AUTHORIZATION TO LEND AND REPRODUCE THE THESIS As the sole author of this thesis, I authorize Brown University to lend it to other institutions or individuals for the purpose of scholarly research. Date _______________ __________________________________ Emma B. Scarpa, Author I further authorize Brown University to reproduce this thesis by photocopying or other means, in total or in part, at the request of other institutions or individuals for the purpose of scholarly research. Date _______________ __________________________________ Emma B. Scarpa, Author Associations of Dispositional and Situational Mindfulness with Behavioural and Biological Cardiovascular Risk Factors Effects of Mindfulness Interventions on Physical Activity and Fitness: A Systematic Review and Associations Between Dispositional Mindfulness and Blood Lipids By Emma Broderick Scarpa BA, Smith College, 2013 Thesis Submitted in partial fulfilment of the requirements for the Degree of Master of Public Health in the Brown University School of Public Health PROVIDENCE, RHODE ISLAND MAY 2018 This thesis by Emma B. Scarpa is accepted in its present form by the Brown University School of Public Health as satisfying the thesis requirements for the degree of Master of Public Health. Date_________________ _________________ Eric Loucks, PhD, Advisor Date_________________ _________________ David Williams, PhD, Reader Date_________________ _________________ Patrick M. Vivier, MD, PhD Director, Master of Public Health Program Approved by the Graduate Council Date_________________ _ ____________________ Andrew G. Campbell Dean of the Graduate School ii PREFACE AND ACKNOWLEDGEMENTS I owe immense gratitude and thanks to everyone who has supported and encouraged me over these past two years. To my advisor, Dr. Eric Loucks: thank you for your steady and patient guidance, and for giving me multiple and diverse opportunities to build my skills while exploring and developing my interest in mindfulness. And to my reader, Dr. David Williams, thank you for your thoughtful and helpful feedback. Thank you to Akash Radia, for your contributions to this thesis and concurrent social support, and to Carin Northius for teaching me the ways of the systematic review, and always responding promptly to all of my questions about Abstrackr, EndNote, and SRDR. Thank you to Kristi Paiva and the Physical Activity and Nutrition team at the Rhode Island Department of Health, for your constant and kind encouragement and mentorship. And lastly, thank you to my family for believing in me always, and to Brandon for being my best friend, my biggest cheerleader, and my rock. iii TABLE OF CONTENTS Part 1 – Systematic Review: Effects of Mindfulness Based Interventions on Physical Activity and Fitness: A Systematic Review……………………………………………….1 Abstract……………………………………………………………………………………2 Background………………………………………………………………………………..3 Objectives…………………………………………………………………………………7 Methods………………………………………………………………………………...…7 Results…………………………………………………………………..………………..11 Discussion………………………………………………………………………………..19 Conclusion………………………………………………………………………...……..23 Acknowledgements………………………………………………………………………24 Appendix A: Search Strategy………………………………………………...…………..25 References………………………………………………………………………………..40 Part 2 – Research Paper: Associations Between Dispositional Mindfulness and Blood Lipids………………………………………………...…………………………………..43 Abstract…………………………………………………………………………………..44 Background…………………………………………………………………...………….45 Objectives………………………………………………………………………………..48 Methods……………………………………………………………………………..…....49 Results……………………………………………………………………………..……..55 Discussion………………………………………………………………………………..56 Conclusion…………………………………………………………………………...…..63 References………………………………………………………………………………..65 iv LIST OF TABLES AND FIGURES Part 1 – Systematic Review: Effects of Mindfulness Based Interventions on Physical Activity and Fitness: A Systematic Review Figure 1: PRISMA flow diagram for selection of studies………………………….……29 Table 1: Characteristics of interventions………………………………………..…….…30 Table 2: Characteristics of participants in included studies………………………..…….33 Table 3: Intervention outcomes for physical activity measures……………………….…35 Table 4: Intervention outcomes for physical fitness measures……………………..……38 Table 5: Results of Cochrane Risk of Bias assessment…………………………...……..39 Part 2 – Research Paper: Associations Between Dispositional Mindfulness and Blood Lipids Figure 1: Visual representation of participant selection and analytic sample……...……50 Table 1: Participant characteristics………………………………………………………71 Table 2: Multivariable regression results………………………………………...………72 v Part 1: Effects of Mindfulness Interventions on Physical Activity and Fitness: A Systematic Review 1 Abstract Objectives: This study aimed to systematically assess the effectiveness of mindfulness- based interventions on increasing exercise and/or physical activity, physical fitness, and physical capacity related to cardiovascular health. A further aim was to compare efficacy between different intervention types, and to identify specific intervention elements with the greatest impact on these outcomes. Methods: The PubMed, EMBASE, CINAHL, PsychInfo and Cochrane Library databases were systematically searched using tailored search strings comprised of terms related to mindfulness and exercise, physical activity, and physical fitness. Included studies were peer reviewed, randomized controlled studies, where the exposure was a mindfulness- based intervention, the outcome included physical activity, exercise, or fitness, the comparison group did not receive any mindfulness training, and outcome measurement tools were validated. Studies were excluded if they were quasi-experimental, singled armed, systematic reviews or meta-analyses. Abstract screening and data extraction were performed by two separate reviewers, and extracted data were qualitatively summarized. Results: Of the initial 1,493 records retrieved, 10 fully met inclusion criteria and were included in the review. Six studies included physical activity outcome measures, two included fitness outcome measures, and two included both physical activity and fitness outcomes. Six of the eight studies that measured physical activity reported significant increases in physical activity measures in intervention participants. Respiratory fitness was the only fitness measure positively impacted by the interventions. Conclusions: Mindfulness-based interventions show promise for increasing physical activity and improving respiratory fitness, however methodologically rigorous research is needed to investigate directionality and mechanisms by which these changes occur. Specifically, randomized controlled trials should be conducted that measure both changes in mindfulness, and in physical activity and fitness. 2 Background Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality for men and women of all backgrounds, both in the United States, and worldwide.1 Physical activity represents one important behavioural tool for preventing cardiovascular disease and improving cardiovascular health, at the individual and population levels.2,3 Regular participation in physical has the potential to reduce mortality risk by at least 35% for cardiovascular disease related mortality, and 33% for all cause mortality,4 and to improve overall cardiovascular health via mechanisms including body weight regulation, blood pressure reduction, and regulation of lipids and lipoproteins.2 This association is dose respondent, with greater frequency and intensity associated with larger reductions in risk profiles.3,4 We know from observational research that both physical activity and cardio-respiratory fitness predict multiple risk factors related to cardiovascular disease over a period of 15 years,5 while two systematic reviews and meta-analyses reveal a positive impact of aerobic exercise on blood lipids and lipoproteins in both women6 and men7 with cardiovascular disease. Despite this, only 43% of adults and 29% of children and adolescents report meeting the 2008 federal guidelines for aerobic and muscle strengthening activity.8 Even when interventions are successful at improving physical activity levels among participants, these changes are rarely maintained over the long term.9 Mindfulness is a metacognitive state of non-judgmental awareness defined as “the ability to attend in a non-judgmental way to one’s own physical and mental processes during ordinary, everyday tasks”.10 Over thirty years ago, Jon Kabat-Zinn (1982) spurred interest in mindfulness meditation as a potentially powerful means of training attention, 3 lessening aversive reactions, gaining acceptance, and increasing overall quality of life in chronic pain patients, while more recent scholarship suggests the same potentiality in sustaining and improving other areas of physical, behavioural, and mental health.11,12 An emerging area of research examines relationships between mindfulness and cardiovascular health, in which attention control, emotion regulation and self-awareness are hypothesized to contribute to self-regulatory pathways that operate on risk factors including health behaviours (eg. smoking, PA, glucose regulation, diet) and biological markers/processes (eg. obesity, blood pressure, glucose levels and blood lipids).13,14 While researchers are careful to differentiate between dispositional or “trait” mindfulness (defined as the quality of being naturally mindful in everyday life) and “state” mindfulness (or the immediate experience of being mindful),15,16 there is evidence that each may be both cultivated and increased through training and sustained practice.17 Within the mindfulness intervention literature there exist a range of frameworks that incorporate mindfulness practice and meditation, of which Jon Kabat-Zinn’s Mindfulness-Based Stress Reduction (MBSR) is the most widely studied. A structured 8- week program, MBSR uses mindfulness meditation (attending the breath to promote passive observation and acceptance of thoughts and feelings) and Hatha yoga (gentle stretching with an awareness of the breath, and the sensations which arise) in a group setting, combined with home practice and reflective journaling to teach mindful, non- judgmental awareness of the present moment.18 More recently, interventionists and researchers have begun modifying the MBSR program to target a variety of specific patient populations, communities, and diagnoses, including depression, addiction, diet, and more.11,19 Other mindfulness-based intervention (MBI) designs include Mindfulness 4 Based Cognitive Therapy (MBCT), another 8 week program, which teaches participants to bring focused, mindful attention to patterns of rumination and negative thinking, and develop skills for acknowledging and addressing uncomfortable or unwanted emotions, thoughts and sensations,20 Acceptance and Commitment Therapy (ACT) which facilitates compassionate acceptance combined with identification of a personally valuable and meaningful life, and commitment to actions and behaviours that align with those values,21 and dialectical behavioural therapy (DBT), which draws on the Cognitive Behavioural Therapy framework to deliver a multi-level intervention focused on fostering mindfulness, effective interpersonal relationships, emotion regulation and acceptance of physical and emotional distress and discomfort.22 Cross-sectional research suggests a positive association of dispositional mindfulness with levels of engagement in overall physical activity, defined as any musculoskeletal movement that increases overall energy expenditure, and exercise, a subset of physical activity that is planned and structured with the goal of increasing or sustaining physical fitness.23 Those high in dispositional mindfulness report greater physical activity among participants of the New England Family Study,13 moderate and vigorous physical activity among Midwestern college students,24 exercise initiation and maintenance among adult YMCA residents,25 and adult MBSR participants.13,24-26 Mindfulness, as a practice of cultivating moment-to-moment awareness and acceptance of things as they are, may provide a counterbalance to over-identification with experiences of pain and discomfort often associated with engaging in unfamiliar physical activities, or beginning a new exercise regimen, while greater awareness and attention control may deepen awareness of and appreciation for the longer term, positive effects of 5 sustained physical engagement. Thus, it may be that more mindful individuals are more accepting of bodily discomfort or limitations that may arise while being physically active, and/or experience greater attunement and satisfaction,27 with the longer term physical, mental and emotional benefits of sustained physical activity than those who are less mindful, resulting in greater motivation to initiate engagement in and maintain consistent routines, and lower risk of relapse among these individuals.25 Beyond the well- documented health benefits incurred, changes in physical and cardiovascular fitness that contribute to enhanced performance following a new or augmented physical activity practice may be also be powerful motivators to behaviour change maintenance, the effects of which may be enhanced by mindful qualities. Research on the impact of MBSR and other mindfulness interventions on physical activity and other health behaviours is sparse10 and what scholarship does exist offers little insight into the unique contributions of mindfulness and mindful movement on behaviour change overall, or in distinct clinical populations. For example, a 2013 study of adult MBSR participants with a variety of health conditions, found that the only significant physical activity related change among participants following the 8 week program was in self-reported sedentary behaviour (p=.035). The same study also reported significant improvement in mean score for participant strength/flexibility (p=.001), however both improvements were attributed to the inclusion of mindful movement in the MBSR curriculum.26 To our knowledge, there is currently no systematic evaluation of how interventions that teach and/or develop mindfulness skills may impact frequency or duration of physical activity engagement, or outcomes related to physical and 6 cardiovascular fitness. A clearer understanding of these mechanisms and the relationships between them has important implications for the development and delivery of future physical activity interventions. Thus, a systematic review is needed to evaluate the effectiveness of interventions that increase mindfulness on physical activity and fitness. Objectives The primary objective of this systematic review is to assess the effectiveness of mindfulness interventions on exercise and/or physical activity levels, physical fitness, and physical capacity related to cardiovascular health. Secondary objectives are to compare efficacy between interventions, to identify specific elements that most impact efficacy, and to elucidate and explore promising areas for future research. Methods The review, which utilized PRISMA guidelines for best practices, along with the Cochrane Handbook of Systematic Reviews, was conducted according to a pre-specified protocol, submitted to the international systematic review database PROSPERO on November 7, 2017 (CRD42018081097; available at https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=81097). Search strategy A systematic search was conducted of the following electronic databases: PubMed, EMBASE, CIHAHL, PsychINFO, and the Cochrane Library. In collaboration with Brown University Health Services librarian (E.S), tailored search strings comprised of terms related to mindfulness and exercise, physical activity, and physical fitness were 7 developed for each database searched. Where appropriate, the strategies used Medical Subject Headings (MeSH) for the exposure and outcome terms, as well as asterisks (*) truncation to capture all variations of the root term, in combination with database specific filters designed to restrict results to randomized controlled trials. The initial search terms included mindfulness, exercise, physical activit*, motor activit*, sport*, athletic*, fitness, recreation, walk*, run*, jog*, swim*, bicycl*, biking, cycling. Randomized controlled trial designs were identified with the use of tailored filters developed for each database to account for differences in thesaurus structures and differences in indexing practices across databases. Filters used were validated by the Cochrane Collaborative, and selected to maximize search sensitivity in order to return the greatest number of results. The full search strings for each database, including RCT filters used, are provided in Appendix A. No restrictions were placed on language, age, or publication date. The final search was conducted October 28, 2017, and yielded an overall total of 1493 citations. Study selection Titles and abstracts were compiled into reference management software,28 then imported into Abstrackr, an online abstract screening program.29 Independent assessment by two reviewers (E.B.S, A.R) was undertaken to identify studies for full text review eligibility (96.1% agreement). During this process reviewers assigned a label of “yes”, “no”, or “maybe” to each abstract, and any records displaying only titles and no abstracts were additionally flagged for full text review. The same two reviewers then reviewed full texts of all flagged studies, at which point final inclusion and exclusion decisions were made based on the criteria outlined below. Discrepancies that arose at any stage were discussed among reviewers, and ultimately resolved by a third member of the research 8 team, a senior scientist (E.L) with expertise in mindfulness mechanisms and interventions, and systematic review methodology. Prior to abstract screening or full text assessment, reviewers completed several practice assessments, to finalize inclusion and exclusion criteria, and ensure consistency in methodology across reviewers. Inclusion/exclusion criteria To be considered for inclusion, studies were required to meet the following criteria: 1) Randomized controlled study design; 2) The exposure was an evidence-based mindfulness intervention, where mindfulness training was explicitly addressed as an important component of the intervention methodology (examples of interventions that have a strong evidence base and were thus considered for inclusion in the review include mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and acceptance and commitment therapy (ACT)); 3) The outcome included measurement of changes in physical activity, exercise, or cardiorespiratory and/or musculoskeletal fitness; 4) Outcomes were measured using previously validated instruments; 5) The comparison group did not receive any mindfulness training (all other comparators were considered); 6) The paper had undergone some form of peer or expert review – we included dissertations and theses under these guidelines. Exclusion criteria were as follows: 1) Non randomized controlled design, systematic reviews, and meta-analyses; 2) Exposures did not include an explicitly stated mindfulness component, (for example, interventions based on Yoga or Tai Chi were excluded when mindfulness training was not specifically emphasized); 3) Outcome reported was not a direct measure of physical activity or fitness. For example, studies 9 were excluded if the outcome measures were of motor performance or disability, symptom management, physical function, or functional capacity (such as balance, flexibility and heart rate variability). Data collection Data from each eligible study were extracted into a customized form using the Systematic Review Data Repository (SRDR - http://srdr.ahrq.gov). Data points identified for extraction included participant demographics, definitions and characteristics of intervention design and delivery, features of intervention and control groups, outcome data related to exercise/physical activity, and physical/cardiometabolic fitness. Data extraction were independently performed by two members of the team, (E.B.S, A.R), the results of which were analysed for comparison, and any disagreements were again resolved through discussion and consultation with the team’s senior scientist (E.L). Risk of Bias assessment Quality assessments were conducted for each study, using the Cochrane Risk of Bias tool,30 which assigns a label of “low”, “medium”, “high”, or “unclear” risk of bias to each study, based on evaluation of the following domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome data collection, incomplete outcome data, selected reporting, and any additional sources of bias. Conflicts were discussed with the senior scientist (E.L) until a consensus was reached. Data synthesis 10 Individual trials were the unit of analysis for this study. Extracted data were compiled in SRDR data extraction forms, exported, cleaned, and qualitatively summarized using Microsoft Excel spread sheets. Where additional clarification was warranted, the full texts of articles were re-evaluated. This review reports on study characteristics and descriptive outcome data. Statistical significance was set at .05 for all studies. Results Description of included studies The initial search returned a total of 1493 records. Of these, 272 were from PubMed, 673 were from EMBASE, 125 were from CIHAHL, 275 were from Cochrane Library, and 148 were from PsycInfo. 563 duplicate records were removed from within and across databases using automated de-duplication in conjunction with manual removal, leaving a total of 930 records, which were subsequently screened for inclusion eligibility. 901 studies were excluded as they failed to meet inclusion criteria, leaving a total of 30 studies for full-text review. Of these, excluded studies (n=19) were most commonly excluded on the basis of outcomes that did not include a direct measure of physical activity, cardio-metabolic, or physical fitness (n=12). Other reasons for exclusion were: outcome reported was not measured with a previously validated instrument (n=2), study design was not randomized controlled (n=2), study did not undergo peer-review process (n=2). This left a total of 10 studies that met both inclusion and exclusion criteria and were thus included in this review. Figure 1 (below) provides a visual representation of the study selection process. Study Characteristics 11 Publication dates for included studies ranged from 2004 to 2017, with the majority (n=6) published after 2014.31-36 6 of the 10 were conducted in the United States,32,34,35,37-39 and the remainder took place in United Kingdom,40 the Netherlands,36 Iran,33 and Thailand.31 Sample sizes ranged from a low of 18,38 to a high of 257,36 with an overall mean of 65 (46.9 when the maximum and minimum values are removed). Participant characteristics Clinical characteristics of study participants included overweight/obesity (n=3),32,39,40 cardiovascular disease38 or hypertension33 (n=2), type 2 diabetes (n=1),31 cancer remission (n=1),34 and healthy participants (n=3).35-37 Participants of all ten studies were adults or young adults, with mean ages ranging from 22-64 years. Due to differences in categorization and reporting of participant race/ethnicity, it is difficult to draw demographic comparisons across studies. However, of the seven studies reporting race, the majority race/ethnicity reported by participants was white, ranging from a high of 94.7%35 to a low of 45% - this study’s other participants were 24% Hispanic, 6% Black, 1% Asian, and 9% “Multiracial or Other”.32 None of the four studies conducted outside of the United States reported participant race/ethnicity, which could be due to low heterogeneity within these samples.31,33,36,40 Study participants were predominantly female: in four studies all participants were women,32,37,38,40 in four women made up over 80% of participants,31,34,35,39 while the remaining two studies reported 67%36 and 47%33 female participants respectively. Intervention design Intervention duration ranged from two37 to 26 weeks,36 though most were delivered between eight and 12 weeks, with follow-up periods ranging from zero to 26 12 weeks.35,36 The average number of sessions per intervention was 8.9, with a range of two sessions37 to 36 sessions,31 and session duration ranging from 19 minutes (average)34 to 120 minutes. Most (n=8) interventions were delivered in the group setting, one31 was likely delivered via group meetings (though this was not explicitly stated), three combined group and individual sessions,31,32,36,39 whereas the RENEW study (an adapted MBSR for young adult cancer survivors)34 was delivered only on the individual level. Five interventions included a home practice component,34,36,38-40 while one followed the traditional MBSR protocol, but did not explicitly mention assigned home practice.33 In terms of comparator groups, three studies32,34,38 utilized a waitlist control group, three used active control groups –these included traditional treadmill walking,31 Cognitive Behavioural Stress Management,35 and an evidence based behavioural weight loss program,33,39,40 two received no treatment or treatment as usual33,40 and two received education both generally37 and regarding available facilities.36 Intervention characteristics Because this review included any evidence-based intervention with a strong mindfulness component, interventions drew on a wide variety of mindfulness-based intervention frameworks. These included Mindfulness Based Stress Reduction (MBSR) delivered according to the original program design (n=3),32,33,38 or adapted to the specific participant population (n=2),34,39 Acceptance and Commitment Therapy (ACT) tailored to the population (n=2),37,40 a simple Buddhist walking meditation (n=1),31 mindfulness training (n=1),36 and Yoga Based Stress Reduction (YBSM), which combines mindful yoga practice with a traditional Cognitive Behavioural Stress Management (CBMS) program (n=1).35 Mindfulness techniques explicitly reported by study authors with the 13 most frequency were: mindfulness meditation (n=8), mindful/conscious yoga (n=7), non- yoga mindful movement (n=6), mindful breathing (n=6), and body scan (n=5). Other techniques were mindful eating, present moment awareness, mindful walking, mountain meditation, loving kindness meditation, informal practice (such as being mindful during everyday tasks), non-judgemental self-observation and logging pleasant and unpleasant occurrences. It should also be noted that participant engagement in structured physical activity was an intervention component in 6/10 studies. Of these, two included muscular or aerobic physical activity in both the intervention and control groups31,39 intervention groups in five studies practiced yoga as part of the intervention,32-34,37,39,40 while intervention group participants engaged in muscular or aerobic physical in three studies.31,34,39 Outcomes measured Six studies included physical activity related outcome measures,32-34,37,39,40two included fitness outcome measures only,31,38 and two reported measures for both physical activity and fitness.34,35 Of the eight studies measuring physical activity, seven used participant self-report to assess the frequency, duration, and intensity of physical activity participation – minutes per week spent in physical activity of varying intensities, or overall,32,34,36 count of physical activity sessions over time,33,40 and weekly caloric expenditure.39 One study used gym entry card swipes to determine frequency of weekly visits to a university athletic center,37 while two combined subjective self-report of physical activity engagement with accelerometer measurements of 1) average physical activity counts over 3 days,34 and 2) weekly minutes spent engaging in physical activity.36 14 Risk of Bias in included studies Risk of bias for included studies was deemed to be moderate to high, primarily due to studies providing insufficient or unclear details on study methodology (see Table 5). Because only randomized controlled trials were included in the review, participants in all studies were randomized, however the method of random sequence generation was only described in six of the ten studies,31,36,38-40 one of which described a random selection process using the numbers “1 and 2”38 which was considered a “high risk” methodology. Allocation was adequately concealed in three studies,31,34,35 while concealment methods were not clearly described in the remaining seven.32,33,36-40 Due to the behavioural nature of the interventions and study design, there was a marked risk of performance bias across studies, as almost half the studies explicitly reported no blinding of participants,32,34,36,38,40 or personnel,32,34,36,38 while the remainder did not specify how/if participants or personnel were blinded. As many of the behavioural outcome measures were self-reported by participants, it is possible that lack of blinding of participants also resulted in substantial detection bias across studies, and only one study40 describes adequate blinding of data collectors. Risk of attrition bias was high in three studies, in which more than 20% of participants had dropped out or were lost to follow-up.34,35,40 Selective reporting was either high or unclear, as few studies included a pre-specified protocol. Synthesized review findings Evidence of effects on physical activity Individual study results are displayed in Table 3. Eight studies explored 15 relationships between mindfulness interventions and frequency or duration of engagement in physical activity.32-37,39,40 Two were based on an adapted ACT framework – for weight loss,29 and for physical activity37,40 - two were traditional MBSR programs,32,33 two were adapted MBSR programs for physical activity,34 and for diet,39 one combined CBT with mindful yoga,35 and one was an 8 week intervention developed by the researchers to target leisure time physical activity.36 Six studies described statistically significant increases in self-reported physical activity levels among intervention compared to control participants.32-35,37,40 In four studies, these behavioural improvements were maintained at follow-up assessment points.33-36 Two interventions did not result in any change in physical activity by group or over time.36,39 The strongest positive effects were seen in the MBSR and adapted MBSR interventions (MBSR and Conscious Yoga, RENEW, YBSM), while the ACT and adapted ACT trials reported effects that were moderate, or were not sustained over time.37,40 No significant impact was reported in the Mindful Vitality in Practice36 or the SBWP + MB- EAT trials,39 both of which utilized active comparison groups, and interventions designed or modified by investigators. However, it should be noted that the Mindful Vitality in Practice intervention was the only study reviewed in which only vigorous physical activity was measured (both objectively and via self-report).36 In the MBSR and Conscious Yoga intervention for adults with hypertension,33 mean weekly physical activity frequency increased significantly in the intervention groups compared to no- treatment control groups both following the intervention and at follow-up (F=2.37, p=0.03, Eta=.718). In the RENEW trial for young cancer survivors, intervention group participants saw a significant increase of 8.7 average daily minutes of at least moderate 16 physical activity compared to the control group (p=.0002, d=1.30) however this difference was not replicated with an objective (accelerometer) measure.34 Interestingly, the Yoga Based Stress Management trial used an active control such that the key difference between groups was the addition of mindful yoga in the YBSM group, and reported significant increase in physical activity frequency and intensity in both groups over time (F=4.42, p=.011), an increase that was only statistically significantly greater in the intervention group compared to control (F=2.83, p=.046).35 The interventions with the strongest impact on physical activity levels were generally observed among those designed for clinical populations,33,34,40 whereas the studies with healthier participants saw less improvement in duration or frequency of physical activity post intervention or at follow-up.35-37 The exception to this trend was in trials for participants with overweight/obesity, where findings were mixed. For example, whereas the WHAM intervention reported higher median minutes spent walking (135 vs. 105), and in light (145 vs. 120) and moderate/vigorous (77.5 vs. 60) physical activity in the intervention group compared to a waitlist control, this difference did not reach statistical significance,32 while the SBWP + MB-EAT study reported no significant differences in exercise among those who received a mindfulness based eating program in addition to the standard behavioural weight loss program also received by the control group (data not reported).39 Evidence of effects on physical and cardiovascular fitness Individual study results are presented in Table 4. Three studies reported on cardiorespiratory and muscular fitness outcome measures.31,35,38 One study used an 17 MBSR framework, with a specific focus on relaxation,38 one was based on CBT with the addition of mindful yoga,35 and one trained participants in a simple Buddhist meditation to foster mindfulness while walking.31 All three assessed and reported on resting heart rate, two on oxygen consumption,31,38 one on leg muscle strength,31 and one on components of breathing patterns, which included breathing frequency, tidal volume, and ventilation.38Active control groups were the comparators in two studies,31,35 while one used a waitlist control.38 No study reported significant group by time interaction effects for any outcome. Due to the small number of studies, and significant heterogeneity in outcomes, measurements, and intervention frameworks across these studies, these results are reported broadly by study, rather than by finding. In the Buddhist Walking Meditation trial among patients with type 2 diabetes, in which a treadmill walking meditation group to was compared to a traditional treadmill walking control group, Gainey et al found significant increases in maximal oxygen uptake in participants in both the intervention (+2.4 ml/kg, p<.05) and control groups (+5.1, p<.05) following the intervention, but no significant differences in resting heart rate, or leg muscle strength in either group.31 The Yoga Based Stress Management trial reported a significant reduction in resting heart rate in both groups over the course of the study (F=4.07, p=.018).35 Lastly, following the 8 week intervention program for female participants with cardiovascular disease in MBSR and Relaxation trial, both intervention and control groups were directed to “practice a relaxation response” (a statement which was open to individual interpretation) while riding a stationary bike, while researchers measured breathing patterns, oxygen consumption, and heart rate. Although the intervention did not significantly impact submaximal exercise responses, the authors of 18 this study found significant improvements measures of ventilation between groups and breathing frequency over time in both groups, suggesting that while the relaxation techniques learned in the MBSR program may be effective at improving breathing patterns over time, breathing patterns may also be improved via the practice of conscious awareness during the act of exercise.38 Discussion The purpose of this review was to systematically assess the evidence for the impact of mindfulness based interventions on physical activity and physical fitness. To our knowledge, this is the first review of its kind. Findings were mixed overall, but offer support for mindfulness training as one tool for increasing physical activity in a variety of populations, which may also have implications for improving physical fitness. While mindfulness interventions resulted in some improvement in exercise and physical activity, this finding was not consistent across studies, or over follow up time. For fitness, mindfulness interventions were found to impact outcomes related to breathing patterns and maximal oxygen consumption, but not other measures, such as resting heart rate or muscle strength. In general, the interventions with the greatest impacts were those utilizing study designs with a waitlist or “treatment as usual” control group. The exception to this was the Yoga Based Stress Management study, in which the addition of a mindful yoga practice to CBSM appeared to have an important impact on increasing non-yoga physical activity. This study was unique in two ways. First, the use of a CBSM comparator means that the practice of mindful yoga was the only difference between the intervention and control groups. Second, participation in this trial was limited to those who indicated they 19 were NOT ready to participate in physical activity, making the observed improvements in participant physical activity, which were consistently maintained over time, all the more striking. These findings led the study’s authors to suggest that, by helping participants gain familiarity and ease with their own bodies in motion, the mindful yoga practice may have operated as a sort of “gateway exercise”, with the ability to “attenuate exercise avoidance, increase awareness of endogenous need for movement, and foster enhanced engagement in physical movement”.35 This is somewhat consistent with the findings from cross-sectional research by Tsafou et al, who reported a strong relationship between mindfulness and physical activity engagement, but only among those without a strongly established physical activity routine.27 Notably, the studies that included physical activity as part of the intervention generally had the strongest and most consistent impact on physical activity behaviour after the intervention ended, compared to non-physical activity based mindfulness interventions. One such example, with somewhat puzzling findings, was the RENEW adapted MBSR study,34 in which participants were both provided with yoga training, and guided to increase the frequency and duration of their daily moderate level physical activity over the course of the study. While changes in self-reported physical activity increased significantly following the intervention, and were maintained, these improvements were not reflected in objective accelerometer measurements. One possible explanation for this discrepancy is that these tools were poorly matched, however previous literature suggests that overall consistency across accelerometry and self- reported measures of physical activity over time is generally poor.41,42 Another possibility 20 is that mindfulness interventions impact stamina once one is already in motion, but have less of an influence on motivating the initiation of physical activity or exercise practices. Lack of similarity across studies in participant populations, intervention designs, and significant variability in participation rates across studies may all have contributed to variable and/or contradictory outcomes. Additionally, there was wide variety in terms of physical activity exposure, type, duration, and intensity across studies, as well as in participants’ previous experience and baseline levels, precluding clear comparisons across studies. In the healthier populations we may be observing a ceiling effect. Further, to ensure a sufficient number of studies in this preliminary review, the inclusion criteria did not require studies to measure or assess changes in mindfulness over time. While some studies did measure mindfulness, included studies as a whole lacked this positive manipulation check. Lastly, heterogeneity in findings may reflect differing goals across included interventions – for example, it is possible that framing physical activity as a means to an end (such as with a weight-loss based intervention) rather than an end unto itself compromises the sense of satisfaction or intrinsic motivation needed for long-term behaviour change, which has previously been associated with higher dispositional mindfulness.25 This study has several important strengths worth noting. First, while previous research has assessed the impact of mindfulness training on obesity and weight loss43, athletic performance44 and flow states among elite athletes,45 to our knowledge, this study is the first to systematically compare the effects of mindfulness interventions on physical activity among a diversity of populations. The inclusion of physical fitness measures in the review is also novel, and may reveal important information about mechanisms and 21 relationships that would not be possible by studying behavioural outcomes in isolation. Additionally, our study demonstrated methodological rigor with our strict inclusion criteria, by limiting our review to only randomized controlled intervention trials, and by including both objective and subjective outcome measures for both physical activity and fitness. There are also important limitations that must be addressed. Many of the included studies suffered from significant design and methodological issues including small sample sizes, lack of demographic diversity within and between studies, lack of blinding of participants and personnel, and questionable quality and reliability of physical activity related outcome measures. Intervention frameworks also ranged substantially, making it difficult to determine which components of mindfulness training were most important. In the majority of included studies, physical activity or fitness were not the primary outcomes of interest. Additionally, there was a paucity of existing studies that met our inclusion criteria, limiting our analysis to just ten studies, among which there was significant heterogeneity. The inclusion of theses and dissertations in our review could be considered both a strength and a limitation. This decision was based on the understanding that while these papers might lack the methodological rigor of those published in peer reviewed journals, the dissertation process involves close supervision and review by experts in the relevant topic area and/or methodology, and their exclusion could introduce publication bias into the current review.46 The one dissertation that was included, SBWP + MB-EAT39 had null findings, but was also of relatively low methodological quality. If the mindfulness based programs that were successful at increasing participant physical activity did so by increasing or enhancing individual mindfulness (as 22 hypothesized), the failure of other programs to have a similar impact should be attributed to either the intervention not increasing mindfulness, or to changes in mindfulness not leading to the predicted improvements in physical activity. By not limiting our review to those studies that measured and reported on participant mindfulness, the current narrative review included several studies that did not assess participant mindfulness before and after intervention delivery, and thus is unable to answer this critical question definitively. Therefore, future research is needed to explore these mechanisms in greater depth. Specifically, a quantitative analysis of how changes in mindfulness levels resulting from these interventions relates to physical and behavioural changes (or lack thereof) is warranted. A meta-analysis of data extracted from these ten studies is currently underway, and concurrent sub-analysis of those studies will provide valuable insight into these mechanisms. Additionally, more high quality randomized controlled trials are needed, which quantitatively capture both specific exposures and participant adherence, and which specific elements of mindfulness based interventions and programs are most salient to initiating and supporting physical activity related behaviour change. Conclusion In conclusion, mindfulness based interventions represent one promising arena for supporting physical activity related behaviour change, and improvements in measures related to respiratory fitness. In the future, methodologically rigorous randomized controlled trials should be conducted to investigate if those mindfulness based interventions that result in changes in physical activity and fitness do so via changes in participant mindfulness, if changes in mindfulness directly correlate to changes in physical activity, specific mechanisms by which changes in mindfulness impact physical 23 activity and fitness, and how these impacts and mechanisms differ across populations. Acknowledgements We would like to express gratitude to Brown University medical librarian Erika Sevetson for her assistance with the search strategy and search method for this review. 24 Appendix A: Exact Search Strings, by Database PubMed #1 mindfulness[MeSH Terms] OR mindful* #2 exercise[MeSH Terms] OR exercise OR “physical activity” #3 “physical fitness”[MeSH Terms] OR “physical fitness” OR fitness #4 “motor activity” #5 sports[MeSH Terms] OR sports OR sport OR athletics OR athletic #6 recreation[MeSH Terms] OR recreation #7 walking[MeSH Terms] OR walking OR walk #8 running[MeSH Terms] OR running OR jog OR jogging #9 swimming[MeSH Terms] OR swimming OR swim #10 bicycling[MeSH Terms] OR bicycling OR biking OR cycling #11 (randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized[tiab] OR placebo[tiab] OR drug therapy[sh] OR randomly[tiab] OR trial[tiab] OR groups[tiab] NOT (animals [mh] NOT humans [mh]))21 #12 #2 or #3 or #4 or #5 or #6 or # 7 or #8 or #9 or #10 #13 #1 and #11 and #12 Expands to: (("mindfulness"[MeSH Terms] OR (mindful[All Fields] OR mindful'[All Fields] OR mindful2work[All Fields] OR mindfulheart[All Fields] OR mindfullness[All Fields] OR mindfully[All Fields] OR mindfulness[All Fields] OR mindfulness'[All Fields] OR mindfulness's[All Fields] OR mindfulnessand[All Fields] OR mindfulnessbased[All Fields] OR mindfulnessbaserade[All Fields] OR mindfulnessjpb[All Fields] OR mindfulnessmeditation[All Fields] OR mindfulnesstraining[All Fields] OR mindfulnessxdepletion[All Fields] OR mindfulohio[All Fields] OR mindfulpsychology[All Fields])) AND ((((((((("exercise"[MeSH Terms] OR ("exercise"[MeSH Terms] OR "exercise"[All Fields]) OR "physical activity"[All Fields]) OR ("physical fitness"[MeSH Terms] OR "physical fitness"[All Fields] OR fitness[All Fields])) OR "motor activity"[All Fields]) OR ("sports"[MeSH Terms] OR ("sports"[MeSH Terms] OR "sports"[All Fields]) OR ("sports"[MeSH Terms] OR "sports"[All Fields] OR "sport"[All Fields]) OR ("sports"[MeSH Terms] OR "sports"[All Fields] OR "athletics"[All Fields]) OR ("sports"[MeSH Terms] OR "sports"[All Fields] OR "athletic"[All Fields]))) OR ("recreation"[MeSH Terms] OR ("recreation"[MeSH Terms] OR "recreation"[All Fields]))) OR ("walking"[MeSH Terms] OR ("walking"[MeSH Terms] OR "walking"[All Fields]) OR ("walking"[MeSH Terms] OR "walking"[All Fields] OR "walk"[All Fields]))) OR ("running"[MeSH Terms] OR ("running"[MeSH Terms] OR "running"[All Fields]) OR jog[All Fields] OR ("jogging"[MeSH Terms] OR "jogging"[All Fields]))) OR ("swimming"[MeSH Terms] OR ("swimming"[MeSH Terms] OR "swimming"[All Fields]) OR ("swimming"[MeSH Terms] OR "swimming"[All Fields] OR "swim"[All Fields]))) OR ("bicycling"[MeSH Terms] OR ("bicycling"[MeSH Terms] OR "bicycling"[All Fields]) OR biking[All Fields] OR cycling[All Fields]))) AND (randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized[tiab] OR placebo[tiab] OR "drug therapy"[Subheading] OR randomly[tiab] OR trial[tiab] OR groups[tiab] NOT ("animals"[MeSH Terms] NOT "humans"[MeSH Terms])) 25 Embase #1 'mindfulness'/exp OR 'mindfulness' OR mindful* #2 'exercise'/exp OR exercise #3 'physical activity'/exp OR 'physical activity' #4 'recreation'/exp OR 'recreation' #5 'sport'/exp OR 'sport' OR 'sports' OR 'athletic' OR ‘athletics’ #6 'fitness'/exp OR 'fitness' #7 ‘motor activity’/de #8 ‘walking’/exp OR walking OR walk #9 ‘running’/exp OR running #10 ‘jogging’/exp OR jogging OR jog #11 ‘swimming’/exp OR swimming OR swim #12 ‘cycling’/exp OR cycling OR bicycling OR biking #13 'crossover procedure':de OR 'double-blind procedure':de OR 'randomized controlled trial':de OR 'single-blind procedure':de OR random*:de,ab,ti OR factorial*:de,ab,ti OR crossover*:de,ab,ti OR ((cross NEXT/1 over*):de,ab,ti) OR placebo*:de,ab,ti OR ((doubl* NEAR/1 blind*):de,ab,ti) OR ((singl* NEAR/1 blind*):de,ab,ti) OR assign*:de,ab,ti OR allocat*:de,ab,ti OR volunteer*:de,ab,ti21 #14 #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 #15 #1 AND #13 AND #14 CINAHL #1 (MH Mindfulness) OR mindful* #2 (MH "Exercise+") OR exercise #3 (MH "Physical Activity") OR "physical activity" #4 (MH "Recreation+") OR recreation #5 (MH "Sports+") OR sports OR sport #6 (MH "Physical Fitness+") OR "physical fitness" OR fitness OR athletic OR athletics #7 (MH "Motor Activity+") OR "Motor Activity" #8 (MH "Walking+") OR walking OR walk #9 (MH "Running+") OR running #10 (MH Jogging) OR jogging OR jog #11 (MH Swimming) OR swimming OR swim #12 (MH "Cycling") OR cycling OR bicycling OR biking #13 #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 #14 TX allocat* random* OR (MH "Quantitative Studies") OR (MH "Placebos") OR TX placebo* OR TX random* allocat* OR (MH "Random Assignment") OR TX randomi* control* trial* OR TX ( (singl* n1 blind*) OR (singl* n1 mask*) ) OR TX ( (doubl* n1 blind*) OR (doubl* n1 mask*) ) OR TX ( (tripl* n1 blind*) OR (tripl* n1 mask*) ) OR TX ( (trebl* n1 blind*) OR (trebl* n1 mask*) ) OR TX clinic* n1 trial* OR PT Clinical trial OR (MH "Clinical Trials+")47 #15 #1 AND #13 #16 #14 AND #15 26 Cochrane Library: #1 MESH descriptor [Mindfulness] explode all trees #2 mindful*:ti,ab,kw #3 #1 or #2 #4 MeSH descriptor: [Exercise] explode all trees #5 MeSH descriptor: [Physical Fitness] explode all trees #6 MeSH descriptor: [Recreation] explode all trees #7 MeSH descriptor: [Sports] explode all trees #8 MeSH descriptor: [Motor Activity] explode all trees #9 MeSH descriptor: [Walking] explode all trees #10 MeSH descriptor: [Running] explode all trees #11 MeSH descriptor: [Jogging] explode all trees #12 MeSH descriptor: [Swimming] explode all trees #13 MeSH descriptor: [Bicycling] explode all trees #14 "physical activity":ti,ab,kw #15 fitness:ti,ab,kw #16 exercise:ti,ab,kw #17 athletic*:ti,ab,kw #18 recreation:ti,ab,kw #19 sport*:ti,ab,kw #20 "motor activity":ti,ab,kw #21 walk*:ti,ab,kw #22 run*:ti,ab,kw #23 jog*:ti,ab,kw #24 swim*:ti,ab,kw #25 bicycling:ti,ab,kw #26 biking:ti,ab,kw #27 cycling:ti,ab,kw #28 #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25 or #25 or #27 #29 #3 and #28 PsycINFO (Ebscohost) S1 MA mindfulness OR TX mindful* S2 MA exercise OR TX exercise OR TX 'physical activity' S3 MA “physical fitness” OR TX fitness S4 TX "motor activity" S5 MA sports OR TX sport OR TX sports OR TX athletic OR TX athletics S6 MA recreation OR TX recreation S7 MA walking OR TX walking OR TX walk S8 MA running OR TX running OR TX jogging OR TX jog S9 MA swimming OR TX swimming OR TX swim 27 S10 MA bicycling OR TX bicycling OR TX biking OR TX cycling S11 S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 S12 S1 AND S11 S13 SU.EXACT("Treatment Effectiveness Evaluation") OR SU.EXACT.EXPLODE("Treatment Outcomes") OR SU.EXACT("Placebo") OR SU.EXACT("Followup Studies") OR placebo* OR random* OR "comparative stud*" OR clinical NEAR/3 trial* OR research NEAR/3 design OR evaluat* NEAR/3 stud* OR prospectiv* NEAR/3 stud* OR (singl* OR doubl* OR trebl* OR tripl*) NEAR/3 (blind* OR mask*)48,49 S14 S12 AND S13 28 Figure 1: PRISMA flow diagram for selection of studies Number of records identified through Identification systematic electronic database search (N=1493) Duplicates removed within and between databases (N=562) Number of titles and abstracts screened Screening against inclusion/exclusion criteria (N=931) Number of records excluded (N=901) Number of full-text articles assessed for Eligibility eligibility (N=30) Number of articles excluded based on full text review (N=20): • No direct measure of physical activity or fitness (n=13) • Outcome measure not validated (n=3) • Not RCT (n=2) • Not peer reviewed (n=2) Number of articles included Included (N=10) Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed100009 29 Table 1: Characteristics of Interventions Intervention Group Control Group First Author Intervention Outcome(s) Duration Number of Session setting Intervention session format Formally Type Framework Measured (weeks) sessions and content Assigned Home Study Practice Session Delivery personnel Description duration Materials Butryn Brief physical Physical Intervention: 2 2 Group sessions held in Group: Skills for mindfulness, None Education activity activity a university setting values clarification, and ACT for intervention Follow-up: 4 120 mins willingness to experience Physical activity education Physical based on ACT An advanced graduate distress in the service of based on ACSM Activity student and a clinical behavior change guidelines - included psychologist safety, improvement measurement Gainey Buddhist Physical Intervention: 12 36 Weekly exercise Group: Warm-up, workout, None Active control walking fitness sessions, likely held in cool down, stretching Buddhist meditation Follow up: 0 50 mins group setting, but not • Phase 1: mild-moderate Traditional treadmill Walking explicitly stated intensity training (50-60% walking Meditation max heart rate) Not reported • Phase 2: moderate intensity training (60-70% maximum heart rate) Ingraham MBSR Physical Intervention: 12 12 Weekly support group Group: Evidence-based None Waitlist control activity sessions held at a techniques (MBSR, education) WHAM Follow up: 4 Not community health to focus on nutrition and reported center physical activity, incorporating participants' lived experience Facilitated by licensed social worker/clinical Individual: meetings with psychologist, registered personal trainer and registered dietician and certified dietician-goal setting and personal trainer tailored guidance to meet goals Nejati MBSR Physical Intervention: 6 8 Weekly group treatment Group: MBSR curriculum + Likely, but not No treatment activity sessions held in a conscious yoga. explicitly MBSR and Follow up: 8 90 mins hospital setting mentioned Conscious (traditional Yoga Two people with MBSR graduate degrees in curriculum) psychology 30 Rabin Adapted Physical Intervention: 12 15 12 week telephone Individual: One on one Participants were Waitlist control MBSR activity delivered intervention meeting between each asked to practice RENEW Follow up: 12 ~19 mins participant and PD at baseline meditations Physical avg The study project followed by tailored, weekly outside of class fitness director phone calls from PD included at least 4 days behavioral coaching on each week physical activity and meditation, progress review, Mindfulness CD problem solving and goal setting Riley Yoga Based Physical Intervention: 8 8 Two 8 week worksite Group: Kripalu yoga based None Active control Stress activity group sessions, at a workplace wellness YBSM Reduction Follow up: 26 60 mins large regional hospital intervention. Content included Group Cognitive in New England stress management education Behavioral Stress (mindful yoga combined with yogic training Management + CBT) Kripalu yoga instructors and practice (intervention); CBT trained licensed clinical psychologists (control) Robert MBSR Physical Intervention: 8 8 8 weekly group MBSR Group: Participants trained in Daily home Waitlist control McComb fitness meetings held on a body scan, sitting meditation, practice Follow up: 1 120 mins university medical Hatha Yoga encouraged MBSR and school campus Relaxation Audiotapes of Delivery personnel not meditation specified techniques Spadaro Evidence Physical Intervention: 24 24 Weekly group meetings Group: Supervised exercise, Participants were Active control based activity held at the University of interactive group discussion, encouraged to standard Follow up: 0 60 mins Pittsburgh Physical behavioral instruction on self- practice at home Evidence based standard SBWP+ behavioral Activity and Weight monitoring, dietary behavioral weight loss MB-EAT weight loss Management Research recommendations, exercise CD/DVDs with program program, plus Center mindful modified Individual: One-on-one phone meditation MBSR Trained and supervised session with intervention practices program (MB- Physical Activity and leaders for those who missed EAT) Weight Management a group session Research Center interventionist; Mindfulness meditation led by PI Tapper Acceptance Physical Intervention: 4 12 Four group workshops. Group: Adapted ACT concepts Participants Usual care and activity Intervention location not and exercises comprised of: assigned Commitment Follow up: 22 120 mins specified, but likely values, cognitive defusion, homework Instructed to continue their ACT for Therapy (ACT) delivered at local acceptance. Didactic between current weight loss Weight intervention university or other instruction, use of metaphor, sessions and strategies 31 Loss adapted for academic institution participatory exercises, and encouraged to weight loss written tasks practice at home ACT trained study author Manual with assignment details, CD with meditation exercises Van Berkel Mindfulness Physical Intervention: 26 8 in- 8 weekly group Group: Mindfulness training, e- Participants Education worksite activity person, mindfulness training coaching, lunch walking routes assigned formal Mindful wellness Follow up: 26 sessions conducted at a and fruit consumption. Weekly and informal Information on accessible Vitality in intervention 8 e- Dutch research themes included: training meditations and facilities at workplace Practice for physical coaching institution mindful attention, switching mindfulness activity, diet, from doing to being, exercises, and sedentary 90 mins ea. Four certified maintaining your center designed to take behavior mindfulness-based appx. 30 trainers (Society of Individual: 8 e-coaching mins/day, 5 Mindfulness-Based sessions. Participants asked days/week Trainers) questions, received feedback on Personal Energy Plan 2 CDs of guided ("what do I need to do, to feel meditations, and well at work?") a booklet tailored to workplace settings to support home and work practice MB=Mindfulness Based ACT=Acceptance and Commitment Therapy PD=Project Director MBSR=Mindfulness Based Stress Reduction CBT=Cognitive Behavioral Therapy PI=Principal Investigator YBSM=Yoga Based Stress Management ACSM=American College of Sports Medicine 32 Table 2: Characteristics of Participants in Included Studies First Author Countr N Population Exclusion criteria Clinical Status Mean Female Race y Randomized age (%) Study Inclusion criteria (Operationalization) (years) Butryn United CG: 19 Female university students -Freshman None CG: 24.3 100% White: 57.2% States IG: 35 ages 18-30, who wanted to -Participate in varsity or club sport IG: 22.2 Black: 7.4% ACT for increase physical activity Hispanic: 1.9% Physical Asian: 1.3% Activity Native American: 1.9% Multiracial/Other: 18.6% Gainey Thailan CG: 13 Adults aged 40-75, recruited -Diabetic complications Type 2 diabetes CG: 63 83% Not reported d IG: 14 from a hospital in Samut -Comorbid disorders that could IG: 58 Buddhist Prakan Province limit walking (AbA1c 7%-9%) Walking -Normal resting EKG -On oral medication but not insulin Meditation -Participation in exercise program in previous six months Ingraham United CG: 39 Self-identified None Overweight or obese CG: 55 100% White: 45% States IG: 41 lesbian/bisexual women over IG: 52** Black: 6% WHAM age 40, recruited through (BMI greater than or Hispanic: 24% community settings in San equal to 27) Asian: 1% Francisco Multiracial/Other: 9% Nejati Iran CG: 15 Adults aged 30-55, with at -Physical or mental health Hypertension CG: 46.7% Not reported IG: 15 least a high school referred comorbidities 43.13 MBSR and to Imam Hossein Hospital in -History of MI (Blood pressure IG: Conscious 2013 with a HT -Pregnant greater than 130/80 43.66 Yoga mmHg) Rabin United CG: 16 Young adult cancer survivors -Medical or psychiatric conditions Cancer remission CG: 33.8 82.9% White: 74.3% States IG: 19 aged 18-39 years that would compromise PA IG: 33.3 Non-White: 25.7% RENEW -Diagnosed in past 10 years participation Hispanic: 14.3% -Completed all cancer -Pregnant treatment -Physician clearance to participate 33 Riley United CG: 19 Frontline mental health care None None 44.6 84.4% White: 94.7% States IG: 19** providers, recruited from Non-White: 5.3% Psychiatry department of a Yoga Based large New England hospital Stress -Able to safely engage in Management physical activity -Answered “No” to all PAR-Q items assessing readiness to engage in physical activity Robert United CG: 9 Women with documented None Cardiovascular CG: 64.1 100% White: 89% McComb States IG: 9 heart disease recruited from disease IG: 57.4 Non-White: 11% a Southwestern community; Hispanic: 5% MBSR and cleared for participation by Relaxation attending cardiologist Spadaro United CG: 25 Adults over age 18 with -Current exercise regimen of at Overweight/obese CG: 44.8 87% White: 78.3% States IG: 24 overweight/obesity recruited least 20 mins/day 3+ days/week IG: 45.8 Non White: 21.7% SBWP+ MB- from the local Pittsburgh -Recent participation in PA (BMI between 25 and EAT community program (prev. 6 months) 39.9 kg/m^2) -Current or planned pregnancy -History of conditions that could compromise exercise participation -History of MI or heart surgery -Non-medicated HT -Psychological issues Tapper United CG: 31 Women over age 18 -Pregnant Overweight CG: 37.6 100% Not reported Kingdo IG: 31 attempting to lose weight, -Using weight-impacting IG: 43.9 ACT for m recruited from university and medications (BMI over 20) Weight Loss local community -Not able to attend 3/4 intervention workshops Van Berkel Nether- CG: 128 Healthy government -On sick leave for more than four None CG: 45.1 67% Not reported lands IG: 129 employees, who perform weeks IG: 46.0 Mindful sedentary work -Pregnant Vitality in Practice EKG=electrocardiogram IG=Intervention Group * Two each intervention and control groups, collapsed for **Median reported HT=hypertension CG=Control Group analysis MI=myocardial infarction PAR-Q = Physical Activity Readiness Questionnaire 34 Table 3: Intervention Outcomes for Physical Activity Measures First author Time points N Analyzed Outcome(s) Measurement Tool(s) Main Effects Interaction Effects assessed* Analyzed Study (weeks) Outcome calculation Measurement unit Butryn BL (0) CG: 18 Drexel Athletic Identification card swipes Significant increase in DAC visits Time x Group: Center (DAC) over time • Significantly greater increase in DAC visits for ACT for IG: 28 F(1,42)=30.80, p<.01, η2=.62 ACT compared to Education group from BL to PI (4) Physical Visits/week PI: F(1,42)=3.90, p=.05, η2=.15] Activity • Similar findings from BL to FU F(1,42)=2.91, FU (7) p=.09, η2=.07], but did not reach significance. • No significant interaction effect from PI to FU. • Similar results with intent-to-treat analysis: more visits in ACT group compared to Education from BL to PI F(1,50)=5.3, p<.05, η2=.09, • Difference in number of visits no longer significant at FU Ingraham BL (0) CG: 39 Moderate/Vigorous International Physical Median number of minutes of PA Not Reported PA, participant Activity Questionnaire was higher in the intervention group WHAM IG: 41 reported (IPAQ) compared to the control group for all levels, but this difference was not PI (16) Light PA Minutes per day x statistically significant. number of days Walking • moderate/vig: 77.5 (IG) vs. 60 (CG) Minutes/week • light: 145 (IG) vs 120 (CG) • walking: 135 (IG) vs. 105 (CG) Rabin BL (0) CG: 12 Physical Activity, Seven Day Physical 7 Day PAR: Pooled analysis PAR: participant reported Activity Recall (PAR) showed significant changes in mean • Significant increase in weekly minutes of at RENEW IG: 15 PA minutes over time (M=140.9, least moderate intensity PA in intervention Minutes/week spent SE=23.2 p<.001) group (M=113.8, SE=23.5) compared to control in at least moderate group (M=-8.7, SE=27.1), p=.0002, d=1.30. PA • Changes maintained over time, with no significant change in IG from PI to FU. PI (12) Physical Activity Accelerometer Accelerometer : No statistically significant difference in 35 FU (24) Activity counts Average of activity accelerometer measured physical recorded over 3 counts activity frequency from BL to PI days (data not reported) Riley BL (0) CG: 19 Exercise/Physical Paffenbarger Physical Significant increase in both groups Group x Time: Significantly greater increase in Activity, participant Activity Questionnaire over time (F=4.42, p=.011) YBSM group over time, compared to CBSM group Yoga Based IG: 19 reported (PAAQ) (F=2.83, p=.046) Stress PI (8) Management Kcal/week FU 1 (16) FU 2 (32) Spadaro BL (0) CG: 24 Exercise/Physical Paffenbarger Physical • Only F scores (for time effect) No significant group x time interaction Activity, participant Activity Questionnaire and P values reported. SBWP+ MB- IG: 22 reported (PAAQ) • No significant difference by EAT MI (12) groups at any time point. Kcal/week • Both groups had an increase PI (24) (doubling their score) at mid- intervention assessment (p<.00) but had a decrease (~7.5%) from 3 months to 6 months Van Berkel BL (0) CG: 111 Vigorous Physical Short Questionnaire to SQUASH: No significant effects of No significant group x time interaction Activity, participant Assess Health intervention on weekly vigorous PA Mindful IG: 121 reported Enhancing Physical at either post intervention or 12 Vitality in Activity (SQUASH) month FU Practice Minutes/week PI (26) Physical Activity Accelerometer Accelerometer: No significant Not reported effects of intervention on weekly Minutes/week minutes of PA at either post intervention or 12 month FU FU (52) Tapper BL (0) ITT1: Physical Activity, Brief Physical Efficacy: Significant effect of Significant group x time effect for PA GC:31, IG: participant reported Assessment Tool (BPAT) intervention on PA from BL to FU F(1, 60) = 6.63, p<.013 ACT for 31 [F(1,60) =6.63, p<.013], Weight Loss Sessions/week Total activity ITT analysis: Significant increase in 36 PI (16) sessions/week mean PA in IG (+1.66, SD=4.28) ITT2:IG: 23 Mean change in (vigorous=2 sessions) compared to CG (-.74, SD=2.91), CG: 23 total number of p<.05, effect size=.31 weekly physical activity sessions ITT (excluding participants who did not attend any sessions): FU (26) Significant increase in mean PA sessions in IG [+2.20 (SD=4.35)], decrease in CG [-.61 (SD=3.34)] effect size=.34, p<.05 Nejati BL (0) CG: 15 Physical Activity Walker's Health Significant increase in mean PA Not reported Promoting Lifestyle frequency in intervention group MBSR and IG: 15 mean frequency Questionnaire (WHPLQ) compared to control group both at Conscious PI (8) PI and at FU Yoga • Post: F=2.37, p=0.03, Eta=.718 FU (16) • FU: F=2.260, p=.035, Eta=.705 BL=Baseline, PI=Post-intervention, FU=Follow-up 37 Table 4: Intervention Outcomes for Physical Fitness Measures First author Assessment N Analyzed Outcome(s) Measurement Tool(s) Main Effect Interaction Effect time points* Analyzed Outcome calculation Study in Measurement unit (weeks) Gainey BL (0) CG:11 Resting Heart Rate HR No significant pre/post differences in mean Not reported (RHR) RHR or MLS between or within groups Buddhist PI (12) IG: 12 AT REST following the intervention Walking beats/min Meditation Significant increase in V02 Max for both groups Leg muscle strength Isometric leg strength test, following the intervention, but no analysis of (MLS) using back/leg muscle strength group effects Kg dynamometer • CG BL: 15.6, Post: 18, p<.05 • IG BL: 18, Post: 23.1, p<.05 Maximum oxygen Metabolic cart during treadmill consumption (V02 test Max) Ml/kg/min Riley BL (0) CG: 19 Resting Heart Rate NR Significant reduction in resting heart rate in No significant group x (HR) beats/min both groups over the course of the study time interaction (F=4.12) Yoga Based PI (8) IG: 19 (F=4.07, p=.018) Stress Management FU1 (16) FU2 (32) Robert BL (0) CG: 9 Resting Heart Rate All measured using HR: No significant difference between groups No significant group x McComb MedGraphics CardiO2 Breath- time interaction for any PI (9) IG: 9 Oxygen consumption by-Breath System avg. last 5 V02: 7% decrease in V02 during RR (both measure: MBSR and (V02 ) mL/min^-1 mins of data groups) Relaxation HR: (F=.17) Breathing frequency Breath x Breath system Breathing patterns (BR, VE, Vt) – Significant V02: (F=.45) (BR) breaths/min^-1 interfaced with EKG to measure difference between groups: BR: (F=.47) HR • Decreased BR for intervention VE=(F=1.20) Tidal volume (Vt) group (p<.01), resulting in increased Vt: (F=.73) L/min^-1 All measured under 3 Vt (VE=BRxVt) conditions – 2 “control” • Significant main effect for group Ventilation (VE) conditions, and one in which [F=8.84, p<.01, effect size=.7] and L/min^-1 “Relaxation Response (RR)” for time [F=10.42, p<.01, effect was elicited size=.80] BL=Baseline, PI=Post-intervention, MI=Mid-intervention, FU=Follow-up 38 Table 5: Results of risk-of bias-assessment*, based on Cochrane risk-of-bias tool Selection Performance Detection Attrition Reporting Other Study Random Allocation Blinding of Blinding of Blinding of Incomplete Selective Other bias sequence concealment participants personnel outcome outcome data Reporting generation assessor Yoga Based Stress Management ?  ? ? ?  ?  SBWP + MB-EAT  ? ? ? ?    MBSR and Relaxation  ?     ? ? 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Mindfulness: A proposed operational definition. Clinical psychology: Science and practice. 2004;11(3):230-241. 16. Lau MA, Bishop SR, Segal ZV, et al. The Toronto mindfulness scale: Development and validation. Journal of clinical psychology. 2006;62(12):1445-1467. 17. Kiken LG, Garland EL, Bluth K, Palsson OS, Gaylord SA. From a state to a trait: Trajectories of state mindfulness in meditation during intervention predict changes in trait mindfulness. Personality and individual differences. 2015;81:41-46. 18. Kabat-Zinn J. Full catastrophe living: The program of the stress reduction clinic at the University of Massachusetts Medical Center. New York: Delta; 1990. 40 19. Dimidjian S, Segal ZV. Prospects for a clinical science of mindfulness-based intervention. American Psychologist. 2015;70(7):593. 20. Teasdale JD, Moore RG, Hayhurst H, Pope M, Williams S, Segal ZV. Metacognitive awareness and prevention of relapse in depression: empirical evidence. Journal of consulting and clinical psychology. 2002;70(2):275. 21. Hayes S, Strosahl K, Wilson K. Acceptance and commitment therapy: Understanding and treating human suffering. New York: Guilford. 1999. 22. Linehan MM. Cognitive behavioral therapy of borderline personality disorder. Vol 51: New York: Guilford Press; 1993. 23. Richiardi L, Bellocco R, Zugna D. Mediation analysis in epidemiology: methods, interpretation and bias. International journal of epidemiology. 2013;42(5):1511-1519. 24. Gilbert D, Waltz J. Mindfulness and health behaviors. Mindfulness. 2010;1(4):227-234. 25. Ulmer CS, Stetson BA, Salmon PG. Mindfulness and acceptance are associated with exercise maintenance in YMCA exercisers. Behaviour research and therapy. 2010;48(8):805-809. 26. Salmoirago-Blotcher E, Hunsinger M, Morgan L, Fischer D, Carmody J. Mindfulness-based stress reduction and change in health-related behaviors. Journal of Evidence-Based Complementary & Alternative Medicine. 2013;18(4):243-247. 27. Tsafou KE, De Ridder DT, van Ee R, Lacroix JP. Mindfulness and satisfaction in physical activity: A cross-sectional study in the Dutch population. Journal of health psychology. 2016;21(9):1817- 1827. 28. Analytics C. EndNote. Clarivate analytics. 2016. 29. Wallace BC, Small K, Brodley CE, Lau J, Trikalinos TA. Deploying an interactive machine learning system in an evidence-based practice center: abstrackr. Paper presented at: Proceedings of the 2nd ACM SIGHIT International Health Informatics Symposium2012. 30. Higgins JP, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Bmj. 2011;343:d5928. 31. Gainey A, Himathongkam T, Tanaka H, Suksom D. Effects of Buddhist walking meditation on glycemic control and vascular function in patients with type 2 diabetes. Complementary therapies in medicine. 2016;26:92-97. 32. Ingraham N, Harbatkin D, Lorvick J, Plumb M, Minnis AM. Women's Health and Mindfulness (WHAM): A Randomized Intervention Among Older Lesbian/Bisexual Women. Health promotion practice. 2017;18(3):348-357. 33. Nejati S, Zahiroddin A, Afrookhteh G, Rahmani S, Hoveida S. Effect of Group Mindfulness-Based Stress-Reduction Program and Conscious Yoga on Lifestyle, Coping Strategies, and Systolic and Diastolic Blood Pressures in Patients with Hypertension. The journal of Tehran Heart Center. 2015;10(3):140-148. 34. Rabin C, Pinto B, Fava J. Randomized Trial of a Physical Activity and Meditation Intervention for Young Adult Cancer Survivors. Journal of adolescent and young adult oncology. 2016;5(1):41-47. 35. Riley KE, Park CL, Wilson A, et al. Improving physical and mental health in frontline mental health care providers: Yoga-based stress management versus cognitive behavioral stress management. Journal of Workplace Behavioral Health. 2017;32(1):26-48. 36. van Berkel J, Boot CR, Proper KI, Bongers PM, van der Beek AJ. Effectiveness of a worksite mindfulness-based multi-component intervention on lifestyle behaviors. The international journal of behavioral nutrition and physical activity. 2014;11:9. 41 37. Butryn ML, Forman E, Hoffman K, Shaw J, Juarascio A. A pilot study of acceptance and commitment therapy for promotion of physical activity. Journal of physical activity & health. 2011;8(4):516-522. 38. Robert McComb JJ, Tacon A, Randolph P, Caldera Y. A pilot study to examine the effects of a mindfulness-based stress-reduction and relaxation program on levels of stress hormones, physical functioning, and submaximal exercise responses. Journal of alternative and complementary medicine (New York, NY). 2004;10(5):819-827. 39. Spadaro KC. Weight loss: Exploring self-regulation through mindfulness meditation, University of Pittsburgh; 2008. 40. Tapper K, Shaw C, Ilsley J, Hill AJ, Bond FW, Moore L. Exploratory randomised controlled trial of a mindfulness-based weight loss intervention for women. Appetite. 2009;52(2):396-404. 41. Prince SA, Adamo KB, Hamel ME, Hardt J, Gorber SC, Tremblay M. A comparison of direct versus self-report measures for assessing physical activity in adults: a systematic review. International Journal of Behavioral Nutrition and Physical Activity. 2008;5(1):56. 42. Dyrstad SM, Hansen BH, Holme IM, Anderssen SA. Comparison of self-reported versus accelerometer-measured physical activity. Medicine & Science in Sports & Exercise. 2014;46(1):99-106. 43. Ruffault A, Czernichow S, Hagger MS, et al. The effects of mindfulness training on weight-loss and health-related behaviours in adults with overweight and obesity: A systematic review and meta-analysis. Obesity research & clinical practice. 2017;11(5):90-111. 44. Sappington R, Longshore K. Systematically reviewing the efficacy of mindfulness-based interventions for enhanced athletic performance. Journal of Clinical Sport Psychology. 2015;9(3):232-262. 45. Swann C, Keegan RJ, Piggott D, Crust L. A systematic review of the experience, occurrence, and controllability of flow states in elite sport. Psychology of Sport and Exercise. 2012;13(6):807-819. 46. McAuley L, Tugwell P, Moher D. Does the inclusion of grey literature influence estimates of intervention effectiveness reported in meta-analyses? The Lancet. 2000;356(9237):1228-1231. 47. Forsyth L, Graham K, Harbour R. SIGN 50: A guideline developers’ handbook. Edinburgh: Scottish Intercollegiate Guidlines Network. 2004. 48. Lefebvre C, Manheimer E, Glanville J. Searching for studies. Cochrane handbook for systematic reviews of interventions: Cochrane book series. 2008:95-150. 49. Watson R, Richardson P. Identifying randomized controlled trials of cognitive therapy for depression: comparing the efficiency of Embase, Medline and PsycINFO bibliographic databases. Psychology and Psychotherapy: Theory, Research and Practice. 1999;72(4):535-542. 42 Part 2: Associations Between Dispositional Mindfulness and Blood Lipids 43 Abstract Background: Cardiovascular diseases are a leading cause of morbidity and mortality. Dispositional mindfulness, characterized non-judgemental awareness of one’s own mental and physical processes, is associated with overall cardiovascular health. Blood lipid profiles are important contributors to cardiovascular health, but their relationship to dispositional mindfulness is unknown. Objective: This study aimed to address gaps in the mindfulness and cardiovascular health literature by exploring relationships between dispositional mindfulness and high density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides, and total cholesterol, among a prospective birth cohort. Methods: Participants (n=391) were members of the New England Family Study birth cohort born in Providence, RI. Dispositional mindfulness was assessed using the Mindful Attention Awareness Scale (MAAS), and stratified in ordinal categories representing low, medium, and high mindfulness. Measurements of total serum cholesterol, HDL cholesterol, and triglycerides were obtained with enzymatic plasma samples. LDL cholesterol estimations were calculated using the Friedewald formula. Associations between exposures and outcomes were analysed using multivariable linear regression, with adjustment for confounders (age, sex, race/ethnicity and childhood socioeconomic index) and potential mediators (body mass index, education, depressive symptomology, smoking, fruit and vegetable consumption, and physical activity). Results: HDL cholesterol concentrations were 5.37 mg/dL lower in participants with the lowest, compared to the highest MAAS scores (p=.01). Triglycerides were 15 mg/dL higher for low MAAS participants (p<.05), but this relationship was attenuated after adjustment for hypothesized mediators. There was no association between MAAS scores and either total cholesterol or LDL cholesterol. Conclusions: Lower HDL cholesterol and higher triglycerides were found among those with the lowest compared to the highest mindfulness scores, but no association was seen for total or LDL cholesterol. Future research is needed to investigate mediational mechanisms, and also to explore if interventions that increase mindfulness also improve HDL cholesterol and triglycerides. 44 Background Cardiovascular diseases (CVD) – particularly coronary heart disease (CHD) and stroke - remain leading causes of morbidity and mortality for men and women of almost every race/ethnicity, both in the United States, and worldwide.1,2 Recent (2016) estimates suggest that the prevalence of CVD is over 40% in the United States, with an annual combined cost of $555 billion in 2015, an expense that is projected to more than double by 2035.3 Blood lipids, inheritable but modifiable compositions of fatty acids and blood fats, are well documented contributors to overall cardiovascular health and coronary heart disease morbidity and mortality risk.4 Specifically, dyslipidemia, a condition marked by elevated levels of total cholesterol, low density lipoprotein (LDL) cholesterol and triglycerides, and low levels of high density lipoprotein (HDL) is associated with increased risk of coronary heart disease (CHD), atherosclerosis, stroke, and other circulatory disorders.5,6 While LDL cholesterol contributes to arterial plaque formation, HDL cholesterol protects against heart disease by removing cholesterol from the arteries, and .6,7 Thus, behavioral and pharmacological interventions for management and improvement of lipid profiles are both important tools in both the prevention and treatment of CHD.4,5 Mindfulness is a metacognitive state of non-judgmental awareness which can be defined as “the ability to attend in a non-judgmental way to one’s own physical and mental processes during ordinary, everyday tasks”.8 Dispositional (or trait) mindfulness is characterized by qualities of acceptance and non-judgmental awareness of the present moment,9 and the ability to observe and explain physical and emotional states and 45 experiences without emotional reactivity,10 and occurs in varying degrees among the general population.11 Qualities associated with trait mindfulness are inherent to individuals and persist over time and across a variety of situations, but may also be cultivated and even increased through mindfulness training and long term practice.12,13 Both state and trait mindfulness show promise for positively impacting physical and mental health, through self-regulatory pathways that operate on both behavioral and biological processes.14,15 A relatively new area of scholarship examines relationships between cardiovascular health and state and trait mindfulness, hypothesizing that mindfulness may exert a positive influence on cardiovascular health, through changes in attention control, emotion regulation, and self-awareness.14,15 The New England Family Study, a cross- sectional investigation, reported a prevalence ratio of 1.83 (95% confidence interval 1.07- 3.13) for composite scores of good overall cardiovascular health among those with high compared to low scores on the Mindful Attention Awareness Scale (MAAS), a measure of dispositional mindfulness.14 While this study did not reveal any association of mindfulness with total cholesterol, individual lipid profile components were not analyzed, and relationships between blood lipid levels and mindfulness attributes is an area that remains largely unexplored in the literature to date.14,15 Another recent (2018) cross sectional study exploring associations between mindfulness and the metabolic syndrome (MetS) among French adults found that higher trait mindfulness (measured by Five Facet Mindfulness Questionnaire scores) was associated with both higher HDL cholesterol and lower odds of developing metabolic syndrome (p<.05) in participants with depression.16 46 There is also preliminary intervention research that suggests that increases in mindfulness may correspond to improvements in triglyceride/HDL ratios, which are predictive of CVD risk and mortality.7 A randomized controlled mindfulness trial testing the efficacy of mindfulness based diet and exercise program for adults with obesity found that although the intervention did not have a substantial impact on weight loss (the primary outcome), significant improvements were observed in intervention group participants’ triglyceride/HDL ratio at both 12 month (−0.57; 95% CI: −0.95, −0.18; P = 0.004) and 18 month follow ups (−0.36; 95% CI: −0.74, 0.03; P = 0.07), and the improvements were directly related to quantity of mindfulness practice.17 Research on mind/body practices and cardiovascular health provide similarly fascinating findings. A brief intervention for adults with hypertension improved blood lipid profiles following a 10-day yoga based lifestyle intervention. Post intervention, mean fasting plasma glucose, serum total cholesterol, triglycerides and LDL cholesterol were all significantly reduced (p <.01), while HDL cholesterol increased slightly, but significantly (p<.001), with the greatest improvements observed among those with hyperglycemia or hypercholesterolemia (p<.005).18 Another cross sectional study looking at components of metabolic syndrome (MetS) and self-reported engagement in a mind/body practices (broadly defined) found inverse associations between these practices and triglyceride levels, adjusting for age, sex, education, smoking, alcohol, ADL, grief, and depressive symptoms (beta=-.02, 95% CI=-.04, .01, p=.037).19 Although these studies do not measure mindfulness specifically, they offer a compelling contribution to a body of research that invites further investigation. 47 We hypothesize that serum lipids may be associated with dispositional mindfulness because lipid concentrations are partially impacted by lifestyle and health behaviors, many of which are also associated with both dispositional14,20 and situational17,21 mindfulness. The capacity to direct non-judgmental attention to one’s thoughts, emotions, physical sensations, and behavioral response patterns, in conjunction with an enhanced ability to self regulate emotions and behaviors may contribute to health enhancing behaviors and lifestyle choices associated with lipid profiles, such as physical activity,22,23 dietary intake,24 smoking,25,26 and alcohol consumption.27 Investigation into whether different levels of mindfulness correspond to differing levels of triglycerides, HDL, LDL and total cholesterol will provide greater mechanistic insight into the relationship between mindfulness and overall cardiovascular health and risk factors. Additionally, a deeper understanding of if and how individual lipid profiles relate to dispositional mindfulness has important implications for the targeted design, modification and delivery of interventions to improve cardiovascular health and related health outcomes. Objective The aim of the current study was to address existing gaps in the mindfulness and cardiovascular health literature by exploring relationships between dispositional mindfulness (measured by the validated MAAS scale) and blood lipid profiles among a prospective birth cohort. 48 Methods Study Population and Design The study population consisted of a subpopulation of the New England Family Study (NEFS), a prospective birth cohort following the offspring of pregnant female Collaborative Perinatal Project participants from Providence, RI and Boston, MA between 1959 and 1974 (n=17,921). The NEFS subpopulation included in the current study was comprised of participants of the Longitudinal Effects on Aging Perinatal (LEAP) Project, born in Providence, RI and sampled with preference for racial/ethnic minority groups. From an original sample of 1400, 796 participants were eligible, and of these 522 were contacted and invited to participate in the study. 95 (19%) of eligible individuals contacted refused to participate, and 27 (5%) were unable to schedule assessments within the necessary timeframe, leaving 400 participants who were enrolled and completed assessments in 13 months between 2010 and 2011. After excluding any respondents who were missing valid response data for the mindfulness measures (n=9), the final analytic sample was 391. Although measurements were taken at multiple time-points, the current study reports on measurements taken at age seven, and again in adulthood. Data were available for the following number of participants for each variable included: MAAS score (391), Total cholesterol (386), HDL (386), LDL (308), Triglycerides (386), Age (391), Gender (391), Race/ethnicity (391), Childhood SES (385), Depressive symptomology (390), Education (387), Smoking (376), BMI (390), Fruit and vegetable consumption (381), Physical activity (372), Alcohol consumption (384). 49 Figure 1: Visual representation of selection of LEAP participants and analytic sample New England Family Study participants N=17,921 LEAP Project participant sample N=1400 Eligible LEAP participants N=796 Invited to participate N=522 Unable or unwilling to participate N=217 Eligible LEAP participants enrolled N=400 Incomplete data for MAAS scores N=9 Analytic sample N=391 Definitions of Exposure Dispositional mindfulness was measured using the Mindful Attention Awareness Scale (MAAS), a validated, 15-item self- report, 6-point Likert-style scale designed to assess present-moment awareness and attention, which are core characteristics of dispositional mindfulness.28 MAAS items are designed to capture frequency of mindlessness (or lack of attention to the present moment) and include statements such as 50 “I break or spill things because of carelessness, not paying attention, or thinking of something else”, and “I find it difficult to stay focused on what’s happening in the present”. For each item, respondents indicate frequency with answers ratings ranging from 1 (almost always) to 6 (almost never). Mean participant scores range from 1-6, with a higher score indicating greater dispositional mindfulness.28 The MAAS has been found to have good internal consistency (a= .82, p<.0001) and test/retest reliability (intraclass correlation=.81, p<.0001),10,28 and, despite continuing debate among researchers and practitioners about how best to operationalize and measure mindfulness and related constructs, is currently considered a “gold standard” measure in the mindfulness literature.14,15,29 For the purposes of the current analysis, MAAS scores were broken into three ordinal categories, corresponding to the following levels of dispositional mindfulness: low (less than 4; n=78), medium (4-5; n=128), and high (greater than 5; n=171). Definitions of Outcomes Total serum cholesterol, HDL cholesterol and triglyceride measurements were obtained with enzymatic plasma samples at Harvard Medical School’s CDC certified CERLab (Boston, MA), using FDA approved reagents and calibrators (Roche Diagnostics, Indianapolis, IN).30 LDL cholesterol estimations were calculated using participants’ levels of total cholesterol, HDL cholesterol and triglyceride using the Friedewald formula where LDL=total cholesterol - HDL - (triglycerides/5), and where participants have fasted for at least 8 hours prior to the blood draw.31 Definitions of Confounders 51 Age was calculated by subtracting participants’ date of birth (which was recorded in initial assessments) from the date of the adult assessment. Gender was self reported by participants. Race/ethnicity data were self reported - participants were directed to self identify as one of the following: Asian, Pacific Islander, African American/Black, Caucasian/White, Native American, Other, Don’t know, Prefer not to answer. Race/ethnicity responses were collapsed to create a dichotomous variable representing White or not White. Childhood socioeconomic status was a composite index, calculated based on income, and education and occupation of both parents at offspring age 7, and weighted in comparison to the general United States population.32 Definitions of Potential Mediators Depression was measured using the Center for Epidemiologic Studies Depression Score (CES-D) which is used to assess depressive symptomology in the general population and has high internal consistency and moderate test/retest reliability (a=.88).33 CESD scores, which range from 0-30 with higher scores indicating greater depressive symptomology, summed and dichotomized to represent low (less than 10) or high (greater than or equal to ten) self reported depressive symptomology, according to previously described protocols.34 Educational attainment was self-reported by highest level of schooling completed, and dichotomized to represent at least a high school vs. less than high school. 52 Smoking was self-reported. A derived variable with self-reported current smoking status represented whether the participant did or did not currently smoke. Body mass index (BMI) was calculated using the formula BMI= weight (in kg)/height (in meters squared). Participant weight and height were measured from participants wearing light clothing and no shoes. Measurements were obtained by trained research nurses using a calibrated stadiometer and scale. Fruit and vegetable consumption was a mean score of daily fruit and vegetable servings, excluding fruit juice and potatoes, based on participant self-report. Alcohol consumption was assessed via participant self report on how often they consumed beer, wine, or liquor given the following response options: Never or less than 1 per month, 1-3 per month, 1 per week, 2-4 per week, 1 per day, 2-3 per day, 4-5 per day, More than 5 per day, Don’t know, Prefer not to answer. Because data were both continuous and categorical, average weekly alcohol consumption was calculated, and dichotomized to represent those who did or did not consume fourteen or more alcoholic beverages each week (or two a day), on average. Physical activity was measured using the International Physical Activity Questionnaire (IPAQ), a validated instrument for assessing healthy physical activity in adults in four domains of daily life – transportation, work, leisure, and exercise including participation in sports.35-37 Metabolic equivalent of task (MET) scores represents the energy expenditure involved in a given activity, where MET minutes = MET level x activity minutes x weekly events. “Moderate” physical activity is operationalized as at least 3 days of at least 20 minutes of vigorous activity, OR at least 30 minutes of moderate intensity physical activity or walking, 5 or more days a week OR at least 600 53 MET minutes per week. Individuals with “low” physical activity are those who do not meet the minimum criteria for at least moderate physical activity. Here, physical activity was dichotomized as “low” or “not low”. Statistical Analysis Participant demographics were assessed using Kruskall-Wallis and Chi squared tests, for continuous and categorical variables respectively, to compare differences in covariates across MAAS levels (low, medium, high). Estimates are reported as percentages for categorical variables, and as medians with interquartile ranges for continuous variables (Kruskall-Wallis median tests are used for variables with skewed distributions). Multivariable linear regression was used to explore associations between MAAS score level and total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides, with adjustment for the age, gender, race/ethnicity (Model 1), Model 1 variables with the addition of childhood socioeconomic status (Model 2), and Model 1 plus Model 2 variables with the addition of hypothesized mediators - body mass index, education, depressive symptomology, fruit and vegetable consumption, alcohol consumption, and physical activity (Model 3). Triglycerides were log-transformed to account for skew and kurtosis. All regressions were run using complete case analysis. All tests of significance were two-sided, and significance was set at p<.05. All statistical tests were conducted using SAS University Edition, version 9.4 (SAS Institute Inc., Cary, NC, USA). 54 Results Participant Characteristics Complete participant characteristics, both overall and stratified by MAAS level, are presented in Table 1. On average, participants were around 47 years old, with a total range of 44-51 years. 57% of the sample was female, 66% self identified as white, and the majority (70%) had less than a high-school education. Almost half (46%) had “high” MAAS scores (more than five out of six points), 34% had “medium” MAAS scores (between four and five out of a possible six), while 20% had MAAS scores considered “low” (less than 4). Among all participants, average total cholesterol was 191 mg/dL, average HDL cholesterol was 53 mg/dL, average LDL was 115 mg/dL and average triglycerides were 103 mg/dL. Unadjusted analysis revealed significant differences in participant age (p=.03), prevalence of depressive symptomology (p<.0001), and current smoking status (p=.02) across MAAS levels, with differences between groups trending toward significance for body mass index (p=.07) and low physical activity (p=.052). HDL cholesterol was somewhat higher among those in the highest MAAS score category compared to low and medium MAAS participants, average LDL cholesterol levels were lowest among those with medium MAAS scores, and triglycerides decreased with MAAS scores, although none of these associations reached statistical significance. Total cholesterol levels were also not significant, as they remained consistently close to the overall average of 191 mg/dL across all MAAS groups. Associations of Exposure and Outcomes 55 Results from multivariable linear regression models (presented in Table 2) with adjustment for age, sex, and race/ethnicity show that HDL cholesterol concentrations were more than 5 mg/dL lower in participants with the lowest MAAS scores, compared to those with the highest (95% confidence interval = -9.77, -0.96, p=.01). The point estimate for change in HDL cholesterol decreased slightly, to just below 5 mg/dL after additional adjustment, but the association remained significant (Model 2: -4.70; 95% confidence interval=-9.08, -.32, p=03; Model 3: -4.93, 95% confidence interval=-9.84, - 0.022, p=0.05). Likewise, triglycerides were slightly over 15 mg/dL higher in those with the lowest compared to the highest MAAS scores in the first model (ln=.15, 95% confidence interval=.03-.30, p=.04), an association that remained significant and virtually identical after adjustment for childhood socioeconomic index, but was attenuated after adjusting for the hypothesized mediators. Relationships between total and LDL cholesterol did not reach significance in any model, and there were also no significant differences in medium vs. high MAAS groups for any lipid in any model. Discussion Overview of Findings The findings of this study support an association of HDL cholesterol and triglycerides with dispositional mindfulness, adjusting for age, sex, race/ethnicity and childhood socioeconomic index. More specifically, HDL cholesterol concentrations were about 5 mg/dL lower among study participants who were lowest in MAAS scores 56 compared to those with the highest MAAS scores, suggesting that dispositional mindfulness is positively associated with levels of HDL cholesterol. Additionally, dispositional mindfulness was negatively associated with triglyceride levels, such that those with the lowest MAAS scores had triglyceride concentrations that were about 15 mg/dL higher than those with the highest MAAS scores. No association was found between MAAS scores and total cholesterol or LDL cholesterol. Connections to Previous Research To our knowledge, only two other studies have explored associations of dispositional mindfulness with blood lipids, in any capacity. In the study by Loucks et al, dispositional mindfulness was not related to overall cholesterol,14 a finding that is replicated in this study. While the 2018 study by Guyot and colleagues of mindfulness and metabolic syndrome found a significant association of dispositional mindfulness with higher HDL cholesterol, the HDL and mindfulness association was only significant among participants with depression, compared to those without depression, and no association was found with triglycerides.16 There are several possible mechanisms related to lifestyle and health behaviors, psychological and emotional processes, personality traits, and the relationships between them that may provide insight into our findings. First, high triglycerides and low HDL are usually coincident, and both are highly responsive to changes in lifestyle factors and health behaviors, many of which are also correlated with mindfulness levels. LDL, on the other hand, is less likely to be impacted by behavioral changes or interventions,38 which may explain why we did not observe the same associations with trait mindfulness in this study. The health behaviors most 57 consistently correlated with these lipid profiles are physical activity,22,23 smoking,25,26 alcohol consumption,27 and diet.24 In our study, 49% of those with the lowest MAAS scores reported low physical activity compared to 32% and 36% of medium and high MAAS scorers, respectively. Meta-analysis has shown that aerobic exercise can increase HDL cholesterol by 2.53 mg/dL in one study,39,40 and increase HDL by 4% while decreasing triglycerides by 6% in another,41 and there is cross sectional evidence that high mindfulness is associated with greater self reported physical activity engagement14 and maintenance,42 though the directionality of this relationship remains uncertain. While it is possible that that more mindful individuals experience greater attunement with both positive and negative bodily sensations that arise during physical activity,42,43 and possibly greater satisfaction with both the experience long term benefits of exercise44 than their less mindful counterparts, there is also evidence suggesting that enhanced awareness of bodily functions induced by vigorous exercise may in fact increase dispositional mindfulness, at least among men.45 Likewise, cigarette smoking has been linked to dose-response increases in triglycerides, and decreased HDL cholesterol,46,47 whereas high alcohol consumption increases plasma triglycerides.48 While dispositional mindfulness is negatively associated with both problem drinking49,50 and tobacco use,51 randomized controlled research on mindfulness interventions also shows promise for smoking cessation,52,53 and alcohol relapse prevention.54 It has been suggested that greater self-regulation and the ability to notice and attend to cravings, without acting on them may be one way that trait mindfulness is protective against the use and abuse of these particular substances.15,53,55 In our study, a greater proportion of low MAAS scorers reported being current smokers, 58 compared to medium or high scorers. That this pattern did not hold for alcohol consumption is likely attributable to the low overall proportion of heavy drinkers in this sample (less than 3%). Diets associated with improvements in overall lipid profiles include those low in carbohydrates and saturated fat,56 particularly low fat, whole grain, high protein diets high in Omega 3 fatty acids, such as the Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets.57-59 Fruit and vegetable consumption is inversely associated with LDL concentrations,60 but not, to our knowledge, with mindfulness.14 Future research should explore contributions of dietary intake including of different micronutrients on associations between mindfulness and lipids. Our results are relatively consistent with previous psychosocial research that finds associations of high HDL cholesterol and/or low triglycerides (but not LDL or total cholesterol) with certain personality traits also related to dispositional mindfulness. For example, one recent (2018) longitudinal study, self-acceptance (as a function of overall wellbeing, but not of mindfulness specifically) was linked to high HDL cholesterol and low triglycerides, but no similar association was found with LDL cholesterol.61 Other relevant traits include openness,62-64 conscientiousness,62,65 hostility,66 impulsivity65, stress reactivity,62,64 and possibly neuroticism,62,64 and all are highly correlated with dispositional mindfulness.67-71 Openness to experience and dispositional mindfulness both exemplify states of attention, receptivity, and curiosity,67 and openness has been positively associated with HDL cholesterol and negatively associated with triglycerides.62-64 Similarly, conscientiousness and mindfulness are both characterized by an ability to respond 59 deliberately, and to self-regulate behaviours and emotions, and conscientiousness is associated positively with HDL cholesterol and negatively with triglycerides.62,65 People high in openness and conscientiousness are more likely to engage in health promoting behaviours such as physical activity and healthy diets72-74 that contribute to lower triglyceride and higher HDL cholesterol. In a longitudinal study, associations of openness and conscientiousness with low triglycerides and high HDL cholesterol were attenuated, but still marginally significant after controlling for physical activity, providing some support for this theory.62 Neuroticism, too, has been negatively associated with HDL and positively associated with triglycerides, although in several studies the significance of these relationships was attenuated after controlling for physical activity (HDL) and physical activity, body weight, smoking status (triglycerides),62,64 supporting the hypothesis that these relationships operate at least partially through the afore mentioned behavioral pathways. Additionally, people high in impulsivity are at a heightened risk of elevated triglycerides,65 which, as one researcher hypothesizes, may be due to dietary choices, as impulsivity is associated with preferences for foods and beverages that are sweet and high in carbohydrates.75 Lastly, acute and chronic stress and distress76,77 have also been inversely linked to both state and trait mindfulness,78,79 and stress vulnerability is associated with low HDL cholesterol.64 The ability to bring mindful awareness to stressors and undesirable emotional states redirects the mind to the present moment, reducing both emotional reactivity and rumination, which enables skillful and non- reactive responses to these adverse states, potentially reducing the strength of the 60 physiological stress response, and subsequent detrimental effects on HDL and triglycerides.80,81 In our study, the covariate with the most striking (and statistically significant) difference across MAAS subgroups was depression, which has previously been identified as an important mediator in the relationship between mindfulness and overall cardiovascular risk.14 65% of low MAAS scoring participants reported depressive symptomology, compared to 35% of medium MAAS and just 12% of low MAAS scorers (p<.0001). HDL cholesterol is consistently associated with major depressive disorder,82-84 and an extensive literature documents overall negative relationships between depression and mindfulness.68,85 Traits of open curiosity and non judgmental present moment awareness characteristic of both dispositional and situational mindfulness may provide protective buffers against correlates of depression such as rumination and overall negative cognition.68,85-87 Because depression is also strongly associated with salient health behaviors,88 particularly smoking,89,90 physical activity and inactivity,91,92 and heavy alcohol consumption,93 its role as a potential mediator in the observed relationship is worthy of further study. Strengths and Limitations The greatest limitation of this study is that it was cross-sectionally analyzed, which precludes causal inference. Randomized, controlled intervention studies are needed to determine if increasing mindfulness through structured training result in changes in HDL and/or triglycerides, while longitudinal research should be conducted to assess changes in these relationships over time. Another limitation is that LDL 61 cholesterol levels were calculated from total cholesterol, HDL cholesterol and triglyceride levels using the Friedewald formula, which requires 1) participants to fast for eight hours, and 2) triglyceride levels below 400 mg/dL.24 In the current sample, 67 participants did not fully meet the fasting criteria, and two had triglycerides over 400 mg/dL, resulting in 69 patients missing valid triglyceride data, which represents 17% of the total sample. There may be important but unmeasured systematic differences between participants with and without valid data on this measure, biasing our results. The American Heart Association defines “heavy drinking” as more than two alcoholic beverages a day for women, and more than three for men.94 In our study, the response categories were bracketed in such a way that creation of a variable that represented these ideal categories was not possible. However, it is likely that the use of self reported data for alcohol consumption and other behavioral variables represents a greater limitation to the study than the classification of alcohol consumption categories. Additionally, although the MAAS has been validated in multiple populations, has high internal consistency, reliability, construct validity and responsiveness,29 and is one of the most commonly used measures of dispositional mindfulness, there are clear limitations to using a self report tool to measure trait characteristics such as mindfulness. A notable analytical challenge is that adjustment for potential mediators (which may lay in the causal pathway between exposure and outcome) in our third regression model may have introduced bias into the model,95 obscuring important information about the indirect effects of covariates. Future research is needed to investigate mediational mechanisms, and next steps include a mediation analysis to test direct and indirect effects of the hypothesized mediators with MAAS levels and HDL cholesterol and triglycerides. 62 Lastly, even the strongest models had a relatively low r-squared value (in the fully adjusted models r-squared was .27 for HDL cholesterol and .21 for triglycerides, but only .04 and .03 for total cholesterol and LDL cholesterol), which suggests that the overall model may have been a poor fit for the data, and key covariates may have been excluded. Despite these limitations, this study has several important strengths. To our knowledge, this is the first study to explicitly examine associations of dispositional mindfulness with discrete lipid levels in a healthy population, and as such provides important information for a more nuanced understanding of connections between trait mindfulness and one component of cardiovascular health. Additionally, our regression model was able to adjust for childhood socioeconomic index, a novel, prospectively gathered covariate which has been linked to increased risk of cardiovascular disease in adulthood, including coronary heart disease, myocardial infarction, and stroke,96 as well as metabolic syndrome,97 and overall metabolic function.98 Other strengths include the use of direct, objective measures of all lipids analyzed, and the longitudinal cohort design, which allows for multiple and repeated assessments over time. Conclusion In conclusion, the current analysis found a positive association of dispositional mindfulness with some, but not all, blood lipid concentrations. Lower HDL cholesterol and higher triglycerides were found among those with the lowest compared to the highest mindfulness scores, while no association was seen for total or LDL cholesterol. This is the first study we are aware of that explicitly examines dispositional mindfulness and discrete lipid levels in a healthy population, and, when considered in combination with 63 previous research, these results offer compelling insights into some of the mechanisms linking mindfulness and cardiovascular health. A clearer understanding of direct and indirect contributions of hypothesized mediators, as well as directionality of these relationships is needed, and should be prioritized by future research endeavors. 64 References: 1. Organization WH. Mortality and burden of disease estimates for WHO Member States in 2004. 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Psychosomatic medicine. 2005;67(6):846-854. 70 Table 1: Participant characteristics overall, and stratified by Mindful Attention Awareness (MAAS) level MAAS Level Overall (n=391) Low (n=79) Medium (n=133) High (n=179) p-value Total cholesterol (mg/dL) 191 (172-216) 189 (168-224) 192 (168-212) 191 (173-217) 0.930 HDL cholesterol (mg/dL) 52.9 (42.0-64.9) 52.6 (40.3-61.9) 51.0 (41.7-63.5) 53.8 (42.4-68.0) 0.390 LDL (mg/dL) 115.5 (93.5-136.9) 115.3 (87.6-148.1) 117.6 (93.5-133.6) 113.8 (96.6-137.1) 0.940 Triglycerides (mg/dL) 103 (71-150) 108 (82-165) 107 (68-149) 99 (67-149) 0.280 Confounders Age, years 47 (46-48) 47 (46-48) 47 (44-48) 47 (46-49) 0.030 Gender, % female 56.5 63.3 57.9 52.5 0.250 Race/ethnicity, % white 65.5 67.0 70.0 61.4 0.280 Childhood socioeconomic index 41 (25-57) 38.5 (23-35) 38.5 (24-54) 44.0 (27-58) 0.310 Potential mediators Body mass index, kg/m^2 29.3 (25.4-34.1) 30.5 (26.9-35.5) 28.5 (24.8-34.4) 28.9 (25.0-33.6) 0.070 Education, %/=10 Smoking, % current smoker 36.4 49.4 35.9 31.0 0.020 Fruits and vegetables, daily 1.4 (.9-3.3) 1.1 (.5-3.3) 1.4 (.9-2.9) 1.4 (.9-2.9) 0.220 servings Alcohol consumption, % avg. 2.4 2.6 2.3 2.4 0.980 >2 per day Physical activity, % low 37.6 49.3 32.5 36.3 0.052 HDL=high density lipoprotein, LDL=low density lipoprotein, CESD=Center for Epidemiologic Studies Depression Scale MAAS = Mindful Attention Awareness Scale (range 1-6). Low MAAS<4, Medium 4-5, High >5 Point estimates represent percentages and medians (interquartile range) p-values calculated with chi-squared tests for categorical variables and Kruskal-Wallis test for continuous variables 71 Table 2: Multivariable adjusted regression analysis showing change in total cholesterol, HDL, LDL, and triglycerides (95% confidence intervals), by Mindfulness Awareness Attention Scale (MAAS) score level Model adjustment Age, sex, race/ethnicity, childhoo socioeconomic index, body mass index, education, depressive Age, sex, race/ethnicity, symptomology, smoking, fruit an MAAS childhood socioeconomic vegetable consumption, physical Lipid outcome level Age, sex, race/ethnicity index activity Total cholesterol Low .51 (-10.5, 11.52) 1.79 (-9.39, 12.98) 5.95 (-7.40, 12.29) Med -3.23 (-12.65-6.19) -2.62 (-12.33, 7.08) -1.85 (-12.68, 8.97) High 0 0 0 HDL cholesterol (mg/dL) Low -5.37 (-9.77, -0.96)* -4.70 (-9.08, -.32)* -4.93 (-9.85, -0.02)* Med -3.01 (-6.78, 0.76) -2.32 (-6.12, 1.49) -3.19 (-7.17, .80) High 0 0 0 LDL cholesterol (mg/dL) Low 1.07 (-10.71, 12.86) -.60 (-11.77, 10.57) 3.84 (-9.46, 17.14) Med -5.33 (-15.84, 5.18) -3.78 (-13.70, 6.12) -4.22 (-15.26, 6.80) High 0 0 0 Triglycerides (mg/dL)+ Low 0.15 (.003, .30)* 0.15 (.003, .30)* .12 (-.04,.28) Med 0.05 (-.07, 0.17) 0.05 (-.08-.17) 0.08 (-.05, .21) High 0 0 0 HDL= high density lipoprotein, LDL=low density lipoprotein mg/dL = milligrams per deciliter; represents blood serum lipid concentrations MAAS = Mindful Attention Awareness Scale (range 1-6). Low MAAS<4, Medium 4-5, High >5; High MAAS is the referent category + Value reported is the natural log * Indicates p<.05 72 73