@phdthesis{Peitz2024,
  author    = {Peitz, Diana},
  title     = {Mindful Eating},
  doi       = {10.25932/publishup-63451},
  url       = {http://nbn-resolving.de/urn:nbn:de:kobv:517-opus4-634515},
  school      = {Universit{\"a}t Potsdam},
  pages     = {XII, 178},
  year      = {2024},
  abstract  = {Maladaptive eating behaviors such as emotional eating, external eating, and loss-of-control eating are widespread in the general population. Moreover, they are associated to adverse health outcomes and well-known for their role in the development and maintenance of eating disorders and obesity (i.e., eating and weight disorders). Eating and weight disorders are associated with crucial burden for individuals as well as high costs for society in general. At the same time, corresponding treatments yield poor outcomes. Thus, innovative concepts are needed to improve prevention and treatment of these conditions. The Buddhist concept of mindfulness (i.e., paying attention to the present moment without judgement) and its delivery via mindfulness-based intervention programs (MBPs) has gained wide popularity in the area of maladaptive eating behaviors and associated eating and weight disorders over the last two decades. Though previous findings on their effects seem promising, the current assessment of mindfulness and its mere application via multi-component MBPs hampers to draw conclusions on the extent to which mindfulness-immanent qualities actually account for the effects (e.g., the modification of maladaptive eating behaviors). However, this knowledge is pivotal for interpreting previous effects correctly and for avoiding to cause harm in particularly vulnerable groups such as those with eating and weight disorders. To address these shortcomings, recent research has focused on the context-specific approach of mindful eating (ME) to investigate underlying mechanisms of action. ME can be considered a subdomain of generic mindfulness describing it specifically in relation to the process of eating and associated feelings, thoughts, and motives, thus including a variety of different attitudes and behaviors. However, there is no universal operationalization and the current assessment of ME suffers from different limitations. Specifically, current measurement instruments are not suited for a comprehensive assessment of the multiple facets of the construct that are currently discussed as important in the literature. This in turn hampers comparisons of different ME facets which would allow to evaluate their particular effect on maladaptive eating behaviors. This knowledge is needed to tailor prevention and treatment of associated eating and weight disorders properly and to explore potential underlying mechanisms of action which have so far been proposed mainly on theoretical grounds. The dissertation at hand aims to provide evidence-based fundamental research that contributes to our understanding of how mindfulness, more specifically its context-specific form of ME, impacts maladaptive eating behaviors and, consequently, how it could be used appropriately to enrich the current prevention and treatment approaches for eating and weight disorders in the future. Specifically, in this thesis, three scientific manuscripts applying several qualitative and quantitative techniques in four sequential studies are presented. These manuscripts were published in or submitted to three scientific peer-reviewed journals to shed light on the following questions: I. How can ME be measured comprehensively and in a reliable and valid way to advance the understanding of how mindfulness works in the context of eating? II. Does the context-specific construct of ME have an advantage over the generic concept in advancing the understanding of how mindfulness is related to maladaptive eating behaviors? III. Which ME facets are particularly useful in explaining maladaptive eating behaviors? IV. Does training a particular ME facet result in changes in maladaptive eating behaviors? To answer the first research question (Paper 1), a multi-method approach using three subsequent studies was applied to develop and validate a comprehensive self-report instrument to assess the multidimensional construct of ME - the Mindful Eating Inventory (MEI). Study 1 aimed to create an initial version of the MEI by following a three-step approach: First, a comprehensive item pool was compiled by including selected and adapted items of the existing ME questionnaires and supplementing them with items derived from an extensive literature review. Second, the preliminary item pool was complemented and checked for content validity by experts in the field of eating behavior and/or mindfulness (N = 15). Third, the item pool was further refined through qualitative methods: Three focus groups comprising laypersons (N = 16) were used as a check for applicability. Subsequently, think-aloud protocols (N = 10) served as a last check of comprehensibility and elimination of ambiguities. The resulting initial MEI version was tested in Study 2 in an online convenience sample (N = 828) to explore its factor structure using exploratory factor analysis (EFA). Results were used to shorten the questionnaire in accordance with qualitative and quantitative criteria yielding the final MEI version which encompasses 30 items. These items were assigned to seven ME facets: (1) 'Accepting and Non-attached Attitude towards one's own eating experience' (ANA), (2) 'Awareness of Senses while Eating' (ASE), (3) 'Eating in Response to awareness of Fullness' (ERF), (4) 'Awareness of eating Triggers and Motives' (ATM), (5) 'Interconnectedness' (CON), (6) 'Non-Reactive Stance' (NRS) and (7) Focused Attention on Eating' (FAE). Study 3 sought to confirm the found facets and the corresponding factor structure in an independent online convenience sample (N = 612) using confirmatory factor analysis (CFA). The study served as further indication of the assumed multidimensionality of ME (the correlational seven-factor model was shown to be superior to a single-factor model). Psychometric properties of the MEI, regarding factorial validity, internal consistency, retest-reliability, and observed criterion validity using a wide range of eating-specific and general health-related outcomes, showed the inventory to be suitable for a comprehensive, reliable and valid assessment of ME. These findings were complemented by demonstrating measurement invariance of the MEI regarding gender. In accordance with the factor structure of the MEI, Paper 1 offers an empirically-derived definition of ME, succeeding in overcoming ambiguities and problems of previous attempts at defining the construct. To answer the second and third research questions (Paper 2) a subsample of Study 2 from the MEI validation studies (N = 292) was analyzed. Incremental validity of ME beyond generic mindfulness was shown using hierarchical regression models concerning the outcome variables of maladaptive eating behaviors (emotional eating and uncontrolled eating) and nutrition behaviors (consumption of energy-dense food). Multiple regression analyses were applied to investigate the impact of the seven different ME facets (identified in Paper 1) on the same outcome variables. The following ME facets significantly contributed to explaining variance in maladaptive eating and nutrition behaviors: Accepting and Non-attached Attitude towards one`s own eating experience (ANA), Eating in Response to awareness of Fullness (ERF), the Awareness of eating Triggers and Motives (ATM), and a Non-Reactive Stance (NRS, i.e., an observing, non-impulsive attitude towards eating triggers). Results suggest that these ME facets are promising variables to consider when a) investigating potential underlying mechanisms of mindfulness and MBPs in the context of eating and b) addressing maladaptive eating behaviors in general as well as in the prevention and treatment of eating and weight disorders. To answer the fourth research question (Paper 3), a training on an isolated exercise ('9 Hunger') based on the previously identified ME facet ATM was designed to explore its particular association with changes in maladaptive eating behaviors and thus to preliminary explore one possible mechanism of action. The online study was realized using a randomized controlled trial (RCT) design. Latent Change Scores (LCS) across three measurement points (before the training, directly after the training and three months later) were compared between the intervention group (n = 211) and a waitlist control group (n = 188). Short- and longer-term effects of the training could be shown on maladaptive eating behaviors (emotional eating, external eating, loss-of-control eating) and associated outcomes (intuitive eating, ME, self-compassion, well-being). Findings serve as preliminary empirical evidence that MBPs might influence maladaptive eating behaviors through an enhanced non-judgmental awareness of and distinguishment between eating motives and triggers (i.e., ATM). This mechanism of action had previously only been hypothesized from a theoretical perspective. Since maladaptive eating behaviors are associated with eating and weight disorders, the findings can enhance our understanding of the general effects of MBPs on these conditions. The integration of the different findings leads to several suggestions of how ME might enrich different kinds of future interventions on maladaptive eating behaviors to improve health in general or the prevention and treatment of eating and weight disorders in particular. Strengths of the thesis (e.g., deliberate specific methodology, variety of designs and methods, high number of participants) are emphasized. The main limitations particularly regarding sample characteristics (e.g., higher level of formal education, fewer males, self-selected) are discussed to arrive at an outline for future studies (e.g., including multi-modal-multi-method approaches, clinical eating disorder samples and youth samples) to improve upcoming research on ME and underlying mechanisms of action of MBPs for maladaptive eating behaviors and associated eating and weight disorders. This thesis enriches current research on mindfulness in the context of eating by providing fundamental research on the core of the ME construct. Thereby it delivers a reliable and valid instrument to comprehensively assess ME in future studies as well as an operational definition of the construct. Findings on ME facet level might inform upcoming research and practice on how to address maladaptive eating behaviors appropriately in interventions. The ME skill 'Awareness of eating Triggers and Motives (ATM)' as one particular mechanism of action should be further investigated in representative community and specific clinical samples to examine the validity of the results in these groups and to justify an application of the concept to the general population as well as to subgroups with eating and weight disorders in particular. In conclusion, findings of the current thesis can be used to set future research on mindfulness, more specifically ME, and its underlying mechanism in the context of eating on a more evidence-based footing. This knowledge can inform upcoming prevention and treatment to tailor MBPs on maladaptive eating behaviors and associated eating and weight disorders appropriately.},
  language  = {en}
}
@article{KawasakiAkamatsuOmorietal.2020,
  author    = {Kawasaki, Yui and Akamatsu, Rie and Omori, Mika and Sugawara, Masumi and Yamazaki, Yoko and Matsumoto, Satoko and Fujiwara, Yoko and Iwakabe, Shigeru and Kobayashi, Tetsuyuki},
  title     = {Development and validation of the Expanded Mindful Eating Scale},
  series = {International journal of health care quality assurance},
  volume    = {33},
  journal   = {International journal of health care quality assurance},
  number    = {4-5},
  publisher = {Emerald Group Publishing Limited},
  address   = {Bingley},
  issn      = {0952-6862},
  doi       = {10.1108/IJHCQA-01-2020-0009},
  pages     = {309 -- 321},
  year      = {2020},
  abstract  = {Purpose To develop and validate the Expanded Mindful Eating Scale (EMES), an expanded mindful eating model created for the promotion of health and sustainability. Design/methodology/approach A cross-sectional study using self-administered questionnaire surveys on Ochanomizu Health Study (OHS) was conducted. The survey was provided to 1,388 female university students in Tokyo, Japan. Exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and a partial correlation analysis were used to confirm construct and criterion validity. Internal consistency of the EMES was confirmed to calculate Cronbach's alpha. Findings The response rate was 38.7 \% (n = 537). Mean BMI was 20.21 +/- 2.12, and 18.8\% of them were classified as "lean" (BMI < 18.5). The authors listed 25 items and obtained a final factor structure of five factors and 20 items, as a result of EFA. Through CFA, the authors obtained the following fit indices for a final model: GFI = 0.914, AGFI = 0.890, CFI = 0.870 and RMSEA = 0.061. The total EMES score was significantly correlated with BMI, mindfulness, body dissatisfaction, drive for thinness and life satisfaction (r = -0.138, -0.315, -0.339, -0.281 and 0.149,p < 0.01, respectively). Cronbach's alpha for all items in this scale was 0.687. Practical implications The authors suggest the possibility that practitioners and researchers of mindful eating that includes this new concept can use authors' novel scale as an effective measurement tool. Originality/value The EMES, which can multidimensionally measure the concept of the expanded model of mindful eating was first developed in this study.},
  language  = {en}
}