Impact of emotional awareness and parental bonding on emotional eating in obese women

Appetite 59 (2012) 21–26

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Research report

Impact of emotional awareness and parental bonding on emotional eating in obese women Delphine Rommel a,⇑, Jean-Louis Nandrino a, Claire Ducro a, Séverine Andrieux b, François Delecourt c, Pascal Antoine a a b c

URECA EA1059, University Lille North of France, 59653 Villeneuve d’Ascq, France Department of Nutrition, Centre Hospitalier d’Arras, Arras, France Day-unit of Endocrinology & Diabetology, Hôpital Saint Philibert, GHICL, Lille, France

a r t i c l e

i n f o

Article history: Received 10 October 2011 Received in revised form 24 February 2012 Accepted 5 March 2012 Available online 13 March 2012 Keywords: Obesity Emotional awareness Emotional eating Parental bonding

a b s t r a c t This study aimed to: (1) determine whether obese women have deficits in emotional awareness and more frequently use emotional eating to regulate their emotions, (2) assess the impact of emotional awareness on the use of emotional eating, and (3) explore the impact of parental bonding on patient level of emotional awareness. A sample of 94 obese women was compared with 56 control participants. All participants answered questionnaires concerning their eating habits (Dutch Emotional Behavior Questionnaire), emotional awareness (Level of Emotional Awareness Scale) and parental bonding (Parental Bonding Inventory). Obese women exhibited deficits in emotional awareness and used emotional eating as an emotion regulation strategy more often than controls. Regression analyses showed that paternal and maternal overprotection negatively influenced obese patients’ levels of emotional awareness and that emotional awareness positively influenced their emotional eating. Ó 2012 Elsevier Ltd. All rights reserved.

Introduction Stice (1994, 2001) proposed a sociocultural model (the dual pathway model) to explain the development of bulimic behaviors such as compulsive overeating resulting from body dissatisfaction. Stice suggested that patients who suffer from bulimia nervosa or binge eating disorder are characterized by high levels of body dissatisfaction that indirectly influence compulsive overeating via two pathways. Body dissatisfaction results in restrained eating, which creates a risk for overeating according to the restraint eating theory (see Herman & Polivy, 1980). Body dissatisfaction also generates negative emotions that may lead to compulsive overeating as emotion regulation strategy. van Strien, Engels, Leuwe, and Snoek (2005) examined and expanded upon the dual pathway model in clinical and non-clinical samples of female adolescents (see Fig. 1a). Although they did not find a relationship between restrained eating and overeating, they confirmed the impact of negative affect on overeating. Moreover, van Strien et al. (2005) found that the relationship between negative affect and overeating was not direct, but mediated by poor interoceptive awareness. This latter term is defined as a difficulty in recognizing and accurately identifying emotion and the visceral sensations related to hunger and satiety (Bruch, 1973).

⇑ Corresponding author. E-mail address: [email protected] (D. Rommel). 0195-6663/$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.appet.2012.03.006

According to these authors, poor interoceptive awareness is positively correlated with the use of emotional eating (overeating in response to emotional states) and places an individual at risk for overeating and obesity. In fact, emotional eating is related to emotional processing disturbances such as higher levels of alexithymia (van Strien, 2006), decreased emotional clarity (Larsen, van Strien, Eisinga, & Engels, 2006), lower attention to emotion (Moon & Berenbaum, 2009) and poor interoceptive awareness (Ouwens, van Strien, van Leeuwe, & van der Staak, 2009; van Strien, 2006) in the general population. In clinical population, Sim and Zeman (2004) observed poor interoceptive awareness in patients who suffered from bulimia nervosa. Moreover, van Strien, Herman, and Verheijden (2009) found that emotional eating occurred more often in overweight people compared with normal-weight people. The difficulty in differentiating internal states has been studied using various concepts such as interoceptive awareness, attention to emotional states, clarity of emotional states and alexithymia. To assess these competences, professionals typically use self-report questionnaires such as the ‘‘lack of interoceptive awareness’’ dimension on the Eating Disorder Inventory 2 (EDI 2; Garner, 1991), the Trait Meta-Mood Scale (TMMS, Salovey, Mayer, Goldman, Turvey, & Palfai, 1995) and the TAS-20 (Taylor, Bagby, & Parker, 1992). However, these tools are limited because they ask participants to judge their own emotional awareness. In fact, it is paradoxical to ask people with alexithymia, who may be

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Restraint eating Overeating Low body esteem Emotional eating

Interoceptive awareness Negative affect

Fig. 1a. The Stice’s extended model to clinical samples by van Strien et al. (2005).

unaware of their emotional states, to judge their own level of emotional awareness. Lane and Schwartz (1987) and Lane, Quinlan, Schwartz, Walker, and Zeitlin (1990) developed a performancebased instrument, the Level of Emotional Awareness Scale (LEAS), through which people identify their own emotional state as well as the emotional states of others without evaluating their own emotional competencies. One of the advantages of this methodology is that it avoids asking participants to judge their own ability to identify or describe feelings (Parling, Mortazavi, & Ghaderi, 2010; Subic-Warna, Bruder, Thomas, Lane, & Köle, 2005). The first aim of the current study is to explore the levels of emotional awareness among obese people using the LEAS and to assess their use of emotional eating. The second aim is to examine the impact of the level of emotional awareness on emotional eating in obese women. Finally, this study explores the factors that affect patient levels of emotional awareness such as parental bonding. Some studies of patients who suffering from eating disorders have already explored the relationships among family organization, emotional awareness and emotion regulation from a developmental perspective. De Panfilis, Rabbaglio, Rossi, Zita, and Maggini (2003) found a correlation between maternal care and the abilities to self-identify and describe feelings among patients who suffer from an eating disorder, whereas Fukunishi (1998) found the same results in a sample of college students with subclinical eating disorder symptoms. Tasca et al. (2009) found that emotion regulation mediated the relationship between attachment style and eating disorder symptoms. More recently, some studies have found a link between parenting styles and emotional eating (Schuetzmann, Richter-Appelt, Schulte-Markwort, & Schimmelmann, 2008; Snoek, Engels, Janssens, & van Strien, 2007; Topham et al., 2011). Topham et al. (2011) showed that an authoritative parenting style negatively predicted emotional eating among 6- to 8-year-olds. Schuetzmann et al. (2008) also observed a relationship between emotional eating and rejection of parenting in 8- to 11-year-olds. Finally, Snoek et al. (2007) found that parenting style affects adolescent emotional eating. Specifically, emotional eating predominated when adolescents experienced less maternal support, more maternal psychological control and less maternal behavioral control.

Methods

informed that refusing participation would have no effect on the quality of their medical treatment. Fifty-six healthy women were recruited at a university and consented to serve as members of the control group. The control participants were healthy, normal-weight people recruited at a university and in the environment of the investigator. A clinical interview conducted by the psychologist in charge of the study ensured that patients and controls who suffered from neurological disorders, comorbid posttraumatic stress disorders, intellectual deficits, recent histories of drug or alcohol abuse, psychoses or bipolar disorder were excluded from this study. Table 1 provides group characteristics. Measures Patients and controls answer questionnaires concerning eating habits, emotional processes and parental bonding. Eating habits Dutch Eating Behaviour Questionnaire (DEBQ; van Strien, Frijters, Bergers, & Defares, 1986; French translation and validation: Lluch et al., 1996). The DEBQ is a 33-item self-report questionnaire that measures three dimensions: ‘‘restrained eating’’ ‘‘emotional eating’’ and ‘‘external eating’’. These dimensions were also found in the French version of the questionnaire, which has a high internal consistency (‘‘restrained eating’’ a = .91, ‘‘emotional eating’’ a = .96 and ‘‘external eating’’ a = .82). Emotional processes Level of Emotional Awareness Scale (LEAS; Lane et al., 1990; French translation: Berthoz et al., 2000; French validation: Bydlowski et al., 2002). The LEAS is composed of 20 scenarios that involve two people in emotionally evocative situations. Participants respond to two questions: ‘‘How would you feel?’’ and ‘‘How would the other person feel?’’ Their answers are scored according to the emotional value of the words using a glossary. These scenes are designed to elicit four types of emotion (anger, fear, happiness and sadness) at five levels of increasing complexity from bodily sensations to more complex and differentiated emotional states. There

Table 1 Clinical characteristics of the samples. Controls (n = 56) M (SD)

Obese group (n = 94) M (SD)

Controls vs. Obese group t (p)

41.20 (11.28)

1.22 (.23)

BMI

38.64 (13.04) 22.61 (2.26)

39.16 (6.31)

23.07**

Education level

N

N

17 39

43 51

Fisher’s exact test (p) 3.46 (.09)

Participants The sample was composed of obese female patients who sought treatment in a day-unit of a general hospital in Lomme, France, a nutrition unit in Roubaix, France, or a nutrition unit in Arras, France. Of the 130 people who were asked to join the experiment by the physician or the psychologist of the unit, 25 refused because they had difficulty understanding French, were not interested, or both. Eleven people were excluded from the research due to missing data. Thus, 94 patients were included in the final sample. After all participants had been informed of the study objectives, they signed consent forms to voluntarily participate. The patients were

Age

Undergraduate Graduate/ postgraduate BMI, body mass index. p < .001.

**

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are two subscales of emotional awareness: ‘‘emotional awareness for oneself’’ (LEAS self) and ‘‘emotional awareness of others’’ (LEAS other). In addition, there is a global score of emotional awareness (LEAS total). The French translation of this questionnaire has high internal consistency (a = .70).

Parental bonding Parental Bonding Inventory (PBI; Parker, Tupling, & Brown, 1979; French translation and validation: Mohr, Preisig, Fenton, & Ferreo, 1999). The PBI consists of two 25-item self-report questionnaires that assess parental bonding along two dimensions: ‘‘care’’ and ‘‘overprotection’’. The first questionnaire assesses maternal bonding and the second (which is otherwise identical to the first) assesses paternal bonding. Three dimensions were found in the French translation of this questionnaire. The first dimension, ‘‘care’’, is the same as in the original version, but the ‘‘overprotection’’ dimension is divided into two distinct constructs: ‘‘encouragement of behavioral freedom’’ and ‘‘denial of psychological autonomy’’. For the French translation, Cronbach’s a values measuring the internal consistencies of the three subscales were a = .86, .84, and .72 for the ‘‘care’’, ‘‘encouragement of behavioral freedom’’ and ‘‘denial of psychological autonomy’’ subscales, respectively.

Statistical analyses Data were analyzed in three steps using SPSS 20.0. The results section only presents the significant results. First, Student’s t-tests compared obese patients with controls in term of age and body mass index (BMI). Fisher’s exact tests compared obese and control groups with regard to education level. Second, Student’s t-tests compared the obese and control groups with regard to the hypothesis concerning emotional processes. Bonferroni corrections controlled for type-I errors. Thus, the alpha level used was p = .017 for all comparisons. Cohen’s d was used as a measure of effect size for these comparisons. Finally, with regard to the second and third hypotheses, linear regression analyses using the stepwise variable-selection method determined whether emotional awareness predicted emotional eating and whether parental bonding predicted emotional awareness within the obese group (statistical threshold, p = .05).

Table 2 Comparisons between obese participants and controls with regard to emotional dimensions. Controls (n = 56) M (SD)

Obese group (n = 94) M (SD)

Controls vs. Obese group

LEAS Total LEAS Self LEAS Other

58.23 (9.28) 51.45 (10.23) 47.27 (9.89)

51.48 (10.09) 44.67 (11.31) 38.20 (11.48)

4.04** 3.63** 4.86**

0.70 0.63 0.85

DEBQ Rest DEBQ Emo DEBQ Ext

26.96 (8.89) 26.91 (11.04) 26.00 (6.17)

29.25 (8.20) 41.77 (14.30) 26.04 (6.51)

1.60 (.11) 7.12** 0.04 (.97)

– 1.16 –

t (p)

Effect size (d)

Rest, restrained eating; Emo, emotional eating; Ext, external eating. Cohen’s d: 0.20 = small, 0.50 = medium, 0.80 = large. ** p < .001.

Table 3 Regression coefficients predicting emotional eating (DEBQ Emo scores) from emotional awareness (LEAS scores) in obese women. Predictors

DEBQ Emo t

LEAS Total LEAS Self LEAS Other

p

1st regression 2.25 .03 2nd regression 2.61 .01 – –

B (SE)

Adjusted R2

.33 (.15)

.04

.34 (.13) –

.06 –

–: This predictor was excluded because it was not significant in the regression model. Emo, emotional eating.

Predicting emotional eating from emotional awareness The results are presented in Table 3 and Fig. 2. We found a significant positive relationship between the total LEAS score and the emotional eating score, which accounted for 4% of the explained variance in obese patients. Moreover, we found a significant positive relationship between the LEAS self and emotional eating scores, which accounted for 6% of the explained variance in obese patients. These results underline that obese patients with higher levels of emotional awareness of oneself report more emotional eating. Importantly, the level of the emotional awareness of others did not affect the use of emotional eating.

Results Predicting emotional awareness from parental bonding Group characteristics There were no between-group differences with regard to age and education level. As expected, the BMI of the obese group was higher than that of the control group (see Table 1).

Emotional processes Table 2 presents the results concerning emotional processes. Obese patients had lower total LEAS (Cohen’s d = .70), LEAS self (Cohen’s d = .63), and LEAS other scores (Cohen’s d = .85). Obese patients seemed to have more trouble differentiating their own feelings as well as the emotional states of others. Obese patients had a higher ‘‘emotional eating’’ DEBQ score than the control group (Cohen’s d = 1.16). Obese patients reported more emotional eating; that is to say that they used eating as an emotional regulation strategy more often than normal-weight people.

The results are presented in Table 4 and Fig. 2. Maternal overprotection significantly and negatively predicted emotional awareness (especially of oneself) in obese patients, which accounted for 4% of the explained variance. Specifically, high maternal overprotection predicted less emotional awareness in obese patients. This finding was especially true along the ‘‘maternal denial of psychological autonomy’’ dimension, which explained the level of emotional awareness for oneself in obese patients and accounted for 4% of the explained variance. A greater denial of psychological autonomy predicted less emotional awareness for oneself. There was also a significant negative relationship between paternal overprotection and the global LEAS score that accounted for 6% of the explained variance. Moreover, there was a negative relationship between paternal overprotection and the LEAS self and LEAS other scores that accounted for 6% and 4% of the explained variance, respectively. High paternal overprotection predicted less emotional awareness in obese patients. This finding

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Table 4 Regression coefficients predicting emotional awareness (LEAS scores) from parental bonding (PBI scores) in obese women. Predictors

LEAS Total t

PBI Mat. Overprotection PBI Mat. Care PBI Mat. Denial PBI Mat. Encgt PBI Mat. Care PBI Pat. overprotection PBI Pat. Care PBI Pat. Denial PBI Pat. Encgt PBI Pat. Care

1st regression 2.03 – 2nd regression – – – 3rd regression 2.46 – 4th regression – 3.05 –

LEAS Self p

B (SE)

Adjusted R

.05 –

–

.04 –

– – –

– – –

– – –

.016 –

–

– .01 –

.26 (.13)

2

.31 (.13)

– .61 (.20) –

.06 – – .09 –

t

p

5th regression 2.33 .02 – – 6th regression 2.04 0.44 – – – – 7th regression 2.74 .007 – – 8th regression – – 2.54 .013 – –

LEAS Other B (SE)

Adjusted R

.33 (.14)

.05 –

.52 (.25)

.04 – –

.38 (.14)

.07 –

–

– –

– – .58 (.23) –

2

– .06 –

t

p

9th regression – – – – 10th regression – – – – – – 11th regression 2.11 .038 – – 12th regression – – 2.69 .01 – –

B (SE)

Adjusted R2

– –

– –

– – –

– – – .30 (.14)

– – .61 (.23) –

.04 – – .07 –

–: This predictor was excluded because it was not significant in the regression model. Denial, denial of psychological autonomy; Encgt, encouragement of behavioral freedom. The 1st regression concerns the maternal care and overprotection dimensions, the 2nd regression concerns the maternal denial, encouragement and care dimension and so on.

was especially true along the ‘‘paternal encouragement of behavioral freedom’’ dimension, which explained the global level of emotional awareness score, the LEAS self score and the LEAS other score by accounting for 9%, 6% and 7% of the explained variance in obese patients, respectively. Because the ‘‘encouragement of behavioral freedom’’ dimension was reverse scored, the results mean that less paternal encouragement of behavioral freedom predicted less emotional awareness for oneself and others. Discussion This study explored the level of emotional awareness and the use of emotional eating in obese women. Furthermore, it sought to determine whether their levels of emotional awareness affected the use of emotional eating and whether parental bonding partly explained emotional awareness. Emotional awareness and emotional eating First, this study found reduced awareness of their own emotions in obese patients compared with normal-weight people as measured by the LEAS. This finding is consistent with those of previous studies using self-report questionnaires (Golay et al., 1997; Larsen et al., 2006; Pinaquy, Chabrol, Simon, Louvet, & Barbe, 2003). Moreover, obese patients are less able to discriminate the emotional states of others. This result is also consistent with previous studies that have shown that obese patients have greater difficulties in identifying the emotions of others via facial expressions (Baldaro et al., 1998; Cserjési, Vermeulen, Lénárd, & Luminet, 2011) or film sequences (Baldaro et al., 2003). In addition to difficulties in identifying emotions, obese patients use emotional eating to regulate their emotions more often than controls. These observations are consistent with Ganley (1989) who showed that higher levels of emotional eating are observed in obese people, particularly when they experience negative emotions. More recently, Geliebter and Aversa (2003) also observed higher levels of eating behaviors in overweight people compared with normal-weight people when negative emotional states were experimentally induced. Predicting emotional eating from emotional awareness In our sample of obese women, we found that the level of emotional awareness positively and significantly predicted the use of

emotional eating (see Fig. 1b). This finding was unexpected based on the previous literature of clinical samples. Despite the fact that the percentages of explained variance were small in our study, they were significantly different from previous findings that link emotional eating with poor interoceptive awareness (Ouwens et al., 2009; van Strien, 2006; van Strien et al., 2005), increased alexithymia symptoms (van Strien, 2006), reduced emotional clarity (Larsen et al., 2006) and a lower attention to emotions (Moon & Berenbaum, 2009). As previously mentioned, all prior studies were conducted using self-report questionnaires, whereas we used a performance-based instrument. Among our sample of obese patients (who had less emotional awareness than the control group), those with the highest emotional competencies used more emotional eating. Bruch’s (1973) psychosomatic theory and, more recently, the Stice model (1994, 2001) as extended by van Strien et al. (2005) suggest that the use of emotional eating is primarily due to a lack of interoceptive awareness. The absence of this result in our study suggests that other hypotheses explain the use of emotional eating. One can suppose that the predominant use of emotional eating in people who are obese could be explained by a limited repertoire of emotion regulation strategies or the persistent use of one emotion regulation strategy. Whiteside et al. (2007) already reported greater difficulties in accessing emotion regulation strategies, which might affect the presence of compulsive eating behaviors. Spoor, Bekker, van Strien, and van Heck (2007) also suggest that emotional eaters have fewer efficient emotion regulation strategies. We believe conducting additional research on the ability of obese patients to access and efficient emotion regulation strategies is necessary. Predicting emotional awareness from parental bonding Another major result of our study concerns the significant relationship between parental bonding and emotional awareness in obese patients (see Fig. 2). In general, our finding suggests that parental overprotection has a negative impact on the level of emotional awareness. Overprotective parents may induce lower levels of emotional awareness in obese women. Our results, in a sample of obese patients, are not congruent with those of De Panfilis et al. (2003) or Fukunishi (1998), both of whom reported correlations between maternal care and the abilities to self-identify and describe feelings in patients as measured using self-report questionnaires. Our results revealed a specific effect of parental overprotection but not maternal care.

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Restraint eating Overeating Low body esteem Interoceptive awareness

Emotional eating +

Negative affect

Emotional awareness Parental overprotection

Fig. 1b. The impact of parental overprotection on the level of emotional awareness and the use of emotional eating in Stice’s extended model by van Strien et al. (2005).

Parental bonding

Emotional awareness

Emotion regulation strategy

Denial of psychological autonomy Maternal overprotection

.035

Encouragement of behavioral freedom

.061

self

Emotional awareness

Denial of

.044

Emotional eating

others

.063

psychological autonomy Paternal overprotection

.092

.071

Encouragement of behavioral freedom

Fig. 2. The impact of parental bonding on emotional awareness and emotional eating (with adjusted R2). The results presented for the French version of the PBI with three dimensions (Mohr et al., 1999). represents a negative prediction; represents a positive prediction.

A careful inspection of our results regarding the ‘‘overprotection’’ PBI dimension reveals that a maternal denial of psychological autonomy negatively affects the level of emotional awareness, whereas greater amounts of paternal encouragement of behavioral freedom positively affected emotional awareness. Developing further additional research concerning the possible compensation of maternal or paternal behaviors have on their children’s behaviors will be interesting. Obesity research often has focused on the relationship between family structure and emotional eating. Topham et al. (2011) found that parents’ minimizing responses to their first-grade children’s negative emotions predicted emotional eating behaviors in the children. Snoek et al. (2007) found that low levels of maternal support, high levels of psychological control and high levels of behavioral control were related to increased emotional eating in adolescents. This study did not find an immediate impact of family structure on emotional eating in obese adults; rather, we found an indirect relationship mediated by the level of emotional awareness (see Fig. 2). Limitations and perspectives This study has several limitations that should be mentioned. Some authors have underlined the effects of gender (Larsen et al.,

2006), age (Snoek et al., 2007) and eating disorders (van Strien et al., 2005) on emotional processes. Consequently, we chose to study a specific population: women who sought treatment for obesity. Therefore, we cannot generalize these results to obese men or to the general population. Moreover, additional research should examine the impact of anxiety, depression and illness duration on emotional processes in obese patients who seek treatment to confirm our results (Konttinen, Männistö, Sarlio-Lähteenkorva, Silventoinen, & Haukkala, 2010; Luppino et al., 2010), because we did not control these factors. The use of a self-report questionnaire to assess emotional eating is also a limitation that might lead to experimental bias. In fact, studies that have used self-report questionnaires to assess emotional eating are not consistent. On the one hand, Evers, de Ridder, and Adriaanse (2009) and Adriaanse, de Ridder, and Evers (2011) did not find a link between self-report questionnaire responses and their experimental observations. On the other hand, van Strien (2010) supports the use of self-report measures of emotional eating because she found a positive relationship between her experimental observations and the answers to a self-report questionnaire. In addition, van Strien, Herman, Anschutz, Engels, and de Weerth (2012) used a new methodology to add support for the value of self-reported measures of emotional eating in participants with sufficiently extreme emotional eating scores.

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