Intuitive eating and physical and mental health

Academic research on intuitive eating is now 25 years old, with the first paper published in 1998 [9]. Early studies tended to focus on the potential role of intuitive eating in combating the “obesity crisis”. Soon, however, it became clear that, although higher scores on intuitive eating measures were indeed associated with lower BMI, even stronger associations existed between intuitive eating and an array of psychological and psycho-social measures, such as psychological distress, depression, body image, and disordered eating. Indeed, most clinical studies testing an intuitive eating intervention (with, generally, a group of women with BMI >25kg/m² found small and sometimes short-lived reductions in weight or BMI, but stronger improvements in participants’ feelings about themselves and their bodies [1, 7].

As the focus for improving public health has moved away from reducing obesity per se towards improving health and wellbeing, so too has the intuitive eating literature focus shifted. The evidence is now firmly established that eating intuitively is associated with an array of positive physical and mental health indicators [2]. Moreover, recent longitudinal research found that the causal direction is from intuitive eating to health outcomes. A study of adolescents in the Minneapolis/St Paul area in the U.S. found that greater baseline levels of intuitive eating and increases in intuitive eating from baseline to follow-up were both associated with lower odds of high depressive symptoms, low self-esteem, high body dissatisfaction, unhealthy weight control behaviors (e.g., fasting; skipping meals), extreme weight control behaviors (e.g., taking diet pills; vomiting), and binge eating at eight-year follow-up [3]. These findings make a clear argument for encouraging the adoption of intuitive eating to improve population health and wellbeing.

Low rates of intuitive eating

Rates of intuitive eating, however, appear to be low. Estimates vary, depending on the population and the operationalisation of intuitive eating. The only general population statistics we found–a survey of rural Australians—found the rates of intuitive eating to be 9% for women and 26% for men, using a cut-off of 4.0 or higher (out of 5) on the Tylka Intuitive Eating Scale—a cut-off suggested by Tylka [10]. A study of 419 women who had given birth within the previous 6–48 months found that 32% were classified as intuitive eaters, with intuitive eating defined as a score above 3.5 on the same Tylka Intuitive Eating Scale [11]. Much higher rates of intuitive eating were found in a survey of young adults. In this study, however, intuitive eating was operationalised as two items adapted from the Tylka Intuitive Eating Scale: “I trust my body to tell me how much to eat” and “I stop eating when I am full”. Among young adult men, 74.8% indicated that they trusted their body to tell them how much to eat, and 79.1% reported that they stopped eating when full. Among young adult women, 64.8% indicated that they trusted their body to tell them how much to eat, and 76.4% reported that they stopped eating when full [12]. Men consistently report higher levels of intuitive eating than do women [10]; this gender difference is particularly large for Caucasians [2].

Feasibility of adopting intuitive eating at a population level

Several studies have examined the feasibility of adopting intuitive eating within the confines of clinical trials (e.g., [13–15]). Larkey [16] investigated dietitians’ perceptions of barriers to the implementation of intuitive eating and Health at Every Size (an intuitive eating and mindfulness program) in community settings. No study we are aware of, however, has investigated the feasibility of adopting intuitive eating in the general population. In addition, little research exists regarding the extent to which the general public is aware of or understands intuitive eating. This is despite recent public interest in and exposure to body positivity, including the naming of body image activist Taryn Brumfitt as the 2023 Australian of the Year. Body positivity and intuitive eating share common elements, such as respecting one’s body [17].

The aim of this study was to explore peoples’ understanding of and reactions to intuitive eating, including perceived barriers and enablers to implementation, to provide a foundational understanding upon which public health policy around healthful eating can be built.

Study design and participants

Three focus group discussions were conducted with a total of 23 participants. Demographic characteristics of each group consisted of: (1) young women, aged 18–24, with no children; (2) women aged 35–45 with primary school aged children; and (3) men, aged 35–50, living with a partner and with pre- or primary school aged children. These three group demographics were selected to target significant age and life-stages in which shifts in eating behaviours may occur [18]. The groups were conducted in a hotel conference facility in Bendigo, a regional centre of Victoria, Australia, with participants recruited from Bendigo city and outlying areas. A non-metropolitan area was chosen for this research because rates of people with a BMI > 30kg/m² are generally higher in non-metropolitan areas in Australia [19].

The focus group discussions were guided by a Discussion Guide jointly developed by MM, NV, and ED. The Discussion Guide was not pilot tested. Repeat interviews were not carried out. The number of focus groups and participants was based on inclusion of an adequate representation of key demographic groups and budget, rather than data saturation. Therefore, findings should be considered preliminary.

Focus group moderator and reflexivity

MM conducted the three focus groups. MM holds a Graduate Diploma in Applied Psychology and a Diploma of Applied Science (Naturopathy). He has 20 years’ experience conducting qualitative research. At the time of the study, MM was Director of Qualitative Research at the Social Research Centre. MM is male and uses he/him pronouns. Prior to study commencement, MM had no relationship with the focus group participants. Participants knew nothing about the researcher, other than that he would be talking to them about their eating habits and how they made decisions around food. At the time of conducting the focus groups, MM’s BMI was approximately 25–26 kg/m². He was using an intuitive eating approach some of the time.

Procedure

Recruitment was conducted by a professional recruitment agency over the telephone from databases of people who had previously agreed to take part in market and social research. During the recruitment process, a screening questionnaire was used that included several questions about body weight and history of weight loss diets. To ensure a good mix of respondents for the discussions, the following quotas were set for each group: at least two in each group who had previously been on a weight loss diet and at least two who had never been on a weight loss diet; and at least three in each group who reported that they were “over my most healthy weight”. Each participant provided oral informed consent before participation. Prior to the start of each focus group, MM provided a verbal explanation of the research and its purpose, and asked participants if they consented to having the discussion recorded and for the recordings to be used for the purposes of analysis and producing papers and reports. Participants were paid AUS$70. This approach was approved by the IRB.

The concept of intuitive eating was introduced to each of the groups following a discussion about diets and eating patterns. The term, intuitive eating, was first mentioned without any explanation and participants were prompted to discuss what they thought it might mean. This was followed by the provision of an explanation of intuitive eating, and a subsequent detailed discussion of the concept. The following definition of intuitive eating was provided:

There are lots of ways to decide when, what, and how much to eat, such as because it’s mealtime, the food looks really good, your friends are having it, out of habit, because you’re following a diet, because you’re hungry, etcetera.

I’m going to explain an approach to eating called Intuitive Eating. The basic idea is that, if listened to, the body intuitively “knows” how much and what kinds of food to eat, both to maintain a healthy diet and an appropriate weight. This concept is sometimes referred to as “body wisdom”. There are many things that work to override this innate body wisdom, such as diets, being made to clean one’s plate as a child, eating because it’s “dinner time”, advertisements encouraging people to eat even when they’re not hungry, and so on.

The fundamental principles of intuitive eating are to regain body wisdom so that you eat only when you’re hungry and stop eating when you’re no longer hungry. There is also no restriction on the types of food you can eat (so, no “good” and “bad” foods) because the body will naturally choose a variety of foods that provide you with nutritional balance.

Data collection

The focus groups and coding were conducted in 2010. Only MM and the participants were present during the discussions. With the permission of participants, all research sessions were recorded and transcribed. The topic of intuitive eating was introduced first by name, followed by a definition. Participants were then asked what they thought about such an approach, and any barriers they saw in implementing such an approach. Each focus group lasted approximately 90 minutes. After each focus group, MM documented his initial reflections. Transcripts were not returned to participants for comment and/or correction.

Data analysis

The transcriptions were thematically analysed by MM using an inductive descriptive approach [20] located within a constructionist perspective [21], following the general step-by-step approach outlined in Murphy et al [22]. An inductive descriptive approach was used to allow the data to drive the analysis, which was appropriate given the exploratory and descriptive purpose of the study. Themes were created by grouping codes with a central organising concept [23, 24]. A constructionist perspective assumes that multiple views of reality exist and attempts to understand the social construction of reality from the viewpoint of the study participants [25].

The analysis approach involved the following steps: (1) reading a sample of transcriptions to identify initial key themes and subthemes; (2) preparing a coding guide based on these themes and sub-themes; (3) reading/re-reading each transcript and coding against the guide, adjusting themes and sub-themes as necessary; (4) collating coded responses for each theme and subtheme. The results were discussed with the other co-authors and the first author also read the transcripts. All three authors agreed with the findings.

A selection of quotes has been included to illustrate themes; they do not necessarily reflect the specific attitudes of or differences between each demographic group. Each quote has been identified according to the group in which it was said. Participants did not provide feedback on the findings.

Ethics

This project received ethics approval from Charles Sturt University (2010/144).

Initial perceptions (prior to explanation)

Prior to participation in the focus groups, none of the participants had ever heard of intuitive eating. Initial reactions to the term were indicative of responses that might be expected if these participants were to come across such a reference in the public domain. In response to the term, the common perception was that intuitive eating was about eating what you feel like. Overall, participants believed that this was unlikely to be a good thing, as they believed that they were more likely to desire food that was not healthy (i.e., high in fat and sugar and based on looks and taste rather than nutrition) than food that was consistent with a healthy diet. Similarly, some were concerned that intuitive eating would be the same as responding to cravings, and based on their experience, cravings tended to be for foods that were not healthy.

Given these initial reactions, it was apparent that, without a more detailed explanation, intuitive eating was regarded as being similar to emotional eating, and unlikely to be perceived as eating healthily. It was apparent that participants did not really trust themselves to base food choices on what food they wanted or to make healthy choices intuitively.

“If I tried that I’d die of chocolate poisoning in about three weeks.”

(Men, 35–50)

“It could be dangerous… what you crave is quick fixes, quick anything fixes and that’s what you get through sugar, so it can be dangerous, yes.”

(Women, 35–45)

Across the groups, a small number of participants had a reasonably accurate idea of what the term might mean, although even amongst these people there were doubts about the application of the concept.

“I think, like intuition, and intuition to me is like, your body telling you what you should be eating, so I’d think maybe if you were low on calcium, that’s the day you feel like a really big glass of cold milk, I think that’s what it would be to me.”

(Women, 18–24)

“Knowing what you need rather than what you want.”

(Men, 35–50)

“Something along the lines of, um, eating…letting your body guide you to what you need to eat and when you need to eat it.”

(Women, 35–45)

Some participants in the group of men thought that the concept sounded boring, as they perceived it as suggesting that food be regarded primarily as fuel, rather than being valued for taste. One of the men was concerned that “intuitive” meant unsubstantiated by evidence. From this perspective, he believed that intuitive eating was likely to be another fad that had no scientific backing. Several other participants also felt that the concept sounded like a fad, suggesting the need for evidence of its effectiveness.

“Intuition as a word, it’s a belief system, without facts, it’s the intuition, I just believe it, but I can’t justify that belief system, so if you are going to go down that path, intuitive eating is, I believe it’s useful for this purpose, but I really don’t have the facts to back that up.”

(Men, 35–50)

“It kind of still sounds like another fad thing though.”

(Women, 18–24)

Response to explanation

Once the definition of intuitive eating was provided, participants were somewhat more interested in the concept, although they had substantial doubts about its efficacy.

“It would be good if it worked.”

(Women, 18–24)

“It makes sense… eat when you are hungry and don’t eat when you are not. Hello!”

(Women, 18–24)

“I like the idea of just eating when you are hungry.”

(Women, 35–45)

Intuitive eating did appear to make inherent sense to most participants, but many also immediately stated that they believed that our lives are so far from being lived intuitively that eating intuitively did not seem realistic. Participants discussed several aspects of our modern existence that they believed potentially interrupted the capacity for intuition with respect to food. These included time demands–that so much of modern life needs to operate according to set times of the day and week. Another was availability of foods–that the choice of food products, including processed and manufactured foods, means that what people consume is not in itself intuitive. This was thought to be a far bigger lifestyle issue than just about eating, and would require substantive lifestyle changes. Finally, participants mentioned use of time, including daily and yearly cycles. In this context, two participants referred to intuitive eating as what they were more likely to do if they were camping, because then their eating patterns would be more in tune with daily cycles. Most participants had difficulty seeing how intuitive eating could be added into their lifestyles, but rather was regarded as requiring a significant change of lifestyle.

“Like, it would be more a lifestyle thing than a diet…. it’s not a short-term thing, it’s a change [in lifestyle].”

(Women, 18–24)

“Unless you were living a very alternate lifestyle you’re not going to change all the other influences.”

(Women, 18–24)

“It would be if we went back to an idyllic rural lifestyle, you know if we went back to a situation where we were in touch with you know your sheep, your vegie patch… you go fishing, your hunting, your gathering.”

(Men, 35–50)

“You can do that, but we live in, one of the reasons we have an obesity problem, is there’s too much access, food is everywhere.”

(Men, 35–50)

“It doesn’t fit into western culture.”

(Women, 35–45)

In addition, some participants strongly disagreed with the notion that there was no such thing as good or bad food. Several participants referred to “junk foods” as a counter argument; some referred to specific food products or additives as being “non-food” and therefore “bad food”.

“I agree that everything…like the five food group, anything in moderation you can have oils, fat, protein, carb, anything in moderation, I agree with that, but I don’t think that some of the foods that are available to us in the supermarket are any good for us at all. There’s no point in having them; they don’t have any nutrition, and they actually have things that harm your body.” (Women, 35–45)

“Things that have got trans fats, I don’t think we should be eating.”

(Women, 35–45)

Some participants believed that the “no good or bad food” aspect of the message would result in their putting on a lot of weight, because they would not be modifying their eating behaviours to restrict high fat or high sugar content foods in the way that they did at the moment.

“Gives you a lot of leeway, so if you are wanting to lose weight, you are allowed to eat bad food in this?”

(Women, 18–24)

“I reckon I’d put on weight… yeah, the no good or bad foods, I’d be like, well if it it’s not bad for me, so I can just eat it.”

(Women, 18–24)

One of the men, who throughout the discussion had talked about his diet in a way that indicated that he ate excessively and not in a very well-balanced manner, responded to the explanation of intuitive eating with the comment that this was his approach to eating–to eat whatever he felt like. He believed that the explanation was suggesting that his was an appropriate way to eat. These responses demonstrated that a significant amount of education would be needed for the concept to be properly understood. Several participants mentioned this need for education around food and intuitive eating.

“You also need to have education, we’ve been exposed to so many of the bad foods, so we don’t actually know the equivalent in the good foods, so if you knew that, oh I’m really craving, like chicken Twisties, but you could have roast chicken instead and it would satisfy the same craving.”

(Women, 18–24)

“So you have to go back to the beginning and recondition. I think we don’t know what food is. A lot of people don’t know what food is.”

(Women, 35–45)

Moreover, while participants agreed that there was something interesting in the idea of intuitive eating, the impression of it as being unrealistic meant that they would be unlikely to spend a great deal of time or effort finding out more about it.

“Ahm, I like the sound of it, but like you just said, [if I saw it as a heading in a magazine I would] read it and move on, I always flick through the magazines… but to be fair, it might just end up in the same pile of, ‘not going to happen’.”

(Women, 18–24)

Perceived barriers to eating intuitively

While some of the immediate responses presented above were barriers to the idea of intuitive eating, the notion of barriers was specifically probed and explored in the groups. Perceived barriers included food availability, overcoming existing food habits, difficulty differentiating between desire and cravings, removing temptations, and life structures and patterns that limit flexibility.

Perceived benefits and motivators to eating intuitively

Despite these perceived difficulties, most participants felt that if they were able to overcome the barriers and achieve a state of intuitive eating, there would be a range of benefits. Overall, the idea of living more in tune with one’s body was considered appealing.

“Yeah, I think it would be good. I think that it would be…you would feel like you were… in tune.”

(Women, 35–45)

Participants felt that, with an intuitive eating approach, they would eventually improve their food habits, with the main benefits that they would end up eating smaller portions and a healthier range of foods. As a consequence, they believed that they would eventually attain a better diet and healthier body weight. There was some understanding that it would take time for eating to become intuitive. These thoughts were premised on the idea documented previously, that people’s existing food habits had developed patterns that were not intuitive, and that it would take some time to overcome these. Some appreciated that over time they would eat different foods and adopt different eating patterns, and that these approaches would eventually become their new pattern of eating.

“But I reckon if you’d been doing that for two years, you would know, like your body clock would… form a pattern.”

(Men, 35–50)

“You have to take it slow, we’ve all patterned now, and we are too old, if you had an empty slate and tried it, with lots of choice.”

(Men, 35–50)

“Your body would get used to it, it would just kind of naturally want to pick the good foods… like you are consciously thinking about it, so you’d get more attuned to your own body and your own needs.”

(Women, 18–24)

Study strengths and limitations

This study is the first we are aware of to explore the concept of intuitive eating with a general population. Its focus on people living in a regional town is an important feature given that research is often conducted in major cities, which can have a very different food environment and lifestyle. This study was conducted with 23 people from three demographic groups from a small area in regional Victoria, Australia. Additional research with larger numbers and other types of people, both within and outside of Australia, would be useful to understand the extent to which these findings hold more broadly. Identified barriers and enablers to uptake of intuitive eating are likely to be similar in other western populations.

The definition of intuitive eating provided to participants included the statement: “The basic idea [of intuitive eating] is that, if listened to, the body intuitively ‘knows’ how much and what kinds of food to eat, both to maintain a healthy diet and an appropriate weight.” Participants may have interpreted ‘an appropriate weight’ as a lower body weight according to societal norms. A single researcher conducted the focus groups and analysed the data. With thematic analysis, coding quality is not dependent on multiple coders [42]. The results were discussed with the other co-authors and the first author also read the transcripts. All three authors agreed with the findings.

Finally, the focus groups were conducted in 2010 and we cannot be confident that the findings would be identical now. In particular, these findings do not reflect the potential impact on attitudes towards intuitive eating and eating choices of the COVID pandemic and associated lockdowns.