Mindful Eating With Diabetes

What Is Mindfulness?

Mindfulness is an awareness or state of consciousness that emerges through purposely paying attention in the present moment without judgment regarding the events occurring moment by moment (16). Mindfulness approaches are not relaxation or mood-management techniques; rather, they are a form of mental training to alleviate the automatic or reactive modes of mind (17). The cultivation and practice of mindfulness, primarily through meditation, is believed to mediate observed effects on mood and behavior. Broadly conceptualized, mindfulness is a nonelaborative, nonjudgmental, present-centered awareness in which each thought, feeling, or sensation that arises in the attentional field is acknowledged and accepted as it is (17). Thoughts and feelings are observed without reacting to them in an automatic, habitual pattern of reactivity. This state of self-observation can introduce a “space” between an individual’s perception and response and enable one to respond more reflectively.

From a conceptual framework, mindfulness includes two primary components (Figure 1) (17). The first involves the self-regulation of attention on the immediate experience to acknowledge mental events in the present moment. Sustained attention to maintain a state of vigilance for prolonged periods of time is needed. Many meditation practices focus sustained attention on the breath so that thoughts, feelings, and sensations can be detected. The breath is used as a focal point because it is always present; by slowing down and focusing on the breath, a shift in awareness occurs. Skill in attention switching allows one to bring attention back to the breath when inevitably a thought, feeling, or sensation is acknowledged. Attention includes experiencing events in the mind and body; thoughts (e.g., Am I doing this right?) or events (e.g., My nose itches) are considered objects of observation, not distractions. Once acknowledged, attention is brought back to the breath, preventing further elaboration.

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FIGURE 1.

Key components of mindfulness (17).

The second component of mindfulness involves adopting a particular orientation toward the present experience, with curiosity, openness, and acceptance (17). All experiences are seen as relevant and subject to observation. The goal is not to suppress thoughts and feelings or to produce a state such as relaxation. A decision is made to be open to the reality of the present moment and receptive to whatever happens to occur in the field of awareness. Through observation, a greater understanding of the nature of thoughts and feelings can be obtained. Noticing how a feeling evokes a judgmental thought and then the judgmental thought heightens the unpleasantness of the feeling is one example of the process of observation. The impermanence, or transient nature, of thoughts and feelings is a central point. Thoughts are recognized simply as thoughts that are not “real.” In summary, mindfulness is a skill that can be developed with practice that focuses on altering the impact of and response to thoughts, feelings, and sensations.

Applying Mindfulness to Eating Behaviors

The practice of mindfulness may promote more healthful eating behaviors. Mindful eating can interrupt automatic and inattentive responding to external food cues and emotional triggers that generally provoke habitual responses and unnecessary food consumption (18). Automatic eating can include emotional, impulsive, and habitual eating (19). Through training and practice, mindfulness can prevent the quick reaction of the impulsive system and allow for a more deliberate process to occur.

One common meditation exercise is to eat a single raisin mindfully, as if for the first time. This exercise is specific to food consumption and involves noticing the appearance, color, texture, and smell of the raisin before placing it in the mouth and then chewing it with deliberate attention to taste and sensory stimuli. By eating a raisin without impulse, distraction, or emotional interference, one can break the automatic cycle of eating.

Mindfulness-Based Eating Awareness Training (MB-EAT) is one intervention designed to promote mindful eating (20). MB-EAT draws on traditional mindfulness meditation techniques such as the raisin meditation and guided meditation to address issues pertaining to weight and eating-related self-regulation. The intervention addresses the role of hunger and satiety cues and stresses eating in response to those cues instead of eating in response to automatic patterns. Each intervention session incorporates meditation practice, particularly eating-related guided meditations, to focus attention on sensations, thoughts, and emotions related to hunger, satiety, and eating triggers. Several eating-related meditations use food, beginning with the raisin meditation, moving toward more complex foods, and culminating with making food choices mindfully between just two foods, then at a potluck meal, and finally at a restaurant buffet. “Mini” meditations are encouraged before eating as a way to bring awareness to the present moment. Participants are asked to take a few deep breaths, become aware of sensations in the body, including hunger, and then choose how to respond. The process can enable participants to think about which foods they want to eat and how much to eat based on their hunger level.

MB-EAT places an emphasis on inner wisdom (i.e., mindful awareness of inner experiences) and outer wisdom (i.e., personal use of nutrition knowledge and solutions to challenging situations) to help participants incorporate knowledge regarding the energy and nutrient content of food and individual health needs into everyday food choices. A core component of MB-EAT is a focus on the processes involved in sensory-specific satiety, in which taste buds decrease their sensitivity to taste after a relatively small amount of a food (21). Tuning into the immediate experience of taste and then becoming aware when the pleasure or satisfaction from a specific food decreases helps individuals maximize pleasure from smaller food portions. An example of this is provided in Table 1 (22).

In summary, MB-EAT is designed to help individuals cultivate awareness of both internal and external triggers to eating, interrupt automatic eating, and eat in response to the natural physiological cues of hunger and satiety.

Are Mindful Eating Interventions Effective?

MB-EAT was originally developed for people with binge eating disorder (BED) (15). BED is characterized by frequent episodes of consuming unusually large quantities of food, followed by feelings of lack of control, distress, and guilt. Mindful meditation may modify the dysregulated processes associated with BED and be an effective treatment approach. Mindful eating also may be an effective intervention for minimizing weight gain and promoting weight loss given its focus on disrupting automatic eating (8). Table 2 summarizes the studies conducted to date that incorporated mindful eating meditation techniques as a primary intervention in adult samples. 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). A sixth study specifically targeted restaurant eating to help participants develop self-regulation skills when dining out to prevent weight gain but was not adapted from the original MB-EAT curriculum (24).

Study findings revealed significant improvement in dysregulated eating, including binge episodes and disinhibited eating (i.e., susceptibility to compulsive overeating), cognitive restraint of eating, and awareness of hunger cues post-intervention across studies (12,15,21,23). In the study conducted among adults with type 2 diabetes, the MB-EAT intervention was modified for diabetes self-management (MB-EAT-D), rather than for BED. The intervention incorporated training in mindful meditation, mindful eating, and bodily awareness of hunger and satiety cues. Basic information regarding energy, carbohydrate, and fat intake was provided to assist with diabetes management, and participants were encouraged to self-monitor food intake, physical activity, and glucose levels. Among participants randomized to MB-EAT-D, a significant but modest mean (± SE) reduction in weight (–1.53 ± 0.54 kg, P = 0.005) and significant improvement in A1C (–0.83 ± 0.24%, P = 0.0008) was observed 3 months after the intervention (7). Cognitive control or restraint toward eating, disinhibited eating, and eating self-efficacy also improved (all P <0.001) (12). Participants reported greater ability to minimize overeating in various situations and less eating beyond satiety (lower disinhibition). These findings indicate that training in mindful eating may help people with diabetes develop more healthful eating patterns.

Can Mindful Eating Be Incorporated Into DSME?

Given the findings regarding mindful eating effects on weight, A1C, and eating-related outcomes, incorporating principles from mindful eating may be beneficial in DSME (Table 3). Previous research has included a variety of meditation practices and suggests that mindfulness interventions become more effective for weight regulation when they specifically target eating behaviors (19). People may try to learn and practice meditation from a CD or book. However, it is usually more effective to practice meditation in a group with an instructor. Thus, group-based DSME classes could be a viable avenue for delivering mindful eating techniques. Diabetes educators or group facilitators should be trained in mindfulness meditation and have a consistent practice.

Caveats Regarding Mindfulness

A few caveats regarding mindfulness should be noted. First, as a rule, it is not enough to remind oneself to “just let go” to be mindful (16). In the early stages of becoming more mindful, most of us are unaware of our habitual eating patterns. One cannot immediately decide to live in the present moment and then instantly realize the state of being. Rather, a mindful state develops over time and with regular practice, both formally and informally, on a daily basis. Second, more DSME practitioners need to receive training in mindfulness and meditation to be able to offer this approach to a broader array of people with diabetes. Currently, there is no formal academic credentialing process; however, training is available through reputable institutions (Table 4). Third, the long-term impact of mindful eating on diabetes outcomes is unknown. Longer follow-up is needed to determine whether study participants continue to engage in mindful eating as a way of life. Fourth, most of the mindful eating research completed has been conducted in primarily female samples. More research is needed to identify better ways to attract men to these interventions and the acceptability and outcomes of a mindfulness approach among men. Finally, the field of mindful eating is in the early stages of empirical research. More work is needed to determine whether mindfulness mediates the relation between mindfulness training and the outcome of interest (e.g., weight regulation). Whether mindfulness is the mechanism by which mindfulness interventions work remains to be determined.

Conclusion

In summary, with greater awareness and attention to the present moment without judgment, individuals can respond reflexively rather than continue habitual patterns of eating and behavior that may be inconsistent with their goals and health needs. Mindfulness provides the opportunity to gain insight and reduce the pain and suffering commonly experienced with dysregulated eating. Incorporating mindfulness into DSME could be a novel approach and offer people with diabetes greater choices in meeting their self-management needs and goals.