Metaanalisis Mindfulness

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research-articleXXXX
AJLXXX10.1177/1559827614537789American Journal of Lifestyle MedicineAmerican Journal of Lifestyle Medicine
vol. 9 • no. 3 American Journal of Lifestyle Medicine
David Victorson, PhD, Mitchell Kentor, BBA, Carly Maletich, MA,

Rachel C. Lawton, MSc, Vered Hankin Kaufman, PhD,
Maria Borrero, BA, BS, Lauren Languido, BA, Katherine Lewett, BA,
Hannah Pancoe, BA, and Carla Berkowitz BA
Mindfulness Meditation to
Promote Wellness and Manage
Chronic Disease: A Systematic
Review and Meta-Analysis of
Mindfulness-Based Randomized
Controlled Trials Relevant to
Lifestyle Medicine
Abstract: Lifestyle medicine is a medicine. In addition to organizing for mindfulness-based interventions
patient-engaged field that has grown and highlighting mindfulness research to provide short-term benefits across
in tandem with our increasing studies that are relevant to the field of a wide range of lifestyle medicine–
knowledge of the importance of
lifestyle factors and modifiable health
behaviors for disease prevention, health
Mindfulness is a multisensory,
promotion, and the management contemplative meditative tradition
of chronic illness. Stress is at the
epicenter of many negative behaviors that is formally practiced while sitting,
that contribute to unhealthy lives,
such as smoking, overeating, and lying, eating, walking, or engaging
unhealthy diets, and lack of activity.
Mindfulness meditation is a stress in gentle yogic postures.
reduction practice that teaches
awareness, appreciation, and
nonjudgmental acceptance of one’s lifestyle medicine, we also empirically relevant populations and study
present experience, thereby short- examine the impact of study design outcomes, particularly focusing on the
circuiting reactive, automatic stress issues (eg, use of different controls, areas of diet and weight management
reactions. Our systematic review intervention length and duration, and symptom burden. Numerous
and meta-analysis focuses on the sample size, primary outcomes) on outcome measures were used; however,
application of randomized controlled the magnitude of effect of mindfulness the most common were the Perceived
mindfulness intervention studies across interventions in lifestyle medicine. Stress Scale and the State Trait Anxiety
a broad range of populations and Overall, this systematic review and Inventory. This analysis also provides
conditions that are relevant to lifestyle meta-analysis found partial evidence evidence for mindfulness-based
DOI: 10.1177/1559827614537789. Manuscript received March 20, 2013; revised March 17, 2014; accepted March 19, 2014. From the Department of Medical Social
Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois (DV, MK, CM, RCL, VHK, MB, LL, KL, HP, CB); Osher Center for Integrative Medicine,
Northwestern Medical Group, Chicago, Illinois (DV, CB). Address correspondence to David Victorson, PhD, Department of Medical Social Sciences, Northwestern University
Feinberg School of Medicine, Chicago, IL 60611; e-mail: [email protected].
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2014 The Author(s)
185
American Journal of Lifestyle Medicine May • Jun 2015
interventions that have fewer than fosters the inhibition of secondary (depression, anxiety) and pain,
20 individuals per group, as well as elaborative cognitive processing improvements in sleep, and overall
partial support for interventions that (rumination); and (b) an orientation health-related quality of life.29
are less than the standard 8 weeks in toward internal and external experiences Mindfulness-based interventions may
duration. characterized by openness, curiosity, and also have an important role in reducing
acceptance.12 the physiological effects of stress on the
Keywords: mindfulness meditation; Over the past 2 decades, a structured body and have been associated with
lifestyle medicine; randomized intervention called mindfulness-based reestablishing normal patterns of cortisol
controlled trials; systematic review; stress reduction (MBSR) has become one secretion,30 decreases in pro-
meta-analysis of the most commonly evaluated and inflammatory cytokines, and possible
empirically supported treatments for beneficial changes in HPA axis
helping people reduce stress and functioning in cancer patients.31 Despite
L
ifestyle medicine is an approach to manage disease and treatment related these reviews, little empirical evidence
medical care that focuses on the sequelae in both healthy and chronic exists on whether modifications to MBSR
adoption and maintenance of disease samples.13-15 Based primarily on (eg, implementing it less than 8 weeks,
positive health behaviors to prevent the the instruction of mindfulness meditation adding additional tailored content to the
development or worsening of disease, and gentle yoga, MBSR is a group-based, lessons) or study design differences (eg,
promote healthy living and wellness, and 8-week program that was developed at having relatively smaller group sizes,
optimally manage existing chronic the University of Massachusetts Stress using a wait-list control vs an active
medical conditions and related burden.1 Reduction Clinic under the direction of control) significantly affect primary
This field has evolved considerably over Jon Kabat-Zinn.11 As a nonreligious outcomes of mindfulness randomized
the past decade as an adjunct to practice, MBSR facilitates the cultivation controlled trials (RCTs) that are relevant
conventional medical care and often of nonjudgmental, moment-to-moment to lifestyle medicine. We were also
consists of leveraging evidence-based awareness through a process of curious about what study outcomes
interventions in exercise/physical activity, attentional single-mindedness (eg, relevant to lifestyle medicine would see
diet/nutrition, smoking cessation, and mindfulness). MBSR is composed of a the greatest or most significant change as
stress management to prevent or reduce systematic, developmentally sequenced a result of mindfulness training. The
lifestyle-related health problems such as curriculum that uses a group format to purpose of this study was to (a)
obesity,2 cardiovascular disease,3 experientially instruct participants in the systematically review published
hypertension,4 type 2 diabetes,5 and practice of mindfulness meditation and mindfulness-based RCTs with relevance
other chronic conditions.6 Lifestyle Hatha yoga. Each session includes to lifestyle medicine (eg, those that
medicine is a patient-centered practice different forms of meditation practice, focused on adopting and/or maintaining
that relies greatly on the engagement of such as cultivating awareness of mindfulness practices as a means of
patients themselves to be active agents of thoughts, feelings, and bodily sensations, preventing or managing existing medical
their own health and wellness.7 and learning to incorporate this conditions and symptoms or promoting
Given the pivotal and accumulative role awareness during stressful emotional health and wellness among the general
of psychological and physiological stress and/or physical life situations.16 population) and (b) utilize meta-analytic
in the onset, continuation, and outcomes Several other related mindfulness-based procedures to determine whether study
of chronic disease,8-10 one particularly interventions have been adapted from design characteristics, intervention
important lifestyle medicine–based MBSR for other patient groups or modifications, and choice of specific
intervention is stress management and conditions, including Mindfulness Based outcomes meaningfully affect variability
reduction. An increasingly studied type Cognitive Therapy (MBCT),17-19 of effect size magnitude across studies.
of stress reduction involves the Mindfulness-Based Relapse Prevention
cultivation of mindfulness, or the practice (MBRP),20 Mindfulness-Based Eating
Methods
of paying attention on purpose, in the Interventions (MB-EAT21 and MEAL22),
present moment, without judgment.11 and so on. Recent systematic reviews We followed guidelines from the
Mindfulness is a multisensory, have been conducted on mindfulness- Preferred Reported Items for Systematic
contemplative meditative tradition that is based interventions focusing on Reviews and Meta-Analyses (PRISMA)32
formally practiced while sitting, lying, substance-use disorders,23 lower back and the Cochrane Collaboration33 for this
eating, walking, or engaging in gentle pain,24 eating disorders,25 cancer study.
yogic postures. It has been operationally survivors,26,27 and anxiety disorders.28
defined as a bivariate mode or state of Overall, these reviews suggest that Literature Search and Strategy
consciousness, involving (a) the MBSR, MBCT, and their adaptations have Our literature search included the
self-regulation of sustained attention and demonstrated promising results in the following databases and sites over the
attentional shifting, which subsequently reduction of emotional distress past 10 years (between 2002 through
186
2012): PUBMED, OVID/MEDICINE, chronic disease management, we kept but standard errors or confidence
PROQUEST, PSYCHINFO, MINDFULNET. this category broad in our search strategy intervals of the intervention means were,
ORG, and Mindfulness Research Monthly to allow for as many lifestyle medicine we obtained standard deviations by
(http://www.mindfulexperience.org/). relevant studies as possible where the multiplying the standard error by the
We adapted the following complete key primary purpose of the mindfulness square root of the sample size
word search strategy as necessary per intervention was to facilitate wellness, ( SD = SE × N ) , or by dividing the
database: Lifestyle Medicine, Mindfulness improve quality of life, or promote health length of the confidence interval by 3.92,
Meditation, Mindfulness Based Stress and well-being. With regard to and multiplying it by the square root of
Reduction, MBSR, Mindfulness Based psychiatric and substance use studies, we the sample size (SD = N × (upper limit
Cognitive Therapy, MBCT, Mindfulness limited the types of publications to less − lower limit)/3.92. This provided a
Based Relapse Prevention, Mindfulness severe, community-based populations (vs suitable estimate for effect size
Based Intervention, Mindfulness Based intensive programs or inpatient facilities) calculation purposes.
Eating Awareness Training, and Mindful where symptomatology (eg, depressive We selected each study’s stated primary
Eating and Living. We also filtered results symptoms, cannabis use) could be outcome on which to calculate effect
by the following criteria: published in widely generalizable to others without sizes, which could include psychological
English, between 2002 and 2012, peer psychiatric problems or diagnoses. In the constructs such as anxiety or stress, as
reviewed journal, clinical trial, end, we included patient populations well as other lifestyle medicine–relevant
randomized trials, systematic review, highlighted in the American College of outcomes such as systolic blood
review, meta-analysis, human. All initially Lifestyle Medicine’s Evidence Review,1 pressure, or number of cigarettes smoked
retrieved abstracts were read by 2 including cancer, cardiovascular disease, per day. Studies that included multiple
reviewers (DV and MK). We reviewed all metabolic syndrome, musculoskeletal experimental arms (eg, mindfulness
articles in their entirely that contained and joint problems, neurological interventions vs usual care vs active
sufficient information to calculate effect disorders, pain disorders, and psychiatric control condition) were coded so that
sizes. Once all eligible studies were and respiratory illness. each treatment was included as a
identified, each article was reviewed in separate unit of analysis. We used
full and abstracted accordingly. Data Extraction. We followed published Hedge’s g as a standardized measure of
recommendations to establish meta- effect size, which is very similar to
Eligibility Criteria analytic decision rules34,35 and the PICOS Cohen’s d; however, it is less prone to
Interventions. Given our study framework (Population, Interventions, positive bias, especially when smaller
questions, we included group-based Comparators, Outcomes, Study Design)36 sample sizes are included. The formula
clinical mindfulness intervention studies to abstract relevant articles. Our research for calculating Hedge’s g is the following:
of at least 2 weeks or longer such as team (all study authors) engaged in a
M1 − M 2
MBSR, MBCT, MB-EAT, and so on, or systematic and iterative data Hedge’s g = *
SDpooled
modified derivatives where similar identification, review, and indexing
mindfulness training was the primary process. Following the initial creation of ( n1 − 1) SD12 + ( n2 − 1) SD22
*
focus of the intervention. the study database (MK and DV), article SDpooled =
n1 + n2 − 2
reviewers (all coauthors with individually
Study Type. We only included published subdivided reviewing/abstracting Effect size estimates can be interpreted in
RCTs (including wait-list control designs) assignments) independently coded study similar ways to correlation coefficients (eg,
and excluded observational or characteristics, including the following: Cohen’s criteria: small = .20; medium = .50;
nonrandomized studies or published study title, authors, and publication year; large = ≥.80).37
abstracts. We excluded follow-up studies population under study; clinical issue
of previously published original trials as addressed and primary outcome; study Study Quality and Risk of Bias. We
well as laboratory-based experiments type; characteristics of the intervention assessed study quality and risk of bias by
that did not involve intensive group- (eg, number of weeks, modifications); having at least 2 coders per article
based mindfulness training as a means of control group characteristics; sample provide numeric quality ratings (1 = low
improving a lifestyle medicine–relevant size; adult or pediatric focus; gender, quality, 2 = medium quality, 3 = high
outcome or goal (eg, emotional age, study outcomes, and measures; quality) at 2 separate reviews (based on
regulation, smoking cessation). study quality; and relevance to lifestyle the Cochrane criteria) followed by a third
medicine. round of bias risk examination (DV)
Patients Populations and Relevance to Authors CM and DV abstracted means where Cochrane Risk of Bias criteria
Lifestyle Medicine. In view of the broad and standard deviations for primary were applied to each publication that
focus and applicability of lifestyle study outcomes from the baseline and was ultimately selected. The Cochrane
medicine practices that span disease immediate follow-up assessments. When Risk of Bias Assessment tool examines
prevention, health promotion, and standard deviations were not reported selection bias, performance bias,
187
detection bias, attrition bias, reporting smoking cessation/substance use, weight low. All included studies reported
bias, and other bias.38 management, diabetes, blood pressure, utilizing a random component in the
and heart disease. See Tables 1 and 2 for sequence generation process. While a
Data Summary and Analysis. We used included studies and population small number of studies reported
SPSS version 22 and publically available classifications. allocation concealment and blinding of
meta-analysis software from Durham The majority of studies focused on participants, personnel, and outcomes, it
University (see http://tinyurl.com/ adults (average age = 46.6), and the was not clear in the majority of studies
ntu94ns)). Using a random effects model, average total sample size per study was whether these measures were taken.
we pooled and tested effect sizes for 67.7 (18-229). Females were included in Using the Cochrane tool’s criteria, an
homogeneity to determine whether roughly 75% of all studies, whereas unclear rating is suggested when
individual study variation estimates are males were included in roughly 25%. See insufficient information does not permit
true population parameters. Given that Table 3 for full study characteristics. judgment of low risk or high risk.
studies varied widely in intervention, Considering that the majority of studies
population, and outcomes, we also Intervention and Control Condition utilized a wait-list control group where
weighted study effect sizes by sample Characteristics. See Tables 3 and 4 for blinding participants is not feasible, the
size.34 Next, we examined effect size details on intervention and control majority of studies likely fall within the
variation between study characteristics condition characteristics. The majority of high-risk category; however, insufficient
and intervention conditions. studies reported using the original information is available.
Homogeneity assumptions were tested 8-week MBSR intervention11 (44.6%) and
using Levine’s test. Planned comparisons a wait-list control condition (57%). Outcome Measures and Domains. A
were conducted using the least squared Among weekly interventions (whether variety of different outcome measures
difference statistic on significant F tests. MBSR, MBCT, or an offshoot), the were used in the included studies;
average course length was 7.8 weeks however, the most common were
(2-12 weeks), with an 8-week or longer measures to assess self-reported anxiety
Results
intervention being used in 83.1% of all (33.8%) and perceived stress (20%) (see
Literature Search studies. Outside of adjusting the course Tables 4 and 5).
Our initial search yielded 973 articles, length, other components that were
which after reexamination and removal added to MBSR included things like Effect Size Variability Across Studies and
of duplicates and nonrelevant papers qigong,39 mindful parenting or Study Characteristics. See Table 6 for the
was reduced to 600 articles for full teaching,40 diet/exercise,41,42 and mindful average effect size variation across study
abstract review and a first round of mothering,43 and 2 studies relied on the characteristics and Figure 2 for effect sizes
coding. Following training, each Internet as a means of delivering the and 95% confidence intervals by primary
coauthor reviewed and coded roughly 75 intervention.44,45 Active controls consisted outcome and population. Within the
articles each, which subsequently led to of things such as social support or different mindfulness interventions
the reduction of our pool of studies to support groups,46 pharmacotherapy,47 delivered, we first examined the total effect
184. The primary reason for removal was smoking cessation education,48 life skills of allocation to study condition
due to nonrandomized studies. education,49 health education,49 (mindfulness, wait-list/usual care, or active
Following another round of discussion massage,50 relaxation training,51 stress control) on effect size variability in primary
and training, each coauthor reviewed and coping psychoeducation,52 and outcomes. Overall, mindfulness
and abstracted the remaining articles in nutrition education.53 In 70.8% of the interventions were significantly different to
full. This lead to a final review, studies, the mindfulness intervention was all other conditions (P < .01) with a large
reduction, and reorganization of 59 fully reported to be superior to controls (eg, pooled effect size compared to weak
abstracted articles, which were selected significantly different in the hypothesized effects for waitlist and usual care groups
for analysis and presentation in this direction). In 22% of studies, both (.1 and .2, respectively) and moderate
current systematic review. mindfulness and control conditions effects for active control conditions (.5).
reported significant improvements, and The active control condition effect size was
Study, Setting, and in 8% of studies, neither mindfulness nor also significantly stronger compared to the
Patient Characteristics control reported significant changes in waitlist/usual care. The assumption that all
We classified the 59 studies into 13 the primary outcomes. effect sizes were estimating the same
general categories based on population- population mean (eg, homogeneity) was
specific details. Most categories were also Risk of Bias. See Figure 1 for risk of bias not met however, indicating heterogeneity
subdivided into specific populations or assessment for each study. In all studies, of variance within these studies.
foci. Cardiovascular relevant studies were risk of selection bias (based on allocation Next, we examined whether effect sizes
the most frequently categorized (n = 10), to the intervention), selective bias, or differed by type of primary outcome. To
which included specific areas such as incomplete outcomes data was generally organized this varied literature, we first
188
Table 1.
Overview of Included Studies by General Category and Specific Population.
General Category Specific Population No. of Studies
Autoimmune/Psychosomatic Fibromyalgia 3
Irritable bowel syndrome 3
Chronic insomnia 1
Chronic fatigue syndrome 1
Cardiovascular Smoking cessation and substance use 2
Weight management 3
Diabetes 1
Blood pressure 2
Heart disease 2
Caregiver Dementia 1
Special needs children 1
Community-Based (Adult) Attentional control 1
Psychological well-being 6
Perceived control 1
Emotional regulation 1
Musculoskeletal and Arthritic Rheumatoid arthritis 2
Chronic pain 1
Failed back surgery syndrome 1
Low back pain 1
Psychiatric Depression 2
Bipolar disorder 1
Respiratory COPD 1
Asthma 1
School/University-Based (Adult) Psychological well-being 5
School/University-Based (Pediatric) Academic performance and self-concept 1
Neurology Epilepsy 1
Multiple sclerosis 1
Oncology Mixed cancer sample 3
Breast cancer 2
Prostate cancer 2
Transplantation Solid organ recipients 1
Viral Disease HIV 1
Women’s Health Disordered eating 1
Hot flashes 1
Pregnant/postpartum 1
Abbreviations: COPD, chronic obstructive pulmonary disease.
189
Table 2.
Published Trials Included in Systematic Review and Meta-Analysis (N = 59).
1. Alberts HJ, Mulkens S, Smeets M, Thewissen R. Coping with food cravings. Investigating the potential of a mindfulness-based intervention. Appetite.
2010;55(1):160-163.
2. Alberts HJ, Thewissen R, Raes L. Dealing with problematic eating behaviour. The effects of a mindfulness-based intervention on eating behaviour, food
cravings, dichotomous thinking and body image concern. Appetite. 2012;58(3):847-851.
3. Anderson ND, Lau MA, Segal ZV, Bishop SR. Mindfulness-based stress reduction and attentional control. Clin Psychol Psychother. 2007;14(6):
449-463.
4. Astin JA, Berman BM, Bausell B, Lee WL, Hochberg M, Forys KL. The efficacy of mindfulness meditation plus Qigong movement therapy in the treatment of
fibromyalgia: a randomized controlled trial. J Rheumatol. 2003;30(10):2257-2262.
5. Benn R, Akiva T, Arel S, Roeser RW. Mindfulness training effects for parents and educators of children with special needs. Dev Psychol. 2012;48(5):
1476-1487.
6. Branstrom R, Kvillemo P, Brandberg Y, Moskowitz JT. Self-report mindfulness as a mediator of psychological well-being in a stress reduction intervention for
cancer patients—a randomized study. Ann Behav Med. 2010;39(2):151-161.
7. Brewer JA, Mallik S, Babuscio TA, et al. Mindfulness training for smoking cessation: results from a randomized controlled trial. Drug Alcohol Depend.
2011;119(1-2):72-80.
8. Carmody J, Olendzki B, Reed G, Andersen V, Rosenzweig P. A dietary intervention for recurrent prostate cancer after definitive primary treatment: results of a
randomized pilot trial. Urology. 2008;72(6):1324-1328.
9. Carmody JF, Crawford S, Salmoirago-Blotcher E, Leung K, Churchill L, Olendzki N. Mindfulness training for coping with hot flashes: results of a randomized
trial. Menopause. 2011;18(6):611-620.
10. Daubenmier J, Kristeller J, Hecht FM, 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.
11. de Dios MA, Herman DS, Britton WB, Hagerty CE, Anderson BJ, Stein MD. Motivational and mindfulness intervention for young adult female marijuana users.
J Subst Abuse Treat. 2012;42(1):56-64.
12. Delgado LC, Guerra P, Perakakis P, Vera MN, Reyes del Paso G, Vila J. Treating chronic worry: psychological and physiological effects of a training
programme based on mindfulness. Behav Res Ther. 2010;48(9):873-882.
13. Esmer G, Blum J, Rulf J, Pier J. Mindfulness-based stress reduction for failed back surgery syndrome: a randomized controlled trial. J Am Osteopath Assoc.
2010;110(11):646-652.
14. Foley E, Baillie A, Huxter M, Price M, Sinclair E. Mindfulness-based cognitive therapy for individuals whose lives have been affected by cancer: a randomized
controlled trial. J Consult Clin Psychol. 2010;78(1):72-79.
15. Franco Justo C, de la Fuente Arias M, Salvador Granados M. Impact of a training program in full consciousness (mindfulness) in the measure of growth and
personal self-realization. Psicothema. 2011;23(1):58-65.
16. Gaylord SA, Palsson OS, Garland EL, et al. Mindfulness training reduces the severity of irritable bowel syndrome in women: results of a randomized
controlled trial. Am J Gastroenterol. 2011;106(9):1678-1688.
17. Gayner B, Esplen MJ, DeRoche P, et al. A randomized controlled trial of mindfulness-based stress reduction to manage affective symptoms and improve
quality of life in gay men living with HIV. J Behav Med. 2012;35(3):272-285.
18. Geschwind N, Peeters F, Drukker M, van Os J, Wichers M. Mindfulness training increases momentary positive emotions and reward experience in adults
vulnerable to depression: a randomized controlled trial. J Consult Clin Psychol. 2011;79(5):618-628.
19. Gluck TM, Maercker A. A randomized controlled pilot study of a brief web-based mindfulness training. BMC Psychiatry. 2011;11:175.
20. Gross CR, Kreitzer MJ, Reilly-Spong M, et al. Mindfulness-based stress reduction versus pharmacotherapy for chronic primary insomnia: a randomized
controlled clinical trial. Explore. 2011;7(2):76-87.
21. Gross CR, Kreitzer MJ, Thomas W, et al. Mindfulness-based stress reduction for solid organ transplant recipients: a randomized controlled trial. Altern Ther
Health Med. 2010;16(5):30-38.
(continued)
190
Table 2. (continued)
22. Grossman P, Kappos L, Gensicke H, et al. MS quality of life, depression, and fatigue improve after mindfulness training: a randomized trial. Neurology.
2010;75(13):1141-1149.
23. Hartmann M, Kopf S, Kircher C, et al. Sustained effects of a mindfulness-based stress-reduction intervention in type 2 diabetic patients: design and first
results of a randomized controlled trial (the Heidelberger Diabetes and Stress study). Diabetes Care. 2012;35(5):945-947.
24. Hebert JR, Hurley TG, Harmon BE, Heiney S, Hebert CJ, Steck SE. A diet, physical activity, and stress reduction intervention in men with rising prostate-
specific antigen after treatment for prostate cancer. Cancer Epidemiol. 2012;36(2):e128-e136.
25. Henderson VP, Clemow L, Massion AO, Hurley TG, Druker S, Hebert JR. The effects of mindfulness-based stress reduction on psychosocial outcomes and
quality of life in early-stage breast cancer patients: a randomized trial. Breast Cancer Res Treat. 2012;131(1): 99-109.
26. Hoffman CJ, Ersser SJ, Hopkinson JB, Nicholls PG, Harrington JE, Thomas PW. Effectiveness of mindfulness-based stress reduction in mood, breast-
and endocrine-related quality of life, and well-being in stage 0 to III breast cancer: a randomized, controlled trial. J Clin Oncol. 2012;30(12):
1335-1342.
27. Jacobs TL, Epel ES, Lin J, et al. Intensive meditation training, immune cell telomerase activity, and psychological mediators. Psychoneuroendocrinology.
2011;36(5):664-681.
28. Jain S, Shapiro SL, Swanick S, et al. A randomized controlled trial of mindfulness meditation versus relaxation training: effects on distress, positive states of
mind, rumination, and distraction. Ann Behav Med. 2007;33(1):11-21.
29. Kang YS, Choi SY, Ryu E. The effectiveness of a stress coping program based on mindfulness meditation on the stress, anxiety, and depression experienced
by nursing students in Korea. Nurse Educ Today. 2009;29(5):538-543.
30. Kaviani H, Foroozan J, Hatami N. Mindfulness-based cognitive therapy (MBCT) reduces depression and anxiety induced by real stressful setting in non-
clinical population. Int J Psychol Psychol Ther. 2011;11(2):12.
31. Klatt MD, Buckworth J, Malarkey WB. Effects of low-dose mindfulness-based stress reduction (MBSR-ld) on working adults. Health Educ Behav.
2009;36(3):601-614.
32. Lee WK, Bang HJ. The effects of mindfulness-based group intervention on the mental health of middle-aged Korean women in community. Stress Health.
2010;26(4):341-348.
33. Ljotsson B, Falk L, Vesterlund AW, et al. Internet-delivered exposure and mindfulness based therapy for irritable bowel syndrome—a randomized controlled
trial. Behav Res Ther. 2010;48(6):531-539.
34. MacCoon DG, Imel ZE, Rosenkranz MA, et al. The validation of an active control intervention for mindfulness based stress reduction (MBSR). Behav Res Ther.
2012;50(1):3-12.
35. Mackenzie CS, Poulin PA, Seidman-Carlson R. A brief mindfulness-based stress reduction intervention for nurses and nurse aides. Appl Nurs Res.
2006;19(2):105-109.
36. Morone NE, Greco CM, Weiner DK. Mindfulness meditation for the treatment of chronic low back pain in older adults: a randomized controlled pilot study.
Pain. 2008;134(3):310-319.
37. Mularski RA, Munjas BA, Lorenz KA, et al. Randomized controlled trial of mindfulness-based therapy for dyspnea in chronic obstructive lung disease. J Altern
Complement Med. 2009;15(10):1083-1090.
38. Nyklicek I, Kuijpers KF. Effects of mindfulness-based stress reduction intervention on psychological well-being and quality of life: is increased mindfulness
indeed the mechanism? Ann Behav Med. 2008;35(3):331-340.
39. Oken BS, Fonareva I, Haas M, et al. Pilot controlled trial of mindfulness meditation and education for dementia caregivers. J Altern Complement Med.
2010;16(10):1031-1038.
40. Palta P, Page G, Piferi RL, et al. Evaluation of a mindfulness-based intervention program to decrease blood pressure in low-income African-American older
adults. J Urban Health. 2012;89(2):308-316.
41. Pbert L, Madison JM, Druker S, et al. Effect of mindfulness training on asthma quality of life and lung function: a randomised controlled trial. Thorax.
2012;67(9):769-776.
42. Pradhan EK, Baumgarten M, Langenberg P, et al. Effect of mindfulness-based stress reduction in rheumatoid arthritis patients. Arthritis Rheum.
2007;57(7):1134-1142.
(continued)
191
43. Rimes KA, Wingrove J. Mindfulness-based cognitive therapy for people with chronic fatigue syndrome still experiencing excessive fatigue after cognitive
behaviour therapy: a pilot randomized study. Clin Psychol Psychother. 2013;20(2):107-117.
44. Robert McComb JJ, Tacon A, Randolph P, Caldera Y. A pilot study to examine the effects of a mindfulness-based stress-reduction and relaxation program on
levels of stress hormones, physical functioning, and submaximal exercise responses. J Altern Complement Med. 2004;10(5):819-827.
45. Robins CJ, Keng SL, Ekblad AG, Brantley JG. Effects of mindfulness-based stress reduction on emotional experience and expression: a randomized controlled
trial. J Clin Psychol. 2012;68(1):117-131.
46. Schmidt S, Grossman P, Schwarzer B, Jena S, Naumann J, Walach H. Treating fibromyalgia with mindfulness-based stress reduction: results from a
3-armed randomized controlled trial. Pain. 2011;152(2):361-369.
47. Sephton SE, Salmon P, Weissbecker I, et al. Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia: results of a randomized
clinical trial. Arthritis Rheum. 2007;57(1):77-85.
48. Shapiro S, Astin, JA, Bishop, SR, Cordova, M. Mindfulness-based stress reduction for health care professionals: results from a randomized trial. Int J Stress
Manage. 2005;12(2):13.
49. Tacon AM, McComb J, Caldera Y, Randolph P. Mindfulness meditation, anxiety reduction, and heart disease: a pilot study. Family Community Health.
2003;26(1):25-33.
50. Thompson NJ, Walker ER, Obolensky N, et al. Distance delivery of mindfulness-based cognitive therapy for depression: project UPLIFT. Epilepsy Behav.
2010;19(3):247-254.
51. Timmerman GM, Brown A. The effect of a mindful restaurant eating intervention on weight management in women. J Nutr Educ Behav. 2012;44(1):22-28.
52. van der Lee ML, Garssen B. Mindfulness-based cognitive therapy reduces chronic cancer-related fatigue: a treatment study. Psychooncology.
2012;21(3):264-272.
53. Vieten C, Astin J. Effects of a mindfulness-based intervention during pregnancy on prenatal stress and mood: results of a pilot study. Arch Womens Mental
Health. 2008;11(1):67-74.
54. Warnecke E, Quinn S, Ogden K, Towle N, Nelson MR. A randomised controlled trial of the effects of mindfulness practice on medical student stress levels.
Med Educ. 2011;45(4):381-388.
55. Williams JM, Alatiq Y, Crane C, et al. Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: preliminary evaluation of immediate effects on
between-episode functioning. J Affect Disorders. 2008;107(1-3):275-279.
56. Wong SY, Chan FW, Wong RL, et al. Comparing the effectiveness of mindfulness-based stress reduction and multidisciplinary intervention programs for
chronic pain: a randomized comparative trial. Clin J Pain. 2011;27(8):724-734.
57. Wright LB, Gregoski MJ, Tingen MS, Barnes VA, Treiber FA. Impact of stress reduction interventions on hostility and ambulatory systolic blood pressure in
African American adolescents. J Black Psychol. 2011;37(2):210-233.
58. Zautra AJ, Davis MC, Reich JW, et al. Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for
patients with and without history of recurrent depression. J Consult Clin Psychol. 2008;76(3):408-421.
59. Zernicke KA, Campbell TS, Blustein PK, et al. Mindfulness-based stress reduction for the treatment of irritable bowel syndrome symptoms: a randomized
wait-list controlled trial. Int J Behav Med. 2013;20(3):385-396.
grouped study outcomes into the (number of tobacco cigarettes smoked demonstrated statistically significant
following 6 thematic categories: Diet and and number of marijuana cigarettes differences. Diet and Weight
Weight Management (body image smoked); Symptom Burden (hot flash Management (P < .01) and Symptom
concern, emotional food cravings, bother, irritable bowel syndrome Burden (P < .05) effect sizes were each
emotional eating, saturated fat intake, symptoms, insomnia, global symptom significantly more robust for mindfulness
and weight loss); Negative Affect severity, dyspnea, and fatigue); and (.9 and 1.1, respectively) compared with
(anxiety, perceived stress, hostility, Cardiovascular (systolic blood pressure). all other groups (see Figure 3).
tension, neuroticism, emotional The homogeneity assumption was met When comparing different types of
exhaustion, and worry); Pain (general for 3 categories (Diet and Weight mindfulness interventions delivered, the
pain, fibromyalgia pain, and low back Management; Smoking and Substance original MBSR group effect size (g = .8)
pain); Smoking and Substance Use Use; and Symptom Burden), of which 2 was significantly larger compared to
192
Table 3.
Study Characteristics.
Mean SD Min Max

Group size 33.2 19.3 8 111
Intervention length (weeks) 7.8 1.9 2 12
Effect size (Hedges g) 0.53 0.66 −1 3
Total sample size 67.7 39.2 18 229
Immediate follow-up (weeks) 9.3 6 4 52
Number of men 17.2 24.4 0 117
Number of women 51.2 39.6 0 229
Age 46.6 14.1 15 75
Population Percentage Population Percentage
Cardiovascular 16.9% Caregiver 4.6%
Community-based 13.8% Psychiatric 4.6%
Autoimmune 13.8% Neurological 3.1%
Oncology 12.3% Respiratory 3.1%
School 10.8% Viral 1.5%
Musculoskeletal 9.2% Transplantation 1.5%
Women’s health 4.6%
Primary Study Outcome Percentage Primary Study Outcome Percentage
Anxiety 33.8% Smoking cessation 3.1%
Stress 20.0% Saturated fat intake 3.1%
Symptom bother 13.8% Food craving 3.1%
Pain 10.8% Body image 1.5%
Blood pressure 4.6% Positive affect 1.5%
Depression 3.1% Weight loss 1.5%
Study Condition Percentage Type of Mindfulness Intervention Percentage
Mindfulness intervention 50.0% Original MBSR 44.6%
Wait-list group 28.5% Original MBCT 10.8%
Active control group 15.4% Modified MBSR 23.1%
Usual care 6.2% Other mindfulness interventions 13.8%
Mindful Eating 4.6%
(continued)
193
Smaller Versus Larger Group

Sizes Percentage Group Performance Percentage
Group had ≥20 participants 71.5% Mindfulness significantly better 70.8%
Group had ≤19 participants 28.5% Mindfulness control both 21.5%
significant
No significant differences 7.7%
between groups
Intervention Length Percentage
≥8 weeks 83.1%
Between 2 and 7 weeks 16.9%
Abbreviations: MBSR, mindfulness-based stress reduction; MBCT, mindfulness-based cognitive therapy.
wait-list/usual care (g = .2) and active of weeks of the mindfulness intervention interventions are superior to no treatment
control (g = .4); however, homogeneity of was relatively less (eg, between 2 and 7 at all, or simply the passage of time.
variance assumptions were not met. Of all weeks) or more (eg, 8 weeks or more). Being placed on a wait-list may be
types of mindfulness interventions The mindfulness condition had demoralizing for the person who does not
delivered, the only group where the significantly larger effect sizes than the want to wait (possibly influencing their
homogeneity assumption was met and wait-list/usual care groups (P < .01; g = outcome scores negatively), or create a
demonstrated a significant difference was 1.1) in both intervention periods and was positive expectancy effect knowing that
in “other mindfulness interventions” where also significantly larger than the active their turn is coming (possibly influencing
mindfulness had significantly larger effect control conditions in the “8 weeks or their outcome scores positively). Using
sizes (g = .6) compared with the wait-list/ more” (P < .01; g = .8). The homogeneity wait-list controls is understandable in
usual care condition (g = .1). This “other” assumption was not met for either the “2 behavioral medicine research, especially
category was made up of studies focusing to 7 week” or “8 weeks or more” in the early, pilot testing of an
on diet and weight management (22%), comparisons (see Figure 6). intervention where the primary aim is
negative affect (67%), and smoking and feasibility, acceptability, and safety.
substance use (11%) (see Figure 4). However, given the apparent viability and
Discussion
Next, we compared effect size tolerability of mindfulness interventions,
differences between studies with 19 or Overall, this systematic review and as evidenced by their widespread
less participants in a group with those meta-analysis found partial evidence for application across numerous different
that had 20 or more per group. In both mindfulness-based interventions to populations and conditions, continued
the “19 or less” and “20 or more” groups, provide short-term benefits across a wide efforts should be made to develop, test,
the mindfulness condition had range of lifestyle medicine–relevant and use good active control conditions
significantly larger effect sizes (P < .01) populations and study outcomes, (eg, MacCoon et al.’s54 Health
compared with the wait-list/usual care particularly focusing on the areas of diet Enhancement Training) to mirror the
and active control groups; however, the and weight management and symptom social-emotional and educational
homogeneity assumption was only met burden. Mindfulness-based interventions components of MBSR and similar courses.
in the “19 or less” group (g = .8). In are inherently lifestyle medicine While these multiweek mindfulness
addition, the active control also had interventions that have the potential to courses are not intended to be “support
significantly higher effect sizes (P < .01; address a wide range of issues, from groups,” they are undoubtedly
g = .6) compared to the wait-list/usual disease prevention and health promotion “supportive” to many, and therefore a
care group in the “20 or more” group; to chronic disease management. formidable placebo condition would
however, the homogeneity assumption Wait-list conditions were the allow the unique effects of mindfulness
was not met (see Figure 5). predominant control group in the training to be more exquisitely examined.
Finally, we compared the possible included studies, and our meta-analytic While relatively small sample sizes can
effect size differences when the number findings suggest that mindfulness be observed across many of the included
194
Table 4.
vol. 9 • no. 3
Characteristics of Included Studies.
General Category Specific Population Author Year N Intervention/Control Primary Aim Outcomes
Women’s Health Disordered eating Alberts 2012 26 8-Week modified mindfulness-based Decrease disordered eating behavior in a Intervention showed significantly lower levels of food
eating program (n = 12) vs wait-list female community sample cravings, dichotomous thinking, body dysfunction,
control (n = 14) emotional eating and external eating, as well as increase
in mindfulness.
Cardiovascular Weight management Alberts 2010 19 All participants completed a 10-week Reduce food cravings in obese Intervention showed significantly lower food cravings,
weight management program individuals higher acceptance of food cravings, decreased
followed by a 7-week mindfulness preoccupation with food, and lower rating of perceived
training program (n = 10) vs usual reinforcing value of food.
care control (n = 9)
Community-Based Attention Anderson 2007 72 8-Week MBSR (n = 39) vs wait-list Examine the role of sustained attention No differences found between the 2 groups in terms of
(Adult) control (n = 33) and related factors in the experience attentional control. However, the intervention group
of mindfulness in a healthy adult showed direct improvements in mindfulness and
community sample emotional well-being and indirect improvement in object
detection.
Autoimmune/ Fibromyalgia Astin 2003 128 8-Week MBSR + Qigong training (n Reduce myalgia and depression and Both the intervention and control groups showed
Psychosomatic = 32) vs 8-week time/attention improve physical functioning in comparable gains at postintervention, 16 and 24 weeks.
matched education and support primarily female fibromyalgia sufferers
control (n = 33)
Caregiver Special needs children Benn 2012 60 5-Week (biweekly) mindfulness Improve psychological wellness in Intervention showed significantly greater reduction in
training based on MBSR + mindful parents and educators of children with stress and anxiety, increased mindfulness, self-
parenting/teaching (n = 35) vs wait- special needs compassion, personal growth, empathic concern and
list control (n = 35) forgiveness, both at program completion and at the
2-month follow-up.
Oncology Mixed cancer sample Bränström 2010 71 8-Week modified MBSR (no daylong Improve psychological well-being in Intervention showed significantly larger reduction of
retreat; n = 32) vs wait-list control mixed cancer patient sample psychological distress and increase in positive states of
(n = 39) mind and mindfulness.
Cardiovascular Smoking cessation Brewer 2011 87 4-Week (biweekly) mindfulness Decrease cigarette use in community- MBSR intervention showed significantly greater
and substance use intervention (n = 41) vs 4-week based sample of adult smokers reduction of cigarettes smoked during treatment and
American Lung Association smoking posttreatment.
cessation control (n = 46)
Oncology Prostate cancer Carmody 2008 36 11-Week dietary + mindfulness Change dietary habits to a plant-based Intervention showed significantly greater dietary change
support intervention (n = 17) vs diet + fish in men with prostate cancer and improved quality of life at 3 months. Percentage of
usual care (n = 19) vegetable protein intake and reduction in animal protein
correlated with frequency of mindfulness practice.
(continued)
American Journal of Lifestyle Medicine
195
196
Women’s Health Hot flashes Carmody 2011 110 8-Week MBSR (n = 57) vs wait-list Decrease bother from hot flashes and Intervention resulted insignificantly less bother of hot
control (n = 53) night sweats in menopausal women flashes, anxiety, and perceived stress and greater
improvements in quality of life and sleep quality at 3
months.
Cardiovascular Weight management Daubenmier 2011 47 9-Week mindfulness intervention Reduce abdominal adiposity among Intervention showed significantly greater mindfulness,
adapted from MBSR, MBCT, and overweight and obese women body responsiveness, and decreased anxiety and external
MB-EAT (n = 24) vs wait-list control eating. No group differences in cortisol, abdominal
(n = 23) fat, fat distribution, and weight. Subgroup analyses
indicated obese participants demonstrated significant
improvements in cortisol and body weight when
compared to their wait-list control counterparts.
Cardiovascular Smoking cessation de Dios 2011 34 2-Week mindfulness intervention (n = Reduce marijuana use in community- Intervention showed significantly less marijuana use,
and substance use 22) vs control (n = 12) based sample of female marijuana which was moderated by meditation frequency.
users
School/University- Psychological well- Delgado 2010 36 5-Week (biweekly) mindfulness Reduce chronic worry in a female Both groups showed reductions in anxiety, depression,
Based (Adult) being training (n = 15) vs 5-week undergraduate college student sample and health complaints. The mindfulness group showed
relaxation, education and support with high self-reported worry significantly higher levels of emotional meta-cognition
(n = 21) and greater improvement in physiological states such as
slower heart rate.
Musculoskeletal Failed back surgery Esmer 2011 25 8-Week MBSR + traditional therapy Improve quality of life in patients with Intervention showed significantly greater pain acceptance,
and Arthritic syndrome (n = 15) vs usual care control group failed back surgery syndrome quality of life, and increased sleep quality and decreased
(n = 10) functional limitation and pain level.
Oncology Mixed cancer sample Foley 2010 115 8-Week MBCT (n = 55) vs wait-list Decrease distress and improve quality of Intervention showed significantly less anxiety, depression,
control (n = 60) life among cancer patients and distress and greater mindfulness at 10 weeks and
3 months.
School/University- Academic Franco 2011 60 10-Week mindfulness training (n = Improve academic performance and Intervention showed significantly greater improvements in
Based (Pediatric) performance and 31) vs wait-list control (n = 30) self-concept and decrease anxiety academic achievement, self-concept, and anxiety.
self-concept among Spanish high school students
Autoimmune/ IBS Gaylord 2011 75 8-Week MBSR (n = 36) vs social Reduce irritable bowel syndrome MBSR Intervention showed immediate, significant, and
Psychosomatic support matched control (n = 39) symptoms, psychological distress, durable improvements in IBS symptom severity and
and visceral anxiety among female delayed significant improvement in measures of quality
IBS patients of life, psychological distress, and visceral anxiety at 3
months.
(continued)
May • Jun 2015
vol. 9 • no. 3
Viral Disease HIV Gayner 2011 117 8-Week MBSR (n = 78) vs wait-list Manage affective symptoms and Intervention exhibited significantly lower behavioral
control (n = 39) improve quality of life in gay men living avoidance and higher increases in positive affect and
with HIV mindfulness at both posttreatment and 6-month follow
up.
Psychiatric Depression Geschwind 2011 130 8-Week MBCT (n = 64) vs wait-list To increase momentary positive Intervention showed significantly greater increased
control (n = 66) emotions for patients with a history of momentary positive emotions and greater appreciation of
depression pleasant daily-life activities.
Community-Based Psychological well- Glück 2011 49 2-Week Web-based mindfulness Improve psychological well-being in Feasibility of Web-based approach confirmed. No
(Adult) being training (n = 28) vs wait-list control a community-based adult sample of statistically significant group differences on outcomes.
(n = 21) primarily females
Autoimmune/ Insomnia Gross 2011 30 8-Week MBSR (n = 18) vs Compare MBSR to pharmacotherapy for Both MBSR and pharmacotherapy participants saw similar
Psychosomatic pharmacotherapy (n = 9) chronic primary insomnia decreases in sleep onset latency and improvements in
sleep quality both at 8 weeks and 5 months.
Transplantation Solid organ recipients Gross 2011 137 8-Week MBSR (n = 72) vs peer-lead Decrease distress and improve quality Intervention showed significantly lower depression,
health education control (n = 66) of life among solid organ transplant anxiety, and improved sleep quality of transplant
recipients patients, lasting throughout the year of the study.
Neurology Health-related quality Grossman 2010 150 8-Week MBSR (n = 76) vs usual care Decrease distress and improve quality Intervention showed significantly lower depression, anxiety
of life control (n = 76) of life among relapse–remitting and fatigue which remained significant at 6 months.
or secondary progressive multiple
sclerosis
Cardiovascular Diabetes Hartmann 2012 110 8-Week MBSR (n = 53) vs usual care Reduce distress, nephropathy Intervention showed significantly lower depression
control (n = 57) progression, and improve health in and stress and improved health status. No significant
type 2 diabetes difference was found between groups in albuminuria.
Oncology Prostate cancer Hérbert 2011 47 12-Week diet, exercise, and Reduce tumor and disease progression No group differences were observed in disease-related
mindfulness training (n = 26) vs markers in men with prostate cancer measures. Intervention did show decreased saturated
wait-list control (n = 21) fatty acid, and energy intake while maintaining prostate-
specific antigen levels.
Oncology Breast cancer Henderson 2011 216 8-Week MBSR (n = 53) vs nutrition Decrease distress and improve quality of MBSR intervention showed significantly greater benefit in
education control (n = 52) vs usual life among breast cancer patients psychosocial adjustment, meaningfulness, depression,
care (n = 58) hostility, anxiety, unhappiness, emotional control, and
paranoid ideation as compared to both control groups at
4 months postintervention.
(continued)
197
198
Oncology Breast cancer Hoffman 2012 229 8-Week MBSR (n = 103) vs waitlist Improve mood, breast- and endocrine- Intervention showed significantly improved mood states,
control (n = 111) specific quality of life and well-being well-being, and disease-specific quality of life over
after hospital treatment in women with 3-month follow-up.
stage 0 to III breast cancer
Neurology Health-related quality Thompson 2010 53 8-Week MBCT via telephone or Reduce psychological distress and Intervention showed significantly greater knowledge, skills,
of life Internet (n = 26) vs wait-list control increase quality of life among and reduction in depressive symptoms compared to the
(n = 27) individuals diagnosed with epilepsy control group.
Community-Based Perceived control Jacobs 2011 60 12-Week intensive mindfulness Increase telomerase activity and Intervention showed significantly greater telomerase
(Adult) meditation retreat (n = 30) vs wait- perceived control and decrease activity increase, increase in perceived control. and a
list control (n = 30) neuroticism in an intensive meditation decrease in neuroticism.
sample
School/University- Psychological well- Jain 2007 108 4-Week modified MBSR (n = 27) vs Decrease psychological distress and Both intervention groups showed significant decreases
Based (Adult) being 4-week somatic relaxation (n = 24) ruminative thoughts and increase in distress and increases in positive state of mind
vs usual care (n = 30) positive states of mind and spiritual versus the control. The mindfulness meditation group
perception among graduate nursing showed greater results for positive state of mind than
students for relaxation. It also showed a decrease in ruminative
thoughts. No significant effects found on spiritual
experience.
School/University- Psychological well- Kang 2009 41 8-Week mindfulness meditation Decrease stress, anxiety, and depression Intervention group showed significantly lower stress levels
Based (Adult) being training (n = 16) vs stress and among nursing students in Korea and reduction in the anxiety. No significant difference in
coping lecture control (n = 16) depression between groups.
School/University- Psychological well- Kaviani 2011 45 8-Week MBCT (n = 20) vs wait-list Decrease psychological distress among Intervention showed significantly reduced levels of
Based (Adult) being control (n = 25) Iranian college students depression, anxiety, dysfunctional attitudes, and negative
automatic thoughts.
Community-Based Psychological well- Klatt 2009 45 6-Week modified MBSR (n = 22) vs Reduce stress and increase mindfulness Intervention showed significantly lower stress and higher
(Adult) being wait-list control (n = 20) in healthy working adults mindfulness. Both groups showed improved sleep.
Psychiatric Depression Lee 2010 60 8-Week MBCT (n = 30) vs wait-list Improve the psychological well-being Mindfulness and self-compassion both had significant
control (n = 30) of middle-aged Korean women who increases. Psychological well-being and depression
complained of depressed mood scores also improved.
Autoimmune/ IBS Ljótsson 2010 85 10-Week Internet-delivered cognitive Decrease gastrointestinal distress Intervention demonstrated significantly greater symptom
Psychosomatic behavioral/mindfulness group (n = and improve quality of life among reduction and improvements in quality of life at 3
42) vs wait-list control (n = 43) community-based sample of Swedish months.
women with irritable bowel syndrome
(continued)
May • Jun 2015
vol. 9 • no. 3
Cardiovascular Heart disease Tacon 2003 20 8-Week MBSR (n = 9) vs wait-list Reduce anxiety and improve stress Intervention showed significantly lower anxiety and higher
control (n = 9) management in women with heart ability to control negative emotions, compared to control.
disease
Community-Based Psychological well- MacCoon 2011 57 8-Week MBSR (n = 27) vs 8-week Compare MBSR to structurally matched MBSR intervention showed significantly higher pain
(Adult) being health enhancement program (n health enhancement intervention to threshold compared with health enhancement program
= 30) determine MBSR’s unique effects in a over time. Both interventions showed similar decrease in
community-based sample distress and symptoms.
Community-Based Psychological well- Mackenzie 2006 30 4-Week modified MBSR (n = 16) vs Reduce stress and improve quality of life Intervention showed significantly greater improvements in
(Adult) being wait-list control (n = 14) for nurses and nurse aides at a large, emotional regulation, self-awareness, and greater sense
urban hospital for long-term geriatric of work accomplished.
patients and residents
Musculoskeletal Low back pain Morone 2007 37 8-Week MBSR (n = 13) vs wait-list Decrease pain intensity and increase Intervention showed significantly greater improvements
and Arthritic control (n = 17) pain acceptance, quality of life and in physical function and overall pain experience over 3
physical function in a community- months.
based sample of older chronic low
back pain sufferers
Respiratory COPD Mularski 2009 86 8-Week mindfulness based breathing Improve respiratory symptoms and No group differences in dyspnea, health-related quality
therapy modified from MBSR (n = quality of life in patients with chronic of life, or exacerbation rates were found. Support group
44) vs a support group control (n obstructive lung diseases (COPD) showed better physical function.
= 42)
Community-Based Psychological well- Nyklícek 2008 57 8-Week MBSR (n = 30) vs wait-list Improve psychological well-being and Intervention showed significantly lower symptoms of
(Adult) being control (n = 30) quality of life in community-based distress and improved quality of life.
adult sample
Caregiver Dementia Oken 2010 41 7-Week modified MBCT (n = 10) vs Decrease stress and improve quality of Both active interventions showed significantly less
3-hour weekly respite care control life among caregivers of individuals caregiver perceived stress compared to the respite care
(n = 10) vs dementia caregiver with dementia control; however, no other differences were observed.
educational group (n = 11)
Cardiovascular Blood pressure Palta 2012 20 8-Week MBSR (n = 12) vs social Reduce blood pressure in a community Intervention demonstrated significantly larger reductions
support control (n = 8) sample of primarily female, low- in systolic and diastolic blood pressure compared to
income, African American adults controls after 8 weeks.
(continued)
199
200
Respiratory Asthma Pbert 2012 83 8-Week MBSR (n = 42) vs Health Reduce stress and anxiety in individuals Intervention showed significantly greater improvements in
Living Course control (n = 41) who have asthma to improve their asthma-related quality of life, and significant decreases
quality of life and lung function in self-perceived stress levels at their 12-month follow-
up.
Musculoskeletal Rheumatoid arthritis Pradhan 2007 63 8-Week MBSR (n = 31) vs wait-list Reduce depressive symptoms and No immediate effect of intervention on outcomes; however,
and Arthritic control (n = 32) improve overall psychological status in at 6 months intervention showed significant improvement
individuals with rheumatoid arthritis in mindfulness and psychological status and significant
decrease in depressive symptoms.
Autoimmune/ Chronic fatigue Rimes 2011 35 8-Week MBCT (n = 15) vs wait-list Reduce excessive fatigue after cognitive Intervention showed significantly lower levels of fatigue,
Psychosomatic syndrome control (n = 19) behavioral therapy among individuals which persisted at 2- and 6-month follow-up. MBCT
with chronic fatigue syndrome group also exhibited significantly better outcomes on
impairment, depressed mood, catastrophic thinking
about fatigue, all-or-nothing behavioral responses,
unhelpful beliefs about emotions, mindfulness and self-
compassion.
Cardiovascular Heart disease Robert 2004 18 8-Week MBSR (n = 9) vs wait-list Lower stress hormone levels and No differences between groups in stress hormone levels,
McComb control (n = 9) improve submaximal exercise submaximal exercise responses, or overall physical
responses in women with heart functioning. Intervention showed significantly better
disease ventilation and lower breathing frequency during
exercise.
Community-Based Emotional regulation Robins 2012 41 8-Week MBSR (n = 28) vs wait-list Improve emotional regulation among Intervention participants reported significantly decreased
(Adult) control (n = 28) community-based adults levels of absent-mindedness, emotional dysregulation,
worry, emotional anxiety, and anger suppression/
overexpression and reported significantly increased
measures of mindfulness and self-compassion, which
persisted through 2-month follow-up.
Autoimmune/ Fibromyalgia Schmidt 2011 221 8-Week MBSR (n = 53) vs muscle Improve quality of life and well-being in No significant differences between groups in health-related
Psychosomatic relaxation/stretching (n = 56) vs a community-based sample of females quality of life. MBSR or relaxation/stretching reported
waitlist control (n = 59) with fibromyalgia greater reductions in anxiety postintervention. MBSR
group showed significantly greater mindfulness when
compared to other groups.
Autoimmune/ Fibromyalgia Sephton 2007 91 8-Week MBSR (n = 51) vs wait-list Alleviates depressive symptoms in Intervention showed significantly lower symptoms of
Psychosomatic control (n = 40) community-based sample of women depression compared to participants allocated to the
with fibromyalgia control group.
(continued)
May • Jun 2015
vol. 9 • no. 3
Community-Based Psychological well- Shapiro 2005 28 8-Week MBSR (n = 19) vs wait-list Increase quality of life among health Intervention reported significantly greater reductions in
(Adult) being control (n = 19) care professionals stress and increases in self-compassion.
Cardiovascular Weight management Timmerman 2012 35 6-Week mindfulness eating group (n Increase mindful restaurant eating Intervention demonstrated significantly greater
= 19) vs wait-list control (n = 16) awareness in women who eat out ≥3 improvements in weight, 3-day calorie and fat
times per week consumption, diet-related self-efficacy, and barriers to
intake consumption while dining out.
Oncology Mixed cancer sample van der Lee 2010 83 9-Week MBCT (n = 59) vs wait-list Reduce chronic cancer-related fatigue in Intervention participants demonstrated significantly lower
control (n = 24) a sample of cancer survivors fatigue and significantly higher reports of well-being,
which persisted through 2 months.
Women’s Health Pregnant/postpartum Vieten 2008 31 8-Weekly mindfulness motherhood Decrease stress and improve mood Intervention participants demonstrated significantly greater
sessions (n = 13) vs waitlist control among community-based sample of reductions in state anxiety as well as negative affect. At
(n = 18). Mindfulness sessions pregnant or postpartum women 3-month follow-up, these intergroup differences were no
focused on awareness of developing longer statistically significant.
fetus, mindful labor pain/anxiety,
and movement
School/University- Psychological well- Warnecke 2011 65 8-Week MBSR (n = 31) vs wait-list Decrease psychological stress among Intervention participants reported significantly decreased
Based (Adult) being control (n = 34) Australian medical students perceived stress and anxiety. These improvements were
maintained at 2-month follow-up assessment.
Psychiatric Bipolar disorder Williams 2008 55 8-Week MBCT (n = 14) vs waitlist Decrease between episode depression Intervention showed significantly improved anxiety in the
control (n = 20) and anxiety in people with bipolar bipolar group. Both bipolar and unipolar participants in
disorder the MBCT group exhibited lower residual depressive
symptoms when compared to the wait-list group.
Musculoskeletal Chronic pain Wong 2011 99 8-Week MBSR (n = 51) vs active Decrease pain intensity and distress While measures of pain intensity and pain distress
and Arthritic comparison control (n = 48) that and improve quality of life and mood improved significantly for both groups, there were no
focused on comprehensive chronic- among patients with chronic pain significant between-group differences in outcome.
pain education and support
Cardiovascular Blood pressure Wright 2011 156 12-Week MBSR-based Breathing Reduce hostility and 24-hour ambulatory Both Breathing Awareness Meditation and Life Skills
Awareness Meditation (n = 35) vs blood pressure in African American training resulted in significant decreases in hostility;
Health Education (n = 44) vs Life adolescents however, in the Breathing Awareness Meditation group,
Skills Training (n = 42) reductions in hostility were related to lower systolic
blood pressure and heart rate measures. These trends
persisted in participants whose hostility measures
continued to decrease from postintervention to final
evaluation.
(continued)
201
202
Musculoskeletal Rheumatoid arthritis Zautra 2008 147 8-Week mindfulness meditation and Reduce stress, pain, and depression and Cognitive behavior intervention participants showed
and Arthritic emotion regulation therapy (n = improve the quality of life for adults greatest improvement in self-reported pain control, while
41) vs cognitive behavioral therapy with rheumatoid arthritis cognitive behavioral and mindfulness showed more
for pain (n = 30) vs education-only improvement in coping efficacy than education-only.
group (n = 43)
Autoimmune/ IBS Zernicke 2012 90 8-Week MBSR (n = 43) vs wait-list Decrease symptoms and improve quality Intervention showed clinically significant improvements
Psychosomatic control (n = 47) of life in IBS in symptom severity, reducing from severe to moderate
levels of IBS. Intervention groups’ outcomes remained
consistent through to 6-month follow-up. Over time,
the wait-list control group showed slight, gradual
improvement as well, probably due to the increased
attention from the research group and the promise of
potentially engaging in a helpful treatment.
Abbreviations: MBSR, mindfulness-based stress reduction; MBCT, mindfulness-based cognitive therapy; MB-EAT, mindfulness-based eating awareness training; IBS, irritable bowel syndrome; COPD, chronic
obstructive pulmonary disease.
May • Jun 2015
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Legend
H = High risk of bias
L = Low risk of bias
? = Unclear risk of bias
*Personnel blinded but not participants
**Personnel and participants blinded
Types of Bias Examined
1. Selection bias (random sequence generation and allocation concealment)
2. Performance bias (blinding of participants and personnel)
3. Detection bias (blinding of outcome assessment)
4. Attrition bias (incomplete outcome data)
5. Reporting bias (selective reporting& other bias)
203
Table 5.
Study Measurement Tools and Domains Assessed.
Measurement Tool or Method Domain Number of Studies Used
24-Hour Dietary Recall Nutrition Data System Saturated Fat 1
4-Point Hot Flash Bother Rating Hot Flash Bother 1
7-Item Positive Affect Adjective Scale Positive Affect 1
Average Number of Cigarettes Smoked Cigarettes Smoked 2
Beck Anxiety Inventory Anxiety 3
Beck Depression Inventory Depression 2
Blood Pressure Cuff Systolic Blood Pressure 2
Body Shape Questionnaire Body Image Concern 1
Brief Symptom Inventory Global Symptom Severity 1
Chalder Fatigue Scale Fatigue 1
Checklist Individual Strength Fatigue Severity Subscale Fatigue 1
Dutch Eating Behavior Questionnaire Emotional Eating 1
Fibromyalgia Impact Questionnaire Fibromyalgia Pain 1
General Food Craving Questionnaire–Trait Emotional Food Cravings 1
Hamilton Anxiety Rating Scale Anxiety 1
Hospital Anxiety & Depression Scale–Anxiety Anxiety 1
Insomnia Severity Index Insomnia 1
Irritable Bowel Syndrome Severity Scale Irritable Bowel Syndrome Symptom Severity 2
Likert Scale Pain Intensity Rating Pain 1
Maslach Burnout Inventory Emotional Exhaustion 1
McGill Pain Questionnaire Low Back Pain 1
Modified Borg Dyspnea Scale Dyspnea 1
Neo-5 Neuroticism Neuroticism 1
Pain Intensity Numeric Rating Scale Pain 2
Patient Health Questionnaire Stress Score Perceived Stress 1
Penn State Worry Questionnaire Worry 1
Perceived Stress Scale Perceived Stress 10
Profile Of Mood States Tension/Anxiety Tension/Anxiety 1
Saturated Fat Intake Saturated Fat Intake 1
State Trait Anxiety Inventory Anxiety 8
Summary VAS for Pain Pain 1
Symptom Check List-90-Revised Anxiety Anxiety 2
Visceral Sensitivity Index GI Anxiety 1
Weight Scale Weight Loss 1
204
Table 6.
vol. 9 • no. 3
Average Effect Size Variation Across Study Characteristicsa.
Mindfulness Wait-List/Usual Care Active Control
Effect Effect Effect

Size SD n Size SD n Size SD n Homogeneity Sig Pairwise Comparisons
Mindfulness sig better than wait-list/usual

care and active control; Active control
All Studies 0.9 0.6 65 0.1 0.3 44 0.6 0.9 21 <.05 <.01 significantly better than waitlist/usual care
Primary outcomes
Diet and Weight 0.9 0.5 6 0.0 0.3 6 NA NA 0 >.05 <.01 Mindfulness significantly better than wait-list/
Management usual care
Negative Affect 0.7 0.5 38 0.1 0.3 30 0.1 0.4 8 <.05 <.01 Mindfulness significantly better than all groups
PAIN 1.2 1.0 7 0.0 0.1 2 1.1 1.0 5 <.05 >.05 No significant group differences
Smoking and 1.5 1.2 2 0.1 NA 1 1.7 NA 1 >.05 >.05 No significant group differences
Substance Use
Symptom Burden 1.1 0.6 9 0.2 0.4 5 0.9 1.1 4 >.05 <.05 Mindfulness sig better than all groups
Cardiovascular 0.5 0.2 3 NA NA 0 0.1 0.1 3 <.05 <.01 Mindfulness sig better than active control
Types of mindfulness interventions used
Original MBSR 0.8 0.6 29 0.2 0.2 19 0.4 0.8 10 <.05 <.01 Mindfulness significantly better than all groups
Original MBCT 0.9 0.4 7 0.0 0.5 7 NA NA 0 >.05 >.05 Mindfulness significantly better than wait-list/
usual care
Modified MBSR 1.1 0.7 15 0.1 0.3 7 1.0 1.0 8 <.05 <.05 Mindfulness and Active Control significantly
better than wait-list/usual care
Modified MBCT 0.7 0.8 2 0.5 NA 1 −0.3 NA 1 >.05 >.05 No significant group differences
Mindful eating 0.5 0.6 3 0.0 0.1 2 −0.1 NA 1 <.05 >.05 No significant group differences
Other mindfulness 0.6 0.3 9 0.1 0.2 8 0.4 NA 1 >.05 <.01 Mindfulness significantly better than wait-list/
interventions usual control
205
206
Mindfulness Wait-List/Usual Care Active Control
Effect Effect Effect

Size SD n Size SD n Size SD n Homogeneity Sig Pairwise Comparisons
Mindfulness sig better than wait-list/usual

care and active control; Active control
All Studies 0.9 0.6 65 0.1 0.3 44 0.6 0.9 21 <.05 <.01 significantly better than waitlist/usual care
Proportions per group
<19 per group 0.8 0.5 19 0.0 0.2 13 0.3 1.2 5 >.05 <.01 Mindfulness significantly better than wait-list/
usual care and active control
>20 per group 0.9 0.6 46 0.2 0.3 31 0.6 0.8 16 <.05 <.01 Mindfulness significantly better than wait-list/
usual care and active control; Active Control
significantly better than wait-list/usual care
Lengths of intervention
2-7 Weeks of 1.1 0.9 11 0.1 0.3 8 1.0 0.7 3 <.05 <.01 Mindfulness is significantly better than wait-
intervention list/usual care
>8 Weeks of 0.8 0.5 54 0.1 0.3 36 0.5 0.9 18 <.05 <.01 Mindfulness significantly better than all groups
intervention
a
All analyses weighted by sample size; pairwise comparisons done with least squared differences statistic.
May • Jun 2015
studies, our empirical findings suggest

Figure 2. that this has not affected the power to
Effect Sizes and 95% Confidence Intervals by Primary Outcome and Population. detect statistically significant findings or
risk type II errors, nor has it contributed
Primary Outcome Population Mindfulness Control
to comparably smaller effect sizes.
Rheumatoid Arthritis
Similarly, modifying MBSR in different
ways to the original 8-week course
continued to produce large effect sizes
Chronic Pain
across studies.
Pain Low Back Pain
Compared to other medical social
Community
Sample
science disciplines, the use of eHealth as
Failed Back
a tool for the delivery of mindfulness
Surgery
interventions was comparatively small in
Fibromyalgia
our review. Provided current trends in
Disordered
Eating the use of technology-based self-
management interventions,55,56 this
Weight
Diet & Weight Loss delivery method will undeniably increase
Management
Community
over time. Instead of applying a
Sample
one-size-fits all design/development/
Cancer delivery approach from other fields such
as behavioral or preventive medicine,
Postpartum
mindfulness researchers will benefit from
Rheumatoid Arthritis
Asthma
exploring novel informatics applications
Heart Disease
that parallel the specific intricacies and
Epilepsy mechanisms of the mindfulness construct
Diabetes itself, so that intervention and method of
Negative
Multiple Sclerosis delivery go hand in hand.
Affect
Organ Transplant
We also observed that the vast majority
Mental Health HX
of studies conducted with US patient
HIV
Irrita ble Bowel Syndrome

samples were with English-speaking,
School/University
Caucasian, female participants.
Cancer
Mindfulness interventions have
Caregiver tremendous potential to affect real
Fibromyalgia change in health disparities that involve
Community Based
modifiable, lifestyle medicine-relevant
-2.0 -1.0 0.0 1.0 2.0 3.0 4.0 5.0
outcomes. Continued efforts should be
made to further develop, refine,
Smoking &
Substance Use
Nicotine & Marijuana
Dependent Adults culturally tailor, validate, and empirically
examine the effects of mindfulness
Chronic Fatigue
interventions with non-English-speaking
COPD
patient groups to address these issues.
Insomnia
This study is not without limitations.
Symptom
Burden
Irritible Bowel Syndrome
First, publication bias was not examined
School/University across included studies. Second, as can be
Menopause seen in Figure 1, many studies failed to
Cancer
report important risk of bias criteria,
Blood Pressure
specifically allocation of concealment,
Cardiovascular
blinding of participants, and blinding of
outcomes. While these are important
-2.0 -1.0 0.0 1.0 2.0 3.0 4.0 5.0 factors for mindfulness researchers to
include, it is also understandable that
Note: Hedges g effect sizes shown; Control contains studies with wait-list/usual care and/or active
controls.
given the unique qualities of a
mindfulness intervention, concepts such as
207
Figure 3.
Effect Size Differences Between Condition and Primary Outcome.
Mindfulness Waitlist/Usual Care Homogeneity of
Varience Assumed Significance
Symptom Burden (n=9) Yes p<.05
Smoking (n=2) No p>.05
Pain (n=7)
No p>.05
Negative Affect (n=38) No p<.01
Diet & Weight Management (n=6) Yes p<.05
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0
Mindfulness Acve Control
Cardiovascular (n=3)
No p<.01
Symptom Burden (n=9)

Yes p<.05
Smoking (n=2)
No p>.05
Pain (n=7)
No p>.05
Negative Affect (n=38)

No p<.01
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0
Note: Hedges g effect sizes shown.
Figure 4.
Effect Size Differences Between Condition and Type of Mindfulness Intervention.
Mindfulness Waitlist/Usual Care Acve Control Homogeneity of Significance
Groups
Varience Assumed
Other Mindfulness Interventions (n=9)

Yes p<.01 M>WL
Mindfulful Eating Interventions (n=3)

Yes p>.05 NA
Modified MBCT Interventions (n=2)

No p>.05 NA
Modified MBSR Interventions (n=15)

No p<.05 M>WL;
AC>WL
Original MBCT Interventions (n=7) Yes p<.05 M> WL
Original MBSR Interventions (n=29) M > WL &

No p<.01
AC
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0
Note: Hedges g effect sizes shown. M, Mindfulness; WL, Waitlist/Usual Care; AC, Active Control.
208
Figure 5.
Effect Size Differences Between Condition and Group Size.
Homogeneity of
Mindfulness Waitlist/Usual Care Acve Control Varience Assumed Significance
Interventions ≥ 20
people per group No <.01
(n=46)
Interventions with
≤19 people per group No <.01
(n=19)
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0
Figure 6.
Effect Size Differences Between Condition and Weeks.
Homogeneity of
Mindfulness Waitlist/Usual Care Acve Control Varience Assumed Significance
Interventions > No <.01

8 weeks in length
(n=54)
Interventions between
2-7 weeks in length No <.01
(n=11)
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0
blinding do not necessarily apply when Conclusion Based on our findings and the overall
the control group is a wait-list, which characteristics of these studies,
several of these studies utilized. Future This systematic review and meta- recommendations for future mindfulness
mindfulness RCTs that utilize active or analysis found partial evidence of the intervention trials include the following:
matched controls will add rigor to the short-term effectiveness of largely wait- (a) utilizing reliable, active control
body of empirical evidence on these list-controlled mindfulness-based conditions when appropriate; (b)
interventions by continuing to abide by interventions applied to a variety of providing greater transparently of
and improve on design and reporting lifestyle medicine–relevant contexts. Cochrane risk of bias criteria as it
standards. A third limitation is that for Examples including the benefits of allows; (c) actively shaping how
several of the analytic comparisons, the mindfulness interventions in managing intervention delivery will be the most
homogeneity of variance assumption was symptom burden and affecting important effective for mindfulness trials, whether
not met, which indicates that more modifiable health behaviors such as in face-to-face or eHealth modes, and
variation may have been present in the smoking and eating practices. This (d) increasing enrollment and
comparison of combined effects than from analysis also provides evidence for participation of non-White/English
mere chance alone. For this reason, we mindfulness-based interventions that speaking samples, and (e) working to
used a random effects approach; however, have fewer than 20 individuals per make mindfulness interventions more
caution should be taken when interpreting group, as well as partial support for accessible and culturally relevant for
results from significant comparisons where interventions that are less than the ethnically diverse and non-English
the assumption was not met. standard 8 weeks in duration. speaking samples of individuals affected
209
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537789

vol. 9 • no. 3 American Journal of Lifestyle Medicine

David Victorson, PhD, Mitchell Kentor, BBA, Carly Maletich, MA,

General Category Specific Population No. of Studies

Irritable bowel syndrome 3

Chronic fatigue syndrome 1

Cardiovascular Smoking cessation and substance use 2

Special needs children 1

Community-Based (Adult) Attentional control 1

Musculoskeletal and Arthritic Rheumatoid arthritis 2

Failed back surgery syndrome 1

Low back pain 1

School/University-Based (Adult) Psychological well-being 5

School/University-Based (Pediatric) Academic performance and self-concept 1

Oncology Mixed cancer sample 3

Transplantation Solid organ recipients 1

Viral Disease HIV 1

Women’s Health Disordered eating 1

Abbreviations: COPD, chronic obstructive pulmonary disease.

Mean SD Min Max

Smaller Versus Larger Group

Abbreviations: MBSR, mindfulness-based stress reduction; MBCT, mindfulness-based cognitive therapy.

Characteristics of Included Studies.

$XWKRU <HDU 5LVN$VVHVVPHQW5DWLQJV $XWKRU <HDU 5LVN$VVHVVPHQW5DWLQJV

Measurement Tool or Method Domain Number of Studies Used

24-Hour Dietary Recall Nutrition Data System Saturated Fat 1

4-Point Hot Flash Bother Rating Hot Flash Bother 1

7-Item Positive Affect Adjective Scale Positive Affect 1

Average Number of Cigarettes Smoked Cigarettes Smoked 2

Beck Anxiety Inventory Anxiety 3

Beck Depression Inventory Depression 2

Blood Pressure Cuff Systolic Blood Pressure 2

Body Shape Questionnaire Body Image Concern 1

Brief Symptom Inventory Global Symptom Severity 1

Chalder Fatigue Scale Fatigue 1

Checklist Individual Strength Fatigue Severity Subscale Fatigue 1

Dutch Eating Behavior Questionnaire Emotional Eating 1

Fibromyalgia Impact Questionnaire Fibromyalgia Pain 1

General Food Craving Questionnaire–Trait Emotional Food Cravings 1

Hamilton Anxiety Rating Scale Anxiety 1

Hospital Anxiety & Depression Scale–Anxiety Anxiety 1

Insomnia Severity Index Insomnia 1

Likert Scale Pain Intensity Rating Pain 1

Maslach Burnout Inventory Emotional Exhaustion 1

McGill Pain Questionnaire Low Back Pain 1

Modified Borg Dyspnea Scale Dyspnea 1

Neo-5 Neuroticism Neuroticism 1

Pain Intensity Numeric Rating Scale Pain 2

Patient Health Questionnaire Stress Score Perceived Stress 1

Penn State Worry Questionnaire Worry 1

Perceived Stress Scale Perceived Stress 10

Profile Of Mood States Tension/Anxiety Tension/Anxiety 1

Saturated Fat Intake Saturated Fat Intake 1

State Trait Anxiety Inventory Anxiety 8

Summary VAS for Pain Pain 1

Symptom Check List-90-Revised Anxiety Anxiety 2

Visceral Sensitivity Index GI Anxiety 1

Weight Scale Weight Loss 1

Mindfulness Acve Control