Why I suck at intuitive eating

As I mentioned in my last post, I don’t always get along with hunger and fullness cues. There are any number of reasons for it, not the least of which is having a chronic eating disorder. But it might not be the only reason.

Welcome to the strange world of impaired interoception. For those who are obsessed with the idea like me, interoception is the perception of the internal state of your body. It includes feelings like hunger, tiredness, emotions, pain, and disgust, and is generally processed and integrated in a region of the brain known as the insula. Here’s a brief description of interoception and the insula from a piece I wrote on the subject for Scientific American Mind:

We know whether we are full or hungry, hot or cold, itchy or in pain when receptors in the skin, muscles and internal organs send signals to a region of the brain called the insula. This small pocket of neural tissue is nestled in a deep fold of the brain’s external layer near the ears. It cultivates an awareness of the body’s internal state and, in doing so, plays an important role in self-awareness and emotional experience. Interoceptive data combine in the insula with external information about the body. This region will, for example, connect the sharp pain we experience when touching a hot stove with the red welt that appears on our palm.

Several studies have linked impaired interoception to the development and maintenance eating disorders. A new study, published in the journal Appetite, found that interoception is linked to a person’s ability to be successful at intuitive eating. The better your interoception, the better you are at intuitive eating (Herbert et al., 2013).

Which goes a long way in explaining why I suck at intuitive eating.

Granted, I’ve never formally tested my interoception (though you can take a quick test below. If you know your general resting pulse rate, your results will be biased, but if you don’t, it could be fun. Also from my SciAm Mind piece.), but given my general abilities at those types of skills (short answer: they suck), my guess is that my interoception is somewhat less than stellar.

What the researchers found

They assessed 111 female university students from the University of Tubingen, measuring their aptitude at Intuitive Eating, current and long-term levels of anxiety, and their interoception. Intuitive Eating is roughly defined as eating out of physical (rather than emotional) hunger, eating freely from what you choose, and stopping when you’re full. The Intuitive Eating Scale measures three specific aspects of IE:

  • unconditional permission to eat when hungry and what food is desired
  • eating for physical rather than emotional reasons
  • reliance on internal hunger cues on when and how much to eat

Thus a key component of IE are the perception of interoceptive cues like hunger and fullness. But no one had ever measured the links between the two areas.

To test interoception, the researchers use the “heartbeat test” where you try to feel your pulse without formally measuring it. People who have good interoceptive awareness do a good job of guessing their pulse because they can feel the subtle lubdub-lubdub of their heart. Previous studies have found both that the heartbeat test does a good job of capturing the many aspects of interoception such as sensing hunger and fullness (Herbert et al., 2012) and that people with anorexia perform worse on the heartbeat test than healthy women (Pollatos et al., 2008).

Test your interoception

Here’s a simple way to measure your interoceptive skills—that is, how well you sense your own hunger, pain, body temperature, and the like. Find a stopwatch and a calculator. Sit quietly in a comfortable chair and take a few deep breaths. Now start your stopwatch and count your heartbeats for a minute just by feeling your heart’s rhythm. Don’t touch your wrist or your neck. Write this number down.

Next, take your pulse in the normal way. Put your finger on your wrist or your neck and count beats for a minute. Wait for two minutes, then take your pulse again. Average your two measurements.

Calculate the difference between your heartbeat estimate and the average of your two pulse counts. Take the absolute value of the difference—you don’t need to know whether you overshot or undercounted, just the amount by which you missed the mark. Then divide by your average pulse and subtract that result from 1. The formula for this calculation appears below:

interoception formula

Interpreting Your Score

If your result was 0.80 or higher, your interoceptive ability is very good.
A score of 0.60 to 0.79 means you have a moderately good sense of self.

A result below 0.59 indicates poor interoception.

Those who scored highest on the heartbeat test also scored better on two of the IE subscales: eating for physical rather than emotional reasons and reliance on internal hunger cues. Given that the first of these three subscales doesn’t have much to do with interoception, it’s not surprising that it wasn’t affected by it. No differences were found in either immediate or long-term levels of anxiety.

Interestingly, the higher a person scored on the IE test, however, the lower their BMI. It definitely throws a wrench into the idea that if you give yourself permission to eat what you want, according to hunger, that you will turn into that giant marshmallow monster from Ghostbusters.

Still, IE is seen as sort of the pinnacle of recovery in eating disorders. While flexibility in eating is a good thing, as is learning when you might be more or less hungry or full, many people with EDs require a bit more structure than IE naturally provides. While using the principles of IE is a good thing, you may need more structure and that’s fine. I never really thought of the links between IE and interoception before I saw this study, but it makes a lot of sense to me.

References:

Herbert et al. (2012). Interoception across Modalities: On the Relationship between Cardiac Awareness and the Sensitivity for Gastric Functions. PLoS ONE. doi:10.1371/journal.pone.0036646

Herbert et al. (2013). Intuitive eating is associated with interoceptive sensitivity. Effects on body mass index. Appetite. doi: 10.1016/j.appet.2013.06.082

Pollatos et al. (2008). Reduced perception of bodily signals in anorexia nervosa. Eating Behaviors. doi: 10.1016/j.eatbeh.2008.02.001

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20 Responses to “Why I suck at intuitive eating”

  1. I do not understand how to perform this test. I sat and sat and sat and tried to feel my heartbeat from the inside without pressing my finger into my neck and I simply cannot feel it. Can most people?

    • I had the same problem. I tried to “feel” my heat’s rhythm and nothing happened! Are you supposed to be able to feel anything?

    • Well, you’re supposed to guess. I think the idea is also that we can be aware of our heartbeat more subconsciously even if we can’t count the beats.

      When I took it, I was in the moderate category, but I have a good idea of my resting pulse, which totally alters the test’s accuracy.

  2. I must have low interoception because I have never had much success with IE either. The reasoning behind IE is logical, but I still don’t eat enough if I attempt to follow my hunger/fullness cues. I agree with you that for some of us in ED recovery there needs to be more structure. Eating without emotions attached is difficult even for normal eaters, so I think sucking at IE perfectly acceptable. :)

  3. Tried to do the heartbeat thing and failed miserably. I go between not being able to feel my heartbeat to perceiving it is going really fast (which it might have been because I was becoming more and more anxious at the idea I might “fail” the test). *facepalm*
    The concept of interoception is fascinating and I think explains a lot about anorexia. I ran cross-country while still severely anorexic and was always dealing with muscle, tendon, ligament pulls because I overtrained and didn’t fuel well. I remember one time when I had a pulled butt muscle (piriformis) and refused to take a day off, the athletic trainer commented that most runners are really good at listening to their bodies and knowing when they need to rest. I just stared at him, shrugged, and thought to myself “ha, that’s a load of bullshit.”
    I basically told my RD that I will not do intuitive eating because it freaks me out so badly. And I find I also usually default to not eating enough when structure is taken away. Partly because my desire to maintain a healthy weight is not too high, and also healthy is not “natural” to me, so eating “normally” to maintain that healthy weight is just preposterous to me. Eating as much as I do still feels too much to me even though I am maintaining a healthy weight.
    If I have to stick with a basic meal plan (exchanges) for the rest of my life I am fine with that, because it will keep me alive. Just because I can’t do intuitive eating doesn’t mean I fail at eating disorder recovery.

    • I think you nailed a key point: not everyone can do intuitive eating, and that’s okay. I do use the principles (if I want to eat more, I’m working on generally letting myself) but I can’t do it full stop.

  4. Charlene McLaughlin Reply July 13, 2013 at 2:47 pm

    I found this article very interesting. I was able to take the test and came out with a .82 which means I should be fairly good at intuitive eating. However it is a struggle for me because how I am “feeling” tends to influence food choices and portions. Having BED, tracking everything I eat or drink, how much I exercise usually puts me in to a tail spin and a binge. I think my hardest thing to do is deal with my emotions and my self worth. I think if I could recover from that my eating would be very intuitive. Thanks for sharing your findings. I enjoy reading your entries.

    • Keep in mind that these are statistical averages: not every person who has good interoception is good at intuitive eating, just that, when you add up all the numbers, ON AVERAGE they are. It doesn’t always hold true at the individual level.

      Nor have researchers looked at the role of interoception in EDs outside of AN, so it’s unclear exactly what role that plays. I don’t know whether IE has been studied in BED, but it hasn’t much in AN/BN. Despite that, it’s seen as sort of the pinnacle of recovery despite the fact that we don’t know whether it’s possible to ask large numbers of AN/BN sufferers to do IE.

  5. This is fascinating, though it is true that many ED patient, especially those who have been IP are hyper aware of their resting heartrates.
    I scored a .60, though part of my problem was my anxiety about not doing the test “right” caused my heartrate to jump and fall over the minute.
    My score reflects my eating habits, I still set reminders on my phone, and pt post it notes on my computer before I sit down for a long study/writing/editing session.
    I’ve had this disorder most of my life, and I assume it will be sticking around for while (though playing less of a starring role). I agree that not being able to eat intuitively is not a failure of recovery, eating keeps me alive and as long as I’m doing it “properly” then I will stick with my timers and meal plans.

  6. Interesting article! Thank you for posting it. I’ve been struggling with Intuitive Eating, too, because without some sort of structure I sometimes just won’t eat at all, especially if I’m upset (obviously). Can you recommend a source for meal planning/exchanges to help stay on track to maintain a healthy weight?

    • See a dietitian for that. It’s so individual for what each person needs, and it will vary over time, too.

  7. That’s so interesting… My guess was literally only 2 heartbeats off from the average pulse.

  8. AH…intuitive eating. Eating disorder recovery was a great thing when applied to my 20-year-old self. But fast forward 12 years (which were all eating disorder FREE, thank you Jesus!) and I’ve been pregnant/breastfeeding for 9 of those 12 years. How do you intuitive eat after/during pregnancy/breastfeeding and the beyond? Your hormones are all whacky, and this doesn’t even include heartrate and the like. After five babies and the stress that that encompasses, it is really hard to remember what healthy eating looks like, much less think about what I want to eat, how full I’m feeling and whatnot. It’s an Uncrustable PB&J sandwich or two with a glass of milk in between diapers and laundry! Was I hungry? Did I need two? I DON’T KNOW!
    The point is recovery encompasses real life. And YES, we need to make ourselves important enough to carve out that time to think on these things that matter to our recovery. Easier said than done, right?
    So, the other night I ate the WHOLE box of Triscuits. Why? Because I needed salt (the next day I literally was liking that Mexican salt stuff off my palm and shaking it on again). Who knows! But we have to trust our bodies sometimes to realize that intuitive eating doesn’t always mean eating perfectly. Sometimes it includes overeating. My therapist once told me that normal eating is a)eating exactly what you need b)overeating at times c)undereating at times. That helped me deal with my hormonal rages immensely.
    As I try to regain my own sense of “intuitive eating”, I have to give myself the grace (which includes stumbling off the banister of “perfect eating”) to learn and then MOVE ON.

  9. Thanks for this piece of research, Carrie! I’m left with some questions, though. Those with severe anorexia may also have harder to detect heartbeats–wouldn’t that bias the study? And I’m confused about the higher BMI/lower IE–I would expect that disregulation of food intake on either side–over or under eating– would be associated with poor interoception.
    It’s also hard to know which comes first–the pattern of restricting which decreases hunger and increases sensitivity to fullness, or a built in problem with interoception–somehow I suspect the former.

  10. If intuitive eating isn’t for you I say step away from the recrimination and perhaps externally supported is just peachy. And who says its the pinnacle or gold standard of ED achievement anyhow? Why is externally supported eating any less?

    Athletes do this. They do because they have a purpose and typically see nutrition as fuel for a purpose. Their body is accomplishing a goal (or two or three).

    As a caregiver I say: acceptance of what works can perhaps go a lot further than recrimination and accomplish the same goal.

    • It’s seen in some recovery circles as an example that you’re not “fully recovered.” I don’t consider myself fully recovered, nor do I conceive of recovery that way. I consider my illness mostly (but not completely) in remission, and I’m getting better at dealing with the loose ends and instances of symptom emergence. It’s not frequent, but it does happen. But that’s another story.

  11. adultchildofalieninvaders Reply August 18, 2013 at 3:22 pm

    0.86. I can usually feel/hear my heart beat, it’s absolutely not a problem when I’m somewhere very quiet which wasn’t the case when I did this test. There’s a flip side to this, though: imagine trying to fall asleep in the evening and instead being bothered by a loud and clear thump-thump-thump. It’s my understanding that usually the brain filters out this sound — you do hear it, but you don’t pay attention to it — but this has not been my experience. And I get kind of inordinately hung up on normal bodily sensations, which again interferes with falling asleep or trying to relax. It’s a tradeoff, I guess.

    Otherwise, yes, the results sound about right, except that I’ve been accidentally undereating for the past year or two! (IBS -> cutting out grains -> accidental low carb -> oops restriction.) Still, I also have thirty years of mostly sane eating under my belt and a BMI that has tended to stay between 21 and 24.5, higher now that I’m trying to build serious muscle.

  12. Fascinating post- thank you for sharing! Intuitive eating is definitely based on interoceptive awareness, and if awareness is low, becoming an intuitive eater is hard. However, interoceptive awareness is not static. It can be both developed and lost. Part of the work of becoming an intuitive eater (and it *is* work!) is increasing your awareness of internal signals. I personally am much more interoceptively aware than I was when I was younger, and I have also watched my clients become more interoceptive. I fully respect your experience and your viewpoint. No one has to become an intuitive eater. I just wanted to share my own insights.

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    [...] Why Intuitive Eating Can Be Difficult - Several studies have linked impaired interoception to the development and maintenance eating disorders. A new study, published in the journal Appetite, found that interoception is linked to a person’s ability to be successful at intuitive eating. The better your interoception, the better you are at intuitive eating. Learn More. [...]

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