Received: 18 October 2017 Revised: 12 January 2018 Accepted: 4 February 2018

DOI: 10.1111/eip.12546

BRIEF REPORT

Meals, Mindfulness, & Moving Forward: A feasibility study

to a multi-modal lifestyle approach in early psychosis
Craigan Usher1 | Andie Thompson2 | Meridith Griebeler1 | Angela Senders2,3 |
Celeste Seibel4 | Richard Ly1 | Charles Murchison2 | Kirsten Hagen2 | Keith-Allen Afong5 |
Dennis Bourdette2 | Rachel Ross2 | Alena Borgatti2 | Lynne Shinto2

1
Department of Psychiatry, Oregon Health &
Science University, Portland, Oregon Aim: The primary aim was to demonstrate adherence to a novel 6-week lifestyle intervention
2
Department of Neurology, Oregon Health & program (“Meals, Mindfulness, & Moving Forward” [M3]) designed to help improve lifestyle
Science University, Portland, Oregon practices of youth with a history of at least 1 psychotic episode.
3
Helfgott Research Institute, National Methods: M3 used a non-equivalent control group design involving clients from a community
University of Natural Medicine, Portland,
early intervention program. Seventeen individuals in the active M3 program and 16 controls
Oregon
4
were assessed for secondary outcomes at baseline, 6-weeks, and 12-weeks (6 weeks post-
Regional Research Institute - Social Work,
Portland State University, Portland, Oregon intervention) on cardiometabolic and symptomatic outcomes.
5
University of Hawaii at Manoa, Manoa, Results: The program met its primary aim with 88% (15/17) of participants meeting adherence
Hawaii criteria. Compared with the controls, M3 participants showed significant improvement in posi-
Correspondence tive psychotic symptoms (P = .002).
Lynne Shinto, Department of Neurology, Conclusion: This pilot study showed that young people involved in a community early interven-
Oregon Health & Science University, 3181
tion program adhered to an activity-based lifestyle program which included mindfulness medi-
SW Sam Jackson Park Rd, CR120, Portland,
OR 97239. tation, yoga and nutrition education, warranting further evaluation with a larger sample size.
Email: shintol@ohsu.edu
KEYWORDS
Funding information cardiovascular disease, diet, exercise, mind body, psychotic disorders
Oregon Health & Science University
Foundation; von Schelgell family

1 | I N T RO D UC T I O N Carney, French, et al., 2016; Firth, Carney, Jerome, et al., 2016).

Young people with schizophrenia-spectrum disorders (SSD) often lead
sedentary lifestyles, are impacted by medication side-effects, and
have increased cardiovascular disease risk, contributing to decreased
life expectancy (Bonfioli, Berti, Goss, Muraro, & Burti, 2012; Brown,
Kim, Michell, & Inskip, 2011; Thornicroft, 2011). Thus, designing
interventions to mitigate cardiometabolic risks and improve overall
health is important.
Diet and fitness in youth (age 14-25 years) with early stage psy-
chosis have shown promise. A pilot study conducted by Curtis
et al. (2016) showed that a 12-week individualized nutrition and
physical activity intervention attenuated weight gain. An aerobic
exercise intervention decreased psychotic symptom severity in young
men with early psychosis (Firth, Carney, Elliot, et al., 2016; Firth,
However, maintaining healthier lifestyle habits after completing pro-
gramming is difficult; social support (ie, program partners) may be
crucial to sustaining healthy life practices (Aschbrenner et al., 2016;
Firth, Carney, French, et al., 2016; Firth, Carney, Jerome, et al., 2016).
There is growing interest in the use of mindfulness and
acceptance-based practices in psychosis, with such interventions
shown to improve symptoms and shorten the duration of hospital re-
admissions (Aust & Bradshaw, 2016; Khoury et al., 2013). Targeting
deficits in self-awareness and maladaptive thoughts and feelings
through yoga and mindfulness meditation may assist individuals in
maintaining lifestyle changes (Vancampfort et al., 2011).
Studies on exercise, nutrition education and mindfulness medita-
tion led our group to investigate means of augmenting programming
offered by the Early Assessment and Support Alliance (EASA), a

Early Intervention in Psychiatry. 2018;1–4. wileyonlinelibrary.com/journal/eip © 2018 John Wiley & Sons Australia, Ltd 1
2 USHER ET AL.
family assertive community treatment model implemented through-
out Oregon. EASA programs provide service coordination, nursing
and psychiatric visits, housing, and academic/employment support,
and in some counties occupational therapy for young people with
early stage psychosis (EASA, 2016; Melton et al., 2013; Melton et al.,
2013). We convened a stake-holder meeting that included clinicians,
EASA care team leaders and EASA program graduates to consider
creative ways to promote health and recovery. Informed by this pro-
cess, a multi-modal program was designed and named “Meals, Mind-
fulness, & Moving Forward” (M3). M3 involved 6 4-hour sessions on
consecutive Saturdays; sessions included mindfulness meditation,
physical activity, hands-on cooking and nutrition coursework, and
facilitated group sharing. On the basis of stakeholder discussions, the
primary aim of this study was to examine adherence to M3 and deter-
mine if sufficient numbers of service users would attend weekend
consecutive weekend lifestyle sessions. Secondary aims included
measures of cardiometabolic health (BMI, waist circumference and
blood pressure), psychotic symptoms and self-reported measures of
resilience and quality of life.
2 | METHODS
2.1 | Ethics statement
This pilot study protocol was approved on February 1, 2015 by the
Oregon Health & Science University (OHSU) Institutional Review
Board, and registered at ClinicalTrials.gov as NCT02398292 on
March 20, 2014. Written informed consent was obtained from each
study participant and their study partner prior to participation.
2.2 | Design
The study used a non-randomized control group design. Participants
included EASA clients from 3 county sites in the Portland, Oregon
metropolitan area. For both M3 and control groups, EASA clients
received information on the study from posters and brochures avail-
able at clinics and clinicians during regular outpatient visits. Interested
clients were given study contact information or consented to be con-
tacted by our study team. Participants were recruited for either the
active M3 group or the control group at non-concurrent time points,
with outcomes collected at baseline, 6-weeks, and 12-weeks. The
control group was a usual care group aware that they would not par-
ticipate in the active program, but would receive the M3 resource
binder upon completing outcome measures. Yoga studio and kitchen
space limited enrolment to a maximum of 10 participants and
10 study partners for each M3 group. Study partners were chosen by
the participant to provide social support during the sessions and to
support adherence for lifestyle modification outside of the program.
2.3 | Inclusion criteria
Age 15 to 25 years; current EASA client or graduate (within past
2 years); having a willing study partner; having primary care and/or
mental health provider; and able to read and write in English. Exclu-
sion criteria included active suicidal or homicidal thoughts within
1 month of starting M3; a mental status suggestive of high-risk of dis-
ruptiveness to group process; or being dangerous to self or others
(evaluated during baseline interview with a psychiatrist). Study part-
ners had to be 15 years or older, attend all program sessions with the
participant, and could not be a current EASA client.
2.4 | Intervention
M3 was based on holistic behaviour intervention models that teach
practical ways of improving wellness in daily life. Mindfulness medita-
tion; cooking classes; field trips to a supermarket and a low cost fast-
food restaurant for hands-on learning; nutrition education; exercise
(walking, home-exercises, taiko drumming and ju jitsu); and moder-
ated group discussion were utilized to facilitate healthier living
(Bonfioli et al., 2012; Brown et al., 2011; Gehue, Scott, Hermens,
Scott, & Hickie, 2015; Melton, Blea, et al., 2013; Melton, Roush,
et al., 2013; Montag, Heinz, Kunz, & Gallinat, 2007). Study partners
participated in all activities alongside their partners. At each session,
at least 1 member from the study team and 3-5 study volunteers
directed participants and study partners to activity areas. Each activ-
ity had a lead facilitator—for example, a chef, yoga instructor, and
personal trainer, all of whom had experience working with youth, but
none of whom had prior experience working with young people with
psychosis. A study team member facilitated discussion during group
sharing at the end of each session (Table 1).
2.5 | Outcome measures
The primary outcome of feasibility was measured by participant atten-
dance at sessions. A predetermined attendance target was defined as
≥50% of enrolled participants attending at least 4 out of 6 sessions,
equating to the majority of participants attending more than half of
the sessions. Secondary outcomes were measured at baseline,
6-weeks (end of M3 program), and 12-weeks (6 weeks post-M3).
These included change from baseline to 12-weeks on BMI, waist
circumference, blood pressure, psychotic symptoms (Quick Scale for
the Assessment of Negative and Positive Symptoms [QSANS-
QSAPS]), resilience (Conner-Davidson Resilience Scale [CD-RISC] and
the Child and Youth Resilience Measure [CYRM]), and quality of life
(Short Form Health Survey [SF-12]).
2.6 | Statistical analysis
Baseline characteristics compared M3 to control groups using inde-
pendent t tests for continuous variables and Fisher's exact test for
categorical variables. Statistical analysis utilized a combination of lin-
ear mixed-effects models and ordinary least squares regression to
investigate group effect on secondary study outcomes. In addition to
naïve correlations, an ANCOVA design was used to correct for
effects of age, gender, neuroleptic medication use (use vs not), and
racial background (white vs not white). All statistical analyses were
done using R 3.3.2 with additional utility from the “lme4” package
(R Core Team, 2016; Bates, Mächler, Bolker, & Walker, 2015) and sig-
nificance set at P < .05.
USHER ET AL. 3

TABLE 1 Session activities

Session schedule outline

10:30 Welcome and introductions Lead facilitator (M3 staff ) 15 min
10:45-11:15 Mindfulness practice Street yoga 30 min
11:15-11:30 Snack/break 15 min
11:30-12:30 Activity session Lead facilitator 60 min
2/7 4/18 Week 1: Walk M3 staff
2/14 4/25 Week 2: Yoga Street yoga
2/21 5/2 Week 3: Yoga Street yoga
2/28 5/9 Week 4: Jiu Jitsu River City warriors
3/7 5/16 Week 5: Taiko drumming En Taiko
3/14 5/23 Week 6: Self-directed exercise March wellness
12:30-13:30 Cooking demo/lunch Lead facilitator 60 min
2/7 4/18 Week 1: Nutrition lesson EASA Yamhill county occupational therapist
2/14 4/25 Week 2: Cooking skills lesson Portland kitchen
2/21 5/2 Week 3: Cooking demo Community chef
2/28 5/9 Week 4: Field trip—dining out M3 staff
3/7 5/16 Week 5: Field trip—smart shopping at M3 staff
grocery market
3/14 5/23 Week 6: Group potluck M3 staff
13:30-14:30 Break Weekly mindfulness themes 15 min
3
14:15-15:00 2/7 4/18 Facilitated group share (lead by M staff ) Embodiment 45 min
2/14 4/25 Breath and breathing
2/21 5/2 Strength and Stamina
2/28 5/9 Noticing
3/7 5/16 Choice and power
3/14 5/23 Integrations and Connection

Group 1: February 7, 2015-March 14, 2015. Group 2: April 18, 2015-May 23, 2015.

3 | RESULTS 4 | DI SCU SSION

Identifying therapies that decrease risk and change the health trajec-
3.1 | Participant characteristics and feasibility
tory of youth with FEP is important. High adherence to the M3 pro-
Thirty-three participants (out of 44 contacted) were enrolled and gram demonstrates that an activity-based program incorporating
included in analysis (M3 = 17, Control = 16). There were no signifi- mindfulness training, exercise, and diet/nutrition education is a desir-
cant differences between groups in baseline characteristics of age, able complement to standard programming for clients of a community-
medication use, BMI or psychotic symptoms (QSANS/QSAPS), how- based early intervention program (EASA). The involvement of EASA
ever the control group had more males and more whites than the M3 team leaders, former EASA clients and community members in creating
group (Table 2). The primary outcome was met with an 88% (15/17)
completion rate of 4 or more sessions (mean 4.29, SD 1.26), with TABLE 2 Baseline characteristics
only 2 participant discontinuations. M3 (n = 17) Control (n = 16) Between-groups
mean (SD) or % mean (SD) or % P value
Age (y) 19.5 (3.8) 19.6 (2.7) 0.977
Gender (male) 5/17 (29.4%) 13/16 (81.3%) 0.005a
3.2 | Secondary outcomes
Race (white) 7/17 (41.20%) 13/16 (81.38%) 0.012a
The active M3 group had a significant mean decrease in positive
Medication use 11/17 (64.7%) 11/16 (68.8%) 1.000
symptoms (QSAPS) compared to controls from baseline to 12 weeks
BMI 30.5 (6.8) 30.2 (6.3) 0.904
(t = −3.29; P = .002). The model also showed that psychotropic medi-
QSANS 41.9 (21.3) 41.1 (22.6) 0.920
cation use was significantly associated with an improvement in posi-
QSAPS 21.0 (15.3) 26.9 (15.9) 0.300
tive symptoms (t = −3.10, P = .004). M3 group assignment and
Abbreviations: QSANS, Quick Scale for the Assessment of Negative
medication use did not have an interactive effect on positive symp-
Symptoms; QSAPS, Quick Scale for the Assessment of Positive Symp-
toms; each shows an independent relationship with positive symp- toms. T-test was used to compare group differences on continuous vari-
ables and Fisher's exact test was used for categorical variables.
toms. There were no significant cardiometabolic differences between
groups, although the M3 group had a trend in BMI attenuation com- a
Statistically significant difference.
b
pared to controls from baseline to 12 weeks (t = 1.77, P = .086). Psychotropic medication.
4 USHER ET AL.
M3, and a study partner to support healthy behaviours, may have led
to higher than expected attendance for the weekend programming.
One interesting result of M3 participants were significant improve-
ments in positive psychotic symptoms and trends in attenuation of
BMI increase compared to the control group at 6-weeks post-program.
Improvements in psychotic symptoms and BMI increase have also been
reported in studies that evaluate coping/social support and physical
activity, respectively (Firth, Carney, French, et al., 2016; Firth, Carney,
Jerome, et al., 2016; Nordtentoft et al., 2015).
This study has a number of limitations. It used a non-randomized
design and had small sample size. In addition, we could not determine
the extent to which change in symptoms were mediated by M3 or
potentially influenced by interventions participants were receiving as
part of their standard care; EASA employs a non-manualized, flexible
care model wherein not all clients receive the same interventions.
Some might receive more intensive employment assistance, while
others may engage in cognitive behaviour therapy or multi-family
group treatment. In the future we will track the care each participant
receives outside M3.
Data analysis was adjusted for age, gender, medication use and
race to account for potential confounders. To decrease bias, future
studies will employ a pragmatic trial design (NIH Collaboratory, 2016)
that implements randomisation by outpatient clinic to groups, allow-
ing for better blinding and equality of demographic characteristics.
5 | CO NC LUSIO N
The M3 study demonstrated that youth with early stage psychosis had
high adherence to a 6-week active lifestyle intervention. To address
long-term health risks in individuals with schizophrenia-spectrum dis-
orders, our pilot study suggests implementing stakeholder-informed
multi-modal therapies to existing care is warranted.
ACKNOWLEDGEMEN TS
The authors wish to acknowledge the von Schelgell family for funding
the study. In addition, we would like to acknowledge EASA Teams
from Multnomah, Clackamas and Washington Counties; Ryan Melton,
PhD; and Tamara Sale at Portland State University for help with
recruitment.
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How to cite this article: Usher C, Thompson A, Griebeler M,
et al. Meals, Mindfulness, & Moving Forward: A feasibility
study to a multi-modal lifestyle approach in early psychosis.
Early Intervention in Psychiatry. 2018;1–4. https://doi.org/10.
1111/eip.12546