Versions of internally regulated eating

by Ellyn Satter, MS, MSSW, Dietitian and Family Therapist​

For a PDF of this newsletter, click here

Growing out of your own or others’ misery about eating and weight, are you among the many dietitians/ health professionals shifting your practice from prescription and control to acceptance and trust? You might use defined and established approaches, such as the Satter Eating Competence Model (ecSatter), Intuitive Eating (IE), or nonspecific approaches^1-3 such as Health at Every Size (HAES), non-dieting, mindful eating (ME), or “intuitive eating” (e.g. generic description that can encompass non-dieting, HAES, and ME).^4-6 Or you might use an eclectic mix that you have created or gleaned from others, such as psychoeducation and persuasion. Subjects who score high on ecSI 2.0 or IES 2 score relatively high on biological and psychosocial indicators and show lower BMIs.^{7, 8} Those who indicate internally regulated eating in unvalidated testing show improved psychological health^{4, 5} and lower odds of chronic dieting and binge eating.^{5, 6}

What do internally regulated eating practices have in common?

Interventions that heal eating attitudes and behaviors have this in common:

• Are food neutral: Give strong permission to eat preferred food, without in any way stipulating “healthy” or “unhealthy” food.
• Support internally regulated eating: Give strong permission to eat as much as is wanted based on hunger, appetite, and satiety.
• Are weight neutral: Give strong acceptance of weight.
• Incorporate positive discipline: In the context of strong permission to eat, manage the eating environment to allow paying attention to self and eating.

Consider research

Let’s face it: Research is the only way to change policy and stop this epidemic of misery about eating and weight. For convincing research, an intervention has to be based on  grounded theory,⁹ be so clearly and concretely defined that someone else can reproduce it, and be supported by data. The use of validated instruments for before-and-after testing raises effectiveness evaluation from subjective (and possibly biased) clinical observation to objective assessment. ecSatter is concretely described,¹ reproducible,^{10, 11} has a validated test, ecSI 2.0,² and is supported by outcome data.^{10, 11} Intuitive Eating lays out general principles and practice in a self-help lay publication;¹² those principles are given objective support by being used as the basis for a validated test, IES 2.0.¹³ The other approaches are variously and often vaguely defined.

Using ecSI 2.0 or IES 2.0

Can ecSI 2.0 or IES 2.0 be used for before-and-after testing of nonspecific or eclectic approaches? Before-and-after testing, yes. Both have been tested for reliability. Capturing changes, maybe. Getting permission to use the tools aside, ecSI 2.0 or IES 2.0 may or may not capture the changes brought about by your intervention. Here is what each inventory addresses:

• ecSatter’s four components: context management, positive attitudes, internal regulation, and food acceptance.
• Intuitive Eating eschews structure and measures unconditional permission to eat, eating for physical rather than emotional reasons, and relying on internal hunger/satiety cues.

 Consider your stance on emotional eating

Do you regard all emotional eating as negative and obesogenic? Do you take the IE perspective that emotional eating causes weight gain and that identifying underlying issues and preventing emotional eating will produce weight loss? Or do you take the ecSatter perspective that emotional eating is normal and legitimate? ecSatter gives permission to eat for emotional reasons and, in the context of the permission and discipline of Competent Eating, emotional eating does not disrupt energy homeostasis.

Consider your stance on structure

Do you see structure as critical? Or do you regard structure as substituting external rules for inner experience and therefore being tantamount to restriction? The former would be ecSatter, the latter, IE. Research contradicts the notion that structure breeds restraint, as high ecSI 2.0 scores correlate with low scores on cognitive restraint^14-16 and restrained feeding.¹⁶ Parents who score high on sDOR.2-6y also score high on ecSI 2.0, and do particularly well with context.¹⁶ Consistent meals and snacks are the backbone of both ecSatter and sDOR.

Consider your stance on nutritional guidance

Can you address nutrition and food selection without taking away permission to eat preferred food? Or do you avoid discussing it at all? Nutritional excellence is an integral component of ecSatter.^{17, 18} Working with ecSatter, food selection is addressed in the context of meal-building, giving strong permission to eat preferred foods. Growing out of the positive meal habit, as described by the Satter Hierarchy of Food Needs,⁶  adults experientially evolve Eating Competence, food security, food variety, and dietary quality.^{19 14, 15, 20-22} IE encourages gentle nutrition: “In matters of taste, consider nutrition; in matters of nutrition, consider taste.”¹²

Consider your clarity

Can you be so clear and concrete in describing your intervention that others can do what you do? How do you educate and address uncomplicated eating issues? How do you treat established problems?

• ecSatter addresses uncomplicated eating issues with counseling guidance²³ and published self-help information.^{24, 25} ecSatter assesses and treats^{10, 11} complicated and established issues with the “How to Eat” method,²⁶which restores positive eating attitudes and behaviors using a variety of evidence-based cognitive-behavioral techniques such as relaxation and desensitization training.
• For eating problems in general as well as in clinical intervention, IE utilizes flooding: encouraging access to unlimited amounts of “forbidden” foods until the foods’ fear potential is neutralized. IE utilizes in-session teaching, discussion, and encouragement to replace negative eating attitudes and behaviors with positive ones.¹²

Make your decision

It is certainly up you, the clinician, whether you use a loosely described intervention or one that is “research-ready.” It all comes down to whether you are willing to clearly define your intervention, test it, and accumulate data. It all represents a lot of work, and not everyone enjoys it! ESI Faculty Member Cristen Harris can help. She does training on doing clinical research²⁷ and can compile your ecSatter-based data with that of others and help get your contribution into print.

​