ArticlePDF Available

A longitudinal study on the association between facets of mindfulness and eating disorder symptoms in individuals diagnosed with eating disorders

Authors:

Abstract and Figures

Mindfulness‐based treatments for eating disorders could be improved by understanding how facets of mindfulness predict eating disorder symptoms over time. We examined whether facets of mindfulness predict eating disorder symptoms over time and vice versa. Individuals with an eating disorder diagnosis (N = 124; 87.9% diagnosed with anorexia nervosa) and an undergraduate sample (N = 290) completed measures of mindfulness at baseline. The clinical sample also completed these measures 1 month later. Individuals in the clinical sample had lower acting with awareness and higher observing than individuals in the undergraduate sample (ps < 0.002). In the clinical sample, higher body dissatisfaction prospectively predicted lower acting with awareness (p = 0.02). Lower acting with awareness prospectively predicted higher drive for thinness (p < 0.01) and bulimic symptoms (p < 0.01). Acting with awareness shows potential as a process that can be altered to effect positive outcomes on drive for thinness and bulimic symptoms.
Content may be subject to copyright.
RESEARCH ARTICLE
A longitudinal study on the association between facets of
mindfulness and eating disorder symptoms in individuals
diagnosed with eating disorders
Margarita Sala
1
| Irina A. Vanzhula
2
| Cheri A. Levinson
2
1
Department of Psychology, Southern
Methodist University, Dallas, Texas, USA
2
Department of Psychological and Brain
Sciences, University of Louisville,
Louisville, Kentucky, USA
Correspondence
Cheri A. Levinson, Department of
Psychological and Brain Sciences,
University of Louisville, Louisville, KY
40292.
Email: cheri.levinson@louisville.edu
Funding information
National Science Foundation Graduate
Research Fellowship, Grant/Award Num-
ber: DGE1645420; NIH, Grant/Award
Number: 5T32DA00726117
Abstract
Mindfulnessbased treatments for eating disorders could be improved by
understanding how facets of mindfulness predict eating disorder symptoms
over time. We examined whether facets of mindfulness predict eating disorder
symptoms over time and vice versa. Individuals with an eating disorder diagno-
sis (N= 124; 87.9% diagnosed with anorexia nervosa) and an undergraduate
sample (N=290) completed measures of mindfulness at baseline. The clinical
sample also completed these measures 1 month later. Individuals in the clinical
sample had lower acting with awareness and higher observing than individuals
in the undergraduate sample (ps < 0.002). In the clinical sample, higher body
dissatisfaction prospectively predicted lower acting with awareness
(p= 0.02). Lower acting with awareness prospectively predicted higher drive
for thinness (p< 0.01) and bulimic symptoms (p< 0.01). Acting with aware-
ness shows potential as a process that can be altered to effect positive outcomes
on drive for thinness and bulimic symptoms.
KEYWORDS
anorexia nervosa, body dissatisfaction, bulimia nervosa, eating disorders, mindfulness
1|INTRODUCTION
Mindfulness involves paying attention to present
moment experiences with an attitude of acceptance and
nonjudgmental awareness (Baer, Smith, Hopkins,
Krietemeyer, & Toney, 2006; KabatZinn, 2006).
Mindfulnessbased interventions are widely used tech-
niques in the treatment of various psychological disor-
ders, including eating disorders (WandenBerghe, Sanz
Valero, & WandenBerghe, 2010). However, findings
related to the efficacy of mindfulnessbased interventions
in the treatment of eating disorders are mixed (Hepworth,
2010; Marek, BenPorath, Federici, Wisniewski, & War-
ren, 2013; Morgan, Lazarova, Schelhase, & Saeidi, 2014).
A more thorough understanding of how specific facets
of mindfulness relate to eating disorder symptoms may
be informative for improving mindfulnessbased treat-
ments for eating disorders.
1.1 |Mindfulness and Eating Disorder
Symptoms in NonClinical Samples
Mindfulness is a multifaceted construct, with five
relatively independent facets: observing (i.e., noticing
sensory experiences), describing (i.e., labeling internal
experiences), acting with awareness (i.e., attending to
present moment activities), nonjudgement (i.e., taking
anonevaluative stance towards thoughts and feelings),
and nonreactivity (i.e., letting thoughts and feelings
come and go without getting caught up in them; Baer
et al., 2005). It has been suggested that the mindfulness
Received: 16 January 2018 Revised: 7 October 2018 Accepted: 1 November 2018
DOI: 10.1002/erv.2657
Eur Eat Disorders Rev. 2018;111. © 2018 John Wiley & Sons, Ltd and Eating Disorders Association.wileyonlinelibrary.com/journal/erv 1
facets of acting with awareness, observing, and
nonreactivity may be relevant to eating disorder
symptoms. Higher acting with awareness should lead
to increased awareness of the processes involved in
food choice and decreased behavioral automaticity in
regard to food choice (Kristeller & Wolever, 2011),
which for individuals with eating disorders may result
in lower eating disorder symptoms, given that eating
disorder symptoms are largely driven by automatic
process (Steinglass & Walsh, 2006). Individuals higher
in acting with awareness may stop and think regarding
their actions before continuing to engage in maladap-
tive eating disorder behaviours (Levin, Dalrymple,
Himes, & Zimmerman, 2014). Additionally, higher
acting with awareness may enable individuals to recog-
nise potential triggers to eating disorder behaviours.
This proposition has been supported by research show-
ing that acting with awareness is negatively associated
with symptoms of bulimia nervosa (BN Adams et al.,
2012; Sala & Levinson, 2017) and anorexia nervosa
(AN; Adams et al., 2012) in female smokers (Adams
et al. 2012) and young adult women (Sala & Levinson,
2017). It has been suggested that nonreactivity should
help an individual become unattached to emotional
experiences when experiencing distress (Lavender,
Gratz, & Tull, 2011), thus decreasing the need to use
eating disorder symptoms to regulate emotions. This
proposition has been supported by empirical findings
showing that nonreactivity is negatively associated with
bulimic symptoms (Sala & Levinson, 2017) and eating
pathology (i.e., Eating Attitudes Test26 scores;
Lavender et al., 2011) in young adult women (Sala &
Levinson, 2017; Lavender et al., 2011). In contrast,
individuals with higher observing may have higher
eating disorder symptoms because high observing with-
out other aspects of mindfulness could be an indication
of hypervigilance and signal attention biases that
perpetuate disordered eating (e.g., noticing greater
external cues for eating; Levin et al., 2014). This
proposition has been supported by empirical findings
showing that higher observing is associated with
higher anorexia symptoms (Adams et al., 2012) and
higher restrained eating (Tak et al., 2015) in female
smokers (Adams et al. 2012) and individuals with Type
1 or Type 2 diabetes (Tak et al., 2015). Overall, empir-
ical findings show that, in nonclinical samples, higher
acting with awareness as well as higher nonreactivity
are associated with lower eating disorder symptoms,
whereas higher observing is associated with higher
eating disorder symptoms. However, it is important to
note that because these studies were not conducted in
clinical samples, it is unclear if these findings are of
clinical relevance to individuals with eating disorders.
1.2 |Mindfulness and eating disorder
symptoms in clinical samples
Less research has examined the extent to which facets of
mindfulness differ in individuals with eating disorders
(vs. nonclinical samples). Compare, Callus, and Grossi
(2012) found that individuals diagnosed with binge eating
disorder (BED) reported lower acting with awareness,
nonreactivity, and observing than a nonclinical sample.
However, no study has compared mindfulness in individ-
uals with anorexia nervosa (AN) and bulimia nervosa
(BN) to nonclinical samples. There is also little research
examining the relationships between specific facets of
mindfulness and eating disorder symptoms in clinical
samples. Compare et al. found that higher acting with
awareness and nonreactivity was associated with less
binge eating episodes in individuals diagnosed with
BED but not controls. In three crosssectional studies,
Lattimore et al. (2017) found differing patterns of associ-
ations between acting with awareness and nonreactivity
on the one hand and bulimic symptoms and drive for
thinness on the other hand, in an eating disorder versus
a nonclinical sample. In the clinical sample, higher act-
ing with awareness and nonreactivity were associated
with lower drive for thinness but not bulimic symptoms.
In the nonclinical sample, higher acting with awareness
and nonreactivity were associated with lower bulimic
symptoms, and only higher nonreactivity was associated
with lower drive for thinness. In a clinical sample of
women in residential treatment for an eating disorder,
Butryn et al. (2013) found that higher awareness was
associated with lower eating disorder symptoms (i.e.,
drive for thinness, bulimic symptoms, and body dissatis-
faction) throughout the course of treatment. However,
Butryn et al. examined correlations between changes in
mindfulness facets and eating disorder symptoms, rather
than examining how mindfulness impacts eating disor-
ders prospectively in crosslagged analyses. Overall,
research suggests that mindfulness is negatively associ-
ated with eating disorder symptoms in individuals with
eating disorders. There is also some evidence that individ-
uals with BED report lower acting with awareness, non
reactivity, and observing than controls. However, it is
unclear whether this finding holds in individuals with
other eating disorders.
1.3 |Prospective relationships between
mindfulness and eating disorder symptoms
To date, only one study has examined the temporal
sequence of mindfulness and eating disorder symptoms.
In a nonclinical sample, Sala and Levinson (2017)
2SALA ET AL.
examined the associations between mindfulness and
disinhibited eating and found that nonreactivity
inversely predicted bulimic symptoms across 6 months
but that bulimic symptoms did not prospectively predict
observing, nonreactivity, or acting with awareness. How-
ever, this study did not examine the prospective relation-
ship between mindfulness facets and drive for thinness
and body dissatisfaction. No research study has examined
the prospective relationship between mindfulness facets
and eating disorder symptoms in a sample of individuals
diagnosed with an eating disorder, and no research study
has examined the prospective relationship between mind-
fulness facets on the one hand and drive for thinness and
body dissatisfaction on the other hand.
1.4 |Study purpose
The literature suggests that mindfulness in general and
acting with awareness, nonreactivity, and observing spe-
cifically are associated with eating disorder symptoms.
However, most of the existing research examining the
relationship between mindfulness and disordered eating
symptoms is crosssectional and has been conducted in
nonclinical samples. No prospective study has examined
the relationship between mindfulness and eating disorder
symptoms in a sample of individuals diagnosed with an
eating disorder. Further understanding the prospective
relation between mindfulness facets and eating pathology
will enable us to enhance treatment by targeting impor-
tant facets of mindfulness that predict eating pathology.
The current study tested the prospective relationships
between mindfulness facets (acting with awareness,
observing, and nonreactivity) and eating disorder symp-
toms (drive for thinness, bulimic symptoms, body dissat-
isfaction) in individuals with eating disorders. Of note,
we recruited the sample after discharge in order to test
whether mindfulness predicts relapse and recovery. Addi-
tionally, we did not include the describing and non
judging facets as we did not measure them. Finally, we
tested whether acting with awareness, observing, and
nonreactivity differed in individuals with eating disor-
ders compared with an undergraduate comparison sam-
ple. However, we did not test prospective relationships
between mindfulness and eating disorders in the under-
graduate sample.
Specifically, we tested the following: (a) Whether indi-
viduals with eating disorders differed in facets of mindful-
ness from a normative undergraduate sample and (b)
Whether facets of mindfulness predict eating disorder
symptoms over time and vice versa in individuals with
eating disorders. Based on theory and previous empirical
findings (Butryn et al., 2013; Compare et al., 2012;
Lattimore et al., 2017), we hypothesized that (a) individ-
uals with eating disorders would report lower acting with
awareness and nonreactivity, but higher observing, than
an undergraduate comparison sample and (b) higher
nonreactivity and acting with awareness would prospec-
tively predict lower future drive for thinness, bulimic
symptoms, and body dissatisfaction, but that observing
would prospectively predict higher eating disorder symp-
toms (given that previous research suggests that observ-
ing is positively associated with eating disorder
symptoms). We also did not expect that eating disorder
symptoms would prospectively predict future mindful-
ness. Given that our first hypothesis is based on primarily
individuals with BED (Compare et al., 2012), this hypoth-
esis is exploratory for AN and BN patients.
2|METHODS
2.1 |Participants
Participants in the clinical sample were 124 individuals
(87.9% diagnosed with AN) recently discharged from a
residential and/or partial hospitalization eating disor-
der facility in the Midwestern United States (median
days since discharge at start of study = 140 days,
range = 1868 days; SD = 40.12). Measures at Time
1 were completed after discharge. Seventyfour partici-
pants (59.7%) completed Time 2 (1 month later). Par-
ticipants in the undergraduate comparison sample
included 290 undergraduate students at a university
in the Southern United States. Participants in the
undergraduate sample were recruited to complete a
study on personality and mood in order to receive class
credit. See Table 1 for demographics and diagnostic
information. 96% of the clinical sample was female,
compared with 79% of the undergraduate sample. Of
note, the age of the two samples differed significantly
(p< 0.001): The clinical sample was older than the
undergraduate comparison sample. However, univari-
ate linear modelling analyses suggested that there were
no significant differences in mindfulness by age or gen-
der in either data set (ps > 0.12).
2.2 |Measures
2.2.1 |Body mass index
Body mass index (BMI) was calculated from selfreported
height and weight.
SALA ET AL.3
2.2.2 |Eating Disorder Diagnostic Scale
(Stice, Telch, & Rizvi, 2000)
The Eating Disorder Diagnostic Scale (EDDS) was used to
confirm that participants had an eating disorder diagno-
sis. The EDDS is a brief selfreported measure used to
diagnose eating disorders, such as AN, BN, and BED.
The EDDS has adequate testretest reliability, internal
consistency, and validity (Stice et al., 2000; Stice, Fisher,
& Martinez, 2004). In the current study, internal consis-
tency was adequate (α= 0.78). Example items include:
Has your weight or shape influenced how you judge
yourself as a person? And During the past 3 months
have there been times when you have eaten what other
people would regard as an unusually large amount of
food (e.g., a pint of ice cream) given the circumstances?
2.2.3 |The Five Facet Mindfulness
Questionnaire (Baer et al., 2006)
The Five Facet Mindfulness Questionnaire is a self
reported measure of trait mindfulness. In the current
study, we included 23 items that measured three of five
factors: (a) acting with awareness, (b) observing, and (c)
nonreactivity. We included these subscales as previous
theory and research have suggested that these subscales
are most relevant to eating disorder symptoms. Each of
the three factors has been demonstrated to have good
psychometric properties (Baer et al., 2006). In the current
study, internal consistencies were adequate to excellent
(αs= 0.730.92). Example items from the acting with
awareness scale include: When I do things, my mind
wanders off and I'm easily distracted and I don't pay
attention to what I'm doing because I'm daydreaming,
worrying, or otherwise distracted.Example items from
the observing scale include: I pay attention to how my
emotions affect my thoughts and behaviour and I notice
how foods and drinks affect my thoughts, bodily sensa-
tions, and emotions.Example items from the non
reactivity scale include:I perceive my feelings and emo-
tions without having to react to them and I watch my
feelings without getting lost in them.
2.2.4 |The Eating Disorder Inventory2
(Garner, 1991)
The Eating Disorder Inventory2 (EDI2) is a self
reported questionnaire that measures core features asso-
ciated with AN and BN. In the current study, we utilised
the three main EDI2 subscales that measure eating dis-
order symptoms: (a) drive for thinness, (b) bulimic symp-
toms, and (c) body dissatisfaction. The EDI2 has been
demonstrated to have good psychometric properties
(Eberenz & Gleaves, 1994; Spillane, Boerner, Anderson,
& Smith, 2004; Thiel & Paul, 2006). In the current study,
internal consistencies were adequate to good (αs= 0.75
TABLE 1 Demographics and diagnostic descriptions
Clinical (N= 124)
NonClinical
(N= 290)
n(%) Range n(%) Range
Age (M, SD) 25.31 (8.38) 1459 20.41 (3.22) 1750
Female 119 (96.0%) 229 (79%)
BMI (M, SD) 21.39 (4.67) 14.9244.91 25.01(5.65) 16.7658.90
Ethnicity
European American 115 (92.7%) 205 (70.7%)
African American 1 (0.8%) 32 (11.0%)
Hispanic 3 (2.4%) 11 (3.8%)
Asian 1 (0.8%) 16 (5.5%)
Other 4 (3.2%) 26 (9.0%)
Diagnosis
AN/Atypical AN 109 (87.9%) 8 (2.7%)
BN 7 (5.6%) 4 (1.4%)
BED 0 (0.0%) 2 (0.7%)
EDNOS 8 (6.5%) 2 (0.7%)
Note. BMI: Body mass index; AN: anorexia nervosa; BN: bulimia nervosa; BED: binge eating disorder; EDNOS: eating disorder not otherwise specified.
4SALA ET AL.
0.85). Example items from the drive for thinness scale
include: I think about dieting and I am preoccupied
with the desire to be thinner.Example items from the
bulimic symptoms scale include: I eat when I am upset
and I stuff myself with food.Example items from the
body dissatisfaction scale include: I think my stomach
is too big and I think my thighs are too large.
2.3 |Procedures
Participants in the clinical sample were recruited from a
research database from an eating disorder clinic in the
Midwestern United States. All participants had been
recently discharged from either a partial hospital or resi-
dential program for eating disorders. Participants in the
clinical sample completed all measures outlined above
after discharge (Time 1) and 1 month after baseline
(Time 2) online. Participants in the undergraduate com-
parison sample were recruited from undergraduate psy-
chology courses to complete the eating disorder and
mindfulness measure online. They received course credit
for their participation. The Institutional Review Boards at
Washington University in St. Louis (clinical sample) and
the University of Louisville (undergraduate comparison
sample) approved these procedures.
2.4 |Statistical analysis
We conducted ttests to compare mindfulness facets
between the clinical and undergraduate comparison sam-
ples. We used Mplus Version 7.1 to conduct crosslagged
path analyses. For longitudinal analyses, the multiple lin-
ear regression (MLR) estimator, an Mplus option for max-
imum likelihood estimation with robust standard error,
was used to report standardized path estimates. MLR
was used because it is robust to potential nonnormal
data and is able to estimate missing data efficiently using
robust estimates. Specifically, MLR handles missing data
using a full maximum likelihood estimator. Therefore,
we could use all data and did not have to exclude partic-
ipants who did not complete Time 2 (n = 50, 40.3%)
(Muthen & Muthen, 1998).
Model fit was evaluated using the comparative fit index
(CFI; Bentler, 1990), the TuckerLewis incremental fit
index (TLI; Tucker & Lewis, 1973), the root mean square
error of approximation (RMSEA; Steiger & Lind, 1980),
the standardized root mean square residual (SRMR;
Jöreskog & Sörbom, 1981), and chisquare values (χ
2
;
Kline, 2016). For the CFI and TLI, values above or equal
to 0.90 were considered adequate and values above or
equal to 0.95 were considered very good (Hu & Bentler,
1999). For the RMSEA and SRMR, values below or equal
to 0.08 were considered adequate and values below or
equal to 0.05 were considered very good (Hu & Bentler,
1999). In addition, we tested whether models with non
significant paths removed fit the data better than the satu-
rated models by computing the SatorraBentler χ
2
differ-
ence test statistic (Bryant & Satorra, 2012; Satorra &
Bentler, 2001; Satorra & Bentler, 2010). Satorra and Bentler
showed that the difference between two meanadjusted χ
2
follows a χ
2
distribution only when divided by a scaling cor-
rection factor; degrees of freedom (df) is the difference in df
between the two models. A significant difference or test
statistic indicates the model with the lower χ
2
value fits
the data better. A nonsignificant statistic suggests the
more parsimonious model is best (i.e., when comparing
the saturated model and model with nonsignificant paths
removed, the model with nonsignificant paths removed
would be best; Raykov & Marcoulides, 1999).
Three prospective twowave models with all the
mindfulness facets (acting with awareness, observing,
nonreactivity) paired with each of the three disordered
eating symptom variables (drive for thinness, bulimic
symptoms, body dissatisfaction) spanning from initial
assessment (Time 1) to 1 month later (Time 2) were
tested. All models were adjusted for baseline levels of
the outcome variable and for BMI. All missing data for
Time 2 were efficiently estimated because the MLR esti-
mator was used. Eating disorder symptoms were tested
in three separate models because the present study did
not seek to examine shared risk factors between the three
disordered eating symptoms.
3|RESULTS
3.1 |Comparisons to a normative
undergraduate sample
Descriptive information for the clinical and undergradu-
ate comparison sample, as well as ttest results, are
reported in Table 2. As hypothesised, individuals with
an eating disorder had significantly lower acting with
awareness than the undergraduate comparison sample.
Also as hypothesized, individuals with an eating disorder
had significantly higher observing than the undergradu-
ate comparison sample. However, against our hypothesis,
the scores on the nonreactivity facet did not significantly
differ between individuals in the clinical sample and the
undergraduate comparison sample. Of note, although
individuals with eating disorders had higher drive for
thinness and body dissatisfaction than the nonclinical
samples, there were no significant differences in bulimic
symptoms among the two groups (see Table 2).
SALA ET AL.5
3.2 |Clinical sample zeroorder
correlations
Please see Table 3 for zeroorder correlations in the clin-
ical sample. Overall, eating disorder symptoms were pos-
itively correlated with each other and mindfulness facets
were positively correlated with each other (with the
exception of observing not being consistently significantly
correlated with the other mindfulness facets). Acting with
awareness was significantly negatively correlated with all
eating disorder symptoms. Nonreactivity was signifi-
cantly negatively correlated with drive for thinness and
body dissatisfaction. Observing was not significantly asso-
ciated with any of the eating disorder symptoms.
3.3 |Crosslagged path analyses
3.3.1 |Model 1. Drive for thinness
We first tested the amount of variance left to be explained
in Time 2 scores given T ime 1 scores for drive for thin-
ness. Time 1 drive for thinness predicted 82.3% of vari-
ance in Time 2 drive for thinness, indicating that there
was 17.7% variance left to explain by mindfulness and
other factors. We tested a model that included Time 1
and Time 2 acting with awareness, nonreactivity, observ-
ing, and drive for thinness. The initial model was satu-
rated and therefore had a perfect fit. When non
significant paths were removed, fit remained very good
(CFI = 0.99, TLI = 0.99, RMSEA = 0.03, SRMR = 0.06,
χ
2
= 267.12). The more parsimonious model fit the data
better than the saturated model (SatorraBentler χ
2
differ-
ence = 14.192, p= 0.36). As can be seen in Figure 1 and as
hypothesized, lower acting with awareness significantly
prospectively predicted higher drive for thinness. In addi-
tion, a higher BMI significantly prospectively predicted
higher drive for thinness. Nonreactivity (p=0.46) and
observing (p=0.59) did not significantly predict drive for
thinness. As hypothesized, drive for thinness did not signif-
icantly predict acting with awareness (p=0.10), non
reactivity (p=0.27), or observing (p=0.93). BMI did not
predict mindfulness (ps = 0.110.84).
3.3.2 |Model 2. Bulimic symptoms
We first tested the amount of variance left to be explained
in Time 2 scores given Time 1 scores for bulimic symp-
toms. Time 1 bulimic symptoms predicted 92.1% of vari-
ance in Time 2 bulimic symptoms, indicating that there
was 7.9% variance left to explain by mindfulness and
other factors. We tested a model that included Time 1
and Time 2 acting with awareness, nonreactivity, observ-
ing, and bulimic symptoms. The initial model was satu-
rated and therefore had a perfect fit. When non
significant paths were removed, fit remained excellent
(CFI = 1.00, TLI = 1.01, RMSEA = 0.00, SRMR = 0.05,
χ
2
= 275.76). The more parsimonious model fit the data
better than the saturated model (SatorraBentler χ
2
differ-
ence = 8.11, p= 0.62). As can be seen in Figure 2 and as
hypothesized, lower acting with awareness significantly
TABLE 2 Comparisons (ttest) for facets of mindfulness by sample
Clinical sample Nonclinical sample
Variable MSDRange MSDRange t
Acting with awareness 23.86 6.49 840 25.81 6.39 540 2.83**
Observing 25.45 5.61 1238 23.57 5.81 238 3.09**
Nonreactivity 18.00 4.79 829 18.89 5.31 132 1.61
Bulimia nervosa 15.17 8.14 739 14.16 6.07 740 1.39
Drive for thinness 23.12 6.84 532 21.35 9.29 742 2.15*
Body dissatisfaction 42.68 10.39 1054 30.75 10.80 954 10.57**
Note. M: Mean; SD: standard deviation.
*p< .05;
**p< .01.
TABLE 3 Zeroorder correlations for time 1 in clinical sample
Variable 1 2 3 4 5 6
1.Bulimia Nervosa ——
2.Drive for Thinness .29** ———
3.Body Dissatisfaction .27** .81** ——
4.Acting with Awareness .24* .41** .44** ——
5.Observing .03 .04 .05 .05 ——
6.Nonreactivity .18 .36** .41** .45** .22*
Note:
*p< .05.
**p< .01.
6SALA ET AL.
FIGURE 1 A prospective model of
acting with awareness, nonreactivity,
observing, and drive for thinness. All
relationships were modelled. Only
significant relationships are shown.
Autoregressive parameters are shown in
gray to ease interpretation. All estimates
are standardized estimates of effect sizes.
BMI: body mass index. Time 1: initial
assessment point; Time 2: measures
collected 1 month after Time 1. ***
p< 0.001, ** p< 0.01, * p<0.05
FIGURE 2 A prospective model of
acting with awareness, nonreactivity,
observing, and bulimic symptoms. All
relationships were modelled. Only
significant relationships are shown.
Autoregressive parameters are shown in
gray to ease interpretation. All estimates
are standardized estimates of effect sizes.
Time 1: initial assessment point; T ime 2:
measures collected 1 month after Time 1.
Analyses controlled for BMI. *** p< 0.001,
** p< 0.01, * p<0.05
SALA ET AL.7
prospectively predicted higher bulimic symptoms.
Observing (p=0.89) and nonreactivity (p=0.57) did
not significantly predict bulimic symptoms. As hypothe-
sized, bulimic symptoms did not significantly predict act-
ing with awareness (p=0.89), observing (p=0.67), or
nonreactivity (p=0.11). BMI did not predict mindful-
ness or bulimic symptoms (ps = 0.140.64).
3.3.3 |Model 3. Body dissatisfaction
We first tested the amount of variance left to be explained
in Time 2 scores given Time 1 scores for body dissatisfac-
tion. Time 1 body dissatisfaction predicted 86.1% of vari-
ance in Time 2 body dissatisfaction, indicating that
there was 13.9% variance left to explain by mindfulness
and other factors. We tested a model that included Time
1 and Time 2 acting with awareness, nonreactivity,
observing, and body dissatisfaction. The initial model
was saturated and therefore had a perfect fit. When
nonsignificant paths were removed, fit was adequate
(CFI = 0.94, TLI = 0.90, RMSEA = 0.08, SRMR = 0.08,
χ
2
= 237.96). The more parsimonious model fit the data
better than the saturated model (SatorraBentler χ
2
differ-
ence = 16.13, p= 0.10). As can be seen in Figure 3 and
against hypothesis, higher body dissatisfaction signifi-
cantly prospectively predicted lower acting with aware-
ness. Higher BMI trended towards predicting higher
body dissatisfaction (p=0.08). Acting with awareness
(p=0.14), observing (p=0.81), and nonreactivity
(p=0.20) did not significantly predict body dissatisfac-
tion. Body dissatisfaction did not significantly predict
observing (p=0.38) or nonreactivity (p=0.32). BMI
did not predict mindfulness (ps = 0.160.84).
4|DISCUSSION
In this study, we examined whether facets of mindfulness
differ among individuals with eating disorders and an
undergraduate comparison sample as well as whether
facets of mindfulness predict eating disorder symptoms
over time and vice versa in individuals with eating disor-
ders. Overall, we found that individuals with an eating
disorder (mostly AN) had lower acting with awareness
and higher observing than an undergraduate comparison
sample. We also found that in individuals with an eating
disorder, lower acting with awareness prospectively pre-
dicted higher drive for thinness and bulimic symptoms.
In addition, we found that in individuals with an eating
disorder, higher body dissatisfaction prospectively pre-
dicted lower acting with awareness.
Our first hypothesis was partially supported. We
hypothesized that individuals with an eating disorder
would score lower on nonreactivity and acting with
awareness, but higher on observing, than a comparison
undergraduate sample. We found that acting with aware-
ness was significantly lower in individuals with an eating
FIGURE 3 A prospective model of
acting with awareness, nonreactivity,
observing, and body dissatisfaction.All
relationships were modeled. Only
significant relationships are shown.
Autoregressive parameters are shown in
gray to ease interpretation. All estimates
are standardized estimates of effect sizes.
Time 1: initial assessment point; T ime 2:
measures collected 1 month after Time 1.
Analyses controlled for BMI. *** p< 0.001,
** p< 0.01, * p<0.05
8SALA ET AL.
disorder than in an undergraduate comparison sample.
This finding is in line with a previous study that found
that individuals diagnosed with BED had lower acting
with awareness than controls (Compare et al., 2012) and
suggests that low mindful awareness may be one facet
of mindfulness most strongly implicated in eating disor-
der psychopathology. Also supporting our hypothesis,
individuals with an eating disorder had higher observing
than an undergraduate comparison sample. This result
differs from findings from the same study that individuals
diagnosed with BED had lower observing than controls
(Compare et al., 2012). This finding may be because our
sample primarily consisted of individuals diagnosed with
AN and had no participants diagnosed with BED. It is
possible that observing may be higher in individuals with
AN than in individuals with BED because individuals
with AN may be more likely to notice food items and
smells. In addition, the observe facet has been previously
found to be positively correlated with psychopathology
symptoms, dissociation, and thought suppression in a
nonclinical sample (Baer et al., 2006). Baer et al. (2006)
suggested that observe items may not adequately capture
noticing or attending to experience and unlike other
facets rely mostly on external stimuli.
Interestingly, acting with awareness was the only
one of three components to be predictive of subsequent
eating disorder symptoms and to be predicted by body
dissatisfaction. This finding suggests that acting with
awareness may be particularly relevant to eating disor-
der symptoms. Brown and Ryan (2003) described acting
with awareness as the central defining core of mindful-
ness. Consistent with our hypothesis, we found that
higher acting with awareness prospectively predicted
lower drive for thinness and bulimic symptoms over
time. This finding is in line with a previous study in
which participants who experienced the most improve-
ments with awareness during treatment also showed
the most improvement in drive for thinness, bulimic
symptoms, and body dissatisfaction (Butryn et al.,
2013). It may be that higher awareness of present
moment experiences leads individuals to lower their
behavioural automaticity, which for individuals with
eating disorders may result in lower eating disorder
symptoms, as research suggests that eating disorder
symptoms are largely driven by automatic process (i.e.,
habit) (Steinglass & Walsh, 2006). Acting with aware-
ness may predict drive for thinness and bulimic symp-
toms but not body dissatisfaction because body
dissatisfaction is the least behaviouraloriented eating
disorder symptom. These findings have specific implica-
tions for clinical treatment, suggesting that development
of mindfulness interventions for eating disorders should
focus on targeting acting with awareness. Such
interventions may lower bulimic symptoms and drive
for thinness. Future research is needed to test if the
development of such targeted interventions impacts eat-
ing disorder symptoms. Interventions focused on
targeting acting with awareness should focus on teach-
ing individuals to engage in the present moment with
undivided attention and reduce their proneness to dis-
traction. For example, individuals could be asked to
engage in focusedattention meditation (Lutz, Slagter,
Dunne, & Davidson, 2008).
Contrary to our hypothesis, higher body dissatisfac-
tion prospectively predicted lower acting with awareness.
These findings differ from our previous prospective study
in a nonclinical sample, in which eating disorder symp-
toms did not prospectively predict mindfulness (Sala &
Levinson, 2017). However, in our previous study, we did
not examine the relationship between mindfulness facets
and body dissatisfaction specifically. It may be that being
dissatisfied with one's body leads individuals with eating
disorders to focus on their body shape and size, perhaps
engaging in weighing, body comparisons, and body
checking, resulting in decreased awareness to present
moment experiences. It is possible that body dissatisfac-
tion may contribute to decreased mindful awareness,
which in turn contributes to drive for thinness and
bulimic symptoms. Further research should examine the
mediating role of mindful awareness between body dis-
satisfaction and other eating disorder symptoms.
There are limitations to this study. First, the mindful-
ness facets of nonjudging and describing were not
assessed. In addition, we were not able to test whether
unidimensional mindfulness (i.e., overall mindfulness
rather than specific mindfulness facets) prospectively pre-
dicts eating disorder symptoms. Future research should
consider the prospective relationship between these other
two facets and unidimensional mindfulness and eating
disorder symptoms in individuals diagnosed with an eat-
ing disorder. Second, we used a selfreported diagnostic
interview (rather than a structured clinical interview) to
determine diagnosis. However, there is a strong literature
behind the usage of the EDDS (e.g., Stice et al., 2000; Stice
et al., 2004) and all participants had recently been
discharged from a residential or partial hospitalization
treatment program for eating disorders, which increases
our confidence in the diagnostic procedure. Third, we
assessed mindfulness with a selfreported measure. It
has been suggested that a certain degree of mindfulness
is needed to identify one's own trait mindfulness
(Grossman, 2011). In addition, individuals with AN have
several cognitive and emotional difficulties that can make
it more challenging for them to comment on their own
mindfulness. Therefore, it is possible that individuals
with eating disorders may have inaccurately reported
SALA ET AL.9
their own mindfulness, which may have attenuated the
reported correlations. Fourth, our sample was a treatment
seeking sample. It is unclear if these results generalize to
individuals who do not seek treatment. Relatedly,
although treatment was focused on weight restoration,
it is possible that participants received some form of
mindfulnessbased therapy, which could have affected
their scores on mindfulness facets. Future research
should test if these findings generalise beyond a
treatmentseeking sample. Fifth, most of our sample
consisted of individuals with AN. It is unclear the extent
to which these results generalise to individuals with BN
and BED. Future research should test these hypotheses
in individuals with different types of eating disorders.
Sixth, we only had a 1month followup period. Future
research should test if these findings hold with longer
term followup periods. Seventh, we were unable to
examine how gender differences might influence our
results due to the low number of men in this study.
Eighth, we did not include growth charts for the interpre-
tation of BMI in children and adolescents and did not age
adjust BMI. Finally, this study was not experimental.
Therefore, causality cannot be inferred.
Despite these limitations, the strengths of the study
should be acknowledged. The current study was the first
study to prospectively examine the relationships between
acting with awareness, observing, and nonreactivity and
eating disorder symptoms in a clinical sample across
1 month. Our findings reveal a number of relationships
between these facets of mindfulness and eating disorder
symptoms. In addition, some of these relationships
between mindfulness and eating disorder symptoms dif-
fer from those in an undergraduate sample (Sala &
Levinson, 2017). Specifically, we found that in individuals
with an eating disorder, lower acting with awareness pro-
spectively predicted higher drive for thinness and bulimic
symptoms. In addition, we found that in individuals with
an eating disorder, higher body dissatisfaction prospec-
tively predicted lower acting with awareness. If these
findings are replicated, future research should develop
interventions to test if targeting acting with awareness
specifically can lead to positive outcomes on drive for
thinness and bulimic symptoms and decrease the high
amount of suffering present in eating disorders.
FUNDING INFORMATION
This research was supported by 5T32DA00726117 NIH.
Margarita Sala is supported by the National Science
Foundation Graduate Research Fellowship under Grant
No. DGE1645420. Any opinion, findings, and conclu-
sions or recommendations expressed in this material are
those of the authors and do not necessarily reflect the
views of the National Science Foundation.
ORCID
Margarita Sala http://orcid.org/0000-0002-6775-9607
Irina A. Vanzhula http://orcid.org/0000-0001-8323-1290
Cheri A. Levinson http://orcid.org/0000-0002-8098-6943
REFERENCES
Adams, C. E., McVay, M. A., Kinsaul, J., Benitez, L., Vinci, C., Stew-
art, D. W., & Copeland, A. L. (2012). Unique relationships
between facets of mindfulness and eating pathology among
female smokers. Eating Behaviors,13(4), 390393. https://doi.
org/10.1016/j.eatbeh.2012.05.009
Baer, R. A., Fischer, S., & Huss, D. B. (2005). Mindfulnessbased
cognitive therapy applied to binge eating: A case study. Cognitive
and Behavioral Practice,12(3), 351358. https://doi.org/10.1016/
S10777229(05)800574
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L.
(2006). Using selfreport assessment methods to explore facets
of mindfulness. Assessment,13(1), 2745. https://doi.org/
10.1177/1073191105283504
Bentler, P. M. (1990). Comparative fit indexes in structural models.
Psychological Bulletin,107(2), 238246. https://doi.org/10.1037/
00332909.107.2.238
Brown, K., & Ryan, R. (2003). The benefits of being present: Mind-
fulness and its role in psychological wellbeing. Journal of
Personality and Social Psychology,84(4), 822848. https://doi.
org/10.1037/00223514.84.4.822
Bryant, F. B., & Satorra, A. (2012). Principles and practice of scaled
difference chisquare testing. Structural Equation Modeling: A
Multidisciplinary Journal,19(3), 372398. https://doi.org/
10.1080/10705511.2012.687671
Butryn, M. L., Juarascio, A., Shaw, J., Kerrigan, S. G., Clark, V.,
O'Planick, A., & Forman, E. M. (2013). Mindfulness and its rela-
tionship with eating disorders symptomatology in women
receiving residential treatment. Eating Behaviors,14(1), 1316.
https://doi.org/10.1016/j.eatbeh.2012.10.005
Compare, A., Callus, E., & Grossi, E. (2012). Mindfulness trait, eat-
ing behaviours and body uneasiness: A casecontrol study of
binge eating disorder. Eating and Weight Disorders,17(4),
e244e251. https://doi.org/10.3275/8652
Eberenz, K. P., & Gleaves, D. H. (1994). An examination of the
internal consistency and factor structure of the Eating Disorder
Inventory2 in a clinical sample. International Journal of Eating
Disorders,16(4), 371379. https://doi.org/10.1002/1098
108X(199412)16:4<371::AIDEAT2260160406>3.0.CO;2W
Garner, D. M. (1991). Manual for eating disorder inventory. Odessa:
Psychological assessment resources.
Grossman, P. (2011). Defining mindfulness by how poorly I think I
pay attention during everyday awareness and other intractable
problems for psychology's (re) invention of mindfulness:
10 SALA ET AL.
Comment on Brown et al. Psychological Assessment,23(4),
10341040. https://doi.org/10.1037/a0022713
Hepworth, N. S. (2010). A mindful eating group as an adjunct to
individual treatment for eating disorders: A pilot study. Eating
Disorders,19(1), 616. https://doi.org/10.1080/
10640266.2011.533601
Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in
covariance structure analysis: Conventional criteria versus new
alternatives. Structural Equation Modeling: A Multidisciplinary
Journal,6(1), 155. https://doi.org/10.1080/10705519909540118
Jöreskog, K., & Sörbom, D. (1981). LISREL: Analysis of linear struc-
tural relationships by the method of maximum likelihood (5th
ed.). Chicago: National Education Resources, Inc.
KabatZinn, J. (2006). Mindfulnessbased interventions in context:
Past, present, and future. Clinical Psychology: Science and Prac-
tice,10(2), 144156. https://doi.org/10.1093/clipsy.bpg016
Kline, R. B. (2016). Principles and practice of structural equation
modeling (4th ed.). New York, NY: Guilford.
Kristeller, J. L., & Wolever, R. Q. (2011). Mindfulnessbased eating
awareness training for treating binge eating disorder: The con-
ceptual foundation. Eating Disorders: The Journal of Treatment
and Prevention,19(1), 4961. https://doi.org/10.1080/
10640266.2011.533605
Lattimore, P., Mead, B. R., Irwin, L., Grice, L., Carson, R., & Mali-
nowski, P. (2017). I cant accept that feeling': Relationships
between interoceptive awareness, mindfulness and eating disor-
der symptoms in females with, and atrisk of an eating disorder.
Psychiatry Research,247, 163171. https://doi.org/10.1016/j.
psychres.2016.11.022
Lavender, J. M., Gratz, K. L., & Tull, M. T. (2011). Exploring the
relationship between facets of mindfulness and eating pathology
in women. Cognitive Behaviour Therapy,40(3), 174182. https://
doi.org/10.1080/16506073.2011.555485
Levin, M. E., Dalrymple, K., Himes, S., & Zimmerman, M. (2014).
Which facets of mindfulness are related to problematic eating
among patients seeking bariatric surgery? Eating Behaviors,
15(2), 298305. https://doi.org/10.1016/j.eatbeh.2014.03.012
Lutz, A., Slagter, H. A., Dunne, J. D., & Davidson, R. J. (2008).
Attention regulation and monitoring in meditation. Trends in
Cognitive Sciences,12, 163169. https://doi.org/10.1016/j.
tics.2008.01.005
Marek, R. J., BenPorath, D. D., Federici, A., Wisniewski, L., & War-
ren, M. (2013). Targeting premeal anxiety in eating disordered
clients and normal controls: A preliminary investigation into
the use of mindful eating vs. distraction during food exposure.
International Journal of Eating Disorders,46(6), 582585.
https://doi.org/10.1002/eat.22152
Morgan, J. F., Lazarova, S., Schelhase, M., & Saeidi, S. (2014). Ten
session body image therapy: Efficacy of a manualised body
image therapy. European Eating Disorders Review,22(1), 6671.
https://doi.org/10.1002/erv.2249
Muthen, L., & Muthen, B. (1998). Mplus User's Guide (7th ed.). Los
Angeles, California: Muthen & Muthen.
Raykov, T., & Marcoulides, G. A. (1999). On desirability of parsi-
mony in structural equation model selection. Structural
Equation Modeling: A Multidisciplinary Journal,6(3), 292300.
https://doi.org/10.1080/1070551990954013
Sala, M., & Levinson, C. A. (2017). A longitudinal study on the asso-
ciation between facets of mindfulness and disinhibited eating.
Mindfulness,8(4), 893902. https://doi.org/10.1007/s12671016
06630
Satorra, A., & Bentler, P. M. (2001). A scaled difference chisquare
test statistic for moment structure analysis. Psychometrika,
66(4), 507514. https://doi.org/10.1007/BF02296192
Satorra, A., & Bentler, P. M. (2010). Ensuring positiveness of the
scaled difference chisquare test statistic. Psychometrika,75(2),
243248. https://doi.org/10.1007/s113360099135y
Spillane, N. S., Boerner, L. M., Anderson, K. G., & Smith, G. T.
(2004). Comparability of the eating disorder inventory2
between women and men. Assessment,11(1), 8593. https://
doi.org/10.1177/1073191103260623
Steiger, J. H., & Lind, J. C. (1980). Statistically based tests for the
number of common factors (pp. 424453). Iowa City, IA.
Steinglass, J., & Walsh, B. T. (2006). Habit learning and anorexia
nervosa: A cognitive neuroscience hypothesis. International
Journal of Eating Disorders,39(4), 267275. https://doi.org/
10.1002/eat.20244
Stice, E., Fisher, M., & Martinez, E. (2004). Eating disorder diagnos-
tic scale: Additional evidence of reliability and validity.
Psychological Assessment,16(1), 6071. https://doi.org/10.1037/
10403590.16.1.60
Stice, E., Telch, C. F., & Rizvi, S. L. (2000). Development and valida-
tion of the eating disorder diagnostic scale: A brief selfreport
measure of anorexia, bulimia, and bingeeating disorder. Psycho-
logical Assessment,12(2), 123131. https://doi.org/10.1037//
10403590.12.2.123
Tak, S. R., Hendrieckx, C., Nefs, G., Nyklíček, I., Speight, J., &
Pouwer, F. (2015). The association between types of eating
behaviour and dispositional mindfulness in adults with diabetes.
Results from Diabetes MILES. Appetite,87, 288295. https://doi.
org/10.1016/j.appet.2015.01.006
Thiel, A., & Paul, T. (2006). Testretest reliability of the eating disor-
der inventory 2. Journal of Psychosomatic Research,61(4),
567569. https://doi.org/10.1016/j.jpsychores.2006.02.015
Tucker, L. R., & Lewis, C. (1973). A reliability coefficient for maxi-
mum likelihood factor analysis. Psychometrika,38,110. https://
doi.org/10.1007/BF02291170
WandenBerghe, R. G., SanzValero, J., & WandenBerghe, C.
(2010). The application of mindfulness to eating disorders treat-
ment: A systematic review. Eating Disorders,19(1), 3448.
https://doi.org/10.1080/10640266.2011.533604
How to cite this article: Sala M, Vanzhula IA,
Levinson CA. A longitudinal study on the
association between facets of mindfulness and
eating disorder symptoms in individuals diagnosed
with eating disorders. Eur Eat Disorders Rev.
2018;111. https://doi.org/10.1002/erv.2657
SALA ET AL.11
... Group (n = 18) and idiographic (n = 1) networks were calculated using intensive longitudinal data (i.e., 784 data points per person; 14,112 total data points). Based on previous longitudinal research in ED samples (Sala et al., 2019;Sala & Levinson, 2017), we hypothesized that, at the group level, present-moment awareness, acceptance, and nonjudgment would be negatively associated with ED behaviors in a given moment (contemporaneously) and across time (temporally). Given that EDs are highly heterogenous , we also hypothesized that, at the idiographic level, there would be a high degree of variability between individuals in the associations between present-moment awareness, acceptance, and nonjudgment, and ED behaviors. ...
... We found that in the contemporaneous network, mindfulness facets were associated differentially with specific ED behaviors. Present-moment awareness was negatively associated with eating small meals, which is in line with research showing that present-moment awareness negatively predicts drive for thinness among individuals with EDs (Sala et al., 2019). This builds on prior research as we were able to examine state (rather than trait) mindfulness. ...
Article
Full-text available
Objectives Mindfulness has been proposed as a potential intervention for eating disorders (EDs). However, a better understanding of the relationships between state mindfulness and restrictive ED symptoms for those with anorexia nervosa and atypical anorexia nervosa (AN-spectrum) is needed to design effective mindfulness-based interventions. Additionally, individualized longitudinal modeling of state mindfulness and ED behaviors could inform development of personalized mindfulness-based interventions for those with AN-spectrum disorders. Methods Participants (n = 18; 784 data points per participant; 14,112 data points) with AN-spectrum disorders completed four daily ecological momentary assessments of ED behaviors, nonjudgment, acceptance, and present-moment awareness for 14 days. Contemporaneous and temporal group-level and idiographic (i.e., one-person, individual) networks were calculated to identify associations among mindfulness variables and ED behaviors. Results In contemporaneous networks (i.e., within a single timepoint), present-moment awareness was negatively associated with eating small meals but positively associated with avoiding foods due to anxiety. Acceptance was positively associated with eating small meals. In temporal networks, nonjudgment was negatively associated with following eating rules and avoiding foods due to anxiety, whereas acceptance negatively predicted restriction prospectively. Idiographic networks were heterogenous; state mindfulness facets demonstrated positive and negative associations with ED behaviors depending on the individual. Conclusions At the group level, state mindfulness tends to relate to lower engagement in restrictive ED behaviors over time. High heterogeneity in individual networks illustrates the need for personalized assessment of relationships between state mindfulness and ED behaviors. These types of methodologies can lead to the development of personalized mindfulness-based interventions for those with AN-spectrum disorders. Preregistration This study is not preregistered.
... When suffering with ED's, individuals engage in behaviors perpetuating disembodiment including greater self-judgment and self-observing (Leppanen et al., 2022). Emerging research suggests the success of mindfulness and embodiment focused interventions for the prevention and treatment of ED's (Borden & Cook-Cottone, 2020;Cook-Cottone, 2020;Estey et al., 2022;Lattimore et al., 2017;Perey & Cook-Cottone, 2020;Sala et al., 2019). On a journey towards positive embodiment, yoga serves as a path for developing mind-body connection, interoceptive awareness, and mindful self-care (Cook-Cottone, 2020). ...
Article
Objective: This study evaluated the acceptability and effectiveness of the Eat Breathe ThriveTM (EBT) program as an eating disorder prevention intervention among women collegiate athletes. Method: Change over time in eating disorder risk and competencies of positive embodiment were examined in 94 women (n = 48 EBT participants and n = 46 matched-controls) from one National Collegiate Athletic Association (NCAA) Division I-classified university in the United States. Eating disorder risk factors were measured using the Eating Disorder Examination Questionnaire (EDE-Q) and State Trait Anxiety Inventory (STAI). Aspects of positive embodiment were measured using the Multidimensional Assessment of Interoceptive Awareness (MAIA) and The Mindful Self-Care Scale (MSCS). Data were collected through participants’ completion of online surveys across three time-points. Results: Repeated measures ANOVAS revealed EBT participants reported experiencing significantly less state anxiety and greater interoceptive body trusting over time relative to matched-controls. No other significant interactions were found. Respondents found the EBT program acceptable. Discussion: Acceptability and partial support for integrative, yoga-based, interventions targeting Division I student-athletes is indicated.
... In a Dutch general population, emotional eating was significantly and negatively associated with depression and this relationship was mediated by acting with awareness [16]. Interestingly, higher levels of observing predicted greater emotional eating in some studies [7,34,35]. ...
Article
Full-text available
PurposeEmotional eating is common in bariatric surgery candidates, and often is associated with depression and poorer weight loss outcomes following surgery. However, less is known about other modifiable risk factors that may link depression and emotional eating. The aim of the current study was to examine facets of mindfulness as potential mediators of the relationship between emotional eating and depression severity in bariatric surgery candidates.Methods Bariatric surgery candidates (n = 743) were referred by their surgeons for a comprehensive psychiatric pre-surgical evaluation that included self-report questionnaires assessing depression severity, emotional overeating, and facets of mindfulness. Mediation effects were examined for each mindfulness facet based on prior research.ResultsOnly the nonjudging mindfulness facet significantly mediated the relationship between emotional eating and depression, suggesting that greater emotional eating may be associated with greater depression severity through higher levels of judgement towards thoughts and emotions. A reverse mediation analysis showed that depression severity was not a significant mediator of the relationship between nonjudging and emotional eating.Conclusion Fostering a nonjudgmental stance towards thoughts and feelings may be helpful in improving eating habits that would support greater post-surgical success. Other clinical and research implications are discussed.Level of evidenceLevel V, descriptive study.
... In a Dutch general population, emotional eating was signi cantly and negatively associated with depression and this relationship was mediated by acting with awareness [16]. Interestingly, higher levels of observing predicted greater emotional eating in some studies [7,32,33]. ...
Preprint
Full-text available
Purpose: Emotional eating is common in bariatric surgery candidates, and often is associated with depression and poorer weight loss outcomes following surgery. However, less is known about other modifiable risk factors that may link depression and emotional eating. The aim of the current study was to examine facets of mindfulness as potential mediators of the relationship between emotional eating and depression severity in bariatric surgery candidates. Methods: Bariatric surgery candidates (n=743) were referred by their surgeons for a comprehensive psychiatric presurgical evaluation that included self-report questionnaires assessing depression severity, emotional overeating, and facets of mindfulness. Mediation effects were examined for each mindfulness facet based on prior research. Results: Only the nonjudging mindfulness facet significantly mediated the relationship between emotional eating and depression, suggesting that greater emotional eating may be associated with greater depression severity through higher levels of judgement towards thoughts and emotions. A reverse mediation analysis showed that depression severity was not a significant mediator of the relationship between nonjudging and emotional eating. Conclusion: Fostering a nonjudgmental stance towards thoughts and feelings may be helpful in improving eating habits that would support greater postsurgical success. Other clinical and research implications are discussed. Level of Evidence: Level V, descriptive study
... En la literatura reciente donde se han aplicado este tipo de programas en mujeres con TCA, se ha demostrado que, al potenciar la actitud consciente, se producían cambios en la ingesta emocional. En la misma línea, las conclusiones arrojaban información sobre que, a mayores puntuaciones en actitud consciente, no reactividad, observación y aceptación, menor enjuiciamiento, niveles más bajos de crítica interna, mejoras en sintomatología ansioso/depresiva y reducción de la ingesta incontrolada y emocional y, por tanto, de los atracones; es decir, trabajando mindfulness y mindful eating se reducía la sintomatología propia del TCA y mejoraban variables clínicas asociadas a estos trastornos (Cura, 2020;Sala et al., 2018). ...
Article
Introducción. A las personas con un trastorno de la conducta alimentaria (TCA) les resulta complicado sentir o reconocer señales corporales, ya que presentan un bloqueo emocional acompañado de pensamientos obsesivos entorno al peso, comida y cuerpo. Objetivo. Describir en un grupo de mujeres con un TCA las variables conciencia y disociación corporales, actitud consciente, no enjuiciamiento, restricción cognitiva, sintomatología ansioso/depresiva y estilos de ingesta, relacionar esas variables entre sí y, por último, analizar si existen diferencias con un grupo de población general. Método. Estudio descriptivo de carácter transversal. Se realizó un muestreo incidental y participaron 31 mujeres diagnosticadas de TCA con una media de 30,32 años (DT=11,19) y 66 mujeres de la población general con características sociodemográficas equivalentes a las participantes del grupo de pacientes, donde la media de edad fue de 28,97 años (DT=9,75). Para la evaluación se emplearon los cuestionarios DASS-21, FFMQ-E, TFEQ-R18, DEBQ, SBC y un cuestionario sociodemográfico elaborado Ad-hoc. Resultados. Existen diferencias significativas entre el grupo de TCA y el grupo de población general en las variables ingesta incontrolada (p=,003), dieta restrictiva (p=,001), comer emocional (p=,001) y comer externo (p=,001). Conclusiones. Los resultados sugieren la relevancia de incluir intervenciones centradas en el mindful eating en estas pacientes.
... Nonreactivity helps individuals become unattached to emotional experiences when experiencing distress (Lavender et al., 2011), leading to decreasing the possibility of using ED symptoms to regulate emotions. Higher acting with awareness may enable individuals to recognize potential triggers to eating problems (Sala et al., 2018) and lower their behavioral automaticity, which for individuals may result in lower eating problems (Levin et al., 2014). Similar to acting with awareness, higher nonjudging levels may promote accepting thoughts and feelings about one's body and food without acting upon them by engaging in disordered eating behaviors (Sala et al., 2020). ...
Article
Full-text available
Previous research has shown a negative association between mindfulness and its facets and eating problems. Few studies have examined the mechanism involved between them. As an important cognitive factor of eating problems, self-objectification may be a mediating variable in the prediction of eating problems as they relate to mindfulness. We examined the relation between mindfulness and its facets and eating problems using an ambulatory assessment and follow-up test as well as the mediating effect of self-objectification. A total of 106 college students were recruited to complete the full study. State mindfulness, state self-objectification, and eating problems in daily life were measured by an ambulatory assessment. Trait self-objectification and overall eating problems were measured at a two-month follow-up. For the ambulatory assessment, state mindfulness and five facets of mindfulness could not predict eating problems at the next moment in daily life, and there was no mediating effect of state self-objectification. For the longitudinal survey, acting with awareness, as a facet of mindfulness, can predict eating problems. Trait self-objectification mediated the relationship between acting with awareness and overall eating problems. The findings indicate that the association between mindfulness and eating problems mainly occurs at the trait level.
... In order to target these difficulties, the use of non-conventional treatments, such as those based on new technologies, could be considered. In this line, different approaches have been adopted in ED and GD with the aim of improving ER, such as the use of serious videogames (Fernandez-Aranda et al., 2015;Lorenzetti et al., 2018;Mena-Moreno et al., 2019;T arrega et al., 2015), mobile applications (Beck, 2017), or mindfulness (Plaza, Demarzo, Herrera-Mercadal, & Garc ıa-Campayo, 2013;Sala et al., 2018). ...
Article
Full-text available
Background and aims: Difficulties in Emotion Regulation (ER) are related to the etiology and maintenance of several psychological disorders, including Eating Disorders (ED) and Gambling Disorder (GD). This study explored the existence of latent empirical groups between both disorders, based on ER difficulties and considering a set of indicators of personality traits, the severity of the disorder, and psychopathological distress. Methods: The sample included 1,288 female and male participants, diagnosed with ED (n = 906) and GD (n = 382). Two-step clustering was used for the empirical classification, while analysis of variance and chi-square tests were used for the comparison between the latent groups. Results: Three empirical groups were identified, from the most disturbed ER profile (Subgroup 1) to the most functional (Subgroup 3). The ER state showed a linear relationship with the severity of each disorder and the psychopathological state. Different personality traits were found to be related to the level of emotion dysregulation. Discussion and conclusion: In this study, three distinct empirical groups based on ER were identified across ED and GD, suggesting that ER is a transdiagnostic construct. These findings may lead to the development of common treatment strategies and more tailored approaches.
Article
Full-text available
Após os tratamentos para perda de grandes montantes de peso, é recorrente a insatisfação com a imagem corporal e a falta de reconhecimento do próprio corpo. Estes fatores constituem elementos de estudo devido às dificuldades encontradas na manutenção dos resultados, em longo prazo, também no tratamento cirúrgico da obesidade. A falta de identidade com a nova forma e a insatisfação com a imagem corporal têm sido apontadas como fatores mantenedores dos maus hábitos alimentares e do comer emocional que leva à recidiva do peso. Neste sentido, foi suscitado o interesse em saber se: Teriam as pequenas intervenções do tipo mindfulness a capacidade de melhorar a imagem corporal e favorecer o reconhecimento das distorções corporais, para então prevenir a recidiva de peso em pacientes submetidos a cirurgias bariátricas? O presente artigo tem como objetivo averiguar a aplicabilidade das pequenas estratégias meditativas do tipo mindfulness na prevenção da recidiva de peso em pacientes bariátricos. O método apresentado é um relato de caso através de 12 encontros, em regime semanal, com uma cliente do sexo feminino, 48 anos de idade, IMC pré-operatório de 42 Kg/m2 e IMC pós-operatório de 21,67 Kg/m2. Os temas dos encontros foram: psicoeducação sobre a cirurgia bariátrica, abordagem familiar, avaliação e psicoeducação acerca dos padrões cognitivos, avaliação da imagem corporal e da identidade corporal através de composição de fotografias. Os demais encontros foram distribuídos entre as pequenas práticas de mindfulness: respiração, movimento, comer com atenção plena e varredura corporal. As práticas demonstraram eficácia na diminuição da discrepância entre a percepção subjetiva interna do corpo (interocepção) e a imagem corporal (exterocepção). Houve experiência positiva do corpo fora das exigências estéticas, alcance de maior identidade com a forma corporal, saída do padrão perfeccionista e melhora avaliativa da forma e tamanho corporais. As pequenas estratégias meditativas do tipo Mindfulness mostraram-se eficazes na terapia cognitivo-comportamental para a prevenção da recidiva de peso em pacientes bariátricos.
Article
Full-text available
After treatments for loss of large amounts of weight, the dissatisfaction with body image and the lack of recognition of the body itself is recurrent. These factors are elements of study due to the difficulties encountered in maintaining the results, in the long term, also in the surgical treatment of obesity. The lack of identity with the new form and dissatisfaction with body image have been pointed out as maintaining factors of poor eating habits and emotional eating that leads to weight recurrence. In this sense, the interest was raised as to whether: Would small mindfulness interventions have the ability to improve body image and favor the recognition of body distortions, in order to prevent weight recurrence in patients undergoing bariatric surgeries? This article aims to investigate the applicability of small mindfulness meditative strategies in the prevention of weight recurrence in bariatric patients. The method presented is a case report through 12 weekly meetings with a female client, 48 years of age, preoperative BMI of 42 Kg/m2 and postoperative BMI of 21.67 Kg/m2. The themes of the meetings were: psychoeducation about bariatric surgery, family approach, evaluation and psychoeducation about cognitive patterns, assessment of body image and body identity through photo composition. The other meetings were distributed among the small practices of mindfulness: breathing, movement, eating with mindfulness and body scanning. The practices demonstrated efficacy in reducing the discrepancy between the internal subjective perception of the body (interoception) and body image (exteroception). There was a positive experience of the body outside the aesthetic requirements, achievement of greater identity with body shape, exit from the perfectionist pattern and evaluation improvement of body shape and size. The small mindfulness-like meditative strategies have been shown to be effective in cognitive behavioral therapy for the prevention of weight recurrence in bariatric patients.
Article
Higher trait mindfulness may be protective against eating disorder (ED) pathology. However, little is understood about which specific mindfulness processes connect to specific ED symptoms. This study (N = 1,056 undergraduates) used network analysis at the symptom/process level to identify: (1) central nodes, or symptoms/processes with the greatest collective connection with all other symptoms/processes; and (2) bridge nodes, or symptoms/processes driving interconnection between mindfulness processes and ED symptoms. We conducted analyses both with and without food- and body-related mindfulness items. Central nodes included: describing how one feels in detail, expressing how one feels in words, and feeling guilty about eating due to shape/weight. Bridge nodes connecting higher mindfulness processes with lower ED symptoms included: the eating disorder symptom, being uncomfortable about others seeing one eat, and the mindfulness process, not criticizing oneself for having irrational/inappropriate emotions. Bridge nodes connecting higher mindfulness processes with higher ED symptoms included: noticing sensations of the body moving when walking and noticing how food/drinks affect thoughts, bodily sensations, and emotions. Findings suggest that future research should explore whether mindfulness-based interventions for EDs may be more effective by targeting mindfulness processes related to describing, expressing, and accepting emotions, accepting discomfort when eating with others, and reducing hyper-focus on and reactivity to food-and-body related sensations.
Article
Full-text available
This article describes the development and validation of a brief self-report scale for diagnosing anorexia nervosa, bulimia nervosa, and binge-eating disorder. Study 1 used a panel of eating-disorder experts and provided evidence for the content validity of this scale. Study 2 used data from female participants with and without eating disorders (N = 367) and suggested that the diagnoses from this scale possessed temporal reliability (mean κ = .80) and criterion validity (with interview diagnoses; mean κ = .83). In support of convergent validity, individuals with eating disorders identified by this scale showed elevations on validated measures of eating disturbances. The overall symptom composite also showed test–retest reliability (r = .87), internal consistency (mean α = .89), and convergent validity with extant eating-pathology scales. Results implied that this scale was reliable and valid in this investigation and that it may be useful for clinical and research applications.
Article
Full-text available
Disinhibited eating (i.e., emotional and external eating), as well as associated features such as binge eating, bulimic symptoms, and eating concern are inversely associated with the mindfulness facets of acting with awareness, observing, and non-reactivity. However, it is unclear whether higher mindfulness is a precursor to lower disinhibited eating behaviors and symptoms or whether lower disinhibited eating behaviors and symptoms are a precursor to higher mindfulness (or both). The current study examined if acting with awareness, non-reactivity, and observing (describing and non-judging were not assessed) prospectively predicted several disinhibited eating features (emotional eating, external eating, bulimic symptoms, binge eating, and eating concern) and vice-versa across 6 months. Young adult women (N = 300) completed measures of these constructs at baseline and 6 months later. Non-reactivity inversely predicted binge eating and bulimic symptoms across 6 months. Observing predicted higher external and emotional eating across 6 months. In the opposite direction, disinhibited eating did not predict observing, non-reactivity, or acting with awareness. Interventions focusing on increasing non-reactivity could be effective in preventing and treating binge eating and bulimic symptoms.
Article
Mindfulness based therapies (MBTs) for eating disorders show potential benefit for outcomes yet evidence is scarce regarding the mechanisms by which they influence remission from symptoms. One way that mindfulness approaches create positive outcomes is through enhancement of emotion regulation skills. Maladaptive emotion regulation is a key psychological feature of all eating disorders. The aim of the current study was to identify facets of emotion regulation involved in the relationship between mindfulness and maladaptive eating behaviours. In three cross-sectional studies, clinical (n=39) and non-clinical (n=137 & 119) female participants completed: 1) the Eating Disorder Inventory (EDI) eating specific scales (drive-for-thinness and bulimia) and the EDI psychological symptom scales (emotion dysregulation and interoceptive deficits); and 2) mindfulness, impulsivity, and emotion regulation questionnaires. In all samples mindfulness was significantly and inversely associated with EDI eating and psychological symptom scales, and impulsivity. In non-clinical samples interoceptive deficits mediated the relationship between mindfulness and EDI eating specific scales. Non-acceptance of emotional experience, a facet of interoceptive awareness, mediated the relationship between mindfulness and eating specific EDI scores. Further investigations could verify relationships identified so that mindfulness based approaches can be optimised to enhance emotion regulation skills in sufferers, and those at-risk, of eating disorders.