Effects of a Mindfulness-Based Weight Loss Intervention on Long-Term Psychological Well-Being Among Adults with Obesity: Secondary Analyses from the Supporting Health by Integrating Nutrition and Exercise (SHINE) Trial

Objective

This study tested whether a mindfulness-based intervention for obesity that included components aimed at emotion regulation and mindful eating improved psychological outcomes including stress, anxiety, positive emotion, and depression, during the intervention period and at longer-term follow-up.

Methods

Adults with obesity (N=194) were randomized to a 5.5-month diet-exercise weight loss intervention with or without mindfulness training focused on emotion regulation and mindful eating. Participants completed self-report measures of mindfulness and psychological well-being, which were planned secondary outcomes, at baseline, mid-intervention (3 months), and at 6-, 12-, and 18-months post-baseline (maintenance period). Mixed effects models and linear regression were used to test between- and within-group changes in psychological well-being. Finally, this study explored whether changes in mindfulness (from baseline to each 6- and 18-months post-baseline) mediated the effects of intervention arm on changes in psychological outcomes during those respective time periods. This study explored whether changes in mindfulness from baseline to 6 months mediated the effects of intervention arm on changes in psychological outcomes from baseline to 18 months.

Results

Participants randomized to the mindfulness arm had significant increases in positive emotions at all follow-up times compared to controls. There were statistically significant increases in mindfulness, psychological flexibility, and reflection, as well as decreases in anxiety and depressive symptoms at 12 months compared to control participants. These changes remained significant for psychological flexibility and reflection at 18 months. There were no significant differences in perceived stress. Among mindfulness participants, greater increases in mindfulness from 6-18 months was associated with greater positive emotions and psychological flexibility as well as lower perceived stress, anxiety, depressive symptoms, and rumination at 18 months, adjusting for 6-month values. Mediation analyses indicated that randomization to the mindfulness intervention arm was associated with 6-month increases in mindfulness, and these increases were in turn associated with improved psychological outcomes at 6 months and 18 months. Changes from baseline to 18 months did not mediate 18-month changes in psychological outcomes.

Conclusions

Mindfulness training in emotion regulation and mindful eating may provide greater longer-term psychological well-being benefits in non-clinical populations with obesity compared to conventional diet-exercise interventions.

Exploring the Multidimensional Assessment of Interoceptive Awareness in youth aged 7-17 years

OBJECTIVE

This study aimed to adapt the Multidimensional Assessment of Interoceptive Awareness (MAIA) questionnaire for younger respondents.

METHOD

The language of the MAIA was revised and children aged 7-10 years (n = 212) and adolescents aged 11-17 years (n = 217) completed the questionnaire.

RESULTS

The original eight-factor model was tested for fit using confirmatory factor analysis. The model had an acceptable fit in the total sample and younger subsample and overall fit in the older subsample was adequate following modification. Internal consistency was good, except for the Noticing, Not-Distracting and Not-Worrying scales. Results also demonstrated a negative linear relationship between the trusting scale and age, suggesting that youths may lose trust in their body as they age.

CONCLUSION

The adapted MAIA can be used with a younger population and, depending on the research question, individual MAIA scales may be selected. The survey is available at https://osher.ucsf.edu/maia.

A Community Choir Intervention to Promote Well-Being Among Diverse Older Adults: Results From the Community of Voices Trial

OBJECTIVES

To test effects of the Community of Voices choir intervention on the health, well-being, and health care costs of racial/ethnically diverse older adults.

METHOD

Twelve Administration-on-Aging-supported senior centers were cluster randomized into two groups: the intervention group started the choir immediately and a wait-list control group began the choir 6 months later. The choir program was designed for community-dwelling adults aged 60 years and older. The multimodal intervention comprises activities that engage participants cognitively, physically, and socially. Outcome measures assessed these three domains as well as health care utilization and costs. The intention-to-treat comparison was at 6 months.

RESULTS

The sample (N = 390) had a mean age of 71.3 years (SD = 7.2); 65% were nonwhite. Six-month retention was 92%. Compared to controls, intervention group members experienced significantly greater improvements in loneliness (p = .02; standardized effect size [ES = 0.34] and interest in life (p = .008, ES = 0.39). No significant group differences were observed for cognitive or physical outcomes or for health care costs.

DISCUSSION

Findings support adoption of community choirs for reducing loneliness and increasing interest in life among diverse older adults. Further efforts need to examine the mechanisms by which engagement in choirs improves aspects of well-being and reduces health disparities among older adults, including potential longer-term effects.

CLINICALTRIALS.GOV REGISTRATION

NCT01869179 registered January 9, 2013.

A Randomized Controlled Trial of a Mindfulness-Based Weight Loss Intervention on Cardiovascular Reactivity to Social-Evaluative Threat Among Adults with Obesity

Objective

Mindfulness-based interventions have been found to reduce psychological and physiological stress reactivity. In obesity, however, stress reactivity is complex, with studies showing both exaggerated and blunted physiological responses to stressors. A nuanced view of stress reactivity is the "challenge and threat" framework, which defines adaptive and maladaptive patterns of psychophysiological stress reactivity. We hypothesized that mindfulness training would facilitate increased challenge-related appraisals, emotions, and cardiovascular reactivity, including sympathetic nervous system activation paired with increased cardiac output (CO) and reduced total peripheral resistance (TPR) compared to a control group, which would exhibit an increased threat pattern of psychophysiological reactivity to repeated stressors.

Methods

Adults (N=194) with obesity were randomized to a 5.5-month mindfulness-based weight loss intervention or an active control condition with identical diet-exercise guidelines. Participants were assessed at baseline and 4.5 months later using the Trier Social Stress Task. Electrocardiogram, impedance cardiography, and blood pressure were acquired at rest and during the speech and verbal arithmetic tasks to assess pre-ejection period (PEP), CO, and TPR reactivity.

Results

Mindfulness participants showed significantly greater maintenance of challenge-related emotions and cardiovascular reactivity patterns (higher CO and lower TPR) from pre to post-intervention compared to control participants, but groups did not differ in PEP. Findings were independent of changes in body mass index.

Conclusions

Mindfulness training may increase the ability to maintain a positive outlook and mount adaptive cardiovascular responses to repeated stressors among persons with obesity though findings need to be replicated in other populations and using other forms of mindfulness interventions.

The Multidimensional Assessment of Interoceptive Awareness, Version 2 (MAIA-2)

Interoception, the process by which the nervous system senses, interprets, and integrates signals originating from within the body, has become major research topic for mental health and in particular for mind-body interventions. Interoceptive awareness here is defined as the conscious level of interoception with its multiple dimensions potentially accessible to self-report. The Multidimensional Assessment of Interoceptive Awareness (MAIA) is an 8-scale state-trait questionnaire with 32 items to measure multiple dimensions of interoception by self-report and was published in November 2012. Its numerous applications in English and other languages revealed low internal consistency reliability for two of its scales. This study's objective was to improve these scales and the psychometrics of the MAIA by adding three new items to each of the two scales and evaluate these in a new sample. Data were collected within a larger project that took place as part of the Live Science residency programme at the Science Museum London, UK, where visitors to the museum (N = 1,090) completed the MAIA and the six additional items. Based on exploratory factor analysis in one-half of the adult participants and Cronbach alphas, we discarded one and included five of the six additional items into a Version 2 of the MAIA and conducted confirmatory factor analysis in the other half of the participants. The 8-factor model of the resulting 37-item MAIA-2 was confirmed with appropriate fit indices (RMSEA = 0.055 [95% CI 0.052-0.058]; SRMR = 0.064) and improved internal consistency reliability. The MAIA-2 is public domain and available (www.osher.ucsf.edu/maia) for interoception research and the evaluation of clinical mind-body interventions.

A randomized, controlled trial of mindfulness-based stress reduction in HIV infection

OBJECTIVE

Evidence links depression and stress to more rapid progression of HIV-1 disease. We conducted a randomized controlled trial to test whether an intervention aimed at improving stress management and emotion regulation, mindfulness-based stress reduction (MBSR), would improve immunological (i.e. CD4+ T-cell counts) and psychological outcomes in persons with HIV-1 infection.

METHODS

We randomly assigned participants with HIV-1 infection and CD4 T-cell counts >350 cells/μl who were not on antiretroviral therapy in a 1:1 ratio to either an MBSR group (n = 89) or an HIV disease self-management skills group (n = 88). The study was conducted at the University of California at San Francisco. We assessed immunologic (CD4, c-reactive protein, IL-6, and d-dimer) and psychological measures (Beck Depression Inventory for depression, modified Differential Emotions Scale for positive and negative affect, Perceived stress-scale, and mindfulness) at 3, 6 and 12 months after initiation of the intervention; we used multiple imputation to address missing values.

RESULTS

We observed statistically significant improvements from baseline to 3-months within the MBSR group in depression, positive and negative affect, perceived stress, and mindfulness; between group differences in change were significantly greater in the MBSR group only for positive affect (per item difference on DES-positive 0.25, 95% CI 0.049, 0.44, p = .015). By 12 months the between group difference in positive affect was not statistically significant, although both groups had trends toward improvements compared to baseline in several psychological outcomes that were maintained at 12-months; these improvements were only statistically significant for depression and negative affect in the MBSR group and perceived stress for the control group. The groups did not differ significantly on rates of antiretroviral therapy initiation (MBSR = 39%, control = 29%, p = .22). After 12 months, the mean decrease in CD4+ T-cell count was 49.6 cells/μl in participants in the MBSR arm, compared to 54.2 cells/μl in the control group, a difference of 4.6 cells favoring the MBSR group (95% CI, -44.6, 53.7, p = .85). The between group differences in other immunologic-related outcomes (c-reactive protein, IL-6, HIV-1 viral load, and d-dimer) were not statistically significant at any time point.

CONCLUSIONS

MBSR improved positive affect more than an active control arm in the 3 months following the start of the intervention. However, this difference was not maintained over the 12-month follow-up and there were no significant differences in immunologic outcomes between intervention groups. These results emphasize the need for further carefully designed research if we are to translate evidence linking psychological states to immunological outcomes into evidence-based clinical practices.

Weight Loss Maintenance and Cellular Aging in the Supporting Health Through Nutrition and Exercise Study

OBJECTIVE

The aim of the study was to determine, within a weight loss clinical trial for obesity, the impact of intervention arm, weight change, and weight loss maintenance on telomere length (TL).

METHODS

Adults (N = 194) with a body mass index between 30 and 45 were randomized to a 5.5-month weight loss program with (n = 100) or without (n = 94) mindfulness training and identical diet-exercise guidelines. We assessed TL at baseline and 3-, 6-, and 12-month postbaseline in immune cell populations (primarily in peripheral blood mononuclear cells [PBMCs], but also in granulocytes and T and B lymphocytes). We defined weight loss maintenance as having lost at least 5% or 10% of body weight (tested in separate models) from preintervention to postintervention, and having maintained this loss at 12 months. We predicted that greater weight loss and weight loss maintenance would be associated with TL lengthening.

RESULTS

Neither weight loss intervention significantly predicted TL change nor did amount of weight change, at any time point. Across all participants, weight loss maintenance of at least 10% was associated with longer PBMC TL (b = 239.08, 95% CI = 0.92 to 477.25, p = .049), CD8+ TL (b = 417.26, 95% CI = 58.95 to 775.57, p = .023), and longer granulocyte TL (b = 191.56, 95% CI = -4.23 to 387.35, p = .055) at 12 months after accounting for baseline TL. Weight loss maintenance of 5% or more was associated with longer PBMC TL (b = 163.32, 95% CI = 4.00 to 320.62, p = .045) at 12 months after accounting for baseline TL. These tests should be interpreted in light of corrections for multiple tests.

CONCLUSIONS

Among individuals with obesity, losing and maintaining a weight loss of 10% or more may lead to TL lengthening, which may portend improved immune and metabolic function. TL lengthening in this study is of unknown duration beyond 12 months and requires further study.

TRIAL REGISTRATION

Clinicaltrials.govidentifierNCT00960414; Open Science Framework (OSF) preregistration: https://osf.io/t3r2g/.

Recruitment and baseline characteristics of the Community of Voices choir study to promote the health and well-being of diverse older adults

Objective

To describe the recruitment and baseline results of the Community of Voices study that aims to examine the effect of a community choir intervention on the health and well-being of older adults from diverse racial/ethnic and socioeconomic backgrounds.

Method

Using community-based participatory research methods, we recruited adults age 60 and over from 12 Administration on Aging-supported senior centers in San Francisco into a 2-arm cluster-randomized controlled trial of the community choir intervention. Multiple outreach methods were used. We tracked outreach, screening, and recruitment metrics and collected demographics and baseline outcomes via community-based, interviewer-administered surveys and performance measures of cognition, physical function, and psychosocial variables.

Results

The study contacted 819 individuals, screened 636, and enrolled 390 diverse older adults over a 42-month, phased recruitment period. The mean age was 71.2 (SD = 7.3), and the majority were women. Two-thirds of the sample are non-white, and 20% of participants reported having financial hardship.

Discussion

Outreach and recruitment methods used in the Community of Voices trial facilitated enrollment of a large proportion of minority and lower-SES older adults in the final sample. Similar recruitment approaches could serve as a model for recruiting diverse racial/ethnic and socioeconomic older adults into research.

Improving Assessment of the Spectrum of Reward-Related Eating: The RED-13

A diversity of scales capture facets of reward-related eating (RRE). These scales assess food cravings, uncontrolled eating, addictive behavior, restrained eating, binge eating, and other eating behaviors. However, these scales differ in terms of the severity of RRE they capture. We sought to incorporate the items from existing scales to broaden the 9-item Reward-based Eating Drive scale (RED-9; Epel et al., 2014), which assesses three dimensions of RRE (lack of satiety, preoccupation with food, and lack of control over eating), in order to more comprehensively assess the entire spectrum of RRE. In a series of 4 studies, we used Item Response Theory models to consider candidate items to broaden the RED-9. Studies 1 and 2 evaluated the abilities of additional items from existing scales to increase the RED-9's coverage across the spectrum of RRE. Study 3 evaluated candidate items identified in Studies 1 and 2 in a new sample to assess the extent to which they accounted for more variance in areas less well-covered by the RED-9. Study 4 tested the ability of the RED-13 to provide consistent coverage across the range of the RRE spectrum. The resultant RED-13 accounted for greater variability than the RED-9 by reducing gaps in coverage of RRE in middle-to-low ranges. Like the RED-9, the RED-13 was positively correlated with BMI. The RED-13 was also positively related to a diagnosis of type 2 diabetes as well as cravings for sweet and savory foods. In summary, the RED-13 is a brief self-report measure that broadly captures the spectrum of RRE and may be a useful tool for identifying individuals at risk for overweight or obesity.

Randomized controlled trial of a positive affect intervention for people newly diagnosed with HIV

OBJECTIVE

We conducted a randomized controlled trial to determine whether IRISS (Intervention for those Recently Informed of their Seropositive Status), a positive affect skills intervention, improved positive emotion, psychological health, physical health, and health behaviors in people newly diagnosed with HIV.

METHOD

One-hundred and fifty-nine participants who had received an HIV diagnosis in the past 3 months were randomized to a 5-session, in-person, individually delivered positive affect skills intervention or an attention-matched control condition.

RESULTS

For the primary outcome of past-day positive affect, the group difference in change from baseline over time did not reach statistical significance (p = .12, d = .30). Planned secondary analyses within assessment point showed that the intervention led to higher levels of past-day positive affect at 5, 10, and 15 months postdiagnosis compared with an attention control. For antidepressant use, the between group difference in change from baseline was statistically significant (p = .006, d = -.78 baseline to 15 months) and the difference in change over time for intrusive and avoidant thoughts related to HIV was also statistically significant (p = .048, d = .29). Contrary to findings for most health behavior interventions in which effects wane over the follow up period, effect sizes in IRISS seemed to increase over time for most outcomes.

CONCLUSIONS

This comparatively brief positive affect skills intervention achieved modest improvements in psychological health, and may have the potential to support adjustment to a new HIV diagnosis. (PsycINFO Database Record

Impact of a Mindfulness-Based Weight-Loss Intervention on Sleep Quality Among Adults with Obesity: Data from the SHINE Randomized Controlled Trial

BACKGROUND AND OBJECTIVE

Sleep disturbance is a common problem among adults with obesity. Mindfulness interventions have been shown to improve sleep quality in various populations but have not been investigated in adults with obesity. The aim of this study was to compare the effects of a mindfulness-based weight-loss intervention with an active control on self-reported sleep quality among adults with obesity.

METHOD

This study was a secondary analysis of a randomized controlled trial and included 194 adults with a body mass index in the range 30-45 kg/m². The treatment intervention included mindfulness-based eating and stress-management practices, and the active control intervention included training in progressive muscle relaxation (PMR). Both groups received identical diet and exercise guidelines in 17 group sessions conducted over 5.5 months that were matched for time, attention, and social support. The primary outcome of this analysis was between-group change in self-reported sleep quality, which was assessed using the Pittsburgh Sleep Quality Index (PSQI) global score at baseline and at 6, 12, and 18 months.

RESULTS

Between-group differences in mean PSQI change scores in the mindfulness group (n = 100) compared to the control group (n = 94) were -0.27 (-0.68, 1.22; p = 0.58) at 6 months, -0.57 (-0.35, 1.50; p = 0.22) at 12 months, and -0.50 (-0.53, 1.53; p = 0.34) at 18 months, all in the direction of more sleep improvement in the mindfulness group but none reaching statistical significance. In the mindfulness group, average weekly minutes of meditation practice time was associated with improved sleep quality from baseline to 6 months.

CONCLUSIONS

No statistically significant evidence was found that a weight-loss program that incorporates mindfulness improves self-reported sleep quality compared to a control diet/exercise intervention that included PMR. Within the mindfulness group, average weekly minutes of mindfulness practice was associated with improved sleep quality.

Socioeconomic Differences in the Effects of Prayer on Physical Symptoms and Quality of Life

The extent to which religiosity is related to well-being may differ as a function of race/ethnicity, education or income. We asked 155 caregivers to complete measures of religiosity, prayer, physical symptoms and quality of life. Lower education and, to a lesser extent, lower income were correlated with religiosity and prayer. There were few direct relationships of religiosity and prayer with quality of life and health symptoms. However, the relationships became significant when education and, to a lesser degree, income were taken into account. Prayer was associated with fewer health symptoms and better quality of life among less educated caregivers.

Effects of a mindfulness-based intervention on mindful eating, sweets consumption, and fasting glucose levels in obese adults: data from the SHINE randomized controlled trial

We evaluated changes in mindful eating as a potential mechanism underlying the effects of a mindfulness-based intervention for weight loss on eating of sweet foods and fasting glucose levels. We randomized 194 obese individuals (M age = 47.0 ± 12.7 years; BMI = 35.5 ± 3.6; 78% women) to a 5.5-month diet-exercise program with or without mindfulness training. The mindfulness group, relative to the active control group, evidenced increases in mindful eating and maintenance of fasting glucose from baseline to 12-month assessment. Increases in mindful eating were associated with decreased eating of sweets and fasting glucose levels among mindfulness group participants, but this association was not statistically significant among active control group participants. Twelve-month increases in mindful eating partially mediated the effect of intervention arm on changes in fasting glucose levels from baseline to 12-month assessment. Increases in mindful eating may contribute to the effects of mindfulness-based weight loss interventions on eating of sweets and fasting glucose levels.

Effects of a mindfulness-based weight loss intervention in adults with obesity: A randomized clinical trial

OBJECTIVE

To determine whether adding mindfulness-based eating and stress management practices to a diet-exercise program improves weight loss and metabolic syndrome components.

METHODS

In this study 194 adults with obesity were randomized to a 5.5-month program with or without mindfulness training and identical diet-exercise guidelines. Intention-to-treat analyses with multiple imputation were used for missing data. The primary outcome was 18-month weight change.

RESULTS

Estimated effects comparing the mindfulness to control arm favored the mindfulness arm in (a) weight loss at 12 months, -1.9 kg (95% CI: -4.5, 0.8; P = 0.17), and 18 months, -1.7 kg (95% CI: -4.7, 1.2; P = 0.24), though not statistically significant; (b) changes in fasting glucose at 12 months, -3.1 mg/dl (95% CI: -6.3, 0.1; P = 0.06), and 18 months, -4.1 mg/dl (95% CI: -7.3, -0.9; P = 0.01); and (c) changes in triglyceride/HDL ratio at 12 months, -0.57 (95% CI: -0.95, -0.18; P = 0.004), and 18 months, -0.36 (95% CI: -0.74, 0.03; P = 0.07). Estimates for other metabolic risk factors were not statistically significant, including waist circumference, blood pressure, and C-reactive protein.

CONCLUSIONS

Mindfulness enhancements to a diet-exercise program did not show substantial weight loss benefit but may promote long-term improvement in some aspects of metabolic health in obesity that requires further study.

Reduced reward-driven eating accounts for the impact of a mindfulness-based diet and exercise intervention on weight loss: Data from the SHINE randomized controlled trial

Many individuals with obesity report over eating despite intentions to maintain or lose weight. Two barriers to long-term weight loss are reward-driven eating, which is characterized by a lack of control over eating, a preoccupation with food, and a lack of satiety; and psychological stress. Mindfulness training may address these barriers by promoting awareness of hunger and satiety cues, self-regulatory control, and stress reduction. We examined these two barriers as potential mediators of weight loss in the Supporting Health by Integrating Nutrition and Exercise (SHINE) randomized controlled trial, which compared the effects of a 5.5-month diet and exercise intervention with or without mindfulness training on weight loss among adults with obesity. Intention-to-treat multiple mediation models tested whether post-intervention reward-driven eating and psychological stress mediated the impact of intervention arm on weight loss at 12- and 18-months post-baseline among 194 adults with obesity (BMI: 30-45). Mindfulness (relative to control) participants had significant reductions in reward-driven eating at 6 months (post-intervention), which, in turn, predicted weight loss at 12 months. Post-intervention reward-driven eating mediated 47.1% of the total intervention arm effect on weight loss at 12 months [β = -0.06, SE(β) = 0.03, p = .030, 95% CI (-0.12, -0.01)]. This mediated effect was reduced when predicting weight loss at 18 months (p = .396), accounting for 23.0% of the total intervention effect, despite similar weight loss at 12 months. Psychological stress did not mediate the effect of intervention arm on weight loss at 12 or 18 months. In conclusion, reducing reward-driven eating, which can be achieved using a diet and exercise intervention that includes mindfulness training, may promote weight loss (clinicaltrials.gov registration: NCT00960414).

Feasibility and Preliminary Efficacy of a Novel RDoC-Based Treatment Program for Adolescent Depression: "Training for Awareness Resilience and Action" (TARA)-A Pilot Study

BACKGROUND

The novel group treatment program Training for Awareness, Resilience, and Action (TARA) was developed to target specific mechanisms based on neuroscience findings in adolescent depression and framed within the National Institute of Mental Health Research Domain Criteria. TARA contains training of autonomic and emotional self-regulation, interoceptive awareness, relational skills, and value-based committed action.

METHODS

We performed a single-arm trial to test the feasibility and preliminary efficacy of TARA in reducing depression and anxiety levels and assessed whether the specific targeted domains of function reflected the hypothesized symptom change. Twenty-six adolescents (14-18 years old, 7 males and 19 females) participated in the 12-week group program. Assessment was performed before (T0), immediately after (T1), and 3 months after the end of TARA (T2).

RESULTS

Significant improvement was seen in depression symptoms (Reynolds Adolescent Depression Scale Second Edition) between T0-T1 (t-value = -3.56, p = 0.002, CI = -6.64, -1.77) and T0-T2 (t-value = -4.17, p < 0.001, CI = -11.20, -3.75) and anxiety symptoms (Multidimensional Anxiety Scale for Children) between T0-T1 (t-value = -2.26, p = 0.033, CI = -4.61, -0.21) and T0-T2 (t-value = -3.06, p = 0.006, 95% confidence interval = -9.02, -1.73). Significant improvements in psychological flexibility, sleep, and mindfulness skills were also found between T0 and T2.

LIMITATIONS

The sample size was small without a control condition. The pilot design did not allow for testing the hypothesized brain changes and effect of TARA on relevant systemic biomarkers.

CONCLUSION

TARA is feasible in a sample of clinically depressed and/or anxious adolescents and preliminary efficacy was demonstrated by reduced depression and anxiety symptoms. The specific symptom and behavioral outcomes corresponded well with the hypothesized mechanisms of change.

Acute responses to opioidergic blockade as a biomarker of hedonic eating among obese women enrolled in a mindfulness-based weight loss intervention trial

There are currently no commonly used or easily accessible 'biomarkers' of hedonic eating. Physiologic responses to acute opioidergic blockade, indexed by cortisol changes and nausea, may represent indirect functional measures of opioid-mediated hedonic eating drive and predict weight loss following a mindfulness-based intervention for stress eating. In the current study, we tested whether cortisol and nausea responses induced by oral ingestion of an opioidergic antagonist (naltrexone) correlated with weight and self-report measures of hedonic eating and predicted changes in these measures following a mindfulness-based weight loss intervention. Obese women (N = 88; age = 46.7 ± 13.2 years; BMI = 35.8 ± 3.8) elected to complete an optional sub-study prior to a 5.5-month weight loss intervention with or without mindfulness training. On two separate days, participants ingested naltrexone and placebo pills, collected saliva samples, and reported nausea levels. Supporting previous findings, naltrexone-induced cortisol increases were associated with greater hedonic eating (greater food addiction symptoms and reward-driven eating) and less mindful eating. Among participants with larger cortisol increases (+1 SD above mean), mindfulness participants (relative to control participants) reported greater reductions in food addiction symptoms, b = -0.95, SE(b) = 0.40, 95% CI [-1.74, -0.15], p = .021. Naltrexone-induced nausea was marginally associated with reward-based eating. Among participants who endorsed naltrexone-induced nausea (n = 38), mindfulness participants (relative to control participants) reported greater reductions in food addiction symptoms, b = -1.00, 95% CI [-1.85, -0.77], p = .024, and trended toward reduced reward-based eating, binge eating, and weight, post-intervention. Single assessments of naltrexone-induced cortisol increases and nausea responses may be useful time- and cost-effective biological markers to identify obese individuals with greater opioid-mediated hedonic eating drive who may benefit from weight loss interventions with adjuvant mindfulness training that targets hedonic eating.

Tired telomeres: Poor global sleep quality, perceived stress, and telomere length in immune cell subsets in obese men and women

Poor sleep quality and short sleep duration are associated with increased incidence and progression of a number of chronic health conditions observed at greater frequency among the obese and those experiencing high levels of stress. Accelerated cellular aging, as indexed by telomere attrition in immune cells, is a plausible pathway linking sleep and disease risk. Prior studies linking sleep and telomere length are mixed. One factor may be reliance on leukocytes, which are composed of varied immune cell types, as the sole measure of telomere length. To better clarify these associations, we investigated the relationships of global sleep quality, measured by the Pittsburgh Sleep Quality Index (PSQI), and diary-reported sleep duration with telomere length in different immune cell subsets, including granulocytes, peripheral blood mononuclear cells (PBMCs), CD8+ and CD4+ T lymphocytes, and B lymphocytes in a sample of 87 obese men and women (BMI mean=35.4, SD=3.6; 81.6% women; 62.8% Caucasian). Multiple linear regression analyses were performed adjusting for age, gender, race, education, BMI, sleep apnea risk, and perceived stress. Poorer PSQI global sleep quality was associated with statistically significantly shorter telomere length in lymphocytes but not granulocytes and in particular CD8+ T cells (b=-56.8 base pairs per one point increase in PSQI, SE=20.4, p=0.007) and CD4+ T cells (b=-37.2, SE=15.9, p=0.022). Among separate aspects of global sleep quality, low perceived sleep quality and decrements in daytime function were most related to shorter telomeres. In addition, perceived stress moderated the sleep-CD8+ telomere association. Poorer global sleep quality predicted shorter telomere length in CD8+ T cells among those with high perceived stress but not in low stress participants. These findings provide preliminary evidence that poorer global sleep quality is related to telomere length in several immune cell types, which may serve as a pathway linking sleep and disease risk in obese individuals.

Environmental enrichment alters splenic immune cell composition and enhances secondary influenza vaccine responses in mice

Chronic stress has deleterious effects on immune function, which can lead to adverse health outcomes. However, studies investigating the impact of stress reduction interventions on immunity in clinical research have yielded divergent results, potentially stemming from differences in study design and genetic heterogeneity, among other clinical research challenges. To test the hypothesis that reducing glucocorticoid levels enhances certain immune functions, we administered influenza vaccine once (prime) or twice (boost) to mice housed in either standard control caging or environmental enrichment (EE) caging. We have shown that this approach reduces mouse corticosterone production. Compared with controls, EE mice had significantly lower levels of fecal corticosterone metabolites (FCMs) and increased splenic B and T lymphocyte numbers. Corticosterone levels were negatively associated with the numbers of CD19(+) (r(2) = 0.43, p = 0.0017), CD4(+) (r(2) = 0.28, p = 0.0154) and CD8(+) cells (r(2) = 0.20, p = 0.0503). Vaccinated mice showed nonsignificant differences in immunoglobulin G (IgG) titer between caging groups, although EE mice tended to exhibit larger increases in titer from prime to boost than controls; the interaction between the caging group (control versus EE) and vaccine group (prime versus boost) showed a strong statistical trend (cage-group*vaccine-group, F = 4.27, p = 0.0555), suggesting that there may be distinct effects of EE caging on primary versus secondary IgG vaccine responses. Vaccine-stimulated splenocytes from boosted EE mice had a significantly greater frequency of interleukin 5 (IL-5)-secreting cells than boosted controls (mean difference 7.7, IL-5 spot-forming units/10(6) splenocytes, 95% confidence interval 0.24-135.1, p = 0.0493) and showed a greater increase in the frequency of IL-5-secreting cells from prime to boost. Our results suggest that corticosterone reduction via EE caging was associated with enhanced secondary vaccine responses, but had little effect on primary responses in mice. These findings help identify differences in primary and secondary vaccine responses in relationship to stress mediators that may be relevant in clinical studies.

Illness appraisals and depression in the first year after HIV diagnosis

Illness appraisals provide important context to help understand the way individuals cope with chronic illness. In the present study, a qualitative approach to the analysis of HIV diagnosis experience narratives in a sample of 100 people newly diagnosed with HIV revealed five groups that differed in their initial illness appraisals: HIV as Chronic Illness, Concern about Dying, Stigmatization, Threat to Identity, and Other Threats Overshadow HIV. When compared on quantitatively measured depressive mood, the groups differed on level and trajectory over the course of the first year post-diagnosis. Although the experience of living with HIV has changed significantly with the advent of effective Antiretroviral Therapies (ART), there were a number of similarities between the appraisals of this group of participants who were diagnosed post ART and groups who were diagnosed before ART became widely available. Posttest counselors and other HIV service providers should take individual differences in illness appraisals into account in order to help newly HIV-positive clients manage their healthcare and cope adaptively with their diagnosis.

A positive affect intervention for people experiencing health-related stress: development and non-randomized pilot test

In this article we present background, theoretical rationale, and pilot data on the development of an intervention designed to increase positive affect in people living with serious health-related stress. This proof-of-concept study demonstrated that a multiple-component positive affect intervention is feasible and acceptable for people newly diagnosed with HIV. Retention in the intervention and adherence to home practice were high. Participants reported significant increases in positive affect and significant decreases in negative affect. This positive affect intervention can serve as a template for programs to be developed to help people experiencing health-related and other types of life stress.

The calm mouse: an animal model of stress reduction

Chronic stress is associated with negative health outcomes and is linked with neuroendocrine changes, deleterious effects on innate and adaptive immunity, and central nervous system neuropathology. Although stress management is commonly advocated clinically, there is insufficient mechanistic understanding of how decreasing stress affects disease pathogenesis. Therefore, we have developed a "calm mouse model" with caging enhancements designed to reduce murine stress. Male BALB/c mice were divided into four groups: control (Cntl), standard caging; calm (Calm), large caging to reduce animal density, a cardboard nest box for shelter, paper nesting material to promote innate nesting behavior, and a polycarbonate tube to mimic tunneling; control exercise (Cntl Ex), standard caging with a running wheel, known to reduce stress; and calm exercise (Calm Ex), calm caging with a running wheel. Calm, Cntl Ex and Calm Ex animals exhibited significantly less corticosterone production than Cntl animals. We also observed changes in spleen mass, and in vitro splenocyte studies demonstrated that Calm Ex animals had innate and adaptive immune responses that were more sensitive to acute handling stress than those in Cntl. Calm animals gained greater body mass than Cntl, although they had similar food intake, and we also observed changes in body composition, using magnetic resonance imaging. Together, our results suggest that the Calm mouse model represents a promising approach to studying the biological effects of stress reduction in the context of health and in conjunction with existing disease models.

Yoga breathing for cancer chemotherapy-associated symptoms and quality of life: results of a pilot randomized controlled trial

BACKGROUND

Many debilitating symptoms arise from cancer and its treatment that are often unrelieved by established methods. Pranayama, a series of yogic breathing techniques, may improve cancer-related symptoms and quality of life, but it has not been studied for this purpose.

OBJECTIVES

A pilot study was performed to evaluate feasibility and to test the effects of pranayama on cancer-associated symptoms and quality of life.

DESIGN

This was a randomized controlled clinical trial comparing pranayama to usual care.

SETTING

The study was conducted at a university medical center.

SUBJECTS

Patients receiving cancer chemotherapy were randomized to receive pranayama immediately or after a waiting period (control group).

INTERVENTIONS

The pranayama intervention consisted of four breathing techniques taught in weekly classes and practiced at home. The treatment group received pranayama during two consecutive cycles of chemotherapy. The control group received usual care during their first cycle, and received pranayama during their second cycle of chemotherapy.

OUTCOME MEASURES

Feasibility, cancer-associated symptoms (fatigue, sleep disturbance, anxiety, depression, stress), and quality of life were the outcomes.

RESULTS

Class attendance was nearly 100% in both groups. Sixteen (16) participants were included in the final intent-to-treat analyses. The repeated-measures analyses demonstrated that any increase in pranayama dose, with dose measured in the number of hours practiced in class or at home, resulted in improved symptom and quality-of-life scores. Several of these associations--sleep disturbance (p=0.04), anxiety (p=0.04), and mental quality of life (p=0.05)--reached or approached statistical significance.

CONCLUSIONS

Yoga breathing was a feasible intervention among patients with cancer receiving chemotherapy. Pranayama may improve sleep disturbance, anxiety, and mental quality of life. A dose-response relationship was found between pranayama use and improvements in chemotherapy-associated symptoms and quality of life. These findings need to be confirmed in a larger study.

Disclosure and nondisclosure among people newly diagnosed with HIV: an analysis from a stress and coping perspective

Disclosing HIV status to friends, family, and sex partners is often stressful. However, HIV disclosure has been associated with improved physical health, psychological well-being, and improved health behaviors. The aim of this study was to address some of the gaps in the literature regarding the disclosure process by conducting a mixed-methods study of disclosure in people newly diagnosed with HIV and the relationship of disclosure to stigma and social support. The CHAI (Coping, HIV, and Affect Interview) Study was a longitudinal cohort study that followed individuals who were newly diagnosed with HIV. The study took place from October 2004 to June 2008 in the San Francisco Bay Area. This sample includes data from 50 participants who were interviewed 1, 3, and 9 months following diagnosis with HIV. We identified four main approaches to HIV disclosure that revealed distinct differences in how participants appraised disclosure, whether disclosure was experienced as stressful, and whether disclosure or nondisclosure functioned as a way of coping with an HIV diagnosis. Implications of these findings for disclosure counseling are discussed.

Positive Affect in the Midst of Distress: Implications for Role Functioning

Stress has been shown to deplete the self-regulation resources hypothesized to facilitate effective role functioning. However, recent research suggests that positive affect may help to replenish these vital self-regulation resources. Based on revised Stress and Coping theory and the Broaden-and-Build theory of positive emotion, three studies provide evidence of the potential adaptive function of positive affect in the performance of roles for participants experiencing stress. Participants were students (Study 1), caregivers of ill children (Study 2), and individuals recently diagnosed with HIV (Study 3). In cross sectional analyses, using role functioning as an indicator of self-regulation performance, we found that positive affect was significantly correlated with better self regulation performance, independent of the effects of negative affect. The effects were not as strong longitudinally, however, and there was little evidence of a reciprocal association between increases in positive affect and improvements in role functioning over time. The results provide some modest support for hypotheses stemming from the Broaden and Build model of positive emotion and revised Stress and Coping theory, both of which argue for unique adaptive functions of positive affect under stressful conditions.

Male street prostitution in Dublin: a psychological analysis

This study assessed the mental health characteristics of 12 male street prostitutes (MSPs) in Dublin, with particular regard to issues of homelessness, substance abuse, depression, suicidal ideation, and self-esteem. Participants completed five psychometric tests, which indicated that all of the participants had above average levels of depression and suicidal ideation and low levels of self-esteem. This study found that candidates likely to become MSPs are young males with a combination of factors, including a background of childhood sexual or physical abuse, leaving school early, running away from home, and a dependence on heroin.

What works in coping with HIV? A meta-analysis with implications for coping with serious illness

Knowledge of effective ways of coping with HIV is critical to help individuals with HIV maintain the best possible psychological and physical well-being. The purpose of the present article is to determine, through meta-analysis, the strength of the evidence regarding 2 questions: (a) Which types of coping are related to psychological and physical well-being among people with HIV? and (b) Do contextual (pre?post introduction of highly active antiretroviral therapies [HAART]; time since diagnosis), measurement (HIV-related event vs. generic prompts for coping measurement), or individual (gender) variables affect the extent to which coping is related to physical and psychological well-being? The authors' analysis demonstrates that Direct Action and Positive Reappraisal were consistently associated with better outcomes in people coping with HIV across affective, health behavior, and physical health categories. In contrast, disengagement forms of coping, such as Behavioral Disengagement and Use of Alcohol or Drugs to Cope, were consistently associated with poorer outcomes. The findings also indicate that in some cases, coping effectiveness was dependent on contextual factors, including time since diagnosis and the advent of HAART.

Positive affect uniquely predicts lower risk of mortality in people with diabetes

OBJECTIVE

To determine whether positive affect predicts mortality among people with diabetes and among a comparison group of people with no chronic health conditions.

DESIGN

Longitudinal cohort study.

MAIN OUTCOME MEASURE

Mortality.

RESULTS

Positive affect was significantly associated with lower risk of all-cause mortality in people with diabetes (N = 715). Enjoyed life was associated with lower risk of mortality over and above the effects of negative affect or other significant predictors of mortality. In a comparison sample without chronic illness (N = 2,673), positive affect was not associated with mortality. However, when the analysis was restricted to those over the age of 65, specific positive affects, in particular hopeful and enjoyed life were significantly associated with lower risk of mortality, again independent of negative affect. Enjoyed life remained significantly predictive of lower risk of mortality in the older sample when other predictors of mortality were statistically controlled. Positive affect was particularly protective among those over the age of 65 who reported higher levels of stress.

CONCLUSION

These findings are discussed in light of possible stress-buffering functions of positive affect.

Symptom management with massage and acupuncture in postoperative cancer patients: a randomized controlled trial

The level of evidence for the use of acupuncture and massage for the management of perioperative symptoms in cancer patients is encouraging but inconclusive. We conducted a randomized, controlled trial assessing the effect of massage and acupuncture added to usual care vs. usual care alone in postoperative cancer patients. Cancer patients undergoing surgery were randomly assigned to receive either massage and acupuncture on postoperative Days 1 and 2 in addition to usual care, or usual care alone, and were followed over three days. Patients' pain, nausea, vomiting, and mood were assessed at four time points. Data on health care utilization were collected. Analyses were done by mixed-effects regression analyses for repeated measures. One hundred fifty of 180 consecutively approached cancer patients were eligible and consented before surgery. Twelve patients rescheduled or declined after surgery, and 138 patients were randomly assigned in a 2:1 scheme to receive massage and acupuncture (n=93) or to receive usual care only (n=45). Participants in the intervention group experienced a decrease of 1.4 points on a 0-10 pain scale, compared to 0.6 in the control group (P=0.038), and a decrease in depressive mood of 0.4 (on a scale of 1-5) compared to +/-0 in the control group (P=0.003). Providing massage and acupuncture in addition to usual care resulted in decreased pain and depressive mood among postoperative cancer patients when compared with usual care alone. These findings merit independent confirmation using larger sample sizes and attention control.

Caregiving time in sickle cell disease: psychological effects in maternal caregivers

BACKGROUND

Providing home care for a child with a chronic illness can be stressful for the family. The purpose of this paper is to examine patterns of caregiving and the associated psychological impact on maternal caregivers of children with sickle cell disease (SCD).

PROCEDURE

Fourteen maternal caregivers of children with SCD were interviewed as part of a larger study of maternal caregivers of children with chronic illness. Forty-four caregivers of children with HIV and 36 caregivers of healthy children were included as comparison groups. Interviews included questions regarding amount of time spent providing care for the child (technical care, non-technical care, health care management), hospitalization, emergency room visits, illness stigma, and mental health of the caregiver.

RESULTS

Children with SCD had significantly lower functional status and significantly more hospitalizations in the previous 3 months than children with HIV. Caregivers of children with SCD were more likely to work full-time and had higher incomes than caregivers of children with HIV. The three caregiving groups did not differ significantly on amount of total care, although caregivers of children with SCD and caregivers of children with HIV both reported significantly more time spent in technical care than caregivers of healthy children. Despite lower functional status of the children in the SCD group, when group comparisons on caregiving time variables were adjusted for child's functional status, the differences between groups increased. This appeared to be due to the fact that caregivers in the HIV group spent more time in all caregiving categories except skin, crisis, and other care. In terms of caregiver mental health, caregivers of children with HIV and SCD had significantly higher depressive mood scores than caregivers of healthy children but the groups did not differ on caregiving burden.

CONCLUSIONS

The perceived care burden of caregivers of children with SCD may be related to the unpredictable nature of the crisis care they provide. Additional attention is warranted to developing adequate resources for caregivers of children with SCD to mitigate the stress of unexpected crises.

The economic burden of home care for children with HIV and other chronic illnesses

OBJECTIVES

We compared types, amounts, and costs of home care for children with HIV and chronic illnesses, controlling for the basic care needs of healthy children to determine the economic burden of caring for and home care of chronically ill children.

METHODS

Caregivers of 97 HIV-positive children, 101 children with a chronic illness, and 102 healthy children were surveyed regarding amounts of paid and unpaid care provided. Caregiving value was determined according to national hourly earnings and a market replacement method.

RESULTS

Chronically ill children required significantly more care time than HIV-positive children (7.8 vs 3.9 hours per day). Paid care accounted for 8% to 16% of care time. Annual costs were $9300 per HIV-positive child and $25,900 per chronically ill child. Estimated national annual costs are $86.5 million for HIV-positive children and $155 to $279 billion for chronically ill children.

CONCLUSIONS

Informal caregiving represents a substantial economic value to society. The total care burden among chronically ill children is higher than that among children with HIV.

Randomized, controlled trial of breath therapy for patients with chronic low-back pain

CONTEXT

Patients suffering from chronic low back pain (cLBP) are often unsatisfied with conventional medical care and seek alternative therapies. Many mind-body techniques are said to help patients with low back pain by enhancing body awareness, which includes proprioception deficit in cLBP, but have not been rigorously studied in cLBP. Breath therapy is a western mind-body therapy integrating body awareness, breathing, meditation, and movement. Preliminary data suggest benefits from breath therapy for proprioception and low back pain.

OBJECTIVE

To assess the effect of breath therapy on cLBP.

DESIGN

Randomized, controlled trial.

SETTING

Academic medical center.

PARTICIPANTS

Thirty-six patients with cLBP.

INTERVENTIONS

Six to eight weeks (12 sessions) of breath therapy versus physical therapy.

MAIN OUTCOME MEASURES

Pain by visual analog scale (VAS), function by Roland Scale, overall health by Short Form 36 (SF-36) at baseline, six to eight weeks, and six months. Balance as a potential surrogate for proprioception and body-awareness measured at the beginning and end of treatment.

RESULTS

Pre- to post-intervention, patients in both groups improved in pain (VAS: -2.7 with breath therapy, -2.4 with physical therapy; SF-36: +14.9 with breath therapy and +21.0 with physical therapy). Breath therapy recipients improved in function (Roland: -4.8) and in the physical and emotional role (SF-36: +15.5 and 14.3). Physical therapy recipients improved in vitality (SF-36: +15.0). Average improvements were not different between groups. At six to eight weeks, results showed a trend favoring breath therapy; at six-months, a trend favoring physical therapy. Balance measures showed no improvements and no correlations with other outcomes.

CONCLUSIONS

Patients suffering from cLBP improved significantly with breath therapy. Changes in standard low back pain measures of pain and disability were comparable to those resulting from high-quality, extended physical therapy. Breath therapy was safe. Qualitative data suggested improved coping skills and new insight into the effect of stress on the body as a result of breath therapy. Balance measures did not seem to be valid measures of clinical change in patients' cLBP.

Pediatric adherence: perspectives of mothers of children with HIV

This study approached pediatric adherence practices from the perspective of mothers of children with HIV in the USA. The study aimed to articulate what is involved in the daily life experience of giving or supervising a child's HIV medication (i.e., adherence practices) in order to clarify, in more dynamic terms than is often found in adherence research, what promotes or impedes adherence. A team-based qualitative analytic approach was used to analyze the narrative responses of 71 maternal caregivers of children with HIV to interview questions regarding the activities and stresses of caring for a child with HIV. Four themes of dealing with medication on a daily basis that impacted mothers' adherence practices emerged from the analysis: (1) Mothers' attitudes and feelings related to adherence practices. (2) The impact of the medications on adherence practices. (3) Interactions of mothers and children related to adherence practices. (4) Developmental issues and responsibility for medication adherence. These themes, taken together, demonstrate the contextual and longitudinal factors that impact adherence and illustrate the complexity of influences on adherence practices. We found that adherence practices were impacted in a positive way by mothers' commitment to adherence, and in a negative way by feelings of stigma and guilt, by the effects of bereavement on children and by children adopting their mothers' attitudes about medications. The interactive process of giving medication was shaped by children's behavior, mothers' developmental expectations for children, and, for mothers with HIV, their adherence for themselves. We found that pediatric adherence often came at a cost to the caregiving mother's well-being.