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SMAD SMAD How to cite this article Barbosa MR, Penaforte FRO, Silva AFS. Mindfulness, mindful eating and intuitive eating in the approach to obesity and eating disorders. SMAD, Rev Eletrônica Saúde Mental Álcool Drog. 2020;16(3):118-135. doi: https://dx.doi.org/10.11606/issn.1806-6976.smad.2020.165262 SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. 2020 May-June;16(3):118-135 DOI: 10.11606/issn.1806-6976.smad.2020.165262 www.revistas.usp.br/smad/ * This article refers to the call “Mindfulness and other contemplative practices”. 1 Universidade Federal de Uberlândia, Faculdade de Medicina, Uberlândia, MG, Brazil. 2 Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil. 3 Universidade Federal de Uberaba, Curso de Nutrição, Uberaba, MG, Brazil. 4 Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil. Marina Rodrigues Barbosa1,2 https://orcid.org/0000-0001-7502-243X Fernanda Rodrigues de Oliveira Penaforte3 https://orcid.org/0000-0001-8483-1562 Ana Flavia de Sousa Silva4 https://orcid.org/0000-0003-0000-8953 Objective: to examine and summarize studies of mindfulness, mindful eating and intuitive eating in the approach of overweight / obesity and eating disorders. Method: for this integrative review, PubMed, PePSIC, PsycINFO, LILACS, IBECS, SciELO and BVS-Psi databases were consulted, and published articles published in the last 10 years. After analyzing the recovered studies, 38 articles made up the final review corpus. Results: the studies demonstrated the benefits of approaches centered on mindfulness, mindful eating and intuitive eating on eating behavior and on the emotional and psychological aspects of overweight and eating disorders individuals, harmful or emotional, followed by external factors and compulsive eating; as well as levels of stress, anxiety and depression. For weight loss, the results are less consistent, since several studies have found no difference for this parameter. Conclusions: as selected focused on mindfulness, mindful eating and intuitive eating are promising for addressing obesity and obesity and eating disorders, especially with regard to eating behavior and psycho-emotional aspects. Descriptors: Mindfulness; Eating Behavior; Cognitive Behavioral Therapy; Intuitive Eating; Eating Disorder; Mindfulness-Based Intervention. Mindfulness, mindful eating and intuitive eating in the approach to obesity and eating disorders* Review Article  www.revistas.usp.br/smad 2 SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. 2020 May-June;16(3):118-135 Mindfulness, mindful eating e comer intuitivo na abordagem da obesidade e transtornos alimentares Objetivo: realizar uma revisão integrativa da literatura acerca do papel das intervenções baseadas em mindfulness, mindful eating e comer intuitivo na abordagem do sobrepeso e obesidade e dos transtornos alimentares. Método: para esta revisão foram consultadas as bases PubMed, PePSIC, PsycINFO, LILACS, IBECS, SciELO e BVS-Psi, e incluídos artigos publicados nos últimos 10 anos. Após o processo de análise dos estudos recuperados, 38 artigos compuseram o corpus final da revisão. Resultados: os estudos demonstraram os benefícios das abordagens centradas no mindfulness, mindful eating e comer intuitivo no comportamento alimentar e nos aspectos emocionais e psicológicos dos indivíduos com excesso de peso e transtorno alimentar, reduzindo o comer emocional, comer guiado por fatores externos, e episódios de binge eating; bem como reduzindo os níveis de estresse, ansiedade e depressão. Para a perda de peso, os resultados são menos consistentes, haja visto que diversos estudos não observaram diferença para este parâmetro. Conclusões: as intervenções centradas no mindfulness, mindful eating e comer intuitivo são promissoras para a abordagem do sobrepeso/obesidade e dos transtornos alimentares, especialmente no que tange ao comportamento alimentar e aos aspectos psicoemocionais. Descritores: Atenção Plena; Comportamento Alimentar; Comer Intuitivo; Transtorno Alimentar; Terapia Cognitivo Comportamental; Intervenções Baseadas em Mindfulness. Atención plena, alimentación consciente y alimentación intuitiva en el abordaje del obesidad y de los trastornos alimentarios Objetivo: desarrollar una revisión integrativa de la literatura sobre el papel de las intervenciones basadas en el mindfulness, mindful eating y alimentación intuitiva en el abordaje del sobrepeso / obesidad y de los trastornos alimentarios. Método: para esta revisión, se consultaron las bases de datos PubMed, PePSIC, PsycINFO, LILACS, IBECS, SciELO y BVS-Psi, y se incluyeron artículos publicados en los últimos 10 años. Después de analizar los estudios recuperados, 38 artículos constituyeron el corpus final de la revisión. Resultados: los estudios han demostrado los beneficios las intervenciones basadas en el mindfulness, ME y alimentación intuitiva para el comportamiento alimentario y los aspectos emocionales y psicológicos de las personas con sobrepeso/obesidad y trastornos alimentarios, reduciendo la alimentación emocional, el comer basado en factores externos y en los episodios de binge eating; además de reducir los niveles de estrés, ansiedad y depresión. Para la pérdida de peso, los resultados son menos consistentes, dado que varios estudios no han encontrado diferencias para este parámetro con las intervenciones. Conclusiones: las intervenciones basadas en el mindfulness, mindful eating y alimentación intuitiva son prometedoras para el abordaje del sobrepeso/obesidad y de los trastornos alimentarios, especialmente con respecto al comportamiento alimentario y los aspectos psicoemocionales. Descriptores: Conducta Alimentaria; Atención Plena; Terapia Cognitivo-Conductual; Alimentación Intuitiva; Trastorno Alimentario; Intervención Basada en la Atención Plena.  www.revistas.usp.br/smad 3 Barbosa MR, Penaforte FRO, Silva AFS. Introduction Excess body weight is one of the most challenging public health problems today. Despite its increasing prevalence, and the vast knowledge about its numerous negative health consequences(1), the treatment for this condition remains difficult to be adhered to. Consequently, much has been questioned about the principles on which the traditional approaches to overweight are focused, which commonly rely almost exclusively on the premise of diets, with quantitative and/or qualitative restriction on food intake. It is speculated that the unsatisfactory results of this approach are mainly related to the non-promotion of changes in dysfunctional eating behaviors(2-3). In turn, eating disorders (EDs), mainly characterized by persistent disturbance in eating or in the behavior related to eating, resulting in excessive intake or strict avoidance of food(4), although they are considered of low prevalence, also present significant degrees of morbidity and mortality, in addition to great personal and psychosocial losses(5). The approach to overweight and EDs is complex and difficult to manage, especially because they are conditions that are related to dysfunctional relationships with eating and food, and with impairment of the psychosocial functioning of the subject(6-7). In this scenario, innovative strategies employed in the approach of dysfunctional eating behaviors have emerged, with emphasis on mindfulness, mindful eating, and intuitive eating. Mindfulness is described as a state of consciousness that emerges through the attention that is intentionally given to the present moment without judgment. Because it is a state of awareness, mindfulness can be developed and trained, through formal and informal practices(8). Within mindfulness, with a special look at attention to aspects related to eating and food, mindful eating (ME), or “eating with full attention”, emerges. ME recommends that the subjects make their food choices consciously and attentive to the physical signs of hunger and satiety(9). Another important premise of ME is the attention to the entire experience involved in eating, noting the effects of food on the senses and on the physical and emotional sensations that occur before, during and after eating, with openness and without judgments(10-11). Intuitive eating (IE) or “intuitive nutrition”, although less known, follows the same line and is generally used interchangeably with ME, especially since both recommend eating being guided by the physiological signs of hunger and satiety(12). IE has ten principles, with emphasis on rejection of diets, unconditional permission to eat; eating for physical, not emotional reasons; and confidence in the body and in the signals of hunger and satiety to determine when and how much to eat(13-15). Because these are innovative approaches, the systematization of knowledge regarding their outcomes for the health of subjects with overweight and EDs, are few, although growing in numbers. Some reviews were conducted with the objective of evaluating the effects of mindfulness-based approaches on weight loss(16-17), on the treatment of obesity and eating disorders(18-19), or on the specific treatment for eating disorders(14,20-21); others sought to verify the effects of mindful eating on weight loss(22) or on the approach to obesity and eating disorders(23). However, no reviews were found that gathered the results of interventions based on mindfulness, mindful eating and intuitive eating in the eating behavior, physical aspects and psychoemotional aspects in overweight and obese individuals, and with EDs. Specifically in the national scenario, only one integrative review study was found in the specific theme of mindful eating(23). Therefore, this study aimed to conduct an integrative review of the literature of the growing body of research studies that investigated the role of mindfulness, mindful eating, and intuitive eating in the approach of overweight, obesity and EDs, especially with regard to results in the eating behavior and in the physical and psychoemotional aspects, seeking to contribute to the reduction of this knowledge gap. The systematization of this knowledge is important to broaden the understanding of its applicability, especially for conditions that are related to dysfunctional eating behaviors. Method This is an integrative review of the scientific literature, which aims to synthesize and deepen the knowledge about a given subject matter, seeking consolidated evidence for evidence-based practice(24-25). For this review, standardized procedures were adopted(26), namely: (1) identifying the theme and the guiding question; (2) establishing inclusion/exclusion criteria; (3) categorizing the studies; (4) evaluating the studies; (5) interpreting the results; (6) synthesis of knowledge(26). The international protocol for systematic review studies and meta-analyses, PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was also adopted to guide both the inclusion and exclusion of the articles in the review, as well as the writing of this study(27). For this review, the guiding question was defined using the PICO method, which provides for  www.revistas.usp.br/smad 4 SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. 2020 May-June;16(3):118-135 the definition of the participant (P), intervention (I), comparison (C) and outcome (O)(28). The comparison item was not used in this study, so criterion C was excluded from the writing of the question. This change is foreseen in the PICO methodology in some cases. The main question of the study was the following: What are the results in the eating behavior, physical aspects and psychoemotional aspects (O) of approaches centered on mindfulness, mindful eating and intuitive eating (I) in subjects with overweight, obesity and eating disorders (P)? Article selection path The selection of the articles took place between October and December 2019. Searches were carried out in the PubMed, PePSIC, PsycINFO, Latin American and Caribbean Literature in Health Sciences (Literatura Latino-Americana e do Caribe em Ciências da Saúde, LILACS), IBECS, Scientific Eletronic Library Online (SciELO) and BVS-Psi databases. Academic papers in Portuguese, English and Spanish were considered. These databases were chosen because they encompass vast literature, in the national and international scopes, published on the topic of interest, and also because they include renowned journals in the health area. For the searches, indexed descriptors were used according to DeCs/MeSh standardization, in their Portuguese and English versions. The indexed descriptors used were the following: transtorno alimentar (eating disorder or feeding disorder), comportamento alimentar (eating behavior), atenção plena (Mindfulness), obesidade (obesity) and excesso de peso (overweight). Other non-indexed descriptors, but directly related to the theme, were also used, namely: mindful eating and intuitive eating. These keywords appeared in at least one of the following search fields: title, abstract, subject or keyword. The following criteria were adopted for including the articles: (a) articles published between January 2009 and December 2019; (b) empirical studies that explicitly and specifically used programs with approaches centered on mindfulness, mindful eating and intuitive eating; (c) studies conducted with adults; (d) which were freely available for reading in full; and (e) published in Portuguese, English and Spanish. The exclusion criteria were the following: (a) studies with children and older adults; (b) materials such as monographs, editorials, books, book chapters, reviews and abstracts in conference proceedings; (c) literature review articles; (d) articles from clinical cases; (e) qualitative studies; (f) studies on the elaboration and/or validation of scientific protocols or instruments; (g) studies carried out with intervention programs/techniques that use some elements of mindfulness, mindful eating and/ or intuitive eating, but are not focused on these approaches. Studies that were repeated in more than one database were computed only once. To check whether the articles found met the inclusion and exclusion criteria, their respective titles and abstracts were read. This procedure was performed by two independent judges, both familiar with the topic. In case of disagreement, the analysis was made by a third judge, also with experience in the theme. The articles selected in this first stage were retrieved for reading in full, and the inclusion and exclusion criteria were again applied in the full texts. The articles that remained, after analysis by full reading, made up the final analysis corpus of this study. For the analysis stage, a record was made of all the articles that made up the final corpus, compiling the following information: title, authors, year, place of publication, method/type of study, sample, objectives and main results. The full analysis of the articles allowed for the organization of categories that aim to answer the guiding question of this review. Results Categorization of the articles The searches in the databases resulted in a total of 785 articles. The database with the largest number of articles was Pubmed, followed by SciELO, IBECS and LILACS. The first stage of the analysis led to the exclusion of 40 articles that were duplicated. Subsequently, 528 articles were excluded, especially because they are association studies or for approaching the subject in a tangential manner. Of the 54 remaining articles to be read in full, 16 were excluded. These exclusions occurred, for example, because they were studies that only described a program to be implemented, or because they used interventions that presented only specific elements of mindfulness, ME or IE. Thus, a total of 38 articles made up the final corpus of this review. Figure 1 shows the flowchart of the study selection strategy, according to the PRISMA protocol. The articles that make up this review are exclusively international and are written in the English language. The country with the largest number of publications was the United States (n=27; 71.0%), followed by Portugal (n=03; 7.9%), England (n=02; 5.2%), Australia (n=2; 5.2%), Holland (n=01; 2.6%), Canada (n=01; 2.6%), New Zealand (n=01; 2.6%), and Iran (n=01; 2,6%). The year with the  www.revistas.usp.br/smad 5 Barbosa MR, Penaforte FRO, Silva AFS. highest number of publication was 2017 (n=09; 23.7%), followed by 2016 (n=06; 15.8%). The years 2010, 2014, 2018 and 2019 contributed with four studies (10.8%) each year. The years 2011 and 2013 were the ones with the lowest number of publications, with only 01 article (2.7%) each year. The sample size of the studies ranged from 10 (smallest sample) (9) to 194 (largest sample) participants. The surveys with the largest sample size(29-30) were derived from the same research protocol. Most of the studies were conducted with men and women (n=21; 55.2%); however, an important portion of the studies was carried out exclusively with women (n=17; 44.7). It was observed that most of the studies (n=31, 81.6%) were carried out with overweight individuals, with 06 studies (15.8%) carried out with ED patients, and only 01 (2.6%) conducted with women with overweight and binge eating. Studies conducted with people with specific clinical conditions were few in number. Research studies were found with women with a current or previous history of cancer (n=03, 7.9%), with pregnant women (n=02, 5.2%), and with individuals in the postoperative period of bariatric surgery (n=01, 2.6%). Regarding the type of study, most of the articles fall into the randomized type (n=21; 55.2%), followed by the evaluation of the participants before and after the intervention (n=13; 34,2%). The longest intervention lasted 6 months(31) and the shortest, one month(32-33). The intervention time most commonly found in the studies was 8 weeks (n=08, 21.0%), followed by 10-week interventions (n=07, 18.4%). Most of the studies used the mindfulness-based intervention (n=18; 47.3%), followed by interventions that used mindful eating (n=11; 28.9%), mindfulness and mindful eating in association (n=5; 13.1%), and intuitive eating (n=04; 10.5%). It is also important to mention that most of the research studies with a control group had an active control group (n=20; 52.6%), that is, the participants received some type of intervention that did not involve mindfulness, mindful eating or intuitive eating. Only 03 studies (7.8%) did not perform any type of intervention in the control group. The results presented below will be organized based on the full reading of the studies that comprised the corpus of this review, aiming to answer the guiding question: (1) results of approaches centered on mindfulness, mindful eating and intuitive eating in the eating behavior; (2) results of approaches focused on mindfulness, mindful eating and intuitive eating in physical aspects; and (3) results of approaches centered on mindfulness, mindful eating and intuitive eating in psycho-emotional aspects. Articles identified by means of the search in the selected databases (n=785) Articles excluded (n=528) Reasons for the exclusion: - Review studies; - Association studies; - Studies with children or adolescents. Articles excluded through abstract and title reading (n=65) Reasons for the exclusion: - Studies conducted with individuals with no obesity or eating disorder; - Single clinical case; - Qualitative studies. Exclusion based on full reading (n=16) Reasons for the exclusion: - Studies with no intervention; - Studies with only one intervention session. Articles after removal of duplicates (n=745) Articles selected (n=217) Articles selected for full reading (n=54) Studies included for analysis (n=38) Identified Selected Eligible Included Figure 1 - Flowchart of the study selection process, prepared according to the PRISMA recommendations(27).  www.revistas.usp.br/smad 6 SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. 2020 May-June;16(3):118-135 Category 1) Results of the approaches centered on mindfulness, mindful eating and intuitive eating in eating behavior. Studies with overweight and obese subjects that had among their objectives improvements in eating behavior (55.3%) bring promising results. With interventions supported by mindfulness, ME or IE, reductions in food craving levels were observed, as well as in eating guided by external stimuli, emotional eating, eating guided by reward, episodes of compulsive eating and of binge eating compared to the control groups. For the interventions with evaluation of the before and after type, improvements were seen in eating awareness, reduction in binge eating episodes, increases in scores of mindful eating and intuitive eating, and improved fruit and vegetable intake. For the studies with ED patients (18.4%), a reduction in the number of episodes of binge eating was observed, as well as a reduction in the scores of the Eating Attitudes Test (EAT), an increase in the IE levels, and a decrease in the eating psychopathology levels after participating in the interventions (Figures 2 and 3). Few studies (7.9%) found no differences between the experimental groups and the control group for the eating behavior parameters evaluated. For example, the study(34) that identified improvement in the levels of emotional eating, uninhibited eating, and symptoms of dependence on food in both groups of pregnant women (intervention and control), with no difference between them. It is important to note that the control group, in this study, also received an intervention, referred to as Emotional Brain Training (EBT), whose objective was to train the participants› emotional self- regulation, with a view to reducing their stress levels(34). Similar results were obtained in another study(35), especially in reducing stress-related eating at the end of the intervention, in all the groups, with no difference between them. Also in this study, all the groups received some type of intervention, according to the following combinations: (1) stress reduction intervention based on mindfulness (Mindfulness Based Stress Reduction program), (2) stress reduction intervention based on the interrelationship between stress, food and well- being, supported by cognitive behavioral therapy, and (3) a combination of interventions from groups 1 and 2 (Figures 2 and 3). Category 2) Results of the approaches centered on mindfulness, mindful eating and intuitive eating in physical aspects. The research studies with interventions with evaluation of the before and after type, carried out with overweight individuals, obtained satisfactory results with regard to physical aspects, since the majority (66.7%) observed a significant reduction in weight, in the BMI and in the C-reactive protein levels. It is also worth mentioning that most of the randomized studies (72.7%), in which the participants were divided into an intervention group (mindfulness and mindful eating) and active control group (who received some type of intervention), found no significant differences between the groups for weight loss. However, there was a significant reduction in fasting glycaemia and in the TG/HDL ratio in the experimental group in relation to the control group(36) (Figure 3). Regarding studies with ED patients, the results point to a reduction in concern about weight, physical shape and overvaluation of weight after participating in mindfulness-based interventions, compared to the control group. There was also an increase in body satisfaction, showing the benefits of such interventions for the participants. Category 3) Results of the approaches centered on mindfulness, mindful eating and intuitive eating in psycho-emotional aspects. Among the studies carried out with overweight and obese individuals, 27.0% had among their objectives the assessment of the impacts of mindfulness-based interventions on emotional and psychological aspects such as depression, anxiety, stress, psychological flexibility, and general mental health. These studies also bring promising results, since 80.0% of them identified an improvement in the parameters related to psychological distress, depression or anxiety(37-38). The studies indicate that, after the intervention based on mindfulness and mindful eating, there was a significant reduction in the levels of depression, anxiety, perceived stress and cortisol (9,39-40). In addition, some positive impacts were observed, such as an improvement in the ability to respond to bodily sensations, psychological flexibility and psychological acceptance, also described as a reduction in experiential avoidance(41-42) (Figure 2). In studies conducted with individuals diagnosed with EDs, only 5.2% had among their objectives the assessment of the impacts of the mindfulness-based interventions on the emotional and psychological aspects. One of these studies was carried out with women with EDs(43), with a 12-week intervention integrating concepts of psychoeducation and mindfulness, where a significant reduction in psychological inflexibility, external shame and self-criticism was observed; as well as increased engagement with life, self-compassion, and levels of self-confidence and of mindfulness. It is important to note that these gains were maintained in reevaluations 3 and 6 months after the intervention.  www.revistas.usp.br/smad 7 Barbosa MR, Penaforte FRO, Silva AFS. In another study, also conducted with women with EDs(33), the authors performed a mindfulness-based intervention during four weeks and observed a reduction in the symptoms of depression and stress, as well as an improvement in psychological flexibility in relation to body image, when compared to the control group (Figure 2). Title, authors, year and country of publication Study type Population evaluated (size for analysis) Intervention type Duration and components of the intervention Mindfulness practices present in the intervention Alberts et al. (2010) Netherlands(44) Randomized intervention study: control and intervention groups Adults with obesity (n = 19) Mindfulness-based intervention 7 weeks. Group sessions (1h30) with formal practice at home Body scan and Mindful breathing seated Courbasson et al (2010) Canada(45) Intervention study: comparison before and after Adults with eating disorder and substance use (n = 38) Mindfulness-based intervention associated with CBT * 16 weeks. Group sessions (2 hours) with formal practice at home Mindfulness practice participants were encouraged to adopt a non- judgmental, non-striving and open mind stance. Dalen et al (2010) USA(9) Pilot intervention study: comparison before and after Adults with obesity (n = 19) Mindfulness-based intervention created for individuals with obesity and overweight (MEAL†) 6 weeks. Weekly group sessions (2 hours) with formal practice at home Mindfulness meditation, mindful eating, awareness of body sensations and triggers to overeat. Hepworth (2010) Australia(46) Pilot intervention study: comparison before and after Women with eating disorders (n= 33) Outpatient care, with group activity 10 weeks. Group sessions (duration not informed) with formal practice at home Mindful breathing seated and minduful eating Daubenmier et al. (2011) USA(39) Pilot randomized clinical study: control and intervention groups Women with overweight and / or obesity (n = 47) Intervention based on the MBSR‡; MBCT§ and MB-EAT|| protocols 8 weeks. Group sessions (2,5 hours) and a retreat (7 hours) with daily and informal formal practice (6 days/week) Mindful breathing seated; body scan; mindful yoga stretches, loving kindness meditations, the “3 minute breathing space” and ME¶ at meals Anglin (2012) USA(47) Randomized clinical study: control and intervention groups Adults with obesity, sedentary, and without a history of chronic diseases (n = 16) Intervention based on intuitive eating; and control group with caloric restriction 6 weeks Not mentioned Daubenmier et al. (2012) USA(38) Pilot randomized clinical study: control and intervention groups Women with overweight and / or obesity (n = 47) Intervention based on the MBSR‡; MBCT§ and MB-EAT|| protocols 8 weeks. Group sessions (2,5 hours) a retreat (7 hours) with daily and informal formal practice (6 days/ week) Mindful breathing seated; body scan; mindful yoga stretches; loving kindness meditations, the “3 minute breathing space” and ME¶ at meals Woolhouse et al. (2012) Australia(49) Intervention study: comparison before and after Women with eating disorders (n= 54) Mindfulness-based intervention with CBT * association for eating disorder (MEG Program) 10 weeks. Group session (3 hours), and a follow-up session after 3 months Sitting meditation; body scan and manegment feelings practice related to food. Kidd et al. (2013) USA(50) Intervention study: comparison before and after Women with obesity (n= 12) ME¶-based intervention 8 weeks. Group sessions (1 - 1h30) Awareness practtice about of the senses and patterns without pressure to change; without judgment. Corsica et al. (2014) USA(35) Randomized clinical study: 3 groups Women (98%) with overweight (n = 53) Groups: (1) MBSR ‡; (2) CBT*; and (3) combined intervention 6 weeks. Group sessions (50 to 80 minutes) with formal and informal practice at home Body scan; mindful breathing seated, mindful yoga stretches, loving kindness meditations, and informal practice Daubenmier et al. (2014) USA(40) Pilot randomized clinical study: control and intervention groups Women with overweight and / or obesity (n = 47) Intervention based on the MBSR‡; MBCT§ and MB-EAT|| protocols 8 weeks. Group sessions (2,5 hours) and a retreat (7 hours) with daily and informal formal practice (6 days/week) Mindful breathing seated; body scan; mindful yoga stretches; loving kindness meditations, the “3 minute breathing space” and ME¶ at meals Kristeller et al. (2014) USA(11) Randomized clinical study: control and intervention groups Adults with overweight and / or obesity (n = 150) Groups: (1) MB-EAT||; intervention; (2) psychoeducational and cognitive-behavioral intervention; and (3) passive control group 9 weeks. Group sessions (1h30- 2h) and 3 monthly reinforcements Mindful breathing seated and and ME¶ at meals (the Figure 2 continue in the next page...)  www.revistas.usp.br/smad 8 SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. 2020 May-June;16(3):118-135 Mantzios et al. (2014) England(51) Randomized clinical study: control and intervention groups Adults with overweight and / or obesity (n = 152) Mindful Attention and Awareness in both groups, one performed in a group and the other with individual practice 6 weeks. Group (2 hours) and individual sessions, with formal practice at home Mindful breathing seated; and body scan Asadollahi et al. (2015) Iran(52) Randomized clinical study: 4 groups Adults with obesity (n = 60) Groups: (1) MBCT§; (2) nutritional orientation; (3) association of interventions 1 and 2; and (4) passive control group 8 weeks. Group sessions (2 hours) with formal practice at home Tthe “3 minute breathing space” practice, body scan and stomach checking practice at meals Stites et al. (2015) USA(32) Randomized clinical study: intervention and late intervention groups Adults with overweight and / or obesity (n =28) ME¶-based intervention 4 weeks. Group sessions (1h30) Not mentioned Boucher et al. (2016) New Zealand(42) Pilot intervention study: comparison before and after Women with overweight (n= 40) Intervention based on intuitive eating and associated with a psychological approach 14 weeks. 12 group sessions (15-20 minutes) Not mentioned Chacko et al. (2016) USA(53) Randomized clinical study: control and intervention groups Adults after bariatric surgery (1 to 5 years) (n = 18) Intervention based on the MBSR ‡, MB-EAT||, and Mindful Self- compassion (MSC) protocols 10 weeks. Group sessions (1h30) and a retreat (4 hours) with formal practice at home Mindful breathing seated; loving kindness meditations, body scan and mindful yoga. Chung et al. (2016) EUA(54) Intervention study: comparison before and after Women with overweight and a history of breast cancer (treatment completed at least 3 months) (n = 22) ME¶-based intervention associated with dietary orientation for weight loss 12 weeks. Group sessions for 6 weeks Mindful breathing seated; ME¶ at meals, body scan and mindful walking exercise, Daubenmier et al. (2016 USA(36) Randomized clinical study: control and intervention groups Adults with obesity (n= 194) Intervention based on the MBSR ‡, MBCT§ and MB-EAT|| protocols 12 weeks. 16 group sessions (2-2h30), with formal and informal practice at home Mindful breathing seated; mindful walking, exercise, loving Kindness meditations, yoga and ME¶ at meals Lucas et al. (2016) USA(55) Intervention study: comparison before and after Women with overweight and / or obesity and cancer history (n = 17) Mindfulness-based intervention and dietary orientation 8 weeks Mindful breathing seated; and mindful yoga Mason et al. (2016) USA(29) Randomized clinical study: control and intervention groups Adults with overweight (n= 194) Intervention group: diet / exercise and mindfulness Control group: diet and exercise. 12 weeks. 16 group sessions (2-2h30), with formal and informal practice at home Mindful breathing seated, mindful walking, loving kindness meditations and mindful yoga Mason et al. (2016) USA(56) Randomized clinical study: control and intervention groups Adults with obesity (n= 194) Mindfulness-based intervention. Control and intervention groups received nutritional and exercise orientation. (SHINE clinical trial). 12 weeks. 16 group sessions (2-2h30), with formal practice at home Mindful breathing seated, mindful walking, loving kindness meditations and mindful yoga Pinto Gouveia (2016) Portugal(43) Intervention study: comparison before and after Women with eating disorder and overweight (n = 31) BEfree is a psychological program with psychoeducational strategies and new contextual-behavioral approaches, such mindfulness and self- compassion. 12 weeks. Group sessions (2h30) Mindful breathing seated, and body scan Adler et al.(2017) USA(30) Randomized clinical study: control and intervention groups Adults with obesity (n= 194) Mindfulness-based intervention. Control and intervention groups received nutritional and exercise orientation. (SHINE clinical trial). 12 weeks. 16 group sessions (2-2h30) Mindful breathing seated, mindful walking, loving kindness meditations and mindful yoga Carpenter et al. (2017) USA(57) Pilot randomized clinical study: control and intervention groups Adults with overweight (n= 194) Mindfulness-based intervention. Control and intervention groups received orientations about weight loss. 11 weeks. Telephone intervention (weekly, with a practice of 60 seconds) Mindful breathing seated, and ME¶ Duarte et al. (2017) Portugal(33) Pilot randomized clinical study: control and intervention groups Women with eating disorder and overweight (n = 20) Brief intervention based on mindfulness and compassion. 4 weeks. A group session (2h30) and 3 weeks of individual audio-guided practice Mindful breathing seated, body scan, ME¶ and presentation of compassionates images (the Figure 2 continue in the next page...)  www.revistas.usp.br/smad 9 Barbosa MR, Penaforte FRO, Silva AFS. Palmeira et al. (2017) Portugal(37) Randomized clinical study: control and intervention groups Women overweight and / or obese (n = 52) Intervention based on MB-EAT||, acceptance and compassion therapy. 10 weeks. Group sessions (2h30) and 2 additional reinforcement sessions every 3.5 months, with formal practice at home Loving kindness meditations, ME¶ and mindful breathing seated Raja-Khan et al. (2017) USA(38) Randomized clinical study: control and intervention groups Women overweight and / or obese (n = 86) MBSR‡ 8 weeks. Group sessions (2h30) and a retreat (6 hours), with formal practice at home Not mentioned Richards et al.(2017) USA(58) Pilot intervention study: comparison before and after Women with eating disorder (n= 120) Program based on the 10 principles of Intuitive Eating 10 weeks. Individual sessions Not mentioned Spadaro et al. (2017) USA(31) Pilot randomized clinical study: control and intervention groups Adults with overweight (n= 46) Intervention based on the MBSR ‡ and MB-EAT || associated with calorie restriction and physical exercise orientations. 6 months. Group sessions (1-1h30) Body scan and mindful breathing seated, three minutes check-in, loving kindness meditations and ME¶ Kristeller et al. (2018) USA(59) Randomized clinical study: control and intervention groups Adults with obesity (n= 117) MB-EAT|| intervention group 10 weeks. Group sessions (2h30) with 2 reinforcement sessions (2 hours) Mindful breathing seated, ME¶ at meals, body scan and e Forgiveness meditation. Laraia et al.(2018) USA(34) Non-randomized clinical study: control and intervention groups Pregnant woman (12–19 gestational weeks) with overweight and / or obesity (n = 46) Intervention based on MBSR ‡; MBCT§, and MB-EAT|| 8 weeks. Group sessions (2 hours) Mindful breathing seated, loving kindness meditations and compassion meditation Mason et al. (2018) USA(60) Intervention study: comparison before and after Adults with overweight (n= 104) ME¶-based intervention 28 days. Individual session (5-10 minutes) with daily telephone call Mindful breathing seated and ME¶ Vieten et al. (2018) USA(41) Intervention study: comparison before and after Pregnant women with overweight (8 - 20 gestational weeks) (n = 110) Intervention based on MBSR ‡; MBCT§, and MB-EAT|| 8 weeks. Group sessions (2 hours), with formal practice at home Mindful breathing seated, mindful walking, loving kindness meditations and body scan. Cole et al. (2019) USA(61) Pilot intervention study: comparison before and after Adults with overweight and/or obesity (n= 56) Intervention based on the principles of intuitive eating (My Body Knows When program - MBKW) 10 weeks. Group sessions online and in person (1h30) Not mentioned Hanson et al. (2019) United Kingdom(62) Pilot randomized clinical study: control and intervention groups Adults with grade 3 obesity (n = 33) Mindfulness-based intervention. Control group: individuals who did not complete the intervention. 8 weeks. Group sessions every 2 weeks (1h30) Not mentioned Stice et al. (2019) USA(63) Randomized clinical study: control and intervention groups Women with eating disorder (n = 84) Mindfulness-based intervention. Control group: Body Project eating disorder –BPT. 8 weeks. Group sessions (1 hour) Not mentioned Thomas et al. (2019) USA(64) Randomized clinical study: control and intervention groups Women with overweight and / or obesity and history of cancer (in remission or active) (n = 51) Mindfulness-based intervention associated with CBT elements * and positive psychology principles. Both groups received nutritional counseling. 10 weeks. Group sessions (1h30), with formal practice at home Not mentioned *CBT = Cognitive behavioral therapy; †MEAL = Mindful Eating and Living; ‡MBSR= Mindfulness - Based Stress Reduction; §MBCT= Mindfulness - Based Cognitive Therapy; ||MB-EAT = Mindfulness – Based Eating Awareness Training; ¶ME = Mindful Eating Figure 2 - Summary of the analysis of the included articles: description of the sample, type and duration of the intervention explored, Ribeirão Preto, SP, Brazil, 2019  www.revistas.usp.br/smad 10 SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. 2020 May-June;16(3):118-135 Title, authors, year and place of publication Instruments applied Outcomes/Parameters assessed Results found Alberts et al. (2010) Netherlands(44) General Food Craving Questionnaire Trait (a) weight; (b) food cravings; (c) hours of daily practice The experimental group participants reported significantly lower food cravings after the intervention. Courbasson et al (2010) Canada(45) Structured Clinical Interview for DSM-IV disorders; Eating Disorder Examination Questionnaire; BDI* (a) number of compulsive eating episodes; (b) number of compulsive eating days Reduction in the number of compulsive eating episodes reported. Fewer concerns about shape, weight and diet over time. Dalen et al (2010) USA(9) BES†; BDI*; PSS§; TFEQ||; KIMS¶; Beck Anxiety Inventory (a) changes in weight and BMI‡; (b) eating behavior; (c) psychological stress; (d) physiological stress markers Increased measures of awareness around eating, and reductions in weight, compulsive eating and depression. There was a reduction in the C-Reactive Protein. Hepworth (2010) Australia(46) EAT**-26 Disordered eating symptoms Reductions were found in all the subscales of **EAT-26. Daubenmier et al. (2011) USA(39) KIMS¶; DEBQ†† (a) level of full attention, (b) eating behavior, (c) weight, abdominal fat and (d) response to cortisol Increased attention and responsiveness to bodily sensations, reducing anxiety and emotional eating. Anglin (2012) USA(47) Did not apply a specific instrument (a) weight; (b) waist circumference; (c) BMI‡ There was weight loss or maintenance in both groups. Total weight loss was greater in the calorie restriction group. Daubenmier et al. (2012) USA(38) PSS§; DEBQ††; KIMS¶ e; Block Food Frequency; State-Trait Anxiety Scale- Trait Form; (a) psychological distress; (b) eating behavior; (c) metabolic parameters (d) telomerase activity Both groups had an increase in telomerase activity. Woolhouse et al. (2012) Australia(49) DEBQ††; Eating Disorders Inventory-3 Symptom Checklist; Multifactorial Assessment of Eating Disorders Scale; Eating Self-Efficacy Scale; Emotional Overeating Questionnaire; Cognitive and Affective Mindfulness Scale-Revised Frequency and severity of compulsive eating events Significant reduction in the frequency and severity of compulsive eating and dissatisfaction with body image. Kidd et al. (2013) USA(50) 20-item Weight Efficacy Lifestyle Questionnaire; 28-Mindful Eating Questionnaire (MEQ); 20-item Center for Epidemiologic Studies-Depression Scale (a) depressive symptoms; (b) weight, height, body composition, blood pressure, (c) lifestyle; (d) level of ; Mindfull eating (ME) There was an increase in self-efficacy for weight loss and eating habits. Corsica et al. (2014) USA(35) PSS§-10; Eating and Appraisal Due to Emotions and Stress Questionnaire; Emotion- and Stress-Related Eating subscale (a) perceived stress; (b) stress-related eating and (c) weight loss The combined intervention resulted in greater reductions in perceived stress and produced short-term weight loss. Daubenmier et al. (2014) USA(40) DEBQ††; BES†; Body Responsiveness Questionnaire (a) level of full attention, (b) emotional eating (c) weight, abdominal fat and (d) cortisol Higher levels of cortisol were related to greater emotional and restrictive food intake, and to lower interoceptive awareness. Kristeller et al. (2014) USA(11) BES†; TFEQ||; Power of Food Scale; Rosenberg Self-Esteem (a) compulsive eating; (b) food intake; (c) craving for a certain type of food; (d) depression; (e) self-esteem; (f) BMI‡ After the intervention, 95% of the individuals in the mindful eating group no longer met the eating disorder criteria; against 76% receiving the other intervention. Mantzios et al. (2014) England(51) Mindful Attention and Awareness Scale; Barratt Impulsivity Scale; Cognitive-Behavioral Avoidance Scale; (a) weight; (b) attention and awareness; (c) impulsivity The group intervention produced greater weight loss. The individual intervention increased the rates of mindfulness and reduced impulsivity for food. Asadollahi et al. (2015) Iran(52) SCL‡‡-90-r (a) psychiatric symptoms; (b) BMI‡, weight and height The combined intervention had a greater impact on the participants’ weight loss compared to performing the interventions alone. Stites et al. (2015) USA(32) MEQ§§ (a) weight and ; (b) metabolic parameters The intervention produced a reduction in the consumption of calories and fat at lunch compared to the late intervention. Boucher et al. (2016) New Zealand(42) Intuitive Eating Scale (IES-1); Disorder Examination-Screening Version (EDE-S); Acceptance and Action Questionnaire-II; Short Form 12-item Health Survey (a) BMI‡; (b) intuitive feeding; (c) compulsive eating; (d) psychological flexibility; (d) mental health Increased scoring on intuitive eating, psychological flexibility and mental health scales. And reduction in compulsive eating. Chacko et al. (2016) USA(53) TFEQ||-R1; Quality of life (QOL) (a) weight; (b) eating behavior; (c) compulsive eating; (d) metabolic parameters The intervention was effective in reducing emotional eating. Chung et al. (2016) USA(54) MEQ§§ (a) weight and BMI‡; (b) levels of mindful eating Significant increase in the level of mindful eating and weight and *BMI reductions. (the Figure 3 continue in the next page...)  www.revistas.usp.br/smad 11 Barbosa MR, Penaforte FRO, Silva AFS. Title, authors, year and place of publication Instruments applied Outcomes/Parameters assessed Results found Daubenmier et al. (2016 USA(36) 9-item Reward-based Eating Drive PSS§-10; (a) weight and height, (b) blood pressure; (c) waist circumference; (d) fasting blood glucose lipid profile Improvement of blood glucose parameters and lipid profile of the intervention group at 12 and 18 months. Lucas et al. (2016) USA(55) Five Facet Mindfulness Questionnaire (FFMQ); Mindfulness Attention Awareness Scale MAAS; Food Habits Questionnaire); Physical Activity Questionnaire; Physical Performance Battery; Pittsburg Sleep Quality Index. (a) level of mindfulness; (b) quality of the diet; (c) quality of life; (d) physical activity; (e) sleep There was an increase in the level of mindfulness, consumption of fruits and vegetables, and in the quality of sleep after the intervention. Mason et al. (2016) USA(29) PSS§-10; 9-item Reward-based Eating Drive (RED) scale (a) weight loss; (b) food reward mechanisms The mindfulness group presented lower levels for the RED scale. Mason et al. (2016) USA(56) MEQ§§ (a) level of mindfulness; (b) consumption of sweets; (c) fasting blood glucose The intervention group showed greater increases in Mindfulness levels immediately after and maintained 12 months later. The control group showed an increase in the consumption of sweets between 6 and 12 months after. Pinto Gouveia (2016) Portugal(43) BES†; FFMQ|||| ; Acceptance and Action Questionnaire-II; Cognitive Fusion Questionnaire-Body Image; Engage Living Scale; Forms of Self-Criticising/Attacking & Self- Reassuring Scale; Self-Compassion Scale (a) disordered eating behavior and attitudes; (b) psychological inflexibility Reduction of compulsive eating and eating psychopathology, psychological inflexibility, cognitive fusion of body image, external shame and self- criticism. There was an increase in engagement with valued life, levels of self-compassion, confidence and mindfulness. Adler et al.(2017) USA(30) FFMQ|||| e Pittsburgh Sleep Quality Index (a) sleeping quality; (b) level of mindfulness Both groups showed improvements in sleep quality, especially with the highest scores in FFMQ|||| . Carpenter et al. (2017) USA(57) BES†; MEQ§§; FFMQ||||–Short Form; Patient Health Questionnaire-2. (a) eating behavior; (b) level of mindfulness; (c) level of mindful eating; (d) weight Improved scores for mindful eating, eating behavior, acceptance and psychological flexibility related to weight. Duarte et al. (2017) Portugal(33) BES†; FFMQ||||; Body Image Shame Scale; 21‐item Depression, Anxiety, and Stress Scale; Cognitive Fusion Questionnaire for food craving; Body Image Acceptance and Action Questionnaire; 22-item Forms of Self‐Criticism and Self‐Reassurance Scale; (a) disturbed behaviors; (b) body image; (c) depression and stress symptoms; (d) BMI‡ The intervention reduced symptoms of eating disorder, depression and stress, as well as indicators of psychopathology, overvaluation of weight and shape. There was an improvement in psychological flexibility in relation to body image. Palme...