RESEARCH

Review

The Influence of Mindful Eating and/or Intuitive

Eating Approaches on Dietary Intake: A
Systematic Review
Hannah S. Grider, MS, RD; Steve M. Douglas, PhD; Hollie A. Raynor, PhD, RD, LDN

ARTICLE INFORMATION ABSTRACT

Article history: Background Stimuli that promote eating in the absence of the physiological need for
Submitted 09 February 2020 food are pervasive and can facilitate excessive energy intake. The practices of mindful
Accepted 16 October 2020 eating (ME) and intuitive eating (IE) have been developed to minimize external drivers
of energy intake by helping individuals emphasize the sensory properties of foods and
internal indicators of hunger and fullness.
Keywords: Objective To enhance understanding about the effect of ME and IE interventions on
Intuitive eating
dietary intake, this systematic review included randomized trials of ME and IE in-
Mindful eating
Energy intake terventions that examined dietary intake, defined as energy intake or diet quality, in
Diet quality adults of varying weight status without a diagnosis of an eating disorder.
Methods The selection of literature followed the Preferred Reporting Items for Sys-
Supplementary materials:
Table 1 is available at www.jandonline.org
tematic Reviews and Meta-Analyses systematic review process, in which PubMed,
CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO da-
tabases were searched for studies published between January 1980 and November 2019.
2212-2672/Copyright ª 2021 by the Academy of
Studies were included if they met the following criteria: randomized trial design in
Nutrition and Dietetics.
https://doi.org/10.1016/j.jand.2020.10.019 which 1 arm was an intervention with an ME or IE component and there was at least 1
control or active comparison arm; enrolled participants were of a healthy weight or
with overweight or obesity and reported not having an eating disorder (ie, anorexia,
bulimia nervosa, or binge eating disorder) or other health conditions in which dietary
restrictions were applied; were at least 18 years of age; and outcomes of energy intake
or diet quality were reported at baseline and post intervention. The modified Downs
and Black checklist was used to assess risk of bias for each study that met inclusion
criteria.
Results A total of 13 studies, including 8 investigating ME interventions and 5 inves-
tigating IE interventions, represented in 14 articles, were included in the review. Seven
of the 9 articles reporting on energy intake did not find significant group differences.
Eight of the 12 articles reporting on diet quality did not find significant group differ-
ences. The mean bias assessment score was 13.6 out of 28, indicating poor quality.
Conclusions Little evidence suggests that ME and IE interventions influence energy
intake or diet quality. To draw strong conclusions about the effect of ME and IE on di-
etary intake, future research using study designs of high rigor are needed.
J Acad Nutr Diet. 2021;121(4):709-727.

A
N INDIVIDUAL’S EATING BEHAVIOR IS OFTEN people to reduce external motivators of ingestive behavior
assumed to be in response to hunger, which repre- (eg, eating away from distractions) and elevate the impor-
sents the biological need for food in order to survive tance of the sensory properties of foods and internal moti-
and maintain homeostasis (ie, depleted energy vators of ingestive behavior (eg, physiological cues).5 These
stores, biological need for food, and food consumed until interventions focus on mindful eating (ME) and intuitive
satiated).1,2 However, our social and cultural environment eating (IE).
(eg, easily available highly palatable foods and large portion ME is the act of paying attention to food during con-
sizes) can promote eating in the absence of the physiological sumption, and having awareness and focusing on the expe-
need for food.3 This produces eating in the absence of ho- rience with food.6 The intent is not weight loss or to restrict
meostatic signals. intake; however, it is believed that if one is mindful of their
When eating is for reasons other than homeostatic regu- food experience and consumption, the result can be that
lation, regulation by intrinsic homeostatic signals to initiate awareness of how food makes one feel increases, which can
or end an eating event are either not provided or overridden.4 lead to the selection of healthier options.6 Similarly, the IE
Two types of practices have been developed that instruct model encourages individuals to reject the “diet mentality.”7

ª 2021 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 709
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The diet mentality is the process of relying on non-

physiological factors, such as cognitive control, to determine RESEARCH SNAPSHOT
intake rather than relying on the body’s natural self-
Research Question: Do mindful eating and intuitive eating
regulation system. IE is eating with an intentional focus on
interventions influence energy intake or diet quality?
physiological hunger and satiety cues rather than external
cues to guide intake.7 External cues can include emotions, Key Findings: Fourteen articles were identified, with 9 and 5
food availability, seeing or smelling food, social settings articles investigating mindful eating and intuitive eating,
where eating is encouraged or the norm, serving sizes, or respectively. Seven of 9 articles reporting on energy intake
food packaging. IE involves training an individual to focus on found no significant group differences. Eight of 12 articles
responding to physical sensations in order to determine the reporting on diet quality found no significant group
body’s needs.7 differences. Studies were of low quality for risk bias.
Although the aim of ME and IE is to listen to the body’s cues
to drive eating, few systematic reviews have focused on how
these approaches influence dietary intake, defined as energy acceptance approach,16,17 with 1 finding significant between-
intake (caloric intake) or quality of the diet consumed. Previ- group differences in diet quality,17 while the other did not.16
ous systematic reviews have focused on examining the effects The third investigation, examining an ME intervention, found
of ME and IE on other psychological and health factors.8-10 For greater reductions in trans fat, fiber, and sugar intake for the
example, one 2016 systematic review of 24 cross-sectional ME intervention group compared with a diabetes self-
studies examined the relationship between IE and disor- management education-based intervention.15 However, this
dered eating, body image, emotional functioning, and other study also did not measure ME before or after the interven-
psychosocial correlates in adult women.10 Results showed that tion. Therefore, conclusions cannot be drawn in regard to
IE was inversely associated with eating pathology and posi- how the intervention influenced ME or how ME influences
tively associated with positive body image and better diet quality.
emotional management, with diet not reported. Although the aim of ME and IE is to listen to the body’s cues
Another systematic review of randomized controlled trials to drive eating, examining the effect of these interventions on
(RCTs), quasi-experimental designs, and prospective cohort dietary intake has not been the main focus of any previous
studies conducted by Schaefer and Magnuson9 examined the systematic review, making it challenging to draw conclusions
physical and psychological outcomes from IE interventions in about their influence on dietary intake. Therefore, the aim of
samples that were predominantly adult females, with studies this investigation was to examine, in adults of varying weight
involving participants with a clinically diagnosed eating dis- status without a diagnosis of an eating disorder, whether ME
order excluded. Four of the 20 studies included in this review and IE interventions affect energy intake or quality of diet
assessed dietary intake.11-14 Of the 3 studies assessing energy consumed compared with a control or active intervention in
intake,11-13 only 1 study reported a significant decrease in randomized trials. Measures of ME and IE were also reported
mean energy intake in the intervention group compared with when assessed with a validated tool in trials included in the
the control.12 For the 2 other studies measuring energy systematic review.
intake, 1 found significant within-group differences, but no
differences compared with the control, and the other found METHODS
no change in energy intake.11,13 In regard to diet quality, one12
of the 4 studies11-14 assessing diet quality observed a signif-
Protocol and Registration
icant decrease in fat intake in the intervention group The review of the literature was conducted according to the
compared with the control. However, within-group compar- guidelines specified by the Preferred Reporting Items for
isons reported by 2 studies suggest improvements in diet Systematic Reviews and Meta Analyses (PRISMA) state-
quality for both the intervention and control groups with no ment.18 The systematic review protocol was registered with
between-group differences.11,14 One significant limitation of the International Prospective Register of Systematic Reviews
these studies is that none measured IE.9 Without assessing IE, (PROSPERO) on May 17, 2019 with registration number
it is unclear whether the aforementioned interventions CRD42019128135.
influenced IE and whether the dietary outcomes were driven
by changes in IE. Eligibility Criteria
Clifford and colleagues8 conducted a separate systematic Studies included were randomized trials that included an
review of RCTs and quasi-experimental studies on nondiet intervention of ME or IE with at least an initial appointment
approaches (eg, ME, IE, Health at Every Size, joyful movement and at least 1 follow-up (ie, phone, in-person, or mobile
[emphasizes finding pleasure in body movement], and size application). The ME or IE interventions included could
acceptance) to determine the effects of these approaches on contain other intervention components (ie, physical activity
different health outcomes, including weight, biochemical goals) or be an intervention that focused solely on ME or IE.
measures (eg, blood lipids and glucose), food and activity The ME or IE intervention taught and encouraged partici-
behaviors, body image, and mental health. The majority of pants to eat intuitively, mindfully, or based on hunger and
the studies had female participants with overweight or fullness cues. Trials had 1 arm that was an intervention with
obesity. Two of the studies reviewed assessed energy intake an ME or IE component and there was at least 1 other arm
in adults with overweight or obesity, with 1 testing a size that was a control (ie, usual care or non-intervention con-
acceptance approach and 1 ME, and no between-group dif- trols, such as wait-list control and assessment-only control)
ferences were observed.15,16 Of the 3 studies reviewed that or active comparison without an ME or IE component, and
examined dietary quality,15-17 2 were testing a size had to be published in the English language. There was no

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specified intervention setting and no restriction on inter- assessment time points with retention rate; intervention
vention personnel for inclusion purposes. Studies were contact time; ME/IE intervention components; dietary inter-
included if participants were adults 18 years and older; were vention components included in ME/IE interventions; other
of a healthy weight or with overweight or obesity; and re- components included in ME/IE interventions; control/com-
ported not having an eating disorder (ie, anorexia, bulimia parison interventions; validated ME/IE measurements
nervosa, or binge eating disorder) or other health conditions (although measures of ME/IE were not an inclusion/exclusion
in which dietary restrictions were applied (eg, individuals criterion, measures of ME and IE when collected using a
with dietary goals that need to be followed due to medication validated tool were reported); dietary assessment methods
issues). with length of recall; and indication of reported energy
Studies were included if the outcomes of energy intake intake and/or diet quality variables. One reviewer (H.R.)
or diet quality were reported at baseline and post inter- reviewed the summary table and verified the data. One
vention. Energy intake was defined as the total kilocalo- reviewer (H.G.) created a key findings table, which was
ries or kilojoules consumed from food and beverage reviewed and verified by another reviewer (H.R.), to sum-
sources. Diet quality was defined based on dietary com- marize outcomes of energy intake and/or diet quality and ME
ponents targeted in the Dietary Guidelines for Americans and IE measures (Table 3). The studies were separated by
(DGA)19 or based on a Healthy Eating Index score.20 To be comparison group (either control group and active inter-
included in the review, studies needed to report at least 1 vention comparison) because of expected within-group dif-
component of the DGA to be considered as reporting on ferences in dietary intake when following an intervention.
diet quality. An improvement in diet quality was reflected The focus in the key findings table was on between-group
by an increase in foods/nutrients within the DGA that are comparisons, reporting comparisons between the interven-
commonly targeted to increase (ie, fruits, vegetables, tion group and either a comparison and/or control group. If a
whole grains, fat-free or low-fat dairy, a variety of protein study had 3 groups, comparisons among all 3 groups were
foods, and oils containing monounsaturated and poly- reported. Significant and nonsignificant findings were
unsaturated fat).19 Diet quality improvement was also reported.
considered observed if there was a decrease in foods/ The modified Downs and Black checklist was used to assess
nutrients that are commonly targeted within the DGA to risk of bias for each study that met the inclusion criteria.35
decrease (ie, added sugars, saturated fat, sodium, and The modified Downs and Black checklist is a checklist for
alcohol).19 Higher scores on the Healthy Eating Index the assessment of the methodological quality of randomized
indicated higher diet quality. studies of health care interventions.35 The checklist is a 27-
item scale with possible values ranging from 0 to 28. The
Search Strategy checklist has 5 different assessment categories: reporting,
For this review, PubMed, CINAHL (Cumulative Index to external validity, internal validityebias, internal
Nursing and Allied Health Literature) and PsycINFO electronic validityeconfounding, and power. The modified checklist
databases were searched. In addition, references of eligible simplified the evaluation of power by awarding a single point
studies were examined. Studies published or in press be- if a study had sufficient power to detect an effect, where the
tween 1980—as no earlier date has been used for systematic probability value for a difference being due to chance was
reviews of ME or IE8—and an end date of November 2019 <5%. A higher score indicates better quality, with 28 to 24
were included. No authors were contacted for the review and points considered excellent, 23 to 19 points considered good,
the gray literature was not searched. The selection of litera- 18 to 14 points considered fair, and fewer than 14 points
ture followed the PRISMA systematic review process by 2 considered poor.36
reviewers (S.D. and H.G.) using the search terms (intuiti* OR
mindful*) AND (eat* OR diet* OR food* OR energ*) to search RESULTS
for RCTs only, which included individual collection of studies After duplicates were removed, a total of 129 records were
that met inclusion criteria (Table 1; available at www. retrieved (Figure). The abstract screening resulted in 37
jandonline.org).18 articles identified for fulltext review. After reading the full
texts, 14 articles, representing 13 studies, were identified
Selection Process for inclusion in the review. Of the 14 included articles, 2
The initial reviewer determined rejection of studies through articles reported different measures of diet quality collected
abstract screening. If the abstract could not be rejected with in the same study, resulting in 2 articles representing 1
certainty, the full-text article was obtained for further eval- study.15,33
uation. For articles pulled to review, 2 reviewers (H.G. and
H.R.) independently assessed and determined a study’s Study Characteristics
eligibility. Any doubts for inclusion were discussed and See Table 2 for included study characteristics. Studies were
resolved. grouped into 2 categories based on comparison group: con-
trol group comparison (ie, no intervention and wait-list
Data Extraction and Quality Evaluation control) and active comparisons. Eight of the 13 included
A summary table was formulated by 1 reviewer (H.G.) from studies, represented in 9 of 14 articles, were ME
each study that was included (Table 2). The table included interventions12,15,21,23,25,28,31,33,34 and 5 were IE
documentation of study authors and year published; sample interventions.13,22,26,29,32 Comparison groups of the included
size; participant sex; mean participant body mass index; studies varied. Eight studies included a control group com-
participant age (mean in years); intervention duration; parison with either no intervention or wait-list comparison

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Table 2. Summary table of the studies, grouped according to the comparison condition of control group comparison (ie, no intervention and wait-list control) and active
intervention, acquired from the literature search evaluating how mindful eating and intuitive eating influence dietary intake
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Time of
follow-up
Study measures Dietary
first (retention measure Diet
author rate at Diet for Other parts ME/IE (length of Energy quality (unit
(year) Sample Contact measures) ME/IEa ME/IE of ME/IE Comparison measure recall) intake measured)

Comparison
condition:
control group
Carmodyb n ¼ 36 11 wk; eleven 2.5- 11 wk (66.7%) ME: 11 dietary Increase plant- Spouse/peer Wait-list NVMe 24-h Yes %kcal fat
(2008)21 Male: 100% h group 3 mo (66.7%) and cooking based foods, support system control diet %kcal saturated
BMIc: 30.1  4.4d sessions (27.5 classes that fish, whole recall fat
Age: 69.1  9.0 yd h) integrated grains, and soy %kcal protein
mindfulness, foods; avoid Animal protein (g)
instructed on meat, poultry, Vegetable protein
bringing and dairy (g)
attention to products Fiber (g)
reactions, Soluble fiber (g)
thoughts, and Insoluble fiber (g)
habitual
judgments
concerning
food choices
and
consumption
Coleb (2010)22 n ¼ 61 10 wk; ten 10 wk (60.7%) IE: Instructed to None None No NVM 3-d food record Yes %kcal fat
Female: 100% 1-h group 6 mo (52.5%) follow the 10 IE intervention HEIhi year NRj %kcal
BMI sessions (10 h) principles carbohydrate
Intervention: 32.3 %kcal protein
 6.8f Fiber (g)
Cg: 29.0  7.3f HEI (score 0-100)
Age
Intervention: 37.5
 8.5 yf
April 2021 Volume 121 Number 4

C: 37.0  10.1 yf
Daubenmier n ¼ 47 4 mo; nine 4 mo (78.7%) ME: 2-h nutrition and Meditation, body Wait-list control NVM Block 2005 FFQp Yes %kcal fat
(2012)23 Female: 100% 2.5-h group MBSRlm þ MB- exercise scan, and (baseline: over %kcal
BMI sessions þ one EATno: session aimed mindful yoga the past year; carbohydrate
Intervention: 31.4 7-h group Instructed to at weight loss stretches as post %kcal protein
 4.7k session (29.5 h) recognize taught in intervention:
C: 30.8  4.8k physical MBSRm

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Table 2. Summary table of the studies, grouped according to the comparison condition of control group comparison (ie, no intervention and wait-list control) and active
intervention, acquired from the literature search evaluating how mindful eating and intuitive eating influence dietary intake (continued)
Time of
follow-up
Study measures Dietary
first (retention measure Diet
author rate at Diet for Other parts ME/IE (length of Energy quality (unit
(year) Sample Contact measures) ME/IEa ME/IE of ME/IE Comparison measure recall) intake measured)

Age sensations of over the

Intervention: 40.4 hunger, previous 3 mo)
 8.0 yk fullness, taste
C: 41.4  6.7 yk satisfaction,
and
responding
mindfully to
food cravings
and eating
triggers
Ingraham (2017)25 n ¼ 80 12 wk; 4 mo after ME Increase PAs goals set with Wait-list control MEQt Questions No Fruit (unit of
Female: 100% 12 group sessions enrollment Women’s Health vegetable and personal adapted from measure NR)
BMI (NR) (88%) and fruit intake, trainer during the Behavioral Vegetables (unit
Mean: NR Mindfulness: make more 1-on-1 sessions Risk Factor of measure NR)
BMI  27 Instructed on nutritious Surveillance
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Age mindful eating choices when System

Intervention: 52 y adapted from eating out,
(40-73 y)q MBSR program, goals set with
C: 55 y (43-76 y)q activities an RDr
included
learning
mindful eating
and increasing
awareness of
emotional
eating patterns
through food
and emotion
journaling
Järvelä-Reijonen n ¼ 219 8 wk; 10 wk (93.6%) IE None Relaxation, and No intervention IESuv 48-h diet recall for No IDQx (score 0-15)
(2018)26 Female: 85% Intervention 1: 9 mo (91.3%) ACT face-to-face everyday PA, IDQw score
BMI acceptance and mobile: hyperlink to a

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Intervention 1: and Instructed on public
31.0  3.1 commitment recognizing nutritional
Intervention 2: therapy (ACT) physical website
31.6  2.7 face to face ¼ sensations of provided
C: 31.2  2.8 six 90-min hunger and
713

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714

Table 2. Summary table of the studies, grouped according to the comparison condition of control group comparison (ie, no intervention and wait-list control) and active
intervention, acquired from the literature search evaluating how mindful eating and intuitive eating influence dietary intake (continued)
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Time of
follow-up
Study measures Dietary
first (retention measure Diet
author rate at Diet for Other parts ME/IE (length of Energy quality (unit
(year) Sample Contact measures) ME/IEa ME/IE of ME/IE Comparison measure recall) intake measured)

Age group sessions fullness, and

Intervention 1: (9 h) awareness of
50.3  7.2 y Intervention 2: emotional and
Intervention 2: ACT mobile ¼ stress eating;
49.1  7.7 y one 90-min instructed to
C: 49.2  7.4 y group observe eating-
session þ related
mobile app (1.5 thoughts and
h þ median 4.7 feeling and be
h of app usage) aware of the
effects of not
eating
mindfully
Leblanc (2012)13 n ¼ 140 4 mo 4 mo (83.6%) IE None Workbook given Wait-list control NVM 3-d food record (2 Yes %kcal fat
Female: 100% HAESy: thirteen 3- HAES: Instructed to help guide weekdays þ 1 %kcal
BMI: 30.4  3.0d h group to recognize self-reflection weekend day) carbohydrate
Age: 42.4  5.6 yd sessions þ one physical %kcal protein
6-h group sensations of %kcal alcohol
session (45 h) hunger and Fiber (g)
SSz: fourteen 2-h fullness, Sodium (mg)
group sessions identify Calcium (mg)
(28 h) external
influences on
eating
behaviors and
food intake
SS: Same as HAES
except
April 2021 Volume 121 Number 4

structural social
support
provided by
the group itself
Timmermanb n ¼ 35 6 wk; six 2-h 6 wk (100%) ME Reduce calorie General principles Wait-list control NVM 24-h dietary recall Yes Total fat (g)
(2012)12 Female: 100% group sessions Mindful and fat intake of weight (2 weekdays þ
BMI: 31.8  6.8d (12 h) restaurant when eating management 1 weekend
Age: 49.6  6.8 yd eating: out day)

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Table 2. Summary table of the studies, grouped according to the comparison condition of control group comparison (ie, no intervention and wait-list control) and active
intervention, acquired from the literature search evaluating how mindful eating and intuitive eating influence dietary intake (continued)
Time of
follow-up
Study measures Dietary
first (retention measure Diet
author rate at Diet for Other parts ME/IE (length of Energy quality (unit
(year) Sample Contact measures) ME/IEa ME/IE of ME/IE Comparison measure recall) intake measured)

Instructed to
focus on sight,
smell, and
texture
throughout
eating, and
recognize
physical
sensations of
hunger and
fullness
van Berkelb n ¼ 257 6 mo; eight 90- 6 mo (91.4%) ME None Free fruit and No intervention NVM Short Fruit and No Fruit intake
(2014)28 Female: 67% min group 12 mo (90.2%) Mindful VIPbb: vegetables Vegetable (servings/d)
BMI (% >25)aa sessions þ 8 Instructed on provided, Questionnaire
Intervention: sessions of e- eating with lunch walking (average week)
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

35.4% coaching (12 mindful routes, support

C: 41.3% h þ e-coaching attention system,
Age length NR) included
Intervention: 46.0 mindfulness
 9.4 y homework
C: 45.1  9.6 y exercises
Comparison
condition:
active
intervention
Anglin (2013)29 n ¼ 16 6 wk Wk 1 (NR) IE Unclear whether a Supervised CRdd: Same NVM Daily food record Yes None
Female: NR Contact time NR Wk 2 (NR) Instructed to calorie goal exercise 3 contact time (42 d)
Male: NR Wk 3 (NR) follow the 10 IE provided times/wk for 30 and
BMI Wk 4 (NR) principles min on a components as
Intervention: 34.6 Wk 5 (NR) stationary bike IE without
 2.3cc Wk 6 (NR) instruction on
C: 33.7  2.1cc IE principles,

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Age given dietary
Mean: NR instructions at
20-48 y baseline and
midpoint with

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Table 2. Summary table of the studies, grouped according to the comparison condition of control group comparison (ie, no intervention and wait-list control) and active
intervention, acquired from the literature search evaluating how mindful eating and intuitive eating influence dietary intake (continued)
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Time of
follow-up
Study measures Dietary
first (retention measure Diet
author rate at Diet for Other parts ME/IE (length of Energy quality (unit
(year) Sample Contact measures) ME/IEa ME/IE of ME/IE Comparison measure recall) intake measured)

daily portion
intake, portion
sizes, and
sample menus
based on
calorie goal,
unclear but
suggested
calorie goal of
1,200-1,800
kcal/d
Mason (2016)31 n ¼ 194 5.5 mo; 6 mo (80.4%) ME Decrease 500 Increase activity C: Same contact MEQ 2005 Block FFQ No %kcal sweets
Female: 78% 16 group session 12 mo (76.8%) MB-EAT: kcal/d, throughout the time and (past 30 d)
BMI lasting 2-2.5 h Instructed to decrease day þ components as
Intervention: 35.4 each þ one recognize energy-dense, structured MB-EAT
 3.5 6.5-h weekend physical nutrient-poor exercise, without MB-
C: 35.6  3.8 group session sensations of foods, increase instructed on EAT and MBSR
Age (38.5-46.5 h) hunger and fresh fruit and MBSR
Intervention: 47.2 fullness, and vegetable techniques,
 13.1 y awareness of consumption, instructed to
C: 46.8  12.4 y emotional and healthy oils meditate 30
stress eating and proteins min/d
Mensinger n ¼ 80 6 mo twenty-four 6 mo (90.0%) IE None Participant WLff: Same IES RL-QOLhh No Fruit
(2016)32 Female: 100% 90-min group 24 mo (50.0%) WNee: Instructed support contact time as (average day) Vegetables (score
BMI sessions (36 h) to recognize network WN. LEARNgg 2-10)
Intervention: 37.4 physical provided Program for
 0.6 sensations of weight
C: 38.6  0.7 hunger and management,
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Age fullness which included

Intervention: 39.8 caloric
 4.3 y restriction, but
C: 39.4  3.9 y amount NR,
participant
support
network
provided

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Table 2. Summary table of the studies, grouped according to the comparison condition of control group comparison (ie, no intervention and wait-list control) and active
intervention, acquired from the literature search evaluating how mindful eating and intuitive eating influence dietary intake (continued)
Time of
follow-up
Study measures Dietary
first (retention measure Diet
author rate at Diet for Other parts ME/IE (length of Energy quality (unit
(year) Sample Contact measures) ME/IEa ME/IE of ME/IE Comparison measure recall) intake measured)

Miller (2012)15 n ¼ 68 3 mo ten 2.5-h 3 mo (76.5%) ME None Meditation DSMEkk Smart NVM 2005 Block FFQ Yes %kcal fat
Female: 63%ii group sessions 6 mo (76.5%) MB-EAT-Djj: practice Choices: Same (previous year) Monounsaturated
BMI (25 h) Instructed to contact time as fat (g/1,000
Intervention: 36.2 recognize MB-EAT-D, goal kcal)
 1.2ii physical of 500 kcal/ Polyunsaturated
C: 36.1  1.2 ii sensations of d deficit with fat (g/
Age hunger and w50% of 1,000kcal)
Intervention: 53.9 fullness, and carbohydrate, Saturated fat (g/
 8.2ii awareness of and <30% of 1,000kcal)
C: 54.0  7.0ii emotions and fat, received Trans fat (g/1,000
experiences MNTll for kcal)
associated with portion control, Cholesterol (mg/
eating; carbohydrate 1,000 kcal)
instructed to counting,
be aware of guidelines for
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

social choosing low

pressures to fat/saturated
eat and fat foods,
preferences dining out
regarding food guidelines, and
choices the glycemic
index, 1 session
on PA and
several
sessions
included a 15-
to 20-min walk,
PA goals NR
Miller (2014)33 n ¼ 68 3 mo; ten 2.5-h 3 mo (76.5%) ME None Meditation DSME NVM 2005 Block FFQ Yes Vegetables
Female: 63%ii group sessions 6 mo (76.5%) MB-EAT-D: practice Smart Choices: (previous year) (servings/1,000
BMI (25 h) Instructed to Same contact kcal)
Intervention: 36.2 recognize time as MB- Fruit (servings/

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 1.2ii physical EAT-D, goal of 1,000 kcal)
C: 36.1  1.2ii sensations of 500 kcal/ Grains (servings/
Age hunger and d deficit with 1,000 kcal)
Intervention: 53.9 fullness, and w50% of Meat, fish, poultry,
 8.2ii awareness of carbohydrate, and egg
C: 54.0  7.0ii emotions and and <30% of (servings/1,000
717

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Table 2. Summary table of the studies, grouped according to the comparison condition of control group comparison (ie, no intervention and wait-list control) and active
intervention, acquired from the literature search evaluating how mindful eating and intuitive eating influence dietary intake (continued)
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Time of
follow-up
Study measures Dietary
first (retention measure Diet
author rate at Diet for Other parts ME/IE (length of Energy quality (unit
(year) Sample Contact measures) ME/IEa ME/IE of ME/IE Comparison measure recall) intake measured)

experiences fat. Received kcal)

associated with MNT for Fats/oils, sweets,
eating; portion control, soda (servings/
instructed to carbohydrate 1,000 kcal)
be aware of counting, Dairy (servings/
social guidelines for 1,000 kcal)
pressures to choosing low
eat and fat/saturated
preferences fat foods,
regarding food dining out
choices guidelines, and
the glycemic
index, 1 session
on PA and
several
sessions
included a 15-
to 20-min walk,
PA goals NR
Spadaro (2018)34 n ¼ 46 6 mo; twenty-four 3 mo (91.3%) ME 1,200-1,800 kcal/ Supervised SBWP: Same NVM Block 1998 FFQ Yes None
Female: 87% 1-h group 6 mo (76.1%) SBWPmmþMMnn: d, balanced exercise 30 min contact time (length of
BMI seessions (24 Instructed on macronutrient weekly; and recall NR)
Intervention: 32.1 h) the techniques intake, moderate components as
 3.8 of MB-EAT, recorded daily intense SBWPþMMoo
C: 33.0  3.5 which included food intake to exercise 5 d/ without any
Age recognizing assess wk, instructed MM instruction
Intervention: 45.8 physical achievement of on MBSRm (MB-EAT,
 7.2 y sensations of dietary goal techniques MBSR)
C: 44.8  9.1 y
April 2021 Volume 121 Number 4

hunger and
fullness, and
awareness of
emotional and
stress eating
 a
ME/IE ¼ mindful eating/intuitive eating.
April 2021 Volume 121 Number 4

b
Study that did not report excluding participants with a healthy weight.
c
BMI ¼ body mass index; calculated as kg/m2.
d
Only whole sample mean reported.
e
NVM ¼ no validated measure.
f
Based on those that completed the program.
g
C ¼ comparison with no ME/IE intervention.
h
HEI ¼ Healthy Eating Index
i
HEI assessed: conformance with the Dietary Guidelines for Americans and a higher score indicates higher diet quality.
j
NR ¼ not reported.
k
Information from a different reference.24
l
MBSR ¼ mindfulness-based stress reduction.
m
MBSR techniques including body scan meditation, self-acceptance, and loving kindness meditation, mindful yoga, and mindful sitting meditation.
n
MB-EAT ¼ mindfulness based eating awareness training.
o
MBSR þ MB-EAT ¼ mindfulness-based stress reduction and mindfulness based-eating awareness training.
p
FFQ ¼ food frequency questionnaire.
q
Range reported, no standard deviation reported.
r
RD ¼ registered dietitian.
s
PA ¼ physical activity.
t
MEQ ¼ Mindful Eating Questionnaire.
u
IES ¼ Intuitive Eating Scale.
v
Information from a different reference.27
w
IDQ ¼ Index of Diet Quality.
x
IDQ assessed whole grains, fat-containing foods, liquid dairy, vegetables, fruits and berries, sugary products.
y
HAES ¼ Health At Every Size.
z
SS ¼ social support.
aa
Only percent of participants with BMI >25 reported.
bb
VIP ¼ vitality in practice.
cc
Information from a different reference.30
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

dd
CR ¼ calorie restriction.
ee
WN ¼ weight neutral.
ff
WL ¼ weight loss.
gg
LEARN ¼ Lifestyle, Exercise, Attitudes, Relationships, and Nutrition.
hh
RL-QOL ¼ Red Lotus Health and Well-Being Questionnaire.
ii
Based on the 52 participants who received the allocated intervention and completed data collection.
jj
MB-EAT-D ¼ mindfulness-based eating awareness training for diabetes.
kk
DSME ¼ diabetes self-management education.
ll
MNT ¼ medical nutrition therapy.
mm
SBWP ¼ standard behavioral weight loss program.
nn
MM ¼ mindfulness meditation.
oo
SBWPþMM ¼ standard behavioral weight loss program and mindfulness meditation.

RESEARCH
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720

Table 3. Key findings table from the studies, grouped according to the comparison condition of control group comparison (no intervention and wait-list control) and
active intervention, acquired from the literature search evaluating how mindful eating and intuitive eating influence dietary intakea
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Study author (year) Energy intake Diet quality ME/IEb

Comparison condition: control group

Carmody (2008)21 11 wk: NRc 11 wk: NR NAg
3 mo: NSd 3 mo:
%kcal fat: NS
Saturated fat: YIe vs Cf (P ¼ 0.0004)
%kcal protein: NS
Animal protein: YI vs C (P ¼ 0.03)
Vegetable protein: [I vs C (P ¼ 0.0002)
Fiber: [I vs C (P ¼ 0.02)
Soluble fiber: NS
Insoluble fiber: [I vs C (P ¼ 0.01)
Cole (2010)22 NS %kcal protein: NS NA
%kcal carbohydrate: NS
%kcal fat: NS
Fiber: NS
Health Eating Index score: NS
Daubenmier (2012)23 NS %kcal fat: NS NA
%kcal carbohydrate: NS
%kcal protein: NS
Ingraham (2017)25 NA Fruits and vegetables: NS MEQh: NS
Järvelä-Reijonen (2018)26 NA IDQi score: NS IESj: NS
13
Leblanc (2012) NS %kcal fat: NS NA
%kcal carbohydrate: NS
%kcal protein: NS
%kcal alcohol: NS
Fiber: NS
Sodium: NS
April 2021 Volume 121 Number 4

Calcium: NS
Timmerman (2012)12 YI vs C (P ¼ 0.002) Fat: YI vs C (P ¼ 0.001) NA
van Berkel (2014)28 NA Fruit: NS NA
Comparison condition: active intervention
Anglin (2013)29 Mean: NS NA NA
Wk 1, 2, 4: NS
Wk 3, 5, 6: YC vs I (P ¼ 0.01, 0.05, 0.02)

(continued on next page)

April 2021 Volume 121 Number 4

Table 3. Key findings table from the studies, grouped according to the comparison condition of control group comparison (no intervention and wait-list control) and
active intervention, acquired from the literature search evaluating how mindful eating and intuitive eating influence dietary intakea (continued)

Study author (year) Energy intake Diet quality ME/IEb

Mason (2016)31 NA Sweets consumption: MEQ:

0-6 mo: Δk NS 0-6 mo: Δ NS
0-12 mo: Δ NS 0-12 mo: Δ [I vs C (P ¼ 0.036)
6-12 mo: Δ [C vs I (P ¼ 0.035) 6-12 mo: Δ NS
Mensinger (2016)32 NA 6 mo: fruits and vegetables: NS 6 mo: IES: [I vs C (P ¼ 0.006)
24 mo: fruits and vegetables: NS 24 mo: IES: NS
Miller (2012)15 3 mo: NR 3 mo: NR NA
6 mo: Δ NS 6 mo:
%kcal fat: Δ NS
SF: Δ NS
MUFl: Δ NS
PUFm: Δ NS
Trans fat: Δ YC vs I (P ¼ 0.0489)
Cholesterol: Δ NS
Miller (2014)33 3 mo: NR 3 mo: NR NA
6 mo: Δ NS 6 mo:
Vegetables: Δ NS
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Fruit: Δ NS
Grains: Δ NS
Meat, fish, poultry, eggs: Δ NS
Fats/oils, sweets, soda: Δ NS
Dairy: Δ NS
Spadaro (2018)34 3 mo: NR NA NA
6 mo: Δ NS
a
Only between-group comparisons reported in the table.
b
ME/IE ¼ mindful eating/intuitive eating.
c
NR ¼ not reported.
d
NS ¼ not significant.
e
I ¼ intervention.
f
C ¼ comparison.
g
NA ¼ not applicable.

RESEARCH
h
MEQ ¼ Mindful Eating Questionnaire.
i
IDQ ¼ Index of Diet Quality.
j
IES ¼ Intuitive Eating Scale
k
Δ ¼ change.
l
MUF ¼ monounsaturated fat.
m
PUF ¼ polyunsaturated fat.
721
RESEARCH

Records identified through

database searching
Identification
(n = 185)
PubMed (n = 99) Additional records identified
PsycINFO (n = 25) through other sources
CINAHL (n = 61) (n = 2)

Records excluded
Screening

after title and abstract

Records after duplicates are removed
screening
(n = 129)
(n = 92)

Full-text articles
excluded
(n = 23)
Eligibility

Full-text articles Reason for exclusion:

assessed for eligibility No diet quality or
(n = 37) energy intake
measure (n = 11)

No follow-up (n = 5)

Intervention not ME or
IE (n = 4)

Comparison group
Included

Articles included in
synthesis included ME or IE
(n = 14) (n = 1)

Duplicate (n = 1)

Text not available in

English (n = 1)

Figure. Flow diagram of the literature search and filtering results for a systematic review of how mindful eating (ME) and intuitive
eating (IE) influence dietary intake. CINAHL ¼ Cumulative Index to Nursing and Allied Health Literature.

group.12,13,21-23,25,26,28 Six articles, representing 5 studies, studies included interventions that were mindfulness-based
included a comparison that contained an active interven- stress reduction interventions with ME training.23,25,31,34
tion.15,29,31-34 Comparisons that were active interventions One study incorporated IE alongside acceptance and
were interventions that focused on dietary prescriptions with commitment therapy.26 Lastly, Carmody and colleagues’21
calorie or macronutrient goals and/or physical activity com- intervention was dietary and cooking classes that incorpo-
ponents.15,29,31-34 rated ME. Six studies included physical activity
Participants in the included studies were predominantly components.25,26,28,29,31,34 ME and IE interventions varied in
female, with a reported mean body mass index per study aspects of nutrition goals. Seven articles, representing 6
indicating having overweight or obesity. The duration of the studies, included no nutrition-specific goal for the ME or IE
interventions included were between 6 weeks12,29 and 6 intervention13,15,22,26,28,32,33; 3 studies provided specific
months.28,32,34 Intervention total contact time varied among nutrition goals,25,31,34 such as caloric restriction; 3 studies
studies, with the shortest length of contact time being 9 provided nutrition education12,21,23; and for 1 study it was
hours26 and the longest being 46.5 hours.31 All but 1 of the unclear whether a specific dietary goal was provided.29 All
interventions involved group classes for implementation.29 studies that included additional dietary interventions were
Some included ME and IE interventions were multicom- ME-focused interventions.12,21,23,25,31,34
ponent interventions.12,21,23,25,26,28,29,31,34 One study included Eight studies, represented in 9 articles, reported energy
a standard behavioral weight-loss program with ME incor- intake.12,13,15,21-23,29,33,34 Eleven studies, represented in 12
porated,34 and another study included general principles of articles, reported on diet quality.12,13,15,21-23,25,26,28,31-33
weight management alongside ME training.12 Four of the 13 Studies varied in dietary assessment measures. Four studies,

722 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS April 2021 Volume 121 Number 4
 RESEARCH

represented in 5 articles, used a food frequency but differed in implementation of ME in the intervention and
questionnaire.15,23,31,33,34 Three studies used food re- comparison arms.31,34 One of these 2 studies measured en-
cords.13,22,29 Two studies used 24-hour dietary recalls.12,21 For ergy intake and found no significant difference in intake
diet quality, various questionnaires were used among between conditions.34 One of these 2 studies, Mason and
studies,28,32 and others developed questions from the colleagues,31 measured diet quality (change in sweets con-
Behavioral Risk Factor Surveillance System.25 Other studies sumption) and observed no between-group change for 0 to 6
that measured diet quality used various indexes to determine months and 0 to 12 months. However, when change in sweet
diet quality.22,26 Four studies used validated tools to measure consumption was assessed for 6 to 12 months, a significant
ME or IE.25,26,31,32 Two studies used the Intuitive Eating increase in the comparison group was observed compared
Scale26,32 and 2 used the Mindful Eating Questionnaire.25,31 with the ME intervention group (P ¼ 0.035).
Three investigations, represented in 4 articles, had different
Control Group Comparison dietary interventions between the ME and IE intervention
and comparison groups, with the comparison group having
See Table 3 for the key findings. Five of the 8 studies with a
an energy-deficit prescription.15,29,32,33 Two studies
control group comparison were ME interventions12,21,23,25,28
measured energy intake; Anglin and colleagues29 found
and 3 were IE interventions.13,22,26 Five of the 8 studies
significantly lower energy intake in the comparison group
measured energy intake.12,13,21-23 Four of these studies did
compared with the IE intervention group during week 6 (P ¼
not find significant between-group differences in energy
0.02), and both articles (1 study) by Miller and colleagues15,33
intake.13,21-23 However, Timmerman and Brown12 found a
found no significant difference in change in energy intake
significantly lower energy intake for the ME intervention
between the conditions. Two studies measured diet qual-
group compared with the comparison group (P ¼ 0.002).
ity.15,32,33 One study found no significant difference in fruit
All 8 studies with a control group comparison reported on
and vegetable intake between the 2 intervention groups.32
diet quality. van Berkel and colleagues28 measured fruit
Miller and colleagues33 found no between-group differ-
intake, which resulted in no significant between-group dif-
ences for change in vegetables; fruits; grains; meat, fish,
ferences. Ingraham and colleagues25 examined fruit and
poultry, and eggs; fats/oils, sweets, and soda; and dairy. They
vegetable intake with no between-group differences
did observe a significant decrease in trans fat for the com-
observed. Three studies assessed fiber intake.13,21,22 One
parison group compared with the ME intervention group (P <
study reported significantly higher intake in the intervention
0.05).15 However, changes in saturated fat, monounsaturated
compared with the comparison group (P ¼ 0.02),21 and the
and polyunsaturated fat, cholesterol, and percent calories
other 2 studies found no significant differences.13,22 Three
from fat were not different between groups.15
studies measured percent calories from protein, carbohy-
Two of the studies with active intervention comparisons
drate, and fat and reported no significant differences,13,22,23
used a validated IE or ME measure.31,32 Mensinger and col-
and 1 study measured percent calories from protein and fat
leagues32 found the intervention group having a higher IE
and found no significant difference.21 Cole and Horacek22 also
score compared with the comparison group at 6 months (P ¼
measured Healthy Eating Index and no significant between-
0.006). However, by the 24-month assessment, the difference
group differences were observed. Only 1 study included
was no longer significant. Mason and colleagues31 measured
measurements of sodium, calcium, and percentage of calories
ME and found no change differences between the groups at
from alcohol, which were not different between groups.13
0 to 6 months and 6 to 12 months, but did find that change
Järvelä-Reijonen and colleagues26 measured participant’s
from 0 to 12 months was significantly greater for the ME
index of diet quality score and no significant between-group
intervention than the comparison group (P ¼ 0.036).
differences were found.
Timmerman and Brown12 examined fat intake, which was
lower for the ME intervention group compared with the Risk of Bias
comparison group (P ¼ 0.001). In addition, Carmody and See Table 4 for the table of modified Downs and Black
colleagues21 examined saturated fat intake and found checklist scores. The modified Downs and Black Checklist was
significantly lower intake in the ME intervention group used to assess the methodological quality of the included
compared with the comparison group (P ¼ 0.0004). Carmody studies.35 Of a possible total score of 28, the majority of scores
and colleagues21 also examined animal and vegetable protein were low; highest score was 21 and lowest score was 10.
intake. Animal protein intake was lower for the ME inter- Mean bias assessment score was 13.6, which indicates a poor-
vention compared with the comparison group (P ¼ 0.03), and quality assessment rating. Mean score for the reporting
vegetable protein intake was higher for the intervention category was 7.1 of 11 points. Mean score for the external
compared with the comparison group (P ¼ 0.0002).21 One validity category was 0.3 of 3 points. In regard to internal
study included a validated tool to measure ME,25 and 1 study validity, the bias category averaged 3.1 of 7 points, and the
measured IE26 with a validated tool. Neither study found a confounding category averaged 3.1 of 6 points. For the power
significant difference in ME or IE between groups.25,26 category, the mean score was 0.3 of 1 point.

Active Intervention Comparison DISCUSSION

Of the 5 studies, represented in 6 articles, that had an active The purpose of this systematic review was to examine how
intervention comparison group, 3 studies were ME15,31,33,34 ME and IE interventions, evaluated using a randomized trial
and 2 were IE interventions.29,32 Two of the studies (2 arti- design, influence energy intake and diet quality in individuals
cles) appeared to have somewhat similar dietary in- of varying weight status who did not have a diagnosis of an
terventions between the intervention and comparison arms, eating disorder. Of the 9 articles12,13,15,21-23,29,33,34 that

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RESEARCH

Table 4. Summary of modified Downs and Black checklista scores for each study grouped according to the comparison
condition of control group (no intervention and wait-list control) and active intervention, acquired from the literature search
evaluating how mindful eating and intuitive eating influence dietary intake

Internal Validity
External Confounding Bias assessment score:
First author (year) Reporting Validity Bias (selection bias) Power (Downs and Black checklist, n/28)

Comparison condition:
control group
Carmody (2008)21 9 0 3 2 0 14
Cole (2010)22 6 0 2 2 0 10
23
Daubenmier (2012) 7 0 4 4 0 15
Ingraham (2017)25 6 1 3 3 0 13
26
Järvelä-Reijonen (2018) 6 0 3 2 0 11
Leblanc (2012)13 8 0 4 4 1 17
12
Timmerman (2012) 6 0 3 4 0 13
van Berkel (2014)28 8 3 4 5 1 21
Comparison condition:
active intervention
Anglin (2013)29 7 0 3 2 0 12
31
Mason (2016) 7 0 4 4 0 15
Mensinger (2016)32 6 0 3 4 0 13
15
Miller (2012) 7 0 3 2 1 13
Miller (2014)33 7 0 3 2 1 13
34
Spadaro (2018) 8 0 2 3 0 13
a
The checklist is a 27-item scale with possible values ranging from 0 to 28. The scores from each assessment category (reporting [out of 11], external validity [out of 3], interval validity-bias
[out of 7], internal validity-confounding [out of 6], and power [out of 1]) were added together for a total bias assessment score. A higher score indicated better quality with 28-24 points
considered excellent, 23-19 points considered good, 18-14 points considered fair, and fewer than 14 points considered poor.

measured energy intake, only 2 (one29 included active com- lack of ME or IE measurement in the included in-
parison) revealed significant differences12,29 with mixed re- vestigations.12,13,15,21-23,28,29,33,34 In previously published re-
sults in regard to what group had a lower energy intake (the views,8,9 no studies reviewed by Schaefer and Magnuson9
study with the active comparison found more favorable and only one37 reviewed by Clifford and colleagues8
outcomes in the active comparison group). Of the 12 arti- measured IE, which resulted in no significant differences in
cles12,13,15,21-23,25,26,28,31-33 that measured diet quality, 8 IE total scores between the intervention and comparison
found no significant differences between the group. Similar to the aforementioned systematic reviews, a
groups.13,22,23,25,26,28,32,33 Among the studies observing dif- paucity of studies from this investigation measured ME or IE
ferences in diet quality, the directionality of the findings were with validated tools. It is not clear whether the interventions
inconsistent, with some studies finding diet quality to be were actually effective at increasing ME or IE.
higher in the intervention group12,21,31 (one31 included active This investigation also found that the included studies
comparison), and another finding higher diet quality in the were of poor quality in regard to risk bias. In Schaefer and
active comparison group.15 Results as a whole fail to consis- Magnuson’s review,9 risk of publication bias was noted, as
tently support the hypothesis that ME and IE interventions only nine11,12,22,38-43 of the studies reviewed were RCTs, and
alter energy intake or diet quality. in Clifford and colleagues’ review,8 it was noted that although
In comparison with other systematic reviews reporting on studies included in their review had a comparison or control
nondieting approaches and dietary intake,8,9 results from this group, the study’s design quality or statistical power was not
review were similar. From the review by Schaefer and Mag- part of the study inclusion/exclusion criteria. In regard to this
nuson,9 IE interventions did not appear to influence dietary review, the majority of the included studies showed a poor
intake. Although Clifford and colleagues8 found that nondiet (fewer than 14 points) quality assessment score through the
interventions enhanced psychological outcomes, such as modified Downs and Black Checklist, indicating a high risk of
depression, self-esteem, and emotional well-being, they did bias among included studies. Investigations scored poorly in
not influence dietary intake. Another finding from this every category of the checklist. However, the external validity
investigation that is consistent among previous reviews is the (0.3 average out of 3 points) and power (0.3 average out of 1

724 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS April 2021 Volume 121 Number 4
 RESEARCH

point) categories were consistently low, affecting the overall collection of studies that meet inclusion criteria, formation of
average score. Specifically, the majority of samples used in a summary table, and verifying key findings. This review also
the investigations were small and homogeneous, containing included several sources to identify relevant articles that met
mostly women with overweight or obesity; therefore, inclusion criteria, PubMed, CINAHL and PsycINFO databases.
generalizability to other populations is limited. Furthermore, Another strength was examining only outcomes collected
there was a lack of consistency in what comprised an ME or IE from RCTs that included a comparison group. Although there
intervention. For example, in this review, some ME or IE in- are several strengths, there are also several limitations of this
terventions did not include a dietary goal, and others did. systematic review. Although the review included RCTs, there
One aspect to consider with implementation of ME and IE were issues in methodology among included studies that
practices is that these practices involve reflecting on the reduced the rigor of the investigations. Dietary intake was
physiological signs of hunger and fullness to control eating. assessed by self-reported measures, which leaves margin for
However, these approaches may not be helpful for in- error in outcomes collected.47 As mentioned previously, in-
dividuals with a health condition that alters the “natural” terventions included in the review failed to assess and
cues of hunger and fullness. For example, excess weight may demonstrate consistent improvements in ME or IE. Therefore,
alter the response to natural cues of hunger and fullness, it is unclear whether procedures employed were effective in
suggesting ME and IE might not be helpful for treating changing the independent variable of interest (ie, ME or IE).
overweight or obesity.44 It is important to note that the Participant inclusion and exclusion criteria combined pop-
majority of the included investigations contained samples in ulations with a health condition that alters the natural cues of
which the mean body mass index indicated that participants hunger and fullness (overweight and obesity) and pop-
had overweight or obesity, which could influence outcomes. ulations without these conditions. Although compiling re-
Other health conditions, such as thyroid disease that causes sults into a meta-analysis would add value to the literature,
hyper- and hypothyroidism, can also alter appetite regulation heterogeneity across studies regarding intervention imple-
due to hormonal imbalances.45 In hyperthyroidism, the mentation (eg, curricula, dietary goals, intervention length,
overactive thyroid hormones can act on the hypothalamus and contact time), dietary outcomes, and how dietary out-
and stimulate the feeling of hunger, thus altering the natural comes were assessed make it currently impossible to
cue of hunger. The same type of mechanism occurs in hy- combine study findings in a meta-analysis. Furthermore, the
pothyroidism, the lack of thyroid hormone production sup- lack of standardization of ME or IE interventions might make
presses the feeling of hunger, resulting in lack of appetite and these studies more challenging to identify in systematic
no desire to eat.45 Finally, apart from the presence of a health literature searches. Finally, this review focused on reporting
condition, lifestyle habits (ie, lack of sleep) can alter the energy intake and diet quality, and other diet-related vari-
physiological markers of hunger and fullness.46 When ho- ables more closely related to eating pathology were not
meostatic regulation of appetite is altered/defected, ME and reviewed.
IE interventions might not be appropriate.
The findings from this review highlight the need for the CONCLUSIONS
development of a standardized protocol for ME and IE in-
This review identified key areas of future research in the area
terventions, along with the inclusion of measured changes in
of ME and IE interventions and their influence on dietary
ME and IE using a validated tool. The lack of assessing ME or
intake. Future research needs to include study designs of high
IE in the majority of the investigations included in the review,
rigor that measure ME and IE in order to determine inter-
combined with the poor outcomes regarding ME and IE in
vention implementation effects. At this time, little evidence
interventions designed to increase ME or IE that were
suggests that ME and IE interventions influence energy
included in the review, indicates that it is not clear whether
intake or diet quality.
an intervention has been designed that is efficacious
regarding enhancing ME and IE. Furthermore, due to the lack
of measures regarding ME or IE, even if changes in dietary References
1. Huda MS, Wilding JP, Pinkney JH. Gut peptides and the regulation of
intake were found between the groups in the reviewed appetite. Obes Rev. 2006;7(2):163-182.
studies, it is not clear that the ME or IE intervention actually 2. Erlanson-Albertsson C. Appetite regulation and energy balance. Acta
increased ME or IE. A change in dietary intake might not be a Paediatr Suppl. 2005;94(448):40-41.
consequence of ME or IE, but might instead be a consequence 3. Blundell J, de Graaf C, Hulshof T, et al. Appetite control: Methodo-
of other unmeasured variables. This means that the actual logical aspects of the evaluation of foods. Obes Rev. 2010;11(3):251-
270.
mechanism, or mediator, that produced any change in dietary
intake is unknown. The 2 investigations included in the re- 4. Berthoud HR. Homeostatic and non-homeostatic pathways involved
in the control of food intake and energy balance. Obesity (Silver
view that reported changes or differences in ME or IE be- Spring). 2006;14(suppl 5):197S-200S.
tween the intervention and comparison conditions at some 5. Mathieu J. What should you know about mindful and intuitive
assessment point in the study found no significant changes in eating? J Am Diet Assoc. 2009;109(12):1982-1987.
dietary intake at that same measured time point.31,32 Of these 6. Nelson JB. Mindful eating: The art of presence while you eat. Diabetes
2 studies, 1 study reported that change in ME was not Spectr. 2017;30(3):171-174.
significantly related to change in sweet consumption at 12 7. Tribole E, Resch E. Intuitive Eating: A Recovery Book for the Chronic
Dieter. New York: St. Martin’s Press; 1995.
months, which is when there were significant differences in
change in ME between the ME intervention and active 8. Clifford D, Ozier A, Bundros J, Moore J, Kreiser A, Morris MN. Impact
of non-diet approaches on attitudes, behaviors, and health out-
intervention comparison group.31 comes: A systematic review. J Nutr Educ Behav. 2015;47(2):143-155.
There were several strengths of this review. This review 9. Schaefer JT, Magnuson AB. A review of interventions that promote
followed the PRISMA guidelines, which included individual eating by internal cues. J Acad Nutr Diet. 2014;114(5):734-760.

April 2021 Volume 121 Number 4 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 725
RESEARCH

10. Bruce LJ, Ricciardelli LA. A systematic review of the psychosocial 29. Anglin JC, Borchardt N, Ramos E, Mhoon K. Diet quality of adults
correlates of intuitive eating among adult women. Appetite. 2016;96: using intuitive eating for weight lossePilot study. Nutr Health.
454-472. 2013;22(3-4):255-264.
11. Ciampolini M, Lovell-Smith D, Sifone M. Sustained self-regulation of 30. Anglin JC. Assessing the effectiveness of intuitive eating for weight
energy intake. Loss of weight in overweight subjects. Maintenance of lossePilot study. Nutr Health. 2012;21(2):107-115.
weight in normal-weight subjects. Nutr Metab (Lond). 2010;7:4. 31. Mason AE, Epel ES, Kristeller J, et al. Effects of a mindfulness-based
12. Timmerman GM, Brown A. The effect of a mindful restaurant eating intervention on mindful eating, sweets consumption, and fasting
intervention on weight management in women. J Nutr Educ Behav. glucose levels in obese adults: Data from the SHINE randomized
2012;44(1):22-28. controlled trial. J Behav Med. 2016;39(2):201-213.
13. Leblanc V, Provencher V, Begin C, Corneau L, Tremblay A, Lemieux S. 32. Mensinger JL, Calogero RM, Stranges S, Tylka TL. A weight-neutral
Impact of a Health-At-Every-Size intervention on changes in dietary versus weight-loss approach for health promotion in women with
intakes and eating patterns in premenopausal overweight women: high BMI: A randomized-controlled trial. Appetite. 2016;105:364-
Results of a randomized trial. Clin Nutr. 2012;31(4):481-488. 374.
14. Hawley G, Horwath C, Gray A, et al. Sustainability of health and 33. Miller CK, Kristeller JL, Headings A, Nagaraja H. Comparison of a
lifestyle improvements following a non-dieting randomised trial in mindful eating intervention to a diabetes self-management inter-
overweight women. Prev Med. 2008;47(6):593-599. vention among adults with type 2 diabetes: A randomized controlled
15. Miller CK, Kristeller JL, Headings A, Nagaraja H, Miser WF. Compar- trial. Health Educ Behav. 2014;41(2):145-154.
ative effectiveness of a mindful eating intervention to a diabetes self- 34. Spadaro KC, Davis KK, Sereika SM, Gibbs BB, Jakicic JM, Cohen SM.
management intervention among adults with type 2 diabetes: A Effect of mindfulness meditation on short-term weight loss and
pilot study. J Acad Nutr Diet. 2012;112(11):1835-1842. eating behaviors in overweight and obese adults: A randomized
16. Rapoport L, Clark M, Wardle J. Evaluation of a modified cognitive- controlled trial. J Complement Integr Med. 2018;15(2).
behavioural programme for weight management. Int J Obes Relat 35. Downs SH, Black N. The feasibility of creating a checklist for the
Metab Disord. 2000;24(12):1726-1737. assessment of the methodological quality both of randomised and
17. Greene GW, White AA, Hoerr SL, et al. Impact of an online healthful non-randomised studies of health care interventions. J Epidemiol
eating and physical activity program for college students. Am J Health Community Health. 1998;52(6):377-384.
Promot. 2012;27(2):e47-e58. 36. O’Connor SR, Tully MA, Ryan B, Bradley JM, Baxter GD,
18. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items McDonough SM. Failure of a numerical quality assessment scale to
for systematic reviews and meta-analyses: The PRISMA statement. identify potential risk of bias in a systematic review: A comparison
PLoS Med. 2009;6(7):e1000097. study. BMC Res Notes. 2015;8:224.
19. US Department of Health and Human Services, US Department of 37. Linda AK, Dawn EC, August B, Petra K, Michelle NM. Examination of a
Agriculture. 2015e2020 Dietary Guidelines for Americans. 8th ed. peer-led, non-diet nutrition and exercise adherence pilot program
Published December 2015. Accessed October 26, 2020. https:// on a college campus: FitU. Cal J Health Promot. 2013;11:84-96.
health.gov/our-work/food-and-nutrition/2015-2020-dietary- 38. Gagnon-Girouard MP, Begin C, Provencher V, et al. Psychological
guidelines/ impact of a "Health-at-Every-Size" intervention on weight-
20. Krebs-Smith SM, Pannucci TE, Subar AF, et al. Update of the Healthy preoccupied overweight/obese women. J Obes. 2010;2010:928097.
Eating Index: HEI-2015. J Acad Nutr Diet. 2018;118(9):1591-1602. 39. Provencher V, Begin C, Tremblay A, Mongeau L, Boivin S, Lemieux S.
21. Carmody J, Olendzki B, Reed G, Andersen V, Rosenzweig P. A dietary Short-term effects of a "health-at-every-size" approach on eating
intervention for recurrent prostate cancer after definitive primary behaviors and appetite ratings. Obesity (Silver Spring). 2007;15(4):
treatment: Results of a randomized pilot trial. Urology. 2008;72(6): 957-966.
1324-1328. 40. Bacon L, Keim NL, Van Loan MD, et al. Evaluating a ’non-diet’ well-
22. Cole RE, Horacek T. Effectiveness of the "My Body Knows When" ness intervention for improvement of metabolic fitness, psycholog-
intuitive-eating pilot program. Am J Health Behav. 2010;34(3):286- ical well-being and eating and activity behaviors. Int J Obes Relat
297. Metab Disord. 2002;26(6):854-865.
23. Daubenmier J, Lin J, Blackburn E, et al. Changes in stress, eating, and 41. Carroll S, Borkoles E, Polman R. Short-term effects of a non-dieting
metabolic factors are related to changes in telomerase activity in a lifestyle intervention program on weight management, fitness,
randomized mindfulness intervention pilot study. Psychoneur- metabolic risk, and psychological well-being in obese premeno-
oendocrinology. 2012;37(7):917-928. pausal females with the metabolic syndrome. Appl Physiol Nutr
Metab. 2007;32(1):125-142.
24. Daubenmier J, Kristeller J, Hecht FM, et al. Mindfulness intervention
for stress eating to reduce cortisol and abdominal fat among over- 42. Ciliska D. Evaluation of two nondieting interventions for obese
weight and obese women: An exploratory randomized controlled women. West J Nurs Res. 1998;20(1):119-135.
study. J Obes. 2011;2011:651936. 43. Tanco S, Linden W, Earle T. Well-being and morbid obesity in
25. Ingraham N, Harbatkin D, Lorvick J, Plumb M, Minnis AM. Women’s women: A controlled therapy evaluation. Int J Eat Disord. 1998;23(3):
health and mindfulness (WHAM): A randomized intervention 325-339.
among older lesbian/bisexual women. Health Promot Pract. 44. Lean ME, Malkova D. Altered gut and adipose tissue hormones in
2017;18(3):348-357. overweight and obese individuals: Cause or consequence? Int J Obes
26. Järvelä-Reijonen E, Karhunen L, Sairanen E, et al. The effects of (Lond). 2016;40(4):622-632.
acceptance and commitment therapy on eating behavior and diet 45. Amin A, Dhillo WS, Murphy KG. The central effects of thyroid hor-
delivered through face-to-face contact and a mobile app: A ran- mones on appetite. J Thyroid Res. 2011;2011:306510.
domized controlled trial. Int J Behav Nutr Phys Act. 2018;15(1):22. 46. Knutson KL, Cauter E. Associations between sleep loss and increased
27. Tylka TL. Development and psychometric evaluation of a measure of risk of obesity and diabetes. Ann N Y Acad Sci. 2008;1129:287-304.
intuitive eating. J Couns Psychol. 2006;53(2):226-240. 47. Trabulsi J, Schoeller DA. Evaluation of dietary assessment in-
28. van Berkel J, Boot CRL, Proper KI, Bongers PM, van der Beek AJ. Effec- struments against doubly labeled water, a biomarker of habitual
tiveness of a worksite mindfulness-based multi-component inter- energy intake. Am J Physiol Endocrinol Metab. 2001;281(5):E891-
vention on lifestyle behaviors. Int J Behav Nutr Phys Act. 2014;11:9. E899.

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AUTHOR INFORMATION
H. S. Grider is a student, Department of Nutrition, University of Tennessee, Knoxville. S. M. Douglas is a postdoctoral fellow, Department of
Nutrition, University of Tennessee, Knoxville. H. Raynor is a professor, Department of Nutrition, University of Tennessee, Knoxville.
Address correspondence to: Hollie Raynor, PhD, RD, LDN, Department of Nutrition, University of Tennessee, Jessie Harris Building Room 229, 1215
West Cumberland Ave, Knoxville, TN 37996-1920. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT
There is no funding to disclose.
AUTHOR CONTRIBUTIONS
H. S. Grider and H. Raynor developed the study aim. S. M. Douglas and H. S. Grider performed the search of all articles. H. S. Grider and H. Raynor
independently assessed and determined each study’s eligibility. H. S. Grider wrote the first draft with contributions from H. Raynor. S. M. Douglas
revised the final draft with contributions from H. S. Grider and H. Raynor.

THE ART OF DIETETICS

Eigenbau or homegrown vegetables are a favorite in the Saturday markets in Germany. Photo taken by Valerie M. Houghton, RD, LD.
(Images featured in “The Art of Dietetics” are available for educational use at www.jandonline.org/content/photocontestgallery. Want
to make your own Art of Dietetics contribution? Submission details are available at: www.jandonline.org/artofdietetics.)

April 2021 Volume 121 Number 4 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 727
RESEARCH

Table 1. Example of the database search strategy using

PubMed, PsychINFO, and CINAHLa for a systematic review of
how mindful eating and intuitive eating influence dietary
intake

Database Search termsb

PubMedc (intuiti* OR mindful*) AND (eat* OR diet*

OR food* OR energ*)
PsycINFOd (intuiti* OR mindful*) AND (eat* OR diet*
OR food* OR energ*)
CINAHLe (intuiti* OR mindful*) AND (eat* OR diet*
OR food* OR energ*)
a
CINAHL ¼ Cumulative Index to Nursing and Allied Health Literature.
b
Asterisk is used to capture multiple endings within database search (eg, intuiti* will
include results containing the words intuitive and intuitively).
c
Applied filters: published dated: January 1, 1980 to November 30, 2019; randomized
controlled trial; adult.
d
Applied filters: published dated: January 1, 1980 to November 30, 2019; clinical trial;
age: adulthood.
e
Limiters: published dated: January 1, 1980 to November 30, 2019; randomized
controlled trials; age: all adult.

727.e1 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS April 2021 Volume 121 Number 4