June/July 2025 Issue

Intuitive Eating in Bariatric Care
By Chaundra Evans, RD, LDN
Today’s Dietitian
Vol. 27 No. 6 P. 26

Considerations for Incorporating This Approach

The Intuitive Eating (IE) framework, developed by two RDs three decades ago, is based on 10 principles designed to foster attunement to internal physical sensations, thereby supporting biological, including psychological, needs.1 Its primary goal is to eliminate obstacles to this attunement, often stemming from diet culture’s ingrained rules, beliefs, and thoughts. As a weight-inclusive, evidence-based model with a validated assessment scale and substantial empirical support, IE is increasingly being incorporated into dietetic practice.2

However, RDs may question its suitability for patients who have undergone metabolic and bariatric surgery (MBS). While IE promotes the removal of food rules, MBS patients typically benefit from maintaining some dietary boundaries. It can be valuable for RDs to educate bariatric patients on how to adapt the IE model to accommodate their unique needs and limitations.

MBS alters the physiological landscape, and incorporating IE into the early postoperative stage presents some challenges. Nonetheless, it can help patients transition from active weight loss to weight maintenance.3 IE also plays a role in preventing relapse into disordered eating or eating disorders.4

Evidence for IE in Bariatric Care
In 2020, Bariatric Times published an online survey conducted by the University of Massachusetts Memorial Bariatric Center, using the Intuitive Eating Scale-2.5 The study concluded that bariatric patients who adopted IE principles experienced greater satisfaction from meals, ate more mindfully, demonstrated increased self-efficacy in maintaining prolonged behavior modification, felt more in control of their choices, spent more time relaxing and being active, developed a more positive relationship with eating, and prioritized self-care. They also experienced reduced emotional eating, diminished fear of weight regain, and perceived lower levels of stress.

Studies have demonstrated the effectiveness of IE in improving both physical and mental health.6 Notably, a 2019 study published in the American Journal of Clinical Nutrition explored the relationship between IE and weight loss.3 Using the Intuitive Eating Scale-2, the study found a significant association between the use of IE practices and a lower BMI postsurgery. Specifically, eating for physical sensations of hunger rather than emotional impulse was the primary factor linked to a lower BMI.

Tailoring IE Principles in Bariatrics
Both research and clinical practice support the effectiveness of the IE approach in MBS patients. Adapting IE principles to focus on bariatric wellness may offer enhanced, long-term support for this population. This article explores how dietitians can support bariatric patients by modifying some of the IE principles to meet their specific needs.

Bariatrics Is a Lifestyle
The primary guiding principle of IE is rooted in rejecting the diet mentality. Common triggers causing postop MBS clients to backslide into unhealthy or extreme dieting behaviors include actual or perceived weight recurrence and fear of weight gain. RDs can help debunk ineffective or overly restrictive diet programs, emphasizing how MBS may further increase risk of malnutrition. Overrestriction via dieting can also lead to overeating or binging, perpetuating weight cycling.

Bariatric patients benefit from lengthy conversation identifying differences between ineffective diet rules and intrusive mental chatter vs health goals that are realistic and sustainable. Specific to bariatric patients is the importance of integrating the following health goals beyond weight loss:

• reducing medication reliance;
• staying hydrated;
• improving fitness; and
• learning to listen to body cues.

When working with bariatric patients, it’s important to acknowledge their weight loss goals without overly focusing on them. Dismissing these desires entirely can lead to feelings of shame, isolation, and a lack of support. Celebrate their nonscale victories in session or propose that they keep a journal of achievements such as the following:

• flying comfortably without a seatbelt extender;
• enjoying activities like riding a bike;
• comfortably wearing their wedding band again; and
• walking with increased confidence and comfort.

While strict dieting is harmful, providing MBS patients with specific nutritional recommendations and dietary guidelines can ensure optimal nutritional status. A few guidelines may include the following:

• limiting fat and sugar intake, as these can exacerbate malabsorption and cause gastrointestinal issues;

• prioritizing protein intake to aid recovery from surgery, help maintain muscle mass, and support metabolic rate; and

• separating fluids from mealtimes to help prevent dumping syndrome and optimize nutrient absorption.

To Weigh or Not to Weigh
Traditional IE embraces staying off the scale. Tailor this principle to consider the bariatric patient’s individual best interests. Explore their relationship with the scale. Do they weigh compulsively? Do they avoid the scale entirely? Does in-session weighing trigger anxiety? Does it bring even more anxiety for someone to get rid of the scale? Some individuals, especially those with a history of eating disorders, find it beneficial to avoid the scale altogether; others thrive with less frequent weigh-ins or “blind” weighing, where they receive feedback without focusing on a specific number. Blind weigh-ins can be a valuable tool for recognizing medically relevant weight fluctuation patterns while minimizing the emotional impact often associated with seeing a specific number on the scale.

Focusing on weight trends in a neutral and respectful way gradually diminishes the emotional impact of the number on the scale while creating space to explore insights into contributing factors such as constipation, mindless eating, and water retention. The number on a scale is never the sole measure of one’s health.

Recognizing Hunger Signals After MBS
Another key principle of IE is to honor hunger. Bariatric surgery causes anatomical and hormonal changes, including suppressed levels of insulin, ghrelin, and leptin, and increased levels of GLP-1.7 Due to these changes and the fact that most MBS patients do not experience traditional hunger cues, it’s beneficial for bariatric patients to establish a regular eating pattern early on postoperatively. Tracking food intake and following some external guidelines around meal timing aids in accountability that nutritional needs are being met. When eating patterns are irregular, the body may signal hunger through symptoms such as dizziness, light-headedness, weakness, irritability, fatigue, or mood fluctuations. For most bariatric patients, the body eventually learns to send small portions of ghrelin to the brain, regaining a natural urge to eat.

Honoring a New Feeling of Fullness
It’s also common for bariatric patients to experience a heightened sensitivity to fullness due to their small pouch. This can lead to undereating and nutritional deficiencies. The difference between comfortable fullness and feeling overly full can be as little as one or two bites. Some may experience physical cues like a sigh, deep breath, hiccup, sneeze, pressure, or burp when they are full. The presence of thick, frothy saliva (better known as “the foamies”) can indicate consuming too much food, taking large bites, or eating too fast. Implementing mindful eating practices such as slowing down and thorough chewing can help one recognize comfortable fullness, preventing unwanted symptoms.

As bariatric clients progress and begin to reconnect with their body’s natural hunger and fullness cues, the gradual introduction of additional IE techniques can be a valuable tool.

Consider suggesting clients honor their hunger and fullness when they are in tune with it, which often occurs when overall stress levels are relatively lower, including after adequate sleep, when they feel grounded and clear-minded. On days when they feel exhausted, emotions are heightened, or they feel distracted, they can rely more on external guidelines. Some days they will use a combination of both skills. When they experience feeling overly full, discuss what they’ve learned rather than focusing on what they may have done “wrong.” Discovering boundaries is a process of trial and error—it’s all part of the learning experience.

Making Peace With Food in Bariatrics
Within IE, making peace with food can often seem like an unattainable principle for many bariatric patients. This is understandable, as a significant portion of this population has historically had a complex and challenging relationship with food. Bariatric surgery changes far more than the size of one’s stomach. For most, both their body and relationship with food have been significantly impacted. Focusing on physical sensations after eating a particular food can be a helpful starting place to make peace. While many patients want a simple yes or no answer about whether they can eat specific foods after the initial postop diet phases, the reality is more nuanced. Each person’s tolerance and reactions can vary significantly.

Bread, for example, is a common food that MBS patients have heard is off-limits. While it’s true that bread is often poorly tolerated after surgery because it swells in the presence of gastric juices and can plug the small stoma and result in pain or vomiting, a handful of tips can allow clients to enjoy bread in moderation. Bread is tolerated much better if it’s thinly sliced, consumed in half portions, and toasted. Untoasted bread forms into a sticky dough ball while toasted, thin bread is crunchier and easier to digest. Having a variety of reasonable choices contributes to more peaceful meal planning.

Food Satisfaction After MBS
Discovering the satisfaction factor can be a fun IE principle to explore. For most bariatric patients, appetite and cravings will return after surgery. Bariatric patients are encouraged to honor their cravings after surgery; RDs can offer guidance on how to do so within their postbariatric guidelines. For example, presurgery, a craving for Mexican food might have included mindless munching on the bottomless basket of chips, queso, margaritas, a large combo meal, and feelings of regret. This might have created a negative association with certain foods, resulting in swinging between avoidance and splurging. Suggest alternatives to help honor cravings, such as preparing tacos with ground turkey topped with salsa and avocado, or preparing a chicken and black bean enchilada casserole with Greek yogurt. For patients eating in a restaurant, suggest ordering a kids’ plate, saying no thanks to refills on the chip basket, or sharing protein-rich entrees. By providing practical strategies, clients can begin to feel satisfied by honoring their cravings and creating pleasurable eating experiences.

MBS patients are initially dependent on protein drinks to meet their nutritional needs. Help them explore a variety of flavors and combinations of ingredients for enhanced enjoyment. Creative flavors to blend into shakes may include fresh ginger, frozen berries, mango slices, cinnamon, or unsweetened coconut. Choices based solely on taste may not provide adequate nourishment, while those based solely on health may leave patients feeling unsatisfied. Clients deserve to feel sustained, satisfied, and energized by their meals.

Bariatric Food Boundaries
The concept of “food police” refers to the internalized voice that can generate feelings of guilt or shame around food choices. This voice may dictate that certain foods are always “bad” or even lead to the belief that a person is inherently “bad” for making certain choices. While a traditional IE approach advocates rejecting all rules, bariatric patients benefit from establishing healthy boundaries around food choices. Bariatric patients are given specific guidelines around food, like those with diabetes, celiac disease, and food allergies; these guidelines are considered essential for their health vs an unnecessary restriction. Differentiate between rigid, often dichotomous rules of diet culture and helpful guidelines supporting health. By emphasizing nutritional needs, clients better understand why their bodies require specific foods. This knowledge can empower them to make more intuitive choices based on a desire for well-being, rather than a sense of obligation.

Reframe the conversation to support discovering enjoyable and nutritious ways to prepare yummy foods that may have been deemed “bad.” For instance, explore creative solutions for bariatric-friendly pizza. This could include options like thin crust, meat crust, or cauliflower crust topped with lean protein sources such as turkey pepperoni, Canadian bacon, or leftover rotisserie chicken. Add plenty of colorful vegetable toppings like mushrooms, peppers, onions, olives, sun-dried tomatoes, garlic, and spinach.

There is a middle ground when it comes to “policing.” Strict boundaries can lead to struggles with special events and disordered eating. Inadequate boundaries can lead to self-worth issues, neglecting personal needs, and increased risk for negative health effects. Flexible boundaries are key to finding balance and creating space for joy in various situations.

Cultivating Self-Respect and Self-Compassion
Self-compassion is foundational to IE. For bariatric patients, it can be a useful therapeutic target for reducing internalized weight bias, internalized shame, and emotional eating.7 Self-compassion involves extending kindness and understanding to oneself in moments of perceived inadequacy, failure, or suffering. Given that most MBS patients experience weight bias, feel they’ve failed at countless weight-loss attempts, and may have suffered from obesity-related health issues, cultivating self-compassion may have a remarkably positive impact on their overall well-being. RDs can model and encourage self-compassion during nutrition sessions when discussing food, movement, and body image.

Modeling compassionate and respectful self-talk can enable patients to use their own voice to change the tape in their head. All bodies are worthy of honor, respect, and dignity. Clients may complain about loose skin, stretch marks, or sagging breasts—listen with empathy and shift the focus to body appreciation. Teach clients to respect their evolving body and its need for nourishment, movement, and rest.

The Role of the Gut-Brain Axis in MBS
Emotional eating is a complex, maladaptive coping strategy prevalent in 38% to 59% of bariatric candidates.8 It provides temporary comfort, then backfires with guilt, shame, physical discomfort, and weight recurrence. This cycle perpetuates the underlying emotional issues, making emotional eating a mostly ineffective and ultimately unkind response to oneself.

Exploring how MBS impacts the gut-brain axis can help clients understand how mood, cognition, and gut health are connected. Firstly, MBS modifies the digestive system, which in turn affects the balance of gut microorganisms, which can have a direct impact on emotions.9 Secondly, nutrient absorption, particularly of essential vitamins like B12, can be altered after MBS, potentially influencing mood and cognitive function.10 Thirdly, MBS leads to a decrease in hunger hormones like ghrelin, which play a role in mood and brain function.11 Lastly, many bariatric patients experience emotional and psychological shifts following surgery, impacting their overall mood and mental health.

Prioritizing gut health is essential for maintaining a healthy gut-brain axis. This can be achieved through proper hydration, incorporating prebiotics and probiotics into the diet, ensuring micronutrient and protein needs are being met, and including adequate omega-3 fatty acids. Additionally, adequate sleep, gentle movement, and managing sources of psychosocial stress are crucial. By understanding these factors, bariatric patients may feel motivated to actively manage their mind and body connection with curiosity and compassion.

The Takeaway
While MBS patients may initially experience more dietary limitations, the bariatric lifestyle ultimately embraces an “almost-all-foods-fit” approach. Normal eating encompasses both nourishment and pleasure. Reminding clients that they will eventually be able to enjoy a wider variety of foods while exploring current pleasurable modifications helps them focus on building a sustainable and fulfilling lifestyle. By challenging external rules and subconscious habits around food, IE can support weight management and contribute to the well-being of those who choose to have bariatric surgery.

— Chaundra Evans, RD, LDN, holds certification in adult weight management from the Academy of Nutrition and Dietetics, is an integrated health regular associate member of the American Society for Metabolic and Bariatric Surgery, and has been recognized as an approved supervisor by the International Association of Eating Disorder Professionals as a certified eating disorder registered dietitian. She is the coauthor of BariEDucated: An Integrated Health Guide for Dietitians and Behavioral Health Specialists Caring for Bariatric Surgery Patients.

TECHNOLOGY SUPPORT FOR MBS PATIENTS
Recovery Record is a highly recommended self-monitoring platform rooted in cognitive behavioral therapy. This extremely customizable app enables bariatric patients to comprehensively record specific targets, including their thoughts, emotions, body feelings, experiences, and behaviors. It also facilitates clinician-client connection and offers features to log meals, utilize coping skills, track bowel movements and alcohol consumption, set personalized goals, and more.

References
1. Tribole E, Resch E. The Intuitive Eating Workbook. New Harbinger Publications; 2017.

2. Tylka TL, Maïano C, Fuller-Tyszkiewicz M, et al. The intuitive eating scale-3: development and psychometric evaluation. Appetite. 2024;199:107407.

3. Nogué M, Nogué E, Molinari N, Macioce V, Avignon A, Sultan A. Intuitive eating is associated with weight loss after bariatric surgery in women. Am J Clin Nutr. 2019;110(1):10-15.

4. Virani N, Goodpaster K, Perugini R. A353 intuitive eating predicts healthier relationship with food in post-surgical bariatric patients. Surg Obes Relat Dis. 2019;15(10):S145.

5. Virani N, Goodpaster KPS, Perugini R. Intuitive eating is associated with a healthier relationship with food. Bariatric Times. September1, 2020. https://bariatrictimes.com/intuitive-eating-healthier-relationship/. Accessed January 14, 2025.

6. Hazzard VM, Telke SE, Simone M, Anderson LM, Larson NI, Neumark-Sztainer D. Intuitive eating longitudinally predicts better psychological health and lower use of disordered eating behaviors: findings from EAT 2010-2018. Eat Weight Disord. 2021;26(1):287-294.

7. Braun TD, Gorin AA, Puhl RM, et al. Shame and self-compassion as risk and protective mechanisms of the internalized weight bias and emotional eating link in individuals seeking bariatric surgery. Obes Surg. 2021;31(7):3177-3187.

8. Romeijn MM, Schellekens J, Bonouvrie DS, et al. Emotional eating as predictor of weight loss 2 years after Roux-en-Y gastric bypass. Clin Obes. 2021;11(4):e12458.

9. Kumar A, Pramanik J, Goyal N, et al. Gut microbiota in anxiety and depression: unveiling the relationships and management options. Pharmaceuticals (Basel). 2023;16(4):565.

10. Muscaritoli M. The impact of nutrients on mental health and well-being: insights from the literature. Front Nutr. 2021;8:656290.

11. Casimiro I, Sam S, Brady MJ. Endocrine implications of bariatric surgery: a review on the intersection between incretins, bone, and sex hormones. Physiol Rep. 2019;7(10):e14111.