American Journal of Health Education

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ujhe20

Development, Feasibility, and Initial Results of a

Mindful Eating Intervention: Project Mindful Eating
and Exercise (MEE): Feeding the Mind, Body, and
Soul

Linda L. Knol, Susan J. Appel, Kristi M. Crowe-White, Caroline Brantley,

Opeyemi E. Adewumi & Katelyn E. Senkus

To cite this article: Linda L. Knol, Susan J. Appel, Kristi M. Crowe-White, Caroline Brantley,
Opeyemi E. Adewumi & Katelyn E. Senkus (2021) Development, Feasibility, and Initial
Results of a Mindful Eating Intervention: Project Mindful Eating and Exercise (MEE): Feeding
the Mind, Body, and Soul, American Journal of Health Education, 52:4, 171-184, DOI:
10.1080/19325037.2021.1930615

To link to this article: https://doi.org/10.1080/19325037.2021.1930615

Published online: 10 Jun 2021.

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AMERICAN JOURNAL OF HEALTH EDUCATION
2021, VOL. 52, NO. 4, 171–184
https://doi.org/10.1080/19325037.2021.1930615

Development, Feasibility, and Initial Results of a Mindful Eating Intervention:

Project Mindful Eating and Exercise (MEE): Feeding the Mind, Body, and Soul
Linda L. Knol , Susan J. Appel, Kristi M. Crowe-White , Caroline Brantley, Opeyemi E. Adewumi,
and Katelyn E. Senkus
The University of Alabama

ABSTRACT ARTICLE HISTORY

Background: The aim of this study was to develop a mindful eating intervention and evaluate Received 16 December 2020
potential changes in selected outcomes. The Transactional Model of Stress and Coping was used to Accepted 11 February 2021
guide the curriculum development and selection of evaluation measures.
Purpose: The purpose of this study was to test the feasibility and acceptability of implementing a
behavioral intervention entitled, “Project MEE (Mindful Eating and Exercise): Feeding Your Mind, Body,
and Soul.”
Methods: Pre-menopausal women, 25–50 years, with a body mass index (BMI) of 25–40 kg/m2
participated in the development of the curriculum (n = 13) and initial testing of the final eight-week
intervention (n = 18). Selected measures included the Perceived Stress Scale (PSS), Mindful Eating
Questionnaire (MEQ), Eating and Appraisal Due to Emotions and Stress Questionnaire (EADES), BMI,
waist circumference, blood pressure, and serum hydrophilic (H-AOX) and lipophilic (L-AOX) anti­
oxidant capacity. Paired t-tests were used to assess for significant changes between baseline and
follow-up measures.
Results: Although PSS scores improved slightly, MEQ scores (p = .001), stress-related eating scores
(p = <0.001), body weight (p = .02), waist circumference (p < .001), systolic blood pressure (p = .05),
H-AOX (p = .02), and L-AOX (p < .001) improved significantly.
Discussion: Project MEE intervention has the potential to reduce maladaptive coping efforts, such
as mindless and stress-related eating, and produce changes in health status.
Translation to Health Education Practice: Health educators may want to include mindful eating
strategies and use this behavioral theory when designing programs for stress-related eating.

Background five deaths.6 In addition, one out of every 16 women

over the age of 20 years have CVD.6 To reduce the risk,
According to the Centers for Disease Control and
women are encouraged to know and manage their num­
Prevention, approximately 35.9% of adults in the U.S. are
bers (blood pressure, blood glucose, triglycerides, and
obese and an additional 35.0% are overweight.1 Perceived
cholesterol), maintain a healthy body weight, limit alco­
psychological stress and difficulties in coping with stress
hol, eliminate tobacco use, reduce stress, and eat
can affect emotional- and stress-related eating, which may a healthy diet.6 Noting that CVD is still under-
lead to obesity, and poor treatment outcomes within beha­ recognized in women, interventions are warranted to
vioral weight loss interventions.2–4 In an effort to compen­ alleviate this disparity. National programs like Million
sate for dysregulated stress, primary mediators, such as Hearts® and Well-Integrated Screening and Evaluation
norepinephrine, epinephrine, and cortisol, give rise to sec­ for WOMen Across the Nation (WISEWOMANTM)
ondary outcomes such as dysregulation of metabolic, focus on screening and prevention.7,8 However, if stress
inflammatory, and cardiovascular biomarkers, which leads to stress-related eating, obesity, and CVD risk,
leads to cardiovascular disease (CVD).2 Unfortunately, then behavioral interventions should focus not only on
results from the 2019 Stress in America Survey suggest dietary intake but also on stress and maladaptive coping
that over 75% of adults report symptoms associated with efforts. In addition, multiple studies have demonstrated
stress such as headache, fatigue, or changes in sleep habits.5 that increases in arterial stiffness and CVD outcomes
Women tend to report greater levels of stress than men.5 across the lifespan are influenced largely by oxidative
In 2017, CVD was the leading cause of death for stress.9,10 Acknowledging the detrimental effects of
women in the United States, representing one in every unchecked oxidative stress on all aspects of human well-

CONTACT Linda L. Knol lknol@ches.ua.edu Department of Human Nutrition and Hospitality Management, The University of Alabama, Box 870311,
Tuscaloosa, AL 35487.
© 2021 SHAPE America
172 L. L. KNOL ET AL.

being, it is important to understand whether an inter­ and engaging with an object of interest (usually the breath),
vention impacts measures of oxidative stress. sustaining focus, monitoring distractions, disengaging
from distractions and reengaging with the object.16 With
consistent mindfulness meditation practice, the attention
Dietary management of CVD
networks of the brain become more efficient and attention
To lower cardiometabolic risk, both the American interference is reduced.14 Attitude is considered the way in
Heart Association and the Dietary Guidelines for which the individual attends. When one attends to internal
Americans recommend the Dietary Approaches to and external cues with openness and in a nonjudgmental
Stop Hypertension (DASH) pattern.11 The DASH pat­ way, then one may view thoughts more objectively and
tern is high in fruits and vegetables, low fat dairy, fish, clearly. This process allows a person to step back from the
legumes, nuts and seeds, and whole grains and low in situation and regulate emotions through the use of self-
saturated fat, sodium and sugar.12 Adherence to this regulatory skills.14,16 In this manner, with consistent mind­
pattern has been shown to lower blood pressure, cho­ ful meditation practice, one builds automatic mechanisms
lesterol levels, and improve total antioxidant capacity, to cope with emotions and stress, thus, reducing physiolo­
a biomarker of fruit and vegetable intake and oxidative gical mediators of stress such as catecholamines (epinephr­
stress.12 In the PREMIER study, researchers found that ine and norepinephrine), glucocorticoids (cortisol), and
the DASH pattern improved weight loss and blood cytokines.14 Mindfulness-based stress reduction (MBSR),
pressure among 800 hypertensive adults when com­ a clinically, standardized meditation program, can reduce
pared to advice only.13 If caloric restriction may stress in healthy adults.19
increase stress leading to changes in weight status and
other stress-related biomarkers, then an alternative
Mindful eating and mindful eating interventions
approach to altering dietary intake is needed.2–4
Although mindfulness in general is linked with many
health outcomes,19 the adoption of mindful eating
Mindfulness
(ME) skills may have a greater impact on outcomes
Mindfulness is defined in four ways: “1. A temporary specific to the eating experience and weight manage
state of non-judgment, non-reactive, present-centered ment.20–37 Mindful Eating Interventions (MEIs) are
attention and awareness that is cultivated during medi­ behavioral interventions that incorporate mindful
tation; 2. An enduring trait that can be described as meditation and apply mindfulness techniques to
a dispositional pattern of cognition, emotion, or beha­ develop an awareness of: hunger and satiety cues, emo­
vioral tendency; 3. A meditation practice; and 4. An tional states associated with eating, and external trig­
intervention.”14 Formal practice, an essential compo­ gers to eat.20–22 Previous MEIs have reduced emotional
nent of any mindfulness program, involves daily medi­ eating,20,21,23–26 severity and frequency of binge eating
tation to cultivate the ability to pay attention in the episodes,20,21,27,28 reward-driven eating,29 mindless
present moment.15 Informal practice is the application eating,25,26 disinhibition,23,25,26,28,30 stress-related eati
of mindfulness principles when completing routine ng,31 perceived weight loss barriers,32 caloric and fat
tasks such as eating. The theoretical framework that intake,27,33 consumption of sweets,34 weight when wei
describes the processes by which mindfulness practice ght loss is the primary goal,24,27,28,35,36 abdominal fat,33
improves mental and physical health is complex and insulin resistance,33,35 and glucose levels.33,35
continues to evolve.14,16–18 Current thought suggests Although the science of mindful eating shows great
that mindfulness meditation may lead to greater control promise, only a few programs have used a behavioral
of attention, awareness of the body, and regulation of theory to guide the educational components and
emotions, which in turn may lead to greater levels of evaluation.21 In addition, most MEI studies use either
self-regulation that impact health status.16,18–20 the Mindfulness-based Eating Awareness Training
Three fundamental building blocks of the mindfulness (MB-EAT) curriculum or similar content that is
model are intention, attention, and attitude.16 With con­ adapted to the audience.22,24 These curriculums were
sistent mindfulness meditation practice, intention (goals initially designed to normalize eating patterns as well
and practice instructions) is replaced by an increased as attitudes and beliefs toward eating among partici­
awareness of the physiological and psychological benefits pants diagnosed with binge eating disorder (BED).22,24
of mindfulness meditation, which in turn increases internal This manualized curriculum focused on attention and
motivation to continue the practice.14,16 Attention is the non-judgment through informal meditation practice.
process of experiencing internal and external cues in the However, formal practice, a staple of MBSR, is encour­
“here and now.”16 Attention regulation includes orienting aged. MB-EAT has been tested in overweight/obese
 DEVELOPMENT, FEASIBILITY, AND INITIAL RESULTS OF A MINDFUL EATING INTERVENTION 173

adults without BED with favorable, sustained meta­ feasibility and initial changes in behavioral targets
bolic and cardiorespiratory changes in the mindful were assessed.
eating group compared to controls.33 Weight loss was
slightly greater, but not statistically different, in the
mindful eating group when compared to the controls. Phase 1: development of the behavioral
Few studies have assessed the synergistic effects of ME intervention
and a dietary pattern known to reduce CVD risk and Selection of a theory (pathway) to guide the
biomarkers of oxidative stress. In other words, does intervention
meditation and mindful eating strategies improve diet­ The Transactional Model of Stress and Coping was used
ary compliance? In order to test this question, an to guide the development of the educational program
intervention that includes meditation, mindful eating, and selection of outcome measures.38 This model sug­
and the DASH eating pattern needs to be developed gests a framework for how an individual perceives and
and tested. copes with stressful events. The model suggests that
when faced with a stressor, one will assess the stressor
in two ways: significance of the stressor and threat (pri­
Purpose
mary appraisal) and ability to alter the situation and
Thus, the purpose of this study was to test the feasibility manage emotions (secondary appraisal). Every person
and acceptability of implementing a behavioral inter­ builds a repertoire of ways in which they cope with stress
vention entitled, “Project MEE (Mindful Eating and (coping effort). Coping effort affects outcomes such as
Exercise): Feeding Your Mind, Body, and Soul.” This health status and health behaviors. Stress-related eating
ME intervention is novel because it includes formal and mindfulness strategies can be used to cope with
meditation and a dietary pattern known to lower cardi­ stress. Therefore, the model is appropriate for a ME
ometabolic risk (DASH). The assumption is that an intervention where the outcome of interest is reduction
intervention designed to improve stress-related eating, in stress-related eating and its sequalae.
mindless eating, and dietary intake of antioxidant nutri­
ents will improve biomarkers associated with oxidative Educational program
stress (redox balance), and CVD outcomes. Thus, the The intervention was designed to improve three beha­
aims of this study were to 1.) develop and refine the viors: stress-related eating, mindless eating, and dietary
program with assistance from the target audience, and compliance to the DASH diet. To meet these goals, the
2.) evaluate the feasibility, acceptability, retention rates, intervention focused on meditation, mindful eating tips,
evaluation strategy, and preliminary changes in selected nutrition education, and self-regulatory skills. Each ses­
outcomes. sion followed a similar agenda and included the follow­
ing components:
Methods
● Meditation demonstration,
The Obesity-related Behavioral Intervention Trials ● Opener (facilitated discussion of homework
(ORBIT) consortium recommends a process of defin­ activities),
ing, refining, and optimizing behavioral interventions ● Build a Habit (demonstration of a new mindful
prior to full efficacy (Phase 3) and effectiveness eating technique),
(Phase 4) trials.37 This process was used in the devel­ ● Food for Thought (DASH diet topic),
opment of Project MEE. In Phase 1, the behavioral ● Path to Progress (self-regulatory skills including
intervention was developed and refined based on target goal setting, contingency planning, and use of non-
audience feedback. Goals of this phase included: 1). food rewards), and
determine a pathway by which the intervention would ● Homework (mindful eating homework and medi­
lead to a change in one or more clinical outcomes, and tation were assigned).
2.) develop feasible and acceptable treatment compo­
nents that include adequate dose and duration. The end The meditation sessions introduced the mindful check-
goal of this phase was a protocol that is ready for in, sitting meditation, body scan, and meditative move­
preliminary testing. In the early stages of Phase 2, the ment such as walking meditation. The mindful eating
team tested proof of concept with a quasi-experimental components (Build a Habit) encouraged a pattern of
design using a treatment only arm. Acceptability, meal consumption that reflected hunger and satiety
174 L. L. KNOL ET AL.

cues, awareness in the moment, and reduced environ­ for at least one year could participate. Exclusion criteria
mental (cue-driven), distracted, and emotion- and were based on whether the participant had a condition
stress-related eating. The Food for Thought components where weight loss could cause harm, affect the interven­
were adapted from the PREMIER Study and updated tion results, or alter selected outcomes. Therefore, the
based on current nutrition science.39 Lastly, the Path to following participants were excluded: pregnant or
Progress component focused on building self-regulatory breastfeeding, history of eating disorder treatment, sta­
techniques that improved resources to cope with stress tus post-bariatric surgery, recent weight loss of greater
and developed new coping efforts. This section of each than 10% of usual body weight, post-menopausal, pre­
lesson focused on assessment of current behavior, goal vious experience in mindfulness techniques, diagnosed
setting, development of an action plan, and selection of with anxiety disorder or severe, acute depression, smo­
reward. Rewards needed to focus on health-promoting ker or substance abuser, uncontrolled diabetes or hyper­
behaviors to build resources to cope with stress. Lesson 4 tension, significant heart disease (previous heart attack
focused specifically on the stress response, short- and or stroke), polycystic ovary syndrome, or taking medi­
long-term complications of stress, building resources to cations that may alter biomarkers such as hormone
cope, and developing coping efforts that established replacement, steroid use, diabetes medications other
healthy habits. than metformin, or steroids.
Habits related to mindless eating require considerable
attention to change. Thus, the curriculum included Refining the program
homework assignments, such as the development of To help develop the educational program, Phase 1 par­
meditation practice and ME activities that mimicked ticipants attended each of the educational sessions and
the Build a Habit component. Food for Thought, provided feedback by completing an evaluation after
Mindful Eating, and Mindful Meditation components each of the session. They also tracked their homework
were matched based on a theme for the lesson. For activities and adherence to goal behaviors. In the tenth
example, body scan meditation was matched with session, these women were asked to speak freely about
understanding hunger and satiety cues and the selection the strengths and weaknesses of the program. This infor­
of nutrient dense foods over energy dense foods. mation was used to refine the program.
Participant workbooks and facilitator guides were
developed.
Phase 2: testing the protocol using a
quasi-experimental design
Program delivery
The typical length of a ME intervention is 10 weeks.22 To further test acceptability and feasibility, and initial
Thus, the initial intervention was planned as 10 weekly, changes in behavioral targets, Phase 2 participants who
45–50 minute, group educational sessions. No more met our eligibility criteria were recruited to a quasi-
than ten participants were allowed per cohort to experimental study where they completed the refined
enhance participant interaction. The Institutional educational program and all assessments. As an incen­
Review Board at the University of Alabama approved tive to participate in the study, participants could earn
this research. employee wellness program points for attending at least
five sessions. Feasibility, acceptability, and retention
Participants and recruitment rates were assessed at each educational session.
Phase 1 and Phase 2 participants were recruited in the Outcome measures were assessed pre- and post-
same manner using the same eligibility requirements. intervention. Women who did not complete all of the
Phase 1 participants helped to develop and refine the pre-intervention assessments were excluded from parti­
educational program. Phase 2 participants completed cipating in the intervention.
the educational program and assessments. Participants
were recruited through advertisements on campus, Feasibility, acceptability, and retention rates
employee newsletters, campus-wide e-mails, and First, the Project MEE Log was used to track participant
employee wellness screenings. Participants were goals, goal attainment, rewards, time spent in meditation,
screened via telephone for inclusion and exclusion cri­ and number of homework assignments completed.
teria. Inclusion criteria included: premenopausal Logging which behaviors were selected and used helped
women, 25–50 years old, with a BMI of 25–40 kg/m2, the research team understand which elements of the
who wanted to lose weight. Women who had hyperten­ program were most desirable and changeable for the
sion and/or diabetes (treated by diet and/or metformin target audience. This set of measures also assessed the self-
only) and had been taking the same medication and dose regulatory skills taught in the program. Acceptability was
 DEVELOPMENT, FEASIBILITY, AND INITIAL RESULTS OF A MINDFUL EATING INTERVENTION 175

measured through session evaluation forms. Participants month (Cronbach α = 0.78).40 Participants recorded
rated the content and usefulness of each lesson on a scale their ratings on a 5-point Likert-type response scale
of 1 to 5, where 5 was the highest rating. Lastly, attendance from 0 (Never) to 4 (Very Often). Total scores ranged
was taken at each session. Participants who did not attend from 0 to 40, with higher scores indicating greater per­
a session were called to determine the reasons that they ceived stress. Stress-related eating and appraisal were
could not attend. Participants were allowed to miss up to assessed using two of the three sub-scales of the vali­
three sessions before being dropped from the study. dated Eating and Appraisal Due to Emotions and Stress
(EADES) Questionnaire: emotion- and stress-related
Outcome evaluation eating (Cronbach α = 0.94), and appraisal of resources
The Transactional Model of Stress and Coping was used and abilities to cope (Cronbach α = 0.87.41 All items
to guide the selection of outcome measures (Figure 1).38 were scored from 1 to 5 (strongly disagree to strongly
To evaluate changes in behavior and selected model agree). The EADES questionnaire was developed based
outcomes, participants completed pre- and post- on the Transactional Model of Stress and Coping with
assessments that included an online survey, three days a sample of university employees. So, the questionnaire
of 24-hour diet recalls, and a laboratory visit where assessed changes in the theory-based components used
anthropometrics and blood pressure were measured, within the educational curriculum. Mindful eating (cop­
and fasting urine and blood samples were collected. At ing effort) was assessed using the Mindful Eating
the completion of the program, participants completed Questionnaire (MEQ).42 The MEQ includes 28 items
the same set of measures. The survey contained pre­ divided into five subscales: disinhibition, awareness,
viously validated questionnaires to assess stressors, external cues, emotional response, and distraction. All
appraisal, and coping effort as either mindful or stress- items were scored from 1 to 5, where higher scores
related eating. To assess, the consequences of coping reflect more mindful responses. The MEQ has been
efforts, the following outcomes were selected: dietary validated in adults previously with internal consistencies
intake (overall energy and fruit and vegetable consump­ for each sub-scale ranging from 0.64 to 0.83.42
tion), redox balance (serum assessment of antioxidants Demographic information was collected to characterize
and lipid peroxides (a measure of oxidative stress)), and the study population.
cardiometabolic health (weight, BMI, waist circumfer­ Dietary Intake. To assess changes in dietary intake,
ence, pulse, and systolic and diastolic blood pressure). participants completed three-days of dietary recall data
The survey included several valid questionnaires that through the ASA24 app or the ASA24 online program.43
assessed constructs from our model, specifically, the This automated program/app was developed by the
Perceived Stress Scale40 (stressors), the Eating and National Cancer Institute to assist researchers when
Appraisal Due to Emotions and Stress (EADES) collecting dietary data. The program/app guided the
Questionnaire41 (appraisal and stress-related eating), participant through a series of questions that produced
and the Mindful Eating Questionnaire42 (mindful eat­ a list of all items consumed over a 24-hour period
ing) (Figure 1). The 10-item Perceived Stress Scale (PSS) including amounts and serving sizes. The program con­
was used to assess stressful experiences over the last verted data into total nutrient and food group intake.

Figure 1. Transactional Model of Stress and Coping: applications in mindful eating.

176 L. L. KNOL ET AL.

Participants were asked to complete three days of diet normality were not found. Descriptive statistics were
recalls (Monday or Tuesday, Wednesday or Thursday, computed. Evaluation of the intervention began by test­
and Saturday or Sunday). ing for changes in PSS, EADES, and MEQ scores (base­
Anthropometrics and Selected Biomarkers. After the line and follow-up) using 2 tailed, paired t-tests.
participants completed the dietary recalls, they met the Changes in total caloric intake, fruit and vegetable
study team at the research lab. Height, weight, and waist intake, average systolic and diastolic blood pressure,
circumference were assessed using standard protocols BMI, body weight, waist circumference, and laboratory
and recorded to 0.1 cm and 0.1 kg.44 BMI was calculated values were assessed in the same way. Equality of var­
from the height and weight measures. Blood pressure iances were assessed. When the folded F-test was sig­
was measured with an automated oscillometric device in nificant or below 0.01, then the pooled method was used
accordance with recommendations by the American to assess significance. Otherwise, the Satterthwaite
Heart Association.45 Measurements were taken after method was used. Due to the number of statistical tests
participants rested 10 minutes in a seated position with completed to assess within group differences, an a priori
the arm supported at heart level. Three readings were alpha of <0.01 was used as a conservative adjustment.
taken at intervals of two minutes, and the second and
third readings were averaged. A blood sample was
obtained after a 10-hour overnight fast by a certified Results
phlebotomist. Additionally, a urine sample was collected Phase 1: development the behavioral intervention
for analysis. Upon collection and processing, serum
samples were stored at −80°C and urine at −20°C until Fifteen women, who met the eligibility criteria, were
time of analysis. recruited to help develop the initial program. Among
Biomarker testing was completed using the following these women, 13 finished the 10-week program and
tests. To assess antioxidant capacity, serum was depro­ provided input on the educational lessons. Using the
teinated using methanol/acetonitrile/acetone (1:1:1, v/v/ session evaluation forms, participants rated the content
v) added to samples in a ratio of 1:4 (v/v).46 This method and usefulness of each lesson on a scale of 1 to 5, where 5
enables detection of small molecular weight antioxidants was excellent. The average ratings across all lessons for
(<6kDa). Hydrophilic and lipophilic antioxidant capa­ content and usefulness were 4.8 and 4.8, respectively. No
cities (H-AOX and L-AOX, respectively) were measured lesson received less than a rating of 4 by any participant.
using the oxygen radical absorbance capacity assay on Participants were asked to complete the homework at
a FLUOstar Optima plate reader (BMG Labtech).47 The least 5 days within a week. Participants reported com­
compound 2,2-azobis (2-amidino-propane) dihy­ pleting the homework 75% of the days. Participants were
drochloride was used as the peroxyl radical generator also asked to develop a meditation practice. On average,
and Trolox, a water-soluble analogue of vitamin E, the participants completed 37 minutes of meditation per
served as the reference antioxidant standard. Results week (Range 3.3−104 minutes per week). A list of med­
were expressed as uM Trolox equivalents (TE). itation resources used by these participants was devel­
Malondialdehyde (MDA), a product of lipid peroxida­ oped and incorporated into the final educational
tion, is a biomarker of oxidative stress. Serum lipid program. Additionally, participants found the online
peroxides were quantified according to the thiobarbitu­ survey and dietary recalls easy to complete. Barriers to
ric acid reactive substances assay as previously attendance included previously scheduled meetings, ill­
described.48 Results are expressed as mM MDA. ness, or out of town conferences.

Refining the program

Analysis
After the initial participant review, the program was
Data were downloaded from a secure online server revised to eight-weekly sessions with one bonus session
(Qualtrics® Dallas, TX, 2016) and the ASA24 website. to be completed independently during fall or spring
Dietary intake data were averaged over the three days. break. This format fit the academic calendar better
Blood pressure, anthropometrics, and laboratory data than the initial, 10-week format and allowed for several
were recorded in the lab and later transferred to an weeks of recruiting and screening at the beginning of
Excel spreadsheet and double checked for accuracy. each semester. Our exit interview revealed that partici­
Data from all sources were imported into the Statistical pants enjoyed the mindful meditation demonstrations,
Analysis Software (SAS) version 9.4. (Cary, NC discussion, and build a habit components. The mindful
2002–2012) and merged into one file using a common eating information was new information for most parti­
identifier. Scales were created and violations of cipants. The 10-minute discussion at the beginning of
 DEVELOPMENT, FEASIBILITY, AND INITIAL RESULTS OF A MINDFUL EATING INTERVENTION 177

each class enhanced motivation by reinforcing benefits barriers included lack of time, distractions, family meals,
of the ME techniques and helped participants discuss and lack of reminders. Participants reported 36 minutes
how to overcome barriers. Suggestions from these dis­ of mindful meditation on average per week (range 1.1–
cussions were added to the final educational materials. 121 minutes). Participants used a variety of tools to
The participants considered the “food for thought” com­ assist with their meditation practice including record­
ponents as a needed review of nutrition principles. ings from shared files, and apps such as Calm®,
When taught in combination with the mindful eating Headspace, and the Mindfulness Coach. Many of the
components, participants felt the mindful eating com­ participants would switch from one free app to another
ponent augmented the dietary component. Lastly, the when the limited free trial period ended.
employees felt that the DASH diet pattern was difficult
to attain. The two participants who dropped out of the Outcome evaluation
program reported that they could not follow the diet. Although PSS scores remained unchanged (−1.8,
Thus, in the final revision of the educational materials, t = −0.91, p = .38), MEQ scores (+0.50, t = 3.92,
participants were asked to select one or two aspects of p = .001), and Emotion and Stress-related Eating
the DASH pattern for improvement. Table 1 depicts the Scores (+0.64, t = 4.90, p = <0.001) improved signifi­
content taught within each lesson. cantly (Table 3). Among the MEQ scores, there were
significant changes in disinhibition (+0.43, t = 3.01,
p = .01), eating with awareness (+0.58, t = 3.92,
Phase 2: testing the protocol using a
p = .001), and emotional eating (+0.80, t = 4.59,
quasi-experimental design
p = <0.001).
To test the revised program, four cohorts of participants Although changes in caloric intake improved slightly,
were asked to complete the eight-week program over Fall (−200 kilocalories, t = −1.44, p = .17), body weight
2018 to Fall 2019 semesters. Among the 66 participants (−0.79 kg, t = 2.58, p = .02), BMI (−0.30 kg/m2,
who contacted the principal investigator, 42 were eligible t = −2.53, p = .02), waist circumference (−3.22 cm,
for the study (Figure 2). Among the 32 participants who t = −4.65, p < .001), and systolic blood pressure
started the study, 18 completed at least five of the eight (−5.6 mm HG, t = −2.15, p = .05) improved significantly.
lessons and pre- and post-assessments (Table 2). The Although fruit and vegetable intake increased only
majority of participants who completed the program slightly, serum antioxidant capacity reflected in
were non-Hispanic white (77.7%), married or living H-AOX (+42.3 uM TE, t = 2.55, p = .02), and L-AOX
with a partner (66.7%), and living with at least one adult (+223.5,uM TE t = 4.33, p < .001) improved
(72.3%). The average age of the participants was 38.1 ± significantly.
6.1 years. Half the participants had at least one child
under the age of 18 years living in their home.
Discussion
Feasibility, acceptability, and retention rates This paper describes the development and initial testing
The Project MEE Log was completed at the beginning of of a mindful eating intervention for women who are
each session by a trained research assistant who tracked overweight or obese. This intervention was innovative
participant goals, goal attainment, rewards, time spent because it includes formal meditation practice, mindful
in meditation, perceived stress, and number of home­ eating strategies, and the DASH dietary pattern. Based
work assignments completed. Table 1 depicts attendance on the results of this study, Project MEE: Feeding the
by lesson. Absenteeism was random. However, weeks 4, Mind, Body, and Soul has met Phase 1 and Phase 2
5, and 7 seemed to be skipped the most often. Topics milestones described by the ORBIT consortia.37
within these sessions included stress-related eating, eat­ A behavioral intervention with a fixed protocol and
ing in slow motion, and mindful movement. Reasons for manualized curriculum has been developed, refined,
absenteeism were meetings, conferences, and participant and tailored to the audience. Initial participants assisted
or child illness. Participants were asked to complete the in the development of educational content and the inter­
homework at least 5 days per week. Approximately four vention dose was reduced from ten to eight 45-minute,
days of homework were completed on average per week. weekly sessions. Secondly, recruitment, implementation
Participants were asked to rate the difficulty of the of the intervention, and evaluation were acceptable and
homework assignments on a scale of 1 (very easy) to 5 feasible to the target audience. Most of the women rated
(very difficult). The average rating fell within the middle the lessons as excellent and useful. Homework comple­
of the range for most lessons. Lastly, participants were tion rates, a measure of intervention implementation,
asked about barriers to homework completion. Frequent were high (75%). Lastly, the pilot study with 18 women
 178
L. L. KNOL ET AL.

Table 1. Components of final Project MEE, attendance, and homework completion by session.
Number of Days/Week Average Rating for
Lesson Food for Thought Mindful Eating Components Build a Habit Mindful Meditation Attendance Completed Homeworka Homework Difficultyb
1. Goal setting approach to weight loss Introduction to Mindfulness and Mindful Eating Awareness Activity Mindful Check-in 16/18 4.2 2.1
Eating. (2–3 minute
Self-appraisal of ME habits meditation)
Assess cues and consequences
Rewards = Resources to Cope
2. Build an Eating Pattern: introduction to Six Hungers: differentiating physical Eating Awareness Activity Sitting Meditation 15/18 3.9 2.5
the DASH Diet Plan hunger from other cues
3. Nutrient and Energy Density within Food Hunger and Satiety Cues Hunger and Satiety Gauge Body Scan 15/18 3.7 2.5
Groups Technique: assess internal cues Activity
4. None Emotion and Stress-related Eating Mindfully Eat a Comfort Loving Kindness 13/18 4.1 2.5
Assessment of Comfort Foods Food Activity Meditation
Technique: Change the channel, break the
cycle, expand calming activities
5. Let’s Plan: Meal Planning, Grocery Eating in Slow Motion (SLO-MO) Forks Down Activity Mountain Meditation 12/18 3.6 1.9
Shopping, Reading Food Labels Technique: pause, chew, pause
6. Cooking with less sugar, saturated fat, Taste Satisfaction Sensory Eating and the Leaves in the Stream 15/18 4.4 2.3
and sodium Use of sensory specific satiety Flavor Meter Activity
Meal pre-prep
7. Eating at work and in restaurants Mindful Movement Making Choices: Mindful walking 13/18 3.2 2.7
Distracted Eating Managing the Buffet
Environmental Cues to Eat Activity
8. Using goal setting to continue progress Putting it Together: taste, stomach, body, Use all techniques at 16/18 n/a n/a
and break weight loss plateaus and emotional satisfaction a shared meal
Self-assessment
9. Balance beverages Distracted eating Remodel the Kitchen n/a n/a n/a
Bonus Environmental cues to eat Activity
a
Participants were encouraged to complete homework activities at a minimum of five days of the week.
b
Average Participant rating of homework on a scale of 1 = very easy to 5 = very difficult.
 DEVELOPMENT, FEASIBILITY, AND INITIAL RESULTS OF A MINDFUL EATING INTERVENTION 179

Figure 2. Recruitment and retention.

in the target audience appeared to change key behaviors five sub-scales of mindful eating significantly improved
and health outcomes identified in our model. Although between baseline and follow-up among our participants.
the inclusion and exclusion criteria were extensive, the Distracted eating and eating due to environmental cues
researchers were able to utilize the existing infrastruc­ trended in the right direction but were not significant.
ture along with wellness screenings and incentives to Previous research that used the MEQ to assess adher­
ensure recruiting targets were met. Thus, the Project ence to the intervention have found similar
MEE curriculum is ready for the next step in testing or results.26,30,34 In a randomized control trial, Gravel and
a small, randomized test with controls. colleagues evaluated their intervention using all five
Project MEE has the potential to change mindless components of the MEQ and found significant improve­
eating among adult women who are overweight or ments in the disinhibition component only among
obese. Overall mindful eating scores, and three of the restrained eaters when compared to the wait-listed
180 L. L. KNOL ET AL.

Table 2. Characteristics of participants in the pilot study (n = 18). distracted and environmental cues to eat. These
Characteristic N (%) women frequently ate lunch at their desks and reported
Race/Ethnicity 14 (77.7) that colleagues brought “treats” to work often. In the
Non-Hispanic white 2 (11.1)
Non-Hispanic black 1 (7.1) final version of Project MEE, additional content is
Hispanic 1 (7.1) needed on how to address these barriers.
Asian/Pacific Islander
Marital Status 12 (66.7) Project MEE also has the ability to change selected mea­
Married or living with partner 6 (33.3) sures from the Transactional Model of Stress and Coping,
Single, divorced, widowed
Number of Adults in the Home 5 (27.8)
specifically appraisal of resources to cope and coping efforts
Lives alone 12 (66.7) such as emotion- and stress-related eating. Although scores
Lives with 1 adult 1 (5.6) from the PSS did not change, scores from the EADES
Lives with 2 adults
Number of Children, <18 years in the Home 9 (50.0) questionnaire significantly improved indicating greater
None 4 (22.2) resources to cope with stress and decreased emotion- and
One 3 (16.7)
Two 2 (11.1) stress-related eating. Participants in this study were
Three employees at a large university. One possible reason for
Mean ± SD
Age 38.1 ± 6.1 not seeing a change in PSS is that baseline data were taken at
the beginning of the semester when stress levels may be
lower. In a six-week mindfulness-based stress reduction
program augmented with six lessons on stress-related eat­
controls.30 In a group of parents and grandparents com­ ing, Corsica and colleagues31 found significant improve­
pleting a 4-week childhood obesity prevention program, ments in both PSS scores and the overall EADES scores.
Knol and colleagues26 found significant changes in over­ However, sub-scales of the EADES were not assessed.
all mindful eating, disinhibition, and emotional eating Project MEE has the potential to improve fruit and
but not distracted eating. Environmental eating was not vegetable intake and decrease caloric intake. Each of
assessed in that study. Lastly, Mason and colleagues34 these dietary measures trended in the right direction.
used the overall MEQ scores only to assess changes in Mean baseline intake of fruit and vegetables was extre­
mindful eating between an intervention group receiving mely low at 0.7 and 1.8 servings of fruits and vegetables,
a 12-week ME intervention based on MB-EAT curricu­ respectively. Mindful eating interventions have focused
lum versus controls receiving diet, exercise, and stress- on changing eating behaviors rather than attempting to
reduction education. They found greater improvements get participants to consume a specific calorie intake or
in MEQ in the intervention group. During sessions, increase specific food groups. The educational compo­
Project MEE participants reported difficulties with nent of Project MEE encourages consumption of the

Table 3. Changes in PSS, EADES, mindful eating, dietary intake, anthropometrics, blood pressure, and select biomarkers
over the course of an eight-week mindful eating intervention (n = 18).
baseline Follow-up diff t p-value*
Perceived Stress Scale 14.8 ± 6.0 13.6 ± 4.7 −1.8 −0.91 0.38
Appraisal of Resources to Cope 4.0 ± 0.4 4.3 ± 0.5 0.21 2.26 0.04
Emotion and Stress-Related Eating 3.0 ± 0.9 3.7 ± 0.6 0.64 4.90 0.0001
Total Mindful Eating Score 3.3 ± 0.5 3.8 ± 0.4 0.50 3.92 0.001
Disinhibition 3.3 ± 0.6 3.7 ± 0.5 0.43 3.01 0.01
Eating with Awareness 3.3 ± 0.6 3.8 ± 0.5 0.58 3.92 0.001
Emotional Eating 3.0 ± 1.0 3.8 ± 0.6 0.80 4.59 0.0003
Distracted Eating 2.9 ± 0.9 3.2 ± 0.4 0.33 1.45 0.17
Environmental Eating 3.7 ± 0.6 4.0 ± 0.6 0.31 1.99 0.06
Dietary Intake
Energy (Kcals) 1806 ± 422 1606 ± 625 −200 −1.44 0.17
Food Groups
Fruit (svg) 0.7 ± 0.6 1.1± 0.8 0.41 1.97 0.07
Vegetable (svg) 1.8 ± 0.8 2.2±0.7 0.32 1.52 0.15
Anthropometrics
Weight (kg) 85.0 ± 13.5 84.2 ± 13.8 −0.79 −2.58 0.02
BMI (kg/m2) 31.6 ± 5.1 31.3 ± 5.3 −0.30 −2.53 0.02
Waist circumference (cm) 96.0 ± 12.9 92.8 ± 13.8 −3.22 −4.65 0.0002
Systolic BP (mmHg) 120.6 ± 15.1 114.9 ± 11.3 −5.6 −2.15 0.05
Diastolic BP (mmHg) 83.6 ± 12.5 81.9 ± 9.4 −1.7 −0.85 0.41
Pulse (bpm) 73.6 ± 13.4 66.8 ± 17.8 −6.3 −1.42 0.18
Lipid Peroxides (mM MDA) 0.19 ± 0.14 0.14 ± 0.17 −0.04 −1.30 0.21
L-AOX (uM TE) 574.4 ± 153.0 797.9 ± 176.1 223.5 4.33 0.0005
H-AOX (uM TE) 265.7 ± 51.3 308.0 ± 75.4 42.3 2.55 0.02
*Paired t-tests were used to assess differences in each score baseline to follow-up. Differences were considered significant at p <0.01.
 DEVELOPMENT, FEASIBILITY, AND INITIAL RESULTS OF A MINDFUL EATING INTERVENTION 181

DASH dietary pattern through the use of progressive improve emotion- and stress-related eating, mindless
goal setting. Goals set by clients often included reduc­ eating, and dietary intake. Initial evaluation shows that
tions in sugar containing foods while increasing fruit the program has the capacity to improve weight, blood
and vegetable servings. pressure, and markers of oxidative stress. Unlike other
Poor health outcomes that are usually associated mindful eating interventions, Project MEE was designed
with inappropriate or maladaptive coping efforts using the Transactional Model of Stress and Coping.
improved slightly but significantly between baseline The mindfulness techniques were used as replacements
and follow-up. Body weight, BMI, waist circumference, for maladaptive coping efforts, such as stress-related
and systolic blood pressure improved significantly or eating. Although perception of stress did not change,
trended in the right direction. ME interventions usually perceptions of resources to cope, coping efforts, health-
focus on improving disinhibition, restrained eating, related behaviors, and health outcomes improved.
and binge eating. Many ME interventions do not
focus on weight loss. However, when the primary goal
is weight loss, ME interventions have been shown to Translation to Health Education Practice
decrease weight24,27,28,35,36 and abdominal fat.33
Behavioral weight loss interventions typically have poor
A novel outcome of this study was the inclusion of
outcomes, which can be frustrating for the intervention­
biomarkers of oxidative stress and antioxidants. As adi­
ist. The underlying reasons for treatment failure need to
pose tissue is a metabolically-active endocrine organ, it
be investigated and addressed in the design of these
exacerbates homeostatic mechanisms by producing free
programs. Stress-related and emotional-eating are mala­
radicals leading to oxidative stress imbalances.49
daptive coping techniques that can lead to increased
Unfortunately, these increases in oxidative stress have
intake or an inability to follow a prescribed diet long-
been observed concurrently with greater perception of
term. Although the science regarding the efficacy of
perceived stress.50 To reduce oxidative stress, the diet
mindful eating interventions is evolving, these interven­
must compensate by providing antioxidants and sub­
tions show promise in altering health outcomes asso­
strates for the production of antioxidant enzymes.51
ciated with the stress response. Health educators can
However, if the composition of the diet is inadequate
play a role in the development of these programs by
in nutrients, oxidative stress is left unchecked. Thus,
assisting in the selection of appropriate theories or
strategies to reduce oxidative stress by increasing con­
adapting existing programs so that the design is guided
sumption of dietary antioxidants are warranted. Results
by behavioral theory. In this instance, a mindful eating
of this study suggest that a ME intervention can increase
intervention was designed using the Transactional
circulating levels of antioxidants. Future investigations
Model of Stress and Coping. Mindfulness components,
incorporating ME would be strengthened by the inclu­
whether formal and informal, were taught and partici­
sion of similar metabolic biomarkers in order to holisti­
pants were encouraged to replace maladaptive coping
cally assess the intervention impact on health outcomes.
efforts with these practices.
This study is not without limitations. First, a control
This study addressed several competencies in health
group and larger sample size is needed to draw conclu­
education practice as set forth by the National
sions regarding the efficacy of the intervention and gen­
Commission for Health Education Credentialing, Inc.52
eralizability to the larger population. However, the focus
First, the Transactional Model of Stress and Coping was
of this study was the development and initial testing of
used as a logic model in the development and selection of
the intervention. It is unclear which portion of the
evaluation measures (Sub-Competency 4.1.7: select
intervention produced the results. A study is needed
a model for evaluation). The ORBIT consortium recom­
where each aspect of the program is tested against this
mendations and Health Education Specialist Practice
synergistic program. Many participants did not com­
Analysis 2015 Competencies and Sub-competencies sug­
plete the program in its entirety due to time constraints
gest that an interventionist conduct a pilot test of strategies/
and interference with job duties. Lastly, although the
interventions (Sub-competency 2.3.9) and refine strategies/
MEQ, PSS, and EADES are valid measures, these mea­
interventions (Sub-competency 2.3.10). Health educators
sures are subject to self-report bias.
who would like to develop similar programs either need to
seek extensive training in mindfulness-based stress reduc­
tion, mindful eating techniques, and mindfulness medita­
Conclusion
tion, or “engage with partners and stakeholders” such as
Project MEE: Feeding the Mind, Body and Soul is an certified meditation instructors, certified mindful eating
eight-week, weight management program that may teachers, dietitians, eating disorder specialists, and
182 L. L. KNOL ET AL.

psychologists (Sub-competency 2.1.1: identify priority questionnaire. J Amer Diet Assoc. 2008;108:49–56.
populations, partners, and other stakeholders). Advanced doi:10.1016/j.jada.2007.10.011.
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reach. https://www.apa.org/topics/stress Accessed
however, educational programs in mindfulness-based February 6, 2021.
stress reduction, mindfulness meditation, and mindful eat­ 6. Centers for Disease Control and Prevention. Women
ing are available online. Lastly, the EADES questionnaire is and heart disease. https://www.cdc.gov/heartdisease/
one of the first developed to assess constructs of the women.htm Accessed February 6, 2021.
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to weight loss efforts. Health educators can assist research­ hearts®. https://millionhearts.hhs.gov/ Accessed February
6, 2021.
ers in validating this questionnaire with a variety of audi­
8. Centers for Disease Control and Prevention.
ences (Sub-competencies 4.3.3 (create new data collection WISEWOMANTM (Well-Integrated Screening and
instruments), 4.3.4 (identify useable items from existing Evaluation for WOMen Across the Nation) https://www.
instruments), 4.3.5 (adapt/modify existing items),4.3.7 cdc.gov/wisewoman/index.htm. Accessed February 6,
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to impaired endothelium-dependent dilation and upregu­
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Disclosure statement e8.
10. Rodríguez-Mañas L, El-Assar M, Vallejo S, et al.
No potential conflict of interest was reported by the author(s). Endothelial dysfunction in aged humans is related
with oxidative stress and vascular inflammation. Aging
Cell. 2009;8(3):226–238. doi:10.1111/j.1474-9726.2009.
Funding 00466.x.
11. U.S. Department of Health and Human Services and
This research was funded by Dietitians in Integrative and U.S. Department of Agriculture. Dietary Guidelines for
Functional Medicine DPG; Academy of Nutrition and American 2015–2020. 8th ed. http://health.gov/dietary
Dietetics and Research Grant Committee; University of guidelines/2015/guidelines/. Published December 2015.
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