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Eating with Wisdom: Cultivating Mindful Eating

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1 Eating with Wisdom: Cultivating Mindful Eating
Jean L. Kristeller, Ph.D. Center for the Study of Health, Religion, and Spirituality The Center for Mindful Eating Dept. Of Psychology, Indiana State University This work is based on a number of years of research on meditation -- including basic physiological research, effects of meditation on anxiety and behavior, and recently, the spiritual effects of meditation in cancer patients who are novice meditators. I should also note that unlike Dr. Newberg, I have worked primarily with novice meditators -- but have also worked within various meditative traditions, including transcendental meditation and vipassana, or mindfulness meditation.

2 This work was supported by grants from
National Center for Complementary and Alternative Medicine National Institutes of Health U.S. Department of Health and Human Services Funded by Grants #1R-21 AT and U01-AT to Jean Kristeller from the National Center for Complementary and Alternative Medicine

3 Richard Surwit, Ph.D. and Richard Liebowitz, M.D.
Acknowledgments Indiana State University Brendan Hallett, Psy.D. and Virgil Sheets, Ph.D. Juli Buchanan, M.A., Brandy Dean, M.A., and Janis Leigh, B.A. Duke University Ruth Quillian-Wolever, Ph.D. Sasha Loring, M.S.W., Jennifer Davis, M.S., and Jennifer Best, Ph.D. Richard Surwit, Ph.D. and Richard Liebowitz, M.D. This work is based on a number of years of research on meditation -- including basic physiological research, effects of meditation on anxiety and behavior, and recently, the spiritual effects of meditation in cancer patients who are novice meditators. I should also note that unlike Dr. Newberg, I have worked primarily with novice meditators -- but have also worked within various meditative traditions, including transcendental meditation and vipassana, or mindfulness meditation.

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9 “The faculty of voluntarily bringing back a wandering attention, over and over again, is the very root of judgment, character, and will…. An education which should include this faculty would be the education par excellence...” William James. (1918). Principles of Psychology. Vol. 1, p. 424. So -- get started. What is meditation?

10 “MEDITATION …. A family of techniques which have in common a conscious attempt to focus attention in a non-analytical way, and an attempt not to dwell on discursive, ruminating thought.” Deane Shapiro, 1980 So -- get started. What is meditation?

11 “ Mindfulness … moment to moment non-judgmental awareness cultivated by paying attention.”
Jon Kabat-Zinn So -- get started. What is meditation?

12 MINDFULNESS: a cognitive state, marked by attentional stability, that disengages habitual reactions and allows for inner wisdom to emerge. Review meanings of mindfulness. Comment about Langer??

13 The Elephant

14 Process ? Mechanisms ? Effects ?
Mindfulness Meditation: Making Sense of the Parts? Process ? Mechanisms ? Effects ?

15 Meditation as an Attentional Self-Regulatory Process
Focus on an object, often repetitive, and often the breath to train attention and disengage ruminative thinking (quietening the ‘monkey mind’) A physically awake state Quiet detached noting of other thoughts, experiences, sounds, feelings, etc., as they arise A gentle return to the original point of focus whenever attention has wandered Use of mindfulness to increase awareness of, and a shift in response in, other aspects of functioning, such as pain, anxiety, relation to others, eating, etc.

16 Meditation: Mechanisms and Misunderstandings
Meditation is NOT primarily a trance state. Meditation is NOT primarily a relaxation tool. Meditation is FUNDAMENTALLY a cognitive-attentional process that promotes self-regulation. It has potential effects across MULTIPLE DOMAINS of psychological functioning: cognitive, physiological, emotional, behavioral, relation to self/others, and spiritual.

17 Habitual Reactivity and Disregulation
The brain/mind is designed to be constantly scanning -- both externally and internally -- for meaningful information. Threatening, gratifying, novel, or personally-meaningful information has predominance. Much of this happens without awareness. Responses are then triggered as rapidly as possible. Such responses may be particularly characteristic of disregulation disorders, such as anxiety reactions, chronic depression, addictions, and eating disorders.

18 Usual Processing: Conditioning Model & Eating Problems
Usual Thoughts and Experiences Conditioning ~~ Survival ~~ Attachment/Avoidance XX Cognition/Attention Emotions Self/Others Physiology/Health Spiritual Behavior

19 Usual Thoughts and Experiences
Usual Processing Usual Thoughts and Experiences Automatic Reactions Cognition/Attention Emotions Self/Others Physiology/Health Spiritual Behavior

20 Meditation: Self/Transcendent/Spiritual Model
Meditation Practice Engagement of Transcendent Self/No-self/Spirit Cognition/Attention Emotions Self/Others Physiology/Health Spiritual Behavior

21 Meditation: Physiological/Stress Reactivity Model
Meditation Practice Engagement of Relaxation Response Cognition/Attention Emotions Self/Others Physiology/Health Spiritual Behavior

22 Mindfulness Processing: Multi-Domain Model
Usual Thoughts and Experiences Mindfulness: Disengagement of Automatic Responses Engagement of More Integrated “Wiser” Responses Cognition/Attention Emotions Self/Others Physiology/Health Spiritual Behavior

23 Mindfulness Meditation: Self-Regulation and a Multi-Domain Model
The first stage of mindfulness meditation heightens awareness of the reactive process. The second stage disengages the automatic reactivity. The third stage allows emergence of more integrative response potentials in whichever domain of functioning is being engaged.

24 Mindfulness Meditation and Treatment of Anxiety Disorders
Pre-Treatment Treatment Post-Treatment Kabat-Zinn, Massion, Kristeller et al. (1992). Am. J. Psychiatry

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26 The Six Domain Model: Eating Mindlessly
Cognitive: Preoccupation with food/eating; black and white thinking. Physiological: 1) hyper-reactivity around food. 2) Disconnect from normal hunger and satiation cues. Emotional: Depression; craving; anxiety. Behavioral: Binge eating; highly conditioned responses to food; general overeating. Relationship to Self/Others: Poor self-acceptance; self- hatred; anger at others; over-valuing thinness. Spiritual: No wise eating; spirituality does not engage honoring body; value and meaning attached to food abundance.

27 Psychiatric Criteria for Binge Eating Disorder (DSM-IV)
Recurrent binges, characterized by: Eating, in a discrete period of time, much more than most people would eat. A sense of lack of control during the episode. At least two episodes of binge eating per week for six months. Associated with eating more rapidly, eating until uncomfortably full, eating without being physically hungry &/or feeling very guilty or depressed afterwards. Marked distress regarding binge eating.

28 3500 KCalories: Overeating vs. Bingeing
Overeating Pattern Time KCal 7 am 2 eggs, bacon 2 slices toast OJ 450 10 am Doughnut 150 Noon Whopper Medium Fries 1130 6 pm 6 oz. Steak Baked potato 2 vegies, roll Apple pie 1320 10 pm 2 oz. Doritos 1 beer 450 TOTAL 3500 Bingeing Pattern Kcal Cereal/milk OJ Salad/diet dressing Roll Diet Coke 300 3 oz steak Baked potato 2 vegies 500 2 pieces Apple pie 7 oz. Doritos 1 pint ice cream 2440 TOTAL

29 Models of Binge Eating Disorder
Cognitive-Behavioral Models: Binging serves various conditioned functions, including positive reinforcement and escape from negative experiences (inc. anxiety, intrusive thoughts, etc.). (Fairburn). Chronic Dieting/Restraint Models/Abstinence Violation Effects: Chronic dieting and efforts at food avoidance leads to both physiological and psychological deprivation. (Herman & Polivy; Marlatt). Appetite and Satiety Disregulation: Binge eaters have disrupted hunger and satiety regulation. (Heatherington & Rolls; Bartoshuk; Geliebter). Affect Regulation/Escape Models: Binge eaters find eating particularly comforting in the face of negative affect, particularly situations that create a vulnerable sense of self, including trauma history. Eating disorders often reflect a rejection of self, depression, and feelings of helplessness. (Baumeister).

30 Mindfulness Processing: Multi-Domain Model
Usual Thoughts and Experiences Mindfulness: Disengagement of Automatic Responses Engagement of More Integrated “Wiser” Responses Cognition/Attention Emotions Self/Others Physiology/Health Spiritual Behavior

31 Current Treatment for BED
Cognitive-Behavioral Therapy Wilfley, Agras, Telch et al. (1993). JCCP; Agras, Telch et al. (1994). Behavior Therapy; Wilfley, Welch, Stein et al. (2002). Arch Gen Psychiatry Interpersonal Therapy Wilfley, Agras, Telch et al. (1993). JCCP; Wilfley, Welch, Stein et al. (2002). Arch Gen Psychiatry Appetite Awareness Training Allen & Craighead (1999). Behavior Therapy. Dialectical Behavior Therapy Telch, Agras & Linehan (2001). JCCP; Baer, in progress. Nutritional Counseling/Weight Loss Therapy Agras, Telch et al. (1995). JCCP

32 Binge Eating and Meditation: A Disregulation-Self-regulation Model
Disregulation Model: A combination of these processes leads to chronic “disconnections” between normal and flexible controls of food intake and actual intake, in regard to both appetite & satiety mechanisms. Heightening awareness (biofeedback model) tends to increase regulation (Schwartz; Rodin). Binge eating - a disconnection between psychological and physiological needs for food. Binging - a lack of balanced response to normal hunger and satiation cues. Eating disorders - often reflect a rejection of self, depression, and feelings of helplessness. Mindfulness meditation may therefore be well suited to promoting Self-Regulation: awareness of physical hunger and satiation cues, emotional cues, and dysfunctional self-talk, and to bringing these into better balance.

33 Stages in Current Research
Clinical Development: Clinical use and manual development (at Brown, UMMC, ISU, and Duke). Unfunded Pilot Study: Single group design, 7 sessions, 1 month followup (Kristeller & Hallett, 1998). NIH-funded Two Year Randomized Trial: Completed research, at ISU and Duke University Center for Integrative Medicine, with 9 sessions, active and waiting list control, 4 month followup, and further manual development. NCCAM Multiple Linked Trials: Three sites (ISU, Duke, Penn), with broader samples, adding weight loss as goal, and neuro-imaging. Other Research: Currently in progress or under development at UC-SF, UNM, Georgia Medical School.

34 MB-EAT: Mindfulness-Based Eating Awareness Training
Mindfulness meditation Eating experience meditations: Awareness of binge triggers Awareness of hunger Awareness of satiety (taste-specific, fullness) Food-related meditations: raisin, chocolate, cheese/crackers, pot luck meal/buffet. Mini-meditations with daily meals and snacks. Forgiveness and wisdom meditations Homework: meditation practice, mindful eating.

35 MB-EAT: Outline of Sessions
Introduction to mindfulness meditation. Mindfully eating a raisin. Introduction to “mini-meditation”. Mindfully eating cheese and crackers. Binge trigger meditation. Mindfully eating sweet, high fat food. Hunger Signals meditation (physical vs. emotional hunger). Taste-Specific Satiation Signals meditation. Chips and cookies. Stomach Fullness Satiety meditation. Pot luck meal. Forgiveness meditation. Wisdom meditation. Have others noticed?; where do you go from here?

36 Basic Elements of the Pilot Study
Participants: 18 obese women who met DSM criteria for BED; avg. age ~ 42; avg. wt. = 242 lbs. Design: Singe-group extended baseline design (3 week baseline line and followup period) Intervention: 6 week (7 session) mindfulness meditation based group treatment Measures: Binge Eating Scale, measures of depression and anxiety (BDI and BAI), behavioral measures, ratings of mindfulness, and awareness of hunger and satiety.

37 Number of Binges per Week (n = 18, pre/post mean: t = 6.37**)

38 Changes in the Binge Eating Scale across Treatment (n = 18, pre/post mean: t = 9.86**)

39 Summary of Pilot Study Binges decreased from 4/week to 1.5/week.
Depression and anxiety decreased significantly. Decreases on the Binge Eating Scale correlated with using eating-related meditations (r=.66) but not use of general mindfulness meditation. Sense of control around food and enjoyment of food increased.

40 NIH Trial NCCAM-funded randomized clinical trial with 3 groups: Meditation-based; Psycho-educational; Waiting List. Two-site design (ISU and Duke). 9 week manualized intervention 1 and 4 month followups More extensive measures including process measures and change in biological markers of self-regulation (lipid and metabolic profiles)

41 Sample Sample size: N = 150 evaluated on all baseline measures; 14% men. Approximately 14% African-American recruitment Average age = 47.5; Avg. Wt. = 240 lbs.; Avg. BMI = 39.

42 Treatment Effects on Binge Eating Scale
p<.001 (N =85)

43 Changes in Number of Binges in Previous Month

44 Treatment Effects on Beck Depression Scale

45 Treatment Effects on the Three Factor Questionnaire: Cognitive Restraint
p<.001 MM vs. PE: p <.05 (N =85)

46 Treatment Effects on the Three Factor Questionnaire: Disinhibition
p<.001 MM vs. PE: p <.01 (N =85)

47 Treatment Effects on the Three Factor Questionnaire: Hunger
p<.001 MM vs. PE: p <.10 (N =85)

48 Treatment Effects on Lowe’s Power of Food Scale
MB vs. PE: p<.10 (N =85)

49 Treatment Effects on Weight

50 Treatment Effects on Post-prandial Glucose

51 Relationship Between Practice and Improvement in Relation to Eating (n = 31-34)
Change in: Type of Practice BES Less Disinhibition Less Hunger Weight General Mindfulness -.28 -.17 -.26 -.20 Eating Meditation -.34+ Mini-Meditations -.51** -.19 -.33+ Combined Index -.52** -.38* -.41*

52 Change in # of Days Binging and Change in HbA1Cs and Fasting Levels (n = 43-50)
Fasting Glucose Fasting Insulin Insulin Sensitivity Change in # of Binge Days .33* .28** .36** .35** Change in Weight (M=.07 lbs.; range: -15 to +45) .05 .10 .22 .20 Change in # of Binge Days, Controlling for Wt. .31* .27* .34*

53 Relationship between Improvement in Bingeing and Psychological Measures
Change in: Change in Binge Days per Month and… Eating Self-Efficacy Food Available (Lowe’s PoF) Food Present Dis-inhibition (TFEQ) Cog Restr BDI: Beck Depression Inventory MB-EAT Group -.37* .38* .35* .45** -.15 .43* Psycho- Ed Group -.32+ .51** -.23 .12

54 Rosenberg Self-Esteem
Relationship between Improvement in Depression and Psychological Measures Change in: Change in Depression and… Binge Days Food Available (Lowe’s PoF) Eating Self-Efficacy Dis-inhibition (TFEQ) Cog Restr Rosenberg Self-Esteem MB-EAT Group .43 .23 .15 .04 -.09 -.25 Psycho- Ed Group .12 .57** .48** .42* -.42* -.66**

55 Results in Relation to the Multi-Domain Model
Cognitive: Disengagement from food preoccupation. Physiological: Normalization of hunger and satiation cues; improvement in physiological/metabolic regulation. Emotional: Decreased depression. Behavioral: Decreased binging, interruption of highly conditioned responses. Relationship to Self/Others: Improved self-acceptance; anecdotally, forgiveness of others. Spiritual: Anecdotally, sense of connecting with the higher, wiser self; using meditation as prayer time.

56 Current NIH Study: MB-EAT II Mindfulness Meditation: Regulating Eating and Obesity PI: Jean L. Kristeller, Ph.D., ISU NCCAM-funded randomized clinical trial with 2 groups: MB-EAT vs. Wait List Control. Focus on obesity - moderately to morbidly obese (BMI>34). 12 week manualized intervention with increased focus on weight loss, plus 3 month support followup. 6 month total followup.

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59 j-kristeller@indstate.edu The Center for Mindful Eating www.TCME.org
I’m going to talking about meditation, about creating mental space – about the process of doing so – and about the value of this for creating change in a very fundamental aspect of human behavior – eating, and the enjoyment of food. I’ll be talking about how creating this space through meditative practice may lead to balance, self-regulation and even wisdom - .


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