Emotional eating as a mediator between depression and weight gain
Introduction
Meta-analyses of longitudinal studies suggest that depression and obesity are reciprocally linked, with obesity increasing the risk for depression (Luppino et al., 2010) and depression predicting later weight gain and obesity (Blaine, 2008, Luppino et al., 2010). Depression and obesity are common conditions with severe medical consequences (Alonso et al., 2004, Berghöfer et al., 2008). Because numbers of obesity and depression are still rising (Mathers & Loncar, 2006) there is an urgent need to reduce the incidence of obesity and depression. The exploration of possible underlying mechanisms in the depression-obesity link may provide the key. Here we focus on mechanisms underlying the impact of depressive feelings on subsequent weight gain. Various physiological, psychological and behavioural mechanisms may be involved and in this study three different psychological eating styles are tested as underlying mechanisms.
The first possible mediator of the depression-weight gain link is emotional eating. Emotional eating is eating in response to negative emotions such as depressive feelings. Feeling depressed is normally associated with loss of appetite and subsequent weight loss, however, a depression subtype exists, which is characterized by the a-typical features of increased appetite (American Psychiatric Association, 2013), elevated risk of obesity (Levitan et al., 2012), and subsequent weight gain (Lasserre et al., 2014). Emotional eating may be a marker of this a-typical depression subtype (Kräuchi et al., 1997, Van Strien et al., 2010b), because it shares with this depression subtype the a-typical feature of increased appetite in response to distress.1 There is indeed accumulating evidence from cross-sectional research that the link between atypical depression and obesity is mediated by emotional eating in both sexes (Goldschmidt et al., 2014, Konttinen et al., 2010), and in women (Clum, Rice, Broussard, Johnson, & Webber, 2014). Whether emotional eating also mediates the link between depression and future weight gain has to the best of our knowledge not yet been investigated. The present longitudinal study is therefore the first to investigate whether emotional eating is a possible mediator in the link between depressive feelings and future weight gain.
External eating would also be a good candidate for mediating the depressive feelings-weight gain link. External eating is eating in response to food stimuli such as sight, smell and taste of attractive food regardless of internal feelings of hunger and satiety. Like emotional eating, external eating has been proposed as a marker for a-typical depression (Kräuchi et al., 1997). According to the escape from self-awareness theory of Heatherton and Baumeister (1991), some individuals may narrow their level of attention to the current and immediate stimulus environment (accessible food cues such as snacks) in order to shift the attention away from negative affect. Earlier, a positive relation between depression and external eating was found (Ouwens, van Strien, & van Leeuwe, 2009), whilst external eating in its turn, was found to be associated with increases in body weight (Song, Lee, & Sung, 2014). We are not aware of any published study that tested the possible mediation effect of external eating in the link between depression and future weight. Hence, the current study is the first one to investigate this possibility.
The third possible mediator in the depression-weight gain link is restrained eating. Restrained eating is eating less than desired to maintain or lose body weight. In a classic study by Polivy and Herman (1976), unrestrained eaters showed the typical response to depression, which is weight loss. In contrast, restrained eaters reacted to depression with the a-typical response of weight gain, a finding that was explained by Herman and Polivy (1980) in terms of ‘emotional turmoil’ disrupting the dietary restraint of the restrained eaters (disinhibition effect; see Wallis and Hetherington (2004) for more possible explanations). Mixed results are found with regard to restrained eating and body weight. Restrained eating was found to be associated with increases in body weight three years later in women (Van Strien, Herman, & Verheijden, 2014), but it was not associated with weight gain four years later in patients with Type 2 diabetes (Van Strien et al., 2007). Restrained eating did not mediate the link between depression and body mass index (Clum et al., 2014). However, this was a cross-sectional study including women only. Because of this lack of clarity, it is of interest to investigate the possible mediation effect of restrained eating in a prospective study that includes both men and women.
This study aims at exploring the possible mediation effects of the three eating styles (emotional eating, external eating, and restrained eating) on the link between baseline depression and future weight gain in a sample of Dutch adults by using a longitudinal five-year follow-up design. Because of sex-differences in depression, emotional eating and restrained eating, and because we were interested in finding out whether there would be sex differences in any mediation effects, all analyses were performed separately for the fathers and the mothers.
A potential mediation effect of emotional eating on the association between depressive feelings and future weight gain may be related to genetic predisposition. One important candidate is the serotonin transporter-linked polymorphic region (5-HTTLPR). We have previously shown that adolescents with depressive feelings showed more increase in emotional eating if they carried the 5-HTTLPR genotype that results in lower serotonin activity (s-allele) (Van Strien, van der Zwaluw, et al., 2010). While this increase was found in both sexes in the younger adolescents (mean age: 13 years), this increase was only found in the girls among the older adolescents (mean age: 15 years) (see the discussion section of Van Strien, van der Zwaluw, et al. (2010) for possible explanations of this finding). Additionally, the 5-HTTLPR is well-known to be associated with depression (Caspi et al., 2003, Karg et al., 2011) specifically atypical depression (Willeit et al., 2003). There is also evidence for an association between the 5-HTTLPR s-allele and increased body weight (Sookoian, Gianotti, Gemma, Burgueño, & Pirola, 2008), although this association may be dependent on the individual's affective state (Markus & Capello, 2012). Because the mediation effect might be stronger for carriers of the 5-HTTLPR s-allele than for no carriers of the s-allele, we were additionally interested in whether the 5-HTTLR genotype moderated the potential mediation effect of emotional eating on the depressive feelings-weight gain link.
Section snippets
Participants and procedure
The sample consisted of Dutch parents who participated in the longitudinal Family and Health study (Van der Vorst et al., 2005, Van Strien et al., 2010b). Both at baseline (T1) and at 5-year follow-up (T2), they were visited by trained interviewers who made sure that extensive questionnaires were filled out separately and individually. When all family members had completed the questionnaires, the family received a voucher of 30 Euros. When excluding the two participants with at T1 (2002/2003)
Statistics
The frequencies and Pearson correlations of the variables can be found in Table 1. Emotional eating was significantly associated with depressive feelings in both the fathers and the mothers. Only in the mothers there was a significant positive association between emotional eating on the one hand and BMI at T1 and T2 on the other hand. Both external eating and restrained eating showed a significant positive association with BMI at T1 and T2 in the fathers and the mothers. External eating was
Discussion
The present study demonstrates that emotional eating acts as mediator between depression and future body weight gain in the mothers, but not in the fathers. In neither sex there were mediation effects for external eating or restrained eating. An overall effect between depression and future weight gain was also non-significant in both sexes. The emotional eating mediation effect as found here in a longitudinal setting extends previous findings derived from cross-sectional research that emotional
Conflict of interest
Tatjana van Strien has a copyright and royalty interest in the Dutch Eating Behaviour Questionnaire (DEBQ) and manual.
Role of funding source
This study was supported by the Dutch Organization for Scientific Research (no.400-05-051) and the Radboud University Nijmegen. Funding of Ms Winkens was provided by the European Union FP7 MoodFood Project ‘Multi-country collaborative project on the role of Diet, Food-related behaviour, and Obesity in the prevention of Depression’ (grant agreement no. 613598). Neither organization had any role in the study design, in the collection, analysis and interpretation of data; in the preparation of the
Contributors
Dr van Strien prepared the first draft of the manuscript and supervised the conduction of the analyses. Dr Konttinen conducted the SEM analyses and wrote the statistical analysis and result section. Dr Homberg contributed to the sections of the manuscript related to genes. Dr Engels was responsible for the study design and oversight of the data collection. Ms Winkens was responsible for editing drafts of the manuscript and preparing the manuscript for submission. All authors contributed to and
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