Mindfulness and Cardiovascular Risk in College Students

Abstract: 

Mindfulness refers to a cognitive style characterized by awareness without judgment. Mindfulness can be measured in four facets: observing, accepting without judgment, acting with awareness, and describing. As a specific way of experiencing the world, mindfulness may have protective influences on cardiovascular functions, as has been found in mindfulness meditation interventions. A sample of undergraduate psychology students at the University of North Texas was administered a battery of self-report questionnaires to assess various psychological variables, including mindfulness. During a second session, approximately 2 weeks later, blood pressure readings were taken. Pearson’s product-moment correlation coefficients revealed no statistically significant relationships between scores on mindfulness facets and either systolic or diastolic blood pressure. We posit that the protective benefits of youth in our sample may be masking relationships between mindfulness and blood pressure.

Table of Contents: 

    Introduction

    Mindfulness is a particular style or method of thinking and perceiving that emphasizes attention to one’s surroundings and internal sensations without making negative or positive judgments (Kostanksi & Hassed, 2008). A relatively unfamiliar construct for much of Western culture, mindfulness has been discussed at length in Buddhist literature and advocated as a positive and beneficial way of experiencing the world. Originally translated from the Pali word sati, mindfulness, or “right mindfulness,” is the seventh point on the eightfold path to enlightenment in Buddhist tradition. Practicing Buddhists often define mindfulness as a kind of pure sight, a heightened awareness of one’s reality and surroundings without positive or negative judgment (Bram, 1971; Gunaratana, 2010). It is supposed that when one refrains from judging an event or experience as good, or bad, one can then view it realistically and achieve adaptive response or acceptance. In Western psychology, mindfulness is defined as a construct separated from its spiritual history within Buddhism and practiced as a set of skills. This set of skills is often taught and cultivated in various intervention programs, such as Mindfulness-Based Stress Reduction (MBSR) therapy (Kabat-Zinn, 2003).

    Previous research has demonstrated relationships between mindfulness and physical health. For example, Roth and Robbins demonstrated in 2004 that a group receiving Mindfulness-Based Stress Reduction therapy showed more improvement than a control group on measures of health and health-related quality of life. MBSR is traditionally an 8-week program designed to improve mindfulness skills of participants who engage in guided meditation for 45 minutes per day (Kabat-Zinn, 1990). It is possible that mindfulness training and programs which cultivate mindfulness may have beneficial effects on the immune system as well. In 2004, Davidson et al. (2003) conducted a small study in which individuals receiving mindfulness meditation training showed greater antibody development in response to the influenza vaccine than did a control group.

    Mindfulness skills training shows promise for improving the lives and functioning of young people. A small study was done to examine the relationships between psychological factors (specifically stress, rumination, forgiveness, and hope) and meditation-based stress management tools in college undergraduate students (Oman, Shapiro, Thoresen, Plante, & Flingers, 2008). Oman et al. showed reduced stress and improved forgiveness in participants given the MBSR intervention. In one qualitative study, participants from graduate counseling courses in a 15-week long MBSR program also reported various positive mental, emotional, and physical effects (Schure, Christopher, J., & Christopher, S., 2008).

    Mindfulness has been conceptualized in the research literature both as a state and a trait. Trait mindfulness is closely related to personality and is a more stable quality in an individual, whereas state mindfulness is a more transitory, heightened state of awareness, like that achieved during meditation (Kostanski & Hassed, 2008). We seek to measure trait mindfulness in individuals, and to determine whether this particular quality—or the lack thereof— has any implications for cardiovascular health. To do this, it is first necessary to operationally define trait mindfulness as a construct. One method of doing this has been to relate this relatively young and new construct to older, more established theories. One of the most popular theories on personality traits is the big-five theory (Sternberg, 2000), which organizes individual differences in personality into five major groups: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness (Giluk, 2009). In one large meta-analysis, it was found that mindfulness displayed appreciable relationships to all five factors (Giluk, 2009). Mindfulness was negatively correlated with neuroticism (r = -.58), and positively correlated with conscientiousness (r = .44). Additionally, mindfulness was positively correlated with extraversion (r = .15), openness to experience (r = .20), and agreeableness (r = .30).

    Trait mindfulness is commonly measured using self-report methods, such as the Kentucky Inventory of mindfulness Skills (KIMS; Baer et al., 2004). The question remains, however, whether self-report is a valid or reliable measure of trait mindfulness. One method which could be utilized to assess this is to measure mind wandering, the approximate opposite of mindfulness. Mind wandering has been assessed using both behavioral and physiological markers (Smallwood, Beach, Schooler, & Handy, 2008). Individuals high in trait mindfulness should, therefore, show low levels of mind wandering. While evidence has been found for the existence of mind wandering (Smallwood et al., 2008), no available studies have yet examined the relationship between mind wandering and mindfulness.

    Trait mindfulness has been examined in relation to various constructs and has been related to a variety of positive psychological traits. Notably, the available literature indicates that trait mindfulness is negatively correlated with various identified cardiovascular risk factors, such as anxiety, anger, and depression (Cohen, Panguluri, Na, & Whooley, 2010; Sirois & Burg, 2003). One study found that trait mindfulness was negatively associated with certain types of neural activity, such as patterns found in those with depressive symptoms (Way, Creswell, Eisenberger, & Lieberman, 2010). Additionally, when viewing images of emotional faces, amygdala reactivity was higher in depressed individuals and lower in mindful individuals. This research suggests that trait mindfulness is associated with specific types of neural activity and is negatively correlated with depressive symptomatology (Way, Creswell, Eisenberger, & Lieberman, 2010). Using correlational, quasi-experimental, and laboratory studies, Brown and Ryan (2003) found that mindfulness was negatively correlated with neuroticism, anxiety, depression, unpleasant affect, and negative affectivity. Another study found that mindfulness was negatively correlated with self-reported aggression (Heppner et al., 2008).

    Brown and Ryan conducted a study measuring trait mindfulness in undergraduate university students, adults from a northeastern United States community, and cancer patients referred from the Canadian cancer center (2003). Trait mindfulness predicted positive emotional states as well as self-regulated behavior in undergraduate students, and was associated with less stress and mood disturbance in cancer patients.

    A large body of research expresses the negative correlation between mindfulness and constructs such as anger, hostility, anxiety, and depression (Baer et al., 2004; Brown & Ryan, 2003; Way et al., 2010). The underlying processes, however, have yet to be determined, although it has been suggested that mindfulness may lead to decreased anger, hostility, and aggression by decreasing rumination (Borders, Earleywine, & Jajodia, 2010).

    Cardiovascular Health

    As the number one cause of death in the United States (Center for Disease Control, 2005), cardiovascular disease (CVD), is a serious public health concern. Atherosclerosis (hardening of the arteries) is the process by which various products such as calcium and cholesterol build up in the inner layers of the arteries and is inextricably linked with blood pressure (BP) and overall cardiovascular health. Portions of this buildup, known as plaques, may rupture, leading to blood clots. If this clot occurs in an artery that feeds the heart, blood cannot travel efficiently to the heart to be oxygenated, leading to a heart attack (American Heart Association, 2010). In 1998, Berenson et al. determined that the CVD risk factors of body mass index (BMI), BP, and lipid levels predicted higher incidence of asymptomatic atherosclerosis in individuals aged 2 to 39 years. Additionally, Williams, Hayman, Daniels, Robinson, and Steinberger of the American Heart Association (2002) confirmed that atherosclerosis begins in childhood and young adulthood, and is associated with higher incidence of CVD. One goal of health psychology would be to educate young adults on these risks and persuade them to adopt healthier lifestyle habits, including mindfulness exercises.

    Cardiovascular health may also be affected by psychosocial and behavioral influences that begin to take shape in early adulthood. For example, depression, anger/hostility, and anxiety have all been identified as health risk factors for coronary heart disease (CHD; Cohen et al., 2010; Sirois & Burg, 2003). Research suggests that a negatively evaluative emotion-processing style characteristic of depression (and not mindfulness) provides for poor cardiovascular health outcomes (Doyle, Conroy, McGee, & Delaney, 2010; Kop et al., 2010).

    Blood Pressure

    The force with which blood is pumped by the heart against arterial walls is blood pressure (BP). BP is measured in two numbers; systolic and diastolic. While systolic measures force as the heart beats, diastolic measures force as the heart muscle relaxes. BP is expressed as a ratio of systolic over diastolic. “Normal” or “healthy” BP is considered to be less than 120 over less than 80. Higher than normal BP places undue stress on the heart muscle, leads to hardening of the arteries (atherosclerosis), and increased risk of CVD (National Heart Lung and Blood Institute, 2009). In 2001, Franklin, Larson, Khan, Wong, and Leip measured systolic, diastolic, and pulse BP in a large sample of men and women between the ages of 20 and 79. Results indicated that in adults under 50 years of age, diastolic BP was the strongest predictor of coronary heart disease.

    Hypothesis

    Mindfulness-based interventions have been related to improved physical and psychological functioning. Mindfulness meditation has been associated with positive brain and immune system function in healthy people (Davidson et al., 2003) as well as improvement of symptoms of depression, sleep disturbance, and anxiety in recipients of organ transplants (Gross et al., 2004). Mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990) has been successful in aiding smoking cessation (Davis, Fleming, Bonus, & Baker, 2007), helping to improve general health and social functioning for inner-city medical patients (Roth & Robbins, 2004), and helping to reduce sleep and stress symptoms in cancer outpatients (Carlson & Garland, 2005).

    Additionally, trait mindfulness has been associated with good psychological health, as evident in negative correlations with established cardiovascular risk markers such as depressive symptomatology (Way et al., 2010), aggression (Heppner et al., 2008), and anxiety (Brown & Ryan, 2003).

    Based on a precedent of positive associations between mindfulness and good mental and physical health in research, we hypothesize that higher scores in mindfulness will be associated with healthier systolic and diastolic BP in a sample of college students.

    Method

    Participants

    This study was conducted using a sample of undergraduate students from a large southwestern university. A representative sample of the student population of the University of North Texas during the fall of 2007 was recruited, as assessed using the UNT 2007-2008 fact book (Institutional Research and Effectiveness, 2007).

    In order to be eligible, participants were required to be enrolled in an undergraduate course at the University of North Texas, be at least 18 years old, fluent in written and spoken English, and be able to safely fast for one night before the session involving BP assessment. Those who could not fast due to pregnancy or health issues such as diabetes or anemia were excluded from participation.

    Procedure

    After securing approval from the University of North Texas Institutional Review Board, data collection for the study began in fall 2006 semester and concluded in spring 2008 semester. The study was conducted in two phases. Each phase took approximately 1 hour to complete. In the beginning of each phase, participants were provided a general description of the data collection, analysis, and publication of findings by a trained staff member, who additionally explained the informed consent process. Both phases were completed in the same building but in different rooms. In the first phase, psychological factors were assessed, and in the second phase, physiological readings were taken.

    Phase I

    Phase I was conducted in meeting rooms where individuals completed their questionnaires. Before beginning data collection, participants were given two copies of the informed consent document, one to keep, and one to leave with the research assistant. Only after reading the informed consent document and being given the opportunity to ask questions, if necessary, did participants sign the document. Data collection began after informed consent was obtained from the participants. General demographic information, such as age and gender, was collected and a physical symptom checklist was administered during the background information portion of the questionnaires. Additional self-report surveys measured a variety of psychological risk factors with implications for cardiovascular health, including mindfulness. Mindfulness was assessed using the Kentucky Inventory of Mindfulness Skills (KIMS; Baer et al., 2004), located towards the end of a packet of questionnaires. After completing these self report measures, participants met with a research assistant to schedule a time to complete Phase II of the study.

    Phase II

    Participants were instructed to fast (no food or drink except water) during the 12 hour period before their scheduled time until the conclusion of Phase II. Participants were also asked to refrain from taking herbal supplements or over-the-counter drugs, not to smoke cigarettes 2 hours beforehand, and to avoid exercising 30 minutes before their appointment time. Informed consent was obtained for Phase II of the study, and participants were once again provided the opportunity to ask questions. Participants confirmed that they had been able to fast and were then monitored for heart rate variability. A small sample of blood was also taken for lipid profiling. At the conclusion of Phase II, a brief survey was also administered. After this survey, participants were monitored for BP. Participants were then provided with a debriefing form explaining the purposes of the study, as well as contact numbers for the University of North Texas (UNT) Health and Wellness Center and the UNT Counseling Center.

    Measures

    The Kentucky Inventory of Mindfulness Skills (KIMS). The Kentucky Inventory of Mindfulness Skills (KIMS) is a 39 item self-report scale (Baer et al., 2004). Respondents rate the accuracy of each item for them personally on a 5 point Likert scale (ranging from 1, meaning never or very rarely true, to 5, meaning very often or always true). Mindfulness is viewed as a multidimensional construct made up of different skills or facets. Four facets of mindfulness are measured: observing, describing, acting with awareness, and accepting without judgment. Rather than summing scores from all facets, the KIMS derives separate scores for each facet, with higher scores indicating greater mindfulness skill in each particular area.

    Observing is characterized as paying careful attention to various stimuli. These stimuli include internal sensations, such as physical or mental feelings, as well as external stimuli, like odors and sounds. Observing involves immersing oneself in the senses, both of the external and the internal world. For example, in one item designed to assess observing, the KIMS asks the participant to answer using a Likert scale, “I notice changes in my body, such as whether my breathing slows down or speeds up.” Describing involves the non-judgmental application of words and labels to observations. Labels applied should not be evaluative, but explanatory and descriptive. Mindful describing should not progress to rumination, but instead be a short pause before return to observing. An example of a KIMS item measuring this concept is, “I can easily put my beliefs, opinions, and expectations into words.” As for the concept, acting with awareness, people often perform daily tasks and react to events automatically, without much thought. In contrast, to act with awareness, an individual must focus his or her undivided attention on only one task or stimulus at a time, rather than split attention among multiple activities. To act with awareness may be to truly experience all qualities of one activity or experience. To accept without judgment is to avoid making value statements about an experience or event while remaining wholly conscious of it. When faced with an unwanted experience, an individual is to avoid using evaluative labels like good or bad, but rather to calmly observe and describe the event before accepting it and moving on. A sample item from the KIMS is “When I’m reading, I focus all my attention on what I’m reading.” Accepting without judgment requires a certain amount of objectivity in the assessment of one’s own thoughts and experiences while remaining fully immersed in them. Accepting without judgment is not equivalent to resignation. An example of a KIMS item measuring this concept is “I make judgments about whether my thoughts are good or bad.” In practice, it is often combined with observing and describing. A person who is able to accept reality, without trying to change or avoid it, may be able to react more adaptively to various everyday scenarios. For example, if a person is delayed by traffic, evaluating the situation as horrible will not change it. Rather, he should acknowledge the situation, accept it, and in response, perhaps, engage in a pleasurable activity like listening to the radio, rather than becoming angry or stressed. The KIMS, however, does not readily or obviously differentiate between adaptive acceptance and resignation.

    Baer et al. (2004) assessed content validity of items using the expert ratings of five psychologists and six doctoral students, all well-educated in the concept of mindfulness. Experts classified items into the four facet groups and rated the fit for each category. A mean of 86% of experts placed items within the categories for which they were intentionally written. The KIMS was administered to volunteer university undergraduate participants. To assess internal consistency, items were separated into the four facets and evaluated separately by facet. After calculation of coefficient alpha and examination of item-total and inter-item correlations, it was determined that internal consistency was adequate to good. The coefficient alphas for the four categories were as follows: Observe .91; Describe, .84; Act With Awareness, .83; and Accept Without Judgment, .87 (Baer et al., 2004). Results indicated that mindfulness skills had shown appropriate relationships to neuroticism, psychological symptoms, emotional intelligence, alexithymia (the inability to express one’s feelings in words), experiential avoidance, dissociation, and absorption.

    Blood Pressure (BP). After the HRV assessment in Phase II, participants were shown to a small private room across the hallway. A trained research staff member then took a small sample of blood for lipid profile assessment, had the participant fill out a short paper and pencil survey, and then proceeded to take BP readings. Research staff members took two readings of BP using a standard sphygmomanometer, additionally taking a third reading if the first two differed from one another by 5 mm Hg or more.

    Preliminary Analyses

    Analyses were performed using SPSS 17 (Pallant, 2007). Measures from the KIMS were entered into a database by a trained research assistant and then checked by two other research assistants. Additionally, errors in data entry during transfer from the paper and pencil self-report measure to the computer database were corrected. Descriptive analyses, including mean, standard deviations, ranges, and percentages were performed on all variables of interest and are reported in Table 1. As the KIMS yields four distinct measures of mindfulness skills, there are four independent variables: scores for observing, describing, acting with awareness, and accepting without judgment. In order to determine whether a relationship between these variables and BP exists, there are two dependent variables, mean systolic blood pressure (SBP) and mean diastolic blood pressure (DBP). Analyses consisted of examining a correlation matrix among major variables and using multiple linear regression to use the mindfulness skills to predict BP.

    Results

    Participant Characteristics

    The overall undergraduate student population of the University of North Texas during fall 2007 was 64.9% European-American, 12.6% African-American, 11.2% Hispanic, 4.8% Asian/Pacific Islander, 0.8% American Indian/Alaskan Native, 4.5% nonresident alien, and 1.2% other/unknown. Undergraduate students of the university were 56.5% female, and 43.4% male (Institutional Research and Effectiveness, 2007). The mean age of the population was 22.7 (SD = 5.4). Our sample was 58% European-American, 19% African-American, 12% Latino/a, and 11% American Native/Alaskan Native, Asian or Asian American, Middle Eastern or Biracial, combined into one group termed “other ethnicity.”

    Hypothesis Evaluation

    We hypothesized that higher scores in mindfulness will be associated with healthier systolic and diastolic BP.

    Correlation analyses were used to determine the relationships among the four facets of mindfulness and systolic and diastolic blood pressure. At a significance level of p > .01, no relationships were observed among observing, accepting without judgment, acting with awareness, or describing with systolic or diastolic blood pressure (see Table 2).

    Standard multiple regression analysis was performed in order to better determine whether the four facets of mindfulness predicted blood pressure. Analysis was performed using SBP as a dependent variable and each of the four facets of mindfulness as predictor variables before a second analysis was performed with DBP as a dependent variable and facets of mindfulness as independent variables.

    Using the enter method in SPSS, no significant models emerged for SBP (F4, 292 = .476, p < .753, R2 = .006). All variables are shown in Table 3. Using the same method, a significant model did not emerge for DBP (F4, 292 = .479, p < .751, R2 = .007). All variables for multiple regression with DBP are shown in Table 4.

    Discussion

    Mindfulness and Blood Pressure

    There is a sizable body of literature to suggest the possibility of a relationship between mindfulness skills and blood pressure. Mindfulness-based interventions used in clinical samples and healthy populations have met with marked success in improving both physical and psychological health (Davidson et al., 2004; Oman et al., 2008; Roth & Robbins, 2004; Schure et al., 2008). While the available literature concerning trait mindfulness and cardiovascular health is scant, research also indicates a possible relationship here, as qualities typically associated with poor cardiovascular outcomes have been negatively correlated with mindfulness (Brown & Ryan, 2003; Heppner et al., 2008; Way et al., 2010). In this particular study, however, no statistically significant relationships between BP and mindfulness skills emerged.

    It is possible that mindfulness as a trait may operate much like any long-term quality in its relationship to blood pressure and cardiovascular health. Blood pressure has a tendency to rise with age (National Heart, Lung, and Blood Institute, 2010), and the effects of certain health behaviors and traits may be revealed later in life, when the protective factors of youth are no longer present. Mindfulness may operate in a similar fashion. If so, our sample, which consisted mainly of young people in their early and mid-twenties, would not show much of a relationship at this point in their lives. It may take time for the stressful consequences of a lack of mindfulness to manifest physiologically.

    Additionally, measures of mindfulness as a trait are still in their infancy and are not yet unequivocally established. The four facets of mindfulness are related to one another, yet are conceptualized as different individual skills all springing from one philosophy. It is not always clear how differentiated each facet is from the others. For example, in the KIMS, describing includes the ability to label phenomena (Baer et al., 2004), which appears somewhat counterintuitive to another facet, accept without judgment, as labeling often involves some type of judgment. For example, if one labels an object as ‘blue,’ it is first necessary to judge the color of the object before making the distinction. While the KIMS items measuring accept without judgment appear to specifically target the value judgment of oneself (for example, “My thoughts are bad,” or “I shouldn’t be thinking this way”), accepting without judgment descriptions do not specify what type of judgment to avoid. Critical thinking is a crucial process in making wise decisions about one’s health and daily life, and naturally requires some type of judgment of current circumstances. Additionally, the correlation between accept without judgment and observe has been negative, both in the seminal research article (r = -.14; Baer et al., 2004) and in our findings (r = -.20). One would expect the correlations among facets to be somewhat modestly and positively related to one another.

    Strengths and Limitations

    In the present study, a convenience sample of college students in psychology courses was used. Our sample was also from a university in the southern United States. Therefore, our results may not be representative of the population at large.

    In addition, longitudinal research is needed to ascertain the more robust long term health effects of behaviors taking shape in early adulthood. This type of research would answer questions as to any long-term effects of mindfulness on cardiovascular risk factors such as BP.

    Conclusions and Recommendations

    The present study contributes to the literature on cardiovascular health in young people as well as the assessment of mindfulness. Future research is needed in the area of trait mindfulness assessment, as the individual facets of the KIMS are somewhat unclearly differentiated.

    Longitudinal studies beginning in early adulthood and continuing into middle age and beyond are also recommended in future research in order to better determine the long-term benefits and costs of health behaviors and individual traits.

    Preventative measures, including mindfulness based options, should continue to be explored. While surgical procedures are available for those already suffering from cardiovascular disease, such procedures are costly, dangerous, and invasive. Earlier and gentler techniques, such as relaxation training, coping skills training, and mindfulness based interventions, may prove useful and effective in the prevention of the initial development of high blood pressure and cardiovascular disease.

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    Table 1: Means, Standard Deviations, Ranges, and Percentages

    Demographic Variables Mean SD Range Percentage
    Age 21.39 4.78 18 – 55 -
    Females - - - 71%
    African-Americans - - - 19%
    Latino/a - - - 12%
    “Other ethnicity” - - - 11%
    European-Americans - - - 58%
    Psychological Variables        
    Observing 3.22 0.71 1.25 – 5.00 -
    Accepting without judgment 3.31 0.77 1.00 – 5.00 -
    Acting with awareness 2.78 0.62 1.20 – 4.60 -
    Describing 3.45 0.79 1.25 – 5.00 -
    Physiological Variables        
    SBP 112.80 12.06 68 – 150 -
    DBP 72.45 10.43 39 – 114 -

    Note: Participants who identified their ethnicity as American Native/Alaskan Native, Asian or Asian American, Middle Eastern, or Biracial were combined into one group labeled “Other Ethnicity.”

    Table 2: Correlations among Variables

    Variables Acting With Awareness Mean Observe Mean Acceptance without Judgment Mean Describe Mean SBP Mean DBP Mean
    Acting With Awareness Mean 1 .043 .327** .334* .068 .007
    Observe Mean .043 1 -.195** .394* -.009 -.036
    Acceptance without Judgment Mean .327** -.195** 1 .152** .063 .072
    Describe Mean .334** .394** .152** 1 .030 -.022
    SBP Mean .068 -.009 .063 .030 1 .640**
    DBP Mean .007 -.036 .072 -.022 .640** 1

    1Note: SBP=Systolic Blood Pressure; DBP=Diastolic Blood Pressure
    2Note** = Correlation is significant at the 0.01 level (2-tailed).

    Table 3: Standard Multiple Regression Analysis SBP

    Variable B SE B 95% CI β t P-Value
    Acting With Awareness Mean .986 1.260 -1.494—3.467 .051 .783 .434
    Observe Mean -.105 1.121 -2.311—2.102 -.006 -.093 .926
    Acceptance without  Judgment Mean .688 1.008 -1.297—2.672 .044 .682 .496
    Describe Mean .129 1.042 -1.922—2.180 .008 .124 .902
    Note: SBP = Systolic Blood Pressure

    Table 4: Standard Multiple Regression Analysis DBP

    Variable B SE B 95% CI β t P-Value
    Acting with Awareness Mean -.148 1.090 -2.293—1.998 -.009 -.136 .892
    Observe Mean -.147 .970 -2.055—1.762 -.010 -.151 .880
    Acceptance Without Judgment Mean 1.055 .872 -.661—2.772 .077 1.210 .227
    Describe Mean -.359 .901 -2.133—1.415 -.027 -.398 .691
    Note: DBP = Diastolic Blood Pressure