A Review of Interventions That Promote Eating by Internal Cues PDF

RESEARCH
Review
A Review of Interventions that Promote Eating

by Internal Cues
Julie T. Schaefer, MS, RD; Amy B. Magnuson, PhD, RD, LD/N
ARTICLE INFORMATION ABSTRACT

Article history: Traditional diet programs that encourage individuals to consciously restrict their dietary
Accepted 22 December 2013 intake have not only been ineffective in terms of weight outcomes, but have also been
Available online 14 March 2014 counterproductive, promoting psychological distress and unhealthy eating behaviors.
Nondiet approaches shift the focus away from weight outcomes to the improvement of
Keywords: health outcomes and psychological well-being. One such approach, intuitive eating,
Intuitive eating
Dieting promotes dietary intake based on internal cues of hunger and fullness, body acceptance,
Health-centered approach and making behavior choices based on health as well as enjoyment. Several studies have
Internal cues implemented such ideas into intervention programs. The purpose of our review was to
Supplementary materials:
examine the physical and psychological effects of these programs. Twenty interventions
PowerPoint presentation available at were identied. Overall, studies had positive results, demonstrating improvements in
www.andjrnl.org eating habits, lifestyle, and body image as measured by dietary restraint, restrictive
dieting, physical activity, body satisfaction, and drive for thinness. Participants also
Copyright 2014 by the Academy of Nutrition experienced improved psychological health as measured by depression, ineffectiveness,
and Dietetics. anxiety, self-esteem, negative affect, and quality of life. Several improvements were
2212-2672/$36.00 sustained through follow-up periods as long as 2 years. Completion rates were as high
http://dx.doi.org/10.1016/j.jand.2013.12.024 as 92% in nondieting groups. In addition, improvements in eating behaviors and
maintaining a nondiet approach, increased self-esteem, and decreased body dissatis-
faction were sustained long-term. Overall, studies that encourage individuals to eat
intuitively help participants abandon unhealthy weight control behaviors, improve
metabolic tness, increase body satisfaction, and improve psychological distress. Results
from our review favor the promotion of programs that emphasize a nonrestrictive
pattern of eating, body acceptance, and health rather than weight loss.
J Acad Nutr Diet. 2014;114:734-760.
D
IETING AND THE PURSUIT FOR THINNESS IS control behaviors, binge eating and bulimic pathology, and
entrenched in Western culture and leads to eating disorders.7,10
increasing numbers of programs that restrict di- Physiologically, dieting or energy deprivation activates
etary intake, promote maladaptive eating, and portions of the brain responsible for attention (anterior
necessitate external food rules to induce weight loss. In cingulate cortex) and reward (amygdala) of food.11 Increasing
addition, traditional diets that restrict energy, or particular the reward value of high-energy foods in the brain increases
nutrients, to induce weight loss have achieved little long- the likelihood of food intake and may result in binge eating.
term success. These programs have high attrition rates; par- This may also explain why energy deprivation weight loss
ticipants rarely maintain weight loss and sometimes gain diets typically do not produce lasting weight loss. Frequency
back even more weight than they lost during the pro- of dieting is also associated with negative psychological at-
gram.1-5 In fact, there is evidence that frequency of dieting tributes such as body dissatisfaction, depression, lower self-
is directly associated with weight gain.6-9 esteem,12,13 and negative effect.14 Still, more than half of all
In addition to being an ineffective means to weight loss, adolescent girls and more than a quarter of adolescent boys
dieting is a well-established risk factor for unhealthy weight report dieting7 with dieting reported in girls as young as
8 years old.15
Researchers are now raising attention to the serious ethical
concern with recommending diets for weight loss due to
long-term ineffectiveness and adverse effects.3,16 As a result,
To take the Continuing Professional Education quiz for this article, log in to
much attention has been brought to a health-centered non-
www.eatright.org, click the myAcademy link under your name at the top of
the homepage, select Journal Quiz from the menu on your myAcademy diet approach, commonly referred to as intuitive eating.17
page, click Journal Article Quiz on the next page, and then click the Researchers have identied four central features of intuitive
Additional Journal CPE Articles button to view a list of available quizzes, eating: unconditional permission to eat, eating for physical
from which you may select the quiz for this article.
rather than emotional reasons, reliance on internal hunger
734 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2014 by the Academy of Nutrition and Dietetics.
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and satiety cues, and bodyefood choice congruence.17-19 intuitive eating, mindful eating, nondiet, non-diet, Health at Every
Higher levels of intuitive eating are associated with a lower Size weight intervention, and attuned eating. The search pro-
body mass index.18,20,21 As opposed to those identied as duced 452 results. Abstracts were reviewed to determine
low intuitive eaters, high intuitive eaters have signicantly relevance of these results and 28 potentially relevant studies
higher high-density lipoprotein (HDL) cholesterol levels, but were identied. Reference lists of these articles were also
do not differ signicantly in glucose, total cholesterol reviewed for further interventions, yielding 10 more articles.
and low-density lipoprotein (LDL) cholesterol levels, or body
fat.20 In addition, there is a strong inverse relationship be- RESULTS
tween intuitive eating and disordered eating attitudes, body
dissatisfaction, pressure for thinness, thin-ideal internaliza- Study Selection
tion, and poor ability to respond to hunger and satiety in Six studies were excluded because they included either ad-
college-aged women.18 Intuitive eating is also associated with olescents36 or populations with clinical eating disorders.37-41
psychological well-being, as demonstrated by self-esteem, Another six studies were excluded because although lan-
optimism, proactive coping, and overall life satisfaction.18 guage was used such as nondiet, these studies did not
In a large cohort study of teens and young adults,21 those specify the use of intuitive eating or referred only to dietary
who report trusting their bodies to tell them how to eat were change that subtly implies dietary restraint.42-47 One study
less likely to exhibit disordered eating habits and chronic was a mindfulness program to be used alongside participants
dieting. In particular, two distinct components of intuitive own weight loss plans; that study included no instruction on
eatingeating for physical rather than emotional reasons intuitive eating and was eliminated.48 Finally, one study was
and reliance on internal hunger/satiety cuesuniquely con- eliminated although researchers did train women to elimi-
tribute to psychological well-being and account for more nate dieting and eat intuitively. That study was a laboratory
variance in psychological measures than low eating disorder experiment assessing immediate dietary intake following a
symptomology alone.22 This evidence supports the notion preload to test restraint theory.49 Thus, our review included
that intuitive eating is not simply a lack of eating disorder 24 articles regarding 20 different studies (see the Figure).
symptomology, but is a positive and adaptive eating style.
There are a number of interventions that implement Characteristics of Included Studies
intuitive eating and similar principles. In addition to intuitive
Twenty peer-reviewed weight interventions were identied
eating,17 similar approaches have been termed Health at
that encouraged participants to eat according to internal
Every Size (HAES),23-26 nondiet,27,28 demand feeding,29,30
signals (see the Table). Most participants were white, over-
initial hunger meal pattern,31 mindful eating,32,33 natural
weight or obese women who struggled with dieting.
eating,34 and eating competence.35 These approaches focus
Few studies implemented their intervention using
on reversing the fallouts from dieting while encouraging a
behavior change theory, but most studies achieved positive
healthy relationship with food and ones body. Studies that
outcomes.
implement intuitive eating have been conducted for two
decades, but have yet to be collectively evaluated.
Risk of Bias
METHODS Risk of publication bias should be noted in our review.
Inclusion Criteria Studies that encouraged intuitive eating that did not result
in positive changes may have not been considered for peer-
Studies that conducted an intervention that taught and
reviewed publication. Furthermore, only nine of the 20
encouraged participants to eat intuitively were included.
studies were randomized, controlled trials.24,26,27,31,33,50-53
Studies must have specied in the description of the inter-
One was randomized, but did not include a control group.28
vention that participants were taught to recognize and follow
One was quasi-experimental and nonrandomized, but
internal cues of hunger, fullness, or satiety. Only studies with
included a control group.30 The remaining nine prospective
adults were included. Studies that involved participants with
cohort studies did not include comparison groups.28,29,32,54-60
clinical eating disorders were excluded. All randomized
Results of all studies are discussed because the purpose of our
controlled trials, quasi-experimental controlled trials, and
review was to do a preliminary review of all evidence
prospective cohort studies were reviewed that had been
regarding intuitive eating.
published before December 2012. No date restrictions were
enforced. Studies were not evaluated or eliminated based on
methodologic quality because the purpose of our review was Health Outcomes
to conduct a preliminary evaluation of all intuitive eating One criticism of traditional dieting programs is that partici-
programs. More specically, we focused on dietary intake of pants are instructed to focus on body weight. Conversely,
program participants, health outcomes, long-term effects of intuitive eating discourages this focus and promotes body
program participation, and attrition rates. In addition, acceptance. Many studies still collected data regarding
behavior change theories used as a theoretical framework in body weight for clinical purposes. In six studies, overweight
program development were identied. or obese participants who learned to eat intuitively
achieved signicant decreases in weight or body mass
Search Strategy index.24-26,31-33,56,59 In other studies, participants main-
The databases Medline, Academic Search Complete, PsycInfo, tained their weight.23,27,28,30,51,52,57,61 In one study, normal
and Cumulative Index to Nursing and Allied Health Literature weight participants were able to maintain body weight
were searched for this review. The search terms included except those with high blood glucose levels, who lost
May 2014 Volume 114 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 735
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Figure. Flow diagram demonstrating selection of studies for systematic review of interventions that promote eating by internal
cues. aCINAHLCumulative Index to Nursing and Allied Health Literature. NOTE: Information from this gure is available online at
www.andjrnl.org as part of a PowerPoint presentation.
weight.31 In another study, 59% of subjects lost or main- study, although participants did signicantly decrease weight,
tained weight, but at the 1-year follow-up, 41% had gained there were no changes observed in metabolic panel.32 The
weight and 31% had lost weight.54 latter two studies had a 1-year and 3-month follow-up,
Five studies assessed markers of cardiovascular risk, but respectively, whereas the former study followed participants
ndings were inconsistent. Despite a lack of weight loss, HAES for 2 years.23 A longer period of time may be necessary to see
participants in one study did signicantly decrease total and changes in biomarkers of cardiovascular risk.
LDL cholesterol, whereas the traditional diet group did not Carroll and colleagues50 observed a signicant increase in
improve on either of these cholesterol measures at follow- HDL cholesterol level, but no change in triglycerides level.
up.23 In another study, both the diet and nondiet groups They also saw an improvement in cardiorespiratory tness as
improved blood pressure and blood lipid levels, but neither measured by peak oxygen uptake.50 Despite these ndings,
sustained change at follow-up.27 Steinhardt and colleagues30 there were no signicant differences in the intervention
did not observe a change in cholesterol in either the intuitive compared with the control group in terms of symptoms of
eating or the traditional weight control group. In yet another metabolic syndrome.50 Several studies also assessed blood
736 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2014 Volume 114 Number 5
May 2014 Volume 114 Number 5
Table. Description and results of interventions that encourage eating based on internal cues
Intervention
Authors Sample description Results of internal eating groupa Results of comparison groupa
Bacon and n78 Participants were Health at Every Size Traditional diet program
colleagues, women randomized to Weight: no signicant difference Weight: no signicant difference
200227; Bacon either 24 weekly (101.113.3 kg to 101.516.3 kg) (101.213.8 kg to 98.014.3 kg)
and colleagues, sessions, 90 min BMI:b no signicant difference (35.94.6 to BMI: no signicant difference (36.74.2 to
200523 each of either 36.05.4) 35.54.6)
the Health at Total cholesterol: signicantly decreased Total cholesterol: no signicant difference
Every Size (4.610.80 mmol/L to 4.070.77 mmol/Lc)* (4.500.74 mmol/L to 4.240.72 mmol/L)
intervention or LDL:d signicantly decreased LDL: no signicant difference
a traditional diet (3.010.83 mmol/L to 2.530.51 mmol/Lc)* (2.990.95 mmol/L to 2.630.57 mmol/L)
program, both HDL:e signicantly decreased HDL: signicantly decreased
followed by 6 (1.290.29 mmol/L to 1.030.16 mmol/Lc)*** (1.200.27 mmol/L to 1.010.25 mmol/L)**
mo aftercare Systolic blood pressure: signicantly decreased Systolic blood pressure: signicantly decreased
group support (125.814.2 mm Hg to 119.511.7 mm Hg)* (127.611.3 mm Hg to 121.316.9 mm Hg)
sessions; 1-y Diastolic blood pressure: no signicant differ- Diastolic blood pressure: no signicant differ-
follow-up ence (70.39.0 mm Hg to 68.38.0 mm Hg) ence (73.28.0 mm Hg to 73.310.6 mm Hg)
conducted Cognitive restraint: signicantly decreased Cognitive restraint: no signicant difference
(7.64.0 to 5.43.3)* (7.94.9 to 9.64.7)
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
Disinhibition: signicantly decreased (12.12.5 Disinhibition: signicantly decreased (12.22.1

to 8.23.9)* to 10.33.1)
Susceptibility to perceptions of hunger: Susceptibility to perceptions of hunger: no
signicantly decreased (8.42.9 to 6.14.0)*** signicant difference (8.13.5 to 7.13.9)*
Drive for thinness: signicantly decreased Drive for thinness: maintained (4.64.6 to
(7.16.1 to 2.63.6)** 3.73.2)
Bulimia: signicantly decreased (3.83.4 to Bulimia: no signicant difference (4.64.0 to
1.11.4)** 2.73.7)
Body dissatisfaction: signicantly decreased Body dissatisfaction: no signicant difference
(17.94.5 to 11.96.6)** (17.55.9 to 16.88.0)
Interoceptive awareness: signicantly Interoceptive awareness: no signicant differ-
improved (4.64.5 to 2.43.1)* ence (3.54.3 to 2.33.2)
Depression: signicantly decreased (10.39.5 Depression: no signicant change (7.57.2 to
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to 6.68.8)** 6.65.6)
Self-esteem: signicantly increased (30.93.8 Self-esteem: signicantly decreased (31.25.5
to 33.74.5)** to 29.15.8)*
(continued on next page)
737
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738
Table. Description and results of interventions that encourage eating based on internal cues (continued)
Intervention
Body image avoidance: signicantly decreased Body image avoidance: no signicant change
(38.911.2 to 30.310.0)** (38.38.1 to 34.26.5)
Results for ineffectiveness, interpersonal Results for ineffectiveness, interpersonal
distrust, maturity fears, and perfectionism did distrust, maturity fears, and perfectionism did
not change (numeric results not reported) not change (numeric results not reported)
Carrier and n79 Twenty class Eat for Eat for Long-term Change, Image of Self, Fun, N/Ag
colleagues, (61 female; sessions over 6 Enjoyment of Eatingf
199429 18 men) mo, 45 min Dieting behavior: frequency signicantly
each of the Eat decreased (6.29 to 2.86)***
for Long-term Self-acceptance: signicantly increased
Change, Image (2.04 to 2.23)*
of Self, Fun, Self-esteem: signicantly increased
Enjoyment of (3.09 to 3.49)***
Eating program; Physical activity: signicantly increased
3-y follow-up (235 kcal/kg/wk to 239 kcal/kg/wk)*
Carroll and n31 women Twelve weeks of Weight, Healthy Eating, and Exercise in Leeds Control group
colleagues, the Weight, Weight no signicant change (110.716.3 kg Weight: no signicant change (102.426.3 kg
200750 Healthy Eating, to 108.818.3 kg) to 104.624.1 kg)
and Exercise in BMI: no signicant change (41.76.7 to BMI: no signicant change (38.89.5 to
Leeds 41.17.6) 40.18.7)
intervention VO2:h signicantly increased (2,253322 L/min VO2: no signicant change (2,157321 L/min
was delivered to 2,381382 L/min)** to 2,093322 L/min)
within a Health VO2: signicantly increased (20.643.40 VO2: no signicant change (21.693.5 mL/kg/
at Every Size mL/kg/min to 22.33.70 mL/kg/min)* min to 20.53.2 mL/kg/min)
framework; no Fasting glucose: no signicant change Fasting glucose: no signicant change
follow-up (5.550.70 mmol/L to 5.710.79 mmol/Li) (5.982.5 mmol/L to 5.880.93 mmol/Li)
HDL: signicantly increased (1.080.15 HDL: signicantly increased (1.350.34 mmol/L
mmol/L to 1.300.25 mmol/L)*** to 1.540.35 mmol/L)***
Triglycerides: no signicant change (1.800.84 Triglycerides: no signicant change (1.720.81

mmol/L to 1.800.69 mmol/Lj) mmol/L to 1.910.49 mmol/Lj)
Systolic blood pressure: no signicant change Systolic blood pressure: no signicant change
(137.018.9 mm Hg to 134.217.3 mm Hg) (139.217.9 mm Hg to 136.619.2 mm Hg)
Diastolic blood pressure: signicantly decreased Diastolic blood pressure: signicantly decreased
(89.09.7 mm Hg to 84.011.5 mm Hg)* (87.811.2 mm Hg to 85.08.3 mm Hg)*
Intervention
General well-being: signicantly increased General well-being: no signicant change
(51.921.8 to 61.321.2; P value not reported) (51.112.3 to 49.013.7; P value not reported)
Body image dissatisfaction: no signicant Body image dissatisfaction: signicantly
change (3.51.0 to 3.51.2) increased (3.620.9 to 3.90.8)
Perceived stress: no signicant difference Perceived stress: no signicant difference
(27.910.6 to 26.87.3) (32.77.2 to 30.35.9)
Ciampolini and n181 Training of the Trained groupk Control groupk
colleagues, (79 women; Initial Hunger Premeal blood glucose: signicantly decreased Premeal blood glucose: signicantly increased
201031 70 men) Meal Pattern (86.88.7 mg/dL to 78.86.8 mg/dLi)*** (85.79.0 mg/dL to 89.38.2 mg/dLi)**
over two Vegetable intake: signicantly increased Vegetable intake: signicantly increased
instructional (274166 g/d to 449218 g/d)*** (246188 g/d to 427263 g/d)**
visits and a Fruit intake: no signicant change (221122 Fruit intake: no signicant change
variable number g/d to 266174 g/d) (193155 g/d to 173160 g/d)
of telephone Energy intake: signicantly decreased Energy intake: signicantly decreased
calls over 7 wk; (1,756585 kcal/d to 1,069487 kcal/d)*** (1,728551 kcal/d to 1,310532 kcal/d)**
3-mo follow-up BMI: signicantly decreased (28.73.5 to BMI: signicantly decreased (29.15.6 to
26.53.5)*** 28.25.6)*
Weight: no signicant difference (78.010.2 kg Weight: signicantly decreased (76.116.6 kg

to 72.210.1 kg)*** to 73.816.2 kg)*
Arm skinfold thickness: signicantly decreased Arm skinfold thickness: signicantly decreased
(25.89.2 mm to 19.97.7 mm)*** (25.410.0 mm to 21.07.6 mm)**
Leg skinfold thickness: signicantly decreased Leg skinfold thickness: signicantly decreased
(32.112.6 mm to 25.110.2 mm)*** (34.513.0 mm to 29.710.7 mm)**
Outdoor and gym hours: no signicant change Outdoor and gym hours: no signicant change
(3.23.2 h/d to 3.73.1 h/d) (3.63.5 h/d to 3.03.0 h/d)
Systolic blood pressure: signicantly decreased Systolic blood pressure: signicantly decreased
(125.414.0 mm Hg to 112.215.3 mm Hg)*** (123.818.7 mm Hg to 116.28.7 mm Hg)*
Diastolic blood pressure: signicantly Diastolic blood pressure: no signicant differ-
decreased (76.39.8 mm Hg to ence (73.88.7 mm Hg to 70.411.4 mm Hg)
68.69.5 mm Hg)*
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Ciliska, 199851 n78 women Twelve Psychoeducation Control group
educational Self-esteem: signicantly increased (28.16.8) Self-esteem: no signicant change
sessions once a to 32.45.6)*** (26.426.75.9)
week, 1 h each; Feelings of inadequacy: signicantly decreased Feelings of inadequacy: no signicant change
no follow-up (57.516 to 49.314.9) (65.218 to 64.415.1)
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740
Intervention
Body dissatisfaction: signicantly decreased Body dissatisfaction: no signicant change
(21.35.8 to 177) (215.8 to 19.37)
Restraint scale: signicantly decreased Restraint scale: no signicant change (244.5
(23.93.8 to 18.33.4)** to 235.1)
Restraint, disinhibition, and susceptibility to Restraint, disinhibition, and susceptibility to
hunger: signicantly decreased (30.55.6 to hunger: no signicant change (325.4 to
22.27) 29.86.5)
Diastolic blood pressure: signicantly Diastolic blood pressure: no signicant change
decreased (79 mm Hg to 76 mm Hg)f (numeric results not reported)
Weight: no signicant change (numeric results Weight: no signicant change (numeric results
not reported) not reported)
Depression: signicantly decreased (numeric Depression: no signicant change (numeric
results not reported)* results not reported)
Social adjustment: signicantly improved Social adjustment: no signicant change
(numeric results not reported)* (numeric results not reported)
Bulimia scores: signicantly decreased Bulimia scores: no signicant change (numeric
(numeric results not reported)*** results not reported)
Drive for thinness scores: signicantly Drive for thinness: no signicant change
decreased (numeric results and P value not (numeric results not reported)
reported)
Education
Self-esteem: no signicant change (25.55.4
to 285.5)
Feelings of inadequacy: no signicant change
(62.213.4 to 57.413.6)
Body dissatisfaction: no signicant change
(23.53.9 to 19.56.6)
Restraint scale: no signicant change
(26.63.8 to 20.83.5)
Restraint, disinhibition, and susceptibility to
hunger: no signicant change (31.53.9 to
257.1)
Diastolic blood pressure: no signicant change
(numeric results not reported)
Intervention
Weight: no signicant change (numeric results
not reported)
Depression: no signicant change (numeric
results not reported)
Social adjustment: no signicant change
(numeric results not reported)
Bulimia scores: signicantly decreased
(numeric results not reported)***
Drive for thinness scores: signicantly
decreased (numeric results and P value not
reported)
Cole and Horacek, n61 women Ten My Body My Body Knows When Control group
201052 Knows When Diet mentality: signicantly decreased Diet mentality: change signicance not
sessions, once a (83.110.7 to 73.521.7)* reported (80.98.5 to 96.241.1)
week; 6-mo
follow-up
Dalen and n10 Six weekly Mindful Eating and Living N/A
colleagues, (7 women; sessions, 2 h Restraint: signicantly increased (8.86.1 to

201032 3 men) each of the 13.86.2)*
Mindful Eating Disinhibition: signicantly decreased (9.54.6
and Living to 4.52.5)*
intervention; Susceptibility to hunger: no signicant change
12-wk follow-up (7.63.9 to 4.63.5)*
Binge eating: signicantly decreased (16.25.4
to 7.22.3)
Depression: signicantly decreased (12.59.6
to 7.85.5)*
Anxiety: no signicant change (13.412.1 to
10.010.7)
Perceived stress: signicantly decreased
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(18.07.6 to 13.97.8)*
Physical symptoms: signicantly decreased
(15.06.3 to 9.38.7)**
Negative affect: signicantly decreased
(23.98.9 to 17.88.7)*
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742
Intervention
Positive affect: no signicant change (32.86.1
to 35.76.5)
Weight: signicantly decreased
(101 kg to 97 kg)f**
BMI: signicantly decreased (37 to 35.7)f**
C-reactive protein signicantly decreased
(0.30 mg/dL to 0.24 mg/dLl)f*
Glucose: no signicant change (numeric
Adiponectin: no signicant change (numeric
LDL: no signicant change (numeric results not
reported)
Plasminogen activator inhibitor-1: no
signicant change (numeric results not
reported)
Gagnon-Girouard n144 Four months of Health at Every Size Social support only group
and colleagues, women the Health at Weight: signicantly decreased (78.841.34 kg Weight: no signicant change (81.031.39 kg
201024 Every Size to 77.451.34 kg)** to 80.391.40 kg)
intervention; 1-y Depression: signicantly decreased (9.391.05 Depression: signicantly decreased (8.691.08
follow-up to 7.481.05)* to 8.611.08)**
Self-esteem: signicantly increased Self-esteem: signicantly increased
(28.630.80 to 30.560.80)*** (29.270.83 to 30.510.83)*
Quality of life: signicantly increased Quality of life: signicantly increased
(76.211.80 to 80.821.80)*** (78.151.87 to 79.921.87)*
Binge eating: signicantly decreased Binge eating: signicantly decreased
(13.701.01 to 10.401.04)*** (12.751.04 to 10.791.04)**
Body satisfaction (appearance): signicantly Body satisfaction (appearance): signicantly
increased (1.310.09 to 1.730.09)*** increased (1.340.09 to 1.530.09)***

Body satisfaction (weight): signicantly Body satisfaction (weight): signicantly
increased (0.870.08 to 1.270.08)*** increased (0.820.09 to 1.020.09)***
Intervention
Wait list group
Weight: no signicant change (80.771.37 kg
to 80.591.37 kg)
Depression: no signicant change (9.411.06
to 7.961.07)
Self-esteem: signicantly increased
(28.580.81 to 29.670.82)*
Quality of life: signicantly increased
(76.561.84 to 79.361.84)***
Binge eating: no signicant change
(12.991.03 to 11.791.03)
Body appearance: satisfaction signicantly
increased (1.450.09 to 1.620.09)**
Body weight satisfaction: signicantly
increased (0.960.08 to 1.140.08)**
Higgins and Gray, n82 women The Free From Free From Dieting N/Am
199854 Dieting Restrained eating: signicantly decreased
program was (3.280.53 to 2.450.71)**

delivered over Emotional eating: signicantly decreased
six 2-h sessions (3.830.91 to 2.720.92)**
and a review External eating: signicantly decreased
meeting 2 wk (3.650.55 to 2.940.56)*
later; 12-mo Body shape concern: no signicant change
follow-up (131.9123.66 to 88.0729.00)
Trait self-esteem: signicantly increased
(59.7916.76 to 73.2715.23)***
Jackson, 200855 n36 women Thirteen weekly Eating Order N/A
sessions of the Eating disturbance: signicantly decreased
course Eating (19.36.1 to 5.15.4)***
Order, 2 h each; Problems with self-esteem: signicantly
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no follow-up decreased (43.218.8 to 29.015.0)***
Restrained eating: signicantly decreased
(23.34.2 to 17.35.4)***
Satisfaction with body and self-attributes:
signicantly increased (315.439.2 to
743
368.436.5)***
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744
Intervention
Katzer and n225 Ten-week Relaxation Group (P1)n N/A

colleagues, women nondieting Diet quality score: signicantly increased by
200928; Hawley interventions 1.72.8*; baseline: 10.92.9
and colleagues, were delivered Stress management behaviors: signicantly
200864 in 3 forms: a increased by 0.500.61***; baseline: 2.10.4
group-based Eating self-efcacy signicantly: improved by
program with 11.131.5**; baseline: 101.130.0
relaxation Perceived psychological distress: signicantly
training (P1), a decreased by 0.150.28***; baseline:
group-based 0.500.36
program Depression symptoms: signicantly decreased
without by 0.240.52**; baseline: 0.750.62
relaxation Frequency of medical symptoms: signicantly
training (P2), decreased by 5.710.3***; baseline: 21.414.4
and a mail- Discomfort from medical symptoms: signi-
delivered self- cantly decreased by 9.520.0***;
directed version baseline: 26.217.4
of the rst Interference of medical symptoms: signi-
program (P3); cantly decreased by 7.219.6**;
2-y follow-up baseline: 21.620.1
Body weight: no signicant change (mean
change: e1.86.2 kg; baseline: 95.515.7 kg)
Systolic blood pressure: signicantly
decreased by 3.510.4 mm Hg**;
baseline: 133.214.3 mm Hg
Diastolic blood pressure: signicantly
baseline 84.59.7 mm Hg
Nonrelaxation group (P2)n

Diet quality score: signicantly increased by
2.43.5;*** baseline: 11.02.9
Stress management behaviors: signicantly
increased by 0.180.41;** baseline: 2.20.4
Intervention
Eating self-efcacy: no signicant change
(mean change: e1.638.0; baseline:
103.530.9)
Perceived psychological distress: signicantly
decreased by 0.120.37*; baseline: 0.560.44
Depression symptoms: no signicant change
0.760.65)
Frequency of medical symptoms: no signi-
cant change (mean change: 0.613.7; base-
line: 26.919.3)
Discomfort from medical symptoms: no sig-
nicant change (mean change: e3.05.1;
baseline: 34.922.4)
Interference of medical symptoms: no signi-
cant change (mean change: e4.714.0; base-
line: 30.023.4)

baseline: 136.017.9 mm Hg
decreased by 5.410.1 mm Hg*; baseline:
83.611.2 mm Hg
Self-directed group (P3)n
Diet quality score: signicantly increased by
1.33.1***; baseline: 11.12.7
Stress management behaviors: signicantly
increased by 0.300.55***; baseline: 2.30.5
RESEARCH
Eating self-efcacy: signicantly improved by
12.936.4**; baseline: 98.928.8
Perceived psychological distress: no signicant
change (mean change: e0.050.21; baseline:
0.410.30)
745

RESEARCH
746
Intervention
Depression symptoms: no signicant change
0.530.46)
Frequency of medical symptoms: no signi-
cant change (mean change: e0.99.8;
baseline: 19.912.6)
Discomfort from medical symptoms: no sig-
nicant change (mean change: e1.112.2;
baseline: 24.818.0)
Interference of medical symptoms: no signi-
cant change (mean change: e0.45.8;
baseline: 20.417.2)
decreased by 5.712.7 mm Hg**; baseline:
134.017.5 mm Hg)
decreased by 4.610.1 mm Hg**; baseline:
84.310.4 mm Hg)
Mellin and n22 (21 Twelve weekly The Solution Methodn N/A
colleagues, women; sessions of The Weight signicantly decreased by 7.9 kg (95%
199756 1 man) Solution CI e12.5 to e3.3)**; baseline: 93.018.8 kg
Method with Systolic blood pressure: signicantly decreased
the option of by 13.8 mm Hg (95% CI e22.9 to 4.7)*;
completing the baseline: 134.84.2 mm Hg
program twice; Diastolic blood pressure: signicantly
2-y follow-up decreased by 15.1 mm Hg (95% CI e21.8 to
e8.4)***; baseline 93.310.5 mm Hg

Exercise signicantly increased by 189.1 min/wk
(95% CI 109.5 to 269.7)***; baseline:
103.4134.0 min/wk
Depression: no signicant change; mean
change: e2.6 (95% CI e6.2 to 1.0); baseline:
6.44.6
Intervention
Polivy and n18 women Ten weekly The Undieting Programo N/A
Hermann, sessions of The Drive for thinness: signicantly decreased
199257 Undieting (12.565.37 to 7.275.30)***
Program, 2 h Body dissatisfaction: no signicant change
each (22.065.93 to 21.674.94)
Bulimia: signicantly decreased (8.065.43 to
4.675.09)**
Interoceptive awareness: signicantly
improved (8.066.26 to 4.134.05)**
Ineffectiveness: signicantly improved
(7.116.44 to 3.604.85)*
Perfectionism: no signicant change
(6.564.85 to 6.404.14)
Interpersonal distrust: no signicant change
(2.002.22 to 2.132.88)
Maturity fears: no signicant change
(3.224.15 to 2.602.85)
Restrained eating: signicantly decreased

(25.283.06 to 19.874.41)**
Depression: signicantly decreased
(14.6711.82 to 6.506.20)**
Self-esteem: signicantly increased
(77.2824.18 to 89.0022.69)**
State self-esteem: signicantly increased
(57.6115.41 to 78.5418.30)***
Weight: no signicant change
(228.6741.82 lb to 241.1448.56 lb)
Omichinski and n208 (196 Ten weekly HUGSf N/A
Harrison, 199558 women; 12 sessions of the Self-acceptance: signicantly increased
men) HUGS nondiet (28.1 to 40.2)***
RESEARCH
lifestyle Self-nourishment: signicantly increased
program, 11/2 to (20.8 to 30.3)***
2 h each Overall nondiet lifestyle: signicantly increased
(48.9 to 70.3)***
747
RESEARCH
748
Intervention
Provencher and n144 Fourteen weekly Health at Every Size Social support only group
colleagues, women sessions of the BMI: no signicant change BMI: no signicant change
200726; Health at Every Cognitive restraint no signicant change Cognitive restraint: no signicant change
Provencher and Size Disinhibition signicantly decreased*** Disinhibition: signicantly decreased***
colleagues, intervention; 1-y Susceptibility to hunger signicantly Susceptibility to hunger: signicantly
200961; follow-uppq decreased* decreased*
LeBlanc and LDL: no signicant change LDL: no signicant change
colleagues, HDL: no signicant change HDL: no signicant change
201225 Triglycerides: no signicant change Triglycerides: no signicant change
Diastolic blood pressure: no signicant change Diastolic blood: pressure no signicant change
Systolic blood pressure: no signicant change Systolic blood: pressure no signicant change
Energy intake: no signicant change Energy intake: no signicant change
(2,013513 kcal to 1,998474 kcal) (2,029394 kcal to 1,976365 kcal)
Percent of energy from fat: no signicant Percent of energy from fat: no signicant
change (34.55.5 to 34.87.1) change (33.54.5 to 35.44.7)
Percent of energy from carbohydrate: no sig- Percent of energy from carbohydrate: no sig-
nicant change (47.35.4 to 46.27.0) nicant change (47.65.0 to 47.07.6)
Percent of protein from protein: no signicant Percent of protein from protein: no signicant
Percent of energy from alcohol: no signicant Percent of energy from alcohol: no signicant
Fiber: no signicant change (21.68.2 g to Fiber: no signicant change (20.66.7 g to
22.68.8 g) 21.37.8 g)
Sodium: no signicant change (2,9771,077 Sodium: no signicant change (3,121885 mg
mg to 2,824574 mg) to 3,120699 mg)
Calcium: no signicant change (921399 mg Calcium: no signicant change (897289 mg
to 968359 mg) to 917307 mg)
Meal frequency per day: no signicant change Meal frequency per day: no signicant change
(2.90.3 to 3.00.3) (2.90.2 to 2.90.2)

Snack frequency per day: no signicant Snack frequency per day: no signicant
Percent energy from breakfast: no signicant Percent energy from breakfast: no signicant
Percent energy from snacks: no signicant Percent energy from snacks: no signicant
Intervention
Percent energy after 5:00 PM: no signicant Percent energy after 5:00 PM: no signicant
Percent energy from snacks after 5:00 PM: no Percent energy from snacks: after 5:00 PM no
signicant change (8.47.8 to 7.17.3) signicant change (6.55.5 to 5.96.0)
Control group
Energy intake: no signicant change
(2,006399 kcal to 1,830467 kcal)
Percent of energy from: fat no signicant
change (34.55.1 to 34.04.8)
Percent of energy from carbohydrate: no sig-
nicant change (46.85.8 to 47.55.9)
Percent of protein from protein: no signicant
change (17.73.5 to 18.94.7)
Percent of energy from alcohol: no signicant
change (3.03.0 to 2.02.5)
Fiber: no signicant change (19.94.8 g to
20.46.5 g)
Sodium: no signicant change (3,052851 mg
to 2,872914 mg)
Calcium: no signicant change (860318 to
mg to 792280 mg)
Meal frequency: no signicant change
(2.90.2 to 2.90.2)
Snack frequency: no signicant change
(2.11.7 to 1.71.3)
Percent energy from breakfast: no signicant
change (21.06.7 to 22.16.9)
Percent energy from snacks: no signicant
change (14.511.3 to 13.311.0)
Percent energy after 5:00 PM: no signicant
RESEARCH
change (44.39.5 to 43.68.2)
Percent energy from snacks after 5:00 PM: no
signicant change (7.98.7 to 6.87.6)
749
RESEARCH
750
Intervention
Roughan and n87 women Ten weekly Interventionf N/A

colleagues, sessions, 2 h Weight: signicantly decreased
199059 each; 2-y (87.6 kg to 84.5 kg)**
follow-up BMI: signicantly decreased (31.7 to 30.7)*
Mastery: no signicant change (2.44 to 2.55)
Assertion: signicantly improved
(10.45 to 2.63)**
Disordered eating attitudes: signicantly
decreased (21.7 to 16.2)***
Satisfaction with body: signicantly increased
(134.1 to 146.3)***
Satisfaction with self: signicantly increased
(165.1 to 184.0)***
Depression signicantly: decreased
(13.1 to 9.16)***
Self-esteem signicantly increased
(3.64 to 4.64)***
Smith and n25 Eight weekly Mindfulness-Based Stress Reduction N/A
colleagues, (20 women; sessions of a Binge eating signicantly: decreased
200660 5 men) mindfulness- (10.129.60 to 7.127.12)**
based stress State anxiety: signicantly decreased
reduction (37.729.03 to 32.209.99)*
course Depressive symptoms signicantly decreased
(11.647.49 to 4.324.76)**
Mindful awareness and attention: signicantly
increased (3.700.85 to 4.230.76)**
Self-acceptance: signicantly increased
(4.461.12 to 5.000.96)**
Steinhardt and n357 (180 Ten weeks of the Diet Free Forever Program Traditional weight control program
colleagues, women; 177 Diet Free Restrained eating (Restrained Eating Scale): Restrained eating (Restrained Eating Scale): no
199930 men) Forever signicantly decreased for women only (men: signicant change (men: 15.94.3 to 16.93.8;
program; 1-y 18.24.7 to 18.13.9; women: 19.14.9 to women: 18.74.3 to 18.83.6)
follow-up 16.93.9***)
Intervention
Restrained eating (Dutch Eating Behavior Restrained eating (Dutch Eating Behavior
Questionnaire): signicantly decreased in Questionnaire): signicantly increased in
overall group (men: 29.95.5 to 30.06.7; overall group (men: 27.25.8 to 29.35.0;
women: 29.025.16.6)*** women: 30.05.6 to 32.15.5)***
Emotional eating: no signicant change Emotional eating: no signicant change
(men: 33.931.413.2; women: 43.413.1 (men: 29.29.4 to 26.711.6; women:
to 38.310.2) 38.712.1 to 31.34.8)
External eating: no signicant change (men: External eating: no signicant change (men:
32.54.7 to 31.04.6; women: 34.86.0 to 31.74.3 to 30.54.1; women: 33.65.6 to
31.65.2) 31.34.8)
Body preoccupation: signicantly decreased in Body preoccupation: signicantly decreased in
women: 27.45.6 to 23.76.2)*** women: 27.45.7 to 24.86.4)***
Physical self-esteem: signicantly increased in Physical self-esteem: signicantly increased in
women: 29.97.3 to 34.37.9)*** women: 31.56.4 to 36.27.9)***
Body weight: no signicant change (men: Body weight: no signicant change (men:
21013 lb to 21032 lb; women: 17634 lb to 21041 lb to 20641 lb; women: 15928 lb to
17835 lb) 15822 lb)
Systolic blood pressure: no signicant change Systolic blood pressure no signicant change
(men: 12712 mm Hg to 12615 mm Hg; (12312 mm Hg to 12413 mm Hg; women:
women: 12013 mm Hg to 11814 mm Hg) 11513 mm Hg to 11412 mm Hg)
Diastolic blood pressure no signicant change Diastolic blood pressure no signicant
(8410 mm Hg to 8110 mm Hg; women: change (men: 829 mm Hg to 7511 mm Hg;
788 mm Hg to 718 mm Hg) women: 7310 mm Hg to 699 mm Hg)
Total cholesterol no signicant change (men: Total cholesterol: no signicant change (men:
20131 mg/dL to 21337 mg/dL; women: 21135 mg/dL to 21629 mg/dL; women:
19743 mg/dL to 20444 mg/dL) 18833 mg/dL to 19931 mg/dL)
Nonvolunteer control group
Restrained eating (Restrained Eating Scale):
RESEARCH
signicantly increased in overall group
(men: 13.83.7 to 15.63.8*; women: 13.83.7
to 15.63.8**)
751
RESEARCH
752
Intervention
Restrained eating (Dutch Eating Behavior
Questionnaire): signicantly increased in
overall group (men: 25.97.4 to 27.66.7;
women: 28.06.7 to 29.26.7)*
Emotional eating: no signicant change
(27.110.4 to 26.48.4; women: 30.211.7 to
27.39.7)
External eating: no signicant change (men:
30.74.9 to 29.84.6; women: 30.64.6 to
30.34.9)
Body preoccupation: no signicant change
(men: 18.84.3 to 18.44.0; women: 21.15.2
to 20.66.0)
Physical self-esteem: no signicant change
(men: 39.55.8 to 39.95.5; women: 37.26.4
to 38.67.8)
Body weight: no signicant change (men:
19446 lb to 19238 lb; women: 14833 lb to
15236 lb)
Systolic blood pressure: no signicant change
(men: 12714 mm Hg to 12616 mm Hg;
women: 11611 mm Hg to 11410 mm Hg)
(men: 799 mm Hg to 789 mm Hg; women:
739 mm Hg to 6712 mm Hg)
Total cholesterol: no signicant change
(men: 20449 mg/dL to 20939 mg/dL;
women: 20032 mg/dL to 21034 mg/dL)
Control group
Restrained eating (Restrained Eating Scale): no
signicant change (men: 13.45.4 to 12.84.7;
women: 17.25.1 to 18.05.7)
Restrained eating (Dutch Eating Behavior
Questionnaire): no signicant change
(men: 25.67.6 to 25.76.8; women: 30.26.7
to 31.85.8)
Intervention
Emotional eating: no signicant change
(men: 27.29.0 to 27.510.6; women:
35.510.9 to 34.211.2)
External eating: no signicant change (men:
31.54.2 to 30.84.5; women: 32.15.0 to
30.94.7)
Body preoccupation: no signicant change
(men: 20.65.0 to 20.24.9; women: 24.84.8
to 23.64.8)
Physical self-esteem: signicantly increased
(men: 37.56.3 to 39.26.7; women: 34.88.0
to 36.37.9)**
Body weight: no signicant change (men:
19934 lb to 19431 lb; women: 15534 lb
to 15440 lb)
Systolic blood pressure: no signicant change
(men: 12513 mm Hg to 12214 mm Hg;
women: 11815 mm Hg to 11419 mm Hg)

(men: 8013 mm Hg to 799 mm Hg; women:
769 mm Hg to 7211 mm Hg)
Total cholesterol: signicantly decreased in over-
all group (men: 22143 mg/dL to 21642 mg/dL;
women: 20835 mg/dL to 19548 mg/dL)*
Tanco and n50 women Eight weekly Cognitive Treatment Program Standard behavior
colleagues, sessions of Proportion exercising regularly: no signicant Proportion exercising regularly no signicant
199753 cognitive difference (0.42 vs 0.58)** difference (0.44 to 0.44)
therapy, 2 h Weight: signicantly decreased (111.215.7 kg Weight: signicantly decreased (106.519.6 kg
each; 6-mo to 106.313.5 kg)* to 97.618.1 kg)**
follow-upr BMI: signicantly decreased (39.25.2 to BMI: signicantly decreased (39.96.8 to
RESEARCH
37.54.9)* 36.66.4)**
Depression: signicantly decreased (15.210.6 Depression: no signicant difference (13.99.3
to 8.06.8)* to 11.311.1)
State anxiety: signicantly decreased State anxiety: no signicant difference
(41.814.2 to 34.911.0)* (36.316.7 to 35.49.3)
753
RESEARCH
754
Intervention
Trait anxiety: signicantly decreased Trait anxiety: no signicant difference
(47.011.9 to 36.511.4)* (40.414.1 to 41.816.2)
Self-control: no signicant difference Self-control: no signicant difference
(109.123.3 to 130.326.3)*** (128.046.1 to 124.748.9)
Drive for thinness: no signicant difference Drive for thinness: no signicant difference
(5.85.9 to 4.43.9)*** (5.73.7 to 7.15.2)
Bulimia: no signicant difference (4.95.4 to Bulimia: no signicant difference (3.21.7 to
1.41.5)** 4.04.3)
Body dissatisfaction: no signicant difference Body dissatisfaction: no signicant difference
(20.66.0 to 18.67.0)* (20.65.9 to 18.46.0)
Inefcacy: no signicant difference Inefcacy: no signicant difference (5.24.8 to
(7.37.4 to 3.44.1)* 5.96.2)
Perfectionism: no signicant difference Perfectionism: no signicant difference
(7.94.3 to 8.04.2) (4.83.1 to 4.85.0)
Interpersonal distrust: no signicant difference Interpersonal distrust: no signicant difference
(6.17.4 to 2.82.6) (2.42.8 to 2.22.8)
Maturity fears: no signicant difference Maturity fears: no signicant difference
(1.41.7 to 1.31.8) (1.61.3 to 1.01.8)
Timmerman and n35 women Six weekly Mindful Restaurant Eating Interventions Controls
Brown, 201233 sessions of the Weight gain: signicantly lower* Weight gain: signicantly greater*
Mindful Waist circumference: no signicant difference Waist circumference: no signicant difference
Restaurant (102.014.2 cm to 99.313.9 cm) (91.211.6 cm to 91.810.7 cm)
Eating Average energy intake: signicantly lower Average energy intake: signicantly greater
intervention, (1,774.2408.9 kcal to 1,417.1330.1 kcal)** (1,806.2351.7 kcal to 1,782.0400.1 kcal)**
2 h each; no Average fat intake: signicantly lower Average fat intake: signicantly greater
follow-up (71.819.6 g/d to 52.1.114.3 g/d)*** (74.626.5 g/d to 70.319.8 g/d)***
Total eating out episodes in 3 d: no signicant Total eating out episodes in 3 d: no signicant
difference (4.11.8 to 3.31.9) difference (4.21.8 to 4.62.3)
Energy intake per eating out episode: Energy intake per eating out episode:
no signicant difference (690.6339.8 kcal to no signicant difference (696.5268.1 kcal to
518.6244.2 kcal) 687.3338.6 kcal)
Intervention
Fat intake per eating out episode: no signi- Fat intake per eating out episode: no signi-
cant difference (59.849.8 g to 22.212.8 g) cant difference (52.024.1 g to 29.816.8 g)
Emotional eating: no signicant difference Emotional eating: no signicant difference
(53.216.5 to 53.115.0) (47.917.9 to 51.317.5)
Self-efcacy for eating behavior: signicantly Self-efcacy for eating behavior: signicantly
greater (182.819.7 to 195.822.5)* greater (177.320.2 to 174.124.8)*
Barriers to weight management: signicantly Barriers to weight management: signicantly
lower (61.614.3 to 47.611.8)*** greater (62.714.5 to 60.416.9)***
a
Results over time are reported (preintervention to postintervention or latest reported follow-up); differences between groups not reported in the Table.
b
BMIbody mass index.
c
To convert mmol/L cholesterol to mg/dL, multiply mmol/L by 38.6. To convert mg/dL cholesterol to mmol/L, multiply mg/dL by 0.0259. Cholesterol of 5.18 mmol/L200 mg/dL.
d
LDLlow-density lipoprotein.
e
HDLhigh-density lipoprotein.
f
No standard deviations were reported in the results.
g
N/Anot available.
h
VO2oxygen uptake.
i
To convert mmol/L glucose to mg/dL, multiply mmol/L by 18.0. To convert mg/dL glucose to mmol/L, multiply mg/dL by 0.0555. Glucose of 3.9 mmol/L70 mg/dL.
j
To convert mmol/L triglyceride to mg/dL, multiply mmol/L by 88.6. To convert mg/dL triglyceride to mmol/L, multiply mg/dL by 0.0113. Triglyceride of 1.80 mmol/L159 mg/dL.
k
Results presented are for overweight participants.
l
To convert mg/L C-reactive protein to nmol/L, multiply mg/L by 9.524. To convert nmol/L C-reactive protein to mg/L, multiply nmol/L by 0.105. C-reactive protein of 0.080.76 nmol/L.
m
No follow-up data were collected for the control group because the control participants received the intervention when the experimental group completed the intervention.
n
Results presented as baseline score and average change from baseline.
o
Results presented are for postintervention because follow-up data were available for fewer than half of the participants.
p
Numeric values for 1-year follow-up were not reported.
q
No follow-up data were collected for dietary intake variables.
r
Follow-up was not completed for the control participants.
s
Signicant differences over time were not presented; only signicant differences between groups at postintervention were reported.
*P<0.05.
**P<0.01.
***P<0.001.
RESEARCH
755
RESEARCH
pressure; most resulted in an improvement,23,27,31,50,51,56 in body satisfaction was found among the intervention par-
although one did not observe a change.30 ticipants, body dissatisfaction increased in control partici-
According to Tribole and Resch,17 one principle of intuitive pants.50,57 Because body satisfaction often decreases for
eating is to feel the difference that exercise can make by adults, particularly if frequent self-weighing occurs,63 an
moving the body rather than focusing on burning calories. intuitive eating program may help to prevent decreases in
Feeling energized from regular exercise can be a better body satisfaction. In addition, several studies observed
motivating factor than trying to lose weight. In addition, improvements in depression,23,24,27,28,32,51,53,56,57,60,62 self-
Tribole and Resch17 explain that when linked with a weight esteem,23,24,27,29,30,51,54,55,57,59 negative affect,32 and quality of
loss diet, exercising can be a struggle, but when honoring life.24 Still others improved measures of ineffectiveness,57
ones hunger and feeding the body through intuitive eating, anxiety,28,53,60,62 interpersonal sensitivity,28 and general
exercise can feel good, enhance mood, and be enjoyable. well-being.50
Several interventions promoted nding ways to be physi-
cally active that are fun and enjoyable while decreasing Attrition
barriers such as negative body attitudes.23,27,50,52,56 Most Programs that implement the intuitive approach to eat-
studies demonstrate a signicant increase in physical ing show lower dropout rates than comparison
activity28,29,50,53,56 or energy expenditure.27 In one study groups.23,26,27,51,52 Completion rates were as high as 92% in
HAES participants signicantly increased moderate (but not nondieting groups.23,26,54 Furthermore, participants in the
rigorous or very rigorous) and overall activity levels at follow- intuitive eating groups evaluated the programs much more
up, whereas the traditional diet group initially increased positively.23,27 In two studies, researchers experienced rela-
activity after the intervention but did not sustain effects at tively high attrition rates.28,52 Although Cole and Horacek52
follow-up.23 In only two studies, levels of physical activity did observed a seemingly high attrition rate of 39% in the inter-
not improve.25,52 Because increases in physical activity often vention group, the control group observed a 67% attrition
contribute to an elevation in mood, programs that result in rate. Greater participation was associated with greater
increased activity levels may also help participants feel more improvement in outcomes.28,29,58
condent and invigorated.
Contrary to dieting, intuitive eating also has positive
effects on measures of eating behaviors and eating pathology.
Long-Term Effects
Individuals are encouraged to abandon dieting behaviors in Follow-up data are important in assessing long-term benets
the hopes of refuting the effects of dieting. One proxy to of program participation compared with the short-term
measure this behavior is through dietary restraint, the outcomes. Some studies did not report any follow-
conscious control of food intake due to concerns about body up.25,33,50,55,58 Other studies reported signicant results at
weight. Participants in most studies decreased dietary re- 3 to 6 months follow-up.32,53,57 In one study, mindful eating
straint23,26,27,29,30,51,54,55,57 or restrictive dieting.52 Several was maintained at 3 months.32 In two additional studies,
increased interoceptive awareness, the ability to recognize positive response to hunger57 and normalized, nondiet eating
and respond to internal states such as emotions, hunger, and was maintained at 6-month follow-up.53 Several studies fol-
satiety.23,27,53,57 In only one study, cognitive restraint signif- lowed participants for 1 year.24,26,27,30,51,54,61 Lower choles-
icantly increased32 and in one other study, dietary restraint terol level and blood pressure, increased physical activity,
did not change.25 Provencher and colleagues26 used an improved eating behaviors, increased self-esteem, decreased
appetite rating system and found that those in the intuitive body dissatisfaction, weight loss, and maintaining a nondiet
eating group increased desire to eat and feelings of hunger in approach were sustained after 12 months.24,26,27,30,51,54,61
a fasting state, whereas no changes were observed in the Four studies followed participants for 2 years.23,56,59,64
comparison and control groups. Those who learned to eat Decreased cholesterol level, blood pressure, restrained
intuitively also decreased disordered eating behaviors such as eating, thin-ideal internalization, body dissatisfaction, disor-
disinhibition, the loss of control that follows self-imposed dered eating, and depression in addition to increased diet
rules,16,26,27,32,51 binge eating,23,27,32,51,53,57,60,62 and signs quality, physical activity, stress management, and self-esteem
and symptoms of anorexia nervosa.59 Others measured were factors maintained after 2 years. One study followed
emotional and external eating; a signicant decrease was participants for 3 years and found participants maintained an
observed in one study,54 whereas no signicant changes were increase in physical activity, self-esteem, and a decrease in
found in the other.30 Omichinski and Harrison58 helped par- restrained eating.29 In one study, researchers were able to
ticipants increase self-nourishment, a construct that included contact 17 of 26 participants 10 years after the intervention
intuitive eating, satisfaction with food, and staying active, all was completed.31 Fourteen subjects maintained intuitive
consistent with the intuitive eating lifestyle. eating and the ability to successfully identify hunger.31
Some studies evaluated whether or not a change occurred
with psychological well-being. In programs that addressed Nutrition and Dietary Intake
and encouraged body satisfaction, participants improved The effect of the intervention on nutrition or dietary intake
self-acceptance,23,29,58 decreased body image avoidance,27 was measured by ve studies.25,28,31,33,52 Katzer and col-
improved body satisfaction,24,27,51,53-55,59 decreased body leagues28 used the nutrition subscale of the Health-
preoccupation,30 decreased drive for thinness,23,27,51,53,57 and Promoting Lifestyle Prole65 and observed a signicant
decreased negative self-talk.52 One study found an improvement in nutrition behaviors. LeBlanc and col-
improvement in the general psychological well-being scores leagues25 used a 3-day food log to assess dietary intake
of participants at posttest, suggestive of a potential with no signicant differences seen after intervention. The
improvement in quality of life.50,57 Although no improvement authors cite compliance among other limitations with using a
RESEARCH
self-report method.25 For this reason, Timmerman and particularly positive outcomes. These theories warrant
Brown33 used a multiple pass 24-hour recall to enhance further investigation in this area.
accuracy. The researchers collected data on 2 weekdays and
1 weekend day to measure a representative intake.33 The Social Support
assessment determined that mindful eaters signicantly
Although ve studies implemented theory, four studies
decreased their energy and fat intake and consumed signi-
included an element of social support.23,27,29,61 In one study
cantly less energy and fat than the control group after the
that compared an intuitive eating group with a social
intervention.33 Ciamolini and colleagues31 identied an in-
support group, only intuitive eaters improved physical and
crease in fruit and vegetable intake among subjects able to
psychological outcomes.24 Provencher and colleagues26,61
identify initial hunger.
observed improvements in their social support group as
well as their HAES group. The authors caution that social
Theory support alone runs the risk of some members spreading
inappropriate dietary messages and encouraging maladap-
In addition to generally being more effective,66 interventions
tive behaviors.61 As a result, they recommend that a social
that employ a theoretical framework provide an opportunity
support group be implemented after a nondiet intervention
to further the understanding of which components work
to enhance sustainability of effects and behaviors.61
and which do not.67 Only ve studies specied the use of a
behavior change theory. Carroll and colleagues50 designed
their intervention within the theoretical psychological DISCUSSION
framework of Self-Determination Theory, a theory of moti- Overall, encouraging intuitive eating seems to achieve posi-
vation supporting natural tendencies to behave in healthy tive physical and psychological effects. The studies in
ways. The intervention was intended to build competence our review found a decrease in several disordered eating
and foster intrinsic motivation to change. Cole and Horacek52 habits. Participants were able to decrease dietary restraint
implemented the comprehensive Precede/Proceed Health or dieting behavior. In only one study did cognitive re-
Promotion Model, a public health model introduced by Green straint signicantly increase; however, disinhibition and
and Kreuter.68 That model is used in planning community binge eating decreased in this study.32 In addition, only one
health promotion interventions based on the premise that study reported weight gain in subjects during the 1-year
behavior change is voluntary and programs should be plan- follow-up period.54 The remaining studies demonstrated
ned and evaluated with those who will implement them and signicant weight loss or weight maintenance. Because
others who will be affected by them. traditional programs tend to focus unsuccessfully on losing
Timmerman and Brown33 implemented their intervention weight, several programs emphasized body acceptance
following the Health Promotion Model by reducing barriers, instead.23,27,29,51,55,57-59 It has been widely documented
increasing perceived benets, increasing self-efcacy, that obesity is related to a variety of negative health
committing to a plan of action, and goal setting. Likewise, consequences, including diabetes, hypertension, and high
Mellin and colleagues56 based their intervention on Family cholesterol.69 This relationship is the primary reason that
Systems Theory. The authors designed their intervention weight loss is often recommended to improve health.
following the philosophy that the mind, body, and lifestyle Although weight remains a highly regarded clinical indicator
skills addressed in their intervention are usually developed of health, it is important to note that intuitive eating pro-
during childhood in those raised with authoritative parenting grams often take a more health-centered approach. The focus
style and are less likely to be developed in those raised with is on overall well-being and improving physical and mental
an authoritarian or permissive parenting style.56 The authors healthweight loss may or may not occur. Essentially, studies
theorize that these skills can be mastered at any age, trig- demonstrated that weight loss is not necessary for improving
gering adaptive behaviors and a healthier lifestyle.56 In systolic blood pressure,23,27 diastolic blood pressure,50 total
addition to weight loss, the authors also attribute decreased cholesterol level,23,27 HDL cholesterol level,23,50 LDL choles-
substance abuse (smoking and alcohol use) to this model.56 terol level,23,27 triglyceride level,27 and cardiorespiratory
Finally, Higgins and Gray54 implemented their intervention tness (eg, oxygen consumption during exercise).23,27,50,51
through Control Theory, which asserts four key elements. The psychological and physical health of patients are key
First, behavior is a proactive choice rather than a reactive concerns for health professionals and research suggests that
response to personal circumstances. Second, behaviors cho- intuitive eating may be superior in this respect compared
sen in different situations are adaptive and likely to preserve with approaches that focus on weight.
the match between desired and perceived circumstances. One concept common to these studies and one of the key
Third, behavior must achieve a balance across the basic needs principles of intuitive eating, is unconditional permission to
of survival, power/competence, freedom, love/belonging, and eat.18,19 Generally diets rely on external rules such as
fun. Fourth, effective and lasting behavior is achieved when following portion sizes or avoiding bad foods, which often
individuals are able to review and evaluate their circum- results in weight obsession and disordered eating patterns.58
stances and choose new behavior compatible with their By removing all diet rules and dietary restrictions, partici-
perceptions. Their intervention was initially effective in pants in almost all of the studies were still able to lose or
achieving positive effects on eating behaviors and psycho- maintain weight. Only one study identied in our review
logical outcomes and these effects were maintained 1 year observed weight gain during follow-up.54 Even though
later.54 Overall, studies that implemented theory had incon- weight loss was not always achieved in these programs,
sistent results. The studies that implemented the Health many of the negative psychological outcomes and maladap-
Promotion Model33 and Family Systems Theory56 achieved tive dietary behaviors associated with dieting were resolved.
RESEARCH
One intuitive eating principle described by Tribole and were published after these tools were available, it is possible
Resch17 is that of respecting your body. This principle pro- that these tools were not available at the start of the studies.
motes acceptance of body size and shape and encourages Several studies used proxy measures such as interoceptive
realistic expectations with weight and weight loss. Eating awareness.23,27,51,57 Interoceptive awareness refers to the
intuitively will likely be easier if one is less critical of his ability to recognize and respond to all internal states, not
or her weight or shape.17 Body dissatisfaction may lead simply hunger and satiety. Others simply measured the
to disordered eating behaviors,70 making it extremely dif- construct as a decrease in dietary restraint.23,25,27,51,55,57
cult to eat intuitively while appropriately identifying and Previous research has demonstrated that intuitive eating is
honoring hunger. One study demonstrated that body esteem not simply a lack of disordered eating22; thus, to assume that
was the only signicant psychological predictor of weight a decrease in dietary restraint is equivalent to an increase in
maintenance during a 1-year follow-up, supporting the intuitive eating may be inaccurate.
assumption that an increase in body acceptance could lead to Another limitation of the studies is that only a few actually
further improvement in weight and health management.24 measured the effect of the intervention on nutrition or di-
Another reported that self-esteem and self-acceptance etary intake.25,28,31,33,52 Future research should focus on
increased in nondiet participants, whereas depressive assessing the dietary inuence of adopting a nondiet lifestyle.
symptoms and the incidence of eating-related psychopa- One of the principles of intuitive eating is gentle nutrition,
thology decreased.54 This entry in the literature supports the which reects the tendency for intuitive eaters to choose
notion that unrealistic weight loss goals are associated with foods that taste good while honoring their health and body
high dropout rates in weight programs,71 whereas intuitive function.17 The updated version of the Intuitive Eating Scale
eating programs encourage acceptance of size and shape. recently developed by Tylka and Kroon Van Diest19 reects
Furthermore, body image issues, in the form of body accep- this principle as a subscale. Using this subscale could help
tance and body appreciation, may play a key role in the advance the research regarding the effect of intuitive eating
development of intuitive eating, as demonstrated by Avalos on nutritional quality of dietary intake.
and Tylka.72,73 In addition, a majority of the studies only included women.
Another nondiet approach that often goes hand in hand Only two studies included men in their sample.30,31 Only
with intuitive eating and HAES is to eat consciously; that is, three other studies were open to men.56,59,60 More research is
mindfully.17 Mindful eating has been described as nonjudg- needed to examine the effects of a nondiet approach in men.
mental awareness of the physical and emotional sensations There is also evidence that men are less likely to diet and
associated with eating.74 Mindfulness has been shown to be thus, may respond better to an intuitive eating approach.62,79
an effective technique to improve psychological and physio- Similarly, most participants in these studies are white.
logic symptoms.75,76 In mindful eating, individuals are Research efforts should be made to include more diverse
encouraged to eat according to internal cues of hunger and populations.
satiety and recognize, but not respond to, external cues such
as advertisements or emotions.74 Mindful eating training has CONCLUSIONS
been effective in treating binge eating disorder38,39 and other Findings in the studies we reviewed support the notion of
eating disorders.40,41 Two studies in our review applied shifting the focus from dieting for weight loss to adopting
meditation techniques or mindfulness training to eating an intuitive eating lifestyle. Interventions that encourage
habits.32,60 intuitive eating decrease unhealthy eating behaviors such as
Concepts that are often associated with mindfulness are dietary restraint and binge eating, signifying a healthier
relaxation and spirituality. Katzer and colleagues28 incorpo- relationship with food. Results regarding physiologic markers
rated relaxation into a nondieting program and found of cardiovascular risk are less clear and merit further
signicantly greater improvement in stress management28 research, but improvements have been identied in blood
and depression at 2-year follow-up.64 Another study identi- pressure,23,27,50 blood lipid levels,23,27,50 and cardiorespira-
ed a strong correlation of intuitive eating with women who tory tness23,27,50,51 in the absence of weight loss. Overall,
regularly practice yoga and have a high spiritual readiness physical activity levels increased, but were not consistently
(eg, meaningfulness, spiritual seeking, and purpose). Those addressed in all programs. Furthermore, although dieting is
women also scored high on body satisfaction.77 Hawley and associated with negative psychological effects, intuitive
colleagues64 found improvements in stress management eating programs decrease depression and anxiety, increase
behaviors, depression, and eating self-efcacy after incorpo- self-esteem, and improve body image. More research is
rating relaxation training into a nondiet program for over- needed on these programs, especially regarding adoption of
weight women.64 There appears to be evidence that intuitive eating, effects on diverse populations, and whether
relaxation and spirituality can be incorporated into nondiet or not programs that employ a theoretical framework are
approaches to promote intuitive eating principles,28,64,64 more effective than those without a framework. Overall
including body satisfaction.77 physical, psychological, and emotional well-being should be
One limitation of many of the programs is that it is difcult considered when assessing health, rather than body weight
to measure adoption of an intuitive eating lifestyle. Because it alone. Our review of studies indicates that a nondiet
is a combination of attitudes and behaviors, intuitive eating approach shows promise for an effective, long-term solution
cannot be simply measured by one distinct behavior.52 Two to improve these imperative dimensions of health.
validated intuitive eating scales currently exist,18,78 one of
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AUTHOR INFORMATION
J. T. Schaefer is a doctoral candidate, Department of Social and Behavioral Sciences, College of Public Health, Kent State University, Kent, OH. A. B.
Magnuson is health promotion director and an adjunct faculty member, Department of Nutrition, Food, and Exercise Sciences, College of Human
Sciences, Florida State University, Tallahassee.
Address correspondence to: Julie T. Schaefer, MS, RD, Department of Social and Behavioral Sciences, College of Public Health, Kent State
University, PO Box 5190, Kent, OH 44242-0001. E-mail: jschae15@kent.edu
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conict of interest was reported by the authors.
FUNDING/SUPPORT
There is no funding to disclose.

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A Review of Interventions that Promote Eating

ARTICLE INFORMATION ABSTRACT

Disinhibition: signicantly decreased (12.12.5 Disinhibition: signicantly decreased (12.22.1

Triglycerides: no signicant change (1.800.84 Triglycerides: no signicant change (1.720.81

Weight: no signicant difference (78.010.2 kg Weight: signicantly decreased (76.116.6 kg

(continued on next page)

colleagues, (7 women; sessions, 2 h Restraint: signicantly increased (8.86.1 to

(continued on next page)

increased (1.310.09 to 1.730.09)* increased (1.340.09 to 1.530.09)*

program was (3.280.53 to 2.450.71)**

Katzer and n225 Ten-week Relaxation Group (P1)n N/A

Nonrelaxation group (P2)n

Body weight: no signicant change (mean

(continued on next page)

e8.4)***; baseline 93.310.5 mm Hg

Restrained eating: signicantly decreased

(2.90.3 to 3.00.3) (2.90.2 to 2.90.2)

Roughan and n87 women Ten weekly Interventionf N/A

women: 11815 mm Hg to 11419 mm Hg)

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