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…

HUNGER FULLNESS SCALE FOR YOUR CLIENT WITH DIABETES

—FROM    THE  DIABETES  COMFORT  FOOD  DIET  COOKBOOK    

DIET

 

As  defined  by  Webster’s  dicHonary…  

Habitual  Nourishment  

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?  

THREE STAGES OF EATING C/O OLIVER-PYATT CENTER

Meal  Planning    

Mindful  Ea4ng    

Intui4ve  Ea4ng  

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.  

COGNITIVE BEHAVIORAL THERAPY FOOD & BLOOD GLUCOSE LOG

—FROM  THE  DIABETES  COMFORT  FOOD  DIET  COOKBOOK    

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