Appetite Awareness Training

AAT is very compatible with the principles of intuitive eating, but there are a few differences that we find make it easier for many clients to do than the less specific/directive guidelines for intuitive eating. AAT focuses very explicitly on getting in touch with stomach sensations and relying more on these signals to guide your eating decisions than trying to discern what your body "wants". AAT recognizes clearly that most people enjoy and therefore "want" many low nutrition/empty calorie foods that make it more difficult to achieve or maintain a weight that is both healthy and satisfying.

AAT helps with emotional eating primarily by raising the person's awareness in the moment that what they are doing is emotional eating (as they see clearly on the monitoring that they want to eat even though they know they are not physically hungry). It also facilitates posthoc learning that emotional eating is a very short-term fix and that fairly quickly, the person regrets what they have eaten. The app (Mindful Eating Coach 2) asks them in each case to rate the episode as Worth It and Not Worth It. Reducing emotional eating is a slow process because the person has to both increase awareness that this strategy is not working well for them and to develop a repertoire of non-food ways to respond to problematic negative emotions. It is also useful to identify if the client is using eating as a way to enhance positive emotions (eating is a very important way that they celebrate or treat themselves). Again, they have to develop a repertoire of non-food ways to enhance positive emotions.

From my point of view, fasting is not ever a helpful way to improve appetite awareness. The goal of AAT is to help individuals avoid getting very hungry, as that is when they are more likely to overeat and feel not great about what they chose to eat. Within the structure of at least 3 meals per day, it can be helpful to encourage a person to wait until they are moderately hungry before they eat, especially if they have ignored hunger cues for a long time in order to restrict or diet. This might mean delaying lunch until 1 or even 2 instead of eating at 12 if one is not hungry at 12, but it would not mean skipping lunch entirely or fasting all day until dinner. People who are not naturally hungry at all first thing in the morning may wait and eat a late breakfast/or brunch but again no all-day fasting until dinner.

For a person who is experiencing strong food cravings, the first advice is to adopt a regular 3 meal/2 snack pattern as food cravings are most often triggered by deprivation and having forbidden foods. If the cravings persist despite regular eating of moderate amounts of the craved foods, it is likely a strongly entrenched learned response (you may think of it as a ritualistic behavior that the person feels unable to stop despite awareness even in the moment that they do not want to eat that food). If so, it may only respond to a strategy based on the principle of exposure and response prevention (originally developed to manage OCD rituals). Our app describes a self-help way to work on reducing these cravings, but many individuals will require a therapist trained in exposure therapy to get the best outcome.

I am generally very supportive of the primary message of the HAES movement. Clearly, health is way more important than weight/size and way more healthy than yo-yo dieting. But it is also true that for most individuals, at some point, weight does begin to have negative health implications, so that message needs to be balanced with medical concerns. The other problem is that it is so hard for clients to make that huge attitude shift. I find the goal of mindful eating is both consistent with the good aspects of HAES and more easily accepted by clients. Mindful eating encourages accepting a weight that one can maintain without highly effortful dieting but also provides a positive strategy for the client in which they feel like they are doing what they can to both get or stay healthy but also to validate their particular body size/type instead of striving for some usually unrealistic body ideal.

My suggestion would be to carefully evaluate the client's goals and the appropriate sequence for treatment-generally it is much more important and ultimately would be more effective for the eating issues to address the trauma first before attempting to focus on eating and weight. Then the client would be better able to take advantage of the AAT (https://craigheadlab.weebly.com/appetite-awareness.html)- trying to address multiple goals at once can be overwhelming to a client - you may have to help explain this to the client as sometimes clients want to prioritize weight over other issues that may be more important to address first.

That time lag is the reason we ask people to focus on stomach fullness (a physical sensation in the stomach that will register much more quickly than the brain's response to blood sugar). We encourage people to check in with their stomach halfway thru whatever portion they are eating, and it helps if you will put your hand on your stomach to notice any distension that is starting to occur. The goal is to stop eating at the first sign of stomach distension and to remember that the size of your stomach is the size of your fist, so any amount greater than that is likely to ultimately feel too full. You also have to learn through experience how you end up feeling a half hour after eating a certain portion size (like 2 pieces of pizza) we call this posthoc learning, and over time you get better at predicting how you are likely to feel 20 minutes after eating a specific portion of a specific food; then you can start making decisions about how much to eat that end up feeling better after you stop eating.

While ATT's primary focus is to reduce overeating regardless of what food you are eating and to allow yourself to eat foods that you enjoy within those limitations, It is helpful to educate individuals about the typical body responses to different types of food as that will help them choose wisely if they are in fact trying to lose weight in addition to stopping binge or overeating. So yes, we remind individuals that protein usually helps with satiation and that high sugar or caffeine may provide quick energy or make one feel better in the short run, but that doesn't last long, and one may feel hungry when the effect wears off (and need to eat again). If asked about diets, we say that there is the most data for following a Mediterranean diet if one wants dietary guidance. However, AAT believes it is important to first reduce overeating (focus on the amount of food) before one works on modifying the type of food eaten. This is because trying to limit the type of food may trigger feelings of deprivation that sabotage efforts to lose weight.

Some people do find their preoccupation with food (and worry about their weight) increases temporarily, but this is usually short-lived because as the individual starts to feel more in control of their eating, they have more hope that they may be able to manage their eating/weight in a way that will feel better. However, the most important way to respond to disgust and shame is to work very hard to increase your self-compassion. In the app, we recommend monitoring your appetite (The Mindful Eating Coach-2 available free on the app store) prompts the user to respond with self-compassion. I also highly recommend the workbook on developing self-compassion written by Dr. Kristen Neff (https://www.amazon.com/gp/product/1462526780/ref=as_li_tl?ie=UTF8&tag=selfcompassio-20&camp=1789&creative=9325&linkCode=as2&creativeASIN=1462526780&linkId=0ef7d4127d25166a4c010cb49ec1b047).

Yes, AAT is usually very helpful for people who want to lose weight- regardless of whether or not they binge eat, overeat or just choose high calorie/empty calories much of the time. Research shows that individuals who are binge eating will do better if they first set the goal to eliminate binge eating before they attempt to lose weight. The goal of AAT is to avoid getting too hungry before you eat, learn to stop eating when just moderately full even when the food tastes good, and you would like more, and to encourage finding non-food alternatives when you want to eat but are not biologically hungry. All these goals will contribute positively to any weight-loss effort and will be especially critical to maintaining any weight that is lost through whatever diet or surgical procedure is utilized.

There is always some risk, but this approach minimizes that risk because the specific target is to stop eating when just moderately full and notice each time when one doesn't actually feel that overeating ended up feeling good fairly shortly after eating (even though you enjoyed it while you were overeating). Focusing on the more immediate natural negative consequences of eating too much (how you feel) works better than just focusing on the very long-term positive consequences of weight loss (as noticeable weight loss takes too long to be reinforcing in the beginning).

People are encouraged to eat at least 3 times a day because the main point is to avoid getting very hungry before you eat. When you are very hungry and start eating, you are more likely to eat quickly, eat whatever is easily available and fail to notice when you start feeling full. You are likely to eat more than you would eat if you were not so hungry. Many people follow the standard 3 meal/2 snack pattern recommended in CBT because eating using a schedule helps them avoid forgetting to eat until they are quite hungry (or avoid deliberate restriction because they want to lose weight). The point in AAT is to find out how your particular body reacts to specific types and amounts of food because people vary so much in how they process and react to various foods; this is why no diet ever invented has worked for everyone who has tried it. Intuitive eating is one strategy for doing this, but it is quite difficult for many people with eating issues as they are so "not in touch with what they really want" that they can't do that very well. AAT provides more structure and guidance to help individuals get back in touch with hunger and fulness and eat what works for their body and their life instead of having to figure out what they "want," which is more likely to lead to overeating or less nutritious choices. In sum, you will do best to eat BEFORE you get very hungry (the prevent defense), which is likely to be 3 to 6 times a day for most people.