In the realm of health and wellness, the quest for effective weight loss strategies continues to be a prominent topic. While many approaches focus on calorie restriction and increased physical activity, a different perspective has emerged, emphasizing intuitive eating and a holistic view of health. This article delves into weight loss tips, drawing from the principles of intuitive eating, the Health at Every Size (HAES) approach, and innovative methods like implementation intention interventions.
The Health at Every Size Approach
Since the early 2000s, the Health at Every Size approach [HAES (1)] has challenged traditional public health views stating that obesity and overweight are unilaterally linked to major negative health consequences (2), and that the effective means to assist obese and overweight individuals is to combine a reduction in caloric intake with an increased physical activity to reduce their weight and their risk for chronic illness [e.g., Ref. (3, 4)]. Specifically, the HAES approach supports “intuitive eating” and “intuitive exercise.”
Intuitive Eating: A Path to Mindful Consumption
Intuitive eating, also known in the literature as “attuned eating” or “mindful eating,” encourages the awareness of body’s response to food and the learning on how to make food choices that reflect one’s own “body knowledge” (5). This process allows people to make connections between what they eat and how they feel [e.g., mood, satiety, ease of bowel movements, and comfort eating (5-11)]. There is considerable evidence that intuitive eating can be learned [e.g., Ref. (1, 13, 22-26)]. Nevertheless, coming to eat intuitively is a challenging and gradual process, which requires replacing old food habits by new ones (5).
The Role of Implementation Intentions
In the present research project, we advance that the implementation of intention interventions in health behavior change could be used as a promising and complementary established approach for stimulating intuitive eating and active embodiment by bridging the gap between intentions to perform a particular behavior and the actual behavioral change (27-30). Implementation intentions are behavioral strategies that follow an “if-then” structure, which aims to create a strong link between a specific situation and a response. Implementation intentions will allow people to select the appropriate response when confronted to a specified situation [e.g., Ref. (31, 32)]. These “if-then” strategies will enhance health behavior by linking a critical situation (e.g., “IF I am taking the stairs instead of the elevator”) with an appropriate response (e.g., “… THEN I will enjoy the feeling of having my body active”).
This study protocol will thus examine the impact of implementation intentions (i.e., an established intervention procedure) as an initial intervention for initiating intuitive eating and active embodiment (i.e., an established intervention approach) in overweight and obese patients. A couple of studies have already examined the effect of implementation intention and goal planning intervention in obesity (33-36). It has been shown that the development of implementation intentions to adhere to a weight-loss program (e.g., “I will try to lose 1 kg by consuming 3-4 portions of fruit”) can achieve greater weight reduction (34, 35). Two ongoing studies are currently examining the impact of implementation intention on physical exercise, energy/calorie intake, and eating strategies (33, 36).
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Mobile Applications: A Modern Approach
Another innovative aspect of this study is that the implementation intention intervention will be undertaken through the use of a mobile-phone application. A main advantage of using mobile devices is its ease of use, as compared with paper tools (48-51): mobile-phone applications have repeatedly been found to improve the completeness and accuracy of patient documentation. Hence, because it allows the direct coding of behavior observations, the use of a mobile app device could provide accurate [e.g., diminished memory bias (52)] and detailed information in the enactment of specific strategies of implementation intention [e.g., frequency, time, subjective experience of efficiency, difficulty, or satisfaction (53)].
The building of the design and structure of the “IF → THEN” mobile app took place between July 2016 and May 2017. It was the result of several multidisciplinary meetings of scientific researchers (Université Libre de Bruxelles) and clinical practitioners (CITO unit). The aim was to create a mobile tool and to select implementation intention strategies that should have the greatest impact and adherence rate in obese patients with regard to mindful eating and embodiment-like physical activity.
The “IF → THEN” mobile app includes two main categories of implementation intention strategies: “EATING,” which focuses on mindful eating; and “MOVING,” which focuses on intuitive exercise (i.e., embodiment-like physical activity). Each category includes 5 strategies of implementation intention (i.e., 10 strategies in total).
Components of the Mobile App
The EATING category includes an optional step of observation, namely: the recognition of (i) the intensity of hunger, (ii) inner body sensation, and (iii) affective state. Participants will be invited to undertaken these steps before eating. Specifically, participant will be first requested to self-report the level of their hunger (on a 10-point scale). Thereafter, they will have to (i) select the bodily regions in which they feel increasing or decreasing (divided in 13 regions-of-interest; see also Figure S1 in Supplementary Material) based on a topographical self-report method (55) and (ii) identify their affective state based on the State-Anxiety Inventory (56): calm, secure, tense, strained, at ease, upset, satisfied, frightened, comfortable, self-confident, nervous, jittery, indecisive, relaxed, content, worried, confused, steady, and pleasant.
After these aforementioned (non-mandatory) steps of observation (i.e., the intensity of hunger, inner body sensation, and affective state), participants will have the possibility to report on the use of an EATING strategy. Participants will also be able to report directly after they used a strategy without going through the first steps of observation. Participants will report on each strategy use, by indicating (i) the level of difficulty associated with the enactment of the strategy (on a 10-point scale); and (ii) the level of satisfaction associated with the enactment of the strategy (on a 10-point scale). Participant will be instructed to report on the strategy after finishing eating, not to interfere with its enactment and with the action of eating.
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In the MOVING category, the participants will be simply requested to “push” on the implementation intention strategy that they just have been undertaken. Thereafter, the participants will be asked (i) to rate the level of difficulty associated with the enactment of the strategy (on a 10-point scale); (ii) to rate the level of satisfaction associated with the enactment of the strategy (on a 10-point scale); and (iii) to validate their observation. Participants will be instructed to report on the strategy after their physical exercise not to interfere with the activity.
For both the EATING and MOVING categories, participants will have access to numerical information related to their observations. Specifically, participants will be able to see for each strategy the frequency (i.e., the number of time that a strategy is used), the average level of difficulty (i.e., calculated across each strategy use), and the average level of satisfaction (i.e., calculated across each strategy use). Participants will also have the opportunity to view these numbers according to a specific time interval (i.e., last week, total).
Study Protocol and Assessments
The study protocol will be explained in detail to the patients during the first day of the CITO therapy. Patients will receive information on (i) implementation intention strategies on the MOVING and EATING categories and (ii) how to use the app in his/her daily life. Patients who accept to participate to the study will be asked to sign the informed consent. All patients will receive the standard of care of the psychotherapeutic CITO program. Patients accepting to participate will have the possibility to use the app additionally to the standard care. This individualized tutorial session will be organized after 2 weeks after the presentation of the app.
During this session, a member of our research group will give detailed instructions to the participant on how to use the app in his/her daily life. Then, participant’s subjective motivation to use the mobile application will be assessed by asking the following question: “Are you motivated to use this app for 4 weeks?” (on a 7-points scale, ranging from “non-motivated” to “highly motivated”). Next, participant will complete the French version of the Intuitive Eating Scale-2 (57) and the Intuitive Exercise Scale (58).
The Intuitive Eating scale is a 18-items self-reported questionnaire (5-point Likert scale; ranging from “Strongly Disagree” to “Strongly Agree”) that includes three dimensions: (i) eating for physical rather than emotional reasons (eight items; e.g., “I find other ways to cope with stress and anxiety than by eating”); (ii) reliance on hunger and satiety cues (six items; e.g., “I trust my body to tell me when to eat”), and (iii) unconditional permission to eat (four items; e.g., “I do not follow eating rules or dieting plans that dictate what, when, and/or how much to eat.”).
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The Intuitive Exercise Scale is a 14-items self-reported questionnaire (5-point Likert scale; ranging from “Strongly Disagree” to “Strongly Agree”) that includes four dimensions: emotional exercise (5 items; e.g., “I use exercise to help soothe my negative emotion”), body trust (3 items; “I trust my body to tell me how much exercise to do”), exercise rigidity (3 items; “I engage in a variety of different types of exercise”), and mindful exercise (3 items; “When my body feels tired, I stop exercising”). The Intuitive Exercise Scale will be translated into French by using back translation. Participants will also complete the French version of the 13-item Brief Self-Control Scale [BSCS (59, 60)], a widely used measure of trait self-control. Items (e.g., “I am good at resisting temptation”) are endorsed on a 5-point scale, where 1 = not at all like me and 5 = very much like me. This measure was added to the protocol on the basis of previous studies which have shown that high trait self-control predicts both positive health behaviors and success in weight loss [e.g., Ref.
This session will occur 4 weeks after the individualized tutorial session. First, the participant will be asked to send the data from the “IF → THEN” app by pushing on the “send” icon. This procedure will allow to save the data (under.xls file format) to a secure server. To protect against loss of confidentiality, all data will be identified by a unique numeric ID code. The list linking the participants’ ID codes with their names will be stored in a password-protected file on an internal server, accessible only to the experimenters and selected project staff. Secondly, the participant will complete the Intuitive Eating Scale-2 and the Intuitive Exercise Scale. The study protocol has been approved by the CHU-Brugmann University Hospital Institutional Review Board (REF: B077201732743/I/U).