A Preliminary Study of the Effects of a Modified Mindfulness Intervention on Binge Eating

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1 MINDFULNESS ARTICLES A Preliminary Study of the Effects of a Modified Mindfulness Intervention on Binge Eating Bruce W. Smith, PhD Brian M. Shelley, MD Lisa Leahigh, RN Betsy Vanleit, PhD, OTR/L The purpose of this study was to explore the feasibility of a modified mindfulness intervention for reducing binge eating. Participants (n = 25) were recruited from the general public for a Mindfulness-Based Stress Reduction (MBSR) course. The standard MBSR format was modified to include brief eating exercises. There was no control group. Participants completed the Binge Eating Scale and other self-report measures before and after the course. There was a decline in binge eating as well as state anxiety and depressive symptoms. Reduced binge eating was related to increased self-acceptance and reduced state anxiety. The results are discussed with regard to laying the foundation for future research on the effects of mindfulness on eating. Keywords: mindfulness; obesity; binge; eating; emotion Mindfulness meditation involves the cultivation of moment-to-moment awareness in which people learn to accurately label their inner experience while detaching from judging it (Grossman, Niemann, Schmidt, & Walach, 2004; Kabat-Zinn, 1994). One of the most important effects of mindfulness interventions may be on the regulation of health behaviors. Eating is a primary health behavior, and poor eating habits are at the heart of many of the most costly health problems. Of these poor eating habits, binge eating is particularly dangerous because it may lead to weight gain and obesity (Yanovski, 2003). Researchers have begun to explore the possibility that mindfulness meditation may reduce binge eating (Kristeller & Hallett, 1999). This research was partially supported by the McCune Charitable Foundation. We gratefully acknowledge their support. Complementary Health Practice Review, Vol. 11 No. 3, October DOI: / Sage Publications 133

2 134 B. W. Smith et al. BINGE EATING Binge eating may represent an important failure to self-regulate. It has been defined as the repeated, uncontrolled consumption of a large amount of food (Gormally, Black, Daston, & Rardin, 1982). Binge eating disorder (BED) is one of several eating disorders identified in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000). The prevalence of BED has been found to be 3.5% in women and 2.0% in men (Hudson, Hiripi, Pope, & Kessler, 2006) and 5.0% in obese individuals (Spitzer et al., 1993). There is evidence, however, that binge eating behavior is even more common (Johnson, Rohan, & Kirk, 2002). Binge eating may result from attempts to regulate one s emotions, difficulty knowing when one is hungry or full, or social and cultural conditioning to overeat (Fairburn & Wilson, 1993; Lowe & Levine, 2005). The term emotional eating has been coined to describe eating in response to emotions rather than hunger cues (Arnow, Kenardy, & Agras, 1995; Masheb & Grilo, 2006). One reason emotional eating may occur is a lack of awareness of or ability to distinguish between emotional distress and hunger (Pinaquy, Chabrol, Simon, Louvet, & Barbe, 2003). Another reason it may occur is that one may be aware of distressing emotions but may use eating as a way to reduce this distress (Heatherton & Baumeister, 1991; Lynch, Everingham, Dubitzky, Hartman, & Kasser, 2000). Whatever the reasons for binge eating, the consequences can be harmful with regard to both mental and physical health. The feelings of failure, guilt, and being out of control that can result from binging have been associated with low self-esteem and depression (Smith, Marcus, Lewis, Fitzgibbon, & Schreinder, 1998; Stice, Presnell, & Spangler, 2002). Just as important, binge eating has been linked to long-term weight gain and obesity (Hasler et al., 2004; Yanovski, 2003). The weight gain that can result from binge eating and other poor eating habits is a major risk factor for diabetes, heart disease, and increased mortality (Yan et al., 2006). Despite growing awareness of the negative consequences of binge eating, there are few interventions that have lasting effects. Because eating is a behavior, several psychological and behavioral approaches have been tried for treating binge eating. Although studies of psychological interventions such as cognitive-behavioral therapy and interpersonal psychotherapy have found some empirical support for reducing binge eating (Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000), there are many people who do not respond and for whom other approaches may be more effective. MINDFULNESS AND BINGE EATING Researchers have studied the use of mindfulness and acceptance-based psychological approaches for the prevention and treatment of binge eating (Wilson, 1996). Westernbased cognitive approaches have focused on gaining control over and changing dysfunctional thinking. In contrast, mindfulness-based approaches focus more on the totality of thoughts, feelings, and sensations rather than thoughts alone (Kabat-Zinn, 1990). Because of the promise that mindfulness may hold for reducing binge eating, Jean Kristeller has developed a mindfulness-based intervention specific for people with binge eating problems. Kristeller and colleagues conducted a pilot study of Mindfulness Based Eating Awareness Training (MB-EAT) for obese women with BED (Kristeller & Hallett, 1999). After the 6-week intervention, depression and the number of binge episodes per week were greatly reduced, although weight loss was not demonstrated. MB-EAT is now being investigated in other obese individuals, with or without BED (Kristeller, Baer, & Quillian-Wolever, 2006). Why might mindfulness be important for reducing binge eating behavior? First, the self-acceptance that mindfulness encourages may make it possible for people to more fully

3 Mindfulness and Binge Eating 135 examine their eating behavior. Second, the increased self-awareness associated with mindfulness may make it possible for people to better distinguish between subtle emotional distress and subtle hunger pangs. Pinaquy et al. (2003) found that alexithymia, or difficulty in identifying and describing emotions, was a predictor of emotional eating in individuals with BED. Third, mindfulness may provide a more healthy and effective way of reducing emotional distress than eating. Finally, how might the effects of mindfulness on binge eating behavior vary across the spectrum of low to high binge eating? Although Kristeller and colleagues have examined the effects of mindfulness interventions on people with binge eating disorder and obesity (Kristeller & Hallet, 1999; Kristeller et al., 2006), what effect would mindfulness have on those with milder levels of binge eating who may be at risk for increased binge eating? The answer to this question may shed light on the potential of more general mindfulness interventions for the prevention of the development of more severe binge eating and obesity. THE PRESENT STUDY The purpose of this study was to gather preliminary data to explore the effects of a modified mindfulness intervention on binge eating. We did this by recruiting from the general public for an 8-week MBSR course and modifying the standard MBSR format to include an increased focus on eating. We wanted to provide a link between a standard MBSR course and mindfulness interventions that specifically target BED or obesity (Kristeller & Hallett, 1999; Kristeller et al., 2006). We believed that such a middle way might be important for assessing the feasibility of using modified mindfulness interventions for addressing binge-type eating in overweight and obese individuals. HYPOTHESES For this exploratory study, the primary hypothesis was that a mindfulness course modified to emphasize eating behaviors would result in reduced binge eating as has MB-EAT (Kristeller et al., 2006). We predicted this would occur by way of the general effects of mindfulness on self-awareness and self-regulation and the addition of brief eating exercises to a standard MBSR course. The secondary hypothesis was that reduced binge eating would be correlated with reduced anxiety and depressive symptoms and increased mindful awareness and selfacceptance. We expected reduced binge eating to be related to reduced anxiety and depression because the reductions in anxiety and depression normally associated with mindfulness interventions may make emotional eating less necessary. Conversely, reduced binging might also improve mood as people begin to feel better about the way they eat (Kristeller & Hallett, 1999). We expected reduced binge eating to be related to increased mindful awareness and self-acceptance because these latter qualities may make it possible to become more aware of and to examine one s eating behavior. METHOD Participants The participants were 25 adult women and men recruited from an 8-week ongoing mindfulness program course with open enrollment at the University of New Mexico in April-May All participants started and finished the course at the same time. The

4 136 B. W. Smith et al. course was not specifically for individuals with obesity or BED. The course was advertised as a Mindfulness Based Stress Reduction course, which is a blend of meditation, yoga, and every day tasks and is designed to help people relax and deal with stress. There was no mention of any special emphasis on binge eating in the advertisement, the institutional review board proposal was not written with the specific objective of exploring binge eating, and the consent form only talked about collecting measures in a general way and did not mention binge eating. The only inclusion criterion was the willingness to commit to the course and the research study. The exclusion criteria were severe acute mood disorder, psychosis, and substance abuse. Participants were recruited through the university intranet, primary care referrals, and local newspaper media. Procedure There was a group orientation session for the MBSR course held 1 week prior to the first session of the 8-week course. At this orientation session, the instructors (authors BMS and BV) told prospective participants about the course and gave them the opportunity to participate in this study. Prospective participants were told that study participation would involve filling out questionnaires before and after the course and that they would receive a $20 reduction in the course fee. The total cost of taking the course was $195 (with 75% scholarships for people as needed). Thirty people signed up for the course, 27 enrolled in the research study, and 25 of the 27 completed the course and research study. Participants were considered to have completed the course if they attended an all-day session and at least six of eight weekly sessions. Participants signed up to make individual appointments to complete the pre- and post-mbsr questionnaires. These were completed at a separate location with research assistants (author LL) who were not involved in teaching the course. The instructors were not aware of which course participants were enrolled in the research study, but they knew that it was a large majority. Mindfulness Intervention The intervention was a modified 8-week Mindfulness Based Stress-Reduction (MBSR) course taught by two professionally trained MBSR instructors (authors BMS and BV). Everyone in the course always met as one large group, and both instructors were present at all times. The course closely paralleled the MBSR curriculum developed at the University of Massachusetts Medical Center and included a full-day silent retreat during the sixth week of the course. The weekly sessions were 3 hrs long and aimed at increasing mindfulness through the use of breathing, body scans, meditation, gentle Hatha yoga, and group discussion. Also, like the standard MBSR curriculum, the course included the use of a workbook, home practice assignments, and CDs to follow when practicing at home. The participants did not record their compliance with home practice assignments. The only significant modification from the original MBSR was an increased focus on eating. The conventional 8-week MBSR course contains several mindful eating exercises. These include a 10-min raisin-eating exercise in the first class, encouragement to try to eat mindfully during the week, and a silent brown-bag lunch during the all-day session. For our modified MBSR course, mindful eating exercises were added to the first six weekly classes. The first week was the same as the standard MBSR course, in that it included the raisin exercise. In subsequent weeks, as in MB-EAT, healthy snack foods, high-fat foods, and high-sugar foods were also used to explore the relationships with these kinds of common foods. Exercises also focused on taste awareness and making

5 Mindfulness and Binge Eating 137 choices about what foods to eat. Finally, the all-day session included a potluck lunch and was held in silence. Measures Questionnaires were administered during the week before the start of the course and within 1 week after the end of the course. The questionnaires assessed demographics, binge eating, personal characteristics, and several other aspects of health. The measures of binge eating and other outcomes were in both the pre- and post-mbsr questionnaires. Height and weight were assessed before but not after the intervention. Thus, it was not possible to determine how participants weight changed during the intervention, and weight loss was not a goal of this study. The body mass index (BMI) was calculated from height and weight (wt. in kg/ht. in m 2 ). Binge eating. The Binge Eating Scale (BES) assesses the severity of binge eating and the uncontrolled consumption of a large amount of food (Gormally et al., 1982). The BES includes 16 items with four possible responses (each with a weighted value on a 0-3 scale). For example, the statement choices (and values) in one item are, I feel capable to control my eating urges when I want to (0) ; I feel like I have failed to control my eating more than the average person (1) ; I feel utterly helpless when it comes to feeling in control of my eating urges (3) ; and Because I feel so helpless about controlling my eating I have become very desperate about trying to get in control (3). The range for the measure with all items summed is 0 to 46, with higher scores representing greater binge eating severity. Cronbach s alpha reliability for this measure was.94 before and.92 after the intervention. Depressive symptoms. The Beck Depression Inventory (BDI) was used to assess depressive symptoms over the previous 2 weeks (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The BDI includes 21 items scored on a 0 to 3 scale (e.g., Sadness: 0 = I do not feel sad, 1 = I feel sad much of the time, 2 = I am sad all the time, and 3 = I am so sad or unhappy that I can t stand it ). Higher scores indicate more depressive symptoms. Cronbach s alpha for this measure was.91 before and.88 after the intervention. Mindful awareness and attention. The Mindful Awareness Attention Scale (MAAS) is a measure of receptive awareness of and attention to present-moment events and experience (Brown & Ryan, 2003). The MAAS includes 15 reverse scored items scored on a 1 to 6 scale (e.g., I feel it difficult to stay focused on what s happening in the present ). Higher scores indicate greater levels of mindfulness awareness and attention. Cronbach s alpha for this measure was.92 before and.92 after the intervention. Self-acceptance. Self-acceptance was assessed using a three-item measure from the Scales of Psychological Well-Being (Ryff & Keyes, 1995). High scores on this measure indicate a positive attitude toward the self and acceptance of multiple aspects of the self, including good and bad qualities. The items are scored on a 1 to 6 scale (e.g., When I look at the story of my life, I am pleased with how things have turned out ). Higher scores indicate a greater amount of self-acceptance. Cronbach s alpha for this measure was.70 before and.79 after the intervention. State anxiety. Anxiety was assessed using the State Anxiety scale of the State-Trait Anxiety Inventory (Spielberger, 1983). This scale includes a measure of current anxiety symptoms. This measure includes 20 statements and asks participants to rate their agreement

6 138 B. W. Smith et al. with them on a 1 to 4 scale (e.g., I am tense and I feel frightened ). Higher scores indicate a greater level of state anxiety. Cronbach s alpha for this measure was.88 before and.70 after the intervention. Statistical Analyses SPSS version 14.0 was used for all data analyses. Because there was no control group, the analyses involved the within-subjects comparison of pre- and postintervention scores. The following is a description of the a priori analyses that were conducted to test the three hypotheses: The first hypothesis was examined using t tests to determine whether there were prepost reductions in binge eating and Cohen s d to examine the effect size of any changes. For the secondary exploratory hypothesis, we used correlation analyses to examine the association between binge eating change and changes in state anxiety, depression, mindfulness awareness, and self-acceptance. The alpha level used for testing the hypotheses was p <.05, although trends (p <.10) are noted because of the small sample size. Tests for multiple comparisons were not used because this is a feasibility study and an exploratory analysis. Cohen s d is used as an indicator of effect size and is interpreted using Cohen s (1988) guidelines (small = 0.20, moderate = 0.50, large = 0.80). The summary scores were used for the BES, BDI, and state anxiety. The mean scores were used for the MAAS and self-acceptance. RESULTS The mean age of the participants was 47.8 years (SD = 13.1; range = 27-75) and the sample was 80% female, 48% married, and 80% were employed. The mean income range was $50,000 to $74,999, and 76% had completed college. The mean weight was 178 pounds (SD = 54.3; range = ), and the mean BMI was 27.9 (SD = 7.4; range = 19-43). Table 1 displays the scores for binge eating and each of the other outcome measures before and after the intervention. The first hypothesis was that there would be a decrease in binge eating after the intervention as compared with before the intervention. Table 1 shows that this preliminary study suggests support for this hypothesis. There was a small to moderate decrease in binge eating. There was also a large decrease in depressive symptoms, a moderate decrease in state anxiety, a moderate increase in self-acceptance, and a moderate to large increase in the MAAS. Next, we wanted to explore the effects of the intervention on binge eating change for participants with different initial levels of binge eating. The BES scale has been used to categorize people as having serious ( 27), moderate (18-26), and mild or no (0-17) binge eating problems. The cutoffs for these categories were established by comparing BES scores with ratings of semistructured interviews that identify binge eating (Greeno, Marcus, & Wing, 1995; Marcus, Wing, & Hopkins, 1988). In addition to these categories, we divided the mild or no category into mild and no binge eating categories by dividing the 0 to 17 range in half (no binge eating = 0-8 and mild binge eating = 9-17). We did this because we wanted to determine the effects of the intervention on people with mild binge eating and because we expected floor effects to limit the reduction in binge eating for those with no binge eating problems. Table 2 shows the results for participants with these different initial levels of binge eating. For the 13 participants with no initial binge eating, there was essentially no change. For the 7 participants in the mild range, there was a large reduction and the pre-post difference was significant despite the small sample size. For the 2 participants in the moderate range and the 3 participants in the serious range, there was also a large reduction

7 Mindfulness and Binge Eating 139 TABLE 1. Mean Scores for the Outcome Variables Variable Pre-MBSR Post-MBSR Change t d Binge eating (9.60) 7.12 (7.12) 3.00 (4.68) 3.20** 0.36 State anxiety (9.03) (9.99) 5.52 (12.03) 2.12* 0.58 Depressive symptoms (7.49) 4.32 (4.76) 7.32 (8.02) 4.56** 1.20 Mindful awareness 3.70 (0.85) 4.23 (0.76) 0.53 (0.60) 4.40** 0.66 and attention Self-acceptance 4.46 (1.12) 5.00 (0.96) 0.54 (0.68) 3.92** 0.51 Note. Standard deviations are in parentheses. MBSR = Mindfulness-Based Stress Reduction. *p <.05. **p <.01. TABLE 2. Mean Binge Eating Scores at Different Levels of Initial BES Score Initial Binge BES Eating Range N Pre-MBSR Post-MBSR Change t d None (2.69) 3.31 (2.63) 0.07 (2.56) Mild (1.95) 5.00 (2.08) 6.14 (3.85) 4.22** 3.05 Moderate (0.71) (3.54) 3.00 (4.24) Severe (5.51) (1.53) 8.34 (6.11) Note. Standard deviations are in parentheses. BES = Binge Eating Scale. **p <.01. TABLE 3. Correlations Between Change in Binge Eating and Change in Other Outcomes Binge Eating Scale Mindful awareness and attention.345 Self-acceptance.515**.144 Depressive symptoms *.389* State anxiety.430* *.430* *p <.05. **p <.01. although the differences were not significant. Finally, when the 12 participants in the mild, moderate, and serious categories were considered together, there was a 6.17 (SD = 4.43) point reduction in binge eating, with a moderate to large and significant reduction in binge eating (d =.71, t = 4.82, p <.01). The secondary hypothesis was that reductions in binge eating would be associated with decreased anxiety and depressive symptoms, as well as increased mindful awareness and self-acceptance. Table 3 shows the correlations between pre-post changes in each of these variables. As predicted, reduced binge eating was associated with reduced state anxiety and increased self-acceptance. Reductions in binge eating, however, were not significantly related to BDI changes, and there was a nonsignificant trend toward a relationship between increased MAAS and reduced BES scores. Also, increased self-acceptance was associated with reduced state anxiety and depressive symptoms, suggesting that self-acceptance may be involved in both improved mental health and reduced binge eating.

8 140 B. W. Smith et al. DISCUSSION The purpose of this study was to explore the feasibility of a mindfulness intervention modified to include brief eating exercises to reduce binge eating. Specifically, we wanted to determine whether an MBSR intervention with a greater focus on eating would result in reduced binge eating. We were also interested in whether changes in binge eating were related to reductions in state anxiety and depression as well as increased mindful awareness and self-acceptance. Our primary hypothesis was that participants would have reductions in binge eating. We found a small to moderate decrease in binge eating, suggesting that these preliminary data support this hypothesis. In addition, when we examined the pre-post binge eating scores of participants with different initial levels of binge eating, we found that the 13 participants with no initial binge eating problems showed no change whereas the 12 participants with mild or greater binge eating problems showed a moderate to large and significant reduction. Although the results are only suggestive because of the small sample size, the 7 participants in the mild category showed a large and significant reduction in binge eating. Although it is not surprising that there was no change in those with no initial binge eating problems, there are two reasons it is important that those with at least mild levels of binge eating showed reductions. First, it shows that it is possible for a mindfulness intervention to have an impact on people with a mild level of binge eating, which may have implications for preventing increases in binge eating and obesity. Second, it demonstrates that a mindfulness intervention may not have to focus solely on eating to have a significant impact in reducing binge eating. One implication is that standard MBSR interventions, with minor modifications, may reduce binge eating as well as improve other aspects of health (e.g., anxiety and depression). Another possible implication is that the kind of brief eating exercises used in this study may have an important impact on binge eating. Our secondary hypothesis was that changes in binge eating would be associated with increased mindful awareness and attention, increased self-acceptance, and decreased anxiety and depressive symptoms. This hypothesis was generally supported in that increased self-acceptance and decreased state anxiety were related to less binge eating while there was a nonsignificant trend for mindful awareness and attention to be related to reduced binge eating. It is important, however, to stress the preliminary nature of these data because the sample size was small and we did not do corrections for multiple comparisons. If replicated, the relationship between increased self-acceptance and reduced binge eating could be intriguing. It may seem paradoxical that a practice that increases selfacceptance would also make behavior change possible. A relationship between acceptance and change, however, has been noted in the literature with other interventions that also address acceptance (Hayes, Jacobsen, Follette, & Dougher, 1994; Miller & Rollnick, 2002). It may be that an initial step in reducing binge eating is to first become aware of, appreciate, and accept the full range of one s impulses, sensations, feelings, and thoughts with regard to eating. Future research on mindfulness and eating might try to illuminate the relationship between acceptance and change. The relationship that was found between reduction in anxiety and reduction in binge eating is consistent with the idea that mindfulness may reduce the need for emotional eating (Arnow et al., 1995; Masheb & Grilo, 2006). It may be that people engage in less binge eating because they have less anxiety to try to reduce by eating. The correlational nature of our findings, however, makes it impossible to eliminate the possibility that reductions in binge eating may reduce anxiety or that both anxiety and binge eating may be influenced by third variables. Future studies could attempt to disentangle these relationships by measuring how these variables change over time (e.g., weekly) and attempting to see what changes first.

9 Mindfulness and Binge Eating 141 LIMITATIONS AND FUTURE DIRECTIONS There are several important limitations to this study, and each suggests directions for future research. First, the sample size was small, making it difficult to know whether some important effects would have reached significance with more participants. Also, there were no corrections made for multiple comparisons, which, if made, could have reduced the number of significant results. Our sample size of 25 gave.75 power to detect a large effect size of r =.50 at p <.05 (Cohen, 1988). With another 50 participants, we could have detected a moderate effect size of (r =.30) with the same power. We are continuing to collect data using the same intervention to determine whether the effects that we found can be replicated. Second, there was no control group, making it impossible to know how much the reduction in binge eating may have resulted from improvements that would have taken place without an intervention. Yet even without a control group, we were able to examine the associations between changes in binge eating and personal characteristics and changes in other outcomes. In a future study, based on this preliminary study, we plan to add a cognitive-behavioral therapy based control group and randomly assign participants to both mindfulness and control groups. Third, although we found reductions in binge eating, we did not examine weight loss itself, the number of binge eating episodes, or home practice as a potential mediator of treatment effects. Thus, we cannot say whether a reduction in binge eating in our study led to weight loss or whether our binge eating measure was related to the actual number of binges. We are currently doing a study to examine the effects of a mindfulness intervention on weight loss itself. In this study, we are assessing weight loss as well as a full array of endocrine measures to try to explain binge eating changes, and including qualitative analyses to better understand participants perspectives on changes. CONCLUSION Overall, this preliminary study provided support that a modified MBSR intervention can reduce binge eating for participants openly enrolled from the general public. The intervention significantly reduced binge eating in the sample as a whole and when only considering those with mild initial levels of binge eating. Thus, the modified intervention does appear to be feasible for examining the relationship between mindfulness and binge eating, as measured by the BES. Furthermore, our findings suggest that reductions in binge eating may be associated with increased self-acceptance and reduced state anxiety. Future research should continue to examine the relationship between modified mindfulness interventions and eating using larger samples, physiological measures, and randomized controlled trials. REFERENCES Agras, W. S., Walsh, T., Fairburn, C. G., Wilson, G. T., & Kraemer, H. C. (2000). A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Archives of General Psychiatry, 57, American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Arnow, B., Kenardy, J., & Agras, W. S. (1995). The Emotional Eating Scale: The development of a measure to assess coping with negative affect by eating. International Journal of Eating Disorders, 18,

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11 Mindfulness and Binge Eating 143 Pinaquy, S., Chabrol, H., Simon, C., Louvet, J. P., & Barbe, P. (2003). Emotional eating, alexithymia, and binge-eating disorder in obese women. Obesity Research, 11, Ryff, C. D., & Keyes, C. L. M. (1995). The structure of psychological well-being revisited. Journal of Personality and Social Psychology, 69, Smith, D. E., Marcus, M. D., Lewis, C. E., Fitzgibbon, M., & Schreinder, P. (1998). Prevalence of binge eating disorder, obesity, and depression in a biracial cohort of young adults. Annals of Behavioral Medicine, 20, Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (STAI). Palo Alto, CA: Consulting Psychologists Press. Spitzer, R. L., Yanovski, S., Wadden, T., Wing, R., Marcus, M. D., Stunkard, A., et al. (1993). Binge eating disorder: Its further validation in a multisite study. International Journal of Eating Disorders, 13, Stice, E., Presnell, K., & Spangler, D. (2002). Risk factors for binge eating onset in adolescent girls: A 2-year prospective investigation. Health Psychology, 21, Wilson, G. T. (1996). Acceptance and change in the treatment of eating disorders and obesity. Behavior Therapy, 27, Yan, L. L., Daviglus, M. L., Liu, K., Stamler, J., Wang, R., Pirzada, A., et al. (2006). Midlife body mass index and hospitalization and mortality in older age. Journal of the American Medical Association, 295, Yanovski, S. Z. (2003). Binge eating disorder and obesity in 2003: Could treating an eating disorder have a positive effect on the obesity epidemic? International Journal of Eating Disorders, 34, S117-S120. Biographical Data. Bruce W. Smith is Assistant Professor in the Department of Psychology at the University of New Mexico; Brian M. Shelley is Assistant Professor in the Department of Internal Medicine at the University of New Mexico; Lisa Leahigh is a graduate at the School of Nursing at the University of New Mexico; Betsy Vanleit is Assistant Professor in Occupational Medicine at the University of New Mexico. Address correspondence to: Bruce W. Smith, MSC , Department of Psychology, University of New Mexico, Albuquerque, NM,