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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: DGE‐1645420; NIH, Grant/Award
Number: 5T32DA007261–17
Abstract
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 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
non‐judgmental awareness (Baer, Smith, Hopkins,
Krietemeyer, & Toney, 2006; Kabat‐Zinn, 2006).
Mindfulness‐based interventions are widely used tech-
niques in the treatment of various psychological disor-
ders, including eating disorders (Wanden‐Berghe, Sanz‐
Valero, & Wanden‐Berghe, 2010). However, findings
related to the efficacy of mindfulness‐based interventions
in the treatment of eating disorders are mixed (Hepworth,
2010; Marek, Ben‐Porath, 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 mindfulness‐based treat-
ments for eating disorders.
1.1 |Mindfulness and Eating Disorder
Symptoms in Non‐Clinical 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
anon‐evaluative 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;1–11. © 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 Test‐26 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 non‐clinical 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. non‐clinical samples). Compare, Callus, and Grossi
(2012) found that individuals diagnosed with binge eating
disorder (BED) reported lower acting with awareness,
non‐reactivity, and observing than a non‐clinical sample.
However, no study has compared mindfulness in individ-
uals with anorexia nervosa (AN) and bulimia nervosa
(BN) to non‐clinical 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 non‐reactivity was associated with less
binge eating episodes in individuals diagnosed with
BED but not controls. In three cross‐sectional studies,
Lattimore et al. (2017) found differing patterns of associ-
ations between acting with awareness and non‐reactivity
on the one hand and bulimic symptoms and drive for
thinness on the other hand, in an eating disorder versus
a non‐clinical sample. In the clinical sample, higher act-
ing with awareness and non‐reactivity were associated
with lower drive for thinness but not bulimic symptoms.
In the non‐clinical sample, higher acting with awareness
and non‐reactivity were associated with lower bulimic
symptoms, and only higher non‐reactivity 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 cross‐lagged 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 non‐clinical sample, Sala and Levinson (2017)
2SALA ET AL.
examined the associations between mindfulness and
disinhibited eating and found that non‐reactivity
inversely predicted bulimic symptoms across 6 months
but that bulimic symptoms did not prospectively predict
observing, non‐reactivity, 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, non‐reactivity, 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 cross‐sectional and has been conducted in
non‐clinical 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 non‐reactivity) 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
non‐reactivity 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 non‐reactivity, but higher observing, than
an undergraduate comparison sample and (b) higher
non‐reactivity 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 = 1–868 days; SD = 40.12). Measures at Time
1 were completed after discharge. Seventy‐four 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 self‐reported
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 self‐reported measure used to
diagnose eating disorders, such as AN, BN, and BED.
The EDDS has adequate test–retest 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)
non‐reactivity. 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= 0.73–0.92). 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 Inventory‐2
(Garner, 1991)
The Eating Disorder Inventory‐2 (EDI‐2) is a self‐
reported questionnaire that measures core features asso-
ciated with AN and BN. In the current study, we utilised
the three main EDI‐2 subscales that measure eating dis-
order symptoms: (a) drive for thinness, (b) bulimic symp-
toms, and (c) body dissatisfaction. The EDI‐2 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)
Non‐Clinical
(N= 290)
n(%) Range n(%) Range
Age (M, SD) 25.31 (8.38) 14–59 20.41 (3.22) 17–50
Female 119 (96.0%) 229 (79%)
BMI (M, SD) 21.39 (4.67) 14.92–44.91 25.01(5.65) 16.76–58.90
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 cross‐lagged
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 non‐normal
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 Tucker‐Lewis 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 chi‐square 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 Satorra‐Bentler χ
2
‐differ-
ence test statistic (Bryant & Satorra, 2012; Satorra &
Bentler, 2001; Satorra & Bentler, 2010). Satorra and Bentler
showed that the difference between two mean‐adjusted 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 non‐significant statistic suggests the
more parsimonious model is best (i.e., when comparing
the saturated model and model with non‐significant paths
removed, the model with non‐significant paths removed
would be best; Raykov & Marcoulides, 1999).
Three prospective two‐wave models with all the
mindfulness facets (acting with awareness, observing,
non‐reactivity) 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 t‐test 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 non‐reactivity 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 non‐clinical
samples, there were no significant differences in bulimic
symptoms among the two groups (see Table 2).
SALA ET AL.5
3.2 |Clinical sample zero‐order
correlations
Please see Table 3 for zero‐order 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. Non‐reactivity 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 |Cross‐lagged 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, non‐reactivity, 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 (Satorra–Bentler 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. Non‐reactivity (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 = 0.11–0.84).
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, non‐reactivity, 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 (Satorra‐Bentler 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 Non‐clinical sample
Variable MSDRange MSDRange t
Acting with awareness 23.86 6.49 8–40 25.81 6.39 5–40 −2.83**
Observing 25.45 5.61 12–38 23.57 5.81 2–38 3.09**
Non‐reactivity 18.00 4.79 8–29 18.89 5.31 1–32 −1.61
Bulimia nervosa 15.17 8.14 7–39 14.16 6.07 7–40 1.39
Drive for thinness 23.12 6.84 5–32 21.35 9.29 7–42 2.15*
Body dissatisfaction 42.68 10.39 10–54 30.75 10.80 9–54 10.57**
Note. M: Mean; SD: standard deviation.
*p< .05;
**p< .01.
TABLE 3 Zero‐order 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.Non‐reactivity −.18 −.36** −.41** .45** .22* —
Note:
*p< .05.
**p< .01.
6SALA ET AL.
FIGURE 1 A prospective model of
acting with awareness, non‐reactivity,
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, non‐reactivity,
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 non‐reactivity (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
non‐reactivity (p=0.11). BMI did not predict mindful-
ness or bulimic symptoms (ps = 0.14–0.64).
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, non‐reactivity,
observing, and body dissatisfaction. The initial model
was saturated and therefore had a perfect fit. When
non‐significant 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 (Satorra‐Bentler 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 non‐reactivity
(p=0.20) did not significantly predict body dissatisfac-
tion. Body dissatisfaction did not significantly predict
observing (p=0.38) or non‐reactivity (p=0.32). BMI
did not predict mindfulness (ps = 0.16–0.84).
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 non‐reactivity 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, non‐reactivity,
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
non‐clinical 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 behavioural‐oriented 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 focused‐attention 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 non‐clinical 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 non‐judging 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 self‐reported 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 self‐reported 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
mindfulness‐based therapy, which could have affected
their scores on mindfulness facets. Future research
should test if these findings generalise beyond a
treatment‐seeking 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 1‐month follow‐up period. Future
research should test if these findings hold with longer
term follow‐up 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 non‐reactivity 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 5T32DA007261–17 NIH.
Margarita Sala is supported by the National Science
Foundation Graduate Research Fellowship under Grant
No. DGE‐1645420. 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
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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;1–11. https://doi.org/10.1002/erv.2657
SALA ET AL.11