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INTUITIVE EATING FOR DIABETES Is it possible? How to apply it?
PRESENTED BY LAURA CIPULLO, RD, CDE, CDN, CEDRD
OBJECTIVES ¢ What is Intui4ve Ea4ng? ¢ What is Mindful Ea4ng? ¢ What is the difference between Intui4ve Ea4ng and Mindful Ea4ng?
¢ Can someone with diabetes eat using internal regula4on? Mindful ea4ng?
¢ How—and why—do RDs teach their clients to manage their food and blood sugar while being intui4ve?
DEFINED ¢ Intui4on
� a natural ability or power that makes it possible to know something without any proof or evidence
� a feeling that guides a person to act a certain way without fully understanding why
¢ Mindfulness � a state of being aware
DEFINED BY WEBSTER’S
INTUITIVE EATING versus MINDFUL EATING ¢ Similari4es
• Both encompass compassion and developing a mastery of internal awareness—what you feel on the inside such as hunger and fullness.
• Both say “no” to fad diets and stress learning how to eat all foods in a saHsfying manner.
¢ Differences • Intui&ve Ea&ng (IE) is based on 10 disHnct principles, summarized by three core characterisHcs1 1. Eat for physical rather than emo,onal reasons 2. Rely on internal hunger and saHety cues 3. UncondiHonal permission to eat—when hungry and whatever food is desired
• Mindful Ea&ng (ME) is related to specific Eastern principles of mindfulness. Whatever path moves you forward is the one you should take.2
INTUITIVE EATING THE TEN PRINCIPLES3
1. Reject the Diet Mentality. Throw out the diet books and magazine arHcles that offer you false hope of losing weight quickly, easily, and permanently. No small hopes for quick fixes—it will prevent you from being free to rediscover IntuiHve EaHng.
2. Honor Your Hunger. Keep your body biologically fed with adequate energy and carbohydrates. Otherwise, you can trigger a primal drive to overeat. Set the stage for re-‐building trust with yourself and food.
3. Make Peace with Food. Call a truce; stop the food fight! Give yourself uncondiHonal permission to eat. If you tell yourself that you can't or shouldn't have a parHcular food, it can lead to intense feelings of deprivaHon o\en leading to binging or secret eaHng.
4. Challenge the Food Police. Scream a loud “NO” to thoughts in your head that declare you're “good” for eaHng minimal calories or “bad” because you ate a piece of chocolate cake.
5. Respect Your Fullness. Listen for the body signals—no longer hungry, comfortably full.
INTUITIVE EATING THE TEN PRINCIPLES3 CONTINUED
6. Discover the Sa4sfac4on Factor. When you eat what you really want, in an environment that is inviHng and conducive, the pleasure you derive will help you feel saHsfied and content. You will find that it takes much less food to decide you've had “enough.”
7. Honor Your Feelings Without Using Food. Find ways to comfort , nurture, distract, and resolve your issues without using food.
8. Respect Your Body. Accept your geneHc blueprint. Respect your body so you can feel be_er about who you are. It's hard to reject the diet mentality if you are unrealisHc and overly criHcal about your body shape.
9. Exercise—Feel the Difference. Forget militant exercise. Just get acHve and feel the difference. Shi\ your focus to how it feels to move your body, rather than the calorie burning effect of exercise.
10. Honor Your Health—Gentle Nutri4on. Make food choices that honor your health and taste buds while making you feel well. Remember that you don't have to eat a perfect diet to be healthy. You will not suddenly get a nutrient deficiency or gain weight from one snack, one meal, or one day of eaHng. It's what you eat consistently over Hme that ma_ers. Progress, not perfecHon, is what counts.
RD SPEAK:
� There are no “good” and “bad” foods. No value or moral judgments. � Use internal self regulaHon via a hunger fullness scale. Say “no” to fad diets, skipping meals, restricHng or extreme behaviors.
� There are three types of hunger: • Physical—fuel: belly and brain • Behavioral—Hme of day, habit, social • EmoHonal—happy, sad, angry
� Eat mostly for physical reasons and some pleasure. � Focus on how food makes you feel.
When thinking about food…
RESEARCH Improving diabetes self-‐management through acceptance, mindfulness, and values: A randomized controlled trial.4
� 81 paHents in a low-‐income community health center w/DM II one-‐day educaHon workshop.
� EducaHon (manage DM) alone versus a combinaHon of educaHon plus
acceptance and commitment therapy (ACT).
� EducaHon and ACT learned to apply acceptance and mindfulness skills to difficult diabetes-‐related thoughts and feelings.
� 3 months later, ACT-‐condiHoned group was more likely to use coping strategies, report be_er diabetes self-‐care, and have HbA1C values in target range.
� Analyses indicated that changes in acceptance, coping, and self-‐management behavior mediated the impact of treatment on changes in HbA1C.
MINDFULNESS-BASED STRESS REDUCTION (MBSR)5
MINDFULNESS-BASED STRESS REDUCTION IS ASSOCIATED WITH IMPROVED GLYCEMIC CONTROL IN TYPE 2 DIABETES MELLITUS: A PILOT STUDY
STEVEN ROSENZWEIG, MD; DIANE K. REIBEL, PHD; JEFFREY M. GREESON, PHD; JOEL S. EDMAN, DSC; SAMAR A. JASSER, MD; KATHY D. MCMEARTY, BA; BARRY J. GOLDSTEIN, MD, PHD
� 8-‐week group intervenHon shown to reduce stress-‐related symptoms in various paHent populaHons.
� The core of MBSR involves training in mindfulness meditaHon—a pracHce of self-‐regulaHng a_enHon that lowers reacHvity to stress triggers.
� Obj -‐ To esHmate changes in glycemic control, weight, blood pressure, and stress-‐related psychological symptoms in paHents with type 2 diabetes.
MINDFULNESS-BASED STRESS REDUCTION (MBSR)5 � 8 weekly 150-‐minute sessions (1 per week) plus a 7-‐hour
weekend session. � Follows the curriculum developed at the University
of Massachuse_s Stress ReducHon Program by Dr. Jon Kabat-‐Zinn.
� A range of mindfulness meditaHon techniques are taught: body scan, awareness of breathing, mindful walking, mindful eaHng, and mindful communicaHon.
� ParHcipants are trained to pay full a_enHon to present-‐moment experience, choosing to respond skillfully rather than react automaHcally to external events, thoughts, or emoHons.
� Home pracHce -‐ at least 20 to 30 minutes of formal meditaHon per day, 6 days per week.
MINDFULNESS-BASED STRESS REDUCTION (MBSR)5 ¢ Results: Improved glycemic regulaHon in type 2 diabetes. Mean body weight did not change, making unreported significant changes in diet or exercise unlikely. ¢ Explana4on: Counter-‐regulatory effects of the physiological response to stress. Stress-‐mediated producHon of corHsol, norepinephrine, beta endorphin, glucagon, and growth hormone increases blood glucose and insulin resistance. Mindfulness training appears to down-‐regulate an individual’s psychological reac4vity to stress triggers, which may miHgate physiological stress response and thereby improve glycemic regulaHon. ¢ Limita4ons: Absence of a control group and a small cohort size. Findings warrant further invesHgaHon of MBSR with a randomized clinical trial.
COMPARATIVE EFFECTIVENESS OF A MINDFUL EATING INTERVENTION TO A DIABETES SELF MANAGEMENT INTERVENTION AMONG ADULTS WITH TYPE 2 DIABETES: A PILOT STUDY ¢ Do intervenHon techniques that enhance mindful self-‐awareness
improve well-‐being, including anxiety and depression, eaHng disorders, food cravings, and weight loss?
¢ Mindful eaHng, as taught in Mindfulness-‐Based EaHng Awareness Training (MB-‐EAT)6—making conscious food choices, developing awareness of physical versus psychological hunger and saHety cues, and eaHng healthfully in response to those cues.
RESULTS OF MB-EAT
¢ Subjects who parHcipated in a 9-‐week mindfulness-‐based eaHng program had less insulin resistance a\er meals than subjects who received convenHonal weight-‐loss educaHon.
¢ This result was a_ributed to the relaxaHon response, a byproduct of mindfulness.6
IE AND DIABETES—HAES Weight Science: Evalua4ng the Evidence for a Paradigm Shi`—HAES8 ¢ “An appropriate, healthy weight for an individual cannot be determined by the numbers on a scale, by a height/weight chart, or by calculaHng body-‐mass index or body fat percentages, rather, HAES defines a ‘healthy weight’ as the weight at which a person se_les as they move toward a more fulfilling and meaningful lifestyle.” Robinson
¢ HAES folks say, everybody isn’t at a weight that’s healthy for them. However, they say, “movement toward a healthier lifestyle over Hme will produce a healthy weight for that person.” � Weight cycling not healthy � Obesity may be a symptom of Diabetes not vice versa
IE AND DIABETES—HAES
¢ U.S. Department of Agriculture’s Agricultural Research Service detailed a study that pi_ed two teams of obese women against each other.9 � Every Size group improved cholesterol, blood pressure and
exercise at 2 years (vs dieters)
HAES—HEALTH AT EVERY SIZE Self-‐acceptance: affirmaHon and reinforcement of human beauty and worth, regardless of differences in weight, physical size, and shape; Physical acHvity: support for increasing social, pleasure-‐based movement for enjoyment and enhanced quality of life; and Normalized eaHng: support for discarding externally imposed rules and regimens for eaHng and a_aining a more peaceful relaHonship with food by relearning to eat in response to physiologic hunger and fullness cues.
HAES—HEALTH AT EVERY SIZE ¢ The overarching goal for health professionals is to help people live
healthier, more fulfilling lives by caring for the bodies they presently have.
¢ HAES offers an effecHve, compassionate alternaHve to the failures of tradiHonal approaches. There is a significant body of literature that clearly demonstrates that most so-‐called weight-‐related problems can be treated effecHvely with li_le if any weight loss.
¢ Even in type 2 diabetes, blood glucose can be normalized without weight loss even when the paHent remains markedly obese by tradiHonal medical standards. Further strengthened by the research showing that obese individuals who are acHve and fit have lower mortality rates than normal-‐weight persons who are inacHve and unfit. Recent research HAES approach is superior to state-‐of-‐the-‐art, behavioral weight-‐loss intervenHon for improving the long-‐term health of obese parHcipants.10
TEACHING OUR CLIENTS Ini4al Nutri4on Evalua4on
� Is the client ready and or wanHng to learn how to eat in such a manner? What are his/her objecHves?
(RD to idenHfy “Stages of Change”) � Is the client on insulin, OHA or meds that may affect blood
glucose? � What do the client’s food and blood glucose logs reflect? � Does the client report categorizing food as “good” or “bad,”
a dieHng mentality, yo-‐yo weight pa_erns and/or feelings of loss and shame for not being able to manage his/her blood sugar?
DIABETES AND MEAL PLANNING ¢ Consistent Carbohydrate Coun4ng—
� 3 meals, 3 snacks -‐ ? Eat q 3-‐4 hrs � For Type I, II, GestaHonal, Teens…
¢ Mindful Ea4ng � PracHce mindfulness (guided meditaHon, using an app,
breathing and/or centering) before and a\er meals. � IdenHfy why you are eaHng:
? Physical Hunger ? EmoHonal Hunger ? Behavioral Hunger
� Decide if you want to eat.
ABOUT TO EAT AND…
In the beginning: 1. Take blood glucose and log 2. Choose grams of carbs, likely 45 to 60 grams 3. For clients using insulin: take insulin as needed for grams
of carbs 4. IdenHfy number on Hunger Fullness Scale and log 5. Complete part of CBT food and blood glucose log 6. Center/Breathe
(Apps such as Buddhify or MeditaHon Oasis: h_p://buddhify.com or h_p://www.meditaHonoasis.com)
THE EXPERIENCE OF EATING 1. Use five senses: Touch, Taste, Listen, Smell, Look
(The M and M Experience)
2. Stop at about 7 on H/F Scale (Protein and Fat) 3. Mindful Exercise again a\er meal 4. Complete CBT food log 5. Take blood sugar two hours later (one hour later for GM) 6. Ascertain whether this food combinaHon was filling,
saHsfying and appropriate for blood glucose management
In 4me, can this client swing between Mindful Ea4ng and Intui4ve Ea4ng?
CASE EXAMPLE ¢ Male age 65 ¢ Dx: DM x 19 yrs, HTN, High Chol, Club Foot, and Depression
¢ Obj – wt loss 20-‐30# � Reports 3-‐4 yrs eaHng out
of control � 6 yrs ago: 170# � 2 yrs ago: 180# � First session reports –
190# – I did not weigh Ht 5’5”
¢ Meds Mewormin, Glyburide, StaHn, Actos, Aspirin, Buprion
¢ Labs � TG 275 � Glu 130 fasHng � HgA1C 10.7
CASE EXAMPLE ¢ Educate on C, P, F ¢ How affects bld glu ¢ Set small goals
¢ 2 weeks later Checked blood glu post breakfast of oatmeal with almonds x 3 – 164, 184, 189
¢ Likes Greek Yogurt Fage, added nuts to oatmeal, enjoying GoLean
¢ Found a bread with 3 grams fiber
¢ 2 slices bread ¢ Walking 15 min 4 Hmes week
2 MONTHS LATER ¢ Walking 15-‐20 minutes during lunch hours at work ¢ Walking 30-‐45 minutes on weekends ¢ 2 hours post dinner: 135 – 140 mg/dl ¢ Lost 7-‐8 pounds
CASE EXAMPLE RW ¢ Knew concept of CCC from gest. DM x 2
¢ Borderline DM, HTN ¢ Introduce no good food or bad food
¢ Educate on nutrient density and how affects blood sugar and energy
¢ Introduce moving for self care and your own Hme
¢ Introduce Mindfulness
¢ RW story in DCFDC ¢ Guest blogger on MDIO ¢ Lost 22 pounds and kept off over one year now
¢ Moves daily and loves it ¢ Favorite Hme of day is riding her bike, walking to/from Penn StaHon
¢ Blood Glu, HTN & Heart
WHAT IF… ¢ Overea4ng ¢ High postprandial blood glucose
¢ Intake of high glycemic index foods
¢ Pacing of meals ¢ Sessions
� 1 on 1 � groups
¢ Overea4ng/binge ea4ng is suspected… � A temporary break with
the ulHmate goal of reintegraHng client mindfully and moderately
� H/F cues/Internal Regulators can take months (years) to fully return
� Eat 60-‐90 minutes a\er waking, eat every 3-‐4 hours...
ADDITIONAL RESOURCES—BOOKS The Diabetes Comfort Food Diet Cookbook
By Laura Cipullo, RD, CDE, CEDRD & the editors of PrevenHon rodalestore.com/diabetes-‐comfort-‐food-‐diet-‐cookbook.html?___SID=U
Eat What You Love, Love What You Eat with Diabetes By Michelle May, MD and Megre_e Fletcher, MED, RD, CDE
Intui&ve Ea&ng: A Revolu&onary Program That Works By Evelyn Tribole, MS, RD and Elyse Resch, MS, RD, FADA
Choose Your Foods: Exchange List for Diabetes ADA and AND
ONLINE RESOURCES
Diabetes, Intuitive Eating,
HAES, Eating Disorders,
and how to apply real life
solutions…
¢ www.diabetesselfmanagement.com
¢ h_p://www.lindabacon.org (HAES)
¢ h_p://EaHngandLivingModerately.com
¢ h_p://iaedpny.com -‐ internaHonal associaHon of eaHng disorder professionals NY
¢ h_p://BEDAonline.com
¢ h_p://MomDishesItOut.com
PRESENTED BY LAURA CIPULLO RD, CDE, CDN, CEDRD www.LauraCipulloLLC.com www.EaHngandLivingModerately.com www.MomDishesItOut.com President iaedpNY Chapter Follow Me @MomDishesItOut (917) 572-‐7137
REFERENCES
1. Tylka, Tracy L. “Development and Psychometric EvaluaHon of a Measure of IntuiHve EaHng.” Journal of Counseling Psychology, 52.2 (2006): 226-‐40. Web. 4 Nov. 2013.
2. Albers, Susan. “5 Intriguing Facts About IntuiHve EaHng.” Psychology Today. Sussex Publishers, LLC, 17 Jan. 2012. Web. 4 Nov. 2013.
3. “10 Principles of IntuiHve EaHng.” The Original Ea,ng Pros – Crea,ng a Healthy Rela,onship with Food, Mind & Body. IntuiHveEaHng.org, 2013. Web. 4 Nov. 2013.
4. Gregg, J. A., Callaghan, G. M., Hayes, S. C., and Glenn-‐Lawson, J. L. “Improving Diabetes Self-‐Management through Acceptance, Mindfulness, and Values: A Randomized Control Trial.” Journal of Consul,ng and Clinical Psychology 75.2 (2007): 336-‐43. Web. 4 Nov. 2013.
5. Rosenzweig, S., Reibel, D. K., Greeson, J. M., Edman, J. S., McMearty, K. D., et al. (2007). “Mindfulness – Based Stress ReducHon is associated with Improved Glycemic Control in Type 2 Diabetes Mellitus: A Pilot Study.” Alterna,ve Therapies in Health and Medicine, 13, 36-‐38. Web. 4 Nov. 2013.
6. Horowitz, Sala. “TreaHng EaHng Disorders Mindfully.” Alterna,ve and Complementary Therapies, 15.1(2009): 11-‐16. Web. 4 Nov. 2013.
7. Hammond M. Mindful eaHng: Tuning in to your food. Diabetes Self Management, 2007; 24: 36,38,40. Web. 4 Nov. 2013.
8. Bacon, L., Aphramor L. “Weight Science: EvaluaHng the Evidence for a Paradigm Shi\.” Nutr J 2011; 10: 1-‐13. Web. 4 Nov. 2013.
9. Van Loan, M. D., Keim, N. L. “Health at Every Size: New Hope for Obese Americans?” ARS: News & Events. Agricultural Research Magazine, Mar. 2006. Web. 4 Nov. 2013. 10. “Health at Every Size: Toward a New Paradigm of Weight and Health.” Medscape Mul,specialty. Web. 4 Nov. 2013.
PRESENTATION BY LAURA CIPULLO, RD, CDE, CDN, CEDRD