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Spreckley M, de Lange J, Seidell J, Halberstadt J. Primary care-led weight-management intervention: qualitative insights into patient experiences at one-year follow up. Int J Qual Stud Health Well-being 2023; 18:2256669. [PMID: 37703440 PMCID: PMC10501160 DOI: 10.1080/17482631.2023.2256669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 09/05/2023] [Indexed: 09/15/2023] Open
Abstract
INTRODUCTION The global prevalence of overweight and obesity is continuously increasing. Long-term weight loss results remain disappointing. This study aims to identify factors and strategies for successful long-term weight loss in a primary care-led weight-loss intervention from the perspective of participants. MATERIALS AND METHODS This qualitative interview study is the first follow-up study in a 2-year study series of participants with overweight or obesity. Methods utilized are semi-structured interviews (n = 20) with quantitative self-description. The data were transcribed from audio-taped interviews and analysed thematically. RESULTS This study found that clear, continuously evolving self-monitoring strategies facilitated by strong routines and a long-term focus enhanced successful outcomes. Challenges faced included stress, disappointment and loss of routine along with external criticism and discouragement. Benefits experienced due to weight loss included improved health, self-esteem, communal support and encouragement, which continued to fuel motivation. Receiving continuous support and encouragement from healthcare practitioners was instrumental for long-term success. CONCLUSION This study highlighted the complex, multifaceted experiences patients encounter in the pursuit of trying to achieve long-term weight loss. Personalized treatment protocols taking into account the diverse requirements and circumstances of individuals have the potential to improve treatment outcomes. Continuous, professional support may enhance long-term outcomes.
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Affiliation(s)
- Marie Spreckley
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Judith de Lange
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jaap Seidell
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jutka Halberstadt
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Saadati K, Jahangasht Ghoozlu K, Chaboksavar F, Shamsalinia A, Kordbageri MR, Ghadimi R, Parvizi S, Ghaffari F. Evaluation of psychometric properties of the eating restriction questionnaire and food involvement inventory in Iranian adults. Sci Rep 2023; 13:13553. [PMID: 37599286 PMCID: PMC10440337 DOI: 10.1038/s41598-023-39885-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 08/01/2023] [Indexed: 08/22/2023] Open
Abstract
The objectives of this study were to translate and validate the Persian version of the food involvement inventory (FII) and eating restriction questionnaire (ERQ) and to determine the measurement invariance based on gender, body mass index (BMI) status, and age. This cross-sectional study included 1100 Iranian adults. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to evaluate the construct validity of FII and ERQ. Convergent and discriminant validity, measurement invariance in gender, BMI and age, reliability including internal consistency, and stability were investigated for FII and ERQ. The results showed that the four-factor construct of the FII and the one-factor construct of the ERQ were 44.27% and 55.12% of the total variance, respectively. The factor loadings of all items were > .3 in both scales and none of the items were deleted. Fitting indices indicated that the four-factor construct of the FII and the one-factor construct of the ERQ had a good and acceptable fit among the Iranian adults. The Persian versions of the FII and ERQ, translated into Persian and localized according to international standards, had high construct, convergent and discriminant validity as well as high reliability.
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Affiliation(s)
- Kiyana Saadati
- Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Khadije Jahangasht Ghoozlu
- Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Islamic Republic of Iran
| | - Fakhreddin Chaboksavar
- Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Islamic Republic of Iran
| | - Abbas Shamsalinia
- Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Islamic Republic of Iran
| | | | - Reza Ghadimi
- Social Determinants of Health Research center, Health Research Institute, Babol University of Medical Sciences, Babol, Islamic Republic of Iran
| | - Shabnam Parvizi
- Babol University of Medical Sciences, Babol, Islamic Republic of Iran
| | - Fatemeh Ghaffari
- Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Islamic Republic of Iran.
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Annesi JJ. Theory to treatment to theory: Evolving a community-based obesity intervention. EVALUATION AND PROGRAM PLANNING 2023; 98:102270. [PMID: 36921406 DOI: 10.1016/j.evalprogplan.2023.102270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 03/06/2023] [Indexed: 05/17/2023]
Abstract
Within weight-loss treatments, a better understanding of psychosocial correlates of exercise and controlled eating is required to improve lagging outcomes. Within this two-phase study, women with obesity participating in community-based treatments with educational (Phase 1 n = 57, Phase 2 n = 44) and behavioral (Phase 1 n = 80, Phase 2 n = 53) formats were contrasted on psychosocial variables over 3 and 6 months and their interrelations based on the mood-behavior-model and coaction theory. Phase 1 findings informed curricular extensions in Phase 2. In Phase 1, there were significant overall improvements in total mood disturbance, self-regulation of exercise, self-regulation of eating, and weight, which were more pronounced in the behavioral vs. educational format group (-3.5 % vs. -1.4 % weight loss, respectively). Mediation analyses indicated that change in self-regulation of exercise mediated the prediction of change in self-regulation of eating by mood change. Phase 2 findings were similar; however, effect sizes were greater (-6.2 % vs. -2.9 % weight loss, respectively). Within both phases, increased self-regulation of eating significantly predicted weight reduction. Paths from changes in mood→self-regulation of exercise→self-regulation of eating suggested future program attention focus on treatment-associated mood change reinforcing self-regulation, and self-regulation generalizing from an exercise to eating context. Methods of progressing treatment curricula via theory-testing were suggested.
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Affiliation(s)
- James J Annesi
- University of Alabama at Birmingham, School of Health Professions, Birmingham, AL, USA; California State University, Monterey Bay, Seaside, CA, USA; Central Coast YMCA, Monterey, CA, USA.
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Uncovering Barriers and Facilitators of Weight Loss and Weight Loss Maintenance: Insights from Qualitative Research. Nutrients 2023; 15:nu15051297. [PMID: 36904294 PMCID: PMC10005538 DOI: 10.3390/nu15051297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/02/2023] [Accepted: 03/04/2023] [Indexed: 03/08/2023] Open
Abstract
Long-term weight loss maintenance is often difficult to achieve. This review analysed qualitative data on self-perceived barriers and facilitators of weight loss and weight loss maintenance among weight loss intervention participants. A literature search was conducted using electronic databases. Qualitative studies written in English and published between 2011-2021 were eligible for inclusion if they explored the perspectives and experiences of individuals who received standardised dietary and behavioural support for weight loss. Studies were excluded if weight loss was achieved through self-directed methods, only increasing physical activity, or surgical or pharmacological interventions. Fourteen studies were included, totaling 501 participants from six countries. Thematic analysis was used to identify four aggregate themes: internal factors (i.e., motivation and self-efficacy), programme-specific factors (i.e., the intervention diet), social factors (i.e., supporters and saboteurs), and environmental factors (i.e., an obesogenic environment). Our findings demonstrate that internal, social, and environmental factors all influence weight loss success, as well as the acceptability of the weight loss intervention. Future interventions may be more successful if they prioritise participant acceptability and engagement by, for example, providing tailored interventions, a structured relapse management plan, strategies to enhance autonomous motivation and emotional self-regulation, and extended contact during weight loss maintenance.
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Jones RA, Richards R, Palat R, Hughes C, Hill AJ, Vincent A, Griffin SJ, Ahern AL, Duschinsky R. Participants' experiences of mental health during a COVID-19 tailored ACT-based behavioural weight management intervention: a qualitative study. Int J Qual Stud Health Well-being 2022; 17:2123093. [PMID: 36097888 PMCID: PMC9481081 DOI: 10.1080/17482631.2022.2123093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2022] [Indexed: 10/27/2022] Open
Abstract
PURPOSE We aimed to explore participants' experiences of mental health during an acceptance and commitment therapy (ACT)-based guided self-help intervention to support weight management in adults with overweight or obesity during the COVID-19 pandemic (SWiM-C: Supporting Weight Management during COVID-19). METHODS We conducted semi-structured telephone interviews with twenty participants and used reflexive thematic analysis to identify patterns of meaning across the dataset relevant to mental health. RESULTS Four themes were conceptualized: i) Mental health changes associated with SWiM-C, ii) External factors negatively impacted mental health and intervention engagement, iii) Use and impact of coping responses, and iv) Intervention preferences based on psychological needs. CONCLUSIONS Findings suggest that participants were exposed to multiple factors, both related to and external to the intervention, that negatively impact their mental health, yet ACT-based aspects of the SWiM-C intervention appeared to support participants to adaptively manage the decline in their mental health. The findings can be used to inform the development of future weight management interventions, such as through intervention personalization and the inclusion of more strategies that target emotional regulation.Trial registration: ISRCTN 12107048, https://www.isrctn.com/ISRCTN12107048.
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Affiliation(s)
| | | | - Roshni Palat
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Carly Hughes
- Fakenham Medical Practice, Norfolk, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Andrew J Hill
- Division of Psychological & Social Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - Ann Vincent
- Department of Medicine, University College London, London, UK
| | - Simon J Griffin
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Amy L. Ahern
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Robbie Duschinsky
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Spreckley M, de Lange J, Seidell JC, Halberstadt J. Patient insights into the experience of trying to achieve weight-loss and future expectations upon commencement of a primary care-led weight management intervention: A qualitative, baseline exploration. PLoS One 2022; 17:e0270426. [PMID: 35767563 PMCID: PMC9242434 DOI: 10.1371/journal.pone.0270426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/09/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction The long-term effects of interventions aiming to achieve substantial, sustainable weight loss maintenance have been disappointing. Most people regain their lost weight over time but some seem to be able to maintain their weight loss. We are following the experiences of patients over time prospectively. This study forms the baseline to provide insights into patient experiences prior to entering a primary care-led weight management intervention and their expectations going forward. Materials and methods We recruited 21 adult male and female patients of varying ethnicity with a BMI between 27.7kg/m2 and 48.4kg/m2 from a cohort of patients entering a primary care-led weight management intervention. Patients were offered video and audio interview options during the COVID-19 lockdown. In total, twenty chose the audio option, while one chose the video option. The interview format was semi-structured with room for individual exploration. Discussion We found that participants experienced feeling unable to control their weight and encountered a multitude of internal and external barriers to weight management. Some had supportive environments, while others experienced discouraging external influences. Though personal characteristics varied, motivations, goals and expected benefits were similar across this cohort. Most participants had previously experienced transient successful weight-loss attempts with varying approaches. COVID-19 was experienced as an opportunity or barrier for change. Conclusion This study illustrates the importance of gaining comprehensive insights into the diverse experiences patients encounter when trying to achieve weight loss. Personalized support taking into account individual experiences and circumstances may enhance long-term treatment outcomes. Future research into the complexities of weight management based on individual accounts can aid in the creation of improved treatment protocols.
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Affiliation(s)
- Marie Spreckley
- Faculty of Science, Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
- * E-mail:
| | - Judith de Lange
- Faculty of Science, Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Jacob C. Seidell
- Faculty of Science, Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Jutka Halberstadt
- Faculty of Science, Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
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Salvo V, Sanudo A, Kristeller J, Schveitzer MC, Martins P, Favarato ML, Demarzo M. Mindful eating for overweight and obese women in Brazil: An exploratory mixed-methods pilot study. Nutr Health 2021; 28:591-601. [PMID: 34913753 DOI: 10.1177/02601060211052794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Worldwide, approximately 95% of obese people who follow diets for weight loss fail to maintain their weight loss in the long term. To fill this gap, mindfulness-based interventions, with a focus on mindful eating, are promising therapies to address this challenging public health issue. Aim: To verify the effects of the Mindfulness-Based Eating Awareness Training (MB-EAT) protocol by exploring quantitative and qualitative data collected from Brazilian women. Methods: A single-group, mixed-methods trial was conducted at a public university with adult women (n = 34). Four MB-EAT groups were offered weekly for 2.5-h sessions over 12 weeks. Pre- and post-intervention assessments included body mass index (BMI) and self-report measures of anxiety, depression, mindfulness, self-compassion, and eating behaviour. Qualitative information was collected using focus groups in the last session of each group, including both participants and MB-EAT instructors. The qualitative data were examined using thematic analyses and empirical categories. Results: Twenty participants (58.8%) completed both pre- and post-intervention assessments, with adequate attendance (≥4 sessions). There was a significant average decrease in weight of 1.9 ± 0.6 kg from pre- to post-intervention. All participants who had scored at the risk level for eating disorders on the EAT-26 decreased their score below this risk level. Qualitative analysis identified that participants were able to engage a more compassionate perspective on themselves, as well as greater self-awareness and self-acceptance. Conclusion: The MB-EAT showed preliminary efficacy in promoting weight loss and improvements in mindfulness and eating behaviour. This intervention promoted effects beyond those expected, extending to other life contexts.
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Affiliation(s)
- Vera Salvo
- Mente Aberta, Brazilian Center for Mindfulness and Health Promotion, 58804Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Adriana Sanudo
- Department of Preventive Medicine, 58804Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | | | - Mariana Cabral Schveitzer
- Department of Preventive Medicine, 58804Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Patricia Martins
- Mente Aberta, Brazilian Center for Mindfulness and Health Promotion, 58804Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Maria Lucia Favarato
- Mente Aberta, Brazilian Center for Mindfulness and Health Promotion, 58804Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marcelo Demarzo
- Mente Aberta, Brazilian Center for Mindfulness and Health Promotion, 58804Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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Spreckley M, Seidell J, Halberstadt J. Perspectives into the experience of successful, substantial long-term weight-loss maintenance: a systematic review. Int J Qual Stud Health Well-being 2021; 16:1862481. [PMID: 33455563 PMCID: PMC7833027 DOI: 10.1080/17482631.2020.1862481] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Purpose: In light of the increasing prevalence of overweight and obesity, understanding the experiences, strategies and challenges encountered when trying to achieve substantial, sustainable weight loss is an important area to investigate. We systematically evaluated qualitative studies focusing on the accounts of individuals who have achieved sustained weight loss to create a comprehensive picture of the experience of sustainable weight loss. Methods: Included studies were peer-reviewed studies that qualitatively assessed the views and experiences of adults who previously had or currently have overweight or obesity who successfully lost weight and who subsequently maintained or regained weight. The evidence was systematically synthesized, which enabled the formulation of clear themes and recommendations. Results: The 15 chosen studies included the accounts of 294 individuals. We found that continuous monitoring and goal setting, driven by sustained motivation and encouraging experiences, while resisting ever present challenges and enduring discouraging experience encapsulates the experience of sustained, substantial weight loss. Conclusions: This review aims to provide a comprehensive understanding of the experiences, strategies and challenges encountered when trying to achieve substantial, sustained weight loss. Additional research taking into account findings from this review and others of its kind will enhance the formulation of treatment protocols.
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Affiliation(s)
- Marie Spreckley
- Faculty of Science, Department of Health Sciences, Vrije Universiteit Amsterdam , Amsterdam, Netherlands
| | - Jaap Seidell
- Faculty of Science, Department of Health Sciences, Vrije Universiteit Amsterdam , Amsterdam, Netherlands
| | - Jutka Halberstadt
- Faculty of Science, Department of Health Sciences, Vrije Universiteit Amsterdam , Amsterdam, Netherlands
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Hoge EA, Acabchuk RL, Kimmel H, Moitra E, Britton WB, Dumais T, Ferrer RA, Lazar SW, Vago D, Lipsky J, Schuman-Olivier Z, Cheaito A, Sager L, Peters S, Rahrig H, Acero P, Scharf J, Loucks EB, Fulwiler C. Emotion-related constructs engaged by mindfulness-based interventions: A systematic review and meta-analysis. Mindfulness (N Y) 2021; 12:1041-1062. [PMID: 34149957 PMCID: PMC8210838 DOI: 10.1007/s12671-020-01561-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Mindfulness-based interventions (MBIs) have been widely implemented to improve self-regulation behaviors, often by targeting emotion-related constructs to facilitate change. Yet the degree to which MBIs engage specific measures of emotion-related constructs has not been systematically examined. METHODS Using advanced meta-analytic techniques, this review examines construct and measurement engagement in trials of adults that used standardized applications of the two most established MBIs: Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT), or modified variations of these interventions that met defined criteria. RESULTS Seventy-two studies (N=7,378) were included (MBSR k=47, MBCT k = 21, Modified k=4). MBIs led to significant improvement in emotion-related processing overall, compared to inactive controls (d=0.58; k =36), and in all constructs assessed: depression (d=0.66; k=26), anxiety (d =0.63; k=19), combined mental health (d =0.75; k=7 ) and stress (d =0.44; k=11). Reactions to pain, mood states, emotion regulation, and biological measures lacked sufficient data for analysis. MBIs did not outperform active controls in any analyses. Measurement tool and population-type did not moderate results, but MBI-type did, in that MBCT showed stronger effects than MBSR, although these effects were driven by a small number of studies. CONCLUSIONS This review is the first to examine the full scope of emotion-related measures relevant to self-regulation, to determine which measures are most influenced by MBCT/MBSR. Compared to extant reviews, which typically focused on MBI outcomes, this work examined mechanistic processes based on measurement domains and tools. While effect sizes were similar among measurement tools, this review also includes a descriptive evaluation of measures and points of caution, providing guidance to MBI researchers and clinicians for selection of emotion-related measurement tools.
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Affiliation(s)
- Elizabeth A. Hoge
- Department of Psychiatry, Georgetown University School of Medicine, 2115 Wisconsin Ave NW Suite 200, Washington, DC 20007, USA
| | - Rebecca L. Acabchuk
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, 06269, USA
| | - Hannah Kimmel
- School of Public Health, Brown University, 121 South Main Street, Providence, Rhode Island 02903, USA
| | - Ethan Moitra
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, 700 Butler Dr., Providence, RI 02906, USA
| | - Willoughby B. Britton
- School of Public Health, Brown University, 121 South Main Street, Providence, Rhode Island 02903, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, 700 Butler Dr., Providence, RI 02906, USA
| | - Travis Dumais
- School of Public Health, Brown University, 121 South Main Street, Providence, Rhode Island 02903, USA
| | - Rebecca A. Ferrer
- Basic Biobehavioral and Psychological Sciences Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD 20892, USA
| | - Sara W. Lazar
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - David Vago
- Osher Center for Integrative Medicine, Vanderbilt University, 3401 West End Avenue, Suite 380, Nashville, TN 37203, USA
| | - Jonah Lipsky
- School of Public Health, Brown University, 121 South Main Street, Providence, Rhode Island 02903, USA
| | - Zev Schuman-Olivier
- Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, 1493 Cambridge St., Cambridge MA 02139, USA
| | - Aya Cheaito
- School of Public Health, Brown University, 121 South Main Street, Providence, Rhode Island 02903, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, 700 Butler Dr., Providence, RI 02906, USA
| | - Lauren Sager
- School of Public Health, Brown University, 121 South Main Street, Providence, Rhode Island 02903, USA
| | - Sarah Peters
- School of Public Health, Brown University, 121 South Main Street, Providence, Rhode Island 02903, USA
| | - Hadley Rahrig
- School of Public Health, Brown University, 121 South Main Street, Providence, Rhode Island 02903, USA
| | - Pamela Acero
- School of Public Health, Brown University, 121 South Main Street, Providence, Rhode Island 02903, USA
| | - Jodi Scharf
- School of Public Health, Brown University, 121 South Main Street, Providence, Rhode Island 02903, USA
| | - Eric B. Loucks
- School of Public Health, Brown University, 121 South Main Street, Providence, Rhode Island 02903, USA
| | - Carl Fulwiler
- Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, 1493 Cambridge St., Cambridge MA 02139, USA
- Department of Psychiatry, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
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