11ALTERNATIVE AND COMPLEMENTARY THERAPIES DOI: 10.1089/act.2009.15101 • MARY ANN LIEBERT, INC. • VOL. 15 NO. 1FEBRUARY 2009

Eating disorders are prevalent, and they are associated with other serious health problems and high-risk behaviors. Exam-ples of mindfulness-based and other approaches to treating an-orexia nervosa, bulimia nervosa, and binge eating are discussed here in the context of current trends in, and understanding of, these disorders.

Epidemiology

Approximately 10 million Americans struggle with anorexia nervosa and bulimia nervosa. Because of the secretiveness of-ten associated with eating disorders, this statistic is considered an underestimate of their actual prevalence. Many other people engage in binge eating. According to the National Eating Dis-orders Association (see Resources), the incidence of anorexia and bulimia* has been steadily increasing. The incidence of bulimiatripledin10–39-year-oldfemalesbetween1988and1993, while the incidence of anorexia nervosa in young women ages15–19has riseneverydecadesince the1930s.1 The in-cidence of eating disorders also increased in the U.S. military from 1998 to 2006.2 In a prospective study of 12,524 children ages9–15,4.3%offemalesand0.8%ofmalesbeganpurgingto control their weight during the 7-year period in which they were followed.3

Once regarded as primarily affecting affluent young white females, eating disorders increasingly affect females and males

of all ages, ethnic, and socioeconomic groups in our dieting-fixated, yet increasingly overweight, society. Athletes in certain sports, fashion models, and performers in the arts are at par-ticularly high risk. Yet, the majority of individuals with eating disorders do not receive adequate care.1

Diagnostic Issues

The overlap among diagnostic criteria for eating disorders listed in DSM-IV † has led to criticism among some experts in the field. (See Clinical Criteria of the Major Types of Eating Disorders.) Christopher Fairburn, M.D., of the Ox-ford University department of psychiatry in Oxford, Eng-land, stated: “The existing scheme for classifying eating dis-orders is unsatisfactory and anomalous. . . .[F]ar more unites the three categories of eating disorder than separates them.” “Mixed” eating disorders are in fact the most common eat-ing disorders encountered in clinical practice.4 Because of this overlap in symptoms, Dr. Fairburn suggests adopting a transdiagnostic perspective.5

This concern calls into question the validity and clini-cal utility of these diagnoses and also raises the issue of whether recovery or remission is the correct way to view eating disorders.6Becauseofthehighrateofrelapse,45%at 5 years in a study of 2881 women with bulimia,7 some experts regard eating disorders as chronic diseases with ep-isodic periods of remission. Also at issue are how to define “frequent” episodes of binging,8 how to establish weight criteria for patients with anorexia nervosa,9 and how to de-termine whether patients with binge eating disorder have personality traits distinct from those with nonbinging eat-ing disorder.10

Treating Eating Disorders Mindfully

Sala Horowitz, Ph.D.

*Anorexia and bulimia are used here synonymously with anorexia nervosa and bulimia nervosa, respectively.†DSM-IV is the American Psychiatric Association’s (APA) Diagnos-tic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: APA, 1994.

15_1ACT.indd 11 2/20/09 2:20:37 PM

12

ALTERNATIVE AND COMPLEMENTARY THERAPIES • FEBRUARY 2009

MARY ANN LIEBERT, INC. • VOL. 15 NO. 1

Risk Factors

Eating disorders represent a constellation of issues surround-ing body image and self-esteem. Cultural socialization, family attitudes and relations, and traumatic experiences contribute to bodyimage–relatedexperiencesandattitudesmediatedbyper-sonality attributes and genetic propensities.11 These risk factors are common to both genders, but attitudes and patterns of be-havior may be gender-specific.

DietingBecause dieting and excessive focus on body image to meet so-

ciocultural (family, peer, and media) pressures serve as a “gateway” to eating disorders in more than one third of dieters,1 Cynthia Bulik, Ph.D., a professor of eating disorders and director of the UNC Eating Disorders Program at the University of North Car-olina at Chapel Hill, advises against diets of any kind.8 A recent longitudinalstudyofyouthages9–15(n=6916girlsand5618boys) confirmed frequent dieting as an independent predictor of binge eating in females (but not males) in this age group.3

Developmental History Dysfunctional family eating patterns during childhood (i.e.,

parental preoccupation with food and control) were predictive of eating disorders later in life in a study of 879 persons re-

ferred for assessment of eating disorders, compared with 785 healthy controls.12 For girls younger than 14, maternal history of an eating disorder was associated with a three times higher risk of purging at least weekly than their peers. For boys, fa-thers’ negative comments about their sons’ weight was predic-tive of the onset of binging.3 In a retrospective study, family criticism regarding weight, figure, or eating had long-lasting negative effects in 455 college women with high weight and figure concerns.13

Surveys of girls in 9th through 12th grade (n = 4163) found that those who had been abused by a dating partner were at higher risk for eating disorders, suicidality, and other serious health risk behaviors.14

Depression, Addiction, and Other Anxiety DisordersThe prevalence of obsessive-compulsive disorder is much

higher among patients with eating disorders than the general population—41%versus2–3%—andappearstoprecedeonsetof eating disorders. A similar pattern holds for social phobia

(another anxiety disorder)15 and compulsive exercising to con-trol weight and physique.16 Individuals with eating disorders are also at greater risk for depression and suicide; the mortal-ity rate of anorexia nervosa is the highest for any psychiatric disorder. In a study of 432 persons with current or lifetime anorexia(410femaleand22male),17%reportedatleastonesuicide attempt; this rate was highest among subjects with the bingeeatingsubtype(29%)andlowestamongthosewiththerestrictingsubtype(7%).17

Genetic Factors Aheritabilityfactorof50%hasbeenascribedtoeatingdis-

orders. A study of 1002 female twins with and without eating disorders supported the hypothesis that anorexia nervosa may represent a family propensity for a temperament that empha-sizes perfectionism, a need for order, and sensitivity to praise and reward.18 Other contributing genetic factors include low testosterone levels in women19 and variants in the sensitiv-ity of dopamine-reward pathways,20 neurotrophin-signaling pathways,21 and the peptide hormone melanocortin 4 receptor (MC4R)—identified as a major phenotype for binge eating.22

Associated Health Problems

Eating disorders are associated with other health problems and maladaptive behaviors. Anorexia nervosa in adolescents is as-sociated with low bone-mineral density, amenorrhea, and other

Clinical Criteria of the Major Types of Eating Disorders*

• Anorexia nervosa—Consists of self-starvation with intense anxiety about gaining weight and a distorted body image; low body weight for age and height (< 85% of normal) with denial of the problem; for post-menarchal females, includes 3 consecutive missed menstrual periods

• Restricting type—This consists of self-starvation only.

• Binge eating/purging type—This consists of regularly engaging in binge eating and purging to prevent weight gain (through self-induced vomiting; misuse of laxatives, emetics, diuretics, or enemas; or excessive exercise).

• Bulimia nervosa—This consists of recurrent bouts of binge eating followed by compensatory purging at least twice a week for 3 months. Binge eating is characterized by consum-ing a substantially larger-than-normal amount of food in a short period of time and a sense of lack of control of behavior during such episodes. Self-evaluation is unduly influenced by body image and weight.n Purging type —This is self-explanatory.n Nonpurging type—This consists of regular use of inap-

propriate compensatory behaviors (e.g., fasting, excessive exercise), but not self-induced vomiting or other means of purging.

• Binge eating disorder—This consists of chronic binge eating without purging or other compensatory behaviors, with a sense of lack of control during episodes and marked negative feelings about oneself afterwards; occurs an average of at least 2 days a week for 6 months.

*American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: APA, 1994).

The mortality rate of anorexia nervosa is the highest for any

psychiatric disorder.

15_1ACT.indd 12 2/20/09 2:20:38 PM

13

ALTERNATIVE AND COMPLEMENTARY THERAPIES • FEBRUARY 2009

MARY ANN LIEBERT, INC. • VOL. 15 NO. 1

endocrine and metabolic disruptions. The low car-diovascular risk profile normally associated with low body weight is coun-teracted by hormonal disruptions in anorexia.23 The life expectancy of a woman who has had an-orexia since age 15 is pre-dicted to be 25 years less than for a person in the normal population.24

Binge eating may lead to obesity with its well-known health risks. Obesity is associated with eating disorders’ psychosocial markers of body dissatisfaction, anxiety, and interpersonal distrust. Onan eatingdisorders inventory, students ages 10–17,whowere overweight (n = 1057), scored high on such attitudes.25 From structured interviews with 150 probands with binge eat-ing disorder and 150 without the disorder, and 888 of their first-degree relatives (135 had the disorder and 54 had some symptoms), researchers concluded that there was a significant lifetime co-occurrence of binge eating disorder with psychi-atric and medical disorders, including major depression and substance abuse.26

Ithasbeenestimatedthatbetween30%and70%ofpatientsdiagnosedwithbulimianervosa,andupto18%ofpatientswithanorexia nervosa, abuse—or are addicted to—drugs, including alcohol and tobacco.27 A crosscultural study of 979 persons with eating disorders compared with 785 healthy controls likewise found that subjects with eating disorders had significantly higher lifetime and current tobacco and general drug, but not alcohol, use.28 Diet pill use was among the compulsive weight-control behaviors and types of substance abuse seen in 1345 women.29 Treatment for alcohol dependence may lead to reduction of eat-ing pathology.30 Therefore, screening for all types of substance abuse is advised for patients with eating disorders.

Substance abuse, sexual promiscuity, and suicidal and other self-injurious behaviors appear to be part of a multi-impulse control disorder in some patients with bulimia.31 Patients with both bulimia and an impulse control disorder (compul-sive shopping and kleptomania being the most common) have greater psychopathology and poorer prognoses.32

For reasons that are not well-understood, women with bulimia, like those with anorexia, may also cease menstruat-ing regularly and experience infertility. Irregular periods due to stress or caloric restriction between binging, and vomiting birth control pills while purging, have been hypothesized as possible causes.8 Miscarriage and low birth weight were found to be significantly higher among women with a history of eat-ing disorders, compared with more than 10,000 women with no eating disorders, even subjects with other psychiatric ill-

nesses. Women with anorexia (n = 171) delivered babies of lower birth weight, whereas women with bulimia (n = 199) had higher miscarriage rates.33

In a follow-up study of the same cohort, infants of women with anorexia nervosa were at higher risk for feeding diffi-culties between 0 and 6 months, and babies of women with bulimia were significantly more likely to be overweight at 9 months, compared with babies of controls.34

A study of 49 women with eating disorders revealed a higher rate of delivery by cesarean section and postpartum depression than the general population.35 Obstetric complications were associated with higher rates of impairment in neonatal devel-opment, which may, in turn, have a role in the pathogenesis of eating disorders.36

Mindful Eating Approaches

Psychologist Jean Kristeller, Ph.D., is a professor of psy-chology at Indiana State University in Terre Haute, where she developed the Mindfulness-Based Eating Awareness Training

Board of Directors of The Center for Mindful Eating. Back row (standing): Char Wilkins, L.C.S.W.; Mark Blackwood, M.D.; Megrette Fletcher, M.Ed., R.D., C.D.E.; Donald Altman, M.A.; Molly Kellogg, L.C.S.W., R.D.; and Ronna Kabatznick, Ph.D. Front row (sitting): Ronald Thebarge, Ph.D.; Dhammacarini Amala (co-founder of the Center); and Jean Kristeller, Ph.D.Jean Kristeller, Ph.D., Indiana State University.

Tell Your PatientsPrinciples of Mindful Eating*

Advise patients:

• Drawonyourinnerwisdomtobecomeawareofthepositiveaspects of food preparation and consumption.

• Drawonallthesensesinchoosingpleasing,nurturingfood.

• Acknowledgebothpositiveandnegativeresponsestofoodsin a nonjudgmental way.

• Learntobecomeawareofphysicalcuesofhungerandsati-ety.†

*CME–www.tcme.org/principles.htm

†www.eatingmindfully.com/bookoverview/nutrition.html

15_1ACT.indd 13 2/20/09 2:20:40 PM

14

ALTERNATIVE AND COMPLEMENTARY THERAPIES • FEBRUARY 2009

MARY ANN LIEBERT, INC. • VOL. 15 NO. 1

(MB-EAT) program. Dr. Kristeller is also the cofounder and president of The Center for Mindful Eating (see Resources). The MB-EAT program is based on the mindfulness medita-tion principles applied by Jon Kabat-Zinn, Ph.D., emeritus professor of medicine and founding director of the Stress Re-duction Clinic and the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School at Worcester. Dr. Kabat-Zinn defined mind-fulness as “paying attention in a particular way: on purpose in the present moment, non-judgmentally.”37

In the MB-EAT program, mindfulness exercises help partic-ipants with binge eating disorders and weight issues to become aware of hunger and satiety cues. Dr. Kristeller said: “Rather than assuming that such deficits are biologically driven, they may instead be due to a ‘disconnection’ related to overdieting or to using food primarily to meet emotional needs.”38 In a pilot study involving 18 obese women, Dr. Kristeller found that a mindfulness approach reduced the number and sever-ity of binge eating episodes, anxiety, and depression, and also elevated a sense of control.39 A larger study, in collaboration with the Duke University Center for Integrative Medicine, in Durham, North Carolina, replicated these findings.40

Megrette Hammond Fletcher, M.E., R.D., C.D.E. [certi-fied diabetes educator], the executive director of The Center for Mindful Eating, teaches patients mindful eating for diabetes self-management. Ms. Hammond reported that, in a study conducted

by Dr. Kristeller and her colleagues, subjects who participated in a 9-week mindfulness-based eating program had less insulin resistance after meals than subjects who received conventional weight-loss education. This result was attributed to the relaxation response, a byproduct of mindfulness.41 Other dietitians are in-corporating the concept of mindful eating into their practices.42 Stephanie Vangsness, R.D., a registered dietitian at Brigham and Women’s Hospital in Boston, has noted that “when [the] mind is tunedoutduringmealtime,thedigestiveprocessmaybe30–40%less effective.”43

Michelle L. Bailey, M.D., a pediatrician at the Duke Uni-versity Center for Integrative Medicine, applies Dr. Kris-teller’s mindfulness approach to treating children and ado-lescents with eating disorders at the practice’s Center for

Nutritional Disorders and Obesity. Keeping a daily food log is one of the program’s components.44 Patients who under-go bariatric surgery for morbid obesity are another popula-tion being taught the principles of mindful eating pre- and postoperatively.45

The Eat, Drink, and Be Mindful WorkshopsTM offered by psychologist Susan Albers, Psy.D., at the Cleveland Clinic Women’s Health Center, are intended to teach attitudes and skills to prevent serious eating disorders in patients who have issues with weight, body image, and self-esteem, and who have mindless dieting or eating habits. As in the MB-EAT pro-gram, participants learn about developing a nonjudgmental awareness and acceptance of their weight, eating habits, and self.46 Dr. Albers’ approach involves promoting mindfulness of aspects of one’s mind, body, feelings, and thoughts through meditation, visualization, keeping a food diary, and other prin-ciples and exercises, designed to help patients understand and overcome the cravings and motivations underlying mindless eating.47

According to Dr. Albers, a mindful eater is one who is “so closely in touch with what is going on inside that you know the exact moment you are satisfied rather than stuffed or starving by learning the why, what, when and how you eat.”48

Other Treatment Options

Psychotherapy Treatment for eating disorders typically entails some form

of psychotherapy, with or without the use of antidepressant medications, focused on helping patients understand issues leading to the disorder and establish a healthier relationship with food. Psychotherapy options include cognitive-behavioral

ResourcesOrganizations

Academy for Eating Disorders (AED) 36841 Treasury Center Chicago, IL 60694-6800 Phone: (847) 498-4247 Fax: (847) 480-9282 Website: www.aedweb.org

The AED is a multidisciplinary professional organization that fosters prevention, clinical treatments, research, and public awareness in the field of eating disorders. The AED publishes the International Journal of Eating Disorders.

The Center for Mindful Eating (TCME) P.O. Box 88 West Nottingham, NH 03291 Phone: (603) 778-5841 E-mail: info@tcme.org Website: www.tcme.org

TCME offers resources and training for professionals across disci-plines about mindful eating practices, research, and education.

National Eating Disorders Association (NEDA) Website: www.nationaleatingdisorders.org Information and referral helpline (24-hour): (800) 931-2237

The NEDA is an online patient support organization, which offers information, resources, and referrals for patients, family, friends, and health professionals.

BookEating Mindfully: How to End Mindless Eating

By Susan Albers, Psy.D. Oakland, CA: New Harbinger Publications, 2003

Subjects in a mindfulness-based eating program had less insulin

resistance after meals than subjects who received weight-loss education.

15_1ACT.indd 14 2/20/09 2:20:41 PM

15

ALTERNATIVE AND COMPLEMENTARY THERAPIES • FEBRUARY 2009

MARY ANN LIEBERT, INC. • VOL. 15 NO. 1

therapy (CBT); individual, group, and/or family counseling; and support groups. CBT and support groups are discussed in more detail below.

Cognitive-Behavioral TherapyInordertobreakthediet–binge–purgecycle,anappetite-

focused model of CBT involves teaching patients to learn (or relearn) physiologic cues of hunger and satiation rather than depending on stress-related or external cues. This pro-cess involves self-monitoring of appetite, food and fluid in-take, cues for problem eating, consequences of such behavior, associated thoughts, and progress in cognitive restructuring and behavior change. However, discussions about CBT do not indicate whether the nutritional counseling component is coordinated with a dietitian and/or the patients’ primary care providers.50

Pharmacologic Drugs Antidepressants, particularly selective serotonin reuptake

inhibitors (SSRIs), are often prescribed to treat the accompa-nying depression, anxiety, or obsessive/compulsive symptoms. SSRIs have proven to be more effective in treating bulimia rather than anorexia. But studies have not been conducted on SSRIs and other medication use with pediatric patients, al-though eating disorders generally begin in adolescence.49

Support Groups Facilitated or self-help support groups can be a helpful psy-

chosocial adjunct for coping with eating disorders or obesity issues. Patients who find spirituality to be a path to healing may wish to attend meetings of Overeaters Anonymous with its 12-Step approach involving appeal to a higher power.51 A study examining adherence to an internet eating disorder prevention program (“Student Bodies”) found significant re-duction in predisposing attitudes and behaviors in college-age women (n = 209) and reduced development of eating disorders in high-risk subgroups.52 However, practitioners, patients, and families should be aware that some internet sites (e.g., pro-anorexia “communities”) reinforce the sociocultural messages that contribute to eating disorders.53

Relaxation TherapiesIn a study, relaxation training, consisting of such approaches

as progressive muscle relaxation, guided imagery, or self-di-rected relaxation, for 15 days reduced postmeal anxiety in 64 females with anorexia nervosa. Reducing meal-related anxi-ety appears to be a critical step in nutritional education and weight-restoration treatment programs.54

Light TherapyBright light therapy has been shown to be efficacious for

treating bulimia, both for patients with comorbid seasonal affective disorder (SAD) and for those who do not have SAD. Light therapy may work by synchronizing circadian rhythms or enhancing serotonin levels disturbed by binge eating.55

ConclusionEating disorders are multidimensional, undertreated health

challenges that are a growing concern for both males and fe-males. Further research is warranted on mindfulness treatment approaches that emphasize healthy food-related attitudes and behaviors rather than dieting. n

References

1. National Eating Disorders Association. Statistics: Eating Disorders and their Precursors. Online document at: www.nationaleatingdisorders.org/p.asp?WebPage_ID=286&Profile_ID=411 Accessed September 16, 2008.2. Antczak AJ, Brininger TL. Diagnosed eating disorders in the U.S. military: Anineyearreview.EatingDisord2008;16:363–377.3. Field AE, Javaras KM, Aneja P, et al. Family, peer, and media predictors of becomingeatingdisordered.ArchPediatrAdolescMed2008;162:574–579.4. Fairburn CG, Cooper Z, Bohn K, et al. The severity and status of eating dis-order NOS: Implications for DSM-V.BehavResTher2007;45:1705–1715.5.FairburnCG,HarrisonPJ.Eatingdisorders.Lancet2003;361:407–416.6. Eddy KT, Dorer DJ, Franko DL, et al. Diagnostic crossover in anorex-ia nervosa and bulimia nervosa: Implications for DSM-V. Am J Psychiatry 2008;165:245–250.7. Keski-Rahkonen A, Hoek HW, Linna MS, et al. Incidence and outcomes of bulimia nervosa: A nationwide population-based study. Psychol Med 2008;September8;1–9;e-pubaheadofprint].8. Gura T. Lying in Weight: The Hidden Epidemic of Eating Disorders in Adult Women. New York: HarperCollins, 2007.9. Thomas JJ, Roberto CA, Brownell KD. Eighty-five percent of what? Dis-crepancies in the weight cut-off for anorexia nervosa substantially affect the prevalenceofunderweight.PsycholMed2008;September8:1–11;e-pubaheadof print.10. Davis C, Levitan RD, Carter J, et al. Personality and eating disorders: A case-controlstudyofbingeeatingdisorder.IntJEatDisord2008;41:243–250.11. Hrabosky JI, Cash TF. Self-help treatment for body-image disturbances. In: Latner JD, Wilson GT, eds. Self-Help Approaches for Obesity and Eating Disorders:ResearchandPractice.NewYork:GuilfordPress,2007:118–138.12. Krug I, Treasure J, Anderluh M, et al. Association of individual and fam-ily eating patterns during childhood and early adolescence: A multicentre European study of associated eating disorder factors. Br J Nutr 2008;August 28:1–10;e-pubaheadofprint.13. Taylor CB, Bryson S, Celio Doyle AA, et al. The adverse effect of negative comments about weight and shape from family and siblings on women at high riskforeatingdisorders.Pediatrics2006;118:731–738.14. Silverman JG, Raj A, Mucci LA, et al. Dating violence against adolescent girls and associated substance abuse, unhealthy weight control, sexual risk be-havior,pregnancy,andsuicidality.JAMA2001;286:572–579.15. Kaye WH, Bulik CM, Thornton L, et al. Comorbidity of anxiety disorders withanorexiaandbulimianervosa.AmJPsychiatry2004;161:2215–2221.16. Dalle Grave R, Calugi S, Marchesini G. Compulsive exercise to control shape or weight in eating disorders: Prevalence, associated features, and treat-mentoutcome.ComprPsychiatry2008;49:346–352.17. Bulik CM, Thorton L, Pinheiro AP, et al. Suicide attempts in anorexia nervosa.PsychosomMed2008;70:378–383.18. Wade TD, Tiggemann M, Bulik CM, et al. Shared temperament risk fac-torsforanorexianervosa:Atwinstudy.PsychosomMed2008;70:239–244.19. Miller KK, Wexler TL, Zha AM, et al. Androgen deficiency: Association with increased anxiety and depression symptom severity in anorexia nervosa. J ClinPsychiatry2007;68:959–965.

15_1ACT.indd 15 2/20/09 2:20:41 PM

16

ALTERNATIVE AND COMPLEMENTARY THERAPIES • FEBRUARY 2009

MARY ANN LIEBERT, INC. • VOL. 15 NO. 1

20. Davis C, Levitan RD, Kaplan AS, et al. Reward sensitivity and the D2 dopamine receptor gene: A case-control study of binge eating disorder. Prog NeuropsychopharmacolBiolPsychiatry2008;32:620–628.21. Mercader JM, Saus E, Aguera Z, et al. Association of NTRK3 and its interaction with NGF suggest an altered cross-regulation of the neurotrophin signalingpathwayineatingdisorders.HumMolGenet2008;17:1234–1244.22. Branson R, Potoczna N, Kral JG, et al. Binge eating as a major pheno-type of melanocortin 4 receptor gene mutations. N Engl J Med 2003;348: 1098–1103.23. Misra M, Miller KK, Tsai P, et al. Uncoupling of cardiovascular risk mark-ersinadolescentgirlswithanorexianervosa.JPediatr2006;149:763–769.24. Harbottle EJ, Birmingham CL, Sayani F. Anorexia nervosa: A survival analysis.EatWeightDisord2008;13:e32–e34.25. Thiels C, Patel J. Survey of disordered eating and behavior in chil-dren and adolescents [in German]. Z Kinder Jugendpsychiatr Psychother 2008;36:265–274.26. Javaras KN, Pope HG, Lalone JK, et al. Co-occurrence of binge eating disor-derwithpsychiatricandmedicaldisorders.JClinPsychiatry2008;69:266–273.27. Vastag B. What’s the connection? No easy answers for people with eating disordersanddrugabuse.JAMA2001;285:1006–1007.28. Krug I, Treasure J, Anderluh M, et al. Present and lifetime comorbidity of tobacco, alcohol, and drug use in eating disorders: A European multicenter study.DrugAlcoholDepend2008;97:169–179.29. Reba-Harrelson L, Von Holle A, Thornton IM, et al. Features asso-ciated with diet pill use in individuals with eating disorders. Eat Behav 2008;9:73–81.30. O’Malley SS, Sinha R, Grilo CM, et al. Naltrexone and cognitive behav-ioral coping skills therapy for the treatment of alcohol drinking and eating disorder features in alcohol-dependent women: A randomized controlled trial. AlcoholClinExpRes2007;31:625–634.31.FichterMM,QuadfliegN,RiefW.Courseofmulti-impulsivebulimia.PsycholMed1994;24:591–604.32. Fernandez-Aranda F, Pinheiro AP, Thorton LM, et al. Impulse control disordersinwomenwitheatingdisorders.PsychiatryRes2008;157:147–157.33. Micali N, Simonoff E, Treasure J. Risk of major adverse perinatal out-comesinwomenwitheatingdisorders.BrJPsychiatry2007;190:255–259.34. Micali N, Simonoff E, Treasure J. Infant feeding and weight in the first year of life in babies of women with eating disorders. J Pediatr 2008;Septem-ber 9;e-pub ahead of print.35. Franko DL, Blais MA, Becker AE, et al. Pregnancy complications and neonatal outcomes in women with eating disorders. Am J Psychiatry 2001;158:1461–1466.36. Favaro A, Tenconi E, Santonastaso P. Perinatal factors and the risk of devel-opinganorexianervosaandbulimianervosa.AmJPsychiatry2006;63:82–88.37. Athens [Georgia] Regional Medical Center. Mindfulness Based Eating. Online document at:https://web1.armc.org/body.cfm?id=744 Accessed Octo-ber 26, 2008.38. Rich LE. Bringing more effective tools to the weight-loss table. APA Online. Online document at: www.apa.org/monitor/jan04/bringing.html Ac-cessed October 26, 2008.39. Kristeller JL, Hallett B. An exploratory study of a meditation-based inter-ventionforbingeeatingdisorder.JHealthPsych1999;4:357–363.

40. The Center for Mindful Eating. The Board: Jean Kristeller, Ph.D., Co-founder. Web document at: www.tcme.org/borad/j_kristeller.htm Accessed October 27, 2009. 41. Hammond M. Mindful eating: Tuning in to your food. Diabetes Self Manag 2007;24:36,38,40.42. Hammond M. Ways dietitians are incorporating mindfulness and mind-ful eating into nutrition counseling. The Digest;2007. Online document at: www.tcme.org/documents/PH_Fall2007_Final.pdf Accessed October 27, 2008. 43. Vangsness S. Mastering the Mindful Meal. [Brigham and Women’s Hos-pital special topics and articles.] Online document at: www.brighamandwom-ens.org/healtheweightforwomen/special _topics/int Accessed November 18, 2008.44. Duke Children’s Hospital & Health Center. Nutritional Disorders and Obesity. Online document at: www.dukechildrens.org/services/nutritional_disorders_and_obesity Accessed November 18, 2008.45. Ballen K. Mindful eating: An interview with Dr. David Engstrom. Bariat-ricNursSurgPatientCare2007;2:237–243.46. Albers S. Eating Mindfully: How to End Mindless Eating and Enjoy a Balanced Relationship with Food. Oakland, CA: New Harbinger Publica-tions, 2003.47. Eat, Drink & Be Mindful: Workshop Information. Online document at: www.eatingmindfully.com/contact/index.html Accessed September 18, 2008.48. Eat, Drink & Be Mindful: Eating Mindfully and Nutrition. Online docu-ment at: www.eatingmindfully.com/bookreview/nutrition.html Accessed Sep-tember 18, 2008.49. Reinblatt SP, Redgrave GW, Guarda AS. Medication management of pe-diatriceatingdisorders.IntRevPsychiatry2008;20:183–188.50. McIntosh VVW, Jordan J, Carter JD, et al. Appetite-focused cognitive-behavioral therapy for binge eating. In: Latner JD, Wilson GT, eds. Self-Help Approaches for Obesity and Eating Disorders: Research and Practice. New York:GuilfordPress,2007:325–346.51. Overeaters Anonymous website: www.oa.org/twelve_steps.html Accessed February 2, 2009.52. Manwaring JL, Bryson SW, Goldschmidt AB, et al. Do adherence vari-ables predict outcomes in an online program for the prevention of eating dis-orders?JConsultClinPsychol2008;76:341–346.53. Taylor CB, Jones, M. Internet-based prevention and treatment of obe-sity and body dissatisfaction. In: Latner JD, Wilson GT, eds. Self-Help Ap-proaches for Obesity and Eating Disorders: Research and Practice. New York: GuilfordPress,2007:141–165.54. Shapiro JR, Pisetsky EM, Crenshaw W, et al. Exploratory study to de-creasepostprandialanxiety.IntJEatDisord2008;41:728–733.55. Lam RW, Goldner EM. Seasonality of bulimia nervosa and treatment with light therapy. In Lamb RW, ed. Seasonal Affective Disorder and Beyond: Light Treatment for SAD and Non-SAD Conditions. Washington, DC: AmericanPsychiatricPress,1998:211–214.

To order reprints of this article, e-mail Karen Ballen at: Kballen@liebertpub.com or call (914) 740-2100.

15_1ACT.indd 16 2/20/09 2:20:42 PM