Mindfulness Promotes Positive Health Behaviors by Enhancing Self-Regulation, Motivation, and Learning: Perspectives from Research and Clinical Care

Laura S. Redwine

E. Robert Schwartz

Eric L. Garland

Editor's Note: Mindfulness is probably one of the biggest success stories of integrative health ever; an approach that brings together medicine, psychology, and traditional healing systems. And an approach that provides evidence-based treatment for a wide variety of conditions. Mindfulness was also my gateway into the world of integrative health. In this commentary, the 14th through the JICM column partnership with the Osher Collaborative for Integrative Health, the authors provide an unusual view on mindfulness: a mechanistic one. And show why mindfulness could be part of the answer to the global increase in noncommunicable diseases. Laura S. Redwine, PhD, is Clinical Research Director, and E. Robert Schwartz, MD, FAAFP, is Director of the Osher Center for Integrative Health, Miller School of Medicine at the University of Miami. Eric L. Garland, PhD, LCSW, is Director of the Center on Mindfulness and Integrative Health Intervention Development (C-MIIND) at the University of Utah. JICM is proud to be partnering with the Osher Collaborative for Integrative Health and such high-profile columnists.

—Holger Cramer, PhD, Editor-in-Chief, Journal of Integrative and Complementary Medicine

Psychological factors such as chronic psychological stress, anxiety, depression, and social isolation not only strongly impact quality of life but are also frequently comorbid risk factors and influence noncommunicable/noninfectious disease development and prognosis.¹ Meanwhile, noncommunicable diseases account for 71% of all deaths globally, including cardiovascular diseases, cancers, respiratory diseases, and diabetes. Unhealthy behaviors such as tobacco use, unhealthy diets, physical inactivity, and the harmful use of alcohol and other drugs (e.g., opioids) all contribute substantially to the risk of death from noncommunicable diseases.² However, healthy behavioral changes are difficult to initiate and maintain.³

Mindfulness-based interventions (MBIs) are effective in reducing psychological distress,⁴ and by improving emotion regulation, may elicit receptiveness and adherence to behavior changes such as diet, physical activity, and reduction of harmful substance use.^5–7 With a better understanding of the therapeutic mechanisms of mindfulness, MBIs can be optimized to improve psychological and physical health outcomes. Randomized controlled trials implemented in health care settings are needed to elucidate mechanisms of mindfulness-based behavior change. At the Osher Centers for Integrative Health, we strive to fulfill a unique opportunity for research and clinical care to offer valuable insights into methods for improving health and well-being in the community and in clinical settings.

MBIs for Improved Health

The National Center for Complementary and Integrative Health (NCCIH) at the National Institutes of Health (NIH) suggests health and disease are not discrete states but rather exist on a bipolar continuum.⁸ MBIs target a range of therapeutic mechanisms to help patients move toward health behaviors and away from disease. This article illustrates the use of mindfulness strategies grounded in mechanistic foundations to improve health behaviors, in both research and clinical primary care practice.

Mindfulness is described as meta-awareness and acceptance of present moment thoughts, emotions, and sensations.⁹ One key aim of mindfulness is to develop awareness of automatic habitual patterns of reactivity to sensations, thoughts, and emotions and to gain insight into how they can generate feelings of stress and emotional distress,^10,11 which can lead to stress-related unhealthy behaviors (e.g., overeating, drug, and alcohol use).⁷ The mental capacity of mindfulness is cultivated through a range of practices, including mindful breathing and body scan meditations. MBIs provide training in these techniques, in addition to psychoeducation and group support, to promote positive behavior change.¹¹

Mechanistic Models of MBIs on Health Behavior Change

MBIs are often undertaken in response to personal goals to improve health and well-being. They usually involve the integration of mindfulness techniques with strategies to enhance positive health behaviors and extinguish negative health behaviors. Various overlapping theoretical models postulate that MBIs improve health behaviors through mechanisms, including enhanced self-regulation, knowledge of positive health practices, and motivation to change (Fig. 1). Mindfulness practices enhance self-regulation through attentional control and meta-awareness, which in turn facilitate decentering from maladaptive thoughts and emotions, and thereby improve emotion regulation capacity.¹² Notably, as mindfulness experience and expertise develops over time, practitioners shift from needing to exert a high degree of cognitive effort to a form of “effortless awareness” to gain self-control over health behaviors.¹³

FIG. 1.

Mindfulness-based practice is theorized to increase self-regulation mechanisms, which work together with learning and motivation for change to influence health behaviors.

Healthy choices can be made with less effortful cognitive control when the reward value of healthy behavioral choices is restructured vis-à-vis the reward value of unhealthy choices. When integrated with educational and motivational components in MBIs, mindfulness is theorized to enhance self-regulation by restructuring the reward value of healthy behaviors relative to unhealthy behaviors, facilitating a shift from overvaluing maladaptive, appetitive behaviors such as drinking or smoking to valuing salutary behaviors such as eating nutritious meals or engaging in social affiliation.¹⁴ Furthermore, using mindfulness to cultivate awareness, acceptance, and regulation of negative emotional and physiological reactivity to stressors can reduce stress-related health behaviors such as self-medicating negative affect with drug use or overeating, or other consequences such as sleep disturbances.⁷

Research on MBI Interventions on Health Behaviors

Many studies have examined the mechanisms of MBIs on producing behavior change, with promising results. An MBI called Mindfulness-Oriented Recovery Enhancement (MORE) developed by ELG has been shown to decrease opioid misuse among chronic pain patients in the primary care setting by 45%, more than doubling the effect of standard supportive therapy.¹⁵ The effects of MORE on decreasing opioid misuse and craving have been shown to be associated with restructuring of reward processes from valuing opioid-related rewards back to valuing natural healthy rewards,^16–18 and increased neurophysiological markers of cognitive control and self-regulation.^19,20

Furthermore, MBIs are associated with reduced impulsive eating and binge eating as well as increased physical activity levels,²¹ with positive changes in eating behaviors associated with changes in the reward value of food.²² As another example, in a study within a primary care setting, MBI have been found to facilitate chronic disease self-management behaviors through improved self-regulation through emotion regulation.²³

Osher Centers for Integrative Health researchers continue to explore the mechanisms of mindfulness-based health behavior change. For instance, the laboratory of LSR is currently involved in conducting an NIH-funded study of an optimized health behavior intervention incorporating mindfulness-based strategies, including body scans and mindful-eating and walking exercises to improve lifestyle behaviors for rural Latino parents and their children with obesity in southwest Florida.²⁴ In addition, they are collecting data on a mindfulness/lifestyle intervention for patients with cancer receiving hematopoietic stem cell transplantation.²⁵ The aim is to fill a gap in the literature by examining the effects of mindfulness strategies and the mechanisms involved in lifestyle behavior changes in rural Latino community members and in hospital-based populations.

In sum, there is mounting evidence of benefits of MBIs for behavior change that can mediate the positive health effects. Self- and emotion regulation in combination with educational components suggest improved health behavior outcomes. However, more research is needed to confirm and extend these findings.

Applying Mindfulness Practices in Clinical Care

Many patients suffering from mental health conditions are seen by primary care physicians but do not necessarily come to their clinic visits due to these symptoms. Many of these patients have histories of alcohol or narcotic addictions as a way of coping with chronic stress or physical pain. They are often diagnosed by a detailed history or by the astute clinician willing to take the extra time to probe the patient's psychosocial history.

We know that most primary care visits originate in issues around hypertension, diabetes, cardiovascular disease, hyperlipidemia, and musculoskeletal problems, to name a few. The challenge for the health care professional is to be able to take the time to inquire about the mental health status of their patients, their personal and family history, and the potential for traumas that have occurred in their patients' lives. We are well aware of the impact of these underlying mental health issues and their multitude of manifestations, such as psychosomatic disorders, post traumatic stress disorder (PTSD), major depression, and generalized anxiety disorder.

Because other than treating patients' physical ailments with medications, and other medical interventions, for the most part, Western medicine has been deficient in helping people to undertake the management of their health care by promoting self-awareness and self-regulation of health behaviors. Much of modern medicine is designed to provide a patient with a pill or procedure to exogenously produce a healing response. In contrast, mind–body medicine uses tools such as meditation, mindfulness, imagery, yoga, and Tai Chi to endogenously stimulate the individual's innate capacity for healing. Non-Western cultures have relied upon these practices for thousands of years to generate solutions to disease derived from innate human resources. Aristotle and Hippocrates, progenitors of evidence-based medicine, were among the many ancient healers who used relaxation and mind–body techniques to help relieve patients' experiences of pain.

In my (E.R.S.) clinical experience over the years, working with patients identified as having emotional problems as part of their history, I have provided mind–body techniques to my patients to not only help them cope with their problems, whether they be chronic pain symptoms or emotional traumas from past traumatic life events. I have used standard techniques of deep breathing, meditation, imagery, and relaxation response with varied success. I have found that a patient's response is largely a function of their willingness to trust the process and the provider, and their commitment to engage in regular mind–body practice. I often tell patients that taking a pill for pain, anxiety, or depression is much easier.

Learning mind–body techniques takes dedication on the part of the patient as well as the practitioner in seeking positive outcomes. It is important to select patients carefully for these techniques because it is possible to unmask unaddressed psychological trauma during mindfulness and other mind–body techniques. Therefore, taking a psychosocial history, and making referrals as needed to primary trauma treatment, is extremely important before embarking on the meditative treatment process. To be clear, patients with severe PTSD can experience significant relief from MBIs when delivered by clinicians with training in trauma therapy.^26,27

Conclusions

Research indicates mindfulness can produce positive outcomes for various psychological and physical disorders. There is growing evidence of benefits of MBIs for behavior change that can mediate their positive health effects. MBIs appear to produce therapeutic change by strengthening self-regulation and self-awareness, in addition to enhancing motivation and learning that may lead to behavior change. By understanding these mechanisms of mindfulness, programs targeting health behaviors may be optimized for a range of clinical practice settings.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Dr. Redwine was supported during the preparation of this manuscript by funding from National Institutes of Health, R34AT010661 and R34AT010661-SA. Dr. Garland was supported during the preparation of this manuscript by funding from National Institutes of Health, R01AT011772, R01DA056537, R01DA057631, and R01DA048094.