Training Adults to Identify Hunger: Do Kids Need "Training?"

 Recently, an interesting journal article has been making the rounds about training adults to recognize and respond to hunger cues. Essentially, the researchers asked study participants to pay attention to when they felt hunger: described as "EHS" or empty hollow sensation of the stomach, and "inanition," or more of the feelings of anxiousness, fatigue, headache etc. that often come later. They then tested blood sugar levels in the subjects and by doing so, were able to help subjects link the objective low blood sugar with hunger, helping to differentiate hunger from other cues. The theory is that many adults can no longer recognize hunger, eating for other reasons (pain, boredom, social cues, nausea) and that this contributes to insulin resistance and weight gain in the subjects and overall population. Subjects in this weight loss study were then instructed to eat when they felt hungry. (Contrary to typical advice for diabetes and weight loss diets to stop when you no longer feel hungry, or when you feel full...)Here are some of the findings/comments from the authors I found most interesting/useful:

• "Eat when you feel hungry" feels very different from "stop when you are full." "Stop when full" often feels restrictive, confusing and negative, and is part of why so many diets fail.
• It can more difficult to sense fullness vs. hunger, and insulin resistance can make it even more difficult to sense initial feelings of satiety.
• Eating is recognized as pleasurable, and the participants were not told to eat less, but to eat at the onset of subjective hunger (confirmed with objective measures). This is more likely to lead to compliance since it does not deny pleasure, nor does it feel restrictive.
• Rating hunger on a scale seems less useful and more difficult for folks than merely recognizing its presence, and that may be enough. EHS comes before inanition, and subjects were not asked to wait until inanition, but to eat at any indication of hunger (readiness to digest).
• Subjects did not report change in activity or energy level.
• Trained subjects learned relatively quickly to correlate internal sensations with blood glucose measures.
• Blood glucose and insulin sensitivity improved in the trained group, they also lost weight overall (so did the standard diet group, but by the end of the seven weeks, the diet group intake was increasing, suggesting "disinhibition," or falling off the proverbial diet wagon.
• Some of the "normal weight" folks lost weight, though most did not. There were no goal weights, though it was a "weight loss study..."
• IH meal pattern emerges: "subjects were able to arrange their meal size and composition to ensure that IH appeared just prior to the following meal-time with a mean error of half an hour in 80% of adults and 90% of children*"-(though I can't find the reference for this statement or an indication as tho which children this refers to...) Lends support to offering regular opportunities for meals and snacks with some flexibility.

Questions I have:

• One concern is that the control group followed typical dieting practices, so we are comparing the intervention to a control group that is partaking in what we already know to be harmful and counterproductive. How would the study have differed if the control groups had been given different instructions, or none at all?
• Study only went on for 7 weeks, what might this look like 6 months or a year out, when they weren't participating in a weight loss study?
• This was a weight loss study, which may color the motivations and maintenance outcomes.
• Did the study participants ability to tune in to hunger cues and eat accordingly continue, or was the process somehow cumbersome or hard to maintain?
• I would have liked to see a breakdown of weight and blood glucose/insulin by participant. Did some of the "overweight" subjects maintain weight, but still see blood sugar and insulin improve? Just as some "normal weight" improved with blood measures while weight stayed stable? Would be curious to see more.
• Average BMI before the study was about 28-29. Does this differ at various BMI ranges, and depending on personal history as in life-long dieting, or history of or active eating disorder? Would have liked to know more about study participants and those who dropped out.
• Would love to know more about the timing of meals that resulted. One area said that study participants delayed meals waiting for hunger signals from "2-48 hours..." Explain please.
• Seemed like authors approached things differently, with one author advising "light meals" in response to inanition, so perhaps there was some restriction? This concerned me in terms of whether the researchers were following similar protocols, and if there was indeed restriction or asking them to eat based on external, vs. internal cues. Not clear.

I was most struck with their strong recommendation to teach children hunger signals, "Training in Hunger Recognition should begin in infancy and continue through childhood."  Though they admit that there is controversy between those who believe hunger is instinctive and doesn't need to be taught, but supported (as I and others do, I don't want to speak for others but it seems consistent with Ellyn Satter's eating competence model and Tribole and Resch's Intuitive Eating) vs. hunger cues must be taught. I think this is a critical distinction. The authors mention several common tactics that bury inborn skills, like insisting on a clean plate, but offer no concrete examples or resources on how to "train" children to recognize hunger cues.Seems clear that these authors come down on the side of teaching kids hunger cues. I don't mind theorizing about why many children and adults lose touch with hunger cues, but I take issue with their conclusion that children need to be taught hunger cues, and bet that this study will be cited as support for teaching children hunger cues, while the study did not include actual children.I believe that hunger and satiety are innate, and that with supportive feeding, children learn to rely on and eat according to those cues. I worry that someone doing a casual read of this article, or only reading a headline, might try "training" small children in ways that are ultimately harmful, interfere with the natural process,  and are developmentally inappropriate. The last thing I want to see is a bunch of preschoolers being harangued after every bite to check in with a hunger and fullness rating scale...I do find that this is hopeful as it supports  the idea that adults can learn to tune in to cues again. I like to say that we can feed children in ways that support or bury internal cues. (Different than saying destroy or leave adults unable to get back to internally regulated eating.)What are your reactions to the study, and my musings?*The article overall was confusing for me as it reviewed several studies, one in infants and diarrhea for example, and mentions "children" in one area with no reference, or connection to the main study. The central study in the piece is training hunger recognition and correlating with blood sugar was done on adults.