- Email: [email protected]
Eating when depressed, anxious, bored, or happy: Are emotional eating types associated with unique psychological and physical health correlates?
Accepted Manuscript Eating when depressed, anxious, bored, or happy: Are emotional eating types associated with unique psychological and physical health correlates? Abby Braden, Dara Musher-Eizenman, Tanya Watford, Elizabeth Emley PII:
S0195-6663(17)31593-3
DOI:
10.1016/j.appet.2018.02.022
Reference:
APPET 3798
To appear in:
Appetite
Received Date: 1 November 2017 Revised Date:
1 February 2018
Accepted Date: 20 February 2018
Please cite this article as: Braden A., Musher-Eizenman D., Watford T. & Emley E., Eating when depressed, anxious, bored, or happy: Are emotional eating types associated with unique psychological and physical health correlates?, Appetite (2018), doi: 10.1016/j.appet.2018.02.022. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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RUNNING HEAD: Emotional Eating
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Eating when Depressed, Anxious, Bored, or Happy: Are Emotional Eating Types associated with Unique Psychological and Physical Health Correlates?
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Abby Braden
Dara Musher-Eizenman
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Tanya Watford
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Elizabeth Emley
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Corresponding Author:
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Abby Braden, Ph.D.
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Assistant Professor
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Bowling Green State University
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Bowling Green, OH 43403
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[email protected]
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419-372-9405
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Abstract
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The majority of research on emotional eating has examined general emotional eating, to the exclusion of more distinct emotions such as boredom and positive emotions. The current
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study aimed to examine whether specific types of emotional eating (i.e., eating in response to
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depression (EE-D), anxiety/anger (EE-A), boredom (EE-B), and positive emotions (EE-P)) were
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related to a range of psychological (i.e., global psychological well-being, eating disorder
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symptoms, emotion regulation) and physical health variables. A sample of adults (n = 189) with
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overweight/obesity were recruited via Amazon Mechanical Turk. Participants self-reported
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height and weight and completed a battery of questionnaires. Correlational analyses showed that
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more frequent EE-D, EE-A, and EE-B were related to poorer psychological well-being, greater
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eating disorder symptoms, and more difficulties with emotion regulation. EE-P was not
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significantly related to outcome variables. In regression analyses, eating in response to
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depression (EE-D) was the type of emotional eating most closely related to psychological well-
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being, eating disorder symptoms, and emotion regulation difficulties. Exploratory analyses
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revealed associations between EE-D, EE-A, and EE-B and facets of emotion regulation and
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specific disordered eating symptoms. Findings suggest that unique patterns exist between
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specific types of emotional eating and psychological outcomes.
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Keywords: Emotional Eating; Obesity; Emotion Regulation.
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Emotional eating refers to the tendency to eat in response to emotional triggers as opposed to a true physiological need for food.1 Although normal weight individuals report
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emotional eating,2 it is an even greater problem for overweight adults. Approximately half
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(57.3%) of overweight/obese adults endorse high levels of emotional eating.3 Emotional eating
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is associated with increased body mass index (BMI), greater waist circumference, and more body
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fat.4 In a convenience sample of adults, subjects who endorsed the highest levels of emotional
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eating were 13.38 times more likely to be overweight or obese than subjects who endorsed low
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levels of emotional eating.5 Emotional eating is also predictive of weight gain over time6 and
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difficulty losing weight.7 As compared to non-emotional eaters, emotional eaters report greater
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consumption of sweet and high fat foods,8 eating in response to stressors,9 and more frequent
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snacking.9 Despite the negative consequences of emotional eating, emotional eating research has
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been limited by a focus on eating in response to general, as opposed to specific emotions.1
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Furthermore, most emotional eating studies exclude positive emotions as possible eating triggers.
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Conceptualization of emotional eating behavior can be improved by investigating links between
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specific, varied types of emotional eating and health outcomes. A small amount of emotional eating research has examined distinct relationships between
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specific emotions and eating behavior. According to Macht’s five-way model,10 emotions that
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differ in valence and intensity have unique influences on eating. Support for this conclusion has
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been found in cross-sectional and experimental studies. In a study that included obese binge
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eaters, overweight non-binge eaters, and normal weight adults, each group reported that the urge
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to eat varied significantly in response to 23 different emotions.11 Furthermore, experimental data
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showed that eating in response to anxiety12 and trait anxiety13 predicted food intake in a
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laboratory setting, whereas eating in response to anger and trait anger did not. A recent review
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paper highlighted stress, anxiety, and depression as emotions commonly associating with eating,
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further supporting the importance of examining links between specific emotions and eating.14 To
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address previous limitations, the Emotional Eating Scale (EES) was designed to measure eating
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in response to specific, as opposed to general negative emotions.1 The EES assesses eating in
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response to 25 specific, negative emotions and yields three subscales: depression, anxiety, and
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anger/frustration. However, only 1 item from the EES directly assesses eating in response to
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boredom, and, none of the previously described emotional eating assessments measure positive
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emotions as eating triggers.
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eating, some studies have suggested that these are emotional eating triggers that should be
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examined more closely. College students15 and male adults seeking bariatric surgery16 endorsed
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boredom as the emotion that most commonly triggers eating. In two separate laboratory studies,
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completion of a boring task was associated with snacking desire17 and food consumption.18
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Furthermore, results from a diary study showed that boredom was predictive of calorie and fat
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consumption.17 Due to an increased interest in boredom, the EES was recently revised to include
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a more comprehensive focus on boredom.19 However, the EES-revised does not assess the urge
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to eat due to positive emotions even though positive emotions have been associated with greater
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meal consumption.20 A diary study showed that positive emotions were more likely than
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negative to induce eating in a sample of university students.21 The Emotional Appetite
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Questionnaire (EMAQ) was designed to examine eating in response to negative and positive
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emotions.22 Despite evidence for boredom and positive emotions as triggers for eating, it
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remains unknown whether eating in response to these emotions has similar negative physical and
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psychological correlates as eating in response to typically examined negative emotions (e.g.,
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sadness, anxiety).
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Prior studies have shown a link between general emotional eating and psychopathology symptoms. For example, emotional eating has been linked to greater symptoms of depression in
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clinical23-25 and population-based samples.2 Similarly, higher levels of emotional eating was
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related to more severe neuroticism (e.g., anxiety and depression) in a treatment-seeking sample
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of adults with obesity.26 A recent investigation showed that among Portuguese undergraduate
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students, emotional eating was associated with a range of psychopathological symptoms
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including obsessive compulsive behaviors, psychoticism, and hostility, in addition to depression
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and anxiety.27 However, previous studies have exclusively examined associations between
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general emotional eating and psychopathology. No studies have examined relationships between
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eating in response to boredom or positive emotions and mood or anxiety symptoms. Given that
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boredom and positive emotions are common eating triggers,17,19 eating in response to these
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emotions may resemble more normative eating behaviors, associated with less pathology,
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particularly in non-clinical populations.
Consistent findings also show that emotional eating is related to binge eating and other
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eating disordered behaviors. Since it is well established that emotions serve as a common trigger
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for binge episodes,28 it is unsurprising that the link between emotional eating and binge eating
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has been replicated in multiple samples.29,30 In addition to the greater presence of emotional
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eating among binge eaters, a study that examined emotional eating in various groups of eating
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disordered patients showed that emotional eating was also elevated in patients with anorexia (i.e.,
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restricting and binge/purge types) and bulimia.31 Furthermore, compared to non-emotional
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eaters, emotional eaters reported significantly greater drive for thinness and body
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dissatisfaction.32 However, it is possible that the link between general emotional eating and
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disordered eating is stronger than the link between eating triggered by boredom or positive
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emotions and disordered eating. For example, in a recent study, eating due to positive and
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negative emotions were significantly related to binge eating, restrained eating, and preoccupation
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with body image and weight.33 However, eating due to negative emotions was more strongly
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correlated with binge eating than eating due to positive emotions. The relationship between
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boredom eating and disordered eating has not yet been investigated. Thus, eating in response to
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boredom or positive emotions may be less closely related to eating disordered symptoms than
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eating in response to other emotions.
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In addition to general psychopathology and specific eating disorder symptoms, emotional eating has been related to emotion regulation difficulties. Affect regulation models argue that
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emotional eating is the result of poor emotion regulation, as opposed to negative emotion per
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se.34 Several studies have concluded that various facets of emotion regulation (i.e., general
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difficulties in emotion regulation, poor mood regulation expectancies, and emotional awareness)
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were associated with more frequent emotional eating.35 In addition, two laboratory studies have
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also demonstrated links between experimentally manipulated emotion regulation strategies (i.e.,
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suppression and lack of emotional awareness) and food intake.36 Despite evidence showing a
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relationship between emotional eating and poor emotion regulation, it is unknown whether
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similar patterns exist between eating triggered by boredom or positive emotions and emotion
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regulation. One recent study concluded that difficulties in emotion regulation was associated
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with eating in response to boredom in a college student sample.37 And, to our knowledge, no
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prior studies have examined whether eating due to positive emotions is related to poor emotion
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regulation. Thus, it is possible that eating triggered by boredom is associated with poor emotion
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regulation, but eating triggered by positive emotions may not be. The current study builds upon emotional eating research by simultaneously examining
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correlates of eating in response to specific negative (i.e., depression, anxiety/anger, boredom)
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and positive emotions in a sample of adults with overweight/obesity. The primary aim of the
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study was to examine whether boredom and positive emotional eating were associated with
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similar, negative psychological (i.e., global psychological well-being, eating disorder symptoms,
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and emotion regulation) and physical health variables as emotional eating due to depression and
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anxiety/anger. The present study also examined which types of emotional eating (i.e., eating in
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response to depression (EE-D), anxiety/anger (EE-A), boredom (EE-B), and positive emotions
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(EE-P)) are most closely associated with psychological and physical health variables. Even
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though eating in response to positive emotions and boredom have been frequently reported, it is
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unknown whether these behaviors are likely to co-occur with related negative psychosocial
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factors. Furthermore, certain types of emotional eating (e.g., EE-D, EE-A) may be more closely
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related to negative outcomes than others (e.g., EE-B, EE-P). Finally, the present study examines
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physical health as a correlate of emotional eating; because, although emotional eating has been
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associated with certain health outcomes such as BMI4 and weight gain,38 prior studies have not
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examined whether eating in response to various negative and positive emotions is associated
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with physical health more broadly. Given links between emotional eating and weight-related
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variables, it is expected that emotional eating in response to depression and anxiety/anger will be
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associated with poorer physical health, but it is hypothesized that this same relationship will not
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be observed between physical health and eating in response to boredom or positive emotions.
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Methods
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Participants Adults with overweight or obesity (n=189) were recruited to participate in a cross-
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sectional study on eating behaviors and health. Inclusion criteria included adulthood (≥18
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years), resident of the U.S., English fluency, and overweight or obesity (i.e., BMI ≥25 kg/m2). A
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total of 288 adults were initially recruited, and 99 of them were excluded from the final sample.
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Participants were excluded for evidence of random responding on the survey (i.e., failure to
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correctly answer at least 4 out of 5 quality control items and/or survey completion in less than 10
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minutes; 10.4% of the total sample), if the computer IP address fell outside of the U.S. (1%), if
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the reported BMI was <25 (10.8%), for the reported presence of a severe medical condition affecting weight or appetite (e.g., insulin dependent diabetes, cancer requiring active
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chemotherapy; 11.8%), or failure to report height and weight (.3%).
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Measures
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Demographics. Participants self-reported demographic characteristics including age, sex, marital
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status, ethnicity, education level, income, and employment status.
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Anthropometry. Subjects were asked to report their height in feet and inches and their weight in
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pounds. Self-reported height and weight were used to calculate BMI (kg/m2).
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Types of Emotional Eating.
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EE-D, EE-A, & EE-B. Eating in response to depression (EE-D), anxiety/anger (EE-A),
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and boredom (EE-B) were measured with a revised version of the Emotional Eating Scale
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(EES).1 The EES includes 25-items that assess the urge in eat in response to various negative
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emotions (e.g., nervous, sad, furious). Item response options are rated on a 5-point scale ranging
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from 1 (no desire to eat) to 5 (overwhelming desire to eat). Reliability and validity for the EES
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have been established in clinical1 and non-clinical samples.39 The original EES yielded 3
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subscales, depression, anxiety, and anger/frustration. Koball and colleagues15 modified the
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original EES to include 6 items that measure eating in response to boredom (e.g., restless,
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unstimulated). After the modification, factor analytic results yielded 3 subscales: depression,
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anxiety/anger, and boredom. Furthermore, Koball and colleagues15 reported high levels of
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internal consistency for the total scale and subscales. In the current sample of adults, internal
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consistency of EES scales was high (Cronbach’s alpha for EE-D = .94; EE-A = .91; EE-B = .91). EE-P. The Emotional Appetite Questionnaire (EMAQ)22 includes 22-items designed to
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assess eating in response to positive and negative emotions and situations. In the current study,
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the 5-item positive emotions subscale was used to specifically evaluate eating in response to
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positive emotions (i.e., confident, happy, relaxed, playful, enthusiastic). Response options range
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from 1-9, and anchors include “much less,” “the same,” and “much more.” Subjects can also
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select “NA” if the item does not apply or “DK” if the answer is unknown. Test-retest reliability,
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internal consistency,22 and construct validity40 have been established. Internal consistency of the
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eating in response to positive emotions subscale in the current sample was adequate (Cronbach’s
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alpha = .83).
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Global Psychological Well-Being. Psychological well-being was assessed with the Symptom
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Checklist-90-Revised (SCL-global).41 The SCL-90 is a self-report measure of a wide range of
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psychological symptoms. Subjects are asked to endorse how much they were bothered by 90
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different mental health symptoms during the past week on a 5-point likert scale ranging from
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“not at all” to “extremely.” The present study utilized the global severity index which is the
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average rating assigned to all items. The SCL-90 has demonstrated good psychometric
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properties, and it has been widely used with clinical and community samples.41 Excellent
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internal consistency was confirmed in the current sample (Cronbach’s alpha = .99).
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Eating Disorder Symptoms. The Eating Disorders Examination Questionnaire (EDE-Q)42 is a
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self-report measure that was developed as an alternative to the Eating Disorder Examination, 43
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the gold-standard clinical interview used for eating disorder diagnosis. The EDE-Q includes 36-
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items that assess eating disorder symptoms present over the previous 28 days. Item responses
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are provided on a 7-point scale with higher scores indicating more severe eating disorder
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psychopathology. The EDE-Q is comprised of 4 subscales: restraint, shape concerns, weight
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concerns, and eating concerns. The current study used the subscale scores and the global score,
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which is the average of the subscale scores. The EDE-Q has been previously used with
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overweight/obese adults, and strong reliability and validity have been demonstrated.44 Internal
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reliability was also confirmed in the current sample with Cronbach’s alpha ranging from .81 - .93
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for global and subscale scores.
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Emotion Regulation. The Difficulties in Emotion Regulation Scale (DERS)45 is a 36-item self-
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report measure designed to measure difficulties in various dimensions of emotion regulation.
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Subjects are asked to endorse how frequently each item applies to themselves with response
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options ranging from 1 (almost never) to 5 (almost always). Ten items are reverse scored so that
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higher scores indicate more problems with emotion regulation. Sample items include: “When
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I’m upset, I feel guilty for feeling that way” and “I pay attention to how I feel.” The DERS
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yields 6 subscales that include nonacceptance of emotional responses, difficulties engaging in
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goal-directed behavior, impulse control difficulties, lack of emotional awareness, limited access
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to emotion regulation strategies, and lack of emotional clarity. The DERS demonstrated good
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psychometric properties in a sample of overweight/obese adults.35 In the present sample, internal
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consistency was high for the total score and subscales with Cronbach’s alpha ranging from .85 -
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.96.
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Physical Health. The short-form health survey (SF-12)46 was administered to examine general
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physical health. The SF-12 includes 12 items that evaluate eight broad domains of health
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including physical functioning (i.e., limitations in physical activity due to health problems), role-
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physical (i.e., limitations in role activities due to physical health problems), bodily pain (i.e.,
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presence of pain and limitations due to pain), general health (i.e., 1-item rating of general health),
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vitality (i.e., energy level and fatigue), social functioning (i.e., limitations in social activities due
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to physical or emotional problems), role-emotional (i.e., limitations in role activities due to
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emotional health problems), and mental health (i.e., psychological stress and well-being). The
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SF-12 can be used to derive a Physical Component Summary (PCS) score and a Mental
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Component Summary (MCS) score. Only the PCS was used in the current study. Scores range
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from 0-100 with higher scores indicating better functioning. The SF-12 has been extensively
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used and validated with community and clinical samples.47 Internal consistency was adequate in
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the present sample of adults (Cronbach’s alpha = .79).
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Procedures
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Amazon Mechanical Turk (MTurk) was utilized to recruit subjects and distribute the online survey. MTurk has been shown to provide quality data and recruit a diverse sample.48
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Informed consent was obtained via an electronic form at the beginning of the survey. Then,
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participants completed a series of self-report questionnaires, lasting approximately 20-30
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minutes in duration. A total of 5 quality control items were included to identify possible subjects
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who were randomly responding to survey questions (i.e., “When you are finished reading this
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statement, select 66-90%;” “I want you to answer this item by selecting ‘Almost Always;’”
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“Choose the answer ‘6-12 days’ for this item;” “I try to answer all these questions honestly;”
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“Please select ‘moderately’ for this question”). Eligible subjects who completed the survey were
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compensated by crediting online accounts with $0.50.
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Statistical Analyses Of the final sample of 189 adults with overweight/obesity, 1 participant was excluded due
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to a reported BMI that was identified as an outlier. Outliers were defined as values that were
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greater than 1.5 interquartile ranges below the first or above the third quartile. Descriptive
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statistics were calculated to examine sample demographics. Next, correlations were calculated
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between types of emotional eating (i.e., EE-D, EE-A, EE-B, EE-P) and demographic variables
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(i.e., age, sex, BMI, income). Correlations were then calculated between types of emotional
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eating and psychological (i.e., global psychological well-being, eating disorder symptoms, and
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emotion regulation) and physical health variables.
Regression analyses were used to further examine associations between types of
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emotional eating and outcome variables that were related in bivariate analyses, and a Bonferroni
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adjustment was used. Each regression model was tested at a significance level of .004 (.05/12).
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In each regression analysis, BMI was entered at Step 1, types of emotional eating were entered
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simultaneously as independent variables at Step 2, and outcome variables were entered as the
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dependent variable. Given the relationship between BMI and emotional eating,4 BMI was
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entered as a covariate in regression models to examine whether types of emotional eating and
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outcome variables were related, independent of the influence of BMI.
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Exploratory analyses were used to examine relationships between types of emotional
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eating and facets of emotion regulation. Additional exploratory analyses were calculated to
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examine relationships between types of emotional eating and specific eating disorder symptoms.
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In each regression analysis, BMI was entered at Step 1, types of emotional eating were entered
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simultaneously as independent variables at Step 2, and outcome variables were entered as the
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dependent variable. All calculations were performed using SPSS 20.0 (www.SPSS.com). Results
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Descriptive Statistics
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Preliminary analyses examined characteristics of the study sample of 188 adults with overweight/obesity (mean BMI = 33.17, SD = 6.98). Approximately two-thirds (64.9%) of the
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sample were women. Mean age was 41.78 (13.61), and ages ranged from 19-83. The majority
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of participants identified as non-Latino white (87.2%), and almost half (44.1%) were married.
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Education level varied. Approximately half (49.5%) of the sample reported earning a bachelor’s
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or graduate degree, one-third (36.2%) reported some college or a technical/vocation school, and
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14.4% reported less education (i.e., some high school or a high school degree). Approximately
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two-thirds of the sample was employed part-time (12.2%) or full-time (55.9%). Reported
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income was less than $20,000 (19.7%), $20-50,000 (39.4%), $50-75,000 (21.3%), and greater
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than $75,000 (19.7%).
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Correlations
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Correlations between types of emotional eating, demographics (i.e., age, sex, BMI, and
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income), and outcome variables (i.e., psychological well-being, eating disorder symptoms, and
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difficulties in emotion regulation) were calculated (see Table 1). Greater BMI was related to EE-
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D (r = .21, p <.01) and EE-A (r = .29, p <.001). Female sex was related to greater EE-D (r = .15,
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p <.05) and EE-B (r = .15, p <.05). EE-P was not related to any demographic characteristics.
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Eating in response to depression, anxiety/anger, and boredom (i.e., EE-D, EE-A, and EE-B) were
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related to poorer psychological well-being, greater eating disorder symptoms, and more
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difficulties with emotion regulation. EE-P was unrelated to main outcome variables (i.e.,
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psychological well-being, eating disorder symptoms, and difficulties in emotion regulation) and
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was therefore not included in primary regression analyses. All types of emotional eating were
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unrelated to physical health (SF-12).
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Regression Analyses
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To examine which types of emotional eating were most closely associated with outcome variables, a series of regression analyses were conducted. BMI was entered at Step 1, and EE-D,
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EE-A, and EE-B were entered at Step 2 in each regression model. The first model was
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significant (F = 21.51, p <.002) and explained 31.3% of the variance in psychological well-being
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(Table 2). EE-D was the only type of emotional eating significantly associated with
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psychological well-being (β = .40, p <.002). The second model was significant (F = 20.18, p
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<.002) and explained 29.1% of the variance in eating disorder symptoms (Table 3). EE-D was
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the only type of emotional eating significantly associated with eating disorder symptoms (β =
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.36, p <.002). The third model was also significant (F = 20.07, p <.002) and explained 30.2% of
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the variance in emotion regulation (Table 4). EE-D (β = .32, p <.002) was the only type of
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emotional eating significantly associated with emotion regulation. BMI was not significantly
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related to outcome variables in the final models.
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Exploratory Analyses
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eating (EE-D, EE-A, EE-B, EE-P) and facets of emotion regulation, after controlling for BMI
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(Table 5). The model predicting lack of emotional awareness was not significant (p = .14). All
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other models were significant (p < .05) and explained 13.1% - 28.1% of the variance in specific
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facets of emotion regulation. EE-D was significantly associated with nonacceptance of
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emotions, difficulties engaging in goal-directed behavior, impulse control difficulties, and
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limited access to emotion regulation strategies. EE-B was significantly associated with
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difficulties engaging in goal-directed behavior and lack of emotional clarity. EE-A was
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significantly associated with impulse control difficulties. EE-P and BMI were not significantly
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associated with facets of emotion regulation in multivariate models.
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Additional exploratory analyses were conducted to examine associations between types
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of emotional eating and (EE-D, EE-A, EE-B, EE-P) and EDE-Q subscales, after controlling for
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BMI (Table 6). The model predicting restraint was not significant (p = .07). All other models
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were significant (p < .05) and explained 25.2% - 43.3% of the variance in EDE-Q subscales (i.e.,
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eating, weight, and shape concerns). EE-D was significantly associated with eating, weight, and
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shape concerns. EE-A was significantly associated with eating concerns. EE-B was
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significantly associated with shape concerns. EE-P and BMI were not significantly associated
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with facets of emotion regulation in multivariate models.
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Discussion
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To our knowledge, the present study is the first to simultaneously examine psychosocial correlates of eating in response to depression, anxiety/anger, boredom, and positive emotions. In
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the current sample of adults with overweight/obesity, eating triggered by depression,
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anxiety/anger, and boredom were associated with poorer psychological well-being, greater eating
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disorder symptoms, and more emotion regulation difficulties. Eating triggered by positive
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emotions was not associated with negative outcomes. Furthermore, all types of emotional eating
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were unrelated to poorer self-reported physical health. Despite recent interest in eating in
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response to positive emotions, eating in response to negative emotions seems to be more closely
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related to problematic psychological outcomes. Furthermore, the unique pattern of relationships
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that emerged provides further support for the importance of examining emotional eating as a
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multi-dimensional construct.
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In multivariate models, eating triggered by depression was the type of emotional eating that was most closely related to lower psychological well-being, eating disorder symptoms, and
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poor emotion regulation. Findings are consistent with previous research that has demonstrated
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links between more emotional eating and increased symptoms of depression,23 anxiety,26 and
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disordered eating behaviors.31 The current study builds upon previous research by showing that
8
eating triggered by depression was more closely associated with lower psychological well-being,
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eating disorder symptoms, and emotion regulation difficulties than eating triggered by other
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negative and positive emotions. Overweight/obese adults report a tendency to eat in response to
11
various emotions,11 but adults who experience the urge to eat in response to depression may be
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most at risk for experiencing related psychological difficulties.
Despite significant correlational relationships, in multivariate models, eating triggered by
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boredom and anxiety/anger were not uniquely associated with negative outcomes, suggesting
15
that eating due to boredom and anxiety/anger may be indicative of less psychopathology than
16
eating due to depression. It is possible that eating when bored or anxious/angry could be most
17
problematic when occurring in the presence of other types of negative emotional eating (i.e.,
18
eating when depressed). It is important to note that in the present sample, correlations showed a
19
fairly high level of overlap between eating when depressed, anxious/angry, and bored,
20
suggesting that these behaviors often occur simultaneously. Nonetheless, adults with
21
overweight/obesity who rarely eat when feeling depressed (e.g., exclusively boredom eaters)
22
may represent a less pathological sub-group of emotional eaters who are less likely to report co-
23
morbid psychological symptoms.
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Perhaps surprisingly, eating in response to positive emotions was not significantly related
2
to poorer psychological well-being, greater eating disorder symptoms, or emotion dysregulation.
3
Despite a recent interest in the presence of eating triggered by positive emotions, very little
4
research has been done to examine its relationship to negative outcomes. Our findings are
5
somewhat in contrast to a previous study which showed that eating in response to positive
6
emotions was associated with disordered eating symptoms, but to a lesser degree than was eating
7
in response to negative emotions.33 In the current study, eating in response to positive emotions
8
was unrelated to negative psychological factors, suggesting that adults with overweight/obesity
9
who eat in response to positive emotions exclusively may not experience additional, problematic
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psychological symptoms. Of note, the Sultson study33 included a broad sample of women, not
11
restricted by weight, which may explain the differing results. Relatedly, some authors have
12
suggested that eating triggered by positive emotions is a separate construct than eating triggered
13
by negative emotions.49 In the present sample, positive emotional eating was related to boredom
14
eating but unrelated to eating in response to depression or anxiety/anger.
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Contrary to our hypothesis, none of the types of emotional eating were associated with poorer physical health in our sample of adults with overweight/obesity. Despite this, as
17
expected, greater BMI was significantly associated with physical health impairment.
18
Consequently, this null finding may be explained by the inclusion of a sample of adults with a
19
restricted weight range. Previous studies that used the same physical health measure
20
administered in the current study (i.e., SF-12)46 found that similar physical health functioning
21
was reported among obese non-binge eaters and binge eaters (with and without obesity),50,51 and
22
that these scores were lower than scores obtained from non-obese, non-binge eaters.50 Thus,
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given the health consequences of obesity, it is likely that physical functioning is broadly
2
impaired in this group, regardless of the level of emotional eating.
3
Exploratory analyses suggest possible unique relationships between types of emotional eating and specific facets of emotion regulation. Difficulties engaging in goal-directed behavior
5
emerged as a specific facet of emotion regulation that was associated with eating triggered by
6
depression and boredom. It is possible that when experiencing low intensity negative emotions
7
(e.g., depression, boredom), an inability to attend to alternative, adaptive tasks may increase
8
vulnerability for eating as a strategy for regulating negative affect. Lack of emotional clarity was
9
also uniquely related to eating due to boredom (but not other negative emotions). Thus, when
10
adults with overweight/obesity are feeling bored, confusion about what they are feeling could
11
promote eating. Impulse control difficulties were closely related to the tendency to eat in
12
response to depression and anxiety/anger which suggests that these two types of emotional eating
13
may share an underlying impairment in inhibition. Other facets of emotion regulation (i.e.,
14
nonacceptance of emotional reactions and limited access to emotion regulation strategies) were
15
also related to eating triggered by depression. Few studies have examined how specific aspects
16
of emotion regulation are related to emotional eating. Findings from the present study build
17
upon a previous study that identified limited access to emotion regulation strategies, difficulties
18
engaging in goal-directed behavior, and lack of emotional clarity as the emotion regulation
19
strategies most closely related to emotional overeating (i.e., eating in response to general
20
negative emotions) in a sample of treatment-seeking adults with obesity and binge eating
21
disorder.35 Taken together, findings suggest that certain emotion regulation strategies may be
22
more closely linked to various types of emotional eating. Future research investigations may aim
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to examine whether treatment programs should target and teach specific emotion regulation
2
strategies to different types of emotional eaters.
3
Exploratory analyses also showed that types of emotional eating may be more closely related to specific eating disorder symptoms than others. Similar to the pattern described above,
5
eating triggered by depression was the type of emotional eating most closely associated with
6
several eating disorder symptoms (i.e., concerns about eating, shape, and weight). This provides
7
further evidence that emotional eating triggered by a depressed mood is most indicative of
8
related psychopathology. Additional findings showed that eating in response to boredom was
9
uniquely related to shape concerns, and eating in response to anxiety/anger was uniquely related
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to eating concerns. Thus, although eating triggered by anxiety/anger and boredom are less
11
robustly associated with negative outcomes than eating triggered by feelings of depression, they
12
can be independently associated with disordered eating symptoms.
The current study is limited by a cross-sectional design and reliance on self-report
14
questionnaires that are subject to bias. Recent studies have critiqued the use of self-report
15
measures of emotional eating, suggesting that these scales may not actually be assessing true
16
emotional eating behavior.52 In addition, multiple analyses were conducted in the present study;
17
and, although a Bonferroni was used to determine significance in multivariate analyses, the
18
possibility of Type I error remains, particularly for correlational and exploratory analyses.
19
Furthermore, the current study recruited a general sample of adults with overweight/obesity
20
which may not be representative of emotional eaters who are not overweight/obese or a
21
treatment-seeking sample. Despite its limitations, the current study makes an important
22
contribution to the emotional eating literature by examining correlates of eating in response to
23
discrete emotions. It appears that various types of emotional eating are associated with unique
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psychological factors. Adults who eat in response to feelings of depression, anxiety/anger,
2
boredom, or positive emotions likely have distinct psychosocial characteristics and consequently,
3
may require tailored treatment approaches.
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References
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Table 1. Correlations between types of emotional eating, demographics, and outcome variables Variable 1 2 3 4 5 6 7 8 9 --
2. EE-A
.74***
--
3. EE-B
.61***
.53***
--
4. EE-P
-.04
.06
.23**
--
5. age
-.12
-.04
-.08
.08
--
6. sex
.15*
.07
.15*
-.13
.04
7. income
.02
.08
.04
-.01
.05
8. BMI
.21**
.29***
.13
-.07
.04
9. SCL-90
.57***
.51***
.39***
.02
10. EDE-Q
.54***
.47***
.40***
-.04
11. DERS
.52***
.44***
.45***
12. SF-12
-.11
-.12
-.08
11
12
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1. EE-D
10
--
--
.03
.01
--
.23
.01
-.12
.14
--
-.13
.18
-.08
.13
.45***
--
EP
TE D
.01
-.29***
-.01
.02
.08
.65***
.45***
--
-.02
-.13
-.04
.02
-.22**
-.12
.01
.03
AC C
.07
--
Note. EE-D = depression subscale of the Emotional Eating Scale; EE-A = anxiety/anger subscale of the Emotional Eating Scale; EE-B = boredom subscale of the Emotional Eating Scale; EE-P = positive emotions subscale of the Emotional Appetite Questionnaire; SCL90 = Symptom Checklist-90-revised; EDE-Q = Eating Disorders Examination Questionnaire; DERS = Difficulties in Emotion Regulation Questionnaire; SF-12 = Short-Form Health Survey. * p <.05; ** p < .01; *** p < .001
ACCEPTED MANUSCRIPT 29
Table 2. Regression analysis examining associations between types of emotional eating and global psychological well-being (SCL-90) Variable
B
SE B
.02
.01
BMI
.01
.01
EE-D
.03
.01
EE-A
.02
.01
EE-B
.01
.01
Β
.02
M AN U
Step 2
.16
.40*
SC
BMI
RI PT
Step 1
.18
.09
AC C
EP
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Note. EE-D = depression subscale of the Emotional Eating Scale; EE-A = anxiety/anger subscale of the Emotional Eating Scale; EE-B = boredom subscale of the Emotional Eating Scale * Significant based on Bonferroni correction alpha level of 0.004.
ACCEPTED MANUSCRIPT 30
Table 3. Regression analysis examining associations between types of emotional eating and eating disorder symptoms (EDE-Q) Variable
B
SE B
.02
.01
BMI
-.01
.01
EE-D
.05
.01
EE-A
.02
.01
EE-B
.02
.01
β
-.01
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Step 2
.12
.36*
SC
BMI
RI PT
Step 1
.10
.12
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Note. EE-D = depression subscale of the Emotional Eating Scale; EE-A = anxiety/anger subscale of the Emotional Eating Scale; EE-B = boredom subscale of the Emotional Eating Scale * Significant based on Bonferroni correction alpha level of 0.004.
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Table 4. Regression analysis examining associations between types of emotional eating and emotion regulation (DERS) Variable
B
SE B
.31
.27
BMI
-.17
.24
EE-D
.89
.27
EE-A
.41
.34
EE-B
.65
.25
Β
-.04
M AN U
Step 2
.08
.32*
SC
BMI
RI PT
Step 1
.12
.20
AC C
EP
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Note. EE-D = depression subscale of the Emotional Eating Scale; EE-A = anxiety/anger subscale of the Emotional Eating Scale; EE-B = boredom subscale of the Emotional Eating Scale * Significant based on Bonferroni correction alpha level of 0.004.
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Table 5. Regression analyses examining associations between types of emotional eating and facets of emotion regulation (DERS), after controlling for BMI
Goals
Impulse
Awareness
Strategies
RI PT
Nonacceptance
Clarity
B
SE B
β
B
SE B
Β
B
SE B
Β
B
SE B
β
B
SE B
Β
B
SE B
β
EE-D
.19
.07
.29**
.18
.06
.33**
.13
.06
.23*
.01
.06
.01
.33
.09
.40***
.07
.05
.17
EE-A
.09
.09
.10
.02
.07
.02
.20
.07
.26**
-.02
-.04
.11
.10
.10
.01
.06
.01
EE-B
.11
.07
.14
.13
.06
.21*
.06
.06
.09
.12
.06
.21
.07
.08
.08
.12
.05
.24*
EE-P
.21
.37
.04
.02
.29
.01
.47
.30
.11
-.55
.30
-.13
.65
.43
.10
-.19
.23
-.06
SC
Variable
TE D
M AN U
.07
AC C
*p < .05, **p < .01, **p <.001.
EP
Note. EE-D = depression subscale of the Emotional Eating Scale; EE-A = anxiety/anger subscale of the Emotional Eating Scale; EE-B = boredom subscale of the Emotional Eating Scale; EE-P = positive emotions subscale of the Emotional Appetite Questionnaire; Nonacceptance = nonacceptance of emotional reactions; Goals = difficulties engaging in goal-directed behavior; Impulse = impulse control difficulties; Awareness = lack of emotional awareness; Strategies = limited access to emotion regulation strategies; Clarity = lack of emotional clarity.
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Table 6. Regression analyses examining associations between types of emotional eating and EDE-Q subscales after controlling for BMI Eating Concerns
Shape Concerns
Weight Concerns
RI PT
Restraint SE B
β
B
SE B
Β
B
SE B
Β
B
SE B
β
EE-D
.02
.02
.09
.07
.02
.42***
.05
.02
.31**
.05
.02
.31**
EE-A
.02
.02
.10
.05
.02
.23**
.03
.02
.12
.02
.02
.10
EE-B
-.01
.02
-.01
.02
.02
.10
.04
.02
.18*
.03
.02
.17
EE-P
-.22
.10
-.17
.08
.08
.06
.11
.09
-.08
-.05
.08
-.04
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Variable B
AC C
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Note. EDE-Q = Eating Disorders Examination Questionnaire; EE-D = depression subscale of the Emotional Eating Scale; EE-A = anxiety/anger subscale of the Emotional Eating Scale; EE-B = boredom subscale of the Emotional Eating Scale; EE-P = positive emotions subscale of the Emotional Appetite Questionnaire. *p < .05, **p < .01, **p <.001.
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S0195-6663(17)31593-3
DOI:
10.1016/j.appet.2018.02.022
Reference:
APPET 3798
To appear in:
Appetite
Received Date: 1 November 2017 Revised Date:
1 February 2018
Accepted Date: 20 February 2018
Please cite this article as: Braden A., Musher-Eizenman D., Watford T. & Emley E., Eating when depressed, anxious, bored, or happy: Are emotional eating types associated with unique psychological and physical health correlates?, Appetite (2018), doi: 10.1016/j.appet.2018.02.022. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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RUNNING HEAD: Emotional Eating
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Eating when Depressed, Anxious, Bored, or Happy: Are Emotional Eating Types associated with Unique Psychological and Physical Health Correlates?
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Abby Braden
Dara Musher-Eizenman
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Tanya Watford
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Elizabeth Emley
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Corresponding Author:
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Abby Braden, Ph.D.
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Assistant Professor
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Bowling Green State University
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Bowling Green, OH 43403
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[email protected]
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419-372-9405
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Abstract
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The majority of research on emotional eating has examined general emotional eating, to the exclusion of more distinct emotions such as boredom and positive emotions. The current
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study aimed to examine whether specific types of emotional eating (i.e., eating in response to
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depression (EE-D), anxiety/anger (EE-A), boredom (EE-B), and positive emotions (EE-P)) were
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related to a range of psychological (i.e., global psychological well-being, eating disorder
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symptoms, emotion regulation) and physical health variables. A sample of adults (n = 189) with
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overweight/obesity were recruited via Amazon Mechanical Turk. Participants self-reported
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height and weight and completed a battery of questionnaires. Correlational analyses showed that
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more frequent EE-D, EE-A, and EE-B were related to poorer psychological well-being, greater
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eating disorder symptoms, and more difficulties with emotion regulation. EE-P was not
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significantly related to outcome variables. In regression analyses, eating in response to
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depression (EE-D) was the type of emotional eating most closely related to psychological well-
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being, eating disorder symptoms, and emotion regulation difficulties. Exploratory analyses
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revealed associations between EE-D, EE-A, and EE-B and facets of emotion regulation and
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specific disordered eating symptoms. Findings suggest that unique patterns exist between
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specific types of emotional eating and psychological outcomes.
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Keywords: Emotional Eating; Obesity; Emotion Regulation.
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Emotional eating refers to the tendency to eat in response to emotional triggers as opposed to a true physiological need for food.1 Although normal weight individuals report
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emotional eating,2 it is an even greater problem for overweight adults. Approximately half
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(57.3%) of overweight/obese adults endorse high levels of emotional eating.3 Emotional eating
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is associated with increased body mass index (BMI), greater waist circumference, and more body
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fat.4 In a convenience sample of adults, subjects who endorsed the highest levels of emotional
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eating were 13.38 times more likely to be overweight or obese than subjects who endorsed low
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levels of emotional eating.5 Emotional eating is also predictive of weight gain over time6 and
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difficulty losing weight.7 As compared to non-emotional eaters, emotional eaters report greater
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consumption of sweet and high fat foods,8 eating in response to stressors,9 and more frequent
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snacking.9 Despite the negative consequences of emotional eating, emotional eating research has
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been limited by a focus on eating in response to general, as opposed to specific emotions.1
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Furthermore, most emotional eating studies exclude positive emotions as possible eating triggers.
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Conceptualization of emotional eating behavior can be improved by investigating links between
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specific, varied types of emotional eating and health outcomes. A small amount of emotional eating research has examined distinct relationships between
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specific emotions and eating behavior. According to Macht’s five-way model,10 emotions that
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differ in valence and intensity have unique influences on eating. Support for this conclusion has
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been found in cross-sectional and experimental studies. In a study that included obese binge
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eaters, overweight non-binge eaters, and normal weight adults, each group reported that the urge
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to eat varied significantly in response to 23 different emotions.11 Furthermore, experimental data
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showed that eating in response to anxiety12 and trait anxiety13 predicted food intake in a
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laboratory setting, whereas eating in response to anger and trait anger did not. A recent review
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paper highlighted stress, anxiety, and depression as emotions commonly associating with eating,
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further supporting the importance of examining links between specific emotions and eating.14 To
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address previous limitations, the Emotional Eating Scale (EES) was designed to measure eating
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in response to specific, as opposed to general negative emotions.1 The EES assesses eating in
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response to 25 specific, negative emotions and yields three subscales: depression, anxiety, and
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anger/frustration. However, only 1 item from the EES directly assesses eating in response to
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boredom, and, none of the previously described emotional eating assessments measure positive
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emotions as eating triggers.
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eating, some studies have suggested that these are emotional eating triggers that should be
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examined more closely. College students15 and male adults seeking bariatric surgery16 endorsed
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boredom as the emotion that most commonly triggers eating. In two separate laboratory studies,
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completion of a boring task was associated with snacking desire17 and food consumption.18
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Furthermore, results from a diary study showed that boredom was predictive of calorie and fat
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consumption.17 Due to an increased interest in boredom, the EES was recently revised to include
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a more comprehensive focus on boredom.19 However, the EES-revised does not assess the urge
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to eat due to positive emotions even though positive emotions have been associated with greater
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meal consumption.20 A diary study showed that positive emotions were more likely than
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negative to induce eating in a sample of university students.21 The Emotional Appetite
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Questionnaire (EMAQ) was designed to examine eating in response to negative and positive
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emotions.22 Despite evidence for boredom and positive emotions as triggers for eating, it
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remains unknown whether eating in response to these emotions has similar negative physical and
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psychological correlates as eating in response to typically examined negative emotions (e.g.,
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sadness, anxiety).
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Prior studies have shown a link between general emotional eating and psychopathology symptoms. For example, emotional eating has been linked to greater symptoms of depression in
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clinical23-25 and population-based samples.2 Similarly, higher levels of emotional eating was
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related to more severe neuroticism (e.g., anxiety and depression) in a treatment-seeking sample
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of adults with obesity.26 A recent investigation showed that among Portuguese undergraduate
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students, emotional eating was associated with a range of psychopathological symptoms
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including obsessive compulsive behaviors, psychoticism, and hostility, in addition to depression
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and anxiety.27 However, previous studies have exclusively examined associations between
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general emotional eating and psychopathology. No studies have examined relationships between
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eating in response to boredom or positive emotions and mood or anxiety symptoms. Given that
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boredom and positive emotions are common eating triggers,17,19 eating in response to these
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emotions may resemble more normative eating behaviors, associated with less pathology,
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particularly in non-clinical populations.
Consistent findings also show that emotional eating is related to binge eating and other
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eating disordered behaviors. Since it is well established that emotions serve as a common trigger
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for binge episodes,28 it is unsurprising that the link between emotional eating and binge eating
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has been replicated in multiple samples.29,30 In addition to the greater presence of emotional
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eating among binge eaters, a study that examined emotional eating in various groups of eating
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disordered patients showed that emotional eating was also elevated in patients with anorexia (i.e.,
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restricting and binge/purge types) and bulimia.31 Furthermore, compared to non-emotional
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eaters, emotional eaters reported significantly greater drive for thinness and body
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dissatisfaction.32 However, it is possible that the link between general emotional eating and
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disordered eating is stronger than the link between eating triggered by boredom or positive
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emotions and disordered eating. For example, in a recent study, eating due to positive and
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negative emotions were significantly related to binge eating, restrained eating, and preoccupation
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with body image and weight.33 However, eating due to negative emotions was more strongly
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correlated with binge eating than eating due to positive emotions. The relationship between
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boredom eating and disordered eating has not yet been investigated. Thus, eating in response to
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boredom or positive emotions may be less closely related to eating disordered symptoms than
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eating in response to other emotions.
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In addition to general psychopathology and specific eating disorder symptoms, emotional eating has been related to emotion regulation difficulties. Affect regulation models argue that
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emotional eating is the result of poor emotion regulation, as opposed to negative emotion per
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se.34 Several studies have concluded that various facets of emotion regulation (i.e., general
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difficulties in emotion regulation, poor mood regulation expectancies, and emotional awareness)
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were associated with more frequent emotional eating.35 In addition, two laboratory studies have
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also demonstrated links between experimentally manipulated emotion regulation strategies (i.e.,
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suppression and lack of emotional awareness) and food intake.36 Despite evidence showing a
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relationship between emotional eating and poor emotion regulation, it is unknown whether
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similar patterns exist between eating triggered by boredom or positive emotions and emotion
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regulation. One recent study concluded that difficulties in emotion regulation was associated
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with eating in response to boredom in a college student sample.37 And, to our knowledge, no
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prior studies have examined whether eating due to positive emotions is related to poor emotion
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regulation. Thus, it is possible that eating triggered by boredom is associated with poor emotion
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regulation, but eating triggered by positive emotions may not be. The current study builds upon emotional eating research by simultaneously examining
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correlates of eating in response to specific negative (i.e., depression, anxiety/anger, boredom)
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and positive emotions in a sample of adults with overweight/obesity. The primary aim of the
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study was to examine whether boredom and positive emotional eating were associated with
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similar, negative psychological (i.e., global psychological well-being, eating disorder symptoms,
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and emotion regulation) and physical health variables as emotional eating due to depression and
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anxiety/anger. The present study also examined which types of emotional eating (i.e., eating in
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response to depression (EE-D), anxiety/anger (EE-A), boredom (EE-B), and positive emotions
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(EE-P)) are most closely associated with psychological and physical health variables. Even
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though eating in response to positive emotions and boredom have been frequently reported, it is
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unknown whether these behaviors are likely to co-occur with related negative psychosocial
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factors. Furthermore, certain types of emotional eating (e.g., EE-D, EE-A) may be more closely
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related to negative outcomes than others (e.g., EE-B, EE-P). Finally, the present study examines
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physical health as a correlate of emotional eating; because, although emotional eating has been
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associated with certain health outcomes such as BMI4 and weight gain,38 prior studies have not
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examined whether eating in response to various negative and positive emotions is associated
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with physical health more broadly. Given links between emotional eating and weight-related
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variables, it is expected that emotional eating in response to depression and anxiety/anger will be
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associated with poorer physical health, but it is hypothesized that this same relationship will not
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be observed between physical health and eating in response to boredom or positive emotions.
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Methods
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Participants Adults with overweight or obesity (n=189) were recruited to participate in a cross-
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sectional study on eating behaviors and health. Inclusion criteria included adulthood (≥18
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years), resident of the U.S., English fluency, and overweight or obesity (i.e., BMI ≥25 kg/m2). A
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total of 288 adults were initially recruited, and 99 of them were excluded from the final sample.
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Participants were excluded for evidence of random responding on the survey (i.e., failure to
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correctly answer at least 4 out of 5 quality control items and/or survey completion in less than 10
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minutes; 10.4% of the total sample), if the computer IP address fell outside of the U.S. (1%), if
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the reported BMI was <25 (10.8%), for the reported presence of a severe medical condition affecting weight or appetite (e.g., insulin dependent diabetes, cancer requiring active
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chemotherapy; 11.8%), or failure to report height and weight (.3%).
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Measures
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Demographics. Participants self-reported demographic characteristics including age, sex, marital
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status, ethnicity, education level, income, and employment status.
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Anthropometry. Subjects were asked to report their height in feet and inches and their weight in
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pounds. Self-reported height and weight were used to calculate BMI (kg/m2).
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Types of Emotional Eating.
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EE-D, EE-A, & EE-B. Eating in response to depression (EE-D), anxiety/anger (EE-A),
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and boredom (EE-B) were measured with a revised version of the Emotional Eating Scale
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(EES).1 The EES includes 25-items that assess the urge in eat in response to various negative
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emotions (e.g., nervous, sad, furious). Item response options are rated on a 5-point scale ranging
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from 1 (no desire to eat) to 5 (overwhelming desire to eat). Reliability and validity for the EES
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have been established in clinical1 and non-clinical samples.39 The original EES yielded 3
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subscales, depression, anxiety, and anger/frustration. Koball and colleagues15 modified the
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original EES to include 6 items that measure eating in response to boredom (e.g., restless,
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unstimulated). After the modification, factor analytic results yielded 3 subscales: depression,
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anxiety/anger, and boredom. Furthermore, Koball and colleagues15 reported high levels of
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internal consistency for the total scale and subscales. In the current sample of adults, internal
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consistency of EES scales was high (Cronbach’s alpha for EE-D = .94; EE-A = .91; EE-B = .91). EE-P. The Emotional Appetite Questionnaire (EMAQ)22 includes 22-items designed to
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assess eating in response to positive and negative emotions and situations. In the current study,
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the 5-item positive emotions subscale was used to specifically evaluate eating in response to
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positive emotions (i.e., confident, happy, relaxed, playful, enthusiastic). Response options range
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from 1-9, and anchors include “much less,” “the same,” and “much more.” Subjects can also
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select “NA” if the item does not apply or “DK” if the answer is unknown. Test-retest reliability,
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internal consistency,22 and construct validity40 have been established. Internal consistency of the
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eating in response to positive emotions subscale in the current sample was adequate (Cronbach’s
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alpha = .83).
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Global Psychological Well-Being. Psychological well-being was assessed with the Symptom
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Checklist-90-Revised (SCL-global).41 The SCL-90 is a self-report measure of a wide range of
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psychological symptoms. Subjects are asked to endorse how much they were bothered by 90
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different mental health symptoms during the past week on a 5-point likert scale ranging from
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“not at all” to “extremely.” The present study utilized the global severity index which is the
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average rating assigned to all items. The SCL-90 has demonstrated good psychometric
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properties, and it has been widely used with clinical and community samples.41 Excellent
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internal consistency was confirmed in the current sample (Cronbach’s alpha = .99).
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Eating Disorder Symptoms. The Eating Disorders Examination Questionnaire (EDE-Q)42 is a
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self-report measure that was developed as an alternative to the Eating Disorder Examination, 43
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the gold-standard clinical interview used for eating disorder diagnosis. The EDE-Q includes 36-
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items that assess eating disorder symptoms present over the previous 28 days. Item responses
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are provided on a 7-point scale with higher scores indicating more severe eating disorder
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psychopathology. The EDE-Q is comprised of 4 subscales: restraint, shape concerns, weight
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concerns, and eating concerns. The current study used the subscale scores and the global score,
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which is the average of the subscale scores. The EDE-Q has been previously used with
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overweight/obese adults, and strong reliability and validity have been demonstrated.44 Internal
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reliability was also confirmed in the current sample with Cronbach’s alpha ranging from .81 - .93
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for global and subscale scores.
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Emotion Regulation. The Difficulties in Emotion Regulation Scale (DERS)45 is a 36-item self-
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report measure designed to measure difficulties in various dimensions of emotion regulation.
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Subjects are asked to endorse how frequently each item applies to themselves with response
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options ranging from 1 (almost never) to 5 (almost always). Ten items are reverse scored so that
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higher scores indicate more problems with emotion regulation. Sample items include: “When
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I’m upset, I feel guilty for feeling that way” and “I pay attention to how I feel.” The DERS
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yields 6 subscales that include nonacceptance of emotional responses, difficulties engaging in
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goal-directed behavior, impulse control difficulties, lack of emotional awareness, limited access
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to emotion regulation strategies, and lack of emotional clarity. The DERS demonstrated good
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psychometric properties in a sample of overweight/obese adults.35 In the present sample, internal
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consistency was high for the total score and subscales with Cronbach’s alpha ranging from .85 -
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.96.
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Physical Health. The short-form health survey (SF-12)46 was administered to examine general
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physical health. The SF-12 includes 12 items that evaluate eight broad domains of health
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including physical functioning (i.e., limitations in physical activity due to health problems), role-
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physical (i.e., limitations in role activities due to physical health problems), bodily pain (i.e.,
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presence of pain and limitations due to pain), general health (i.e., 1-item rating of general health),
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vitality (i.e., energy level and fatigue), social functioning (i.e., limitations in social activities due
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to physical or emotional problems), role-emotional (i.e., limitations in role activities due to
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emotional health problems), and mental health (i.e., psychological stress and well-being). The
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SF-12 can be used to derive a Physical Component Summary (PCS) score and a Mental
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Component Summary (MCS) score. Only the PCS was used in the current study. Scores range
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from 0-100 with higher scores indicating better functioning. The SF-12 has been extensively
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used and validated with community and clinical samples.47 Internal consistency was adequate in
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the present sample of adults (Cronbach’s alpha = .79).
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Procedures
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Amazon Mechanical Turk (MTurk) was utilized to recruit subjects and distribute the online survey. MTurk has been shown to provide quality data and recruit a diverse sample.48
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Informed consent was obtained via an electronic form at the beginning of the survey. Then,
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participants completed a series of self-report questionnaires, lasting approximately 20-30
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minutes in duration. A total of 5 quality control items were included to identify possible subjects
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who were randomly responding to survey questions (i.e., “When you are finished reading this
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statement, select 66-90%;” “I want you to answer this item by selecting ‘Almost Always;’”
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“Choose the answer ‘6-12 days’ for this item;” “I try to answer all these questions honestly;”
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“Please select ‘moderately’ for this question”). Eligible subjects who completed the survey were
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compensated by crediting online accounts with $0.50.
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Statistical Analyses Of the final sample of 189 adults with overweight/obesity, 1 participant was excluded due
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to a reported BMI that was identified as an outlier. Outliers were defined as values that were
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greater than 1.5 interquartile ranges below the first or above the third quartile. Descriptive
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statistics were calculated to examine sample demographics. Next, correlations were calculated
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between types of emotional eating (i.e., EE-D, EE-A, EE-B, EE-P) and demographic variables
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(i.e., age, sex, BMI, income). Correlations were then calculated between types of emotional
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eating and psychological (i.e., global psychological well-being, eating disorder symptoms, and
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emotion regulation) and physical health variables.
Regression analyses were used to further examine associations between types of
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emotional eating and outcome variables that were related in bivariate analyses, and a Bonferroni
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adjustment was used. Each regression model was tested at a significance level of .004 (.05/12).
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In each regression analysis, BMI was entered at Step 1, types of emotional eating were entered
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simultaneously as independent variables at Step 2, and outcome variables were entered as the
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dependent variable. Given the relationship between BMI and emotional eating,4 BMI was
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entered as a covariate in regression models to examine whether types of emotional eating and
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outcome variables were related, independent of the influence of BMI.
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Exploratory analyses were used to examine relationships between types of emotional
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eating and facets of emotion regulation. Additional exploratory analyses were calculated to
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examine relationships between types of emotional eating and specific eating disorder symptoms.
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In each regression analysis, BMI was entered at Step 1, types of emotional eating were entered
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simultaneously as independent variables at Step 2, and outcome variables were entered as the
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dependent variable. All calculations were performed using SPSS 20.0 (www.SPSS.com). Results
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Descriptive Statistics
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Preliminary analyses examined characteristics of the study sample of 188 adults with overweight/obesity (mean BMI = 33.17, SD = 6.98). Approximately two-thirds (64.9%) of the
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sample were women. Mean age was 41.78 (13.61), and ages ranged from 19-83. The majority
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of participants identified as non-Latino white (87.2%), and almost half (44.1%) were married.
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Education level varied. Approximately half (49.5%) of the sample reported earning a bachelor’s
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or graduate degree, one-third (36.2%) reported some college or a technical/vocation school, and
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14.4% reported less education (i.e., some high school or a high school degree). Approximately
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two-thirds of the sample was employed part-time (12.2%) or full-time (55.9%). Reported
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income was less than $20,000 (19.7%), $20-50,000 (39.4%), $50-75,000 (21.3%), and greater
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than $75,000 (19.7%).
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Correlations
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Correlations between types of emotional eating, demographics (i.e., age, sex, BMI, and
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income), and outcome variables (i.e., psychological well-being, eating disorder symptoms, and
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difficulties in emotion regulation) were calculated (see Table 1). Greater BMI was related to EE-
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D (r = .21, p <.01) and EE-A (r = .29, p <.001). Female sex was related to greater EE-D (r = .15,
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p <.05) and EE-B (r = .15, p <.05). EE-P was not related to any demographic characteristics.
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Eating in response to depression, anxiety/anger, and boredom (i.e., EE-D, EE-A, and EE-B) were
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related to poorer psychological well-being, greater eating disorder symptoms, and more
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difficulties with emotion regulation. EE-P was unrelated to main outcome variables (i.e.,
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psychological well-being, eating disorder symptoms, and difficulties in emotion regulation) and
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was therefore not included in primary regression analyses. All types of emotional eating were
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unrelated to physical health (SF-12).
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Regression Analyses
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To examine which types of emotional eating were most closely associated with outcome variables, a series of regression analyses were conducted. BMI was entered at Step 1, and EE-D,
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EE-A, and EE-B were entered at Step 2 in each regression model. The first model was
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significant (F = 21.51, p <.002) and explained 31.3% of the variance in psychological well-being
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(Table 2). EE-D was the only type of emotional eating significantly associated with
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psychological well-being (β = .40, p <.002). The second model was significant (F = 20.18, p
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<.002) and explained 29.1% of the variance in eating disorder symptoms (Table 3). EE-D was
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the only type of emotional eating significantly associated with eating disorder symptoms (β =
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.36, p <.002). The third model was also significant (F = 20.07, p <.002) and explained 30.2% of
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the variance in emotion regulation (Table 4). EE-D (β = .32, p <.002) was the only type of
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emotional eating significantly associated with emotion regulation. BMI was not significantly
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related to outcome variables in the final models.
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Exploratory Analyses
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eating (EE-D, EE-A, EE-B, EE-P) and facets of emotion regulation, after controlling for BMI
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(Table 5). The model predicting lack of emotional awareness was not significant (p = .14). All
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other models were significant (p < .05) and explained 13.1% - 28.1% of the variance in specific
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facets of emotion regulation. EE-D was significantly associated with nonacceptance of
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emotions, difficulties engaging in goal-directed behavior, impulse control difficulties, and
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limited access to emotion regulation strategies. EE-B was significantly associated with
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difficulties engaging in goal-directed behavior and lack of emotional clarity. EE-A was
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significantly associated with impulse control difficulties. EE-P and BMI were not significantly
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associated with facets of emotion regulation in multivariate models.
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Additional exploratory analyses were conducted to examine associations between types
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of emotional eating and (EE-D, EE-A, EE-B, EE-P) and EDE-Q subscales, after controlling for
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BMI (Table 6). The model predicting restraint was not significant (p = .07). All other models
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were significant (p < .05) and explained 25.2% - 43.3% of the variance in EDE-Q subscales (i.e.,
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eating, weight, and shape concerns). EE-D was significantly associated with eating, weight, and
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shape concerns. EE-A was significantly associated with eating concerns. EE-B was
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significantly associated with shape concerns. EE-P and BMI were not significantly associated
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with facets of emotion regulation in multivariate models.
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Discussion
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To our knowledge, the present study is the first to simultaneously examine psychosocial correlates of eating in response to depression, anxiety/anger, boredom, and positive emotions. In
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the current sample of adults with overweight/obesity, eating triggered by depression,
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anxiety/anger, and boredom were associated with poorer psychological well-being, greater eating
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disorder symptoms, and more emotion regulation difficulties. Eating triggered by positive
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emotions was not associated with negative outcomes. Furthermore, all types of emotional eating
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were unrelated to poorer self-reported physical health. Despite recent interest in eating in
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response to positive emotions, eating in response to negative emotions seems to be more closely
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related to problematic psychological outcomes. Furthermore, the unique pattern of relationships
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that emerged provides further support for the importance of examining emotional eating as a
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multi-dimensional construct.
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In multivariate models, eating triggered by depression was the type of emotional eating that was most closely related to lower psychological well-being, eating disorder symptoms, and
5
poor emotion regulation. Findings are consistent with previous research that has demonstrated
6
links between more emotional eating and increased symptoms of depression,23 anxiety,26 and
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disordered eating behaviors.31 The current study builds upon previous research by showing that
8
eating triggered by depression was more closely associated with lower psychological well-being,
9
eating disorder symptoms, and emotion regulation difficulties than eating triggered by other
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negative and positive emotions. Overweight/obese adults report a tendency to eat in response to
11
various emotions,11 but adults who experience the urge to eat in response to depression may be
12
most at risk for experiencing related psychological difficulties.
Despite significant correlational relationships, in multivariate models, eating triggered by
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boredom and anxiety/anger were not uniquely associated with negative outcomes, suggesting
15
that eating due to boredom and anxiety/anger may be indicative of less psychopathology than
16
eating due to depression. It is possible that eating when bored or anxious/angry could be most
17
problematic when occurring in the presence of other types of negative emotional eating (i.e.,
18
eating when depressed). It is important to note that in the present sample, correlations showed a
19
fairly high level of overlap between eating when depressed, anxious/angry, and bored,
20
suggesting that these behaviors often occur simultaneously. Nonetheless, adults with
21
overweight/obesity who rarely eat when feeling depressed (e.g., exclusively boredom eaters)
22
may represent a less pathological sub-group of emotional eaters who are less likely to report co-
23
morbid psychological symptoms.
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Perhaps surprisingly, eating in response to positive emotions was not significantly related
2
to poorer psychological well-being, greater eating disorder symptoms, or emotion dysregulation.
3
Despite a recent interest in the presence of eating triggered by positive emotions, very little
4
research has been done to examine its relationship to negative outcomes. Our findings are
5
somewhat in contrast to a previous study which showed that eating in response to positive
6
emotions was associated with disordered eating symptoms, but to a lesser degree than was eating
7
in response to negative emotions.33 In the current study, eating in response to positive emotions
8
was unrelated to negative psychological factors, suggesting that adults with overweight/obesity
9
who eat in response to positive emotions exclusively may not experience additional, problematic
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psychological symptoms. Of note, the Sultson study33 included a broad sample of women, not
11
restricted by weight, which may explain the differing results. Relatedly, some authors have
12
suggested that eating triggered by positive emotions is a separate construct than eating triggered
13
by negative emotions.49 In the present sample, positive emotional eating was related to boredom
14
eating but unrelated to eating in response to depression or anxiety/anger.
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Contrary to our hypothesis, none of the types of emotional eating were associated with poorer physical health in our sample of adults with overweight/obesity. Despite this, as
17
expected, greater BMI was significantly associated with physical health impairment.
18
Consequently, this null finding may be explained by the inclusion of a sample of adults with a
19
restricted weight range. Previous studies that used the same physical health measure
20
administered in the current study (i.e., SF-12)46 found that similar physical health functioning
21
was reported among obese non-binge eaters and binge eaters (with and without obesity),50,51 and
22
that these scores were lower than scores obtained from non-obese, non-binge eaters.50 Thus,
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given the health consequences of obesity, it is likely that physical functioning is broadly
2
impaired in this group, regardless of the level of emotional eating.
3
Exploratory analyses suggest possible unique relationships between types of emotional eating and specific facets of emotion regulation. Difficulties engaging in goal-directed behavior
5
emerged as a specific facet of emotion regulation that was associated with eating triggered by
6
depression and boredom. It is possible that when experiencing low intensity negative emotions
7
(e.g., depression, boredom), an inability to attend to alternative, adaptive tasks may increase
8
vulnerability for eating as a strategy for regulating negative affect. Lack of emotional clarity was
9
also uniquely related to eating due to boredom (but not other negative emotions). Thus, when
10
adults with overweight/obesity are feeling bored, confusion about what they are feeling could
11
promote eating. Impulse control difficulties were closely related to the tendency to eat in
12
response to depression and anxiety/anger which suggests that these two types of emotional eating
13
may share an underlying impairment in inhibition. Other facets of emotion regulation (i.e.,
14
nonacceptance of emotional reactions and limited access to emotion regulation strategies) were
15
also related to eating triggered by depression. Few studies have examined how specific aspects
16
of emotion regulation are related to emotional eating. Findings from the present study build
17
upon a previous study that identified limited access to emotion regulation strategies, difficulties
18
engaging in goal-directed behavior, and lack of emotional clarity as the emotion regulation
19
strategies most closely related to emotional overeating (i.e., eating in response to general
20
negative emotions) in a sample of treatment-seeking adults with obesity and binge eating
21
disorder.35 Taken together, findings suggest that certain emotion regulation strategies may be
22
more closely linked to various types of emotional eating. Future research investigations may aim
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to examine whether treatment programs should target and teach specific emotion regulation
2
strategies to different types of emotional eaters.
3
Exploratory analyses also showed that types of emotional eating may be more closely related to specific eating disorder symptoms than others. Similar to the pattern described above,
5
eating triggered by depression was the type of emotional eating most closely associated with
6
several eating disorder symptoms (i.e., concerns about eating, shape, and weight). This provides
7
further evidence that emotional eating triggered by a depressed mood is most indicative of
8
related psychopathology. Additional findings showed that eating in response to boredom was
9
uniquely related to shape concerns, and eating in response to anxiety/anger was uniquely related
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to eating concerns. Thus, although eating triggered by anxiety/anger and boredom are less
11
robustly associated with negative outcomes than eating triggered by feelings of depression, they
12
can be independently associated with disordered eating symptoms.
The current study is limited by a cross-sectional design and reliance on self-report
14
questionnaires that are subject to bias. Recent studies have critiqued the use of self-report
15
measures of emotional eating, suggesting that these scales may not actually be assessing true
16
emotional eating behavior.52 In addition, multiple analyses were conducted in the present study;
17
and, although a Bonferroni was used to determine significance in multivariate analyses, the
18
possibility of Type I error remains, particularly for correlational and exploratory analyses.
19
Furthermore, the current study recruited a general sample of adults with overweight/obesity
20
which may not be representative of emotional eaters who are not overweight/obese or a
21
treatment-seeking sample. Despite its limitations, the current study makes an important
22
contribution to the emotional eating literature by examining correlates of eating in response to
23
discrete emotions. It appears that various types of emotional eating are associated with unique
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psychological factors. Adults who eat in response to feelings of depression, anxiety/anger,
2
boredom, or positive emotions likely have distinct psychosocial characteristics and consequently,
3
may require tailored treatment approaches.
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References
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Table 1. Correlations between types of emotional eating, demographics, and outcome variables Variable 1 2 3 4 5 6 7 8 9 --
2. EE-A
.74***
--
3. EE-B
.61***
.53***
--
4. EE-P
-.04
.06
.23**
--
5. age
-.12
-.04
-.08
.08
--
6. sex
.15*
.07
.15*
-.13
.04
7. income
.02
.08
.04
-.01
.05
8. BMI
.21**
.29***
.13
-.07
.04
9. SCL-90
.57***
.51***
.39***
.02
10. EDE-Q
.54***
.47***
.40***
-.04
11. DERS
.52***
.44***
.45***
12. SF-12
-.11
-.12
-.08
11
12
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1. EE-D
10
--
--
.03
.01
--
.23
.01
-.12
.14
--
-.13
.18
-.08
.13
.45***
--
EP
TE D
.01
-.29***
-.01
.02
.08
.65***
.45***
--
-.02
-.13
-.04
.02
-.22**
-.12
.01
.03
AC C
.07
--
Note. EE-D = depression subscale of the Emotional Eating Scale; EE-A = anxiety/anger subscale of the Emotional Eating Scale; EE-B = boredom subscale of the Emotional Eating Scale; EE-P = positive emotions subscale of the Emotional Appetite Questionnaire; SCL90 = Symptom Checklist-90-revised; EDE-Q = Eating Disorders Examination Questionnaire; DERS = Difficulties in Emotion Regulation Questionnaire; SF-12 = Short-Form Health Survey. * p <.05; ** p < .01; *** p < .001
ACCEPTED MANUSCRIPT 29
Table 2. Regression analysis examining associations between types of emotional eating and global psychological well-being (SCL-90) Variable
B
SE B
.02
.01
BMI
.01
.01
EE-D
.03
.01
EE-A
.02
.01
EE-B
.01
.01
Β
.02
M AN U
Step 2
.16
.40*
SC
BMI
RI PT
Step 1
.18
.09
AC C
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Note. EE-D = depression subscale of the Emotional Eating Scale; EE-A = anxiety/anger subscale of the Emotional Eating Scale; EE-B = boredom subscale of the Emotional Eating Scale * Significant based on Bonferroni correction alpha level of 0.004.
ACCEPTED MANUSCRIPT 30
Table 3. Regression analysis examining associations between types of emotional eating and eating disorder symptoms (EDE-Q) Variable
B
SE B
.02
.01
BMI
-.01
.01
EE-D
.05
.01
EE-A
.02
.01
EE-B
.02
.01
β
-.01
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Step 2
.12
.36*
SC
BMI
RI PT
Step 1
.10
.12
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Note. EE-D = depression subscale of the Emotional Eating Scale; EE-A = anxiety/anger subscale of the Emotional Eating Scale; EE-B = boredom subscale of the Emotional Eating Scale * Significant based on Bonferroni correction alpha level of 0.004.
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Table 4. Regression analysis examining associations between types of emotional eating and emotion regulation (DERS) Variable
B
SE B
.31
.27
BMI
-.17
.24
EE-D
.89
.27
EE-A
.41
.34
EE-B
.65
.25
Β
-.04
M AN U
Step 2
.08
.32*
SC
BMI
RI PT
Step 1
.12
.20
AC C
EP
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Note. EE-D = depression subscale of the Emotional Eating Scale; EE-A = anxiety/anger subscale of the Emotional Eating Scale; EE-B = boredom subscale of the Emotional Eating Scale * Significant based on Bonferroni correction alpha level of 0.004.
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Table 5. Regression analyses examining associations between types of emotional eating and facets of emotion regulation (DERS), after controlling for BMI
Goals
Impulse
Awareness
Strategies
RI PT
Nonacceptance
Clarity
B
SE B
β
B
SE B
Β
B
SE B
Β
B
SE B
β
B
SE B
Β
B
SE B
β
EE-D
.19
.07
.29**
.18
.06
.33**
.13
.06
.23*
.01
.06
.01
.33
.09
.40***
.07
.05
.17
EE-A
.09
.09
.10
.02
.07
.02
.20
.07
.26**
-.02
-.04
.11
.10
.10
.01
.06
.01
EE-B
.11
.07
.14
.13
.06
.21*
.06
.06
.09
.12
.06
.21
.07
.08
.08
.12
.05
.24*
EE-P
.21
.37
.04
.02
.29
.01
.47
.30
.11
-.55
.30
-.13
.65
.43
.10
-.19
.23
-.06
SC
Variable
TE D
M AN U
.07
AC C
*p < .05, **p < .01, **p <.001.
EP
Note. EE-D = depression subscale of the Emotional Eating Scale; EE-A = anxiety/anger subscale of the Emotional Eating Scale; EE-B = boredom subscale of the Emotional Eating Scale; EE-P = positive emotions subscale of the Emotional Appetite Questionnaire; Nonacceptance = nonacceptance of emotional reactions; Goals = difficulties engaging in goal-directed behavior; Impulse = impulse control difficulties; Awareness = lack of emotional awareness; Strategies = limited access to emotion regulation strategies; Clarity = lack of emotional clarity.
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Table 6. Regression analyses examining associations between types of emotional eating and EDE-Q subscales after controlling for BMI Eating Concerns
Shape Concerns
Weight Concerns
RI PT
Restraint SE B
β
B
SE B
Β
B
SE B
Β
B
SE B
β
EE-D
.02
.02
.09
.07
.02
.42***
.05
.02
.31**
.05
.02
.31**
EE-A
.02
.02
.10
.05
.02
.23**
.03
.02
.12
.02
.02
.10
EE-B
-.01
.02
-.01
.02
.02
.10
.04
.02
.18*
.03
.02
.17
EE-P
-.22
.10
-.17
.08
.08
.06
.11
.09
-.08
-.05
.08
-.04
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Variable B
AC C
EP
TE D
Note. EDE-Q = Eating Disorders Examination Questionnaire; EE-D = depression subscale of the Emotional Eating Scale; EE-A = anxiety/anger subscale of the Emotional Eating Scale; EE-B = boredom subscale of the Emotional Eating Scale; EE-P = positive emotions subscale of the Emotional Appetite Questionnaire. *p < .05, **p < .01, **p <.001.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
34