The evidence behind mindful eating

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2 The evidence behind mindful eating Shawn N. Hondorp, PhD, ABPP Board Certified Clinical Health Psychologist Division of Psychiatry and Behavioral Medicine Spectrum Health System, Grand Rapids, MI Adjunct Professor, Michigan State University College of Human Medicine

3 Objectives Define mindful eating and mindfulness-based interventions Rationale for utility Effect of mindful eating interventions on: Eating behavior (e.g., binge eating, external eating) Lifestyle changes/weight** 3 **The Center for Mindful Eating position statement on weight concerns does not promote any program that includes or promote weight loss measures or procedures

4 Disclosures None 4

5 Questions to address What do mindfulness-based interventions for eating concerns look like? What is the evidence base for mindfulness-based interventions for eating or weight concerns? How does it compare to other treatment options? 5

6 Focus for this talk Primarily mindfulness-based interventions or mindful eating interventions Less focus on ACT, DBT, etc Rationale: hard to dis-entangle intervention components effects 6

7 Mindful eating Mindful Eating is allowing yourself to become aware of the positive and nurturing opportunities that are available through food selection and preparation by respecting your own inner wisdom. By using all your senses in choosing to eat food that is both satisfying to you and nourishing to your body, acknowledging your responses to food (likes, dislikes or neutral) without judgment, and becoming aware of physical hunger and satiety cues to guide your decisions to begin and end eating you can change your relationship to food. Taken from The Center for Mindful Eating website on 3/25/

8 Mindfulness-based interventions Intensive skills-based programs aimed at reducing distress and improving well-being through the cultivation and practice of mindfulness (Kabat-Zinn, 1990) Mindfulness is often defined as a state of nonjudgmental awareness and acceptance of moment-to-moment experience (Bishop et al., 2004) 8

9 Why mindfulness for eating/weight concerns? Cultivating awareness of internal experiences (e.g., emotions, physical sensations) increases connection between mind and body Including appetite and body s physical needs (Caldwell, Baime, & Wolever, 2012) Re-engage the body s innate feedback mechanisms that help regulate weight (Caldwell, Baime, & Wolever, 2012) Increasing self-acceptance, cognitive flexibility, compassion, thus improving emotional coping Reduced need to use food to cope 9 Baer, Fischer, & Huss, 2005; Dallman, 2010; Kristeller, Baer, & Quillian-Wolver, 2006; Kristeller & Wolever, 2011

10 Why mindfulness for eating/weight concerns? Reduced biological stress response and thus reduced hunger, preference for high sugar/high fat foods, and reduced abdominal fat deposition Increased physical activity may be cultivated through becoming mindful of the body s innate need for movement (Caldwell, Baime, & Wolever, 2012) Decreased reactivity to food cues and other triggers to eat 10 Wolever & Best, 2009; Dallman, 2010; Kristeller & Wolever, 2011

11 Mindfulness-based Stress Reduction Developed by Jon Kabat-Zinn in weeks, hour sessions, 1 all day retreat Home practice: 45 mins, 6 days/wk Mindfulness meditation practices: Body scan Sitting meditation Hatha yoga Mindful walking Mindfulness in everyday life Eating specific: Mindful raisin eating 11

12 Mindfulness-based Cognitive Therapy 8 weeks, developed to prevent depression relapse Similar time commitment and homework emphasis 3 minute breathing space Not cognitive restructuring but decentered approach to internal experience Depression-specific components (e.g., mastery, behavioral activation, relapse prevention plans) 12 Segal et al., 2002

13 Mindfulness-based eating awareness training Increase awareness of experiences related to eating Traditional mindfulness meditation practice (e.g., from MBSR, MBCT) Eating-specific exercises and discussion: Emotional vs physical hunger Mindfulness of food choice Emotional regulation pertinent to selfconcept and stress management 13 (Kristeller et al., 2013; Kristeller, Wolever, & Sheets, 2014)

14 Mindfulness-based eating awareness training Mindful walking Chair yoga Mindful meals Mini-meditations In session mindful eating Pot luck meal Mindful snack choice Guided mediations E.g., Forgiveness meditation 14

15 Review of Intervention Programs Reviewed primarily mindfulness-based interventions that had eating or weight as an outcome 14 studies reviewed (Katterman et al., 2014) 4 studies published since then One larger RCT (Daubenmier et al., 2016) All but 2 recruited individuals with eating or weight concerns Veterans (Kearney et al., 2012) Adults interested in stress reduction (Smith et al., 2008) 15

16 Review of Intervention Samples Women with problematic eating Women who binge eat Adults with BED and substance use disorder Obese adults Overweight women stress eaters Veterans Overweight women who binge eat Obese adults, 66% BED Post-bariatric surgery adults who binge eat Adults with DM-2 Adults with DM-2 Adults paying for stress reduction Women who eat out 3x/wk Obese adults Obese post-menopausal women 1-5 years post-bariatric surgery Adults (98% women) with stress-eating and at risk for obesity 16

17 Review of Intervention Programs Length: 6-16 weeks, most 8-10 weeks Most sample sizes were relatively small (range: 7 to 156) and only two studies had a total sample over 100 Mindfulness groups were therefore even smaller Largest was 84 17

18 Review of Intervention Programs All but 3 interventions had eating-specific modifications Standard MBSR measured in 3 studies (Kearney et al., 2012; Rosenzwieg et al., 2008; Corsica et al., 2014) 18

19 Review of Intervention Programs Healthy eating guidance ranged from no specific guidance (e.g., Kearney et al., 2012, Alberts et al., 2012; MBSR group in Corsica et al., 2014) to a standard 5.5 month calorie reduction program (e.g., Daubenmier et al., 2016) Acceptance-based behavioral therapy, included in prior reviews (Olson & Emery, 2015), combines mindfulness, acceptance/ willingness,with behavioral recommendations (e.g., Forman et al., 2016) Could create quite a bit of variability in terms of internal vs external guidance on choices E.g., I m hungry, but over my calories for the day. 19

20 Mindful eating components Mindful Eating is allowing yourself to become aware of the positive and nurturing opportunities that are available through food selection and preparation by respecting your own inner wisdom. By using all your senses in choosing to eat food that is both satisfying to you and nourishing to your body, acknowledging your responses to food (likes, dislikes or neutral) without judgment, and becoming aware of physical hunger and satiety cues to guide your decisions to begin and end eating you can change your relationship to food. Taken from The Center for Mindful Eating website on 3/25/

21 External vs Internal Guidance Weight loss or even healthy eating guidance could keep unbalanced eating going Our culture is already full of diet mentality reminders and shoulds for eating Variability in this area may be challenging to avoid 21

22 Eating behavior outcomes Mindfulness-based interventions reduce: Binge eating, effect sizes medium to large Emotional eating/stress eating, effect sizes medium to large among individuals who report stress-eating Reductions in cravings (Alberts et al., 2010) Reductions in reward driven eating (Mason et al., 2016) 22 Katterman et al., 2014; Carriere et al., 2017

23 Comparison to other interventions CBT and MB-EAT had similar effects on binge eating among obese adults (66% with BED) (Kristeller, Wolever, & Sheets, 2014) and adults looking for stress reduction (Smith et al., 2008) A novel cognitive-behavioral intervention for stress-related eating reduced stress eating comparable to MBSR, but the combination of MBSR and the CBT program produced the greatest effect (Corsica et al., 2014) These effect sizes are similar to other binge eating treatment programs (e.g., DBT) 23

24 Summary for eating behaviors Consistent evidence for reductions in stress and binge eating that is comparable to other treatment options Sustained at follow up, though limited long-term data 24

25 Weight change: Mindfulness-only Study Intervention Weight/BMI post-tx Weight /BMI follow up Alberts et al., 2012 MBCT/MB-EAT -0.4 kg/m 2 n/a Kearney et al., 2012 MBSR +0.8 kg +1.2 kg (24 wks) Kristeller & Hallett, 1999 Rozenweig et al., 2007 MBSR no change no change MBSR +0.9 kg +1.8 kg (12 wks) Corsica et al., 2014 MBSR +~2 lbs 0 (12 wks) 25

26 Weight Change: Weight-specific info Study Weight-loss components Weight/BMI posttx Alberts et al., 2010 Info on healthy food choices; 1 hour of exercise each session -1.9 kg (±1.7) n/a Weight /BMI follow up Dalen et al., 2010 General info on nutrition, exercise, calories; encouraged increase in physical activity of 5-10% each week not given -4.0 kg** (12 wks) Daubenmeier et al., hour nutrition and exercise information session aimed at moderate weight loss kg (±3.1) n/a Kristeller et al., 2013 Weight management info briefly introduced in session 4 in the context of physical hunger and calorie balance, reinforced in session 9, not a primary focus -0.1 kg/m kg/m 2 (28 wks) Miller et al., 2012 Basic info on energy and nutrition intake; participants were encouraged to engage in physical activity and mindful movement; however, no specific diet or activity goals were provided -1.8 kg (±0.5)** -1.5 kg (±0.5)** (24 wks) 26

27 Weight Change: Weight-specific info Study Weight-loss components Weight/BMI post-tx Weight /BMI follow up Timmerman & Brown, 2012 General info on weight management; problem-solving and behavioral goal setting in each session -1.7 kg* n/a Chacko et al., 2016 Behavioral skills +1.0 kg (±1.76) +2.6 kg (±3.6) (24 wks) Corsica et al., 2014 General behavioral guidelines for healthy eating (e.g., 3 meals per day, generally nutritionally balanced) -.4 lbs lbs (12 wks) Daubenmeier et a., 2016 Healthy food choices and 500 calorie per day reduction, reducing calorie-dense nutrient poor foods, increased exercise -1.9 kg -1.7 kg Smith et al., 2017 Increased physical activity recommended each week ~-3 kg ~-7 kg 27

28 Daubenmier et al., adults, BMI 30-45, (average ~35 kg/m 2 ) Both groups got diet and exercise guidelines including modest calorie reduction Mindfulness group: MB-EAT Active control group Measured weight, lipids, HbA1c, and other metabolic outcomes up to 18 months 28

29 Daubenmier et al., 2016 Adherence: Meditated an average of 2.1 hours per week 57% of their meals eaten mindfully 70% of recommendation Retention at 18 month follow up: N = 81, 81% (Mindfulness) N = 67, 71% (Control) 29

30 Daubenmier et al., (Daubenmier et al., 2016)

31 Smith et al., obese post-menopausal women assigned to: Mindful eating and living group Control group: goal setting, nutrition information, and support Monthly booster sessions and measurements up to 1 year Both groups reduced binge eating and lost weight Mindful eating group showed greater reductions in inflammation markers (e.g., interluekin-6 and c-reactive protein) 31

32 Daubenmier et al., overweight or obese women assigned to: Mindful eating intervention Waitlist control Intervention group improved in mindfulness, anxiety and external eating Obese individuals in the mindfulness group lost weight, while those in the control group gained weight Improvements in mindfulness, stress and cortisol awakening response were associated with reductions in abdominal fat deposition 32

33 Direct comparison to other interventions In adults with type 2 diabetes, the CBT and mindfulness group had reductions in weight and improved blood sugar control, but weight loss was slightly larger in CBT group at post-intervention (Miller et al., 2012) A novel stress-eating intervention produced a moderate effect on short-term weight loss, compared to MBSR alone or in combination (Corsica et al., 2014) 33

34 Limitations Limited diversity High percentage Caucasian and female, noted as a concern among RCTs in binge eating as a whole (Franko et al., 2012) Mostly individuals with BMI between kg/m 2 Limited information among minority groups (e.g., African American, Hispanic individuals) Small study of Latino adolescents (23 total study completers; Daly et al., 2016) indicated some benefits of a 6 week mindful eating intervention on BMI compared to controls 34

35 Limitations Many studies have not measured mindfulness, making it challenging to determine whether changes in mindfulness are driving changes in other outcomes Limited information on comparative effectiveness Limited research on individual differences ABBT group was more helpful for those with uncontrolled eating, and responsiveness to the food environment, compared to SBT for weight loss (Formal et al., 2016) Limited long-term follow up 35

36 Future Directions Larger studies with longer-term follow up and direct comparisons Measurements of mindfulness but also of one s internal or intrinsic motivation to eat to make their bodies feel good (e.g., intuitive eating, intrinsic motivation for healthier eating or exercise) 36

37 Key Points Mindfulness-based interventions reduce emotional eating and binge eating among individuals reporting those concerns Effect sizes: medium to large Effects similar to cognitive-behavioral therapy overall but very preliminary evidence that mindfulness-based interventions may have a benefit for improving metabolic health (e.g., reducing inflammation, reducing abdominal fat) Primarily mindfulness-based interventions have not consistently been associated with significant weight loss in the short-term, in the absence of additional behavioral strategies Evidence of benefit when mindfulness is combined with other healthrelated interventions 37

38 Clinical Application Discuss the evidence for standard approaches to weight loss (e.g., behavioral modifications, diets ) versus a mindful eating based approach Encourage reflection on internal values and internal reactions to changes, from a non-judgmental place of curiosity Provide information, including that we have a lot to learn Support patient choice 38

39 39 Thank You

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41 References Baer, R. A., Fischer, S., & Huss, D. B. (2005). Mindfulness and acceptance in the treatment of disordered eating. Journal of Rational-Emotive & Cognitive-Behavioral Therapy. Bishop, S. R., Lau, M. A., Shapiro, S. L., Carlson, L. E., Anderson, N. D., Carmody, J. F., et al. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11, Carriere, K., Khoury, B., Gunak, M. M., & Knauper, B. (2017). Mindfulness-based interventions for weight loss: A systematic review and meta-analysis. Obesity Reviews, 19. Daubenmier, J., Moran, P. J., Kristeller, J., Acree, M., Bacchetti, P., Kemeny, M. E. Hecht, F. M. (2016). Effects of a mindfulness-based weight loss intervention in adults with obesity: A randomized clinical trial. Obesity, 24, Franko, D. L., Thompson-Brenner, H., Thompson, D. R., Boisseau, C. L., Davis, A. Forbush, K. T.,... Wilson, G. T. (2012). Racial/ethnic differences in adults in randomized clinical trials of binge eating disorder. Journal of Consulting and Clinical Psychology, 80(2), Kabat-Zinn, J. (1990). Full catastrophe living. New York, NY: Delacorte Press. 41

42 References Katterman, S. N., Kleinman, B., Hood, M. M., Nackers, L. M., & Corsica, J. (2014). Mindfulness meditation as an intervention for obesity and overeating behaviors: A systematic review. Eating Behaviors, 15, Kristeller, J. L., Baer, R. A., & Quillian-Wolever, R. (2006).Mindfulness-based approaches to eating disorders. In R. A. Baer (Ed.), Mindfulness-based treatment approaches (pp ). Burlington, MA: Academic Press. Kristeller, J. L., & Wolever, R. Q. (2011). Mindfulness-based eating awareness training for treating binge eating disorder: The conceptual foundation. Eating Disorders, 19, Kristeller, J., Wolever, R. Q., & Sheets, V. (2014). Mindfulness-based eating awareness training (MB-EAT) for binge eating: A randomized controlled trial. Mindfulness, 5, Olson, K. L., Emery, C. F. (2015). Mindfulness and weight loss: A systematic review. Psychosomatic Medicine, 77, O Reilley, G. A., Cook, L., Spruijt-Metz, & Black, D. S. (2014). Mindfulness-based interventions for obesity-related eating behaviours: a literature review. Obesity Reviews, 15,

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