Application of Mindfulness in a Tier 3 Obesity Service Improves Eating Behavior and Facilitates Successful Weight Loss

Petra Hanson; Emma Shuttlewood; Louise Halder; Neha Shah; FT Lam; Vinod Menon; Thomas M. Barber

Disclosures

J Clin Endocrinol Metab. 2019;104(3):793-800. 

In This Article

Discussion

We report a study to explore the effects of mindfulness techniques, taught within group sessions in the context of a tier 3–based obesity service, on eating-related behavior and subsequent weight loss. We demonstrate significant improvements in self-reported eating behavior (particularly fast-foodism) and subsequent weight loss following attendance at four group sessions where mindfulness techniques were taught.

Similar positive effect of mindfulness-based techniques on eating-related behavior and body-weight have been observed in the pilot study (Mindful Eating and Living) undertaken in America in 2006.[16] This study had 10 participants who were followed over 3 months. Additionally, a randomized controlled trial with 46 participants from the United States showed that mindfulness meditation enhanced weight loss by 2.8 kg compared with the standard weight loss program.[21] A more recent meta-analysis also provides evidence to support application of mindfulness-based interventions in improving obesity-related eating behaviors and weight reduction.[22] Our own data corroborate the data from these other studies, and provide proof of concept that mindfulness techniques can be implemented successfully in group-based sessions within a tier 3 obesity service.

The utility of mindfulness in the obesity context rests primarily on improved self-awareness of current emotional state and habitual food-related behavior. A common maladaptive behavior pattern in obesity is the misuse of unhealthy and automated eating in response to unpleasant or negative emotional cues. Adoption of mindfulness equips patients with insight and awareness of their own emotional state and the mental tools to avoid habitual unhealthy eating patterns, instead adopting a healthier and more appropriate response to negative emotions. Furthermore, adoption of mindfulness can improve self-compassion (as demonstrated in our study), thereby reducing the negative impact of occasional reversions to unhealthy eating-related behavior.

Other self-reported benefits of the group attendance included social fulfillment and improved self-confidence of self-management of body weight. These benefits are likely to have contributed toward the facilitation of successful weight loss following attendance at the group sessions.

The importance of social interaction in the context of obesity management should not be underestimated. This aspect of management has perhaps not been given as much attention as it deserves. In one study by Tarrant and colleagues, it was shown that the whole experiential perception of patients attending a group session for obesity management was dependent upon their psychological connections with other members of the group.[23] The shared social identity within the group was fundamentally important for successful behavioral change, and it was argued by the authors that social interaction and the establishment of a shared social identity should be a priority in effective management of obesity.[23] Although not a main focus of our study, we did demonstrate self-reported social fulfillment in the participants of our study following attendance at the group sessions. Although it is possible that this would have occurred regardless of the content of the group work, it seems likely that at least some of the improved social benefits stemmed from instilled mindfulness within the group members. Further focused studies on the social consequences of mindfulness, and the mental, emotional, and behavioral implications of such social changes are required.

Increased physical activity is an important part of any weight loss program. In our study we have not investigated the effect of mindfulness on physical activity. However, we believe that application of mindfulness techniques to improve physical activity is certainly possible. Evidence to support our hypothesis would require use of activity monitors and step counters to demonstrate activity-related effects of mindfulness techniques, and future studies should focus on this important topic.

Our study has several limitations. Because this was an observational study registered as a service evaluation, we could not include a prospective and randomized control group to compare the effect of the mindfulness-based course with standard of care, as all patients who entered the obesity service at the time of enrollment into our study were offered inclusion in the mindfulness-based group sessions. We were, however, able to include a retrospective control group for comparison of weight-loss data. Unfortunately, because the timing of the data derived from this retrospective control group predated the commencement of our study, it was not possible to compare changes in self-reported eating behaviors. Furthermore, because mindfulness teaching has now been incorporated into our standard group sessions within our obesity service following this study, we are not able to prospectively assess changes in eating-related behavior following non–mindfulness-based group sessions. These factors are limitations of our study.

Because the focus of our study was to explore changes in eating-related behavior and subsequent body weight, we did not measure mindfulness scores in the participants. Finally, in a real-world tier 3 obesity management setting, not all patients are inclined to attend group sessions, with some patients preferring one-to-one interactions with HCPs. There are many possible reasons for this preference. In some cases, lack of motivation for lifestyle implementation could be one contributor toward a disinclination to attend regular group sessions. It is possible that the participants who attended all their group sessions are highly motivated patients who are therefore more likely to engage with mindfulness techniques. The adoption of mindfulness may be less successful in less motivated patients. It is interesting that there was a relatively high dropout rate from our mindfulness group sessions. Attendance at the group sessions required a lot of commitment and motivation and not all participants could get the time off from work to attend them, for example. The greater baseline body weight and height for dropouts compared with completers could be explained in part by differences in social inhibition for group attendance based on these parameters, although this is purely speculative.

To conclude, we show evidence for clinical benefit of adopting mindfulness strategies into group sessions within the context of a tier 3 obesity management service in the United Kingdom. This resulted in improved eating-related behavior, social interaction, and self-reported self-management of body weight. Attendance at the group sessions also facilitated longer-term weight loss over 6 months. Following the success demonstrated by our study, the adoption of mindfulness techniques has now been fully integrated into our tier 3 obesity management pathway at UHCW and consistently receives excellent feedback from patients who attend these group sessions.

Adoption of mindfulness techniques has potential for substantial positive impact on patients and their psychosocial milieu. In our study, mindfulness was taught within the context of group sessions. Alternative means of administering mindfulness (such as via online tools) in patients with obesity should be explored, given that attendance at regular group sessions is apparently not feasible or practical for a sizable minority of patients based on our data. This way, the implementation of mindfulness could be truly administered at scale on a population level, thereby helping to fulfill one of the most important unmet needs in today's National Health Service and global health care setting: the implementation of an affordable and effective weight-loss strategy that is implementable directly to the burgeoning population with obesity. Traditional lifestyle strategies for weight loss have focused on dietary change and physical activity. This is notoriously difficult to implement and maintain. Perhaps adoption of mindfulness techniques will provide the requisite mental and emotional tools for healthful behavior change and enable successful implementation and maintenance of lifestyle strategies for weight loss in the future.

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