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The Concept of Mindfulness in Integrative Preventive Medicine 

The Concept of Mindfulness in Integrative Preventive Medicine
The Concept of Mindfulness in Integrative Preventive Medicine
Integrative Preventive Medicine

Kim Aikens

and Shauna Shapiro


The widespread clinical applications of mindfulness are based on a few general principles whose simplicity and power have sparked a literature examining the integration of mindfulness into psychology and medicine. Our intention is to explore the applications of mindfulness, specifically within an integrative preventive medicine context. Our goal is to demonstrate that the multidimensional nature of mindfulness has far-reaching applications for prevention in healthcare.

And yet, if mindfulness is to be integrated into Western medicine, we must find ways of translating its nonconceptual, nondual and paradoxical nature into a language that physicians, patients, scientists, scholars—all of us—can understand and agree on. Although the concept of mindfulness is most often associated with Buddhism, its phenomenological nature is embedded in most religious and spiritual traditions, as well as Western philosophical and psychological schools of thought.1 And yet more importantly, mindfulness is a universal human capacity that transcends culture and religion.

“Mindfulness” is the English translation of the Pali word Sati combined with Sampajañña, which as a whole can be translated as “awareness, circumspection, discernment, and retention.” Bhikku Bodhi, Theravadan scholar and monk, integrates these multiple definitions of mindfulness as meaning to remember to pay attention to what is occurring in one’s immediate experience with care and discernment.2

We define mindfulness as the awareness that arises through intentionally attending in an open, caring, and discerning way.3

Mindfulness comprises three core elements: intention, attention, and attitude.4 Intention, attention, and attitude are not separate processes or stages—they are interwoven aspects of a single cyclic process and occur simultaneously, the three elements informing and feeding back into each other (see Box 5.1). Mindful practice is this moment-to-moment process.


Intention is simply knowing why we are practicing mindfulness meditation, what is our aspiration and motivation for practice. When Western psychology attempted to extract the essence of mindful practice from its original religious/cultural roots, to some extent we lost the aspect of the intention of the practice, which for Buddhism was freedom from suffering for oneself and all beings. While this was a logical attempt at ethical neutrality on the part of the original Western interpreters; the concept of intention continues to be overlooked in some contemporary definitions.5 However intention (i.e., why one is practicing) is highlighted in Buddhist teachings as a central component of mindfulness and thus considered crucial to understanding the process as a whole.

In order to understand mindful practice accurately and deeply, it is essential to explicitly reincorporate the aspect of intention.6 As Kabat-Zinn writes, “Your intentions set the stage for what is possible. They remind you from moment to moment of why you are practicing in the first place.”7(p32) He continues, “I used to think that meditation practice was so powerful . . . that as long as you did it at all, you would see growth and change. But time has taught me that some kind of personal vision is also necessary.”7 (p46) This personal vision, or intention, is often dynamic and evolving. For example, a therapist may begin a mindful practice to decrease her own stress. As her mindful practice continues, she may develop an additional intention of relating to patients in a more empathic, present way.

The role of intention in meditation practice is exemplified by Shapiro’s study,8 which explored the intentions of meditation practitioners and found that as meditators continued to practice, their intentions shifted along a continuum from self-regulation, to self-exploration, and finally to self-liberation1/selfless-service.8 Further, the study found that outcomes correlated with intentions. Those whose goal was self-regulation and stress management attained self-regulation, those whose goal was self-exploration attained self-exploration, and those whose goal was self-liberation moved toward self-liberation and compassionate service. Similar results were found by Mackenzie, Carlson et al when they interviewed cancer patients who had been practicing meditation for several years.9 At first, the practice was used to control specific symptoms such as tension and stress, but later on, the focus became more about spirituality and personal growth. These findings correspond with our definition of intentions as dynamic and evolving, which allows them to change and develop with deepening practice, awareness, and insight. As meditation teacher and psychotherapist Jack Kornfield puts it, “Intention is a direction not a destination.”

Not only is it important to be clear about one’s intentions, it is necessary to reflect on whether they are wholesome or unwholesome, for the benefit or harm of self and others. Value issues are often seen as problematic in Western scientific traditions since modernist theory viewed science as objectively neutral. However, postmodernism and science and technology studies challenge that assumption—there are always values driving behavior. So it’s not a question of whether values are operating—in the individual, in the client-therapist interaction, in society—but how and to what extent we can bring these values to consciousness.

Mindful practice helps us (1) bring unconscious/nonconscious values to awareness; (2) decide whether they are really the values we want to pursue—whether they are wholesome, or merely biologically reflexive or culturally conditioned; (3) develop wholesome and skillful values and to decrease unwholesome ones. Intentions should also be differentiated from the concept of “striving” or “grasping” for certain outcomes from meditation practice. Intentions are not seen as goals or outcomes one actively strives toward during each meditation practice. Intentions are not a destination, they are a direction. Our intention sets the compass of our heart in the direction we want to head.


A second fundamental component of mindfulness is attention, observing the operations of one’s moment-to-moment, internal and external experience. This is what Husserl refers to as a “return to things themselves,” that is, suspending (and/or noting) all the ways of interpreting experience and attending to experience itself, as it presents in the here and now. In this way, one learns to attend not only to the surrounding world but also to the contents of one’s consciousness, moment by moment.

Attention has been suggested in the field of psychology as critical to the healing process. Mindfulness involves a deep and penetrating attention, not simply grazing the surface. As Bhikku Bodhi notes, “whereas a mind without mindfulness ‘floats’ on the surface of its object the way a gourd floats on water, mindfulness sinks into its object the way a stone placed on the surface of water sinks to the bottom” (from the Dhammasangani Malatika).2

Mindful practice involves a dynamic process of learning how to cultivate attention that is discerning and nonreactive, sustained and concentrated, so that we can see clearly what is arising in the present moment (including our emotional reactions, if that’s what comes up.) As Germer notes, “An unstable mind is like an unstable camera; we get a fuzzy picture.”10


How we attend is also essential. According to Kabat-Zinn, mindfulness is understood “not just as a bare attention but as an affectionate attention.”11 The qualities one brings to attention have been referred to as the attitudinal foundations of mindfulness.6,7,12,13 Siegel (2007) used the acronym COAL to refer to a similar list of qualities: curiosity, openness, acceptance, and love.13

Often, the quality of mindful awareness is not explicitly addressed. However, the qualities, or attitude, one brings to the act of paying attention are crucial. For example, attention can have a cold, critical quality, or it can include an openhearted compassionate quality. It is helpful to note that the Japanese characters for mindfulness are composed of two interactive figures: one is mind, and the other, heart. Therefore, perhaps a more accurate translation of “mindfulness” from the Asian languages is heart-mindfulness, which underlines the importance of including “heart” qualities in the attentional practice of mindfulness.

We posit that, with practice and right effort, persons can learn to attend to their own internal and external experiences, without evaluation or interpretation, and practice acceptance, kindness, and openness even when what is occurring in the field of experience is contrary to deeply held wishes or expectations. This attitudinal dimension of mindfulness must be explicitly introduced as part of the practice.

Attending without bringing the attitudinal qualities into the practice may result in practice that is condemning or judgmental of inner (or outer) experience. Such an approach may well have consequences contrary to the intentions of the practice; for example, cultivating patterns of judgment and striving instead of equanimity and acceptance. The field of neuroplasticity demonstrates that our repeated experiences shape our brain. If we continually practice meditation with a cold, judgmental, and impatient attention, these are the pathways that will get stronger. Our intention instead is to practice with an attitude of open, caring attention.

The attitudinal qualities do not add anything to the experience itself, but rather infuse the container of attention with acceptance, openness, caring, and curiosity. For example, if while practicing mindfulness impatience arises, the impatience is noted with acceptance and kindness. However, these qualities are not meant to be substituted for the impatience or to make the impatience disappear, they are simply the container. These attitudes are an essential part of the mindful practice as Kabat-Zinn states, “The attitude with which you undertake the practice of paying attention . . . is crucial”(p31) and “Keeping particular attitudes in mind is actually part of the training itself.”7(p32) The attitudes are not an attempt to make things be a certain way, they are an attempt to relate to whatever is in a certain way.

With intentional training, one becomes increasingly able to take interest in each experience as it arises and also to allow what is being experienced to pass away (i.e., not held onto). By intentionally bringing the attitudes of patience, compassion, and nonstriving to the attentional practice, one relinquishes the habitual tendency of continually striving for pleasant experiences, or of pushing aversive experiences away. Instead, bare awareness of whatever exists in that moment occurs, but within a context of gentleness, kindness, and acceptance.

Mindfulness Meditation, Mindfulness, and Preventive Medicine

Simply put, meditation is about learning to do one thing at a time. It is a practice of concentrated focus on an object such as the breath, sound, a visualization, or physical sensation. Contrary to “zoning out,” mindfulness meditation is a way to “zone in” on one’s experience. During mindfulness meditation using breath focus, for example, thoughts and emotions may arise, which can be observed with curiosity, in a nonjudgmental way, as part of one’s experience in the moment. In this way, mindfulness meditation uses the focus object as a means to harness and train the mind, ultimately leading to greater awareness of mental processes. It involves learning to watch thoughts, feelings, and sensations as they arise and pass, without becoming caught up in them.

The practice of mindfulness meditation helps to cultivate general mindfulness in everyday life. However, mindfulness is much more than a specific meditation technique. Mindfulness refers to one’s moment-to-moment awareness, and is more a way of being than a specific practice. It is about being fully present and aware of what you are thinking, feeling, or doing whether you are walking the family dog, talking to a friend or loved one, or doing the dishes. This is mindfulness in action.

Fundamentally, we view mindfulness as a natural human capacity that can be cultivated and strengthened. Seen through this lens, mindfulness can become an important component in integrative preventive medicine since mindfulness has the potential to help prevent illness and increase optimal health.

Health and Preventive Medicine

Health is difficult to define but important in the light of both mindfulness and preventive medicine. The World Health Organization defines health as the “state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”14 Preventive medicine works to improve the lives of individuals by enabling them to enhance their health. The literature suggests that mindfulness can be a crucial adjunct to preventive medicine strategies aimed at improving health and well-being from both a health promotion and disease management standpoint.

Traditionally, preventive medicine has been viewed as enhancing health through strategies targeted at three different levels.15 Primary prevention seeks to prevent the advent of disease by either eliminating the causes of disease or by increasing disease resistance. Secondary prevention targets early detection and treatment of presymptomatic disease in order to avoid symptom onset. Lastly, tertiary prevention strives to curtail the physical, mental, and social consequences of established symptomatic disease.16 Goldston describes these levels as “prevention, treatment, and rehabilitation,” although the terms “primary,” “secondary,” and “tertiary” continue to prevail today.17

Mindfulness-Based Interventions

Research shows that mindfulness skills can be taught and can be beneficial to health.18,19 Mindfulness-based stress reduction (MBSR) was the first mindfulness-based intervention (MBI) to be introduced in a Western medical setting. Originally developed in 1979 by Jon Kabat-Zinn, MBSR teaches core mindfulness concepts through training in formal mindfulness meditation practices and gentle mindful yoga.7 In addition, MBSR provides education on the effects of stress on health and well-being. Various adaptations of MBSR have been developed for other conditions, including mindfulness-based cognitive therapy (MBCT) for recurrent depression.20 In general, MBSR, which primarily focuses on the manifestations of stress, has typically been used for chronic medical conditions such as cancer, chronic pain, heart disease, and fibromyalgia. On the other hand, MBCT focuses on cognition and has been used in the treatment of mental health and eating disorders as well as in burnout. Acceptance and commitment therapy (ACT) is another common mindfulness-based intervention, which teaches mindfulness concepts but lacks instruction in formal meditation practices.21

Primary Prevention and Mindfulness

The goal of primary prevention is the reduction of disease incidence through risk factor identification and modification or through the enhancement of disease resistance. Directed at the predisease level, primary prevention includes activities of health promotion, which enhance generalized, nonspecific wellness as well as specific protection, targeted to prevent a specific disease type.16 Health promotion activities are principally lifestyle focused and geared toward decreasing known risk factors prior to the establishment of the disease process. Examples include healthy nutrition, increased physical activity, smoking cessation, and stress mitigation. In general, the goal of health promotion is to increase well-being while modifying risk factors in order to prevent disease inception. Specific protection, on the other hand, is targeted to a specific disease with the goal of preventing said disease from occurring. Examples include immunization against flu and fluoridation of water to prevent dental caries.

Health Promotion

Health promotion, through healthy lifestyle, nutrition, and environment, is a crucial step toward mitigation of disease.22 Human behavior regarding health habits is a critical element in health promotion. Modifiable lifestyle behaviors such as cigarette smoking, poor diet, lack of exercise, poor sleep hygiene, and chronic stress strongly contribute to many of the primary causes of death today, both worldwide and in the United States.23 For example, unhealthy dietary habits and physical inactivity are important modifiable risk factors in the development of cardiovascular disease, the current leading cause of death globally,24 as well as major contributors to the early development of obesity, metabolic syndrome, type II diabetes, and stroke.25,26,27 Promoting sustainable change in these behaviors is a significant public health challenge. In light of this, six health behaviors are currently recommended for overall health promotion:28

  • Regular physical activity

  • Tobacco abstinence

  • Stress management

  • Limitation of dietary fat, particularly saturated and trans fat

  • Consumption of at least five servings of fruits and vegetables daily

  • Weight loss (if needed)

Novel approaches to health promotion have significant potential to improve both public and individual health. Mindfulness is one such novel approach that has the potential to yield significant results in the realm of health promotion. The mainstreaming of MBIs reflects the quality and quantity of scientific studies done over recent decades. Of interest to primary prevention are the results of this work as it pertains to health promotion and lifestyle.

Mindfulness and Diet

Good dietary choices are critical to both the maintenance of health and the prevention of disease. The study of mindfulness with regard to dietary intake, although preliminary, shows promise. Dispositional mindfulness, or the basic human capability to be aware and to bring nonjudgmental acceptance to present moment experience, is a basic human trait, which can be innately present at varying levels.18 A study of morbidly obese adults and diabetics found that those with higher levels of dispositional mindfulness exhibited more restrained and less emotional eating.29,30 With regard to the effect of MBIs on diet, early research has shown mixed results with some studies remaining inconclusive31 or showing no effect on the dietary intake of energy, fat, sugar, fruit, or vegetables.32 Diet has been principally evaluated in studies, which involve MBSR programs. For example, a recent analysis by Salmoirago-Blotcher et al. of 174 participants who completed an MBSR program showed improvement in overall dietary behaviors with reduction in the number of desserts eaten, fast-food meal intake, consumption of sweetened beverages, and use of fats.33 In addition, a recent randomized controlled trial (RCT) of a Web-based mindfulness program found significant increases in fruit and vegetable intake as well as a decrease in fast food consumption following the mindfulness intervention.34 Furthermore, a program in MBSR, delivered in conjunction with a vegetable-based dietary intervention, led to decreased saturated fat intake and an increased intake of vegetable protein in men with prostate cancer.35,36,37

Mindfulness and Obesity

Over the past several decades, the rate of obesity, with its association to chronic disease38,39 and decreased life expectancy,40 has increased significantly with 33.9% of US adults considered overweight and 41.5% obese.41 Consequently, the effect of mindfulness as a primary prevention weight loss strategy is intriguing. Recent research in a large population (N = 63,628) has shown that men and women with higher levels of dispositional mindfulness are more physically active and less obese. In this study, overall mindfulness in women was associated with lower odds of being overweight, and to an even greater extent, obese. In men, higher mindfulness was associated with lower odds of obesity only.42 Further research has shown that dispositional mindfulness may be inversely associated with both obesity and central adiposity,43 reported serving sizes of energy dense foods,44 binge eating,45 and unhealthy eating habits.46

Although mindfulness is an inherent trait, research shows that it is modifiable and can be trained.18,19 Mindfulness-based therapies help to cultivate a nonreactive and nonjudgmental form of awareness in the face of aversive experience, such as stressors, unpleasant thoughts, emotions, and sensations. The development of less reactivity and enhanced self-efficacy, which can result from mindfulness training, may lead to a decreased dependency on the unhealthy behaviors previously used to cope with stress and negative emotion.47 For example, emotional and stress eating, in addition to food craving and binge eating, are well known obesity-related eating behaviors, which may be impacted by mindfulness training.48,49 Furthermore, ongoing mindfulness practice may lead to decreased stress and emotional sensitivity, which may help prevent relapse to unhealthy behaviors, thereby helping to support long-term weight maintenance.47

Research has evaluated the impact of MBIs on obesity, with weight loss shown in some but not all studies. A review by Katterman et al. that examined only studies in which mindfulness was the primary treatment modality (e.g., MBSR and MBCT), found that effects on weight at postintervention were small and mainly nonsignificant.49 However, those studies in which weight was the principle outcome, and mindful eating an important interventional component, did report significant weight loss among mindfulness participants.50,51,52 A later review, which focused on MBIs for obesity-related eating behaviors, also found efficacy, with 9 out of 10 studies demonstrating either weight loss or weight stabilization with a small effect size (Cohen’s d = .19).53 However, this review included studies with and without control groups. The most recent review by Olsen et al. of randomized controlled trials and observational studies, in which weight loss was a primary outcome, found significant decreases in 13 out of 19 mindfulness interventions. However, researchers concluded that methodological weaknesses limited evidence strength.54 Furthermore, studies using control groups have shown that MBIs positively impact eating behaviors such stress-related eating,31 diet composition,33,37 emotional eating,48 food craving,55,56 and binge eating.48 In general, evidence points to a floor effect such that those participants with higher weight, or those who are attempting to lose weight, may have greater benefit from mindfulness interventions.57

Mindfulness and Physical Activity

Physical activity can have a major impact on healthy lifestyle and is associated with positive health benefits, improved quality of life,58 happiness,59 and increased life satisfaction.60 Epidemiological evidence supports a direct relationship between volume of physical activity and health as well as an inverse relationship to cardiovascular and overall mortality.61 With regard to mindfulness and physical activity, research is mixed. For example, a study of 441 college women did not show a relationship between dispositional mindfulness and exercise frequency although mindfulness did strongly predict physical health.46 This is in contrast to studies in which mindfulness was positively associated with physical activity levels, satisfaction and enjoyment of physical activity,62 exercise maintenance over time,63 and perception of overall health.45,62,64

To date, the effect of MBIs on physical activity has not been extensively researched. Current results have been mixed with some studies showing no increase in activity levels either during or after a mindfulness intervention.34,65 This is in contrast to research in men with prostate cancer, in which a composite mindfulness training, delivered together with an exercise and dietary intervention, significantly increased physical activity levels at 3 months post training.36,37,66 In addition, Salmoirago-Blotcher et al. found partial changes in sedentary behavior following MBSR training with increases in participant strength and flexibility scores.33 Interventions using ACT have also been studied, with three out of four RCTs finding significant positive effects on physical activity outcomes.67,68,69,70

Mindfulness and Smoking

Tobacco smoking is a common cause of preventable premature death and is responsible for one out of five deaths in the United States each year.71 Furthermore, it is estimated that smoking results in a decreased average life expectancy of at least 10 years for smokers as compared to nonsmokers.72 Although some forms of behavioral smoking cessation therapy have shown efficacy, only approximately 5% to 20% of smokers will remain cigarette free at 6 months following a cessation attempt.73 Initial research suggests that mindfulness may be linked to improved smoking cessation outcomes. For example, Vidrine et al. found that higher levels of dispositional mindfulness were inversely associated with nicotine dependence and withdrawal severity. In addition, mindfulness was positively associated with self-efficacy in smoking avoidance as well as greater expectation in the ability to control emotion without the assistance of smoking.74 Furthermore, Hepner et al. found that African American smokers with greater mindfulness had a greater likelihood of abstinence up to 26 weeks post quit.75 Additional studies have shown the importance of dispositional mindfulness in the reduction of smoking frequency in adolescents.76

Mindfulness training has also shown promise as therapy for smoking cessation. A recent literature review by Weiss de Souza et al. examined 13 controlled studies on mindfulness and smoking through April 14, 2014. The majority of studies examined in this review showed positive effects of mindfulness on quit rates when compared with controls despite heterogeneity in methodology.77 For example, Brewer et al. compared mindfulness training to the American Lung Association’s standard Freedom From Smoking (FFS) program and found that mindfulness training resulted in a greater decrease in the number of cigarettes smoked, which was maintained at 17-week follow-up. In addition, mindfulness participants had significantly higher abstinence at 4 months as compared with the FFS group, with rates of 31% versus 6%, respectively.78 An additional study by Davis et al. in low-income adults also found significantly higher abstinence rates in participants who received mindfulness training plus nicotine replacement (38.7%) versus those who were given quit line counseling plus nicotine replacement (20.6%) at 24 weeks.79 Phone app80 or Web-based81 MBIs have also been found to be effective with smoking abstinence rates for a Web-based intervention group significantly greater than controls at 3-month follow-up.

Mindfulness and Stress Management

Chronic, long-term stress in daily life can have serious health consequences and is associated with detrimental health behaviors such as alcoholism, smoking, and obesity.82,83 In addition, exposure to prolonged periods of acute and chronic stress is a risk factor in many disease states including upper respiratory infections,84 cardiovascular disease,85,86,87 stroke,88 autoimmune disorders,89,90 and total mortality.91,92 Stress also leads to an increased risk of mental health problems including depression93,94,95 and chronic anxiety.96 Higher levels of dispositional mindfulness have been found to be associated with better mental health including lower levels of perceived stress, depression, and anxiety.97,98,99 In addition, greater mindfulness is strongly associated with greater well-being100 as well as perceived physical and psychological health.99 Research suggests that the buffering effect of mindfulness against the negative effect of stress on mental health is cross-generational, and has been found in an adolescent population101 as well as in young adults and the elderly.102

With regard to the impact of mindfulness training, MBSR programs, in particular, have shown strong potential for increasing well-being and decreasing stress-related complaints. A recent review of studies from 2009–2014 found positive changes in stress-related psychological or physiological measures in 15 out of 17 studies, while two studies had mixed results. However, only two studies out of the 15 with positive changes used randomized control designs. Despite study limitations, this review concluded that MBSR is a promising intervention for stress reduction in a healthy population.103 This echoed the 2009 review findings by Cheisa et al, who found similar positive results regarding the efficacy of MBSR on stress.104

Mindfulness and Cardiovascular Disease Risk

Individuals with good cardiovascular health have healthy levels of seven known cardiovascular risk factors, including blood pressure, total cholesterol, fasting glucose, body mass index, smoking, diet, and physical activity.105 Preliminary research shows that dispositional mindfulness, principally through its association with BMI, smoking, fasting glucose, and physical activity, is positively associated with good cardiovascular health. For example, a study of 382 individuals found that those with high versus low dispositional mindfulness had an 86% higher likelihood of having good cardiovascular health. In this study, sense of control and depressive symptomatology were potential mediating mechanisms.106 It has been suggested that more mindful individuals have greater awareness and pay more attention to their behavior, which results in improved capability to initiate or prevent the behavior.18,107 The net result may be an increased capability of maintaining healthy lifestyle behaviors. In addition, both mindfulness interventions and dispositional mindfulness are related to positive affect including lower levels of anxiety and depression.97,108 Depression is an independent risk for pathophysiologic progression of cardiovascular disease (CVD) and is associated with an increased incidence of cardiovascular morbidity and mortality.109 Furthermore, depressed patients may be less likely to adhere to heart healthy behaviors, such as smoking cessation and dietary changes, leading to further increases in CVD risk.110 Consequently, the positive impact of mindfulness on depression may be a significant factor in decreasing CVD risk.

Research on the effect of MBIs on CVD risk is currently in a nascent phase with mixed results and general tendency to poor methodology and small sample size.47 Overall, however, intervention studies regarding the association of mindfulness with CVD health appear promising, particularly in regard to smoking, blood pressure, obesity, diabetes, diet, and physical activity. Loucks at al. propose that mindfulness exerts its effect on CVD health through three different pathways: (1) attention control, which allows increased ability to hold attention to physical sensation related to CVD risk—for example, smoking, overeating; (2) emotional regulation with reduced stress response and ability to manage cravings; and (3) heightened awareness of physical sensation, thoughts, and emotions.57

Secondary Prevention and Mindfulness

Secondary prevention includes activities such as screening, case finding, and appropriate treatment in order to keep disease from becoming symptomatic.22 Mindfulness interventions have the potential to enhance secondary prevention, particularly in diseases with strong lifestyle or mental health components.

Mindfulness and Blood Pressure

A mindfulness program as potential treatment for a patient with presymptomatic hypertension is an example of mindfulness training as a secondary prevention strategy. The research is promising, although not definitive, for mindfulness training as an adjunct in hypertension therapy. A recent review and meta-analysis of four randomized controlled trials of mindfulness-based interventions for hypertension found significant, although moderate, effects for Systolic Blood Pressure (Standardized Mean Difference – 0.78, p = .03) and Diastolic Blood Pressure (Standardized Mean Difference - 067, p = .03).111 However, the studies included in this analysis showed high heterogeneity and included participants with unmedicated prehypertension,112 unmedicated grade 1 hypertension,113 a combination of unmedicated grade 1 and 2 hypertension,114 and participants at high risk for diabetic complications.115 Further analysis excluding the RCT by de la Fuente et al. in which effect sizes were significantly higher, resulted in no significance for either SPB or DBP, although intervention was still favored.111 The difference in effect sizes between these studies may pertain to floor effects, in which those participants with the highest blood pressure (unmedicated stage 1 or 2 hypertension) showed the greatest response to intervention, possibly indicating that mindfulness training may be most beneficial to those with the highest baseline blood pressure.111 Consequently, although promising, mindfulness training as a secondary treatment strategy for asymptomatic hypertension requires further rigorous methodological research.116

Mindfulness, Diabetes, and Glucose Regulation

Several studies have evaluated the effect of mindfulness training in the treatment of diabetes. To date, studies that used standard mindfulness training programs, such as MBSR115 and MBCT,117,118 have not influenced glucose regulation. However, interventions that provided mindfulness training, in addition to education regarding diet, physical activity, glucose monitoring, and medication usage, significantly improved glucose regulation, with resultant reductions in HbA-1C and fasting glucose.119,120

Tertiary Prevention and Mindfulness

The goal of tertiary prevention is to curtail the physical, psychological, and social damage that is the consequence of chronic symptomatic disease. Tertiary prevention consists of two components; disability limitation with specific treatment to limit damage from or progression of disease and rehabilitation.22 Typically, there is no cure for the illnesses in which tertiary prevention is applicable and symptoms of stress, depression, and anxiety are common. Consequently, mindfulness has gained in popularity as an adjunct therapy in chronic care and is particularly applicable to the rehabilitation component of tertiary prevention.

Mindfulness and Chronic Pain

A meta-analysis by Veehof et al. in 2010, which included 22 studies (nine randomized controlled trials (RCT), five controlled clinical trials (CCT), five noncontrolled) of mindfulness in chronic pain, showed small but significant effects for pain intensity, depression, anxiety, physical well-being, and quality of life in mindfulness participants. When analysis was restricted to the nine RCTs, small but significant effects were found for pain intensity and depression. This review concluded that mindfulness therapies, including MBSR and ACT, had small to moderate effects that were comparable to cognitive-behavioral therapy (CBT) on physical and mental health in chronic pain patients.121 A review of fibromyalgia patients also found significant improvements in quality of life and depression as a result of MBSR.122 However, a meta-analysis for low back pain did not show significant improvements in pain or disability when compared to a program in health education.123

Mindfulness and Cardiovascular Disease

The effectiveness of MBSR and MBCT in individuals with cardiovascular disease was analyzed in a review by Abbott et al., which included 9 RCTs and 578 participants. Overall, evidence was found for significant decreases in stress, anxiety, and depression with medium effect sizes.111

Mindfulness and Cancer

An overview of systematic reviews with meta-analysis of 12 mindfulness RCTs in cancer patients found significant changes in psychological health but not in physical health. Significant improvements were consistently found for depression, anxiety, quality of life, and stress, with a dose response between enhanced mood and meditation time. In addition, participants who attended more mindfulness training sessions showed greater reduction in stress levels.124

Mindfulness and Depression

A review and meta-analysis by Cheisa et al. of MBCT in mental health disorders, suggested that MBCT plus treatment as usual (TAU) has an additive effect when compared to TAU alone in major depressive disorder (MDD). Analysis showed that MBCT plus TAU resulted in a significant reduction in relapse rates occurring over 1 year in patients with three or more major depressive episodes. Findings also suggested that MBCT, when combined with the gradual discontinuation of antidepressants, was similar to antidepressant continuation for prevention of depression relapse over 1 year. Kuyken et al., who randomized 424 recurrently depressed patients to either MBCT with antidepressant discontinuation or antidepressant maintenance over 2 years, echoed these findings. Rates of relapse/recurrence over the study period indicated no difference between conditions, suggesting that MBCT provided relapse protection on par with maintenance antidepressant pharmacotherapy.125 In addition, a meta-analysis by Piet et al. found that, in the subgroup of participants with three or more depressive episodes, the relapse rate for MBCT treated patients was 36% as compared to 63% for controls, with an associated risk reduction ratio of 43% in favor of MBCT. This study concluded that that MBCT is an effective intervention for relapse prevention in individuals with major MDD in remission.126

Mindfulness, Chronic Disease, and Psychological Distress

As previously stated, the goal of tertiary prevention is to curtail not only the physical consequences of chronic disease but also the psychological and social damage. Unsurprisingly, higher levels of psychological distress are more common in patients with chronic disease. This is illustrated by a study done in Australia, which examined clients in a community health services program. This study found that 20% of patients with chronic disease reported very high levels of psychological distress127 as compared to only 2.4% of the general population.128 In general, chronic disease places a significant psychological adjustment burden on the patient. Some individuals adjust well to this ongoing challenge, while others encounter serious decline from an emotional and interpersonal standpoint. Adjustment is a multifaceted and often difficult process. Stanton et al. has conceptualized this adjustment as consisting of five different constructs: (1) absence of psychological disorder, (2) low negative affect, (3) maintenance of functional status, (4) learning and mastery of disease-specific tasks, and (5) perceived quality of life.129 In addition, the presence or absence of associated depression is significant, as depression has been shown to adversely effect functional status130 while increasing the risk of noncompliance with medical regimens in chronic disease patients.131 Furthermore, maintenance of positive mood, and an ongoing sense of meaning and purpose in life, have been shown to be positive indicators of adjustment.129 The mindfulness literature suggests that mindfulness-based interventions can significantly enhance overall adjustment to chronic disease through their positive effects on stress coping, depression, anxiety, mood, and quality of life. These interventions may work through multiple mechanisms of action. For example, they may work through enhancement of self-regulation and an increased sense of control in which thoughts, sensations, and emotions are observed as passing events that are not always acted on. In addition, they may work through the development of increased emotional regulation and “positive reappraisal” in which difficult circumstances or events are reconstructed as positive or meaningful. Furthermore, they may work through enhancement of self-awareness combined with an enhanced ability to “decenter” and observe experiences as they arise and pass away with a sense of nonjudgmental awareness and acceptance.132

As the literature demonstrates, mindfulness-based interventions, including both MBSR and MBCT, are well suited as tertiary prevention strategies with the potential for significant benefit. A 2010 review by Merkes looked at 13 studies of MBSR in patients with chronic disease of varying types and showed overall positive change with enhanced coping, improved well-being, and increased quality of life among MBSR participants. Anxiety was measured in eight studies, with all eight showing significant reductions following MBSR. Of the eight studies, which looked at depression, six showed significant improvements in MBSR participants, while two reported no changes. In the six articles that looked at quality of life and well-being, all showed improvements and four were statistically significant.133 A more recent 2015 systemic review and meta-analysis by Gotink et al. of 115 unique mindfulness-based RCTs and 8,683 individuals concluded that MBSR and MBCT had significant positive effects in chronic pain, cardiovascular disease, cancer treatment, somatic disorders, depression, and anxiety. Improvements were due to increased quality of life, improved physical outcomes, and decreased anxiety, stress, and depression found in the intervention groups.124 Overall, the evidence indicates that mindfulness training can minimize disability and impairment from chronic disease, particularly on a psychological and quality of life level.

Mindfulness as Prevention for Psychological Health

Mindfulness as a practice may have broad benefits on mental health, sense of well-being, mood, self-acceptance, and ability to cope with stressful situations.

Mindfulness and Psychological Health

Although methodological limitations exist within each body of literature, there is good evidence suggesting that mindfulness is positively associated with healthy lifestyle as well as improvements in depressive symptoms, stress, anxiety, quality of life, and selective physical outcomes. However, as previously noted, health is not only defined by the absence of disease but is hallmarked by physical, mental, and social well-being.14 Certainly, “well-being” is a keyword embedded within this definition. Although it is obvious that physical well-being has a large impact on morbidity and mortality, the literature also shows that psychological well-being is critical to positive health outcomes.134 For example, a quantitative review and meta-analysis by Chida et al. found that positive affect, including energy, happiness, vigor, emotional well-being, positive mood, and joy, as well as positive trait-like outlooks such as hopefulness, optimism, sense of humor, and life satisfaction were associated with decreased overall mortality (19% reduction in hazard ratio) and cardiovascular mortality (29% reduction) in healthy populations.135 Furthermore, a study by Xu et al. found that subjective well-being and positive feelings, including positive affect and satisfaction with life, significantly predicted longevity in a population of 6586 individuals followed over 28 years.136 Consequently, in order to be fully aligned with the view of prevention as enhancing health, it is critical to consider the ramifications of mindfulness on positive psychological constructs that potentially improve not only physical but also psychological well-being.

To date, numerous studies have pointed to an association between self-reported mindfulness and psychological health. For example, higher levels of trait mindfulness have been associated with increased levels of well-being,137,138,139,140,141,142 positive affect,143,144 life satisfaction,145 agreeableness,146,147 conscientiousness,146 spirituality,148,149 self-compassion,150,151,152 self-esteem,97,153 resilience,34 vigor,34 optimism,97 forgiveness,154 hope,137 and empathy137,155 in both clinical and nonclinical populations. Furthermore, current evidence suggests that these changes could be robust and tend to be maintained over time.152 Trait mindfulness has also been negatively correlated with depression,97,156 rumination,157,158 experiential avoidance,141,144 social anxiety,153 cognitive reactivity,159,160 neuroticism,155 and overall psychological distress.149,161

Mindfulness, Well-Being, and Positive Affect

Well-being can be simply defined as a state of optimal functioning and experience.162 Traditionally, philosophers such as Aristotle have differentiated well-being into hedonic and eudaimic frameworks.163 Hedonic well-being focuses on pleasure and happiness164 and is reflected in a commonly used scale of subjective well-being (SWB), which measures the emotional quality of daily life, including the balance of positive to negative emotions such as joy, sadness, affection, or anger, in addition to life satisfaction.162,165 The eudaimic approach, on the other hand, focuses on meaning, personal growth, and self-realization.162 Consistent with the eudaimic construct, Ryff et al. formulated a model of psychological well-being (PWB), which encompasses personal growth, purpose in life, self-acceptance, environmental mastery, and autonomy.166,167 Research suggests that mindfulness positively impacts both SWB and PWB.168 For example, Kong et al. examined mindfulness and well-being in 290 healthy university students in China. Behavioral studies showed that higher levels of student dispositional mindfulness were related to greater SWB, in the form of higher positive affect and lower negative affect, as well as higher PWB. In addition, neuroimaging studies provided initial evidence for links between individual differences in mindfulness and spontaneous brain activity in the left orbitofrontal cortex, left parahippocampal gyrus, and right insula, suggesting a possible neurobiological mechanism for the mindfulness/well-being connection.168 Likewise, research by Singleton et al. examined PWB in participants who had completed an 8-week course in MBSR. Neuroimaging studies showed that the more PWB improved, the greater the increase in observed gray matter concentration in areas of the brainstem responsible for the synthesis and release of the neurotransmitters norepinephrine and serotonin. Since these neurotransmitters are involved in the modulation of arousal and mood as well as basic functions such as sleep and appetite, this preliminary study suggests that enhanced PWB has a neural correlate.169 Furthermore, Hollis-Walker et al. found that mindfulness was significantly correlated with PWB, as well as self-compassion, agreeableness, and openness, and accounted for 57% of the predictive variance in PWB in a sample of nonmeditating subjects.147

With regard to SWB, the balance of positive affect (PA) to negative affect (NA) is critical. Not only is the presence of PA a strong predictor of meaning in life,170 but research also suggests it is protective against the development of mental health disorders.171,172 Mindfulness has been found to be positively associated with PA. For example, in a 2012 meta-analysis on the effects of different forms of meditation, Erbeth et al. found that MBSR led to significant increases in PA in nonclinical populations.173 In addition, a study by Cousin et al. of healthy adults found a significant increase in PA following an 8-week MBCT course. This increase in PA was mediated by decreases in the use of disengagement coping strategies, such as wishful thinking, problem avoidance, self-criticism, and social withdrawal, when facing daily stressors.144 Furthermore, a recent RCT by Batink et al. examining the effect of affect, as well as cognitive variables (worry, rumination), in patients with depression found that increases in PA mediated 61% of the effect of MBCT on depressive symptoms.143

Mindfulness, Compassion, and Self-Compassion

Compassion can be defined as the feeling that arises when seeing the suffering of others, which engenders a subsequent desire to help.174 Self-compassion turns compassion inward, allowing an attitude of caring and kindness for oneself in the face of one’s suffering.175 As defined by Neff, self-compassion encompasses three primary components: self-kindness, a sense of common humanity, and a balanced awareness of one’s emotional experience (mindfulness).176 Research findings have revealed an association between self-compassion and positive well-being, happiness, optimism, positive affect, and life-satisfaction177 as well as with lower levels of psychopathology.178 Furthermore, self-compassion, and the ability to care for self, is closely linked to compassion or the ability to care for others.179 With regard to mindfulness, there is growing evidence showing an association between mindfulness and self-compassion. Research has shown that MBIs frequently lead to increased self-compassion in both adults147,151,152 and adolescents.180,181 A recent meta-analysis by Gu et al. concluded that there is preliminary, though still inconsistent, evidence for the mediating effect of self-compassion on the psychological outcomes of MBIs.159 In addition, Cheisa suggests that, although improvements in both mindfulness and self-compassion may mediate clinical outcomes, self-compassion could be a stronger predictor of outcomes than changes in mindfulness.152 Furthermore, a 2012 study by Keng et al. on a nonclinical, nonmeditating sample found that increases in mindfulness independently mediated effects of MBSR on emotional regulation, while increases in self-compassion independently mediated intervention effects on worry. Researchers concluded that mindfulness and self-compassion may have different impacts on clinical and psychological outcomes, allowing these constructs to work together to produce observed improvements.182

There is also evidence that mindfulness practices can facilitate the development of compassion in adults.183,184 A recent study by Condon et al. examined compassionate responses in a group of 69 undergraduate students who were randomized to either a Web-based mindfulness meditation program or an active control group using a Web-based cognitive training program. Results showed that participants in the mindfulness program showed significantly higher compassion and were 37% more likely to exhibit altruistic behavior by giving up their seat to someone perceived to be in pain than did active controls (14%).183

Mindfulness and Adaptive Coping

The ability to cope effectively with adversity is important when dealing with health issues. In general, individuals tend to use either engagement (approach) or disengagement (avoidant) strategies when coping with stressors.185 Avoidance strategies are characterized by responses that provide distance from the stressor and avoidance of the problem. Individuals who exhibit avoidant behavior may react with heightened levels of negative feelings, such as intense anxiety, or maladaptive behaviors, such as substance abuse or aggression, which are aimed at avoiding or minimizing the difficult feelings related to a distressing event.186 Evidence indicates that avoidant strategies tend to be associated with decreased overall well-being as well as increased psychopathology.186 In addition, avoidant strategies have been negatively correlated with improvements in treatment outcomes.187 Engagement, on the other hand, includes strategies such as acceptance, problem-solving, and social support, which allows movement toward the stressor and the emotional and cognitive reactions related to it.144

Mindfulness may facilitate the use of adaptive coping strategies, thereby protecting well-being, particularly in the face of difficult and distressing circumstances. Key to mindfulness practice is the adoption of a stance of curiosity as well as an accepting, nonjudgmental attitude to all experience, whether or not it is pleasant or aversive.188 In addition, mindfulness encourages attention to the present moment, allowing for greater awareness of positive experiences and emotions, which may be present in the midst of adversity. Furthermore, potentially distressing mental content may be moderated through the cognitive process of stepping back from thoughts, emotions, and sensations. Such perspective shifting, also known as decentering189 or reperceiving,4 allows the viewing of thoughts and emotions as passing mental events rather than accurate images of reality. This mental shifting, with the concomitant ability to recognize and let go of automatic thoughts and repetitive negative thinking, may result in change mechanisms such as self-regulation, values clarification, cognitive flexibility, and exposure.4 Such mechanisms, when present, may allow for the development of effective coping as well as more efficient recovery from distressing events.

Current research suggests multiple ways in which mindfulness may lead to adaptive coping. For example, evidence suggests an inverse relationship between mindfulness and experiential avoidance, although some discrepant results have been observed. Moreover, some studies point to the possible superiority of mindfulness to other treatments in reducing avoidant coping strategies.152 In addition, an RCT by Cousin et al. found that decreased avoidance mediated improvements in positive affect following MBCT.144 The literature also suggests other mechanisms of action that may help facilitate adaptive coping. For instance, investigators have found an association of both state and trait mindfulness to an increased use of positive reappraisal.190,191,192,193 The use of positive reappraisal, in which stressful events are actively reinterpreted as benign, beneficial, or meaningful,194 has been associated with positive mental health outcomes.195 For example, a heart attack may be initially perceived as life ending but later be construed as a wake up call, leading to improved lifestyle and a renewed appreciation for life. In addition, mediation analysis performed by Gu et al. concluded that decreased repetitive negative thinking, including worry and rumination, was a unique mediator of the effects of MBIs on clinical outcomes. Researchers have also found that decreased emotional and cognitive reactivity, or the degree to which a mildly dysphoric state retriggers repetitive negative thinking and emotional patterns, is another significant mediator of mindfulness training on outcomes.159 Such decreases in negative thought patterns and rumination, combined with decreased cognitive and emotional reactivity, may enhance the ability to engage with, and adapt to, difficult stressors. Ultimately, these combined mechanisms may allow enhanced navigation of adversity, thereby improving self-efficacy, emotional self-regulation, resiliency, well-being, and quality of life. In fact, greater mindfulness has been associated with resilience,196,197 with increased resiliency levels found following mindfulness-based interventions.34,198,199 It is possible that the ability to bounce back from stressful situations may be, at least in part, due to the use of mindfulness coping, which may be characterized by a decentered stance, broadened awareness, heightened insight, cognitive flexibility, and positive reappraisal.

Conclusion and Future Directions

The potential applications of mindfulness to preventive integrative medicine are far reaching, and the fruits of such work are already visible. Decades of research demonstrate that mindfulness-based therapies have significant beneficial effects for a wide array of preventive and health-enhancing applications. In addition, innovative clinical applications are underway with the development of new MBIs for specific populations. Further, mindfulness practice shows promise for cultivating positive psychological qualities previously given little attention by Western researchers. Mindfulness can help enlarge our paradigm of health and healing, deepen the intentions we aspire toward, and expand our vision of what is possible. The field of mindfulness is still young, and the possibilities for its integration into Western healthcare are vast.


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2 These categories are offered heuristically, reflecting the general idea that there are mindfulness qualities that characterize the attention during the mindfulness practice.

1 Self-liberation refers to the experience of transcending (i.e., becoming free of or dis-identifying from) the sense of being a separate self.

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