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Abstract

Lifestyle medicine is a patient-engaged field that has grown in tandem with our increasing knowledge of the importance of lifestyle factors and modifiable health behaviors for disease prevention, health promotion, and the management of chronic illness. Stress is at the epicenter of many negative behaviors that contribute to unhealthy lives, such as smoking, overeating, and unhealthy diets, and lack of activity. Mindfulness meditation is a stress reduction practice that teaches awareness, appreciation, and nonjudgmental acceptance of one’s present experience, thereby short-circuiting reactive, automatic stress reactions. Our systematic review and meta-analysis focuses on the application of randomized controlled mindfulness intervention studies across a broad range of populations and conditions that are relevant to lifestyle medicine. In addition to organizing and highlighting mindfulness research studies that are relevant to the field of lifestyle medicine, we also empirically examine the impact of study design issues (eg, use of different controls, intervention length and duration, sample size, primary outcomes) on the magnitude of effect of mindfulness interventions in lifestyle medicine. Overall, this systematic review and meta-analysis found partial evidence for mindfulness-based interventions to provide short-term benefits across a wide range of lifestyle medicine–relevant populations and study outcomes, particularly focusing on the areas of diet and weight management and symptom burden. Numerous outcome measures were used; however, the most common were the Perceived Stress Scale and the State Trait Anxiety Inventory. This analysis also provides evidence for mindfulness-based interventions that have fewer than 20 individuals per group, as well as partial support for interventions that are less than the standard 8 weeks in duration.

Keywords

mindfulness meditation lifestyle medicine randomized controlled trials systematic review meta-analysis

‘Mindfulness is a multisensory, contemplative meditative tradition that is formally practiced while sitting, lying, eating, walking, or engaging in gentle yogic postures.’

Lifestyle medicine is an approach to medical care that focuses on the adoption and maintenance of positive health behaviors to prevent the development or worsening of disease, promote healthy living and wellness, and optimally manage existing chronic medical conditions and related burden.¹ This field has evolved considerably over the past decade as an adjunct to conventional medical care and often consists of leveraging evidence-based interventions in exercise/physical activity, diet/nutrition, smoking cessation, and stress management to prevent or reduce lifestyle-related health problems such as obesity,² cardiovascular disease,³ hypertension,⁴ type 2 diabetes,⁵ and other chronic conditions.⁶ Lifestyle medicine is a patient-centered practice that relies greatly on the engagement of patients themselves to be active agents of their own health and wellness.⁷

Given the pivotal and accumulative role of psychological and physiological stress in the onset, continuation, and outcomes of chronic disease,^8-10 one particularly important lifestyle medicine–based intervention is stress management and reduction. An increasingly studied type of stress reduction involves the cultivation of mindfulness, or the practice of paying attention on purpose, in the present moment, without judgment.¹¹ Mindfulness is a multisensory, contemplative meditative tradition that is formally practiced while sitting, lying, eating, walking, or engaging in gentle yogic postures. It has been operationally defined as a bivariate mode or state of consciousness, involving (a) the self-regulation of sustained attention and attentional shifting, which subsequently fosters the inhibition of secondary elaborative cognitive processing (rumination); and (b) an orientation toward internal and external experiences characterized by openness, curiosity, and acceptance.¹²

Over the past 2 decades, a structured intervention called mindfulness-based stress reduction (MBSR) has become one of the most commonly evaluated and empirically supported treatments for helping people reduce stress and manage disease and treatment related sequelae in both healthy and chronic disease samples.^13-15 Based primarily on the instruction of mindfulness meditation and gentle yoga, MBSR is a group-based, 8-week program that was developed at the University of Massachusetts Stress Reduction Clinic under the direction of Jon Kabat-Zinn.¹¹ As a nonreligious practice, MBSR facilitates the cultivation of nonjudgmental, moment-to-moment awareness through a process of attentional single-mindedness (eg, mindfulness). MBSR is composed of a systematic, developmentally sequenced curriculum that uses a group format to experientially instruct participants in the practice of mindfulness meditation and Hatha yoga. Each session includes different forms of meditation practice, such as cultivating awareness of thoughts, feelings, and bodily sensations, and learning to incorporate this awareness during stressful emotional and/or physical life situations.¹⁶

Several other related mindfulness-based interventions have been adapted from MBSR for other patient groups or conditions, including Mindfulness Based Cognitive Therapy (MBCT),^17-19 Mindfulness-Based Relapse Prevention (MBRP),²⁰ Mindfulness-Based Eating Interventions (MB-EAT²¹ and MEAL²²), and so on. Recent systematic reviews have been conducted on mindfulness-based interventions focusing on substance-use disorders,²³ lower back pain,²⁴ eating disorders,²⁵ cancer survivors,^26,27 and anxiety disorders.²⁸ Overall, these reviews suggest that MBSR, MBCT, and their adaptations have demonstrated promising results in the reduction of emotional distress (depression, anxiety) and pain, improvements in sleep, and overall health-related quality of life.²⁹ Mindfulness-based interventions may also have an important role in reducing the physiological effects of stress on the body and have been associated with reestablishing normal patterns of cortisol secretion,³⁰ decreases in pro-inflammatory cytokines, and possible beneficial changes in HPA axis functioning in cancer patients.³¹ Despite these reviews, little empirical evidence exists on whether modifications to MBSR (eg, implementing it less than 8 weeks, adding additional tailored content to the lessons) or study design differences (eg, having relatively smaller group sizes, using a wait-list control vs an active control) significantly affect primary outcomes of mindfulness randomized controlled trials (RCTs) that are relevant to lifestyle medicine. We were also curious about what study outcomes relevant to lifestyle medicine would see the greatest or most significant change as a result of mindfulness training. The purpose of this study was to (a) systematically review published mindfulness-based RCTs with relevance to lifestyle medicine (eg, those that focused on adopting and/or maintaining mindfulness practices as a means of preventing or managing existing medical conditions and symptoms or promoting health and wellness among the general population) and (b) utilize meta-analytic procedures to determine whether study design characteristics, intervention modifications, and choice of specific outcomes meaningfully affect variability of effect size magnitude across studies.

Methods

We followed guidelines from the Preferred Reported Items for Systematic Reviews and Meta-Analyses (PRISMA)³² and the Cochrane Collaboration³³ for this study.

Literature Search and Strategy

Our literature search included the following databases and sites over the past 10 years (between 2002 through 2012): PUBMED, OVID/MEDICINE, PROQUEST, PSYCHINFO, MINDFULNET.ORG, and Mindfulness Research Monthly (http://www.mindfulexperience.org/). We adapted the following complete key word search strategy as necessary per database: Lifestyle Medicine, Mindfulness Meditation, Mindfulness Based Stress Reduction, MBSR, Mindfulness Based Cognitive Therapy, MBCT, Mindfulness Based Relapse Prevention, Mindfulness Based Intervention, Mindfulness Based Eating Awareness Training, and Mindful Eating and Living. We also filtered results by the following criteria: published in English, between 2002 and 2012, peer reviewed journal, clinical trial, randomized trials, systematic review, review, meta-analysis, human. All initially retrieved abstracts were read by 2 reviewers (DV and MK). We reviewed all articles in their entirely that contained sufficient information to calculate effect sizes. Once all eligible studies were identified, each article was reviewed in full and abstracted accordingly.

Eligibility Criteria

Interventions

Given our study questions, we included group-based clinical mindfulness intervention studies of at least 2 weeks or longer such as MBSR, MBCT, MB-EAT, and so on, or modified derivatives where similar mindfulness training was the primary focus of the intervention.

Study Type

We only included published RCTs (including wait-list control designs) and excluded observational or nonrandomized studies or published abstracts. We excluded follow-up studies of previously published original trials as well as laboratory-based experiments that did not involve intensive group-based mindfulness training as a means of improving a lifestyle medicine–relevant outcome or goal (eg, emotional regulation, smoking cessation).

Patients Populations and Relevance to Lifestyle Medicine

In view of the broad focus and applicability of lifestyle medicine practices that span disease prevention, health promotion, and chronic disease management, we kept this category broad in our search strategy to allow for as many lifestyle medicine relevant studies as possible where the primary purpose of the mindfulness intervention was to facilitate wellness, improve quality of life, or promote health and well-being. With regard to psychiatric and substance use studies, we limited the types of publications to less severe, community-based populations (vs intensive programs or inpatient facilities) where symptomatology (eg, depressive symptoms, cannabis use) could be widely generalizable to others without psychiatric problems or diagnoses. In the end, we included patient populations highlighted in the American College of Lifestyle Medicine’s Evidence Review,¹ including cancer, cardiovascular disease, metabolic syndrome, musculoskeletal and joint problems, neurological disorders, pain disorders, and psychiatric and respiratory illness.

Data Extraction

We followed published recommendations to establish meta-analytic decision rules^34,35 and the PICOS framework (Population, Interventions, Comparators, Outcomes, Study Design)³⁶ to abstract relevant articles. Our research team (all study authors) engaged in a systematic and iterative data identification, review, and indexing process. Following the initial creation of the study database (MK and DV), article reviewers (all coauthors with individually subdivided reviewing/abstracting assignments) independently coded study characteristics, including the following: study title, authors, and publication year; population under study; clinical issue addressed and primary outcome; study type; characteristics of the intervention (eg, number of weeks, modifications); control group characteristics; sample size; adult or pediatric focus; gender, age, study outcomes, and measures; study quality; and relevance to lifestyle medicine.

Authors CM and DV abstracted means and standard deviations for primary study outcomes from the baseline and immediate follow-up assessments. When standard deviations were not reported but standard errors or confidence intervals of the intervention means were, we obtained standard deviations by multiplying the standard error by the square root of the sample size $(S D = S E \times \sqrt{N})$ , or by dividing the length of the confidence interval by 3.92, and multiplying it by the square root of the sample size (SD = $\sqrt{N}$ × (upper limit − lower limit)/3.92. This provided a suitable estimate for effect size calculation purposes.

We selected each study’s stated primary outcome on which to calculate effect sizes, which could include psychological constructs such as anxiety or stress, as well as other lifestyle medicine–relevant outcomes such as systolic blood pressure, or number of cigarettes smoked per day. Studies that included multiple experimental arms (eg, mindfulness interventions vs usual care vs active control condition) were coded so that each treatment was included as a separate unit of analysis. We used Hedge’s g as a standardized measure of effect size, which is very similar to Cohen’s d; however, it is less prone to positive bias, especially when smaller sample sizes are included. The formula for calculating Hedge’s g is the following:

Hedge ’ s g = \frac{M_{1} - M_{2}}{S D_{pooled}^{*}}

S D_{pooled}^{*} = \frac{\sqrt{(n_{1} - 1) {SD}_{1}^{2} + (n_{2} - 1) {SD}_{2}^{2}}}{n_{1} + n_{2} - 2}

Effect size estimates can be interpreted in similar ways to correlation coefficients (eg, Cohen’s criteria: small = .20; medium = .50; large = ≥.80).³⁷

Study Quality and Risk of Bias

We assessed study quality and risk of bias by having at least 2 coders per article provide numeric quality ratings (1 = low quality, 2 = medium quality, 3 = high quality) at 2 separate reviews (based on the Cochrane criteria) followed by a third round of bias risk examination (DV) where Cochrane Risk of Bias criteria were applied to each publication that was ultimately selected. The Cochrane Risk of Bias Assessment tool examines selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias.³⁸

Data Summary and Analysis

We used SPSS version 22 and publically available meta-analysis software from Durham University (see http://tinyurl.com/ntu94ns)). Using a random effects model, we pooled and tested effect sizes for homogeneity to determine whether individual study variation estimates are true population parameters. Given that studies varied widely in intervention, population, and outcomes, we also weighted study effect sizes by sample size.³⁴ Next, we examined effect size variation between study characteristics and intervention conditions. Homogeneity assumptions were tested using Levine’s test. Planned comparisons were conducted using the least squared difference statistic on significant F tests.

Results

Literature Search

Our initial search yielded 973 articles, which after reexamination and removal of duplicates and nonrelevant papers was reduced to 600 articles for full abstract review and a first round of coding. Following training, each coauthor reviewed and coded roughly 75 articles each, which subsequently led to the reduction of our pool of studies to 184. The primary reason for removal was due to nonrandomized studies. Following another round of discussion and training, each coauthor reviewed and abstracted the remaining articles in full. This lead to a final review, reduction, and reorganization of 59 fully abstracted articles, which were selected for analysis and presentation in this current systematic review.

Study, Setting, and Patient Characteristics

We classified the 59 studies into 13 general categories based on population-specific details. Most categories were also subdivided into specific populations or foci. Cardiovascular relevant studies were the most frequently categorized (n = 10), which included specific areas such as smoking cessation/substance use, weight management, diabetes, blood pressure, and heart disease. See Tables 1 and 2 for included studies and population classifications.

Table 1.

Overview of Included Studies by General Category and Specific Population.

General Category	Specific Population	No. of Studies
Autoimmune/Psychosomatic	Fibromyalgia	3
	Irritable bowel syndrome	3
	Chronic insomnia	1
	Chronic fatigue syndrome	1
Cardiovascular	Smoking cessation and substance use	2
	Weight management	3
	Diabetes	1
	Blood pressure	2
	Heart disease	2
Caregiver	Dementia	1
	Special needs children	1
Community-Based (Adult)	Attentional control	1
	Psychological well-being	6
	Perceived control	1
	Emotional regulation	1
Musculoskeletal and Arthritic	Rheumatoid arthritis	2
	Chronic pain	1
	Failed back surgery syndrome	1
	Low back pain	1
Psychiatric	Depression	2
	Bipolar disorder	1
Respiratory	COPD	1
	Asthma	1
School/University-Based (Adult)	Psychological well-being	5
School/University-Based (Pediatric)	Academic performance and self-concept	1
Neurology	Epilepsy	1
	Multiple sclerosis	1
Oncology	Mixed cancer sample	3
	Breast cancer	2
	Prostate cancer	2
Transplantation	Solid organ recipients	1
Viral Disease	HIV	1
Women’s Health	Disordered eating	1
	Hot flashes	1
	Pregnant/postpartum	1

Abbreviations: COPD, chronic obstructive pulmonary disease.

Table 2.

Published Trials Included in Systematic Review and Meta-Analysis (N = 59).

1. Alberts HJ, Mulkens S, Smeets M, Thewissen R. Coping with food cravings. Investigating the potential of a mindfulness-based intervention. Appetite. 2010;55(1):160-163.

2. Alberts HJ, Thewissen R, Raes L. Dealing with problematic eating behaviour. The effects of a mindfulness-based intervention on eating behaviour, food cravings, dichotomous thinking and body image concern. Appetite. 2012;58(3):847-851.

3. Anderson ND, Lau MA, Segal ZV, Bishop SR. Mindfulness-based stress reduction and attentional control. Clin Psychol Psychother. 2007;14(6):449-463.

4. Astin JA, Berman BM, Bausell B, Lee WL, Hochberg M, Forys KL. The efficacy of mindfulness meditation plus Qigong movement therapy in the treatment of fibromyalgia: a randomized controlled trial. J Rheumatol. 2003;30(10):2257-2262.

5. Benn R, Akiva T, Arel S, Roeser RW. Mindfulness training effects for parents and educators of children with special needs. Dev Psychol. 2012;48(5):1476-1487.

6. Branstrom R, Kvillemo P, Brandberg Y, Moskowitz JT. Self-report mindfulness as a mediator of psychological well-being in a stress reduction intervention for cancer patients—a randomized study. Ann Behav Med. 2010;39(2):151-161.

7. Brewer JA, Mallik S, Babuscio TA, et al. Mindfulness training for smoking cessation: results from a randomized controlled trial. Drug Alcohol Depend. 2011;119(1-2):72-80.

8. Carmody J, Olendzki B, Reed G, Andersen V, Rosenzweig P. A dietary intervention for recurrent prostate cancer after definitive primary treatment: results of a randomized pilot trial. Urology. 2008;72(6):1324-1328.

9. Carmody JF, Crawford S, Salmoirago-Blotcher E, Leung K, Churchill L, Olendzki N. Mindfulness training for coping with hot flashes: results of a randomized trial. Menopause. 2011;18(6):611-620.

10. Daubenmier J, Kristeller J, Hecht FM, et al. Mindfulness intervention for stress eating to reduce cortisol and abdominal fat among overweight and obese women: an exploratory randomized controlled study. J Obes. 2011;2011:651936.

11. de Dios MA, Herman DS, Britton WB, Hagerty CE, Anderson BJ, Stein MD. Motivational and mindfulness intervention for young adult female marijuana users. J Subst Abuse Treat. 2012;42(1):56-64.

12. Delgado LC, Guerra P, Perakakis P, Vera MN, Reyes del Paso G, Vila J. Treating chronic worry: psychological and physiological effects of a training programme based on mindfulness. Behav Res Ther. 2010;48(9):873-882.

13. Esmer G, Blum J, Rulf J, Pier J. Mindfulness-based stress reduction for failed back surgery syndrome: a randomized controlled trial. J Am Osteopath Assoc. 2010;110(11):646-652.

14. Foley E, Baillie A, Huxter M, Price M, Sinclair E. Mindfulness-based cognitive therapy for individuals whose lives have been affected by cancer: a randomized controlled trial. J Consult Clin Psychol. 2010;78(1):72-79.

15. Franco Justo C, de la Fuente Arias M, Salvador Granados M. Impact of a training program in full consciousness (mindfulness) in the measure of growth and personal self-realization. Psicothema. 2011;23(1):58-65.

16. Gaylord SA, Palsson OS, Garland EL, et al. Mindfulness training reduces the severity of irritable bowel syndrome in women: results of a randomized controlled trial. Am J Gastroenterol. 2011;106(9):1678-1688.

17. Gayner B, Esplen MJ, DeRoche P, et al. A randomized controlled trial of mindfulness-based stress reduction to manage affective symptoms and improve quality of life in gay men living with HIV. J Behav Med. 2012;35(3):272-285.

18. Geschwind N, Peeters F, Drukker M, van Os J, Wichers M. Mindfulness training increases momentary positive emotions and reward experience in adults vulnerable to depression: a randomized controlled trial. J Consult Clin Psychol. 2011;79(5):618-628.

19. Gluck TM, Maercker A. A randomized controlled pilot study of a brief web-based mindfulness training. BMC Psychiatry. 2011;11:175.

20. Gross CR, Kreitzer MJ, Reilly-Spong M, et al. Mindfulness-based stress reduction versus pharmacotherapy for chronic primary insomnia: a randomized controlled clinical trial. Explore. 2011;7(2):76-87.

21. Gross CR, Kreitzer MJ, Thomas W, et al. Mindfulness-based stress reduction for solid organ transplant recipients: a randomized controlled trial. Altern Ther Health Med. 2010;16(5):30-38.

22. Grossman P, Kappos L, Gensicke H, et al. MS quality of life, depression, and fatigue improve after mindfulness training: a randomized trial. Neurology. 2010;75(13):1141-1149.

23. Hartmann M, Kopf S, Kircher C, et al. Sustained effects of a mindfulness-based stress-reduction intervention in type 2 diabetic patients: design and first results of a randomized controlled trial (the Heidelberger Diabetes and Stress study). Diabetes Care. 2012;35(5):945-947.

24. Hebert JR, Hurley TG, Harmon BE, Heiney S, Hebert CJ, Steck SE. A diet, physical activity, and stress reduction intervention in men with rising prostate-specific antigen after treatment for prostate cancer. Cancer Epidemiol. 2012;36(2):e128-e136.

25. Henderson VP, Clemow L, Massion AO, Hurley TG, Druker S, Hebert JR. The effects of mindfulness-based stress reduction on psychosocial outcomes and quality of life in early-stage breast cancer patients: a randomized trial. Breast Cancer Res Treat. 2012;131(1): 99-109.

26. Hoffman CJ, Ersser SJ, Hopkinson JB, Nicholls PG, Harrington JE, Thomas PW. Effectiveness of mindfulness-based stress reduction in mood, breast- and endocrine-related quality of life, and well-being in stage 0 to III breast cancer: a randomized, controlled trial. J Clin Oncol. 2012;30(12):1335-1342.

27. Jacobs TL, Epel ES, Lin J, et al. Intensive meditation training, immune cell telomerase activity, and psychological mediators. Psychoneuroendocrinology. 2011;36(5):664-681.

28. Jain S, Shapiro SL, Swanick S, et al. A randomized controlled trial of mindfulness meditation versus relaxation training: effects on distress, positive states of mind, rumination, and distraction. Ann Behav Med. 2007;33(1):11-21.

29. Kang YS, Choi SY, Ryu E. The effectiveness of a stress coping program based on mindfulness meditation on the stress, anxiety, and depression experienced by nursing students in Korea. Nurse Educ Today. 2009;29(5):538-543.

30. Kaviani H, Foroozan J, Hatami N. Mindfulness-based cognitive therapy (MBCT) reduces depression and anxiety induced by real stressful setting in non-clinical population. Int J Psychol Psychol Ther. 2011;11(2):12.

31. Klatt MD, Buckworth J, Malarkey WB. Effects of low-dose mindfulness-based stress reduction (MBSR-ld) on working adults. Health Educ Behav. 2009;36(3):601-614.

32. Lee WK, Bang HJ. The effects of mindfulness-based group intervention on the mental health of middle-aged Korean women in community. Stress Health. 2010;26(4):341-348.

33. Ljotsson B, Falk L, Vesterlund AW, et al. Internet-delivered exposure and mindfulness based therapy for irritable bowel syndrome—a randomized controlled trial. Behav Res Ther. 2010;48(6):531-539.

34. MacCoon DG, Imel ZE, Rosenkranz MA, et al. The validation of an active control intervention for mindfulness based stress reduction (MBSR). Behav Res Ther. 2012;50(1):3-12.

35. Mackenzie CS, Poulin PA, Seidman-Carlson R. A brief mindfulness-based stress reduction intervention for nurses and nurse aides. Appl Nurs Res. 2006;19(2):105-109.

36. Morone NE, Greco CM, Weiner DK. Mindfulness meditation for the treatment of chronic low back pain in older adults: a randomized controlled pilot study. Pain. 2008;134(3):310-319.

37. Mularski RA, Munjas BA, Lorenz KA, et al. Randomized controlled trial of mindfulness-based therapy for dyspnea in chronic obstructive lung disease. J Altern Complement Med. 2009;15(10):1083-1090.

38. Nyklicek I, Kuijpers KF. Effects of mindfulness-based stress reduction intervention on psychological well-being and quality of life: is increased mindfulness indeed the mechanism? Ann Behav Med. 2008;35(3):331-340.

39. Oken BS, Fonareva I, Haas M, et al. Pilot controlled trial of mindfulness meditation and education for dementia caregivers. J Altern Complement Med. 2010;16(10):1031-1038.

40. Palta P, Page G, Piferi RL, et al. Evaluation of a mindfulness-based intervention program to decrease blood pressure in low-income African-American older adults. J Urban Health. 2012;89(2):308-316.

41. Pbert L, Madison JM, Druker S, et al. Effect of mindfulness training on asthma quality of life and lung function: a randomised controlled trial. Thorax. 2012;67(9):769-776.

42. Pradhan EK, Baumgarten M, Langenberg P, et al. Effect of mindfulness-based stress reduction in rheumatoid arthritis patients. Arthritis Rheum. 2007;57(7):1134-1142.

43. Rimes KA, Wingrove J. Mindfulness-based cognitive therapy for people with chronic fatigue syndrome still experiencing excessive fatigue after cognitive behaviour therapy: a pilot randomized study. Clin Psychol Psychother. 2013;20(2):107-117.

44. Robert McComb JJ, Tacon A, Randolph P, Caldera Y. A pilot study to examine the effects of a mindfulness-based stress-reduction and relaxation program on levels of stress hormones, physical functioning, and submaximal exercise responses. J Altern Complement Med. 2004;10(5):819-827.

45. Robins CJ, Keng SL, Ekblad AG, Brantley JG. Effects of mindfulness-based stress reduction on emotional experience and expression: a randomized controlled trial. J Clin Psychol. 2012;68(1):117-131.

46. Schmidt S, Grossman P, Schwarzer B, Jena S, Naumann J, Walach H. Treating fibromyalgia with mindfulness-based stress reduction: results from a 3-armed randomized controlled trial. Pain. 2011;152(2):361-369.

47. Sephton SE, Salmon P, Weissbecker I, et al. Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia: results of a randomized clinical trial. Arthritis Rheum. 2007;57(1):77-85.

48. Shapiro S, Astin, JA, Bishop, SR, Cordova, M. Mindfulness-based stress reduction for health care professionals: results from a randomized trial. Int J Stress Manage. 2005;12(2):13.

49. Tacon AM, McComb J, Caldera Y, Randolph P. Mindfulness meditation, anxiety reduction, and heart disease: a pilot study. Family Community Health. 2003;26(1):25-33.

50. Thompson NJ, Walker ER, Obolensky N, et al. Distance delivery of mindfulness-based cognitive therapy for depression: project UPLIFT. Epilepsy Behav. 2010;19(3):247-254.

51. Timmerman GM, Brown A. The effect of a mindful restaurant eating intervention on weight management in women. J Nutr Educ Behav. 2012;44(1):22-28.

52. van der Lee ML, Garssen B. Mindfulness-based cognitive therapy reduces chronic cancer-related fatigue: a treatment study. Psychooncology. 2012;21(3):264-272.

53. Vieten C, Astin J. Effects of a mindfulness-based intervention during pregnancy on prenatal stress and mood: results of a pilot study. Arch Womens Mental Health. 2008;11(1):67-74.

54. Warnecke E, Quinn S, Ogden K, Towle N, Nelson MR. A randomised controlled trial of the effects of mindfulness practice on medical student stress levels. Med Educ. 2011;45(4):381-388.

55. Williams JM, Alatiq Y, Crane C, et al. Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: preliminary evaluation of immediate effects on between-episode functioning. J Affect Disorders. 2008;107(1-3):275-279.

56. Wong SY, Chan FW, Wong RL, et al. Comparing the effectiveness of mindfulness-based stress reduction and multidisciplinary intervention programs for chronic pain: a randomized comparative trial. Clin J Pain. 2011;27(8):724-734.

57. Wright LB, Gregoski MJ, Tingen MS, Barnes VA, Treiber FA. Impact of stress reduction interventions on hostility and ambulatory systolic blood pressure in African American adolescents. J Black Psychol. 2011;37(2):210-233.

58. Zautra AJ, Davis MC, Reich JW, et al. Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression. J Consult Clin Psychol. 2008;76(3):408-421.

59. Zernicke KA, Campbell TS, Blustein PK, et al. Mindfulness-based stress reduction for the treatment of irritable bowel syndrome symptoms: a randomized wait-list controlled trial. Int J Behav Med. 2013;20(3):385-396.

The majority of studies focused on adults (average age = 46.6), and the average total sample size per study was 67.7 (18-229). Females were included in roughly 75% of all studies, whereas males were included in roughly 25%. See Table 3 for full study characteristics.

Table 3.

Study Characteristics.

	Mean	SD	Min	Max
Group size	33.2	19.3	8	111
Intervention length (weeks)	7.8	1.9	2	12
Effect size (Hedges g)	0.53	0.66	−1	3
Total sample size	67.7	39.2	18	229
Immediate follow-up (weeks)	9.3	6	4	52
Number of men	17.2	24.4	0	117
Number of women	51.2	39.6	0	229
Age	46.6	14.1	15	75
Population	Percentage				Population	Percentage
Cardiovascular	16.9%				Caregiver	4.6%
Community-based	13.8%				Psychiatric	4.6%
Autoimmune	13.8%				Neurological	3.1%
Oncology	12.3%				Respiratory	3.1%
School	10.8%				Viral	1.5%
Musculoskeletal	9.2%				Transplantation	1.5%
Women’s health	4.6%
Primary Study Outcome	Percentage				Primary Study Outcome	Percentage
Anxiety	33.8%				Smoking cessation	3.1%
Stress	20.0%				Saturated fat intake	3.1%
Symptom bother	13.8%				Food craving	3.1%
Pain	10.8%				Body image	1.5%
Blood pressure	4.6%				Positive affect	1.5%
Depression	3.1%				Weight loss	1.5%
Study Condition	Percentage				Type of Mindfulness Intervention	Percentage
Mindfulness intervention	50.0%				Original MBSR	44.6%
Wait-list group	28.5%				Original MBCT	10.8%
Active control group	15.4%				Modified MBSR	23.1%
Usual care	6.2%				Other mindfulness interventions	13.8%
					Mindful Eating	4.6%
Smaller Versus Larger Group Sizes	Percentage				Group Performance	Percentage
Group had ≥20 participants	71.5%				Mindfulness significantly better	70.8%
Group had ≤19 participants	28.5%				Mindfulness control both significant	21.5%
					No significant differences between groups	7.7%
Intervention Length	Percentage
≥8 weeks	83.1%
Between 2 and 7 weeks	16.9%

Abbreviations: MBSR, mindfulness-based stress reduction; MBCT, mindfulness-based cognitive therapy.

Intervention and Control Condition Characteristics

See Tables 3 and 4 for details on intervention and control condition characteristics. The majority of studies reported using the original 8-week MBSR intervention¹¹ (44.6%) and a wait-list control condition (57%). Among weekly interventions (whether MBSR, MBCT, or an offshoot), the average course length was 7.8 weeks (2-12 weeks), with an 8-week or longer intervention being used in 83.1% of all studies. Outside of adjusting the course length, other components that were added to MBSR included things like qigong,³⁹ mindful parenting or teaching,⁴⁰ diet/exercise,^41,42 and mindful mothering,⁴³ and 2 studies relied on the Internet as a means of delivering the intervention.^44,45 Active controls consisted of things such as social support or support groups,⁴⁶ pharmacotherapy,⁴⁷ smoking cessation education,⁴⁸ life skills education,⁴⁹ health education,⁴⁹ massage,⁵⁰ relaxation training,⁵¹ stress and coping psychoeducation,⁵² and nutrition education.⁵³ In 70.8% of the studies, the mindfulness intervention was reported to be superior to controls (eg, significantly different in the hypothesized direction). In 22% of studies, both mindfulness and control conditions reported significant improvements, and in 8% of studies, neither mindfulness nor control reported significant changes in the primary outcomes.

Table 4.

Characteristics of Included Studies.

General Category	Specific Population	Author	Year	N	Intervention/Control	Primary Aim	Outcomes
Women’s Health	Disordered eating	Alberts	2012	26	8-Week modified mindfulness-based eating program (n = 12) vs wait-list control (n = 14)	Decrease disordered eating behavior in a female community sample	Intervention showed significantly lower levels of food cravings, dichotomous thinking, body dysfunction, emotional eating and external eating, as well as increase in mindfulness.
Cardiovascular	Weight management	Alberts	2010	19	All participants completed a 10-week weight management program followed by a 7-week mindfulness training program (n = 10) vs usual care control (n = 9)	Reduce food cravings in obese individuals	Intervention showed significantly lower food cravings, higher acceptance of food cravings, decreased preoccupation with food, and lower rating of perceived reinforcing value of food.
Community-Based (Adult)	Attention	Anderson	2007	72	8-Week MBSR (n = 39) vs wait-list control (n = 33)	Examine the role of sustained attention and related factors in the experience of mindfulness in a healthy adult community sample	No differences found between the 2 groups in terms of attentional control. However, the intervention group showed direct improvements in mindfulness and emotional well-being and indirect improvement in object detection.
Autoimmune/Psychosomatic	Fibromyalgia	Astin	2003	128	8-Week MBSR + Qigong training (n = 32) vs 8-week time/attention matched education and support control (n = 33)	Reduce myalgia and depression and improve physical functioning in primarily female fibromyalgia sufferers	Both the intervention and control groups showed comparable gains at postintervention, 16 and 24 weeks.
Caregiver	Special needs children	Benn	2012	60	5-Week (biweekly) mindfulness training based on MBSR + mindful parenting/teaching (n = 35) vs wait-list control (n = 35)	Improve psychological wellness in parents and educators of children with special needs	Intervention showed significantly greater reduction in stress and anxiety, increased mindfulness, self-compassion, personal growth, empathic concern and forgiveness, both at program completion and at the 2-month follow-up.
Oncology	Mixed cancer sample	Bränström	2010	71	8-Week modified MBSR (no daylong retreat; n = 32) vs wait-list control (n = 39)	Improve psychological well-being in mixed cancer patient sample	Intervention showed significantly larger reduction of psychological distress and increase in positive states of mind and mindfulness.
Cardiovascular	Smoking cessation and substance use	Brewer	2011	87	4-Week (biweekly) mindfulness intervention (n = 41) vs 4-week American Lung Association smoking cessation control (n = 46)	Decrease cigarette use in community-based sample of adult smokers	MBSR intervention showed significantly greater reduction of cigarettes smoked during treatment and posttreatment.
Oncology	Prostate cancer	Carmody	2008	36	11-Week dietary + mindfulness support intervention (n = 17) vs usual care (n = 19)	Change dietary habits to a plant-based diet + fish in men with prostate cancer	Intervention showed significantly greater dietary change and improved quality of life at 3 months. Percentage of vegetable protein intake and reduction in animal protein correlated with frequency of mindfulness practice.
Women’s Health	Hot flashes	Carmody	2011	110	8-Week MBSR (n = 57) vs wait-list control (n = 53)	Decrease bother from hot flashes and night sweats in menopausal women	Intervention resulted insignificantly less bother of hot flashes, anxiety, and perceived stress and greater improvements in quality of life and sleep quality at 3 months.
Cardiovascular	Weight management	Daubenmier	2011	47	9-Week mindfulness intervention adapted from MBSR, MBCT, and MB-EAT (n = 24) vs wait-list control (n = 23)	Reduce abdominal adiposity among overweight and obese women	Intervention showed significantly greater mindfulness, body responsiveness, and decreased anxiety and external eating. No group differences in cortisol, abdominal fat, fat distribution, and weight. Subgroup analyses indicated obese participants demonstrated significant improvements in cortisol and body weight when compared to their wait-list control counterparts.
Cardiovascular	Smoking cessation and substance use	de Dios	2011	34	2-Week mindfulness intervention (n = 22) vs control (n = 12)	Reduce marijuana use in community-based sample of female marijuana users	Intervention showed significantly less marijuana use, which was moderated by meditation frequency.
School/University-Based (Adult)	Psychological well-being	Delgado	2010	36	5-Week (biweekly) mindfulness training (n = 15) vs 5-week relaxation, education and support (n = 21)	Reduce chronic worry in a female undergraduate college student sample with high self-reported worry	Both groups showed reductions in anxiety, depression, and health complaints. The mindfulness group showed significantly higher levels of emotional meta-cognition and greater improvement in physiological states such as slower heart rate.
Musculoskeletal and Arthritic	Failed back surgery syndrome	Esmer	2011	25	8-Week MBSR + traditional therapy (n = 15) vs usual care control group (n = 10)	Improve quality of life in patients with failed back surgery syndrome	Intervention showed significantly greater pain acceptance, quality of life, and increased sleep quality and decreased functional limitation and pain level.
Oncology	Mixed cancer sample	Foley	2010	115	8-Week MBCT (n = 55) vs wait-list control (n = 60)	Decrease distress and improve quality of life among cancer patients	Intervention showed significantly less anxiety, depression, and distress and greater mindfulness at 10 weeks and 3 months.
School/University-Based (Pediatric)	Academic performance and self-concept	Franco	2011	60	10-Week mindfulness training (n = 31) vs wait-list control (n = 30)	Improve academic performance and self-concept and decrease anxiety among Spanish high school students	Intervention showed significantly greater improvements in academic achievement, self-concept, and anxiety.
Autoimmune/Psychosomatic	IBS	Gaylord	2011	75	8-Week MBSR (n = 36) vs social support matched control (n = 39)	Reduce irritable bowel syndrome symptoms, psychological distress, and visceral anxiety among female IBS patients	MBSR Intervention showed immediate, significant, and durable improvements in IBS symptom severity and delayed significant improvement in measures of quality of life, psychological distress, and visceral anxiety at 3 months.
Viral Disease	HIV	Gayner	2011	117	8-Week MBSR (n = 78) vs wait-list control (n = 39)	Manage affective symptoms and improve quality of life in gay men living with HIV	Intervention exhibited significantly lower behavioral avoidance and higher increases in positive affect and mindfulness at both posttreatment and 6-month follow up.
Psychiatric	Depression	Geschwind	2011	130	8-Week MBCT (n = 64) vs wait-list control (n = 66)	To increase momentary positive emotions for patients with a history of depression	Intervention showed significantly greater increased momentary positive emotions and greater appreciation of pleasant daily-life activities.
Community-Based (Adult)	Psychological well-being	Glück	2011	49	2-Week Web-based mindfulness training (n = 28) vs wait-list control (n = 21)	Improve psychological well-being in a community-based adult sample of primarily females	Feasibility of Web-based approach confirmed. No statistically significant group differences on outcomes.
Autoimmune/Psychosomatic	Insomnia	Gross	2011	30	8-Week MBSR (n = 18) vs pharmacotherapy (n = 9)	Compare MBSR to pharmacotherapy for chronic primary insomnia	Both MBSR and pharmacotherapy participants saw similar decreases in sleep onset latency and improvements in sleep quality both at 8 weeks and 5 months.
Transplantation	Solid organ recipients	Gross	2011	137	8-Week MBSR (n = 72) vs peer-lead health education control (n = 66)	Decrease distress and improve quality of life among solid organ transplant recipients	Intervention showed significantly lower depression, anxiety, and improved sleep quality of transplant patients, lasting throughout the year of the study.
Neurology	Health-related quality of life	Grossman	2010	150	8-Week MBSR (n = 76) vs usual care control (n = 76)	Decrease distress and improve quality of life among relapse–remitting or secondary progressive multiple sclerosis	Intervention showed significantly lower depression, anxiety and fatigue which remained significant at 6 months.
Cardiovascular	Diabetes	Hartmann	2012	110	8-Week MBSR (n = 53) vs usual care control (n = 57)	Reduce distress, nephropathy progression, and improve health in type 2 diabetes	Intervention showed significantly lower depression and stress and improved health status. No significant difference was found between groups in albuminuria.
Oncology	Prostate cancer	Hérbert	2011	47	12-Week diet, exercise, and mindfulness training (n = 26) vs wait-list control (n = 21)	Reduce tumor and disease progression markers in men with prostate cancer	No group differences were observed in disease-related measures. Intervention did show decreased saturated fatty acid, and energy intake while maintaining prostate-specific antigen levels.
Oncology	Breast cancer	Henderson	2011	216	8-Week MBSR (n = 53) vs nutrition education control (n = 52) vs usual care (n = 58)	Decrease distress and improve quality of life among breast cancer patients	MBSR intervention showed significantly greater benefit in psychosocial adjustment, meaningfulness, depression, hostility, anxiety, unhappiness, emotional control, and paranoid ideation as compared to both control groups at 4 months postintervention.
Oncology	Breast cancer	Hoffman	2012	229	8-Week MBSR (n = 103) vs waitlist control (n = 111)	Improve mood, breast- and endocrine-specific quality of life and well-being after hospital treatment in women with stage 0 to III breast cancer	Intervention showed significantly improved mood states, well-being, and disease-specific quality of life over 3-month follow-up.
Neurology	Health-related quality of life	Thompson	2010	53	8-Week MBCT via telephone or Internet (n = 26) vs wait-list control (n = 27)	Reduce psychological distress and increase quality of life among individuals diagnosed with epilepsy	Intervention showed significantly greater knowledge, skills, and reduction in depressive symptoms compared to the control group.
Community-Based (Adult)	Perceived control	Jacobs	2011	60	12-Week intensive mindfulness meditation retreat (n = 30) vs wait-list control (n = 30)	Increase telomerase activity and perceived control and decrease neuroticism in an intensive meditation sample	Intervention showed significantly greater telomerase activity increase, increase in perceived control. and a decrease in neuroticism.
School/University-Based (Adult)	Psychological well-being	Jain	2007	108	4-Week modified MBSR (n = 27) vs 4-week somatic relaxation (n = 24) vs usual care (n = 30)	Decrease psychological distress and ruminative thoughts and increase positive states of mind and spiritual perception among graduate nursing students	Both intervention groups showed significant decreases in distress and increases in positive state of mind versus the control. The mindfulness meditation group showed greater results for positive state of mind than for relaxation. It also showed a decrease in ruminative thoughts. No significant effects found on spiritual experience.
School/University-Based (Adult)	Psychological well-being	Kang	2009	41	8-Week mindfulness meditation training (n = 16) vs stress and coping lecture control (n = 16)	Decrease stress, anxiety, and depression among nursing students in Korea	Intervention group showed significantly lower stress levels and reduction in the anxiety. No significant difference in depression between groups.
School/University-Based (Adult)	Psychological well-being	Kaviani	2011	45	8-Week MBCT (n = 20) vs wait-list control (n = 25)	Decrease psychological distress among Iranian college students	Intervention showed significantly reduced levels of depression, anxiety, dysfunctional attitudes, and negative automatic thoughts.
Community-Based (Adult)	Psychological well-being	Klatt	2009	45	6-Week modified MBSR (n = 22) vs wait-list control (n = 20)	Reduce stress and increase mindfulness in healthy working adults	Intervention showed significantly lower stress and higher mindfulness. Both groups showed improved sleep.
Psychiatric	Depression	Lee	2010	60	8-Week MBCT (n = 30) vs wait-list control (n = 30)	Improve the psychological well-being of middle-aged Korean women who complained of depressed mood	Mindfulness and self-compassion both had significant increases. Psychological well-being and depression scores also improved.
Autoimmune/Psychosomatic	IBS	Ljótsson	2010	85	10-Week Internet-delivered cognitive behavioral/mindfulness group (n = 42) vs wait-list control (n = 43)	Decrease gastrointestinal distress and improve quality of life among community-based sample of Swedish women with irritable bowel syndrome	Intervention demonstrated significantly greater symptom reduction and improvements in quality of life at 3 months.
Cardiovascular	Heart disease	Tacon	2003	20	8-Week MBSR (n = 9) vs wait-list control (n = 9)	Reduce anxiety and improve stress management in women with heart disease	Intervention showed significantly lower anxiety and higher ability to control negative emotions, compared to control.
Community-Based (Adult)	Psychological well-being	MacCoon	2011	57	8-Week MBSR (n = 27) vs 8-week health enhancement program (n = 30)	Compare MBSR to structurally matched health enhancement intervention to determine MBSR’s unique effects in a community-based sample	MBSR intervention showed significantly higher pain threshold compared with health enhancement program over time. Both interventions showed similar decrease in distress and symptoms.
Community-Based (Adult)	Psychological well-being	Mackenzie	2006	30	4-Week modified MBSR (n = 16) vs wait-list control (n = 14)	Reduce stress and improve quality of life for nurses and nurse aides at a large, urban hospital for long-term geriatric patients and residents	Intervention showed significantly greater improvements in emotional regulation, self-awareness, and greater sense of work accomplished.
Musculoskeletal and Arthritic	Low back pain	Morone	2007	37	8-Week MBSR (n = 13) vs wait-list control (n = 17)	Decrease pain intensity and increase pain acceptance, quality of life and physical function in a community-based sample of older chronic low back pain sufferers	Intervention showed significantly greater improvements in physical function and overall pain experience over 3 months.
Respiratory	COPD	Mularski	2009	86	8-Week mindfulness based breathing therapy modified from MBSR (n = 44) vs a support group control (n = 42)	Improve respiratory symptoms and quality of life in patients with chronic obstructive lung diseases (COPD)	No group differences in dyspnea, health-related quality of life, or exacerbation rates were found. Support group showed better physical function.
Community-Based (Adult)	Psychological well-being	Nyklícek	2008	57	8-Week MBSR (n = 30) vs wait-list control (n = 30)	Improve psychological well-being and quality of life in community-based adult sample	Intervention showed significantly lower symptoms of distress and improved quality of life.
Caregiver	Dementia	Oken	2010	41	7-Week modified MBCT (n = 10) vs 3-hour weekly respite care control (n = 10) vs dementia caregiver educational group (n = 11)	Decrease stress and improve quality of life among caregivers of individuals with dementia	Both active interventions showed significantly less caregiver perceived stress compared to the respite care control; however, no other differences were observed.
Cardiovascular	Blood pressure	Palta	2012	20	8-Week MBSR (n = 12) vs social support control (n = 8)	Reduce blood pressure in a community sample of primarily female, low-income, African American adults	Intervention demonstrated significantly larger reductions in systolic and diastolic blood pressure compared to controls after 8 weeks.
Respiratory	Asthma	Pbert	2012	83	8-Week MBSR (n = 42) vs Health Living Course control (n = 41)	Reduce stress and anxiety in individuals who have asthma to improve their quality of life and lung function	Intervention showed significantly greater improvements in asthma-related quality of life, and significant decreases in self-perceived stress levels at their 12-month follow-up.
Musculoskeletal and Arthritic	Rheumatoid arthritis	Pradhan	2007	63	8-Week MBSR (n = 31) vs wait-list control (n = 32)	Reduce depressive symptoms and improve overall psychological status in individuals with rheumatoid arthritis	No immediate effect of intervention on outcomes; however, at 6 months intervention showed significant improvement in mindfulness and psychological status and significant decrease in depressive symptoms.
Autoimmune/Psychosomatic	Chronic fatigue syndrome	Rimes	2011	35	8-Week MBCT (n = 15) vs wait-list control (n = 19)	Reduce excessive fatigue after cognitive behavioral therapy among individuals with chronic fatigue syndrome	Intervention showed significantly lower levels of fatigue, which persisted at 2- and 6-month follow-up. MBCT group also exhibited significantly better outcomes on impairment, depressed mood, catastrophic thinking about fatigue, all-or-nothing behavioral responses, unhelpful beliefs about emotions, mindfulness and self-compassion.
Cardiovascular	Heart disease	Robert McComb	2004	18	8-Week MBSR (n = 9) vs wait-list control (n = 9)	Lower stress hormone levels and improve submaximal exercise responses in women with heart disease	No differences between groups in stress hormone levels, submaximal exercise responses, or overall physical functioning. Intervention showed significantly better ventilation and lower breathing frequency during exercise.
Community-Based (Adult)	Emotional regulation	Robins	2012	41	8-Week MBSR (n = 28) vs wait-list control (n = 28)	Improve emotional regulation among community-based adults	Intervention participants reported significantly decreased levels of absent-mindedness, emotional dysregulation, worry, emotional anxiety, and anger suppression/overexpression and reported significantly increased measures of mindfulness and self-compassion, which persisted through 2-month follow-up.
Autoimmune/Psychosomatic	Fibromyalgia	Schmidt	2011	221	8-Week MBSR (n = 53) vs muscle relaxation/stretching (n = 56) vs waitlist control (n = 59)	Improve quality of life and well-being in a community-based sample of females with fibromyalgia	No significant differences between groups in health-related quality of life. MBSR or relaxation/stretching reported greater reductions in anxiety postintervention. MBSR group showed significantly greater mindfulness when compared to other groups.
Autoimmune/Psychosomatic	Fibromyalgia	Sephton	2007	91	8-Week MBSR (n = 51) vs wait-list control (n = 40)	Alleviates depressive symptoms in community-based sample of women with fibromyalgia	Intervention showed significantly lower symptoms of depression compared to participants allocated to the control group.
Community-Based (Adult)	Psychological well-being	Shapiro	2005	28	8-Week MBSR (n = 19) vs wait-list control (n = 19)	Increase quality of life among health care professionals	Intervention reported significantly greater reductions in stress and increases in self-compassion.
Cardiovascular	Weight management	Timmerman	2012	35	6-Week mindfulness eating group (n = 19) vs wait-list control (n = 16)	Increase mindful restaurant eating awareness in women who eat out ≥3 times per week	Intervention demonstrated significantly greater improvements in weight, 3-day calorie and fat consumption, diet-related self-efficacy, and barriers to intake consumption while dining out.
Oncology	Mixed cancer sample	van der Lee	2010	83	9-Week MBCT (n = 59) vs wait-list control (n = 24)	Reduce chronic cancer-related fatigue in a sample of cancer survivors	Intervention participants demonstrated significantly lower fatigue and significantly higher reports of well-being, which persisted through 2 months.
Women’s Health	Pregnant/postpartum	Vieten	2008	31	8-Weekly mindfulness motherhood sessions (n = 13) vs waitlist control (n = 18). Mindfulness sessions focused on awareness of developing fetus, mindful labor pain/anxiety, and movement	Decrease stress and improve mood among community-based sample of pregnant or postpartum women	Intervention participants demonstrated significantly greater reductions in state anxiety as well as negative affect. At 3-month follow-up, these intergroup differences were no longer statistically significant.
School/University-Based (Adult)	Psychological well-being	Warnecke	2011	65	8-Week MBSR (n = 31) vs wait-list control (n = 34)	Decrease psychological stress among Australian medical students	Intervention participants reported significantly decreased perceived stress and anxiety. These improvements were maintained at 2-month follow-up assessment.
Psychiatric	Bipolar disorder	Williams	2008	55	8-Week MBCT (n = 14) vs waitlist control (n = 20)	Decrease between episode depression and anxiety in people with bipolar disorder	Intervention showed significantly improved anxiety in the bipolar group. Both bipolar and unipolar participants in the MBCT group exhibited lower residual depressive symptoms when compared to the wait-list group.
Musculoskeletal and Arthritic	Chronic pain	Wong	2011	99	8-Week MBSR (n = 51) vs active comparison control (n = 48) that focused on comprehensive chronic-pain education and support	Decrease pain intensity and distress and improve quality of life and mood among patients with chronic pain	While measures of pain intensity and pain distress improved significantly for both groups, there were no significant between-group differences in outcome.
Cardiovascular	Blood pressure	Wright	2011	156	12-Week MBSR-based Breathing Awareness Meditation (n = 35) vs Health Education (n = 44) vs Life Skills Training (n = 42)	Reduce hostility and 24-hour ambulatory blood pressure in African American adolescents	Both Breathing Awareness Meditation and Life Skills training resulted in significant decreases in hostility; however, in the Breathing Awareness Meditation group, reductions in hostility were related to lower systolic blood pressure and heart rate measures. These trends persisted in participants whose hostility measures continued to decrease from postintervention to final evaluation.
Musculoskeletal and Arthritic	Rheumatoid arthritis	Zautra	2008	147	8-Week mindfulness meditation and emotion regulation therapy (n = 41) vs cognitive behavioral therapy for pain (n = 30) vs education-only group (n = 43)	Reduce stress, pain, and depression and improve the quality of life for adults with rheumatoid arthritis	Cognitive behavior intervention participants showed greatest improvement in self-reported pain control, while cognitive behavioral and mindfulness showed more improvement in coping efficacy than education-only.
Autoimmune/Psychosomatic	IBS	Zernicke	2012	90	8-Week MBSR (n = 43) vs wait-list control (n = 47)	Decrease symptoms and improve quality of life in IBS	Intervention showed clinically significant improvements in symptom severity, reducing from severe to moderate levels of IBS. Intervention groups’ outcomes remained consistent through to 6-month follow-up. Over time, the wait-list control group showed slight, gradual improvement as well, probably due to the increased attention from the research group and the promise of potentially engaging in a helpful treatment.

Abbreviations: MBSR, mindfulness-based stress reduction; MBCT, mindfulness-based cognitive therapy; MB-EAT, mindfulness-based eating awareness training; IBS, irritable bowel syndrome; COPD, chronic obstructive pulmonary disease.

Risk of Bias

See Figure 1 for risk of bias assessment for each study. In all studies, risk of selection bias (based on allocation to the intervention), selective bias, or incomplete outcomes data was generally low. All included studies reported utilizing a random component in the sequence generation process. While a small number of studies reported allocation concealment and blinding of participants, personnel, and outcomes, it was not clear in the majority of studies whether these measures were taken. Using the Cochrane tool’s criteria, an unclear rating is suggested when insufficient information does not permit judgment of low risk or high risk. Considering that the majority of studies utilized a wait-list control group where blinding participants is not feasible, the majority of studies likely fall within the high-risk category; however, insufficient information is available.

Figure 1.

Risk of Bias Assessment

Outcome Measures and Domains

A variety of different outcome measures were used in the included studies; however, the most common were measures to assess self-reported anxiety (33.8%) and perceived stress (20%) (see Tables 4 and 5).

Table 5.

Study Measurement Tools and Domains Assessed.

Measurement Tool or Method	Domain	Number of Studies Used
24-Hour Dietary Recall Nutrition Data System	Saturated Fat	1
4-Point Hot Flash Bother Rating	Hot Flash Bother	1
7-Item Positive Affect Adjective Scale	Positive Affect	1
Average Number of Cigarettes Smoked	Cigarettes Smoked	2
Beck Anxiety Inventory	Anxiety	3
Beck Depression Inventory	Depression	2
Blood Pressure Cuff	Systolic Blood Pressure	2
Body Shape Questionnaire	Body Image Concern	1
Brief Symptom Inventory	Global Symptom Severity	1
Chalder Fatigue Scale	Fatigue	1
Checklist Individual Strength Fatigue Severity Subscale	Fatigue	1
Dutch Eating Behavior Questionnaire	Emotional Eating	1
Fibromyalgia Impact Questionnaire	Fibromyalgia Pain	1
General Food Craving Questionnaire–Trait	Emotional Food Cravings	1
Hamilton Anxiety Rating Scale	Anxiety	1
Hospital Anxiety & Depression Scale–Anxiety	Anxiety	1
Insomnia Severity Index	Insomnia	1
Irritable Bowel Syndrome Severity Scale	Irritable Bowel Syndrome Symptom Severity	2
Likert Scale Pain Intensity Rating	Pain	1
Maslach Burnout Inventory	Emotional Exhaustion	1
McGill Pain Questionnaire	Low Back Pain	1
Modified Borg Dyspnea Scale	Dyspnea	1
Neo-5 Neuroticism	Neuroticism	1
Pain Intensity Numeric Rating Scale	Pain	2
Patient Health Questionnaire Stress Score	Perceived Stress	1
Penn State Worry Questionnaire	Worry	1
Perceived Stress Scale	Perceived Stress	10
Profile Of Mood States Tension/Anxiety	Tension/Anxiety	1
Saturated Fat Intake	Saturated Fat Intake	1
State Trait Anxiety Inventory	Anxiety	8
Summary VAS for Pain	Pain	1
Symptom Check List-90-Revised Anxiety	Anxiety	2
Visceral Sensitivity Index	GI Anxiety	1
Weight Scale	Weight Loss	1

Effect Size Variability Across Studies and Study Characteristics

See Table 6 for the average effect size variation across study characteristics and Figure 2 for effect sizes and 95% confidence intervals by primary outcome and population. Within the different mindfulness interventions delivered, we first examined the total effect of allocation to study condition (mindfulness, wait-list/usual care, or active control) on effect size variability in primary outcomes. Overall, mindfulness interventions were significantly different to all other conditions (P < .01) with a large pooled effect size compared to weak effects for waitlist and usual care groups (.1 and .2, respectively) and moderate effects for active control conditions (.5). The active control condition effect size was also significantly stronger compared to the waitlist/usual care. The assumption that all effect sizes were estimating the same population mean (eg, homogeneity) was not met however, indicating heterogeneity of variance within these studies.

Table 6.

Average Effect Size Variation Across Study Characteristics^a.

	Mindfulness			Wait-List/Usual Care			Active Control
	Effect Size	SD	n	Effect Size	SD	n	Effect Size	SD	n	Homogeneity	Sig	Pairwise Comparisons
All Studies	0.9	0.6	65	0.1	0.3	44	0.6	0.9	21	<.05	<.01	Mindfulness sig better than wait-list/usual care and active control; Active control significantly better than waitlist/usual care
Primary outcomes
Diet and Weight Management	0.9	0.5	6	0.0	0.3	6	NA	NA	0	>.05	<.01	Mindfulness significantly better than wait-list/usual care
Negative Affect	0.7	0.5	38	0.1	0.3	30	0.1	0.4	8	<.05	<.01	Mindfulness significantly better than all groups
PAIN	1.2	1.0	7	0.0	0.1	2	1.1	1.0	5	<.05	>.05	No significant group differences
Smoking and Substance Use	1.5	1.2	2	0.1	NA	1	1.7	NA	1	>.05	>.05	No significant group differences
Symptom Burden	1.1	0.6	9	0.2	0.4	5	0.9	1.1	4	>.05	<.05	Mindfulness sig better than all groups
Cardiovascular	0.5	0.2	3	NA	NA	0	0.1	0.1	3	<.05	<.01	Mindfulness sig better than active control
Types of mindfulness interventions used
Original MBSR	0.8	0.6	29	0.2	0.2	19	0.4	0.8	10	<.05	<.01	Mindfulness significantly better than all groups
Original MBCT	0.9	0.4	7	0.0	0.5	7	NA	NA	0	>.05	>.05	Mindfulness significantly better than wait-list/usual care
Modified MBSR	1.1	0.7	15	0.1	0.3	7	1.0	1.0	8	<.05	<.05	Mindfulness and Active Control significantly better than wait-list/usual care
Modified MBCT	0.7	0.8	2	0.5	NA	1	−0.3	NA	1	>.05	>.05	No significant group differences
Mindful eating	0.5	0.6	3	0.0	0.1	2	−0.1	NA	1	<.05	>.05	No significant group differences
Other mindfulness interventions	0.6	0.3	9	0.1	0.2	8	0.4	NA	1	>.05	<.01	Mindfulness significantly better than wait-list/usual control
Proportions per group
<19 per group	0.8	0.5	19	0.0	0.2	13	0.3	1.2	5	>.05	<.01	Mindfulness significantly better than wait-list/usual care and active control
>20 per group	0.9	0.6	46	0.2	0.3	31	0.6	0.8	16	<.05	<.01	Mindfulness significantly better than wait-list/usual care and active control; Active Control significantly better than wait-list/usual care
Lengths of intervention
2-7 Weeks of intervention	1.1	0.9	11	0.1	0.3	8	1.0	0.7	3	<.05	<.01	Mindfulness is significantly better than wait-list/usual care
>8 Weeks of intervention	0.8	0.5	54	0.1	0.3	36	0.5	0.9	18	<.05	<.01	Mindfulness significantly better than all groups

All analyses weighted by sample size; pairwise comparisons done with least squared differences statistic.

Figure 2.

Effect Sizes and 95% Confidence Intervals by Primary Outcome and Population.

Next, we examined whether effect sizes differed by type of primary outcome. To organized this varied literature, we first grouped study outcomes into the following 6 thematic categories: Diet and Weight Management (body image concern, emotional food cravings, emotional eating, saturated fat intake, and weight loss); Negative Affect (anxiety, perceived stress, hostility, tension, neuroticism, emotional exhaustion, and worry); Pain (general pain, fibromyalgia pain, and low back pain); Smoking and Substance Use (number of tobacco cigarettes smoked and number of marijuana cigarettes smoked); Symptom Burden (hot flash bother, irritable bowel syndrome symptoms, insomnia, global symptom severity, dyspnea, and fatigue); and Cardiovascular (systolic blood pressure). The homogeneity assumption was met for 3 categories (Diet and Weight Management; Smoking and Substance Use; and Symptom Burden), of which 2 demonstrated statistically significant differences. Diet and Weight Management (P < .01) and Symptom Burden (P < .05) effect sizes were each significantly more robust for mindfulness (.9 and 1.1, respectively) compared with all other groups (see Figure 3).

Figure 3.

Effect Size Differences Between Condition and Primary Outcome.

When comparing different types of mindfulness interventions delivered, the original MBSR group effect size (g = .8) was significantly larger compared to wait-list/usual care (g = .2) and active control (g = .4); however, homogeneity of variance assumptions were not met. Of all types of mindfulness interventions delivered, the only group where the homogeneity assumption was met and demonstrated a significant difference was in “other mindfulness interventions” where mindfulness had significantly larger effect sizes (g = .6) compared with the wait-list/usual care condition (g = .1). This “other” category was made up of studies focusing on diet and weight management (22%), negative affect (67%), and smoking and substance use (11%) (see Figure 4).

Figure 4.

Effect Size Differences Between Condition and Type of Mindfulness Intervention.

Next, we compared effect size differences between studies with 19 or less participants in a group with those that had 20 or more per group. In both the “19 or less” and “20 or more” groups, the mindfulness condition had significantly larger effect sizes (P < .01) compared with the wait-list/usual care and active control groups; however, the homogeneity assumption was only met in the “19 or less” group (g = .8). In addition, the active control also had significantly higher effect sizes (P < .01; g = .6) compared to the wait-list/usual care group in the “20 or more” group; however, the homogeneity assumption was not met (see Figure 5).

Figure 5.

Effect Size Differences Between Condition and Group Size.

Finally, we compared the possible effect size differences when the number of weeks of the mindfulness intervention was relatively less (eg, between 2 and 7 weeks) or more (eg, 8 weeks or more). The mindfulness condition had significantly larger effect sizes than the wait-list/usual care groups (P < .01; g = 1.1) in both intervention periods and was also significantly larger than the active control conditions in the “8 weeks or more” (P < .01; g = .8). The homogeneity assumption was not met for either the “2 to 7 week” or “8 weeks or more” comparisons (see Figure 6).

Figure 6.

Effect Size Differences Between Condition and Weeks.

Discussion

Overall, this systematic review and meta-analysis found partial evidence for mindfulness-based interventions to provide short-term benefits across a wide range of lifestyle medicine–relevant populations and study outcomes, particularly focusing on the areas of diet and weight management and symptom burden. Mindfulness-based interventions are inherently lifestyle medicine interventions that have the potential to address a wide range of issues, from disease prevention and health promotion to chronic disease management.

Wait-list conditions were the predominant control group in the included studies, and our meta-analytic findings suggest that mindfulness interventions are superior to no treatment at all, or simply the passage of time. Being placed on a wait-list may be demoralizing for the person who does not want to wait (possibly influencing their outcome scores negatively), or create a positive expectancy effect knowing that their turn is coming (possibly influencing their outcome scores positively). Using wait-list controls is understandable in behavioral medicine research, especially in the early, pilot testing of an intervention where the primary aim is feasibility, acceptability, and safety. However, given the apparent viability and tolerability of mindfulness interventions, as evidenced by their widespread application across numerous different populations and conditions, continued efforts should be made to develop, test, and use good active control conditions (eg, MacCoon et al.’s⁵⁴ Health Enhancement Training) to mirror the social-emotional and educational components of MBSR and similar courses. While these multiweek mindfulness courses are not intended to be “support groups,” they are undoubtedly “supportive” to many, and therefore a formidable placebo condition would allow the unique effects of mindfulness training to be more exquisitely examined.

While relatively small sample sizes can be observed across many of the included studies, our empirical findings suggest that this has not affected the power to detect statistically significant findings or risk type II errors, nor has it contributed to comparably smaller effect sizes. Similarly, modifying MBSR in different ways to the original 8-week course continued to produce large effect sizes across studies.

Compared to other medical social science disciplines, the use of eHealth as a tool for the delivery of mindfulness interventions was comparatively small in our review. Provided current trends in the use of technology-based self-management interventions,^55,56 this delivery method will undeniably increase over time. Instead of applying a one-size-fits all design/development/delivery approach from other fields such as behavioral or preventive medicine, mindfulness researchers will benefit from exploring novel informatics applications that parallel the specific intricacies and mechanisms of the mindfulness construct itself, so that intervention and method of delivery go hand in hand.

We also observed that the vast majority of studies conducted with US patient samples were with English-speaking, Caucasian, female participants. Mindfulness interventions have tremendous potential to affect real change in health disparities that involve modifiable, lifestyle medicine-relevant outcomes. Continued efforts should be made to further develop, refine, culturally tailor, validate, and empirically examine the effects of mindfulness interventions with non-English-speaking patient groups to address these issues.

This study is not without limitations. First, publication bias was not examined across included studies. Second, as can be seen in Figure 1, many studies failed to report important risk of bias criteria, specifically allocation of concealment, blinding of participants, and blinding of outcomes. While these are important factors for mindfulness researchers to include, it is also understandable that given the unique qualities of a mindfulness intervention, concepts such as blinding do not necessarily apply when the control group is a wait-list, which several of these studies utilized. Future mindfulness RCTs that utilize active or matched controls will add rigor to the body of empirical evidence on these interventions by continuing to abide by and improve on design and reporting standards. A third limitation is that for several of the analytic comparisons, the homogeneity of variance assumption was not met, which indicates that more variation may have been present in the comparison of combined effects than from mere chance alone. For this reason, we used a random effects approach; however, caution should be taken when interpreting results from significant comparisons where the assumption was not met.

Conclusion

This systematic review and meta-analysis found partial evidence of the short-term effectiveness of largely wait-list-controlled mindfulness-based interventions applied to a variety of lifestyle medicine–relevant contexts. Examples including the benefits of mindfulness interventions in managing symptom burden and affecting important modifiable health behaviors such as smoking and eating practices. This analysis also provides evidence for mindfulness-based interventions that have fewer than 20 individuals per group, as well as partial support for interventions that are less than the standard 8 weeks in duration.

Based on our findings and the overall characteristics of these studies, recommendations for future mindfulness intervention trials include the following: (a) utilizing reliable, active control conditions when appropriate; (b) providing greater transparently of Cochrane risk of bias criteria as it allows; (c) actively shaping how intervention delivery will be the most effective for mindfulness trials, whether in face-to-face or eHealth modes, and (d) increasing enrollment and participation of non-White/English speaking samples, and (e) working to make mindfulness interventions more accessible and culturally relevant for ethnically diverse and non-English speaking samples of individuals affected by lifestyle-perpetuated health disparities.

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Mindfulness Meditation to Promote Wellness and Manage Chronic Disease

Abstract

Keywords

Methods

Literature Search and Strategy

Eligibility Criteria

Interventions

Study Type

Patients Populations and Relevance to Lifestyle Medicine

Data Extraction

Study Quality and Risk of Bias

Data Summary and Analysis

Results

Literature Search

Study, Setting, and Patient Characteristics

Intervention and Control Condition Characteristics

Risk of Bias

Outcome Measures and Domains

Effect Size Variability Across Studies and Study Characteristics

Discussion

Conclusion

References