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Mindfulness Meditation as an Intervention for Body Image and Weight Management in College Women

Permanent Link: http://ufdc.ufl.edu/UFE0021905/00001

Material Information

Title: Mindfulness Meditation as an Intervention for Body Image and Weight Management in College Women A Pilot Study
Physical Description: 1 online resource (98 p.)
Language: english
Creator: Blevins, Natalie
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: meditation, mindfulness, obesity, treatment, women
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Behavioral weight loss treatment is a well-established and highly effective intervention for many overweight individuals seeking to lose weight. Some overweight individuals enter weight loss treatment programs to improve their body image as well as to lose weight. Changes in body weight, however, have been shown to be unrelated to changes in body image suggesting that weight loss alone is not sufficient for alleviating body image concerns. Mindfulness, a meditation-based therapeutic process emphasizing a nonjudgmental, self-accepting attitude, has been shown to be an effective intervention across a wide range of clinical syndromes and populations, but has never been examined as an intervention for body image and weight management in young women. Our study used a randomized design to test the effectiveness of a mindfulness-based intervention in combination with a behavioral weight loss treatment protocol on changes in body image, psychological well-being, eating behavior, and weight. Forty-one women aged 18 to 25 with a BMI between 25 and 35 were randomized into one of two conditions: standard behavioral treatment or standard behavioral treatment plus mindfulness. The study consisted of an 8-week intervention phase and a 3-month follow-up phase. Twenty-three participants (56%) completed pre-treatment, post-treatment, and follow-up assessment. The primary outcome measure was body image satisfaction. Secondary outcomes included self-esteem, depressive symptoms, anxiety, binge eating, and weight. Participants in both conditions showed improvements. Specifically, body image satisfaction improved significantly from baseline to post-treatment (p < .001) and showed marginal, but nonsignificant, improvement from baseline to follow-up (p = .053). Self-esteem, depressive symptoms, and anxiety also improved from baseline to post-treatment (all p?s < .005) and from baseline to follow-up (all p?s < .008). Binge eating showed nonsignificant improvement from baseline to post-treatment (p = .08) and significant improvement from baseline to follow-up (p = .009). Weight decreased from baseline to post-treatment (p = .03) and from baseline to follow-up (p = .002). Neither condition regained any weight on average at the 3-month follow-up. Contrary to prediction, standard treatment plus mindfulness did not produce greater improvements than standard treatment alone. Further study of mindfulness-based interventions utilizing a larger sample size and longer follow-up is warranted.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Natalie Blevins.
Thesis: Thesis (Ph.D.)--University of Florida, 2008.
Local: Adviser: Frank, Robert G.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0021905:00001

Permanent Link: http://ufdc.ufl.edu/UFE0021905/00001

Material Information

Title: Mindfulness Meditation as an Intervention for Body Image and Weight Management in College Women A Pilot Study
Physical Description: 1 online resource (98 p.)
Language: english
Creator: Blevins, Natalie
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: meditation, mindfulness, obesity, treatment, women
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Behavioral weight loss treatment is a well-established and highly effective intervention for many overweight individuals seeking to lose weight. Some overweight individuals enter weight loss treatment programs to improve their body image as well as to lose weight. Changes in body weight, however, have been shown to be unrelated to changes in body image suggesting that weight loss alone is not sufficient for alleviating body image concerns. Mindfulness, a meditation-based therapeutic process emphasizing a nonjudgmental, self-accepting attitude, has been shown to be an effective intervention across a wide range of clinical syndromes and populations, but has never been examined as an intervention for body image and weight management in young women. Our study used a randomized design to test the effectiveness of a mindfulness-based intervention in combination with a behavioral weight loss treatment protocol on changes in body image, psychological well-being, eating behavior, and weight. Forty-one women aged 18 to 25 with a BMI between 25 and 35 were randomized into one of two conditions: standard behavioral treatment or standard behavioral treatment plus mindfulness. The study consisted of an 8-week intervention phase and a 3-month follow-up phase. Twenty-three participants (56%) completed pre-treatment, post-treatment, and follow-up assessment. The primary outcome measure was body image satisfaction. Secondary outcomes included self-esteem, depressive symptoms, anxiety, binge eating, and weight. Participants in both conditions showed improvements. Specifically, body image satisfaction improved significantly from baseline to post-treatment (p < .001) and showed marginal, but nonsignificant, improvement from baseline to follow-up (p = .053). Self-esteem, depressive symptoms, and anxiety also improved from baseline to post-treatment (all p?s < .005) and from baseline to follow-up (all p?s < .008). Binge eating showed nonsignificant improvement from baseline to post-treatment (p = .08) and significant improvement from baseline to follow-up (p = .009). Weight decreased from baseline to post-treatment (p = .03) and from baseline to follow-up (p = .002). Neither condition regained any weight on average at the 3-month follow-up. Contrary to prediction, standard treatment plus mindfulness did not produce greater improvements than standard treatment alone. Further study of mindfulness-based interventions utilizing a larger sample size and longer follow-up is warranted.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Natalie Blevins.
Thesis: Thesis (Ph.D.)--University of Florida, 2008.
Local: Adviser: Frank, Robert G.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0021905:00001


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MINDFULNESS MEDITATION AS AN INTERVENTION FOR BODY IMAGE AND
WEIGHT MANAGEMENT IN COLLEGE WOMEN: A PILOT STUDY























By

NATALIE CHRISTINE BLEVINS


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2008


































2008 Natalie Christine Blevins




































To my parents









ACKNOWLEDGMENTS

I thank my committee chair, Dr. Robert Frank, for his continued support, mentorship, and

friendship over the years. I thank my committee members, Dr. Mike Perri, Dr. Dave Janicke,

and Dr. Christy Lemak, for their support and guidance. I thank my parents, Jerry and Diane

Blevins, for their understanding and encouragement, and for instilling in me the qualities of

persistence and determination. I thank my fiance, Franco Dattilo, for his patience and

understanding, for his unwavering support, and for believing in me.









TABLE OF CONTENTS

page

A CK N O W LED G M EN T S ................................................................. ........... ............. .....

LIST O F TA BLE S ............................................................................................. .............

LIST OF FIGURES .................................. .. ..... ..... ................. .8

A B S T R A C T ......... ....................... .................. .......................... ................ .. 9

CHAPTER

1 LITERA TURE REVIEW ........................................................... ..... ............. ..11

Introdu action ......................................................................................... .. ..............11
Body Im age Disturbance ................................. .. .. ................. ........ 12
B ody D dissatisfaction ................ ...... ........ .................................. .... .. ................ 13
Etiological Models of Body Dissatisfaction and Maladaptive Eating .............................14
O b esity ............. .......... ............ .... ... ......................... ...................... ..... 16
Physical and Psychological Consequences of Obesity........ ...............................17
Obesity Prevention and Early Intervention ........................................ ............... 19
T he "Freshm an Fifteen" ........................................................................ ....................20
B behavioral Treatm ent of O besity............................................................................. ...... 21
The "M maintenance Problem ............. ................ ........... ....................... ................ 22
Empirical Support for Addressing Psychological Factors in Behavioral Treatment ......24
M indfulness M meditation ................. ........ .................... ................ ............... 27
Mindfulness as a Clinical Intervention...................... ..... .......................... 28
Mechanisms of Change in Mindfulness .......................................................... 31
Mindfulness versus Traditional Cognitive Therapy ................................................33
Empirical Support for Mindfulness-Based Interventions..........................................34
Mindfulness as a Treatment for Body Image and Eating Issues ...................................36
Study Justification and Prim ary Aim s ............................................................................38

2 M E T H O D ..........................................................................4 0

P articip an ts .........................................................................4 0
P ro c e d u re .............. .... ...............................................................4 0
Intervention.........................................41
M measures ........................................................................................................................... 43
Height, Weight, and Demographic Information.....................................43
B o d y Im a g e ..............................................................................4 3
P psychological Functioning ...........................................................44
Eating B behavior ................................................ 45
M in d fu ln e ss .......................................................................................................4 5









3 R E S U L T S ......................................................................................................................... 4 8

P articip an ts .........................................................................4 8
B a selin e A n aly se s .............................................................................................. .......... 5 0
Post-Treatm ent and Follow -U p A nalyses................................................................... ......50
B o d y Im a g e ..............................................................................5 1
Psychological Functioning ........................................... ................................. 51
Eating B behavior ................................................ 52
W e ig h t .........................................................................5 3
M indfulness ....................................................................................................54
Dependent Variable Pearson Correlations .................................................................... 55
Treatment Completers versus Treatment Adherers ................................. ..........56
Treatment Fidelity Check and Program Evaluation ........................................ .....57
Stu dy H y p oth eses .............................................................................57

4 D IS C U S S IO N ........................................................................................................7 4

LIST OF REFERENCES ..................................................................... .........85

B IO G R A PH IC A L SK E T C H ................................................................................................... 98


































6









LIST OF TABLES


Table page

2-1 Study session matrix ............... ................. ............ ........................... 47

3-1 Demographic and other characteristics of enrolled participants ........................................59

3-2 Baseline data for study starters in each treatment condition ..............................................60

3-3 Baseline values for study completers versus noncompleters.................... ...............61

3-4 Baseline data for study completers in each treatment condition ........................................62

3-5 Primary and secondary outcome measures at pre-treatment, post-treatment, and follow-
up for each treatm ent condition .............................................................. .....................63

3-6 Interaction and main effects for primary and secondary outcome measures .......................64

3-7 Significant improvements as a result of study treatments............................................... 65

3-8 Correlation matrix of changes in study variables from baseline to post-treatment
collapsed across conditions............................................................... ......66









LIST OF FIGURES


Figure page

3-1 Study enrollm ent and retention...................................................................... ...................67

3-2 Changes in MBSRQ-Body Areas Satisfaction Scale (BASS) scores over time by
c o n d itio n ........................................................................6 8

3-3 Changes in Rosenberg Self-Esteem Scale (RSES) scores over time by condition ................69

3-4 Changes in Beck Depression Inventory (BDI) scores over time by condition.....................70

3-5 Changes in State-Trait Anxiety Inventory-Trait subscale (STAI-T) scores over time by
co n d itio n .................................................................................7 1

3-6 Weight in kilograms over time by condition.................... .......... ....................72

3-7 B M I over tim e by condition ......................................................................... ....................73









Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

MINDFULNESS MEDITATION AS AN INTERVENTION FOR BODY IMAGE AND
WEIGHT MANAGEMENT IN COLLEGE WOMEN: A PILOT STUDY

By

Natalie Christine Blevins

August 2008

Chair: Robert G. Frank
Major: Psychology

Behavioral weight loss treatment is a well-established and highly effective intervention for

many overweight individuals seeking to lose weight. Some overweight individuals enter weight

loss treatment programs to improve their body image as well as to lose weight. Changes in body

weight, however, have been shown to be unrelated to changes in body image suggesting that

weight loss alone is not sufficient for alleviating body image concerns. Mindfulness, a

meditation-based therapeutic process emphasizing a nonjudgmental, self-accepting attitude, has

been shown to be an effective intervention across a wide range of clinical syndromes and

populations, but has never been examined as an intervention for body image and weight

management in young women. Our study used a randomized design to test the effectiveness of a

mindfulness-based intervention in combination with a behavioral weight loss treatment protocol

on changes in body image, psychological well-being, eating behavior, and weight.

Forty-one women aged 18 to 25 with a BMI between 25 and 35 were randomized into one

of two conditions: standard behavioral treatment or standard behavioral treatment plus

mindfulness. The study consisted of an 8-week intervention phase and a 3-month follow-up

phase. Twenty-three participants (56%) completed pre-treatment, post-treatment, and follow-up

assessment. The primary outcome measure was body image satisfaction. Secondary outcomes









included self-esteem, depressive symptoms, anxiety, binge eating, and weight. Participants in

both conditions showed improvements. Specifically, body image satisfaction improved

significantly from baseline to post-treatment (p < .001) and showed marginal, but nonsignificant,

improvement from baseline to follow-up (p = .053). Self-esteem, depressive symptoms, and

anxiety also improved from baseline to post-treatment (all p's < .005) and from baseline to

follow-up (all p's < .008). Binge eating showed nonsignificant improvement from baseline to

post-treatment (p = .08) and significant improvement from baseline to follow-up (p = .009).

Weight decreased from baseline to post-treatment (p = .03) and from baseline to follow-up (p =

.002). Neither condition regained any weight on average at the 3-month follow-up. Contrary to

prediction, standard treatment plus mindfulness did not produce greater improvements than

standard treatment alone. Further study of mindfulness-based interventions utilizing a larger

sample size and longer follow-up is warranted.









CHAPTER 1
LITERATURE REVIEW

Introduction

Interest in the construct of mindfulness and its clinical use has increased in recent years.

Mindfulness, a meditation-based therapeutic strategy emphasizing a nonjudgmental, self-

accepting attitude, has been used in stand-alone interventions for anxiety and depression (e.g.,

Kabat-Zinn, 1990; Segal, Williams, & Teasdale, 2002), and as a component of integrative

treatment approaches for borderline personality disorder and substance abuse (e.g., Linehan,

1993; Marlatt & Gordon, 1985). Mindfulness training has also been shown to be effective in

reducing the number of binge eating episodes in a group of obese women (Kristeller & Hallett,

1999). This suggests that mindfulness may be a helpful component in the treatment of binge

eating disorder and obesity.

In the United States, millions of women struggle with issues related to eating, weight, and

body image. It has been estimated that 80% of young women are dissatisfied with their

appearance and an estimated 40 to 50% are trying to lose weight at any point in time, spending

over $40 billion on diet-related products each year (Smolak, Levine, & Streigel-Moore, 1996).

In a survey of college women, it was found that 91% had attempted to control their weight

through dieting, and 22% reported dieting "often" or "always" (Kurth, Krahn, & Nairn, 1995).

Clinically, it has been suggested that approximately 35% of "normal dieters" will likely begin to

use pathological eating behaviors (e.g., extremely restrictive caloric intake, overexercising,

binging and purging, or excessive overeating). And, of those, 20 to 25% will likely progress to

partial or full-syndrome eating disorders (i.e., anorexia nervosa, bulimia nervosa, or binge eating

disorder; Shisslak, Crago, & Estes, 1995). Thus, disturbances of body image, eating, and weight

are significant clinical issues for young women in American society.









The empirical literature increasingly supports the efficacy of mindfulness-based

interventions and symptom reduction has been reported across a wide range of populations and

disorders (Baer, 2003; Baer & Krietemeyer, 2006; Bishop, Lau, Shaprio, Carlson, & Anderson,

2004; Roemer & Orsillo, 2003), but a mindfulness-based approach to enhance body image and

weight management in young women has never been tested.

Prior to describing several evidence-based interventions using mindfulness, the issues and

implications of body image disturbance and maladaptive eating in young women will be

reviewed. Next, the issues associated with being overweight or obese and the necessity of

establishing effective weight management interventions in this population will be addressed.

Then, the potential utility of mindfulness as an intervention for the issues presented will be

reviewed. Finally, a study designed to assess the effectiveness of a mindfulness-based

intervention on body image, eating behavior, and weight management in young women will be

described.

Body Image Disturbance

Body image disturbance is a multidimensional construct consisting of subjective, affective,

cognitive, behavioral, and perceptual processes (Thompson, Heinberg, Altabe, & Tantleff-Dunn,

1999). The affective component consists of feeling upset, distressed, or anxious about one's

appearance. The cognitive component may include the maintenance of an unrealistic expectation

for one's appearance (e.g., the desire to look like a runway fashion model) or the belief that

being thin brings happiness. Examples of the behavioral component include avoiding situations

that draw body scrutiny, such as going to the beach, changing clothes in a locker room, or

working out at a fitness facility.









Body Dissatisfaction

Body dissatisfaction is widely recognized as the most important global measure of body

image disturbance (Thompson et al., 1999). Cash (2002) describes body dissatisfaction as

including two core features: evaluation (i.e., the level of satisfaction with one's appearance) and

investment (i.e., the psychological importance one places on appearance). These may be applied

to one's general appearance or to a specific physical characteristic or feature (including body

weight and shape).

The construct is derived from the notion of self-ideal discrepancy that a person's physical

self-evaluations are based on the subjective congruence between his or her perceived physical

attributes and the set of internalized standards that he or she holds about physical appearance.

Body satisfaction, in turn, will depend on the extent to which the individual believes that his or

her physical characteristics match his or her ideals, and the importance placed on achieving those

ideals.

Body dissatisfaction has been linked to low self-esteem, anxiety, and depression (e.g.,

Cash & Fleming, 2002; Fabian & Thompson, 1989; Keeton, Cash & Brown, 1990; Noles, Cash,

& Winstead, 1985; Powell & Hendricks, 1999; Thompson & Psaltis, 1988). Studies have also

linked body dissatisfaction to maladaptive eating behavior (e.g., Anton, Perri, & Riley, 2000;

Cash & Deagle, 1997; Ricciardelli, Tate, & Williams, 1997; Riva, Marchi, & Molinari, 2000;

Stice, 2002; Stice & Agras, 1998). Indeed, body dissatisfaction has received the greatest

empirical support as a precursor to eating pathology in the general population (Thompson et al.,

1999) and among college women (Cash & Syzmanski, 1995). In a structural modeling analysis,

Riva et al. (2000), found evidence for a causal link between body dissatisfaction and restrained

eating (i.e., chronic dieting). Similarly, results from a study by Ricciardelli et al. (1997) show

that body dissatisfaction served as a mediator between dietary restraint and bulimic patterns of









eating in a sample of college women, suggesting the importance of body dissatisfaction as a

predictor of binge eating. This is clinically relevant because binge eating can lead to significant

weight gain, thus contributing to the cycle of maladaptive eating and psychological pathology.

Etiological Models of Body Dissatisfaction and Maladaptive Eating

Several researchers have investigated the role of environment in the etiology and

maintenance of body dissatisfaction and maladaptive eating (Anderson-Fye & Becker, 2004;

Heinberg, 1996; Thompson et al., 1999). Societal preference toward a thin and fit physique has

led to a societal preoccupation with dieting and weight loss. This preoccupation seems to be

particularly profound in college women. The mechanisms by which sociocultural factors aid in

the development of maladaptive eating behavior in women have been proposed by two models:

(1) the tripartite influence model (Thompson et al., 1999; van den Berg, Thompson, Obremski-

Brandon, & Coovert, 2002) and (2) the dual-pathway model (Stice, 2001; Stice, Nemeroff, &

Shaw, 1996).

The tripartite influence model proposes that peers, parents, and media have a direct impact

on body dissatisfaction. They are also thought to affect body dissatisfaction indirectly, through

two mediational processes: the internalization of societal standards of appearance and excessive

appearance comparison. Body dissatisfaction is hypothesized to have a direct effect on

restrictive eating, which has an effect on bulimic behaviors. This model has received support

with both adult and adolescent female samples (e.g., Keery, van den Berg, & Thompson, 2004;

van den Berg et al., 2002).

The dual-pathway model proposes that body dissatisfaction and bulimic behavior are

linked through two pathways. First is the pathway of dietary restraint and second is the pathway

of negative affect. In the first pathway, body dissatisfaction results in dietary restraint (i.e. eating

less than desired) as a means of weight control. In the second pathway, body dissatisfaction









leads to negative or dysregulated emotions and binge/purge behavior. Bingeing (alone, or in

conjunction with purging) has been hypothesized as a means of coping for individuals with poor

emotion regulation and distress tolerance skills (Heatherton & Baumeister, 1991). Both models

propose that sociocultural pressures to be thin and internalization of the thin-ideal, which is the

extent to which one "buys into" societal standards of appearance and weight both cognitively and

behaviorally (Thompson & Stice, 2001), contribute to pathological eating by fostering the

development of body dissatisfaction. Body dissatisfaction, in turn, is hypothesized to foster

overly restrictive dieting, disordered eating symptoms, and negative affect because the ideal is

nearly impossible for the average female to attain (Heinberg, 1996; Stice, 2001; Thompson et al.,

1999).

Cross-sectional, structural equation modeling studies on undergraduate women have found

broad support for both the tripartite model (van den Berg et al., 2002) and the dual-pathway

model (Stice et al., 1996). Stice (2001) also found support for the dual-pathway model in a

twenty-month prospective study of adolescent girls using random regression growth curve

models. Specifically, Stice (2001) found evidence that initial levels of perceived pressure to be

thin and thin-ideal internalization predicted increases in body dissatisfaction over time. The

results of this study also support the hypothesis that initial levels of body dissatisfaction predict

subsequent increases in dietary restriction and negative affect. Initial levels of negative affect

and dietary restriction prospectively predicted binge eating, and the relationship between body

dissatisfaction and bulimic symptoms was completely mediated by dieting and negative affect.

Collectively, these findings support the theoretical assertion that body dissatisfaction, overly

restrictive dieting, and negative affect can promote the onset of pathological eating behavior.









Obesity

Obesity is characterized by excessive weight (i.e., 20 to 25% above normal for age and

height) and defined as a body mass index (BMI) greater than 30.0 (Devlin, Yanovski, & Wilson,

2000; Flegal, Carroll, Kuczmarski, & Johnson, 1998; World Health Organization, 1998). BMI is

standardized by age and height and is calculated using weight (in kilograms) divided by height

(in meters) squared (Field, Barnoya, & Colditz, 2002). Overweight is defined as a BMI between

25.0 and 29.9 (Devlin et al., 2000; Flegal et al., 1998; World Health Organization, 1998).

Obesity has been conceptualized as a condition with heterogeneous etiology (Brownell &

Wadden, 1992; Devlin et al., 2000). At the most basic level, it arises when an individual

consumes more energy, in the form of food, than is expended (Stein et al., 2000). While this

simple equation inevitably results in weight gain, the factors that lead to this energy imbalance

are multifaceted and complex. A combination of behavioral and biological variables, including

physical inactivity, excessive caloric intake, high fat diets, low resting metabolic rate, low rates

of fat oxidation, insulin sensitivity, and high fat cell numbers, all contribute to the development

and maintenance of obesity (Brownell & Wadden, 1992; Stein et al., 2000; Tataranni &

Ravussin, 2002).

Despite evidence to suggest that up to 70% of the variance in BMI is attributable to genetic

factors, it has been acknowledged that at least some of the remaining 30% non-genetic variance

could be accounted for by "normal physiological variability within a pathoenvironment"

(Tataranni & Ravussin, 2002, p.61). Proponents of an environmental explanation for obesity

describe modern American society as "toxic," characterized by the widespread availability and

marketing of cheap and quick energy dense foods, high in fat and sugar and low in nutritional

value, and an increasingly sedentary lifestyle coupled with a glorification of thinness and

stigmatization of fatness (Battle & Brownell, 1996; Henderson & Brownell, 2004; Irving &









Neumark-Sztainer, 2002; Wadden, Brownell, & Foster, 2002). As Battle and Brownell (1996)

note, "it is difficult to envision an environment more effective than ours for producing nearly

universal body dissatisfaction, preoccupation with eating and weight, and clinical cases of eating

disorders and obesity (p. 761)."

Physical and Psychological Consequences of Obesity

The impact of overweight and obesity on physical health is substantial. Obesity-related

medical conditions include heart disease, stroke, hypertension, hyperlipidemia, gallbladder

disease, osteoarthritis, certain types of cancer, and sleep apnea (Centers for Disease Control

[CDC], 2006). The impact of obesity on life expectancy varies according to level of BMI.

When BMI reaches 30.0, the risk of death is elevated by 30%, and when BMI reaches 40.0, risk

of death becomes 100% higher than for a normal weight person (Manson et al., 1995).

Premature death in obese persons is most often associated with cardiovascular disease, Type 2

diabetes, and some cancers (National Heart, Lung, and Blood Institute [NHLBI], 1998).

Approximately 300,000 deaths per year are related to complications of obesity (Allison,

Fontaine, Manson, Stevens, & Vanltallie, 1999).

In addition to its adverse impact on health and longevity, obesity significantly

compromises psychological functioning and quality of life (Wadden, Womble, Stunkard, &

Anderson, 2002). One study found approximately 16% of a community sample of obese

individuals met criteria for major depressive disorder, compared to 7.5% among normal weight

individuals (Roberts, Kaplan, Shema, & Strawbridge, 2000). Obese persons have been found to

experience prejudice and discrimination in work, school, and interpersonal situations (Puhl &

Brownell, 2002). Consequences of obesity appear to be far worse for women, due to the greater

societal importance placed on appearance in women than in men. One study, for example, found









higher rates of depression and increased risk for suicide in obese women, but not obese men

(Carpenter, Hasin, Allison, & Faith, 2000).

Among obese women seeking treatment for weight loss, depressive symptoms are also

related to body image distress and low self-esteem (Foster, Wadden, & Vogt, 1997; Sarwer,

Wadden, & Foster, 1998). Additionally, a subset of obese women (approximately 8%) report

extreme body dissatisfaction causing clinically significant impairment or distress in social, work-

related, or other areas of functioning (Sarwer et al., 1998). For the majority of overweight

women seeking treatment, body image distress appears to play a significant role in their

motivation to pursue weight loss (Sarwer, Grossbart, & Didie, 2001). Collectively, these

findings suggest that obesity in women can be associated with adverse psychological

consequences such as body dissatisfaction, depression, and low self-esteem.

Overweight and obese women are also more likely to engage in sub-clinical levels of binge

eating (Marcus, 1993) and unhealthy weight control practices (i.e., diet pills, laxatives, diuretics;

Neumark-Sztainer, Story, Faulkner, Beuhring, & Resnick, 1999). Binge eating consists of

consuming unusually large amounts of food, usually high in fat, without the use of compensatory

behaviors such as exercise, purging, or fasting (American Psychiatric Association [APA], 2000).

Other criteria include feeling a lack of control over eating, marked distress and guilt over

bingeing, and secretive eating (Kristeller & Hallett, 1999). Obese binge eaters typically report

greater levels of dysphoria than obese non-bingers (de Zwaan et al., 1994; Wadden, Foster,

Letizia, & Wilk, 1993), have a more perfectionist attitude toward dieting, and report constantly

struggling to control their urges to eat (Gormally, Black, Daston, & Rardin, 1982). Individuals

who binge also have been shown to have a decreased awareness of their hunger and satiety,









which is critical for the regulation of food intake and maintenance of weight (Hadigan, Walsh,

Devlin, LaChaussee, & Kissileff, 1992; Hetherington & Rolls, 1989).

Overweight and obesity prevalence rates are increasing at an alarming pace in the U.S.

(Henderson & Brownell, 2004). Data from the 1999-2002 National Health and Nutrition

Examination Survey (NHANES) conducted by the CDC indicate an estimated 65% of American

adults are either overweight or obese. Overweight and obesity are now considered a major

public health problem, and according to the U.S. Department of Health and Human Services, a

study of national costs attributed to overweight and obesity found that medical expenses

accounted for 9.1% of total U.S. medical expenditures in 1998 and may have reached as high as

$78.5 billion (Finkelstein, Fiebelkom, and Wang, 2003).

Obesity Prevention and Early Intervention

Obesity prevention has become an important public health focus (U.S. Department of

Health and Human Services, 2001; Koplan & Deitz, 1999). One prevention strategy proposed is

to identify critical periods of weight gain across the life span and create targeted interventions for

those at-risk populations (Anderson, Shapiro, & Lundgren, 2003; Levitsky, Halbmaier, &

Mrdjenovic, 2004; Mullis et al., 2004). While weight gain in adulthood is usually a very slow

process, caused by small changes in energy balance (i.e., intake exceeds output) over time, there

is one segment of the population that may be particularly at risk for a large change in energy

balance in a relatively short period of time. The transition from high school to college is

associated with many lifestyle changes that can lead to weight gain, including "all-you-can-eat"

buffet style dining halls, increased availability of fast food and "junk" food, and increased

consumption of alcohol, all of which have been linked to weight gain in college freshmen

(Levitsky, Halbmaier, & Mrdjenovic, 2004). Another study found weight increases in a sample

of college freshmen, with 25% of participants gaining at least 2.3 kg (5.1 lbs) during the first









semester of college (Anderson, Shapiro, & Lundgren, 2003). These researchers found that the

proportion of participants classified as overweight or obese nearly doubled over the first two

semesters of college, highlighting the importance of addressing the issue of weight maintenance

in this population.

The "Freshman Fifteen"

As previously discussed, many college women are preoccupied with thinness and exhibit a

high level of concern about weight and body image. The "Freshman Fifteen," a belief that

college freshmen gain 15 pounds during their first year on campus, may serve to elevate this

level of concern (Graham & Jones, 2002). Although the "Freshman Fifteen" is commonly

believed to be true, there is evidence that the concept may be more myth than fact (Hodge,

Jackson, & Sullivan, 1993; Megel, Wade, Hawkins, Norton, & Sandstrom, 1994). Hodge et al.

(1993) surveyed a sample of college women and found that the majority did not change weight in

the first six months of college. Those women who did gain weight, however, gained an average

of seven pounds. In another sample of college women, Megel et al. (1994) found that the

average weight gain over the freshman year was only two and a half pounds.

Regardless of whether college women gain 15 pounds or five pounds, preoccupation with

body weight in this population has been linked to increased levels of self-degradation and body

dissatisfaction (Britton, Martz, Bazzinin, Curtin, & LeaShomb, 2006) and maladaptive eating

behavior (Ackard, Croll, & Keamey-Cooke, 2001). As young women leave the home

environment for college, they are challenged with the responsibility of balancing exercise,

nutritional intake, and body weight in a culture that equates thinness with attractiveness. Food

consumption patterns of college students are of particular concern because the tendency is to skip

meals, follow overly restrictive diets, eat more "fast" foods, and snack on high-fat, sugary "junk"

foods. Psychological health risks associated with poor nutritional practices include diminished









self-esteem and body dissatisfaction. Based on the dual-pathway model previously presented,

body dissatisfaction in this population can lead to excessive dietary restraint and negative affect,

which can potentially lead to binge eating and weight gain. Collectively, these findings support

the need for an effective weight management and body image intervention targeted for this

population.

Behavioral Treatment of Obesity

In contrast to evidence supporting the dual pathway model, results from experimental

studies of behavioral weight loss programs have not found dietary restraint to be a key factor in

the development of binge eating and other pathological eating behavior. The National Task

Force on the Prevention and Treatment of Obesity (2000) has stated, "concerns that dieting

induces eating disorders or other psychological dysfunction in overweight and obese adults are

generally not supported [and] such concerns should not preclude attempts to reduce caloric intake

and increase physical activity to achieve modest weight loss or prevent additional weight gain"

(p. 2587). Studies of overweight and obese individuals placed on low-calorie diets in controlled

trials have not shown subsequent increases in binge eating (Porzelius, Houston, Smith, Arfkin, &

Fisher, 1995; Wadden, Foster, & Letizia, 1994; Wadden et al., 2004). Furthermore, studies on

obese individuals with binge eating disorder found significant decreases in binging over the

course of behavioral weight loss treatments (Marcus, Wing, & Fairbum, 1995; Porzelius et al.,

1995). Presnell and Stice (2003) replicated these findings in a non-obese sample of young adult

women who were randomly assigned to a six-week, low calorie, behavioral weight loss treatment

or a waitlist control group.

Participants in behavioral interventions learn strategies to help modify their eating and

physical activity patterns, so as to produce a negative energy balance and subsequent weight loss.

The key components of a behavioral program include decreased energy intake (i.e., 1200-1500









kcals/day and < 30% kcals of total/day from fats for women) and increased physical activity

(e.g., energy expenditure > 1000 kcals/ week). The behavioral treatment procedures used to

achieve changes in diet and exercise patterns typically include self-monitoring, problem-solving,

goal setting, and relapse prevention. Reviews of randomized trials have consistently

demonstrated that a 15- to 26-week behavioral intervention produces an average of 8.5 kg weight

loss, approximately 9% of body weight (NHLBI, 1998; Perri & Corsica, 2002).

The ability of weight loss treatments to produce clinically meaningful outcomes has been

well-established and weight loss through diet and exercise is still considered the principle and

most effective method to improve health (NHLBI, 1998). Nevertheless, proponents of what has

been called an "anti-dieting" movement contend that dieting is actually ineffective and harmful.

This argument stems from the well-established finding that dieting is ineffective in producing

long-term weight loss (Garner & Wooley, 1991; Kassirer & Angell, 1998; Miller, 1999; Perri &

Corsica, 2002; Wadden, 1993). Miller (1999) states that "all review articles on the effectiveness

of diet and exercise for weight control over the past 40 years have concluded that diet and

exercise are ineffective in producing substantial long-term weight loss for the majority of

participants" (p.212). Indeed, dieters usually end up weighing more, not less, after a diet.

The "Maintenance Problem"

Perri (1998) has proposed that "the maintenance of treatment effects represents the single

greatest challenge in the long-term management of obesity" (p. 526). Poor maintenance of

weight loss likely results from a combination of physiological, environmental, and psychological

factors. Cooper and Fairbum (2001) have offered a cognitive-behavioral explanation with regard

to the "maintenance problem." They suggest two sets of interrelated factors are responsible for a

person's inability to maintain lost weight. First, overweight individuals present for treatment

with "primary goals" (p. 503) for weight loss that include improving appearance or body









satisfaction, improving attractiveness to others, improving self-confidence and self-esteem,

improving interpersonal relationships, and to a lesser extent, improving health and mobility. At

the end of treatment, body weight is not likely to match the individual's expectation (Foster,

Wadden, Vogt, & Brewer, 1997; Wadden et al., 2003) and the perceived benefits such as

improved attractiveness, self-esteem, and interpersonal relationships typically have not been

achieved (Cooper & Fairbum, 2001). Having reached neither their weight loss goals, nor the

anticipated benefits, participants minimize the significance of their modest weight loss, and

abandon their weight loss efforts. The second reason overweight persons are unable to maintain

weight loss, according to Cooper and Fairburn, is that they do not receive training in the

maintenance of lost weight. For example, participants are not taught how to follow a weight

maintenance diet as opposed to a weight loss diet. Furthermore, they undervalue or discount the

weight loss that they have achieved during treatment, and they are unable to consider or accept

weight maintenance as a worthwhile goal.

In a study of weight maintenance and relapse in obesity, Bryne, Cooper, and Fairbum

(2003) identified several behavioral, cognitive, and affective factors that were found to

discriminate between individuals who were successful in maintaining lost weight and those who

were not. They identified three groups of individuals. "Maintainers" were women with a history

of obesity who, through deliberate caloric restriction, had lost at least 10% of their body weight

in the previous two years and had maintained that weight within 3.2 kg (7.1 lbs) for at least one

year. "Regainers" were women who had lost at least 10% of their body weight in the previous

two years, but had regained weight to within 3.2 kg (7.1 lbs) of their original body weight. The

stable weight group consisted of women without a history of obesity who had maintained a

healthy weight (within a range of 3.2 kg or 7.1 lbs) for at least two years.









In terms of behavior, "Regainers" were less likely to report adherence to a low-fat diet,

regular exercise, and weight monitoring than "Maintainers." In terms of cognitive and affective

factors, "Regainers" were less likely than "Maintainers" to have achieved their goal weights, and

expressed dissatisfaction with their new lower weight. Finally, "Regainers" were found to place

greater importance on weight and shape evaluation and ate in response to negative moods and

adverse events more often than "Maintainers." These results suggest that weight regain may be

due, in part, to unaddressed psychological factors and an inability to self-regulate which

undermines weight control efforts, and that weight management interventions should be designed

to address issues of body acceptance, self-esteem, self-regulation and coping.

Empirical Support for Addressing Psychological Factors in Behavioral Treatment

The studies summarized below all attempted to address psychological factors in

overweight or obese samples seeking to lose weight. These studies emphasized weight

maintenance, size acceptance, and healthy eating, and several of these interventions utilized a

"nondieting" approach in which weight loss through dietary restriction was not the primary

method of treatment.

In a study by Rapoport, Clark, and Wardle (2000), women who focused on self-acceptance

and permanent lifestyle change were successful in achieving modest improvements in body

image dissatisfaction and self-acceptance, but only lost approximately 2 kg (4.4 lbs).

A study comparing a nondieting treatment versus dieting treatment for overweight binge-

eating women showed that the nondieting intervention aimed at helping women manage

psychological issues related to binge eating was not successful in producing short or long-term

weight loss (Goodrick, Poston, Kimball, Reeves, & Foreyt, 1998).

Tanco and colleagues (1998) conducted an 8-week intervention comparing a nondieting

treatment in which participants were simply given instruction on healthy eating against a









behavioral treatment in which participants were instructed to consume 1,200 to 1,500

kCalories/day. Greater improvements in mood and in some measures of eating-related pathology

were seen in the nondieting group compared to the standard group and a wait-list control. Both

treatment groups lost only modest amounts of weight (1.8 kg [3.9 lbs] and 2.6 kg [5.7 lbs],

respectively).

Sbrocco and colleagues (1999) compared a traditional behavioral treatment program using

a 1,200 kCals/day diet against a "behavioral choice" program coupled with a moderately

restricted diet of 1,800 kCals/day. After the 13-week treatment, both groups experienced

significant increases in self-esteem and the behavioral choice group showed a significant

decrease in dietary restraint. The traditional group experienced greater weight loss (5.6 kg [12.3

lbs] vs. 2.5 kg [5.5 lbs]) post-treatment, but after a year, the behavioral choice group had

continued to lose weight (10.1 kg [22.3 lbs] mean weight loss at 1-year follow-up), whereas the

traditional group had actually gained weight (4.3 kg [9.5 lbs] mean weight loss at 1-year follow

up).

Allen and Craighead (1999) compared an 8-week appetite awareness treatment focusing on

responding to moderate signals of hunger and satiety against a wait-list control. At the end of

treatment, the appetite awareness group showed significant improvements in binge eating, self-

esteem, and depression. Neither group showed any significant changes in weight.

Ames et al. (2005) compared a 10-session "reformulated cognitive-behavioral"

intervention designed to address unrealistic expectations and motivations for weight loss against

a standard behavioral weight loss program. At post-treatment, the cognitive-behavioral

intervention produced more realistic weight loss expectations and increased overall self-esteem.









Mean post-treatment weight changes were equivalent across conditions, as were the amounts of

weight regained during a 6-month follow-up.

Notably, none of these trials revealed significant differential results in terms of lost weight.

When successful weight loss over time did occur, the amounts reported fell short of the threshold

for significant health benefits in moderately overweight individuals. However, in each study

there were moderate to significant improvements in various measures of psychological well-

being. These findings generally support the notion that a weight loss intervention designed to

address some of the psychological components of weight loss, as well as the behavioral, may be

more effective in the successful maintenance of lost weight and in the continued improvement of

body image.

Successful long-term weight loss interventions involve two key components. First, a

weight loss of at least 5% of initial body weight is necessary. The can only be achieved through

a negative energy balance (i.e., reduced energy intake and increased energy expenditure). Well-

established behavioral weight loss protocols exist to guide this process (Wing, 2002). However,

weight loss efforts will be partially, if not completely, undermined if the second key component

is not present addressing the psychological issues associated with the weight loss process and

the factors contributing to the maintenance of overweight and obesity.

While behavioral weight loss protocols have been clearly established, parallel standards

addressing interventions for psychological factors in weight loss and weight maintenance remain

a topic of debate. A mindfulness-based intervention may provide an effective treatment

component to improve the efficacy of many well-established interventions. The rationale for

using this type of treatment adjunct will be presented in the following sections.









Mindfulness Meditation

Mindfulness is defined as "the awareness that emerges through paying attention on

purpose, in the present moment, and nonjudgmentally" (Kabat-Zinn, 2003, p. 145). Mindfulness

has been considered "an enhanced attention to and awareness of current experience or present

reality" (Brown & Ryan, 2003, p. 822). Awareness is considered the "background" of

consciousness, or the continual monitoring of internal and external stimuli; attention is the

process of bringing one's conscious awareness into focus. A defining feature of mindfulness is

an "open" or "receptive" awareness and attention, making mindfulness essentially an enhanced

state of focused consciousness. This is in contrast to consciousness that is restricted or divided.

Rumination on the past, for example, or anxiety about the future can pull one's awareness and

attention from the present moment. When one is occupied with multiple tasks or preoccupied

with various concerns, the quality of engagement in the present moment is also likely to be

compromised. Mindfulness is further compromised when individuals act impulsively or

compulsively, without awareness of or attention to one's behavior (Deci & Ryan, 1980), thereby

setting the stage for the potential utility of mindfulness training as a therapeutic or wellness

intervention.

The ability to direct one's awareness and attention in an "open" or "receptive" way is often

developed through meditative practices. Meditation is defined as the intentional self-regulation

of attention from moment to moment (Goleman & Schwarz, 1976; Kabat-Zinn, 1982). While

meditation is often simplistically represented as a "relaxation" technique, it appears to be better

construed as a means for promoting self-awareness and self-regulation, for decreasing emotional

reactivity, and for enhancing insight and integration of perceptual, cognitive, and behavioral

aspects of functioning (Kristeller, 2003). Thus, training in mindfulness meditation may allow for









enhanced self-awareness and insight, and may help modify dysregulated emotional, cognitive,

physiological, and behavioral aspects of functioning (Kristeller & Hallett, 1999).

In sum, mindfulness captures a quality of consciousness characterized by receptive

awareness, clear focus, and the nonjudgmental observation of current experience, both internally

and externally. It stands in contrast to mindless habitual or automatic functioning that can be

chronic and dysfunctional for some individuals. Mindfulness, then, may play an important role

in disengaging individuals from destructive automatic thoughts and unhealthy behavior patterns,

and in fostering self-enhanced emotional and behavioral regulation associated with psychological

wellness (Ryan & Deci, 2000). Indeed, the empirical literature to date on the effects of

mindfulness training suggests that mindfulness interventions may lead to reductions in a variety

of problematic medical and psychological conditions, including chronic pain, stress, anxiety,

depressive relapse, and disordered eating (e.g., Kabat-Zinn, 1982; Kabat-Zinn et al., 1992;

Kristeller & Hallett, 1999; Shapiro, Schwartz, & Bonner, 1998; Teasdale et al., 2000). Several

of these interventions will be reviewed in the next section.

Mindfulness as a Clinical Intervention

Jon Kabat-Zinn, founder of the Center for Mindfulness in Medicine, Health Care, and

Society (CFM) at the University of Massachusetts, developed a mindfulness-based stress

reduction (MBSR) program for use in behavioral medicine settings with chronic pain patients

and others with stress-related disorders. Kabat-Zinn's protocol utilizes a group format offered

over eight to ten weeks. The group offers instruction and practice in mindfulness meditation

skills. These include a 45-minute body scan of sensations, breathing exercises, yoga postures

and stretching, and the practice of mindfulness during activities like walking, standing, and

eating. Participants are instructed to practice these skills between sessions for at least 45 minutes

per day, six days a week. During mindfulness exercises, participants are instructed to focus their









attention on the target of observation (e.g., breathing) and to be aware of it in each moment.

When emotions, sensations, or cognitions arise, they are to be observed nonjudgmentally.

Participants are instructed to notice their thoughts and feelings, but not become absorbed in their

content or try to avoid them or change them (Kabat-Zinn, 1982). Even judgmental thoughts,

such as "this is a foolish waste of time," are to be observed nonjudgmentally and labeled simply

as "thoughts." Attention is then returned to the present moment and the target of observation.

Thus, an important teaching component of mindfulness practice is the realization that most

sensations, thoughts, and emotions, including painful ones, are transient and temporary (Linehan,

1993).

Teasdale, Segal, and Williams (1995) proposed that the skills of attentional control taught

in mindfulness meditation could be helpful in preventing relapse of major depressive episodes

and developed mindfulness-based cognitive therapy (MBCT) based upon this assertion. MBCT

is an 8-week group intervention incorporating elements of cognitive therapy that facilitate a

detached view of one's thoughts, emotions, and bodily sensations. MBCT is designed to prevent

depressive relapse by teaching formerly depressed individuals how to observe their thoughts and

feelings nonjudgmentally, to view them simply as thoughts that come and go, rather than aspects

of themselves, or as accurate reflections of reality (Baer, 2003). This is believed to prevent the

escalation of negative thoughts into ruminative patterns characteristic of major depressive

episodes (Teasdale et al., 1995).

Several other treatment models are congruent with mindful approaches to symptom

reduction. For example, dialectical behavior therapy (DBT) is a comprehensive approach used

most often in the treatment of borderline personality disorder (Linehan, 1993), and recently

adapted for use in the treatment of bulimia nervosa (Safer, Telch, & Agras, 2001) and binge









eating disorder (Telch, Agras, & Linehan, 2001). It is based on a dialectical worldview, which

assumes that reality consists of opposing forces, or dialectics. In DBT, the central dialectic is the

relationship between acceptance and change. Patients are encouraged to balance acceptance of

who they are with changing their dysfunctional behavior in order to "build a life worth living"

(McCabe, LaVia, & Marcus, 2004, p. 235). In addition to mindfulness skills, DBT clients are

taught interpersonal effectiveness, emotion regulation, and distress tolerance skills.

Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) is another

comprehensive treatment approach that includes several strategies consistent with mindfulness

training. ACT clients learn to experience their thoughts and emotions as they happen, without

evaluating or attempting to change or avoid them, but instead accepting them as they are, while

modifying their maladaptive behaviors in constructive ways to improve their lives (Baer, 2003).

Mindfulness skills have been adapted for use in substance abuse relapse prevention as well

(Marlatt & Gordon, 1985). In this context, mindfulness involves acceptance of the present

moment, which is in direct contrast to addiction an inability to accept the present moment and a

persistent seeking of escape, or the next "high." Mindfulness skills enable the client to observe

their urges as they occur, accept them nonjudgmentally, and cope with them in more adaptive

ways, knowing they will pass.

The notion of using meditation in clinical interventions was originally pioneered by

Herbert Benson (1975), physician and founder of the Mind/Body Medical Institute (M/BMI) at

Harvard University, and the value of meditation in treating stress and anxiety has been widely

supported in the literature (Delmonte, 1987; Eppley, Abrams, & Shear, 1989). Mind/body

interventions conducted at the M/BMI include elements of cognitive-behavioral therapy and

lifestyle modification (i.e., diet and exercise), in addition to meditation skills training. These









interventions have been used successfully in the reduction of medical symptoms and in disease

management protocols for hypertension, heart disease, chronic pain, insomnia, infertility,

menopause, and other conditions with an identifiable stress component.

Benson (1975) has written extensively about mind/body medicine and one of its

fundamental elements, the "relaxation response." The relaxation response is elicited through the

repetition of a word, sound, phrase, or activity, and the passive disregard or avoidance of

distracting thoughts. Clearly, there are similarities between mindfulness training and the

elicitation of the relaxation response as described by Benson (1975). One distinction, however,

is in practicing mindfulness, one does not avoid distracting thoughts. Distracting thoughts are

simply thoughts to be observed and accepted. Another distinction is, that although the induction

of relaxation through meditation has been well-documented (Benson, 1975; Orme-Johnson,

1984; Wallace, Benson, & Wilson, 1984), the purpose of mindfulness training is not to induce

relaxation, but to teach nonjudgmental observation of current experience, which might include

autonomic arousal, racing thoughts, and muscle tension, all of which are incompatible with

relaxation (Baer, 2003). Even so, mindfulness meditation is listed as one of several techniques

used to evoke the relaxation response, thus supporting its role as an effective component in the

practice of mind/body medicine and as a potential mechanism for behavior modification. Other

potential mechanisms of change are presented in the next section.

Mechanisms of Change in Mindfulness

Sustained, nonjudgmental observation of negative sensations such as pain, or negative

emotions such as anxiety, without attempts of escape or avoidance, may lead to reductions in the

emotional reactivity typically elicited by such stimuli (Kabat-Zinn et al., 1992). Linehan (1993)

also suggests that prolonged observation of current thoughts and emotions, without trying to

avoid or escape them, can be seen as a type of exposure, which should encourage the extinction









of fear responses and avoidance behaviors previously elicited by these stimuli. Thus, the

practice of mindfulness skills may improve a patient's ability to tolerate negative emotional

states and the ability to cope with them effectively (Baer, 2003).

It has been noted that the practice of mindfulness may also lead to changes in maladaptive

thought patterns, or in attitudes about one's thoughts. The nonjudgmental observation of

anxiety-producing thoughts, for example, may lead to the understanding that they are "just

thoughts" and do not necessitate escape or avoidance (Kabat-Zinn, 1990). Similarly, Linehan

(1993) notes that observing one's thoughts or feelings and applying nonjudgmental labels to

them encourages the understanding that they are not always accurate reflections of reality.

Kristeller and Hallett (1999), in a study of MBSR in patients with binge eating disorder, cite

Heatherton and Baumeister's (1991) theory of binge eating as an escape from self-awareness and

suggest that mindfulness training might develop nonjudgmental acceptance of the aversive

conditions that binge eaters are thought to be avoiding, such as unfavorable comparisons of self

to others. Teasdale (1999) suggests that mindfulness training may enable formerly depressed

individuals to notice depressogenic thoughts and to redirect attention to other aspects of the

present moment, thus avoiding rumination.

Several authors have noted that improved self-observation resulting from mindfulness

training may promote more effective self-management of behavior and the use of more adaptive

coping skills. For example, Kristeller and Hallett (1999) suggest that the self-observation skills

and awareness of physiological signals developed through mindfulness training may lead to

improved recognition of and response to satiety cues in binge eaters. And, as a means of

improving self-acceptance, it may decrease the use of disordered eating as a coping mechanism

(Heatherton & Baumeister, 1991). Marlatt (1994) suggests the increased ability to observe urges









without yielding to them is important for patients recovering from addictions as well.

Mindfulness training may also help in the reduction of maladaptive impulsive behaviors due to a

heightened recognition and understanding of the consequences of such behavior (Linehan, 1993).

The relationship between acceptance and change has become a central component in the

practice of psychotherapy, and the tenet of some empirically-based treatment methods (e.g.,

ACT, DBT). Hayes (1994) suggests that acceptance involves "experiencing events fully and

without defense, as they are" (p. 30). Acceptance is fundamental in the practice of mindfulness

(Kabat-Zinn, 1990), and the understanding that not all unpleasant experiences need to be

changed. For some individuals, it is more important to learn that unpleasant experiences are

transient and can be managed effectively without escape or avoidance.

Mindfulness versus Traditional Cognitive Therapy

Cognitive interventions traditionally have focused on helping clients change aspects of

their thinking. Similar to the mechanisms of change in traditional cognitive therapy, training in

self-directed attention can result in sustained exposure to sensations, thoughts, and emotions,

resulting in desensitization of conditioned responses and reduction of avoidance behavior. In

addition, cognitive change appears to result from viewing one's thoughts as temporary without

inherent worth or meaning, rather than as necessarily accurate reflections of reality.

In contrast to traditional cognitive therapy, mindfulness training does not include the

evaluation and labeling of thoughts as "irrational" or "distorted," nor does it include the

systematic attempt to change such labeled thoughts. Secondly, traditional cognitive-behavioral

procedures typically have a clear goal, such as to change a behavior or thinking pattern, whereas

mindfulness is practiced with an attitude of what has been called, "nonstriving" (Baer, 2003, p.

130). That is, although participants may have sought treatment for a particular purpose, they are

not taught how to relax, reduce their pain, or change their thoughts or emotions. They are simply









taught to observe whatever is happening in each moment without judging it. Nevertheless,

individuals who practice these skills may indeed experience reductions in a variety of symptoms.

The empirical literature addressing this particular issue is reviewed in the next section.

Empirical Support for Mindfulness-Based Interventions

A meta-analysis (Baer, 2003) of twenty-one studies revealed that mindfulness-based

interventions are clinically efficacious for a variety of populations, including patients with Axis I

disorders (e.g., generalized anxiety disorder, binge eating disorder, major depressive disorder),

patients with medical conditions (e.g., fibromyalgia, psoriasis, cancer), mixed populations, and

nonclinical populations. Sample sizes in these studies ranged from 16 to 142, with a mean age of

participants ranging from 38 to 50 years. The gender ratio ranged from 0 to 46% male. Nine

studies used pre-post designs with no control group; nine used between-group designs with

treatment-as-usual (TAU) or wait-list control groups; three were follow-up studies. Dependent

variables for the majority of these studies included self-report measures of pain and other

medical symptoms, anxiety, depression, eating behaviors, and general psychological functioning.

Post-treatment effect sizes ranged from 0.15 to 1.65, with an overall mean effect size of 0.59,

suggesting mindfulness-based interventions have yielded at least medium-sized effects (Cohen,

1977).

Baer's (2003) review included four studies that examined the effects of mindfulness-based

stress reduction (MBSR) on chronic pain patients (Kabat-Zinn, 1982; Kabat-Zinn, Lipworth, &

Burney, 1985; Kabat-Zinn, Lipworth, Burney, & Sellers, 1987; Randolph, Caldera, Tacone, and

Greak, 1999). In general, findings revealed significant improvements in pain ratings, other

medical symptoms, and general psychological symptoms, and many of these changes were

maintained through a series of follow-up evaluations. Her review included one study by Kabat-

Zinn et al. (1992) that examined a sample of 22 patients with generalized anxiety and panic









disorders, and found significant improvements in several measures of anxiety and depression,

both at post-treatment and at a 3-month follow-up evaluation. Miller, Fletcher, and Kabat-Zinn

(1995) reported results from a 3-year follow-up to that study and found treatment gains had been

maintained. Her review also included a study by Teasdale et al. (2000), which examined the

effects of mindfulness-based cognitive therapy (MBCT) on rates of depressive relapse in a large

sample of patients whose major depressive disorder had remitted after psychopharmaceutical

treatment. In a randomized controlled trial comparing an 8-week manualized group treatment

(MBCT) to treatment-as-usual (TAU), results showed much lower relapse rates for MBCT

patients (37%) than for the TAU patients (66%), in those with three or more previous depressive

episodes. With respect to two studies utilizing a nonclinical sample, both Astin (1997) and

Shapiro et al. (1998) found significant effects on various measures of psychological symptoms in

college and medical students who completed training in MBSR.

Of particular relevance to the issues presented here, Kristeller and Hallett (1999) examined

the efficacy of a 6-week MBSR intervention for binge eating disorder in 18 obese women.

Results from this study, which used a pre-post design, showed statistically significant

improvements in several measures of psychological functioning and eating behavior, including a

significant decrease in the number of binges per week and an increased sense of control.

Baer (2003) provides data on attrition, adherence, and maintenance of mindfulness practice

as reported in these studies. The percentage of enrolled participants who completed treatment

ranged from 60 to 97%, with a mean of 85%. Of the three studies that assessed the extent to

which participants completed their assigned homework, one reported that participants engaged in

15.82 hours of meditation across the 6-week intervention period (Kristeller & Hallett, 1999), one

reported that participants practiced meditation for an average of 30 minutes a day, three and a









half days per week (Astin, 1997), and one reported that 90% of their sample practiced three times

per week or more and 57% practiced nearly every day for 15 to 30 minutes each time (Reibel,

Greeson, Brainard, & Rosenzweig, 2001). Three studies reported the extent to which

participants trained in mindfulness skills continued to practice these skills after treatment ended.

Kabat-Zinn et al. (1987) noted that 75% of former participants reported they still practiced

meditation (averaged across intervals of 6 to 48 months). Kabat-Zinn et al. (1992) found that

84% of former participants reported practicing meditation or yoga three or more times per week

at a 3-month follow-up evaluation. Williams et al. (2001) reported that at a 3-month follow-up,

81% of MBSR participants were still practicing meditation, yoga, or awareness of breathing in

their daily lives.

In sum, Baer's (2003) review suggests that mindfulness-based interventions may indeed be

clinically efficacious, but that better designed studies are needed. It was shown that many

participants who enroll in mindfulness-based programs will likely complete their assigned

homework and maintain mindfulness practice upon completion of the intervention. Mindfulness-

based interventions appear to be conceptually consistent with many other empirically supported

treatment approaches and may provide a technology of acceptance to complement the technology

of change exemplified by most traditional cognitive-behavioral procedures (Linehan, 1993).

Mindfulness as a Treatment for Body Image and Eating Issues

It can be argued that an individual's relationship to food and eating encompasses all major

domains of human functioning: physiological, cognitive, emotional, and behavioral. Food is

necessary for basic physiological functioning and the body contains numerous biofeedback

signals to initiate and terminate eating. While most individuals ignore or override hunger and

satiety signals on occasion, some individuals, especially those with overly restrictive diets or

subclinical eating pathology like compulsive binge eating, appear to be particularly disengaged









from this physiological information (Hetherington & Rolls, 1989; Hadigan et al., 1992). These

individuals also often feel out of control, frustrated, disgusted, and guilty when they overeat

(Kristeller, 2003). Unlike other compulsive behaviors in which abstinence is possible (i.e.,

smoking, alcohol abuse), abstinence from eating is not. Moderation, balance, and flexibility

must be learned, and to the extent that being mindful aids in establishing those skills, training in

mindfulness meditation may be particularly helpful.

In our society, many young women develop unhealthy relationships with their bodies and

food, leading to deeply ingrained maladaptive eating patterns and body image distress. This

powerful interaction can obscure basic nutritional needs, as what one chooses to eat becomes a

function of cognitive directive, emotional self-soothing, or external cues instead of biological or

physiological ones. And, the notion of food as a viable source of pleasure or satisfaction

becomes distorted. Mindfulness skills training may be particularly well-suited for treating such

problems by establishing in-the-moment, non-judgmental self-observation skills that reinforce a

sense of acceptance, balance, and control. Kristeller (2003) has proposed that finding a sense of

balance and acceptance in relation to food and eating may foster a greater capacity for self-

regulation and control, which can then be extended and applied to other areas of conflict in a

person's life. Given the growing body of evidence to suggest that chronic dieters and

compulsive eaters are disengaged from internal self-regulatory systems and overly influenced by

external and emotional cues (Rodin, 1981; Kristeller & Rodin, 1989; Heatherton & Baumeister,

1991), this theory may hold merit. By extension, mindfulness training, based on this theory and

adapted for use in this particular population, coupled with basic behavioral skills for weight

management, could be extremely beneficial.









Study Justification and Primary Aims

The potential efficacy of using mindfulness as an adjunct to standard behavioral treatment

to address issues of body image, psychological functioning, eating behavior, and weight

management seems promising. In light of the issues and the implications presented here, the

need for a targeted and structured intervention for weight management and wellness in college

women is warranted.

Furthermore, because of the increasing popularity of interventions based on training in

mindfulness skills, more methodologically sound investigations have been recommended in

order to clarify the construct, and validate its clinical applicability and effectiveness (Baer, 2003;

Brown & Ryan, 2004; Roemer & Orsillo, 2003; Hayes & Feldman, 2004; Kabat-Zinn, 2003).

To date, there have been no published studies comparing behavioral treatment to

behavioral treatment plus mindfulness training in the context of body image and weight

management in college women, with appropriate experimental control for short- and long-term

effects. This study investigated the differential effectiveness of mindfulness training coupled

with a standard behavioral weight loss treatment protocol in a sample of overweight college

women.

The primary outcome measure was self-reported body image. Secondary outcomes

included various aspects of psychological functioning, eating behavior, and weight. Data were

collected at three time periods: before treatment, after treatment, and at three months post-

treatment. It was predicted that compared to standard treatment alone, standard treatment plus

mindfulness training would produce (1) greater improvement in body image satisfaction ratings

after treatment and at follow-up; (2) greater improvement in self-esteem ratings, depressive

symptoms, and state and trait anxiety after treatment and at follow-up; (3) greater improvement









in binge eating after treatment and at follow-up; and (4) better weight maintenance from the end

of treatment to the end of the follow-up period.









CHAPTER 2
METHOD

Participants

Participants for this study were female students recruited from the University of Florida.

Women eligible for inclusion were between the ages of 18 and 25 and had a Body Mass Index

(BMI) greater than 25. Women were excluded from participation if they were unwilling to

provide informed consent, were currently involved in a commercial diet program, were planning

to relocate out of the area, carried a current or past diagnosis of bulimia nervosa, or had a BMI

greater than 35.

Procedure

Participants were recruited through advertisements placed around campus and through

student website announcements. Prospective participants were invited to learn more about the

study by contacting the research coordinator, at which time the study was described briefly and a

preliminary screening was done. Potentially eligible participants were then invited to attend an

informational meeting. At this meeting, the program was described in more detail, and written

informed consent was obtained. Potential participants were then weighed and height

measurements were taken individually and in private. Participants were also asked to complete

the battery of standardized self-report measures with established psychometric properties.

Individuals who endorsed current symptoms of bulimia nervosa (n = 1) were contacted and

provided with a referral for treatment (e.g., Psychology Clinic at the University of Florida &

Shands Hospital). Individuals with a BMI < 25 (n = 1) were also contacted by telephone and

informed of other available counseling and healthy weight management treatment options.

Enrolled participants were then stratified based on a BMI median split and randomized into one

of two treatment conditions: standard behavioral treatment (SBT) or standard treatment plus









mindfulness (MBT). The randomization scheme was created using an online random sequence

generator.

Intervention

One objective in each treatment condition was to decrease caloric intake, so as to produce a

weight loss of 0.5 lb to 1.0 lb per week. Identical behavioral weight management strategies were

presented to participants in each condition. These strategies were offered in a group format used

in previous studies (Ames et al., 2005; Fuller, Perri, Leermakers, & Guyer, 1998). Participants

in each treatment condition were instructed to follow a low-calorie, low-fat diet (e.g., 1200-1500

kCals/day; 45 to 55% primarily complex carbohydrates; 15% protein; 25% total fat with less

than 7% saturated fat). Participants were taught and encouraged to use goal-setting, self-

monitoring, stimulus control, problem solving, social support, reinforcement strategies, and

relapse prevention skills. A treatment manual was distributed to each participant which

contained session-by-session plans with specific learning objectives, methods to accomplish the

objectives, and appropriate self-monitoring materials. A recommendation of 30 minutes

moderate to high intensity physical activity on at least five days per week was made, in

accordance with the exercise recommendations made by the CDC and the American College of

Sports Medicine (ACSM, 2001; Pate et al., 1995). Participants were encouraged to check with a

physician should they have any concerns about initiating an exercise regimen. They were also

given instruction on proper warm-up, cool-down, and stretching activities, and an opportunity to

present any problems they encountered at the weekly group check-in.

In addition to standard behavioral weight loss strategies, participants in the MBT condition

were also given structured lessons on mindfulness meditation, adapted from the mindfulness-

based stress reduction (MBSR) program developed by Kabat-Zinn (1982). Lessons included

instruction on traditional mindfulness meditation techniques and guided meditation exercises









designed to address specific issues pertaining to weight, shape, and eating-related self-regulatory

processes such as appetite and satiety. The meditative process was gradually integrated into

daily activity primarily related to food craving and eating. A separate treatment manual was

developed and distributed which contained session-by-session plans with specific learning

objectives, methods to accomplish the objectives, and appropriate self-monitoring materials.

In the MBT condition, each group session incorporated meditation practice. Participants

were provided with a recorded meditation CD designed to assist them in their weekly meditation

practice between sessions. "Mini-meditations" were also assigned, in which participants were

asked to stop for a few moments at key times during the day, particularly during meal and snack

times, to practice nonjudgmental awareness of thoughts and feelings. Several sessions also

incorporated mindful body work, including a body awareness scan and introductory mindful

yoga. The study session matrix is presented in Table 2-1.

Both interventions were presented in a group format. Sessions were conducted once a

week for eight weeks. A group in each treatment condition was run on two consecutive

weeknight evenings to minimize conflict with class schedules. Each session lasted

approximately two hours. In the SBT groups, 30 minutes was allocated for check-in, review, and

general problem solving, 30 minutes was allocated for didactic training, and 60 minutes was

allocated for group activity, discussion, and homework assignment. In the MBT groups, 30

minutes was allocated for check-in, another 30 minutes was allocated for didactic training, 15

minutes was allocated for group activity, discussion, and homework assignment, and 45 minutes

was allocated for mindfulness training, group activity, and homework assignment.

The sessions were led by advanced graduate students in clinical and health psychology

with experience in behavioral weight loss treatment. Group leaders were counter-balanced by









treatment condition. Group leaders underwent structured training in mindfulness meditation.

They completed a 6-week training course and weekend retreat led by a University of

Massachusetts Center for Mindfulness in Medicine, Health Care, and Society (CFM) certified

instructor. Group leaders met for weekly session planning and participant management during

the treatment phase.

Measures

Height, Weight, and Demographic Information

Height and weight measurements were taken using a calibrated and certified balance beam

scale and stadiometer. Participants were weighed in indoor clothing, without shoes, and with

pockets emptied. BMI, calculated as: [weight (lb) / height (in) / height (in) x 703], was

determined. Participants were asked to provide demographic data, including age and years of

education, and complete a general information form, which asked about the number of previous

diet attempts and any previous experience with yoga, Pilates, or meditation.

Body Image

The Multidimensional Body-Self Relations Questionnaire Appearance Scales (MBSRQ-

AS; Cash, 1994a) was used to measure general appearance satisfaction and body dissatisfaction

in this study. The MBSRQ-AS is a 34-item measure that consists of 5 subscales: Appearance

Evaluation, Appearance Orientation, Overweight Preoccupation, Self-Classified Weight, and the

Body Areas Satisfaction Scale (BASS). The 8-item MBSRQ-BASS was used to assess trait

levels of body dissatisfaction. The MBSRQ-BASS assesses satisfaction with specific body areas

and features, including stomach, hips, thighs, and muscle tone. Respondents rate their level of

satisfaction on a 5-point scale ranging from (1) "Very Dissatisfied" to (5) "Very Satisfied." Low

scores on this subscale indicate higher body dissatisfaction. The female adult norm is 3.23

(Cash, 1994a). The Appearance Evaluation (MBSRQ-AE) subscale was used to assess general









appearance satisfaction. Respondents rate their level of agreement with statements such as, "I

like my looks just the way they are," or "I am physically unattractive," on a 5-point scale, which

ranges from (1) "Definitely Disagree" to (5) "Definitely Agree." High scores on this measure

indicate increased dissatisfaction with general body image. This measure has demonstrated good

reliability and validity in previous studies (Brown, Cash, & Mikulka, 1990).

Psychological Functioning

The Beck Depression Inventory II (BDI-II; Beck, Steer & Brown, 1996) is a revision of

the BDI, one of the most widely used and well-validated measures of depressive

symptomatology, and was used to assess dysphoria, or moderate symptoms of depression.

Anxiety was measured using the trait scale of the State-Trait Anxiety Inventory Y-2 (STAI;

Spielberger, 1983). The STAI is a 20-item self-report measure that prompts individuals to

indicate their agreement with each item on a 4-point scale ranging from (1) "Not at all" to (4)

"Very much so." Higher scores indicate higher levels of anxiety. Several studies have reported

adequate reliability and validity (Kaplan, Smith, & Coons, 1995; Paolini, Yanez, & Kelly, 2006;

Ray, 1984).

The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) was used to assess global

self-esteem. On this 10-item self-report measure, respondents rate statements such as "On the

whole, I am satisfied with myself" and "I feel that I have a number of good qualities" on a 5-

point scale from (1) "Strongly Disagree" to (5) "Strongly Agree." A higher score indicates

higher self-esteem. Two-week test-retest reliability data revealed a coefficient of .85 (Silber &

Tippett, 1965). Crandal (1973) reports a correlation of .59 with Coopersmith's (1959) Self-

Esteem Inventory, and Silber and Tippett (1965) found a correlation of .83 with the Healthy Self-

Images Questionnaire.









Eating Behavior

The Questionnaire of Eating and Weight Patterns Revised (QEWP-R; Nangle, Johnson,

Carr-Nangle, & Engler, 1994) is a 13-item self-report questionnaire developed to screen for

symptoms of bulimia nervosa and binge eating disorder using American Psychiatric Association

diagnostic criteria (Spitzer et al., 1993). Test-retest reliability has been shown to be stable over a

3-week period, and the QEWP-R reliably identifies high and low probability binge eaters

(Nangle et al., 1994). Participants answered questions designed to assess both behavioral (e.g.,

"During the past 6 months, did you often eat within any two hour period what most people would

regard as an unusually large amount of food?") and affective/cognitive symptoms associated

with a binge episode (e.g., "In general, how upset were you by the feeling that you couldn't stop

eating or control what or how much you were eating?"). In the study, this measure was also used

to screen for bulimic behaviors. Potential participants who endorsed the use of compensatory

means to facilitate weight loss (i.e., purging, laxative abuse) were excluded from participation

and provided with a referral for psychological counseling.

Mindfulness

The Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) is a 15-item

instrument measuring the general tendency to be attentive to and aware of present-moment

experience in daily life. Using a 6-point scale from (1) "Almost Never" to (6) "Almost Always,"

respondents rate how often they have experiences of acting on automatic pilot, being

preoccupied, and not paying attention to the present moment. Items include, "I find myself

doing things without paying attention," and "I break or spill things because of carelessness, not

paying attention, or thinking of something else." The authors report strong internal consistency

(alpha = .82) as well as convergent and divergent validity with other measures of psychological

well-being. This measure had been shown to differentiate between the general public and









experienced Zen Buddhist practitioners, a group presumed to have substantial capacity for

mindfulness (MacKillop & Anderson, 2007). Brown and Ryan (2003) demonstrated that scores

on the MAAS improved over time during an 8-week standardized mindfulness-based stress

reduction program and that changes on the MAAS were related to changes in self-reported well-

being. This measure has been validated in college, working adult, and cancer patient populations

and widely used to capture the acquisition of mindfulness skills in research samples.









Table 2-1. Study session matrix
Session SBT lesson
1 Program introduction,
understanding calories and
weight management,
keeping food records
2 Record review (continues all
sessions), importance of
regular eating patterns,
calculating energy balance
3 Importance of a balanced diet,
taking stock of current food
intake, grains
4 Calculating mealtime and non-
mealtime eating, fruits and
vegetables


5 Understanding the importance
of monitoring dietary fats,
understanding the role of
exercise
6 Understanding the role of
protein & the importance of
dairy, self-reward
7 Social eating, navigating high
risk situations

8 Assessing progress, relapse
Prevention, managing a toxic
environment


MBT lesson
Introduction to
mindfulness


The Four Foundations of
Mindfulness


What kind of mindless
eater are you?

Mindfulness and hunger,
understanding hunger
and satiety cues


Mind-FULLness,
understanding satiety
cues

Understanding satiety
cues (continued)

Understanding eating
Triggers

Progress review


MBT group activity
Raisin meditation



Chocolate meditation



Body scan, Mindful Eating
101

What is Hunger?,
mindfully coping with
emotional eating,
physiological vs.
emotional hunger
Moment-to-moment eating,
mindfulness of
movement, mindful yoga
(optional)
Letting go of your
former/future body,
mindful yoga (optional)
Loving kindness guided
Meditation,
mindful yoga (optional)
Assessing progress,
other meditative
outlets/options/resources


MBT assignment
Keep food and mood journal
(continues all sessions)


Eat one snack and one meal per
day mindfully (continues all
sessions)

Meditate with body scan CD,
keep meditation homework
record (continues all sessions)
Eat when physically hungry




Attend to taste and satisfaction



Stop eating when moderately full


Mini-meditation before meals


Eat all meals and snacks
Mindfully, complete follow-up
evaluation


Note: MBT session material adapted from MB-EAT program (Kristeller & Hallett, 1999)









CHAPTER 3
RESULTS

Participants

One-hundred and ninety-three (193) women were screened for participation in the study.

Twenty-four (24) women were screened by phone and 169 women were screened by email. One

hundred and fifty-two (152) women were excluded from participation during this initial

screening process. Two women were excluded for reporting an out-of-range age, eight were

excluded for reporting an out-of-range BMI, nine were excluded for reporting plans to relocate

out of the area, nine women declined participation due to time constraints, and 124 women chose

not to pursue enrollment after being informed of the study inclusion criteria and treatment

protocol. Following this initial screening, 47 women met eligibility for baseline testing. Forty-

three (43) women attended the informational meeting and baseline testing session. One woman

was excluded for endorsing current symptoms of bulimia and one woman was excluded for not

meeting BMI inclusion criteria. Forty-one (41) women were then stratified based on a BMI

median split and randomly assigned to one of two conditions: standard behavioral treatment

(SBT; n = 20) or standard treatment plus mindfulness (MBT; n =21; Figure 3-1).

The mean age of participants was 20.7 years (SD = 1.4 years). Fifty-one percent (51%)

were in their senior year of college. Seventy-eight percent (78%) reported having attempted to

lose weight through dieting in the past. Nine percent (9%) reported having made more than 20

attempts to lose weight through dieting in the past. Fifty-one percent (51%) were African

American, 32% were Caucasian, 12% were Hispanic, and 5% were Asian American.

Characteristics of the study participants are shown in Table 3-1. Of the 41 women who accepted

randomization, 36 attended the first group session and began treatment. Telephone contacts with

the participants who failed to show for treatment indicated that three women declined further









participation due to time constraints and two women were no longer interested in treatment.

There were no significant differences between the participants who began treatment and those

who did not. Preliminary independent-samples t-tests and chi-square tests were conducted to

determine if there were any significant between-condition differences in baseline variables.

There were no significant differences between conditions on any demographic variable or on any

of the self-report measures. Baseline characteristics for the 36 women who started treatment are

presented in Table 3-2.

This study was divided into two phases, a treatment phase and a follow-up phase. The

treatment phase of the program included an 8-week weight loss program for participants in both

the SBT condition and the MBT condition. Treatment groups in each condition were instructed

on behavioral strategies for weight loss. Treatment groups in the IBT condition only were also

instructed on mindful meditation and mindful eating skills. The follow-up phase of the program

included the three months after treatment in which no direct intervention was delivered.

Completion of the treatment phase was defined as participating in both the baseline testing

session and post-treatment data collection. Thirty-one participants (86%) completed the

treatment phase and entered the follow-up phase of the study. Reasons given for drop-out

included time constraint (n = 2), lost interest (n = 1), relocation (n = 1), or death in the immediate

family (n = 1). The rate of drop-out during the treatment phase was not equivalent across

conditions, X2 (1, N= 36) = 7.3,p < .01. All participants who failed to complete testing at Time

2 were in the SBT condition.

Study completion was defined as participation in all three data collection periods (i.e.,

baseline, post-treatment, and follow-up). Twenty-three of the 31 participants (74%) who entered

the follow-up phase of the program completed testing at Time 3 (Figure 3-1). Again, the rate of









drop-out during the follow-up phase was not equivalent across conditions, X2 (1, N= 31) = 5.9, p

< .02. This time, all participants who failed to complete testing at Time 3 were in the MBT

condition.

Baseline Analyses

Independent-samples t-tests were conducted comparing the baseline characteristics of

study completers (n = 23) and study noncompleters (n = 13). There were no significant

differences between completers and noncompleters on any demographic variable or self-report

measure. Baseline characteristics for the study completers and noncompleters are presented in

Table 3-3.

Independent-samples t-tests were also conducted to compare the baseline characteristics of

MBT (n = 12) and SBT (n = 11) study completers. There were no significant between-condition

differences at baseline on any demographic variable or self-report measure. Baseline

characteristics for study completers by condition are presented in Table 3-4.

Post-Treatment and Follow-Up Analyses

Differences between conditions in changes for each of the primary and secondary outcome

variables at post-treatment and follow-up were assessed using a 3 (Time) x 2 (Treatment) mixed-

model repeated-measures analyses of variance (ANOVA). For significant interaction and main

effects, post hoc analyses were conducted to determine where the differences occurred. Effect

sizes (eta squared) were also calculated to judge the magnitude of significant interaction and

main effects for the primary and secondary outcomes. The results reported here include only

study completers. Means and standard deviations at baseline, post-treatment, and follow-up for

all primary and secondary outcome measures are by condition are presented in Table 3-5.









Body Image

The primary outcome for this study was self-reported body image as measured by the

Multidimensional Body-Self Relations Questionnaire Body Areas Satisfaction Scale (MBSRQ-

BASS). It was predicted that, compared to SBT, the MBT intervention would produce greater

improvement in body image satisfaction ratings after treatment and at follow-up. Participants

did report an increase in body image satisfaction at post-treatment and at follow-up (Figure 3-2).

No time X treatment interaction effect was found, but a significant main effect for time was

observed, Wilks'. = .45, F (2, 20) = 12.29, p < .001, r2 = .55. Bonferroni-corrected post hoc

tests indicated that participants' ratings of body image satisfaction significantly improved from

baseline to post-treatment (M= 3.40, SD = .54, p < .001) and showed marginal, but

nonsignificant, improvement from baseline to follow-up (M= 3.32, SD = .90, p = .053).

It was also predicted that, compared to SBT, the MBT intervention would produce greater

improvement in general appearance satisfaction ratings after treatment and at follow-up. Again,

no significant time X treatment interaction effect was found, but a significant main effect for

time was observed, Wilks' k = .40, F (2, 20) = 15.21,p < .001, r2 = .60. Bonferroni-corrected

post hoc tests indicated that participants' ratings of general appearance satisfaction significantly

improved from baseline to post-treatment (M= 3.53, SD = .58, p < .001) and from baseline to

follow-up (M= 3.46, SD = .54, p < .001).

Psychological Functioning

Secondary outcomes for this study included self-esteem ratings as measured by the

Rosenberg Self-Esteem Scale (RSES), depressive symptoms as measured by the Beck

Depression Inventory (BDI-II), and anxiety ratings as measured by the State-Trait Anxiety

Inventory (STAI). It was predicted that, compared to SBT, the MBT intervention would produce









greater improvement in self-esteem ratings, a greater reduction in depressive symptoms, and a

greater reduction in anxiety after treatment and at follow-up.

No significant time X treatment interaction effects were observed for any of the

psychological functioning secondary outcome measures. A significant main effect for time was

observed for changes in self-esteem ratings, Wilks' = .51, F (2, 20) = 9.82,p = .001, r2 = .50,

depressive symptoms, Wilks' = .41, F (2, 20) = 14.39, p < .001, r2 = .59, state, Wilks' = .32,

F (2, 20) = 21.59, p <.001, r2 = .68, and trait anxiety, Wilks' k = .60, F (2, 20) = 6.75, p = .006,

r2 = .40. Means and standard deviations at baseline, post-treatment, and follow-up are presented

in Table 3-5.

Bonferroni-corrected post hoc examination of the means revealed that participants' report

of self-esteem ratings (Figure 3-3), depressive symptoms (Figure 3-4), and trait anxiety (Figure

3-5) significantly improved from baseline to post-treatment (all p's < .005) and from baseline to

follow-up (all p's <.008).

Eating Behavior

Binge eating was measured by the Questionnaire of Eating and Weight Patterns Revised

(QEWP-R) adapted for use in this sample. It was predicted that, compared to SBT, the MBT

intervention would produce greater improvement in binge eating after treatment and at follow-

up.

Participants reported a reduction in the frequency of binge eating behavior from baseline

(M= 4.52, SD = 4.3) to post-treatment (M= 2.70, SD = 2.9) and follow-up (M= 1.95, SD = 1.9).

No significant time X treatment interaction effect was found, but a significant main effect for

time was observed, Wilks' = .62, F (2, 20) = 6.02,p = .009, r = .38. Bonferroni-corrected

post hoc tests indicated that participants' report of binge eating behavior showed marginal, but









nonsignificant, improvement from baseline to post-treatment (p = .08) and significant

improvement from baseline to follow-up (p = .009).

Weight

It was predicted that, compared to SBT, the MBT intervention would not produce

significantly greater weight loss at the end of treatment, but would produce better weight

maintenance from the end of treatment to follow-up.

Participants lost an average of 1.25 kg (SD = 2.0 kg) at the end of the 8-week treatment

and an average net weight loss from baseline to follow-up of 2.28 kg (SD = 2.7 kg). The average

weight loss by condition was 0.99 kg (SD = 1.3 kg) for the SBT participants and 1.5 kg (SD =

2.5 kg) for the MBT participants at the end of treatment. From the end of treatment to follow-up,

SBT participants lost an additional 1.69 kg (SD = 1.9 kg) for a net weight loss of 2.68 kg (SD =

2.7 kg). MBT participants lost an additional 0.42 kg (SD = 2.4 kg) for a net weight loss of 1.91

kg (SD = 2.7 kg). A significant main effect for time was observed, Wilks' X = .55, F (2, 20) =

8.12, p = .003, 2 = .45, with both conditions demonstrating equivalent reductions. Collapsed

across conditions, Bonferroni-corrected post hoc tests indicated that weight significantly

decreased from baseline to post-treatment (p = .03) and from baseline to follow-up (p = .002).

From the end of treatment to follow-up, participants in the SBT condition increased their average

rate of weight loss from 0.12 kg/wk to 0.14 kg/wk whereas participants in the MBT condition

slowed their average rate of weight loss from 0.19 kg/wk to 0.03 kg/wk. Neither condition had

regained any weight on average three months post-treatment. Independent-samples t-test

revealed no significant between-group differences in mean rate of weight loss during treatment

(p = .56) or follow-up (p = .18). Figure 3-6 shows weight in kg by condition at baseline, post-

treatment, and follow-up.









Similarly for BMI estimates, a significant main effect for time was observed, Wilks' X =

.63, F (2, 20) = 6.00, p = .009, r2 = .38. Collapsed across conditions, Bonferroni-corrected post

hoc tests indicated that BMI estimates significantly decreased from baseline to post-treatment (p

= .03) and from baseline to follow-up (p = .008). The average BMI reduction by condition was

0.44 kg/m2 (SD= .55 kg/m2) for the SBT participants and 0.52 kg/m2 (SD= .99 kg/m2) for the

MBT participants at the end of treatment and 0.68 kg/m2 (SD= .74 kg/m2) for the SBT

participants and 0.08 kg/m2 (SD = 1.2 kg/m2) for the MBT participants from the end of treatment

to follow-up. Figure 3-7 shows BMI by condition at baseline, post-treatment, and follow-up.

Mindfulness

This intervention was designed to teach mindfulness meditation techniques and integrate

these skills into daily activity. In the MBT condition, each session incorporated meditation

practice. Several sessions also incorporated mindful body work, including a body awareness

scan and introductory mindful yoga. Beginning in Week 2, MBT participants were instructed to

eat at least one mindful meal per day. Beginning in Week 3, MBT participants were instructed

to begin formal meditation practice for 45 minutes on at least one day per week between

sessions. Participants were provided with a recorded meditation CD designed to assist them in

their weekly meditation practice. Participants reportedly engaged in 8.3 hours of meditation

across the 6-week intervention period during which weekly practice was assigned. However,

only 25% reported participating in meditation practice outside of group at least one time over the

6-week period, and only one participant completed her meditation assignment every week. Of

those who reported their practice, the number of meditation minutes per week ranged from zero

to 45, with an overall sample average of four minutes a week.









Participants reported somewhat greater success with mindful eating. Participants reported

eating 146 mindful meals over the 7-week intervention period during which the mindful eating

assignment was made. Fifty percent reported eating at least one meal mindfully over the 7-week

period, and 25% reported eating at least two mindful meals every week. The number of mindful

meals reportedly eaten per week ranged from zero to eight, with an overall average of five meals

per week.

Mindfulness was measured using the Mindful Attention Awareness Scale (MAAS). All

participants completed this questionnaire at baseline, post-treatment, and follow-up. According

to the measure's authors, higher scores represent greater mindfulness. In this sample, a

significant main effect for time was observed for changes in mindfulness, Wilks' = .70, F (2,

20) = 4.25,p = .03, r2 = .30. Unexpectedly, both conditions demonstrated significant

improvement in mindfulness scores from baseline to follow-up, even though only half of the

sample received direct training in mindfulness skills.

Dependent Variable Pearson Correlations

To examine the relationships between study variables at the end of treatment, changes in

primary and secondary outcomes and mindfulness from baseline to post-treatment were

correlated. Significant associations were observed for increases in body satisfaction and

increases in general appearance satisfaction (p < .001), self-esteem (p =.001), and mindfulness (p

= .03), as well as reductions in depressive symptoms (p = .009), state (p = .006) and trait anxiety

(p < .001). No significant associations were observed between changes in body satisfaction and

changes in binge eating or weight. Increases in mindfulness were significantly associated with

increases in body satisfaction (p = .03) and self-esteem (p = .006) and decreases in depressive









symptoms (p = .01) and trait anxiety (p = .002). Correlations between changes in study variables

from baseline to post-treatment are shown in Table 3-8.

Treatment Completers versus Treatment Adherers

A second set of analyses was conducted to compare differences between conditions on

primary and secondary outcome variables for treatment adherers. Adherence to treatment was

measured using self-report food records in which participants documented daily dietary intake

(e.g., food type, quantity, total calories), and exercise records in which participants documented

weekly leisure time physical activity (e.g., type, minutes spent). In the MBT condition,

participants were also asked to record the number of mindful meals per day and time spent in

meditation practice. Logs were submitted weekly and "graded" on how well participants

adhered to their assignment and met their goal for that week. Logs were rated on a 4-point scale

ranging from (0) "Did not complete/submit" to (4) "Extremely complete and detailed, appears

accurate, met goal on most or all days." Treatment adherence was defined as at least a 50%

submission rate of weekly logs and a mean score of 2.0 or above on the adherence rating scale.

Fourteen of the 23 participants (61%) who completed testing at Time 1, Time 2, and Time

3 and two participants who completed testing at Time 1 and Time 2 met criteria for inclusion in

the adherers analysis (n = 16). Independent-samples t-tests and chi-square tests revealed no

significant differences between adherers and nonadherers on any demographic variable or on any

of the self-report measures at baseline. The pattern of results was similar to those previously

reported. There were no significant between-condition differences on changes in any of the

primary and secondary outcome variables, or mindfulness, at post-treatment or follow-up for

treatment adherers.









Treatment Fidelity Check and Program Evaluation

The study interventionists were evaluated to assess for treatment fidelity. Evaluations

were conducted by two volunteer research assistants who attended a group session in each

condition lead by each interventionist on two consecutive nights. The observers were asked to

rate the effectiveness of the interventionist on 20 items using a 4-point scale ranging from (1)

"Poor" to (4) "Excellent." Assessments were made based on observation of the following:

technique (e.g., "Utilizes treatment manual and other guides/handouts effectively"); planning

(e.g., "Materials for group are organized and available"); participant relations (e.g., "Maintains

participant interest and attention"); and treatment environment (e.g., "Room set-up is

comfortable"). There were no significant differences in mean effectiveness ratings by

interventionist or by condition.

All participants completed a program content evaluation following completion of the

treatment phase. Participants in both conditions completed 18 questions asking them to evaluate

how effective the program was in helping them establish and maintain healthy eating and

exercise habits. All items were rated on a scale from (1) "Strongly Disagree" to (10) "Strongly

Agree." Means for each item ranged from 7.5 to 8.9. There was no significant difference

between conditions in terms of mean program effectiveness ratings. Participants also rated their

overall success from 0 to 100%. The mean self-reported success rate was 64%. There was no

difference between conditions in terms of self-reported success rate.

Study Hypotheses

The primary hypothesis and secondary hypotheses of this study were not supported. Both

treatment conditions produced equivalent results with regard to changes in body image

satisfaction, psychological functioning, binge eating, and weight management. Table 3-7

provides an illustration of the areas of improvement as a result of treatment. Contrary to









prediction, standard behavioral treatment plus mindfulness did not produce significantly greater

improvements than standard treatment alone.









Table 3-1. Demographic and other characteristics of enrolled participants
(N= 41) M (SD) Min Max
Age (yr) 20.7 (1.4) 18.0 24.0
Weight (kg) 78.9 (7.9) 66.2 98.9
Body Mass Index (kg/m2) 29.6 (1.9) 25.5 34.4
(%) n
Race/Ethnicity
African-American 51.2 21.0
Caucasian 31.7 13.0
Hispanic 12.2 5.0
Asian-American 4.9 2.0
Year in school
Freshman 0.0 0.0
Sophomore 7.3 3.0
Junior 31.7 13.0
Senior 51.2 21.0
Graduate Student 9.8 4.0
Previous diet attempt?
Yes 78.0 32.0
No 22.0 9.0
Number of previous diet attempts
0 22.0 9.0
1-10 68.3 28.0
11-20 9.8 4.0
20+ 0.0 0.0
Participation in previous yoga,
Pilates, or meditation class?
Yes 56.0 23.0
No 44.0 18.0









Table 3-2. Baseline data for study starters in each treatment condition


Age (yr)
Weight (kg)
Body Mass Index (kg/m2)
BDI
MBSRQ-BASS
MBSRQ-AE
STAI-S
STAI-T
RSES
QEWP-R


Race/Ethnicity
African-American
Caucasian
Hispanic
Asian-American


SBT (n =16)
M (SD)
21.0 (1.5)
77.0 (6.8)
30.0 (2.1)
15.0 (8.0)
2.8 (0.6)
2.7 (0.7)
44.0 (7.8)
47.0 (9.8)
19.0 (6.5)
4.3 (3.7)
(%) n


56.0 9.0
31.0 5.0
6.0 1.0
6.0 1.0


Abbreviations: BDI, Beck Depression Inventory; MBSRQ-BASS, Multidimensional Body-Self
Relations Questionnaire-Body Areas Satisfaction Scale; MBSRQ-AE, Multidimensional Body-
Self Relations Questionnaire-Appearance Evaluation; STAI-S, State-Trait Anxiety Inventory-
State Scale; STAI-T, State-Trait Anxiety Inventory-Trait Scale; RSES, Rosenberg Self-Esteem
Scale; QEWP-R, Questionnaire of Eating and Weight Patterns Revised


MBT
M
21.0
79.0
30.0
11.0
3.0
3.0
44.0
45.0
19.0
5.2
(%)


50.0
35.0
15.0
0.0


(n = 20)
(SD)
(1.4)
(7.6)
(1.8)
(7.2)
(0.4)
(0.6)
(10.0)
(9.6)
(4.0)
(4.3)


10.0
7.0
3.0
0.0










Table 3-3. Baseline values for study completers versus noncompleters


Age (yr)
Weight (kg)
Body Mass Index (kg/m2)
BDI
MBSRQ-BASS
MBSRQ-AE
STAI-S
STAI-T
RSES
QEWP-R


Completers (n
M (SD)
21.0 (1.5)
78.0 (7.0)
30.0 (1.6)
14.0 (7.6)
2.9 (0.6)
2.9 (0.7)
45.0 (8.8)
47.0 (11.1)
19.0 (5.7)
4.5 (4.3)
(%) n


23) Noncompleters (n
M (SD)
21.0 (1.3)
79.0 (7.8)
30.0 (2.4)
11.0 (8.2)
2.9 (0.5)
2.9 (0.6)
42.0 (9.3)
44.0 (6.0)
19.0 (4.3)
5.2 (3.6)
(%) n


Race/Ethnicity
African-American
Caucasian
Hispanic
Asian-American


48.0
35.0
13.0


11.0
8.0
3.0
1.0


61.0
31.0
8.0
0.0


Abbreviations: BDI, Beck Depression Inventory; MBSRQ-BASS, Multidimensional Body-Self
Relations Questionnaire-Body Areas Satisfaction Scale; MBSRQ-AE, Multidimensional Body-
Self Relations Questionnaire-Appearance Evaluation; STAI-S, State-Trait Anxiety Inventory-
State Scale; STAI-T, State-Trait Anxiety Inventory-Trait Scale; RSES, Rosenberg Self-Esteem
Scale; QEWP-R, Questionnaire of Eating and Weight Patterns Revised


13)
P
.41
.62
.71
.40
.77
.92
.26
.35
.83
.62









Table 3-4. Baseline data for study completers in each treatment condition


Age (yr)
Weight (kg)
Body Mass Index (kg/m2)
BDI
MBSRQ-BASS
MBSRQ-AE
STAI-S
STAI-T
RSES
QEWP-R


SBT (n = 11)
M (SD)
21.0 (1.6)
78.0 (7.1)
30.0 (1.8)
15.0 (7.4)
2.8 (0.6)
2.7 (0.7)
44.0 (7.5)
49.0 (10.7)
19.0 (6.6)
4.5 (4.4)
(%) n


MBT (n = 12)


M
21.0
78.0
29.0
12.0
3.0
3.0
46.0
45.0
19.0
4.6
(%)


(SD)
(1.5)
(7.2)
(1.5)
(7.7)
(0.5)
(0.6)
(10.1)
(11.6)
(5.0)
(4.4)


Race/Ethnicity
African-American
Caucasian
Hispanic
Asian-American


46.0
36.0
9.0
9.0


50.0
33.0
17.0
0.0


Abbreviations: BDI, Beck Depression Inventory; MBSRQ-BASS, Multidimensional Body-Self
Relations Questionnaire-Body Areas Satisfaction Scale; MBSRQ-AE, Multidimensional Body-
Self Relations Questionnaire-Appearance Evaluation; STAI-S, State-Trait Anxiety Inventory-
State Scale; STAI-T, State-Trait Anxiety Inventory-Trait Scale; RSES, Rosenberg Self-Esteem
Scale; QEWP-R, Questionnaire of Eating and Weight Patterns Revised











Table 3-5. Primary and secondary outcome measures at pre-treatment, post-treatment, and follow-up for each treatment condition


SBT (n = 11)


MBT (n = 12)


Collapsed (n = 23)


Weight (kg)

BMI (kg/m2)

BASS

MBSRQ-AE

BDI

STAI-S

STAI-T

RSES


M

77.7

29.9

2.8

2.7

15.2

44.5

49.0

18.9


(SD)

(7.1)

(1.8)

(0.6)

(0.7)

(7.4)

(7.5)

(10.7)

(6.6)


M

76.7

29.4

3.3

3.4

6.2

34.5

39.4

23.7


(SD)

(7.8)

(1.9)

(0.6)

(0.6)

(5.6)

(10.0)

(7.9)

(4.8)


M

75.0

28.7

3.1

3.4

9.5

34.5

41.8

22.9


(SD)

(8.2)

(1.8)

(0.8)

(0.6)

(9.1)

(7.0)

(9.4)

(4.6)


M

78.3

29.3

3.0

3.0

12.0

46.3

45.2

19.3


(SD)

(7.2)

(1.5)

(0.5)

(0.6)

(7.7)

(10.1)

(11.6)

(5.0)


M

76.8

28.7

3.5

3.7

7.1

39.3

38.6

23.1


(SD)

(7.4)

(2.0)

(0.5)

(0.6)

(7.1)

(13.4)

(11.6)

(4.8)


M

78.3

29.3

3.0

3.0

6.4

34.0

37.3

23.8


(SD)

(7.2)

(1.5)

(0.5)

(0.6)

(5.6)

(8.5)

(8.7)

(5.2)


M (SD) M (SD) M (SD)


78.0

29.5

2.9

2.9

13.5

45.4

47.0

19.1


(7.0) 76.8a

(1.6) 29.la

(0.6) 3.4a

(0.7) 3.5a

(7.6) 6.7a

(8.8) 37.0a

(11.1) 39.0a

(5.7) 23.4


(7.4) 75.7b

(1.9) 28.7b

(0.5) 3.3

(0.6) 3.5b

(6.3) 8.1b

(11.9) 34.2b

(9.8) 39.4b

(4.7) 23.4b


(8.0)

(1.8)

(0.9)

(0.5)

(7.4)

(7.6)

(9.1)

(4.9)


4.5 (4.4) 2.1 (1.5) 1.4 (1.0) 4.6 (4.4) 3.3 (3.8) 2.5 (2.4)


4.5 (4.3) 2.7 (2.9) 1.6b (1.9)


Abbreviations: BMI, Body Mass Index; BASS, Multidimensional Body-Self Relations Questionnaire-Body Areas Satisfaction Scale;
MBSRQ-AE, Multidimensional Body-Self Relations Questionnaire-Appearance Evaluation; BDI, Beck Depression Inventory; STAI-
S, State-Trait Anxiety Inventory-State Scale; STAI-S, State-Trait Anxiety Inventory-Trait Scale; RSES, Rosenberg Self-Esteem
Scale; QEWP-R, Questionnaire of Eating and Weight Patterns-Revised. aSignificant difference from T1 to T2 (p < .05). bSignificant
difference from T1 to T3 (p < .05)


QEWP-R









Table 3-6. Interaction and main effects for primary and secondary outcome measures
Time X Treatment Main Effect Treatment Main Effect Time
Wilks' X p Direction Wilks' X p Direction Wilks' X p Direction
MBSRQ-BASS .910 .39 .449 <.001 T2>T1
MBSRQ-AE .931 .49 .397 <.001 T2>T1 T3>T1
RSES .939 .53 .505 .001 T2>T1 T3>T1
BDI .835 .17 .410 <.001 T2 STAI-S .938 .53 .317 <.001 T2 STAI-T .870 .25 .597 .006 T2 QWEP-R .978 .80 .624 .009 T3 Weight (kg) .911 .40 .552 .003 T2 Body Mass Index (kg/m2) .908 .38 .625 .009 T2 Abbreviations: BDI, Beck Depression Inventory; MBSRQ-BASS, Multidimensional Body-Self Relations Questionnaire-Body Areas
Satisfaction Scale; MBSRQ-AE, Multidimensional Body-Self Relations Questionnaire-Appearance Evaluation; STAI-S, State-Trait
Anxiety Inventory-State Scale; STAI-S, State-Trait Anxiety Inventory-Trait Scale; RSES, Rosenberg Self-Esteem Scale;QEWP-R,
Questionnaire of Eating and Weight Patterns-Revised









Table 3-7. Significant improvements as a result of study treatments
From baseline to post-treatment From baseline to follow-up
Support No support Support No support
Body image satisfaction X X
Appearance evaluation X X
Self-esteem X X
Depressive symptoms X X
State anxiety X X
Trait anxiety X X
Binge eating X X
Weight management X X









Table 3-8. Correlation matrix of changes in study variables from baseline to post-treatment collapsed across conditions
(n = 23) BASS AE RSES BDI STAI-S STAI-T QWEP-R Weight BMI
MBSRQ-BASS ---
MBSRQ-AE .711*
RSES .667* .692* ---
BDI -.535* -.397 -.335 ---


STAI-S -.552* -.430* -.374
STAI-T -.832* -.699* -.852*
QWEP-R -.266 -.267 .010
Weight (kg) -.140 -.172 .049
Body Mass Index (kg/m2) -.160 -.198 .019
MAAS .454* .291 .559*
Abbreviations: BDI, Beck Depression Inventory; MAAS, Mindful


.282
.557*
.609*
.119
.192
-.526*
Attention


.551* ---
.169 .327 ---
.070 -.004 .072 ---
.148 .008 .092 .983*
.061 -.622* -.187 .031 .045
Awareness Scale; MBSRQ-BASS, Multidimensional


Body-Self Relations Questionnaire-Body Areas Satisfaction Scale; MBSRQ-AE, Multidimensional Body-Self Relations
Questionnaire-Appearance Evaluation; STAI-S, State-Trait Anxiety Inventory State Scale; STAI-S, State-Trait Anxiety Inventory
- Trait Scale; RSES, Rosenberg Self-Esteem Scale; QEWP-R, Questionnaire of Eating and Weight Patterns Revised










193 individuals
assessed for
eligibility


41 randomized


20 SBT participants


9 lost to follow-up:
4 never started
3 declined to continue
1 relocated
1 other


11 completed study


21 MBT participants


9 lost to follow-up:
1 never started
4 declined to continue
1 relocated
3 reason not given


12 completed study


Figure 3-1. Study enrollment and retention


152 individuals excluded:
19 did not meet criteria
9 declined participation
124 other




































Baseline Post-Treatment


Figure 3-2. Changes in MBSRQ-Body Areas Satisfaction Scale (BASS) scores from Baseline to
Follow-up (p < .05).


8.00


7.00


6.00


5.00


4.00


Q 3.00


2.00


-*- SBT
-- MBT


1.00


0.00


Follow-up























-- SBT
- MBT


Baseline Post-Treatment


Follow-up


Figure 3-3. Changes in Rosenberg Self-Esteem Scale (RSES) scores from Baseline to Post-
Treatment (p < .05) and from Baseline to Follow-up (p < .05).


30.00


25.00


20.00


15.00


10.00



5.00



0.00






















- SBT
- MBT


Baseline Post-Treatment


Follow-up


Figure 3-4. Changes in Beck Depression Inventory (BDI) scores from Baseline to Post-
Treatment (p < .05) and from Baseline to Follow-up (p < .05).


30.00


25.00


20.00


15.00



10.00


5.00


0.00











60.00


55.00


50.00


45.00


40.00


35.00


30.00


25.00


20.00


Baseline Post-Treatment


-0- SBT
- MBT


Follow-up


Figure 3-5. Changes in State-Trait Anxiety Inventory-Trait subscale (STAI-T) scores from
Baseline to Post-Treatment (p < .05) and from Baseline to Follow-up (p < .05).





































Baseline Post-Treatment


Figure 3-6. Changes in Weight (kg) from Baseline to Post-Treatment (p < .05) and from
Baseline to Follow-up (p < .05).


80.00


79.00

78.00

77.00

S76.00

- 75.00

74.00


N.
Ns


-- SBT
-- MBT


73.00

72.00

71.00

70.00


Follow-up







































Baseline Post-Treatment


Figure 3-7. Changes in BMI from Baseline to Post-Treatment (p < .05) and from Baseline to
Follow-up (p < .05).


33.00



32.00



31.00


30.00

2.
o

29.00


--- SBT
.-- MBT


28.00



27.00


Follow-up









CHAPTER 4
DISCUSSION

Mindfulness is a meditation-based technique used in some clinical settings to help focus

one's attention and cultivate a sense of present-moment awareness and acceptance. It is believed

by some that being mindful in certain situations can help break destructive habitual reactions to

stress, promote self-regulation, and minimize psychological processes facilitating dysfunctional

behaviors such as excessive eating. Recently, training in mindfulness meditation has been

applied to a broad range of clinical conditions to determine if the diffuse effects of mindfulness

improve outcomes. This study evaluated the effects of mindfulness training in conjunction with

behavioral weight loss treatment on body image satisfaction, psychological well-being, eating

behavior, and weight management in overweight and obese college women. In general, it was

found that study participants who received standard behavioral weight loss treatment plus

mindfulness showed no greater improvement across a range of outcomes than participants who

received standard treatment alone.

The primary outcome of this study was body image satisfaction. The results showed that

both treatment conditions were equally as effective in improving body image satisfaction. Body

image ratings improved significantly from baseline to post-treatment. This is consistent with

previous reports of improved body image satisfaction in obese individuals who have undergone

behavioral weight loss treatment (Cash, 1994b; Foster, Wadden, & Vogt, 1997; Rosen, Orosan,

& Reiter, 1995). Among obese women, lower levels of body satisfaction appear to be related to

lower self-esteem and increased symptoms of depression (Sarwar & Thompson, 2002). Body

dissatisfaction has also been shown to be a predictor of binge eating in college women

(Ricciardelli et al., 1997; Stice, 2001). In this study, changes in body image were associated

with improved self-esteem, reduced anxiety and depressive symptoms, and changes in









mindfulness. No association between body satisfaction and binge eating behavior was found.

Results showed a marginal, but nonsignificant, improvement in body image satisfaction from

baseline to follow-up (p = .053). Cross-cultural differences in ideal body image have been

reported. For example, African-American women, who were well represented in this study's

sample, have been found to report a larger ideal BMI and less body image dissatisfaction than

Caucasian women (Parker et al., 1999; Becker, Yanek, Koffman, & Bronner, 1999). This finding

may help explain, in part, why greater improvements in body image satisfaction from baseline to

follow-up were not found in this sample.

Change in weight was a secondary outcome of this study. Equivalent weight losses were

observed across conditions at the end of the treatment phase. The mean weight loss achieved in

this 8-week study was 1.25 kg, a 2% reduction in body weight. Behavioral interventions

delivered over a 15- to 26-week period typically produce up to 8.5 kg weight losses, an 8 to 10%

reduction in body weight (Perri & Corsica, 2002). It is not clear why participants did not lose the

amount of weight typically produced by this type of treatment. The women in this sample were

younger than those included in traditional weight loss trials. The women participating in this

study also had a mean baseline BMI of 30, which is lower than in typical trials with women who

record mean baseline BMIs of 33 (Wing, 2002). A relatively high number of African-American

participants were enrolled in the current study (51% identified themselves as African-American).

Newton and Perri (1997) assessed attitudes toward obesity in African-Americans and Caucasians

and found that African-Americans perceived themselves to be more susceptible to becoming

obese, but also perceived the health and psychological consequences of being obese as less

severe than Caucasians did. These findings may help explain, in part, why greater reductions in

weight were not found in this sample over the course of the 8-week intervention. At the end of









the 3-month follow-up phase, participants had not regained any lost weight on average, and had

actually continued to lose weight. This is an atypical finding. During the year following

behavioral treatment, overweight individuals typically regain 30 to 50% of their initial losses

(Jeffery et al., 2000). Conclusions about the effectiveness of treatment in preventing weight

regain, however, are not possible given the small number of treatment completers and the

relatively short follow-up period.

Many women enter weight loss treatment programs to improve appearance, attractiveness,

self-confidence, and reduce social anxiety (Cooper & Fairburn, 2001). Previous studies have

suggested that the reduction in body weight typically produced by standard behavioral treatment

is unlikely to have a substantial impact on appearance and attractiveness and that post-treatment

weight regain may be attributable to not achieving these anticipated benefits (Ames et al., 2005;

Bryne, Cooper, & Fairbum, 2003; Cooper & Fairburn, 2002). It has been proposed that

addressing body image dissatisfaction during treatment may be the most critical mechanism for

successful long-term weight loss and maintenance (Cooper & Fairburn, 2002; Ramirez & Rosen,

2001). It has also been suggested that small losses in weight may yield substantial improvements

in body image (Wadden, Womble, Stunkard, & Anderson, 2002). On the surface, this notion

appears to be supported by the results of the current study. That is, participants lost a small

amount of weight and body image satisfaction improved significantly. Correlational analyses,

however, revealed no significant association between change in weight and body image

satisfaction. Thus, the relationship between body image and body weight, and the implications

for treatment, remains unclear.

Participants in this study showed improvements in self-esteem, anxiety, and depressive

symptoms at the end of treatment and at follow-up. These improvements are consistent with









similar trials enrolling overweight and obese college-age women (Ames et al., 2005).

Correlational analyses revealed significant associations between increases in body image

satisfaction and increases in self-esteem, decreases in depressive symptoms, and decreases in

anxiety. These results are also consistent with previous findings among obese women seeking

weight loss treatment (Sarwar, Wadden, & Foster, 1998). In this study, improvements in

depressive symptoms, self-esteem, and trait anxiety were all associated with changes in

mindfulness. Segal and colleagues (2002) have suggested that the ability to recognize and

disengage from dysfunctional thinking patterns is a defining feature of mindfulness and that

regular practice of mindfulness may produce improvements in mood and anxiety symptoms.

This type of relationship cannot be determined based on the results of the current study and

evidence in support of such a relationship remains equivocal (Toneatto & Nguyen, 2007).

Participants also showed marginal, but nonsignificant, improvement in binge eating

behavior from baseline to the end of treatment and significant improvement from baseline to

follow-up. It has been suggested that obese women who engage in binge eating suffer from

higher levels of depression and anxiety and lower levels of self-esteem than obese women who

do not binge (Johnson, 2002). In this study, a decrease in binge eating behavior was associated

with a decrease in depressive symptomatology, but was not associated with changes in anxiety or

self-esteem. It has been suggested that bingeing may be a maladaptive coping mechanism used

by some individuals with limited ability to self-regulate (Heatherton & Baumeister, 1991).

Contrary to prediction, participants in the MBT condition did not show greater reduction in binge

eating behavior at post-treatment or follow-up when compared to participants in the SBT

condition. It should be noted that the sample of women recruited for this study did not engage in

clinically significant levels of binge eating at baseline. Moreover, women who endorsed









symptoms of bulimia were excluded from participation. Other studies using mindfulness

training have found significant improvement in binge eating, but these studies targeted a sample

of obese individuals who met criteria for binge eating disorder at baseline (e.g., Kristeller &

Hallett, 1999).

Findings from this study are encouraging in that body image satisfaction as well as general

measures of psychological functioning improved significantly in overweight and obese young

women after participation in an 8-week intervention. These improvements may increase

satisfaction with weight loss treatment outcomes and ultimately provide better maintenance of

lost weight. Women who feel better about themselves may be more likely to accept modest

amounts of weight loss as a meaningful accomplishment. Maintenance of even small weight

losses should be encouraged in overweight women given that a 5 to 10% reduction in body

weight will produce clinically significant improvements in health status (Wing & Hill, 2001).

Improved psychological well-being may also improve motivation to maintain changes in diet and

exercise habits achieved during treatment. Future studies with larger samples and longer follow-

up periods are needed to determine if changes in body image satisfaction and psychological well-

being lead to improved long-term maintenance of lost weight and/or the prevention of weight

gain.

This study was designed as a pilot study to examine the impact of mindfulness on body

image satisfaction. Weight loss was a secondary goal of the study. As a pilot study, one

limitation was the small sample size. This small sample resulted in low statistical power limiting

the ability to detect interaction effects for the primary outcome measure at Time 2 and Time 3.

This has significant implications for the findings of this study. The SBT mean body image

satisfaction score at post-treatment was 3.3 and the MBT mean score was 3.5 (standard error =









.55), an effect size of .36. A minimum of 190 participants would be needed in order to have

enough statistical power to detect a between-condition difference in the primary outcome

variable. Given the high attrition rate (approximately 35%), the initial pool of participants would

have to be very large (n = 293) in order to maintain this statistical power.

The high rate of attrition has additional implications for the study. The findings in this

study are based upon data collected from only 64% of the participants who began treatment. It

seems reasonable to assume that participants who did not participate in post-treatment or follow-

up data collection likely had less favorable outcomes. Thus, findings should be interpreted with

some caution. The rate of attrition in this study is similar to other trials investigating weight loss

treatment in college-age participants and may reflect the intensity and duration of the study

(Ames et al., 2005; Donnelly et al., 2003). The present investigation required significant effort

by the subjects. The two hours of on-site contact per week, intensive self-monitoring, and at-

home meditation practice required of participants may have negatively impacted adherence to the

program. Other variables that may have contributed to the high rate of attrition in this study

were the age and minority status of participants. Honas et al. (2003) found that younger

participants had a higher attrition rate and that age was the most significant determinant of drop-

out in a 16-week clinic-based weight loss group treatment program. In their study, only 60% of

participants under age 40 completed the program, similar to the completion rate in the current

study. In addition, a relatively high number of minority participants were enrolled in the current

study (68% of participants identified themselves as Black, Hispanic, or Asian). Kumanyika

(2002) suggests that adherence problems in minority participants may be associated with low

perceived benefits of attending treatment, insufficient motivation for weight loss, and increased









barriers to adopting and maintaining reduced calorie intake and increased physical activity

compared to Caucasian participants.

The study had a relatively short follow-up period of only three months as opposed to a

more typical 12-month to 18-month follow-up period. Participants in behavioral interventions

typically show a consistent pattern of continued weight regain two to five years after behavioral

treatment (Perri, 1998). Thus, only tentative conclusions can be made about the long-term

effects of treatment on weight loss maintenance or improvements in body image satisfaction.

This study relied extensively on participant self-report for the measurement of diet and

exercise adherence, meditation practice, and psychological variables. In addition, study

completion was defined as being present for testing, not necessarily being present for treatment.

An analysis examining the effect of treatment in high adherers to treatment revealed the same

results as those presented here. Nevertheless, this limits the extent to which conclusions about

treatment can be made.

Mindfulness was a central concept in this study. Measures of mindfulness are still in

development. One of the measures used to capture the acquisition of mindfulness skills in this

study was based on the conceptualization of mindfulness as a one-dimensional construct. Recent

factor analysis has yielded several additional facets and a new multi-dimensional measure has

been developed (Five Factor Mindfulness Questionnaire; FFMQ; Baer, Smith, Hopkins,

Krietemeyer, & Toney, 2006). The single factor measure used in the current study may not have

the sensitivity offered by a multi-dimensional model of mindfulness. According to Baer et al.

(2006), the Mindful Attention and Awareness Scale (MAAS; Brown & Ryan, 2003) used in the

current study tends to emphasize an element of mindfulness related to absent-mindedness. The

use of this single factor measure may have limited the ability to detect other aspects of









mindfulness, especially in a sample of relatively inexperienced meditators. This may explain, in

part, why it appears both conditions demonstrated significant improvement in mindfulness over

time. The questionnaire elicited information primarily related to paying attention in everyday

activities. All participants may have improved in that regard as a result of weekly self-

monitoring activities. Future research with inexperienced meditators should include a measure

of mindfulness that captures the multi-faceted nature of the construct and the specific

components targeted by the intervention. The intervention designed for the current study, for

example, targeted self-compassion and acceptance, observation of present moment experience,

and cultivation of non-reactivity to negative stimuli. An instrument designed to capture these

facets of mindfulness may be more useful in assessing differential skill acquisition.

Participants in this study engaged in only 8.3 hours of meditation across the intervention

period. Previous studies using mindfulness-based interventions have reported higher rates of

success with regard to participants' meditation practice outside of session. Kristeller and Hallett

(1999), in a study evaluating the effectiveness of a mindfulness-based intervention for obese

binge eaters, reported 15.82 hours of meditation over a 6-week period. Only 25% of the sample

in the current study reported participating in meditation practice one or more times. In contrast,

90% of the sample used in the study by Reibel and colleagues (2001) reported practicing three or

more times a week. The current intervention included a structured meditation program that

required intensive self-monitoring, attendance at weekly group sessions, and daily practice

between sessions. Based on participant feedback, this required an excessively demanding time

commitment.

Increases in mindfulness have been found to mediate the relationship between formal

mindfulness practice and improvements in psychological functioning, suggesting that the









practice of meditation leads to increases in mindfulness which leads to symptom reduction and

improved well-being (Carmody & Baer, 2008). The sample in the Carmody and Baer study,

however, differed from the sample used in the current study. The average age of participants in

the Carmody and Baer study was 47 years. Their subjects volunteered to participate in an 8-

week MBSR program for stress-related problems and chronic pain. More than 63% of the

Carmody and Baer subjects reported previous participation in psychotherapy. Future studies of

mindfulness should consider participants' age and previous meditation experience. It is likely

that younger subjects, who are largely naive to meditation, require different approaches than

older subjects. Similarly, participants with previous exposure to meditation or mind/body

therapies will likely respond better to the demands of a mindfulness training program.

The current study offers a number of advancements in the assessment of mindfulness. Few

studies in this area have utilized a randomized prospective design, a manualized treatment

protocol, an active control condition, and the administration of process measures to identify

components of treatment that participants felt were particularly helpful. The responses from

participants suggest that the program was effective in helping them learn strategies for healthy

eating and for setting realistic diet and exercise goals. Participants stated that the program

helped them to be less critical of themselves and to focus on things they like about their bodies,

regardless of their weight. Participants reported an increased ability to pay attention and respond

to physiological hunger and satiety cues. Participants noted that treatment helped them

recognize the importance of self-acceptance and compassion. As one participant noted, "Even

though I didn't lose weight, I feel so much better about myself. I have more confidence than

before." Another participant stated, "This group makes me feel empowered. I look forward to it

every week." When asked about the most helpful component of the program, one participant









responded, "Portion size awareness, knowledge of calories, learning how to read food labels, and

mindful eating. Before, I used to feel guilty for overeating now I just accept it and make better

choices the next day. I feel more confident about myself now."

Mindfulness meditation has been suggested to be well-suited for the amelioration of stress-

related medical and psychological conditions (Grossman, Niemann, Schmidt, & Walach, 2004;

Shigaki, Glass, & Schopp, 2006). Conclusions about the effectiveness of mindfulness skills

training as an adjunct or stand-alone therapy remain equivocal (Ospina et al., 2007). The current

study represents an attempt to present preliminary evidence regarding a program integrating

behavioral and mindfulness-based strategies to address body image concerns in overweight and

obese young women. The mindfulness techniques presented to this group of inexperienced

meditators were novel. Analysis of participant report indicated that the level of exposure and

engagement in mindfulness techniques was relatively small, compared to more intensive MBSR

training programs. One of the most important questions that must be addressed in future

research on mindfulness is what constitutes a minimally effective treatment "dose." In other

words, how much exposure is necessary for an effective evaluation of the intervention?

As the prevalence of obesity in the United States reaches epidemic proportions, the need

for more effective methods of weight maintenance is critical. The discrepancy between actual

body size and ideal body size has become increasingly significant. Because this ideal body size

is unattainable for many young women, there currently exists what might be considered an

"epidemic of body dissatisfaction." To the extent that body image dissatisfaction contributes to

binge eating and psychological distress, and compromises the potential effectiveness of certain

types of weight loss treatments, an effective intervention is needed. The clinical significance of

body image dissatisfaction warrants further investigation.









The present study predicted that an intervention designed to teach the principles of

mindfulness in overweight college women would have a greater impact on body image,

psychological functioning, eating behavior, and weight maintenance than standard behavioral

weight loss treatment alone. The results of this preliminary study suggest that behavioral

treatment plus mindfulness is no more effective than behavioral treatment alone in maintaining

short-term improvements in body image, psychological well-being, eating behavior, and weight

management. Although this study did not demonstrate the value of mindfulness training, more

study is warranted. Feedback from participants suggests the mindfulness intervention did have a

meaningful impact on some young women's psychological well-being and approach to healthy

living. Moreover, this study has highlighted a number of methodological issues which must be

addressed to fully evaluate the value of mindfulness training. Specifically, future studies must

recognize the significant levels of compliance needed to accurately evaluate mindfulness

interventions. This level of compliance requires larger clinical samples than many other

approaches. In addition, assessment of mindfulness skills is still fairly primitive. Effective

evaluation of these skills is dependent upon measures able to reflect the complex nuances of

mindfulness. Once these issues are addressed, it will be possible to effectively assess whether

mindfulness skills training is beneficial for weight maintenance and psychological well-being.









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BIOGRAPHICAL SKETCH

I was accepted into the University of Florida's Clinical and Health Psychology program in

fall 1999. The program at the University of Florida provided me with outstanding general

mental health clinical training as well as training with diverse medical populations. While a

student, I had the opportunity to conduct clinical research focused on weight loss and body

image with overweight and obese young women, and exercise interventions for sedentary adults.

I enjoy working with these populations clinically and conducting treatment outcome studies. I

also enjoy teaching mindfulness skills and hope to have the opportunity to continue my research

in this area as well. Ultimately, my goal is to help address the adverse impact of overweight and

obesity on health and psychological well-being. In doing so, I hope to contribute to the body of

literature integrating the science and practice of clinical and health psychology. My ultimate

goal is to contribute significantly to the treatment literature in the areas of behavioral weight

management, eating disorders, and body image issues in women.





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MINDFUL NESS MEDITATION AS AN INTE RVENTION FOR BODY IMAGE AND WEIGHT MANAGEMENT IN COL LEGE WOMEN: A PILOT STUDY By NATALIE CHRISTINE BLEVINS A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2008 1

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2008 Natalie Christine Blevins 2

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To m y parents 3

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ACKNOWLEDGMENTS I thank my committee chair, Dr. Robert Frank, for his continued support, mentorship, and friendship over the years. I thank my committee members, Dr. Mike Perri, Dr. Dave Janicke, and Dr. Christy Lemak, for their support and guid ance. I thank my pare nts, Jerry and Diane Blevins, for their understanding and encouragemen t, and for instilling in me the qualities of persistence and determination. I thank my fianc, Franco Dattilo, for his patience and understanding, for his unwavering s upport, and for believing in me. 4

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TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 LIST OF FIGURES.........................................................................................................................8 ABSTRACT.....................................................................................................................................9 CHAPTER 1 LITERATURE REVIEW.......................................................................................................11 Introduction................................................................................................................... ..........11 Body Image Disturbance........................................................................................................12 Body Dissatisfaction........................................................................................................13 Etiological Models of Body Dissati sfaction and Maladaptive Eating.............................14 Obesity........................................................................................................................ ............16 Physical and Psychological Consequences of Obesity....................................................17 Obesity Prevention and Early Intervention.....................................................................19 The Freshman Fifteen..................................................................................................20 Behavioral Treatment of Obesity............................................................................................21 The Maintenance Problem...........................................................................................22 Empirical Support for Addressing Psychologi cal Factors in Behavioral Treatment......24 Mindfulness Meditation......................................................................................................... .27 Mindfulness as a Clin ical Intervention............................................................................28 Mechanisms of Change in Mindfulness..........................................................................31 Mindfulness versus Trad itional Cognitive Therapy........................................................33 Empirical Support for Mindfulness-Based Interventions................................................34 Mindfulness as a Treatment for Body Image and Eating Issues.....................................36 Study Justification and Primary Aims....................................................................................38 2 METHOD....................................................................................................................... ........40 Participants.............................................................................................................................40 Procedure................................................................................................................................40 Intervention.............................................................................................................................41 Measures.................................................................................................................................43 Height, Weight, and Demographic Information..............................................................43 Body Image.....................................................................................................................43 Psychological Functioning..............................................................................................44 Eating Behavior...............................................................................................................45 Mindfulness.....................................................................................................................45 5

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3 RESULTS ...................................................................................................................... .........48 Participants.............................................................................................................................48 Baseline Analyses.............................................................................................................. .....50 Post-Treatment and Follow-Up Analyses...............................................................................50 Body Image.....................................................................................................................51 Psychological Functioning..............................................................................................51 Eating Behavior...............................................................................................................52 Weight.............................................................................................................................53 Mindfulness.....................................................................................................................54 Dependent Variable Pearson Correlations..............................................................................55 Treatment Completers versus Treatment Adherers................................................................56 Treatment Fidelity Check and Program Evaluation...............................................................57 Study Hypotheses...................................................................................................................57 4 DISCUSSION................................................................................................................... ......74 LIST OF REFERENCES...............................................................................................................85 BIOGRAPHICAL SKETCH.........................................................................................................98 6

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LIST OF TABLES Table page 2-1 Study session matrix...............................................................................................................47 3-1 Demographic and other characteristics of enrolled participants............................................59 3-2 Baseline data for study star ters in each treatment condition..................................................60 3-3 Baseline values for study co mpleters versus noncompleters..................................................61 3-4 Baseline data for study completers in each treatment condition............................................62 3-5 Primary and secondary outcome measures at pre-treatment, post-treatment, and followup for each treatment condition.........................................................................................63 3-6 Interaction and main effects for primary and secondary outcome measures.........................64 3-7 Significant improvements as a result of study treatments......................................................65 3-8 Correlation matrix of changes in study variables from baseline to post-treatment collapsed across conditions................................................................................................66 7

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LIST OF FIGURES Figure page 3-1 Study enrollment and retention............................................................................................ ...67 3-2 Changes in MBSRQ-Body Areas Satisfact ion Scale (BASS) scores over time by condition............................................................................................................................68 3-3 Changes in Rosenberg Self-Esteem Scal e (RSES) scores over time by condition................69 3-4 Changes in Beck Depression Inventory (BDI) scores over time by condition.......................70 3-5 Changes in State-Trait Anxiety Inventor y-Trait subscale (STAI-T ) scores over time by condition............................................................................................................................71 3-6 Weight in kilograms over time by condition..........................................................................72 3-7 BMI over time by condition................................................................................................ ...73 8

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Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy MINDFULNESS MEDITATION AS AN INTE RVENTION FOR BODY IMAGE AND WEIGHT MANAGEMENT IN COL LEGE WOMEN: A PILOT STUDY By Natalie Christine Blevins August 2008 Chair: Robert G. Frank Major: Psychology Behavioral weight loss treatment is a well-established and highly effective intervention for many overweight individuals seeking to lose weight. Some ov erweight individuals enter weight loss treatment programs to improve their body image as well as to lose weight. Changes in body weight, however, have been shown to be unrel ated to changes in body image suggesting that weight loss alone is not sufficient for alle viating body image concer ns. Mindfulness, a meditation-based therapeutic process emphasizi ng a nonjudgmental, self-a ccepting attitude, has been shown to be an effective intervention across a wide range of clinical syndromes and populations, but has never been examined as an intervention for body image and weight management in young women. Our study used a random ized design to test the effectiveness of a mindfulness-based intervention in combination with a behavioral weight loss treatment protocol on changes in body image, psychological we ll-being, eating behavior, and weight. Forty-one women aged 18 to 25 with a BMI be tween 25 and 35 were randomized into one of two conditions: standard behavioral treatme nt or standard behavioral treatment plus mindfulness. The study consisted of an 8-week intervention phase and a 3-month follow-up phase. Twenty-three participants (56%) completed pre-treatment, post-treatment, and follow-up assessment. The primary outcome measure wa s body image satisfaction. Secondary outcomes 9

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10 included self-esteem, depressive symptoms, anxiety, binge eating, a nd weight. Participants in both conditions showed improvements. Sp ecifically, body image satisfaction improved significantly from baseline to post-treatment ( p < .001) and showed marg inal, but nonsignificant, improvement from baseline to follow-up ( p = .053). Self-esteem, depressive symptoms, and anxiety also improved from ba seline to post-treatment (all ps < .005) and from baseline to follow-up (all ps < .008). Binge eating showed nonsigni ficant improvement from baseline to post-treatment ( p = .08) and significant improvement from baseline to follow-up ( p = .009). Weight decreased from baseline to post-treatment ( p = .03) and from baseline to follow-up ( p = .002). Neither condition regained any weight on average at the 3-month follow-up. Contrary to prediction, standard treatment plus mindfulness did not produ ce greater improvements than standard treatment alone. Furt her study of mindfulness-based in terventions util izing a larger sample size and longer follow-up is warranted.

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CHAP TER 1 LITERATURE REVIEW Introduction Interest in th e construct of mindfulness and its clinical use has increased in recent years. Mindfulness, a meditation-base d therapeutic strategy emphasi zing a nonjudgmental, selfaccepting attitude, has been used in stand-alone interventions for anxiety and depression (e.g., Kabat-Zinn, 1990; Segal, Williams, & Teasdale, 2002), and as a component of integrative treatment approaches for borderline personality disorder and substa nce abuse (e.g., Linehan, 1993; Marlatt & Gordon, 1985). Mindfulness training has also been shown to be effective in reducing the number of binge ea ting episodes in a group of obese women (Kristel ler & Hallett, 1999). This suggests that mindfulness may be a helpful component in the treatment of binge eating disorder and obesity. In the United States, millions of women str uggle with issues relate d to eating, weight, and body image. It has been estimated that 80% of young women are dissatisfied with their appearance and an estimated 40 to 50% are trying to lose weight at any point in time, spending over $40 billion on diet-related products each year (Smolak, Levine, & Streigel-Moore, 1996). In a survey of college women, it was found that 91% had attempted to control their weight through dieting, and 22% reported dieting often or always (Kurth, Krahn, & Nairn, 1995). Clinically, it has been suggested that approximately 35% of normal dieters will likely begin to use pathological eating behavior s (e.g., extremely restrictive caloric intake, overexercising, binging and purging, or excessive ov ereating). And, of those, 20 to 25% will likely progress to partial or full-syndrome eating disorders (i.e., anor exia nervosa, bulimia nervosa, or binge eating disorder; Shisslak, Crago, & Estes, 1995). Thus, disturbances of body imag e, eating, and weight are significant clinical issues for young women in American society. 11

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The em pirical literature increasingly s upports the efficacy of mindfulness-based interventions and symptom reduction has been reported across a wide ra nge of populations and disorders (Baer, 2003; Baer & Krietemeyer, 2006; Bishop, Lau, Shaprio, Carlson, & Anderson, 2004; Roemer & Orsillo, 2003), but a mindfulness-based approach to enhance body image and weight management in young wome n has never been tested. Prior to describing several evidence-based inte rventions using mindfulness, the issues and implications of body image disturbance and maladaptive eating in young women will be reviewed. Next, the issues associated with being overweight or obese and the necessity of establishing effective weight management interv entions in this population will be addressed. Then, the potential utility of mindfulness as an intervention for the issues presented will be reviewed. Finally, a study designed to asse ss the effectiveness of a mindfulness-based intervention on body image, eating behavior, a nd weight management in young women will be described. Body Image Disturbance Body i mage disturbance is a multidimensional cons truct consisting of subjective, affective, cognitive, behavioral, and per ceptual processes (T hompson, Heinberg, Altabe, & Tantleff-Dunn, 1999). The affective component consists of feel ing upset, distressed, or anxious about ones appearance. The cognitive component may include the maintenance of an unrealistic expectation for ones appearance (e.g., the desire to look li ke a runway fashion model) or the belief that being thin brings happiness. Examples of the behavioral component incl ude avoiding situations that draw body scrutiny, such as going to the beach, changing clothes in a locker room, or working out at a fitness facility. 12

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Body Dissatisfaction Body dissatisfaction is widely recognized as the most impor tant global measure of body image disturbance (Thompson et al., 1999). Cash (2002) describes body dissatisfaction as including two core features: evaluation (i.e., the level of satisfaction with ones appearance) and investment (i.e., the psychological importance on e places on appearance). These may be applied to ones general appearance or to a specific phys ical characteristic or feature (including body weight and shape). The construct is derived from the notion of self -ideal discrepancy that a persons physical self-evaluations are based on the subjective c ongruence between his or her perceived physical attributes and the set of interna lized standards that he or she ho lds about physical appearance. Body satisfaction, in turn, will depe nd on the extent to which the individual believes that his or her physical characteristics match his or her id eals, and the importance placed on achieving those ideals. Body dissatisfaction has been linked to lo w self-esteem, anxiety, and depression (e.g., Cash & Fleming, 2002; Fabian & Thompson, 1989; Keeton, Cash & Brown, 1990; Noles, Cash, & Winstead, 1985; Powell & Hendricks, 1999; Thompson & Psaltis, 1988). Studies have also linked body dissatisfaction to maladaptive eatin g behavior (e.g., Ant on, Perri, & Riley, 2000; Cash & Deagle, 1997; Ricciardelli, Tate, & W illiams, 1997; Riva, Marchi, & Molinari, 2000; Stice, 2002; Stice & Agras, 1998) Indeed, body dissatisfaction has received the greatest empirical support as a precursor to eating pathology in the ge neral population (Thompson et al., 1999) and among college women (Cash & Syzmanski, 1995). In a structural modeling analysis, Riva et al. (2000), found evidence for a causal link between body dissatisf action and restrained eating (i.e., chronic dieting). Similarly, results from a study by Ricciardelli et al. (1997) show that body dissatisfaction served as a mediator be tween dietary restraint and bulimic patterns of 13

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eating in a sam ple of college women, sugges ting the importance of body dissatisfaction as a predictor of binge eating. This is clinically relevant because binge eating can lead to significant weight gain, thus contributing to the cycle of maladaptive eating and psychological pathology. Etiological Models of Body Dissati sfaction and Maladaptive Eating Several researchers have inve stigated the role of envi ronm ent in the etiology and maintenance of body dissatisfaction and mala daptive eating (Anderson-Fye & Becker, 2004; Heinberg, 1996; Thompson et al., 1999). Societal preference toward a thin and fit physique has led to a societal preoccupation wi th dieting and weight loss. This preoccupation seems to be particularly profound in college women. The mech anisms by which sociocultural factors aid in the development of maladaptive eating behavior in women have been proposed by two models: (1) the tripartite infl uence model (Thompson et al., 1999; van den Berg, Thompson, ObremskiBrandon, & Coovert, 2002) and (2) the dual-path way model (Stice, 2001; Stice, Nemeroff, & Shaw, 1996). The tripartite influence model proposes that pe ers, parents, and media have a direct impact on body dissatisfaction. They are also thought to affect body dissatisfac tion indirectly, through two mediational processes: the in ternalization of societal standa rds of appearance and excessive appearance comparison. Body dissa tisfaction is hypothesized to have a direct effect on restrictive eating, which has an effect on bulimic behaviors. This model has received support with both adult and adolescent female sample s (e.g., Keery, van den Berg, & Thompson, 2004; van den Berg et al., 2002). The dual-pathway model proposes that body dissatisfaction and bulimic behavior are linked through two pathways. First is the pathway of dietary rest raint and second is the pathway of negative affect. In the first pathway, body dissatisfaction results in dietary restraint (i.e. eating less than desired) as a means of weight control. In the second pathway, body dissatisfaction 14

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leads to negative or dysregulated emotions and binge/purge behavior. Bingeing (alone, or in conjunction with purging) has been hypothesized as a m eans of c oping for individuals with poor emotion regulation and distress to lerance skills (Heatherton & Ba umeister, 1991). Both models propose that sociocultural pressures to be thin and intern alization of the thin -ideal, which is the extent to which one buys into societal standards of appearance and weight both cognitively and behaviorally (Thompson & Stice, 2001), contribute to patholog ical eating by fostering the development of body dissatisfaction. Body dissatisf action, in turn, is hypothesized to foster overly restrictive dieting, disordered eating symp toms, and negative affect because the ideal is nearly impossible for the average female to attain (Heinberg, 1996; Stice, 2001; Thompson et al., 1999). Cross-sectional, structural equation modeling studies on und ergraduate women have found broad support for both the trip artite model (van den Berg et al., 2002) and the dual-pathway model (Stice et al., 1996). Sti ce (2001) also found support fo r the dual-pathway model in a twenty-month prospective study of adolescent girls using random regression growth curve models. Specifically, Stice (2001) found evidence that initial levels of perceived pressure to be thin and thin-ideal in ternalization predicted increases in body dissatisfaction over time. The results of this study also suppor t the hypothesis that in itial levels of body di ssatisfaction predict subsequent increases in dietary re striction and negative affect. In itial levels of negative affect and dietary restriction prosp ectively predicted binge eating, and the relationship between body dissatisfaction and bulimic sympto ms was completely mediated by dieting and negative affect. Collectively, these findings support the theoretical assertion that body dissatisfaction, overly restrictive dieting, and negative a ffect can promote the onset of pathological eating behavior. 15

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Obesity Obesity is characterized by excessive weight (i.e., 20 to 25% above normal for age and height) and defined as a body mass index (BM I) greater than 30.0 (Dev lin, Yanovski, & Wilson, 2000; Flegal, Carroll, Kuczmarski, & Johnson, 1998; World Health Organization, 1998). BMI is standardized by age and height a nd is calculated using weight (in kilograms) divided by height (in meters) squared (Field, Barnoya, & Colditz, 2 002). Overweight is defined as a BMI between 25.0 and 29.9 (Devlin et al., 2000; Flegal et al., 1998; World Health Organization, 1998). Obesity has been conceptualized as a condi tion with heterogeneous etiology (Brownell & Wadden, 1992; Devlin et al., 2000). At the most basic level, it arises when an individual consumes more energy, in the form of food, than is expended (Stein et al., 2000). While this simple equation inevitably results in weight gain the factors that lead to this energy imbalance are multifaceted and complex. A combination of be havioral and biological variables, including physical inactivity, excessive caloric intake, high fat diets, low resting metabolic rate, low rates of fat oxidation, insulin sensitivity, and high fat cell numbers, all contribute to the development and maintenance of obesity (Brownell & Wadden, 1992; Stein et al., 2000; Tataranni & Ravussin, 2002). Despite evidence to suggest that up to 70% of the variance in BM I is attributable to genetic factors, it has been acknowledged that at leas t some of the remaining 30% non-genetic variance could be accounted for by normal physiological variability within a pathoenvironment (Tataranni & Ravussin, 2002, p.61). Proponents of an environmental explanation for obesity describe modern American society as toxic, ch aracterized by the widespread availability and marketing of cheap and quick energy dense foods, high in fat and sugar and low in nutritional value, and an increasingly sedentary lifestyle coupled with a glorif ication of thinness and stigmatization of fatness (Battle & Brownell, 1996; Henderson & Brownell, 2004; Irving & 16

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Neum ark-Sztainer, 2002; Wadden, Brownell, & Fost er, 2002). As Battle and Brownell (1996) note, it is difficult to envision an environmen t more effective than ours for producing nearly universal body dissatisfaction, preo ccupation with eating and weight, and clinical cases of eating disorders and obesity (p. 761). Physical and Psychological Consequences of Obesity The im pact of overweight and obesity on physical health is substant ial. Obesity-related medical conditions include heart disease, st roke, hypertension, hyperlipidemia, gallbladder disease, osteoarthritis, certain types of cancer and sleep apnea (Centers for Disease Control [CDC], 2006). The impact of obesity on life ex pectancy varies according to level of BMI. When BMI reaches 30.0, the risk of death is elevated by 30%, and when BMI reaches 40.0, risk of death becomes 100% higher than for a nor mal weight person (Manson et al., 1995). Premature death in obese persons is most often associated with cardiovascular disease, Type 2 diabetes, and some cancers (Nat ional Heart, Lung, and Blood Institute [NHLBI], 1998). Approximately 300,000 deaths per year are related to compli cations of obesity (Allison, Fontaine, Manson, Stevens, & VanItallie, 1999). In addition to its adverse impact on health and longevity, obesity significantly compromises psychological functioning and qua lity of life (Wadde n, Womble, Stunkard, & Anderson, 2002). One study found approximately 16% of a community sample of obese individuals met criteria for major depressive disorder, compared to 7.5% among normal weight individuals (Roberts, Kaplan, Sh ema, & Strawbridge, 2000). Obese persons have been found to experience prejudice and discrimination in wor k, school, and interpersona l situations (Puhl & Brownell, 2002). Consequences of obesity appear to be far worse for women, due to the greater societal importance placed on appearance in wo men than in men. One study, for example, found 17

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higher rates of depression and increased risk for suicide in obese wom en, but not obese men (Carpenter, Hasin, Allison, & Faith, 2000). Among obese women seeking treatment for weig ht loss, depressive symptoms are also related to body image distress and low self-esteem (Foster, Wadden, & Vogt, 1997; Sarwer, Wadden, & Foster, 1998). Additionally, a subset of obese women (approximately 8%) report extreme body dissatisfaction causing c linically significant impairment or distress in social, workrelated, or other areas of func tioning (Sarwer et al., 1998). For the majority of overweight women seeking treatment, body image distress app ears to play a significant role in their motivation to pursue weight loss (Sarwer, Gr ossbart, & Didie, 2001) Collectively, these findings suggest that obesity in women can be associated with adverse psychological consequences such as body dissatisf action, depression, and low self-esteem. Overweight and obese women are al so more likely to engage in sub-clinical levels of binge eating (Marcus, 1993) and unhealthy weight control pr actices (i.e., diet pills laxatives, diuretics; Neumark-Sztainer, Story, Faul kner, Beuhring, & Resnick, 1999). Binge eating consists of consuming unusually large amounts of food, usually hi gh in fat, without the use of compensatory behaviors such as exercise, pur ging, or fasting (American Psychiatric Association [APA], 2000). Other criteria include feeling a lack of control over eating, ma rked distress and guilt over bingeing, and secretive eating (Kristeller & Hallett, 1999). Obese binge eaters typically report greater levels of dysphoria than obese non-bingers (de Zwaan et al ., 1994; Wadden, Foster, Letizia, & Wilk, 1993), have a more perfectionist at titude toward dieting, and report constantly struggling to control their urge s to eat (Gormally, Black, Dast on, & Rardin, 1982). Individuals who binge also have been shown to have a decreased awareness of their hunger and satiety, 18

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which is critical for the regulat ion of food intake and m aintenance of weight (Hadigan, Walsh, Devlin, LaChaussee, & Kissileff, 1992; Hetherington & Rolls, 1989). Overweight and obesity prevalence rates are increasing at an alarming pace in the U.S. (Henderson & Brownell, 2004). Data from the 1999-2002 National Health and Nutrition Examination Survey (NHANES) conducted by the CDC indicate an estimated 65% of American adults are either overweight or obese. Overweight and obesity are now considered a major public health problem, and according to the U.S. Department of Health and Human Services, a study of national costs attributed to overwei ght and obesity found that medical expenses accounted for 9.1% of total U.S. medical expenditu res in 1998 and may have reached as high as $78.5 billion (Finkelstein, Fiebelkorn, and Wang, 2003). Obesity Prevention and Early Intervention Obesity prevention has becom e an important public health focus (U.S. Department of Health and Human Services, 2001 ; Koplan & Deitz, 1999). One prevention strategy proposed is to identify critical periods of weight gain across the life span and create targeted interventions for those at-risk populations (Anderson, Shapiro, & Lundgren, 2003; Levitsky, Halbmaier, & Mrdjenovic, 2004; Mullis et al., 2004). While wei ght gain in adulthood is usually a very slow process, caused by small changes in energy bala nce (i.e., intake exceeds output) over time, there is one segment of the population that may be particularly at ri sk for a large change in energy balance in a relatively short pe riod of time. The transition from high school to college is associated with many lifestyle changes that can lead to weight gain, in cluding all-you-can-eat buffet style dining halls, increa sed availability of fast food and junk food, and increased consumption of alcohol, all of which have been linked to weight gain in college freshmen (Levitsky, Halbmaier, & Mrdjenovic, 2004). Anot her study found weight increases in a sample of college freshmen, with 25% of participants gaining at least 2.3 kg ( 5.1 lbs) during the first 19

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sem ester of college (Anderson, Shapiro, & Lun dgren, 2003). These researchers found that the proportion of participants classified as overweight or obese nearly doub led over the first two semesters of college, highlighting the importance of addressing the issue of weight maintenance in this population. The Freshman Fifteen As previously discussed, m any college women are preoccupied with thinness and exhibit a high level of concern about weight and body imag e. The Freshman Fifteen, a belief that college freshmen gain 15 pounds during their first year on campus, may se rve to elevate this level of concern (Graham & Jones, 2002). Although the Freshman Fifteen is commonly believed to be true, there is evidence that th e concept may be more myth than fact (Hodge, Jackson, & Sullivan, 1993; Megel, Wade, Hawkin s, Norton, & Sandstrom, 1994). Hodge et al. (1993) surveyed a sample of college women and f ound that the majority did not change weight in the first six months of college. Those women w ho did gain weight, howev er, gained an average of seven pounds. In another sample of college women, Megel et al (1994) found that the average weight gain over the freshman year was only two and a half pounds. Regardless of whether college women gain 15 pounds or five pounds, preoccupation with body weight in this population ha s been linked to increased leve ls of self-degradation and body dissatisfaction (Britton, Martz, Bazzinin, Curtin, & LeaShom b, 2006) and maladaptive eating behavior (Ackard, Croll, & Kearney-C ooke, 2001). As young women leave the home environment for college, they are challenged with the responsibility of balancing exercise, nutritional intake, and body weight in a culture th at equates thinness with attractiveness. Food consumption patterns of college students are of pa rticular concern because the tendency is to skip meals, follow overly restrictive diets, eat more "fast" foods, and snack on high-fat, sugary junk foods. Psychological health risk s associated with poor nutritiona l practices include diminished 20

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self-esteem and body dissatisfaction. Based on the dual-pathway model previously presented, body dissatisfaction in this populati on can lead to excessive dietar y restraint and negative affect, which can potentially lead to binge eating and weight gain. Collectively, these findings support the need for an effective weight management and body image intervention targeted for this population. Behavioral Treatment of Obesity In contrast to evidence supporting the dual pa thway m odel, results from experimental studies of behavioral we ight loss programs have not found dietary restraint to be a key factor in the development of binge eating and other pat hological eating behavior The National Task Force on the Prevention and Treatment of Obesity (2000) has stated, concerns that dieting induces eating disorders or other psychological dysfunction in overweight and obese adults are generally not supported [and] such concerns should not preclude attempts to reduce caloric intake and increase physical activity to achieve modest weight loss or prevent additional weight gain (p. 2587). Studies of overweight and obese individuals placed on low-calorie diets in controlled trials have not shown subsequent increases in binge eating (Por zelius, Houston, Smith, Arfkin, & Fisher, 1995; Wadden, Foster, & Letizia, 1994; Wadden et al., 2004) Furthermore, studies on obese individuals with binge eating disorder found significant decreases in binging over the course of behavioral weight loss treatments (Marcus, Wing, & Fairburn, 1995; Porzelius et al., 1995). Presnell and Stice (2003) replicated thes e findings in a non-obese sample of young adult women who were randomly assigned to a six-week, low calorie, behavioral weight loss treatment or a waitlist c ontrol group. Participants in behavioral interventions lear n strategies to help modify their eating and physical activity patterns, so as to produce a nega tive energy balance and s ubsequent weight loss. The key components of a behavioral program include decreased energy intake (i.e., 1200-1500 21

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kcals/day and < 30% kcals of total/day from fats for women) and increased physical activity (e.g., energy expenditure > 1000 kcals/ week). The behavioral treatment procedures used to achieve changes in diet and ex ercise patterns typically includ e self-monitoring, problem-solving, goal setting, and relapse prevention. Reviews of randomized trials have consistently demonstrated that a 15to 26-week behavioral intervention produces an average of 8.5 kg weight loss, approximately 9% of body weight ( NHLBI, 1998; Perri & Corsica, 2002). The ability of weight loss treatments to produce clinically meaningful outcomes has been well-established and weight loss through diet and exercise is still considered the principle and most effective method to improve health (NHL BI, 1998). Nevertheless, proponents of what has been called an anti-dieting movement contend that dieting is actually ine ffective and harmful. This argument stems from the well-established fi nding that dieting is in effective in producing long-term weight loss (Garner & Wool ey, 1991; Kassirer & Angell, 199 8; Miller, 1999; Perri & Corsica, 2002; Wadden, 1993). Mille r (1999) states that all review articles on the effectiveness of diet and exercise for weight control over the past 40 years have concluded that diet and exercise are ineffective in producing substantial long term weight loss for the majority of participants (p.212). Indeed, di eters usually end up weighing more not less, after a diet. The Maintenance Problem Perri (1998) has proposed that t he m aintenance of treatment effects represents the single greatest challenge in the long-te rm management of obesity (p 526). Poor maintenance of weight loss likely results from a combination of physiological, environmental, and psychological factors. Cooper and Fairburn (2001) have offered a cognitive-behavioral explanation with regard to the maintenance problem. They suggest two sets of interrelated factor s are responsible for a persons inability to maintain lost weight. Fi rst, overweight individuals present for treatment with primary goals (p. 503) for weight lo ss that include improving appearance or body 22

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satisfaction, im proving attractiveness to others improving self-confidence and self-esteem, improving interpersonal relationships, and to a lesser extent, improving health and mobility. At the end of treatment, body weight is not likely to match the individuals expectation (Foster, Wadden, Vogt, & Brewer, 1997; Wa dden et al., 2003) and the perc eived benefits such as improved attractiveness, self-est eem, and interpersonal relationships typically have not been achieved (Cooper & Fairburn, 2001). Having reached neither their weight loss goals, nor the anticipated benefits, participants minimize the significance of their modest weight loss, and abandon their weight loss efforts. The second reason overweight persons are unable to maintain weight loss, according to Cooper and Fairburn, is that they do not receive training in the maintenance of lost weight. For example, participants are not taught how to follow a weight maintenance diet as opposed to a weight loss diet. Furthermore, they undervalue or discount the weight loss that they have achieved during treatment, and they are unable to consider or accept weight maintenance as a worthwhile goal. In a study of weight maintenance and relaps e in obesity, Bryne, Cooper, and Fairburn (2003) identified several beha vioral, cognitive, and affectiv e factors that were found to discriminate between individuals who were succe ssful in maintaining lost weight and those who were not. They identified three groups of individuals. Maintainers we re women with a history of obesity who, through deliberate ca loric restriction, had lost at least 10% of their body weight in the previous two years and had maintained that weight within 3.2 kg (7.1 lbs) for at least one year. Regainers were women wh o had lost at least 10% of th eir body weight in the previous two years, but had regained weight to within 3.2 kg (7.1 lbs) of their original body weight. The stable weight group consisted of women without a history of obesity who had maintained a healthy weight (within a range of 3.2 kg or 7.1 lbs) for at least two years. 23

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In term s of behavior, Regainers were less li kely to report adherence to a low-fat diet, regular exercise, and weight monitoring than Maintainers. In terms of cognitive and affective factors, Regainers were less likely than Maint ainers to have achieved their goal weights, and expressed dissatisfaction with their new lower we ight. Finally, Regainers were found to place greater importance on weight and shape evaluatio n and ate in response to negative moods and adverse events more often than Maintainers. Th ese results suggest that weight regain may be due, in part, to unaddressed psyc hological factors and an inability to self-regulate which undermines weight control efforts, and that weig ht management interventions should be designed to address issues of body acceptance, self-esteem, self-regulation and coping. Empirical Support for Addressing Psychol ogical Factors in Behavioral Treatment The studie s summarized below all attempte d to address psychological factors in overweight or obese samples seeking to lose weight. These studies emphasized weight maintenance, size acceptance, and healthy eating, and several of these interventions utilized a nondieting approach in which weight loss through dietary restriction was not the primary method of treatment. In a study by Rapoport, Clark, and Wardle ( 2000), women who focused on self-acceptance and permanent lifestyle change were successf ul in achieving modest improvements in body image dissatisfaction and selfacceptance, but only lost approximately 2 kg (4.4 lbs). A study comparing a nondieting treatment vers us dieting treatment for overweight bingeeating women showed that the nondieting inte rvention aimed at helping women manage psychological issues related to binge eating was not successful in producing short or long-term weight loss (Goodrick, Poston, Kimball, Reeves, & Foreyt, 1998). Tanco and colleagues (1998) conducted an 8week intervention comparing a nondieting treatment in which participants were simply given instruction on healthy eating against a 24

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behavioral treatm ent in which participants were instructed to consume 1,200 to 1,500 kCalories/day. Greater improvements in mood and in some measures of eating-related pathology were seen in the nondieting group compared to th e standard group and a wait-list control. Both treatment groups lost only modest amounts of weight (1.8 kg [3.9 lbs] and 2.6 kg [5.7 lbs], respectively). Sbrocco and colleagues (1999) compared a trad itional behavioral treatment program using a 1,200 kCals/day diet against a behavioral choice program coupled with a moderately restricted diet of 1,800 kCals/day. After the 13-week treatment, bot h groups experienced significant increases in self-esteem and the be havioral choice group showed a significant decrease in dietary restraint. The traditional group experienced greate r weight loss (5.6 kg [12.3 lbs] vs. 2.5 kg [5.5 lbs]) post-treatment, but after a year, the beha vioral choice group had continued to lose weight (10.1 kg [22.3 lbs] mean weight loss at 1-year follow-up), whereas the traditional group had actually gained weight (4.3 kg [9.5 lbs] mean weight loss at 1-year follow up). Allen and Craighead (1999) compared an 8-w eek appetite awareness treatment focusing on responding to moderate signals of hunger and satiety against a waitlist control. At the end of treatment, the appetite awareness group showed significant improvements in binge eating, selfesteem, and depression. Neither group show ed any significant changes in weight. Ames et al. (2005) compared a 10-session reformulated cognitive-behavioral intervention designed to address un realistic expectations and motiv ations for weight loss against a standard behavioral weight loss program. At post-treatment, the cognitive-behavioral intervention produced more realisti c weight loss expectations and increased overall self-esteem. 25

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Mean post-treatm ent weight changes were equiva lent across conditions, as were the amounts of weight regained during a 6-month follow-up. Notably, none of these trials re vealed significant differential resu lts in terms of lost weight. When successful weight loss over time did occur, the amounts reported fell short of the threshold for significant health benefits in moderately overweight individuals. However, in each study there were moderate to signifi cant improvements in various measures of psychological wellbeing. These findings generally support the notion that a weight loss intervention designed to address some of the psychological components of weight loss, as well as the behavioral, may be more effective in the successful maintenance of lost weight and in the continued improvement of body image. Successful long-term weight loss interventions involve two key components. First, a weight loss of at least 5% of initial body weight is necessary. The can only be achieved through a negative energy balance (i.e., reduced energy in take and increased energy expenditure). Wellestablished behavioral weight loss protocols exist to guide this process (Wing, 2002). However, weight loss efforts will be part ially, if not completely, undermi ned if the second key component is not present addressing the psychological issues associated with the weight loss process and the factors contributing to the maintenance of overweight and obesity. While behavioral weight loss protocols have been clearly established, parallel standards addressing interventions for psychological factors in weight loss and weight maintenance remain a topic of debate. A mindfulness-based inte rvention may provide an effective treatment component to improve the efficacy of many wellestablished interventions. The rationale for using this type of treatment adjunct will be presented in the following sections. 26

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Mindfulness Meditation Mindfulness is defined as the awarene ss that emerges through paying attention on purpose, in the present moment, and nonjudgmen tally (Kabat-Zinn, 2003, p. 145). Mindfulness has been considered an enhanced attention to and awareness of current experience or present reality (Brown & Ryan, 2003, p. 822). Awareness is considered the background of consciousness, or the continual monitoring of internal and external stimuli; attention is the process of bringing ones conscious awareness into focus. A de fining feature of mindfulness is an open or receptive awareness and attenti on, making mindfulness essentially an enhanced state of focused consciousness. This is in contrast to consciousness that is restricted or divided. Rumination on the past, for exampl e, or anxiety about the future can pull ones awareness and attention from the present moment. When one is occupied with multiple tasks or preoccupied with various concerns, the quality of engagement in the present moment is also likely to be compromised. Mindfulness is further compromi sed when individuals act impulsively or compulsively, without awareness of or attenti on to ones behavior (Deci & Ryan, 1980), thereby setting the stage for the potential utility of mi ndfulness training as a therapeutic or wellness intervention. The ability to direct ones awareness and atte ntion in an open or receptive way is often developed through meditative practices. Meditation is defined as the in tentional self-regulation of attention from moment to moment (Gol eman & Schwarz, 1976; Kabat-Zinn, 1982). While meditation is often simplistically represented as a relaxation technique, it appears to be better construed as a means for promoting self-awarene ss and self-regulation, for decreasing emotional reactivity, and for enhancing insi ght and integration of perceptu al, cognitive, and behavioral aspects of functioning (Kristeller, 2003). Thus training in mindfulness meditation may allow for 27

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enhanced se lf-awareness and insight, and may help modify dysregulated emotional, cognitive, physiological, and behavioral aspects of functioning (Kristel ler & Hallett, 1999). In sum, mindfulness captures a quality of consciousness characterized by receptive awareness, clear focus, and the nonjudgmental obse rvation of current expe rience, both internally and externally. It stands in contrast to mindl ess habitual or automatic functioning that can be chronic and dysfunctional for some individuals. Mindfulness, then, may play an important role in disengaging individuals from destructive au tomatic thoughts and unhealthy behavior patterns, and in fostering self-enhanced emotional and beha vioral regulation associated with psychological wellness (Ryan & Deci, 2000). Indeed, the empiri cal literature to date on the effects of mindfulness training suggests that mindfulness inte rventions may lead to reductions in a variety of problematic medical and psyc hological conditions, including chronic pain, stress, anxiety, depressive relapse, and disordered eati ng (e.g., Kabat-Zinn, 1982; Ka bat-Zinn et al., 1992; Kristeller & Hallett, 1999; Shapir o, Schwartz, & Bonner, 1998; Teasdale et al., 2000). Several of these interventions will be reviewed in the next section. Mindfulness as a Clinical Intervention Jon Kabat-Z inn, founder of the Center for Mi ndfulness in Medicine, Health Care, and Society (CFM) at the University of Massac husetts, developed a mi ndfulness-based stress reduction (MBSR) program for use in behavioral medicine settings with chronic pain patients and others with stress-related disorders. Kaba t-Zinns protocol utilizes a group format offered over eight to ten weeks. The group offers in struction and practice in mindfulness meditation skills. These include a 45-minute body scan of sensations, breathing exercises, yoga postures and stretching, and the practice of mindfulness during activities like walking, standing, and eating. Participants are instructed to practice these skil ls between sessions fo r at least 45 minutes per day, six days a week. During mindfulness exercises, participants are instructed to focus their 28

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atten tion on the target of observa tion (e.g., breathing) and to be aware of it in each moment. When emotions, sensations, or cognitions aris e, they are to be observed nonjudgmentally. Participants are instructed to notice their thoughts and feelings, but not become absorbed in their content or try to avoid them or change them (Kabat-Zinn, 1982). Ev en judgmental thoughts, such as this is a foolish waste of time, are to be observed nonjudgmentally and labeled simply as thoughts. Attention is then returned to the present moment and the target of observation. Thus, an important teaching component of mindfu lness practice is the realization that most sensations, thoughts, and emotions, including painfu l ones, are transient and temporary (Linehan, 1993). Teasdale, Segal, and Williams (1995) proposed that the skills of attent ional control taught in mindfulness meditation could be helpful in pr eventing relapse of major depressive episodes and developed mindfulness-based cognitive therapy (MBCT) based upon this assertion. MBCT is an 8-week group intervention incorporating el ements of cognitive ther apy that facilitate a detached view of ones thoughts, emotions, and bod ily sensations. MBCT is designed to prevent depressive relapse by teaching formerly depressed individuals how to observe their thoughts and feelings nonjudgmentally, to view them simply as thoughts that co me and go, rather than aspects of themselves, or as accurate re flections of reality (Baer, 2003). This is believed to prevent the escalation of negative thoughts into ruminative pa tterns characteristic of major depressive episodes (Teasdale et al., 1995). Several other treatment models are congrue nt with mindful appr oaches to symptom reduction. For example, dialectical behavior th erapy (DBT) is a comprehensive approach used most often in the treatment of borderline pe rsonality disorder (Linehan, 1993), and recently adapted for use in the treatment of bulimia nervosa (Safer, Telch, & Agras, 2001) and binge 29

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eating disorder (Telch, Agras, & Linehan, 2001). It is based on a dialectical worldview, which assum es that reality consists of opposing forces, or dialectics. In DBT, the central dialectic is the relationship between acceptance and change. Pati ents are encouraged to balance acceptance of who they are with changing their dysfunctional beha vior in order to build a life worth living (McCabe, LaVia, & Marcus, 2004, p. 235). In ad dition to mindfulness skills, DBT clients are taught interpersonal effectiven ess, emotion regulation, and di stress tolerance skills. Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) is another comprehensive treatment approach that includes several strategies cons istent with mindfulness training. ACT clients learn to experience thei r thoughts and emotions as they happen, without evaluating or attempting to change or avoid them but instead accepting them as they are, while modifying their maladaptive behaviors in constr uctive ways to improve their lives (Baer, 2003). Mindfulness skills have been adapted for use in substance abuse relapse prevention as well (Marlatt & Gordon, 1985). In this context, mi ndfulness involves accep tance of the present moment, which is in direct contra st to addiction an inability to accept the present moment and a persistent seeking of escape, or the next high. Mindfulness skills enable the client to observe their urges as they occur, accept them nonjudgmen tally, and cope with them in more adaptive ways, knowing they will pass. The notion of using meditation in clinical interventions was originally pioneered by Herbert Benson (1975), physician and founder of the Mind/Body Medical In stitute (M/BMI) at Harvard University, and the value of meditation in treating stress and anxiety has been widely supported in the litera ture (Delmonte, 1987; Eppley, Ab rams, & Shear, 1989). Mind/body interventions conducted at the M/BMI include el ements of cognitive-behavioral therapy and lifestyle modification (i.e., diet and exercise), in addition to meditation skills training. These 30

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interventions have been used successfully in the reduction of m edical symptoms and in disease management protocols for hypertension, heart disease, chronic pain, insomnia, infertility, menopause, and other conditions with an identifiable stress component. Benson (1975) has written extensively a bout mind/body medicine and one of its fundamental elements, the relaxation response. The relaxation response is elicited through the repetition of a word, sound, phrase, or activity, and the passive disreg ard or avoidance of distracting thoughts. Clearly, there are similarities between mindfulness training and the elicitation of the relaxa tion response as described by Benson (1975). One distinction, however, is in practicing mindfulness, one does not avoid distracting thought s. Distracting thoughts are simply thoughts to be observed and accepted. A nother distinction is, that although the induction of relaxation through meditation has been well-documented (Benson, 1975; Orme-Johnson, 1984; Wallace, Benson, & Wilson, 1984), the purpose of mindfulness training is not to induce relaxation, but to teach nonjudgmental observation of current experience, which might include autonomic arousal, racing thoughts, and muscle tension, all of which are incompatible with relaxation (Baer, 2003). Even so, mindfulness meditation is listed as one of several techniques used to evoke the relaxation response, thus suppor ting its role as an eff ective component in the practice of mind/body medicine and as a potential mechanism for behavior modification. Other potential mechanisms of change ar e presented in the next section. Mechanisms of Change in Mindfulness Sustained, nonjudgm ental observation of negative sensations such as pain, or negative emotions such as anxiety, without attempts of es cape or avoidance, may lead to reductions in the emotional reactivity typically el icited by such stimuli (Kabat-Zi nn et al., 1992). Linehan (1993) also suggests that prolonged observation of cu rrent thoughts and emoti ons, without trying to avoid or escape them, can be seen as a type of exposure, which should encourage the extinction 31

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of fear responses and avoidance behaviors prev iously elicited by these stimuli. Thus, the practice of m indfulness skills ma y improve a patients ability to tolerate negative emotional states and the ability to cope with them effectively (Baer, 2003). It has been noted that the practice of mindfulness may also lead to changes in maladaptive thought patterns, or in attitudes about ones thoughts. The nonjudgmental observation of anxiety-producing thoughts, for example, may l ead to the understandin g that they are just thoughts and do not necessitate escape or avoidance (Kabat-Z inn, 1990). Similarly, Linehan (1993) notes that observing ones thoughts or f eelings and applying nonjudgmental labels to them encourages the understanding that they are not always accurate reflections of reality. Kristeller and Hallett (1999), in a study of MBSR in patients with binge eating disorder, cite Heatherton and Baumeisters (1991) theory of bi nge eating as an escape from self-awareness and suggest that mindfulness trai ning might develop nonjudgmental acceptance of the aversive conditions that binge eaters are t hought to be avoiding, such as unf avorable comparisons of self to others. Teasdale (1999) suggests that mindfulness training may enable formerly depressed individuals to notice depressoge nic thoughts and to redirect attention to other aspects of the present moment, thus avoiding rumination. Several authors have noted that improved self-observation resulting from mindfulness training may promote more effective self-management of behavior and the use of more adaptive coping skills. For example, Kristeller and Halle tt (1999) suggest that th e self-observation skills and awareness of physiological signals developed through mindf ulness training may lead to improved recognition of and response to satiety cues in binge eaters. And, as a means of improving self-acceptance, it may decrease the use of disordered eating as a coping mechanism (Heatherton & Baumeister, 1991). Ma rlatt (1994) suggests the increased ability to observe urges 32

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without yielding to them is im portant for patients recovering from addictions as well. Mindfulness training may also help in the reduct ion of maladaptive impulsive behaviors due to a heightened recognition and understa nding of the consequences of su ch behavior (Linehan, 1993). The relationship between acceptance and change has become a central component in the practice of psychotherapy, and the tenet of so me empirically-based treatment methods (e.g., ACT, DBT). Hayes (1994) suggests that accep tance involves experiencing events fully and without defense, as they are ( p. 30). Acceptance is fundamental in the practice of mindfulness (Kabat-Zinn, 1990), and the understanding that no t all unpleasant experi ences need to be changed. For some individuals, it is more impor tant to learn that unpl easant experiences are transient and can be managed effec tively without escape or avoidance. Mindfulness versus Traditional Cognitive Therapy Cognitive interventions traditionally have fo cused on helping clients change aspects of their thinking. Similar to the mechanisms of ch ange in traditional cognitive therapy, training in self-directed attention can result in sustained exposure to sensations, thoughts, and emotions, resulting in desensitization of conditioned responses and reducti on of avoidance behavior. In addition, cognitive change appears to result from viewing ones thoughts as temporary without inherent worth or meaning, rather than as n ecessarily accurate reflect ions of reality. In contrast to traditional cognitive ther apy, mindfulness training does not include the evaluation and labeling of thought s as irrational or disto rted, nor does it include the systematic attempt to change such labeled thoug hts. Secondly, traditional cognitive-behavioral procedures typically have a clear goal, such as to change a behavior or thinking pattern, whereas mindfulness is practiced with an attitude of what has been ca lled, nonstriving (Baer, 2003, p. 130). That is, although participants may have sought treatment for a particular purpose, they are not taught how to relax, reduce thei r pain, or change thei r thoughts or emotions. They are simply 33

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taught to observe whatever is happening in ea ch m oment without judging it. Nevertheless, individuals who practice th ese skills may indeed experience reduc tions in a variety of symptoms. The empirical literature addressi ng this particular issue is revi ewed in the next section. Empirical Support for Mindfulness-Based Interventions A meta-analysis (Baer, 2003) of twenty-one studies rev ealed that mindfulness-based interventions are clinically efficacious for a vari ety of populations, includi ng patients with Axis I disorders (e.g., generalized anxiety disorder, bing e eating disorder, major depressive disorder), patients with medical conditions (e.g., fibromyalgia, psoriasis, cancer), mixed populations, and nonclinical populations. Sample size s in these studies ranged from 16 to 142, with a mean age of participants ranging from 38 to 50 years. The gender ratio ranged from 0 to 46% male. Nine studies used pre-post designs w ith no control group; nine us ed between-group designs with treatment-as-usual (TAU) or wait-list control gr oups; three were follow-up studies. Dependent variables for the majority of these studies in cluded self-report measur es of pain and other medical symptoms, anxiety, depression, eating be haviors, and general psychological functioning. Post-treatment effect sizes ranged from 0.15 to 1.65, with an overall mean effect size of 0.59, suggesting mindfulness-based inte rventions have yielded at leas t medium-sized effects (Cohen, 1977). Baers (2003) review included four studies that examined th e effects of mindfulness-based stress reduction (MBSR) on chronic pain pati ents (Kabat-Zinn, 1982; Kabat-Zinn, Lipworth, & Burney, 1985; Kabat-Zinn, Lipworth, Burney, & Sellers, 1987; Randolph, Caldera, Tacone, and Greak, 1999). In general, findings revealed si gnificant improvements in pain ratings, other medical symptoms, and general psychological symptoms, and many of these changes were maintained through a series of follow-up evaluati ons. Her review included one study by KabatZinn et al. (1992) that examined a sample of 22 patients with generaliz ed anxiety and panic 34

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disorders, and found significant im provements in several measures of anxiety and depression, both at post-treatment and at a 3-month follow-up evaluation. Miller, Fl etcher, and Kabat-Zinn (1995) reported results from a 3-year follow-up to that study and found treatment gains had been maintained. Her review also included a study by Teasdale et al. (2000), which examined the effects of mindfulness-based cogni tive therapy (MBCT) on rates of de pressive relapse in a large sample of patients whose major depressive disorder had remitted after psychopharmaceutical treatment. In a randomized controlled trial comparing an 8-week manualized group treatment (MBCT) to treatment-as-usual (TAU), results showed much lower relapse rates for MBCT patients (37%) than for the TAU patients (66%), in those with three or more previous depressive episodes. With respect to two studies utilizing a nonclinical sample, both Astin (1997) and Shapiro et al. (1998) found significa nt effects on various measures of psychological symptoms in college and medical students who completed training in MBSR. Of particular relevance to th e issues presented here, Kriste ller and Hallett (1999) examined the efficacy of a 6-week MBSR intervention fo r binge eating disorder in 18 obese women. Results from this study, which used a prepost design, showed statistically significant improvements in several measures of psychologi cal functioning and eatin g behavior, including a significant decrease in the numbe r of binges per week and an increased sense of control. Baer (2003) provides data on attr ition, adherence, and maintenance of mindfulness practice as reported in these studies. The percentage of enrolled participants who completed treatment ranged from 60 to 97%, with a mean of 85%. Of the three studies that assessed the extent to which participants completed their assigned homew ork, one reported that pa rticipants engaged in 15.82 hours of meditation across the 6-week intervention period (Kristeller & Hallett, 1999), one reported that participants pract iced meditation for an average of 30 minutes a day, three and a 35

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half days per week (Astin, 1997), and one reported that 90% of their sam ple practiced three times per week or more and 57% prac ticed nearly every day for 15 to 30 minutes each time (Reibel, Greeson, Brainard, & Rosenzweig, 2001). Three studies reported the extent to which participants trained in mindfulness skills continued to practice these skills after treatment ended. Kabat-Zinn et al. (1987) noted th at 75% of former participants reported they still practiced meditation (averaged across intervals of 6 to 48 months). Kabat-Zinn et al. (1992) found that 84% of former participants repo rted practicing meditation or yoga three or more times per week at a 3-month follow-up evaluation. Williams et al. (2001) reported that at a 3-month follow-up, 81% of MBSR participants were still practici ng meditation, yoga, or awareness of breathing in their daily lives. In sum, Baers (2003) review suggests that mindfulness-based interventions may indeed be clinically efficacious, but that better designed studies are needed. It was shown that many participants who enroll in mindfulness-based pr ograms will likely complete their assigned homework and maintain mindfulness practice up on completion of the intervention. Mindfulnessbased interventions appear to be conceptually consistent with many other empirically supported treatment approaches and may provide a techno logy of acceptance to complement the technology of change exemplified by most traditional cognitive-b ehavioral procedures (Linehan, 1993). Mindfulness as a Treatment for Body Image and Eating Issues It can be argued that an i ndividuals relationship to food a nd eating encompasses all m ajor domains of human functioning: physiological, cognitive, emotional, and behavioral. Food is necessary for basic physiologi cal functioning and the body cont ains numerous biofeedback signals to initiate and terminate eating. While most individuals ignore or override hunger and satiety signals on occasion, some individuals, especially those w ith overly restrictive diets or subclinical eating pathology like compulsive binge eating, appear to be particularly disengaged 36

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from this physiological information (Hetheringto n & Rolls, 1989; Hadigan et al., 1992). These individuals also often feel out of control, frustrated, disguste d, and guilty when they overeat (Kristeller, 2003). Unlike other compulsive behaviors in whic h abstinence is possible (i.e., smoking, alcohol abuse), abstinence from eating is not. Moderation, balance, and flexibility must be learned, and to the extent that being mindf ul aids in establishing those skills, training in mindfulness meditation may be particularly helpful. In our society, many young women develop unhea lthy relationships w ith their bodies and food, leading to deeply ingrained maladaptive eating patterns and body image distress. This powerful interaction can obscure basic nutritional needs, as what one chooses to eat becomes a function of cognitive directive, em otional self-soothing, or external cues instead of biological or physiological ones. And, the notion of food as a viable source of pleasure or satisfaction becomes distorted. Mindfulness skills training may be particularly well-suited for treating such problems by establishing in-the-moment, non-judgme ntal self-observation skills that reinforce a sense of acceptance, balance, and control. Kristeller (2003) has proposed that finding a sense of balance and acceptance in relation to food and eat ing may foster a greater capacity for selfregulation and control, which can then be extended and applied to other areas of conflict in a persons life. Given the growing body of evid ence to suggest that chronic dieters and compulsive eaters are disengaged from internal self-regulatory sy stems and overly influenced by external and emotional cues (Rodin, 1981; Kris teller & Rodin, 1989; H eatherton & Baumeister, 1991), this theory may hold merit. By extensi on, mindfulness training, ba sed on this theory and adapted for use in this particul ar population, coupled with basic behavioral skills for weight management, could be extremely beneficial. 37

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Study Justification and Primary Aims The potential efficacy of using mindfulness as an adjunct to st andard behavioral treatment to address issues of body image, psychological functioning, eating behavior, and weight management seems promising. In light of the issues and the implications presented here, the need for a targeted and structur ed intervention for weight mana gement and wellness in college women is warranted. Furthermore, because of the increasing popular ity of interventions based on training in mindfulness skills, more methodologically sound investigations have been recommended in order to clarify the construct, a nd validate its clinical applicab ility and effectiveness (Baer, 2003; Brown & Ryan, 2004; Roemer & Orsillo, 2003; Hayes & Feldman, 2004; Kabat-Zinn, 2003). To date, there have been no published studi es comparing behavi oral treatment to behavioral treatment plus mi ndfulness training in the cont ext of body image and weight management in college women, with appropriate experimental control for shortand long-term effects. This study investigated the differentia l effectiveness of mindf ulness training coupled with a standard behavioral weight loss treatmen t protocol in a sample of overweight college women. The primary outcome measure was self-re ported body image. Secondary outcomes included various aspects of psychological functioning, eating behavior, and weight. Data were collected at three time periods: before treatm ent, after treatment, and at three months posttreatment. It was predicted that compared to standard treatment alone, standard treatment plus mindfulness training would produce (1) greater improvement in body image satisfaction ratings after treatment and at follow-up; (2) greater improvement in self-esteem ratings, depressive symptoms, and state and trait an xiety after treatment and at follow-up; (3) greater improvement 38

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39 in binge eating after treatment and at follow-up; and (4) better weight maintenance from the end of treatment to the end of the follow-up period.

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CHAP TER 2 METHOD Participants Participan ts for this study were female students recruited from the University of Florida. Women eligible for inclusion were between th e ages of 18 and 25 and had a Body Mass Index (BMI) greater than 25. Women were excluded fr om participation if th ey were unwilling to provide informed consent, were currently involved in a commerc ial diet program, were planning to relocate out of the area, carried a current or past diagnosis of bulimia nervosa, or had a BMI greater than 35. Procedure Participants were recruited through advert isem ents placed around campus and through student website announcements. Prospective partic ipants were invited to learn more about the study by contacting the research coordinator, at which time the study was described briefly and a preliminary screening was done. Po tentially eligible participants were then invited to attend an informational meeting. At this meeting, the prog ram was described in more detail, and written informed consent was obtained. Potential pa rticipants were then weighed and height measurements were taken individually and in privat e. Participants were also asked to complete the battery of standardized self-report measures with established psychometric properties. Individuals who endorsed current symptoms of bulimia nervosa (n = 1) were contacted and provided with a referral for treatment (e.g., Psyc hology Clinic at the Un iversity of Florida & Shands Hospital). Individuals with a BMI < 25 ( n = 1) were also contacted by telephone and informed of other available c ounseling and healthy weight ma nagement treatment options. Enrolled participants were then stratified base d on a BMI median split and randomized into one of two treatment conditions: standard behavioral treatment (SBT) or standard treatment plus 40

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m indfulness (MBT). The randomization scheme was created using an online random sequence generator. Intervention One objective in each treatm ent condition was to decrease caloric intake, so as to produce a weight loss of 0.5 lb to 1.0 lb per week. Identical behavioral weight mana gement strategies were presented to participants in each condition. These strategies were offered in a group format used in previous studies (Ames et al., 2005; Fuller, Perri, Leermakers & Guyer, 1998). Participants in each treatment condition were instructed to follow a low-ca lorie, low-fat diet (e.g., 1200-1500 kCals/day; 45 to 55% primarily complex carbohy drates; 15% protein; 25 % total fat with less than 7% saturated fat). Part icipants were taught and encour aged to use goal-setting, selfmonitoring, stimulus control, problem solving, social support, reinforcement strategies, and relapse prevention skills. A treatment manua l was distributed to each participant which contained session-by-session plans with specific learning objectives, methods to accomplish the objectives, and appropriate self-monitoring ma terials. A recommendation of 30 minutes moderate to high intensity physical activity on at least five days pe r week was made, in accordance with the exercise recommendations ma de by the CDC and the American College of Sports Medicine (ACSM, 2001; Pate et al., 1995). Participants we re encouraged to check with a physician should they have any concerns about initi ating an exercise regi men. They were also given instruction on proper warm-up, cool-down, a nd stretching activities, and an opportunity to present any problems they encountered at the weekly group check-in. In addition to standard behavioral weight lo ss strategies, participants in the MBT condition were also given structured lessons on mindf ulness meditation, adapted from the mindfulnessbased stress reduction (MBSR) program devel oped by Kabat-Zinn (1982). Lessons included instruction on traditional mindfulness medita tion techniques and guided meditation exercises 41

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designed to address specific issu es pertaining to weight, shape, and eating-related self-regulatory processes su ch as appetite and satiety. The me ditative process was gradually integrated into daily activity primarily related to food craving and eating. A separate treatment manual was developed and distributed whic h contained session-by-session plans with specific learning objectives, methods to accomplish the objectives, a nd appropriate self-monitoring materials. In the MBT condition, each group session incorporated meditati on practice. Participants were provided with a recorded meditation CD desi gned to assist them in their weekly meditation practice between sessions. Mini-meditations we re also assigned, in which participants were asked to stop for a few moments at key times during the day, particularly during meal and snack times, to practice nonjudgmental awareness of th oughts and feelings. Several sessions also incorporated mindful body work, including a bod y awareness scan and introductory mindful yoga. The study session matrix is presented in Table 2-1. Both interventions were presented in a gr oup format. Sessions were conducted once a week for eight weeks. A group in each treatment condition was run on two consecutive weeknight evenings to minimize conflict with class schedules. Each session lasted approximately two hours. In the SBT groups, 30 minutes was allocated fo r check-in, review, and general problem solving, 30 minutes was alloca ted for didactic training, and 60 minutes was allocated for group activity, discussion, and homework assignment. In the MBT groups, 30 minutes was allocated for check-in, another 30 mi nutes was allocated for didactic training, 15 minutes was allocated for group activity, discus sion, and homework assign ment, and 45 minutes was allocated for mindfulness training, group activity, and homework assignment. The sessions were led by advanced graduate students in clinical and health psychology with experience in behavioral weight loss treatment. Group le aders were counter-balanced by 42

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treatm ent condition. Group leaders underwent stru ctured training in mindfulness meditation. They completed a 6-week training course and weekend retreat led by a University of Massachusetts Center for Mindfulness in Medici ne, Health Care, and Society (CFM) certified instructor. Group leaders met for weekly sess ion planning and participant management during the treatment phase. Measures Height, Weight, and Demographic Information Height and weight m easurements were taken using a calibrated and certified balance beam scale and stadiometer. Participants were wei ghed in indoor clothing, wi thout shoes, and with pockets emptied. BMI, calculated as: [weight (lb) / height (in) / height (in) x 703], was determined. Participants were asked to provi de demographic data, including age and years of education, and complete a general information fo rm, which asked about the number of previous diet attempts and any previous experien ce with yoga, Pilates, or meditation. Body Image The Multidim ensional Body-Self Relations Qu estionnaire Appearance Scales (MBSRQAS; Cash, 1994a) was used to measure general appearance satisfaction and body dissatisfaction in this study. The MBSRQ-AS is a 34-item measure that consists of 5 subscales: Appearance Evaluation, Appearance Orientation, Overweight Preoccupation, Self-Classified Weight, and the Body Areas Satisfaction Scale (BASS). The 8-item MBSRQ-BASS was used to assess trait levels of body dissatisfaction. The MBSRQ-BASS assesses satisfaction with specific body areas and features, including stomach, hips, thighs, and muscle tone. Respondents rate their level of satisfaction on a 5-point scale ra nging from (1) Very Dissatisfied to (5) Very Satisfied. Low scores on this subscale indi cate higher body dissatisfaction. The female adult norm is 3.23 (Cash, 1994a). The Appearance Evaluation (MBSRQ -AE) subscale was used to assess general 43

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appearance satisfaction. Respondents rate their level of agreem ent with statements such as, I like my looks just the way they are, or I am physically unattractive, on a 5-point scale, which ranges from (1) Definitely Disagree to (5) D efinitely Agree. High scores on this measure indicate increased dissatisfaction with general body image. This measure has demonstrated good reliability and validity in previous studies (Brown, Cash, & Mikulka, 1990). Psychological Functioning The Beck Depress ion Inventory II (BDI-II; Beck, Steer & Brown, 1996) is a revision of the BDI, one of the most widely used a nd well-validated measures of depressive symptomatology, and was used to assess dysphoria or moderate symptoms of depression. Anxiety was measured using the trait scale of the State-Trait Anxiety Inventory Y-2 (STAI; Spielberger, 1983). The STAI is a 20-item se lf-report measure that prompts individuals to indicate their agreement with each item on a 4-point scale ranging fr om (1) Not at all to (4) Very much so. Higher scores i ndicate higher levels of anxiet y. Several studies have reported adequate reliability and validity (Kaplan, Smit h, & Coons, 1995; Paolini, Yanez, & Kelly, 2006; Ray, 1984). The Rosenberg Self-Esteem Scale (RSES; Ro senberg, 1965) was used to assess global self-esteem. On this 10-item self-report measure, respondents rate statements such as On the whole, I am satisfied with myse lf and I feel that I have a number of good qualities on a 5point scale from (1) Strongly Disagree to (5 ) Strongly Agree. A higher score indicates higher self-esteem. Two-week test -retest reliability data revealed a coefficient of .85 (Silber & Tippett, 1965). Crandal (1973) reports a correlation of .59 w ith Coopersmiths (1959) SelfEsteem Inventory, and Silber and Tippett (1965) f ound a correlation of .83 w ith the Healthy SelfImages Questionnaire. 44

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Eating Behavior The Questionnaire of Eating and Weight Patt erns Revised (QEWP-R; Nangle, Johnson, Carr-Nangle, & Engler, 1994) is a 13-item self -report questionnaire developed to screen for symptoms of bulimia nervosa and binge eating di sorder using American Psychiatric Association diagnostic criteria (Spitzer et al., 1993). Test-retest reliability has been shown to be stable over a 3-week period, and the QEWP-R reliably identi fies high and low probability binge eaters (Nangle et al., 1994). Participants answered que stions designed to a ssess both behavioral (e.g., During the past 6 months, did you often eat within any two hour period what most people would regard as an unusually large amount of food?) and affective/cognitive symptoms associated with a binge episode (e.g., In general, how upset were you by th e feeling that you couldnt stop eating or control what or how much you were eatin g?). In the study, this measure was also used to screen for bulimic behaviors. Potential pa rticipants who endorsed th e use of compensatory means to facilitate weight loss (i.e., purging, laxative abuse) were excluded from participation and provided with a referral for psychological counseling. Mindfulness The Mindful Attention Awareness Scale (M AAS; Brown & Ryan, 2003) is a 15-item instrument measuring the general tendency to be attentive to and aware of present-moment experience in daily life. Using a 6-point scale from (1) Almost Never to (6) Almost Always, respondents rate how often they have experi ences of acting on automatic pilot, being preoccupied, and not paying attent ion to the present moment. Items include, I find myself doing things without paying attention, and I brea k or spill things because of carelessness, not paying attention, or thinki ng of something else. The authors report strong internal consistency (alpha = .82) as well as convergent and divergent validity with other measures of psychological well-being. This measure had been shown to differentiate between the general public and 45

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46 experienced Zen Buddhist practitioners, a group presumed to have substantial capacity for mindfulness (MacKillop & Anderson, 2007). Brown and Ryan (2003) demons trated that scores on the MAAS improved over time during an 8week standardized mindfulness-based stress reduction program and that changes on the MAAS we re related to changes in self-reported wellbeing. This measure has been validated in colleg e, working adult, and cancer patient populations and widely used to capture the acquisition of mindfulness skills in research samples.

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Table 2-1. Study session m atrix Session SBT lesson MBT lesson MBT group activity MBT assignment 1 Program introduction, understanding calories and weight management, keeping food records Introduction to mindfulness Raisin meditation Keep food and mood journal (continues all sessions) 2 Record review (continues all sessions), importance of regular eating patterns, calculating energy balance The Four Foundations of Mindfulness Chocolate meditation Eat one snack and one meal per day mindfully (continues all sessions) 3 Importance of a balanced diet, taking stock of current food intake, grains What kind of mindless eater are you? Body scan, Mindful Eating 101 Meditate with body scan CD, keep meditation homework record (continues all sessions) 4 Calculating mealtime and nonmealtime eating, fruits and vegetables Mindfulness and hunger, understanding hunger and satiety cues What is Hunger?, mindfully coping with emotional eating, physiological vs. emotional hunger Eat when physically hungry 5 Understanding the importance of monitoring dietary fats, understanding the role of exercise Mind-FULLness, understanding satiety cues Moment-to-moment eating, mindfulness of movement, mindful yoga (optional) Attend to taste and satisfaction 6 Understanding the role of protein & the importance of dairy, self-reward Understanding satiety cues (continued) Letting go of your former/future body, mindful yoga (optional) Stop eating when moderately full 7 Social eating, navigating high risk situations Understanding eating Triggers Loving kindness guided Meditation, mindful yoga (optional) Mini-meditation before meals 8 Assessing progress, relapse Prevention, managing a toxic environment Progress review Assessing progress, other meditative outlets/options/resources Eat all meals and snacks Mindfully, complete follow-up evaluation Note: MBT session material adapted from MB -EAT program (Kristel ler & Hallett, 1999) 47

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CHAP TER 3 RESULTS Participants One-hundred and ninety-three (193) wom en were screened for participation in the study. Twenty-four (24) women were screened by phone and 169 women were screened by email. One hundred and fifty-two (152) women were exclud ed from participation during this initial screening process. Two women were excluded for reporting an out-of-range age, eight were excluded for reporting an out-of-range BMI, nine were excluded for reporting plans to relocate out of the area, nine women declined participation due to time constraints, and 124 women chose not to pursue enrollment after being informed of the study inclusion criteria and treatment protocol. Following this initial screening, 47 wome n met eligibility for baseline testing. Fortythree (43) women attended the informational meeting and baseline testing session. One woman was excluded for endorsing current symptoms of bulimia and one woman was excluded for not meeting BMI inclusion criteria. Forty-one (41) women were then stratified based on a BMI median split and randomly assigned to one of two conditions: standard behavioral treatment (SBT; n = 20) or standard treatment plus mindfulness (MBT; n =21; Figure 3-1). The mean age of participants was 20.7 years ( SD = 1.4 years). Fifty-one percent (51%) were in their senior year of college. Seventy-eight percent (7 8%) reported having attempted to lose weight through dieting in the past. Nine pe rcent (9%) reported having made more than 20 attempts to lose weight through dieting in th e past. Fifty-one per cent (51%) were African American, 32% were Caucasian, 12% were Hi spanic, and 5% were Asian American. Characteristics of the study participants are s hown in Table 3-1. Of the 41 women who accepted randomization, 36 attended the firs t group session and be gan treatment. Telephone contacts with the participants who failed to show for treatment indicated that three women declined further 48

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participation due to tim e constraints and two wo men were no longer interested in treatment. There were no significant differe nces between the participants who began treatment and those who did not. Preliminary independent-samples t -tests and chi-square te sts were conducted to determine if there were any si gnificant between-condition differen ces in baseline variables. There were no significant differe nces between conditions on any demographic variable or on any of the self-report measures. Baseline characteri stics for the 36 women who started treatment are presented in Table 3-2. This study was divided into two phases, a treatment phase and a follow-up phase. The treatment phase of the program included an 8-week weight loss program for participants in both the SBT condition and the MBT condition. Treatment groups in each condition were instructed on behavioral strategies for weight loss. Treat ment groups in the MBT condition only were also instructed on mindful meditati on and mindful eating skills. The follow-up phase of the program included the three months after treatment in which no direct intervention was delivered. Completion of the treatment phase was defined as participating in both the baseline testing session and post-treatment data collection. Thirty-one participants (86%) completed the treatment phase and entered the follow-up phase of the study. Reasons given for drop-out included time constraint ( n = 2), lost interest (n = 1), relocation ( n = 1), or death in the immediate family ( n = 1). The rate of drop-out during the treatment phase was not equivalent across conditions, X2 (1, N = 36) = 7.3, p < .01. All participants who faile d to complete testing at Time 2 were in the SBT condition. Study completion was defined as participation in all three data collection periods (i.e., baseline, post-treatment, and follow-up). Twenty-t hree of the 31 particip ants (74%) who entered the follow-up phase of the program completed testi ng at Time 3 (Figure 3-1). Again, the rate of 49

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drop-out during the follow-up phase was not equivalent acr oss conditions, X2 (1, N = 31) = 5.9, p < .02. This time, all participants who failed to complete testing at Ti me 3 were in the MBT condition. Baseline Analyses Independent-sam ples t -tests were conducted comparing the baseline characteristics of study completers ( n = 23) and study noncompleters ( n = 13). There were no significant differences between completers and noncompleter s on any demographic vari able or self-report measure. Baseline characteristics for the study completers and noncomplet ers are presented in Table 3-3. Independent-samples t -tests were also conducted to compar e the baseline characteristics of MBT ( n = 12) and SBT ( n = 11) study completers. There were no significant between-condition differences at baseline on any demographic va riable or self-report measure. Baseline characteristics for study completers by condition are presented in Table 3-4. Post-Treatment and Follow-Up Analyses Differences between conditions in changes for each of the prim ary and secondary outcome variables at post-treatment and follow-up were assessed using a 3 (Time) x 2 (Treatment) mixedmodel repeated-measures analyses of variance (ANOVA). For significant interaction and main effects, post hoc analyses were conducted to determine where the differences occurred. Effect sizes (eta squared) were also calculated to judge the magnitude of significant interaction and main effects for the primary and secondary outco mes. The results reported here include only study completers. Means and standard deviations at baseline, post-treatment, and follow-up for all primary and secondary outcome measures are by condition are presented in Table 3-5. 50

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Body Image The primary outcome for this study was self-reported body image as measured by the Multidimensional Body-Self Relations Questionnai re Body Areas Satisfaction Scale (MBSRQBASS). It was predicted that, compared to SBT, the MBT interventi on would produce greater improvement in body image satisfaction ratings after treatment and at follow-up. Participants did report an increase in body imag e satisfaction at post-treatment and at follow-up (Figure 3-2). No time X treatment interaction effect was found, but a significant main effect for time was observed, Wilks = .45, F (2, 20) = 12.29, p < .001, = .55. Bonferroni-corrected post hoc tests indicated that participants ratings of body image satisfaction significantly improved from baseline to post-treatment (M = 3.40, SD = .54, p < .001) and showed marginal, but nonsignificant, improvement from baseline to follow-up ( M = 3.32, SD = .90, p = .053). It was also predicted that, compared to SB T, the MBT intervention would produce greater improvement in general appearan ce satisfaction ratings after tr eatment and at follow-up. Again, no significant time X treatment interaction effect was found, but a signifi cant main effect for time was observed, Wilks .40, F (2, 20) = 15.21, p < .001, = .60. Bonferroni-corrected post hoc tests indicated that participants ratings of general appearance satisfaction significantly improved from baseline to post-treatment ( M = 3.53, SD = .58, p < .001) and from baseline to follow-up ( M = 3.46, SD = .54, p < .001). Psychological Functioning Secondary outcom es for this study included self-esteem ratings as measured by the Rosenberg Self-Esteem Scale (RSES), depressive symptoms as measured by the Beck Depression Inventory (BDI-II), and anxiety ratings as measured by the State-Trait Anxiety Inventory (STAI). It was predicted that, comp ared to SBT, the MBT intervention would produce 51

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greater im provement in self-esteem ratings, a greater reduction in depres sive symptoms, and a greater reduction in anxiety afte r treatment and at follow-up. No significant time X treatment interacti on effects were observed for any of the psychological functioning secondary outcome meas ures. A significant main effect for time was observed for changes in self-esteem ratings, Wilks = .51, F (2, 20) = 9.82, p = .001, = .50, depressive symptoms, Wilks .41, F (2, 20) = 14.39, p < .001, = .59, state, Wilks .32, F (2, 20) = 21.59, p < .001, = .68, and trait anxiety, Wilks .60, F (2, 20) = 6.75, p = .006, = .40. Means and standard deviations at base line, post-treatment, and follow-up are presented in Table 3-5. Bonferroni-corrected post hoc examination of the means revealed that participants report of self-esteem ratings (Figure 33), depressive symptoms (Figure 3-4), and trait anxiety (Figure 3-5) significantly improved from baseline to post-treatment (all p s < .005) and from baseline to follow-up (all ps < .008). Eating Behavior Binge eating was measured by the Questionnaire of Eating and Weight Patterns Revised (QEWP-R) adapted for use in this sample. It was predicted that, compared to SBT, the MBT intervention would produce greater improvement in binge eating after treatment and at followup. Participants reported a reducti on in the frequency of binge eating behavior from baseline ( M = 4.52, SD = 4.3) to post-treatment ( M = 2.70, SD = 2.9) and follow-up ( M = 1.95, SD = 1.9). No significant time X treatment interaction eff ect was found, but a signif icant main effect for time was observed, Wilks .62, F (2, 20) = 6.02, p = .009, = .38. Bonferroni-corrected post hoc tests indicated that participants report of binge eating behavior showed marginal, but 52

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nonsignificant, im provement from baseline to post-treatment (p = .08) and significant improvement from baseline to follow-up ( p = .009). Weight It was pred icted that, compared to SB T, the MBT intervention would not produce significantly greater weight loss at the end of treatment, but would produce better weight maintenance from the end of treatment to follow-up. Participants lost an average of 1.25 kg ( SD = 2.0 kg) at the end of the 8-week treatment and an average net weight loss from baseline to follow-up of 2.28 kg ( SD = 2.7 kg). The average weight loss by condition was 0.99 kg (SD = 1.3 kg) for the SBT participants and 1.5 kg ( SD = 2.5 kg) for the MBT participants at the end of trea tment. From the end of treatment to follow-up, SBT participants lost an additional 1.69 kg ( SD = 1.9 kg) for a net weight loss of 2.68 kg ( SD = 2.7 kg). MBT participants lost an additional 0.42 kg ( SD = 2.4 kg) for a net weight loss of 1.91 kg ( SD = 2.7 kg). A significant main effect for time was observed, Wilks .55, F (2, 20) = 8.12, p = .003, = .45, with both conditions demonstrati ng equivalent reductions. Collapsed across conditions, Bonferroni-c orrected post hoc tests indica ted that weight significantly decreased from baseline to post-treatment (p = .03) and from baseline to follow-up ( p = .002). From the end of treatment to follow-up, participants in the SBT condition increased their average rate of weight loss from 0.12 kg/wk to 0.14 kg/wk whereas participants in the MBT condition slowed their average rate of weight loss from 0.19 kg/wk to 0.03 kg/wk. Neither condition had regained any weight on average three months post-treat ment. Independent-samples t -test revealed no significant between-gro up differences in mean rate of weight loss during treatment ( p = .56) or follow-up ( p = .18). Figure 3-6 shows weight in kg by condition at baseline, posttreatment, and follow-up. 53

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Sim ilarly for BMI estimates, a significant main effect for time was observed, Wilks .63, F (2, 20) = 6.00, p = .009, 2 = .38. Collapsed across conditions, Bonferroni-corrected post hoc tests indicated that BMI estimates significantly decreased from baseline to post-treatment ( p = .03) and from baseline to follow-up ( p = .008). The average BMI reduction by condition was 0.44 kg/m2 ( SD = .55 kg/m2) for the SBT participants and 0.52 kg/m2 ( SD = .99 kg/m2) for the MBT participants at the end of treatment and 0.68 kg/m2 ( SD = .74 kg/m2) for the SBT participants and 0.08 kg/m2 ( SD = 1.2 kg/m2) for the MBT participants from the end of treatment to follow-up. Figure 3-7 shows BMI by condition at baseline, post-treatment, and follow-up. Mindfulness This intervention was designed to teach m indf ulness meditation techniques and integrate these skills into daily activity. In the MB T condition, each session incorporated meditation practice. Several sessions also incorporated mindful body work, including a body awareness scan and introductory mindful yoga. Beginning in Week 2, MBT participants were instructed to eat at least one mindful meal per day. Beginning in Week 3, MBT participants were instructed to begin formal meditation practice for 45 mi nutes on at least one day per week between sessions. Participants were prov ided with a recorded meditation CD designed to assist them in their weekly meditation practice. Participants reportedl y engaged in 8.3 hours of meditation across the 6-week intervention period during which weekly pr actice was assigned. However, only 25% reported participating in meditation practice outside of group at least one time over the 6-week period, and only one participant complete d her meditation assignment every week. Of those who reported their practice, the number of meditation minut es per week ranged from zero to 45, with an overall sample av erage of four minutes a week. 54

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Participan ts reported somewhat greater success with mindful eating. Pa rticipants reported eating 146 mindful meals over the 7-week interv ention period during which the mindful eating assignment was made. Fifty percent reported eati ng at least one meal mindfully over the 7-week period, and 25% reported eating at least two mindful meals every week. The number of mindful meals reportedly eaten per week ranged from zero to eight, with an overall average of five meals per week. Mindfulness was measured using the Mindful Attention Awa reness Scale (MAAS). All participants completed this questionnaire at ba seline, post-treatment, and follow-up. According to the measures authors, higher scores repres ent greater mindfulness. In this sample, a significant main effect for time was observe d for changes in mindfulness, Wilks = .70, F (2, 20) = 4.25, p = .03, 2 = .30. Unexpectedly, both condi tions demonstrated significant improvement in mindfulness scores from baselin e to follow-up, even though only half of the sample received direct training in mindfulness skills. Dependent Variable Pearson Correlations To exam ine the relationships between study vari ables at the end of treatment, changes in primary and secondary outcomes and mindfulness from baseline to post-treatment were correlated. Significant associa tions were observed for incr eases in body satisfaction and increases in general appearance satisfaction ( p < .001), self-esteem (p =.001), and mindfulness ( p = .03), as well as reductions in depressive symptoms ( p = .009), state (p = .006) and trait anxiety ( p < .001). No significant asso ciations were observed between changes in body satisfaction and changes in binge eating or weight. Increases in mindfulness were signifi cantly associated with increases in body satisfaction ( p = .03) and self-esteem ( p = .006) and decreases in depressive 55

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s ymptoms ( p = .01) and trait anxiety (p = .002). Correlations between changes in study variables from baseline to post-treatment are shown in Table 3-8. Treatment Completers versus Treatment Adherers A second set of analyses was conducted to com pare differences between conditions on primary and secondary outcome variables for trea tment adherers. Adherence to treatment was measured using self-report food records in whic h participants documented daily dietary intake (e.g., food type, quantity, total calories), and exerci se records in which pa rticipants documented weekly leisure time physical activity (e.g., t ype, minutes spent). In the MBT condition, participants were also asked to record the number of mindful meals per day and time spent in meditation practice. Logs were submitted w eekly and graded on how well participants adhered to their assignment and me t their goal for that week. Logs were rated on a 4-point scale ranging from (0) Did not complete/submit to (4) Extremely complete and detailed, appears accurate, met goal on most or all days. Treatme nt adherence was defined as at least a 50% submission rate of weekly logs and a mean scor e of 2.0 or above on the adherence rating scale. Fourteen of the 23 participants (61%) who completed testing at Time 1, Time 2, and Time 3 and two participants who comple ted testing at Time 1 and Time 2 met criteria for inclusion in the adherers analysis ( n = 16). Independent-samples t -tests and chi-square tests revealed no significant differences between adherers and nona dherers on any demographic variable or on any of the self-report measures at baseline. The patt ern of results was similar to those previously reported. There were no significant between-co ndition differences on changes in any of the primary and secondary outcome variables, or mindfulness, at post-treatment or follow-up for treatment adherers. 56

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Treatment Fidelity Check and Program Evaluation The study interventionists were evaluated to a ssess for treatment fidelity. Evaluations were conducted by two volunteer research assistants who at tended a group session in each condition lead by each interventionist on two consecutive nights. The observers were asked to rate the effectiveness of the interventionist on 20 items using a 4-point scale ranging from (1) Poor to (4) Excellent. Assessments were made based on observation of the following: technique (e.g., Utilizes treatment manual and other guide s/handouts effectively); planning (e.g., Materials for group are organized and avai lable); participant re lations (e.g., Maintains participant interest and attention); and treatment environment (e.g., Room set-up is comfortable). There were no significant differences in mean effectiveness ratings by interventionist or by condition. All participants completed a program cont ent evaluation following completion of the treatment phase. Participants in both conditions completed 18 questions asking them to evaluate how effective the program was in helping them establish and maintain healthy eating and exercise habits. All items were rated on a scale from (1) Str ongly Disagree to (10) Strongly Agree. Means for each item ranged from 7.5 to 8.9. There was no significant difference between conditions in terms of m ean program effectiveness ratings. Participants also rated their overall success from 0 to 100%. The mean se lf-reported success rate was 64%. There was no difference between conditions in term s of self-reported success rate. Study Hypotheses The prim ary hypothesis and secondary hypotheses of this study were not supported. Both treatment conditions produced equivalent re sults with regard to changes in body image satisfaction, psychological functioning, binge eating, and weight management. Table 3-7 provides an illustration of the areas of improveme nt as a result of treatment. Contrary to 57

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58 prediction, standard behavioral treatment plus mindfulness did not produce signifi cantly greater improvements than standard treatment alone.

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Table 3-1. De mographic and other charac teristics of enrolled participants ( N = 41) M ( SD ) Min Max Age (yr) 20.7 (1.4) 18.0 24.0 Weight (kg) 78.9 (7.9) 66.2 98.9 Body Mass Index (kg/m2) 29.6 (1.9) 25.5 34.4 (%) n Race/Ethnicity African-American 51.2 21.0 Caucasian 31.7 13.0 Hispanic 12.2 5.0 Asian-American 4.9 2.0 Year in school Freshman 0.0 0.0 Sophomore 7.3 3.0 Junior 31.7 13.0 Senior 51.2 21.0 Graduate Student 9.8 4.0 Previous diet attempt? Yes 78.0 32.0 No 22.0 9.0 Number of previous diet attempts 0 22.0 9.0 1-10 68.3 28.0 11-20 9.8 4.0 20+ 0.0 0.0 Participation in previous yoga, Pilates, or meditation class? Yes 56.0 23.0 No 44.0 18.0 59

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Table 3-2. Baseline data for study st arters in each treatm ent condition SBT ( n =16) MBT ( n = 20) M ( SD ) M ( SD ) p Age (yr) 21.0 (1.5) 21.0 (1.4) .51 Weight (kg) 77.0 (6.8) 79.0 (7.6) .43 Body Mass Index (kg/m2) 30.0 (2.1) 30.0 (1.8) .96 BDI 15.0 (8.0) 11.0 (7.2) .09 MBSRQ-BASS 2.8 (0.6) 3.0 (0.4) .23 MBSRQ-AE 2.7 (0.7) 3.0 (0.6) .21 STAI-S 44.0 (7.8) 44.0 (10.0) .92 STAI-T 47.0 (9.8) 45.0 (9.6) .51 RSES 19.0 (6.5) 19.0 (4.0) .91 QEWP-R 4.3 (3.7) 5.2 (4.3) .55 (%) n (%) n Race/Ethnicity African-American 56.0 9.0 50.0 10.0 Caucasian 31.0 5.0 35.0 7.0 Hispanic 6.0 1.0 15.0 3.0 Asian-American 6.0 1.0 0.0 0.0 Abbreviations: BDI, Beck Depression Inventory; MBSRQ-BASS, Multidimensional Body-Self Relations Questionnaire-Body Areas Satisfact ion Scale; MBSRQ-AE, Multidimensional BodySelf Relations Questionnaire-Appearance Evalua tion; STAI-S, State-Tr ait Anxiety InventoryState Scale; STAI-T, State-Tra it Anxiety Inventory-Trait Scale; RSES, Rosenberg Self-Esteem Scale; QEWP-R, Questionnaire of Ea ting and Weight Patterns Revised 60

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Table 3-3. Baseline values for study com pleters versus noncompleters Completers ( n = 23) Noncompleters ( n = 13) M ( SD ) M ( SD ) p Age (yr) 21.0 (1.5) 21.0 (1.3) .41 Weight (kg) 78.0 (7.0) 79.0 (7.8) .62 Body Mass Index (kg/m2) 30.0 (1.6) 30.0 (2.4) .71 BDI 14.0 (7.6) 11.0 (8.2) .40 MBSRQ-BASS 2.9 (0.6) 2.9 (0.5) .77 MBSRQ-AE 2.9 (0.7) 2.9 (0.6) .92 STAI-S 45.0 (8.8) 42.0 (9.3) .26 STAI-T 47.0 (11.1) 44.0 (6.0) .35 RSES 19.0 (5.7) 19.0 (4.3) .83 QEWP-R 4.5 (4.3) 5.2 (3.6) .62 (%) n (%) n Race/Ethnicity African-American 48.0 11.0 61.0 8.0 Caucasian 35.0 8.0 31.0 4.0 Hispanic 13.0 3.0 8.0 1.0 Asian-American 4.0 1.0 0.0 0.0 Abbreviations: BDI, Beck Depression Inventory; MBSRQ-BASS, Multidimensional Body-Self Relations Questionnaire-Body Areas Satisfact ion Scale; MBSRQ-AE, Multidimensional BodySelf Relations Questionnaire-Appearance Evalua tion; STAI-S, State-Tr ait Anxiety InventoryState Scale; STAI-T, State-Tra it Anxiety Inventory-Trait Scale; RSES, Rosenberg Self-Esteem Scale; QEWP-R, Questionnaire of Ea ting and Weight Patterns Revised 61

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Table 3-4. Baseline d ata for study co mpleters in each treatment condition SBT ( n = 11) MBT ( n = 12) M ( SD ) M ( SD ) p Age (yr) 21.0 (1.6) 21.0 (1.5) .89 Weight (kg) 78.0 (7.1) 78.0 (7.2) .83 Body Mass Index (kg/m2) 30.0 (1.8) 29.0 (1.5) .40 BDI 15.0 (7.4) 12.0 (7.7) .32 MBSRQ-BASS 2.8 (0.6) 3.0 (0.5) .34 MBSRQ-AE 2.7 (0.7) 3.0 (0.6) .26 STAI-S 44.0 (7.5) 46.0 (10.1) .64 STAI-T 49.0 (10.7) 45.0 (11.6) .42 RSES 19.0 (6.6) 19.0 (5.0) .89 QEWP-R 4.5 (4.4) 4.6 (4.4) .95 (%) n (%) n Race/Ethnicity African-American 46.0 5.0 50.0 6.0 Caucasian 36.0 4.0 33.0 4.0 Hispanic 9.0 1.0 17.0 2.0 Asian-American 9.0 1.0 0.0 0.0 Abbreviations: BDI, Beck Depression Inventory; MBSRQ-BASS, Multidimensional Body-Self Relations Questionnaire-Body Areas Satisfact ion Scale; MBSRQ-AE, Multidimensional BodySelf Relations Questionnaire-Appearance Evalua tion; STAI-S, State-Tr ait Anxiety InventoryState Scale; STAI-T, State-Tra it Anxiety Inventory-Trait Scale; RSES, Rosenberg Self-Esteem Scale; QEWP-R, Questionnaire of Ea ting and Weight Patterns Revised 62

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Table 3-5. Prim ary and secondary outcome measures at pre-trea tment, post-treatment, and follo w-up for each treatment condition SBT ( n = 11) MBT ( n = 12) Collapsed ( n = 23) T1 T2 T3 T1 T2 T3 T1 T2 T3 M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) Weight (kg) 77.7 (7.1) 76.7 (7.8) 75.0 (8.2) 78.3 (7.2) 76.8 (7.4) 78.3 (7.2) 78.0 (7.0)76.8a (7.4) 75.7b (8.0) BMI (kg/m2) 29.9 (1.8) 29.4 (1.9) 28.7 (1.8) 29.3 (1.5) 28.7 (2.0) 29.3 (1.5) 29.5 (1.6) 29.1a (1.9) 28.7b (1.8) BASS 2.8 (0.6) 3.3 (0.6) 3.1 (0.8) 3.0 (0.5) 3.5 (0.5) 3.0 (0.5) 2.9 (0.6) 3.4a (0.5) 3.3 (0.9) MBSRQ-AE 2.7 (0.7) 3.4 (0.6) 3.4 (0.6) 3.0 (0.6) 3.7 (0.6) 3.0 (0.6) 2.9 (0.7) 3.5a (0.6) 3.5b (0.5) BDI 15.2 (7.4) 6.2 (5.6) 9.5 (9.1) 12.0 (7.7) 7.1 (7.1) 6.4 (5.6) 13.5 (7.6) 6.7a (6.3) 8.1b (7.4) STAI-S 44.5 (7.5) 34.5 (10.0) 34.5 (7.0) 46.3 (10.1) 39.3 (13.4) 34.0 (8.5) 45.4 (8.8)37.0a (11.9) 34.2b (7.6) STAI-T 49.0 (10.7) 39.4 (7.9) 41.8 (9.4) 45.2 (11.6) 38.6 (11.6) 37.3 (8.7) 47.0 (11.1) 39.0a (9.8) 39.4b (9.1) RSES 18.9 (6.6) 23.7 (4.8) 22.9 (4.6) 19.3 (5.0) 23.1 (4.8) 23.8 (5.2) 19.1 (5.7) 23.4a (4.7) 23.4b (4.9) QEWP-R 4.5 (4.4) 2.1 (1.5) 1.4 (1.0) 4.6 (4.4) 3.3 (3.8) 2.5 (2.4) 4.5 (4.3) 2.7 (2.9) 1.6b (1.9) Abbreviations: BMI, Body Mass Index; BASS, Multidimensional B ody-Self Relations Questionnaire -Body Areas Satisfaction Scale; MBSRQ-AE, Multidimensional Body-Se lf Relations Questionnaire-Appearance Evaluation; BDI, Beck Depression Inventory; STAIS, State-Trait Anxiety InventoryState Scal e; STAI-S, State-Trait Anxiety Inventory Trait Scale; RSES, Rosenberg Self-Esteem Scale; QEWP-R, Questionnaire of Ea ting and Weight PatternsRevised. aSignificant difference from T1 to T2 (p < .05). bSignificant difference from T1 to T3 (p < .05) 63

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Table 3-6. Interaction and m a in effects for primary and secondary outcome measures Time X Treatment Main Effect Treatment Main Effect Time Wilks p Direction Wilks p Direction Wilks p Direction MBSRQ-BASS .910 .39 .449 <.001 T2>T1 MBSRQ-AE .931 .49 .397 <.001 T2>T1 T3>T1 RSES .939 .53 .505 .001 T2>T1 T3>T1 BDI .835 .17 .410 <.001 T2
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Table 3-7. Significant improvem ents as a result of study treatments From baseline to post-treatment From baseline to follow-up Support No support Support No support Body image satisfaction X X Appearance evaluation X X Self-esteem X X Depressive symptoms X X State anxiety X X Trait anxiety X X Binge eating X X Weight management X X 65

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Table 3-8. Correlation m atrix of change s in study variables from baseline to post-treatment collapsed across conditions ( n = 23) BASS AE RSES BDI STAI-S STAI-T QWEP-R Weight BMI MBSRQ-BASS --MBSRQ-AE .711* --RSES .667* .692* --BDI -.535* -.397 -.335 --STAI-S -.552* -.430* -.374 .282 --STAI-T -.832* -.699* -.852* .557* .551* --QWEP-R -.266 -.267 .010 .609* .169 .327 --Weight (kg) -.140 -.172 .049 .119 .070 -.004 .072 --Body Mass Index (kg/m2) -.160 -.198 .019 .192 .148 .008 .092 .983* --MAAS .454* .291 .559* -.526* .061 -.622* -.187 .031 .045 Abbreviations: BDI, Beck Depression Inventory; MAAS, Mi ndful Attention Awareness Scale; MBSRQ-BASS, Multidimensional Body-Self Relations Questionnaire-Body Areas Satisfaction Scale; MBSRQ-AE, Multidimensional Body-Self Relations Questionnaire-Appearance Eval uation; STAI-S, State-Trai t Anxiety Inventory State Scale; ST AI-S, State-Trait Anxiety Inventory Trait Scale; RSES, Rosenberg Self-Esteem Scale; QEWP -R, Questionnaire of Eating a nd Weight Patterns Revised 66

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193 individuals assessed for eligibility 152 individuals excluded: 19 did not meet criteria 9 declined participation 124 othe r 41 randomized 20 SBT participants 21 MBT participants 9 lost to follow-up: 4 never started 3 declined to continue 1 relocated 9 lost to follow-up: 1 never started 4 declined to continue 1 reloc ated 3 reason not given Figure 3-1. Study enrollm ent and retention 11 completed study 1 other 12 completed study 67

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0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 BaselinePost-TreatmentFollow-upMBSRQ-BASS Mean Scores SBT MBT Figure 3-2. Changes in MBSRQ-Bo dy Areas Satisfaction Scale (BA SS) scores from Baseline to Follow-up ( p < .05). 68

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0.00 5.00 10.00 15.00 20.00 25.00 30.00 BaselinePost-TreatmentFollow-upMean RSES Scores SBT MBT Figure 3-3. Changes in Rosenberg Self-Esteem Scale (RSES) scores from Baseline to PostTreatment ( p < .05) and from Baseline to Follow-up (p < .05). 69

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0.00 5.00 10.00 15.00 20.00 25.00 30.00 BaselinePost-TreatmentFollow-upMean BDI Scores SBT MBT Figure 3-4. Changes in Beck Depression Inventory (BDI) scor es from Baseline to PostTreatment ( p < .05) and from Baseline to Follow-up (p < .05). 70

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20.00 25.00 30.00 35.00 40.00 45.00 50.00 55.00 60.00 BaselinePost-TreatmentFollow-upMean STAI-T Scores SBT MBT Figure 3-5. Changes in StateTrait Anxiety Inventory-Trait subscale (STAI-T) scores from Baseline to Post-Treatment ( p < .05) and from Baseline to Follow-up (p < .05). 71

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70.00 71.00 72.00 73.00 74.00 75.00 76.00 77.00 78.00 79.00 80.00 BaselinePost-TreatmentFollow-upWeight (kg) SBT MBT Figure 3-6. Changes in We ight (kg) from Baseline to Post-Treatment ( p < .05) and from Baseline to Follow-up ( p < .05). 72

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73 27.00 28.00 29.00 30.00 31.00 32.00 33.00 BaselinePost-TreatmentFollow-upBody Mass Index SBT MBT Figure 3-7. Changes in BMI from Baseline to Post-Treatment ( p < .05) and from Baseline to Follow-up ( p < .05).

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CHAP TER 4 DISCUSSION Mindf ulness is a meditation-based technique used in some clinical settings to help focus ones attention and cultivate a sense of present-moment awareness and acceptance. It is believed by some that being mindful in certain situations can help break destructiv e habitual reactions to stress, promote self-regulation, and minimize ps ychological processes f acilitating dysfunctional behaviors such as excessive eating. Recently, training in mindfulness meditation has been applied to a broad range of clinic al conditions to determine if th e diffuse effects of mindfulness improve outcomes. This study evaluated the effects of mindfulness training in conjunction with behavioral weight loss treatme nt on body image satisfaction, ps ychological well-being, eating behavior, and weight management in overweight and obese college women. In general, it was found that study participants who received standa rd behavioral weight loss treatment plus mindfulness showed no greater improvement across a range of outcomes than participants who received standard treatment alone. The primary outcome of this study was body imag e satisfaction. The results showed that both treatment conditions were equally as eff ective in improving body image satisfaction. Body image ratings improved significantly from baseline to post-treatment. This is consistent with previous reports of improved body image satisfac tion in obese individuals who have undergone behavioral weight loss treatme nt (Cash, 1994b; Foster, Wadden, & Vogt, 1997; Rosen, Orosan, & Reiter, 1995). Among obese women, lower levels of body satisfaction appear to be related to lower self-esteem and increased symptoms of depression (Sarwar & Thompson, 2002). Body dissatisfaction has also been shown to be a predictor of binge ea ting in college women (Ricciardelli et al., 1997; Stice, 2001). In th is study, changes in body image were associated with improved self-esteem, reduced anxiety and depressive sympto ms, and changes in 74

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m indfulness. No association between body satis faction and binge eati ng behavior was found. Results showed a marginal, but nonsignificant, improvement in body image satisfaction from baseline to follow-up ( p = .053). Cross-cultural differences in ideal body image have been reported. For example, African-American wome n, who were well represented in this studys sample, have been found to report a larger id eal BMI and less body image dissatisfaction than Caucasian women (Parker et al., 1999; Becker Yanek, Koffman, & Bronner, 1999). This finding may help explain, in part, why greater improvement s in body image satisfaction from baseline to follow-up were not found in this sample. Change in weight was a secondary outcome of this study. Equivalent weight losses were observed across conditions at the end of the treatm ent phase. The mean weight loss achieved in this 8-week study was 1.25 kg, a 2% reduction in body weight. Behavioral interventions delivered over a 15to 26-week period typically produce up to 8.5 kg weight losses, an 8 to 10% reduction in body weight (Perri & Corsica, 2002). It is not clear w hy participants did not lose the amount of weight typically produced by this type of treatment. Th e women in this sample were younger than those included in traditional weight loss trials. The women participating in this study also had a mean baseline BMI of 30, which is lower than in typical trials with women who record mean baseline BMIs of 33 (Wing, 2002). A relatively high number of African-American participants were enrolle d in the current study (51% identified themselves as African-American). Newton and Perri (1997) assessed at titudes toward obesity in Afri can-Americans and Caucasians and found that African-Americans perceived themselves to be more susceptible to becoming obese, but also perceived the health and psychol ogical consequences of being obese as less severe than Caucasians did. Th ese findings may help explain, in part, why greater reductions in weight were not found in this sample over the cour se of the 8-week intervention. At the end of 75

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the 3-m onth follow-up phase, participants had not regained any lost weig ht on average, and had actually continued to lose weight. This is an atypical finding. During the year following behavioral treatment, overweight individuals typically regain 30 to 50% of their initial losses (Jeffery et al., 2000). Conclusions about the e ffectiveness of treatment in preventing weight regain, however, are not possible given the sma ll number of treatment completers and the relatively short follow-up period. Many women enter weight loss treatment program s to improve appearance, attractiveness, self-confidence, and reduce soci al anxiety (Cooper & Fairburn, 2001). Previous studies have suggested that the reduction in body weight typically produced by standard behavioral treatment is unlikely to have a substantial impact on app earance and attractiveness and that post-treatment weight regain may be attributab le to not achieving these anticip ated benefits (Ames et al., 2005; Bryne, Cooper, & Fairburn, 2003; Cooper & Fa irburn, 2002). It has been proposed that addressing body image dissatisfactio n during treatment may be the most critical mechanism for successful long-term weight loss and mainte nance (Cooper & Fairburn, 2002; Ramirez & Rosen, 2001). It has also been suggested that small lo sses in weight may yield substantial improvements in body image (Wadden, Womble, Stunkard, & A nderson, 2002). On the surface, this notion appears to be supported by the resu lts of the current study. That is, participants lost a small amount of weight and body image satisfaction im proved significantly. Correlational analyses, however, revealed no significant association between change in weight and body image satisfaction. Thus, the relationship between body image and body weight, and the implications for treatment, remains unclear. Participants in this study showed improveme nts in self-esteem, anxiety, and depressive symptoms at the end of treatment and at follo w-up. These improvements are consistent with 76

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sim ilar trials enrolling over weight and obese college-age women (Ames et al., 2005). Correlational analyses revealed significant a ssociations between increases in body image satisfaction and increases in self -esteem, decreases in depressive symptoms, and decreases in anxiety. These results are also consistent with previous findings among obese women seeking weight loss treatment (Sarwar, Wadden, & Fo ster, 1998). In this study, improvements in depressive symptoms, self-esteem, and trait an xiety were all associated with changes in mindfulness. Segal and colleagues (2002) have suggested that the abil ity to recognize and disengage from dysfunctional thi nking patterns is a defining f eature of mindfulness and that regular practice of mindfulness may produce im provements in mood and anxiety symptoms. This type of relationship cannot be determined based on the results of the current study and evidence in support of such a relationship remains equivocal (Toneatto & Nguyen, 2007). Participants also showed marginal, but nonsignificant, improvement in binge eating behavior from baseline to the end of treatmen t and significant improvement from baseline to follow-up. It has been suggested that obese women who engage in binge eating suffer from higher levels of depression and anxiety and lowe r levels of self-esteem than obese women who do not binge (Johnson, 2002). In this study, a decr ease in binge eating behavior was associated with a decrease in depressive symptomatology, but was not associat ed with changes in anxiety or self-esteem. It has been sugge sted that bingeing may be a ma ladaptive coping mechanism used by some individuals with limited ability to se lf-regulate (Heatherton & Baumeister, 1991). Contrary to prediction, participan ts in the MBT condition did not show greater reduction in binge eating behavior at post-treatment or follow-up when compared to participants in the SBT condition. It should be noted that the sample of women recruited for this study did not engage in clinically significant levels of binge eating at baseline. Moreover, women who endorsed 77

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sym ptoms of bulimia were excluded from participation. Other studies using mindfulness training have found significant improvement in binge eating, but these studies targeted a sample of obese individuals who met criteria for binge eating disorder at baseline (e.g., Kristeller & Hallett, 1999). Findings from this study are encouraging in that body image satisfaction as well as general measures of psychological functioning impr oved significantly in overweight and obese young women after participation in an 8-week intervention. These improvements may increase satisfaction with weight loss treatment outcomes and ultimately provide better maintenance of lost weight. Women who feel better about themselves may be more likely to accept modest amounts of weight loss as a meaningful accomplis hment. Maintenance of even small weight losses should be encouraged in overweight women given that a 5 to 10% reduction in body weight will produce clinically significant improvements in health status (Wing & Hill, 2001). Improved psychological well-being may also improve motivation to maintain changes in diet and exercise habits achieved during treatment. Futu re studies with larger samples and longer followup periods are needed to determine if change s in body image satisfacti on and psychological wellbeing lead to improved long-term maintenance of lost weight and/or th e prevention of weight gain. This study was designed as a pilot study to examine the impact of mindfulness on body image satisfaction. Weight loss was a seconda ry goal of the study. As a pilot study, one limitation was the small sample size. This small sample resulted in low statistical power limiting the ability to detect interaction effects for th e primary outcome measure at Time 2 and Time 3. This has significant implications for the fi ndings of this study. The SBT mean body image satisfaction score at post-treatment was 3.3 and the MBT mean score was 3.5 (standard error = 78

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.55), an effect size of .36. A m inimum of 190 part icipants would be needed in order to have enough statistical power to detect a between -condition difference in the primary outcome variable. Given the high attriti on rate (approximately 35 %), the initial pool of participants would have to be very large (n = 293) in order to maintain this statistical power. The high rate of attrition has additional impli cations for the study. The findings in this study are based upon data collected from only 64% of the participants who began treatment. It seems reasonable to assume that participants who did not participate in po st-treatment or followup data collection likely had less fa vorable outcomes. Thus, findings should be interpreted with some caution. The rate of attriti on in this study is similar to othe r trials investigating weight loss treatment in college-age partic ipants and may reflect the inte nsity and duration of the study (Ames et al., 2005; Donnelly et al., 2003). The present investigation required significant effort by the subjects. The two hours of on-site contac t per week, intensive se lf-monitoring, and athome meditation practice required of participants may have negativ ely impacted adherence to the program. Other variables that may have contribu ted to the high rate of attrition in this study were the age and minority status of particip ants. Honas et al. (2003) found that younger participants had a higher attriti on rate and that age was the most significant determinant of dropout in a 16-week clinic-based weight loss group treatment program. In their study, only 60% of participants under age 40 completed the program, similar to the completion rate in the current study. In addition, a relatively high number of minor ity participants were en rolled in the current study (68% of participants iden tified themselves as Black, Hispanic, or Asian). Kumanyika (2002) suggests that adherence problems in minor ity participants may be associated with low perceived benefits of attending treatment, insuffi cient motivation for weight loss, and increased 79

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barriers to adopting and m aintaining reduced ca lorie intake and increased physical activity compared to Caucasian participants. The study had a relatively short follow-up period of only three months as opposed to a more typical 12-month to 18-mont h follow-up period. Participants in behavioral interventions typically show a consistent patter n of continued weight regain two to five years after behavioral treatment (Perri, 1998). Thus, only tentative conclusions can be made about the long-term effects of treatment on weight loss maintenan ce or improvements in body image satisfaction. This study relied extensively on participant se lf-report for the meas urement of diet and exercise adherence, meditation practice, and psychological variables. In addition, study completion was defined as being present for testi ng, not necessarily being present for treatment. An analysis examining the effect of treatment in high adherers to treatme nt revealed the same results as those presented here. Nevertheless, this limits the ex tent to which conclusions about treatment can be made. Mindfulness was a central con cept in this study. Measures of mindfulness are still in development. One of the measures used to capture the acquisition of mindfulness skills in this study was based on the conceptualization of mindfulness as a one-dimensional construct. Recent factor analysis has yielded several additional facets and a new multi-dimensional measure has been developed (Five Factor Mindfulness Questionnaire; FFMQ; Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006). The single factor measure used in the current study may not have the sensitivity offered by a multi-dimensional model of mindfulness. According to Baer et al. (2006), the Mindful Attention a nd Awareness Scale (MAAS; Brown & Ryan, 2003) used in the current study tends to emphasize an element of mindfulness rela ted to absent-mindedness. The use of this single factor measure may have lim ited the ability to de tect other aspects of 80

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m indfulness, especially in a sample of relatively inexperienced meditators This may explain, in part, why it appears both condi tions demonstrated significant improvement in mindfulness over time. The questionnaire elicite d information primarily related to paying attention in everyday activities. All participants ma y have improved in that regard as a result of weekly selfmonitoring activities. Future research with in experienced meditators should include a measure of mindfulness that captures the multi-faceted nature of the construct and the specific components targeted by the intervention. The intervention designed for the current study, for example, targeted self-compassion and acceptance, observation of present moment experience, and cultivation of non-reactivity to negative stimuli. An instrument designed to capture these facets of mindfulness may be more useful in assessing differential skill acquisition. Participants in this study engaged in only 8.3 hours of med itation across the intervention period. Previous studies using mindfulness-based interventions have reported higher rates of success with regard to participan ts meditation practice outside of session. Kristeller and Hallett (1999), in a study evaluating the effectiveness of a mindfulnessbased intervention for obese binge eaters, reported 15.82 hours of meditation over a 6-week period. Only 25% of the sample in the current study reported partic ipating in meditation practice one or more times. In contrast, 90% of the sample used in the study by Reibel an d colleagues (2001) reported practicing three or more times a week. The current intervention included a structured meditation program that required intensive self-monitori ng, attendance at weekly grou p sessions, and daily practice between sessions. Based on participant feedback, this required an excessively demanding time commitment. Increases in mindfulness have been found to mediate the relationship between formal mindfulness practice and improvements in ps ychological functioning, suggesting that the 81

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practice of meditation leads to increases in mindfulness which leads to symptom reduction and improved well-being (Carmody & Baer, 2008). The sample in the Carmody and Baer study, however, differed from the sample used in the cu rrent study. The average age of participants in the Carmody and Baer study was 47 years. Their subjects volunteered to participate in an 8week MBSR program for stress-re lated problems and chronic pain. More than 63% of the Carmody and Baer subjects reported previous participation in ps ychotherapy. Future studies of mindfulness should consider participants age and previ ous meditation experience. It is likely that younger subjects, who are largely nave to meditation, require differe nt approaches than older subjects. Similarly, pa rticipants with previous e xposure to meditation or mind/body therapies will likely respond better to the demands of a mindfulness training program. The current study offers a number of advancements in the assessment of mindfulness. Few studies in this area have u tilized a randomized prospectiv e design, a manualized treatment protocol, an active control condi tion, and the administration of process measures to identify components of treatment that participants felt we re particularly helpful. The responses from participants suggest that the pr ogram was effective in helping them learn strategies for healthy eating and for setting realistic di et and exercise goals Participants stated that the program helped them to be less critical of themselves and to focus on things they like about their bodies, regardless of their weight. Partic ipants reported an increased ab ility to pay attention and respond to physiological hunger and satiety cues. Part icipants noted that treatment helped them recognize the importance of self -acceptance and compassion. As one participant noted, Even though I didnt lose weight, I feel so much bette r about myself. I have more confidence than before. Another participant stated, This group makes me feel empowered. I look forward to it every week. When asked about the most help ful component of the program, one participant 82

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responded, Portion size awareness, knowledge of cal ories, learning how to read food labels, and m indful eating. Before, I used to feel guilty for ov ereating now I just accept it and make better choices the next day. I feel more confident about myself now. Mindfulness meditation has been suggested to be well-suited for the amelioration of stressrelated medical and psychological conditions (Grossman, Niemann, Schmidt, & Walach, 2004; Shigaki, Glass, & Schopp, 2006). Conclusions a bout the effectiveness of mindfulness skills training as an adjunct or stand-alone therapy remain equivoca l (Ospina et al., 2007). The current study represents an attempt to present prelim inary evidence regarding a program integrating behavioral and mindfulness-based strategies to address body image concerns in overweight and obese young women. The mindfulness techniques presented to this group of inexperienced meditators were novel. Analysis of participant report indicated that the level of exposure and engagement in mindfulness techniques was relativ ely small, compared to more intensive MBSR training programs. One of the most important questions that must be addressed in future research on mindfulness is what constitutes a mi nimally effective treatment dose. In other words, how much exposure is necessary for an effective evaluation of the intervention? As the prevalence of obesity in the United St ates reaches epidemic proportions, the need for more effective methods of weight maintenan ce is critical. The discrepancy between actual body size and ideal body size has become increasingl y significant. Because this ideal body size is unattainable for many young women, there currently exists what might be considered an epidemic of body dissatisfaction. To the extent that body image dissatisfaction contributes to binge eating and psychological distress, and compro mises the potential effectiveness of certain types of weight loss treatments, an effective inte rvention is needed. The clinical significance of body image dissatisfaction warrants further investigation. 83

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84 The present study predicted that an interven tion designed to teach the principles of mindfulness in overweight college women would have a greater impact on body image, psychological functioning, eating be havior, and weight maintenan ce than standard behavioral weight loss treatment alone. The results of this preliminary study s uggest that behavioral treatment plus mindfulness is no more effective than behavioral treatment alone in maintaining short-term improvements in body image, psychol ogical well-being, eating behavior, and weight management. Although this study did not demons trate the value of mi ndfulness training, more study is warranted. Feedback from participants suggests the mindfulness intervention did have a meaningful impact on some young womens psychological well-bei ng and approach to healthy living. Moreover, this study has highlighted a nu mber of methodological i ssues which must be addressed to fully evaluate the value of mindfulness training. Sp ecifically, future studies must recognize the significant levels of compliance needed to accurately evaluate mindfulness interventions. This level of compliance requires larger clinical samples than many other approaches. In addition, assessmen t of mindfulness skills is still fairly pr imitive. Effective evaluation of these skills is dependent upon meas ures able to reflect the complex nuances of mindfulness. Once these issues are addressed, it will be possible to effectively assess whether mindfulness skills training is beneficial for we ight maintenance and psychological well-being.

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BIOGRAPHICAL SKETCH I was accepted into the University of Florida s Clinical and Health Psychology program in fall 1999. The program at the University of Florida provided me with outstanding general mental health clinical training as well as tr aining with diverse medical populations. While a student, I had the opportunity to conduct clinical research focused on weight loss and body image with overweight and obese young women, and ex ercise interventions for sedentary adults. I enjoy working with these popula tions clinically and conducting treatment outcome studies. I also enjoy teaching mindfulness skills and hope to have the opportunity to continue my research in this area as well. Ultimately, my goal is to help address the adverse impact of overweight and obesity on health and psychologica l well-being. In doing so, I hope to contribute to the body of literature integrating the scienc e and practice of clinical and health psychology. My ultimate goal is to contribute significantly to the treatm ent literature in the areas of behavioral weight management, eating disorders, and body image issues in women. 98


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