A crash-course ED 101 for dietitians not familiar with eating disorders - What does "normal eating" mean and when does it become "disordered eating?" - What are the spectrum of eating disorders? - What are the causes of eating disorders and what does treatment involve? - What is the dietitian's role in eating disorders? - What are some ways to screen eating disorders and obsessive/compulsive exercise? - Why are "Health at Every Size" and "Intuitive Eating" effective approaches in preventing clinical eating disorders?

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GSDA Winter Conference
Mya Kwon, MPH, RD, CD
March 1, 2016
Eating Disorders 101 & 102

2. Overview
I. Normal Eating, Disordered Eating & Eating Disorders
 Normal eating
 Disordered eating
 DSM-5 Diagnostic criteria for eating disorders
II. Screening & Treatment of Eating Disorders/
Disordered Eating
 Screening tools
 RD’s role in ED
 Role of treatment team (Medical, Nutrition & Mental health)
 ED therapeutic models: HAES & Intuitive Eating
III. Resources / Q & A

3. What is “Normal” Eating?
 Going to the table hungry and eating until satisfied most of the times
—but may overeat at times or under-eat at times.
 Not thinking in terms of “good” and “bad” foods.
 Being able to give some thought to your food selection so you get
nutritious food, but not being so wary and restrictive that you miss out
on enjoyable food
 Giving yourself permission to eat sometimes because you are happy, sad
or bored, or just because it feels good
 Responding to and respecting hunger, then choosing foods based on
what the body says it wants or doesn’t want (most of the times)
 Aiming for enjoyment by staying connected to taste buds and the
feelings of fullness and satisfaction
Most importantly,
Normal Eating is FLEXIBLE!
Adapted from: Secrets of Feeding a Healthy Family by Ellyn Satter, and Rules of Normal Eating by Karen Koenig

4. What is Disordered Eating?
 Preoccupation over calories, grams, portions
 Preoccupation over weight loss or control of food
 Guilt, shame, disgust attached to foods
 Constantly eating for reasons other than hunger or true
cravings
 Believing that one’s identity and self worth is based on
size, weight, or what one eats
Disordered eating is when a person’s attitudes about food, weight and body
size lead to very rigid eating and exercise habits that can jeopardize one’s health and
happiness.
Balance, joy, flexibility, attunement w/ body
is replaced by preoccupation,
rigid rules, moral judgment, & negative feelings

5. Depression, Anxiety, Trauma, Stress
Low Self-Esteem, self-worth
Troubled Relationships
Difficulty managing emotions,
Feelings of inadequacy,
Lack of control in life, etc.
Deeply rooted issues underneath
that feed into ED behaviors :
Food and eating issues at the surface
manifested as ED behaviors:
 Serious psychological conditions that can affect the body physically and cause
significant harm
 Coping mechanisms in which a sufferer uses food or eating as a way of dealing with
difficult, thoughts, emotions and experiences over a period of time
What are Eating Disorders?

6. What causes Eating Disorders?
Psychological
Factors
Interpersonal
Factors
Social
Factors
 Low self-esteem
 Feelings of inadequacy, lack of control in life
 Depression, anxiety, stress, loneliness, trauma
 Troubled relationships
 Difficulty expressing emotions
 Hx of being teased based on size/weight
 Hx of physical or sexual abuse
 Cultural pressures that glorify “thinness” or muscularity
and place value on obtaining the “perfect body”
 Narrow definitions of beauty
 Cultural norms that value people on the basis of physical
appearance and not inner qualities and strengths
Biological
Factors
 Irregular hormone functions
 Genetics

7. Emotional Stress on Eating Disorders
Individuals in the following circumstances should be monitored for disordered
eating behaviors that indicate the use or avoidance food as a method to manage
stress
 Death or illness of a loved one (or other life-changing events)
 Rape, abortion, abuse
 Trauma of any kind
 Threats to safety or security
 Disappointment, particularly social rejection
 Comments about body weight, size or shape
 External pressure to lose or gain weight or a look a certain way for
participation in sport, dance or other activities
Setnick: The Eating Disorders Clinical Pocket Guide, 2nd Edition

8. High Risk Populations for Eating Disorders
Type I Diabetes  “Diabulimia”
 Mortality rate of “diabulimia” is highest in ED at approx. 35%
Female Athletes  High risk for female athlete triad
 disordered eating, low BMD, amenorrhea
Food Allergies
and Intolerances
 Multiple food allergies
 Pre-existing GI conditions: IBS, celiac, etc.
Obesity  Chronic dieting and weight cycling
 30% prevalence of BED in obese population
Individuals with the following conditions are at higher-risk for
developing clinical eating disorders
Adolescents  As many as 1% females between 12-18 have AN
 Up to 10% college students suffer from a clinical or nearly
clinical ED

9. Eating Disorder Cycle
Maintaining Factors
• Controlling food intake
• Black and white thinking
• Guilt / shame / anxiety
• Cognitive distortion
Restrict/Cope with food
• Unhappy with
life/self/body
• Need for control
• Foods as self-harm or self-
medication
Triggers
• Anything that lowers self-
esteem
• Changes in life – role, job, etc.
• Loss – including identity, self
respect, autonomy, money,
health
• Other events/ trauma
Vulnerability
• Culture valuing thinness
• Family rules, roles, expectations
• Adolescence
• Perfectionist
Symptoms/Effects of ED Behaviors
• Obsessed with food and calories
• Mood swings
• Cognitive distortion
• Restrict, binge, purge, etc.
• False sense of control or feeling
out of control
Eating Disorder
Belief Systems

10. Diagnosing Eating Disorders
 Diagnostic and Statistical Manual of Mental Disorders (now in its
5th edition) used almost universally as a reference
 DSM-5 still does NOT capture the wide range of human experience
of eating dysfunction
 Diagnosing eating disorders is not as straightforward as the charts
descriptions
The DSM-5 criteria should be considered a reference
and used in conjunction with clinical judgment,
common sense and professional ethics.

11. Anorexia Nervosa
DSM-5 Criteria
 Restriction of energy intake relative to requirements
leading to a significantly low body weight in the context of
age, sex, developmental trajectory, and physical health.
 Intense fear of gaining weight or becoming fat, or
persistent behavior that interferes with weight gain, even
though at a significantly low weight.
 Disturbance in the way in which one's body weight or
shape is experienced, undue influence of body weight or
shape on self-evaluation, or persistent lack of recognition
in the seriousness of the current low body weight
Subtypes
 Restricting AN
 Binge-eating/purging AN
• Eating disorder characterized by self-induced starvation and excessive weight loss.
• Third most common chronic illness among adolescents
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013). American Psychiatric Association.

12. DSM-5 Anorexia Severity Rating
• Weight in “normal range” (BMI
>18.5)
Atypical Anorexia
(FED-NEC)
• BMI between 17-18.5Mild Anorexia
• BMI between 16-16.9
Moderate
Anorexia
• BMI between 15-15.9Severe Anorexia
• BMI <15Extreme Anorexia

13. Warning signs:
 Significant weight loss
 Distorted body image
 Intense fear/anxiety about gaining weight
 Preoccupation with weight, calories, food, etc.
 Feelings of guilt after eating
 Denial of low weight
 High levels of anxiety and/or depression
 Low self-esteem
 Self-injury
 Withdrawal from friends and activities
 Excuses for not eating/denial of hunger
 Food rituals
 Pale appearance/yellowish skin-tone
 Thin, dull, and dry hair, skin, and nails
 Cold intolerance/hypothermia
 Fatigue/fainting
 Abuse of laxatives, diet pills, or diuretics
 Excessive and compulsive exercise
Anorexia Nervosa
Possible medical complications:
 Amenorrhea
 Abnormally slow and/or irregular heartbeat
 Low blood pressure
 Anemia
 Poor circulation in hands and feet
 Muscle loss and weakness
 Dehydration/kidney failure
 Edema/swelling
 Memory loss/disorientation
 Chronic constipation
 Growth of lanugo hair
 Bone density loss/Osteoporosis
National Eating Disorders Association www.nationaleatingdisorders.org

14. Bulimia Nervosa
DSM-5 Criteria
 Recurrent episodes of binge eating characterized by
BOTH of the following:
1) Eating in a discrete amount of time (within a 2 hour
period)large amounts of food AND feeling lack of
control over eating during an episode.
2) Followed-by a recurrent inappropriate
compensatory behavior in order to prevent weight
gain
 The binge eating and compensatory behaviors both
occur, on average, at least once a week for three months.
• Eating disorder characterized as binging (excessive or compulsive consumption of
food) and purging(e.g. vomiting, use of laxatives/diuretics, fasting and/or excessive
exercise)
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013). American Psychiatric Association.

15. DSM-5 Bulimia Severity Rating
• Less than 1 episode per week or less
than 3 months duration
Bulimia of low freq.
or limited duration
(FED-NEC)
• 1-3 episodes / weekMild Bulimia
• 4-7 episodes / weekModerate Bulimia
• 8-14 episodes / weekSevere Bulimia
• >14 episodes / weekExtreme Bulimia
Based on weekly average of past 3 months

16. Warning signs:
 Bingeing and purging
 Secretive eating and/or missing food
 Visits to the bathroom after meals
 Preoccupation with food
 Weight fluctuations
 Self-injury
 Excessive and compulsive exercise regimes
 Abuse of laxatives, diet pills, and/or diuretics
 Swollen parotid glands in cheeks and neck
 Discoloration and/or staining of the teeth
 Broken blood vessels in eyes and/or face
 Calluses on the back of the hands/knuckles
(from self-induced vomiting)
 Sore throat
 Heartburn/reflux
 Self-criticism and low self-esteem
 High levels of anxiety and/or depression
Bulimia Nervosa
Possible medical complications:
 Electrolyte imbalances
(can lead to irregular heartbeat and seizures)
 Edema/swelling
 Dehydration
 Vitamin and mineral deficiencies
 Gastrointestinal problems
 Chronic irregular bowel movements and
constipation
 Inflammation and possible rupture of the
esophagus
 Tears in the lining of the stomach
 Chronic kidney problems/failure
 Tooth decay
National Eating Disorders Association www.nationaleatingdisorders.org

17. BED: Binge Eating Disorder
DSM-5 Criteria
 At least 1 > week, for 3 months:
• Experience loss of control over eating AND consume an
abnormally large amount of food in a short period of time
 Episodes feature at least 3 of the following:
• consuming food faster than normal;
• consuming food until uncomfortably full;
• consuming large amounts of food when not hungry;
• consuming food alone due to embarrassment;
• feeling disgusted, depressed or guilty after eating a large
amount of food.
 Marked distress regarding binge eating present
 No evidence of regular compensatory behavior associated with BN,
nor do they binge eat solely during an episode of BN or AN.
• Recognized as its own disorder in DSM-5
• Most common ED in the U.S.
• Estimated 3.5% of women, 2% of men, and 30-40% of those seeking wt loss treatment
can be clinically diagnosed with BED

18. Warning signs:
 Eating large quantities of food, without purging
behaviors, when not hungry
 Sense of lack of control over eating
 Eating until uncomfortably/painfully full
 Weight gain/fluctuations
 Feelings of shame and guilt
 Self-medicating with food
 Eating alone/secretive eating
 Hiding food
 High levels of anxiety and/or depression
 Low self-esteem
Binge Eating Disorder
Possible medical complications:
 Overweight or obese
 Type II Diabetes
 Osteoarthritis
 Lipid abnormalities (Including increased
cholesterol)
 Increased blood pressure
 Chronic kidney problems
 Gastrointestinal problems
 Heart disease
 Gallbladder disease
 Joint and muscle pain
 Sleep apnea
National Eating Disorders Association www.nationaleatingdisorders.org

19. Feeding or Eating Disorder
Not Elsewhere Classified
 Characterized as disturbances in eating behavior that do not necessarily fall
into the specific category of anorexia, bulimia, or binge eating disorder
 Most common eating disorder diagnosis
 Without treatment, 80% of FED-NEC patients are likely to develop full-
spectrum eating disorders (particularly AN)
FED-NEC:
Example of Presentations:
 Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met,
except the individual's weight is within or above the normal range.
 Bulimia nervosa (of low frequency and/or limited duration)
 Binge-eating disorder (of low frequency and/or limited duration)
 Purging Disorder: Recurrent purging behavior to influence weight or shape
(e.g., self-induced vomiting, misuse of laxatives, diuretics, or other medications in
the absence of binge eating)
 Night eating syndrome: Recurrent episodes of night eating, as manifested by
eating after awakening from sleep or by excessive food consumption after the
evening meal
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013). American Psychiatric Association.

20. …and more Eating Disorders
 Unspecified Feeding or Eating Disorder (USFED)
o Symptoms of eating disorders causing clinical distress present
o But do NOT meet full diagnostic criteria for any other ED
 Avoidant/Restrictive Food Intake Disorder
 Body Dysmorphic Disorder
o Preoccupation with one or more perceived defects or flaws in physical
appearance that are not observable by others
o Performs repetitive behaviors or repetitive mental acts in response to
appearance concerns
o Preoccupation not better explained by concerns with body fat or weight in
an individual whose symptoms meet diagnostic criteria for an eating
disorder
o Subtype: w/ muscle dyspmorphia
Setnick: The Eating Disorders Clinical Pocket Guide, 2nd Edition
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013). American Psychiatric Association.

21. Orthorexia Nervosa
Common Clinical Features
 Phobic avoidance of foods perceived to be unhealthy
 Severe emotional distress after eating a food considered unhealthy
 Obsession to eat only “natural” and “organic” foods
 Uneasiness of foods prepared by others
 Following a restrictive diet prescribed for a medical condition that the individual does not
have, or in order to prevent illness not known to be influenced by diet.
 Insisting on the healthy benefits of the diet in the face of evidence to the contrary
 Shares features of AN and OCD –drive is to be “pure” or “natural” as opposed to “thin”
 May become malnourished or emaciated d/t food rules, restrictions
 The worse one feels d/t restrictions and limitations, the more one will continue to blame
certain foods or food additives
 Likely an attempt to manage anxiety and/or attempt to bolster self-esteem
• Not yet officially recognized in the DSM-5, but increasingly recognized in the
medical community.
Setnick: The Eating Disorders Clinical Pocket Guide, 2nd Edition
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013). American Psychiatric Association.

22. Red-flag Thoughts & Behaviors
 Preoccupation with food, eating, food rituals, body weight(or body
composition), size, shape and/or weight loss
 Elimination of certain foods, food groups
 Self-worth dependent on weight, size/shape, choice of foods, control of
food
 Excessive weight checking, body checking
 Moral judgment attached to foods eaten or not eaten
 Difficulty focusing on other aspects of life due to focus on controlling food,
body, weight
 Avoidance of enjoyable activities, social functions due to weight/body or
worries around food resulting in self isolation
 Belief in weight loss (or changing body) as a solution to unrelated issues:
e.g. relationships, stress, happiness, etc.
 Willingness to harm self due to weight, body, food goals
 Poor affect management, poor self-care
 Disassociation from internal(hunger/fullness/cravings) cues
and reliance on rigid rules

23. unrealistically
“It’s all about will-power” ?
Restriction:
“I’m Trying to
be Good”
“I’m Bad
now”: guilt &
shame
Increased
thoughts
about Food
“What the
heck”
response:
Binge
Give in.
“I cheated”
Identify the Vicious Cycle
Consequences:
 Weight cycling
 Increased food & body
preoccupation
 Increased sense of failure
 Decreased self-esteem
 Decreased self-worth

24. ED Screening Tools
 Are you terrified about being overweight?
 Do you find yourself preoccupied with food?
 Have you gone on eating binges where you felt if was difficult to stop?
 Have you ever vomited, used laxatives, or obsessively exercised after
eating?
 Do you feel extremely guilty after eating?
 Are you preoccupied with a desire to be thinner?
 Do you think about burning up calories when you exercise?
 Are you preoccupied with the thought of having fat on your body?
 Do you feel that food controls your life?
 Do you think you give too much time and thought to food?
EAT-11 link: http://screening.mentalhealthscreening.org/NEDA
EAT-26 link: http://www.eat-26.com
Obsessive/Compulsive exercise test:
http://www.lboro.ac.uk/media/wwwlboroacuk/content/ssehs/downloads/compulsive-exercise-
test.pdf
EAT-11 (via National Eating Disorders Association)

25. Is it the RD’s job to diagnose ED?
 Never doubt that you may be the first to identify it
 You can address the ED or disordered eating behaviors without naming
them
 Sometimes, naming it can be relieving for the patient
 Bring your findings to the attention of the patient’s treatment team so
that you can advocate for your patient’s treatment
 It is your responsibility to help a patient identify additional treatment
needs
 Opening the door to treatment is an intervention
 Nonjudgmental listening, validation and normalization are interventions
and can provide a foundation for healing by allowing an individual to
speak openly about eating issues without shame.
No, but…
Content of this slide is reproduced with permission from Jessica Setnick, MS, RD

26. Advocating for your (larger) patient
 Always prioritize behavior change rather than weight loss
 Explain the situation to other providers, possibly family members,
including the need for specialized treatment
 Get comfortable recommending counseling and evaluation for psychiatric
care
 Weight loss doesn’t happen on a schedule
 Weight loss for someone with an eating disorder is acceptable as a
consequence of healthy eating habits. –NOT acceptable as a goal.
 That doesn’t mean it’s wrong for the patient to want to lose weight
Content of this slide is reproduced with permission from Jessica Setnick, MS, RD

27. Essential Care Team in ED
Depression, Anxiety, Trauma, Stress
Loneliness, Low Self-Esteem,
Troubled Relationships
Difficulty managing emotions,
Feelings of inadequacy,
Lack of control in life, etc.
Deeply rooted issues underneath
that feed into ED behaviors :
Therapy
Food and eating issues at the surface
manifested as ED behaviors:
Restricting, Binging,
Purging, Emotional/Stress Eating
Nutrition
Monitoring and evaluation
for medical stability
Medical

28. Level of Care for Eating Disorders
Level 1
Out-patient
 Scheduled appointments with multi-disciplinary treatment team
 Medical provider, therapist, dietitian
Level 2
IOP
 Intensive out-patient treatment of 2-3 times week
 Individual therapy, group therapy, nutrition therapy
 Possibly support meals
Level 3
PHP
 Partial hospitalization program/day program
 5 days a week, 8 hours a day
 Similar to IOP, but more intensive and tightly structured
Level 4
Residential
 Residential in-patient
 Long-term care: 24 hours a day treatment
Level 5
Hospital
 Hospital in-patient
 Short-term
 Crisis stabilization

29. Nutrition Intervention Goals of the RD
1. Nutrition rehabilitation to support:
o Medical stability and weight restoration
o Physiological/cognitive function restoration
2. Support “Normalized” eating including:
o Variety and balance of foods
o Nutritional adequacy
o Absence of binge/purging behaviors
3. Gentle and safe physical activities
4. Support client in increasing confidence and skills
in eating through:
o Accurate nutrition knowledge
o Intuitive/Mindful eating
o Reframing irrational beliefs regarding food/
body/weight/eating
o Effective behavioral strategies
5. Support client to live a fuller life with less rigidity,
but more balance and flexibility in food and
nutrition
Nutrition Rehabilitation
: MNT
Ambivalence & Change
MNT, CBT, DBT, IE, HAES
Recover & Thrive
: IE, HAES

30. Treatment Goals
 Ultimate goals of eating disorder treatment
o Medical/physical stability and physical health restoration  fully refed
o “Normalized” eating, including variety, balance, nutritional adequacy and
comfort with food
o “Normalized” and safe physical activities
o Absence of purging behaviors
o Healthy coping mechanisms for triggers
o Improved mental health
o “Good enough” body image
o Sense of flexibility in thoughts of body and food
o Full perceived body experience
o Sense of integration and connection
o Supportive social structure in place to prevent relapse during stress

31. Therapeutic Models for ED Treatment
Modality Philosophy
FBT Most effective for children up to 19 yo residing at home. Parents
as a resource in the treatment of adolescent patients with AN.
CBT Irrational beliefs lead to irrational and destructive responses.
Challenge thoughts to change behavior.
DBT Accept thoughts as flawed, choose alternate behaviors. Coping
skills and distress tolerance promote recovery.
Health at Every Size
(HAES)
Self-acceptance irrespective of body size is the foundation of
good health and normal eating.
Intuitive Eating/
Non-diet Approach
Respectful responsiveness to hunger, satiety and emotions
promotes eating disorder recovery (and effective in prevention!)
Motivational
Interviewing
Increased awareness of internal ambivalence and more
confidence in one’s abilities enhance behavior change.
Selected list from- Setnick: The Eating Disorders Clinical Pocket Guide, 2nd Edition

32. Why Health at Every Size(HAES)?
America’s diet industry = prescription for Eating Disorders
 Private weight-loss industry estimated at $61 billion annually in the U.S.
 Unprecedented levels of body dissatisfaction and repeated attempts to lose
weight
 More than 90% of individuals unable to maintain weight loss over long term
Downfalls of the conventional “weight-focused” paradigm
 Ineffective at producing thinner, healthier bodies (even damaging!)
 Increases food and body weight preoccupation
 Creates “weight-cycling”
 Distraction from other personal health goals and wider health determinants
 Reduced self-esteem
 Increased risk for eating disorders
What is HAES?
 A research-based trans-disciplinary movement that supports taking the focus
off of weight(loss) and putting it on health
 Encourages self-acceptance and self-care as the foundation of one’s health

33. Core Principles of HAES
1. HAES encourages Body-Acceptance and Self-Compassion
 Shame does not motivate beneficial lifestyle change
 Self-acceptance is a cornerstone of self-care
Goss K, Allen S: Compassion focused therapy for eating disorders. Int J of Cognitive Therapy 2010, 3:141-158.
Bacon L, Stern J, Van Loan M, Keim N: Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am
Diet Assoc 2005, 105:929-936.
Acceptance
Increase in self-
care ability
Sustainable improvements in
health behaviors
2. HAES supports reliance on internal regulatory processes, such as
hunger and satiety, as opposed to encouraging cognitively-imposed
dietary restriction
3. HAES supports active embodiment as opposed to encouraging
structured exercise

34. Research supporting HAES
Review of RCT studies comparing “non-diet” approach vs. weight-focused diet
 Non-diet approach associated with statistically and clinically relevant improvements
in:
 Physiological measures (e.g. blood pressure, blood lipids, insulin sensitivity)
 Health behaviors (e.g. physical activity, eating disorder pathology)
 Psychosocial outcomes (e.g. mood, self-esteem, body image)
Bacon, Linda. Weight Science: Evaluating the Evidence for a Paradigm Shift. (2011) Nutrition Journal
Emerging as standard of practice in the ED field, and supported by:
 The Academy for Eating Disorders
 Binge Eating Disorder Association
 Eating Disorder Coalition
 International Association for Eating Disorder Professionals
 National Eating Disorder Association
 The Academy of Nutrition and Dietetics

35. HAES Guidelines for Clinicians
HAES guideline for clinicians as supported by the
“Association for Size Diversity and Health” & “Academy of Eating Disorders”
 Interventions should focus on health, not weight, and should be referred to as
“health promotion” and not marketed as “obesity prevention.”
 Interventions should be constructed from a holistic perspective, where
consideration is given to physical, emotional, social, intellectual, spiritual
aspects of health.
 Interventions should promote self-esteem, body satisfaction, and respect for
size diversity
 Lifestyle-oriented elements of interventions that focus on physical activity and
eating should be delivered from a compassion-centered approach that
encourages self-care rather than as prescriptive injunctions to meet expert
guidelines
 Interventions should focus only on modifiable behaviors where there is
evidence that such a modification will improve health. Weight is not a
behavior and therefore not an appropriate target for behavior modification

36. Why Intuitive Eating?
Restrictive Diets DON’T Work
 90-95% failure rate (of gaining back in within
one year)
 Weight cycling is associated with heavier
weight
 Increases cravings and food obsessions
 Decreases metabolism
 Increases stress, fatigue, feelings of failure,
anxiety, sleep disturbance
IE promotes balance, choice, wisdom and acceptance.
 Increased production of fat-storage enzymes
 Reduced production of appetite-suppressing hormones
Herbert BL, Blechert J, Hautzinger M, Matthias E., Herbert C..(2013). Intuitive eating is associated with interoceptive
sensitivity. Effects on body mass index. Appetite, 70 (Nov) 22-30
Denny KN, Loth K, Eisenberg ME, Neumark-Sztainer D(2013). Intuitive eating in young adults. Who is doing it, and how
is it related to disordered eating behaviors? Appetite. Jan; 60 (1)13-9

37. Key Components of Intuitive Eating
1. Unconditional permission to eat
2. Eating primarily for physical rather than emotional reasons
3. Relying on internal hunger, fullness, and satiety cues
What can be achieved through Intuitive Eating
 Awareness of hunger and fullness
 Recognize non-hunger triggers
 Meet other needs effectively without food
 Eat for nourishment and enjoyment
 Increase satisfaction from eating
 Self-empowerment
 Trusting and listening to one’s own body: non-judgmentally & with
self-compassion
 Invest energy in living a vibrant life (not preoccupation in food)

38. 10 Key Intuitive Eating Principles
1. Reject the Diet Mentality
2. Honor your Hunger
3. Make Peace with Food
4. Challenge the Food Police
5. Respect Fullness
6. Discover your Satisfaction Factor
7. Honor Feelings without Food
8. Respect your Body
9. (Intuitive) Exercise – Feel the Difference
10. Honor your Health (with Gentle Nutrition)
Intuitive Eating is an individual’s attunement with food, mind and body.

39. Readiness for Intuitive Eating in ED
o Biological restoration and balance
o Recognition that the eating disorder is not about weight or
food, but rather something deeper
o Ability to recognize and willingness to deal with feelings
o Ability to identify wants and needs
o Tolerate risk
o Tolerate being uncomfortable
Indicators for when Intuitive Eating approaches may be
appropriate in ED patients
Therefore, IE may not be appropriate in acute stages of
an Eating Disorder

40. Some Take-Aways
 Balance, joy, flexibility, and attunement w/ the body are key components
of “normal” eating
 Rigid rules, moral judgment, negative feelings (guilt/shame), self-worth
tied with food/body/weight are red flags for disordered eating
 Eating disorders are complex conditions that arise from a combination of
long-standing behavioral, emotional, psychological, interpersonal and
social factors
 RDs may be the first ones to identify ED behaviors: refer and advocate
treatment for your patients!
 Nonjudgmental listening, validation and normalization are
interventions and can provide a foundation for healing
 Use HAES approaches to promote healthy behaviors and self-
acceptance regardless of size or weight
 Use Intuitive Eating approaches to help patients reconnect and
work with their bodies, not against them!

42. Book Resources
 Eating Disorders: A Guide to Medical Care and Complications (Philip Mehler, MD.,
Arnold Anderson, MD. )
 Nutrition Counseling in the Treatment of Eating Disorders (Marcia Herrin, Ed.D,
MPH, RD)
 The Compassionate-Mind Guide to Ending Overeating (Ken Goss, Dclin.Psy)
 Overcoming Binge Eating (Chris Fairburn, DM, FMedSci, FRCPsych.)
 Health at Every Size: The surprising truth about your weight (Linda Bacon, Ph.D)
 Body Respect (Linda Bacon, Ph.D)
 Intuitive Eating (Evelyn Tribole, MS, RD.)
 The Rules of Normal Eating (Karen Koenig, LICSW)

43. On-line Resources
 Academy of Eating Disorders: www.aedweb.org
 Behavioral Health Nutrition (Academy of Nutrition & Dietetics):
www.bhndpg.org
 Eating Disorders Coalition: www.eatingdisorderscoalition.org
 International Association of Eating Disorder Professionals:
www.iaedp.com
 International Federation of Eating Disorders Dietitians:
www.eddietitians.com
 National Association of Anorexia and Associated Disorders:
www.anad.org
 National Eating Disorders Association: www.nationaleatingdisorders.org
 Health at Every Size Community
www.HAES.org
 Association for Size Diversity and Health:
www.sizediversityandhealth.org
 Intuitive Eating www.intuitiveeating.com

44. Thank you!
Mya Kwon, MPH, RD, CD
nutrition@myakwon.com
www.myakwon.com