A Preliminary Investigation of the Feasibility of an 8-week Mindfulness Program for Weight Loss Maintenance

Abstract

Objectives:

Over 70% of adults in the United States are overweight or obese. Weight loss is often recommended to improve overall health and risk of disease. However, weight regain is common and diminishes initial health improvements. Mindfulness-based interventions are a novel approach to mitigating weight regain. In this study, we aimed to investigate the feasibility of a mindfulness intervention to prevent weight regain in weight-reduced adults.

Methods:

Women (age: 40.2±10.8; BMI: 28.3±4.3) who achieved 7% reduction in body mass within the previous 2 months were enrolled in an 8-week mindfulness intervention (N=10). Body mass, body composition, and appetite traits (via the Three-Factor Eating Inventory) were assessed at baseline and 8-weeks. Satisfaction was assessed at the conclusion of the intervention.

Results:

Retention, adherence, and satisfaction with content, meetings, and weight loss maintenance (measured via Likert Scale) were favorable (70% retention; 89.3±13.4% attendance; satisfaction: 9.25±1.5; 9.25±1.5; 9.5±1, respectively). Additionally, weight loss was maintained following the 8-week mindfulness intervention (−0.04 ± 3.3% weight change). Lastly, dietary restraint (pre: 11.7±4.1; post: 12.7±4.5), disinhibition (pre: 6.3±4.4; post: 6.6±4.8), and hedonic hunger (pre: 3.7±2.6; post: 2.9±3.8) were stable.

Conclusions:

Mindfulness interventions are feasible and potentially efficacious approaches for short-term weight loss maintenance. Future trials that include matched controls and longer-term follow-up are needed.

Obesity is one of the most prevalent health issues globally and is associated with many chronic diseases, including diabetes, cardiovascular disease, and certain types of cancer.^1,2 Weight loss is often recommended to reduce or treat the cardiometabolic risk associated with obesity.^3,4 Behavioral interventions (diet/exercise) have been shown to elicit weight loss to a desirable degree (~5%−10%)⁵ but long-term weight loss maintenance has been more difficult to achieve.^6–8 This is clinically relevant because the high propensity to regain weight following significant weight loss diminishes initial health improvements.⁹ Because weight regain is perhaps the most challenging obstacle in long-term weight loss success, developing and testing strategies aimed at weight loss maintenance is essential.¹⁰ In the field of obesity medicine, there is currently a lack of effective strategies that emphasize the prevention of weight regain following significant weight loss. This is in part due to complex physiological and reward-related behavioral processes that are activated to restore energy balance.^10–12 Therefore, weight-loss maintenance approaches must be comprehensive and holistic to combat these pervasive systems. Additionally, it is perhaps equally essential that weight-loss maintenance approaches are patient-centered, accessible, and relatively easy to adopt to instill long-term behavior change.¹⁰

Mindfulness-based interventions are novel approaches that may be well suited for weight loss maintenance in some patients. Mindfulness has been used to treat obesity and as a supplement to structured weight loss programs in a growing number of projects.^13,14 Data relating to mindfulness during weight loss are compelling, but the long-term contributions to long-term weight control are unclear. Mindfulness also has been used as an adjunct therapy in treating chronic conditions and behaviors with high relapse susceptibility, such as depression and addiction, with substantial success.^15,16 Considering the high incidence of weight regain following significant weight loss,⁸ which follows a similar pattern to relapse in other chronic conditions, mindfulness is a therapy of interest to break this cycle and prevent weight regain. Additionally, mindfulness-based interventions have been shown to improve conditions that are closely related to weight control such as anxiety, gastrointestinal distress, stress, and cardiovascular disease.¹⁷ Past literature has proposed mindfulness to target mechanisms that minimize the stress response, reduce hedonic drive, and improve self-regulation,^16,18,19 and past research in obesity medicine shows these directional shifts in behaviors to play vital roles in weight loss maintenance success.^20–22 Therefore, delivering a mindfulness intervention following weight loss may address some of the current barriers to successful weight loss maintenance and reduce the high rates of weight regain following clinically significant weight loss.

Our purpose in this study was to evaluate the feasibility of recruiting and retaining adults at risk for weight regain into a mindfulness-based intervention. We employed a single-arm feasibility study employing a commercially available mindfulness-based intervention to prevent weight regain following intentional weight loss. The results of this trial will serve as preliminary data for larger trials and potentially inform the clinical treatment of obesity and its long-term management.

METHODS

Participants

Participants were recruited from commercially available weight loss programs and weight loss research studies conducted at the Anschutz Health and Wellness Center at the University of Colorado Anschutz Medical Campus, as well as the general community. All weight loss programs/studies emphasized traditional goal-setting strategies, focusing on caloric restriction and increased physical activity. The current study was advertised as a weight loss maintenance program. Inclusion criteria included females aged 18–65 from all racial and ethnic backgrounds who had successfully lost 7% or more of their body weight through diet and exercise in the weight loss program within the past 2 months. Exclusion criteria included uncontrolled hypertension, cardiovascular disease, or diabetes; cancer treatment in the past 5 years; HIV infection; significant pulmonary, renal, or gastrointestinal disease; untreated thyroid disease or any other medical condition affecting weight or energy metabolism; current use of weight loss medication; history of bariatric surgery or extensive bowel resection; chronic treatment with systemic corticosteroids; current diagnosis of severe depression or psychotic disorders; self-report of alcohol or substance abuse within the past 12 months; history of an eating disorder; women who were pregnant, lactating, or planning a pregnancy in the next 4 months.

Intervention:

We conducted an 8-week single-arm pilot and feasibility study to assess the feasibility and acceptability of a mindfulness intervention during a weight loss maintenance phase. Each participant completed the KORU Mindfulness Program Basic first, followed by the KORU Mindfulness Program KORU 2.0.^23,24 The KORU curriculum was not originally written for weight loss or weight loss maintenance, nor was it adapted for this study. To our knowledge, KORU has not been used as an intervention for weight loss maintenance in adults who previously had overweight or obesity. Each KORU program was 4 weeks long, adding up to 8 total weeks for the mindfulness intervention. Both programs were delivered by a clinical psychologist trained in KORU as a certified instructor. All sessions were led by the same interventionist. Participants attended weekly 75-minute in-person group classes, for a total of 8 sessions. The intervention programming included formal practice/meditations, informal practice, and group discussion. Formal practices included body scans to promote progressive muscle relaxations, yoga, mindful walking, and meditations (seated, standing, walking, breathing, visual, loving-kindness). Informal practices included mindfulness of routine activities (washing dishes, brushing teeth, shopping, etc), awareness in brief moments of environment, bodily sensations, mindful stretching, and mindful eating. At the end of each session, participants and the interventionist discussed logistics and the homework assignments. The weekly assigned homework included 10 minutes of meditation, assigned readings, a meditation log, and a gratitude log.

Study Flow:

Participants underwent a phone screening, an in-person screening, a consent process, and baseline assessments. After completing the 8-week intervention participants were asked to complete post-intervention assessments. During the study day visits at baseline and post-intervention, anthropometric testing and the Three-Factor Eating Questionnaire (TFEQ) were administered. During the post-intervention, participants were also asked to answer questions regarding the acceptability of the study design as described above.

Anthropometric and Body Composition:

Whereas our overall goal was to evaluate feasibility, we also evaluated anthropometric measures. Body weight and composition were measured at baseline and the end of the 8-week intervention. Body weight was measured using a digital scale accurate to ±0.1 kg. Body composition was evaluated via dual-energy X-ray absorptiometry (DXA, Hologic Discovery W, Bedford, MA). Height was measured to the nearest 1 mm with a wall-mounted stadiometer.

Intervention Acceptability:

Feasibility was assessed by retention rates (i.e., completion of the 8-week follow-up visit) and adherence to the mindfulness intervention (i.e., attendance to the in-person KORU sessions). Acceptability was assessed via questionnaires at the conclusion of the study that queried participants on their satisfaction with major aspects of the intervention. Specifically, participants were asked to rate on a 1–10 Likert scale how satisfied they were with the content of the intervention, the meeting frequency, and their respective weight loss maintenance. The participants were also asked to provide overall feedback on the intervention. This allowed the participants to discuss what they liked or would change.

Three-Factor Eating Questionnaire:

During the study day visit, participants completed the TFEQ in a fasted state to measure dietary restraint (conscious restriction of food intake to prevent weight gain or promote weight loss), disinhibition (tendency to eat opportunistically), and hunger.²⁵ This questionnaire consists of 20 questions about restraint, 16 about disinhibition, and 15 about general levels of hunger. Each item is scored either 0 or 1; therefore, the maximum possible score is 20, 16, and 15 for the restraint, disinhibition, and hunger subscales, respectively.

Data Analysis

Baseline characteristics are presented as mean ± standard deviation (SD) and n (%) by group. Changes in weight, body composition, and TFEQ scores are presented as mean ± SD. Descriptive statistics were used to summarize enrollment, retention, and adherence data. Because this was a pilot feasibility study, no formal pre versus post comparisons were made, as is recommended for pilot studies.^26–28 Therefore, all findings are considered preliminary and exploratory as this study was not designed or powered to detect statistically significant differences between pre-and-post-measurements. All findings are expressed per protocol. Descriptive statistics were computed using R Studio version 1.2.5033 (Vienna, Austria, 2020).

RESULTS

Participants

Eleven participants were screened for enrollment. One participant was dropped immediately after signing the consent document due to a failure to meet the weight loss target for enrollment. Ten participants initiated the mindfulness intervention. Over the course of the intervention, 3 participants dropped out of the study for the following reasons: (1) moved out of state or (2) family circumstances. Participants who completed the 8-week intervention (Age: 40.2 ± 10.8 years; BMI: 27.5 ± 1.2kg/m2; 100% female; Table 1) reported recently losing ≥ 7% of their body weight within the past 2 months (Table 1). All participants reported not having any formal mindfulness practice or training.

Table 1.

Participant Characteristics

Participant Characteristics (N=7; 100% female):
Age, years		40.3 ± 10.9 years
	Race/Ethnicity
Black		1
Asian		1
Hispanic		1
White		4
Characteristics of weight loss event (prior to enrollment in this study; self-reported):
	Prior to weight loss		Following weight loss
BMI	31.6 ± 5.2*		27.5 ± 4.3*
Body Weight (kg)	85.0 ± 15.4*		75.1 ± 14.0*
% Weight Loss		11.6 ± 4.9%*
Characteristics of weight maintenance after KORU mindfulness intervention:
	Baseline		Post-Intervention
BMI	28.3 ± 4.3		28.1 ± 4.4
Body Weight (kg)	76.4 ± 14.6		76.4 ± 15.4
Weight Change (%)		−0.04 ± 3.3%
Body Fat (%)	34.2 ± 5.7		34.0 ± 6.2
TFEQ – Cognitive Restraint	11.7 ± 4.1		12.7 ± 4.5
TFEQ – Dietary Disinhibition	6.3 ± 4.4		6.6 ± 4.8
TFEQ – Hedonic Hunger	3.7 ± 2.6		2.9 ± 3.8

Note.

(* self-reported)

Intervention Satisfaction and Attendance

Retention to the intervention was 70% at 8 weeks. Attendance to the mindfulness sessions was high (89.3 ± 13.4%). Following completion of the intervention, participants were asked to rank the categories relating to their satisfaction with content, meetings, and weight loss maintenance on a Likert scale of 1–10. Satisfaction with content, meetings, and weight loss maintenance was high (Table 2). Feedback on the intervention was positive (representative quotes included in Table 2).

Table 2.

Participant Intervention Feedback/Acceptability

Intervention Feasibility, Acceptability, and Feedback
Enrollment (N)	11
Initiated Intervention (N)	10
Retention (%)	70%
Adherence (%)	89.3 ± 13.4%
Satisfaction with content*	9.25±1.5
Satisfaction with Meetings*	9.25±1.5
Satisfaction with Weight Loss*	9.5±1
Representative Quotes of Feedback from Intervention	“Helped a lot with stress management.”
	“I learned a lot of things.”
	“I believe that the intervention has been very helpful when making decisions overall. I am more calm and thoughtful in my decision making process.”
	“I really enjoyed learning how to do mindfulness. I think it really helps with state of mind and more people could benefit from it”.

Note.

^*N=4 for satisfaction ratings on Likert scale

Anthropometric Changes

Initial weight loss was captured via self-report. Self-reported weight following the initial weight loss event was in agreement with body weight measured by the study team at baseline testing. Weight loss was maintained following the 8-week KORU mindfulness intervention, with an overall weight change of −0.04 ± 3.3% of initial weight (BMI baseline: 28.3 ± 4.3 kg/m2; BMI post: 28.1 ± 4.4 kg/m2; Weight baseline: 76.4 ± 14.6 kg; Weight post: 76.4 ± 15.4kg; Table 1). The body fat percentage measurements were stable, with a baseline average of 34.2 ± 5.7% to 34.0 ± 6.2% at the post-intervention visit (Table 1). Together, these data demonstrate that participants did not regain any of their initially lost weight.

Dietary Disinhibition, Cognitive Restraint, and Hedonic Hunger

Pre-to-post-intervention scores from the TFEQ were relatively stable: cognitive restraint (pre: 11.7 ± 4.1; post: 12.7 ± 4.5), dietary disinhibition (pre: 6.3 ± 4.4; post: 6.6 ± 4.8), and hedonic hunger (pre: 3.7 ± 2.6; 2.9 ± 3.8).

DISCUSSION

Our findings support the feasibility and acceptability of mindfulness as a weight-loss maintenance intervention. We found adherence to the intervention to be high suggesting an 8-week mindfulness program delivered during weight loss maintenance to be feasible. Findings also revealed participants to be satisfied with the content, meetings, and their weight maintenance suggesting the intervention had high acceptability. Additionally, over the 8-week intervention, we did not observe weight regain in adults who had recently lost 7% or more of their body weight. Furthermore, participant appetite traits captured via the Three-Factor Eating Questionnaire shifted in ways that would support a hypothesis of improved eating behaviors following a mindfulness intervention. Specifically, findings reveal a decrease in hedonic hunger scores and an increase in cognitive restraint. Over time, these directional shifts in appetite-related behaviors may support reduced dietary lapses and improved self-regulation, which are strong indicators of weight loss maintenance success.^20–22

Recruitment for this study was successful and suggests a mindfulness-based intervention to be feasible to test in future larger trials. Throughout recruitment efforts, our study team learned that most eligible patients were interested in continuing their weight loss, and were not necessarily ready to focus exclusively on weight loss maintenance. This valuable insight can be incorporated into future trials by placing focus on the prevention of weight regain, rather than the maintenance of weight loss. Nonetheless, the overall high rates of participant satisfaction with the content, the meetings, and weight loss are representative of the intervention’s ability to be patient-centered, accessible, and easy to adopt.

Study Strengths

Our feasibility study had many strengths and contributed to a small, yet growing number of studies assessing the feasibility and participant satisfaction of mindfulness as a health behavior intervention. This study included pre- and post-intervention mixed-methods assessments generating insight into the feasibility and efficacy of this trial. The use of a commercially available mindfulness program as the intervention is relatively unique in this field and supports efforts to use repeatable controlled interventions in the mindfulness literature. Similarly, the interventionist was a trained clinical psychologist certified in the KORU program, further contributing to the strength of this study design. Additionally, the in-person group sessions were a strength of this study as many behavioral interventions often meet one-on-one, over the phone, or in hybrid formats. Lastly, having a female study population is a strength of this study considering the well-established sex-based differences in weight loss and weight control, which shows females often experience less weight loss success than their male counterparts.²⁹ Therefore, having a sample of 100% females provides valuable insight into preventing weight regain in populations that may be historically less successful.

Study Limitations

Although this feasibility study had many strengths, we acknowledge several limitations. First, the study was conducted over a short-term of only 8 weeks. Longer-term studies are needed to improve understanding of the effect of this intervention over timeframes that might more clearly capture shifts in weight (i.e., 6 months or more).³⁰ Second, the present analyses are of a small, relatively non-diverse sample size and the 8-week retention rate of 70% was below the recommended average in studies focused on disease prevention through behavior change.³¹ However, this level of retention may be more typical for weight loss trials, which often experience high attrition rates.³² Nonetheless, these findings cannot be generalized to fit other demographics. Third, this was a single-arm feasibility trial, future control trials are needed to better discern the effects of mindfulness compared to the current standard of care. We also acknowledge that the initial weight loss was reported via self-report which is subject to bias and error.³³ However, we observed self-reported weight (after weight loss) and objective measurement of body weight by our study team, to be in agreement. The small discrepancy (~1.7%) between the self-report weight and objective measurement of weight can be explained by contextual changes (i.e., clothing, fed/fasted, etc). Nonetheless, we do not have an objective measurement of initial weight prior to the weight loss event. We suggest future trials consider enrolling participants prior to weight loss and monitoring their weight loss event, before implementing an intervention to prevent weight regain. Additionally, the intervention utilized in this trial was originally developed for college-aged students²⁴ and was not designed, nor adapted to be, specifically for adults interested in weight loss maintenance. We also acknowledge the indicators of intervention feasibility that are not reported in this study. For example, recruitment capability was not quantitatively measured, and therefore, not included in the present manuscript. Additionally, despite the interventionist being a clinical psychologist trained in KORU, we acknowledge our error in not monitoring intervention fidelity. We also did not include a thorough analysis of the mechanism of action. A more robust analysis of the neurophysiological effects of this mindfulness intervention on variables such as savoring, hedonic drive, and self-regulation is of future interest. Finally, recruitment for participants in this study was difficult due to our chosen phrasing of “weight loss maintenance,” and we learned many of our participants were not interested in maintaining their weight loss but rather would like to continue weight loss. Thus, we suggest future trials to focus on “the prevention of weight regain,” in future study designs.

Our results suggest mindfulness is an intervention of interest during the weight maintenance period to maintain clinically significant weight loss. Future work in this area should employ randomized controlled trial study designs, evaluate weight regain over a longer trajectory, and assess a variety of weight-related outcome variables (appetite, energy intake, physical activity behaviors, etc) to determine the overall lasting effects of mindfulness-based approaches in the context of weight loss maintenance.