Mindfulness intervention for stress eating to reduce cortisol and abdominal fat among overweight and obese women: an exploratory randomized controlled study

“The sample reported significantly greater levels of perceived stress compared to a representative sample of US women in 2006, as assessed by total scores on the Perceived Stress Scale (19.0 ± 5.9 versus 16.1 ± 7.7; t(46) = −166.0; P < .001) [79].”

“Some individuals are more susceptible to stress-induced eating than others and may adopt a self-regulation strategy for coping with aversive states in which attention is shifted away from negative selfappraisal or affect and towards the immediate stimulus environment, such as food [48, 49].”

“Some individuals are more susceptible to stress-induced eating than others and may adopt a self-regulation strategy for coping with aversive states in which attention is shifted away from negative selfappraisal or affect and towards the immediate stimulus environment, such as food [48, 49].”

“Individuals who are identified as “emotional eaters” are more vulnerable to weight gain compared to nonemotional eaters, [43, 50] and they may regain more weight after successful weight loss through either diet and exercise [51] or bariatric surgery [52].”

“Most behavioral weight loss interventions do not aim to reduce psychological stress as a primary goal, if at all, and stress may be one factor contributing to the modest success of long-term weight loss maintenance [51, 53].”

“Some individuals are more susceptible to stress-induced eating than others and may adopt a self-regulation strategy for coping with aversive states in which attention is shifted away from negative selfappraisal or affect and towards the immediate stimulus environment, such as food [48, 49].”

“These findings are congruent with those of rat studies demonstrating a link between stress eating and fat distribution [9].”

“001) [79].”

“However, a lower CAR is also related to fatigue and posttraumatic stress disorder, and norms have not been established to differentiate hypo- from hyper-CAR; thus, careful consideration of sample characteristics is needed when interpreting CAR [29].”

“Thus, abdominal adiposity is an important target for reducing risk of type 2 diabetes and cardiovascular disease (CVD) [2].”

“A mindfulness-based intervention may be effective in reducing stress and improving stress-related overeating as previous studies suggest that mindfulness training reduces psychological stress and enhances psychological well-being for a variety of health conditions, [54–58] may improve cortisol patterns, [59] may reduc…”

“The program was originally developed for binge eating disorder (BED), and in an uncontrolled pilot study and a randomized clinical trial, it was associated with reductions in binge-eating, depression, other indicators of regulation of food intake, as well as weight loss in proportion to amount of mindfulness practice…”

“The combination of chronic stress and a high fat and sugar diet markedly increases visceral adipose tissue through stress-mediated upregulation of neuropeptide Y and its receptors in fat tissues of rodents [42].”

“Increases in cortisol in combination with increased levels of insulin mobilize amino acids and fatty acids from peripheral to abdominal regions for immediate use by the liver for gluconeogenesis and ketones for energy use by the brain [7, 8].”

“Psychological distress and elevated cortisol secretion promote abdominal fat, a feature of the Metabolic Syndrome.”

“A preliminary, novel intervention was developed drawing on components from MindfulnessBased Stress Reduction (MBSR), [54] Mindfulness-Based Cognitive Therapy (MBCT), [56] and Mindfulness-Based Eating Awareness Training (MB-EAT) [69, 70].”

“One day of CAR assessment has been shown to be highly influenced by situational factors and 2–6 days of assessment on work days are needed to achieve sufficient reliability as a trait measure [77].”

“, reverse coded item: “I suppress my bodily feelings and sensations”) [72].”

“Healthy men and women who exhibit increased cortisol reactivity in response to laboratory stress tasks have greater abdominal adiposity [18–20], and among depressed, postmenopausal women, those with higher morning cortisol have greater levels of visceral fat as measured by computed tomography compared to those with lo…”

“…Medicine, Department of Medicine, University of California, San Francisco, CA 94115, USA 2 Department of Psychology, Indiana State University, Terre Haute, IN 47809, USA 3 California National Primate Research Center, University of California, Davis, CA 95616, USA 4 Department of Pediatrics,…”

“Finally, because stress eating is more common in women than in men [67], and women and men differ in fat distribution profiles, we targeted overweight and obese women who felt that stress influenced their eating behavior and weight for recruitment.”

“…Medicine, Department of Medicine, University of California, San Francisco, CA 94115, USA 2 Department of Psychology, Indiana State University, Terre Haute, IN 47809, USA 3 California National Primate Research Center, University of California, Davis, CA 95616, USA 4 Department of Pediatrics,…”

“Individuals who are identified as “emotional eaters” are more vulnerable to weight gain compared to nonemotional eaters, [43, 50] and they may regain more weight after successful weight loss through either diet and exercise [51] or bariatric surgery [52].”

“Laboratory measures of increased HPA axis activity associated with abdominal adiposity include elevated cortisol secretion after lunch [13], elevated cortisol and ACTH levels after administration of corticotrophin-releasing hormone (CRH) [14], and elevated cortisol concentrations after challenges with CRH and arginine…”

“In addition to direct effects of chronic stress on abdominal obesity, psychological stress can also trigger consumption of high fat and sweet food, leading to overall weight gain [31– 41].”

“Individuals who are identified as “emotional eaters” are more vulnerable to weight gain compared to nonemotional eaters, [43, 50] and they may regain more weight after successful weight loss through either diet and exercise [51] or bariatric surgery [52].”

“Some individuals are more susceptible to stress-induced eating than others and may adopt a self-regulation strategy for coping with aversive states in which attention is shifted away from negative selfappraisal or affect and towards the immediate stimulus environment, such as food [48, 49].”

“GR’s are found on visceral compared to peripheral fat cells partly explaining why fat stores are redistributed to intraabdominal regions in the presence of elevated cortisol [9– 11].”

“A naturalistic, noninvasive indicator of basal HPA activity, the cortisol awakening response (CAR), has been related to greater visceral adiposity as measured by waist to hip ratio in men [23–25] and magnetic resonance imaging in adolescent girls [26], although not all studies have shown a positive association [27].”

“Healthy men and women who exhibit increased cortisol reactivity in response to laboratory stress tasks have greater abdominal adiposity [18–20], and among depressed, postmenopausal women, those with higher morning cortisol have greater levels of visceral fat as measured by computed tomography compared to those with lo…”

“However, a lower CAR is also related to fatigue and posttraumatic stress disorder, and norms have not been established to differentiate hypo- from hyper-CAR; thus, careful consideration of sample characteristics is needed when interpreting CAR [29].”

“Laboratory measures of increased HPA axis activity associated with abdominal adiposity include elevated cortisol secretion after lunch [13], elevated cortisol and ACTH levels after administration of corticotrophin-releasing hormone (CRH) [14], and elevated cortisol concentrations after challenges with CRH and arginine…”

“However, a lower CAR is also related to fatigue and posttraumatic stress disorder, and norms have not been established to differentiate hypo- from hyper-CAR; thus, careful consideration of sample characteristics is needed when interpreting CAR [29].”

“Healthy men and women who exhibit increased cortisol reactivity in response to laboratory stress tasks have greater abdominal adiposity [18–20], and among depressed, postmenopausal women, those with higher morning cortisol have greater levels of visceral fat as measured by computed tomography compared to those with lo…”

“…Department of Medicine, University of California, San Francisco, CA 94115, USA 2 Department of Psychology, Indiana State University, Terre Haute, IN 47809, USA 3 California National Primate Research Center, University of California, Davis, CA 95616, USA 4 Department of Pediatrics,…”

“Postmenopausal women were excluded because fat is redistributed to visceral depots after menopause and is primarily determined by alterations in estrogen levels [68].”

“Laboratory measures of increased HPA axis activity associated with abdominal adiposity include elevated cortisol secretion after lunch [13], elevated cortisol and ACTH levels after administration of corticotrophin-releasing hormone (CRH) [14], and elevated cortisol concentrations after challenges with CRH and arginine…”

“74) [78] and was used as an estimate of visceral fat in the present study.”

“Despite evidence linking stress to overeating and abdominal fat accumulation, to our knowledge, no published studies have examined whether behavioral interventions designed to improve stress, stress eating, and/or cortisol responses lead to reductions in abdominal adiposity.”

“A greater density of GR’s are found on visceral compared to peripheral fat cells partly explaining why fat stores are redistributed to intraabdominal regions in the presence of elevated cortisol [9– 11].”

“The link between elevated cortisol concentrations and increased abdominal fat was first observed in patients diagnosed with Cushing’s syndrome who had adrenal tumors leading to hypercortisolemia [12].”

“Given recent evidence that upper trunk as well as visceral fat is associated with increased insulin resistance [64] and leg fat is associated with lower metabolic risk [65, 66], we also examined the overall change in ratio of total trunk to leg fat as an index of relative body fat distribution.”

“A greater density of GR’s are found on visceral compared to peripheral fat cells partly explaining why fat stores are redistributed to intraabdominal regions in the presence of elevated cortisol [9– 11].”

“Cortisol binds to glucocorticoid receptors (GR) on fat cells activating lipoprotein lipase, an enzyme that converts circulating triglycerides into free fatty acids in adipocytes [6].”

“A greater density of GR’s are found on visceral compared to peripheral fat cells partly explaining why fat stores are redistributed to intraabdominal regions in the presence of elevated cortisol [9– 11].”

“Individuals who are identified as “emotional eaters” are more vulnerable to weight gain compared to nonemotional eaters, [43, 50] and they may regain more weight after successful weight loss through either diet and exercise [51] or bariatric surgery [52].”

“Healthy men and women who exhibit increased cortisol reactivity in response to laboratory stress tasks have greater abdominal adiposity [18–20], and among depressed, postmenopausal women, those with higher morning cortisol have greater levels of visceral fat as measured by computed tomography compared to those with lo…”

“Individuals who are identified as “emotional eaters” are more vulnerable to weight gain compared to nonemotional eaters, [43, 50] and they may regain more weight after successful weight loss through either diet and exercise [51] or bariatric surgery [52].”

“A naturalistic, noninvasive indicator of basal HPA activity, the cortisol awakening response (CAR), has been related to greater visceral adiposity as measured by waist to hip ratio in men [23–25] and magnetic resonance imaging in adolescent girls [26], although not all studies have shown a positive association [27].”

“Despite evidence linking stress to overeating and abdominal fat accumulation, to our knowledge, no published studies have examined whether behavioral interventions designed to improve stress, stress eating, and/or cortisol responses lead to reductions in abdominal adiposity.”

“Body responsiveness also increased among overweight and obese women participating in a mindfulness intervention for stress eating compared to waitlist controls [106].”

“…for example, practices involve bringing greater attention to the pleasure of seeing, smelling, tasting, and eating of palatable foods and noticing when the satisfaction subsides, as taste-specific satiety mechanisms become apparent (Kristeller and Wolever, 2010; Daubenmier et al., 2011).”

“Studies reporting positive body weight results used a variety of mindfulness practices including combinations of mindfulness exercises (67,68), acceptance-based practices (57,58), mindful eating exercises (30,59), and programmes such as MBCT (23,37), MBSR (23) and MB-EAT (23,71), thus, not allowing us to make any firm…”

“Attendance was reported in five studies (Dalen et al., 2010; Daubenmier et al., 2011; Kearney et al., 2012; Leahey et al., 2008; Miller et al., 2012) and ranged from 70% (Miller et al.”

“Results are also consistent with other pilot work that has combined elements of the MB-EAT with elements of the MBSR program and showed improvement in eating, weight, mood, physiological regulation (Dalen et al. 2010; Daubenmier et al. 2011; Smith et al. 2006; Timmerman and Brown 2012), and purging behavior (Proulx 20…”

“MBCT or mindfulness action-based therapy Four studies((25,27,33,40)) Mindful eating Four studies((28,29,36,43)) MBSR Three studies((13,30,54)) Mindfulness Three studies((11,32,35,44)) Mindful eating and MB-EAT Three studies((14,16,38,41)) Mindfulness-based action committed therapy Two studies((38,42)) Combination of M…”

“We also suggested that participants in the intervention group follow lifestyle recommendations, including behavioral adherence strategies aimed at increasing positive affect regulation [18] and mindful eating based largely on the Mindfulness-Based Eating Awareness Training program [19,28], using handouts and lesson co…”

“Daubenmier and colleagues (54)) in their investigations.”

“Topics were drawn from two prior behavioral intervention models for diet and health behavior change, including components aimed at increasing positive affect and decreasing depressive symptoms [6] and teaching mindful eating techniques [7].”

“The included studies recruited participants from a range of populations including community samples (36,39,40,44,50,55), universities (43,52), health-related organizations (42,51) and hospitals (41,53–55,57).”

“(31) 92% retention 68% classes attended among all participants 98 (79) self-reported minutes practicing mindfulness per week; 5.”

“Method The parent study of the current study was a randomized waitlist-controlled trial of a mindfulness-based intervention for stress eating (Daubenmier et al., 2011).”

“The Mindfulness-Based Eating Awareness Training (MB-EAT) program (Kristeller & Wolever, 2011) reduced episodes of overeating in obese individuals and improved eating regulation (Daubenmier et al., 2011; Kristeller & Hallett, 1999; Kristeller, Wolever, & Sheets, 2013).”

“Detailed methods adhering to the CONSORT guidelines are described in the parent study (Daubenmier et al., 2011).”

“Mindful eating practices, modeled on the Mindfulness-Based Eating Awareness Training program, were designed to enhance awareness and self-regulation of physical hunger, stomach fullness, taste satisfaction, food cravings, emotions, and other eating triggers in the context of reduced caloric intake (16,17,24).”

“Cortisol is a marker of stress in the body, and eating slowly, with a mindful approach, has been shown to decrease morning cortisol levels.(90) Changing the manner in which food is consumed may be equally as important as the food itself.”

“Interestingly, mindfulness interventions have been shown to improve symptoms associated with each of these conditions (Bowen et al., 2009; Daubenmier et al., 2011; Grossman, Niemann, Schmidt, & Walach, 2004; Hofmann, Sawyer, Witt, & Oh, 2010; Keng, Smoski, & Robins, 2011; Ma & Teasdale, 2004).”

“Mindfulness techniques appear useful for eating disorder treatment/prevention [20, 21] and weight management efforts [22].”

“This finding is consistent with studies conducted in different populations where meditation practice was associated with improvement in diet (Alberts et al., 2012; Daubenmier et al., 2011; Katterman et al., 2014), which could be the reason for improved body composition measures.”

“More recently, researchers have turned to the possibility of mindfulness-based interventions combating the obesity epidemic, by aiding people who want to lose weight (e.g., Dalen et al., 2010; Daubenmier et al., 2011; see also Ludwig & Kabat-Zinn, 2008).”

“The practice of mindfulness includes being consciously aware of habitual patterns of thoughts, emotions, and behaviors and thus allowing for adaptive responses [19].”

“When compared with no/minimal intervention, estimates suggested greater reductions in anxiety for 3wCBT (N = 1),(67) a greater reduction in depression for 3wCBT (N= 1),(40) but found no evidence of a difference in stress (N = 1).(67) Pairwise comparisons found no evidence of differences between 3wCBT and SBT for anxie…”

“Thus, addressing external eating tendencies through such treatments as mindfulness, acceptance and commitment therapy, or behavioral therapy (Alberts, Thewissen, & Raes, 2012; Brewer et al., 2018; Daubenmier et al., 2011; Teixeira et al., 2010) could help address poor dietary habits.”

“In this article, incomplete information on timing of night-time samples (Daubenmier et al., 2011; Oken et al., 2010) limits our interpretation of the accuracy and meaningfulness of intervention effects on diurnal slope.”

“Moreover, mindfulness eating is widely recommended and practiced for reducing the amount of consumed food and improving eating disorder (Daubenmier et al., 2011).”

“…approaches to relieve stress-related behaviors could include the provision of psychological counseling services and workshops related to mindfulness that have shown utility for stress-related activities such as overeating and meal skipping (Bahl et al., 2013; Daubenmier et al., 2011).”

“There is evidence of potential floor effects of interventions, where effects may be greatest in participants of higher weight [12] and in participants who are currently attempting to lose weight [9, 11].”

“For, uncontrolled eating, significant decreases were found in 3 studies [54,55,60], but not in 5 others [51,52,58,59,61].”

“[27] Obesity is a stress with the presence of the weight stigma, which is a vicious cycle in itself where stress leads to obesity and obesity leads to stress.[28] Various pathways are finest for intervention.”

“[51] observed no change in CAR following a 9-week mindfulness intervention, which included a component of yoga training, relative to a control group.”

“A total of 322 women were screened, and 47 women with Body Mass Index (BMI) of 25–40 were enrolled into the study and completed 2 baseline assessments by staff at the UCSF General Clinical Research Center (GCRC) (Daubenmier et al., 2011).”

“Emerging findings from mindfulness-based interventions document improvements in weight, eating habits, and mental health (Alberts, Mulkens, Smeets, & Thewissen, 2010; Alberts, Thewissen, & Raes, 2012; Dalen et al., 2010; Daubenmier et al., 2011).”

“The success of mindfulness interventions for overweight, obesity, and binge eating 361 outside of pregnancy (Dalen et al., 2010; Daubenmier et al., 2011; Kristeller & Wolever, 2010) suggests 362 that these interventions might also be helpful in reducing overconsumption during pregnancy 363…”

“…that focus on the appreciation of and confidence in one’s body signals as well as appetite awareness and mindfulness (e.g., Bacon et al., 2005; Daubenmier et al., 2011; Bloom et al., 2013) have shown promise for the treatment of overweight and obesity, this study gives further support of the…”

“Conversely, a larger RCT of 47 obese women enrolled in a modified 9-week MBSR program found no statistically significant improvements in BMI or weight com- pared with a wait-listed control group (Daubenmier et al., 2011).”

“…(Vieten, 2009; Vieten & Astin, 2008), as well as from the Mindfulness-Based Eating Awareness Training that teaches skills to differentiate hunger cues and emotion responses, and to detect and respond to satiety cues (Daubenmier et al., 2011; Kristeller & Hallett, 1999; Kristeller & Wolever, 2011).”

“52 However, observed changes of interventions such as interoceptive exposure or mindfulness practices that target inter-oception have been largely qualitative and limited, with few validated measures quantifying the mechanism of change.”

“Individuals whose primary challenge is emotional eating may benefit most from CBT [104]; those with high levels of experiential avoidance may respond better to ACT [105,107]; and individuals with high stress reactivity may gain more from mindfulness-based programs [108–110].”

“Five studies used the MBI adapted from the MBCT or MBSR 9,21,30–32 and Johnson et al. 33 modified the MBCT and MBSR for adolescents.”

“…eating’ programs or, generally, mindfulness‐ based interventions for reducing BMI is unclear; our results go in line with some previous research (Daubenmier et al., 2011; Davis, 2008; Fletcher, 2011; Forman et al., 2013; Miller et al., 2012), although one meta‐analysis has concluded that…”

“…focused on awareness of body experiences related to physical hunger, satiety, taste satisfaction and emotional triggers for overeating and showed that the mindfulness group decreased more in emotional and external eating, while no change was found in restraint eating (Daubenmier et al., 2011).”

“It has also been adapted for use with several other populations, including obese adults with Type-II diabetes [24], individuals who identified restaurant meals as particularly challenging [25] and as augmented with stress-management components [25,26].”

“Recently, intervention studies have been done that have examined mindfulness exclusively, or some aspect of mindfulness, on weight loss [16, 22–26] and eating behaviors such as binge eating [16, 27] and emotional eating [28, 29].”

“mindfulness-based stress reduction [70], yoga [71], or”

“As such this controlled experimental examination of the effect of mindful attention on 385 reactions to exposure to foods may offer insights into underlying mechanisms of effects 386 suggested in previous research (e.g. Daubenmier et al., 2011; Hooper, Sandoz, Ashton, 387 Clarke, & McHugh, 2012).”

“The results were consistent with previous literature exploring mindfulness and eating behaviour, especially in regard to mindless eating (Chapman et al. 2014; Daubenmier et al. 2011; Havermans et al. 2015; Katterman et al. 2014; Mathur and Stevenson 2015).”

“Mindfulness intervention has also been shown to reduce chronic stress [17], which could, in turn, reduce abdominal adiposity.”

“The correlation between neuroimaging findings and the behaviors of eating disorders was explored as an eating disorder that was reported to be associated with abdominal obesity (Dallman et al., 2003; Gluck et al., 2004; Daubenmier et al., 2011; Succurro et al., 2015).”

“For example, mindfulness techniques [11] could be combined with progressive muscle relaxation and time management [12].”

“Nonpregnant women with chronic stress have been found to be more prone to emotional eating and visceral deposition of fat (Tomiyama, Dallman, & Epel, 2011) and reduction in abdominal fat was shown among overweight women who experienced a reduction in stress and cortisol awakening response after participating in mindfu…”

“Daubenmier et al., 2016 neglected to report the location in which the study was carried out, however, Daubenmier et al., 2011 was conducted in the United States, and we therefore classified Daubenmier et al., 2016 as having been conducted in the United States.”

“Other researchers have found that mindfulness meditation assisted in weight loss (Dalen et al., 2010; Daubenmier et al., 2011; Mantzios & Wilson, 2015a).”

“…that target awareness and regulation of hedonic eating may be more effective for obese individuals who have altered neurobiological experiences of food-related reward than weight loss programs that mainly emphasize nutritional content and caloric restriction (Daubenmier et al., 2011, 2014).”

“Laurenceau, & Levine, 2008; Fernald & Gunnar, 2009), and lower cortisol reactivity is associated with an improvement in health problems (Daubenmier et al., 2011; Ebrecht et al., 2004; McKinney, Antoni, Kumar, Tims, & McCabe, 1997).”

“For example, stress reduction programs improve not only the stress response, but also eating patterns (Daubenmier et al., 2011).”

“Two of the studies implemented MB-EAT for BED (15,21), two implemented an adaption of MB-EAT for non-BED samples (7,9), and a fifth implemented an intervention for obese individuals that incorporated MB-EAT elements (23).”

“Thus, mindful eating promotes intuitive eating, an eating style that relies on physiological hunger and satiety cues to guide eating, rather than externally driven emotional factors or dieting behaviors.(82,87) The emphasis on calorie reduction taught in traditional weight loss programs depends, to a large degree, on…”

“One study also found that especially external eating changed as a result of a mindfulness intervention in obese women (Daubenmier et al., 2011).”