REVIEW ARTICLE

 

Mindfulness, mindful eating and intuitive eating in the approach to obesity and eating disorders^*

 

 

Marina Rodrigues Barbosa^I,II; Fernanda Rodrigues de Oliveira Penaforte^III; Ana Flavia de Sousa Silva^IV

^IUniversidade Federal de Uberlândia, Faculdade de Medicina, Uberlândia, MG, Brazil
^IIUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
^IIIUniversidade Federal de Uberaba, Curso de Nutrição, Uberaba, MG, Brazil
^IVUniversidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil

Corresponding author

 

 

---

ABSTRACT

OBJECTIVE: to examine and summarize studies of mindfulness, mindful eating and intuitive eating in the approach of overweight / obesity and eating disorders.
METHOD: for this integrative review, PubMed, PePSIC, PsycINFO, LILACS, IBECS, SciELO and BVS-Psi databases were consulted, and published articles published in the last 10 years. After analyzing the recovered studies, 38 articles made up the final review corpus.
RESULTS: the studies demonstrated the benefits of approaches centered on mindfulness, mindful eating and intuitive eating on eating behavior and on the emotional and psychological aspects of overweight and eating disorders individuals, harmful or emotional, followed by external factors and compulsive eating; as well as levels of stress, anxiety and depression. For weight loss, the results are less consistent, since several studies have found no difference for this parameter.
CONCLUSIONS: as selected focused on mindfulness, mindful eating and intuitive eating are promising for addressing obesity and obesity and eating disorders, especially with regard to eating behavior and psycho-emotional aspects.

Descriptors: Mindfulness; Eating Behavior; Cognitive Behavioral Therapy; Intuitive Eating; Eating Disorder; Mindfulness-Based Intervention.

---

 

 

Introduction

Excess body weight is one of the most challenging public health problems today. Despite its increasing prevalence, and the vast knowledge about its numerous negative health consequences⁽¹⁾, the treatment for this condition remains difficult to be adhered to. Consequently, much has been questioned about the principles on which the traditional approaches to overweight are focused, which commonly rely almost exclusively on the premise of diets, with quantitative and/or qualitative restriction on food intake. It is speculated that the unsatisfactory results of this approach are mainly related to the non-promotion of changes in dysfunctional eating behaviors^(2-3).

In turn, eating disorders (EDs), mainly characterized by persistent disturbance in eating or in the behavior related to eating, resulting in excessive intake or strict avoidance of food⁽⁴⁾, although they are considered of low prevalence, also present significant degrees of morbidity and mortality, in addition to great personal and psychosocial losses⁽⁵⁾.

The approach to overweight and EDs is complex and difficult to manage, especially because they are conditions that are related to dysfunctional relationships with eating and food, and with impairment of the psychosocial functioning of the subject^(6-7). In this scenario, innovative strategies employed in the approach of dysfunctional eating behaviors have emerged, with emphasis on mindfulness, mindful eating, and intuitive eating. Mindfulness is described as a state of consciousness that emerges through the attention that is intentionally given to the present moment without judgment. Because it is a state of awareness, mindfulness can be developed and trained, through formal and informal practices⁽⁸⁾.

Within mindfulness, with a special look at attention to aspects related to eating and food, mindful eating (ME), or "eating with full attention", emerges. ME recommends that the subjects make their food choices consciously and attentive to the physical signs of hunger and satiety⁽⁹⁾. Another important premise of ME is the attention to the entire experience involved in eating, noting the effects of food on the senses and on the physical and emotional sensations that occur before, during and after eating, with openness and without judgments^(10-11).

Intuitive eating (IE) or "intuitive nutrition", although less known, follows the same line and is generally used interchangeably with ME, especially since both recommend eating being guided by the physiological signs of hunger and satiety⁽¹²⁾. IE has ten principles, with emphasis on rejection of diets, unconditional permission to eat; eating for physical, not emotional reasons; and confidence in the body and in the signals of hunger and satiety to determine when and how much to eat^(13-15).

Because these are innovative approaches, the systematization of knowledge regarding their outcomes for the health of subjects with overweight and EDs, are few, although growing in numbers. Some reviews were conducted with the objective of evaluating the effects of mindfulness-based approaches on weight loss^(16-17), on the treatment of obesity and eating disorders^(18-19), or on the specific treatment for eating disorders^{(14, 20-21)}; others sought to verify the effects of mindful eating on weight loss⁽²²⁾ or on the approach to obesity and eating disorders⁽²³⁾. However, no reviews were found that gathered the results of interventions based on mindfulness, mindful eating and intuitive eating in the eating behavior, physical aspects and psychoemotional aspects in overweight and obese individuals, and with EDs. Specifically in the national scenario, only one integrative review study was found in the specific theme of mindful eating⁽²³⁾. Therefore, this study aimed to conduct an integrative review of the literature of the growing body of research studies that investigated the role of mindfulness, mindful eating, and intuitive eating in the approach of overweight, obesity and EDs, especially with regard to results in the eating behavior and in the physical and psychoemotional aspects, seeking to contribute to the reduction of this knowledge gap. The systematization of this knowledge is important to broaden the understanding of its applicability, especially for conditions that are related to dysfunctional eating behaviors.

 

Method

This is an integrative review of the scientific literature, which aims to synthesize and deepen the knowledge about a given subject matter, seeking consolidated evidence for evidence-based practice^(24-25).

For this review, standardized procedures were adopted⁽²⁶⁾, namely: (1) identifying the theme and the guiding question; (2) establishing inclusion/exclusion criteria; (3) categorizing the studies; (4) evaluating the studies; (5) interpreting the results; (6) synthesis of knowledge⁽²⁶⁾. The international protocol for systematic review studies and meta-analyses, PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was also adopted to guide both the inclusion and exclusion of the articles in the review, as well as the writing of this study⁽²⁷⁾.

For this review, the guiding question was defined using the PICO method, which provides for the definition of the participant (P), intervention (I), comparison (C) and outcome (O)⁽²⁸⁾. The comparison item was not used in this study, so criterion C was excluded from the writing of the question. This change is foreseen in the PICO methodology in some cases. The main question of the study was the following: What are the results in the eating behavior, physical aspects and psychoemotional aspects (O) of approaches centered on mindfulness, mindful eating and intuitive eating (I) in subjects with overweight, obesity and eating disorders (P)?

Article selection path

The selection of the articles took place between October and December 2019. Searches were carried out in the PubMed, PePSIC, PsycINFO, Latin American and Caribbean Literature in Health Sciences (Literatura Latino-Americana e do Caribe em Ciências da Saúde, LILACS), IBECS, Scientific Eletronic Library Online (SciELO) and BVS-Psi databases. Academic papers in Portuguese, English and Spanish were considered. These databases were chosen because they encompass vast literature, in the national and international scopes, published on the topic of interest, and also because they include renowned journals in the health area.

For the searches, indexed descriptors were used according to DeCs/MeSh standardization, in their Portuguese and English versions. The indexed descriptors used were the following: transtorno alimentar (eating disorder or feeding disorder), comportamento alimentar (eating behavior), atenção plena (Mindfulness), obesidade (obesity) and excesso de peso (overweight). Other non-indexed descriptors, but directly related to the theme, were also used, namely: mindful eating and intuitive eating. These keywords appeared in at least one of the following search fields: title, abstract, subject or keyword.

The following criteria were adopted for including the articles: (a) articles published between January 2009 and December 2019; (b) empirical studies that explicitly and specifically used programs with approaches centered on mindfulness, mindful eating and intuitive eating; (c) studies conducted with adults; (d) which were freely available for reading in full; and (e) published in Portuguese, English and Spanish. The exclusion criteria were the following: (a) studies with children and older adults; (b) materials such as monographs, editorials, books, book chapters, reviews and abstracts in conference proceedings; (c) literature review articles; (d) articles from clinical cases; (e) qualitative studies; (f) studies on the elaboration and/or validation of scientific protocols or instruments; (g) studies carried out with intervention programs/techniques that use some elements of mindfulness, mindful eating and/or intuitive eating, but are not focused on these approaches. Studies that were repeated in more than one database were computed only once.

To check whether the articles found met the inclusion and exclusion criteria, their respective titles and abstracts were read. This procedure was performed by two independent judges, both familiar with the topic. In case of disagreement, the analysis was made by a third judge, also with experience in the theme. The articles selected in this first stage were retrieved for reading in full, and the inclusion and exclusion criteria were again applied in the full texts. The articles that remained, after analysis by full reading, made up the final analysis corpus of this study.

For the analysis stage, a record was made of all the articles that made up the final corpus, compiling the following information: title, authors, year, place of publication, method/type of study, sample, objectives and main results. The full analysis of the articles allowed for the organization of categories that aim to answer the guiding question of this review.

 

Results

Categorization of the articles

The searches in the databases resulted in a total of 785 articles. The database with the largest number of articles was Pubmed, followed by SciELO, IBECS and LILACS. The first stage of the analysis led to the exclusion of 40 articles that were duplicated. Subsequently, 528 articles were excluded, especially because they are association studies or for approaching the subject in a tangential manner. Of the 54 remaining articles to be read in full, 16 were excluded. These exclusions occurred, for example, because they were studies that only described a program to be implemented, or because they used interventions that presented only specific elements of mindfulness, ME or IE. Thus, a total of 38 articles made up the final corpus of this review. Figure 1 shows the flowchart of the study selection strategy, according to the PRISMA protocol.

The articles that make up this review are exclusively international and are written in the English language. The country with the largest number of publications was the United States (n=27; 71.0%), followed by Portugal (n=03; 7.9%), England (n=02; 5.2%), Australia (n=2; 5.2%), Holland (n=01; 2.6%), Canada (n=01; 2.6%), New Zealand (n=01; 2.6%), and Iran (n=01; 2, 6%). The year with the highest number of publication was 2017 (n=09; 23.7%), followed by 2016 (n=06; 15.8%). The years 2010, 2014, 2018 and 2019 contributed with four studies (10.8%) each year. The years 2011 and 2013 were the ones with the lowest number of publications, with only 01 article (2.7%) each year.

The sample size of the studies ranged from 10 (smallest sample) ⁽⁹⁾ to 194 (largest sample) participants. The surveys with the largest sample size^(29-30) were derived from the same research protocol. Most of the studies were conducted with men and women (n=21; 55.2%); however, an important portion of the studies was carried out exclusively with women (n=17; 44.7).

It was observed that most of the studies (n=31, 81.6%) were carried out with overweight individuals, with 06 studies (15.8%) carried out with ED patients, and only 01 (2.6%) conducted with women with overweight and binge eating. Studies conducted with people with specific clinical conditions were few in number. Research studies were found with women with a current or previous history of cancer (n=03, 7.9%), with pregnant women (n=02, 5.2%), and with individuals in the postoperative period of bariatric surgery (n=01, 2.6%).

Regarding the type of study, most of the articles fall into the randomized type (n=21; 55.2%), followed by the evaluation of the participants before and after the intervention (n=13; 34, 2%). The longest intervention lasted 6 months⁽³¹⁾ and the shortest, one month^(32-33). The intervention time most commonly found in the studies was 8 weeks (n=08, 21.0%), followed by 10-week interventions (n=07, 18.4%). Most of the studies used the mindfulness-based intervention (n=18; 47.3%), followed by interventions that used mindful eating (n=11; 28.9%), mindfulness and mindful eating in association (n=5; 13.1%), and intuitive eating (n=04; 10.5%).

It is also important to mention that most of the research studies with a control group had an active control group (n=20; 52.6%), that is, the participants received some type of intervention that did not involve mindfulness, mindful eating or intuitive eating. Only 03 studies (7.8%) did not perform any type of intervention in the control group.

The results presented below will be organized based on the full reading of the studies that comprised the corpus of this review, aiming to answer the guiding question: (1) results of approaches centered on mindfulness, mindful eating and intuitive eating in the eating behavior; (2) results of approaches focused on mindfulness, mindful eating and intuitive eating in physical aspects; and (3) results of approaches centered on mindfulness, mindful eating and intuitive eating in psycho-emotional aspects.

Category 1) Results of the approaches centered on mindfulness, mindful eating and intuitive eating in eating behavior.

Studies with overweight and obese subjects that had among their objectives improvements in eating behavior (55.3%) bring promising results. With interventions supported by mindfulness, ME or IE, reductions in food craving levels were observed, as well as in eating guided by external stimuli, emotional eating, eating guided by reward, episodes of compulsive eating and of binge eating compared to the control groups. For the interventions with evaluation of the before and after type, improvements were seen in eating awareness, reduction in binge eating episodes, increases in scores of mindful eating and intuitive eating, and improved fruit and vegetable intake. For the studies with ED patients (18.4%), a reduction in the number of episodes of binge eating was observed, as well as a reduction in the scores of the Eating Attitudes Test (EAT), an increase in the IE levels, and a decrease in the eating psychopathology levels after participating in the interventions (Figures 2 and 3).

Few studies (7.9%) found no differences between the experimental groups and the control group for the eating behavior parameters evaluated. For example, the study⁽³⁴⁾ that identified improvement in the levels of emotional eating, uninhibited eating, and symptoms of dependence on food in both groups of pregnant women (intervention and control), with no difference between them. It is important to note that the control group, in this study, also received an intervention, referred to as Emotional Brain Training (EBT), whose objective was to train the participants› emotional self-regulation, with a view to reducing their stress levels⁽³⁴⁾. Similar results were obtained in another study⁽³⁵⁾, especially in reducing stress-related eating at the end of the intervention, in all the groups, with no difference between them. Also in this study, all the groups received some type of intervention, according to the following combinations: (1) stress reduction intervention based on mindfulness (Mindfulness Based Stress Reduction program), (2) stress reduction intervention based on the interrelationship between stress, food and well-being, supported by cognitive behavioral therapy, and (3) a combination of interventions from groups 1 and 2 (Figures 2 and 3).

Category 2) Results of the approaches centered on mindfulness, mindful eating and intuitive eating in physical aspects.

The research studies with interventions with evaluation of the before and after type, carried out with overweight individuals, obtained satisfactory results with regard to physical aspects, since the majority (66.7%) observed a significant reduction in weight, in the BMI and in the C-reactive protein levels. It is also worth mentioning that most of the randomized studies (72.7%), in which the participants were divided into an intervention group (mindfulness and mindful eating) and active control group (who received some type of intervention), found no significant differences between the groups for weight loss. However, there was a significant reduction in fasting glycaemia and in the TG/HDL ratio in the experimental group in relation to the control group⁽³⁶⁾ (Figure 3).

Regarding studies with ED patients, the results point to a reduction in concern about weight, physical shape and overvaluation of weight after participating in mindfulness-based interventions, compared to the control group. There was also an increase in body satisfaction, showing the benefits of such interventions for the participants.

Category 3) Results of the approaches centered on mindfulness, mindful eating and intuitive eating in psycho-emotional aspects.

Among the studies carried out with overweight and obese individuals, 27.0% had among their objectives the assessment of the impacts of mindfulness-based interventions on emotional and psychological aspects such as depression, anxiety, stress, psychological flexibility, and general mental health. These studies also bring promising results, since 80.0% of them identified an improvement in the parameters related to psychological distress, depression or anxiety^(37-38).

The studies indicate that, after the intervention based on mindfulness and mindful eating, there was a significant reduction in the levels of depression, anxiety, perceived stress and cortisol ^{(9, 39-40)}. In addition, some positive impacts were observed, such as an improvement in the ability to respond to bodily sensations, psychological flexibility and psychological acceptance, also described as a reduction in experiential avoidance^(41-42) (Figure 2).

In studies conducted with individuals diagnosed with EDs, only 5.2% had among their objectives the assessment of the impacts of the mindfulness-based interventions on the emotional and psychological aspects. One of these studies was carried out with women with EDs⁽⁴³⁾, with a 12-week intervention integrating concepts of psychoeducation and mindfulness, where a significant reduction in psychological inflexibility, external shame and self-criticism was observed; as well as increased engagement with life, self-compassion, and levels of self-confidence and of mindfulness. It is important to note that these gains were maintained in reevaluations 3 and 6 months after the intervention.

In another study, also conducted with women with EDs⁽³³⁾, the authors performed a mindfulness-based intervention during four weeks and observed a reduction in the symptoms of depression and stress, as well as an improvement in psychological flexibility in relation to body image, when compared to the control group (Figure 2).

 

Discussion

This study aimed to conduct an integrative review of the growing number of research studies that investigated the role of interventions based on mindfulness, mindful eating and intuitive eating in the approach of overweight, obesity and EDs, especially with regard to the eating behavior and to the physical and psycho-emotional aspects. Through the studies evaluated, it was observed that such interventions had a positive impact on the eating behavior and on the emotional and psychological aspects of the participants; and also, to some extent, on the physical aspects, with regard to weight loss and the improvement of metabolic parameters.

Eating behavior is defined⁽⁶⁵⁾ as attitudes related to the eating practices associated with intrinsic socio-cultural attributes of the individual or belonging to a community, which are involved with the act of eating or with food itself. In this perspective, far beyond than just dealing with the practices involved with food (which, how much, how, where and with whom we eat), the eating behavior involves subjective aspects around food, which can be socio-cultural or psychological.

In the light of this concept, it is clear that interventions focused especially on ME and IE meet what is part of the human eating behavior, since they value and consider not only the biological aspects, related to "what and how much we eat", but also encompass the psychosocial, emotional and environmental aspects that pervade food. Among its principles, the reconnection with the internal signals of hunger and satiety stands out, and eating guided especially by this signaling, minimizing food intake in response to emotional or environmental factors⁽⁶⁶⁾. It is worth noting that these interventions do not focus on changing the foods that the individual consumes, but rather on understanding the relationship that the individuals have with food, and on how the mind and body understand the experience of eating⁽⁶⁷⁾. In a special way, ME also advocates the non-judgment and non-segmentation of foods into "good and bad", helping the subjects to understand the reasons for their food choices, leaving the automatic pilot, with openness and kindness⁽⁶⁶⁾.

From this discussion, it is observed that the results of the interventions observed in the studies in relation to the eating behavior are related to the fundamentals of mindfulness, ME and IE. Attention, presence and non-judgment in relation to food, and the recognition of internal signs of hunger and satiety, are aspects that favor more flexible food choices and more consistent with this signaling, minimizing excessive eating and eating guided by emotional and/or environmental factors, which reverberates positively in relation to food and to the eating behavior^{(12, 14-19)}.

The recognition and appreciation of the role of emotions in our eating, strongly advocated by these interventions, have an important role in improving the eating behavior of the subjects, especially for the emotional aspect with emphasis on negative emotions, to be considered a primary determinant of overeating episodes^(68-69). Recognizing and welcoming the negative emotions in a gentle and compassionate manner, based on the observation of the experience itself, without judgment or criticism, can avoid eating disorders and the impulse to suppress these feelings through food⁽¹⁰⁾. The results of the studies agree with this premise, since improvements were obtained in emotional eating, eating guided by external factors, episodes of overeating and binge eating.

In addition, studies on women with EDs have also reported improvements in the eating practices, in relation to food and in the acceptance of the body image; as well as reduced emotional eating. These results signal the positive emotional and physical impacts which may result from programs that incorporate and value the principles of ME and IE, making weight loss no longer the only focus/reason for happiness⁽⁹⁾.

Although some studies have carried out their interventions in order to achieve weight reduction, it is important to keep in mind that approaches centered on mindfulness, mindful eating and intuitive eating do not have this objective. The improvements in the relationship with eating and food, and the benefits obtained in the eating behavior that are advocated in these approaches, can consequently lead to weight reduction, even though this is not their focus.

Greater attention to internal and external signals that regulate food intake, eating more slowly, feeling satisfied with a smaller volume of food, and better control of psychological impulses without using food to satisfy psychological/emotional needs, can lead weight loss in this process, even though this is not the purpose of the intervention⁽⁷⁰⁾. From this perspective, the results of the studies that did not observe the superiority of mindfulness, ME and IE for weight loss should not be interpreted as negative.

Following diets that focus on calorie restriction has been the most widely used strategy for weight loss for several decades⁽⁷¹⁾. However, evidence accumulates in the literature indicating the inefficiency of diets for weight loss, as well as for the maintenance of this loss, in the medium and long terms^(2-3). Multiple compensatory mechanisms are involved in the process of recovering the weight that is lost with the practice of diets; with emphasis on the intense disconnection with the internal signaling of hunger and satiety, since the decision of what and how much to eat is transferred to external rules, generating profound negative repercussions on the eating behavior of those on diets^(72-73).

In this sense, the dietary behavior of dieters is cognitively controlled, and it is always necessary to verify that food intake is in accordance with the external rules imposed by the diet. The disconnection with the physical sensations of hunger and satiety ends up deregulating the eating behavior of the subjects, making dieters more fragile to environmental, psychosocial and emotional influences in eating, generating frequent episodes of overeating and emotional eating^(73-74).

Bearing in mind that, contrary to what is recommended by the diets, one of the main objectives of the ME and IE approaches lies in promoting improvements in the eating behavior, especially through a reconnection with the internal signs of hunger and satiety, non-judgment and non-categorization of foods as "permitted and prohibited", and in encouraging health care by taking the focus off body weight, the contradiction in the use of these approaches with the objective of weight loss is clear.

An important point to be considered in relation to the studies concerns the variability of the intervention protocols used, which makes it difficult to replicate them and to compare the results. It is noteworthy that the studies, in general, did not inform aspects inherent to the professionals who conducted the interventions, such as education, training in mindfulness and the clinical experience with the population and the practices employed. In addition, based on the types of studies analyzed and their results, an interest emerges in the experiential dimension of the participants submitted to mindfulness-based interventions, signaling the relevance of studies that qualitatively analyze the subject's experience in their own repertoire of meanings.

Despite the interest in interventions based on mindful eating and intuitive eating is growing, the years of the publications signal that these interventions are a recent phenomenon. Most of the published studies focus on the years 2016 and 2017, and the oldest year of publication is 2010. It is worth noting the fact that 100.0% of the studies that make up the corpus of this review are international, indicating that, although these interventions are being widely discussed and used, the number of countries producing on the subject is still small; in addition, no published studies on approaches in Brazil were found in the studied databases. This note raises the need for caution in generalizing these findings to all populations, especially to individuals living in very diverse cultures, since the human eating behavior reflects interactions between the physiological and psychological state and the external environment in which it is inserted⁽⁷⁵⁾.

The great scarcity of studies in the national setting points out to the need to develop studies on this theme in the country, in order to advance in relation to its understanding, given that these interventions seem to be effective strategies to assist, not only in the good relationship of individuals in relation to eating, but also to avoid dysfunctional eating behaviors.

 

Final Considerations

The studies that make up the present review offer a range of information on the role of the interventions centered on mindfulness, ME and IE and on addressing overweight, obesity and EDs. Their results suggest that such interventions bring benefits to the subjects, especially with regard to the eating behavior and to the psychoemotional aspects. These results are in line with the basic principles of these interventions, more specifically for ME and IE, which are strongly supported in the appreciation of the internal signs of hunger and satiety as the main guide for eating, as well as in openness and non-judgment in relation to food, which can minimize episodes of emotional eating and overeating; besides helping to reduce the levels of stress and anxiety, especially when related to eating and food.

Even though it is not the objective of interventions based on mindfulness, ME and IE, several studies have used them in order to achieve weight loss in overweight individuals. Analyzing the corpus, it is observed that the interventions were not superior, in relation to the control, for this objective; which, a priori, can be interpreted as a negative outcome. However, if we interpret these results in the light of the basic objectives of the ME and IE approaches, we realize that these objectives are aligned, which prioritize helping the subjects not to lose weight, but to establish a healthy relationship with food.

The absence of studies in the Brazilian scenario brings to the fore the need to advance studies on this topic in the country, considering the promising results obtained in the eating behavior and emotional health of individuals with overweight and EDs. The subjects who live with such health conditions present impairments in their mental health and dysfunctional eating behaviors, both of which are a source of great suffering and reduced quality of life. Advancing in relation to the understanding of the theme can enhance the approaches, especially nutritional ones, commonly used in these conditions. In addition, it can also strengthen this field of knowledge in the country, expanding the discussions and reflections on new and promising possibilities in approaching overweight, obesity and EDs, which should even permeate the professional training of those who will deal with these subjects.

 

References

1. World Health Organization. Obesity and overweight. Fact sheet no. 311, 2014. [cited Dec 20, 2020]. Available from: www.who.int/mediacentre/factsheets/fs311/en/.         [ Links ]

2. Freire, R. Scientific evidence of diets for weight loss: Different macronutrient composition, intermittent fasting, and popular diets. Nutrition. 2020; 69:110549. doi: https://doi.org/10.1016/j.nut.2019.07.001.         [ Links ]

3. Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Diets Are Not the Answer. Am Psychol. 2007; 62(3):220-33. doi: https://doi.org/10.1037/0003-066x.62.3.220.         [ Links ]

4. American Psychiatric Association. DSM-5: manual diagnóstico e estatístico de transtornos mentais. 5ª. ed. Porto Alegre (RS): Artmed; 2014. 992p.         [ Links ]

5. Pinzon V, Nogueira FC. Epidemiologia, curso e evolução dos transtornos alimentares. Rev Psiq Clin. 2004; 31(4):158-60. doi: http://doi.org/10.1590/S0101-60832004000400004        [ Links ]

6. Gracia-Arnaiz M. at bodies and thin bodies. Cultural, biomedical and market discourses on obesity. Appetite. 2010; 55(2):219-25. doi: https://doi.org/10.1016/j.appet.2010.06.002        [ Links ]

7. Alvarenga M, Larino MA. Terapia nutricional na anorexia e bulimia nervosas. Rev Bras Psiquiatr. 2002; 24(Suppl3):39-43. doi: http://doi.org/10.1590/S1516-44462002000700009        [ Links ]

8. Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. 2a. ed. New York(NY): Delta; 1990. 720 p.         [ Links ]

9. Dalen J, Smith BW, Shelley BM, Sloan AL, Leahigh L, Begay D. Pilot study: Mindful Eating and Living (MEAL): weight, eating behavior, and psychological outcomes associated with a mindfulness based intervention for people with obesity. Complement Ther Med. 2010; 18(6): 260-4. doi: https://doi.org/10.1016/j.ctim.2010.09.008        [ Links ]

10. Kristeller JL, Wolever RQ. Mindfulness-based eating awareness training for treating binge eating disorder: the conceptual foundation. Eat Disord. 2011; 19(1):49-61. doi: https://doi.org/10.1080/10640266.2011.533605        [ Links ]

11. Kristeller JL, Wolever RQ, Sheets V. Mindfulness-Based Eating Awareness Training (MB-EAT) for binge eating: a randomized clinical trial. Mindfulness. 2014; 5(3): 282-97. doi: https://doi.org/10.1007/s12671-012-0179-1        [ Links ]

12. Warren, JM, Smith, N, Ashwell, M. A structured literature review on the role of mindfulness, mindful eating and intuitive eating in changing eating behaviours: effectiveness and associated potential mechanisms. Nutr Res Rev. 2017; 30(2):272-83. doi: https://doi.org/10.1017/S0954422417000154        [ Links ]

13. Tribole E, Resch E. Intuitive Eating. A revolutionary program that works. New York (NY): St. Martins Griffin Press; 2012. 344 p.         [ Links ]

14. Katterman SN, Kleinman BM, Hood MM, Nackers LM, Corsica JA. Mindfulness meditation as an intervention for binge eating, emotional eating, and weight loss: A systematic review. Eat Beh. 2014; 15:197-204. https://doi.org//10.1016/j.eatbeh.2014.01.005        [ Links ]

15. Olson K, Emery, CF. Mindfulness and Weight Loss: A Systematic Review. Psychosomatic Medicine. 2015; 77(1):59-67. doi: https://doi.org/10.1097/PSY.0000000000000127        [ Links ]

16. Rogers JM, Ferrari M, Mosely K, Lang CP, Brennan L. Mindfulness-based interventions for adults who are overweight or obese: a meta-analysis of physical and psychological health outcomes. Obesity Rev. 2016; 18(1):51-67. doi: https://doi.org/10.1111/obr.12461        [ Links ]

17. Carriere K, Khoury B, Gunak MM, Knauper B. Mindfulness-based interventions for weight loss: a systematic review and meta-analysis. Obesity Rev. 2017; 19(2): 164-77. doi: https://doi.org/10.1111/obr.12623        [ Links ]

18. Godsey J. The role of mindfulness based interventions in the treatment of obesity and eating disorders: an integrative review. Complement Ther Med. 2013; 21(4): 430-9. doi: https://doi.org/10.1016/j.ctim.2013.06.003        [ Links ]

19. O'Reilly GA, Cook L, Spruijt-Metz D, Black DS. Mindfulness-based interventions for obesity-related eating behaviours: a literature review. Obesity Rev. 2014; 15(6): 453- 61. doi: https://doi.org/10.1111/obr.12156        [ Links ]

20. Wanden-Berghe RG, Sanz-Valero J, Wanden-Berghe C. The Application of Mindfulness to Eating Disorders Treatment: A Systematic Review. Eat Disord. 2011; 19(1):34-48. doi: https://doi.org/10.1080/10640266.2011.533604        [ Links ]

21. Godfrey KM, Gallo LC, Afari N. Mindfulness-based interventions for binge eating: a systematic review and meta-analysis. J Behav Med. 2015; 38(2): 348-62. doi: https://doi.org/10.1007/s10865-014-9610-5        [ Links ]

22. Artiles RF, Staub K, Aldakak L, Eppenberger P, Ruhli F, Bender N. Mindful eating and common diet programs lower body weight similarly: Systematic review and meta‐analysis. Obesity Rev. 2019; 20(11): 1619-27. doi: https://doi.org/10.1111/obr.12918        [ Links ]

23. Almeida CC, Assumpção AA. A eficácia do mindful eating para transtornos alimentares e obesidade: revisão integrativa. Pretextos. 2018; 3(6): 25-36.         [ Links ]

24. Benefield LE. Implementing evidence-based practice in home care. Home Healthcare Nurse: J Home Care Hospice Prof. 2003; 21(12): 804-11. doi: https://doi.org/10.1097/00004045-200312000-00005        [ Links ]

25. Broome ME. Integrative literature reviews for the development of concepts. In: Rodgers BL, Knafl KA, editors. Concept development in nursing: foundations, techniques and applications. Philadelphia (USA): WB Saunders; 2000. p. 231-50.         [ Links ]

26. Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto- Enferm. 2008; 17(4):758-64. doi: http://doi.org/10.1590/S0104-07072008000400018        [ Links ]

27. Moher D, Liberati A, Tetzlaff J, Altman DG. The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. Annals Internal Med. 2009; 151(4):264-9. doi: https://doi.org/10.1371/journal.pmed.1000097        [ Links ]

28. Harris JD, Quatman E, Manring MM, Siston RA, Flanigan DC. How to write a systematic review. Am J Sports Med. 2014; 42(11):2761-8. doi: https://doi.org/10.1177/0363546513497567        [ Links ]

29. Mason AE, Epel ES, Aschbacher K, Lustig RH, Acree M, Kristeller J, et al. Reduced reward-driven eating accounts for the impact of a mindfulness-based diet and exercise intervention on weight loss: Data from the SHINE randomized controlled trial. Appetite. 2016; 100(1):86-93. doi: https://doi.org/10.1016/j.appet.2016.02.009        [ Links ]

30. Adler E, Dhruva A, Moran PJ, Daubenmier J, Acree M, Epel ES, et al. Impact of a Mindfulness-Based Weight-Loss Intervention on Sleep Quality Among Adults with Obesity: Data from the SHINE Randomized Controlled Trial. J Altern Compl Med. 2017; 23(3):188-95. doi: https://doi.org/10.1089/acm.2016.0141        [ Links ]

31. Spadaro KC, Davis KK, Sereika SM, Gibbs BB, Jakicic JM, Cohen SM. Effect of mindfulness meditation on short-term weight loss and eating behaviors in overweight and obese adults: A randomized controlled trial. J Compl Integr Med. 2017;15(2). doi: https://doi.org/10.1515/jcim-2016-0048        [ Links ]

32. Stites SD, Singletary SB, Menasha A, Cooblall C, Hantula D, Axelrod S, et al. Pre-ordering lunch at work. Results of the what to eat for lunch study. Appetite. 2015; 84(1):88-97. doi: https://doi.org/10.1016/j.appet.2014.10.005        [ Links ]

33. Duarte C, Pinto-Gouveia J, Stubbs RJ. Compassionate Attention and Regulation of Eating Behaviour: A pilot study of a brief low-intensity intervention for binge eating. Clin Psychol Psychother. 2017; 24(6):O1437-O47. doi: https://doi.org/10.1002/cpp.2094        [ Links ]

34. Laraia BA, Adler NE, Coleman-Phox K, Vieten C, Mellin L, Kristeller JL, et al. Novel Interventions to Reduce Stress and Overeating in Overweight Pregnant Women: A Feasibility Study. Matern Child Health J. 2018; 22(5):670-78. doi: https://doi.org/10.1007/s10995-018-2435-z        [ Links ]

35. Corsica J, Hood MM, Katterman S, Kleinman B, Ivan I. Development of a novel mindfulness and cognitive behavioral intervention for stress-eating: a comparative pilot study. Eat Behav. 2014; 15(4):694-9. doi: https://doi.org/10.1016/j.eatbeh.2014.08.002        [ Links ]

36. Daubenmier J, Moran PJ, Kristeller J, Acree M, Bacchetti P, Kemeny ME, et al. Effects of a mindfulness-based weight loss intervention in adults with obesity: A randomized clinical trial. Obesity. 2016; 24(4):794-804. doi: https://doi.org/10.1002/oby.21396        [ Links ]

37. Palmeira L, Pinto-Gouveia J, Cunha M. Exploring the efficacy of an acceptance, mindfulness & compassionate-based group intervention for women struggling with their weight (Kg-Free): A randomized controlled trial. Appetite. 2017; 112(1):107-16. doi: https://doi.org/10.1016/j.appet.2017.01.027        [ Links ]

38. Raja-Khan N, Agito K, Shah J, Stetter CM, Gustafson TS, Socolow H, et al. Mindfulness-Based Stress Reduction in Women with Overweight or Obesity: A Randomized Controlled Trial. Obesity. 2017; 25(8):1349-59. doi: https://doi.org/10.1002/oby.21910        [ Links ]

39. Daubenmier J, Kristeller J, Hecht FM, Maninger N, Kuwata M, Jhaveri K, et al. Mindfulness Intervention for Stress Eating to Reduce Cortisol and Abdominal Fat among Overweight and Obese Women: An Exploratory Randomized Controlled Study. J Obes. 2011; 2011:651936. doi: https://doi.org/10.1155/2011/651936        [ Links ]

40. Daubenmier J, Lustig RH, Hecht FM, Kristeller J, Woolley J, Adam T, et al. A new biomarker of hedonic eating? A preliminary investigation of cortisol and nausea responses to acute opioid blockade. Appetite. 2014; 74(1):92-100. doi: https://doi.org/10.1016/j.appet.2013.11.014        [ Links ]

41. Vieten C, Laraia BA, Kristeller J, Adler N, Coleman-Phox K, Bush NR, et al. The mindful moms training: development of a mindfulness-based intervention to reduce stress and overeating during pregnancy. BMC Pregnancy Childbirth. 2018; 18(1):201. doi: https://doi.org/10.1186/s12884-018-1757-6        [ Links ]

42. Boucher S, Edwards O, Gray A, Nada-Raja S, Lillis J, Tylka TL, et al. Teaching Intuitive Eating and Acceptance and Commitment Therapy Skills Via a Web-Based Intervention: A Pilot Single-Arm Intervention Study. JMIR Res Protoc. 2016; 5(4):e180. doi: https://doi.org/10.2196/resprot.5861        [ Links ]

43. Pinto-Gouveia J, Carvalho SA, Palmeira L, Castilho P, Duarte C, Ferreira C, et al. Incorporating psychoeducation, mindfulness and self-compassion in a new programme for binge eating (BEfree): Exploring processes of change. J Health Psychol. 2016; 24(4):466-79. doi: https://doi.org/10.1177/1359105316676628        [ Links ]

44. Alberts HJ, Mulkens S, Smeets M, Thewissen R. Coping with food cravings. Investigating the potential of a mindfulness-based intervention. Appetite. 2010; 55(1):160-3. doi: https://doi.org/10.1016/j.appet.2010.05.044        [ Links ]

45. Courbasson CM, Nishikawa Y, Shapira LB. Mindfulness-Action Based Cognitive Behavioral Therapy for concurrent Binge Eating Disorder and Substance Use Disorders. Eat Disord. 2010; 19(1):17-33. doi: https://doi.org/10.1080/10640266.2011.533603        [ Links ]

46. Hepworth NS.A mindful eating group as an adjunct to individual treatment for eating disorders: a pilot study. Eat Disord. 2011; 19(1):6-16. doi: https://doi.org/10.1080/10640266.2011.533601        [ Links ]

47. Anglin JC. Assessing the effectiveness of intuitive eating for weight loss - pilot study. Nutr. Health. 2012; 21(2):107-15. doi: https://doi.org/10.1177/0260106012459994        [ Links ]

48. Daubenmier J, Lin J, Blackburn E, Hecht FM, Kristeller J, Maninger N, et al. Changes in stress, eating, and metabolic factors are related to changes in telomerase activity in a randomized mindfulness intervention pilot study. Psychoneuroendocrinology. 2012; 37(7):917-28. doi: https://doi.org/10.1016/j.psyneuen.2011.10.008        [ Links ]

49. Woolhouse H1, Knowles A, Crafti N. Adding mindfulness to CBT programs for binge eating: a mixed-methods evaluation. Eat Disord. 2012; 20(4):321-39. doi: https://doi.org/10.1080/10640266.2012.691791        [ Links ]

50. Kidd LI, Graor CH, Murrock CJ. A mindful eating group intervention for obese women: a mixed methods feasibility study. Arch Psychiatr Nurs. 2013; 27(5):211-8. doi: https://doi.org/10.1016/j.apnu.2013.05.004        [ Links ]

51. Mantzios M, Giannou K. Group vs. single mindfulness meditation: exploring avoidance, impulsivity, and weight management in two separate mindfulness meditation settings. Appl Psychol Health Well Being. 2014; 6(2):173-91. doi: https://doi.org/10.1111/aphw.12023        [ Links ]

52. Asadollahi T, Khakpour S, Ahmadi F, Seyedeh L, Tahami, Matoo S, et al. Effectiveness of mindfulness training and dietary regime on weight loss in obese people. J Med Life. 2015; 8(4):114-24.         [ Links ]

53. Chacko SA, Yeh GY, Davis RB, Wee CC. A mindfulness-based intervention to control weight after bariatric surgery: Preliminary results from a randomized controlled pilot trial. Compl Ther Med. 2016; 28:13-21. doi: https://doi.org/10.1016/j.ctim.2016.07.001        [ Links ]

54. Chung S, Zhu S, Friedmann E, Kelleher C, Kozlovsky A, Macfarlane KW, et al. Weight loss with mindful eating in African American women following treatment for breast cancer: a longitudinal study. Support Care Cancer. 2016; 24(4):1875-81. doi: https://doi.org/10.1007/s00520-015-2984-2        [ Links ]

55. Lucas AR, Focht BC, Cohn DE, Buckworth J, Klatt MD. A Mindfulness-Based Lifestyle Intervention for Obese, Inactive Endometrial Cancer Survivors: A Feasibility Study. Integr. Cancer Ther. 2017; 16(3):263-75. doi: https://doi.org/10.1177/1534735416668257        [ Links ]

56. Mason AE, Epel ES, Kristeller J, Moran PJ, Dallman M, Lustig RH, et al (A). Effects of a mindfulness-based intervention on mindful eating, sweets consumption, and fasting glucose levels in obese adults: data from the SHINE randomized controlled trial. J Behav Med. 2016; 39(2):201-13. doi: https://doi.org/10.1007/s10865-015-9692-8        [ Links ]

57. Carpenter KM, Vickerman KA, Salmon EE, Javitz HS, Epel ES, Lovejoy JC. A Randomized Pilot Study of a Phone-Based Mindfulness and Weight Loss Program. Behav Med. 2019; 45(4):271-81. doi: https://doi.org/10.1080/08964289.2017.1384359        [ Links ]

58. Richards PS, Crowton S, Berrett ME, Smith MH, Passmore K. Can patients with eating disorders learn to eat intuitively? A 2-year pilot study, Eating Disorders. 2017; 25(2):99-113. doi: https://doi.org/10.1080/10640266.2017.1279907.         [ Links ]

59. Kristeller JL, Jordan KD. Mindful Eating: Connecting With the Wise Self, the Spiritual Self. Front Psychol. 2018; 14;9:1271. doi: https://doi.org/10.3389/fpsyg.2018.01271        [ Links ]

60. Mason AE, Jhaveri K, Cohn M, Brewer JA. Testing a mobile mindful eating intervention targeting craving-related eating: feasibility and proof of concept. J Behav. Med. 2018; 41(2):160-173. doi: https://doi.org/10.1007/s10865-017-9884-5        [ Links ]

61. Cole RE, Meyer SA, Newman TJ1, Kieffer AJ, Wax SG1, Stote K, et al. The My Body Knows When Program Increased Intuitive Eating Characteristics in a Military Population. Mil Med. 2019; 184(7-8):200-6. doi: https://doi.org/10.1093/milmed/usy403        [ Links ]

62. Hanson P, Shuttlewood E, Halder L, Shah N, Lam FT, Menon V, et al. Application of Mindfulness in a Tier 3 Obesity Service Improves Eating Behavior and Facilitates Successful Weight Loss. J Clin Endocrinol Metab. 2019; 104(3): 793-800. doi: https://doi.org/10.1210/jc.2018-00578        [ Links ]

63. Stice E, Rohde P, Shaw H, Gau JM. Randomized Trial of a Dissonance-Based Group Treatment for Eating Disorders Versus a Supportive Mindfulness Group Treatment. J Consult Clin Psychol. 2019; 87(1):79-90. doi: http://doi.org/10.1037/ccp0000365        [ Links ]

64. Thomas EA, Mijangos JL, Hansen PA, White S, Walker D, Reimers C, et al. Mindfulness-Oriented Recovery Enhancement Restructures Reward Processing and Promotes Interoceptive Awareness in Overweight Cancer Survivors: Mechanistic Results From a Stage 1 Randomized Controlled Trial. Integr Cancer Ther. 2019; 18:1534735419855138. doi: https://doi.org/10.1177/1534735419855138        [ Links ]

65. Garcia RW. Representações sociais da alimentação e saúde e suas repercussões no comportamento alimentar. Physis: Rev Saúde Coletiva. 1997; 7(2):51-68. doi: http://doi.org/10.1590/S0103-73311997000200004        [ Links ]

66. Rossy L. The mindfulness-based eating solution. Oakland (CA): New Harbinger Publications; 2016. 224 p.         [ Links ]

67. Camilleri GM, Méjean C, Bellisle F, Andreeva VA, Kesse-Guyot E, Hercberg S, et al. Intuitive Eating Dimensions Were Differently Associated with Food Intake in the General Population-Based NutriNet-Santé Study. J Nutr. 2016; 147(1):61-9. doi: https://doi.org/10.3945/jn.116.234088        [ Links ]

68. Gibson EL. Emotional influences on food choice: Sensory, physiological and psychological pathways. Physiol Behav. 2006; 89(1):53-61. doi: https://doi.org/10.1016/j.physbeh.2006.01.024        [ Links ]

69. Canetti L, Bachar E, Berry EM. Food and emotion. Behavioural Proc. 2002; 60(2):157-64. doi: https://doi.org/10.1016/S0376-6357(02)00082-7        [ Links ]

70. Kabat-Zinn J. Mindfulness‐based interventions in context: past, present, and future. Clin Psychol Sci Pract. 2003; 10(2):144-56. doi: https://doi.org/10.1093/clipsy.bpg016        [ Links ]

71. Foxcroft L. A tirania das dietas. São Paulo(SP): Três Estrelas; 2013. 280 p.         [ Links ]

72. Alvarenga M, Palacow V, Scagliusi F. Dieta e seus efeitos no comportamento alimentar. In: Alvarenga M, Figueiredo M, Timerman F., editores. Nutrição Comportamental. São Paulo(SP): Manole; 2015. p. 69-100.         [ Links ]

73. Stroebe W, Van Koningsbruggen GM. Why Most Dieters Fail but Some Succeed: A Goal Conflict Model of Eating Behavior. Psychol Rev. 2013; 120(1):110-38. doi: https://doi.org/10.1037/a0030849        [ Links ]

74. Herman CP, Polivy JA. boundary model for the regulation of eating. In: Stunkard JA, Stellar E, editors. Eating and its disorders. New York (NY): Raven Press; 1984. p.141-56.         [ Links ]

75. Quaioti TCB, Almeida SS. Determinantes psicobiológicos do comportamento alimentar: uma ênfase em fatores ambientais que contribuem para a obesidade. Psicol USP. 2006;17(4):193-211. doi: https://doi.org/10.1590/S0103-65642006000400011        [ Links ]

 

 

Acknowledgments

To Prof. Dr. Edilaine C. da Silva Gherardi-Donato for her collaboration and encouragement in the search and improvement of the knowledge about the theme.

 

 

Corresponding Author:
Marina Rodrigues Barbosa
E-mail: marinarbarbosarb@gmail.com

Received: Jan 26^th 2020
Accepted: July 29^th 2020

 

 

Author's Contribution
Study concept and design: Marina Rodrigues Barbosa and Fernanda Rodrigues de Oliveira Penaforte. Obtaining data: Marina Rodrigues Barbosa and Fernanda Rodrigues de Oliveira Penaforte. Data analysis and interpretation: Marina Rodrigues Barbosa, Fernanda Rodrigues de Oliveira Penaforte and Ana Flavia De Sousa Silva. Statistical analysis: Marina Rodrigues Barbosa, Fernanda Rodrigues de Oliveira Penaforte and Ana Flavia De Sousa Silva. Drafting the manuscript: Marina Rodrigues Barbosa, Fernanda Rodrigues de Oliveira Penaforte and Ana Flavia De Sousa Silva. Critical review of the manuscript as to its relevant intellectual content: Marina Rodrigues Barbosa.
All authors approved the final version of the text.
Conflict of interest: the authors have declared that there is no conflict of interest.
* This article refers to the call "Mindfulness and other contemplative practices".