Behavioral Medicine

ISSN: 0896-4289 (Print) 1940-4026 (Online) Journal homepage: http://www.tandfonline.com/loi/vbmd20

The Effects of Mindfulness-Based Interventions

on Diabetes-Related Distress, Quality of Life, and
Metabolic Control Among Persons with Diabetes: A
Meta-Analytic Review

Leah M. Bogusch & William H. O'Brien

To cite this article: Leah M. Bogusch & William H. O'Brien (2018): The Effects of Mindfulness-
Based Interventions on Diabetes-Related Distress, Quality of Life, and Metabolic Control
Among Persons with Diabetes: A Meta-Analytic Review, Behavioral Medicine, DOI:
10.1080/08964289.2018.1432549

To link to this article: https://doi.org/10.1080/08964289.2018.1432549

Published online: 04 Apr 2018.

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BEHAVIORAL MEDICINE
https://doi.org/10.1080/08964289.2018.1432549

The Effects of Mindfulness-Based Interventions on Diabetes-Related Distress,

Quality of Life, and Metabolic Control Among Persons with Diabetes:
A Meta-Analytic Review
Leah M. Bogusch and William H. O’Brien
Psychology Department, Bowling Green State University

ABSTRACT KEYWORDS
Mindfulness-based interventions (MBIs) have improved psychological outcomes for multiple chronic diabetes-related distress;
health conditions, including diabetes. A meta-analytic review of the literature was conducted on all meta-analysis; Mindfulness-
located studies (n D 14) investigating MBIs that targeted diabetes-related distress (DRD) and based interventions; type 1
diabetes-related outcomes among people with Type 1 and Type 2 diabetes. PsychInfo, PubMed, diabetes; type 2 diabetes
Medline, and Web of Science were searched for MBIs that were designed to improve DRD and other
secondary outcomes, including quality of life and measures of metabolic control. A meta-analysis of
these outcomes uncovered small-to-moderate effect sizes for intervention studies measuring
pretreatment to posttreatment changes in DRD and metabolic control among treatment group
participants. However, the pretreatment to follow-up comparisons for DRD and metabolic control
were small and unreliable. For control groups, all pre-treatment to post-treatment and pre-
treatment to follow-up comparisons were unreliable for all outcomes. A moderate effect size for
treatment-control comparisons was found for intervention studies measuring quality of life
outcomes at posttreatment, but not at follow-up comparisons. All other effect sizes for treatment-
control comparisons were unreliable. Limitations and implications for MBIs among individuals with
diabetes are discussed.

Introduction
Type 1 and Type 2 diabetes affect approximately 29 mil-
lion people in the United States, about 90%–95% of
whom are people with Type 2 diabetes.1 Type 2 diabetes
is particularly costly to the public in terms of morbidity
with the costs for treatment, disability, and loss of
employment estimating to be $245 billion in 2012 alone.2
Further, it has been estimated that in 2010 over 69,000
deaths were directly linked to the complications of
diabetes, although this estimate may be low due to
underreporting.3
Development of Type 1 diabetes usually emerges dur-
ing childhood when the body no longer produces insulin,
while development of Type 2 diabetes usually occurs
during adulthood and is due to resistance of cells in the
body to the effects of insulin combined with a reduction
of efficiency of beta cells in the pancreas that produce
insulin.2 Current standards of treatment for both types
of diabetes are daily administration of medications
designed to control glucose levels, dietary restriction
(e.g., avoiding foods high in carbohydrates), regular
physical activity, and regular monitoring of blood
glucose for patients who take insulin.4 Interventions
used to improve outcomes typically use behavioral and
educational techniques.5 The aforementioned treatment
components must typically be followed across lengthy
periods of time. For example, the average length of time
that a person manages Type 2 diabetes is 11.4 years.1
Effective management of Type 2 diabetes requires the
affected person to perform many daily self-care behav-
iors. As a result, adherence is a significant challenge for
patients and providers alike. Additionally, poor adher-
ence to diabetes treatment regimens is associated with
increased complexity (e.g., multiple medications, dosing
schedules), greater cost, poor understanding of risks and
benefits of adherence, and depression.6 Finally, a longitu-
dinal study by Aikens found that symptoms of distress
predicted decreased medication adherence and fre-
quency of self-monitoring of blood glucose across a six-
month interval.7
One psychological factor related to psychological well-
being and adherence among people with diabetes is dia-
betes-related distress (DRD). DRD can be conceptualized
as an aversive cognitive and emotional response to

CONTACT Leah M. Bogusch lbogusc@bgsu.edu Psychology Department, Bowling Green State University, Bowling Green, OH 43403.
© 2018 Taylor & Francis Group, LLC
2 L. M. BOGUSCH AND W. H. O’BRIEN
stressors associated with the disease, including feelings of
anger or discouragement, worries about ability to main-
tain a healthy lifestyle, or fear of adverse health out-
comes.8 DRD is itself an indicator of psychological well-
being. DRD has also been linked to reduced medication
adherence, reduced time spent exercising, a less healthy
diet, and poorer blood glucose management as measured
by A1c levels.8–12
Mindfulness, with its core acceptance skills, may be
related to DRD, medication adherence, better metabolic
regulation, and better quality of life among people with
diabetes. According to Schroevers and colleagues13 mind-
fulness can improve psychological well-being, including
DRD and quality of life. Indeed, previous studies of
mindfulness-based interventions (MBIs) among patient
populations have resulted in improved quality of life.14–15
MBIs may promote improved outcomes as follows.
First, it can be that self-care and self-treatment behaviors
such as blood glucose testing, dietary restrictions, and
insulin injections can prompt negative thoughts (e.g., “I
am sick” or “It is too hard to comply with physician rec-
ommendations”) and consequent negative emotional
experiences (e.g., depressed mood, anxiety) among per-
sons with diabetes. Second, when these negative thoughts
are experienced as real and accurate evaluations of a par-
ticular self-care or self-treatment action, a person with
diabetes could be more apt to engage in escape and avoid-
ance behaviors (i.e., nonadherence). MBIs can help per-
sons with diabetes learn to master techniques such as
defusion. Defusion techniques are designed to help a per-
son learn to observe a thought as a cognitive experience
but not necessarily an objective truth. Defusion techniques
are also designed to help a person learn to tolerate dis-
tressing thoughts without engaging in escape and avoid-
ance actions. In addition to defusion, MBIs may
encourage the person to practice adaptive self-care and
self-treatment behaviors while simultaneously experienc-
ing negative thoughts and distress. Taken together,
defusion and the repetitive practice of adaptive behavior
are akin to exposure to distressing internal experiences
with response prevention (i.e., preventing nonadherence
escape and avoidance behaviors). As such, MBIs could
exert a reduction of DRD via defusion while simulta-
neously improving self-care and adherence via repeated
practice of adaptive actions.
Participation in MBIs may also be related to better
health-related outcomes for people with diabetes through
physiological mechanisms. Regular practice of mindfulness
has been associated with a decrease in chronic stress
responding.16 This reduction in stress responding would
then promote better metabolic control.17 For example,
Rosenzwieg and colleagues18 conducted an eight-week
Mindfulness-Based Stress Reduction (MBSR) program to
examine its effects on glycemic control and psychological
distress among individuals with Type 2 diabetes. Among
the 11 participants who completed the MBSR intervention,
post-treatment A1c levels were significantly lower than
pretreatment levels. Further, the magnitude of change in
A1c levels was large (d D 0.88). Psychological distress,
depression, and anxiety were also significantly reduced
among intervention participants, and these reductions
were maintained at one-month follow-up.
To summarize, diabetes is associated with various nega-
tive health outcomes. Reducing DRD using MBIs may be
one factor that could promote better adherence and meta-
bolic regulation. To date, no meta-analytic review has
examined the effects of MBIs on DRD, adherence, or meta-
bolic regulation. However, a previous meta-analysis found
a large effect for behavioral and educational interventions
provided by medical professionals for improving metabolic
regulation and frequency of self-monitoring of blood glu-
cose.9 A qualitative review by Noordali and colleagues19
indicated that MBIs were likely effective at improving psy-
chological well-being among people with Type 1 and Type
2 diabetes. However, these authors also concluded that
there was mixed evidence regarding MBIs and physiologi-
cal outcomes in this population.
This meta-analysis provides a quantitative review of all
relevant studies that evaluated the extent to which MBIs
yielded improvements in psychological and physiological
well-being among persons with Type 1 and Type 2 diabe-
tes. We predicted that participation in MBIs would be asso-
ciated with: (1) reductions in DRD and improved quality of
life, (2) improved physiological well-being, and (3) better
adherence to diabetic treatment regimens.
Methods
This study was conducted according to the PRISMA (Pre-
ferred Reporting Items for Systematic Reviews and Meta-
Analyses) statement guidelines. These guidelines were
used to: (1) search for all studies that evaluated the effects
of MBIs on diabetes outcomes; (2) evaluate study quality;
(3) extract data from studies; and (4) code, aggregate, and
analyze data. The second author has extensive experience
with meta-analytic techniques via graduate level teaching
combined with research activity and publications.20–23
The first author acquired meta-analytic skills via graduate
level training combined with research activity and attend-
ing conference presentations on meta-analytic methods.
Systematic review
Data sources and searches
A search of Psychinfo, Pubmed, Medline, and Web of
Science was conducted. Reference lists of eligible

publications were also searched for additional studies.
Title, abstract, and full-text reviews were conducted by
the first author and a second graduate student reviewer.
Any discrepancies in study selection were resolved by
discussion.
Study Selection
All years of publication were considered with the last
search occurring on November 15, 2016. Only English
language publications were included. Publications in aca-
demic journals and dissertations were also included. The
terms “mindfulness” and “diabetes” were entered into
separate search boxes for PsychInfo and Web of Science
searches. For PubMed and Medline searches, “mindful-
ness AND diabetes” were entered into the search box.
See Figure 1 for details on study search and selection.
Sixteen publications were located. Of these 16 publica-
tions, 14 reported unique data. All 14 studies also met the
following inclusion criteria: (1) an MBI for the manage-
ment of diabetes was provided; (2) the sample consisted of
Figure 1. Study selection.
BEHAVIORAL MEDICINE 3
adults with Type 1 or Type 2 diabetes; (3) DRD, medication
adherence, A1c, fasting blood glucose, continuous blood
glucose, quality of life, and/or frequency of self-monitored
blood glucose were used as outcome variables; (4) the study
was reported in a peer-reviewed publication or dissertation;
and (5) the article was written in English.
Studies conducted among people with prediabetes,
people at risk for diabetes, and people with gestational
diabetes were excluded. Additionally, studies that only
used physical activity as an intervention were excluded if
there was no mindfulness component.
Data extraction and quality assessment
The sample size, mean age, gender, ethnicity, race, and
years since diagnosis of diabetes were coded for demo-
graphic purposes. Self-reported DRD and quality of life
ratings were coded as psychological well-being outcomes.
A1c and fasting blood glucose levels were coded as physi-
ological outcomes. Self-monitoring of blood glucose and
medication adherence were coded as measures of behav-
ioral adherence. Number and length of treatment ses-
sions, duration of treatment in weeks, and treatment
attendance were coded as intervention characteristics.
The means and standard deviations of relevant statistics
at pretreatment, posttreatment, and follow-up were coded
whenever they were reported. When means and standard
deviations were not reported, any other relevant statistic
that could be used to generate effect sizes (e.g., p-values, t-
values, and F-values) were coded. The quality of studies
was also assessed using the Jadad Scale (see Appendix A).24
Meta-analytic review
Data synthesis and analysis
A random effects model was used to calculate Hedge’s d.
Effect sizes for pre-treatment to post-treatment measures
and pre-treatment to follow-up measures were calculated
separately for treatment groups and control groups.
Hedge’s d was also calculated for treatment versus control
group comparisons at posttreatment and at follow-up. Ken-
dall’s Tau was calculated to assess publication bias. Qtotal
was used to evaluate whether the dispersion of effect sizes
exceeded sampling error. Finally, Rosenthal’s fail-safe num-
ber was calculated when the cumulative effect size was sta-
tistically significant, since nonsignificant cumulative effect
sizes automatically generate a fail-safe number of 0.
Results
Study design characteristics
Of the 14 treatment outcome studies, six used Mindful-
ness-Based Stress Reduction (MBSR), three used
4 L. M. BOGUSCH AND W. H. O’BRIEN

Mindfulness-based Cognitive Therapy (MBCT), one
used a mindfulness meditation program combined with
diabetes education, one used mindfulness meditation
alone, one used Acceptance and Commitment Therapy
(ACT), one used Mindful Stress Reduction in Diabetes
Education (Mind-STRIDE), and one used Mindfulness-
based Eating Awareness Training (MB-EAT). Nine of
the 14 treatment outcome studies were randomized con-
trolled trials. Four of these randomized control trials
were pilot studies. The remaining five treatment outcome
studies reported pre-treatment to post-treatment com-
parisons and had no control groups. For treatment
groups, mean interval from pre-treatment to post-treat-
ment was eight weeks (SD D 2.22, range 4–12 weeks).
The mean interval from pre-treatment to follow-up was
five months (SD D 2.75, range 3–12 months).
Among the nine studies with control groups, three used
treatment as usual as a control condition. Four provided an
educational experience as a control condition. One study
had two control groups, one being a psychoeducation
group and the other a walking exercise group. A final study
had two control groups, including a cognitive behavioral
therapy group and a treatment as usual group.
Participant characteristics
Data from a total of 673 individuals were reported in
the 14 unique treatment outcome studies. A majority
of studies reported participant gender (n D 14), race
(n D 10), age (n D 11), type of diabetes (n D 14),
duration of time since the diagnosis of diabetes (n D
11) and A1c levels (n D 12). A smaller proportion of
studies (n D 6) reported participant insulin use statis-
tics. Forty-nine percent of the participants were
female. In terms of race, 44% of the participants were
reported to be Caucasian followed by African Ameri-
can (25%), Asian (4%), Latino (3%), American Indian
(2%), or Mixed/other (1%). The average age of partici-
pants was 58 (SD D 9.3). A majority of participants
were diagnosed with Type 2 diabetes (86%). The mean
time since diagnosis was 11 years (SD D 10.3). The
mean A1c level was 7.97 (SD D 1.3; 64 mmol/mol).
Finally, 52% of the participants used insulin.
Meta-analytic findings: Effect sizes
Treatment vs control at post-treatment and follow-up
Results of treatment versus control comparisons for indi-
vidual studies are summarized in Table 1. Treatment ver-
sus control comparisons at post-treatment on measures
of DRD yielded a small and unreliable overall effect size
(d D 0.18, 95% CI D –0.20, 0.57). The dispersion of indi-
vidual effect sizes was nonsignificant (Qtotal D 6.25, p D
0.28). Kendall’s Tau indicated that the magnitudes of
individual effect sizes were not significantly associated
with sample sizes (t D –0.33, p D 0.35).

Table 1. Individual study characteristics for treatment vs. control at post-treatment and follow-up.
Post-treatment Study (by first author’s last name) Outcome ES(d) Variance 95% C.I.

Gregg A1c 0.32 0.06 ¡0.14 – 0.74

Hartmann A1c ¡0.94 0.04 ¡1.35 – -0.53
Jung FBG ¡0.09 0.10 ¡0.72 – 0.54
FBG ¡0.23 0.11 ¡0.87 – 0.41
Miller A1c 0.00 0.08 ¡0.54 – 0.54
FBG 0.00 0.08 ¡0.54 – 0.54
Tovote A1c 0.27 0.06 ¡0.23 – 0.77
Van son A1c 0.15 0.03 ¡0.18 – 0.48
Gregg Self-management 0.21 0.06 ¡0.28 – 0.70
Rush SMBG ¡0.30 0.21 ¡0.39 – -0.21
Jung DRD 0.50 0.11 ¡0.13 – 1.13
DRD 0.41 0.11 ¡0.23 – 1.05
Schroevers DRD 1.04 0.19 0.19 – 1.89
Tovote DRD 0.09 0.06 ¡0.40 – 0.58
DRD 0.18 0.06 ¡0.32 – 0.68
Van son DRD 0.19 0.03 ¡0.14 – 0.52
Teixeira QOL 0.56 0.21 ¡0.33 – 1.45
Van son QOLmental 0.62 0.03 0.01 – 1.23
Van son QOLphysical 0.45 0.03 0.11 – 0.79
Follow-up Study Outcome ES(d) Variance 95% C.I.
Hartmann A1c 1.98 0.06 1.51 – 2.45
Miller A1c 0.10 0.01 ¡0.04 – 0.24
FBG ¡0.15 0.01 ¡0.20 – -0.10
Rush A1c 0.41 0.21 ¡0.49 – 1.31
Van son A1c 0.08 0.03 ¡0.25 – 0.41
Rush SMBG ¡0.02 0.21 ¡0.91 – 0.87
Van son DRD 0.39 0.03 0.05 – 0.73
Van son QOLmental 0.78 0.03 0.44 – 1.12
Van son QOLphysical 0.40 0.03 0.06 – 0.74

Note: DRD D Diabetes-related distress; SMBG D Self-monitored blood glucose; FBG D Fasting blood glucose, QOL D Quality of life.

Only one treatment-control study collected data on
DRD at follow-up. As a result, a meta-analysis was not
performed.
Treatment versus control comparisons for quality of life
measures at post-treatment resulted in a moderate and reli-
able effect size at post-treatment (d D 0.53, 95% CI D 0.03,
1.04). Dispersion of individual effect sizes was nonsignifi-
cant (Qtotal D 0.48, p D 0.79). The magnitudes of individ-
ual effect sizes were not associated with sample sizes (t D
0.00, p D 1.00) and Rosenthal’s fail-safe number was 17.
The overall effect size for treatment versus control
comparisons for quality of life measures at follow-up
were moderate, but unreliable (d D 0.59, 95% CI D
–01.81, 2.98). Because the overall effect size was unreli-
able and only two studies were included in this analysis,
Qtotal, Kendall’s Tau, and Rosenthal’s fail-safe were not
calculated.
For measures of physiological well-being, a small and
unreliable overall effect size was observed for treatment
versus control comparisons at post-treatment (d D
–0.07, 95% CI D –0.46, 0.32). The dispersion of effect
sizes was nonsignificant (Qtotal D 5.66, p D 0.58). Ken-
dall’s Tau was significant (t D 0.63, p D 0.03) which
indicated that larger effect sizes were produced by studies
with a larger sample sizes. Because the overall effect size
was unreliable, Rosenthal’s fail-safe was not calculated.
Treatment versus control comparisons at follow-up
on measures of physiological well-being yielded a large,
yet unreliable overall effect size (d D 0.83, 95% CI D
–2.16, 3.82). The dispersion of individual effect sizes was
nonsignificant (Qtotal D 1.47, p D 0.48). The magnitudes
of individual effect sizes were not significantly associated
with sample size (t D –0.33, p D 0.60). Because the over-
all effect size was unreliable, Rosenthal’s fail-safe was not
calculated.
Treatment versus control comparisons at post-treat-
ment for behavioral adherence measures yielded a small
and unreliable effect size (d D 0.10, 95% CI D –2.67,
2.87). Because the overall effect size was unreliable and
only two studies were included in this analysis, Qtotal,
Kendall’s Tau, and Rosenthal’s fail-safe were not
calculated.
Only one study examined behavioral adherence data
at follow-up. As a result, a meta-analysis was not
performed.
Pre-treatment to post-treatment and pre-treatment to
follow-up effect sizes for treatment groups
A summary of pre-treatment to post-treatment and pre-
treatment to follow-up comparisons among individual
studies is found in Table 2.
For studies using DRD as an outcome measure, a
moderate and reliable overall effect size was found for
BEHAVIORAL MEDICINE 5
pre-treatment to post-treatment comparisons among
treatment groups (d D 0.41, 95% CI D 0.01, 0.82).
The dispersion of individual effect sizes was nonsig-
nificant (Qtotal D 7.59, p D 0.27). The magnitudes of
individual effect sizes were not associated with sample
sizes (t D 0.00, p D 1.00). Rosenthal’s fail-safe num-
ber indicated that 27 non-significant effect sizes
would be needed to reduce the overall effect size to
non-significance.
Pre-treatment to follow-up comparisons on DRD
measures among treatment groups yielded a moderate
and unreliable overall effect size (d D 0.45, 95% CI D
–.16, 1.06) indicating that treatment effects may not have
been maintained over time. The dispersion of individual
effect sizes was nonsignificant (Qtotal D 0.19, p D 0.91).
The magnitudes of individual effect sizes were not associ-
ated with sample sizes (t D –0.33, p D 0.60). Because the
overall effect size was unreliable, Rosenthal’s fail-safe
was not calculated.
Pre-treatment to post-treatment comparisons on
quality of life measures among treatment groups yielded
a moderate and unreliable overall effect size (d D 0.43,
95% CI D –1.11, 1.98). Because the overall effect size was
unreliable and only two studies were included in this
analysis, Qtotal, Kendall’s Tau, and Rosenthal’s fail-safe
were not calculated.
Pre-treatment to follow-up comparisons on quality of
life measures among treatment groups was moderate
and unreliable (d D 0.48, 95% CI D –1.07, 2.04). Because
the overall effect size was unreliable and only two studies
were included in this analysis, Qtotal, Kendall’s Tau, and
Rosenthal’s fail-safe were not calculated.
Pretreatment to posttreatment comparisons on meas-
ures of physiological well-being among treatment groups
yielded a small and reliable overall effect size (d D 0.23,
95% CI D 0.06, 0.41). The dispersion of individual effect
sizes was nonsignificant (Qtotal D 10.39, p D 0.50). The
magnitudes of individual effect sizes were not associated
with sample sizes ( D –0.25, p D 0.26) and Rosenthal’s
fail-safe number was 33.
Pre-treatment to follow-up comparisons on measures
of physiological well-being yielded a small and unreliable
overall effect size (d D 0.09, 95% CI D –0.24, 0.41), indi-
cating that treatment effects may not have been main-
tained over time. The dispersion of individual effect sizes
was nonsignificant (Qtotal D 7.18, p D 0.41). The magni-
tudes of individual effect sizes were not significantly
associated with sample sizes (t D 0.11, p D 0.71).
Because the overall effect size was unreliable, Rosenthal’s
fail-safe was not calculated.
Pretreatment-posttreatment comparisons on meas-
ures of behavioral adherence yielded a moderate and
unreliable effect size (d D 0.55, 95% CI D –0.85, 1.95).
6 L. M. BOGUSCH AND W. H. O’BRIEN

Table 2. Data exploration treatment and control pretest vs. posttest and pretest vs. follow-up.
Study Outcome ES(d) Variance 95% C.I.

Pre-test vs. Post-test

Tx: Dinardo(a) A1c 0.20 0.33 ¡0.93 – 1.33
Dreger A1c 0.31 0.18 ¡0.53 – 1.15
Gregg A1c 0.41 0.05 ¡0.03 – 0.85
Hartmann A1c 0.08 0.04 ¡0.30 – 0.46
Jung FBG 0.17 0.1 ¡0.44 – 0.78
Mller A1c 0.65 0.04 0.25 – 1.05
Glucose 0.31 0.04 ¡0.09 – 0.71
Rosenzweig A1c 0.44 0.19 ¡0.41 – 1.29
Shuster A1c ¡0.10 0.11 ¡0.75 – 0.55
Tovote A1c 0.10 0.06 ¡0.40 – 0.60
Van son A1c ¡0.09 0.03 ¡0.43 – 0.25
Dreger SMBG 0.19 .18 ¡0.65 – 1.03
Gregg Self-management 1.05 0.06 0.56 – 1.54
Rush SMBG 0.27 0.17 ¡0.53 – 1.07
Dinardo(a) DRD 0.17 0.33 ¡0.96 – 1.30
Dinardo(b) DRD 0.07 0.08 ¡0.47 – 0.61
Jung DRD 0.05 0.1 ¡0.56 – 0.66
Schroevers DRD 1.46 0.21 0.56 – 2.36
Tovote DRD 0.29 0.07 ¡0.21 – 0.79
Van son DRD 0.34 0.03 0.01 – 0.67
Van son QOLmental 0.76 0.03 0.43 – 1.09
Van son QOLphysical 0.13 0.03 ¡0.20- 0.46
Control: Gregg A1c 0.07 0.06 ¡0.41 – 0.55
Hartmann A1c 0.22 0.04 ¡0.17 – 0.61
Jung (Walking) FBG 0.21 0.11 ¡0.46 – 0.88
Jung (Education) FBG 0.19 0.12 ¡0.48 – 0.86
Miller Glucose 0.19 0.05 ¡0.23 – 0.61
Tovote (CBT) A1c 0.08 0.06 ¡0.41 – 0.57
Van son A1c ¡0.15 0.03 ¡0.49 – 0.19
Gregg Self-management 0.37 0.07 ¡0.14 – 0.88
Rush SMBG 0.40 0.25 ¡0.59 – 1.39
Jung (Walking) DRD 0.18 0.11 ¡0.49 – 0.85
Jung (Education) DRD ¡0.16 0.12 ¡0.83 – 0.51
Schroevers DRD 0.19 0.17 ¡0.61 – 0.99
Tovote (CBT) DRD 0.35 0.06 ¡0.14 – 0.84
Tovote (Waitlist) DRD ¡0.02 0.06 ¡0.51 – 0.47
Van son DRD 0.14 0.03 ¡0.20 – 0.48
Van son QOLmental 0.91 0.03 0.57 – 1.25
Van son QOLphysical 0.10 0.03 ¡0.24 – 0.44
Pre-test vs. Follow-up
Tx: Dinardo(a) A1c ¡0.20 0.33 ¡1.33 – 0.93
Dreger A1c 0.29 0.18 ¡0.55 – 1.13
Hartmann A1c 0.08 0.04 ¡0.30 – 0.46
Miller A1c 0.70 0.04 0.30 – 1.10
Miller Glucose 0.01 0.04 ¡0.39 – 0.41
Rosenzweig A1c 0.85 0.2 0.03 – 1.67
Rush A1c ¡0.65 0.18 ¡1.46 – 0.16
Van son A1c ¡0.09 0.03 ¡0.41 – 0.23
Rush SMBG 0.17 0.17 ¡0.63 – 0.97
Dinardo (a) DRD 0.34 0.33 ¡0.79 – 1.47
Dinardo (b) DRD 0.37 0.08 ¡0.17 – 0.91
Schroevers DRD 1.18 0.2 0.31 – 2.05
Van son DRD 0.49 0.03 0.15 – 0.83
Van son QOLmental 0.27 0.03 ¡0.08 – 0.62
Van son QOLphysical ¡0.07 0.03 ¡0.39 – 0.25
Control: Hartmann A1c ¡0.3 0.04 ¡0.69 – 0.09
Miller A1c 0.53 0.05 0.11 – 0.95
Glucose 0.27 0.05 ¡0.15 – 0.69
Rush A1c ¡0.60 0.26 ¡1.60 – 1.60
Van son A1c ¡0.07 0.03 ¡0.40 – 0.26
Rush SMBG ¡0.06 0.25 ¡1.04 – 0.92
Van son DRD 0.17 0.03 ¡0.16 – 0.50
Van son QOLmental 0.19 0.03 ¡0.14 – 0.52
Van son QOLphysical ¡0.15 0.03 ¡0.48 – 0.18

Note: DRD D Diabetes-related distress; SMBG D Self-monitored blood glucose; FBG D Fasting blood glucose.

Because the overall effect size was unreliable and only Pre-treatment to follow-up comparisons on measures
two studies provided data for this overall effect size, Qto- of behavioral adherence resulted in an unreliable effect
tal, Kendall’s Tau, and Rosenthal’s fail-safe were not size (d D 0.18, 95% CI D –3.58, 3.93). Because the overall
calculated. effect size was unreliable and only two studies provided

data for this overall effect size, Qtotal, Kendall’s Tau, and
Rosenthal’s fail-safe were not calculated.
Pre-treatment to post-treatment and pre-treatment to
follow-up effect sizes for control groups
For studies using DRD as an outcome variable, a small
and unreliable overall effect size was found for the com-
parison between pre-treatment and post-treatment
among control groups (d D .13, 95% CI D -.14, .41). The
dispersion of individual effect sizes was nonsignificant
(Qtotal D 1.68, p D 0.89). The magnitudes of individual
effect sizes were not associated with sample sizes (t D
0.20, p D 0.56). Because the overall effect size was unreli-
able, Rosenthal’s fail-safe was not calculated.
Only one study reported follow-up findings for DRD.
Therefore, a meta-analysis was not conducted.
Pre-treatment to post-treatment comparisons of
measures of quality of life yielded a small and unreliable
overall effect size for control groups (d D 0.10; 95% CI D
–2.07, 2.27). Because the overall effect size was unreliable
and only two effect sizes were produced from the litera-
ture, Qtotal, Kendall’s Tau, and Rosenthal’s fail-safe
were not calculated.
Comparisons of pre-treatment to follow-up of meas-
ures of quality of life yielded a small and unreliable over-
all effect size for control groups (d D 0.02; 95% CI D
–2.10, 2.14). Because the overall effect size was unreliable
and only two effect sizes were produced from the litera-
ture, Qtotal, Kendall’s Tau, and Rosenthal’s fail-safe
were not calculated.
Pretreatment to posttreatment comparisons of measures
of physiological well-being yielded a small and unreliable
overall effect size for control groups (d D 0.06, 95% CI D
–0.19, 0.30). The dispersion of individual effect sizes was
nonsignificant (Qtotal D 2.51, p D 0.77). The magnitudes
of individual effect sizes were not associated with sample
sizes (t D –0.20, p D 0.46). Because the overall effect size
was unreliable, Rosenthal’s fail-safe was not calculated.
Comparisons of pre-treatment to follow-up of meas-
ures of physiological well-being yielded a small and unre-
liable overall effect size for control groups (d D 0.10, 95%
CI D –0.60, 0.81) indicating that participants did not
improve over time. The dispersion of individual effect
sizes was nonsignificant (Qtotal D 2.33 p D 0.31). The
magnitudes of individual effect sizes were not signifi-
cantly associated with sample sizes (t D 0.11, p D 0.80).
Because the overall effect size was unreliable, Rosenthal’s
fail-safe was not calculated.
Comparisons of pre-treatment to post-treatment of
measures of behavioral adherence yielded an unreliable
effect size (d D 0.38, 95% CI D –2.57, 3.32). Because the
overall effect size was unreliable and only two studies
BEHAVIORAL MEDICINE 7
provided data for this comparison, Qtotal, Kendall’s Tau,
and Rosenthal’s fail-safe were not calculated.
Only one study reported follow-up data for behavioral
adherence. Therefore, a meta-analyses was not performed.
Exploratory analyses of possible moderators of effect
size
Due to variation the types of interventions used, analyses
were conducted to determine whether there were differ-
ences in effect sizes for studies that provided protocol-
based MBIs relative to studies that used integrated MBIs.
Traditional MBIs are conceptualized here as interven-
tions in which the primary method of intervention is
teaching mindfulness skills, as in MBSR or MBCT.25 In
contrast, integrated MBIs are interventions that use
mindfulness in addition to other methods of interven-
tion, as in ACT, which uses mindfulness skills in addi-
tion to values-based action.
The overall effect size for treatment versus control
comparisons for all outcomes at post-treatment using
traditional MBIs was small and unreliable (d D 0.08,
95% CI D –0.23, 0.36). The overall effect size for treat-
ment versus control comparisons for all outcomes using
integrated interventions was moderate and unreliable
(d D 0.34, 95% CI D –0.47, 1.14). Although the effect
sizes differed in terms of magnitude, the confidence
intervals for each included zero and also overlapped.
This indicated that the differences were unreliable.
The overall pretreatment to posttreatment and pre-
treatment to follow-up effect sizes for all outcomes for
traditional MBIs were respectively d D 0.31 (95% CI D
0.13, 0.49) and d D 0.03 (95% CI D –0.32, 0.38). The
overall pre-treatment to post-treatment and pre-treat-
ment to follow-up effect size for all outcomes for inte-
grated MBIs were respectively d D 0.36 (95% CI D 0.19,
0.53) and d D 0.17 (95% CI D –0.13, 0.47). These results
indicate that, in general, the effect sizes for traditional
MBIs are similar to effect sizes of integrated MBIs.
Exploratory analyses were also conducted to deter-
mine whether effect sizes for A1c outcomes varied as a
function of diagnosis (Type 1 versus Type 2 diabetes),
time intervals between pretreatment to posttreatment
and pretreatment to follow-up, and number of sessions.
Because only 4 studies used a sample of participants with
Type 1 diabetes, meaningful comparisons between Type
1 and Type 2 samples could not be calculated. The corre-
lation between the pre-treatment to post-treatment effect
sizes and time interval was small and non-significant (r
(23) D 0.29, p D 0.17), indicating that variation in time
intervals were not associated variation in effect sizes. The
correlation between pre-treatment to follow-up effect
sizes and time interval was small and non-significant (r
(14) D –0.04, p D 0.89). The correlation between pre-
8 L. M. BOGUSCH AND W. H. O’BRIEN
treatment to post-treatment effect sizes and number of
sessions was small and non-significant (r (23) D –0.07, p
D 0.75) indicating that the number of sessions was not
associated with magnitudes of effect sizes at posttreat-
ment. The correlations between pretreatment to follow-
up effect sizes and number of sessions was also small and
nonsignificant (r (14) D 0.06, p D 0.82) indicating that
number of session was not associated with magnitudes
of effect sizes at follow-up.
Discussion
Effect sizes derived from the meta-analytic review for
MBI treatment outcome studies were mixed. The overall
effect size for treatment versus control comparisons on
quality of life measures at posttreatment was moderate
and reliable. None of the other cumulative treatment
versus control effect sizes were reliable. The overall effect
size for pretreatment to posttreatment comparisons
among treatment groups using DRD as an outcome
variable was moderate and reliable. The overall effect
size for pretreatment to posttreatment comparisons
among treatment groups using measures of physiological
well-being was small and reliable. None of the other
cumulative pretreatment to posttreatment effect sizes or
pretreatment to follow-up effect sizes among treatment
groups were reliable. None of the cumulative effect sizes
for pretreatment to posttreatment or pretreatment to fol-
low-up comparisons for the control groups were reliable.
Treatment versus control comparisons at post-treat-
ment revealed a moderate effect size for quality of life.
This finding is congruent with other studies of patient
populations demonstrating improved quality of life fol-
lowing MBIs.14–15 As noted earlier, it has been theorized
that psychological well-being may improve following
increases in the use of mindfulness skills. Specifically, it
may be that mindfulness skills improve psychological
well-being by reducing attention to negative thoughts
and emotions in favor of paying attention to the present
moment and engaging in values-driven behaviors.
Although a reliable cumulative treatment versus con-
trol effect size was observed at post-treatment for quality
of life measures, treatment groups did not show improve-
ment above and beyond the control groups on measures
of DRD, physiological well-being, or adherence. Addition-
ally, reliable effect sizes were not observed at follow-up
time points. This may have been due to the relatively
short time span between pretreatment and follow-up time
points. This may be particularly relevant for evaluation of
changes in A1c which requires approximately 6–8 weeks
to significantly change in response to treatment.39 Many
of the studies that included control groups had smaller
sample sizes. As a result, they were adversely affected by
low power, increased error variance (meaning that the
impact of a few outlier participants would be substantially
greater), and increased probability of type II error.
Analyses of pre-treatment-post-treatment changes for
MBIs indicated that there were moderate and reliable
decreases reported in DRD as well as small and reliable
improvements in metabolic control. These intervention
effects were most consistently observed immediately fol-
lowing treatment. For participants with diabetes, these
interventions may have decreased negative thoughts and
emotions related to everyday actions required for diabe-
tes management and self-care which can act as
reminders of poor health long-term consequences of
having diabetes. Mindfulness skills may increase expo-
sure to negative thoughts and feelings and ultimately
reduce the salience of such experiences. It is proposed
that through this reduction in avoidance of stressful
thoughts, individuals will become less distressed when
presented with opportunities to participate in diabetes-
specific self-care behaviors and will be more likely to
engage in the behaviors. In turn, this could result in an
improvement in physiological well-being. However, the
present results do not bear out this expectation. It is
likely that other factors contribute to improved physio-
logical well-being; therefore, future research should con-
tinue to investigate potential mediators and moderators
of the relationship between psychological and physiolog-
ical well-being.
The reliable effect sizes generated by pre-treatment-
post-treatment comparisons of DRD measures were not
observed at follow-up. This may have been due to four
studies that did not report follow-up data for treatment
groups. These four studies included over a third (37.0%)
of the original sample, resulting in a significant loss of
potential data that may have influenced the present
results had these data been collected and reported.
In the present analysis, studies tended to be similar in
intensity with most programs offering weekly group ses-
sions lasting 8–12 weeks. However, there was a margin-
ally significant correlation between pre-treatment and
post-treatment effect sizes with pre-treatment A1c (r D
0.43, p D 0.07), indicating that treatment groups that
tended to have higher A1c at pre-treatment showed
greater improvements at follow-up. This may be evi-
dence of possible floor effects such that participants with
lower A1cs at pretreatment did not have much room to
improve during treatment.
Most of the effect sizes reported fell into the small to
moderate range. The limited evidence of large, reliable
effect sizes for behavioral changes could be explained by
the relatively short time from pre-treatment to post-
treatment (M D 8 weeks) and follow-up (M D 5
months). Making changes to lifestyle may increase

anxious feelings related to having a diabetes diagnosis.
Indeed, a review of studies of psychological adjustment
to chronic illnesses found that patients reported that
adherence to manage illness is very difficult and even
provokes fear.40 The interventions used here may not
have allowed sufficient time for participants to adjust to
making lifestyle changes at post-treatment. Examining
follow-up data may have revealed changes in behavioral
adherence, but many studies included in the present
analysis did not collect follow-up data.
One study used ACT for treating participants with
diabetes.26 This study had one of the largest effect
sizes for improving A1c from pre-treatment to post-
treatment (d D 0.41) and the largest effect size for
treatment-control comparisons on A1c at posttreat-
ment (d D 0.32). This intervention was different from
the other MBIs because, in addition to mindfulness, it
emphasized the development of adaptive self-care
behaviors and making incremental improvements in
adaptive self-care behaviors. While this study shows
promise, it must be noted that it is only one study of
ACT for diabetes. Future large-scale randomized, con-
trolled trials should be conducted to continue to
examine the efficacy of MBIs and ACT for persons
with diabetes to determine whether the inclusion of
explicit self-care behavioral goals confers advantages
over traditional MBIs.
Limitations
In many interventions, time to follow-up measurement
points was variable, ranging from three to twelve
months. In addition, of the 14 studies included, 5 stud-
ies reported follow-up data for control groups, and 10
studies reported follow-up data for treatment groups.
This means that for most studies, researchers were
unable to report both long-term comparisons between
control and treatment groups and long-term compari-
sons between control group measurements at pre-
treatment and follow-up. This results in a considerable
loss of data that could have provided increased under-
standing of long-term effects of MBIs; however, given
the unreliable effect sizes at post-treatment for treat-
ment-control comparisons, additional data at follow-
up would have been unlikely to produce reliable effect
sizes. Future designs of randomized controlled trials
should include measurement of the control group at
follow-up time points.
Another limitation of this study was the variability in
types of interventions offered. Nine of the studies pro-
vided an 8–12 week MBSR or MBCT intervention and
four of these were altered to focus on specific challenges
associated with living with diabetes. Of the studies that
BEHAVIORAL MEDICINE 9
did not use MBSR or MBCT, the MBIs were uniquely tai-
lored to deliver mindfulness skills to improve diabetes
outcomes. The diversity of intervention components
combined with the limited number of studies precluded
our ability to compare the effectiveness of the different
types of MBIs and MBI components.
Conclusions
Type 1 and Type 2 diabetes are chronic conditions that
can lead to significant distress and nonadherence. Results
indicate that MBIs show promise for improving psycho-
logical well-being through reductions in DRD and
increases in quality of life. Findings for improving physi-
ological well-being and behavioral adherence, at least in
the long-term, are inconclusive. Future research should
investigate additional treatment factors that contribute
to long-term maintenance of treatment gains.
References
1. National Data. Centers for Disease Control and Preven-
tion. 2014. http://www.cdc.gov/diabetes/data/national.
html. Updated April 27, 2015. Accessed October 14, 2016.
2. National Diabetes Statistics Report. Centers for Disease
Control and Prevention. 2014. http://www.cdc.gov/diabe
tes/pubs/statsreport14/national-diabetes-report-web.pdf.
Accessed September 14, 2015.
3. Statistics about diabetes. American Diabetes Association.
2016. http://www.diabetes.org/diabetes-basics/statistics/.
Updated December 12, 2016.Accessed December 15, 2016.
4. American Diabetes Association. Standards of medical care
in diabetes – 2015. J Clin Appl Res Educ. 2015;38(S1):S1–
S90.
5. Gary TL, Genkinger JM, Guallar E, Peyrot M, Brancati FL.
Meta-analysis of randomized educational and behavioral
interventions in type 2 diabetes. The Diabetes Educator.
2003;29(3):488–501. doi:10.1177/014572170302900313.
PMID: 12854339.
6. Bailey CJ, Kodack M. Patient adherence to medication
requirements for therapy of type 2 diabetes. Int J Clin
Pract. 2011;65(3):314–322. doi:10.1111/j.1742-1241.2010.
02544.x. PMID: 21314869.
7. Aikens JE. Prospective associations between emotional
distress and poor outcomes in Type 2 Diabetes. Diabetes
Care. 2012;35:2472–2478. doi:10.2337/dc12-0181. PMID:
23033244.
8. Rogvi S, Tapager I, Almdal TP, Schiotz ML, Willaing I.
Patient factors and glycaemic control – association and
explanatory power. Diabetic Med. 2012;29:e382–e389.
doi:10.1111/j.1464-5491.2012.03703.x. PMID: 22540962.
9. Potter L, Wallston L, Trief P, Ulbrecht J, Juth V, Smyth J.
Attributing discrimination to weight: Associations with
well-being, self-care, and disease status in patients with
type 2 diabetes mellitus. J Behav Med. 2015;38:863–875.
doi:10.1007/s10865-015-9655-0. PMID: 26133488.
10. Tanenbaum ML, Ritholz MD, Binko DH, Baek RN, Shreck
E, Gonzalez JS. Probing for depression and finding
10 L. M. BOGUSCH AND W. H. O’BRIEN
diabetes: A mixed-methods analysis of depression inter-
views with adults treated for type 2 diabetes. J Affect Disor-
ders. 2013;150:533–539. doi:10.1016/j.jad.2013.01.029.
PMID: 23453278.
11. Whittemore R, Melkus GD, Grey M. Metabolic control,
self-management and psychosocial adjustment in
women with type 2 diabetes. J Clin Nurs. 2005;14
(2):195–203. doi:10.1111/j.1365-2702.2004.00937.x.
PMID: 15669928.
12. Zulman DM, Rosland A, Choi H, Langa KM, Heisler M.
The influence of diabetes psychosocial attributes and self-
management practices on change in diabetes status.
Patient Educ Couns. 2012;87(1):74–80. doi:10.1016/j.
pec.2011.07.013. PMID: 21840149.
 
13. Schroevers MJ, Tovote KA, Keers JC, Links TP, Sander-
man R, Fleer J. Individual mindfulness-based cognitive
therapy for people with diabetes: A pilot randomized con-
trolled trial. Mindfulness. 2015;6:99–110. doi:10.1007/
s12671-013-0235-5.
14. Carlson LE, Speca M, Patel KD, Goodey E. Mindful-
ness based stress reduction in relation to quality of life,
mood, symptoms of stress, and immune parameters in
breast and prostate cancer outpatients. Psychosomatic
Med. 2003;65(4):571–581. doi:10.1097/01.PSY.00000
74003.35911.41.
15. Reibel DK, Greeson JM, Brainard GC, Rosenzweig S.
Mindfulness-based stress reduction and health-related
quality of life in a heterogeneous patient population. Gen
Hosp Psychiat. 2001;23(4):183–192. doi:10.1016/S0163-
8343(01)00149-9.
16. Whitebird RR, Kreitzer MJ, O’Connor PJ. (2009). Mind-
fulness-based stress reduction and diabetes. Diabetes Spec-
trum. 2009;22(4):226–230. doi:10.2337/diaspect.22.4.226.
17. Surwit RS, Van Tilburg MA, Zucker N, et al. Stress man-
agement improves long-term glycemic control in type 2
diabetes. Diabetes Care. 2002;25(1):30–34. doi:10.2337/
diacare.25.1.30. PMID: 11772897.

18. Rosenzweig S, Reibel DK, Greeson, J. M. et al. Mindful-
ness-based stress reduction is associated with improved
glycemic control in type 2 diabetes mellitus: A pilot study.
Altern Ther. 2007;13(5):36–38.
19. Noordali F, Cumming J, Thompson JL. Effectiveness of
Mindfulness-based interventions on physiological and
psychological complications in adults with diabetes: A sys-
tematic review. J Health Psychol. 2015. PMID:
26721631Multiple reference elements are missing from
[20]. Please supply information to complete it..
20. Young, K. M., Northern, J., Lister, K., Drummond, J.,
O’Brien, W. H. A meta-analysis of family-behavioral
weight-loss treatments for adults. Clin Psych Rev.
2007;27:240–249. doi:10.1016/j.cpr.2006.08.003.
21. Kaplar, M. E., Wacholtz, A, B., & O’Brien, W. H. The
Effect of Religious and Spiritual Interventions on the Bio-
logical, Psychological, and Spiritual Outcomes of Oncol-
ogy Patients: A Meta-Analytic Review. J Psych Onc.
2004;22:39–49. doi:10.1300/J077v22n01_03.
22. Lewandowski, L. M., Gebing, T. A., Anthony, J. L., &
O’Brien, W. H. Meta-analysis of cognitive-behavioral
treatment studies for bulimia. Clin Psych Rev.
1997;17:703-717. doi:10.1016/S0272-7358(97)00026-3.
23. Schuler, J. L, & O’Brien, W. H. Cardiovascular recovery
from stress and risk factors associated with hypertension
development: A meta-analytic review. Psychophys.
1997;34:649–659. doi:10.1111/j.1469-8986.1997.tb02141.x.
24. Jadad AR, Moore RA, Carroll, D, et al. Assessing the qual-
ity of reports of randomized clinical trials: is blinding nec-
essary? Control Clin Trials. 1996;17(1):1–12. doi:10.1016/
0197-2456(95)00134-4. PMID: 8721797.
25. Baer, R. A. Mindfulness training as a clinical intervention:
A conceptual and empirical review. Clinical psychology:
Science and practice. 2003;10(2):125–143.

26. Gregg JA, Callaghan GM, Hayes SC, Glenn-Lawson JL.
Improving diabetes self-management through acceptance,
mindfulness, and values: A randomized controlled trial. J
Consult Clin Psych. 2007;75(2):336–343. doi:10.1037/
0022-006X.75.2.336.
27. Hartmann M, Kope S, Kircher C, et al. Sustained effects
of a mindfulness-based stress-reduction intervention in
type 2 diabetic patients. Diabetes Care. 2012;35:945–947.
doi:10.2337/dc11-1343. PMID: 22338101.

28. Jung HY, Lee H, Park J. Comparison of the effects of
Korean mindfulness-based stress reduction, walking, and
patient education in diabetes mellitus. Nurs Health Sci.
2015;17:516–525. doi:10.1111/nhs.12229. PMID: 26275164.

29. Miller CK, Kristeller JL, Headings A, Nagaraja H, Miser
F. Comparative effectiveness of a mindful eating interven-
tion to a diabetes self-management intervention among
adults with type 2 diabetes: A pilot study. J Acad Nutr
Diet. 2012;112:1835–1842. doi:10.1016/j.jand.2012.07.036.
PMID: 23102183.

30. Tovote KA, Fleer J, Snippe E, et al. Individual mindful-
ness-based cognitive therapy and cognitive behavior ther-
apy for treating depressive symptoms in patients with
diabetes: Results of a randomized controlled trial. Diabetes
Care. 2014;37:2427–2434. doi:10.2337/dc13-2918. PMID:
24898301.

31. Tovote KA, Schroevers MJ, Snippe E. Long-term effects
of individual mindfulness-based cognitive therapy and
cognitive behavior therapy for depressive symptoms in
patients with diabetes. Psychother and Psychosom. 2015;84
(3):186–187. doi:10.1159/000375453.

32. van Son J, Nyklicek I, Pop VJ, Blonk MC, Erdtsieck RJ,
Pouwer F. Mindfulness-based cognitive therapy for people
with diabetes and emotional problems: Long-term follow-
up findings from the DiaMind randomized controlled
trial. J Psychosom Res. 2014;77:81–84. doi:10.1016/j.
jpsychores.2014.03.013. PMID: 24913347.

33. van Son J, Nyklicek I, Pop VJ, et al. The effects of a mind-
fulness-based intervention on emotional distress, quality
of life, and A1c in outpatients with diabetes (DiaMind).
Diabetes Care. 2013;36:823–830. doi:10.2337/dc12-1477.
PMID: 23193218.

34. Rush CL. Mindfulness Mediates Neuroticism as a Predic-
tor of Self-Control and Impulsivity: Potential Implications
for Behavioral Regulation. [doctoral dissertation]. Green-
ville, NC: Department of Psychology, East Carolina
University;2013
35. 
Teixeira E. The effect of mindfulness meditation on pain-
ful diabetic peripheral neuropathy in adults older than 50
years. Holist Nurs Pract. 2010;24(5):277–283. doi:10.1097/
HNP.0b013e3181f1add2. PMID: 20706089.
36. 
Dinardo MM. A mindful approach to diabetes self-man-
agement education with stress reduction and healthy cop-
ing for US veterans with diabetes [doctoral dissertation].
 BEHAVIORAL MEDICINE 11

Pittsburgh, PA: School of Nursing, University of
Pittsburgh;2013.
37. Dreger LC, Mackenzie C, McLeod B. Feasibility of a
mindfulness-based intervention for aboriginal adults with
type 2 diabetes. Mindfulness. 2015;6:264–280. doi:10.1007/
s12671-013-0257-z.
38. Schuster K. Effect of mindfulness meditation on A1c levels
in African American females with type 2 diabetes [doctoral
dissertation]. Chicago, IL: Adler School of Professional
Psychology;2009.
39. Nathan, D. M., Kuenen, J., Borg, R., et al. Translating the
A1C assay into estimated average glucose values. Diabetes
care. 2008;31(8):1473–1478. doi:10.2337/dc08-0545.
PMID: 18540046.
40. Ridder, D., Geenen, R., Kuijer, R., et al. Psychological
adjustment to chronic disease. The Lancet. 2008;372:246–
255. doi:10.1016/S0140-6736(08)61078-8.
41. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. Acceptance
and commitment therapy (p. 6). New York: Guilford
Press;1999.

Appendix A
Study quality assessment.

Randomization Control Drop out Intention to Jadad12

Study Design Randomized procedure group Blinding rates treat analysis Funding score

Dinardo 2013a Pre-post Yes Yes Yes No Yes Yes NR 3

Dinardo 2013b Pre-post Yes No Yes No Yes Yes NR 2
Dreger8 Pre-post No No No No Yes NR Yes 1
Gregg10 RCT Yes Yes Yes Yes Yes Yes NR 5
Hartmann11 RCT Yes No Yes NR Yes Yes Yes 2
Jung 2015 Cluster-RCT Yes Yes Yes NR Yes NR NR 3
Miller 2012 RCT Yes Yes Yes NR Yes NR Yes 2
Rosenzweig Pre-post No No No NR Yes NR Yes 0
2007
Rush 2013 RCT Yes Yes Yes No Yes NR NR 3
Schroevers 2015 RCT Yes Yes Yes NR Yes Yes NR 3
Shuster 2009 Pre-post No No No NR Yes NR NR 1
Teixeira 2010 RCT Yes No Yes NR Yes NR NR 2
Tovote 2014 RCT Yes Yes Yes Yes Yes Yes Yes 5
Van son 2013 RCT Yes Yes Yes NR Yes Yes Yes 3

Note: Jadad score ranges from 0–5, with greater scores indicating greater study quality.