Interviews

Mindful Eating Research Phase II & III:
Interview with Dr. Ruth Q. Wolever, Ph.D.
March 2007

By Kelley McCabe

Ruth Q. Wolever, Ph.D., is a clinical health psychologist and Director of Research for Duke Integrative Medicine. Dr. Wolever conducts research on the integration of mind, body, and spirit treatments into mainstream medicine. She has specifically explored such applications to improve sleep, eating behaviors, weight management, diabetes control, and cardiovascular risk factors, along with other health conditions. Much of this work centers on applying mindfulness to behavior in order to develop intrinsic skills and motivation.

Dr. Wolever's research has been funded by the National Institutes of Health (National Heart, Lung and Blood Institute, National Institute of Mental Health, Center for Complementary and Alternative Medicine, and the Office of Women's Health), the Centers for Medicare and Medicaid Services, and by GlaxoSmithKline.

Dr. Wolever was previously the clinic director of Duke Integrative Medicine, and the health psychology director of the Duke University Executive Health Program, Duke Diet and Fitness Center, and the Duke Health and Fitness Center .

I had the good fortune of spending some time recently with Dr. Ruth Q. Wolever. Ruth has been involved as co-Principle Investigator of 3 "Mindful Eating" studies funded by NCCAM ( National Center for Complementary and Alternative Medicine). We wrote an article on the first of these studies in October 2006 when Richard Mahler interviewed Jean Kristeller, Ph.D. from Indiana State University . The paper reporting the results of this study will be submitted in the next few weeks and is expected to be published by the end of the year. Ruth was kind enough to review the purpose of each of the 3 studies and gave me her own thoughts on why "mindfulness" is a useful tool in weight loss and weight management.

Ruth: "In the first study, Jean (Kristeller) was the Principle Investigator (PI) and I was co-PI. That study is finished and analyzed and the results are expected out within the year."

(Note: The subjects of the first study included 160 subjects who were "binge eaters". The purpose of the study was to determine if the use of mindfulness meditation techniques helped binge eaters to regulate their eating habits. I found the following definition for Binge Eating Disorder (BED): " BED is marked by recurrent episodes of binging, accompanied by feelings of loss of control, and involves chronic disregulation of psychological, emotional, and behavioral systems " on the National Institutes of Health (NIH) website.)

Ruth continued, "The 2nd study was a 3 site study, and joining Jean and me was Dr. Michael Baime, an internist from the University of Pennsylvania . They wrote a proposal specific to weight loss (but not binge eating) and other compulsive eating. The subjects had to be obese (with a BMI of greater than 30), but did not necessarily eat out of control. 60 subjects are participating in this study.

Jean is continuing the work on this 2nd study (results are expected to be published in 2009). Michael and Ruth are working on a 3rd study which is focused on the prevention of weight re-gain .

The 3rd study looks at the individual components of decision making. Reviewing the experiences of the Mindfulness-Based Stress Reduction (MBSR) program, we see that mindfulness helps people understand reactivity. Reactivity is the combination of thoughts, emotions, and body sensations that get discharged into behavior. MBSR teaches us how to recognize reactivity: there is some event - either a world event or an internal event, and then we go on automatic pilot - we eat as a way to deal with boredom, anger, and stress. By using mindfulness, people learn to take apart the three components of reactivity: the thoughts, the emotions, and the body sensations.

Not only do eating patterns have to be changed, but physical activity levels need to be significantly increased, in order to prevent weight re-gain. And these changes must be changes for life. While people may eat for emotional reasons, they may also not move their body for emotional reasons.

In deconstructing the events, choices present themselves that either weren't previously available to the person or were not known. In order to make the wisest choice, the person needs to pay attention to the right component. For example, a person may have the thought, "I need to exercise to keep my metabolic rate high, and also the emotion, "I don't feel like exercising", while experiencing the body sensation, "I'm too tired."

In this case, what do we choose? We need to look at the choice between what we want in the present moment vs. looking at what we want for the long term. In effect we are making a choice in the present moment that will have a direct bearing on our future.

Part of the mindful eating class is to get participants to define what they want in the future. We encourage them to write a personal mission statement. A lot of people are not aware of what their personal mission is, so they first have to define that. Then we examine what is required from a health perspective in order to meet those goals.

In addition to the focus on mindful eating, the 3rd study has more of a focus on physical activity than the earlier studies - which is a very key component. We look at the person's needs: what need is (or isn't) being satisfied by eating food?

People are often exhausted. Rather than have ways of creating inner peace and fullness, they eat to keep going. If someone is bored, they look for stimulation. They may watch TV as an antidote to boredom, but TV is generally not very nourishing. So they eat to entertain themselves."

Kelley: "Ruth, tell me what you can about the outcomes of the various studies to date."

Ruth: "The 1st study was very exciting because it showed that the application of mindfulness helped to regulate eating patterns. At the start of the study, participants binged an average of 4 times a week. At the conclusion of the study binge eating had been reduced, on average, to once a week. In addition, this improvement was maintained over 4 months. The application of mindfulness also helped people to metabolize their food better - it increased their insulin sensitivity - which was tracked by monitoring blood glucose and insulin levels after eating. This was independent of weight loss. In the initial study, weight loss was not the primary outcome. The initial study attempted to maintain weight and this was, in fact, the result.

In the 2nd study, weight loss was a primary outcome. We realized the manual needed to be re-tooled. The intervention was lengthened to 12 weeks from 9 weeks. And we've included information about nutrition and physical activity.

The 3rd study is in the process of taking in people who've already lost weight and who have never used mindfulness practices."

Kelley: "Why do you believe mindful eating is effective in managing weight?

Ruth: "Mindful living (it's not just mindful eating) works because it provides people with very specific tools to access internal knowledge. They have knowledge from emotions, thoughts and body sensation but they don't know how to access the knowledge these can provide. Mindfulness gives us a path to access the internal information. Then you need tools in order to use that information."

Kelley: "Would you give me an example?"

Ruth: "Yes. An example would be to find where in the body physical hunger is felt. We use a brief process to get the information about 'hunger'. Is someone experiencing a thought/emotion? Or is it truly physical hunger? If so, we need to give the body the fuel it needs. The next part of the process is to determine personal preferences. What does the body want? Does it need protein? What food choices are available?

In our mindful eating classes we don't talk about specific foods per se - we talk about nutritional basics: the function of fiber, how protein can be used to regulate blood sugar swings. However, in the class participants are not told what specific foods to eat. Those choices must be made by the individual.

The mindful eating class used in the first study had very little information about nutrition and physical activity. We realized we needed to have both external knowledge (like information on nutrition) as well as the internal knowledge to make the best choices."

Kelley: "It's been suggested that "mindfulness" is necessary in order to change a "habit". What is your opinion on this?"

Ruth: "I think 'mindfulness' is a huge component - a habit is, by definition, out of your awareness. A person who wants to change a habit needs to make small shifts that are sustainable - and bring behavior back into awareness - and then deconstruct the component pieces of it. Deconstruction can't take place if it's happening on autopilot.

Mindfulness differs from behavior therapy in that mindfulness is attending to the inner world - thought, emotion AND behavior.

Kelley: "How might mindful eating work for bariatric patients? They have specific needs with respect to the type of foods (high in protein and generally easily digestible) and the amount they can eat at any given time. Many post-op bariatric patients do not experience much, if any, hunger. Are there key elements of mindful eating that would need to be modified to accommodate the bariatric patient?"

Ruth: "That's an interesting question because we don't know what kind of cuing the body is capable of after bariatric surgery. And, if someone before bariatric surgery was living from the neck up, they won't have a good baseline from which to compare feelings of hunger after surgery.

We have a lot to learn from post-op bariatric patients about what they can feel (about hunger) from physical sensations. We need a better sense of what the physiological experience of bariatric surgery is - in the post-op situation. It's not clear how much these patients will be able to rely on their bodies to inform them regarding what their bodies need.

What I think mindfulness can do for bariatric patients is deconstruct reactivity; to look at the different thoughts, emotions, and sensations. Again, they are asking the same question, 'What is the need that food is taking care of?'"

Kelley: "What is the hoped-for outcome of your study in terms of how mindful eating might be implemented in medicine? Assuming mindful eating has the potential to contribute significantly to weight control, how do you (or NCCAM) think it could be utilized to address the "weight-issue" in this country where 1 in 3 people are obese (defined as more than 20 percent over their ideal weight, taking into account the person's height, age, sex, and build )?"

Ruth: "My hoped for outcome is that the field of medicine and community at large will begin to recognize the power of mindfulness as well as the power of the interplay of thought, emotion, and sensation in driving behavior.

If we want to change behavior - we definitely need to be able to deconstruct these three aspects that impact behavior and choices."

Kelley McCabe is the founder and CEO of eMindful and eMindful Bariatrics.