Integrative Medicine - A Clinician's Journal

Whole-person Integrative Eating: A Program for Treating Overeating, Overweight, and Obesity

Deborah Kesten, MPH; Larry Scherwitz, PhD

Abstract

The whole-person integrative eating (WPIE) model and program provides insights into the underlying causes of overeating as well as a comprehensive program for treating overeating, overweight, and obesity. A wide range of guidelines on food and eating from ancient food wisdom from Eastern healing systems, world religions, and cultural traditions, as well as Western nutritional science, were distilled into 6 principles: (1) eat fresh, whole foods; (2) eat with positive feelings; (3) eat with mindfulness; (4) eat with gratitude; (5) eat with loving regard; and (6) eat while dining with others. To assess how well individuals follow these guidelines, an 80-item questionnaire was developed and administered to a large sample of 5256 Americans who participated in a 6-wk, 18-lesson online e-course on integrative eating. Based on a factor analysis of the items, 7 distinct overeating styles emerged that are opposite of the perennial principles: (1) emotional eating, (2) fast foodism, (3) food fretting, (4) task snacking, (5) sensory disregard, (6) unappetizing atmosphere, and (7) solo dining. All were significantly and independently related to overeating frequency, and 5 of the 7 were significantly related to being overweight or obese. The case study presented here demonstrates how a 64-y-old woman who struggled with obesity throughout adolescence and adulthood was able to replace her 7 overeating styles with the 6 perennial integrative-eating guidelines for optimal eating. At the beginning of the year’s coaching intervention, Barbara weighed 107 kg and wore a size 3×; 1 y later, she weighed approximately 75 kg and wears a medium, size 12. She has attributed her weight loss to the wholeness of the integrative-eating program she practices.

Deborah Kesten, MPH, is a principal investigator for the Whole Person Integrative Eating Program in Sausalito, California. Larry Scherwitz, PhD, is a coprincipal investigator for the Whole Person Integrative Eating Program.

Corresponding author: Deborah Kesten, MPH

E-mail address: dkesten@me.com

The obesity epidemic^1-3and the challenges of attaining and maintaining weight loss have generated many studies to identify the best strategies for short- and long-term weight loss. Integrated and whole-person nutritional approaches are emerging,^4,5 but a conventional and well-studied method with some success includes reduced caloric intake; increased physical activity; and the use of behavioral approaches, including an individually tailored diet, self-monitoring, a counselor’s feedback, and social support.⁶

However, of those individuals who are successful in losing 10% of their weight, 80% regain it within 1 year.⁷ At the same time, many studies have suggested that dieting (ie, curtailing calories) does not work,⁸ whereas other studies have posited that overeating may be caused by a hormone deficiency.⁹ Others have proposed that overeating is due to a genuine biological addiction to sugar, flour, and processed foods.^10,11 Given the existing problem in which individuals regain lost weight, clinicians clearly need more insight into the causes, measurement, and treatment of overeating and ensuing weight gain.

To explore causes of overeating, the authors studied cross-cultural food- and nutrition-related guidelines, beliefs, and rituals by reviewing ancient food wisdom that had served humankind for millennia prior to the evolution of nutritional science in the 20th century. Those sources include (1) major world religions—Judaism, Christianity, Islam, Hinduism, and Buddhism; (2) Eastern healing systems—traditional Chinese medicine, ayurvedic medicine, and Tibetan medicine; and (3) cultural traditions—yogic nutrition, African-American soul food, Native-American food beliefs, the Japanese Way of Tea, and Chinese food folklore.^12,13

When the authors distilled dietary recommendations based on the consistency with which they were mentioned across traditions, 6 perennial, optimal-eating themes emerged, each of which has been supported by recent scientific studies. Those themes are the practice of eating (1) fresh, whole foods,^14-18 (2) with positive feelings,^19-21 (3) with mindfulness,^22,23 (4) with gratitude,^24,25 (5) with loving regard,^13,26,27 and (6) while dining with others.^28,29 When the 6 guidelines are practiced together, they cover
4 facets of how to regard food: (1) the biological—what to eat for health; (2) the psychological—how feelings affect food choices and how food affects feelings; (3) the spiritual—to eat with mindfulness, appreciation, and love; and (4) the social—to share the experience of eating with others (Table 1).¹²

Table 1. The 4 Facets and 6 Principles of the WPIE Model: A Self-care, Dietary Lifestyle

Biological Nutrition

1. Eat fresh, whole foods in their natural states as often as possible.

Psychological Nutrition

2. Be aware of feelings before, during, and after eating.

Spiritual Nutrition

3. Bring a moment-to-moment, nonjudgmental awareness to every aspect of each meal.

4. Appreciate food and its origins from the heart.

5. Create union with the Divine by flavoring food with love.

Social Nutrition

6. Unite with others through food.

Abbreviation: WPIE, whole-person integrative eating.

The authors coined the phrase whole-person integrative eating (WPIE) to describe the multidimensional ways in which food can be nourishing. Ultimately, WPIE is not only about what to eat (ie, fresh, whole foods) but also about how to eat for optimal health (ie, with positive feelings, mindfulness, gratitude, and love and by dining with others in a pleasant atmosphere). The objective of the authors’ research was to measure the degree to which individuals practice the 6 WPIE guidelines daily and whether that practice has a link to overeating and weight.

Integrative Eating Research

To assess the frequency of practice for each of the 6 integrative eating guidelines identified in the wisdom and cultural traditions (Table 1), an 80-item questionnaire was developed called “Your Integrative Eating Profile.”¹² Each of the 80 items in the questionnaire is scored on a continuum of responses ranging from never, rarely, and sometimes to usually, almost always, and always.^30,31 “Your Integrative Eating Profile” was administered to 5256 individuals who completed the 80-item questionnaire in exchange for access to a free 18-lesson, online WPIE course offered by the first author. All who completed the questionnaire were included in the sample. Availability of the e-course, hosted on the Web site of Spirituality & Health magazine, was announced at the end of a feature article on WPIE by the first author in Spiritually & Health magazine. In addition to filling out the 80-item WPIE questionnaire, completing demographic data was optional.

Of the 5256 who completed the 80-item questionnaire, 1115 answered questions on weight, height, age, sex, and education. The results showed that most in the sample were highly educated (77% completed college or graduate school), white (92%), and female (91%). The average weight was 82 kg; 483 (42.4%) of the sample were obese, 26.1% were overweight, and 30.4% were normal weight, with only 1% self-classified as underweight.³²

One of the 80 items asked about the frequency of overeating; correlations of the overeating item with the other 79 items showed that 78 items were significantly correlated with overeating. All correlations indicated that the less individuals reported following the 6 optimal eating guidelines, the more they were likely to overeat. To reduce the 79 significant items into a manageable number and to come to a conceptual understanding of whether the items were formed into patterns, a factor analysis was performed on all 79 items. To assess the reliability of the factors, the sample was randomly divided into equal sample sizes and separate analyses were run on each sample; in addition, separate factor analyses were conducted on the sample divided into 3 levels based on the body mass index (BMI): normal, overweight, and obese. Seven distinct factors emerged that were very similar for both the randomly divided samples as well as by the weight levels. Each of the factors were highly coherent as indicated by the Eigenvalues, a measure of intercorrelation ranging from 2.2 to 17.4, where a 1.0 is the minimal level considered to be a viable factor. To refine the 80-item questionnaire into its current 76 items, 10 items were deleted that either did not correlate strongly to a factor or that were repetitive and 6 items were added that asked about eating with friends and family.

The stability of the factors and their coherence suggested that the 7 factors are viable eating styles that may exist in people’s daily lives. A multiple regression analysis revealed that each eating style was significantly and independently predictive of overeating frequency; in fact, the relationships were so predictive that the eating styles accounted for 54% of the variance in overeating.³² Those styles include (1) emotional eating—eating to manage feelings^33-37; (2) fast foodism—eating mostly processed, high-calorie food, with less fresh foods^38,39; (3) food fretting—dieting, self-judgment, and overconcern about food^40-42; (4) task snacking—eating while doing other activities^43,44; (5) sensory disregard—not taking the time to taste and savor food⁴⁵; (6) unappetizing atmosphere—dining in psychologically and aesthetically unpleasant surroundings^46,47; and (7) solo dining—often eating alone (Table 2).²⁹ Because each of the 7 eating styles was significantly related to overeating, with 5 of the 7 linked to being overweight or obese, the authors called them overeating styles. The title of the current 76-item questionnaire is “What’s Your Overeating Style? A Self-Assessment Quiz.”^30,31

The case study that follows illustrates how an obese woman, who scored high on the 7 overeating styles³¹ (Table 2), was coached to replace her overeating behaviors with the 6 perennial principles of WPIE and, in turn, attained and maintained her weight loss.

Table 2. Alignment of the 7 Overeating Styles With 7 Integrative-eating Antidotes

7 Overeating Styles

Rx: 7 Integrative Eating Antidotes

Food Fretting

Dieting and obsessing about the best way to eat.

Enjoyment of Food

Perceiving food and the experience of eating as a social, ceremonial, sensual pleasure.

Task Snacking

Eating while doing other activities.

Mindfulness Eating

Bringing moment-to-moment nonjudgmental awareness to each aspect of a meal.

Emotional Eating

Turning to food to self-medicate for negative feelings.

Appetite-based Eating

Eating for pleasure, with a healthy desire for food.

Fast Foodism

Consuming mostly fast and processed foods.

Fresh, Whole Foods

Choosing fresh, whole foods in their natural states as often as possible.

Solo Dining

Eating alone more often than not.

Shared Fare

Dining with others as often as possible.

Unappetizing Atmosphere

Eating in unpleasant psychological and nonaesthetic environments.

Pleasant Environment

Dining in psychologically and aesthetically pleasing surroundings.

Sensory Disregard

Eating without attention to flavors, aromas, and presentation, etc.

Sensory Delight

Savoring flavors and eating with the senses.

Case Report

History

Barbara was a single, 64-year-old, 168-cm, Caucasian woman who had become progressively obese for most of her adult life. Barbara’s weight gain, which had begun as a preteen, had continued to escalate in the following decades of her life. As an adult, she had had 2 hip replacement surgeries, the first on her left hip in 1999 and the second on the right hip in 2000. Nerve damage due to the surgery had caused a neuromuscular disorder, a foot-drop injury, rendering her incapable of walking without dragging her foot. She also (1) suspected that she had fibromyalgia; (2) had experienced extreme fatigue and pain at a cellular level; (3) had digestive problems (eg, gas, bloating, constipation, and diarrhea); (4) had shortness of breath; (5) had pain in her knees; and (6) had ongoing work-related stress. Since her surgery, Barbara had taken pharmaceutical medications, including painkillers and antibiotics.

Formerly a top-level IT strategist in corporate management, Barbara had consumed multicourse, calorie-rich meals in the evening while entertaining clients at exclusive restaurants, and late at night, she had eaten a lot of processed, crunchy, salty, high-fat, high-sugar foods from room service. Her disordered eating behaviors included night eating syndrome (NES),^48-50 food cravings and compulsive eating,⁵¹ and a belief that she was addicted to substances in food¹¹ to anesthetize her physical pain and to numb the high-stress anxiety she often felt. Despite such challenges, Barbara occasionally participated in water aerobics, led meditation classes, and spent time with her 6-year-old granddaughter.

In mid-2012, Barbara began participating in weekly, 60-minute coaching sessions⁵² during a 1-year period with the first author, via telephone. When she contacted the first author, her key self-treatment strategy for her obesity included attending Overeaters Anonymous (OA) meetings weekly and proactively and consciously practicing and implementing the OA 12-step program. She was motivated to improve her relationship with food, eating, and weight by learning and practicing the WPIE program and to see whether integrative eating could enable her to succeed where other weight-loss approaches had failed.

Pretreatment Assessment

At the start of the coaching sessions, Barbara weighed 107 kg, her highest weight ever. Throughout much of her adult life, she had tried Weight Watchers and all of the traditional diets du jour to lose weight, plus alternative interventions, such as acupuncture and hypnosis. All efforts ended in the yo-yo syndrome and weight cycling; nothing ever lasted. During the intake session for the coaching, Barbara clarified that the psycho-bio-social-spiritual approach of WPIE appealed to her because she did not resonate with conventional treatments for weight loss (ie, restricting calories, following a specific diet plan, and exercising).

The first session focused on how the WPIE program might help her accomplish short- and long-term weight loss, whereas the diagnostic work-up emphasized Barbara’s overeating styles profile³¹ and the extreme degree to which the 7 overeating styles defined her dietary lifestyle of disordered eating.^53,54

Specifically, she often (1) overate high-fat, processed foods (fast foodism) to (2) soothe her stress and satisfy her emotional needs (emotional eating); (3) felt anxiety and concern about what she ate (food fretting); (4) ate while doing other things such as working on the computer (task snacking); (5) rarely took time to savor her food (sensory disregard); (6) ate in an emotionally disagreeable environment (unpleasant atmosphere); or (7) dined alone (solo dining). Such results revealed she was following today’s new-normal ways of eating that increased her odds of overeating or of being overweight or obese.

Therapeutic Intervention

The key goal of her treatment plan was to help Barbara attain and maintain weight loss by replacing each of the 7 overeating styles with 7 optimal WPIE behaviors: (1) enjoying her food,^55,56 (2) eating mindfully^57,58 (3) pursuing appetite-based eating,²⁰ (4) choosing fresh whole foods,^14,15 (5) dining with others,^28,29 (6) eating in psychologically and aesthetically pleasing surroundings,⁵⁹and (7) taking time to taste and savor her food (Table 2).^60,61

The intervention was one-on-one, which was Barbara’s preferred way of working. The therapeutic approach included (1) assessing her readiness to change her relationship to food and eating; (2) evaluating her overeating styles and considering the pros and cons of her current relationship to food; (3) creating a plan of action; (4) overcoming obstacles by applying coaching techniques, such as motivational interviewing and open-ended, nonjudgmental questions⁵²; and (5) using a plethora of integrative-eating training and educational tools (Table 3).

Table 3. The Practice: A 5-phase Training and Education Plan

Phase	Title of Training Tool	Description of Tools
Introduction to WPIE	“Whole Person Integrative Eating”⁶⁴	A white paper that provides an overview of the evidence-based, WPIE dietary lifestyle that has nourished humankind for millennia and its link to weight loss.
	“The TEDx Talk: Make Weight Loss Last”⁶⁵	A video revealing the new-normal ways of eating and thinking about food that may be contributing to individuals’ weight gain and failure to maintain weight loss.
	The Healing Secrets of Food: A Practical Guide for Nourishing Body, Mind, and Soul^12,66	A book that describes the 6 WPIE guidelines for optimal eating, and the 4 facets of food that nourish physically, emotionally, spiritually, and socially; supported by scientific studies.
Assessment Tools	“A Successful Loser Secret? Meet the 5 Stages of Change”⁶⁷	An article that explains the methods of assessing a person’s readiness to change his or her relationship to food, eating, weight, and weight loss prior to proceeding with a WPIE plan of action.
	“What’s Your Overeating Style? Self-Assessment Quiz”³⁰	A 76-item questionnaire with automated scores and interpretations of the 7 overeating styles.
Determine Intervention	n/a	Suggested discussion with client of the preferred training format (ie, self-directed, one-on-one, group meetings, or some combination).
Elements of WPIE	“Study Uncovers 6 Ancient Healing Secrets of Food”⁶⁸	An article that discusses the discovery of 6 the perennial principles of WPIE.
	“Discover the 4 Facets of Food—and Their Power to Heal”⁶⁹	An article on how food nourishes physically, emotionally, spiritually, and socially.
	Make Weight Loss Last: 10 Solutions That Nourish Body, Mind, and Soul^70,71	A book that explains 10 underlying causes of the obesity epidemic and ways to reverse these trends to increase odds of weight loss.
	Feeding the Body, Nourishing the Soul: Essentials of Eating for Physical, Emotional, and Spiritual Well-Being^13,72	A book that reveals ancient food wisdom from the world’s religions and cultural traditions.
Overeating Styles	“A New Recipe for Weight Loss Success: Meet the 7 Overeating Styles”⁷³	An article describing the discovery of the 7 eating styles, their link to overeating, and how to develop a holistic relationship to food to reduce overeating.
Emotional Eating	“Overcoming Emotional Eating”⁷⁴	An article on the key factor in overeating and weight gain, emotional eating, and how to return to appetite-based eating.
	“Blues-Busting Foods: Rx for Emotional Eating?”⁷⁵	An article on why negative feelings lead to out-of-control eating and what foods can reduce the frequency of emotional-eating episodes.
	“Chocolate: Elixir of Love…and Weight Loss?”⁷⁶	An article on how high-cocoa dark chocolate may help reduce overeating and weight.
Food Fretting	“Lose Weight Without Dieting”⁷⁷	An article that describes the “food fretting” overeating style and how to end the cycle of dieting and obsessing about food and weight.
Fast Foodism	“Eat Fresh, Weigh Less”⁷⁸	An article that explains how fast and processed foods threaten weight and health and what to do about it.
Sensory Disregard	“Nourish Your Senses, Lose Weight”⁷⁹	An article about how taking a sensory delight in food can reduce overeating.
	“A New Weight Loss Secret: Feed Your Senses!”⁸⁰	An article that provides evidence that experiencing the sight, smell, and taste of food may reduce the need to overeat.
Task Snacking	“The Weight Loss Power of Mindfulness”⁸¹	An article showing how eating while doing something else leads to overeating and how paying attention intentionally can enhance nourishment and reduce overeating.
	“The Mindfulness Meal Meditation”⁸²	A free guided audio meditation that can help create a conscious connection to food and eating while creating a sense of well-being.
Unappetizing Atmosphere	“Stress More, Eat More”⁸³	An article about how stress can lead to overeating and what to do to combat it.
Solo Dining	“Eat With Others, Eat Less”⁸⁴	An article linking social isolation to overeating and how sharing food with others reduces the need to overeat.
In Action	“Jumpstart: 10 Quick Weight-Loss Tips”^71,85	A quick guide to 10 key weight-loss solutions.
	“Welcome to…‘10-Smart Steps,’ The In Action Program”⁸⁶	A series of articles providing 10 steps to losing and maintaining weight loss.
	“Weight Loss Living” Workbook,⁸⁷ a comprehensive, hands-on, WPIE intervention	A 4-phase, comprehensive workbook that provides practical, hands-on WPIE-based weight-loss lessons, exercises, menu plans, recipes, and more.

Abbreviation: WPIE, whole-person integrative eating.

Assessing Readiness to Change. To increase Barbara’s odds of authentic, lasting, meaningful change without traditional weight-loss strategies,⁶ such as calorie counting and weighing herself regularly, the first session was dedicated to exploring Barbara’s actual stage of readiness to change her relationship to food and eating by using psychologists’ DiClemente and Prochaska’s 5-stage model of change: (1) precontemplation, (2) contemplation, (3) action, (4) maintenance, and (5) relapse.^62,63 Unequivocally, Barbara was in the contemplation stage and was ready to take action to overcome the 7 overeating styles.

Evaluating Overeating Styles. The “What’s Your Overeating Style? Self-Assessment Quiz”^30,31 provided a detailed assessment of the food choices and eating behaviors behind Barbara’s 7 overeating styles. Scored automatically and providing an interpretation of the results the quiz served to introduce Barbara to her trouble spots and to provide clues for creating her personalized plan of action.

Weighing the Pros and Cons. Before proceeding with the actual WPIE intervention, the next 3 sessions focused on considering and assessing the pros and cons of Barbara’s current overeating styles versus the benefits of the whole person integrative-eating approach, which more accurately reflects the relationship to food that she envisioned.

Creating a Plan of Action. Barbara’s plan of action targeted individualized antidotes to the overeating styles she practiced, which had been revealed by the questionnaire. She decided to start with one that was easiest for her to implement (ie, creating a pleasing dining atmosphere) and then progress to the more challenging overeating style, emotional eating.

Overcoming Obstacles. Table 2 provided Barbara with an overview of strategies for overcoming obstacles to changing her overeating styles. Other suggestions to ascertain and overcome areas that warranted attention included (1) readministering the questionnaire periodically to evaluate successes, obstacles, and strategies continuously and to gage her progress; (2) eliciting insights with open-ended questions such as “What elements of integrative eating are easy for you to do? Have you identified any elements you find difficult or challenging?”; and (3) using a wide range of health-and-wellness coaching techniques, such as appreciative inquiry,⁵² that had been designed to facilitate sustainable behavioral change and empower individuals.

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