A Review of Interventions that Promote Eating by Internal Cues RESEARCH A Review of Interventions that Promote Eating by Internal Cues Julie T. Schaefer1, MS, RD and Amy B. Magnuson2, PhD, RD, LD/N 1Department of Social & Behavioral Sciences, College of Public Health, Kent State University, Kent, OH 2Department of Food, Nutrition, & Exercise Sciences, College of Human Sciences, Florida State University, Tallahassee, FL

RESEARCH Introduction Traditional diet programs that emphasize weight loss are often counterproductive and lead to psychological stress (Cachelin et al., 2006; Neumark-Sztainer et al 2006; Pietilainen et al., 2011; Wadden et al., 1993) Dieting is also a well-established risk factor for unhealthy weight control behaviors, binge eating, bulimic pathology and eating disorders (Neumark-Sztainer et al., 2006; Stice et al., 2002) Intuitive eating is a health-centered, non-diet approach that is associated with a lower body mass index (Tylka et al., 2006; Tylka et al., 2013; Hawks et al., 2005) and has an inverse relationship with eating disorder behaviors (Tylka et al., 2006) Schaefer & Magnuson J Acad Nutr Diet. 2014;114(5).

RESEARCH Methods This review included studies that conducted an intervention that taught and encouraged participants to eat intuitively Dietary intake of program participants, health outcomes, long-term effects of program participation, and attrition rates of studies were reviewed Behavior change theories used as a theoretical framework in program development were also identified

RESEARCH Figure 1. Flow diagram demonstrating selection of studies for systematic review of interventions that promote eating by internal cues. Database Search: Medline, Academic Search Complete, PsycInfo, CINAHL Records identified through database search (n=452) Excluded due to lack of intervention or inapplicable intervention (n=424) Determined to be potentially relevant based on title and abstract (n=28) Excluded (n=14): - Adolescents (n=1) - Clinical eating disorders (n=5) - Did not specify intrinsic eating in the intervention or implied dietary restraint (n=7) - Laboratory experiment (n=1)   Reference lists of potentially relevant articles were reviewed for additional references (n=38) Included Articles (n=24)

Twenty studies (from 24 articles) were included in this review RESEARCH Results Twenty studies (from 24 articles) were included in this review Overall, studies showed: Weight loss or maintenance Improved markers of cardiovascular risk Decreased dietary restraint and disordered eating behaviors Improved self-acceptance and body satisfaction Decreased drive for thinness Improved depression, anxiety, and self-esteem Most effects are maintained for at least 1-2 years

RESEARCH Limitations The risk of publication bias should be noted; it is likely that intuitive eating interventions with less favorable outcomes may not have been considered for publication Studies were not excluded based on study design; only 9 of the 20 studies were randomized, controlled trials No studies identified measured intuitive eating attitudes and behavior as an outcome Few studies measured the impact of the intervention on nutrition or dietary intake Most studies included only white women; interventions need to be conducted in more diverse samples

RESEARCH Conclusions Findings support shifting the focus away from dieting for weight loss to promotion of the intuitive eating lifestyle Interventions that encourage intuitive eating decrease unhealthy eating behaviors such as dietary restraint and binge eating, signifying a healthier relationship with food Intuitive eating approaches often result in improvements in eating habits, lifestyle, body image, and psychological health; and help individuals abandon unhealthy weight control behaviors