EVALUATION OF A BRIEF COGNITIVE DEFUSION TRAINING FOR SWEET CRAVINGS AMONG COLLEGE STUDENTS
Maija Broox Taylor
A Dissertation
Submitted to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of
DOCTOR OF PHILOSOPHY
August 2018
Committee:
Harold Rosenberg, Advisor
Susan L Brown Graduate Faculty Representative
Dara Musher-Eizenman
Richard Anderson
William O'Brien ii ABSTRACT
Harold Rosenberg, Advisor
Objective: To compare the short-term impact of an in-lab cognitive defusion training for
sweet food cravings with a control condition (use of a self-selected craving management
strategy) on craving, cognitive fusion, acceptance of and willingness to resist food
cravings, and consumption of sweet foods.
Methods: Undergraduate and graduate volunteers attending Bowling Green State
University were quasi-randomly assigned to either the experimental intervention
condition (n = 50) or the control condition (n = 46). Participants were young (Mage =
20.3, SD = 3.8), primarily female (77%), and non-Hispanic white (82%). The average
body mass index was 25.1 (SD = 6.1), and 31% of the sample was overweight or obese.
Results: There were no main effects for condition on any of the dependent measures, but
self-reported total sweet food consumption and cognitive fusion decreased in both
conditions from baseline to two-week follow-up.
Conclusions: The main effects for time could indicate that participants who are seeking
to reduce consumption of sweet foods benefit from practicing craving management
strategies during exposure to sweet foods, self-monitoring consumption of sweet foods,
and/or receiving text messages prompting use of craving management strategies
regardless of the specific strategies they employ. However, placebo effects, social
desirability biases, and recall errors may also account for the apparent effect of time on
craving and consumption. iii ACKNOWLEDGMENTS
I appreciate all of the people who gave me encouragement and advice throughout this journey. I am grateful for the guidance of my committee members, especially my dissertation advisor. I am appreciative of his wisdom, generosity, and meticulousness. I am also incredibly thankful for the supportive words from my family, boyfriend, and friends throughout this process.
iv
TABLE OF CONTENTS
Page
INTRODUCTION ...... 1
Cravings for Sweet Foods………………………………………………………….. 3
Elaborated Intrusion Theory of Craving……………………………………………. 5
Research on Interventions for Reducing Food Cravings and/or Craved Food
Consumption ……………………………………………………………………… 7
Design of the Current Study…………………………………………………………. 13
Comparison Condition………………………………………………………………. 14
Hypotheses and Analyses…………………………………………………………… 14
METHOD………………………...... …………….. 17
Participants, Recruitment, and Incentives………...... …… 17
Measures……………………………………………………………………………. 18
Procedure…………………………………………………………………………… 25
Content of Cognitive Defusion Experimental Intervention………………………... 29
Content of Typical Tactics Control Condition……………………………………... 30
Preparation for Two-Week Follow-Up and Evaluation of Group Climate………… 31
DATA ANALYSIS……………...... 32
Management of Missing Data and Outliers ...... 32
RESULTS…………………… ...... 33
Participant Characteristics ...... 33
Craving Tactics Used in the Lab ...... 34
Participant Perceptions of Intervention during the Lab Session and at Follow-Up.. . 35 v
Preliminary Analyses ...... 35
Impact of Intervention on State Food Cravings……………………………………. 36
Impact of Intervention on Consumption of Sweet Foods…………………………… 36
Impact of Intervention on Cognitive Fusion………………………………………… 37
Impact of Intervention on Food Craving Acceptance and Willingness……………… 38
Correlations among Trait Craving, Addictive Eating, Mindfulness and Sweet
Consumption ……………………………………………………………………… 38
Tactic Use Frequency………………………………………………………………. 39
Exploratory Analyses on Self-Restraint Tactics for Sweet Food Cravings……… ... 40
DISCUSSION…………...... 41
Limitations………………………………………………………………………….. 44
Conclusions………………………………………………………………………… 46
REFERENCES ...... 48
APPENDIX A. RECRUITMENT DOCUMENTS...... 86
APPENDIX B. ELIGIBILITY SCREENER……………………………………………… 89
APPENDIX C. DEMOGRAPHICS AND GENERAL INFORMATION SURVEY……. . 90
APPENDIX D. CHOCOLATE CANDY AND COOKIE FORMS……………………… . 92
APPENDIX E. FOOD CRAVING QUESTIONNAIRE – TRAIT (FSQ – T) …………... . 93
APPENDIX F. COGNITIVE FUSION QUESTIONNAIRE (CFQ) …………………..… . 96
APPENDIX G. FOOD CRAVING ACCEPTANCE AND ACTION QUESTIONNAIRE
(FAAQ) ………………………………………………………………………………… . 97
APPENDIX H. YALE FOOD ADDICTION SCALE (YFAS) ……………………..…….. 98
APPENDIX I. FIVE FACET MINDFULNESS QUESTIONNAIRE vi
– SHORT FORM (FFMQ-SF) …………………………………………………………. . 100
APPENDIX J. SWEET FOOD CONSUMPTION QUESTIONNAIRE – BASELINE
AND PAST WEEK VERSIONS ………………………………………………………. . 102
APPENDIX K. THE SELF-RESTRAINT TACTICS FOR SWEET CRAVING
QUESTIONNAIRE ...... 104
APPENDIX L. IN-LAB DEPRIVATION, HUNGER, AND CRAVING QUESTIONS
………………….…………………………………………………………………………... 106
APPENDIX M. IN-LAB COMREHENSION……………………………………………. . 109
APPENDIX N. FOOD CRAVING QUESTIONNAIRE – STATE (FSQ – S) ……..…… . 110
APPENDIX O. IN-LAB QUESTIONS ON STRATEGY USE, DIFFICULTY,
IMPLEMENTATION EFFECTIVENESS, AND VALUE ………...... 112
APPENDIX P. GROUP CLIMATE QUESTIONNAIRE (GCQ-S) – MODIFIED…….... . 113
APPENDIX Q. DAILY SWEET FOOD CONSUMPTION SURVEY ……...... …… 114
APPENDIX R. TWO-WEEK FOLLOW-UP QUESTIONS ON STRATEGY
COMPREHENSION, USE, DIFFICULTY, IMPLEMENTATION EFFECTIVENESS,
AND VALUE ………….…………………………………………………………. …... . 115
APPENDIX S. STUDY FLOW CHART…………………………………………….…… 117
APPENDIX T. INFORMED CONSENT DOCUMENT…………………………………. 119
APPENDIX U. DEBRIEFING DOCUMENTS…………………………………..………. 121
APPENDIX V. COGNITIVE DEFUSION SESSION CONTENT……………….……… 123
APPENDIX W. TYPICAL TACTICS SESSION CONTENT…………………………… 127 vii
LIST OF FIGURES
Figure Page
1 Sample Flow Chart………………………………………………………………… 56
viii
LIST OF TABLES
Tables Page
1 Food Selected as Hardest to Resist by Condition ...... 57
2 Number of Items, Possible and Sample Range, Means (SDs) by Condition, and
Cronbach’s Alpha Coefficients of Measures ...... 58
3 Number of Participants by Condition and Session ...... 60
4 Number of Participants by Condition and Intervention Leader……………………. 61
5 Demographic & General Information………………………………………………. 62
6 Meal Arrangement, Body Mass Index Category, Eating Disorders, Dieting,
Prescription Medication, Menstruation, Mindfulness Exposure...... 64
7 Lab-Reported Hunger Level………………………………………………………… 66
8 Average Craving for Non-Sweet Foods, Non-Alcoholic Beverages, Alcohol,
Cigarettes, and Drugs Prior to In-Lab Exposure to Sweet Food….………………… 67
9 Craved Non-Sweet Foods Prior to In-Lab Exposure to Sweet Food……………….. 68
10 Craved Non-Alcoholic Beverages Prior to In-Lab Exposure to Sweet Food………. 69
11 Self-Selected Tactics of Typical Tactics Group……………………………………. 70
12 Combination of Strategies Used by Condition In Lab……………………………… 72
13 In Lab Comprehension, Difficulty, Implementation Effectiveness, and Value by
Condition ………………………………………………………………………… 73
14 Follow-Up Comprehension, Difficulty, Implementation Effectiveness, and Value
by Condition………………………………………………...... 74
15 Correlation Matrix………………………………………………………………….. 75
16 Impact of Intervention on State Sweet Food Craving in the Lab…………………… 77 ix
17 Impact of Intervention on Proportion of Days One Consumed Session-Specific
Sweet Food across Two Weeks………………………………………………….. ... 78
18 Impact of Intervention on Total Self-Reported Sweet Consumption on the
Sweet Craving Information Questionnaire.………………… ...... 79
19 Impact of Intervention on Cognitive Fusion………………………………………. . 79
20 Impact of Intervention on Food Craving Acceptance……………………………… 81
21 Combination of Strategies Used by Condition during the Two Week
Post-Intervention Period………………………… ...... 82
22 Other Craving Strategies Used In the Past Two Weeks other than
Cognitive Defusion - Reported at Follow-Up…………………………...... 83
23 Other Craving Strategies Used In the Past Two Weeks other than Self-Selected
Tactic - Reported at Follow-Up………………………… ...... 84
24 Frequently used Self-Restraint Tactics at Baseline and Follow-Up………………… 85
1
INTRODUCTION
There is an overabundance of nutrient-poor, calorie-dense, highly palatable foods on college campuses (Nelson & Story, 2009). These foods are widely available to college students in dining halls, fast food establishments, convenience stores, and vending machines (Byrd-
Bredbenner et al., 2012; Nelson, Kocos, Lytle, & Perry, 2009). Additionally, college students often store nutrient-poor, calorie-dense convenience foods in their dorm rooms (Nelson & Story,
2009). Because college students have moved away from their family food environment, are able to make more autonomous health behavior decisions, and are developing eating patterns that can impact their long-term health, college students are a prime target for health interventions
(Nelson, Story, Larson, Neumark-Sztainer, & Lytle, 2008). Teaching college students simple and widely-applicable tactics to regulate diet could help them make more healthy dietary choices that would improve their long-term health.
Many nutrient-poor, calorie-dense foods are high in added sugar. Ervin and Ogden
(2013) defined the term added sugars as “all sugars used as ingredients in processed and prepared foods such as breads, cakes, soft drinks, jams, chocolates, and ice cream, and sugars eaten separately or added to foods at the table” (p. 6). Eating large quantities of added sugar is unhealthy, because it is correlated with increased disease prevalence and disease mortality (Basu,
Yoffe, Hills, & Lustig, 2013; Yang et al., 2014).
The average daily amount of added sugar consumed by young adults exceeds the maximum level recommended by the World Health Organization (NCI, 2014; WHO, 2014).
Recent research published by The National Cancer Institute found that, from 2007 to 2010, young adults (19 to 30 years of age) in the United States consumed an average 13 to 14% of their daily calories in the form of added sugar (Britten, Marcoe, Yamini, & Davis, 2006; NCI, 2014). 2
This proportion can be viewed as excessive in light of the recommendations that added sugar
consumption should ideally constitute no more than 5% of daily calories and should not exceed
10% of daily calories (WHO, 2014). When added sugar consumption exceeds these
recommended levels, consumers are more likely to develop diabetes and cardiovascular disease,
independently of body mass index (Basu et al., 2013; Yang et al., 2014).
Long-term excessive consumption of added sugar is associated with increased odds of
dying from cardiovascular disease (Yang et al., 2014), which is the number one cause of death in
the United States (CDC & U.S. Census Bureau, 2013). Yang et al. (2014) found that U.S. adults
who consumed 25% or more daily calories from added sugar, based on a 24-hour dietary recall,
had a significant 2.75 greater odds of cardiovascular disease mortality during a 15-year follow-
up period compared to adults who consumed fewer than 10% of daily calories from added sugar.
These findings were stable after adjustment for potential confounds, including body mass index,
dietary quality, physical activity level, and various socioeconomic status variables.
Consumption of added sugar is not only associated with cardiovascular disease, but Basu
et al. (2013) showed that the availability of added sugar is associated with the prevalence of
diabetes, presumably because availability results in consumption. Using data from 175 countries
spanning the decade of 2000 to 2010, Basu et al. (2013) found that for every 150 calorie increase
in sugar availability there was a corresponding significant 1.1% increase in the prevalence of
diabetes. These findings were stable after adjustment for potential confounds, including body mass index, dietary quality, physical inactivity, and various socioeconomic status variables.
Adults with diabetes are two to four times more likely to have heart disease or experience a stroke than adults without diabetes (CDC, 2015). 3
The development of diabetes and cardiovascular disease is gradual and may begin during
young adulthood. One way to reduce the risk of these disease states is to reduce habitual
consumption of added sugar during young adulthood. One means to achieve this is to help
young adults manage cravings for sweet foods.
Cravings for Sweet Foods
Food cravings are defined as intense desires or urges to eat particular foods (Gendall,
Joyce, & Sullivan, 1997; Weingarten & Elston, 1991). Cravings for a variety of types of foods,
and for sweet foods in particular, are common among college students. Studies have shown that
68 to 100% of college students report that they have experienced food cravings and 35 to 75%
report that they have experienced cravings for sweet foods, such as chocolate, various sweet
baked goods and desserts, ice cream, and candy (Osman & Sobal, 2006; Weingarten & Elston,
1991; Zellman, Garriga-Trillo, Rohm, Centeno, & Parker, 1999). Results from two research studies that asked college students to track their food cravings demonstrated that college students
experienced 9 to 11.5 food cravings during the course of 4 to 7 days (Kemps & Tiggeman, 2013;
Knäuper, Pillay, Lacaille, McCollam, & Kelso, 2011). Using self-monitoring, Hooper, Sandoz,
Ashton, Clark, and McHugh (2012) found that college students craved chocolate 9 to 13 times during a 5-day assessment period.
The foods that college students report craving most intensely are often high in added sugar. Weingarten & Elston (1991) found that 20 to 51% of college students picked a food in the chocolate, ice cream, or sweets and desserts category as their most commonly craved food item.
Chocolate is the most commonly reported sweet food craved by college students, with 9 to 39% of college students reporting that chocolate is their most commonly craved food and 18 to 48% ranking chocolate as one of their top three most commonly craved foods (Hormes & Timko, 4
2011; Osman & Sobal, 2006; Rozin, Levine, & Stoess, 1991; Weingarten & Elston, 1991).
College students have also reported frequent cravings for sweet baked goods that do not contain chocolate. For example, Osman & Sobal (2006) found that 10 to 17% of college students ranked sweet baked goods (cookies, cakes, pies, and pastries) that did not contain chocolate among the top three foods they most craved.
Research has shown that young adults who crave chocolate and sweet baked goods also frequently consume these foods (Welsh, Sharma, Grellinger, & Vos, 2011). Research found that
61 to 78% of college students respond to chocolate craving by consuming chocolate (Hooper et al., 2012; Kemps and Tiggemann, 2013; Osman and Sobal, 2006). Furthermore, food consumption following craving often leads to consumption of a large number of calories. Kemps and Tiggemann (2013) found that when food cravings were indulged, the average caloric intake was 2581 calories per eating occasion and 44% of the foods craved by their sample were for sweet foods.
The frequency with which college students eat sweet foods is likely a combination of taste preference and ready availability of these foods from vending machines, dorm rooms, fast food establishments, and dining halls. For example, Byrd-Bredbenner et al. (2012) surveyed highly-trafficked vending machines at 11 postsecondary college campuses in the United States and found that 44% of the items they contained were sweet foods (candy bars, candy, cookies, pastries and cakes). Additionally, Nelson and Story (2009) found that 75% of college students residing in dorms stocked these sweet foods in their rooms.
Before designing my study, I reviewed research evaluating whether college students perceive craving and/or eating sweet foods as problematic. Schulte, Avena, and Gearhardt
(2015) asked college students whether they had experienced various addictive-like eating 5 patterns in response to certain foods in the past year. Five of the top ten problematic foods reported by students were highly processed, high sugar foods (chocolate, ice cream, cookies, cake, and muffins). Schulte et al. (2015) found that over 90% of the students reported a persistent desire to or repeated unsuccessful attempts to abstain from eating or cut back on consumption of their subjective problematic foods. This information suggested that college students may be motivated to reduce their sweet cravings, because of perceived problematic, addiction-like responses to sweet foods, which may be viewed as incongruent with dietary goals and experienced as distressing.
Elaborated Intrusion Theory of Craving
Because cookies and chocolate candy are frequently craved, readily available at all hours, and frequently consumed, I designed my study to evaluate an intervention intended to reduce consumption of these two types of sweet foods. As a guide for conceptualizing the etiology and maintenance of food craving, and for developing the intervention to be tested in the present study, I selected the Elaborated Intrusion Theory (EIT) of desire (Kavanagh, Andrade, & May,
2005; May, Andrade, Panabooke, & Kavanagh, 2004). This model of craving addresses both external and internal triggers of craving, factors that maintain and escalate craving, and factors that modify the likelihood of consuming craved items.
EIT proposes that external cues (e.g., seeing or smelling the food), anticipatory responses
(e.g., salivation), intrusive thoughts, negative affect, and physiological deficits are sometimes transient and do not result in craving and at other times begin a process that results in craving.
The process that results in craving involves mental elaboration on intrusive thoughts, meaning that the person produces mental images of the properties of the craved items and images of the process of consuming these items. This elaboration results in additional desire thoughts. Mental 6
images and desire thoughts may also be of pleasurable contextual and social factors associated with the craved item (e.g., pleasant settings, enjoyable social connection with particular people) or for substances or other foods that have been paired with the craved item in the past (e.g.,
pleasurable foods, beverages, alcohol, drugs). Elaboration and mental imagery set the
foundation for additional desire thoughts and craving.
According to EIT, imagining and thinking about the craved item can create a sense that
one is actually consuming the item, which can elicit emotions of pleasure and relief typically
associated with previous consumption of the craved item. The mental imagery, pleasant
consumption thoughts, and feelings of pleasure and relief increase personal awareness of current
lack of consumption of the craved item, physiological deficits (e.g., hunger, thirst, and physical
discomfort), and negative affective states.
Prolonged mental elaboration and associated enhanced awareness of unpleasant physical
deficits or negative affect can escalate cravings and result in planning how to obtain and
consume the craved item. Elaborated craving thoughts and imagery and associated planning for
consumption require mental effort and can interfere with engagement in other mental activities.
This mental state can also be experienced as irritating or uncomfortable and may intensify
personal urges to consume the craved item to quiet the mind, improve mental focus, and reduce
associated emotional distress. Cravers’ expectations that they will feel guilty if they consume
the craved item and anxiety that they will not be able to obtain or consume the item, can
compound mental and emotional distress. As Kavanagh, Andrade, & May (2005) eloquently
stated, “the imaginary relish may be sweet, but the deprivation, guilt, and anxiety leave us
tortured” (p. 449). 7
According to EIT, multiple factors can reduce the likelihood of consumption despite the
experience of craving. For example, the likelihood of consumption is lower if the craved item is
unavailable and there are impediments to obtaining the item. Additionally, consumption is less
likely if attention is diverted during the associative cognitive processing of the craved item, such
that the individual engages with mental material that is not related to the craving item. Personal
engagement in consumption-incompatible activities may also reduce the likelihood of
consumption of the craved item. Also, if a person elects to abstain from consuming the craved
item, the person may use various craving management tactics and either reduce or inhibit craved
item consumption. The likelihood of consumption may also be reduced if one must choose
between consuming the craved item or obtaining something of greater value by abstaining. Self-
efficacy – the confidence in one’s ability to refrain from consumption – may also influence
whether a craved item is consumed (Kavanagh, Andrade, & May, 2005).
Research on Interventions for Reducing Food Cravings and/or Craved Food Consumption
The majority of interventions for food cravings developed and evaluated over the past
two decades were tested on normal weight college students (Alberts, Thewissen, &
Middelweerd, 2013; Forman, Hoffman, Juarascio, Butryn, & Herbert, 2013; Forman, Hoffman,
McGrath, Herbert, Brandsma, & Lowe, 2007; Giuliani, Calcott, & Berkman, 2013; Hamilton,
Fawson, May, Andrade, & Kavanagh, 2013; Hooper, Sandoz, Aston, Clarke, & McHugh, 2012;
Jenkins, & Tapper, 2014; Kemps & Tiggemann, 2007; Kemps, Tiggemann, & Bettany, 2012;
Kemps, Tiggemann, & Hart, 2005; Knäuper, Pillay, Lacaille, McCollam, & Kelso, 2011;
Lacaille, Ly, Zacchia, Bourkas, Glaser, & Knäuper, 2014; May, Andrade, Batey, Berry, &
Kavanagh, 2010; Meule, Freund, Skirde, Vögle, & Kübler; Moffitt, Brinkworth, Noakes, &
Mohr, 2012; Skorka-Brown, Andrade, & May, 2014; Skorka-Brown, Andrade, Whalley, & May, 8
2015; Stapleton, Bannatyne, Urzi, Porter, & Sheldon, 2016; van Dillen & Andrade, 2016).
Although some of the interventions appear to reduce food cravings, many of the evaluations had
methodological weaknesses that limit the external validity of their findings. For example, few of
the studies had participants practice strategies during their everyday lives (as opposed to in a
laboratory setting) or over a substantial period of time and few measured food consumption
levels or abstinence (in addition to food craving). Of the studies that involved in situ practice
and/or had participants practice strategies for a sufficient duration and measured craved food
consumption, the most frequently supported strategy was cognitive defusion (Forman et al.,
2007; Jenkins, & Tapper, 2014; Hooper et al., 2012; Lacaille et al., 2014; Moffitt et al., 2012).
Cognitive defusion is a skill that involves separating one’s sense of self from transient
thoughts and images in one’s mind. Applied to craving, cognitive defusion is an active process
of becoming aware of craving thoughts, labeling them as “just thoughts,” thinking of oneself as
an observing self who is different from one’s thoughts, and imagining distancing oneself from
the craving thoughts (Forman et al., 2007; Gillanders et al., 2014; Hooper et al., 2012; Jenkins &
Tapper, 2013; Lacaille et al., 2014).
Cognitive defusion is typically taught in a series of steps. First, clinicians explain the
concept of cognitive defusion and provide a rationale for its use. Then, they provide verbal and
written instructions on how to use the strategy and instruct participants to practice cognitive
defusion in a laboratory context and/or in real life conditions (Forman et al., 2007; Jenkins, &
Tapper, 2014; Hooper et al., 2012; Lacaille et al., 2014).
Clinicians teaching this strategy encourage clients to view craving thoughts as
uncontrollable and to consider that excessive attachment to such thoughts, when they do not match personal eating goals, increases the likelihood of undesired eating behaviors (Forman et 9
al., 2007; Jenkins & Tapper, 2013; Hooper et al, 2012). Clinicians also explain that when people
are very attached to craving thoughts and take their content literally, they may believe that the
craving thoughts cause the eating behavior. Clients are also taught that engagement in cognitive
defusion reduces the likelihood that one will respond to craving with consumption.
Interventionists often use metaphors to help participants learn cognitive defusion (Jenkins
& Tapper, 2014; Lacaille et al., 2014). For example, Jenkins and Tapper (2014) asked
participants to imagine that they were a driver of a bus. They were asked to think of their thoughts about eating as passengers on the bus. The participants were encouraged to describe these passengers (thoughts), let the passengers know who is in charge (the participant), or imagine the passengers speaking with a foreign accent or musical tone. They were asked to use
this metaphor when practicing cognitive defusion on their own.
Several research investigations have explored the use of mindfulness-based interventions
for food cravings experienced by college students (Alberts, Thewissen, & Middelweerd, 2013;
Forman et al., 2007; Hooper et al., 2012; Jenkins, & Tapper, 2014; Lacaille et al., 2014). Two of
these studies investigated cognitive defusion training alone, rather than as part of a
comprehensive mindfulness-based intervention for food craving (Hooper et al., 2012; Jenkins &
Tapper, 2014). Jenkins and Tapper (2014) investigated the impact of cognitive defusion training
versus acceptance training versus progressive muscle relaxation training among people who
liked chocolate. After the initial training session, they provided participants with transparent
bags containing chocolate, told them to carry the bags everywhere, and instructed them to abstain
from eating chocolate for five days. The cognitive defusion group, but not the acceptance group,
consumed significantly less chocolate from the transparent bags as compared to the progressive 10
muscle relaxation group during the study period. There were no differences in consumption
between the cognitive defusion and acceptance groups.
Hooper et al. (2012) compared a cognitive defusion training condition to a thought
suppression condition and a typical tactics control condition among frequent chocolate eaters. In
the typical tactics condition, participants were told to select, practice, and use a tactic they had typically used when faced with food cravings. Following training, the researchers provided the participants with food craving diaries and instructed them to abstain from eating chocolate for a five-day follow-up. After the follow-up, participants returned to the lab and participated in a bogus taste test. The researchers found that consumption of chocolate did not differ between participants in the cognitive defusion training and typical tactics conditions during the abstinence period. However, the cognitive defusion training condition consumed significantly fewer chocolates during the bogus taste test (M = 3.31) compared with the typical tactics condition (M
= 10.93) and the thought suppression condition (M = 14.59). The evidence from Jenkins and
Tapper (2014) and Hooper et al. (2012) suggests that isolated cognitive defusion training has been shown to reduce in situ chocolate consumption and chocolate intake during exposure inside the lab.
Three research studies have included cognitive defusion as one of several strategies in mindfulness-based interventions for food cravings. In the first of these studies, Forman et al.
(2007) compared the impact of an Acceptance and Commitment Therapy (ACT) intervention that included cognitive defusion, a cognitive and behavioral intervention, and a no-instruction control condition in a sample of individuals that liked chocolate. Participants in the cognitive and behavioral intervention were taught behavioral redirection strategies, mental distraction techniques (memory delving, positive imagery, and counting challenges), and cognitive 11
restructuring. After the trainings, the researchers provided participants with transparent boxes
containing chocolate, told them to carry them everywhere, and instructed them to abstain from eating chocolate for 48 hours. The researchers found that individuals in the ACT intervention with a high level of drive toward and responsiveness to palatable foods reported lower food craving intensity across the study period compared to individuals in the no-instruction condition.
Additionally, among individuals high on drive toward and responsiveness to palatable foods, those who engaged in the ACT intervention reported lower food craving temptation and craving- related distress during the study period in comparison to those who engaged in the cognitive and behavioral intervention. These findings indicate that a comprehensive mindfulness-based intervention for food craving may increase the manageability of food cravings for individuals with a strong self-reported drive toward and responsiveness to palatable foods (Forman et al.,
2007).
Lacaille et al. (2014) compared the impact of five different conditions, including (1)
awareness, (2) awareness plus acceptance, (3) awareness plus cognitive defusion, (4) awareness
plus acceptance plus cognitive defusion, and (5) mental distraction (mental counting) in a sample
of chocolate cravers. Following training, participants were instructed to practice the skills they
were taught during the next two weeks. The researchers found that trait craving for chocolate
decreased significantly more from pre-intervention to follow-up among individuals in the
awareness condition and awareness plus cognitive defusion condition compared to the mental
distraction condition. Furthermore, at follow-up, participants in the awareness and awareness plus cognitive defusion conditions showed smaller increases in state chocolate craving during lab
exposure to chocolate candy in comparison to those in the mental distraction condition. There 12
were no significant differences in these craving variables when Lacaille compared the two acceptance conditions to the mental distraction condition.
Alberts, Thewissen, and Middelweerd (2013) compared a mindfulness intervention that included awareness and acceptance training to a thought suppression condition and a control condition (no education on a craving strategy). Those in the mindfulness condition and thought suppression conditions were told to refrain from eating the palatable foods and those in the control condition were allowed to eat freely. After the trainings, the researchers exposed participants to highly palatable sweet and salty foods for six minutes. The researchers found no difference in the level of state food craving between the awareness and acceptance condition and the thought suppression condition.
These three studies did not provide evidence that acceptance is a beneficial component of mindfulness-based interventions for food cravings. Furthermore, the results from one of these studies suggests that training acceptance may weaken the impact of concurrently trained mindfulness skills on trait craving and state craving in response to cue exposure (Lacaille et al.,
2014).
All of the aforementioned interventions were evaluated using primarily normal weight college students. Other research has investigated mindfulness-based interventions for food cravings using older adult samples that included a larger proportion of or exclusively overweight individuals (Forman et al., 2013; Moffitt et al., 2012). Although they did not study college students, these investigations provide some evidence regarding the impact of mindfulness-based interventions on food craving and eating outcomes.
Moffitt et al. (2012) compared the impact of cognitive defusion training versus cognitive restructuring training versus a typical tactics control condition on food craving in a large 13
community sample of adult chocolate cravers, some whom were classified as overweight (MBMI
= 26.5). After trainings, they provided participants with transparent bags of chocolate to carry during a seven-day follow-up. Individuals in the cognitive defusion group had 4.61 times higher odds of abstaining from all chocolate-containing foods than those in the typical tactics condition and had 3.26 times higher odds of abstaining from these foods than the cognitive restructuring group during the follow-up. Furthermore, among the subset of participants who reported a high level of cognitive distress in response to chocolate craving, those who received the cognitive defusion training ate significantly less chocolate-containing foods during follow-up than those who took part in the other conditions.
Forman et al. (2013) compared an ACT intervention that included cognitive defusion against a cognitive and behavioral intervention in a small community sample of overweight and obese (MBMI = 33) adult women who reported frequent occurrence of cravings and consumption of sweet foods. Forman et al. (2013) found no difference between conditions on either craving during the 72-hour follow-up or consumption during a bogus taste test after follow-up.
However, the small sample size (n = 48) and short follow-up duration limited the potential value of this intervention and the strength of the study’s findings.
Design of the Current Study
My broad goal was to design and evaluate a cognitive defusion intervention to help university students manage their cravings for sweet foods. First, I modified content from previous protocols to improve comprehensibility by using simpler language and explanations of concepts. Additionally, I included more experiential training than had previous interventions.
Because mindfulness-based approaches are predicated on the idea that experience promotes personal growth and positive change more than conceptual understanding, I shifted the balance 14
of intervention components to include relatively more experience using cognitive defusion as
compared to pure verbal instruction.
Previous investigators have trained participants to use cognitive defusion without
exposing them to food during training. Assuming that exposure would enhance training by demonstrating that craving need not result in consumption, I had participants engage in cognitive
defusion in the presence of the specific type of sweet food that he/she found particularly hard to resist.
Comparison Condition
Previous interventions have compared cognitive defusion to both active and passive control conditions. I compared my intervention to an active control condition. Specifically, I compared cognitive defusion to a typical tactics condition, in which participants were instructed
to employ a craving management strategy that they had used previously and found useful and to
use it during the study period. This control condition has been used by previous researchers
(Hooper et al., 2012; Moffitt et al., 2012).
Hypotheses and Analyses
• Hypothesis 1: There will be an interaction between condition (cognitive defusion; typical
tactics control) and time (pre; post), such that participants in the typical tactics control
condition will experience a significantly greater increase in scores on the Food Craving
Questionnaire – State from pre-strategy-initiation to post-strategy-use during cue
exposure to their “hardest to resist” sweet food. I conducted two 2 x 2 mixed model
ANOVAs, one for chocolate candy and one for cookies, to test this hypothesis.
• Hypothesis 2: There will be a significant difference in overall sweet food consumption
(Daily Sweet Food Consumption Survey), such that participants in the cognitive defusion 15
intervention will consume significantly fewer total sweet foods than participants in the
typical tactics condition during the two weeks surveyed. I had planned to conduct a t-test
to evaluate this hypothesis, but decided not to do so because of numerous participant
errors when reporting on this aspect of their behavior.
• Hypothesis 3: There will be a significant difference in session-specific (cookie or
chocolate candy) sweet food consumption (Daily Sweet Food Consumption Survey:
cookie consumption and chocolate consumption) by condition (cognitive defusion;
typical tactics control), such that participants in the cognitive defusion intervention will
report significantly lower consumption of session-specific sweet foods during the two
weeks surveyed. I conducted two 2 (Condition: cognitive defusion; typical tactics) X 2
(Lab Session Type: cookie; chocolate candy) univariate ANOVAs with chocolate candy
and cookie consumption as respective outcome variables to test this hypothesis.
• Hypothesis 4: There will be an interaction between condition (cognitive defusion; typical
tactics control) and time (baseline; follow-up), such that participants in the cognitive
defusion intervention will experience a significantly greater decrease in consumption of
all sweet foods from baseline to two-week follow-up (Sweet Craving Information
Questionnaire – Baseline and Past Week versions). I conducted a 2 x 2 mixed model
ANOVA to test this hypothesis.
• Hypothesis 5: There will be an interaction between condition (cognitive defusion;
typical tactics control) and time (baseline; follow-up), such that participants in the
cognitive defusion intervention will show a significantly greater decrease in cognitive
fusion (Cognitive Fusion Questionnaire) from baseline to two-week follow-up. I
conducted a 2 x 2 mixed model ANOVA to test this hypothesis. 16
• Hypothesis 6: There will be an interaction between condition (cognitive defusion; typical
tactics control) and time (baseline; follow-up), such that participants in the cognitive
defusion intervention will show a significantly greater increase in acceptance of urges
and cravings to eat (Food Craving Acceptance and Action Questionnaire – Acceptance
subscale) from baseline to two-week follow-up. I conducted a 2 x 2 mixed model
ANOVA to test this hypothesis.
• Hypothesis 7: There will be an interaction between condition (cognitive defusion; typical
tactics control) and time (baseline; follow-up), such that participants in the cognitive
defusion intervention will show a significantly greater increase in willingness to
experience cravings without eating (Food Craving Acceptance and Action Questionnaire
– Willingness subscale) from baseline to two-week follow-up. I had planned to conduct a
2 x 2 mixed model ANOVA to evaluate this hypothesis, but chose not to do so because
the internal reliability of this subscale was so low at baseline and follow-up.
• Hypothesis 8: In each condition, higher baseline trait craving (Food Craving
Questionnaire-Trait), higher baseline addictive-like responses to palatable foods (Yale
Food Addiction Scale), and lower baseline mindfulness (Five Facet Mindfulness
Questionnaire-Short Form) will be associated with higher consumption of sweet foods
(Sweet Food Consumption Questionnaire – Baseline and Past Week versions) at baseline
and two-week follow-up. I calculated Pearson product moment correlations to test this
hypothesis.
17
METHOD
Participants, Recruitment, and Incentives
I conducted power analyses using G-Power software. Using an alpha level of .05 and a desired power level of .80, I would need a minimum of 153 participants to detect a small bivariate correlation (r = .20), 148 participants to detect a small repeated-measures between factors effect (f = .20), and 52 participants to detect small repeated measures within factors and repeated measures within-between interaction effects. Therefore, I aimed to recruit and enroll a minimum of 160 undergraduate and graduate students enrolled at Bowling Green State
University (BGSU) as participants. Of the 161 undergraduate and graduate students who signed up online for a lab session, 120 individuals attended a lab session. Of those, five were eliminated for not completing the baseline survey, five were eliminated due to a procedural error, seven were eliminated for not completing seven or more daily surveys prior to follow-up, and seven were eliminated for not completing the follow-up survey (see Figure 1: Sample Flow Chart).
The remaining 96 participants comprised the sample for analysis.
Following approval by the Human Subjects Review Board, I recruited participants during the 2015-2016 academic year by posting a notice on the BGSU Sona Research Participation
System and by sending emails to the entire BGSU student body. To be eligible for the study, participants had to be 18 years of age or older, experience cravings for sweet foods 7 or more times per week, eat craved sweet foods 4 or more times per week, have the desire to reduce the frequency of their intake of craved sweet foods, have no food allergies to ingredients commonly found in chocolate candy or cookies, be willing to receive two daily reminder texts for a period of two weeks, and be willing to complete a three-item survey on their eating habits each day for two weeks. Participants who were not eligible for research credit for their courses were provided 18 with a $5 Amazon gift card upon completion of participation in the study. For the recruitment documents refer to Appendix A.
Measures
Eligibility Screener. I designed this questionnaire to assess participant eligibility for the study. It included questions regarding non-minor status, frequency of sweet cravings, frequency of eating sweet foods, presence of food allergies, willingness to receive twice daily reminder texts, and willingness to complete brief daily surveys (see Appendix B).
Demographics and General Information Survey. I designed this questionnaire to assess participants’ demographic characteristics, other potential study covariates (e.g., previous exposure to mindfulness; medication use; dieting status; weight; height; ever diagnosis or professional treatment for an eating disorder; current belief that one has an eating disorder), and to collect participants’ phone numbers for texting purposes (see Appendix C).
Chocolate Candy Form. I designed this form to measure which chocolate candy a participant found most difficult to resist eating (see Appendix D). The form lists the five most frequently purchased chocolate candies at Bowling Green State University (BGSU), based upon information about chocolate candy sales provided by the BGSU dietician. The instructions for the list read “Please select which of the following you would find hardest to resist.” The chocolate candy selected from this list as “hardest to resist” was used during the cue exposure portion of the chocolate candy session. Table 1 provides information on the number of participants who selected each type of chocolate candy as hardest to resist. These items were used during the exposure portion of the lab sessions.
Cookie Form. I designed this form to measure which cookie a participant found most difficult to resist eating (see Appendix D). The form lists five of the six most frequently 19
purchased cookies at BGSU, based upon information about cookie sales provided by the BGSU
dietician. The instructions are identical to those on the Chocolate Candy Form. The cookie
selected from this list as “hardest to resist” was used during the cue exposure portion of the
cookie session. Table 1 provides information on the number of participants who selected each
type of cookie as hardest to resist. These items were used during the exposure portion of the lab
sessions.
Food Craving Questionnaire-Trait. This questionnaire, designed by Cepeda-Benito et al.
(2000), comprises 39 items that measure habitual experience of food cravings (see Appendix E).
Examples of items are “When I crave something, I know I won't be able to stop eating once I
start” and “If I am craving something, thoughts of eating it consume me.” A six-point response
scale (1 = Never/not applicable; 6 = Always) is used to assess agreement with each item.
Evaluation of the trait craving scale using college students (Cepeda-Benito et al., 2000) found
excellent internal consistency (α = .97). Subscales of the Food Craving Questionnaire-Trait have shown convergent validity with subscales of disinhibited eating (rs = .45 - .66) and perceived hunger (rs = .32 - .66). Three-week test-retest reliability was very good (r = .88) (Cepeda-Benito et al., 2000). In my sample, internal consistency reliability was excellent (α = .96). See Table 2
for all measures’ number of items, possible and sample ranges, means and standard deviations by
condition, and Cronbach’s alpha coefficients.
Cognitive Fusion Questionnaire. This questionnaire, designed by Gillanders et al.
(2014), comprises 7 items that measure general cognitive fusion, which is defined as the
tendency for a person to be excessively connected to personal cognitive content and for the
person’s behavior to be excessively regulated and influenced by cognitive events (see Appendix
F). Examples of items are “I get so caught up in my thoughts that I am unable to do the things 20 that I most want to do” and “I tend to get very entangled in my thoughts.” A seven-point response scale (1 = never true, 7 = always true) is used to assess the degree to which item statements hold true for respondents. Among young adults and non-clinical community adults the CFQ’s internal reliability was α = .90 (Gillanders et al., 2014). The 1-month test-retest reliability of the measure has been shown to be r = .81 among a community sample of adults.
The measure has substantial convergent validity with measures of mindfulness (rs = -.50 to -.70). and psychological inflexibility (rs = .72 - .87). In my sample, internal consistency reliability was excellent at baseline (α = .95) and follow-up (α = .94).
Food Craving Acceptance and Action Questionnaire. This questionnaire, designed by
Juarascio, Forman, Timko, Butryn, and Goodwin (2011), comprises 10 items that measure acceptance of urges and cravings to eat and willingness to experience cravings without responding to them with eating (see Appendix G). Examples of items are “I need to concentrate on getting rid of my urges to eat unhealthily” (reverse scored) and “It's OK to experience cravings and urges to overeat, because I don't have to listen to them.” A seven-point response scale (1 = very seldom true; 6 = always true) is used to assess the degree to which item statements hold true for respondents. The items load on one of two subscales: acceptance and willingness. The acceptance subscale measures how accepting an individual is of food-related thoughts that they appraise as personally distressing. The willingness subscale measures an individual’s willingness to control eating despite food cravings. Among female college students
(Juarascio et al., 2011), internal reliability for the full measure was excellent (α = .93) and 3-7 day test-retest reliability was good (ICC = .72). In a sample of both university students and non- student community members the Food Craving Acceptance and Action Questionnaire has shown convergent validity with measures of emotional eating (r = - .34), hyper-responsivity to food (r = 21
-.37), preoccupation with weight and appearance (r = -.42), and psychological flexibility (r =
.33) (Juarascio et al., 2011). In my sample, internal consistency reliability for the Willingness
subscale was poor at baseline (α = .49) and follow-up (α = .51), but internal consistency
reliability for the Acceptance subscale was acceptable at baseline (α = .83) and follow-up (α =
.84).
Yale Food Addiction Scale. This questionnaire, designed by Gearhardt, Corbin, and
Brownell (2009), comprises 16 items that assess the extent to which an individual exhibits signs of addiction to foods high in fat, refined carbohydrates, or added sugar (Appendix H). The measure provides a list of highly palatable foods and then asks how frequently the individual has experienced difficulty with these foods in the past year on a five-point response scale (0 = never;
4 = 4 or more times or daily). Examples of items include “I find that when I start eating certain
foods, I end up eating much more than planned,” “I find myself continuing to consume certain
foods even though I am no longer hungry,” and “I eat to the point where I feel physically ill.”
According to Gearhardt et al. (2009), the internal reliability of the Yale Food Addiction Scale
among college students was low (Kuder–Richardson α = .75). The symptom count score for this
measure shows moderate convergent validity with measures of eating disorder symptomatology
(r = .46), emotional eating (r = .51), and binge eating (r = .35) among college students.
Five Facet Mindfulness Questionnaire – Short Form. This questionnaire, designed by
Bohlmeijer, ten Klooster, Fledderus, Veehof, and Baer (2011), comprises 24 items that measure
respondents’ level of mindfulness (see Appendix I). Examples of items are “It seems I am
“running on automatic” without much awareness of what I’m doing” (reverse scored) and
“Usually when I have distressing thoughts or images I can just notice them without reacting.” A
five-point response scale (1 = never or very rarely true; 5 = very often or always true) is used to 22
assess the degree to which respondents believe that each item describes their attitudes. This
measure has five subscales corresponding to each of the five facets of mindfulness: Observing,
Describing, Acting with awareness, Non-judging of inner experience, and Non-reactivity to inner experience. Bohlmeijer et al. (2011) reported low to excellent internal reliability of the five subscales, Observing α = .78, Describing α = .91, Acting with awareness α = .86, Non-judging of
experience α = .86, and Non-reactivity to inner experience α = .73. In my sample, internal
consistency reliability for the five subscales was acceptable: Observing α = .73, Describing α =
.77, Acting with awareness α = .81, Non-judging of experience α = .76, and Non-reactivity to inner experience α = .71.
Sweet Food Consumption Questionnaire – Baseline and Past Week Versions. I designed these six-item questionnaires to assess typical weekly consumption and past week consumption of six types of sweet food (see Appendix J). A total self-reported sweet consumption variable
was calculated for both baseline and two week follow-up. At baseline, this variable was a sum
of the number of chocolate candies, sweet baked goods, sweet dairy products, non-chocolate
sweets, high sugar cereals, and other sweets that a participant ate in a typical week. At follow-up participants were asked to report on the number of sweets they ate in these categories during the previous week, and the category counts were summed in the same manner.
Self-Restraint Tactics for Sweet Cravings Questionnaire. I designed this questionnaire to measure how often participants’ used forty-two in-the-moment strategies to moderate or abstain from eating sweet foods when craving (see Appendix K).
In-Lab Deprivation, Hunger, and Craving Questions. This question set included an inquiry on deprivation adherence, a hunger rating, and questions about cravings for items other than sweet foods (see Appendix L). 23
In-Lab Comprehension. I designed this question to assess the degree to which participants understood the session content (see Appendix M).
Food Craving Questionnaire-State. This questionnaire, designed by Cepeda-Benito,
Gleaves, Williams, and Erath (2000), comprises 15 items that measure state food cravings (see
Appendix N). For my study, I customized the items to refer to the food category of sweet foods.
Examples of items are “My desire to eat sweet foods seems overpowering” and “Eating sweet
foods would make things seem just perfect.” A five-point response scale (1 = strongly disagree;
5 = strongly agree) is used to assess agreement with each item. Evaluation of the Food Craving
Questionnaire-State using samples of college students (Cepeda-Benito et al., 2000; Meule et al.,
2014) found excellent internal consistency (αs = .89 - .94). Three-week test-retest reliability was r = .56 (Cepeda-Benito et al., 2000). This value, when compared to the corresponding three- week test-retest reliability for the Food Craving Questionnaire-Trait, is consistent with the proposition that state cravings for food are less stable than trait cravings. In my sample, internal consistency reliability for the Food-Craving Questionnaire-State-Cookie Version was excellent immediately after exposure to a preferred cookie (α = .92) and after a five minute period of practicing a craving management strategy with the cookie present (α = .92). Internal consistency reliability for the Food-Craving Questionnaire-State-Chocolate Candy Version in my sample was good immediately after exposure to a preferred chocolate candy (α = .84) and excellent after a five minute period of practicing a craving management strategy with the chocolate candy present
(α = .90).
In-Lab Questions on Strategy Comprehension, Use, Difficulty, Implementation
Effectiveness, and Value. I designed these questions to measure perceived comprehension of the target strategy, difficulty of using the target strategy, effectiveness at implementing the target 24
strategy, and value of the target strategy to help reduce sweet food consumption. This question
set also assessed whether participants used the target strategy, used non-target strategies, and
what non-target strategies they used, if applicable, during the lab session (see Appendix O).
Group Climate Questionnaire – Modified. I modified Mackenzie’s (1983) 12 item measure, which assesses group members’ perceptions of the group atmosphere, to make it applicable to my intervention, in which those who attended the sessions had little interaction with one another (see Appendix P). The modified measure comprised 7 items. Examples of items include “The members were pleasant to each other” and “The members appeared tense and anxious.” A seven-point response scale (0 = not at all; 6 = extremely) is used to assess the extent to which participants believed various descriptions applied to the group he/she was a part of during a session. For the purposes of this study, relevant selected items representing conflict and avoiding were reverse scored and a composite summary score was created from engaged items and reverse scored conflict and avoiding items. Thus, higher scores indicate more positive group climate. In my sample, internal consistency reliability of this modified measure was acceptable (α = .72).
Daily Sweet Food Consumption Survey. I designed this three-item questionnaire to assess daily chocolate candy consumption, daily cookie consumption, and overall sweet food consumption (see Appendix Q). Participants completed daily sweet consumption surveys an average of 12.8 days out of fifteen possible survey days (SD = 2.0), with a range of eight to fifteen total surveys completed. Because some participants did not report their cookie, chocolate, or total sweet food consumption every day during the two-week follow-up, I calculated two dependent measures based on the number of days on which consumption was reported.
Specifically, I calculated (1) the proportion of days a participant consumed chocolate candy 25
divided by the total number of days that the participant reported whether or not he/she had eaten
chocolate candy and (2) the proportion of days a participant ate cookies divided by the total
number of days that the participant reported whether or not he/she had eaten cookies.
Two-Week Follow-Up Questions on Strategy Comprehension, Use, Difficulty,
Implementation Effectiveness, and Value. This six-item measure assessed perceived
comprehension of the target strategy, difficulty of using the target strategy, effectiveness at
implementing the target strategy, and value of the target strategy to help reduce sweet food
consumption in the previous two weeks. This question set also assessed how frequently
participants used cognitive defusion or selected craving-management tactics during the previous
two weeks and whether participants used strategies other than cognitive defusion (experimental
group) or different strategies than originally selected (control group) to manage sweet cravings
during the previous two weeks (see Appendix R). The question sets were customized to the
experimental and control conditions.
Procedure
Participants signed up for a laboratory session based upon which of two sweet categories
-- (1) chocolate candy or (2) cookies -- they craved more intensely. One session for each of
these sweet categories was offered per week. Sessions were scheduled at 4:00, 4:30, 5:00, or
5:30 p.m. on Monday, Tuesday, Wednesday, or Thursday. Each session included 2-8 participants. A total of 28 sessions were held over the course of the fall and spring 2015-2016 academic year. There were an equal number of sessions of each condition and lab session type
(cookie or chocolate candy). Refer to Table 3 for a listing of the number of sessions of each lab session type by condition. For a flow chart of the study design, refer to Appendix S. 26
Sona research system participants were given online instructions to complete a baseline
survey four days before coming to the session by following a web link provided online. They
were also e-mailed the survey link four days prior to the session date that they selected online.
The baseline surveys were tailored to participants’ self-selected preferred sweet food category.
Individuals not eligible for Sona research system credits who expressed interest in the study via
e-mail were provided with upcoming chocolate candy and cookie sessions to choose from and
were e-mailed the relevant baseline survey.
The informed consent document appeared at the beginning of the baseline survey (see
Appendix T). The baseline measures for all sessions were: the Eligibility Screener,
Demographics and General Information Survey, the Food Craving Questionnaire-Trait,
Cognitive Fusion Questionnaire, Food Craving Acceptance and Action Questionnaire, Five Facet
Mindfulness Questionnaire-Short Form, Yale Food Addiction Scale, Sweet Food Consumption
Questionnaire – Baseline Version, and Self-Restraint Tactics for Sweet Cravings Questionnaire.
The Eligibility Screener was administered immediately following the informed consent document. If a given participant answered “No” to any of the screener questions, he/she received a message stating “You are ineligible for this study. Please seek out other studies.”
All eligible participants were permitted to complete the full baseline survey. Individuals signed up for the chocolate candy session were asked to complete the Chocolate Candy Form, to indicate the chocolate candy that they found hardest to resist from a list of five items. At the end of the baseline survey, they were given instructions stating “Please do not consume any chocolate candy or chocolate-containing foods or chocolate-containing beverages for the 24 hours before the study.” Those signed up for the cookie session were asked to complete the
Cookie Form, to indicate the cookie that they found hardest to resist from a list of five items. At 27
the end of the baseline survey, they were given instructions stating “Please do not consume any
cookies or sweet baked goods for the 24 hours before the study.” At the end of the baseline
survey, all participants were instructed to refrain from eating any food and beverages (except
water) for 3 hours before the study. An e-mail message was sent to participants a full day before
the in-person lab sessions repeating the session-specific and general food deprivation
instructions.
Participants were quasi-randomly assigned to either the experimental intervention or
control condition, with the proviso that no two cells differed by eight or more participants. If the
cell sizes became lopsided, the cell with the fewest participants was selected for that session to
redress in the imbalance in cell sizes.
Four female clinical graduate students, including myself, administered the sessions on a
rotating basis, with each student administering one session every two weeks. My research
assistants and I led an equal number of total sessions (Maija: 8, Kristin 7, Sonia 6, Liz: 7), but a
Chi-Square test revealed that there was a significant association between leader and the number
of participants each instructed in each condition (cognitive defusion or typical tactics), χ(1) =
14.2, p = .003. See Table 4 for information on the number of participants in each condition that
each intervention leader instructed.
All sessions were audiotaped and lasted approximately 30 minutes. The four female
graduate student administrators were paired up with another facilitator. Each group facilitator in
a pair listened to all of the audiotapes of her pair mate and provided her with written feedback on
each of her sessions, which included comments on deviations from the protocol, praise for
adherence and enthusiasm, and/or constructive feedback. The pairings of group administrators were different for sessions held during the fall and spring semesters. 28
When participants arrived at the lab, research administrators asked them to sign in by writing down their e-mail address. They were asked individually whether they refrained from eating session-specific foods for the previous 24 hours (Chocolate candy group: chocolate candy, chocolate-containing foods, and chocolate-containing beverages; Cookie group: cookies and sweet baked goods) and from eating all food and beverages (except water) for the previous 3 hours, as instructed. Participants who reported not having complied with these requests (n = 4) were dismissed from their session and given an opportunity to re-schedule for another group session of the same kind. Before teaching session content, remaining participants were asked to complete the In-Lab Deprivation, Hunger, and Craving Questions, which instructed them to rate their hunger on a ten-point scale and report their current level of craving for cigarettes, alcohol, drugs, non-alcoholic beverages, and non-sweet food items and the types of craved items.
To send participants text messages and the daily survey over the two-week follow-up, I used Remind (https://www.remind.com/), a website from which texts can be sent on a daily basis at specified times to multiple cellular devices or e-mail addresses. The twice daily texts to use craving management strategies were sent at 11:00 a.m. and 5:00 p.m. The daily text that featured a web link to the Daily Sweet Food Consumption Survey was sent at 9:00 p.m.
The email for the two-week follow-up survey instructed participants to complete the survey within 48 hours. I e-mailed all participants who did not complete the survey in that time frame and stated that they must complete the survey in the following 48 hours to get Sona credit.
The measures administered at the follow-up included the Two-Week Follow-Up Questions on
Strategy Comprehension, Use, Difficulty, Implementation Effectiveness, and Value, Cognitive
Fusion Questionnaire, Food Craving Acceptance and Action Questionnaire, Sweet Food 29
Consumption Questionnaire – Past Week Version, and Self-Restraint Tactics for Sweet Cravings
Questionnaire.
The two-week follow-up survey also included a debriefing form (see Appendix U), tailored to each condition. Both forms contained information about psychotherapy resources in the area, with specific information on psychotherapeutic resources for people with eating disorders. The debriefing form for the control group also provided information about the cognitive defusion intervention and stated that control group participants could schedule a time with the researcher to receive the experimental intervention if they so desired. No control group participants chose to engage in an experimental session.
Content of Cognitive Defusion Experimental Intervention
Research administrators provided a 20-minute PowerPoint presentation (see Appendix V)
describing cognitive defusion, a rationale for its use, used experiential exercises, and provided
proposed benefits of its use. After this, participants were given an opportunity to ask questions
and were asked to rate the degree to which they understood the instructions. Then participants were handed a small wallet-sized card with two basic steps for applying cognitive defusion to sweet cravings.
The participants were told that they would soon be exposed to their desired chocolate candy or cookie and that they would be asked to practice using cognitive defusion to manage craving thoughts and urges that arose during exposure. Then, research administrators brought out the chocolate candy or cookie items participants had previously reported as hardest to resist, and placed the relevant food item in front of each participant. During cue exposure, the session administrators asked the participants to break their chocolate candy or cookie apart, smell it, and 30
touch it to their lips, but not eat it. Participants were then asked to complete the customized
chocolate-candy or cookie Food Craving Questionnaire-State (Time1).
After initial cue exposure and completion of the Food Craving Questionnaire-State
(Time1), participants were asked to practice cognitive defusion on their own and in silence for 5 minutes, using the cue card as an aid. The customized state craving questionnaire was then re- administered (Time 2). Next, participants recorded what strategies they had used during the 5
minutes to reduce their craving during exposure (to check for adherence), how difficult it was to
use cognitive defusion, how effective they perceived they were in implementing cognitive
defusion, and how valuable they deemed cognitive defusion to be as a strategy to reduce their
consumption of sweets.
Content of Typical Tactics Control Condition
Research administrators provided a 20-minute PowerPoint presentation (see Appendix W)
describing typical tactics, a rationale for their use, used experiential exercises, and provided
proposed benefits of their use. At the end of the presentation, participants were asked to write
down, without speaking aloud, a preferred food craving tactic that they had used to manage food
cravings in the past and had found to be effective. Then, they were handed two cards and asked
to write down a short description of their self-selected tactic on both cards (a blank wallet-size
card and an index card) and their e-mail address on the index card. The latter card was provided
to the researcher. After this, participants were given an opportunity to ask any questions and rate
the degree to which they understood the instructions.
Next, the participants were told that they would soon be exposed to their desired
chocolate candy or cookie and that they would be asked to practice using their selected tactic to
manage any craving thoughts and urges that arose during exposure. Then the same exposure 31
procedure implemented during the cognitive defusion condition was used. Participants then completed the customized chocolate-candy or cookie Food Craving Questionnaire-State (Time
1).
After this, participants were asked to practice their selected tactic on their own and in silence for 5 minutes using the wallet-size description card as an aid, after which the customized state food craving questionnaire was re-administered (Time 2). Next, participants recorded what craving tactics they had used during the 5 minutes to manage their craving during exposure (to check for adherence), how difficult it was to use their selected tactic, how effective they perceived they were in implementing their selected tactic, and how valuable they deemed their selected tactic to be as a strategy to reduce their consumption of sweets.
Preparation for Two-Week Follow-Up and Evaluation of Group Climate
Participants were asked to sign up to receive texts during the session and were provided with sign-up instructions. All participants had cellular devices and I ensured that each participant was successfully signed up to receive texts after his/her lab session. They were also informed about the content and timing of texts reminding them to use their craving management strategies (e.g., “Use Cognitive Defusion” or “Use Your Selected Tactic”) and were informed of the requirement to complete 75% of the Daily Sweet Food Consumption surveys sent to them in order to obtain credit or a $5 Amazon gift card. Participants were told to carry their wallet-size cards with them at all times and, depending on their condition, use either cognitive defusion or their selected tactic for all sweet food cravings during the forthcoming two weeks. At the conclusion of the session, participants were informed that they would be e-mailed a web link to the two-week follow-up survey and were asked to complete the Group Climate Questionnaire –
Modified. 32
DATA ANALYSIS
Management of Missing Data and Outliers
Twenty-five participants had missing data on either the chocolate candy or cookie consumption question on the Daily Sweet Food Consumption Survey on one or more days. I decided to impute each individual’s median number of daily cookies or chocolate candies in place of the missing data points. I chose median imputation rather than mean imputation, because occasionally participants had an outlier value of cookie or candy consumption, which would significantly skew the mean, but would not substantially skew the median. I made a total of thirty-three median imputations, with fifteen imputations for chocolate candy consumption and eighteen imputations for cookie consumption.
There were seven univariate outliers, defined as a Z score ± 3.25 on any measure. For outcome variables, there was one outlier for the Sweet Food Consumption Questionnaire –
Baseline Version (Z = 3.74) and two outliers for the Sweet Food Consumption Questionnaire –
Past Week Version (Z = 4.98; Z = 3.25). There was one outlier for the Group Climate
Questionnaire – Modified (Z = - 4.06), two outliers for age (Z = 7.08, Z = 3.63), and one outlier for body mass index (Z = 4.87). Although four of these Z scores appear notably large, I did not eliminate any outliers because the raw scores were not implausible values.
33
RESULTS
Participant Characteristics
Randomization was successful. Firstly, there were no significant differences between conditions in age or body mass index. Secondly, Chi-Square tests revealed no significant associations between condition and gender, dichotomized race (non-Hispanic white or other), class standing (freshman-and-sophomores or juniors-and-seniors), home type (dorm room or apartment/condo/house), sorority/fraternity membership, or most common meal arrangement
(meal plan or cooking/eating out) respectively. Chi-Square tests also revealed no significant associations between condition and ever being on a diet, having been on a diet in the previous year, ever being diagnosed as having an eating disorder, or believing one currently has an eating disorder respectively. Chi-Square tests also showed no significant associations between condition and reported use of a prescription medication that influenced appetite and/or weight or craving sweet foods and beverages solely during the week before menstruation. In addition, Chi-
Square tests demonstrated that there were no significant associations between condition and knowledge of mindfulness practice, having any experience with mindfulness, and exposure to mindfulness principles and activities. Refer to Tables 5 and 6 for the proportions of participants that endorsed each response option by condition, and statistical tests comparing the conditions.
As Table 7 shows, there was no significant difference in reported hunger level prior to in- lab sweet food exposure in the cognitive defusion (M = 3.6; SD = 1.5) and typical tactics (M =
5.6; SD = 14.2) groups, t(94) = .99, p = .327. As Table 8 shows, the average craving level for non-sweet foods, non-alcoholic beverages, alcohol, cigarettes, and drugs did not differ by condition. Descriptive statistics indicated that, on average, participants were experiencing mild 34
to moderate craving for non-sweet foods and non-alcoholic beverages, and little or no craving for
alcohol, cigarettes, and drugs.
Examining the sample as a whole, 77% were female and 82% self-identified as non-
Hispanic white. Consistent with a mean age of 20.3 (SD = 3.8), 70% of participants were
freshman and sophomore students, 68% resided in on-campus dorms and 80% lived with friends
and/or roommates. Only 19% of the sample reported membership in a sorority or fraternity.
Two-thirds had purchased university meal plans (66%). The average body mass index (BMI) of
participants was 25.1 (SD = 6.1), with 67% of the sample categorized as normal weight (BMI between 18.5 and 24.9), 18% classified as overweight, 13% classified as obese (BMI of 30 or above), and 2% classified as underweight. As Tables 9 and 10 show, the most commonly reported non-sweet foods that were craved were pasta and various carbohydrate and cheese
products (e.g., pizza, pasta with cheese or cream sauce) and the most commonly craved non-
alcoholic beverages were water and soda. In regards to drug cravings, in the cognitive defusion condition one participant reported craving marijuana and one did not specify which drug he/she was craving. In the typical tactics condition, one participant reported craving marijuana and a second participant reported craving both marijuana and cocaine.
Craving Tactics Used in the Lab
The typical tactics group participants were asked to select one craving-reduction strategy
to use when exposed to the sweet food that they found hardest to resist in the lab session and in
the subsequent two weeks. As Table 11 reveals, typical tactics participants most often selected
oral substitution, such as eating healthy foods or drinking water instead of eating the craved
food. The second most commonly selected type of tactic was using logic or persuasion, such as considering consequences of eating the craved food and benefits of not eating the craved food 35
and reminding oneself of health values and goals. Contrary to instruction, 35% of typical tactics
participants wrote down two or more tactics that fell into different categories.
To ascertain whether participants engaged in multiple and non-target strategies during the
in-lab practice period, I asked participants in both conditions whether they used craving-
management strategies besides those they were instructed to use (cognitive defusion or a self- selected tactic). As Table 12 shows, large proportions of individuals in both conditions reported using their target strategy and one or more non-target tactics in the lab session (CD: 52%; TT:
35%).
Participant Perceptions of Intervention during the Lab Session and at Follow-up
As Tables 13 and 14 show, the typical tactics and cognitive defusion groups did not differ on their comprehension of in-lab instructions, perceived difficulty of implementing the target strategy, how effective they believed they were at implementing their respective craving strategies, or the level of value they believed their respective strategies had in reducing their sweet consumption based on their self-reports in the lab and at follow-up.
Preliminary Analyses
As examination of Table 15 reveals, relatively higher correlations were found between scores on the same measure at two different time points as compared to correlations between measures of different constructs. No correlations between distinct measures exceeded an r value of .40. However there were significant albeit small correlations between measures that assessed sweet food consumption (Proportion of Days one Consumed Cookies, Proportion of Days one
Consumed Chocolate, and Baseline and Follow-Up Sweet Craving Information Questionnaire scores), which is unsurprising given that these measures assessed consumption and craving for 36
similar sweet foods. Therefore, I considered my measures sufficiently statistically independent
for further analyses.
Impact of Intervention on State Food Craving
My first hypothesis was that participants in the typical tactics condition would experience a significantly greater increase in state craving scores for chocolate and for cookies from pre-
strategy-initiation to post-strategy-use. First, to test this hypothesis for Chocolate craving, I
conducted a 2 (Time: pre; post) X 2 (Condition: typical tactics; cognitive defusion) mixed model
ANOVA. There was a significant interaction between time and condition, F(1,46) = 6.7, p =
.013, partial η2 = .13. However, contrary to my hypothesis, craving declined from pre-strategy-
initiation to post-strategy-use in both conditions. Even though the cognitive defusion group
reported a larger decline in state chocolate candy craving across time than the typical tactics
group, post-hoc t-tests revealed that there was no difference in state chocolate candy craving at
either time point. See Table 16 for means and standard deviations.
Next, to test this same hypothesis for craving for Cookies, I conducted a 2 (Time: pre;
post) X 2 (Condition: typical tactics; cognitive defusion) mixed model ANOVA. There was a
main effect of time for this measure, F(1,44) = 30.1, p < .001, partial η2 = .41. However, there
was no main effect of condition on state craving for cookies, F(1,44) = .79, p = .379, and no
significant interaction, F(1,44) = 2.0, p = .168. Again, contrary to my hypothesis, craving for
cookies decreased significantly and equivalently in both conditions from pre-strategy-initiation to post-strategy-use. See Table 16 for means and standard deviations.
Impact of Intervention on Consumption of Sweet Foods
My third hypothesis was that the proportion of days participants consumed session- specific foods (chocolate candy or cookies) during the two weeks following training would be 37
lower in the cognitive defusion intervention compared to the typical tactics condition. I conducted two 2 (Condition: cognitive defusion; typical tactics) X 2 (Lab Session Type: cookie; chocolate candy) univariate ANOVAs to test this hypothesis. For chocolate candy, there was no main effect of condition, F(1,92) = 1.9, p = .168, no main effect of lab session type, F(1,92) =
.40, p = .527, and no interaction of condition by type of lab session, F(1, 92) = .56, p = .457. For cookies, there was no main effect of condition, F(1,92) = 1.6, p = .208, no main effect of lab session type, F(1,92) = 2.4, p = .126, and no interaction of condition by type of lab session, F(1,
92) = 1.2, p = .278. Therefore, my third hypothesis was not supported. See Table 17 for means and standard deviations.
My fourth hypothesis proposed that total self-reported sweet consumption would decrease significantly more in the cognitive defusion condition than in the typical tactics condition. Contrary to my hypothesis, the 2 (Time: pre; post) X 2 (Condition: cognitive defusion, typical tactics) mixed model ANOVA revealed no significant interaction, F(1,93) =
3.3, p = .072, and no main effect of condition, F(1, 93) = .12, p = .727. However, there was a main effect of time, F(1,93) = 9.1, p = .003, partial η2 = .09. As examination of Table 18 reveals,
self-reported consumption of sweet foods decreased from baseline to follow-up in both
conditions.
Impact of Intervention on Cognitive Fusion
To evaluate my fifth hypothesis, that participants in the cognitive defusion intervention
would show a significantly greater reduction in cognitive fusion from baseline to two-week
follow-up in comparison to the typical tactics condition, I conducted a 2 (Time: baseline; follow-
up) X 2 (Condition: cognitive defusion, typical tactics) mixed model ANOVA. Contrary to my
hypothesis, the interaction was not significant, F(1,92) = 1.8, p = .178, nor was there a main 38
effect of condition, F(1,92) = .17, p = .686. However, there was a main effect of time for this
measure, F(1,92) =13.3, p < .001, partial η2 = .13. As examination of Table 19 reveals, cognitive
fusion scores decreased in both conditions from baseline to follow-up.
Impact of Intervention on Food Craving Acceptance and Willingness
My sixth hypothesis was that participants in the cognitive defusion intervention would
show a significantly greater increase in acceptance of urges and cravings to eat from baseline to
two-week follow-up in comparison to the typical tactics condition. Contrary to my hypothesis, a
2 (Time: baseline; follow-up) X 2 (Condition: cognitive defusion, typical tactics) mixed model
ANOVA revealed no significant interaction, F(1,94) = 1.03, p = .313, no main effect of time
(F(1,94) = .06, p = .803), and no main effect of condition (F(1,94) = .150, p = .700). See Table
20 for means and standard deviations.
My seventh hypothesis was that participants in the cognitive defusion condition would
show a significantly greater increase in willingness to experience cravings without eating from
baseline to two-week follow-up compared to participants in the typical tactics condition. I
decided not to test this hypothesis, because the internal reliability of this subscale was so low at
both baseline and follow-up, α = .49 and α = .51, that I could not have confidence in any
findings.
Correlations among Trait Craving, Addictive Eating, Mindfulness and Sweet Consumption
Next, I conducted a series of Pearson product moment correlations to evaluate my eighth
hypothesis that higher consumption of sweet foods would be correlated with higher baseline trait
craving, higher baseline addictive-like responses to palatable foods, and lower mindfulness at
both baseline and at two-week follow-up. Because there were no differences in these variables
by condition, I combined the two conditions to calculate these correlations. In partial support of 39
my hypothesis, baseline self-reported typical total sweet food consumption was significantly
associated with higher baseline trait craving (r = .39, p < .001) and higher addictive-like
responses to palatable foods (r = .38, p < .001). Higher self-reported total sweet food
consumption for the past week, reported at follow-up, was associated with higher baseline trait
craving (r = .23, p = .032). However, there was no significant association between total sweet
food consumption for the past week, reported at follow-up, and addictive-like responses to
palatable foods at baseline (r = .20, p = .057). Mindfulness was not associated with self-reported
total sweet food consumption at baseline or follow-up. No significant relationships were found
between the proportion of days one consumed chocolate candy or cookies and baseline trait
craving, addictive-like responses to palatable foods, and mindfulness, respectively.
Tactic Use Frequency
Participants in the cognitive defusion group reported using “cognitive defusion” an average of 9.5 times (SD = 7.0) during the two weeks after the lab session and those in the typical tactic group reported that they used their selected food craving management tactic an average of 12.4 times (SD = 7.4) during the same time period. The number of times participants in each condition employed the target strategy (either cognitive defusion or one’s selected tactic)
did not differ significantly, t(94) = 2.0, p = .051, although the t bordered on significance.
Because craving and consumption could have been influenced by use of non-target
strategies, participants in each condition were also asked whether they used craving-management
strategies besides those they were instructed to use (cognitive defusion or a self-selected tactic)
in the previous two weeks. For a listing of combinations of strategies used (target tactic only,
target tactic and non-target tactics, primarily non-target tactics, or insufficient use of tactics) by
condition, refer to Table 21. As examination of Table 22 reveals, in the cognitive defusion 40 condition, the most commonly employed tactic besides cognitive defusion was using logic or persuasion. As Table 23 shows, in the typical tactics group, the most commonly employed tactics besides those that were self-selected and recorded in the lab were using logic or persuasion and oral substitution.
Exploratory Analysis on Self-Restraint Tactics for Sweet Food Cravings
I decided to conduct an exploratory analysis to determine the most frequently used self- restraint tactics for sweet food cravings at baseline and two-week follow-up, for all participants in both conditions. At baseline, participants reported using one self-restraint strategy three to four times in the previous week and six self-restraint strategies two to three times in the previous week. At follow-up participants reported using three strategies three to four times in the previous week and thirteen self-restraint strategies two to three times in the previous week. For a listing of frequently used strategies, refer to Table 24.
41
DISCUSSION
There were no differences in craving for or consumption of sweet foods between those who participated in my brief cognitive defusion training intervention and those instructed to employ a self-selected craving management tactic. However, participants in both conditions
showed a significant decline in state craving for cookies and chocolate candy in the lab after a craving strategy practice session. Additionally, all participants showed a significant reduction
from baseline to two-week follow-up in cognitive fusion and total self-reported sweet food consumption. Therefore, it appears that one or more factors common to both conditions
produced a decrease in cravings for target sweet foods in the lab and self-reported total sweet food consumption over a two-week period.
One factor common to my cognitive defusion and typical tactics conditions that might explain the similar outcome is cue exposure with response prevention. Specifically, participants in both conditions were exposed to their preferred sweet food for five minutes and were instructed not to eat the food. Including this procedure provided participants with practice abstaining in the presence of their preferred sweet food and may have helped them gain confidence in their ability to abstain from or moderate consumption of that sweet food and other sweet foods. This in turn may have produced decreases in craving and consumption in both conditions.
Another potentially influential component common to both conditions was in situ self- monitoring for two weeks. A review by Burke, Wang, and Sevick (2011) suggests that dietary self-monitoring is significantly associated with weight loss in behavioral weight loss studies, because self-monitoring results in dietary changes that reduce weight. Completing the daily surveys monitoring their intake of sweet foods may have resulted in increased awareness of their 42
urges for sweet foods and their dietary choices. This increased awareness may have helped
participants in both conditions reduce their consumption of sweet foods.
Furthermore, receiving twice daily reminder texts to use a craving management tactic
may have helped participants in both groups reduce their sweet consumption. These texts could
have served as prompts to proactively use one or more craving management tactics to prevent or
manage their cravings for sweet foods.
In addition to reductions in craving and consumption, participants in both conditions
reported a decline in cognitive fusion at the two-week follow-up assessment. The Elaborated
Intrusion Theory of craving posits that diverting one’s attention from thoughts and images of a
desired substance and engaging in craving-incompatible activities interrupts cognitive processing
of a desired substance, thereby reducing the likelihood of consumption (Kavanagh, Andrade, &
May, 2005; May, Andrade, Panabooke, & Kavanagh, 2004). Participants in both conditions
were instructed to employ craving management tactics which could have helped them redirect
their attention and defuse from thoughts and images of their preferred sweet foods. Examples of
tactics which could interrupt elaboration include: convincing themselves that not eating sweet
foods is a healthy choice, considering food consumption goals and values, considering benefits
or consequences of consumption, mental distraction techniques (doing homework, reading,
playing on a smart phone, thinking about other things, counting, listening to music, singing),
physical activity, and leaving the physical location where the food was located.
Another possible explanation for the failure to find an effect of condition is that only 42%
(n = 21) of participants in the cognitive defusion group and only 54% (n = 25) of participants in the typical tactics group used only the one craving strategy they were instructed to use (cognitive defusion) or elected to use (self-selected tactic) during the two-week follow-up. Thus, this 43 investigation may have been an insensitive test of cognitive defusion alone versus a typical tactic alone, and instead many participants in both groups could have been influenced by their use of multiple, diverse tactics during the two-week period.
Another possibility is that how my participants practiced cognitive defusion was insufficient to yield an effect in comparison with typical tactics. In my study, participants were asked to practice cognitive defusion by imagining that their craving thoughts were written on distant clouds that were passing by and to think of themselves as observers who were separate from the thoughts and who could refrain from acting on them. There are other methods of practicing cognitive defusion, such as providing participants with a metaphor. Examples include imagining being a bus driver and picturing the passengers on the bus as one’s thoughts (Jenkins
& Tapper, 2014) or imagining being a surfer and picturing one’s cravings and urges as waves
(Lacaille et al., 2014). Furthermore, some investigators have asked participants to defuse from their thoughts by singing their thoughts to themselves or imagining them being spoken in a foreign accent (Jenkins & Tapper, 2014). Future researchers may want to investigate an experimental cognitive defusion condition featuring these methods in comparison to a typical tactics condition.
Putting my study in the context of previous research that examined cognitive defusion, cravings and consumption of sweet foods, these results were consistent with those of one previous investigation, but inconsistent with findings from two other previous investigations.
For example, similarly to the present study’s results, Hooper et al. (2012) found that consumption of chocolate did not differ between participants in a cognitive defusion and typical tactics group during a five-day chocolate abstinence period. Inconsistent with my study’s results, Lacaille et al. (2014) found that state chocolate craving during lab exposure to chocolate 44
was lower in a cognitive defusion-plus-awareness condition than in a mental distraction
condition. Furthermore, unlike the findings from my study and Hooper et al.’s (2012) study,
Jenkins and Tapper (2014) found that participants in a cognitive defusion group, compared to
those in an acceptance group and those in a relaxation group, consumed significantly less
chocolate from a bag they carried with them and reported less consumption of chocolate over a
five-day abstinence period.
Limitations
One key weakness is that I used only self-report measures to assess covariates and outcome variables. The sole use of self-report measures makes my results vulnerable to recall errors and social desirability biases. For example, participants may have provided ratings they believed the research team wanted to see or responded in ways that made them feel better about themselves. Future researchers should consider directly observing and measuring sweet food intake in the lab or in participants’ natural environment across time.
Another potential shortcoming was that some participants in the typical tactics group picked strategies that were impossible to practice during the lab session. Specifically, some selected tactics required physical resources (e.g., water, gum), required engagement in a particular behavior or abstinence from a certain behavior (e.g., not buying a desired sweet food), or involved moderation or food alternatives rather than abstinence (e.g., eat a healthy food instead). Therefore, some participants used a different craving management strategy during the lab practice period than the one(s) they selected earlier in the lab session. As a result, some participants in the control condition were unable to practice their preferred self-selected tactics during the practice period. 45
Researchers could improve the internal validity of studies comparing typical tactics to
mindfulness-based interventions by instructing participants in the typical tactics condition to
employ “portable” tactics that can be practiced in the lab session. These types of strategies may be more comparable to cognitive defusion, due to their portability, independence from external
constraints to implementation, and versatility. However, it is important to note that this
increased internal validity would come at the cost of reduced external validity.
Two other limitations include the relatively short duration of the intervention phase and
absence of a long-term follow-up. This study involved a two-week strategy use period with
outcome assessment only at the conclusion of the intervention. A longer strategy use period
would allow participants to practice the strategy for longer, which could result in larger eating
behavior changes. A follow-up assessment several weeks after the intervention period would
help determine if self-reported eating behavior changes are sustained over time, and if so, for
how long.
Another possible limitation is that the majority of my participants were undergraduate
non-Hispanic Caucasian females. Females may be more likely to enroll and respond to dietary
interventions because they experience more pressure to reduce their consumption of sweet foods
to gain social approval for their dietary choices and weight. Also, individuals from other racial
and ethnic groups may be influenced by different social and cultural norms regarding food and
weight. For example, certain minority group members may experience more pressure to eat food
or beverages cooked by family members and may be discouraged from losing weight.
Individuals who have never engaged in higher education may have less exposure to nutrition
education and may be unware of the consequences of excess sugar consumption. Thus, they may
be less motivated to engage in a sugar craving intervention. 46
Another factor that could limit generalizability is that participants self-selected into this intervention, which required them to attend an in-lab session, complete a daily survey for two weeks, and complete two online assessments. Therefore, my study participants may have been more motivated to change their eating behavior and more likely to practice craving management strategies regardless of the specific content of the intervention than sweet food cravers who chose not to participate or who failed to complete the study. Therefore, the results of this study may not extend to sweet food cravers who have lower levels of motivation.
Another limitation of the present study was my use of a broad cognitive fusion measure rather than a measure of cognitive fusion to food-related thoughts and images specifically. At the time I designed my study, there was no published measure of eating-related cognitive defusion. However, after my study was completed, Duarte, Pinto-Gouveia, Ferreira, and Silva
(2016) published a measure to assess eating-related cognitive defusion. Future researchers could use this measure to directly assess whether practicing certain craving management tactics reduces eating-related cognitive fusion in addition to broad cognitive defusion.
Conclusions
There were no differences between the conditions in self-reported cravings in the laboratory or consumption of sweet foods in the natural environment, but participants in both conditions showed a significant decline in state craving in the lab. Additionally, all participants showed a significant reduction from baseline to two-week follow-up in cognitive fusion and self- reported total sweet food consumption. Several factors common to both conditions may explain these outcomes. Specifically, all participants engaged in self-monitoring, all had an episode of cue exposure with response prevention, all received text messages that may have motivated dietary restraint, and most used multiple tactics that may have diverted their attention from 47 craving during the two-week intervention phase. Therefore, in retrospect, this study was not as sensitive a test of the impact of cognitive defusion as intended, and further research is warranted to judge the effectiveness, if any, for reduction of cravings for and consumption of sweet foods. 48
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56
Figure 1
Sample Flow Chart
•161 participants signed up for a lab session Starting •120 participants attended a lab session Sample
•5 eliminated for not completing baseline survey •5 eliminated due to procedural error •7 eliminated due to not completing seven or more daily surveys and the follow-up Exclusions •7 eliminated due to completing the daily surveys but not completing the follow-up
•96 participants for the final sample Final Sample
57
Table 1
Food Selected as Hardest to Resist by Condition
Selected Item Cognitive Defusion n Typical Tactics n Cookies (n = 47) Chocolate Chip 6 8 M & M 6 6 Double Chocolate 4 6 Peanut Butter 5 4 Sugar 0 2 Chocolate Candies (n = 49) Reese’s Cups 11 10 Kit Kat 7 4 Hershey’s Cookies ‘n’ 7 1 Creme Snicker’s 4 3 Milky Way 0 2
58
Table 2
Number of Items, Possible and Sample Range, Means (SDs) by Condition, and Cronbach’s Alpha Coefficients of Measures Variable Number Possible Cognitive Typical Sample of Items Range/Range Defusion Tactic α in Sample M (SD) M (SD) Baseline FCQ – Trait 39 39-234/60-207 128.6 (32.6) 126.8 (32.5) .96 Baseline FFMQ-SF 24 24-120/51-99 74.3 (9.9) 74.3 (8.7) .62 -Nonreact 5 5-25/6-22 14.1 (3.4) 14.56 (3.0) .71 -Observe 4 4-20/4-20 13.4 (3.1) 13.5 (2.9) .73 -Act with Awareness 5 5-25/8-25 16.2 (3.4) 16.0 (3.7) .81 -Describe 5 5-25/7-24 16.2 (3.4) 15.5 (3.5) .77 -Non-judgment 5 5-25/8-25 14.4 (3.6) 15.1 (3.7) .76 Baseline YFAS 5 0-5/0-5 1.5 (1.5) 1.8 (1.6) NA (symptom count) Baseline CFQ 7 7-49/7-49 25.9 (10.2) 26.7 (9.9) .95 Follow-up CFQ 7 7-49/7-49 24.6 (9.1) 22.7 (9.8) .94 Baseline FAAQ Total 10 10-60/19-47 32.2 (6.0) 32.2 (5.6) .48 Willingness 6 6-36/11-31 20.5 (4.5) 19.5 (4.2) .49 Acceptance 4 4-24/4-24 11.9 (4.7) 12.6 (4.7) .83 Follow-Up FAAQ Total 10 10-60/19-46 34.6 (6.2) 34.2 (5.6) .61 Willingness 6 6-36/12-31 22.1 (4.2) 21.9 (3.6) .51 Acceptance 4 4-24/4-24 12.4 (4.6) 12.3 (4.1) .84 In-lab Group Climate 7 0-6/2.14-6 5.1 (.77) 5.2 (.72) .72 Questionnaire- Modified In-lab FCQ – State – 15 15-75/28-74 50.0 (10.5) 51.1 (10.7) .92 Cookie – T1 In-lab FCQ – State – 15 15-75/17-67 42.3 (11.8) 46.4 (10.2) .92 Cookie – T2 In-lab FCQ – State – 15 15-75/31-72 55.9 (7.0) 52.4 (9.4) .84 Chocolate Candy – T1 In-lab FCQ – State – 15 15-75/16-68 42.3 (6.7) 44.6 (12.7) .90 Chocolate Candy – T2
Note. FCQ-Trait = Food Craving Questionnaire-Trait, FFMQ-SF = Five Facet Mindfulness Questionnaire – Short Form, YFAS = Yale Food Addiction Scale, CFQ = Cognitive Fusion Questionnaire, FAAQ = Food Craving Acceptance and Action Questionnaire, FCQ = Food 59
Craving Questionnaire. To calculate the YFAS symptom count score you first calculate five subscale scores (withdrawal, excessive time and activity to obtain/use/recover, activities given up or reduced, unsuccessful attempts to cut down, feelings of loss of control), which are then dichotomized into a five scores that tell you if the addiction symptom criteria is met (1) or not met (0).
60
Table 3
Number of Participants by Condition and Session
Cognitive Defusion n Typical Tactics n Cookie 21 26 47 Chocolate Candy 29 20 49 50 46 96
61
Table 4
Number of Participants by Condition and Intervention Leader
Cognitive Defusion Typical Tactics n n Maija 6 19 25 Kristin 19 9 28 Sonia 10 12 22 Liz 15 6 21 50 46 96
62
Table 5
Demographic & General Information
Cognitive Defusion Typical Tactics Chi-Square or n = 50 n = 46 t-test M (SD) M (SD) Age 20.9 (4.8) 19.7 (2.1) t(68) = -1.7 Body Mass Index (BMI) 24.4 (5.6) 25.9 (6.6) t(94) = 1.2 Cognitive Defusion Typical Tactics n = 50 n = 46 n (% within n (% within Condition) Condition) Gender χ(1) = .50 Female 40 (80) 34 (74) Male 10 (20) 12 (26) Undergraduate Class Standing χ(1) = .72 Freshman and Sophomore 32 (73) 35 (76) Junior or Senior 12 (27) 11 (24) Graduate Studenta 6 0 Race/Ethnicity Dichotomized χ(1) = .99 Non-Hispanic White 43 (86) 36 (79) Other Race/Ethnicity 7 (14) 10 (22) Race/Ethnicity N/A Non-Hispanic White 43 (86) 36 (78) American Indian or Native 0 (0) 0 (0) American Hispanic American or Latino 2 (4) 1 (2) Asian American 1 (2) 2 (4) Black or African American 1 (2) 6 (13) Mixed/Other 3 (6) 1 (2) Living Environment χ(1) = .21 Dorm Room 31 (62) 34 (74) Apartment/Condo/House 19 (38) 12 (26) Members of Living Environment (Not mutually exclusive N/A categories) No one 4 6 Roommate or roommates (not 11 12 close friends) One friend 18 18 Few friends 9 6 Large group of friends 2 1 Romantic partner 4 2 Sibling(s) 1 1 63
Parent(s) 2 1 Extended family member(s) 0 1 Sorority/Fraternity Member χ(1) = .84 Yes 9 (18) 9 (20) No 41 (82) 37 (80)
Note. M: mean. SD: standard deviation. aThe Chi-Square test for class standing did not include the graduate students, due to a small number of graduate students in only one of the conditions.
64
Table 6
Meal Arrangement, Body Mass Index Category, Eating Disorders, Dieting, Prescription Medication, Menstruation, Mindfulness Exposure
Cognitive Typical Chi-Square Defusion Tactics test n = 50 n = 46 n (% within n (% within Condition) Condition) Most Common Meal Arrangement χ(1) = .06 Meal Plan: eating on campus or eating out 31 (63) 37 (80) (fast food or sit down restaurants)a Grocery shopping and cooking for self 18 (37) 9 (20) Body Mass Index Categories χ(1) = .25 Underweightb/Normal Weight 37 (74) 29 (63) Overweight or Obese 13 (26) 17 (37) Past or Present Diagnosis of Eating Disorder χ(1) = .72 No 47 (94) 44 (96) Believe You Have an Eating Disorder (Regardless of Diagnosis) χ(1) = .52 No 44 (90) 43 (94) Currently On A Diet χ(1) = .64 No 43 (86) 41 (89) On A Diet In The Past Year χ(1) = .96 No 35 (70) 32 (70) Beliefs on Prescription Medications and χ(2) = 2.2 Appetite & Weight Not on any prescription medications 22 (44) 21 (46) Yes, they influence my appetite or 6 (12) 10 (22) weight No, They don’t influence my appetite or 22 (44) 15 (33) Weight Only Crave Sweet Foods and Beverages χ(2) = 1.8 During the Week Before Menstruation (Females Only) Yes 20 (42) 13 (30) No 17 (35) 21 (49) Not Applicable 11 (23) 9 (21) Any Knowledge about Mindfulness Practice χ(1) = .76 Yes 20 (40) 22 (49) No 30 (60) 23 (51) Any Experience with Mindfulness (practice, χ(1) = .35 meditation, yoga that incorporates mindfulness) Yes 16 (32) 17 (38) No 34 (68) 28 (62) 65
Level of Exposure to Mindfulness Principles χ(1) = .92 and Activities None, Minimal or Some 42 (84) 39 (85) Moderate, High or Very High 8 (16) 7 (15)
Note. M: mean. SD: standard deviation. aFew participants reported that eating out was their primary meal arrangement (CD: 2, TT: 3). bFew participants provided a self-reported height and weight that indicated they were underweight (CD: 1, TT: 1).
66
Table 7
Lab-Reported Hunger Level
Hunger Level Cognitive Defusion n Typical Tactics n Total n Starving 0 3 3 Very Hungry 13 8 21 Moderately Hungry 14 17 31 Slightly Hungry 14 8 22 Hungry for a little bit more 2 2 4 food Have room for a few bites 4 5 9 Slightly full 2 1 3 Moderately full 1 0 1 Very full 0 1 1
67
Table 8
Average Craving for Non-Sweet Foods, Non-Alcoholic Beverages, Alcohol, Cigarettes, and Drugs Prior to In-Lab Exposure to Sweet Food
Craving Item Cognitive Defusion Typical Tactics t-test M (SD) M (SD) Non-Sweet Food 3.6 (2.6) 4.2 (2.9) t(94) = 1.1, p = .275 Non-Alcoholic 3.7 (2.8) 3.9 (2.7) t(94) = .38, p = Beverages .702 Alcohol 2.8 (.78) .76 (.78) t(61) = 1.7, p = .098 Cigarettes .14 (.73) .24 (.85) t(94) = .62, p = .540 Drug .16 (.82) .24 (1.2) t(94) = .39, p = .702
Note. M: mean. SD: standard deviation.
68
Table 9
Craved Non-Sweet Foods Prior to In-Lab Exposure to Sweet Food
Food Cognitive Typical Total n Defusion n Tactics n Pasta 7 6 13 Carbohydrate & Cheese Products 9 4 13 (Pizza, Mac and Cheese, Alfredo Pasta, Lasagna, Grilled Cheese or Bread and Cheese, Nachos, Cheese Fries, Cheese Stick) Meat Sandwich or Wrap (Turkey 4 4 8 Sandwich, Chicken Wrap, Chicken Sandwich, Burger) Meat 2 6 8 (meat, chicken, steak, crab legs, wings, buffalo chicken) Mexican Food (Chipotle, Taco Bell, 5 2 7 Burrito) Potato Product (fries, chips, mashed 0 5 5 potatoes) Bread 1 4 5 (“bread,” Breadsticks, Garlic Bread) Fruit or Fruit Smoothie 2 2 4 Packaged Carb-Heavy Snack Food 3 0 3 (Pretzels, Hot Cheetos, Granola Bar) Salad or Vegetable (including beans/ 1 3 4 legumes/chili) Unspecified Sandwich 1 1 2 Chinese Food (Panda Express) 1 1 2 Soup 0 1 1
Note. Participants were allowed to list multiple craved foods.
69
Table 10
Craved Non-Alcoholic Beverages Prior to In-Lab Exposure to Sweet Food
Drink Cognitive Typical Total n Defusion n Tactics n Water 7 14 21 Soda 10 9 19 Fruit-Flavored/Part Fruit Drink (Lemonade, 1 4 5 Snapple, V8 Fruit Drinks) Iced or Hot Tea 3 2 5 (“tea,” Iced tea, Chai Tea) Diet Beverage (Diet Soda, Diet Fruit 3 1 4 Drink, Flavored Water) Chocolate Milk or Hot Chocolate 2 2 4 Coffee 1 3 4 Sports Drink 2 1 3 Fruit Juice 1 2 3 Sweet Tea 2 0 2 Milk 1 1 2 Sweetened Coffee with Milk (Café Mocha) 0 1 1
Note. Participants were allowed to list multiple craved beverages.
70
Table 11
Self-Selected Tactics of Typical Tactics Group
Strategy (n) Total n Oral Substitution: 22 Balance sweets with nutritious sweet and non-sweet foods (2) Eat a healthy sweet food instead (4) Eat a healthy food instead (7) Drink water instead (6) Chew on gum (2) Brush teeth (1) Using Logic and Persuasion: 12 Reasoning: Convince myself out of eating it, convince self of the lack of necessity of sweets (2) Considering Consequences: Consider how the consequences of eating the food on athletic performance, convince self of disadvantages, remind self that sugar hurts my body, remind self that sugar makes me feel sick and gross (4) Considering Benefits: Consider the advantages of not eating sweets, consider goal of having a fit body, consider how I could use my money on other things I value instead of food (3) Goals, Values, Planning: Remind self of goals and values, remind self of value of eating healthy in order to maintain a good physical appearance, set personal weight loss goal with deadline (3) Distraction: 8 Distraction (2), distract self with homework and reading (1), visual distraction on smart phone (1), thought substitution (1), think of something else (1), listen to music (1), singing (1) Avoidance/Stimulus Control: 7 Look away (1) Increase distance from food (1) Leave the location where the craved food is (3) Reduce access (2) Portion Control/Eating Frequency: 7 Exercise portion control (e.g., buy small amounts of the food) (3) Set a limit on the quantity of the food I will eat (1) Eat the sweet food less frequently (2) Eat small bites (1) Attentive Eating: 6 Check my hunger level (2) Check my boredom level (1) Consider level of desire (1) Eat no more than necessary to satisfy my craving (1) Eat slowly (1) Physical Activity: 4 71
Exercise (2), go to the gym (1), take a walk (1) Positive Imagery: 2 Use peaceful or pleasant imagery (2) Relaxation: 1 Breathing (1) Delay: 1 Use a time delay (1) Social Support and Accountability: 1 Tell significant other about healthy eating values and ask him/her to hold me accountable (1) Thought/Emotion Suppression: 1 Stop cravings (1)
Note. Some participants listed more than one tactic even though they were asked to select one tactic.
72
Table 12
Combination of Strategies Used by Condition in Lab
Combination of Strategies Cognitive Defusion Typical Tactics (n = 50) (n = 46) n within condition n within condition Only Target Strategy (cognitive defusion or 22 22 selected tactic) Used Target Strategy and one or more non-target 26 16 tactic (tactics other than selected tactic or cognitive defusion) Only Used Non-Target Strategy 2 6 Did Not Use Any Craving Management Tactic 0 2
73
Table 13
In Lab Comprehension, Difficulty, Implementation Effectiveness, and Value by Condition
Condition Scale Cognitive Defusion Typical Tactics t-test Result M (SD) M (SD) Comprehension* 3.6 (.67) 3.7 (.50) t(90) = 1.1, p = .257 Difficulty 1.8 (.86) 1.6 (.91) t(93) = -.98, p = .330 Implementation 2.7 (.71) 2.8 (1.0) t(80) = .81, p = .421 Effectiveness* Value 2.9 (.75) 2.7 (.92) t(94) = .75, p = .454
Note. M: mean. SD: standard deviation. *Equal variances not able to be assumed. Comprehension was rated on a scale of very poorly (0), poorly (1), adequately (2), well (3), and very well (4). Difficulty was rated on a scale of very easy (0), easy (1), moderate (2), hard (3), and very hard (4). Implementation effectiveness was rated on a scale of very ineffective (0), ineffective (1), neither effective nor ineffective (2), effective (3), and very effective (4). Value was rated on a scale of not valuable (0), limited value (1), neither valuable or without value (2), valuable (3), and very valuable (4).
74
Table 14
Follow-Up Comprehension, Difficulty, Implementation Effectiveness, and Value by Condition
Condition Scale Cognitive Defusion Typical Tactics t-test Results M (SD) M (SD) Comprehension 3.4 (.70) 3.3 (.86) t(90) = -.74, p = .464 Difficulty 1.8 (.90) 2.0 (1.0) t(94) = 1.1, p = .267 Implementation 2.2 (1.1) 2.4 (.96) t(94) = .94, p = .352 Effectiveness Value 2.2 (1.0) 2.4 (1.1) t(94) = .69, p = .491
Note. M: mean. SD: standard deviation. Comprehension was rated on a scale of very poorly (0), poorly (1), adequately (2), well (3), and very well (4). Difficulty was rated on a scale of very easy (0), easy (1), moderate (2), hard (3), and very hard (4). Implementation effectiveness was rated on a scale of very ineffective (0), ineffective (1), neither effective nor ineffective (2), effective (3), and very effective (4). Value was rated on a scale of not valuable (0), limited value (1), neither valuable or without value (2), valuable (3), and very valuable (4).
75
Table 15
Correlation Matrix
Lab Lab Lab Lab Proportion Proportion BL SCIQ FU BL FU CFQ FAAQ- FAAQ- FCQ-S- FCQ-S- FCQ-S- FCQ-S- Days Days SCIQ CFQ Accept-T1 Accept-T2 Cookie T1 Cookie T2 Choc T1 Choc T2 Cookie Choc
Lab FCQ-S- - .75*** - - .14 -.04 .26 .13 .33* .13 -.21 -.08 Cookie T1
Lab FCQ-S- . - - - .05 -.06 .17 .21 .32* .06 -.13 .06 Cookie T2
Lab FCQ-S- - - - .63*** .06 .23 .28 .23 .19 .10 -.41** -.25 Choc T1
Lab FCQ-S- - - - - .04 .22 .23 .15 .07 .04 -.24 -.16 Choc T2
Proportion Days - - - - - .39*** .28*** .38*** .03 .10 -.11 -.13 Cookie
Proportion Days ------.16 .39*** -.06 .02 -.05 -.05 Choc
BL SCIQ ------.32** .18 .17 -.24* -.06 FU SCIQ ------.14 .27** -.21* -.11 BL CFQ ------.69*** -.43** -.20* 76
FU CFQ ------.39** -.33**
FAAQ- Accept-T1 ------.57**
FAAQ- Accept-T2 ------
Note. Lab FCQ-S-Cookie T1 = Food Craving Questionnaire-State-Cookie-Time 1; Lab FCQ-S-Cookie T2 = Lab Food Craving Questionnaire-State-Cookie Time 2; Lab FCQ-S-Choc T1 = Food Craving Questionnaire-State-Chocolate Candy-Time 1; Lab FCQ-S- Choc T2 = Lab Food Craving Questionnaire-State-Chocolate Candy Time 2; Proportion Days Cookie = Proportion of Days one Consumed Cookies; Proportion Days Choc = Proportion of Days one Consumed Chocolate Candy; BL SCIQ = Baseline Sweet Craving Information Questionnaire; FU SCIQ = Follow-up Sweet Craving Information Questionnaire; BL CFQ = Baseline Cognitive Fusion Questionnaire; FU CFQ = Follow-up Cognitive Fusion Questionnaire; FAAQ-Accept-T1 = Food Craving Acceptance and Action Questionnaire-Acceptance Subscale-Time 1; FAAQ-Accept-T2 = Food Craving Acceptance and Action Questionnaire- Acceptance Subscale-Time 2.
***p < .001, **p < .01, *p < .05 77
Table 16
Impact of Intervention on State Sweet Food Craving in the Lab
Variable Cognitive Defusion Typical Tactics Food Craving Questionnaire-State: Chocolate Candy M (SD) M (SD) t-test Results Pre-strategy-initiation 55.6 (7.0) 52.4 (9.4) t(47) = -1.5, p = .139
Post-strategy use* 42.3 (6.7) 44.6 (12.7) t(27) = .73, p = .472 Food Craving Questionnaire-State: Cookie M (SD) M (SD) t-test Results Pre-strategy-initiation 50.0 (10.6) 51.1 (10.7) t(44) = .34, p = .735 Post-strategy use 42.2 (12.1) 46.4 (10.2) t(45) = 1.3, p = .203
Note. M: Mean. SD: standard deviation. *Equal variances not able to be assumed. 78
Table 17
Impact of Intervention on Proportion of Days One Consumed Session-Specific Sweet Food across Two Weeks
Cookie Session Chocolate Candy Session
Cognitive Typical Tactics Cognitive Defusion Typical Tactics Defusion M (SD) M (SD) M (SD) M (SD) Proportion of Days one .30 (.29) .29 (.22) .28 (.23) .16 (.15) Consumed Cookies Proportion of Days one .40 (.25) .29 (.23) .40 (.28) .36 (.29) Consumed Chocolate Candy
Note. M: Mean. SD: standard deviation. Mean values are representative of a percent. They must be multiplied by 100 to yield a percentage. 79
Table 18
Impact of Intervention on Total Self-Reported Sweet Consumption on the Sweet Craving Information Questionnaire
Variable Cognitive Defusion Typical Tactics t-test results Sweet Craving Information Questionnaire M (SD) M (SD) Baseline 24.2 (8.3) 25.8 (10.4) t(93) = .83, p = .408 Follow-up 22.8 (11.6) 20.0 (10.3) t(94) = -1.2, p = .248
Note. M: Mean. SD: standard deviation. Scores at baseline were a sum of self-reported typical week consumption of chocolate candy, sweet baked goods, sweet dairy products, non-chocolate sweets, high sugar cereal, and other sweet foods. Scores at follow-up were a sum of self-reported past week consumption of chocolate candy, sweet baked goods, sweet dairy products, non-chocolate sweets, high sugar cereal, and other sweet foods. 80
Table 19
Impact of Intervention on Cognitive Fusion
Variable Cognitive Defusion Typical Tactics t-test results Cognitive Fusion Questionnaire M (SD) M (SD) Baseline 26.4 (10.1) 26.7 (9.9) t(94) = .39, p = .700 Follow-up 24.6 (9.1) 22.7 (9.8) t(92) = -.93, p = .353
Note. M: Mean. SD: standard deviation 81
Table 20
Impact of Intervention on Food Craving Acceptance
Variable Cognitive Defusion Typical Tactics Food Craving Acceptance and Action Questionnaire – Acceptance Subscale M (SD) M (SD) Baseline 11.9 (4.7) 12.6 (4.7) t(94) = .79, p = .434 Follow-up 12.4 (4.6) 12.3 (4.1) t(94) = -.13, p = .897
Note. M: Mean. SD: standard deviation 82
Table 21
Combination of Strategies Used by Condition during the Two Week Post-Intervention Period
Combination of Strategies Cognitive Defusion Typical Tactics (n = 50) (n = 46) n within condition n within condition Only Target Strategy (cognitive defusion or 21 25 selected tactic six or more times and no reported use of one or more non-target tactics) Used Target Strategy (six or more times) and 13 13 one or more non-target tactic (tactics other than selected tactic or cognitive defusion) Primary Use of Non-Target Strategy (with use 11 3 of selected tactic or cognitive defusion five or fewer times) Insufficient Use of Tactics (use of cognitive 5 5 defusion or selected tactic five or fewer times and no use of non-target tactics) 83
Table 22
Other Craving Strategies Used In the Past Two Weeks other than Cognitive Defusion - Reported at Follow-Up
Strategy (n) Total n Using Logic or Persuasion: 7 Thought about the negative consequences of eating it (1) Thinking about health (1) Considering how sweet foods are unhealthy (1) Reminding myself how guilty I feel when I eat sweets (1) ”Guilting” myself into not eating sweets (1) Goal setting (1) Asking myself questions including “Do you want this because you’re bored?” and “Is this worth the calorie content?” (1) Oral Substitution: 5 Eat another food , replacing with other foods (1), eating something else (1), substituting a healthier snack (1) Drinking water (2) Distraction: 4 Occupying my mind with other activities (1), doing homework (1), counting (1), listening to music (1) Physical Activity: 4 Taking a walk (2), taking a bike ride (1), working out (1) Avoidance/Stimulus-Control: 4 Go somewhere where the sweets were not around (1), choose not to have sweets in my dorm (1), reducing access to sweets (1), walked away (1) Portion Control: 2 Eating smaller amounts (1), limiting the amounts I had (1) Thought Suppression: 2 Just not think about it (1), tried to not think about the food (1) Social Support and Accountability: 1 My colleague was supportive and held me accountable (1) Delay: 1 Delaying (1) Using Self-Commands: 1 Told myself “no” (1)
Note. Participants were allowed to list more than one strategy. 84
Table 23
Other Craving Strategies Used In the Past Two Weeks other than Self-Selected Tactic - Reported at Follow-Up
Strategy (n) Total n Using Logic or Persuasion: 4 Reasoning (1) Telling myself “I don’t need it” or telling myself “Don’t eat sugar on an empty stomach” (1) When busy, telling myself I’m too busy to have dessert (1) Contemplating how eating the sweets would make me more upset rather than improve the way I was feeling (1) Oral Substitution: 4 Substituted for something healthier (1), eating fruit (1) Drinking water or tea (1) Chewing mint gum (1) Distraction: 3 Distraction (1), distracting myself (1), reading (1) Avoidance/Stimulus-Control: 3 Avoidance (1), keeping it out of my room (1), choosing not to be around baked goods (1) Physical Activity: 2 Exercising (1), running (1) Delay: 1 Telling myself I would eat it the next day (1) Body Visualization: 1 Visualizing a better body (1) Self-Humiliation: 1 Repeatedly poking stomach and thighs (1)
Note. Participants were allowed to list more than one strategy. 85
Table 24
Frequently used Self-Restraint Tactics at Baseline and Follow-Up
Times Used Baseline Follow-Up Per Week 2.0 - 2.9 • Eating an alternate • Turn down an offer of the craved food Times more healthy food • Keep some distance between you and • Drink a healthy the craved food beverage instead of • Drink a healthy beverage instead of eating the craved food eating the craved food • Tell yourself to STOP • Suck on a sugar-free mint or chew thinking about the sugar-free gum craved food • Wait at least a few minutes before • Think about the good eating any of the craved food things that will happen • Look at something interesting on your if you stuck with your phone or computer or play a digital eating goal game instead of eating the craved food • Set a limit on how • Tell yourself to STOP thinking about much of the craved the craved food food you will eat • Don’t give in to your excuses to eat • Keep track of how more of the craved food than you much of the craved want food you have eaten • Repeat to yourself a phrase such as, “I can stick with my eating goal” • Imagine that eating too much of the craved food could make you feel yucky • Accept or serve yourself only a small portion of the craved food • Set a limit on how much of the craved food you will eat • Keep track of how much of the craved food you have eaten 3.0 - 3.9 • Remind yourself that • Remind yourself that you do not want Times you do not want to to consume the calories in the craved consume the calories in food or gain weight the craved food or gain • Eat an alternate more healthy food weight • Think about the good things that will happen if you stick with your eating goal 86
APPENDIX A: RECRUITMENT DOCUMENTS
Sona Systems Study Postings
Study Name Sweet Food Craving Intervention: Chocolate Candy
Study Type Standard (lab) study
Duration 120 minutes
Credits 3 Credits
Abstract Participate in an intervention to help you manage cravings for chocolate and potentially reduce consumption of chocolate for 3 SONA credits.
Description Participate in an intervention to help you manage sweet cravings and potentially reduce your consumption of craved sugary foods. Participate in this branch of the study if you crave chocolate candy more frequently that cookies. If you crave cookies more frequently, participate in the "Sweet Food Craving Intervention: Cookies." You will complete several questionnaires about food cravings, sugar consumption, and other health variables prior to and two weeks following your participation in a 30-minute intervention. The intervention is designed to teach you ways to better manage your sweet food cravings and potentially reduce your sweet food consumption. Total participation – including both face-to-face and filling out questionnaires – will require approximately 2 hours. Sign up 4 or more days before a session. When you sign up for a session, follow the URL link below and complete the baseline online questionnaires 2-4 days before the session (30 minutes). Be sure to follow pre-session eating instructions provided at the end of the online questionnaire set. Next you will come to Room 444 of the Psychology Building for the 30 minute face-to-face intervention session. Following the intervention you will receive nightly texts with a web link to a 3-item survey. You will also receive two daily intervention related texts, which do not require a response. Finally, two weeks following the intervention you will complete more questionnaires (30 minutes).
Eligibility Requirements A BGSU student, 18+ yrs, have cravings for sweet foods 7+x/wk, eat craved sweet foods 4+x/wk, want to reduce intake of craved sweet foods, no food allergies, willing to receive texts, willing to complete daily 3-item survey
Preparation Sign up for a session 4+ days before desired session, complete online survey 2+ days before selected session, follow pre-session eating instructions 87
Study Name Sweet Food Craving Intervention: Cookies
Study Type Standard (lab) study
Duration 120 minutes
Credits 3 Credits
Abstract Participate in an intervention to help you manage cravings for cookies and other baked goods and potentially reduce consumption of cookies and baked goods for 3 SONA credits.
Description Participate in an intervention to help you manage sweet cravings and potentially reduce your consumption of craved sugary foods. Participate in this branch of the study if you crave cookies and baked good more frequently that chocolate candy. If you crave chocolate candy more frequently, participate in the "Sweet Food Craving Intervention: Chocolate Candy." You will complete several questionnaires about food cravings, sugar consumption, and other health variables prior to and two weeks following your participation in a 30-minute intervention. The intervention is designed to teach you ways to better manage your sweet food cravings and potentially reduce your sweet food consumption. Total participation – including both face-to- face and filling out questionnaires – will require approximately 2 hours. Sign up 4 or more days before a session. When you sign up for a session, follow the URL link below and complete the baseline online questionnaires 2-4 days before the session (30 minutes). Be sure to follow pre- session eating instructions provided at the end of the online questionnaire set. Next you will come to Room 444 of the Psychology Building for the 30 minute face-to-face intervention session. Following the intervention you will receive nightly texts with a web link to a 3-item survey. You will also receive two daily intervention related texts, which do not require a response. Finally, two weeks following the intervention you will complete more questionnaires (30 minutes).
Eligibility Requirements A BGSU student, 18+ yrs, have cravings for sweet foods 7+x/wk, eat craved sweet foods 4+x/wk, want to reduce intake of craved sweet foods, no food allergies, willing to receive texts, willing to complete daily 3-item survey
Preparation Sign up for a session 4+ days before desired session, complete online survey 2+ days before selected session, follow pre-session eating instructions 88
BGSU Student Body Recruitment E-mail
Subject line: Want to participate in a Sweet Food Craving Intervention?
Dear Students,
Please participate in a Sweet Food Craving Intervention to help you manage cravings for chocolate or cookies and reduce consumption of one of these foods.
Incentives: You will receive a $5 Amazon gift card or 3 psychology research credits if you are enrolled in a class that requires you to participate in research.
Time: The study requires about 2 hours of participation across the course of two and a half weeks.
Eligibility Requirements: You must be… (1) a BGSU student (2) at least 18 years old (3) experience cravings for sweet foods 7 or more times per week (4) eat craved sweet foods 4 or more times per week (5) want to reduce the frequency of consuming craved sweet foods (6) not have food allergies to ingredients commonly found in chocolate candy or cookies (7) be willing to receive text messages (8) be willing to complete daily three-item surveys
If you want to participate:
Contact the researcher at [email protected] to receive a link to the study or if you are eligible for research credit sign up through BGSU’s Sona research participation system at https://bgsu.sona-systems.com/ 89
APPENDIX B: ELIGIBILITY SCREENER
(Baseline)
Are you 18 years of age or older? Yes No Do you crave sweet foods 7 or more times per Yes week (on average)? No Do you eat craved sweet foods 4 or more times Yes per week (on average)? No Do you have a desire to reduce the frequency Yes with which you consume the sweet foods you No crave? I have NO food allergies that would prevent me True/Yes from touching, smelling, or tasting chocolate False/No candy or cookies (examples of common allergens include but are not limited to casein, lactose, peanuts, tree nuts, eggs, and wheat) Are you willing to receive reminder texts twice Yes daily during the two weeks after you come into No the lab? Are you willing to complete a three-item survey Yes regarding your eating habits once per day that No will be sent via text? 90
APPENDIX C: DEMOGRAPHICS AND GENERAL INFORMATION SURVEY
(Baseline)
Please provide your 9-digit CELL phone ______number with no dashes (including area code) *We need this for texting purposes. Your number will not be shared with anyone besides the primary researcher. After the end of the two week post-lab portion of the study you will not be texted. Age ______(drop down menu)
Gender Male Female
Race/Ethnicity Non-Hispanic White American Indian or Native American Hispanic American or Latino Asian American Black or African American Hawaiian or Pacific Islander Mixed/Other _____
What is your class standing/year in school? Freshman Sophomore Junior Senior Graduate student
How many years have you been in higher ______(drop down menu) education? Round to the nearest half year (e.g., 0.5, 1.5, 2, 2.5) (undergraduate or undergraduate and graduate) What is your current living environment? Dorm room Apartment/Condo House
Who do you currently live with? (check all that No one apply) One friend A few friends A large group of friends Romantic partner Roomate or roomates (not close friends) Sibling(s) Parent(s) Extended family member(s) 91
Are you currently a member of a sorority or Yes fraternity? No What is your most common meal arrangement? Meal plan- eating on campus Grocery shopping and cooking for self Eating out (fast food or sit down restaurants) What is your height? 4’8 ….. 6’8 (drop down menu) What is your weight? _____pounds Are you currently on a diet? Yes No Have you been on a diet in the past year? Yes No Please specify what type of diet, if you ______responded “Yes ” or type in N/A (Not Applicable) Have you been engaged in a healthy eating or Yes weight loss program in the past year? No Please specify what type of program if you ______responded “Yes” or type in N/A Do any of the prescription medications you are I am not on any prescription medications currently taking, including birth control, Yes, they influence my appetite or weight influence your appetite or weight? No, they don’t influence my appetite or weight
If you are female: do you only crave sweet Yes foods or beverages during the week before No menstruation and/or during menstruation? Not applicable Do you have any knowledge about mindfulness Yes practice? No Do you have any experience with mindfulness Yes practice, mindfulness meditation, or yoga that No incorporates mindfulness? Please rate your level of exposure to (0) None information on mindfulness principles and (1) Minimal mindfulness-based activities: (2) Some (3) Moderate (4) High (5) Very High Have you ever been diagnosed with an eating Yes disorder? No
Do you currently think that you have any eating Yes disorder whether or not it has been diagnosed No by a health care professional? 92
APPENDIX D: CHOCOLATE CANDY AND COOKIE FORMS
Chocolate Candy Form (Baseline)
Please select which of the following you would find hardest to resist…
1 Reese’s cups 2 Kit Kat 3 Snickers 4 Hershey’s cookies ’n’creme
5 Milky way
Cookie Form (Baseline
Please select which of the following you would find hardest to resist…
1 Chocolate chip cookie 2 Double chocolate cookie 3 M & M cookie 4 Peanut butter cookie
5 Plain sugar cookie 93
APPENDIX E: FOOD CRAVING QUESTIONNAIRE – TRAIT (FSQ – T)
(Cepeda-Benito, Gleaves, Williams, & Erath, 2000) Contact: Antonio Cepeda-Benito: [email protected]
Indicate how frequently each comment is true for you in general:
Rating Scale: (1) Never or not applicable , (2) Rarely , (3) Sometimes , (4) Often , (5) Usually , (6) Always
Subscale 1 Being with someone who is eating often makes me Cues that may Trigger Food hungry Cravings 2 When I crave something, I know I won't be able to stop Lack of Control over Eating eating once I start 3 If I eat what I am craving, I often lose control and eat Lack of Control over Eating too much 4 I hate it when I give in to cravings Guilt from Cravings and/or from Giving into them 5 Food cravings invariably make me think of ways to get Having Intentions and Plans to what I want to eat Consume Food 6 I feel like I have food on my mind all the time Thoughts or Preoccupation With Food 7 I often feel guilty for craving certain foods Guilt from Cravings and/or from Giving into them 8 I find myself preoccupied with food Thoughts or Preoccupation With Food 9 I eat to feel better Anticipation of Positive Reinforcement That May Result From Eating 10 Sometimes, eating makes things seem just perfect Anticipation of Positive Reinforcement That May Result From Eating 11 Thinking about my favorite foods makes my mouth Craving as a Physiological water State 12 I crave foods when my stomach is empty Craving as a Physiological State 13 I feel as if my body asks me for certain foods Craving as a Physiological State 14 I get so hungry that my stomach seems like a Craving as a Physiological bottomless pit State 15 Eating what I crave makes me feel better Anticipation of Positive Reinforcement That May Result From Eating 94
16 When I satisfy a craving I feel less depressed Anticipation of Relief From Negative States and Feelings as a Result of Eating 17 When I eat what I am craving I feel guilty about myself Guilt from Cravings and/or from Giving into them 18 Whenever I have cravings, I find myself making plans Having Intentions and Plans to to eat Consume Food 19 Eating calms me down Anticipation of Relief From Negative States and Feelings as a Result of Eating 20 I crave foods when I feel bored, angry, or sad Emotions That May Be Experienced Before or During Food Cravings or Eating 21 I feel less anxious after I eat Anticipation of Relief From Negative States and Feelings as a Result of Eating 22 If I get what I am craving I cannot stop myself from Lack of Control over Eating eating it 23 When I crave certain foods, I usually try to eat them as Having Intentions and Plans to soon as I can Consume Food 24 When I eat what I crave I feel great Anticipation of Positive Reinforcement That May Result From Eating 25 I have no willpower to resist my food craving Lack of Control over Eating 26 Once I start eating, I have trouble stopping Lack of Control over Eating 27 I can't stop thinking about eating no matter how hard I Thoughts or Preoccupation try With Food 28 I spend a lot of time thinking about whatever it is I will Thoughts or Preoccupation eat next With Food 29 If I give in to a food craving, all control is lost Lack of Control over Eating 30 When I'm stressed out, I crave food Emotions That May Be Experienced Before or During Food Cravings or Eating 31 I daydream about food Thoughts or Preoccupation With Food 32 Whenever I have a food craving, I keep on thinking Thoughts or Preoccupation about eating until I actually eat the food With Food 33 If I am craving something, thoughts of eating it Thoughts or Preoccupation consume me With Food 34 My emotions often make me want to eat Emotions That May Be Experienced Before or During Food Cravings or Eating 35 Whenever I go to a buffet I end up eating more than Cues that may Trigger Food what I needed Cravings 36 It is hard for me to resist the temptation to eat Cues that may Trigger Food appetizing foods that are in my reach Cravings 95
37 When I am with someone who is overeating, I usually Cues that may Trigger Food overeat too Cravings 38 When I eat food, I feel comforted Anticipation of Positive Reinforcement That May Result From Eating 39 I crave foods when I'm upset Emotions That May Be Experienced Before or During Food Cravings or Eating 96
APPENDIX F: COGNITIVE FUSION QUESTIONNAIRE (CFQ)
(Gillanders et al., 2014) Contact: David Gillanders: [email protected]
Below you will find a list of statements. Please rate how true each statement is for you by circling a number next to it. Use the scale below to make your choice.
Rating Scale: (1) never true , (2) very seldom true , (3) seldom true , (4) sometimes true , (5) frequently true , (6) almost always true , (7) always true
*Item three was reworded from “I over-analyse situations to the point where it’s unhelpful to me” to “I overanalyze situations to the point where it’s unhelpful to me” in order to be in accordance with North American spelling of overanalyze.
1 My thoughts cause me distress or emotional pain 2 I get so caught up in my thoughts that I am unable to do the things that I most want to do 3 I overanalyze situations to the point where it’s unhelpful to me 4 I struggle with my thoughts 5 I get upset with myself for having certain thoughts 6 I tend to get very entangled in my thoughts 7 It’s such a struggle to let go of upsetting thoughts even when I know that letting go would be helpful 97
APPENDIX G: FOOD CRAVING ACCEPTANCE AND ACTION QUESTIONNAIRE (FAAQ)
(Juarascio, Forman, Timko, Butryn, & Goodwin, 2011) Contact: Evan Forman: [email protected]
Rating Scale: (1 = very seldom true to 6 = always true). *Reverse scored items. A summary score is calculated by summing the ten items after reverse scoring.
Below you will find a list of statements. Please rate the truth of each statement as it applies to you.
1 I continue to eat a healthy diet, even when I have the desire to overeat or Willingness make poor eating choices 2 It's OK to experience cravings and urges to overeat, because I don't have to Willingness listen to them 3 It's necessary for me to control my food urges in order to control my Willingness eating* 4 I need to concentrate on getting rid of my urges to eat unhealthily* Acceptance 5 I don't have to overeat, even when I feel like I want to overeat Willingness 6 Controlling my urges to eat unhealthily is just as important as controlling Acceptance my eating* 7 My thoughts and feelings about food must change before I can make Acceptance changes in my eating* 8 Despite my cravings for unhealthy foods, I continue to eat healthily Willingness 9 Before I can make any important dietary changes, I have to get some Acceptance control over my food urges* 10 Even if I have the desire to eat something unhealthy, I can still eat healthily Willingness 98
APPENDIX H: YALE FOOD ADDICTION SCALE (YFAS)
(Gearhardt, Corbin, Brownell, 2009) Contact: Ashley Gearhardt: [email protected]
This survey asks about your eating habits in the past year. People sometimes have difficulty controlling their intake of certain foods such as: - Sweets like ice cream, chocolate, doughnuts, cookies, cake, candy, ice cream - Starches like white bread, rolls, pasta, and rice - Salty snacks like chips, pretzels, and crackers - Fatty foods like steak, bacon, hamburgers, cheeseburgers, pizza, and French fries - Sugary drinks like soda pop
When the following questions ask about “CERTAIN FOODS” please think of ANY food similar to those listed in the food group or ANY OTHER foods you have had a problem with in the past year
Never Once 2-4 2-3 4 or a times times more IN THE PAST 12 MONTHS: month a a times month week a week or daily 1. I find that when I start eating certain foods, I end 0 1 2 3 4 up eating much more than planned
2. I find myself continuing to consume certain foods 0 1 2 3 4 even though I am no longer hungry
3. I eat to the point where I feel physically ill 0 1 2 3 4
4. Not eating certain types of food or cutting down 0 1 2 3 4 on certain types of food is something I worry about
5. I spend a lot of time feeling sluggish or fatigued 0 1 2 3 4 from overeating
6. I find myself constantly eating certain foods 0 1 2 3 4 throughout the day
7. I find that when certain foods are not available, I 0 1 2 3 4 will go out of my way to obtain them. For example, I will drive to the store to purchase certain foods even though I have other options available to me at home. 99
8. There have been times when I consumed certain 0 1 2 3 4 foods so often or in such large quantities that I started to eat food instead of working, spending time with my family or friends, or engaging in other important activities or recreational activities I enjoy.
9. There have been times when I consumed certain 0 1 2 3 4 foods so often or in such large quantities that I spent time dealing with negative feelings from overeating instead of working, spending time with my family or friends, or engaging in other important activities or recreational activities I enjoy.
10. There have been times when I avoided 0 1 2 3 4 professional or social situations where certain foods were available, because I was afraid I would overeat.
11. There have been times when I avoided 0 1 2 3 4 professional or social situations because I was not able to consume certain foods there.
12. I have had withdrawal symptoms such as 0 1 2 3 4 agitation, anxiety, or other physical symptoms when I cut down or stopped eating certain foods. (Please do NOT include withdrawal symptoms caused by cutting down on caffeinated beverages such as soda pop, coffee, tea, energy drinks, etc.)
13. I have consumed certain foods to prevent 0 1 2 3 4 feelings of anxiety, agitation, or other physical symptoms that were developing. (Please do NOT include consumption of caffeinated beverages such as soda pop, coffee, tea, energy drinks, etc.)
14. I have found that I have elevated desire for or 0 1 2 3 4 urges to consume certain foods when I cut down or stop eating them.
15. My behavior with respect to food and eating 0 1 2 3 4 causes significant distress.
16. I experience significant problems in my ability to 0 1 2 3 4 function effectively (daily routine, job/school, social activities, family activities, health difficulties) because of food and eating. 100
APPENDIX I: FIVE FACET MINDFULNESS QUESTIONNAIRE – SHORT FORM (FFMQ-SF)
(Bohlmeijer, ten Klooster, Fledderus, Veehof, and Baer, 2011)
(Baseline)
Below is a collection of statements about your everyday experience. Using the response options below, please indicate how frequently or infrequently you have had each experience in the last month. Please answer according to what really reflects your experience rather than what you think your experience should be.
(1) never of very rarely true, (2) not often true, (3) sometimes true and sometimes not true, (4) often true, (5) very often or always true
*Response option (3) was modified for this study from “sometimes true sometimes not true” to “sometimes true and sometimes not true.”
1 I’m good at finding the words to describe my feelings DS 2 I can easily put my beliefs, opinions, and expectations into words DS 3 I watch my feelings without getting carried away by them NR 4 I tell myself that I shouldn’t be feeling the way I’m feeling /NJ 5 It’s hard for me to find the words to describe what I’m thinking /DS 6 I pay attention to physical experiences, such as the wind in my OB hair or sun on my face 7 I make judgments about whether my thoughts are good or bad /NJ 8 I find it difficult to stay focused on what’s happening in the /AA present moment 9 When I have distressing thoughts or images, I don’t let myself be NR carried away by them 10 Generally, I pay attention to sounds, such as clocks ticking, birds OB chirping, or cars passing 11 When I feel something in my body, it’s hard for me to find the /DS right words to describe it 12 It seems I am “running on automatic” without much awareness of /AA what I’m doing 13 When I have distressing thoughts or images, I feel calm soon after NR 14 I tell myself I shouldn’t be thinking the way I’m thinking /NJ 15 I notice the smells and aromas of things OB 16 Even when I’m feeling terribly upset, I can find a way to put it DS into words 17 I rush through activities without being really attentive to them /AA 18 Usually when I have distressing thoughts or images I can just NR notice them without reacting 19 I think some of my emotions are bad or inappropriate and I /NJ shouldn’t feel them 101
20 I notice visual elements in art or nature, such as colors, shapes, OB textures, or patterns of light and shadow 21 When I have distressing thoughts or images, I just notice them and NR let them go 22 I do jobs or tasks automatically without being aware of what I’m /AA doing 23 I find myself doing things without paying attention /AA 24 I disapprove of myself when I have illogical ideas /NJ
Scoring Information:
*Correct scores for items preceded by a slash (/NJ, /AA, etc) by subtracting them from 6
OB: Observe items =
DS: Describe items =
AA: Act with Awareness items =
NJ: Nonjudge items =
NR: Nonreact items = 102
APPENDIX J: SWEET FOOD CONSUMPTION QUESTIONNAIRE – BASELINE AND PAST WEEK VERSIONS
Sweet Food Consumption Questionnaire - Baseline Version (Baseline)
Please answer the following questions regarding your consumption of various sweet foods in a typical week...
Response Options 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15+
1 How many times do you eat chocolate candy in a typical week? (e.g., chocolate candy bars like Snickers, plain chocolate bars like Hershey’s, M&Ms, Reese’s cups, Hershey’s kisses, chocolate chips, other chocolate-containing candy) 2. How many times do you eat sweet baked goods in a typical week? (e.g., cookies, sweet muffins, sweet granola bars, sweet breads, danishes, Poptarts or toaster strudels, doughnuts, brownies, cake, pie, cupcakes). 3. How many times do you eat sweet dairy products and dairy desserts in a typical week? (e.g., flavored yogurt, frozen yogurt, ice cream, pudding, milkshakes, gelato, sherbet, sweet custard) 4. How many times do you eat non-chocolate candy in a typical week? (e.g., Starburst, Skittles, Sour Patch Kids, Twizzlers, Swedish Fish, jelly beans, gummy candy, lollipops, hard candy, gum with sugar). 5. How many times do you eat high sugar cereal (greater than 8 grams of sugar per serving) in a typical week? (e.g., Frosted Flakes, Cinnamon Toast Crunch, Lucky Charms, Frosted Mini Wheats, Fruit Loops, Raisin Bran, Honey Nut Cheerios or other flavored Cheerios, Honey Bunches of Oats, Cap N’ Crunch, Apple Jacks, Trix, etc.) 6. How many times do you eat other sweet foods (not from the other categories) in a typical week? (e.g., chocolate or honey peanut butter, Nutella, Hershey’s chocolate syrup, caramel sauce, Jello, marshmallows, fruit sorbet or popsicles)
Sweet Food Consumption Questionnaire – Past Week Version (Two-week Follow-up)
Please answer the following questions regarding your consumption of various sweet foods in the past week...
Response Options 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15+
1 How many times did you eat chocolate candy in the past week? 103
(e.g., chocolate candy bars like Snickers, plain chocolate bars like Hershey’s, M&Ms, Reese’s cups, Hershey’s kisses, chocolate chips, other chocolate-containing candy) 2. How many times did you eat sweet baked goods in the past week? (e.g., cookies, sweet muffins, sweet granola bars, sweet breads, danishes, Poptarts or toaster strudels, doughnuts, brownies, cake, pie, cupcakes). 3. How many times did you eat sweet dairy products and dairy desserts in the past week? (e.g., flavored yogurt, frozen yogurt, ice cream, pudding, milkshakes, gelato, sherbet, sweet custard) 4. How many times did you eat non-chocolate candy in the past week? (e.g., Starburst, Skittles, Sour Patch Kids, Twizzlers, Swedish Fish, jelly beans, gummy candy, lollipops, hard candy, gum with sugar). 5. How many times did you eat high sugar cereal (greater than 8 grams of sugar per serving) in the past week? (e.g., Frosted Flakes, Cinnamon Toast Crunch, Lucky Charms, Frosted Mini Wheats, Fruit Loops, Raisin Bran, Honey Nut Cheerios or other flavored Cheerios, Honey Bunches of Oats, Cap N’ Crunch, Apple Jacks, Trix, etc.) 6. How many times did you eat other sweet foods (not from the other categories) in the past week? (e.g., chocolate or honey peanut butter, Nutella, Hershey’s chocolate syrup, caramel sauce, Jello, marshmallows, fruit sorbet or popsicles) 104
APPENDIX K: THE SELF-RESTRAINT TACTICS FOR SWEET CRAVING QUESTIONNAIRE
(Baseline, Two-week Follow-up)
Response Scale Please indicate how often during the past week you used each of the following strategies when you were craving sweets and wanted to limit or not eat those sweets… Response Options: 0 times per week 1 time per week 2 times per week 3 times per week 4 times per week 5 times per week 6 times per week 7 times per week 8 or more times per week
Abstinence 1 Turn down an offer of the craved food 2 Take the offered craved food and get rid of it later 3 Leave the place where the craved food is available 4 Keep some distance between you and the craved food 5 Eat an alternate more healthy food 6 Keep your hands busy so you won’t reach for the craved food 7 Drink a healthy beverage instead of eating the craved food 8 Suck on a sugar-free mint or chew sugar-free gum 9 Tell others you are not going to eat the craved food at that time 10 Tell yourself you can have the craved food tomorrow if you still want it 11 Wait at least a few minutes before eating any of the craved food 12 Don’t eat or drink something that makes the craved food more tempting 13 Take a whiff of perfume, cologne, a candle or other non-food smell when craving the food 14 Look at something interesting on your phone or computer or play a digital game instead of eating the craved food 15 Call someone instead of eating the craved food 16 Take a walk instead of eating the craved food 17 Listen to music instead of eating the craved food 18 Instead of eating the craved food, practice a calming activity 19 Tell yourself to STOP thinking about the craved food 20 Don’t give in to your excuses to eat more of the craved food than you want 21 Repeat to yourself a phrase such as, “I can stick with my eating goal” 22 Instead of eating the craved food, imagine a pleasant place or person 23 Think about the good things that will happen if you stick with your eating goal 105
24 Remind yourself of a time when you got physically sick from eating too much of the craved food 25 Imagine that eating too much of the craved food could make you feel yucky 26 Remind yourself that you do not want to consume the calories in the craved food or gain weight 27 Imagine someone sneezed on or there’s a hair or bug in the craved food 28 Remind yourself that you are not alone – other people are also trying to quit or cut back tempting foods Moderation 29 Accept or serve yourself only a small portion of the craved food 30 Pause between bites of the craved food 31 Take small bites of the craved food 32 Treat yourself to a small amount of the best quality of the craved food 33 Share the craved food if you are with someone 34 Have a less tasty version of the craved food so you eat less of it 35 Eat a type of the craved food made with artificial sweetener or without added sugar 36 Set a limit on how much of the craved food you will eat 37 Set a time limit for eating the craved food 38 Keep track of how much of the craved food you have eaten 39 Alternate eating a healthier food with bites of the craved food 40 Eat less of your craved food by combining it with more healthy foods 41 Pay close attention to the taste, smell, texture, & temperature of what you are eating 42 Forgive yourself for wanting and eating some of the craved food 106
APPENDIX L: IN-LAB DEPRIVATION, HUNGER, AND CRAVING QUESTIONS
Chocolate Candy Version
Both Experimental and Control Condition 1. Did you abstain from eating chocolate candy, chocolate-containing foods, and chocolate- containing beverages for the last 24 hours? (asked aloud on an individual basis) 2. Did you abstain from eating all food and beverages (except water) for the last 3 hours? (asked aloud on an individual basis) 3. Please rate your current hunger (1) Starving (2) Very Hungry (3) Moderately Hungry (4) Slightly Hungry (5) Hungry for a little bit more food (6) Have room for a few bites (7) Slightly full (8) Moderately full (9) Very full (10) Stuffed 4. Please circle the number below indicating how strongly you crave a cigarette right now:
0 1 2 3 4 5 6 7 8 9 10 Not Strongest At all craving ever 5. Please circle the number below indicating how strongly you crave a drug right now (what drug ______):
0 1 2 3 4 5 6 7 8 9 10 Not Strongest At all craving ever 6. Please circle the number below indicating how strongly you crave alcohol right now:
0 1 2 3 4 5 6 7 8 9 10 Not Strongest At all craving ever 7. Please circle the number below indicating how strongly you crave a specific non-sweet food right now (what food ______):
0 1 2 3 4 5 6 7 8 9 10 Not Strongest At all craving ever 8. Please circle the number below indicating how strongly you crave a specific non- alcoholic beverage right now (what beverage ______): 107
0 1 2 3 4 5 6 7 8 9 10 Not Strongest At all craving ever
Cookie Version
Both Experimental and Control Condition 1 Did you abstain from eating cookies and sweet baked goods for the last 24 hours? (asked . aloud on an individual basis) 2 Did you abstain from eating all food and beverages (except water) for the last 3 hours? (asked aloud on an individual basis) 3 Please rate your current hunger . (1) Starving (2) Very Hungry (3) Moderately Hungry (4) Slightly Hungry (5) Hungry for a little bit more food (6) Have room for a few bites (7) Slightly full (8) Moderately full (9) Very full (10) Stuffed 4 Please circle the number below indicating how strongly you crave a cigarette right now: . 0 1 2 3 4 5 6 7 8 9 10 Not Strongest At all craving ever 5 Please circle the number below indicating how strongly you crave a drug right now (what . drug______):
0 1 2 3 4 5 6 7 8 9 10 Not Strongest At all craving ever 6 Please circle the number below indicating how strongly you crave alcohol right now: . 0 1 2 3 4 5 6 7 8 9 10 Not Strongest At all craving ever 7 Please circle the number below indicating how strongly you crave a specific non-sweet . food right now (what food ______):
0 1 2 3 4 5 6 7 8 9 10 108
Not Strongest At all craving ever 8 Please circle the number below indicating how strongly you crave a specific non- . alcoholic beverage right now (what beverage______):
0 1 2 3 4 5 6 7 8 9 10 Not Strongest At all craving ever 109
APPENDIX M: IN-LAB COMREHENSION
Questions for Experimental Condition Questions for Control Condition 1 Do you have any questions? (stated aloud by Do you have any questions? (stated aloud researcher) by researcher) 2 Rate the degree to which you understood the Rate the degree to which you understood instructions …(provided on handout) the instructions …(provided on handout) (0) very poorly (0) very poorly (1) poorly (1) poorly (2) adequately (2) adequately (3) well (3) well (4) very well (4) very well 110
APPENDIX N: FOOD CRAVING QUESTIONNAIRE – STATE (FSQ – S)
Food Craving Questionnaire – State (FSQ – S): Chocolate Candy Specific (Cepeda-Benito, Gleaves, Williams, & Erath, 2000) Contact: Antonio Cepeda-Benito: [email protected]
Indicate the extent to which you agree with each statement: right now, at this very moment:
Rating Scale: (1) Strongly Disagree , (2) Disagree , (3) Neutral , (4) Agree , (5) Strongly Agree
An Intense Desire to Eat 1 I have an intense desire to eat chocolate candy 2 I’m craving chocolate candy 3 I have an urge for chocolate candy Anticipation of Positive Reinforcement that May Result from Eating 4 Eating chocolate candy would make things seem just perfect 5 If I were to eat what I am craving, I am sure my mood would improve 6 Eating chocolate candy would feel wonderful Anticipation of Relief from Negative States and Feelings as a Result of Eating 7 If I ate something, I wouldn’t feel so sluggish and lethargic 8 Satisfying my craving would make me feel less grouchy and irritable 9 I would feel more alert if I could satisfy my craving Lack of Control Over Eating 10 If I had chocolate candy, I could not stop eating it 11 My desire to eat chocolate candy seems overpowering 12 I know I’m going to keep on thinking about chocolate candy until I actually have it Craving as Physiological State (i.e., Hunger) 13 I am hungry 14 If I ate right now, my stomach wouldn’t feel as empty 15 I feel weak because of not eating
Food Craving Questionnaire – State (FSQ – S): Cookie Specific (Cepeda-Benito, Gleaves, Williams, & Erath, 2000) Contact: Antonio Cepeda-Benito: [email protected]
Indicate the extent to which you agree with each statement: right now, at this very moment:
Rating Scale: (1) Strongly Disagree , (2) Disagree , (3) Neutral , (4) Agree , (5) Strongly Agree
An Intense Desire to Eat 1 I have an intense desire to eat a cookie 2 I’m craving a cookie 111
3 I have an urge for a cookie Anticipation of Positive Reinforcement that May Result from Eating 4 Eating a cookie would make things seem just perfect 5 If I were to eat what I am craving, I am sure my mood would improve 6 Eating a cookie would feel wonderful Anticipation of Relief from Negative States and Feelings as a Result of Eating 7 If I ate something, I wouldn’t feel so sluggish and lethargic 8 Satisfying my craving would make me feel less grouchy and irritable 9 I would feel more alert if I could satisfy my craving Lack of Control Over Eating 10 If I had a cookie, I could not stop eating it 11 My desire to eat a cookie seems overpowering 12 I know I’m going to keep on thinking about a cookie until I actually have it Craving as Physiological State (i.e., Hunger) 13 I am hungry 14 If I ate right now, my stomach wouldn’t feel as empty 15 I feel weak because of not eating 112
APPENDIX O: IN-LAB QUESTIONS ON STRATEGY USE, DIFFICULTY, IMPLEMENTATION EFFECTIVENESS, AND VALUE
Questions for Experimental Condition Questions for Control Condition 1 Did you use cognitive defusion when the Did you use the tactic you selected and food item was in front of you? wrote down when the food item was in Yes front of you? No Yes No 2 How easy or hard was it to apply this How easy or hard was it to apply this strategy? strategy? (0) Very easy (0) Very easy (1) Easy (1) Easy (2) Moderate (2) Moderate (3) Hard (3) Hard (4) Very hard (4) Very hard 3 How effective were you in using this How effective were you in using this strategy? strategy? (0) Very ineffective (0) Very ineffective (1) Ineffective (1) Ineffective (2) Neither effective nor ineffective (2) Neither effective nor ineffective (3) Effective (3) Effective (4) Very effective (4) Very effective 4 How valuable do you think cognitive How valuable do you think your selected defusion will be in reducing how much you tactic will be in reducing how much you eat sweets? eat sweets? (0) Not valuable (0) Not valuable (1) Limited value (1) Limited value (2) Neither valuable or without value (2) Neither valuable or without value (3) Valuable (3) Valuable (4) Very valuable (4) Very valuable 5 Did you use strategies other than cognitive Did you use strategies other than your defusion to deal with any craving that you selected tactic to deal with any craving that experienced? you experienced? Please list or write “Not Applicable” Please list or write “Not Applicable” ______113
APPENDIX P: GROUP CLIMATE QUESTIONNAIRE (GCQ-S) – MODIFIED
Original version- (MacKenzie, 1983)
GROUP QUESTIONNAIRE • Read each statement carefully and as you answer the questions think of the group as a whole. • For each statement fill in the box under the MOST APPROPRIATE heading that best describes the group during the session. • Please mark only ONE box for each statement.
(5) Not at all at (0) Not A Little Bit (1) Somewhat (2) Moderately (3) Quite a bit (4) A Great Deal Extremely (6) The members were pleasant to each other……… � � � � � � � The members acted as though the group was � � � � � � � important………………………………………... The members appeared distant and withdrawn � � � � � � � from each other…………………………………. The members appeared tense and anxious……… � � � � � � � The members appeared to have negative attitudes � � � � � � � about participation in the group………………… The members did not follow the leader’s � � � � � � � instructions...... The members were disruptive…………………... � � � � � � � 114
APPENDIX Q: DAILY SWEET FOOD CONSUMPTION SURVEY
1 What is your BGSU email address ______2 How many chocolate candy items did you eat today? ___(drop down menu) 3 How many cookies did you eat today? ___(drop down menu) 4 How many total sweet food items did you eat today? ___(drop down menu) 115
APPENDIX R: TWO-WEEK FOLLOW-UP QUESTIONS ON STRATEGY COMPREHENSION, USE, DIFFICULTY, IMPLEMENTATION EFFECTIVENESS, AND VALUE
Questions for Experimental Condition Questions for Control Condition 1 Rate the degree to which you understood the Rate the degree to which you understood instructions … the instructions … (0) very poorly (0) very poorly (1) poorly (1) poorly (2) adequately (2) adequately (3) well (3) well (4) very well (4) very well 2 Rate the degree to which you understood the Rate the degree to which you understood instructions on cognitive defusion for food the instructions on food craving craving management which were presented management tactics which were during the in-person portion of the study … presented during the in-person portion of (0) Very poorly the study… (1) Poorly (0) Very poorly (2) Adequately (1) Poorly (3) Well (2) Adequately (4) Very well (3) Well (4) Very well 3 How many times did you use cognitive How many times did you use your defusion in the past two weeks when you had selected food craving management tactic a sweet craving? in the past two weeks when you had a ______(dropdown) sweet craving? ______(dropdown) 4 How easy or hard was it to apply this strategy How easy or hard was it to apply this in the past two weeks? strategy in the past two weeks? (0) Very easy (0) Very easy (1) Easy (1) Easy (2) Moderate (2) Moderate (3) Hard (3) Hard (4) Very hard (4) Very hard 5 How effective were you in using this strategy How effective were you in using this in the past two weeks? strategy in the past two weeks? (0) Very ineffective (0) Very ineffective (1) Ineffective (1) Ineffective (2) Neither effective nor ineffective (2) Neither effective nor ineffective (3) Effective (3) Effective (4) Very effective (4) Very effective 6 In the past two weeks, how valuable was In the past two weeks, how valuable was using cognitive defusion in reducing how using your selected tactic in reducing much you ate sweets? how much you ate sweets? (0) Not valuable (0) Not valuable 116
(1) Limited value (1) Limited value (2) Neither valuable or without value (2) Neither valuable or without value (3) Valuable (3) Valuable (4) Very valuable (4) Very valuable 7 In the past two weeks, did you use strategies In the past two weeks, did you use other than cognitive defusion to deal with strategies other than your selected tactic sweet cravings? to deal with sweet cravings? Yes Yes No No 8 If you responded “Yes,” what other strategies If you responded “Yes,” what other did you use? Please list or type "Not strategies did you use? Please list or type Applicable" "Not Applicable" ______117
APPENDIX S: STUDY FLOW CHART
Baseline (online) Self-selection into the cookie or chocolate craving group Informed Consent, Eligibility Screener, Demographics and General Information Survey, CFQ, FAAQ, FFMQ-SF, FCQ-T, YFAS, Sweet Food Consumption Questionnaire - Baseline Version, Self-Restraint Tactics for Sweet Cravings Questionnaire, Cookie Form or Chocolate Candy Form Instructions for 3 hour deprivation from all food and beverages (except water) Instructions for 24 hour deprivation for either chocolate-containing edible products or cookies and sweet baked goods
Cognitive Defusion Condition (lab) Typical Tactics Condition (lab) Deprivation, Hunger, and Craving Deprivation, Hunger, and Craving Assessment Assessment 20 minute cognitive defusion condition 20 minute typical tactics condition Question asking and Comprehension Asked to write selected tactic Question description on two index cards Provided with an cognitive defusion index Question asking and Comprehension card Question Brief cue exposure to hardest to resist Brief cue exposure to hardest to resist chocolate candy or cookie chocolate candy or cookie Customized chocolate candy or cookie Food Customized chocolate candy or cookie Craving Questionnaire-State (FCQ-S) Food Craving Questionnaire-State administered (Time 1) (FCQ-S) administered (Time 1) 5 minute solitary practice of cognitive 5 minute solitary practice of selected defusion with cue exposure and response tactic with cue exposure and response prevention prevention FCQ-S re-administered (Time 2) FCQ-S re-administered (Time 2) Questions on Strategy Use, Difficulty, Questions on Strategy Use, Difficulty, Implementation Effectiveness, and Value Implementation Effectiveness, and Value 118
Homework Explanation and Group Climate Evaluation (in lab) Told to carry cue card with them at all times Told to use cognitive defusion or selected tactic for all sweet craving in the upcoming two weeks Group Climate Questionnaire-Modified administered
Study Period (for two weeks) Twice daily cognitive defusion or selected tactic cue texts to participants Daily texts with web link to Daily Sweet Food Consumption Survey
Follow-Up (two-week) Questions on Strategy Comprehension, Use, Difficulty, Implementation Effectiveness, and Value Sweet Food Consumption Questionnaire- Past Week Version Self-Restraint Tactics for Sweet Cravings Questionnaire CFQ FAAQ
Note. CFQ = Cognitive Fusion Questionnaire, FAAQ = Food Craving Acceptance and Action Questionnaire, FFMQ-SF = Five Facet Mindfulness Questionnaire – Short Form, FCQ-Trait = Food Craving Questionnaire-Trait, YFAS = Yale Food Addiction Scale. 119
APPENDIX T: INFORMED CONSENT DOCUMENT
Introduction: My name is Maija Taylor, M.A., I am a researcher working with Dr. Harold Rosenberg in the Psychology Department at Bowling Green State University. This is a study interested in evaluating an intervention for the management of sweet food cravings.
Purpose: The purpose of this research study is to better understand how individuals typically manage sweet food cravings and the best strategies for managing sweet food cravings. This could improve researchers’ knowledge of how to help individuals reduce consumption of craved sweet foods. If you complete the study, you will receive one of two rewards: (1) If you are enrolled in a psychology course that requires research participation, you will receive 3 research credits. (2) If you are not eligible for research credit, you will receive a $5 Amazon gift card.
To participate, you must be (1) a BGSU student, (2) at least 18 years old, (3) experience cravings for sweet foods 7 or more times per week, (4) eat craved sweet foods 4 or more times per week, (5) want to reduce the frequency of consuming craved sweet foods, (6) not have food allergies to ingredients commonly found in chocolate candy or cookies, (7) be willing to receive text messages, and (8) be willing to complete daily three-item surveys.
Procedure: Before coming in, you will complete an informed consent document, eligibility screener, and several questionnaires (30 minutes). Next you will sign up for an in-lab intervention timeslot, either for chocolate candy or cookie cravings. You must complete online material 48 hours before coming into the lab for the intervention. You will come to room 444 in the psychology building on campus for the face-to-face intervention (30 minutes). All intervention sessions will be audiotaped so that I can check whether the instructors of the session have done their job correctly. Following the intervention you will receive nightly texts with a web link to a three-item survey. You will also receive two daily intervention-related texts, which will not require a response. Finally, two weeks following the intervention you will complete additional questionnaires (30 minutes). Full participation should take about 120 minutes.
Voluntary nature: Your participation in this study is completely voluntary. You are free to withdraw at any time. You may decide to skip questions, not do a particular task, or discontinue participation at any time without penalty. Deciding to participate or not will not affect your grades or class standing or relationship with Bowling Green State University.
Confidentiality: Information you provide will remain confidential. Only the researchers running the study will have access to your responses. Data collected in this study will be stored on a password-protected hard-drive, which will remain with the primary researcher or in a locked research lab at all times. Your phone number and e-mail will be separated from your responses. Your responses will be identified with a number. All session audiotapes will be stored in a locked research lab. Only the researchers running the study will be permitted to access and listen to these audiotapes. As with all computer use, be sure to remember: (1) some employers may use tracking software so you may want to complete your survey on a personal computer, (2) do 120 not leave the survey open if using a public computer or a computer others may have access to, and (3) clear your browser cache and page history after completing the survey.
Risks: There are not any anticipated risks to you in this study that would be greater than those normally encountered in daily life. This study does require interaction with foods that contain common food allergens. The eligibility screener is intended to protect you from adverse health effects, by prohibiting individuals with food allergies to ingredients commonly found in chocolate candy and cookies from participating in the study. If you have an adverse food allergy response to the foods in the study, seek medical attention immediately at a health center or hospital. You will be responsible for any costs associated with this medical attention.
Contact Information: If you have any questions about the research or your participation in the research, you may contact Maija Taylor at [email protected] or (419) 372-8238. You may also contact the research supervisor for this project, Dr. Harold Rosenberg, at [email protected] or (419) 372-7255. Finally, should you have questions about your rights as a participant in this research, you may contact the Chair of the Human Subjects Review Board by phone at (419) 372-7716 or by email at [email protected].
Thank you for your time.
I have been informed of the purposes, procedures, risks, and benefits of this study. I have had the opportunity to have all my questions answered and I have been informed that my participation is completely voluntary. I agree to participate in this research.
By clicking yes and taking the survey, you are consenting to participate in this study:
Yes No 121
APPENDIX U: DEBRIEFING DOCUMENTS
Control Group (Typical Tactics) Debriefing Form
Thank you for participating! Your participation will help us and other researchers understand how to help individuals manage sweet food cravings and reduce consumption of sweet foods. What is presently known is that sweet food cravings are hard to manage and that excess consumption of sugary foods is related to negative health effects.
Other participants in this study received a different intervention. We hypothesized that this other intervention would effectively reduce consumption of all sweet foods and chocolate candy or cookies more specifically. If you would like to receive this intervention, contact the primary researcher at [email protected] to schedule a time.
For some people, thinking about food cravings and eating behavior can be upsetting. If you think you need help with eating or other difficulties, below are a few psychological resources:
Psychological Services Center: Psychology Building Suite 300 Department of Psychology Bowling Green State University Bowling Green, OH 43403 (419) 372-2540
Counseling Center: WALK-IN HOURS Monday - Friday: 1:30 - 4:00 104 College Park Office Building Bowling Green State University Bowling Green, OH 43403 (419) 372-2081
Psychological Resources Ltd. (Private Practice) Elaine Bruckner Appointment only May be covered by some insurance plans 970 W. Wooster St., Suite 124 Bowling Green, Ohio 43402 (419) 352-6666 122
Experimental Group (Cognitive Defusion) Debriefing Form
Thank you for participating! Your participation will help us and other researchers understand how to help individuals manage sweet food cravings and reduce consumption of sweet foods. What is presently known is that sweet food cravings are hard to manage and that excess consumption of sugary foods is related to negative health effects.
For some people, thinking about food cravings and eating behavior can be upsetting. If you think you need help with eating or other difficulties, below are a few psychological resources:
Psychological Services Center: Psychology Building Suite 300 Department of Psychology Bowling Green State University Bowling Green, OH 43403 (419) 372-2540
Counseling Center: WALK-IN HOURS Monday - Friday: 1:30 - 4:00 104 College Park Office Building Bowling Green State University Bowling Green, OH 43403 (419) 372-2081
Psychological Resources Ltd. (Private Practice) Elaine Bruckner Appointment only May be covered by some insurance plans 970 W. Wooster St., Suite 124 Bowling Green, Ohio 43402 (419) 352-6666 123
APPENDIX V: COGNITIVE DEFUSION SESSION CONTENT
(PowerPoint Slides and Verbal Scripts)
Cognitive Defusion For Sweet Food Cravings (Slide 1)
Sweet Food Cravings (Slide 2) We all have cravings for sweet foods Sometimes we do not want to eat the sweet foods we crave Cognitive defusion is one strategy that can help you meet your eating-related goals
What is Cognitive Defusion for Sweet Food Cravings? (Slide 3) An active process of noticing food craving thoughts as they arise in your mind and using imagery to actively separate yourself from food craving thoughts
What is the Foundation? (Slide 4) All thoughts, including food craving thoughts, are involuntary, which means that we cannot control whether they occur We cannot easily change them or get rid of them no matter how hard we try The more we try to control our food craving thoughts, the stronger they get, and the more they affect our eating behavior
Exercise 1#: Controlling Thoughts (Script read aloud by researcher) I don’t want you to think about something. I’m going to tell you about it very soon. And when I do, don’t think about it even for a second. Here it comes. Remember, don’t think about it. Don’t think of…a golden retriever puppy. You know how its big eyes look lovingly up at you. Don’t think of it! Its tail wagging, it jumping up on you, and trying to give you a kiss. Don’t think of it! You imagine petting its warm and soft fur…Don’t think of it! It’s very important; don’t think about any of this!
Exercise 1# Reflection (Slide 5) What did you learn from this activity? Is it easy to control thoughts?
What Type of Strategy is Cognitive Defusion (Slide 6) Cognitive defusion for food cravings IS NOT a control strategy oriented to reduce or get rid of the food craving thoughts Cognitive defusion IS a strategy oriented to develop an open relationship with your food craving thoughts, so that you can actively respond to them in new, adaptive ways
Fusion with Food Craving Thoughts (Slide 7) 124
When we become fused with a food craving thought we: notice it, become very attached to it, and “buy into” what it tells us.
“I need a burger.” “Nothing would be better than a hot piece of pizza.” “Bacon would taste delicious right now.”
Defusion from Food Craving Thoughts (Slide 8) When we defuse from a food craving thought we: notice it, actively detach from it, and choose how we want to respond to the thought. “I am having a thought that I need a burger.” “What an interesting thought I’m having, that nothing would be better than a hot piece of pizza.” “There’s that thought again that bacon would taste delicious right now.”
What We Learn from Cognitive Defusion from Food Cravings (Slide 9) Food craving thoughts are not causal (Food craving thoughts do not cause us to eat) Our ability to observe our food craving thoughts is continuous. We have been observers of our thoughts our whole lives. Food craving thoughts come and go. However, the you that is aware of what you think does not change.
The Potential Benefits (Slide 10) Short-Term We become aware that we have choices when a food craving thought pops into our mind 1. We can act on the thought and eat the craved food 2. We can eat a healthier alternative food 3. We can engage in a valued activity Long-Term Disrupts automatic patterns of eating in response to food cravings Develop new eating patterns that are consistent with your values and goals
Exercise 2# Cravings on Clouds (Slide 11) This imagery activity will help you practice cognitive defusion for food craving thoughts You will be asked to use this imagery in a short while You can use this imagery whenever you have strong desires or urges to eat sweet foods
Exercise 2#: Cravings on Clouds Imagery (Script read aloud by researcher) Close your eyes. I’d like you to imagine that you are in a grassy yard staring up at the sky. Picture watching clouds as they pass by. Notice, that in time, the particular clouds you had been watching are no longer there. They have floated by, and new clouds have taken their place. Now, shift your attention to any food craving thoughts you are having. As each thought arises, imagine it appearing on one of the clouds you see. Imagine each word of the thought written on the cloud. 125
Notice that each food craving thought is far above you on a cloud. While you, the observer, are below watching. There is a great distance between you and the food craving thought. This distance allows you recognize that you are not the food craving thought. You are an independent observer who can choose to respond to the thought in any way you would like. Your actions are not limited by the thought. As each food craving thought comes into your mind, Imagine it appearing on a cloud. If other thoughts come into your mind, imagine them on clouds too. Notice that each thought placed on a cloud is far away. Watch each thought slowly float by.
Ask “Do you have any questions?”
Administer Instruction Understanding Question Form
Hand out cognitive defusion pre-printed cards
Cue Exposure Investigator Script & Actions (Cookie Session) Soon, I am going to present you with a cookie Then I am going to ask you to fill out a questionnaire. Afterward, I am going to ask you to practice cognitive defusion
Bring out participant-specific cookies and place on paper plates in front of relevant participants, with a napkin
Pick up the cookie and smell it Break off a piece of it and bring it to your lips Notice the taste and texture of the cookie on your lips But don’t eat it
Administer the Food Craving Questionnaire-State for Cookies Time 1
Now begin to practice cognitive defusion for craving thoughts and urges that come into your mind I am going to have you practice it on their own, in silence, for 5 minutes. Look at the card to help you practice. Remember to not eat the cookie.
Start the stopwatch and allow five minutes to pass.
Administer the Food Craving Questionnaire-State for Cookies Time 2
Cue Exposure Investigator Script & Actions (Chocolate Candy Session) Soon, I am going to present you with a chocolate candy 126
Then I am going to ask you to fill out a questionnaire. Afterward, I am going to ask you to practice cognitive defusion
Bring out participant-specific chocolate candies and place on napkins in front of relevant participants, with a napkin
Unwrap the chocolate candy Pick up the chocolate candy and smell it Break off a piece of it and bring it to your lips Notice the taste and texture of the chocolate candy on your lips But don’t eat it
Administer the Food Craving Questionnaire-State for Chocolate Candy Time 1
Now begin to practice cognitive defusion for craving thoughts and urges that come into your mind I am going to have you practice it on their own, in silence, for 5 minutes. Look at the card to help you practice. Remember to not eat the chocolate.
Start the stopwatch and allow five minutes to pass.
Administer the Food Craving Questionnaire-State for Chocolate Candy Time 2
Cognitive Defusion Index Card
Cognitive Defusion
1. Notice food craving thoughts as they arise
2. Use the “Cravings on Clouds” imagery to separate yourself from the thoughts 127
APPENDIX W: TYPICAL TACTICS SESSION CONTENT
(PowerPoint Slides and Verbal Scripts)
Food Craving Management Tactics For Sweet Food Cravings (Slide 1)
Sweet Food Cravings (Slide 2) We all have cravings for sweet foods Sometimes we do not want to eat the sweet foods we crave Using previously used, effective, and preferred tactics (e.g., strategies) to manage food cravings can help you meet your eating-related goals
What is Food Craving Management Using a Tactic? (Slide 3) An active process of using a tactic that you have used before to manage food craving thoughts
What is the Foundation? (Slide 4) We have all learned and used tactics to manage food cravings However, many of us do not use them frequently When a food craving arises we often do not use them We need to actively select preferred food craving tactics that we have found to be effective And remind ourselves to use them
Exercise 1#: Dusty Books on a Shelf (Script read aloud by researcher) I want you to think about the food craving tactics you have used First think about the tactics you have used recently Consider whether you have used them consistently or on-and-off Contemplate how often you experienced a food craving and then did not use the tactics (Pause) Now think of the tactics you have used in the past Consider whether you have used them consistently or on-and-off Contemplate how often you experienced a food craving and then did not use the tactics Over time, we forget about tactics The tactics become like books on the shelf that are gathering dust
Exercise 1# Reflection (Slide 5) What did your learn from this activity? Have we all left some effective tactics on a shelf and forgotten to use them?
What is a Food Craving Management Tactic like? (Slide 6) A tactic for managing food cravings can be anything really! It is a tactic that fits your preferences There is no “one-size-fits all” All that matters is that you think that the tactic has worked pretty well to manage food cravings when you have used it 128
Not Using a Food Craving Management Tactic (Slide 7)
When we do not use a food craving management tactic we: run on autopilot and act in the same way we usually do
Actively Using a Food Craving Management Tactic (Slide 8) When we actively use a selected food craving management tactic we: (1) notice the food craving, (2) remind ourselves to use a selected tactic. This allows us to behave in a different way that usual
What We Learn from Use of Food Craving Management Tactics (Slide 9) We can better manage cravings if we choose a food craving management tactic that suits us and remind ourselves to use it when a food craving arises
The Potential Benefits (Slide 10) Short-Term We become aware that we have choices when we crave a food 1. We can run on autopilot and act in the same way 2. We can behave in a new way
Long-Term Disrupts automatic patterns of eating in response to food cravings Develop new eating patterns that are consistent with your values and goals
Exercise 2# Clouds Imagery (Slide 11) This imagery activity will help clear your mind so that you can come up with a tactic that suits you.
Exercise 2#: Clouds Imagery (Script read aloud by researcher) Close your eyes. I’d like you to imagine that you are in a grassy yard staring up at the sky. Picture watching the clouds. Imagine that they are fluffy and white Set against a bright blue sky. Notice how some of them are different sizes Picture a golden sun peeking out from behind one of the clouds. Then, imagine looking around you. Picture a tall tree nearby. Notice the bark of the tree and its many branches. Imagine that it is full of green leaves Notice that these leaves are moving with the breeze. Picture birds flying around in the sky. Then imagine bringing your gaze down to the green grass around you. Imagine seeing white flowers sprinkled between the blades of grass. Picture a patch of clover. 129
Then bring your gaze back up to the sky. Picture the clouds again Set against a bright blue sky.
Hand one business-size blank card and one index card to each participant
Tactic Selection (Slide 12) Silently come up with a food craving management tactic that suits you. Write a description of the tactic down on the small card and then copy your description to the index card. Write down your BGSU e-mail address on the index card. You will keep the small card and provide the index card to me. I will give you 5 minutes to do this.
Pause and let all participants write down a tactic. Provide full 5 minutes.
Cue Exposure Investigator Script & Actions (Cookie Session) Soon, I am going to present you with a cookie Then, I am going to ask you to fill out a questionnaire. Afterward, I am going to ask you to practice the tactic you selected.
Bring out participant-specific cookies and place on paper plates in front of relevant participants, with a napkin
Pick up the cookie and smell it Break off a piece of it and bring it to your lips Notice the taste and texture of the cookie on your lips But don’t eat it
Administer the Food Craving Questionnaire-State for Cookies Time 1
Now begin to practice your tactic for craving thoughts and urges that come into your mind I am going to have you practice it on their own, in silence, for 5 minutes. Look at the card to help you practice. Remember to not eat the cookie.
Cue Exposure Investigator Script & Actions (Chocolate Candy Session) Soon, I am going to present you with a chocolate candy Then, I am going to ask you to fill out a questionnaire. Afterward, I am going to ask you to practice the tactic you selected
Bring out participant-specific chocolate candies and place on napkins in front of relevant participants, with a napkin Unwrap the chocolate candy Pick up the chocolate candy and smell it 130
Break off a piece of it and bring it to your lips Notice the taste and texture of the chocolate candy on your lips But don’t eat it
Administer the Food Craving Questionnaire-State for Chocolate Candy Time 1
Now begin to practice your tactic for craving thoughts and urges that come into your mind I am going to have you practice it on their own, in silence, for 5 minutes. Look at the card to help you practice. Remember to not eat the chocolate.
Start the stopwatch and allow five minutes to pass.
Administer the Food Craving Questionnaire-State for Chocolate Candy Time 2