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. Author manuscript; available in PMC: 2021 Sep 1.
Published in final edited form as: Mindfulness (N Y). 2020 Jul 7;11(9):2113–2120. doi: 10.1007/s12671-020-01419-1

Mindful Attention and Eating Expectancies among College Students with Obesity and a History of Trauma Exposure

Brooke Y Kauffman 1, Anka A Vujanovic 1, Jafar Bakhshaie 1, Michael J Zvolensky 1,2
PMCID: PMC7880149  NIHMSID: NIHMS1610077  PMID: 33584871

Abstract

Objectives:

Trauma exposure and obesity are highly prevalent among college students and both are associated with disordered eating. There is a need to understand psychological factors that may be related to maladaptive eating behavior among college students with obesity and a history of trauma exposure.

Methods:

Participants included 139 college students with obesity (defined as a BMI ≥ 30) and a history of trauma exposure (76.3% females; Mage = 25.4 years, SD = 8.07). The current study conducted three separate two-step hierarchical regressions examining mindful attention, and its relation to eating expectancies (expectancies of eating to help manage negative affect, expectancies of eating to alleviate boredom, and expectancies of eating to lead to feeling out of control).

Results:

Results indicated that lower levels of mindful attention were related to greater levels of expectancies of eating to help manage negative affect (b = −4.16, SE = 1.08, p = .023, CI95% = −7.72, −0.60, sr2 = .04), expectancies of eating to alleviate boredom (b = −1.09, SE = 0.39, p = .006, CI95% = −1.86, −0.32, sr2 = .06), and expectancies of eating to lead to feeling out of control (b = −1.62, SE = 0.40, p < .001, CI95% = −2.41, −0.83, sr2 = .11). Results were observed over, and above variance accounted for by sex (assigned at birth), body mass index (BMI), and posttraumatic stress disorder (PTSD) symptom severity.

Conclusions:

Overall, the results from the present investigation suggest the potential importance and need for future research in the role of mindful attention in relation to several distinct eating expectancies associated with maladaptive eating.

Keywords: Mindfulness, Eating Expectancies, Obesity, Trauma, Young Adults

Weight-related problems among college students are highly prevalent (American College Health Association, 2013). Specifically, extant work has found that over one-third of college students met criteria for overweight or obesity as indicated by their elevated Body Mass Index (BMI; American College Health Association; 2013). Notably, many college students may be at greater risk for obesity due to food independence (i.e., increased choice over one's food intake and greater access to unhealthy food options; Smith-Jackson & Reel, 2012), access to unhealthy foods (Smith-Jackson & Reel, 2012), stress (Pelletier et al., 2015), substance use (Smith-Jackson & Reel, 2012), and a lack of physical activity (Butler et al., 2004).

History of trauma exposure among college students is highly prevalent (85%; Frazier et al., 2009), and is related to obesity (Chwastiak et al., 2011; Gunstad et al., 2006; Hicks White et al., 2018; Johannessen & Berntsen, 2013; United States Department of Health and Human Services, 2012; Williamson et al., 2002). Williamson et al. (2002), for instance, reported that persons with childhood trauma were at higher risk for obesity. Other work has found that persons with obesity and history of trauma exposure who lost weight evince parallel decreases in posttraumatic stress disorder (PTSD) symptom severity (Johannessen & Berntsen, 2013). The combination of obesity and trauma exposure (and associated symptoms) may be related to increased disability and health-related concerns (e.g., cancer; Sung et al., 2019), especially when occurring early in the lifespan (e.g., young adulthood; Dietz, 2017).

Some research has found that obesity and traumatic exposure may be interrelated due to various biologic mechanisms, such as genetic (Zhang et al., 2014), inflammation (Sah & Geracioti, 2013), cellular (e.g., mitochondrial and endoplasmic reticulum function; Nevell et al., 2014), and endocrine factors (e.g. glucocorticoid pathways; Morris & Rao, 2013). There also is evidence to suggest disordered eating (i.e., engagement in behaviors including binge eating, purging, and use of medications, fasting or excessive exercise to lose weight; Eisenberg et al., 2011) may be more common among college students with obesity and a history of trauma exposure. Indeed, disordered eating is highly prevalent on college campuses (Eisenberg et al., 2011; Kelly-Weeder, 2011) and been found to be related to weight gain among college students (Hunt et al., 2017). Moreover, trauma exposure in childhood and adulthood are associated with disordered eating (e.g., binge eating; Arditte Hall et al., 2018; Trottier & MacDonald, 2017).

To better understand the nature of disordered eating among college students with obesity and a history of trauma exposure, there may be utility in focusing on eating expectancies (Hohlstein et al., 1998). Extant theories suggest that expectancies reflect learned relations between behaviors (e.g., eating) and their consequences (e.g., to manage negative affect, alleviate boredom, lead to feeling out of control) that become stored in memory and guide future behavioral choices (Fischer et al., 2003). There are several distinct eating expectancies that may warrant further attention due to their influence on eating patterns, including expectancies of eating to help manage negative affect, alleviates boredom, and lead to feeling out of control (Hohlstein et al., 1998). Expectancies of eating to manage negative affect and expectancies of eating to alleviate boredom represent cognitive processes (i.e., expectancies) regarding the use of eating to alleviate uncomfortable affective states (e.g., negative mood, boredom) whereas expectancies of eating to lead to feeling out of control reflects a lack of self-control over eating (Hohlstein et al., 1998). Expectations that eating may mitigate uncomfortable mood states (e.g., negative affect, boredom) has been found to be related to a number of factors associated with weight gain and obesity, including emotional eating (Hennegan et al., 2013) and binge eating (Smith et al., 2007). Similarly, extant work has found that individuals who engage in binge eating (a risk-factor for weight gain and obesity; da Luz et al., 2018; Nightingale & Cassin, 2019) often report expecting that eating will lead to feeling out of control (Hohlstein et al., 1998).

Therefore, it is imperative to understand individual difference factors that may be associated with eating expectancies among college students with obesity and a history of trauma exposure. Mindful attention may be one transdiagnostic factor to examine as it relates to eating expectancies. Mindful attention reflects present-oriented attention to, and awareness of, what is occurring in the present moment (Brown & Ryan, 2003). Lower levels of mindful attention are related to poorer eating habits (e.g., overeating, emotional eating) among non-clinical college students (Bahl et al., 2013) and populations with obesity (Ouwens et al., 2015). Notably, extant work has found that individuals who engage in mindful attention practices have lower reported incidence of engagement in poor eating habits (Bahl et al., 2013; Daubenmier et al., 2011; Godsey, 2013). For example, recent work suggests that mindful attention approaches are associated with reduction in overall food consumption, healthier food choices, and practices that slow the eating process among populations with obesity (Godsey, 2013). Among college students, mindful attention training has been found to be related to lower levels of reported overeating (Bahl et al., 2013). Although past work showcases a linkage between mindful attention-based processes and maladaptive eating and expectancies, there is a need to examine these relations in terms of eating expectancies among college students with obesity and a history of trauma exposure.

Theoretically, college students with obesity and a history of trauma exposure may be more apt to experience psychological distress (Avila et al., 2015; Edman et al., 2016; Eisenberg et al., 2007) as a result of the combined effects of these experiences. Such a person with lower mindful attention may experience an inability to identify or cope with their maladaptive inner experiences and may then engage in non-adaptive overt behaviors as a result (Godsey, 2013). For example, they may eat to cope with distressing personal states (e.g., anxiety, boredom; Bennett et al., 2013; Boggiano et al., 2014) or experience a loss of control while eating due to distressing personal states (Goossens et al., 2009). In line with expectancy theory (Fischer et al., 2003), such college students may be more vulnerable to the formation of maladaptive eating expectancies (e.g., manage negative affect, alleviate boredom, loss of control) as a result of this continued pattern of behavior.

The present investigation sought to explore mindful attention in relation to expectancies of eating to manage negative affect, expectancies of eating to alleviate boredom, expectancies of eating to lead to feeling out of control. In these models, we adjusted for variance accounted for by sex (Striegel-Moore et al., 2009), BMI (Hayaki & Free, 2016), and PTSD symptom severity (Dubosc et al., 2012; Hoerster et al., 2015). It was hypothesized that lower levels of mindful attention would relate to higher levels of expectancies of eating to manage negative affect, expectancies of eating to alleviate boredom, and expectancies of eating to lead to feeling out of control.

Method

Participants

Participants were selected from a larger online survey study (N = 808) described below. Participants in the current study were 139 undergraduate and post-baccalaureate students (76.3% females; Mage = 25.4 years, SD = 8.07) who met criteria for obesity (defined as a BMI ≥ 30) and trauma exposure according to DSM-IV-TR PTSD Criterion A (American Psychiatric Association, 2000). In the larger study, 17.2% of the sample were individuals with obesity. Participants reported an average BMI in the larger study of 25.18 (SD = 5.81) and endorsed a mean of 1.94 (SD = 1.47) traumatic life events. Participants in the current study reported an average BMI of 35.24 (SD = 25.03) and endorsed a mean of 2.2 (SD = 1.50) traumatic life events. Participants in the current study indicated the following traumatic event as most disturbing in their lifetime: natural disaster (35.2%), sexual assault by a family member or someone you know (13.6%), sexual contact when you were younger than 18 with someone who was 5 or more years older than you (7.9%), serious accident (7.2%), non-sexual assault by a stranger (5.7%), life-threatening illness (3.6%), sexual assault by a stranger (2.9%), combat (2.1%), non-sexual assault by a family member or someone you know (2.1%), and other (19.4%). The sample was racially/ethnically diverse and representative of the university’s student body: 53.2% White (n = 74), 18% Black (n = 25), 16.5% Asian/Pacific Islander (n = 23), 3.6% Native American/American Indian (n = 5), and 8.6% other (n = 12). Participants identified as 46% Hispanic/Latino (n = 64).

Procedure

The current study included university students enrolled at a large, southwestern university interested in participating in an online survey in order to receive extra credit towards their psychology course. Participants were recruited via flyers and posting on the university extra credit website. The current study was a secondary data analysis of the larger online survey study aimed to better understand the role of emotional-cognitive vulnerability factors and negative health behaviors among college students with a history of trauma exposure. Inclusion criteria for the larger study included being between the ages of 18 and 64, a part or full time undergraduate or post-baccalaureate enrollment at the university where the study took place, endorsement of exposure to at least one lifetime traumatic event per DSM-IV-TR PTSD Criterion A, and proficiency in English (to ensure comprehension of study questions). For the current study, individuals were included only if they met criteria for obesity (BMI of ≥ 30). Prior to participation in the study, all participants provided informed consent. Data collection took place from January 2018 through December 2018 and was collected completely online through a reliable and valid online survey management system (Qualtrics; Shapiro et al., 2013). This study protocol was approved by the Institutional Review Board at the relevant institution.

Measures

Demographic Questionnaire.

A demographic questionnaire was utilized to obtain information on participant’s age, sex (assigned at birth), and race/ethnicity. Demographic variables were utilized for descriptive purposes and sex was included as covariate in the present analysis.

Body Mass Index (BMI).

Participants were asked to self-report height and weight for the current study. Utilizing World Health Organization recommendations BMI was calculated ([weight (pounds)]/[height (inches)2 x 703]); World Health Organization, 2020) and utilized as a covariate in the current study.

Posttraumatic Diagnostic Scale (PDS; Foa, 1995).

The PDS is a 49-item self-report instrument that assesses trauma exposure and the presence of PTSD symptoms based on DSM-IV criteria (American Psychiatric Association, 2000). Respondents were asked to report if they have experienced or witnessed any of the 13 traumatic events (e.g., “serious accident, fire or explosion” “Life-threatening illness”), including an “other” category. Participants were then asked to report the frequency of 17 PTSD symptoms experienced in the past month for the event that bothers them the most. Participants rate each item on a scale ranging from 0 (not at all/or only one time) to 3 (5 or more times a week/almost always). The PDS has evidenced excellent psychometric properties, including excellent internal consistency and good test-retest reliability (Foa et al., 1997). The current study utilized the PDS to screen for trauma exposure and to provide an index of PTSD symptom severity. The 17-item PDS total severity score was used as a study covariate to represent PTSD symptom severity (α = .97).

Mindful Attention and Awareness Scale (MAAS; Brown & Ryan, 2003).

The MAAS is a 15-item questionnaire used to assess respondent’s level of awareness and attention to present events and experiences (e.g., “I find it difficult to stay focused on what’s happening in the present”). Items are rated on a 6-point Likert-type scale from 1 (almost always) to 6 (almost never) which can be summed and averaged to create a total score with lower scores indicating lower levels of mindful attention. The MAAS has shown good psychometric properties and sound test-retest reliability (Brown & Ryan, 2003). In the current study, the MAAS total score demonstrated excellent internal consistency (α = .94).

Eating Expectancy Inventory (EEI; Hohlstein et al., 1998).

The EEI is a self-report questionnaire made up of 5 subscale facets: eating helps manage negative affect; eating is pleasurable and useful as a reward; eating leads to feeling out of control; eating enhances cognitive competence; and eating alleviates boredom. Participants are asked to indicate on a Likert-type scale the degree to which they 1 (completely disagree) to 7 (completely agree) with 34-items related to their cognitive expectancies of eating. Among college, clinical, and adolescent samples, the EEI subscales have shown good psychometric properties (Hohlstein et al., 1998; Simmons et al., 2002). In the current study, eating helps manage negative affect (18 items: Cronbach’s α = .94), eating alleviates boredom (4 items: Cronbach’s α = .64), and eating leads to feeling out of control (4 items: Cronbach’s α = .70) were utilized as criterion variables.

Data Analysis

We first checked the data for quality assurance to remove cases in which there were inappropriate or careless responding. Eight-hundred and fourteen individuals completed the survey and 6 were removed due to poor data. Of the 808 participants, we were missing data for BMI (n = 16). We then conducted Little’s missing completely at random (MCAR) test to determine if the missing data are missing at random. The test was non-significant indicating the missing data were missing at random. Thus, missing data was imputed using the expectation-maximization algorithm in SPSS 25.0. With the expectation-maximization data set, participants with obesity were included by selecting participants with a BMI of ≥ 30. Thus, the final sample consisted of 139 college students with obesity and a history of trauma exposure.

We examined the descriptive statistics of the study variables and correlations. We then examined the relations between our predictor variable (mindful attention) on our three criterion variables; (1) expectancies of eating to help manage negative affect, (2) expectancies of eating to alleviate boredom, and (3) expectancies of eating to lead to feeling out of control. We conducted three separate two-step hierarchical regressions in which step 1 included our covariates of sex (0 = male, 1 = female), BMI, and PTSD symptom severity. In step 2 we added mindful attention. To evaluate model fit we utilized the F statistic as well as change in R2 to evidence an increase in variance accounted for by the addition of mindful attention in step 2. To determine effect size, we utilized the squared semi-partial correlations (sr2).

Results

Zero-order correlations among all study variables are presented in Table 1. Mindful attention was negatively correlated with PTSD symptom severity (r = −.28, p < .01) and all eating expectancies (r’s = −.23-.35, p’s < .01). Average mindful attention scores in the current study (M = 3.83, SD = 1.21) were comparable to normative scores for individuals with obesity (M = 4.04, SD = 0.76; Ufuk et al., 2018), college students (M = 3.72, SD = 1.25; Brown & Ryan, 2003), and individuals with a history of trauma exposure (M = 4.57, SD = 1.30; Viana et al., 2017).

Table 1.

Descriptive Statistics and Bivariate Correlations between Study Variables (N = 139)

Variable Observed Range Mean/n (SD/%) 1 2 3 4 5 6 7
1. Sexa 106 (76.3%) -
2. BMIa 30.04 – 58.57 35.24 (5.03) .02 -
3. PTSD Symptom Severitya 0 – 51 11.16 (12.79) .06 .16 -
4. Mindful Attentionb 1 – 6 3.83 (1.21) .12 .09 −.28** -
5. Eating Expectancies-Negative Affectc 18 – 120 56.21 (24.64) −.10 .09 .15 −.23** -
6. Eating Expectancies-Boredomc 4 – 28 16.29 (5.27) −.06 .04 .01 −.23** .53*** -
7. Eating Expectancies-Controlc 4 – 28 12.48 (5.68) .02 .06 .17* −.35*** .53*** .20* -
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Note.

***

p < .001,

**

p < .01,

*

p < .05.

a

Covariate;

b

Predictor;

c

Criterion; Sex: % listed as females (Coded: 0 = male and 1 = female);

BMI = Body Mass Index; PTSD Symptom Severity = Posttraumatic Diagnostic Scale-Total Severity Score (Foa, 1995); Mindful Attention = Mindful Attention and Awareness Scale (Brown & Ryan, 2003); Eating Expectancies-Negative Affect = Eating Expectancy Inventory-Eating Helps Manage Negative Affect subscale (Hohlstein et al., 1998); Eating Expectancies-Boredom = Eating Expectancy Inventory-Eating Alleviates Boredom subscale (Hohlstein et al., 1998); Eating Expectancies-Control = Eating Expectancy Inventory-Eating Leads to Feeling out of Control subscale (Hohlstein et al., 1998).

Regression results are presented in Table 2. For expectancies of eating to help manage negative affect, step one with covariates was not statistically significant. In step two, mindful attention was a significant predictor (ΔR2 = .08, F(1, 134) = 5.31, p = .023). In terms of expectancies of eating to alleviate boredom, step one with covariates was not significant. In step two, mindful attention was a statistically significant predictor (ΔR2 = .06, F(1, 134) = 7,86, p = .006). Regarding expectancies of eating to lead to feeling out of control, the overall model with covariates was not statistically significant. Mindful attention was added in step two, and it was a statistically significant predictor (ΔR2 = .14, F(1, 134) = 1631, p < .001).

Table 2.

Hierarchical Regression Results

Eating Expectancies: Negative Affect
Model b SE β t p CI (l) CI (u) sr2
1 Sex −6.09 4.88 −0.11 −1.25 .214 −15.73 3.56 .01
BMI 0.34 0.42 0.07 0.80 .424 −0.49 1.17 .00
PTSD Symptom Severity 0.28 0.17 0.15 1.71 .089 −0.04 0.61 .02
2 Sex −4.46 4.85 −0.08 −0.92 .360 −14.06 5.14 .01
BMI 0.47 0.42 0.10 1.13 .259 −0.35 1.30 .01
PTSD Symptom Severity 0.16 0.17 0.08 0.96 .341 −0.17 0.50 .01
Mindful Attention −4.16 1.08 −0.20 −2.30 .023 −7.72 −0.60 .04
Eating Expectancies: Boredom
Model b SE β t p CI (l) CI (u) sr2
1 Sex −0.79 1.06 −0.06 −0.74 .460 −2.89 1.31 .00
BMI 0.05 0.09 0.04 0.49 .622 −0.14 0.23 .00
PTSD Symptom Severity 0.00 0.04 0.01 0.06 .952 −0.07 0.07 .00
2 Sex −0.36 1.05 −0.03 −0.34 .731 −2.43 1.71 .00
BMI 0.08 0.09 0.08 0.90 .370 −0.10 0.26 .01
PTSD Symptom Severity −0.03 0.04 −0.07 −0.79 .429 −0.10 0.04 .00
Mindful Attention −1.09 0.39 −0.25 −2.80 .006 −1.86 −0.32 .06
Eating Expectancies: Control
Model b SE β t p CI (l) CI (u) sr2
1 Sex 0.09 1.13 0.01 0.08 .938 −2.14 2.32 .00
BMI 0.04 0.10 0.03 0.38 .702 −0.15 0.23 .00
PTSD Symptom Severity 0.07 0.04 0.17 1.95 .054 0.00 0.15 .03
2 Sex 0.72 1.08 0.05 0.67 .505 −1.42 2.86 .00
BMI 0.09 0.09 0.08 0.97 .332 −0.09 0.27 .01
PTSD Symptom Severity 0.03 0.04 0.06 0.73 .467 −0.05 0.10 .00
Mindful Attention −1.62. 0.40 −0.34 −4.04 <.001 −2.41 −0.83 .11
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N for analyses is 139 cases. BMI = Body Mass Index; PTSD Symptom Severity = Posttraumatic Diagnostic Scale-Total Severity Score (Foa, 1995); Mindful Attention = Mindful Attention and Awareness Scale (Brown & Ryan, 2003); Eating Expectancies-Negative Affect = Eating Expectancy Inventory-Eating Helps Manage Negative Affect subscale (Hohlstein et al., 1998); Eating Expectancies-Boredom = Eating Expectancy Inventory-Eating Alleviates Boredom subscale (Hohlstein et al., 1998); Eating Expectancies-Control = Eating Expectancy Inventory-Eating Leads to Feeling out of Control subscale (Hohlstein et al., 1998).

Discussion

This study empirically examined the relationship between mindful attention and eating expectancies among college students with obesity and a history of trauma exposure. Findings indicated that lower self-reported levels of mindful attention were related to higher levels of expectancies of eating to help manage negative affect, expectancies of eating to alleviate boredom, and expectancies of eating to lead to feeling out of control. These results are in line with previous work on mindful attention and maladaptive eating behaviors (e.g., overeating, emotional eating; Bahl et al., 2013; Ouwens et al., 2015) and extends this work to college students with obesity and a history of trauma exposure.

The present investigation is consistent with recent evidence suggesting that there may be clinical utility in incorporating a mindful attention component in existing interventions aimed to improve obesity (Godsey, 2013; Jordan et al., 2014). Specifically, eliciting present-oriented awareness to maladaptive coping behaviors may encourage individuals to be more likely to respond adaptively to their unhealthy beliefs (Godsey, 2013). Research has reported that improvements in mindful attention can reduce poor eating habits (e.g., overeating; Bahl et al., 2013; Daubenmier et al., 2011; Godsey, 2013; Jordan et al., 2014; Kristeller & Wolever, 2011). Moreover, Mindfulness-based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2013) has been found to evidence decreases in expectancies of eating to manage negative affect and expectancies of eating to lead to feeling out of control (Baer et al., 2005). The current study further adds to this work by suggesting that mindful attention may be an important clinical target as it relates to healthier eating via greater awareness to inner experiences such as negative emotions (e.g., anxiety, boredom) or feelings of lack of control while eating which may be associated with maladaptive eating (Hohlstein et al., 1998).

Limitations and Future Research

The current study had several limitations worth mentioning. First, the study examined cross-sectional relations and therefore we were not able to test for temporal sequencing. Future work would benefit from longitudinal analysis examining the proposed relations. Second, given the studied variables were assessed via self-report only, there is the possibility that the observed relations were due, in part, to shared method variance. In order to strengthen the analysis, future work would benefit from examining the key variables from a multi-method assessment approach. Third, the sample consisted of mostly female college students who took part in the study in order to receive extra credit for their course. It would be beneficial for future studies to examine the relations among variables among a sample with a larger proportion of males as well as individuals who are not seeking extra credit for their course from participation (e.g., community sample). Fourth, the definitions of trauma and PTSD symptomatology were based upon DSM-IV-TR criteria. Consequently, there is a need to extend the current work to PTSD DSM-5 criteria. Relatedly, students in this sample reported relatively low levels of PTSD symptom severity and inconsistent from previous work (Chwastiak et al., 2011; Gunstad et al., 2006; Hicks White et al., 2018; Johannessen & Berntsen, 2013; Williamson et al., 2002), BMI and PTSD symptom severity were not significantly associated in the current study. The restricted range in PTSD symptom severity and BMI may have influenced these findings, warranting an extension in future research to other samples with more variability. Fifth, the current study was a secondary data analysis of a larger cross-sectional data collection study among college students with a history of trauma exposure. Future studies may benefit from sampling from a population of individuals with and without trauma exposure to examine the impact of trauma exposure (vs no exposure) on the observed relations. Sixth, internal consistency for the eating alleviates boredom subscale was low in the present study which may have been due, in part, to low item count (Tavakol & Dennick, 2011). Future research should apply a more reliable measure to further explore the role of mindful attention as it related to expectancies of eating to alleviate boredom. Seventh, we focused on a priori basis on the main effect of mindful attention. Future research could examine whether mindful attention mediates the relation between PTSD symptom severity and eating expectancies among college students with obesity and a history of trauma exposure. Such work could shed further insight into the mechanistic functions of mindful attention among this population. Finally, the current study utilized the MAAS, which is a unidimensional measure of mindfulness focused on present-oriented awareness (Coffey & Hartman, 2008). Future work would benefit from examining the relationship between other facets of mindfulness (i.e., observing, describing, nonreacting, non-judging; Baer et al., 2006) and eating expectancies among this population.

Together, findings from the present study suggest that mindful attention is relevant to better understanding eating expectancies among college students with obesity and a history of trauma exposure. Research may benefit from extending the current model to include other obesity-related health behavior indicators (e.g., binge eating, BMI). Such data may provide insight into future research development among this high-risk population. In addition, future work may benefit from expanding the current findings among individuals across the BMI spectrum (e.g., underweight, normal weight, overweight) to validate the proposed model and its relevance.

Acknowledgments

Funding: This work was funded by a pre-doctoral National Research Service Award awarded to Ms. Brooke Kauffman (F31-DA046127).

Footnotes

Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.

Statement of Human Rights: All procedures performed in studies involving human participants were in accordance with the ethical standards of the University of Houston Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animals were employed in this research

Informed Consent: Informed consent was obtained from all individual participants included in the study.

Disclosure of Potential Conflicts of Interest: All authors declare that they have no conflict of interest

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