When Intuitive Eating Isn’t The Answer with Laura Pumillo MA, RDN, CDN, CEDRD-S
Intuitive Eating is a highly popular framework that seems perfect on the surface… but is it always the right fit for those struggling with eating disorders?
Laura Pumillo is the owner of Nutrition for Every-Body, a nutrition practice in Manhattan. Laura has over 25 years of experience working with people suffering from eating disorders. Right now, she treats every type of eating disorder: anorexia, bulimia, binge eating… everything.
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Laura is really good at what she does. When someone comes to her, she looks at them as an individual. She has a knack for putting all the pieces of their unique experience and situation together and helping people work toward whatever recovery means to them.
I love the way Laura’s brain works. It is her understanding that the people who come to her know a lot, but her work is trying to bridge the gap between what people know and behavior change. She wants everyone she works with to cultivate a positive relationship with food and their body, and to feel comfortable in their body.
Both of us really appreciate and subscribe to intuitive eating. But part of what’s been going on currently is a very boxed way of thinking – meaning, for example, that intuitive eating is the only way to live and if you’re not eating intuitively, then you’re on a diet and have a messed up relationship with food. Keep in mind that this post is based on nuance. We have to understand that every person is an individual, and intuitive eating is a framework. It will look entirely different for each person. We’re not saying it’s bad or good. We’re saying to be honest with yourself and use it in a way that works for you.
Disclaimer: this episode is very generalized. Please understand that when we talk about some of the limitations of intuitive eating, this is not to say that intuitive eating does not work; it’s just to say intuitive eating might not be the answer for every single person out there.
I am SO excited for this post. So, let’s dive in!
When is intuitive eating NOT appropriate, and why?
Laura firmly believes intuitive eating should never be used for anyone in the early stages of treatment, which she would call fully up to the first 2 years of diagnosis of anorexia nervosa or bulimia nervosa. She says it is doable, but applying the 10 steps simply does not make scientific sense with that population.
Read on for a breakdown of a few of the steps and why they aren’t always appropriate within diagnosed eating disorders.
1. Reject the Diet Mentality
The last line of this principle reads: “If you allow even one small hope to linger that a new and better diet or food plan might be lurking around the corner, it will prevent you from being free to rediscover Intuitive Eating.”
Laura believes this line makes it clear that principles of intuitive eating were specifically designed for people who have been on weight-loss diets, and not someone who is actively struggling with an eating disorder. . “Rediscovering” intuitive eating doesn’t quite work for this population for the following reasons…
2. Honor Your Hunger
This principle specifically does not jive with someone with an eating disorder. Think about someone who is engaging in active restriction for a while and has lost the capacity to notice hunger cues. To tell them to eat only when they are hungry would basically be setting them up for undereating and malnourishment.
Laura notes that, within the United States, many people never have intuitive eating skills. The majority of people are likely born with them, but science, she says, shows that you can lose your intuitive eating skills around the age of 4. Yikes.
Not necessarily in a bad way but in our society, other factors drive eating.
Think about it: we all eat on a schedule, and children will eat based on habit more than anything else. Sometimes, a child cannot eat immediately when they’re hungry; maybe they have siblings at home and they have to wait an hour for dinner to finish cooking.
Those conditions end up breaking the connection with hunger cues.
It starts even before childhood. In the same way, we know that both breastfed and bottle-fed babies are intuitive eaters. But eventually, the reality of life gets in the way of that. Hunger and fullness cues are then not based on what we eat; it’s based on habit. We are externalized eaters.
Need more proof? Studies show we eat more when we’re around family and friends – and the more people at the table, the more we eat. Additionally, the visual appeal of food will make us eat more. Our society has basically made it very difficult for us to stay connected with our hunger-fullness cues. Again, not entirely a bad thing. It just is what it is.
People who meet the criteria for anorexia nervosa have a brain reward system that is actually rewarded through the absence of food, which is incredibly uncommon (3% of the population, according to Laura). So, the hunger cues go away and you can’t use physical hunger cues in this instance. It just doesn’t work.
3. Make Peace with Food
This principle says “give yourself unconditional permission to eat.”
Laura makes this great point: What thing in life do we get unconditional permission for?! Nothing! Everything in life requires balance, and moving from a rigid diet mentality of disordered eating to unconditional permission to eat is just not reasonable.
My thoughts? When someone reads that, it’s possible that they could jump to chaotic eating and find it difficult to stop. So basically we’d have someone going from significant restriction to bingeing. Not what we’re looking for here.
Yes, unconditional permission to eat is supposed to be within the framework of hunger cues and that a person may be able to moderate how they eat based on what their body is telling them. But none of these cues are front and center for someone who has ignored them for so long. We can’t expect a reasonable outcome if we pretended that they could just do this on their own.
Weight
We try to neutralize weight. We try to say it’s not important in determining health but if someone is malnourished, we almost need to focus on the weight.
Laura’s take on this? She’s still a huge advocate of measuring weight – that information is necessary. Weight is a vital sign. It correlates with health – NOT exclusively – but it gives you an objective metric.
Every data point is relevant and useful – including weight, fat cell size, body fat percentage, and BMI. We cannot ignore a piece of information.
This isn’t to say that weight is everything. It isn’t to say that if someone’s weight is lower or higher that it means much about their health. It is to say that weights are important information as part of a larger picture. Same way any other metric is an important factor in understanding someone’s gestalt.
Reasonable Rules
Laura notes that there are reasonable guidelines for all human behavior – even for food and nutrition. Laura has her own guidelines she follows in her practice.
She believes people, at a minimum, should eat 4 times a day. (It could be 6, too.) Breakfast is a must, because there is so much anecdotal evidence and research that shows that breakfast improves glucose metabolism and insulin response.
Additionally, she believes no foods are off limits and that it’s important to be able to eat for pleasure. So yes, you can eat whatever you want – but not in any portion size.
Moreover, she emphasizes the importance of sleep. Sleep is so connected to appetite regulation, specifically hunger. The more REM sleep you miss, the hungrier you are.
Intuitive Eating and Food Insecurity
In order to eat intuitively, you have to have access to means to get the foods that will satisfy you. So how does the intuitive eating framework fit for someone who may not have the means?
When we look at Maslow's hierarchy of needs, you see physiological needs at the bottom (air, water, food, clothing, and so on). If these needs aren’t being met – as is the case with people who struggle with food insecurity – you can’t really move up from there and the framework of intuitive eating doesn’t really apply.
When you don’t know where you’re getting your next meal, there is a constant feeling of starvation and hunger. The idea of pleasure is derived from low-cost, convenient food – AKA, cheap fast food. The idea of intuitive eating, says Laura, is for people who have already had their basic needs met and have higher needs (joy, pleasure, free time, etc.).
So if people are trying to heal from disordered eating but they don’t have the means to go out and honor their cravings, what would someone do for (a) treatment and (b) food?
For treatment, typically there would be one therapist who tends to their basic needs, and makes sure they feel understood. From there, you can recommend certain books you can get from the library and very basic information.
But Laura notes that it’s virtually impossible to get treatment for an eating disorder if you don’t have resources. The majority of nutrition services are not covered, aside from diabetes, kidney diseases, etc, so dietitians are out; look for a therapist.
For food, it’s worth noting that you’re more likely to see binge eating than anorexia nervosa in a lower-income population. It’s not exclusively so, of course; but the ability to refuse food is unlikely to happen in situations where food is already limited for you.
For the most part, if someone is struggling in this situation, it will be a very individualized approach. Anything you hear on a podcast or read in a book might not fit your life, and so really look at your situation and decide what makes sense for recovery at that point.
Tweetable Quotes
“We’ve got early data – but compelling data – about the fact that it is very related to the reward system in the brain. People who meet the criteria for anorexia nervosa have a brain reward system that is actually rewarded by the absence of food.” – Laura Pumillo
“Many, many, many people [in the US] never have intuitive eating skills. Were they born with them? Yes, most likely. But science shows that they can lose them by the age of 4.” – Laura Pumillo
“It’s going to be an individualized process. Anything you hear on a podcast or read in a book – any generalized information might not fit your personal life. So really looking at your situation and what makes sense for recovery at that point is going to be the only way to go.” – Rachelle Heinemann