hunger cues and stress

I am a solid 7+ years recovered and have steadfast hunger cues. However, guess what is the first thing to disappear in times of stress? My hunger. Now, lack of appetite in stressful times is not uncommon. For “normal” people a couple days eating a little less is no big deal. For me however, that could lead to energy deficit and a relapse. If I were to follow intuitive eating, even this strongly recovered, I could risk relapse in times of high stress — or that time of the month when I feel super bloated due to my period. I’m not even going to dabble with my recovery. I’d rather just suck it up and eat.

One of the best decisions that I ever made in recovery, was that I would eat a certain amount or more every day and never less no matter what the circumstance. I have a mental picture in my head of what is adequate. For example, a snack is a giant cookie or a couple pieces of toast, not an apple. For example, a salad never counts as a full meal. For example, fruit is fine so long as I have it alongside — not instead of — a more substantial snack. For example, lunch and dinner always have a dessert alongside. etc, etc,. This is not a meal plan. It is a commitment to eating in a certain manner that I know keeps me safe. It is a commitment that I keep even on days when I don’t feel like it. Even on days I feel bloated and crampy and all PMT. On the days when I am not bloated and crampy, I don’t even have to think about it as I love to eat. It is a safety net rather than a ceiling.

So if intuitive eating is a little dodgy for someone like me, why the hell are people fresh out of IP being told to follow it? Yes, I kid you not, this happens.

 

Intuitive eating can make Anorexia recoverers feel hopeless

Dear dietitian, here is something that your client told me that he couldn’t bring himself to tell you: He came away from his appointment with you feeling hopeless because you told him to eat what he wants and follow his hunger cues. He felt hopeless because of the brain freeze that he sufferers when he thinks about food, and the blank space that comes up when he tries to decide what he wants to eat. He felt hopeless because his hunger cues are not always there. Sometimes, telling a person with Anorexia to follow hunger cues is like telling a blind person to follow the blue arrows.

For some people who cannot eat intuitively, this is just another thing that their eating disorder will use to tell them that they cannot “do” recovery. Most people already have quite enough of those thoughts of failure and don’t need any more.

Mindfullness when eating isn’t always a good thing

I spoke about this in a podcast discussing DBT for eating disorders. Mindfull eating, while a good practice for the general population, is not always a good idea for people with Anorexia.

In fact, for those of us who experience increasing stress and anxiety when we think about what we are eating, mindlessness while eating is a better approach. When I was navigating my own Anorexia recovery I worked out that the way to keep myself calm while eating was to distract and do a crossword at the same time.

Intuitive eating principles teach that each bite should be a mindful decision. Hell, if I had done that it would have taken me 24 hours to get though a plate of food.

In AEDRA’s meal support service, we have found that clients prefer distraction conversation to help them get through their meal. The last thing we have found to be helpful is talking about the food that they are eating.

 

Here’s why intuitive eating is dangerous for people with Anorexia

Here’s a revelation: sustaining Anorexia recovery regularly requires eating when one is not hungry.

As I mentioned above, some treatment centres have started trying to teach intuitive eating in PHP and OP programs. I believe this is irresponsible. One of reasons that I have been able to sustain a robust recovery is that I can force myself to eat when I don’t feel like it. I can and have to sometimes eat when I am not hungry. The last thing a person in recovery from Anorexia needs are these conflicting messages. You have to eat followed three weeks later by you only have to eat when you are hungry. 

This is feckless and also indicates that there is still the misunderstanding out there that weight restoration equals full recovery. A person can gain weight in a treatment centre, but if you tell them on leaving that they only have to eat when hungry, they will likely relapse. That is because weight restoration does not equal full mental or physical recovery. You can tell nothing about an individual’s state of mental health by looking at them.

Why take the risk?

This is the part that vexes me something chronic about all this. Why take the risk? If someone has Anorexia, why bother with the whole intuitive eating thing? Why not just play it safe and tell them to continue to eat a high minimum of food every day?

What is the benefit of telling a person with Anorexia to strive for intuitive eating?

I don’t get it.

Or maybe I do a bit. I think it might seem like a good idea because it leads to less conflict. But only because it appeases the eating disorder. I’ll take an ED tantrum any day if it means the person has a higher chance of getting and staying well.

I’ll make you a deal, intuitive eating. 

Here is my deal: I will eat intuitively so long as this is telling me to eat above and over the amount of food that I know I need to have every day.

My deal is that a person in recovery from Anorexia can follow intuitive eating so long as there is a safety net — and burgers — involved.

 

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About Tabitha Farrar

I work as Head of Marketing for a software startup in Boulder. As a recovered Anorexia sufferer, I advocate for proper understanding of eating disorders in my spare time. On that note, I wrote a book about my own journey into eating again called Love Fat.


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12 thoughts on “Anorexia Recovery: The problem with “intuitive eating”

  • Stephanie Manes

    Tabitha I felt like shouting “Yes! Yes! Yes!” when I read this post, and then sending it to every RD and therapist I have ever worked with. What you have written cannot be emphasized enough and in my experience may be the difference between life and death. And I mean death as the result of starvation or death by hopelessness. Time and time again I have been told while still very underweight that the route to “recovered” is to follow my hunger, both in amount and what I eat. And as you know, for a long-term and still undernourished adult that is literally, at a basic brain level, not possible. Brain freeze is the right description. When I tentatively try to tell treatment providers that given the fact that I am almost 50 and started with AN at 11, I’m not so sure intuitive eating is really in my future, I’m told my goals are too limited and that I’m just trying to hold onto my ED. But when I follow the trail of responsible researchers validating the fact that my AN is chronic brain based mental illness and that my recovery — my life — needs to fully account for that, I feel hope and safety return. Intuitive eating, mindful eating … when will providers stop dangling a means and goal that are the biggest barrier to my well-being?? Thank you so much for being such a strong voice for us….

  • Firecracker!

    I can’t trust my intuition to decide what socks to wear in the morning. I’m not going to say I eat by intuition, that’s for sure. The fact of the matter is this: rules are rules are rules. ED knows my sensitive spots, and it would use intuition in a kumbaya-quinoa-inner child way to kill me. If not kill me, render me completely miserable and lost. Sick. I can appreciate the approach, but it is not at all appropriate for dieticians, doctors, therapists, etc., to be harping on the next grand bandwagon about nifty ways to waste time. There’s no way to avoid the simple fact that restoring the body (thus, mind, soul, spirit) requires enormous amounts of incredible food, on an hourly basis. Please, recovery industry, don’t pretend that eating disorder healing can play games with food. This is serious. Healing does not feel good, nor is it popular and pretty. It’s two hands, one mouth, and action. Thank you, Tabitha. Thank you. I hope this blog post touches nerves and causes upset–you write with such love and compassion, and yet there are those in the audience who will read this as a threat to the sad system they are clinging to. Bless you.

  • Firecracker!

    Intuitive eating has never had a speck of a place in my life, and it never will. In restoration from a life-threatening restrictive mental illness, I will need (and want!!) to eat according to science, not emotion. There will never be a time when I can say I don’t “feel” like eating. My freedom is in my medicine.

  • David

    Tabitha, love your post. Absolutely agree with what you said: “Anorexia messes with hunger cues”. Most of them can’t eat intuitively.

  • Lawrence

    Tabitha, what about the other problem? I currently eat “mechanichally” an amount needed to maintain my post-restoration weight and, despite several attempts, I just can’t manage to eat intuitively because then I would always eat loads and loads of food, likely in a disordered manner. I can’t trust my hunger cues, not because they would lead me to restrict and relapse but for quite the opposite problem. It is incredibly frustrating. I was the king of intuitive eating until like 10 months ago.

  • k

    tysm, this is what i needed and this describes my problem! i’m in recovery for 3+ years but due to some relapses i can’t fully trust my body. i experience mental hunger more often than the physical one. and this whole intuitive eating as described all over the internet stresses me out. i mean it’s important to eat when hungry but also when you’re craving something. for me it’s more important to eat enough (have to estimate calories in order to reach my goal) than follow my hunger cues which still aren’t normal. i’m trying to not put me under pressure, recovery is a long process and the mental part takes more time. i have to be patient and 100% honest to myself. stay strong, guys. we’re all in this together!!

  • MLMS

    Hello, Tabitha,

    To begin, I want to tell you how grateful I am to have found your podcast and, in turn, your blog. Without going into all the details here and now, suffice it to say that your experience and what you write and speak about greatly connects with my own recovery journey (including the OCD component). I don’t know that I would have connected with it prior to “getting sober” 5 years ago (which, for me looked like Magic Plate [although we didn’t know that terminology back then] coupled with complete cessation of exercise, including all those sneaky bits of movement you speak about). Or even in the early years; timing is everything right? From where I am today, I find myself saying, “YES! YES!” when I listen to your podcasts or read your blog posts.

    That said, while I see your point regarding “intuitive eating” here, I wanted to add another perspective (not an argument – I think there is room for both of our viewpoints and experiences – and we’re always welcome to take or leave whatever does or doesn’t connect for us in the moment).

    So, while I agree that introducing “intuitive eating” in the early stages of anorexia recovery is short-sighted and dangerous, in my experience it’s played/playing a part in the latter stages – AFTER more-than-full weight restoration and consistent eating for a matter of years, not days or even months. Prior to that, I could no more “intuitively” eat according to hunger and fullness and taste preferences, etc. without influence of the anorexic mind than a newly blindfolded person can intuit what is right in front of his or her face!
    Okay, I said I wouldn’t go into all the details here, so we’ll leave my experience at that.

    Next, I want to touch on some items from the NEWEST edition of the seminal book on the subject, “Intuitive Eating,” by Evelyn Tribole and Elyse Resch (3d Ed.). This is from the chapter about Intuitive Eating and Eating Disorders:

    Readiness for Intuitive Eating: It’s unlikely that anyone with an eating disorder can fully dive straight into intuitive eating. . . . Here are some of the indicators of when you are ready to move into work on Intuitive Eating. Biological Restoration and Balance: If you have anorexia, this means weight restoration. It’s not realistic to expect yourself to be able to regularly hear hunger signals, let alone honor hunger and fullness.

    Then there is this nifty table/chart that lists each of the 10 principles and how they apply to anorexia (and another column for bulimia, on which I didn’t take any notes). Here are some of the main points/notes I took:

    Principle 1: Reject the Diet Mentality – Restricting is a core issue of anorexia nervosa and can be deadly.
    Principle 2: Honor Your Hunger – Weight restoration is essential. Lack of hunger does not necessarily mean that you don’t need to eat!
    Principle 7: Cope with Your Emotions Without Using Food – Food restriction, rituals, and obsessions shut down emotions.
    Principle 9: Exercise – Feel the Difference – STOP EXERCISING – later, include gentle, fun movement.

    Finally, I am going to end with something that the dietitian (with whom I briefly consulted late fall/early winter last year) wrote in her book, Real World Recovery: “Emotional restricting is similar to emotional eating. When the client is faced with challenging situations or emotions she does not eat or eats very little as a way to cope with or numb her feelings. . . . She will need to be encouraged to eat even if she is upset.” As someone coming from a mental illness diagnosis of Anorexia Nervosa, this fits me to a “T.”

    Oh! And I’ll close with this: As someone who at one time restricted herself to raw organic fruits and vegetables, my intuition has only recently led me back to incorporating some of those into my preferences. And, certainly not every meal, or even every day! You’re more likely to see me eating a burger as pictured in your post. 🙂

    • MLMS

      A BIG P.S.

      So, I heard that the Intuitive Eating authors came out with a companion workbook . . . I had a bookstore gift card . . . I purchased the workbook . . . AND I returned it.

      It is not for me, that is for sure! Nor would I recommend it to anyone with the type of anorexia nervosa that Tabitha writes of so clearly here (OCD-type — whether the OCD came first, second, or concurrently doesn’t matter).

      So that got me curious. When I returned the workbook, I took a gander at the book book again. Lo and behold, ALMOST the same reaction. I feel oh so grateful for my recovery process, which looked like FBT/Magic Plate coupled with hardcore attack on the sneaky movement and behaviors. Until MORE THAN fully weight restored (was this overshoot? maybe. or maybe this is my new normal. I don’t really care. All I know is that if I had once again stopped where the treatment center said I “should,” I would have remained all kinds of crazy — been there done that and lived in that hell for almost a decade before “relapsing” — hah hah — how does one relapse when never fully recovered in the first place)?

      Blah blah blah. I’m not saying anything new here. Tabitha says it all so much better.

      What I AM saying is that it was only from that place of being so close to fully recovered late last year that I believe I was able to look at this IE book, skip all the parts about nutrition, health, exercise, etc. — or read just enough for that new automatic response to pop into my head: “Not for me!” and move on. I didn’t realize until sitting down with it the other night how much of this stuff is within the book. Oh yes, it says over and over — balance . . . flexible . . . don’t turn IE into another set of rules or a diet . . . etc. But, as Tabitha says, for someone with the kind of anorexia nervosa that is out to kill, someone with that OCD component (ME!) — forget about it!

      I realized that the only parts that I really read 6 or 7 months ago were the appendix that I spoke of a bit in my first comment — the table that shows how the 10 Principles apply differently to us with anorexia nervosa — and the chapter that really helped me get over some of the last vestiges re tuning into pleasure. There is NO WAY IN HELL I could have done that in the first four years of active recovery! I had to eat whether I liked it or not (still do, with the added bonus of now being able to recognize and take in enjoyment as well — in more areas of life than food). I can recognize things like Tabitha recently wrote about, such as feeling comfort from being wrapped in a blanket in front of a fire drinking full-fat hot chocolate with marshmallows. That would have been indulgent and forbidden in the prison of anorexia — using the heat, using a soft blanket — maybe a scratchy one would be ok so that I wouldn’t like it too much, it had to be at least slightly painful — etc.

      I mean, I was straight up in AWE when I was told that it is okay at this point to focus on taste, texture, temperature, aroma, etc. Wow. Just another anorexia rule that actually served me pretty well during the first few years — I mean how the hell could I have known what I REALLY preferred or didn’t with anorexia running the show? I couldn’t. I had to be exposed and habituated to eating everything and anything served for a really long time (until more-than weight restored and even time beyond that) before I could even begin to explore that.

      So, yeah. I guess what I’m really trying to say is, listen to Tabitha. She knows what she’s talking about. I Commented too soon above and realize now that I’ve been really really “lucky”/”blessed”/whatever to have not had anyone offer IE as recovery option (to me). AND it’s pretty cool today to be able to order the burger and fries because I WANT something with those burger and fries qualities — including connecting with others — not because I HAVE to and food is my medicine (yucky).

      I’m done taking over the Comments section now. Thank you, Tabitha. 🙂

  • Karen

    Hi Tabitha, this is another really thought-provoking blog post and I totally agree about intuitive eating being the new clean eating and a euphemism for restriction. I think one of the reasons dieticians recommend it is there is such a fear that those recovering/recovered from anorexia will become ‘overweight’ if they eat in a completely unrestricted fashion (which is technically what intuitive meeting should be anyway!) but our society is so massively hung up on the ‘obesity epidemic’, deliberately put in a inverted commas as I do believe many human beings, recovered anorexics or otherwise, have a set point that is deemed an acceptably high by our culture. What are your thoughts on recovering anorexics and those with other eating disorders, who continue to want to eat large amounts of food, is it because they have not yet reached their set point or recovered or is there any truth to the fears dieticians have that we can go too far the other way? Personally I think that’s rubbish but I have a part of me (that is probably still anorexia speaking) fears if I completely let go with eating I will spiral out of control. Like you I make myself eat a certain amount very regularly and my hunger cues are pretty reliable now falling in line with those ample and the unrestricted meals and snacks, but I do find it hard sometimes when hunger increases to always answer it and would love to eat in a truly intuitive way which I do believe it is mindless rather than mindful! Anyway interesting stuff, intuitive eating has no place in anorexia recovery in my opinion.

    • Tabitha Farrar Post author

      Hi Karen

      I have a whole category of posts on this, in the “overshoot” category. For some of us it is actually healthy and needed to put on more weight than our “set point” weight and this is what the body is asking us to do.