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Exploring the Use of Mindful Eating Training in the Bariatric Population
by Terri Bly, PsyD; Megrette Hammond, MEd, RD, CDE; Roger Thomson, PhD; and Paul Bagdade, PhD

INTRODUCTION
Although bariatric surgical procedures are powerful tools in the treatment of obesity, patients and healthcare providers alike can feel frustrated by the difficulties of actually achieving postoperative weight loss objectives, particularly postoperative weight loss maintenance. One result of these surgical interventions is to bring the feeling of fullness into the patient’s consciousness in a dramatically amplified way. However, many obese patients have learned to actively ignore their inner regulatory signals concerning eating. Well established habits of disordered eating and dieting are supported by, and inextricably connected to, a chronic lack of attention to the psychophysiologic experiences of hunger, eating, and satiety. Although surgery can be extremely helpful in reversing these habits, it has limitations in combating years of dysfunctional eating patterns. In order to fully benefit from surgery, patients must retrain themselves to be attentive to their subjective experiences of hunger, eating, and satiety. Learning to eat mindfully—with full attention to the experience of eating—is an invaluable skill for individuals who have had, or are considering, bariatric surgery.

WHAT IS MINDFULNESS?
The word mindful is synonymous with paying attention or taking care. Mindful eating can be a powerful tool for individuals embarking on lifestyle changes. The Center for Mindful Eating published The Principles of Mindful Eating, which describes mindfulness as being composed of three parts.1 The first aspect of mindfulness is deliberately paying attention, without judgment, to one’s experiences. The second aspect of mindfulness is cultivating an openness to, and acceptance of, all experience. The third aspect of mindfulness is that it happens in the present moment.

Most individuals who have struggled with obesity for much of their lives are accustomed to judging themselves, their food cravings, and their food choices. Consequently, these individuals tend to experience strong emotional responses to anything involving food, eating, or weight. This emotional activation can interfere with the ability to make deliberate, wise decisions. Becoming a non-judgmental witness to one’s own thoughts and reactions is an important step in creating the opportunity for change. When incorporating mindfulness, a person begins to train the mind to nonjudgmentally observe reactions during the stages of meal planning, food preparation, and eating. This lack of internal self criticism supports the ability to increase, sustain, and broaden his or her awareness, leading to more empowered decisions with regard to food.

The second aspect of mindfulness is cultivating an openness to and acceptance of all experience. Thus, mindful eating involves an awareness of the whole eating experience, including emotions, thoughts, judgments, tastes, colors, aromas, and textures. By remaining more receptive to the multi-layered experience of eating, an individual can learn what foods might satisfy his or her hunger, be guided to stop eating by his or her own inner experience of satisfaction and satiety, and, finally, experience the pleasures of eating. Both preoperative and postoperative patients can benefit from learning what it feels like to be satiated rather than “full.”

The third aspect of mindfulness is to put aside events from the past and thoughts and hopes for the future, and instead focus for the moment on the here and now. Eating then becomes the activity of the moment and the mind is fully engaged in it. The individual attempts to recognize and let go of worry, anger, fear, rushing, or other mental states that distract from the eating experience. By doing so, he or she can be truly attentive to his or her experiences while eating and can be guided by the understanding of nutritional needs, hunger, and satiety, rather than by hopes, fears, and past experience. The benefits of eating slowly and chewing fully also become apparent.

To help patients bring the concept of mindfulness into their daily eating habits, they are encouraged to adopt an understanding that they have the power to make their own food decisions, even immediately postoperative. Although these choices may be extremely limited at first, choice does exist. Awareness of choice is essential in encouraging the individual to take control.

BRINGING MINDFULNESS TO PROBLEMATIC EATING
Long-term patterns of disordered eating can diminish an individual’s capacity to attend to cues about appetite, enjoyment, and fullness. Many people, including postoperative patients, find it difficult to stop emotional eating. This coping mechanism is not always broken by surgery. Fortunately, using mindfulness to teach awareness of the emotional states surrounding eating has been shown to be effective. Mindfulness skills are a critical foundation for emotion regulation and distress tolerance.2 Frequently, mindful eating is taught in conjunction with meditation and relaxing breathing techniques, which increase the tolerance of difficult emotions. Furthermore, patients are encouraged to explore new behaviors that may lead to the resolution of those emotions that they are currently using food to relieve.

MINDFULNESS TRAINING FOR THE PREOPERATIVE PATIENT
Given its ability to bring awareness back into the eating process, mindfulness can be especially helpful with binge eating in preoperative patients. There is still controversy regarding the prevalence of eatingdisordered behavior among the obese, as well as the impact of this behavior on postoperative outcomes. Many studies have found a higher incidence of disordered eating in preoperative patients than in the general population, and many bariatric professionals prefer that the patient address this behavior prior to surgery. While the prevalence of binge eating disorder (BED) is estimated to be approximately 1.5 percent among females in the general population,3 a study by Dymek- Valentine, et al.,4 found that 14 to 27 percent of bariatric surgery candidates in their sample met full criteria for BED. Powers, et al.,5 found a BED prevalence rate of 16 percent in their sample of 116 individuals presenting for surgery. Other studies have found a high rate of “grazing” in preoperative patients. Burgmer, et al.,6 found that 19.5 percent of its preoperative patients were engaging in regular grazing behavior. Although grazing is not necessarily a diagnosable eating disorder, it can still be classified as “disordered” or “mindless” eating, and can definitely lead to weight gain both before and after surgery. For these reasons, it is important to consider more structured preoperative interventions, such as mindfulness training, to help these patients following surgery.

Kristeller, et al.,7 reported in their original study of 20 women who met criteria for BED that both the rate of bingeing and the amount of food consumed during binges dropped significantly following seven sessions of manualized mindfulness training. Furthermore, these participants reported that their control over eating, mindfulness, and the recognition of hunger and satiety cues increased, while their levels of depression and anxiety decreased. The authors also showed that the magnitude of binge eating decreased substantially with mindfulness training. They found that the strongest predictor of improvement in eating control was the amount of time participants reported engaging in eatingrelated meditations.

Patients who have learned to practice mindfulness often report that it is impossible to engage in binge eating behaviors when they are eating mindfully. Typically, participants in mindful eating programs report a greater sense of control over their eating behaviors. Given these findings, mindfulness training may prove to be an effective tool in assisting weight loss surgery patients who struggle with binge eating, which would in turn greatly benefit patients’ health, wellbeing, and weight loss results, both preoperative and postoperative.

MINDLESS DIETING
As noted, disordered eating comprises a wide spectrum of behaviors that prevent one from becoming aware during the meal. Compulsive dieting, at the other end of the spectrum, has an equally deleterious impact on an individual’s ultimate ability to regulate his or her eating. Chronic dieters often have complex views of, and barriers to, the integration of hunger and fullness cues. It is not uncommon for the caregiver to meet resistance from an individual who has had an extensive dieting history. Diets utilize external guides, such as caloric content, portion size, or planned or pre-packaged meals, to dictate food choice.

These experienced dieters may be externally motivated by the specific numerical weight that they see on the scale. Following surgery, the restrictive postoperative meal plan and the tendency for patients to focus on the number on the scale can reactivate the same dysfunctional beliefs and views of themselves and their weight loss efforts. Moreover, individuals who have a history of chronic dieting may not trust their own internal cues and may believe that listening to them is what causes weight gain. These individuals are actually unable to include their subjective experience in their decisions around eating and can feel controlled by the weight loss plan, rather than feeling in charge of their own food choices. Exploring, accepting, and learning to utilize body cues is an evolving process that increases with practice. Even though it is an essential aspect of healthy eating, diet-fixated individuals may find it challenging to consider the possibility of eating with awareness and making food decisions based on internal awareness, hunger, satiety cues, and their own wisdom. Feelings of anxiety may surface when an individual is asked to be aware of hunger. During counseling, patients may disclose a personal narrative in which, during much of their lives, they have felt that their weight status and wellbeing has depended on their ability to suppress their awareness of hunger and fullness. In fact, these individuals may have difficulty paying attention to any emotional distress or discomfort. Incorporating mindfulness training may offer these diet-hardened individuals a new tool to include subjective information regarding food, fullness, and eating into their decisionmaking process.

It is important for the bariatric clinician to remember that patients can need a great deal of help learning to mindfully respect the new feelings of fullness that are generated by the surgery. Postoperative patients still have ingrained habits of ignoring fullness and will gradually do so after the surgery unless they can learn to honor and guide themselves with this experience. As an additional benefit of mindfulness, taste satiety, which can lag far behind fullness—especially for the postoperative patient—is increased by actually paying attention to the whole experience of eating. Mindfulness helps people derive more pleasure from eating and reduces the need to continue eating beyond fullness.

Steps for individuals to eat more mindfully: Steps to assist providers in bringing the concept of mindful eating to bariatric patients:
  • Mentally arrive at the meal. This often means decreasing external distractions while eating, such as television, phone, computer, or driving.

  • Attempt to focus on the benefits of a food selection – how eating that specific food will help him enjoy the bite, meal selection, or feelings of health that may arise during the change process.

  • Create a committed practice to eat in a more mindful way. The use of the word practice indicates that there are normal and expected setbacks that are part of eating mindfully but the intent is to return to the bite before them.
  • Take steps to create a culture free of judgment with regard to dietary change. Often this requires bariatric programs to shift their focus away from specific weight goal outcomes and rely on other objective measures, such as sense of control with food, feelings of health, and reduction in the severity of comorbidities.

  • Review the tone of educational programs and handouts. Encourage increased freedom and personal choice with regard to food and lifestyle issues to resolve emotional polarization of food beliefs and foster objective selfassessment skills regarding health.

  • Routinely include mindful eating training in both pre- and postoperative phases of bariatric interventions.

 

CONCLUSION: MINDFUL EATING IS HEALTHY EATING
Mindful eating can be the cornerstone of a new relationship with food for the bariatric patient. Awareness of the present moment often helps an individual gain insight into achieving specific health goals. This happens in part because he or she becomes more attuned to the direct experience of eating and his or her own feelings of health and wellbeing. Introducing the concept of mindfulness systematically to individuals pre- and postoperatively may benefit many patients. These concepts are uncomplicated and accessible, and yet their impact on an individual’s life can be profound. As is commonplace now, patients are also asked to have between 3 and 12 months of a nonsurgical, structured weight loss program prior to bariatric surgery. Weaving these principles into existing programs for people battling overeating or eating disorders prior to surgery can facilitate a more joyful eating experience, one of our primary life pursuits. As new research emerges, mindful eating can be seen as a viable option in helping to satisfy these requirements. Patients will inevitably benefit from this training after surgery, especially as they begin to feel hunger again and a wider range of food choices is available to them. Additionally, the individual may apply these concepts beyond food, allowing them to help shape a new approach to daily life in general. Promoting broader integration of these principles can assist in improved self care after weight goals have been achieved. Mindful eating training has been shown to promote self acceptance, which is necessary for our patients both before and after weight loss surgery, to help them achieve maximum success.

REFERENCES
1. The Center for Mindful Eating. Principles of Mindful Eating. 2005. Available at www.tcme.org.
2. Linehan M. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press; 1993.
3. Gotestam KG, Agras WS. General population- based epidemiological study of eating disorders in Norway. Int J Eat Disorders 1995;18:119–26.
4. Dymek-Valentine M, Hoste R, Engelberg M. Psychological assessment in bariatric surgery candidates. In Mitchell JE & de Zwaan M (Eds). Bariatric Surgery: A Guide for Mental Health Professionals. Oxford (UK): Routledge. 2005:101–18.
5. Powers PS, Perez A, Boyd F, Rosemurgy A. Eating pathology before and after bariatric surgery: A prospective study. Int J Eat Disorders 1999;25:293–300.
6. Burgmer R. The influence of eating behavior and eating pathology on weight loss after gastric restriction operations. Obes Surg 2005;15(5):684–91.
7. Kristeller J, Hallette C. An exploratory study of a meditation-based intervention for binge eating disorder. J Health Psychology 1999;4(3):357–63.

ABOUT THE AUTHORS
Terri Elofson Bly, PsyD, conducts preoperative psychological assessments for surgical weight loss programs in the Minneapolis-St. Paul area and leads several monthly bariatric support groups. Megrette Hammond, MEd, RD, CDE, is a registered dietitian and diabetes educator with Wentworth- Douglass Hospital in Dover, New Hampshire, and the Executive Director of the Center for Mindful Eating (www.tcme.org).

Roger Thomson, PhD, is on the faculty of Northwestern University Feinberg School of Medicine and is Codirector of Integrative Health Partners, a practice group which offers mindfulness- informed psychotherapy and courses in mindful eating. He can be reached through his website, www.integrativehealthpartners. org.