Interoception: The Skill Nobody Taught You and Your Body Is Using Anyway
Every client who has ever sat across from a dietitian has been asked some version of the same question. Are you hungry right now. How full do you feel on a scale of one to ten. Can you tell when your stomach is empty.
Underneath that question, the clinician is quietly asking something the client has rarely been asked before. Can you read the inside of your body, and do you believe what it tells you.
That is interoception. And almost no one in this profession was ever trained to teach it.
What interoception actually is
Interoception is the continuous, mostly quiet process by which the nervous system perceives, interprets, integrates, and regulates signals coming from inside the body. Heartbeat, breath, hunger, fullness, bladder, bowel, temperature, muscle tension. The signals run underneath conscious awareness most of the time, and the nervous system uses them to decide what the body needs to do next, whether the person on top of that nervous system has ever paid attention to any of it.
Garfinkel and colleagues describe interoception as three dimensions that matter clinically: interoceptive accuracy, the objective performance of detecting an internal signal like a heartbeat; interoceptive sensibility, how often a person notices internal sensations on their own; and interoceptive awareness, the gentle metacognitive correspondence between the two (Garfinkel et al., 2015). Most of the clients we see have a gap across all three.
That gap is what you are working with in the room.
How the signal goes offline
Interoception erodes gently, over time, in small overrides that add up.
A child learns at age 4 that the adults around her tend to override her when she says she is full, so she slowly stops checking. A teenager learns at 13 that her body's hunger is socially expensive, so she learns to override it. A trauma survivor learns somewhere early on that what her body is feeling is information she has to put down to get through her day, and the wiring goes quiet to keep her safe.
The research carries this pattern. In acute anorexia nervosa, patients show decreased interoceptive sensitivity and a reduced ability to accurately perceive bodily signals, including a disrupted recognition of the visceral sensations that come with hunger (Pollatos et al., 2008). The Interoception Summit consensus described interoceptive dysfunction as a transdiagnostic feature across anxiety, mood, eating, addictive, and somatic symptom disorders, and called for it to be treated as a priority across mental health treatment (Khalsa et al., 2018).
This is what walks into your office on a Tuesday. A client whose interoceptive signal has been offline for years, asking you, with a little hope underneath it, what to eat.
Why this is a dietitian's problem
Food is the domain where interoception fails most visibly.
A client whose interoception is online tends to know when she is hungry, knows when she is full, knows when she is eating past fullness for reasons other than hunger, and can usually name a few of those reasons on her own. A client whose interoception has gone quiet is mostly operating from external information. She knows the clock, she knows the meal plan, she knows what her last provider told her, and the body itself stays mostly silent underneath all of it.
You can hand that client a perfectly calibrated 1,800-calorie meal plan and it will quietly fail in the same way most of those plans quietly fail. The plan assumed a receiver who could feel what 1,800 calories landing in her body was like, and there was no receiver in the room.
Brown and colleagues found, in a network analysis of 428 patients in intensive eating disorder treatment, that the most central symptom bridging interoceptive awareness and eating disorder pathology was feeling unsafe in one's body (Brown et al., 2020). The signal being offline is the first layer of the problem. The body mistrust that meets the signal when it does come through is the second. Two layers of repair sit underneath this work, and both of them ask for time.
What this looks like in the room
A client tells you she has never really been a breakfast person. Probe gently and you find her body has been quietly asking for breakfast for 12 years without anyone in the room hearing the request.
A client says she ate because she was bored. Sit with that for a minute and the boredom turns out to be the only word her vocabulary has for a specific cluster of sensations in her chest and throat that the food reliably quiets.
A client tells you she felt fine all week and then binged Thursday night with no warning. Walk her through Thursday and you find she skipped lunch, drove through an argument with her mother, sat in 90 minutes of traffic, and arrived home with a body that had been asking for her attention since 1pm. The food heard what she could not hear yet.
In each of these, the eating behavior is doing exactly what it has been recruited to do: respond to an internal state the conscious mind cannot quite perceive. The body is still feeling. The brain has stopped listening, sometimes for very good reasons, and the food has been holding the conversation in the meantime.
How to use interoception clinically, inside scope
Three moves that sit comfortably inside Floor 1 of the Psychonutrition House and stay clearly inside dietetic scope of practice.
One. Assess the signal underneath the behavior.
The intake question I ask is: what does hunger feel like in your body, and where do you feel it. Most clients leave the second half blank, or fill it in with a borrowed answer they read somewhere. That blank is your baseline, and it is information with clinical weight. The MAIA-2 is a 37-item validated self-report measure of interoceptive awareness across eight dimensions, including body trust and body listening, and it sits comfortably inside a regular session (Mehling et al., 2018).
Two. Teach the signal before you intervene on the behavior.
If a client cannot feel hunger yet, a meal plan does not have a body to land in. The clinical move is to slow down and back up. Body scans before meals, slow structured breath work that brings the diaphragm back online, naming three sensations in the chest and three in the stomach before the first bite, pausing at the halfway point of the meal and asking the body what it is feeling with no scoring attached. These are interoceptive exposures and they sit inside the scope of an RDN.
Three. Build trust in the signal, alongside access to it.
A client can start to feel hunger arrive at 11am and still override it, because the signal feels unsafe to her after years of being overridden. Access is the first half of the work. Trust is the half that lets the access actually change anything. When she tells you she feels a tightness in her chest, you stay with it for a moment. You ask where it is, how big it is, how long it has been there, what shape it has. You treat the data as data, and the client gets to watch you treat it that way. Over weeks, she borrows that posture. Body trust is built quietly, mostly through being witnessed in a body by someone who is paying close attention.
Where this leaves the field
Interoception is a transdiagnostic mechanism. It sits underneath eating disorders, anxiety, mood, addictive, and somatic symptom disorders (Khalsa et al., 2018). For dietitians, the opportunity is specific. We see clients across the longest time horizon, in the most embodied domain, around the behaviors that interoception most directly governs. We are positioned to operationalize interoceptive repair as a standard part of nutrition care, woven into the way we already work.
This is a clinical sequencing correction. The signal comes before the behavior. The receiver comes before the plan. The body comes before the food.
You have been working with interoception in every session you have ever run. The framework is the part that has been missing.
A reflection for your week
If you see clients, notice one thing this week. Notice how often a client answers a body question with a number, a rule, or a memory of what someone else once told her her body was doing. Notice the small moment of stillness when the answer finally comes from inside the body in the present tense.
That gap is the work. Floor 1 of the Psychonutrition House™ is built to close it slowly, in the way nervous systems actually move.
The waitlist for the Level 1: Foundations of Psychonutrition founding cohort is open at www.newapproach.health/dietitian. Interoception is woven through the foundation and Floor 1 of the curriculum.
References
Brown TA, Vanzhula IA, Reilly EE, et al. Body mistrust bridges interoceptive awareness and eating disorder symptoms. J Abnorm Psychol. 2020;129(5):445-456. doi:10.1037/abn0000516
Garfinkel SN, Seth AK, Barrett AB, Suzuki K, Critchley HD. Knowing your own heart: distinguishing interoceptive accuracy from interoceptive awareness. Biol Psychol. 2015;104:65-74. doi:10.1016/j.biopsycho.2014.11.004
Khalsa SS, Adolphs R, Cameron OG, et al. Interoception and mental health: a roadmap. Biol Psychiatry Cogn Neurosci Neuroimaging. 2018;3(6):501-513. doi:10.1016/j.bpsc.2017.12.004
Mehling WE, Acree M, Stewart A, Silas J, Jones A. The Multidimensional Assessment of Interoceptive Awareness, Version 2 (MAIA-2). PLoS One. 2018;13(12):e0208034. doi:10.1371/journal.pone.0208034
Pollatos O, Kurz AL, Albrecht J, et al. Reduced perception of bodily signals in anorexia nervosa. Eat Behav. 2008;9(4):381-388. doi:10.1016/j.eatbeh.2008.02.001
Emahlea Wilcher, MPH, RD, LD, CPsyN is the founder of New Approach Health and creator of the Psychonutrition framework and CPsyN™ credential.