Ryan Bradley, ND, MPH is a doctor of naturopathic medicine in San Diego, CA. Diabetes is an area of both research and clinical specialization for Dr. Bradley. He practices integrative care for diabetes and heart health as the Director of the Center for Diabetes & Cardiovascular Wellness at the Bastyr University California.
Your Eating Style Profile
Seven Styles of Eating Behavior - Understanding the Emotional and Social Dimensions of Eating and Nutrition
The word “nutrition” has different meanings for each of us. For some, “nutrition” is equal to eating. For others, “nutrition” is the science of individual nutrients, large and small, interacting to give our bodies the energy we use and help it operate correctly. For others still, “nutrition” is a feeling that comes after a good meal shared between family and good friends where the food is only the vehicle for the deeper nourishment that occurs and the quantity of food consumed is limited more by frequent deep belly laughter than by lack of capacity. But realistically, how do we maintain that nourishing space day-to-day? And does how we eat really matter compared to what we eat? Please read on…
Obstacles to NutritionIt is well known that adoption of a healthy lifestyle, especially good nutrition, is the cornerstone of diabetes treatment in type 1 and type 2 diabetes, yet it is the most complex aspect of diabetes management and can be challenging for people to understand and stay motivated1. Following physician and nutritionist advice is frequently considered the most difficult part of diabetes self-management1-3. People attribute their difficulty primarily to factors in their emotions and their way of living rather than a lack of knowledge of nutritional guidelines. For example, people experience psychosocial obstacles from: (1) stress, emotional states, and limitations in quality of their life; (2) disordered eating behaviors tied to underlying emotional disturbances, such as binge eating and night-eating syndrome; (3) restrictive diets that aim to control blood glucose, but may result in feeling deprived and may create an unhealthful attitude towards food. These behaviors are associated with poor well-being, higher body weight, and not following diet and exercise programs to help with blood sugar control.
...adoption of a healthy lifestyle, especially good nutrition, is the cornerstone of diabetes treatment in type 1 and type 2 diabetes...
The Seven Eating Styles
Research suggests many people with diabetes have an internal conflict about how to relate to food and personal nutrition. Correlation between emotional states and diabetes have been demonstrated in men and women with type 2 diabetes, and among people with diabetes and disordered eating, binging in particular, is independently correlated with diabetes4. About 13% of women with type 2 diabetes suffer from a binge eating disorder. Other aspects of disordered eating have also been noted including restrictive eating, out-of-control feelings, and perceptions of dietary deprivation5. Scherwitz and Kesten, two researchers who have focused on holistic nutrition, have identified “Seven Eating Styles” that identify and measure the underlying elements of eating behaviors 6. The following table lists the seven eating styles discovered by Scherwitz and Kesten 6.
Eating Style Definition Proposed Effect on Eating Behaviors in People with Type 2 Diabetes Emotional Eating Eating in response to emotional cues as opposed to hunger Anxiety, depression, loneliness may increase risk for disordered eating habits, resulting in glucose dysregulation. Fresh Food vs. Fast Food Choosing fresh, whole foods over processed convenience foods. Cooking meals at home (meal planning, food preparation) vs. dining out/fast food. Preferences for energy-dense foods over nutrient-dense foods connected to poorer metabolic control, risk of obesity and diabetes. Meal preparation may increase self-efficacy, control over ingredients and portion size. Food Fretting Judgmental thoughts and over-concern about food: worry, compulsive thoughts about food, diet, and its relation to one’s diabetes diagnosis. Dietary deprivation may result from recommended diets, which can lead to psychological deprivation and potentially binging, food obsession, and body image disturbance. Task Snacking Not being “present,” while eating: eating on the run, while on the computer, watching TV, driving, etc. May result in untimely/inappropriate meal times, excessive caloric intake, failure to recognize satiety. “Mindful eating” may improve outcomes. Sensory, Spiritual Nourishment Savoring the sensory aspects of food (aroma, texture, and color); preparing and eating food with meditative mindfulness and appreciation. Mindfulness of the sensory/spiritual aspects of eating may increase satiety and delay hunger. Eating Atmosphere Aesthetics and peacefulness or stressfulness of one’s eating environment may impact blood glucose control. Stressful eating environments may shift people towards a high-fat diet, or indirectly raise insulin through HPA axis. Social Faire Eating alone vs. eating with others Social support may be a critical part of improving eating styles in type 2 diabetics and improving metabolic outcomes. Eating alone may present more barriers to food preparation, healthy eating and socializing.
Five of the seven eating styles were independently predictive of body mass index including: “Emotional Eating,” “Fresh Food, Fast Food,” “Sensory-Spiritual,” Task Snacking,” and “Eating Atmosphere.
People with diabetes who engage in emotional eating, or who suffer from feelings of anxiety and depression have been shown to have poorer diabetes control...
Eating Style 1: Emotional Eating “Emotional Eating” refers to eating in response to emotional cues as opposed to hunger. People with diabetes who engage in emotional eating, or who suffer from feelings of anxiety and depression have been shown to have poorer diabetes control, especially in those diagnosed with eating disorders7. Psychosocial variables like depression, anger, sadness, loneliness, worry, or being upset are all more likely to put people at risk for abnormal eating patterns, such as night-eating syndrome, which can lead to higher rates of obesity and elevated HbA1c8. People with diabetes are also at greater risk for developing eating disorders because strict dietary regimens, food restriction, and ideals of thinness all contribute to lowered body satisfaction and self-esteem, all of which perpetuates a cycle of restrained eating and binging4.
Eating Style 2: Fresh Food vs. Fast Food
The second eating style, “Fresh Food, Fast Food”, refers to choosing fresh, whole food over processed convenience foods. Increased consumption of energy-dense convenience foods with increasing portion sizes, alongside loss of traditional dietary habits in America have significantly influenced the prevalent rise in obesity and diabetes in America9. Eating at buffets, fast-food, and large-chain restaurants, choosing high-fat sources of protein and high-fat menu selections have all shown to result in poorer metabolic control in type 2 diabetes, including higher HbA1c over a two to three month period10.
Eating Style 3: Food Fretting
“Food Fretting”, or judgmental thoughts and over-concern about food, is the third eating style measured by the study. Worrying about food may contribute to binge eating, restraint, and body dissatisfaction, especially in people with type 2 diabetes. People learning dietary management may fret about meal planning, food selection, food preparation, dining out, and portion control. All of these factors may cause feelings of dietary deprivation due to “rigid” nutritional recommendations5. Conversely, of course, complete disregard for food choices also contributes to unhealthy eating patterns such as selecting processed, convenience foods, as discussed above.
Eating Style 4: Task Snacking
The fourth eating style measured was “Task Snacking”, which includes eating on the run, while on the computer, watching TV, driving, etc. Untimely meals or inappropriate meal times such as skipping breakfast, adding or deleting snacks and meals are all associated with higher HbA1c10. A study done on 50,000 non-obese and non-diabetic American nurses showed that those who watched the most television and had the most sedentary lifestyle were highest at risk for developing diabetes or obesity. TV watching not only exposes people to food advertising, but it also results in a lower metabolic rate compared to reading, writing, driving a car, etc., and therefore may play a role in the development of obesity and type 2 diabetes in adults11.
Eating Style 5: Sensory-Spiritual Nourishment
“Sensory-Spiritual Nourishment” is the fifth style of eating behavior and refers to the concepts of savoring the sensory aspects of food such as aroma, texture, and color, as well as preparing and eating food with meditative mindfulness and appreciation. The spiritual aspects of food and eating are often overlooked in Western cultures, and attention to this dimension of eating behavior is important to this study because increased enjoyment of food has been shown to decrease mean HbA1c in adults with type 2 diabetes12. Eating is a sensual experience tied to complex emotions and associations/memories developed throughout the lifecycle!
Adhering to strict dietary guidelines designed to control blood sugar can decrease mindful eating. Food deprivation often leads to psychological deprivation, stress, and hormonal changes that result negative biochemical changes in metabolism13. Many people with type 2 diabetes have been counseled to strictly monitor their intake of carbohydrates, fat, or specific foods, however this may put them at a greater risk for developing psychological deprivation and disordered eating styles. This is especially important because people with diabetes often report difficulty in managing emotional stressors without turning to food as a means for self-comfort. They also report feeling hungry and deprived on dietary regimens, excessive preoccupation with food, and an inability to stop eating after hunger has been satisfied14; all symptoms of unbalanced eating behaviors.
Focusing on the spiritual or communal aspects of eating may be a useful strategy for improving psychological and physiological outcomes. Mindful eating teaches people to listen to hunger, fullness, and taste satiety cues. Cultivating mindful eating practices has been shown to result in greater sustained weight loss and emotional awareness of eating practices in obese individuals15, 16. Culturally relevant spiritual or religious practices serve as sources of social support and as techniques for managing diabetes. In one study, African-American women reported that God plays a central role in providing strength to deal with the daily challenges of diabetes. Spirituality can serve as a source of emotional support, positively influence health, and increase life satisfaction17.
Eating Style 6: Eating Atmosphere
Bringing attention to the eating atmosphere in which we dine is the sixth eating style. The aesthetics and relative peacefulness or stressfulness of the mealtime has been shown to influence metabolic control. A stressful eating environment indirectly may impact insulin resistance via activation of stress hormones by the “fight or flight” response.18 More research needs to be performed to measure the relative risk of increasing insulin resistance by eating in a stressful environment. Nonetheless, social stress has significant effects on body weight and composition: animal studies show that chronically stressed rats shift their food intake to high-fat diets which, in turn, leads to increased obesity, metabolic syndrome, and diabetes19. It is likely that people do the same thing.
In a recent research study supported by Diabetes Action performed at the Bastyr University Research Institute, we conducted a clinical trial in which people with type 2 diabetes learned to follow a naturopathic nutrition program.
Eating Style 7: Social Faire
The final, seventh eating style is “Social Faire”, or eating alone versus eating with others. Social support has repeatedly been shown to be crucial to help people with type 2 diabetes gain glycemic control. Social support also has been shown to improve qualtiy of life with type 2 diabetes20. Individuals with type 2 diabetes who live alone may be less likely to be in the “action” and "maintenance” phases of maintaining a healthy diet, compared to married individuals. Eating alone may present more barriers to food preparation, healthy eating, and socializing21.
In a recent research study supported by Diabetes Action: Research and Education Foundation performed at the Bastyr University Research Institute, we conducted a clinical trial in which people with type 2 diabetes learned to follow a naturopathic nutrition program. Our program included attention to eating behaviors and strategies to address each behavior. Learn about the results of this exciting new research in diabetes in this Complementary Corner article.
Remember, how you eat appears to be as important, if not more important than what you eat. Learn your eating styles by completing this questionnaire:
1. Ary DV, Toobert D, Wilson W, Glasgow RE. Patient perspective on factors contributing to nonadherence to diabetes regimen. Diabetes Care. Mar-Apr 1986;9(2):168-172.
2. Glasgow RE, Toobert DJ, Riddle M, Donnelly J, Mitchell DL, Calder D. Diabetes-specific social learning variables and self-care behaviors among persons with type II diabetes. Health Psychol. 1989;8(3):285-303.
3. Schlundt DG, Rea MR, Kline SS, Pichert JW. Situational obstacles to dietary adherence for adults with diabetes. J Am Diet Assoc. Aug 1994;94(8):874-876, 879; quiz 877-878.
4. Kenardy J, Mensch M, Bowen K, Green B, Walton J, Dalton M. Disordered eating behaviours in women with Type 2 diabetes mellitus. Eat Behav. Summer 2001;2(2):183-192.
5. Yannakoulia M. Eating behavior among type 2 diabetic patients: a poorly recognized aspect in a poorly controlled disease. Rev Diabet Stud. Spring 2006;3(1):11-16.
6. Scherwitz L, Kesten D. Seven eating styles linked to overeating, overweight, and obesity. Explore (NY). Sep 2005;1(5):342-359.
7. Snoek FJ, Hogenelst MH. [Psychological implications of diabetes mellitus]. Ned Tijdschr Geneeskd. Nov 1 2008;152(44):2395-2399.
8. Morse SA, Ciechanowski PS, Katon WJ, Hirsch IB. Isn't this just bedtime snacking? The potential adverse effects of night-eating symptoms on treatment adherence and outcomes in patients with diabetes. Diabetes Care. Aug 2006;29(8):1800-1804.
9. Schroder H. Protective mechanisms of the Mediterranean diet in obesity and type 2 diabetes. J Nutr Biochem. Mar 2007;18(3):149-160.
10. Schmidt LE, Rost KM, McGill JB, Santiago JV. The relationship between eating patterns and metabolic control in patients with non-insulin-dependent diabetes mellitus (NIDDM). Diabetes Educ. Jul-Aug 1994;20(4):317-321.
11. New research establishes importance of specialty care after discharge for an MI. Dis Manag Advis. Apr 2003;9(4):61-63, 50.
12. Deakin TA, Cade JE, Williams R, Greenwood DC. Structured patient education: the diabetes X-PERT Programme makes a difference. Diabet Med. Sep 2006;23(9):944-954.
13. Polivy J. Psychological consequences of food restriction. J Am Diet Assoc. Jun 1996;96(6):589-592; quiz 593-584.
14. Savoca M, Miller C. Food selection and eating patterns: themes found among people with type 2 diabetes mellitus. J Nutr Educ. Jul-Aug 2001;33(4):224-233.
15. Kristeller JL, Hallett CB. An exploratory study of a meditation-based intervention for binge eating disorder. J Health Psychol. 1999;4:357-363.
16. Mathieu J. What should you know about mindful and intuitive eating? J Am Diet Assoc. Dec 2009;109(12):1982-1987.
17. Samuel-Hodge CD, Headen SW, Skelly AH, et al. Influences on day-to-day self-management of type 2 diabetes among African-American women: spirituality, the multi-caregiver role, and other social context factors. Diabetes Care. Jul 2000;23(7):928-933.
18. Schneiderman N, Skyler J. Insulin metabolism, sympathetic nervous system regulation and coronary heart disease prevention. In: Orth-Gomer K, Schneiderman N, eds. Behavioral medicine approaches to cardiovascular disease prevention. Maywah, N.J: Lawrence Erlbaum Associates; 1996:105-133.
19. Tamashiro KL, Hegeman MA, Sakai RR. Chronic social stress in a changing dietary environment. P hysiol Behav. Nov 30 2006;89(4):536-542.
20. Barrera M, Jr., Toobert DJ, Angell KL, Glasgow RE, Mackinnon DP. Social support and social-ecological resources as mediators of lifestyle intervention effects for type 2 diabetes. J Health Psychol. May 2006;11(3):483-495.
21. Vallis M, Ruggiero L, Greene G, et al. Stages of change for healthy eating in diabetes: relation to demographic, eating-related, health care utilization, and psychosocial factors. Diabetes Care. May 2003;26(5):1468-1474.