[Redacted]

December 13, 2013

Catherine HerrickDiabetes Prevention ProgramHoly Cross Hospital Senior Source8580 Second Ave.Silver Spring, MD 20910

Re: Proposal for Program Enhancement – Mindful Eating

Dear Ms. Herrick:

I am pleased to present to you a proposal that I believe will enhance the effectiveness of the Diabetes Prevention Program at Holy Cross Hospital. As you know, I am a Dietetics student at the University of Maryland, and I have been a volunteer with the program since July of 2013. My research regarding mindful eating and its application for preventing diabetes has convinced me that incorporating instruction in mindful eating into the curriculum for the program would substantially increase the program’s effectiveness.

Thank you for taking the time to read and consider my proposal. If you have any questions or comments, please do not hesitate to contact me, and I would be happy to discuss this matter with you further.

Regards,

[Redacted]

Preventing Diabetes with Mindful Eating:A Proposal for Enhancing the Holy Cross Hospital Diabetes Prevention Program

Prepared for Catherine Herrick

By [Redacted]

December 13, 2013

Table of Contents

Introduction 1

Overview of the Diabetes Prevention Program 2

How Effective is the Diabetes Prevention Program? 3

The Challenge of Change 5

Mindfulness: a Tool for Transformation 7

Research on the Effectiveness of Mindfulness-Based Strategies 7

Why Does Mindfulness Work? 9

Recommendations 10Training Instructors 11Meditation 11Mindful Eating 12Yoga 13Curriculum 15

Conclusion 16

Appendices:Sample Handouts 17Works Consulted 21Interview Transcripts 24

Introduction

Reducing the incidence of diabetes continues to present one of the major

public health challenges of our time. According to the Centers for Disease Control

and Prevention’s 2011 National Diabetes Fact Sheet, about 26 million people in the

US are living with diabetes, and about 2 million more are diagnosed every year.

Diabetes afflicts almost 27% of those over the age of 65 and more than 11% of

those over 20. About 35% of US adults over 20 are estimated to be prediabetic.

Type 2 diabetes accounts for more than 90% of cases of diabetes, according

to the 2011 CDC Fact Sheet. Luckily, Type 2 diabetes is a disease that is highly

responsive to lifestyle interventions. The Diabetes Prevention Program at Holy

Cross Hospital (hereafter, the “DPP”) has the potential to make a significant impact

on this critical public health issue by providing effective guidance and motivation

for prediabetic individuals to make long-term behavioral changes that may slow the

progression of their disease to full-blown diabetes, and possibly even reverse their

disease process.

Unfortunately, lifestyle changes are notoriously difficult to make, and even

more notoriously difficult to sustain over the long-term. Physiological,

psychological, and environmental factors can impede an individual’s ability to

choose new behaviors and to commit to making those choices for the rest of his or

her life, even given a life-altering medical diagnosis such as prediabetes or diabetes.

Given these challenges, how can the DPP maximize its effectiveness at preventing

and reversing the progression from prediabetes to diabetes?

1

This report explores the particular challenges faced by individuals

attempting to make long-term lifestyle changes in order to manage prediabetes and

prevent progression to diabetes, and proposes that the practice of mindfulness, a

concept drawn from Eastern spiritual traditions such as Buddhism, may offer a tool

for addressing these challenges. After presenting the evidence for the effectiveness

of this tool, I will describe in practical detail how it can be incorporated into the

existing curriculum of the DPP in order to enhance the successfulness of the

program.

Overview of the DPP

The DPP is modeled after the lifestyle intervention used in the landmark

study by the Diabetes Prevention Program Research Group, published in the New

England Journal of Medicine in 2002, which demonstrated that lifestyle changes

could reduce the incidence of diabetes by 58% among prediabetic individuals. The

lifestyle modification program in the study provided one-on-one personalized

support and education to participants, and encouraged them to reduce their body

weight by 7% and perform 150 minutes of physical activity per week. This

intervention was more effective at preventing progression to diabetes than a drug

treatment, metformin, which only reduced the incidence of diabetes by 31%

(Diabetes Prevention Program Research Group, “Reduction in the Incidence of Type

2 Diabetes,” 393). The curriculum of the DPP is designed to resemble that used in

the 2002 study, although the one-on-one, personalized method of the original study

is replaced by weekly group instructional sessions.

2

How Effective is the DPP?

Statistics from the most recent fiscal year suggest that the DPP at HCH is

moderately but not overwhelmingly successful. In the 2013 fiscal year, about half of

participants exhibited reductions in fasting blood glucose levels immediately

following completion of the program; the other half exhibited slight increases.

About two-thirds of participants exhibited reductions in HbA1c levels immediately

following program completion; the remaining one-third exhibited slight increases.

Data was not available on how many participants achieved weight loss or physical

activity goals. Because data is only collected at the start and end of the twelve-week

program, the long-term impact of participation can not be assessed. Based on this

admittedly limited data, we can reasonably conclude that, overall, somewhere

between one-half and two-thirds of participants are at least temporarily successful

in slowing or possibly reversing their disease progression from prediabetes to full-

blown diabetes.

Based on the data available to us, it is impossible to say with certainty

whether these gains are maintained beyond the end of the twelve-week program.

We can, however, look at the follow up research conducted by the Diabetes

Prevention Program Research Group on their participants. Ten years after their

original study, the Diabetes Prevention Program Research Group examined the long-

term impact of their interventions on participants in their study. Individuals who

lost weight during the original 2.8 year study period subsequently regained some,

but not all, of that weight. Rates of diabetes incidence among individuals who

received the lifestyle intervention, those who received metformin, and those in the

3

placebo control group were similar in the years following the intervention, although

overall diabetes incidence remained reduced in the lifestyle and metformin groups

(Diabetes Prevention Program Research Group, “Ten Year Follow Up,” 1677).

Another study, by Davis and colleagues, examined the energy and fat intake

of participants who received the lifestyle intervention nine years after the original

study. Initially, participants receiving the lifestyle intervention reduced their energy

and fat intake during the intervention. In the 9 years that followed, energy and fat

intake increased, although they never returned to baseline, pre-study levels. Those

participants who were most successful at reducing their energy and fat intake

during the original study showed the most continued success in the nine years that

followed, while those who were less successful during the period of the initial study

continued to exhibit less reductions in the years that followed (1461-1463).

These results suggest that participants who successfully make lifestyle

changes and who experience delayed or arrested disease progression during the

period of the original 12- or 16-week lifestyle intervention program may continue

to successfully manage prediabetes, and that lifestyle changes, although they are not

maintained at the level achieved during the initial intervention, may continue to

exert a lasting effect.

How can we broaden the impact of the diabetes prevention program so that

more than one-half to two-thirds of participants achieve significant reductions in

disease progression during the period of the intervention? And how can we help

participants maintain their lifestyle changes beyond the period of the initial

intervention? In order to answer these questions, it is useful to consider the

4

obstacles that commonly prevent individuals from making and sustaining lifestyle

changes.

The Challenge of Change

The lifestyle changes that bring about weight loss and reduced chronic

disease risk are notoriously difficult to make and often unsustainable. Why is this

the case?

Dorothy Van Buren and Meghan Sinton, in their commentary on the research

regarding the psychology of weight maintenance published in the Journal of the

American Dietetic Association, note that our bodies evolved to cope with scarcity as

a survival strategy. Thus, the body’s homeostatic system, which controls appetite,

and the limbic system, which regulates emotion, are evolutionarily programmed to

be averse to weight-loss behaviors, including reduced calorie intake and increased

physical activity. In practical terms, this means that individuals who attempt to lose

weight are likely to experience discomfort, both physical and psychological (Van

Buren and Sinton 1994). This discomfort must be addressed in order for

participants to make permanent lifestyle changes.

Not surprisingly, research shows that high levels of emotional stress and the

presence of significant stressors such as major life changes generally correlate with

more difficulty losing and maintaining weight (Elfhag and Rossner 71-72). In an

interview, Julia Mutter, dietitian and Certified Diabetes Educator, who has been an

instructor for the DPP for a number of years, identified the presence of stressful life

circumstances as one of the main obstacles that prevents some DPP participants

from meeting goals:

5

… sometimes people have a really bad family dynamic, they have a lot of stress going on so they can’t focus on their health in particular. We have people dropping out because they have to take care of other people, you know, if someone else in the family is sick or they have kids.

Eating provides us with nourishment, not just physically but psychologically as well.

Lifestyle changes that involve reducing overall food intake may be experienced by

program participants as painful self-denial. Often, individuals who are diagnosed

with diabetes or prediabetes already have a strained relationship with food, as

evidenced by the high prevalence of binge eating disorder among those diagnosed

with type 2 diabetes (Crow, Kendall, Praus, and Thuras 222). It is not unusual for

individuals with weight-related health problems such as prediabetes and diabetes to

cycle through a pattern of a period of overly restrictive eating followed by a period

of excessive, unrestrained eating, and each turn of this cycle can result in intense

feelings of guilt, self-judgment, and powerlessness (May and Fletcher 17).

The current DPP curriculum provides ample information on nutritional

topics, covering calorie balance, food groups, calorie and fat content of various

foods, portion control, and other similar nutritional topics. Practical advice is

provided on how to go about incorporating physical activity into one’s daily life.

Certain behavioral strategies, including awareness of social and environmental

eating cues and problem solving, are also offered. However, these strategies may be

insufficient to address the profound psychological challenges that are inherent to

the weight-loss process. How can the psychological challenge be addressed?

6

Mindfulness: a Tool for Transformation

Mindfulness has its roots in the meditative traditions of the Buddhist

religion, particularly in Japanese Zen Buddhism, but in the West it is often taught

and used in a secular fashion. Definitions of mindfulness generally contain two

components: (i) a sustained attentiveness to the present moment, and (ii) an

attitude of openness and non-judgmental acceptance (Bishop, et al, 232).

Mindfulness can be used as a technique for traditional seated meditation, in which

the practitioner sits in silence and practices training his or her attention on his or

her moment-to-moment experience. As thoughts or bodily sensations arise, they

are acknowledged without being labeled “good” or “bad,” and then the practitioner

releases the thought and returns his or her attention to the present moment.

Mindfulness can also be practiced in all of the activities of daily living. Walking,

engaging in conversation, eating, performing work or chores, and any other task

may be performed with the same attentiveness to the present moment, and the

same open, accepting attitude towards any and all experiences and thoughts. Most

instruction in mindfulness, whether religious or secular, emphasizes the importance

and the mutual complementarity of both the traditional meditation practice as well

as the use of mindfulness as a tool for the activities of daily life (for example, in

traditional Zen Buddhist religious services, which incorporate both seated and

walking meditation).

Research on the Effectiveness of Mindfulness-Based Strategies

In “Mindfulness Training as a Clinical Intervention: A Conceptual and

Empirical Review,” Ruth Baer describes the growing use of mindfulness strategies in

7

the context of mental health treatment, where it has grown in popularity since the

late 1970s as a treatment for wide range of conditions including chronic pain,

borderline personality disorder, bipolar disorder, addiction, and eating disorders.

The success of mindfulness instruction in treating eating disorders (Kristeller and

Wolever 58) led to increased interest in the potential of mindfulness as a strategy

for addressing other diet- and weight-related disorders.

Dalen, et al., successfully used the MEAL (Mindful Eating and Living) program

to achieve reductions in the weight and BMI of obese study participants (263). The

MEAL program exposes participants to seated meditation, yoga, and “eating

meditation” in order to increase their awareness of their own eating-related

experiences, emotions, and self-judgments (261). Similarly, Tapper and colleagues

found that obese women who attended educational workshops on mindfulness and

mindful eating and who reported applying the principles learned during the

workshops lost more weight than a control group of women who did not receive the

workshops (396).

Most relevantly, a study published in the Journal of the Academy of Nutrition

and Dietetics entitled “Comparative Effectiveness of a Mindful Eating Intervention to

a Diabetes Self-Management Intervention among Adults with Type 2 Diabetes: A

Pilot Study,” compared adults who received a traditional educational intervention

(similar to that used in the DPP) for type 2 diabetes with adults who only received

training in mindful eating (a protocol called MB-EAT). The mindful eating group

performed as well as the traditional intervention group in weight loss and

8

improvements in lab values, without being put on a diet and exercise regimen

(1837).

Why Does Mindfulness Work?

Dieting, in general, can cause emotional stress, and tends to have a

deleterious effect of mental health and body image, for the reasons explained

earlier. Mindfulness practices, including mindful eating, do exactly the opposite:

they offer practitioners psychological support and healing. Mindful eating offers a

different way of thinking about managing prediabetes through diet and exercise,

one that eliminates the traditional focus on self-control, self-judgment, and the

dichotomy between good foods and bad foods or virtuous choices and lapses.

Instead, making healthful choices becomes an expression of an inner attitude of self-

acceptance and compassion. For example, in their book Savor: Mindful Eating,

Mindful Life, Thich Nhat Hanh and Dr. Lilian Cheung write, “When we look at all

beings, including ourselves, with eyes of love and compassion, we can take care of

ourselves better. With mindfulness, we can nurture ourselves with greater ease and

interest, and our effort will come more naturally,” (30-31).

In my interview with DPP instructor Julia Mutter, Julia identified a pattern of

negative thinking (“I can’t do this,” “I’m a failure,” “This is too hard for me,” etc.) as

one of the significant obstacles that she believes prevents participants from

experiencing success in the program. Mindfulness is a practical tool that can be

used to enable participants to become more aware of their own negative thinking

and how it is affecting their emotional state and their ability to reach their goals.

9

Mindfulness offers participants the chance to experience an attitude of

openness and curiosity about their own experiences. Jan Chozen Bays writes:

In mindful eating we are not comparing or judging. We are simply witnessing the many sensations, thoughts, and emotions that come up around eating. This is done in a straightforward, no-nonsense way, but it is warmed with kindness and sparked with curiosity. (2)

In my interview with Megrette Fletcher-Hammond, an expert on using mindful

eating to treat diabetes, she spoke at length about the importance of cultivating an

attitude of curiosity, and encouraging patients to approach the management of their

disease as a science, in which they perform experiments and nonjudgmentally

observe the results. She explained how this attitude of curiosity can contribute to

managing blood sugar levels: “Mindful eating sparks curiosity, and curiosity is a

lifelong behavior that contributes to blood sugar control. We are curious about

what we care about, and we care about what we are curious about.”

Recommendations

Incorporating instruction in mindfulness practices into the DPP has the

potential to help participants slow or reverse their progression from prediabetes to

diabetes by addressing and alleviating the psychological challenges inherent to the

process of making long-term lifestyle changes regarding physical activity and food

intake. In order to implement this change, I propose (i) providing training for all

instructors in mindfulness practices, including mindful eating in particular; (ii)

incorporating instruction in traditional seated meditation practices and brief guided

meditations into weekly sessions; (iii) incorporating instruction in and guided

practice of mindful eating, also known as “eating meditation,”; (iv) incorporating

hatha yoga instruction into the physical activity component of the program; and (v)

10

adding to the curriculum activities specifically designed to enhance participants’

ability to apply mindfulness to their decisions around physical activity and food.

Training Instructors

Before any of the other recommendations can be implemented, instruction in

mindfulness practices and mindful eating must first be provided to the instructors.

In order to teach the participants, the instructors will need to learn about and

develop some familiarity with mindfulness practices. Trainings in mindfulness and

its application to eating are available through organizations such as the Center for

Mindful Eating and the UC-San Diego Mindfulness-Based Professional Training

Institute.

Meditation

Providing participants with instruction in and opportunities to practice

traditional silent seated meditation will build the foundation for all of the other

work with mindfulness practices. In the first weeks of the program, instructors can

offer participants basic instruction on seated meditation. This would cover how to

sit in a comfortable, upright posture; logistical matters, such as what to wear, how

long to practice, setting a timer, and minimizing disruptions; and the basic

technique – attending to one’s present-moment experience with openness and

acceptance. Each weekly session could include a five-minute guided meditation led

by the instructor, either at the beginning or the end of class. Participants should

also be encouraged to develop a regular daily meditation practice on their own, with

an emphasis on making it an easy, manageable, convenient part of his or her daily

routine. Similar to starting an exercise routine, attempting to suddenly start a forty-

11

five minute per day meditation practice that involves an elaborate set-up of candles

and incense and chimes and absolute silence of the entire household is usually

doomed to failure because it is too impractical, unsustainable, and extreme. Instead,

encourage participants to start small—for example, five minutes of sitting quietly in

a chair before bedtime—and to think of this as an opportunity for “me time,” an act

of self-care.

Mindful Eating

In my interview with mindful eating and diabetes expert Megrette Fletcher-

Hammond, I asked how to teach someone to eat mindfully. Fletcher-Hammond

immediately responded, “You eat with them.” She was emphatic about the need for

diabetes educators to eat—and enjoy—food with clients, and to guide clients

through the process of mindful eating, or what is sometimes called “eating

meditation.”

This is actually the simplest part of this proposal to implement, since weekly

program sessions currently include a healthy, balanced dinner complete with a

portion-controlled, delicious dessert. Currently, instructors delve right into

discussing the topic of the week while participants are eating, which actually

encourages mindless eating, since participants’ attention is necessarily divided

between eating their dinner and paying attention to the material that the instructor

is covering. Instead, the instructors could talk participants through a guided eating

meditation. For example, the instructor would begin by inviting the participants to

pay attention to the appearance and aroma of the food, and inviting the participants

to observe their bodies, noticing if there are any physical signs of hunger or thirst.

12

Next, the instructor could invite the participants to take just one bite of food,

noticing its flavor, its temperature, and its texture. As participants continue to eat,

the instructor could encourage the participants to observe their emotional

responses to their food or the act of eating, noticing if they feel happy and

nourished, or if they feel worried or guilty for eating, without passing judgment on

those thoughts. It would be worthwhile to offer some quiet time, in which

participants can silently enjoy their food and practice observing their own

sensations, thoughts, and emotions. As the 12-week session nears completion, an

increasing amount of time could be devoted to the act of silent eating, as

participants become more familiar with and skilled in this process. However, not

every meal should be silent. It would be beneficial to have some “off” weeks, in

which participants are encouraged to converse while they eat, in order to emphasize

that eating is a pleasurable social activity as well as an opportunity to practice

mindfulness.

Yoga

Currently, each weekly session of the DPP includes about 15 minutes of

aerobic walking, guided by a fitness DVD. Adding yoga to the physical activity

component of the program would augment the effectiveness of the instruction in

mindful eating by training participants to be more attentive to the internal cues that

can guide them in mindful eating.

Our bodies are equipped with mechanisms that naturally help us regulate

what, when, and how much to eat. However, social conditioning (such as learning to

clean one’s plate at dinner), environmental factors (such as the ready availability of

13

delicious junk food, even when one isn’t hungry), and the frequent use of food for

emotional comfort teach many of us to tune out the physical sensations that indicate

hunger and satiety. One aspect of mindful eating is re-learning how to attend to

these internal cues in order to avoid over- (or under-) eating. Research has shown

that yoga practice correlates with improved body awareness and improved capacity

for intuitive eating (Dittman and Freedman 273).

In practical terms, incorporating yoga into the program could involve a

combination of:

Hiring a qualified yoga instructor (preferably someone registered

with yoga alliance at the RYT-200 level or above) to provide thirty to

forty-five minutes of instruction in basic, gentle yoga at one or more

program sessions. This would probably cost less than $50.00 per

session.

Having DPP instructors lead a few gentle, easy breathing exercises

and movements for five to ten minutes at each weekly session.

Providing yoga mats to participants as freebies or prizes, an

investment of approximately $10.00 per mat, if purchased at

wholesale bulk rates.

14

Curriculum

There are a variety of activities, handouts, and discussions that can be used

to instruct participants on how to cultivate more mindfulness in eating as well as in

daily life. The suggestions that follow are just some of the many possibilities.

The classic activity used to introduce the concept of mindful eating is a

guided group eating meditation in which each participant eats one very small food

item; the following explanation is loosely based on that provided by Jan Chozen

Bays, MD, in her book Mindful Eating: A Guide to Rediscovering a Healthy and Joyful

Relationship with Food. Most often, one Hershey’s kiss is distributed to each

participant; one grape, a single raisin, one cherry tomato, or one pretzel are other

alternatives. The instructor begins by inviting the participants to observe their own

initial state: are they hungry? Eager or reluctant to eat? Participants are then asked

to observe the food item with their senses. What does it look like? What does the

texture feel like in the participant’s hand? If it is packaged, what does the wrapper

look like, and what sound does it make while it is being unwrapped? Participants

may then be asked to observe whether their level of hunger and/or desire for the

food item has changed. After all this, the participants are then finally invited to eat

the food item. At first, they are told just to hold it in their mouths, and to observe its

flavor and its mouth feel. They are then invited to chew, slowly, noticing if the flavor

or the texture changes. As the participants continue slowly chewing and, eventually,

swallowing, the instructor continues to ask guiding questions: how does the

participants’ body feel in response to the food? Is there any emotional response?

Afterwards, participants are invited to discuss the experience (11-13).

15

Certain behaviors make eating with mindfulness easier to practice. For

example, if a person divides the food on his or her plate in half, it creates a visual

“speed bump” that can remind him or her to pause halfway through, notice if his or

her mind has wandered away from eating, and if necessary, refocus his or her

attention. A sample handout containing a list of similar tips is included as Appendix

1A.

As explained in the previous section on yoga, participants who are

accustomed to eating mindlessly may have lost their natural awareness of what

hunger feels like. Thus, instruction on mindful eating may include an explanation of

the sensations and feelings that typically accompany hunger. The instructor may

also invite the group to brainstorm other sensations or feelings that they

experience. An example handout to facilitate this explanation and discussion is

included in Appendix 1B. A numeric Hunger/Fullness Scale, such as the one in

Appendix 1C, may also be useful in helping participants understand and respond

appropriately to their own internal cues.

Conclusion

Incorporating instruction in mindfulness practices into the curriculum of the

DPP may enhance the program’s effectiveness at helping participants make the long-

term lifestyle changes necessary for preventing progression from prediabetes to

diabetes. Mindful eating, meditation, yoga, and a philosophical framework that

emphasizes self-awareness, self-acceptance, and compassion may help participants

cope effectively with stress and address the psychological challenges inherent to the

weight loss and lifestyle change process.

16

Appendix 1

Sample Handouts

17

Appendix 1A

Mindful Eating Tips & Tricks

Before you eat: Pause and be grateful. Take a moment before you eat to think

about where your food came from, all of the work done by so many people to bring it to your table, and all of the resources that went into making it.

Choose your portion size with care. Before you serve yourself, notice how hungry you are, and make a mindful and appropriate choice. Err on the side of serving yourself a little less than you might need, since you can always go back for more, if you deliberately choose to.

Create ambience. Eating is more satisfying and enjoyable if you take the time to set the mood! Play some soft music, light a candle, or just take your time to set the table elegantly.

While you eat: Use a “Speed Bump” to remind yourself to slow down. After you

serve your food, divide your food in half on your plate. When you reach the halfway point, take a moment to check in. Has your mind wandered away from eating? If so, what were you thinking about? (Remember, there’s no judgment here, just observation!) How is your body feeling – are you still hungry, or are you starting to get full? When you resume eating, recommit to your practice of mindful eating.

Just eat. Turn off the TV or the computer, put down your book or your newspaper, and put your phone out of reach. Let yourself enjoy single-tasking for a little while!

After you eat: Observe. Are you satisfied – Physically? Emotionally? Spiritually?

Where would you place yourself on the Hunger/Fullness scale?

Adapted from: Eat What You Love, Love What You Eat with Diabetes, by Michelle May, MD, and Megrette Fletcher, M.Ed., RD, CDE

18

Appendix 1B

What Does Hunger Feel Like?

Hunger pangs Growling or grumbling in the

stomach An empty or hollow feeling A slightly queasy feeling Weakness or loss of energy Trouble concentrating Difficulty making decisions Irritability or crankiness A slight headache Light-headedness Shakiness Feeling that you must eat as

soon as possibleAdapted from: Eat What You Love, Love What You Eat with Diabetes, by Michelle May, MD, and Megrette Fletcher, M.Ed., RD, CDE

19

Appendix 1C

Hunger/Fullness Scale

1 – Ravenous2 – Starving3 – Hungry4 – Pangs5 – Satisfied6 – Full7 – Very Full8 – Discomfort9 – Stuffed10 – SickAdapted from: Eat What You Love, Love What You Eat with Diabetes, by Michelle May, MD, and Megrette Fletcher, M.Ed., RD, CDE

20

Works Consulted

American Diabetes Association. “Diagnosing Diabetes and Learning About

Prediabetes.” n.d. 7 November 2013. http://www.diabetes.org.

American Diabetes Association.  “Economic Costs of Diabetes in the U.S. in 2012.”  6

March 2013.  4 November 2013. http://professional.diabetes.org.  

Baer, Ruth. “Mindfulness Training as a Clinical Intervention: a Conceptual and

Empirical Review.” Clinical Psychology: Science and Practice. 10 (2003): 125-

143. DOI: 10.1093/clipsy/bpg015.

Bays, Jan Chozen.  Mindful Eating: A Guide to Rediscovering a Healthy and Joyful

Relationship with Food.  Boston: Shambhala Publications, Inc., 2009.  

Bishop, S., M. Lau, S. Shapiro, L Carlson, N. Anderson, J. Carmody, Z. Segal, S. Abbey,

M. Speca, D. Velting, and G. Devins. 2004. “Mindfulness: A Proposed

Operational Definition.” Clinical Psychology: Science and Practice. 11 (2004):

230-241. DOI: 10.1093/clipsy/bph077.

Centers for Disease Control and Prevention.  National Diabetes Fact Sheet, 2011:

National Estimates and General Information on Diabetes and Prediabetes in

the United States, 2011.  Atlanta, GA: U.S. Department of Health and Human

Services, Centers for Disease Control and Prevention, 2011.   

Crow, Scott, David Kendall, Barbara Praus, and Paul Thuras. “Binge Eating and

Other Psychopathology in Patients with Type II Diabetes Mellitus.”

International Journal of Eating Disorders. 30.2 (2001): 222-226.

21

Dalen, Jeanne, Bruce Smith, Brian Shelley, Anita Sloan, Lisa Leahigh, and Debbie

Begay. “Pilot Study: Mindful Eating and Living (MEAL): Weight, Eating

Behavior, and Psychological Outcomes Associated with a Mindfulness-based

Intervention for People with Obesity.” Complementary Therapies in Medicine.

19 (2010): 260-264.

Davis, Nichola, Ma Yong, Linda Delhanty, Heather Hoffman, Elizabeth Mayer-Davis,

Paul Franks, Janet Brown-Friday, Mae Isonaga, Andrea M. Kriska, Elizabeth

Venditti, and Judith Wylie-Rosett. “Predictors of Sustained Reduction in

Energy and Fat Intake in the Diabetes Prevention Program Outcomes Study

Intensive Lifestyle Intervention.” Journal of the Academy of Nutrition and

Dietetics. 113.10(2013): 1455-1464.

Diabetes Prevention Program Research Group.  “Reduction in the Incidence of Type

2 Diabetes with Lifestyle Intervention or Metformin.”  The New England

Journal of Medicine.  346.6 (2002):393-403.  

Diabetes Prevention Program Research Group.  “10-Year Follow Up of Diabetes

Incidence and Weight Loss in the Diabetes Prevention Program Outcomes

Study.”  Lancet.  374 (2009):1677-86.  

Dittman, K., and M. Freedman. “Body awareness, eating attitudes, and spiritual

beliefs of women practicing yoga.” Eating Disorders. 17.4 (2009): 273-292.

Elfhag, K., and S. Rossner. “Who succeeds in maintaining weight loss? A conceptual

review of factors associated with weight loss maintenance and weight regain.”

Obesity Reviews. 6.1 (2005): 67-85.

Fletcher-Hammond, Megrette.  Personal Interview.  15 November 2013.  

22

Kristeller, Jean L., and Ruth Q. Wolever. “Mindfulness-Based Eating Awareness

Training for Treating Binge Eating Disorder: The Conceptual Foundation.”

Eating Disorders. 19(2011):49-61.

May, Michelle, and Megrette Fletcher.  Eat What You Love, Love What You Eat with

Diabetes: a Mindful Eating Program for Thriving with Prediabetes or Diabetes.

Oakland: New Harbinger Publications, Inc., 2012.  

Miller, Carla, Jean L. Kristeller, Amy Headings, Haikady Nagaraja, and Fred Miser.

“Comparative Effectiveness of a Mindful Eating Intervention to a Diabetes Self-

Management Intervention among Adults with Type 2 Diabetes: a Pilot Study.”

Journal of the Academy of Nutrition and Dietetics. 112.11 (2012): 1835-1842.

Mutter, Julia. Personal Interview. 14 November 2013.

Sizer, F.S. & Whitney, E.   Nutrition: Concepts & Controversies.  Belmont: Wadsworth,

2012.  

Tapper, Katy, Christine Shaw, Joanne Ilsley, Andrew Hill, Frank Bond, and Laurence

Moore. “Exploratory randomized controlled trial of a mindfulness-based

weight loss intervention for women.” Appetite. 52 (2009): 396-404.

Thich Nhat Hanh and Lilian Cheung.  Savor: Mindful Eating, Mindful Life.  New York:

HarperOne, 2011.  

Van Buren, Dorothy, and Meghan Sinton. “Psychological Aspects of Weight Loss and

Weight Maintenance.” Journal of the American Dietetic Association. 109.12

(2009): 1994-1996.

23

Interview with Megrette Fletcher-Hammond, cofounder of the Center for Mindful Eating and author of Eat What You Love, Love What You Eat with Diabetes, dietitian and certified diabetes educator.

11/15/13 10:30 am

What do you think are the main challenges people deal with when making lifestyle changes in order to manage pre-diabetes or diabetes?There’s the first challenge which is knowledge, that’s pretty typical. The second one is finding changes that fit our lifestyle. We have a conflict [trying to go from] facts or knowledge to behavior. There’s a difference between what I know and what I do. How you integrate those two things? How do you integrate knowledge with behavior? It takes practice. You have to do a lot of trial and error. If you think you have to do it “right” that prevents us from trying and experimenting. Good science isn’t saying here’s how to get a good outcome. It’s saying how do I get a good outcome? So the big challenge that I see… [is that] a lot of times we believe what we should a achieve the standards. [This is what I have to do.] But the standards are just the standards. So as an individual – an individual needs to say that’s what the standards [are]. [Now] what am I doing? What are my lab values? What am I eating? Instead of this is what I should do… the analogy is a map. Maps are very useful if you have two piece of information: where you are and where you’re going. You need both. If you only focus on where you’re going, and you never know where you are [it’s not helpful]. Mindfulness is asking where are you? Mindful eating is saying what is the experience of this bite in your mouth? So you know “My experience is x. My experience is Y.” So many times patients come back and say “oh I thought I could only do it this way.” This is interesting that you focus on awareness of where the client is starting, because the other dietitian I spoke with mentioned that denial is a big challenge for people.You can’t deny it this way. There’s no denial there. The thing is, I don’t care where you start. Once you know [what your starting point is], I can come up with a plan to get you where you want to be. In my counseling I say this to my patients: you have to start from a place of I’m a bright able person. You can’t start from this place of I’ve failed, I’ve caused this. I’m a bright and able person, and I’ve dealt with other life challenges, I can deal with this too. Psychologically we have to start from a place of I’m abler rather than I’m not able. We can say I’m able and I also eat a diet that’s high in carborhydatate or that’s contributing to diabetes… that’s very different from a not-able mentality. When I say I’m not able, I caused this, it’s all my fault… you’re stuck in the quicksand of an unpleasant place. Start in the place of I’m a bright and able person, I can do this… it’s amazing how people really respond when they use their map. If they start from that place, it’s amazing how much more willing people are to acknowledge “My diet is really contributing to my blood sugar.”How can mindful eating help with management of pre-diabetes or diabetes and prevention of disease progression?

24

Again, what I tell my client is I will say a lot of things in the next 50 minutes to an hour. I usually take my hand and go “blah blah blah.” You know you’ll go back to your doctor and you will say I don’t remember much of anything Megrette said, but you ‘ll remember Megrette asked me to be curious. That’s what diabetes is about. Mindful eating sparks curiousity, and curiousity is a lifelong behavior that contributes to blood sugar control. We are curious about what we care about, and we care about what we are curious about.What makes mindful eating different from dieting or just “watching what you eat”? The aspects I believe are important are mindful eating asks individuals to evaluate internal and external information. Internal information is info only you the individual has. There’s no machine that can tell me your hunger, your fullness, your appetite, your likes and dislikes. External information is information that is available to all people – calories, time and place where you eat. Could include observations like how quickly you eat . Mindful eating is asking each individual to incorporate internal and external information when making food and eating choices. When we make food choices that’s different from the act of eating. A lot of time in nutrition we focus too much on selection and we’re not helping individual process information once the food is in their mouth. Because for me in mindful eating were including a different information set.There’s also the nonjudgmental aspects of mindful eating. There’s no good or bad food. Ultimately it allows freedom of choice to emerge. How do you approach teaching someone how to eat mindfully?You eat with them. You have to eat with people. You have to have them eat food. You have to create direct experience. I know it’s hard, but it’s really important. It isn’t so much about somebody coming in and teaching them. That’s too cerebral. We have to create direct experience. We create experiments, we ask people to actually taste this cookie. We eat chocolate. We engage in mindful eating at every class. And every single class when we eat with people—it’s the most amazing thing that happens. They light up. They are so excited by the experience. They start making connections like you wouldn’t even believe. It works for everybody. There’s no judgment. It’s very funny when they go back to their doctor and say she had me eat chocolate! We eat crackers and there’ s lots of different food experiences. In the [program] we talk about eating food, going out for dinner, potlucks , stuff like that. It’s an important and necessary aspect of how we teach mindful eating. So the analogy I use in my writing is it’s a lot like trying to watch baseball. You can watch baseball your whole life and it doesn’t make a good player… you gotta put a glove on, you gotta grab a bat, you gotta see what it’s like to actually get out there and play. Do you have any good stories from your own practice about how mindful eating helped your clients? I have lots of stories of people who got a lot out of mindful eating. Asking a gentlemen to create an experiment where he ate something and then took his blood sugar. He had a blood sugar of about 253 [at one point], and I asked what happened here? He said I ate a bowl of raising bran. What did you get from this? Raisin bran jacked my blood sugar. Then later his blood sugar [was less elevated]. What

25

happened there? I had three glass of wine, four cookies and a beer – who would’ve guessed that didn’t jack my blood sugars? You’ve got to learn: what does food do for you? And that’s the thing that’s so interesting for people – they say things like wow, I wouldn’t have guessed this would have happened. I had a lovely young man… really elevated blood sugar, very high , 400 or 500. We talked and came up with a plan, he came back in three months, he had been exercising, he lost 15 pounds. When his blood sugars were high, foods behaved differently than after he lost the weight, and now that his blood sugar was down, he saw he could eat [previously problematic] foods successfully. I love that he figured out how his body responds to food changes due to lots of variables – weight, exercise, medication . Here’s a person who did a really great job creating experiments re: how he could manage his blood sugar. And I give him an inordinate amount of credit. And it really was curiosity. He really is a curious person.So it sounds like one of the key points is that this gives a sense of agency back to the client, instead of telling them what to do. Would you agree with that?And I think that’s really what we’re talking about. I really feel like when I present mindful eating, when I go from the scientific perspective, let’s do this like good science, let’s experiment and find out what works. We’re so hooked into telling people this is what you need to do. That’s not good science. That’s not good research. You have to ask people what happens when you do this? That’s good sicence, that’s good research. Any final thoughts?This stuff is becoming mainstream. This isn’t woowoo stuff. This is pretty mainstream. More people are seeing the usefulness of mindful eating.

26

Interview with Julia MutterThursday November 14, 2013, 1:59 pm.

We know that making lifestyle changes is an effective way to prevent the progression from prediabetes to diabetes, but those challenges are hard for people to make. What are their main obstacles, in your experience?Mainly, people just aren’t ready. Either the health challenge isn’t the motivation they need to get started, or sometimes people have a really bad family dynamic, they have a lot of stress going on so they can’t focus on their health in particular. We have people dropping out because they have to take care of other people, you know, if someone else in the family is sick or they have kids. Having to take care of other people hinders people’s ability to stick with what we ask them to do, the stuff that’s required in order to beat this. Sometimes people have other medical complications. Like for example, one of my current people has MS, so it’s challenging for her to walk, to meet the [physical activity] goal… other health obstacles sometimes prevent them from being able to exercise at the level that we ask. For people who successfully make lifestyle changes, do you notice that they have particular characteristics?Their likelihood of getting diabetes really has clicked for them. They’ve very motivated to not get diabetes. Like “I saw diabetes kill my brother” or “I saw [what diabetes did to] my friend, and I am NOT getting it.” A personal experience with diabetes that is motivating. … people who do the work, do the exercise, and stay in the range of calories that we ask them to have a lot better results than people who sometimes do it, sometimes don’t. Attendance is a big factor. It shows their level of commitment to the program. What sort of complaints or concerns do you hear that come up for people a lot? What makes it challenging for people to stick with lifestyle changes? Especially long term? I can kind of tell who will stick with [the lifestyle change] long term. For example, my day class right now is very challenged, because I don’t know what their long term motivation [will be] without the weekly support. There are some things that come up again and again. We do this class on negative thoughts, and that’s a big thing. I can’t do this. I’m a failure. This is too hard for me. People get in the mindset of the negative thoughts. Another things that hurts people is excuses . It’s too cold to walk. My metabolism is too low. Someone told me that this week. And it’s like, actually, most peoples metabolism falls in a normal range. If you have a thyroid issue, that’s different, but most people can build the lean muscle that they need to lose the weight. Any kind of excuse people come up with. Another thing is denial. I’m doing everything I can, I worked really hard this week. When you look at their book, it’s like, this isn’t what we talked about at all. When you have any kind of lifestyle change, people come up with excuses. Same thing for smoking cessation. What is your subjective impression of how well people do with making long-term changes? What happens to people after the program is over? What do you observe in the support groups after people have completed the class?

27

340 people have come through the program in the last five years. We do three sessions a year. We average like ten per class. [I] have between 20-25 in my night support class, and it really ranges as to who comes. I have six people who always come. And a bunch of people who sometimes come. I have about ten in my day support class. I think the night support class-- I’ve found the people who come to the night class struggle more. The day class usually they’re retired. A few times there are moms or people who work at night. But typically the day class is older, over 65. Night class ranges between in their 40s to in their 60s, and a lot of them are still working. I think that’s why they struggle, because they’re managing [so much]… you know, they work, and someone has a six year old, eight year old, and it’s a lot to manage, taking care of the diagnosis and taking care of other people.Anything else you’d like to add?As for ways to improve program-- Right now we currently don’t [collect] lab [results] [after the end of the program]. Which I think is a huge issue. Like if you can’t get the data, once they stop coming, they’re less likely to get the data themselves.I’d like to see a second class, like a graduate class. The DPP in Pittsburg is 22 weeks. It’s actually double the length of our class. 1.5 hours for first four weeks, then [less than that for the rest of the 22 weeks], then month to month for the long term. They knew that an extra 12 weeks was required, it might make them come and make them more accountable to get their labs done. I would also like to see insurance companies cover prediabetes, they’d save millions of dollars cause it’s easier to prevent the disease rather than treat it. Slowly insurance companies are starting to cover like gym memberships and that sort of thing.

28