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Can Mindfulness Address Maladaptive Eating Behaviors? Why Traditional Diet Plans Fail and How New Mechanistic Insights May Lead to Novel Interventions


Abstract and Figures

Emotional and other maladaptive eating behaviors develop in response to a diversity of triggers, from psychological stress to the endless external cues in our modern food environment. While the standard approach to food- and weight-related concerns has been weight-loss through dietary restriction, these interventions have produced little long-term benefit, and may be counterproductive. A growing understanding of the behavioral and neurobiological mechanisms that underpin habit formation may explain why this approach has largely failed, and pave the way for a new generation of non-pharmacologic interventions. Here, we first review how modern food environments interact with human biology to promote reward-related eating through associative learning, i.e., operant conditioning. We also review how operant conditioning (positive and negative reinforcement) cultivates habit-based reward-related eating, and how current diet paradigms may not directly target such eating. Further, we describe how mindfulness training that targets reward-based learning may constitute an appropriate intervention to rewire the learning process around eating. We conclude with examples that illustrate how teaching patients to tap into and act on intrinsic (e.g., enjoying healthy eating, not overeating, and self-compassion) rather than extrinsic reward mechanisms (e.g., weighing oneself), is a promising new direction in improving individuals’ relationship with food.
Content may be subject to copyright.
fpsyg-09-01418 September 7, 2018 Time: 16:20 # 1
published: 10 September 2018
doi: 10.3389/fpsyg.2018.01418
Edited by:
Alix Timko,
University of Pennsylvania,
United States
Reviewed by:
Katy Tapper,
City, University of London,
United Kingdom
Naomi Kakoschke,
Monash University, Australia
Julia M. Hormes,
University at Albany, United States
Judson A. Brewer
Specialty section:
This article was submitted to
Eating Behavior,
a section of the journal
Frontiers in Psychology
Received: 29 January 2018
Accepted: 20 July 2018
Published: 10 September 2018
Brewer JA, Ruf A, Beccia AL,
Essien GI, Finn LM, van Lutterveld R
and Mason AE (2018) Can
Mindfulness Address Maladaptive
Eating Behaviors? Why Traditional
Diet Plans Fail and How New
Mechanistic Insights May Lead
to Novel Interventions.
Front. Psychol. 9:1418.
doi: 10.3389/fpsyg.2018.01418
Can Mindfulness Address
Maladaptive Eating Behaviors? Why
Traditional Diet Plans Fail and How
New Mechanistic Insights May Lead
to Novel Interventions
Judson A. Brewer1*, Andrea Ruf1, Ariel L. Beccia1,2 , Gloria I. Essien3, Leonard M. Finn4,5 ,
Remko van Lutterveld1and Ashley E. Mason6
1Center for Mindfulness in Medicine, Healthcare, and Society, Division of Mindfulness, University of Massachusetts Medical
School, Worcester, MA, United States, 2Department of Quantitative Health Sciences, University of Massachusetts Medical
School, Worcester, MA, United States, 3Contemplative Studies, Brown University, Providence, RI, United States, 4Needham
Wellesley Family Medicine PC, Wellesley, MA, United States, 5Department of Family Medicine and Community Health,
University of Massachusetts Medical School, Worcester, MA, United States, 6Department of Medicine, Osher Center
for Integrative Medicine, University of California, San Francisco, San Francisco, CA, United States
Emotional and other maladaptive eating behaviors develop in response to a diversity
of triggers, from psychological stress to the endless external cues in our modern food
environment. While the standard approach to food- and weight-related concerns has
been weight-loss through dietary restriction, these interventions have produced little
long-term benefit, and may be counterproductive. A growing understanding of the
behavioral and neurobiological mechanisms that underpin habit formation may explain
why this approach has largely failed, and pave the way for a new generation of non-
pharmacologic interventions. Here, we first review how modern food environments
interact with human biology to promote reward-related eating through associative
learning, i.e., operant conditioning. We also review how operant conditioning (positive
and negative reinforcement) cultivates habit-based reward-related eating, and how
current diet paradigms may not directly target such eating. Further, we describe how
mindfulness training that targets reward-based learning may constitute an appropriate
intervention to rewire the learning process around eating. We conclude with examples
that illustrate how teaching patients to tap into and act on intrinsic (e.g., enjoying healthy
eating, not overeating, and self-compassion) rather than extrinsic reward mechanisms
(e.g., weighing oneself), is a promising new direction in improving individuals’ relationship
with food.
Keywords: maladaptive eating behaviors, disordered eating, obesity, operant conditioning, reward, craving,
mindfulness, mindful eating
Why do we eat when we feel stressed, anxious, or depressed? How does food craving play a role
in the formation of eating habits? Can understandings the underlying mechanisms of these eating
patterns explain why dieting fails, and lead to the development of novel and targeted interventions?
In this article, we will address these questions.
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Brewer et al. Mindfulness for Maladaptive Eating Behaviors
Food- and weight-related issues are highly prevalent in the
United States. Using 2016 data, the US Centers for Disease
Control estimates the overall prevalence of obesity and
overweight in US adults aged 18 years or older to be 29.6 and
35.2%, respectively (Centers for Disease Control and Prevention,
2016). While eating disorders, such as anorexia nervosa and
bulimia nervosa are relatively rare (Smink et al., 2012), sub-
threshold eating disorders are more common (Stice et al., 2009;
Mangweth-Matzek et al., 2014) and disordered eating behaviors
(e.g., binge eating) are prevalent among obese primary care
patients (Chacko et al., 2015). Considering overweight/obesity
and eating disorders as a spectrum, rather than as distinct and
polarized conditions, has been hypothesized as a more effective
approach to their treatment and prevention (Russell-Mayhew
and Grace, 2016).
Empirical support for considering overweight/obesity and
eating as a spectrum comes from recent research into eating
psychology. Historically, two major maladaptive eating styles
have been delineated: restrained eating (deliberate and persistent
food restriction) (Herman and Mack, 1975) and disinhibited
eating (an inability to inhibit eating once started) (Stunkard
and Messick, 1985). Disinhibited eating is further divided into
emotional and external eating, in which the former describes
overeating in response to internal cues (i.e., emotions); while the
latter describes overeating in response to external cues (i.e., seeing
food that looks delicious) (van Strien et al., 1986). However, a
growing body of evidence suggests that the distinctions between
emotional and external eating are not as clear as previously
assumed, and that they may represent a general concept of
concerned and/or uncontrolled eating, characterized by low
perceived self-control and high motivation to eat (Vainik et al.,
2015;Bongers and Jansen, 2016). This is reinforced by recent
findings indicating that emotional eaters tend to overeat in
general (Bongers et al., 2016) it may be that such individuals
tend to attribute overeating to negative affect (possibly due to
mass media’s emphasis on emotional eating) (Adriaanse et al.,
2016) when in reality, a plethora of cues can influence eating
behavior, ranging from product placement at grocery stores, to
frank messaging (e.g., “crafted for your craving”), to enticing
commercial advertisements on billboards, television, and social
media (Jansen et al., 2016).
Our modern food environment is replete with cues to both
eat and not eat, as well as easy access to highly palatable
foods (e.g., sugar-laden sweets). Such an environment plays
a significant role in biasing control of eating behavior away
from innate, internal processes (e.g., physiological hunger
and satiety signals) to more external, artificial, or learned
behavioral processes (e.g., seeing pictures of desirable foods).
Continual exposure to such cues can alter our eating behavior
in the short-term by triggering non-homeostatic eating (i.e.,
eating for reasons other than hunger) (Lowe and Butryn,
2007), or encouraging restriction despite physiological hunger
(Polivy and Herman, 2017). While occasional episodes of over-
or undereating should be considered part of “normal” eating
behavior, over time, these cues may tap into our natural reward-
based learning processes to cultivate habits of non-homeostatic
eating and/or encourage recurrent binge-purge cycles in some
populations (Burger et al., 2016). Perhaps unsurprisingly, many
empirical studies have found correlations between habitual
maladaptive eating behaviors and emotional duress, including
depression, anxiety, and psychological stress (Appleton and
McGowan, 2006;Ouwens et al., 2009;Miller-Matero et al., 2014;
van Strien et al., 2016).
Here, we review what is currently known about the initiation
and maintenance of maladaptive eating behaviors (henceforth
referred to as reward-related eating) and how stress and emotions
can amplify and/or stem from such behavior. We then review
how traditional behavioral weight-loss dieting is insufficient in
addressing reward-related eating mechanisms. Finally, we discuss
how treatments that more directly target these mechanisms (with
a focus on mindfulness training), may be promising strategies for
reducing reward-related eating, and therefore its psychological
and metabolic consequences.
From an evolutionary standpoint, it is adaptive to remember
everything about good sources of food – when, where, and how
to get them. To do this, we rely on one of the most well-
characterized processes of learning: reinforcement or associative
learning (i.e., operant conditioning). This includes both positive
and negative reinforcement: the receipt of a reward or removal
of a noxious stimulus, respectively, that increases the probability
of repeating a behavior in the future (Epstein et al., 2007;
Dayan and Niv, 2008;Singh et al., 2010). Behaviors learned
via positive and negative reinforcement are reinforced by their
consequences (rewards). Once our brains grasp the connection
between a behavior and a reward, we create a powerful emotional
memory that increases the probability of performing reward-
yielding behavior in the future (Skinner, 1963). Put simply, if we
eat a highly palatable food, we feel good, and lay down a memory
that helps us remember under what circumstance we ate it, where
we obtained it, what we liked about it, and so on. This memory
reminds us to perform the same behavior the next time we are
in a similar situation (positive reinforcement). Likewise, if we
eat something that serves to reduce our sadness or anxiety, we
may lay down a memory to eat certain foods to reduce particular
affective states (negative reinforcement) (Figure 1). As such, in
modern day, reward-related learning is still in play when food is
not only plentiful (including a plethora of advertising to point us
to its sources), but is also becoming more and more engineered
to “hijack” the reinforcement learning system. Accordingly (and
ironically), this evolutionarily conserved learning process has
moved from helping us survive, to contributing to increased
obesity-related morbidity and mortality.
Restrained eating may also be governed, in part, by operant
conditioning. Women with eating disorders have been found
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Brewer et al. Mindfulness for Maladaptive Eating Behaviors
FIGURE 1 | The habit loop. Development of habitual reward-based eating via positive and negative reinforcement.
to have an increased tendency to seek pleasurable experiences
and avoid negative ones, which may underlie the binge-
purge cycle (Smyth et al., 2007;Eneva et al., 2017). In
regards to non-clinical populations, diet-related food cues (e.g.,
descriptions of “diet-friendly” food or pictures of thin bodies)
tend to reduce food intake among already restrained eaters
(Polivy and Herman, 2017), likely driven by the positive
reinforcement of working toward or even reaching their
body weight goals. Notably, restrained eating is associated
with subsequent disinhibited, emotional, and/or binge eating
(Polivy and Herman, 1985;Ricca et al., 2009;Péneau et al.,
2013), which may be due to increasing the reinforcing value
of food through repeated deprivation (Epstein et al., 2007).
Such findings highlight the role of operant conditioning in
influencing eating behavior across the spectrum of food-related
There is evidence to suggest that repeatedly consuming highly
processed foods (e.g., processed foods high in combinations of
sugar and fat, salt and fat, or all three) can alter the brain’s
reward circuitry. Such foods stimulates dopamine release along
the same associative learning pathway as substances of abuse, and
in some studies, this release surpasses that associated with cocaine
use (Rada et al., 2005;Avena et al., 2006, 2008;Epstein et al.,
2007;Lenoir et al., 2007;Stice et al., 2013). Although the concept
of “food addiction” remains controversial, sugar and refined-
carbohydrate consumption may lead to similar neuroadaptations
as drugs of abuse, including craving and withdrawal (Ziauddeen
et al., 2012). Repeatedly overconsuming sugar-laden food can
condition individuals to expect pleasurable responses not only
upon consuming a highly palatable food, but also when observing
stimuli that one associates with the food (e.g., seeing a picture
of ice cream) (Volkow et al., 2008). Such stimuli can activate
learned associations that trigger non-homeostatic eating (Born
et al., 2010;Dallman, 2010;Sinha and Jastreboff, 2013;Epel et al.,
These positively and negatively reinforced learning pathways
provide a useful explanatory model for why, how, and when
people set up habits based on the rewarding experiences of
eating and/or restricting, rather than true physical hunger
(Kaplan and Kaplan, 1957;Schachter et al., 1968;Greeno and
Wing, 1994). The more we engage in these habit loops by
experiencing stress (trigger), eating palatable foods or restricting
our eating (behavior), and receiving temporary relief (feeling
better, being distracted from negative affect, moving toward a
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goal, avoiding feelings of guilt for having broken one’s dieting
“rules” etc.), the further obscured our ability to recognize the
difference between homeostatic and non-homeostatic hunger
Given the links between reward-based learning and
maladaptive eating behaviors, it is surprising that to date,
these positively and negatively reinforced habit loops have not
been more explicitly incorporated into treatment paradigms
for obesity and binge eating disorder. Specific aspects of
the habit loop may provide direct and tangible targets for
researchers and clinicians to develop and implement effective
behavioral interventions that break the cycle of reward-related
eating. As shown in Figure 1, craving is a central downstream
component linking both positive and negative emotions to
eating. Food cravings are most commonly defined as intense
desires or longings to eat a specific food (Weingarten and
Elston, 1991). Food cravings fit into a food reward framework
as a psychological state of wanting, or appetitive motivation to
seek out a particular food, which is distinct from liking, or the
pleasure one derives from eating a particular food (Berridge,
2009). Psychological (rather than physical) deprivation is the
more likely primary driver of food cravings (Polivy et al., 2005).
Accordingly, theoretical frameworks, such as the Elaborated
Intrusion (EI) Theory of Desires postulate that the conscious
aspects of desire for a particular substance (i.e., a gracing) falls
along a continuum of appetitive thought (May et al., 2012).
Applied to food and eating, the EI Theory of Desire posits
that cues to eat, be they cognitive, emotional, or physiological,
can trigger seemingly spontaneous thoughts of images. These
thoughts or images then motivate further elaboration and
movement toward the desired food. Recent data map well onto
this framework; for example studies show that food cravings
predict non-homeostatic eating (Willner et al., 1998;Christensen
and Pettijohn, 2001) and binge-eating (Joyner et al., 2015),
and are associated with weight-preoccupation (Lafay et al.,
The standard clinical approach to weight-related medical issues
is weight-loss, most commonly through dietary restriction.
However, data have repeatedly demonstrated that traditional
diet programs yield variable short-term results, and minimal
differences in the long-term (Franz et al., 2007). For example,
a recent systematic review and meta-analysis of 45 trials that
examined the effects of long-term approaches for weight-loss
maintenance found little evidence for the efficacy of lifestyle
interventions (i.e., dieting) in maintaining weight-loss beyond
24 months (Dombrowski et al., 2014). As such, the outcomes
of diet programs are notoriously poor; up to 60% of individuals
regain all or more of the weight that was lost through dieting
(Mann et al., 2007).
By definition, “effective” dieting requires vigilant self-
regulation in order to make both short- and long-term decisions
about food (Wing and Hill, 2001;DelParigi et al., 2007). However,
the idea that one simply needs more willpower (where willpower
is defined as the ability to resist shorter-term pleasures so as
to achieve longer-term goals) to succeed on a diet may be
suboptimal. Goal conflict theory suggests that the friction created
by the desire to consume palatable foods and yet achieve long-
term weight-loss goals, combined with incessant cues to eat in
the modern food environment, sets the stage for self-regulation
failures, leading to disinhibited reward-related eating (Hays
and Roberts, 2008;Stroebe, 2008). As related to reward-based
learning, willpower-based dieting strategies traditionally target
the avoidance of cues, subversion of craving, and/or substitution
strategies that treat “around” the core habit loop, rather than
dismantling the loop itself. For example, one such method termed
“attentional deployment” prescribes that individuals literally
turn and focus their attention away from the craved food
(Giuliani and Berkman, 2015). Although attentional deployment
may effectively defer eating the food in that moment, it may
not actually eliminate the craving itself, thereby allowing the
craving to return when one’s willpower is depleted (Giuliani and
Berkman, 2015). Importantly, many of these strategies depend on
expending effort in the service of reducing craving-related eating,
which to differing extents requires individuals’ willpower.
Factors that hamper willpower include cognitive exertion
following demanding tasks (Vohs and Heatherton, 2000),
attentional distraction, especially of the emotion-laden
variety (Bechara, 2005;Heatherton and Wagner, 2011), and
psychological stress (Arnsten, 2009). Furthermore, the presence
of hunger, anger, loneliness, or/and tiredness (HALT) seems
to promote a vulnerable state for self-regulatory failure (Vohs
et al., 2005;Mead et al., 2009;Arnsten, 2015). Collectively, these
findings suggest that maladaptive eating behaviors are not simply
“food” problems, and thus interventions that treat them as such
may exacerbate the issue. For instance, some interventions have
sought to bolster self-regulatory resources by requiring new
behaviors, such as daily self-weighing (e.g., Wing et al., 2006)
so as to reduce decision-making. A major limitation of these
interventions is that these attempts at automation often require
too much effort to sustain (and, in many cases, even initiate) –
especially when they can feel punitive in nature (ironically, which
can induce negative affect). Other researchers have developed
“small changes” or “behavioral nudge” interventions that focus
on reducing triggers in the environment that tax willpower (Hill,
2009). Although these environmental strategies show promise
(e.g., Eldridge et al., 2016), it is impossible to manipulate or
otherwise control the environments everywhere one goes.
Perhaps most importantly, construing reward-related
eating as a lack of willpower ignores the biology underlying
restriction and cultural context in which such behaviors develop.
Mechanistically, recent research suggests that weight-loss
through dietary restriction is accompanied by hormonal and
metabolic adaptations that promote weight regain through
increased appetite (MacLean et al., 2011;Fothergill et al.,
2016). In addition to these biological influences is a paradoxical
combination of an obesogenic food environment situated within
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a culture that emphasizes thinness for both health and esthetic
purposes. Such an environment has been found to produce a
conflicting set of social norms surrounding food and weight
among women (Whale et al., 2014), which may contribute to,
and reinforce, maladaptive eating behaviors.
Thus, interventions predicated on external methods
(e.g., changing our environment) or on cognitive methods
(e.g., willpower) that do not directly target the habit loop (e.g.,
prescribing restrictive behaviors) have not resulted in reduced
reward-related eating, and for some, may be counterproductive.
As the mechanisms of reward-related eating are now becoming
clearer, can these insights inform currently employed diet
and behavior change interventions? Investigating intervention
modalities that directly target key elements of the habit loop (e.g.,
craving), as compared to attempting to use cognitive strategies
to change them or treat around them (e.g., substitution), may
inform the development of more effective ways to sustainably
reduce reward-related eating.
We have previously found that with habitual behaviors, such
as smoking, craving has been shown to be a critical link
of the habit loop (Brewer et al., 2013b;Elwafi et al., 2013).
Similar to how craving palatable food can lead to non-
homeostatic eating, craving for cigarettes significantly predicts
smoking (Brewer et al., 2011;DiFranza, 2016). Interestingly,
interventions such as mindfulness training have historical roots
in targeting and managing craving itself, rather than treating
“around it” through the use of substitute or avoidance strategies
as described above, suggesting a theoretical overlap between
ancient and modern mechanisms (Bhikkhu, 2013;Brewer et al.,
2013b). Mindfulness can be defined as the awareness that
arises when paying attention in the present moment, on
purpose and non-judgmentally (Kabat-Zinn, 2006). Another
common definition of mindfulness used in research includes two
(1) Self-regulation of attention so that it is maintained on
immediate experience, thereby allowing for increased
recognition of mental events in the present moment,
and (2) Adopting a particular orientation toward one’s
experiences in the present moment, characterized by
curiosity, openness, and acceptance (Bishop et al., 2004). In
other words, “being mindful” means allowing experiences
to unfold with curiosity rather than with attempts at
control, which may enable healthier management of issues
relating to affect-driven cravings (Brewer and Pbert, 2015).
We have found that mindfulness training directly targets
reward-based habit loops (Brewer et al., 2013b). For example,
smokers who underwent mindfulness training quit at five
times the rate of smokers who received the American Lung
Association’s Freedom from Smoking program, which is based
in cognitive strategies (Brewer et al., 2011), likely due to a
decoupling of the association between craving and smoking
(Elwafi et al., 2013). In other words, individuals learned to pay
attention to and “be with” their cravings instead of compulsively
acting on them or painfully struggling with them (Brewer and
Pbert, 2015;Brewer, 2018). Importantly, this is fundamentally
different than other cognitive techniques targeting cravings.
Instead of changing, suppressing, resisting, or avoiding cravings,
mindfulness helps individuals accept and paradoxically move
closer to the thoughts, emotions, and body sensations that make
up cravings. This enables individuals to discover how cravings are
driving them to act, and in doing so, learn to tap into the very
same reward-based learning system to gain mastery over them.
Herein, mindfulness may lead to reductions in cravings over time
through extinction, rather than suppression (Tapper, 2018).
Next-Generation Mindfulness Training
for Reward-Related Eating
Mindfulness training has been shown to reduce maladaptive
eating behaviors (e.g., emotional eating, external eating, binge
eating, reactivity to food cravings, restrained eating, and mindless
eating) across a majority of studies (Godsey, 2013;Katterman
et al., 2014;O’Reilly et al., 2014;Godfrey et al., 2015). How might
mindfulness training help individuals improve their relationship
with eating? Might it target the habit loop in a similar manner to
what has been shown with breaking habits, such as smoking? As
craving may be a core mechanistic link in reward-based learning,
there may be ways to specifically target mindfulness training to
the actual mechanisms driving eating.
Below, we outline three broad steps that individuals take
as they learn to be mindful of their eating habits (increasing
awareness, evaluating outcomes, and making embodied choices),
and provide real-world examples from participants in a newly
developed digitally delivered mindful eating program that
specifically employs these as a way to target reward-based eating
(Table 1).
Step 1: Awareness – We Cannot Change What We
Cannot See
We hypothesize that the first step in changing habitual eating
behavior is becoming aware of such behaviors and their
triggers. Maladaptive eating patterns are often learned and
reinforced for years. For example, children may learn to pair
food with emotional rewards (e.g., parental approval) (Farrow
et al., 2015), and 63% of children aged 5–13 have reported
eating in response to mood (Shapiro et al., 2007). Thus,
reward-related eating can become ingrained early in life. As
such, many individuals report that they do not notice that
they are out of touch with their hunger and satiety signals
until they are experiencing consequences, such as the physical
effects of feeling overly full or extreme hunger. A clear
recognition of elements within the habit loop (i.e., triggers
and behaviors) can help people to begin working with them,
rather than continuing to reinforce the habitual maladaptive
behaviors. This recognition is one of the core principles of
many mindful eating programs that are delivered in person
(Rossy, 2016). Table 1 presents participants’ self-reports about
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TABLE 1 | Examples of experiences with each of the three steps of the mindful eating model, provided from program participants within the smartphone application
1. Awareness “I gained insight today relating to the correlation between my exercise routine and my eating patterns”.
“I am really seeing how the habit loop has driven my life with food”.
“I just realized how my internalized anger, resentment, and self-deprecation are expressed in my eating”.
“It has been so helpful to gradually learn to return again and again and again without criticizing myself. I’m beginning to see how
that same practice might help me with my eating”.
2. Evaluating outcomes “I’m finding that I’m listening to my body, noticing how my feelings are sensations in my body. I’m also tasting my food, and learning
what taste [sic] good and doesn’t. I can already feel the habit loops leading to eating being interrupted. I don’t fight with myself all
day long, either winning the food battle or losing it”.
“I got beyond thoughts of the rewards alone of my craving and reflected on the consequences. Once it hit me that satisfying my
craving wouldn’t fulfill my needs, wouldn’t solve the problem and would in fact only make me feel worse, I began looking at it as less
desirable an action”.
“A shift is happening; I’m choosing more healthy foods. The sugary things are less attractive. Satiety is now coming into focus”.
“Had a piece of chocolate and ate it mindfully, what a difference! Normally it is just eaten quickly and in reality not enjoyed. As it
turned out, the one piece was sufficient, that’s normally not the case. Small win”.
3. Unforced, embodied choice “I wasn’t going to make myself try to eat less but just showing up and being as present with the experience as I could be. That
helped a lot and then I ordered my food and really tried to be there and see what I was eating and feeling and experiencing”.
“I am feeling like I can tune into what my body needs more now my emotions around food are more settled. The protein powder
with berries for breakfast was filling and set me up for the day. I tuned in to my body in the late afternoon and just wanted a banana
and a few nuts – I felt like these carbs were ok and went with my intuition”.
“It’s a birthday party. Food all over the place. Pizza, salads, butter, and caramel cupcakes. With the powerful artillery of mindfulness
and RAIN, I managed to enjoy a little bit of pizza, satisfactory portions of healthy salads and half a cupcake, shared with my
daughter. I felt in control for the first time, I was Superman!”
their experiences while gaining awareness, illustrating how
this newfound awareness often helps people eat when they
are physiologically hungry and not reinforce reward-related
Step 2: Evaluating Outcomes – Clearly Seeing the
True ‘Rewards’ of Our Habits
The second step in changing habitual eating is a clear recognition
of the actual results (rewards) that one is receiving from the
behavior. Specifically, these are the direct physical sensations
and emotional effects of eating beyond satiety or when triggered
in the absence of hunger. This step taps directly into and
utilizes reward-based learning itself. Early theories underlying
mindfulness training suggest that such clear and unbiased
recognition is a critical step for lasting habit change (Brewer
et al., 2013a). By evaluating results or outcomes, we mean an
accurate assessment of everything that results from an episode
of reward-related eating, rather than selectively paying attention
to only certain aspects of the experience. For example, if one
eats to numb themselves from painful feelings and only attends
to the temporary relief, they may not remember accompanying
physical feelings, such as being uncomfortably full and lethargic,
or resultant emotional aspects of the experience, such as feelings
of guilt.
Non-judgmental awareness of the entire experience provides
an opportunity to “add up” all of the elements resulting
in a more accurate calculation of the sum total of the
reward. Outcome evaluation begins a process of disenchantment
with habitual behaviors, as a thorough assessment of the
rewards reveals that they are not as rewarding as once
perceived. Importantly, this evaluation is not an intellectual
interrogation (e.g., “I shouldn’t have eaten this because I will
gain weight”), but rather an exploration of one’s immediate
experience (e.g., “wow, I feel sick, [and guilty]”). Linking
action to experiential outcome is critical for updating the
neural reward-value of one’s behavior in the orbitofrontal
cortex (Kringelbach, 2005), tapping into the very reward-based
learning process that set up the unhealthy behavior in the first
place, rather than relying on will-power or cognitive control
regions of the brain (e.g., lateral prefrontal cortex), which are
susceptible to failure in times of stress and hunger (Arnsten,
This same process can be employed when adopting new eating
behaviors, allowing one to bring awareness to the experience
so as to appreciate the physical and psychological effects of
eating when truly hungry (while also enjoying the experience)
and stopping when full. In pilot studies of brief mindfulness
interventions, hints of carryover effects have even been seen
in which individuals who eat a meal mindfully consume 45%
fewer calories while snacking 2 h later (Seguias and Tapper,
2018), likely due to a heightened ability to sense internal
cues relating to hunger and satiety. Disenchantment with
prior maladaptive eating behaviors combined with the learning
of mindful eating fosters the development of an embodied
wisdom-based eating framework (described in detail below),
rather than a cognitive, knowledge-based one. This learning
process may be critical for long-term and sustainable behavior
change, as it draws from one’s own experiences, unlike standard
cognitive based weight-control strategies. Illustrative examples
of participants’ experiences with this process are presented in
Table 1.
Step 3: Unforced Freedom of Choice – Supporting
Intuitive Self-care
The third step in changing habitual eating is developing the
ability to make unforced, embodied choices about food. The
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framework and specific language for this step was derived from
qualitative data from focus group discussions with participants
of the mindful eating program, based on their direct experience
(Beccia et al., in preparation). Based on our findings, step
three was defined as unforced freedom of choice, emerging
from embodied awareness, in the present moment. In other
words, an awareness of the links between behavior and outcome
cultivates a heightened ability to make “intuitive” choices that
support self-care in a way that feels effortless, rather than forced.
The intuitive sense emerges directly from the disenchantment
learned in step two, such that one consciously or unconsciously
compares the relative rewards from these previous actions
to guide current behavior. Notably, there have been calls to
implement interventions that support self-care and healthy
lifestyles, particularly ones that are patient-centered, within
primary care settings (Greaves and Campbell, 2007); this model
of mindful eating represents such an intervention, as it helps
individuals move away from the “shame and blame” thinking that
comes with cognitively based dieting (“I should eat X,” I shouldn’t
have eaten Y,” etc.), and into more self-compassionate ways of
This is critical, as many individuals spin out into cycles
of shame and blame when stepping onto the scale or looking
in the mirror, which ironically often triggers “eating-to-cope
habit loops. Self-compassion has been proposed to amplify
the effectiveness of mindfulness, and preliminary evidence
suggests that self-compassion promotes intuitive eating and other
positive health behaviors (Mantzios and Wilson, 2014, 2015).
Being compassionate toward oneself builds on the exploration
of the results of self-judgment as part of step two (e.g.,
seeing that self-flagellation or guilt does not feel good), and
importantly, can be deliberately fostered. For example, self-
compassion is formally taught in our mindful eating program
through loving-kindness practices directed toward oneself, and
is specifically framed in the context of the habit loop as
an alternate to emotional eating. In this way, individuals
can contrast the differential results from compassion versus
self-judgment. Over time, as the relative rewards of self-
compassion become more evident and accessible, this type
of self-care becomes more “intuitive,” driven by the updating
of its reward value in the orbitofrontal cortex (as noted
Importantly, and in line with some of the earliest reports
of mindfulness training (Kabat-Zinn, 1982), mindfulness may
constitute a different form of self-regulation than the self-
control that comes with cognitive or deliberate effort – one
that is fostered by an “effortless awareness” (Friese et al.,
2012;Garrison et al., 2013;van Lutterveld et al., 2017). While
attempting to use cognitive control to resist, fight, or distract
oneself from the experience of craving precludes changing
a problematic habit loop (Vohs and Heatherton, 2000), an
unforced, curiosity-based observation of its elements and their
time-course may decrease the likelihood of falling back on
previously learned behaviors (including self-judgment). We have
found with mindful eating as well as smoking cessation programs
that using in-the-moment exercises, such as RAIN (Recognize
the craving, Allow it to exist, Investigate what it feels like
in the body, Note the associated physical sensations from
moment-to-moment) gives pragmatic tools for observing and
even co-existing with cravings rather than using cognitively
based suppression or avoidance techniques (Elwafi et al., 2013).
This open investigation supports the close investigation of what
physical sensations make up cravings, bringing one into her
or his own experience, which is often experienced as pleasant
(or less unpleasant) compared to being caught in the grip of a
In sum, through this three-step progression, mindfulness
training can directly target core aspects of reward-based learning,
and even tap into this very process to update the reward-
value of habitual eating behaviors. Such training improves one’s
relationship with food by facilitating present moment awareness
of one’s direct experience, and may result in lasting behavior
Digital Therapeutic Delivery of Mindfulness Training
Based on the reward-based learning model described above, we
developed a mindful eating program that can be delivered via
smartphone with online community support [described in detail
in Mason et al. (2017)]. Using short daily trainings delivered via
video, audio, and animations, as well as in-the-moment exercises,
this program promotes training in mindfulness skills within the
actual environment in which one develops and reinforces habitual
eating patterns. This intervention first empowers individuals to
understand how they form habitual eating patterns (i.e., the
habit loop) and to clearly see what “rewards” they are receiving
from their behavior. Similar to our app-based training for
smoking cessation (Garrison et al., 2015), this mindful eating
intervention teaches individuals mindfulness tools in a step-by-
step manner to help them change their habitual responses to
food cravings and realign eating with physical hunger and satiety
Some of the original in-person mindful eating programs
begin with an emphasis on mindfulness meditation practices
as a way to foster the development of non-judgmental
awareness of automatic patterns related to eating (e.g.,
Kristeller and Wolever, 2011). Although those programs
and ours are theoretically and conceptually aligned, data
from our early studies with smoking cessation suggested
that short, informal, in-the-moment mindfulness practices
(e.g., RAIN) yielded greater decoupling of craving and
behavior than more formal meditation practices (e.g., sitting
meditation) (Elwafi et al., 2013). Accordingly, we specifically
developed the program to emphasize short, momentary
mindfulness practices directly related to the habit loop in one’s
everyday life that are subsequently supported by more formal
meditation practices as awareness and mindfulness skills are
These principles are based on the same tools we have shown
to moderate the decoupling of craving and smoking behavior in
previous clinical trials focused on craving-related habits (Elwafi
et al., 2013), and are yielding early empirical evidence for
decoupling craving and eating. For example, we administered
our 28-day smartphone-delivered mindful eating program to
104 overweight or obese women, and found that the women
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Brewer et al. Mindfulness for Maladaptive Eating Behaviors
experienced significant reductions in both craving-related eating
(40% reduction, p<0.001) and overeating behavior (e.g., 36%
reduction in eating to cope with negative emotions, p<0.001)
(Mason et al., 2017).
The prevalence and consequences of obesity are frequently
highlighted; lesser discussed are maladaptive eating behaviors,
such as restrained, emotional, and binge eating that can have
serious physical and psychological effects. While the standard
approach to food- and weight-related health and disease issues
is dietary restriction to achieve weight-loss, we contend that
such an approach is inadequate at best and counterproductive
at worst. There is a growing body of evidence suggesting
that it is possible to improve a range of health outcomes
(including metabolic risk factors, heart disease, hypertension,
depression etc.) independent of weight-loss, likely through
enhancing behaviors relating to diet and activity (Bacon and
Aphramor, 2011;Schaefer and Magnuson, 2014;Tylka et al.,
2014;Van Dyke and Drinkwater, 2014). Given the well-
established challenges in maintaining long-term weight-loss
(Wing and Phelan, 2005;Dombrowski et al., 2014), as well
as the social consequences of emphasizing weight, including
prevalent weight-based discrimination (Spahlholz et al., 2016)
and the normalization of body image discontent (Tantleff-Dunn
et al., 2011), adopting strategies to improve eating behaviors
that mitigate the issues inherent in dietary restriction should be
a priority to healthcare providers.
In this article, we have provided the theoretical framework
and early empirical evidence for an intervention that meets
these criteria. Mindful awareness of habitual, maladaptive eating
behaviors may help people to improve their relationships
with food. When people have a clear window through
which to view how habit loops are developed (e.g., eating
when stressed) and maintained (e.g., reward-based learning),
engaging in interventions that directly disrupt these loops
(such as the mindful eating program we have described) can
be an empowering process. That is, honing interventions to
directly focus on core elements of the habit loop, rather than
developing behavioral workarounds, may affect more lasting
Additionally, the recalibration of rewards that results from
mindfulness training may provide a novel way to reframe
the “diet” process. Focusing on intrinsic rewards, defined as
those coming from our own experience of being mindfully
engaged with a process (e.g., savoring food, noticing the rewards
of healthy eating, and stopping when full), may be more
effective than focusing on extrinsic rewards (e.g., feeling a
sugar rush after eating a cupcake), which are fleeting and
therefore feed the habitual process through wanting more.
In the context of mindfulness training, the freedom that
results from disentangling oneself from the demands of old
habits and cravings opens a doorway to direct one’s energies
to more fruitful pursuits, including simply savoring life’s
moments (eating and otherwise). A mindfulness practice is
itself reinforcing and may directly align with values and goals
around healthy eating, with rewards that encourage further
practice and development of insight which sustains long-
term improvements in both mindfulness and healthy lifestyle
As with any paradigm shift, critical questions remain. Namely,
does the process of moving from extrinsic to intrinsic reward
through mindfulness lead to long-term changes, independent of
other lifestyle interventions (such as physical activity instruction
or nutrition education)? At what point is it optimal to pair
mindfulness training with an additional intervention and for
whom? We would predict that mindfulness training in itself
may afford reductions in reward-related eating, with consequent
improvements in overall eating behavior. We also predict that it
may be augmented when paired with nutritional strategies, yet
that the timing of the pairing would be critical; bringing too
many modalities together at once may overwhelm individuals
rather than support them. In light of the considerable racial,
ethnic, gender, and socioeconomic disparities across the range
of food- and weight-related issues (e.g., Marques et al., 2011;
Diggins et al., 2015;Krueger and Reither, 2015;Calzo et al.,
2017), a critical next step is understanding how to disseminate
mindfulness training to individuals from diverse backgrounds.
Also, are mobile or web-based programs effective means of
program implementation, or does the addition of in-person
support (e.g., weekly facilitator led drop-in support groups)
increase effectiveness? Future studies should seek to answer
these questions in order to continue forward progress in
the field of mindfulness and its effects on reward-related
JB and AM contributed conception and design of the manuscript.
JB wrote the first draft of the manuscript. AR, AB, GE, RvL, and
AM wrote sections of the manuscript. All authors contributed to
manuscript revision, read and approved the submitted version.
This publication was supported by the National Center
for Advancing Translational Sciences, National Institutes of
Health, through UCSF-CTSI grant number UL1 TR000004
and also be the National Heart, Lung, and Blood Institute
(NHLBI) grant number K23HL133442-01 to AM, and the
National Cancer Institute (NCI) grant number 1R21CA184254
to JB. Its contents are solely the responsibility of the
authors and do not necessarily represent the official views of
the NIH.
We would like to thank Patricia Holland for her careful review
and feedback on this manuscript.
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Conflict of Interest Statement: JB is the founder of and owns stock in Claritas
MindSciences, the company that developed the mindful eating app (Eat Right
Now). He is also the research lead there. He has not received any payments or
funding from the company for any work related this manuscript.
The remaining authors declare that the research was conducted in the absence of
any commercial or financial relationships that could be construed as a potential
conflict of interest.
Copyright © 2018 Brewer, Ruf, Beccia, Essien, Finn, van Lutterveld and Mason.
This is an open-access article distributed under the terms of the Creative Commons
Attribution License (CC BY). The use, distribution or reproduction in other forums
is permitted, provided the original author(s) and the copyright owner(s) are credited
and that the original publication in this journal is cited, in accordance with accepted
academic practice. No use, distribution or reproduction is permitted which does not
comply with these terms.
Frontiers in Psychology | 11 September 2018 | Volume 9 | Article 1418
... While diet is only one facet underpinning the etiology of obesity, public-health attention and education messages have largely promoted energy balance and nutritious food choice as the primary means of addressing this public-health issue. This biomedical approach (i.e., kilojoule counting, restriction of food type and/or quantity) to diet-related health problems and obesity has not only proven to be ineffective, but it also has the potential to compromise peoples' relationships with food and eating occasions (Brewer et al., 2018;Leahy, 2014;Lupton, 2015;Rothblum, 2018). This approach can contribute to repeated cycles of dieting, accompanied by a sense of failure, shame, guilt, diminished self-worth and an increasing fixation on gaining control of eating, which inadvertently perpetuate poor eating habits, a lack of attunement to internal eating cues, and eating without hunger (O'Loghlen et al., 2021). ...
... A growing understanding of the neurobiological and psychosocial mechanisms that underpin eating behaviours helps to explain this phenomenon and why current public-health efforts and individual approaches to improving rates of diet-related health problems and obesity are failing. It also paves the way for a new generation of intervention that shifts the focus away from a biomedical perspective (Brewer et al., 2018;O'Loghlen et al., 2021). ...
... psychological connections with food that ensures prioritising energy intake. From an evolutionary standpoint, it is advantageous to develop these connections with food and eating experiences so that we remember when, where and how to satisfy physiological needs (Brewer et al., 2018). In our modern food environment, however, these connections to food and eating occasions can be problematic and ultimately drive an incessant desire to eat, even when we aren't hungry. ...
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This paper aims to ‘ignite’ a new approach to the critical agenda of diet-related health problems and obesity; an approach focused on understanding hunger, on reinstating internal cues to eating, and on generating food environments that allow hunger to be honoured. This paper will examine the underpinning factors that contribute to eating without hunger and will help to build an understanding of why current strategies and approaches to diet-related health problems are failing, after which strategies to reconnect people with food and eating experiences will be presented. Examining both individual and population-level drivers of eating behaviours can begin to resolve the incessant need to eat without hunger, while supporting nutritious food choices and overcoming the demeaning ‘diet cycle’ that compromises a healthy relationship with food.
... paying attention to the present moment without judging; [12]) in the context of eating seem so far largely unknown [6,11,13]. Some approaches focus on the attentive component of mindfulness by reducing the amount of food eaten while being with all senses with the food [14] or suppose that mindfulness might disrupt habit loops of maladaptive eating (or what the authors called "rewardrelated eating") and facilitate rewiring eating-related learning processes [15]. Moreover, further preliminary attempts assume that mindfulness may operate through increased awareness of physical hunger and satiety cues as well as increased awareness of and reduced responsiveness to external and emotional cues [7]. ...
... Also, ATM explains a significant amount of variance in emotional as well as uncontrolled eating. This finding indicates that being aware of triggers might facilitate eating according to physiological needs (ERF, third important subfacet) and it is in line with assumptions on reducing reward-related eating through mindfulness by the working group of Brewer and colleagues [15]: The authors argue that the awareness of eating triggers is the first step in changing habitual maladaptive eating patterns. The particular importance of ATM in predicting uncontrolled and emotional eating behaviors in our study could possibly also explain the paradoxical findings regarding the moderating effects of ME on the relationship between emotional functioning and eating styles in overweight and obese women in a recently published study [36], as this subfacet was not sufficiently captured by the ME instrument used by the working group. ...
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Purpose Mindful eating (ME) seems a promising approach to clarify the underlying mechanisms of mindfulness-based interventions for eating and weight-related issues. The current study aimed to investigate the incremental validity of this eating-specific approach beyond a generic conception of mindfulness and explore preliminary indication which subfacets of the multidimensional construct ME might be of particular importance in order to study them more precisely and tailor mindfulness-based interventions for eating and weight-related issues more properly. Methods Self-report data (N = 292) were collected online. Hierarchical regression analyses were used to explore the incremental validity of ME beyond generic mindfulness, predicting maladaptive eating (emotional and uncontrolled eating) and consumption of energy-dense food. Multiple regressions were used to examine the impact of the seven different ME subfacets on the very same outcomes. Results Findings demonstrated the incremental validity of ME on all outcomes. Generic mindfulness no longer predicted emotional eating, uncontrolled eating, or the consumption of energy-dense food when entering ME. The subfacet ‘non-reactive stance’ predicted all three outcomes significantly. For emotional and uncontrolled eating, the subfacets ‘accepting and non-attached attitude toward one’s own eating experience’, ‘eating in response to awareness of fullness’, and the ‘awareness of eating triggers and motives’ additionally showed a significant influence. Conclusion ME seems a valuable approach in clarifying how mindfulness might impact eating and weight-related issues. Beyond that, it might be beneficial for upcoming interventions to strengthen specific ME subfacets, depending on the focused outcomes. Level of evidence Level V, descriptive cross-sectional study.
... For mindfulness-based eating awareness training (MB-EAT), each session includes mindfulness practices for raising awareness of hunger, fullness, taste awareness with different foods, and overeating triggers. The programme provides experiences of inner and outer wisdom (Brewer et al., 2018;Egan & Mantzios, 2018;Kristeller, 2003;Keyte et al., 2020;Kristeller & Hallett, 1999;Kristeller & Jordan, 2018;Kristeller & Wolever, 2011;Kristeller, Wolever, & Sheets, 2013). ...
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Obesity is a chronic and multifactorial disease, with growing rates in the last 50 years worldwide, reaching pandemic levels. It is a major public health problem and is difficult to treat. Different approaches have been used to improve this scenario, including mindfulness-based interventions to enhance dietary behaviour and nutritional status. We compared the effectiveness of a 10-week mindful eating programme with that of a 10-week mindfulness programme and of a no-treatment control group. The sample was composed of adult, low-income women with a body mass index (BMI) ≥ 25 to < 40 receiving primary health care in São Paulo, Brazil. The participants (n = 284) were randomised into 3 groups: the control, mindfulness, and mindful eating. We took anthropometric and body composition measurements, applied psychometric measures, and performed biochemical tests at pre-intervention, post-intervention, and after 3 months. We estimated the regression coefficients among the analysis of adherent participants (per protocol: PP) and among those of all participants randomised to treatment (intention-to-treat: ITT) in addition to multiple imputation (MI). Both groups showed improvement in eating behaviour and reduction of binge eating both in the post-intervention and follow-up periods, but without significant changes in weight or most of the biological tests. Those in the mindful eating programme performed slightly better than those in the mindfulness and control groups in terms of improving eating behaviour and reducing binge eating among low-income overweight women.
... Obesity has become the leading lifestyle disease of the century and is responsible for a myriad of healthrelated ailments [1,2]. It appears that pervasive maladaptive eating behaviors are underappreciated as important factors predisposing and promoting weight gain [3,4]. Furthermore, given the non-sustainable, transient results of restrictive diets, modifications of these eating behaviors are proposed as effective interventions for weight management [3,5]. ...
Introduction Maladaptive eating behaviors are emerging as the most significant determinants of obesity with a promising role in intervention. In the absence of a standardized tool to assess eating variations, an Eating Error Score (EES) tool was devised which comprised five zones for evaluating the severity of obesogenic behaviors as well as the specific area(s) with the highest susceptibility. This pilot study was aimed at evaluating the effectiveness of the EES in quantitating the eating behavior errors associated with excess weight and identifying the most affected zones. Methods The EES questionnaire was designed to explore potential disturbances in five zones of eating behavior related to the impetus to eat (Munger), meal choices and attentiveness to cravings (Impulsive), consumption speed (Speed feeding), cues to stop ingestion (Indulgent) and the social aspect of eating (Relationship). The questionnaire was conducted on adults with varying body mass index (BMI) attending governmental outpatient clinics. The correlation between EES and BMI was determined through Pearson Coefficient. Results A total of 204 participants completed the EES questionnaire. There were 72 males and 132 females with a mean BMI of 27.63 ± 6.16 kg/m2 and with nearly equal distribution between normal weight (37.2%), overweight (32.4%), and obese (29.4%) individuals. Nearly 75% of our cohort had a moderate total EES, and the remainder was equally distributed between the mild and severe ranges. A weak but significant correlation was observed between total EES and BMI (r=0.275, p<0.001) suggesting increasing obesogenic styles in participants with excess weight. In addition, a similar weak but significant correlation was noted between Body Mass Index and the Munger and Impulsive zones (r=0.266 and 0.258 and p<0.001, respectively) suggesting more severe maladaptive eating behaviors in these areas. No correlation was found with the Speed feeding, Indulgent, and Relationship zones. Conclusion The EES may be a useful tool for assessing the extent of maladaptive eating behaviors, which predispose individuals to weight gain and sabotage their weight loss efforts. Undoubtedly, the utility of the tool needs to be corroborated in large population studies. Further, identifying the specific operant zones may show promise as many of these habits are potentially modifiable and can be targeted for weight control, most notably those associated with the Munger and Impulsive zones.
... The increased HFSS snacking at the start of the pandemic may reflect such maladaptive coping mechanisms (63,66). For some individuals, the increase may have been maintained through strengthening of a cue-trigger-reward feedback cycle and habit formation (67). ...
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COVID-19 pandemic restrictions impacted dietary habits during the initial months of the pandemic, but long-term effects are unclear. In this longitudinal study, self-selected UK adults ( n = 1,733, 71.1% female, 95.7% white ethnicity) completed three online surveys (May–June, August–September, and November–December 2020, with a retrospective pre-pandemic component in the baseline survey), self-reporting sociodemographics, lifestyle, and behaviours, including high fat, salt, and sugar (HFSS) snacks, HFSS meals, and fruit and vegetable (FV) intake. Data were analysed using generalised estimating equations. Monthly HFSS snacks portion intake increased from pre-pandemic levels (48.3) in May–June (57.6, p < 0.001), decreased in August–September (43.7, p < 0.001), before increasing back to pre-pandemic levels in November–December (49.2, p < 0.001). A total of 48.5% self-reported increased [25.9 (95% confidence interval: 24.1, 27.8)] and 47.7% self-reported decreased [24.1 (22.4, 26.0)] monthly HFSS snacks portion intakes in November–December compared with pre-pandemic levels. Monthly HFSS meals portion intake decreased from pre-pandemic levels (7.1) in May–June (5.9, p < 0.001), was maintained in August–September (5.9, p = 0.897), and then increased again in November–December (6.6, p < 0.001) to intakes that remained lower than pre-pandemic levels ( p = 0.007). A total of 35.2% self-reported increased [4.8 (4.3, 5.3)] and 44.5% self-reported decreased [5.1 (4.6, 5.6)] monthly HFSS meals portion intakes in November–December compared with pre-pandemic levels. The proportion meeting FV intake recommendations was stable from pre-pandemic through to August–September (70%), but decreased in November–December 2020 (67%, p = 0.034). Increased monthly HFSS snacks intake was associated with female gender, lower quality of life, and – in a time - varying manner – older age and higher HFSS meals intake. Increased monthly HFSS meals intake was associated with female gender, living with adults only, and higher HFSS snacks intake. Reduced FV intake was associated with higher body mass index (BMI) and lower physical activity. These results suggest large interindividual variability in dietary change during the first year of the pandemic, with important public health implications in individuals experiencing persistent increases in unhealthy diet choices, associated with BMI, gender, quality of life, living conditions, physical activity, and other dietary behaviours.
Objective: Sleep disturbance is experienced by nearly 20% of Americans and is highly comorbid with anxiety. Sleep disturbances may predict development of anxiety disorders. Mindfulness training (MT) has shown efficacy for anxiety yet remains limited by in-person based delivery. Digitally delivered MT may target habitual worry processes, yet its effects on sleep have not been studied. This study tested if app-based MT for anxiety could reduce worry and improve sleep and examined the underlying mechanisms. Methods: Individuals reporting worry interfering with sleep were randomized to treatment as usual (TAU, n = 40) or TAU + app-based MT (n = 40). Treatment-related changes in worry-related sleep disturbances (WRSD), worry, non-reactivity, and anxiety were evaluated via self-report questionnaires at 1- and 2-months post treatment initiation. Fitbit devices were used to record total sleep time (TST) and estimate sleep efficiency (SE). At 2 months, TAU received access to app-based MT and both groups were reassessed at 4 months. Results: In a modified intent-to-treat analysis, WRSD scores decreased by 27% in TAU+MT (n = 36) and 6% in TAU (n = 35) at 2 months (median [IQR] change: 11 [4.3] v. 15 [5.0], P = .001). These WRSD reductions were mediated by decreased worry, particularly improved non-reactivity (P's < .001). At 4 months, TAU reported a significant 29% reduction after beginning app-based MT at 2 months and TAU+MT maintained its gains. No significant between-group differences in average estimated TST or SE were found after 2 months of using the app. Conclusions: Few mindfulness-related apps have been evaluated for clinical efficacy and/or mechanism. Results from this study demonstrate a mechanistic link between MT and increased emotional non-reactivity, decreased worry, and reduction in reported sleep disturbances, suggesting that app-based MT may be a viable option to help individuals who report that worry interferes with their sleep.Trial Registration: Targeting Worry to Improve Sleep (NCT03684057). URL -
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Objectives There remains a significant variability in the methods and techniques used to promote mindful eating for individuals with overweight and obesity. This variability in treatment programs may result in incongruent findings as well as present challenges in identifying active processes of behavior change. The purpose of the scoping review was to identify and to describe the various methods and techniques used to cultivate mindful eating behaviors in individuals with overweight and obesity. This discernment process is a crucial first step in better understanding why certain mindful eating programs are more effective than others. Methods Studies published prior to July 26, 2021, were retrieved from PsycINFO, MEDLINE, ProQuest, and Scopus. After screening and full-text review, 19 studies were included. Results The review highlighted several inconsistencies and instructional biases that may explain some of the observed heterogeneity in treatment effects. Specifically, our results showed a discrepancy between formal and informal practices. Although formal approaches encouraged a balance between the attention and attitude elements of mindfulness, informal approaches did not. Conclusions Future mindful eating programs should aim to develop and evaluate informal approaches that integrate both the attention and attitude components of mindfulness. Greater use of standardized language, unambiguous descriptions of core therapeutic components, and the use of validated measures of mindfulness will furthermore improve empirical investigations.
Purpose Physician wellbeing is critical to maximize patient experience, quality of care, and healthcare value. Objective measures to guide and assess efficacy of interventions in terms of enhanced thriving (as opposed to just decreased pathology) have been limited. Here we provide early data on modifiable targets, potential interventions, and comparative impact. Methods In this cross-sectional survey-based study of mixed-level residents at 16 academic General Surgery training programs, gender-identity, race, post-graduate year, and gap years were self-reported. Correlation between our primary outcome variable, flourishing, and measures of resilience (mindfulness, personal accomplishment [PA], workplace support, workplace control) and risk (depression, emotional exhaustion, depersonalization, perceived stress, anxiety, workplace demand) were assessed. Results Of 891 recipients, 300 responded (60% non-male, 41% non-white). Flourishing was significantly positively correlated with all measured resilience factors and negatively correlated with all measured risk factors. In multivariable modelling, mindfulness, PA, and workplace support were positively and significantly associated with flourishing, with PA having the strongest resilience effect. Depression and anxiety were negatively and significantly associated with flourishing, with depression having the strongest risk effect. Conclusions Our results suggest that interventions that increase mindfulness, workplace support, and PA, as well as those that decrease depression and anxiety may particularly impact flourishing (i.e., global wellbeing) in surgical trainees. These findings provide preliminary guidance on allocation of resources toward wellbeing interventions. In particular, cognitive (i.e., mindfulness) training is a feasible intervention with modest but significant association with flourishing, and potential indirect effects through influence on PA, anxiety and depression.
Introduction The rate of obesity in the US population continues to rise, with 42.7% of adults having obesity in 2018. Increased pressure to achieve weight loss for cultural and/or health reasons leads many to seek weight loss through various means. The objective of this study was to assess whether differences exist in health behaviors and weight loss strategies between those who underwent weight loss surgery (WLS) and those seeking non-surgical weight loss (NSWL). Methods This cross-sectional study used data from the 2013–2018 National Health and Nutrition Examination Survey. Weighted statistical analyses included descriptives, ANOVAs, and chi-square tests. Results There was no significant difference between the two groups in dietary quality (p = .12), but those who underwent WLS consumed less calories than those seeking NSWL (p < .001). Those who underwent WLS had 50% lower odds of meeting physical activity recommendations and endorsed higher use of healthy weight loss strategies (OR = 0.02, 95% CI = 0.01–0.05) compared to NSWL participants. Conclusion As WLS directly impacts patients’ eating, WLS patients may be able to modify eating habits more so than physical activity level.
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Mindfulness meditation has a long tradition of being used to manage cravings. This paper reviews 30 experimental studies that have examined the effects of different types of mindfulness practice on cravings for food, cigarettes and alcohol. The findings are interpreted in light of relevant theories of craving. The studies show most support for the elaborated intrusion theory of desire and conditioning models. They suggest that whilst mindfulness strategies may bring about immediate reductions in craving, such effects are likely to stem from working memory load, and will not necessarily be superior to alternative strategies that also load working memory. Likewise, reductions in craving over the medium term may occur due to extinction processes that result from the individual inhibiting craving-related responses. Again, alternative strategies that promote response suppression may be equally effective. Nevertheless, a smaller number of studies show promising results where mindfulness exercises have been repeatedly practiced over a longer period of time. The results of these studies provide tentative support for Buddhist models of craving that suggest mindfulness practice may confer unique benefits in terms of both craving reduction and reducing the extent to which craving leads to consumption. Further research would be needed to confirm this.
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This study examined the effects of applying a mindful eating strategy during lunch on subsequent intake of a palatable snack. It also looked at whether this effect occurred due to improved memory for lunch and whether effects varied with participant gender, level of interoceptive awareness or sensitivity to reward. Participants (n = 51) completed a heartbeat perception task to assess interoceptive awareness. They were then provided with a lunch of 825 calories. Participants in the experimental group ate lunch while listening to an audio clip encouraging them to focus on the sensory properties of the food (e.g. its smell, look, texture). Those in the control group ate lunch in silence. Two hours later participants were offered a snack. They then completed a questionnaire assessing sensitivity to reward as well as other measures assessing various aspects of their memory for lunch. The results showed no significant difference in lunch intake between the two groups but participants in the experimental group consumed significantly less snack than those in the control group; mean = 112.30 calories (SD = 70.24) versus mean = 203.20 calories (SD = 88.05) respectively, Cohen's d = 1.14. This effect occurred regardless of participant gender or level of interoceptive awareness. There was also no significant moderation by sensitivity to reward although one aspect, reward interest, showed a trend towards significance. There was no evidence to indicate that the mindful eating strategy enhanced participants' memory for their lunch. Further research is needed to assess the long-term effects of this strategy, as well as establish the underlying mechanisms. Future work on the relationship between sensitivity to reward and the effects of mindful eating may also benefit from larger sample sizes.
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Theoretically driven smartphone-delivered behavioral interventions that target mechanisms underlying eating behavior are lacking. In this study, we administered a 28-day self-paced smartphone-delivered intervention rooted in an operant conditioning theoretical framework that targets craving-related eating using mindful eating practices. At pre-intervention and 1-month post-intervention, we assessed food cravings among adult overweight or obese women (N = 104; M age = 46.2 ± 14.1 years; M BMI = 31.5 ± 4.5) using ecological momentary assessment via text message (SMS), self-reported eating behavior (e.g., trait food craving), and in-person weight. Seventy-eight participants (75.0%) completed the intervention within 7 months (‘all completers’), and of these, 64 completed the intervention within 3 months (‘timely completers’). Participants experienced significant reductions in craving-related eating (40.21% reduction; p < .001) and self-reported overeating behavior (trait food craving, p < .001; other measures ps < .01). Reductions in trait food craving were significantly correlated with weight loss for timely completers (r = .30, p = .020), this pattern of results was also evident in all completers (r = .22, p = .065). Taken together, results suggest that smartphone-delivered mindful eating training targeting craving-related eating may (1) target behavior that impacts a relative metabolic pathway, and (2) represent a low-burden and highly disseminable method to reduce problematic overeating among overweight individuals. registration: NCT02694731.
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Purpose of review: This review summarized trends and key findings from empirical studies conducted between 2011 and 2017 regarding eating disorders and disordered weight and shape control behaviors among lesbian, gay, bisexual, and other sexual minority (i.e., non-heterosexual) populations. Recent findings: Recent research has examined disparities through sociocultural and minority stress approaches. Sexual minorities continue to demonstrate higher rates of disordered eating; disparities are more pronounced among males. Emerging data indicates elevated risk for disordered eating pathology among sexual minorities who are transgender or ethnic minorities. Dissonance-based eating disorder prevention programs may hold promise for sexual minority males. Continued research must examine the intersections of sexual orientation, gender, and ethnic identities, given emergent data that eating disorder risk may be most prominent among specific subgroups. More research is needed within sexual minorities across the lifespan. There is still a lack of eating disorder treatment and prevention studies for sexual minorities.
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Background Reward and punishment sensitivities have been identified as potential contributors to binge eating and compensatory behaviors, though few studies have examined gender differences in these behaviors. MethodA college-aged sample (N = 1,022) completed both the Eating Disorders Diagnostic Scale (EDDS) and Sensitivity to Punishment/Sensitivity to Reward Questionnaire (SPSRQ). ResultsRates of binge eating were similar in males and females. Among those reporting compensatory behaviors, women reported engaging in compensatory behaviors more frequently than men. Sensitivity to reward and sensitivity to punishment were both positively associated with binge eating frequency in both genders. In contrast, women with high reward sensitivity reported engaging in compensatory behaviors more frequently. Conclusions Rates of binge eating and compensatory weight control behaviors were similar between college-aged males and females, though females who engaged in compensatory behaviors did so more frequently than males. Sensitivity to punishment was greater in females, whereas sensitivity to reward was greater in males. Reward and punishment sensitivity were each positively associated with binge eating in both males and females, while only reward sensitivity was positively associated with compensatory behaviors in females.
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Purpose of review: The purposes of the present review are to organize the recent literature on the effects of food cues on restrained and unrestrained eaters and to determine current directions in such work. Recent findings: Research over the last several years involves both replicating the work showing that restrained eaters respond to attractive food cues by eating more but unrestrained eaters show less responsiveness and extending this work to examine the mechanisms that might underlie this differential responsiveness. Labeling a food as healthy encourages more eating by restrained eaters, while diet-priming cues seem to curtail their consumption even in the face of attractive food cues. Work on cognitive responses indicates that restrained (but not unrestrained) eaters have both attention and memory biases toward food cues. Restrained eaters attend more strongly to food- and diet-related cues than do unrestrained eaters, as evidenced in both their eating behavior and their attention and memory responses to such cues. These effects interact with expectations and manner of presentation of such cues. What remains to be understood is the meaning and mechanism of the attention bias toward food cues in restrained eaters and the implications of such bias for overeating and overweight more broadly speaking.
The human brain has evolved to support our species survival through simple neural mechanisms that help us remember where to find calorie-dense sources of food, while at the same time avoid danger. How do these survival mechanisms function in (Western) modern day, where food is plentiful, and danger exists primarily as theoretical threat? Now add in the cultivation and introduction of chemical substances and social technologies that literally hijack these neural pathways, leading to addictive behaviours such as substance use disorders, gambling, internet pornography and even smart-phone-based texting. Simply put, feeling the pleasant effects of intoxicants (chemical and behavioural) builds and supports a ‘self’ that requires their continued use to survive. New links are now being drawn between early Buddhist psychological models of the perpetuation of self-related processes (e.g. ‘dependent origination’) and modern-day science (e.g. operant conditioning) that may shed light on current conundrums surrounding an increasingly addicted society. Further, clinical trials involving specific training targeted towards the very behavioural mechanisms highlighted as problematic (e.g. feeling tone and its relationship to craving) suggest potent therapeutics – and even ways to tap into or ‘hack’ these very mechanisms for benefit, while neurobiological studies illuminate brain mechanisms linking modern-day science back to the Buddhist origins of suffering.
There is a general perception that almost no one succeeds in long-term maintenance of weight loss. However, research has shown that ≈20% of overweight individuals are successful at long-term weight loss when defined as losing at least 10% of initial body weight and maintaining the loss for at least 1 y. The National Weight Control Registry provides information about the strategies used by successful weight loss maintainers to achieve and maintain long-term weight loss. National Weight Control Registry members have lost an average of 33 kg and maintained the loss for more than 5 y. To maintain their weight loss, members report engaging in high levels of physical activity (≈1 h/d), eating a low-calorie, low-fat diet, eating breakfast regularly, self-monitoring weight, and maintaining a consistent eating pattern across weekdays and weekends. Moreover, weight loss maintenance may get easier over time; after individuals have successfully maintained their weight loss for 2–5 y, the chance of longer-term success greatly increases. Continued adherence to diet and exercise strategies, low levels of depression and disinhibition, and medical triggers for weight loss are also associated with long-term success. National Weight Control Registry members provide evidence that long-term weight loss maintenance is possible and help identify the specific approaches associated with long-term success.