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Brown KL, Bettencourt AF, Hines AL, Cooper LA, Gudzune KA. Association Between Maladaptive Eating Behaviors Among Black Women and Vicarious Racial Discrimination Following a High-Profile Event. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-01994-2. [PMID: 38578573 DOI: 10.1007/s40615-024-01994-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE Evidence suggests that racial discrimination causes stress among non-Hispanic Black women, and some Black women may cope with exposure to vicarious racial discrimination by engaging in maladaptive eating behaviors. METHODS We examined eating behaviors among Black women (N = 254) before and after Freddie Gray's death while in police custody. Maladaptive eating behaviors were assessed using the three-factor eating questionnaire. Our independent variables included the following: (1) time period and (2) geographic proximity to the event. Three two-way analysis of covariance tests were conducted to assess potential effects of geographic proximity (close, distant), time period in relation to unrest (before, after unrest), and their interaction on emotional eating, uncontrolled eating, and cognitive restraint controlling for participant age. RESULTS There was a statistically significant main effect of proximity to the unrest on emotional eating, F (1, 252) = 5.64, p = .018, and partial η2 = .022 such that women living in close geographic proximity to the unrest reported higher mean levels of emotional eating as compared to those living more distant to the unrest. There was also a borderline statistically significant interaction between geographic proximity and time period on cognitive restraint, F (1, 252) = 3.89, p = .050, and partial η2 = .015. CONCLUSION Our study found a relationship between vicarious racial discrimination and maladaptive eating behaviors among Black women. Future work should examine stress related to vicarious racial discrimination and maladaptive eating behaviors longitudinally.
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Affiliation(s)
- Kristal Lyn Brown
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
- Department of Creative Arts Therapies, College of Nursing and Health Professions, Drexel University, Philadelphia, PA, 19104, USA.
| | - Amie F Bettencourt
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Anika L Hines
- Department of Health Policy, Virginia Commonwealth University School of Population Health, Richmond, VA, USA
| | - Lisa A Cooper
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kimberly A Gudzune
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Rossi AA, Pietrabissa G, Castelnuovo G, Mannarini S. Cognitive restraint, uncontrolled eating, and emotional eating. The Italian version of the Three Factor Eating Questionnaire-Revised 18 (TFEQ-R-18): a three-step validation study. Eat Weight Disord 2024; 29:16. [PMID: 38402372 PMCID: PMC10894126 DOI: 10.1007/s40519-024-01642-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/29/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND The Three Factor Eating Questionnaire-Revised 18 (TFEQ-R-18) is an extensively used questionnaire to measure three transdiagnostic features of eating behavior: cognitive restraint, uncontrolled eating, and emotional eating. OBJECTIVE This research aims to investigate the psychometric properties of the Italian version of the TFEQ-R-18 in three large community samples. METHOD Cross-sectional research designs were employed. In Study 1 (N = 537), an exploratory graph analysis (EGA) was used to examine item clustering within the TFEQ-R-18. In Study 2 (N = 645), a confirmatory factor analysis (CFA) was conducted to test its structural validity. In Study 3 (N = 346), a MANOVA was employed assessing mean differences across eating disorders (e.g., anorexia nervosa, bulimia nervosa, binge eating disorder). RESULTS In Study 1, the EGA accurately identified the three original dimensions of the TFEQ-R-18. Study 2 showed that the Italian TFEQ-R-18 has good fit indexes (CFI = 0.989, RMSEA = 0.064; 90% CI [0.058, 0.070], SRMR = 0.062), and possesses robust psychometric properties. Study 3 reveals distinct, statistically significant differences among eating disorders. CONCLUSION The TFEQ-R-18 proves to be a concise and precise tool for measuring transdiagnostic eating behaviors. Its applicability in the Italian context, supported by robust psychometric properties, suggests its utility for both research and clinical purposes. The findings affirm its potential to inform interventions aimed at enhancing psychological health. LEVEL OF EVIDENCE Level V, descriptive study.
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Affiliation(s)
- Alessandro Alberto Rossi
- Department of Philosophy, Sociology, Education, and Applied Psychology, Section of Applied Psychology, University of Padova, Padua, Italy.
- Center for Intervention and Research on Family studies - CIRF, Department FISPPA, University of Padova, Padua, Italy.
| | - Giada Pietrabissa
- Clinical Psychology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Dipartimento di Psicologia, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Gianluca Castelnuovo
- Clinical Psychology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Dipartimento di Psicologia, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Stefania Mannarini
- Department of Philosophy, Sociology, Education, and Applied Psychology, Section of Applied Psychology, University of Padova, Padua, Italy
- Center for Intervention and Research on Family studies - CIRF, Department FISPPA, University of Padova, Padua, Italy
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Asquith E, Bould K, Catling JC, Day EJ, Holt A. Behaviour regulation and the role of mental health in non-alcoholic fatty liver disease. BMC Gastroenterol 2023; 23:306. [PMID: 37700260 PMCID: PMC10496395 DOI: 10.1186/s12876-023-02941-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND AND AIMS Non-alcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease in wealthy societies, and is responsible for a significant rise in liver morbidity and mortality. Current treatments prioritise lifestyle interventions, predominantly diet and exercise management, but patients frequently fail to make the necessary behavioural adjustments. The current study seeks to identify those factors which influence patients' behaviour with respect to adherence to treatment regimes. METHODS Novel areas of interest were investigated; locus of control, behavioural regulation and a range of mental health measures, due to their links to either poor lifestyle choices or abnormal eating as identified in previous literature. Data was gathered using self-report questionnaires, from 96 participants, who were split into three groups, NAFLD patients, non-NAFLD liver disease patients and healthy controls RESULTS: Data was analysed using a MANOVA, and followed up with a Tukey post-hoc test. Three factors were found to be significant by group; cognitive restraint, uncontrolled eating and SAPAS score (a measure of personality disorders). An association between personality disorders and NAFLD was identified. CONCLUSION It is suggested that NAFLD patients are screened for personality disorders and, if identified, treated prior to the commencement of diet and exercise management.
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Affiliation(s)
- E Asquith
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - K Bould
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - J C Catling
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - E J Day
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - A Holt
- Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham, UK
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Oliveira JPT, do Carmo SG, Aragão BDA, Cunha J, Botelho PB. Meditation practices and their relationship with eating behavior, weight changes, and mental health in adults from different regions of Brazil: A cross-sectional study. Nutrition 2023; 109:111972. [PMID: 36753914 DOI: 10.1016/j.nut.2023.111972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/19/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023]
Abstract
OBJECTIVES This study aimed to evaluate the effect of different meditation practices on eating behavior, changes in body weight, and mental health. METHODS A virtual questionnaire was used to evaluate meditation practices and current and prepandemic weights. The questionnaire comprised specific and validated instruments to evaluate body image (silhouette scale), eating behavior (21-item three-factor eating questionnaire), current sleep quality (Pittsburgh Sleep Quality Index), and anxiety (Beck Anxiety Inventory). Initially, data from all the respondents were assessed (n = 764). Mindfulness was the most common type of meditation practice in most Brazilian regions. RESULTS Lower scores in uncontrolled eating (meditation practitioners = 32.19 ± 19.72 and non-meditation practitioners = 35.17 ± 20.50; P = 0.038) and higher weight loss (meditation practitioners = -0.77 ± 8.44 and non-meditation practitioners = 1.29 ± 6.39; P = 0.013) were observed among those who practiced some type of meditation. To verify the influence of weight, we analyzed the data of individuals who had body mass index ≥25 kg/m²; overweight individuals presented lower uncontrolled eating scores when they practiced meditation. However, no statistical difference was observed between meditation practitioners and non-practitioners when only adequate weight individuals were evaluated. The practice also influenced the perception of body image among men and resulted in lower uncontrolled eating scores on the 21-item three-factor eating questionnaire and greater weight loss during the pandemic among women. Those practicing meditation for >13 mo had a lower final score on the anxiety assessment instrument compared with those practicing for <12 mo (P = 0.002). CONCLUSIONS The findings indicate that the inclusion of meditation practice as part of the management of overweight may reduce dysfunctional eating behaviors and negative emotions, thereby contributing to weight loss, especially in the long term.
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Affiliation(s)
| | - Simone Gonzaga do Carmo
- Department of Nutrition, Faculty of Health Science, University of Brasília, Brasília, Brazil.
| | - Bruna de Almeida Aragão
- Department of Nutrition, Faculty of Health Science, University of Brasília, Brasília, Brazil
| | - Juliana Cunha
- Faculty of Nutrition, Federal University of Goias, Goiânia, GO, Brazil
| | - Patrícia Borges Botelho
- Department of Nutrition, Faculty of Health Science, University of Brasília, Brasília, Brazil
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Colombarolli MS, de Oliveira J, Cordás TA. Craving for carbs: food craving and disordered eating in low-carb dieters and its association with intermittent fasting. Eat Weight Disord 2022; 27:3109-3117. [PMID: 35999438 PMCID: PMC9398050 DOI: 10.1007/s40519-022-01437-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/22/2022] [Indexed: 01/04/2023] Open
Abstract
Studies point to positive outcomes in a diet with reduction of carbohydrates and that the associated practice of intermittent fasting (IF) might increase weight loss. Although dieting might be related to disordered eating, little evidence is available about the role of restrictive carbohydrates diets on disordered eating. This study aimed to explore if doing low-carb (LC) diets was related to disordered eating and if IF would increase these symptoms. The sample comprised university students (n = 682), with a mean age of 22 years old and average BMI of 23.6 kg/m2 (SD = 4.3). Twenty-seven percent (n = 188) of respondents reported doing LC diet in the last three months. Of those, 31% (n = 58) reported doing LC diet combined with periods of IF. Mean scores were compared using parametric tests, and effects size and correlations between variables were calculated. Dieters showed higher levels of binge eating, food cravings, cognitive restraint, cognitive restraint toward carbohydrates when compared to non-dieters. The association of LC and IF was related to an increase in disordered eating, especially binge eating and food cravings, specifically 'Lack of control', 'Thoughts or preoccupation with food,' and 'Guilt from cravings and/or for giving in to them'. These results provide evidence that restrictive carbohydrate diets and IF may increase cognitive restraint and, consequently, food cravings.Level III: Evidence obtained from cohort or case-control analytic studies.
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Affiliation(s)
- Maíra Stivaleti Colombarolli
- Faculty of Philosophy, Sciences and Letters of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
- Department of Psychology, University of Turin, Turin, Italy
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | - Jônatas de Oliveira
- School of Medicine, University of Sao Paulo, São Paulo, Brazil.
- Eating Behavior and Trauma Project (AMBULIM), São Paulo, Brazil.
- Eating Disorders Program (AMBULIM/PROTAD), Institute of Psychiatry of the School of Medicine, University of São Paulo, R. Dr. Ovídio Pires de Campos, 785-Cerqueira César, São Paulo, 05403-010, Brazil.
| | - Táki Athanássios Cordás
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
- Eating Behavior and Trauma Project (AMBULIM), São Paulo, Brazil
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Filippone L, Shankland R, Hallez Q. The relationships between social media exposure, food craving, cognitive impulsivity and cognitive restraint. J Eat Disord 2022; 10:184. [PMID: 36434703 PMCID: PMC9701005 DOI: 10.1186/s40337-022-00698-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Young adults are increasingly exposed to social media and their image/video-based activities. They use these platforms to share images, videos and advice in different fields like food and nutrition with: recipe ideas, nutritional opinions or specific diets. Along with the rise of digital technologies, the prevalence of eating disorders in young adults continues to grow. The present study analyzes the psychological and eating processes through which exposure to social media may lead to the development of food craving and problematic eating behaviors. METHODS A total of 103 young adult men (n = 15) and women (n = 88) answered questionnaires measuring their impulsivity (Barratt Impulsiveness Scale), eating habits (Three-Factor Eating Questionnaire), food craving (Food Cravings Questionnaire-Trait-reduced), and time exposure to social media. RESULTS The results showed two significant serial mediations. We found a correlational link between time exposure to social media and food craving scores. This positive relation is indirectly mediated by cognitive impulsivity. We also found a positive correlation between cognitive impulsivity and food craving scores that was mediated by cognitive restraint. CONCLUSION A better understanding of the existing links between social media, food craving and eating behaviors such as cognitive restraint could help researchers and clinicians to better guide young adults in their use and appropriation of social media food contents.
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Affiliation(s)
- Lisa Filippone
- Laboratoire Développement, Individu, Processus, Handicap, Éducation (DIPHE), Institut de Psychologie, Université Lumière Lyon 2, 5 avenue Pierre Mendès-France, Bron, France.
| | - Rebecca Shankland
- Laboratoire Développement, Individu, Processus, Handicap, Éducation (DIPHE), Institut de Psychologie, Université Lumière Lyon 2, 5 avenue Pierre Mendès-France, Bron, France.,Institut Universitaire de France, Paris, France
| | - Quentin Hallez
- Laboratoire Développement, Individu, Processus, Handicap, Éducation (DIPHE), Institut de Psychologie, Université Lumière Lyon 2, 5 avenue Pierre Mendès-France, Bron, France
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Ehrlicher SE, Chui TK, Clina JG, Ellison KM, Sayer RD. The Data Behind Popular Diets for Weight Loss. Med Clin North Am 2022; 106:739-766. [PMID: 36154698 DOI: 10.1016/j.mcna.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Both scientific evidence and popular diet trends have sought to identify the ideal diet for weight loss with strategies focused on either restricting carbohydrates or fat. While there is a strong physiologic rationale for either carbohydrate restriction or fat restriction to achieve a calorie deficit needed for weight loss, evidence from randomized controlled trials suggest either type of diet is effective for weight loss. The level of adherence, rather than macronutrient content, is the driver of successful weight loss.
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Affiliation(s)
- Sarah E Ehrlicher
- Department of Nutrition Sciences, University of Alabama at Birmingham, Webb 256, 1675 University Boulevard, Birmingham, AL 35294, USA.
| | - Tsz-Kiu Chui
- Department of Nutrition Sciences, University of Alabama at Birmingham, Webb 630, 1675 University Blvd, Birmingham, AL 35294, USA
| | - Julianne G Clina
- Department of Nutrition Sciences, University of Alabama at Birmingham, Webb 630, 1675 University Blvd, Birmingham, AL 35294, USA
| | - Katie M Ellison
- Department of Nutrition Sciences, University of Alabama at Birmingham, Webb 630, 1675 University Blvd, Birmingham, AL 35294, USA
| | - R Drew Sayer
- Department of Nutrition Sciences, University of Alabama at Birmingham, Webb 634, 1675 University Boulevard, Birmingham, AL 35294, USA
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McLean CP, Moeck EK, Sharp G, Thomas NA. Characteristics and clinical implications of the relationship between veganism and pathological eating behaviours. Eat Weight Disord 2022; 27:1881-1886. [PMID: 34786670 DOI: 10.1007/s40519-021-01330-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/29/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Veganism may serve as a socially acceptable means to restrict food intake and disguise pathological eating behaviours. Studies that include vegan participants typically group them with other meat avoiders (e.g., vegetarians), potentially masking risk factors unique to veganism. METHOD We addressed this issue by recruiting two Amazon Mechanical Turk samples of 110 vegan and 118 omnivore participants, with comparable gender composition. We aimed to examine whether vegans showed higher disordered eating than omnivores, and if motives for pursuing a vegan diet impacted disordered eating. We assessed disordered eating using the Eating Attitudes Test, the Eating Disorder Examination-Questionnaire, and the Eating Pathology Symptom Inventory. RESULTS Vegans displayed more pathological eating behaviours than omnivores, which was significantly predicted by cognitive restraint. However, body dissatisfaction levels were higher in omnivores than vegans. Diet motives did not influence vegans' disordered eating. CONCLUSION We propose vegans have high levels of cognitive restraint, possibly due to their intention to avoid animal products. In turn, cognitive restraint subscales in eating disorder measures might be over-pathologising rates of eating disorders in vegans. Future research should monitor the progression of people's eating-related attitudes and behaviours before and after they transition to veganism to establish whether veganism increases the risk of disordered eating, or vice versa. LEVEL OF EVIDENCE IV, cross-sectional study.
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Affiliation(s)
- Courtney P McLean
- Monash Alfred Psychiatry Research Centre, Monash University, Level 4, 607 St Kilda Rd, Melbourne, VIC, 3004, Australia.
| | - Ella K Moeck
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Australia
| | - Gemma Sharp
- Monash Alfred Psychiatry Research Centre, Monash University, Level 4, 607 St Kilda Rd, Melbourne, VIC, 3004, Australia
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Zerón-Rugerio MF, Hernáez Á, Cambras T, Izquierdo-Pulido M. Emotional eating and cognitive restraint mediate the association between sleep quality and BMI in young adults. Appetite 2021; 170:105899. [PMID: 34968561 DOI: 10.1016/j.appet.2021.105899] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 01/08/2023]
Abstract
This cross-sectional study was designed to investigate whether diet quality and eating behaviors could mediate the association between sleep quality and body mass index (BMI) in young adults. For all participants (n = 925; aged 21.4 ± 2.5 years; 77.8% women) we evaluated: BMI, sleep quality, diet quality, and eating behavior dimensions (emotional eating, cognitive restraint, and uncontrolled eating). Linear regression models were used to test associations between exposure and outcome variables. Path analysis was conducted with all potential mediators and covariates entered at the same time. Results showed that emotional eating (β = 0.04 [95% CI: 0.03; 0.06]), cognitive restraint (β = 0.03 [95% CI: 0.01; 0.04]), uncontrolled eating (β = 0.02 [95% CI: 0.01; 0.04]) and diet quality (β = -0.14 [95% CI: 0.19;-0.08]) were significantly associated with sleep quality. Additionally, BMI was significantly associated with PSQI score (β = 0.09 [95% CI: 0.01; 0.17]), emotional eating (β = 0.89 [95% CI: 0.60; 1.18]), and cognitive restraint (β = 1.37 [95% CI: 1.02; 1.71]). After testing for mediation, results revealed that emotional eating and cognitive restraint evidenced a significant mediating effect on the association between sleep quality and BMI. Additionally, diet quality was significantly associated with emotional eating (β = -0.35 [95% CI: 0.56;-0.13]), cognitive restraint (β = 0.53 [95% CI: 0.27; 0.79]), and uncontrolled eating (β = -0.49 [95% CI: 0.74;-0.25]). In conclusion, young adults with poor sleep quality are more likely to deal with negative emotions with food, which, in turn, could be associated with higher cognitive restraint, becoming a vicious cycle that has a negative impact on body weight. Our results also emphasize the role of eating behaviors as determinants of diet quality, highlighting the importance of considering sleep quality and eating behaviors when designing obesity prevention strategies in this population.
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Affiliation(s)
- María Fernanda Zerón-Rugerio
- Department of Nutrition, Food Science and Gastronomy, Campus de l'Alimentació Torribera, University of Barcelona, Av. Prat de la Riba, 171, 08921, Santa Coloma de Gramenet, Barcelona, Spain; INSA-UB, Nutrition and Food Safety Research Institute, University of Barcelona, Av. Prat de la Riba, 171, 08921, Santa Coloma de Gramenet, Barcelona, Spain
| | - Álvaro Hernáez
- Center for Fertility and Health, Norwegian Institute of Public Health, Marcus Thranes Gate 2, 0473, Oslo, Norway; CIBER Physiopathology of Obesity and Nutrition, Instituto de Salud Carlos III, Madrid, Spain; Blanquerna School of Health Sciences, Universitat Ramon Llull, Carrer de Padilla, 326, 08025, Barcelona, Spain
| | - Trinitat Cambras
- Department of Biochemistry and Physiology, School of Pharmacy and Food Science, University of Barcelona, Av. de Joan XXIII, 27-31, 08028, Barcelona, Spain
| | - Maria Izquierdo-Pulido
- Department of Nutrition, Food Science and Gastronomy, Campus de l'Alimentació Torribera, University of Barcelona, Av. Prat de la Riba, 171, 08921, Santa Coloma de Gramenet, Barcelona, Spain; INSA-UB, Nutrition and Food Safety Research Institute, University of Barcelona, Av. Prat de la Riba, 171, 08921, Santa Coloma de Gramenet, Barcelona, Spain.
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Mehak A, Racine SE. 'Feeling fat' is associated with specific eating disorder symptom dimensions in young men and women. Eat Weight Disord 2021; 26:2345-51. [PMID: 33389705 DOI: 10.1007/s40519-020-01074-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/13/2020] [Indexed: 10/22/2022] Open
Abstract
PURPOSE 'Feeling fat,' the somatic experience of having excess body weight that is not fully explained by true adiposity, correlates with eating pathology in clinical and non-clinical samples. It is unknown whether 'feeling fat' more strongly relates to specific eating disorder symptom dimensions that typically characterize anorexia nervosa, bulimia nervosa, and/or binge eating disorder. Understanding the significance of 'feeling fat's relationship with specific eating disorder symptom dimensions-cognitive restraint, dietary restriction, binge eating, and purging-may suggest its relevance to particular forms of eating pathology and elucidate treatment directions for addressing 'feeling fat'. METHODS Questionnaires were completed by 989 undergraduates (54.3% female). RESULTS Path analyses indicated significant associations between feeling fat and all symptom dimensions; these paths were not moderated by gender. The best fitting model was the model including paths from 'feeling fat' to all symptom dimensions; no other model had equivalent fit. CONCLUSION 'Feeling fat' relates to all examined symptoms of eating disorders in a mixed-gender non-clinical population. These results indicate that 'feeling fat' is associated with multiple core symptoms of eating pathology, pointing to 'feeling fat's significance to eating pathology maintenance across the spectrum of eating pathology. Future research should compare the influence of 'feeling fat' on these symptoms in mixed-gender clinical samples. LEVEL OF EVIDENCE Level V, cross-sectional descriptive study.
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Watson P, Le Pelley ME. A meta-analysis of the relationship between eating restraint, impaired cognitive control and cognitive bias to food in non-clinical samples. Clin Psychol Rev 2021; 89:102082. [PMID: 34547636 DOI: 10.1016/j.cpr.2021.102082] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 08/10/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022]
Abstract
AIM Food restriction is argued to be a precursor for unhealthy preoccupation with food, possibly leading to the development of an eating disorder. We updated previous meta-analyses that examined the relationship between eating restraint and deficits in either general or food-related attentional and inhibitory control. We hypothesized that inconsistencies in the literature around eating restraint, impaired cognitive control, impulsivity and cognitive biases for food could be attributed to the scale used to measure eating restraint. METHOD A (preregistered) subgroup meta-analysis examined whether patterns of impaired cognitive control and cognitive bias for food in predominantly healthy (non-clinical) samples differed as a function of the scale used to measure eating restraint. A series of exploratory meta-analyses were carried out for specific attentional bias tasks. In total 57 datasets were included. RESULTS The subgroup analysis did not provide evidence that the relationship between eating restraint and impaired or biased cognitions differed significantly as a function of restraint scale. Heterogeneity across studies was high. When examining specific attentional bias tasks there was no evidence that increased eating restraint was associated with increased attentional bias or distraction by food cues, regardless of which scale was used to measure eating restraint. CONCLUSIONS There is little experimental evidence for the common narrative that increased eating restraint is related to impaired cognitive control generally or increased cognitive bias for food, in non-clinical samples.
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12
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Tang C, Cooper M, Wang S, Song J, He J. The relationship between body weight and dietary restraint is explained by body dissatisfaction and body image inflexibility among young adults in China. Eat Weight Disord 2021; 26:1863-1870. [PMID: 33034869 DOI: 10.1007/s40519-020-01032-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/24/2020] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Eating disorders and obesity are commonly recognized as key public health concerns worldwide. Although rates of obesity and disordered eating have traditionally been lower in China than Western countries, these rates are on the rise. As such, interest is growing in identifying mechanisms that may address these conditions. While associations between body weight and dissatisfaction are well established, burgeoning research aims to examine how these factors are related to dietary restraint and body image inflexibility. This study aimed to explore the possible mediation effect of body dissatisfaction and body image inflexibility between body weight (body mass index) and dietary restraint. Furthermore, we explored how these relationships differed across men and women. METHODS A sample of 1068 young adults (563 females and 505 males) in China participated in the study. Participants completed the Eating Disorder Inventory and Three-Factor Eating Questionnaire as well as the Body Image-Acceptance and Action Questionnaire. RESULTS Results showed that: (1) body dissatisfaction and body image inflexibility fully mediated the relationship between body mass index and dietary restraint; (2) this model fit both genders, although differences were found in the regression coefficients between the mediation model for men and women. CONCLUSION These findings support body image dissatisfaction and inflexibility as mediators of the relationship between body weight and dietary restraint, highlighting these as potential mechanisms for treatment. LEVEL OF EVIDENCE Level III, case-control analytic study.
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Affiliation(s)
- Chanyuan Tang
- School of Humanities and Social Science, Chinese University of Hong Kong, Shenzhen, 518172, China
| | - Marita Cooper
- Eating Disorders Program, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, US
| | - Saihai Wang
- College of Economics and Management, Northeast Forestry University, Harbin, China
| | - Jianwen Song
- School of Humanities and Social Science, Chinese University of Hong Kong, Shenzhen, 518172, China
| | - Jinbo He
- School of Humanities and Social Science, Chinese University of Hong Kong, Shenzhen, 518172, China.
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13
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López-Cepero AA, Mattei J, Frisard C, Riseberg E, Jimenez J, Lemon SC, Rosal MC. Dysfunctional Eating Behaviors and Dietary Intake in Puerto Rico. J Immigr Minor Health 2021; 23:867-870. [PMID: 33733376 DOI: 10.1007/s10903-021-01156-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2021] [Indexed: 11/25/2022]
Abstract
Dysfunctional eating behaviors (DEB: emotional eating (EE), uncontrolled eating (UE) and cognitive restraint (CR)) are prevalent in U.S. Latinos and may influence diet. However, this has not been studied in Puerto Rico (PR). This study documents DEB in PR, and explores associations with diet. Cross-sectional study of adults (n = 92) in Ponce, PR. DEB were measured with the TFEQ-R18-V2. The Block Fat and Fruits and Vegetables Screener measured dietary intake. Analysis included adjusted proportions, means and linear regressions. 76%, 88%, and 87% of participants experienced EE, UE and CR, respectively. EE was associated with calories from fats (β = 1.95, 95% CI 0.40, 3.51) and saturated fats (β = 3.26, 95% CI 0.67, 5.85), and CR with fruits and vegetables (β = 0.69, 95% CI 0.20, 1.19). A large percentage of the sample experienced DEB. EE and CR were associated with dietary intake. Studies are needed to understand associations between DEB, diet and health in PR.
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Affiliation(s)
| | - Josiemer Mattei
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Christine Frisard
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Emily Riseberg
- Department of Community Health, Tufts University, Medford, MA, USA
| | - Julio Jimenez
- Ponce Health Sciences University, Ponce, Puerto Rico, USA
| | - Stephenie C Lemon
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Milagros C Rosal
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
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Buckland NJ, Swinnerton LF, Ng K, Price M, Wilkinson LL, Myers A, Dalton M. Susceptibility to increased high energy dense sweet and savoury food intake in response to the COVID-19 lockdown: The role of craving control and acceptance coping strategies. Appetite 2020; 158:105017. [PMID: 33161044 PMCID: PMC8580210 DOI: 10.1016/j.appet.2020.105017] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/15/2020] [Accepted: 10/31/2020] [Indexed: 01/02/2023]
Abstract
Emerging evidence indicates that for some people, the COVID-19 lockdowns are a time of high risk for increased food intake. A clearer understanding of which individuals are most at risk of over-eating during the lockdown period is needed to inform interventions that promote healthy diets and prevent weight gain during lockdowns. An online survey collected during the COVID-19 lockdown (total n = 875; analysed n = 588; 33.4 ± 12.6 years; 82% UK-based; mostly white, educated, and not home schooling) investigated reported changes to the amount consumed and changes to intake of high energy dense (HED) sweet and savoury foods. The study also assessed which eating behaviour traits predicted a reported increase of HED sweet and savoury foods and tested whether coping responses moderated this relationship. Results showed that 48% of participants reported increased food intake in response to the COVID-19 lockdown. There was large individual variability in reported changes and lower craving control was the strongest predictor of increased HED sweet and savoury food intake. Low cognitive restraint also predicted greater increases in HED sweet snacks and HED savoury meal foods. Food responsiveness, enjoyment of food, emotional undereating, emotional overeating and satiety responsiveness were not significant predictors of changes to HED sweet and savoury food intake. High scores on acceptance coping responses attenuated the conditional effects of craving control on HED sweet snack intake. Consistent with previous findings, the current research suggests that low craving control is a risk factor for increased snack food intake during lockdown and may therefore represent a target for intervention.
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Affiliation(s)
- Nicola J Buckland
- Department of Psychology, University of Sheffield, Cathedral Court, 1 Vicar Lane, Sheffield, S1 2LT, United Kingdom.
| | - Lucy F Swinnerton
- Department of Psychology, University of Sheffield, Cathedral Court, 1 Vicar Lane, Sheffield, S1 2LT, United Kingdom
| | - Kwok Ng
- School of Educational Sciences and Psychology, University of Eastern Finland, 80101, Joensuu, Finland; Physical Activity for Health Research Cluster, Department of Physical Education and Sport Sciences, University of Limerick, Limerick, Ireland
| | - Menna Price
- Department of Psychology, College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, SA2 8PP, United Kingdom
| | - Laura L Wilkinson
- Department of Psychology, College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, SA2 8PP, United Kingdom
| | - Anna Myers
- Sheffield Hallam University, Advanced Wellbeing Research Centre, Olympic Legacy Park, Sheffield, S9 3TU, United Kingdom
| | - Michelle Dalton
- School of Social and Behavioural Sciences, Leeds Trinity University, Horsforth, Leeds, LS18 5HD, United Kingdom
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15
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Strodl E, Wylie L. Childhood trauma and disordered eating: Exploring the role of alexithymia and beliefs about emotions. Appetite 2020; 154:104802. [PMID: 32717292 DOI: 10.1016/j.appet.2020.104802] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/04/2020] [Accepted: 07/11/2020] [Indexed: 11/21/2022]
Abstract
Although often perceived as non-threatening, disordered eating poses a significant risk to physical and psychological wellbeing. Given the modest effectiveness of current interventions, there is a need to identify specific psychological targets for treatment. One risk factor that has long been liked to eating issues is childhood trauma. The present study aimed to clarify the associations between five distinct forms of trauma and three disordered eating behaviours (Cognitive Restraint, Uncontrolled Eating, and Emotional Eating). In addition, it aimed to determine the role of alexithymia and beliefs about emotions in this association. Three hundred and thirty-two participants from the Australian community completed an online questionnaire measuring alexithymia, beliefs about emotions, disordered eating, and childhood trauma. Hierarchical multiple regression analyses were conducted to examine total effects between independent forms of childhood trauma and eating behaviours, followed by bootstrapped confidence intervals to delineate indirect effects. A significant direct association was evidenced between Childhood Emotional Abuse and Cognitive Restraint, in addition to Childhood Sexual Abuse and Emotional Eating. Numerous indirect effects were detected involving the beliefs that emotions are 'Overwhelming and Uncontrollable' and 'Damaging'. Findings indicated that experiences of childhood trauma were associated with disordered eating behaviours through the detection of significant total and/or indirect effects. However, effect sizes of indirect effects (involving beliefs about emotions) were small, suggesting that there are additional factors involved. Further longitudinal research is necessary to determine the causal direction of these findings.
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16
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Nelson TD, James TD, Nelson JM, Johnson AB, Mason WA, Yaroch AL, Espy KA. Associations between specific components of executive control and eating behaviors in adolescence: A study using objective and subjective measures. Appetite 2020; 154:104784. [PMID: 32579972 PMCID: PMC7442726 DOI: 10.1016/j.appet.2020.104784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/24/2020] [Accepted: 06/12/2020] [Indexed: 11/17/2022]
Abstract
A growing literature suggests that executive control (EC; also known as "executive functioning" or "EF") in adolescence may play an important role in the development of key health behaviors, including eating behaviors. However, existing literature has significant limitations in the conceptualization and measurement of EC. The current study aims to address these limitations by employing a multidimensional approach to conceptualizing and measuring adolescent EC, including both objective and subjective measures covering multiple components of EC, and examining links with specific eating behaviors. A community sample of adolescents (N = 208; mean age = 14.5 years) completed a battery of performance-based neuropsychological tasks assessing specific components of EC (i.e., working memory, inhibitory control, flexible shifting), a norm-referenced questionnaire covering problems with specific components of EC in daily life, and a measure assessing key eating behaviors (i.e., uncontrolled eating, emotional eating, cognitive restraint). Objectively-measured adolescent working memory was significantly and uniquely associated with cognitive restraint, with stronger working memory associated with less cognitive restraint. No other associations between performance-based EC tasks and eating behaviors were found. In contrast, using subjective reports of EC, problems with inhibitory control were associated with greater uncontrolled eating, and problems with flexible shifting were associated with greater emotional eating. The results suggest links between specific aspects of EC and specific eating behaviors in adolescence, as well as the potential importance of context for understanding the role of EC in eating behavior. Given evidence that EC is modifiable, the findings have potential implications for novel interventions addressing eating behaviors by targeting EC.
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Affiliation(s)
| | - Tiffany D James
- University of Nebraska-Lincoln, Office of Research and Economic Development, USA
| | - Jennifer Mize Nelson
- University of Nebraska-Lincoln, Department of Psychology, USA; University of Nebraska-Lincoln, Office of Research and Economic Development, USA
| | - Anna B Johnson
- University of Nebraska-Lincoln, Department of Psychology, USA
| | - W Alex Mason
- Boys Town, Child and Family Translational Research Center (formerly the National Research Institute), USA
| | | | - Kimberly Andrews Espy
- University of Texas at San Antonio, Department of Psychology, USA; UT Health San Antonio, Long School of Medicine, Department of Psychiatry and Behavioral Science, USA
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Hindle A, De la Piedad Garcia X, Hayden M, O'Brien PE, Brennan L. Pre-operative Restraint and Post-operative Hunger, Disinhibition and Emotional Eating Predict Weight Loss at 2 Years Post-laparoscopic Adjustable Gastric Banding. Obes Surg 2020; 30:1347-1359. [PMID: 32006239 DOI: 10.1007/s11695-019-04274-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION A principal mechanism of action in bariatric surgery is reduction in calorie consumption due to decreased hunger and increased satiety. Patients' ability to perceive post-operative changes to their hunger is therefore central to optimal results. This study examined factors that may impact how patients perceive post-operative hunger and how perception of hunger impacts eating and subsequent weight loss after laparoscopic adjustable gastric banding (LAGB). METHODS Patients undertaking LAGB (n = 147) provided pre-surgery and 2-year weight loss data and pre-surgery and 12-month psychological data (perception of hunger, disinhibition related to eating, emotional eating). RESULTS Path analysis demonstrated that patients with lower levels of pre-surgery cognitive restraint over eating experienced significantly greater reduction in perception of hunger at 12 months post-surgery. Perceived reduction in hunger was significantly associated with lower levels of both emotional eating and disinhibited eating. Finally, reduced emotional eating at 12 months significantly predicted 9% of the variance in percentage of total weight loss (%TWL) at 2 years after surgery. CONCLUSION These initial findings suggest that preparation for bariatric surgery may be enhanced by psychoeducation regarding cognitive restraint over eating and its effect on hunger perception. In addition, psychological treatment that focuses on identifying and responding to changes in hunger may contribute to improved outcomes for those who have difficulty adjusting to post-operative eating behaviours.
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Affiliation(s)
- Annemarie Hindle
- School of Behavioural and Health Sciences, Australian Catholic University, 115 Victoria Parade, Fitzroy, Victoria, 3065, Australia. .,Centre for Eating, Weight, and Body Image, Suite 215, 100 Victoria Parade, East, Melbourne, Victoria, 3002, Australia.
| | - Xochitl De la Piedad Garcia
- School of Behavioural and Health Sciences, Australian Catholic University, 115 Victoria Parade, Fitzroy, Victoria, 3065, Australia
| | - Melissa Hayden
- Faculty of Health, Deakin University Burwood Melbourne Campus, 221 Burwood Highway, Burwood, 3125, Australia
| | - Paul E O'Brien
- Centre for Obesity Research and Education, The Alfred Centre, Monash University Clinical School, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Leah Brennan
- Centre for Eating, Weight, and Body Image, Suite 215, 100 Victoria Parade, East, Melbourne, Victoria, 3002, Australia.,School of Psychology and Public Health, La Trobe University, Albury-Wodonga Campus, 133 McKoy Street, 3689, Wodonga, Victoria, Australia
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18
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Duarte PAS, Palmeira L, Pinto-Gouveia J. The Three-Factor Eating Questionnaire-R21: a confirmatory factor analysis in a Portuguese sample. Eat Weight Disord 2020; 25:247-56. [PMID: 30168033 DOI: 10.1007/s40519-018-0561-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 08/08/2018] [Indexed: 12/18/2022] Open
Abstract
The Three-Factor Eating Questionnaire (TFEQ) is one of the most widely used instruments to study different eating behaviors. It measures three types of eating behaviors namely: cognitive restraint, uncontrolled eating and emotional eating. The present study aims to evaluate the factor structure and reliability of the Portuguese version of the TFEQ-R21, using a confirmatory factor analysis (CFA). The sample includes 468 participants from the general population, with ages ranging from 18 to 60 years. Results from the CFA confirmed the TFEQ-R21 three-factor structure and the model revealed an acceptable fit to the data (χ2(186) = 443.211, p < 0.001; χ2/df = 2.329; CFI = 0.933; TLI = 0.925; RMSEA = 0.054; SMRS = 0.053). Multi-group analysis results support strong measurement invariance across genders. Furthermore, all three dimensions presented adequate psychometric properties. Overall, results support that the Portuguese version of the TFEQ-R21 is a useful, reliable and robust instrument to assess relevant eating behaviors.Level of evidence V, descriptive studies.
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19
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Paans NPG, Bot M, Brouwer IA, Visser M, Roca M, Kohls E, Watkins E, Penninx BWJH. The association between depression and eating styles in four European countries: The MooDFOOD prevention study. J Psychosom Res 2018; 108:85-92. [PMID: 29602330 DOI: 10.1016/j.jpsychores.2018.03.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/07/2018] [Accepted: 03/07/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Depression, one of the most prevalent and disabling disorders in Europe, is thought to be associated with unhealthy eating styles. As prevalence of depression and eating styles potentially differ across Europe, the current study aimed to investigate in a large, European sample, the associations of history of major depressive disorder and depression severity with unhealthy eating styles. METHODS Baseline data of the MooDFOOD prevention study was used. The current analysis included 990 participants of four European countries (The Netherlands, United Kingdom, Germany, Spain). Analyses of Covariance and linear regression analyses were performed with depression history or depression severity as determinants, and emotional, uncontrolled, and cognitive restrained eating (Three Factor Eating Questionnaire Revised, 18 item) as outcomes. RESULTS Depression history and severity were associated with more emotional and uncontrolled eating and with less cognitive restrained eating. Mood, somatic, and cognitive symptom clusters were also associated with more emotional and uncontrolled eating, and with less cognitive restrained eating. The somatic depressive symptoms "increased appetite" and "increased weight" were more strongly associated to unhealthy eating styles compared to other symptoms. No differences in associations between depression and unhealthy eating were found between European countries. CONCLUSION Our results suggest that depression is related to more unhealthy eating styles. Diminishing unhealthy eating styles in subthreshold depressed persons could potentially reduce adverse health consequences like weight gain, unhealthy dietary patterns and weight-related diseases. It is also possible that interventions that decrease depressive symptoms can lead to a decrease in unhealthy eating styles.
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Affiliation(s)
- Nadine P G Paans
- Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands.
| | - Mariska Bot
- Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Ingeborg A Brouwer
- Department of Health Sciences, Faculty of Earth and Life Sciences, Amsterdam Public Health Research Institute, VU University, Amsterdam, The Netherlands
| | - Marjolein Visser
- Department of Health Sciences, Faculty of Earth and Life Sciences, Amsterdam Public Health Research Institute, VU University, Amsterdam, The Netherlands; Department of Internal Medicine, Nutrition and Dietetics, VU University Medical Center, Amsterdam Public Health Research Institute, VU University, Amsterdam, The Netherlands
| | - Miquel Roca
- Institut Universitari d' Investigació en Ciències de la Salut (IUNICS/IDISPA), Rediapp, University of Balearic Islands, Carretera de Valldemosssa km 7,5, Palma de Mallorca 07071, Spain
| | - Elisabeth Kohls
- Department of Psychiatry and Psychotherapy, University Leipzig, Medical Faculty, Leipzig, Germany
| | - Ed Watkins
- Department of Psychology, University of Exeter, Exeter, UK
| | - Brenda W J H Penninx
- Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
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20
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Berg AC, Johnson KB, Straight CR, Reed RA, O'Connor PJ, Evans EM, Johnson MA. Flexible Eating Behavior Predicts Greater Weight Loss Following a Diet and Exercise Intervention in Older Women. J Nutr Gerontol Geriatr 2018; 37:14-29. [PMID: 29494790 DOI: 10.1080/21551197.2018.1435433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Eating behaviors (cognitive restraint, flexible and rigid restraint, disinhibition, hunger) have been associated with obesity and weight loss success in middle-aged individuals, but little is known about these relationships in older adults. This study examined relationships between eating behaviors and weight loss in overweight/obese older women (n = 61; 69 ± 3.6 years; body mass index = 31.1 ± 5.0 kg/m2) completed a 6-month behavioral weight loss intervention. Baseline, postintervention, and change measures of eating behaviors (51-items Three-Factor Eating Questionnaire) were assessed for relationships with weight loss. In the final regression model, an increase in flexible restraint accompanied by a decrease in rigid restraint predicted greater weight loss (adjusted R2 = 0.21, Model F (4, 56) = 4.97, P < 0.01). No associations were found with disinhibition or hunger and degree of weight loss (all P > 0.05). Results suggest encouraging a flexible approach to eating behavior and discouraging rigid adherence to a diet may lead to better intentional weight loss for overweight and obese older women.
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Affiliation(s)
- Alison C Berg
- a Department of Foods and Nutrition , University of Georgia , Athens , Georgia , USA
| | - Kristen B Johnson
- a Department of Foods and Nutrition , University of Georgia , Athens , Georgia , USA
| | - Chad R Straight
- b Department of Kinesiology , University of Georgia , Athens , Georgia , USA
| | - Rachelle A Reed
- b Department of Kinesiology , University of Georgia , Athens , Georgia , USA
| | - Patrick J O'Connor
- b Department of Kinesiology , University of Georgia , Athens , Georgia , USA
| | - Ellen M Evans
- b Department of Kinesiology , University of Georgia , Athens , Georgia , USA
| | - Mary Ann Johnson
- a Department of Foods and Nutrition , University of Georgia , Athens , Georgia , USA.,c Department of Health Policy and Management , University of Georgia, Athens , Georgia , USA
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Aguirre TM, Kuster JT, Koehler AE. Relationship Between Eating Behavior and Dietary Intake in Rural Mexican-American Mothers. J Immigr Minor Health 2017; 19:225-7. [PMID: 26660483 DOI: 10.1007/s10903-015-0324-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We used Spearman's rho correlations and descriptive statistics (α = 0.05) to explore relationships between maternal eating behaviors (disinhibition, cognitive restraint, and susceptibility to hunger) and frequency of consumption of specific food groups (dairy, fruits, vegetables, meats) in a rural Mexican-American population. Analyses were based on the mothers' responses to the Three Factor Eating Questionnaire and Willett's Food Frequency Questionnaire. Cognitive restraint was associated with greater frequency of consumption of vegetables, whereas disinhibition was associated with less frequent consumption of fruit. Susceptibility to hunger may have indirectly influenced the latter by enhancing the level of disinhibition. Mean frequency of consumption of vegetables (1-3 times per month) and fruits (once per week) was less than Healthy People 2020 targets. Additional research is needed to better understand factors contributing to these eating behaviors and patterns. To do so will require developing diet assessment tools that reflect foods typically consumed by this population.
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Coniglio KA, Becker KR, Franko DL, Zayas LV, Plessow F, Eddy KT, Thomas JJ. Won't stop or can't stop? Food restriction as a habitual behavior among individuals with anorexia nervosa or atypical anorexia nervosa. Eat Behav 2017; 26:144-7. [PMID: 28388511 DOI: 10.1016/j.eatbeh.2017.03.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/13/2017] [Accepted: 03/21/2017] [Indexed: 11/20/2022]
Abstract
Food restriction among individuals with anorexia nervosa (AN) is regarded as a goal-directed behavior. However, Walsh (2013) theorized that, although restriction is initially maintained by operant conditioning (with successful weight loss and external praise as salient rewards), it ultimately becomes a classically conditioned habit, persisting regardless of the presence of these once-salient rewards. Understanding food restriction as a well-ingrained habit may provide insight into treatment resistance. Further, it is not clear whether habitual food restriction is present among individuals with atypical AN (i.e. who engage in food restriction but are not low-weight). This study evaluated whether strength of habit predicted self-reported restriction above and beyond cognitive restraint. Seventy-eight individuals with AN or atypical AN completed the Eating Pathology Symptoms Inventory Restriction (EPSI-R) and Cognitive Restraint (EPSI-CR) subscales and the Self-Report Habit Index (SRHI) adapted for food restriction. We used a hierarchical multiple regression model to test whether habit strength predicted food restriction above and beyond cognitive restraint. After adding illness duration (step 1) and diagnosis (step 2) to the model, cognitive restraint (step 3) was not significant in explaining variation in restriction, whereas adding habit strength to the model (step 4) explained 27.9% of the variance in restriction (p<0.001). This is the first study to test a key component of Walsh's theory. Results provide support for food restriction maintenance through habit, rather than through effortful cognitive restraint. Because current models of AN characterize food restriction as purposeful, further research is needed to better understand habitual restriction in AN.
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Rocks T, Pelly F, Slater G, Martin LA. Prevalence of Exercise Addiction Symptomology and Disordered Eating in Australian Students Studying Nutrition and Dietetics. J Acad Nutr Diet 2017; 117:1628-1636. [PMID: 28551315 DOI: 10.1016/j.jand.2017.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 04/03/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Previous research has reported the existence of disordered eating in students studying nutrition and dietetics. However, the occurrence of exercise addiction, previously linked to disordered eating, is poorly understood in this group. OBJECTIVE The main objective of this study was to explore the prevalence of self-reported symptoms of exercise addiction and the association with disordered eating in a sample of students studying nutrition and dietetics. A secondary objective was to compare the prevalence of exercise addiction to students enrolled in another health-related degree. DESIGN We conducted a cross-sectional study in 165 undergraduate students. PARTICIPANTS/SETTING Participants were students of both sexes enrolled in nutrition and dietetics and occupational therapy degree programs at an Australian university in August 2013. MAIN OUTCOME MEASURES Participants completed four validated questionnaires for assessment of exercise- and eating-related attitudes and behaviors measuring scores for exercise addiction, weekly volume of physical activity (PA), eating disorder symptoms, and cognitive restraint. Stretch stature and body mass were measured and body composition was assessed using dual energy x-ray absorptiometry. STATISTICAL ANALYSES PERFORMED Independent t test, Mann-Whitney U test, and χ2 test were completed to compare groups of students based on sex, degree, or eating attitudes. Spearman's correlation was performed to explore associations between continuous variables (exercise addiction scores, PA volume, and scores for eating attitudes and cognitive restraint). RESULTS Approximately 23% of nutrition and dietetics students were found to be at risk of exercise addiction (20% females and 35% males; P=0.205), while the majority demonstrated some symptoms of exercise addiction. A similar proportion of at risk individuals was found in the female occupational therapy group (19%; P=1.000). In females (nutrition and dietetics and occupational therapy combined), the exercise addiction scores were associated with three other outcome measures: PA volume (rs=0.41; P<0.001), eating attitudes scores (rs=0.24; P=0.008), and cognitive restraint (rs=0.32; P<0.001). Comparative analysis indicated that female students with high cognitive restraint had greater exercise addiction scores than those with low cognitive restraint (20.3 [4.8] compared to 17.8 [4.2]; P=0.003). CONCLUSIONS Results suggest high prevalence of exercise addiction in this sample of undergraduate health-related degree students and its link to amount of PA and disordered eating in females. Future research should include larger samples of both sexes to build the existing understanding on these maladaptive behaviors.
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Rocks T, Pelly F, Slater G, Martin LA. The relationship between dietary intake and energy availability, eating attitudes and cognitive restraint in students enrolled in undergraduate nutrition degrees. Appetite 2016; 107:406-414. [PMID: 27567549 DOI: 10.1016/j.appet.2016.08.105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 08/18/2016] [Accepted: 08/18/2016] [Indexed: 12/13/2022]
Abstract
The aim of this research was to explore the relationship of total energy and macronutrient intake, energy balance and energy availability to eating attitudes and cognitive restraint in students enrolled in undergraduate nutrition degrees. Energy and micronutrient intake was assessed in 63 students (n = 50 nutrition, and n = 13 occupation therapy degrees; n = 51 females, n = 12 males) using three 24-h dietary recalls. Energy requirements were calculated based on measured resting metabolic rate, estimated exercise energy expenditure, and dietary induced thermogenesis. Body composition was assessed using dual energy x-ray absorptiometry. Eating attitudes and cognitive restraint were measured using previously validated tools. Eighteen percent of nutrition students were classified as having low energy availability (<30 kcal kgFFM-1d-1) and 38% were in negative energy balance. Eating attitudes and cognitive restraint were not associated with total energy or macronutrient intake. However, female nutrition students with high cognitive restraint had greater exercise energy expenditure and thus lower energy availability than those with low cognitive restraint (371 (302) kcal d-1 compared to 145 (206) kcal d-1, P < 0.01, and 35 (7) kcal d-1 compared to 41 (10) kcal d-1 of fat free mass, P = 0.005). Additionally, in females, disordered eating attitudes and cognitive restraint negatively correlated with energy availability (rs = -0.37, P = 0.02 and rs = -0.51, P < 0.01 respectively). There were no differences in outcomes between nutrition and non-nutrition students. The current study suggests that those students with disordered eating attitudes and cognitive restraint may be controlling their energy balance through exercise, as opposed to restricting food intake.
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Affiliation(s)
- Tetyana Rocks
- School of Health and Sport Sciences, Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Maroochydore DC, Queensland, 4558 Australia.
| | - Fiona Pelly
- School of Health and Sport Sciences, Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Maroochydore DC, Queensland, 4558 Australia.
| | - Gary Slater
- School of Health and Sport Sciences, Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Maroochydore DC, Queensland, 4558 Australia.
| | - Lisa Anne Martin
- School of Health and Sport Sciences, Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Maroochydore DC, Queensland, 4558 Australia.
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Ernst B, Wilms B, Thurnheer M, Schultes B. Eating behaviour in treatment-seeking obese subjects - Influence of sex and BMI classes. Appetite 2015; 95:96-100. [PMID: 26145273 DOI: 10.1016/j.appet.2015.06.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 06/25/2015] [Accepted: 06/27/2015] [Indexed: 10/23/2022]
Abstract
Obese subjects frequently show an adversely altered eating behaviour. However, little is known on differences in eating behaviour across different degree of obesity. We analysed data on the three factor eating questionnaire assessing cognitive restraint, disinhibition, and hunger that were filled in by 664 obese patients (469 women) who seeked treatment in our Interdisciplinary Obesity Center. Patients were divided in five BMI classes (30 - <35 kg/m(2), 35 - <40 kg/m(2), 40 - <50 kg/m(2), and >50 kg/m(2)). Multivariate regression analyses revealed that sex was significantly related to all three eating behaviour traits (all P < 0.042) but no significant relation to BMI (as a continuous variable) was observed. Women in comparison to men showed significantly higher cognitive restraint (9.7 ± 4.3 vs. 7.7 ± 4.4; P < 0.001) and disinhibition (9.0 ± 3.5 vs. 7.7 ± 3.5; P < 0.001) scores and also showed higher hunger scores (6.9 ± 3.7 vs. 6.3 ± 3.5; P = 0.042). Analyses on different BMI classes revealed that cognitive restraint decreased (P = 0.016) while disinhibition (P = 0.010) and hunger (P = 0.044) increased independently of sex with increasing BMI classes. However, above the obesity grade I class (i.e. BMI 30 - < 35 kg/m(2)) there were no differences in eating behaviour variables between the remaining BMI classes. Data indicate profound differences in eating behaviour between women and men that persist across a wide range of obesity. Furthermore, data suggest that while grade I obese patients show higher cognitive restraint and less disinhibition and hunger scores than more severe obese patients these dimensions of eating behaviour do not systematically vary across higher BMI classes.
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Affiliation(s)
- Barbara Ernst
- eSwiss Medical & Surgical Center, Interdisciplinary Obesity Center, CH-9016 St. Gallen, Switzerland
| | - Britta Wilms
- Exercise Physiology Lab, Institute of Human Movement Sciences and Sport, ETH Zurich, Zurich, Switzerland
| | - Martin Thurnheer
- eSwiss Medical & Surgical Center, Interdisciplinary Obesity Center, CH-9016 St. Gallen, Switzerland
| | - Bernd Schultes
- eSwiss Medical & Surgical Center, Interdisciplinary Obesity Center, CH-9016 St. Gallen, Switzerland.
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Löffler A, Luck T, Then FS, Luppa M, Sikorski C, Kovacs P, Tönjes A, Böttcher Y, Breitfeld J, Horstmann A, Löffler M, Engel C, Thiery J, Stumvoll M, Riedel-Heller SG. Age- and gender-specific norms for the German version of the Three-Factor Eating-Questionnaire (TFEQ). Appetite 2015; 91:241-7. [PMID: 25889877 DOI: 10.1016/j.appet.2015.04.044] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 03/04/2015] [Accepted: 04/08/2015] [Indexed: 11/17/2022]
Abstract
The 'Fragebogen zum Essverhalten' (FEV) is the German version of the Three-factor-Eating-Questionnaire (TFEQ). This questionnaire covers three domains of eating behaviour ('cognitive restraint', 'disinhibition' and 'hunger') as well as common problems (e.g. craving for sweets). So far, there is a lack of normative data of the FEV especially for the middle-aged and older population. Aim of this study therefore was to provide age- and gender-specific norms of the FEV for the general population aged 40-79 years. We studied 3144 participants of the ongoing large community-based Leipzig Research Center for Civilization Diseases (LIFE) Health Care Study. We provided age- (four age groups: 40-49, 50-59, 60-69, and 70-79 years) and gender-specific percentile ranks and T-scores for the three domains of the FEV as well as age- and gender-specific frequencies of the common problems in eating behaviour. Females scored significantly higher than males in all three domains of the FEV (p < 0.001). Older individuals showed significantly higher mean scores than the younger ones in the domain of cognitive restraint, but lower mean scores in disinhibition and hunger (p < 0.001). 45.1% of the males and 69.9% of the females reported specific problems in eating. The main problem in both genders was craving for sweets (38.6%). Eating in response to stress was mostly reported in younger individuals. The present study offers current normative data for the FEV in the middle-aged and older general population that can be applied in clinical and non-clinical settings. Information on eating behaviour can be helpful in understanding body weight modulation, and thus, may help to improve interventive and preventive programmes for overweight, obesity, and eating disorders.
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Affiliation(s)
- Antje Löffler
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Philipp-Rosenthal-Str. 55, Leipzig 04103, Germany; LIFE-Leipzig Research Center for Civilization Diseases, Universität Leipzig, Philipp-Rosenthal-Straße 27, Leipzig 04103, Germany.
| | - Tobias Luck
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Philipp-Rosenthal-Str. 55, Leipzig 04103, Germany; LIFE-Leipzig Research Center for Civilization Diseases, Universität Leipzig, Philipp-Rosenthal-Straße 27, Leipzig 04103, Germany
| | - Francisca S Then
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Philipp-Rosenthal-Str. 55, Leipzig 04103, Germany; LIFE-Leipzig Research Center for Civilization Diseases, Universität Leipzig, Philipp-Rosenthal-Straße 27, Leipzig 04103, Germany
| | - Melanie Luppa
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Philipp-Rosenthal-Str. 55, Leipzig 04103, Germany
| | - Claudia Sikorski
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Philipp-Rosenthal-Str. 55, Leipzig 04103, Germany; Leipzig University Medical Center, IFB Adiposity Diseases, University of Leipzig, Liebigstraße 21, Leipzig 04103, Germany
| | - Peter Kovacs
- Leipzig University Medical Center, IFB Adiposity Diseases, University of Leipzig, Liebigstraße 21, Leipzig 04103, Germany
| | - Anke Tönjes
- Leipzig University Medical Center, IFB Adiposity Diseases, University of Leipzig, Liebigstraße 21, Leipzig 04103, Germany
| | - Yvonne Böttcher
- Leipzig University Medical Center, IFB Adiposity Diseases, University of Leipzig, Liebigstraße 21, Leipzig 04103, Germany
| | - Jana Breitfeld
- Leipzig University Medical Center, IFB Adiposity Diseases, University of Leipzig, Liebigstraße 21, Leipzig 04103, Germany
| | - Annette Horstmann
- Max Planck Institute for Human Cognitive and Brain Sciences, Stephanstraße 1a, Leipzig 04103, Germany
| | - Markus Löffler
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Härtelstraße 16-18, Leipzig 04107, Germany
| | - Christoph Engel
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Härtelstraße 16-18, Leipzig 04107, Germany
| | - Joachim Thiery
- Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig, Liebigstraße 27 b, Leipzig 04103, Germany
| | - Michael Stumvoll
- Leipzig University Medical Center, IFB Adiposity Diseases, University of Leipzig, Liebigstraße 21, Leipzig 04103, Germany
| | - Steffi G Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Philipp-Rosenthal-Str. 55, Leipzig 04103, Germany
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Abstract
Alcoholic beverages have long been associated with feasts, celebration and marking special events. Today, it is commonplace to consume alcoholic beverages before, with and/or after a meal. Alcohol provides additional pleasure to the meal and enhances appetite. However, consuming an alcoholic beverage with or before a meal is associated with poor short-term energy compensation; energy from alcohol is additive to total energy intake with the added property of stimulating further eating. Limiting alcohol intake is an obvious means to reduce total energy intake for those who wish to lose weight. However, dieters and restrained eaters drink more and report greater binge drinking than unrestrained eaters despite employing cognitive strategies to reduce their intake. Increased intake may be attributable to greater attentional bias to alcohol related cues as well as to food cues, since these are more salient to those limiting intake. Alcohol increases energy intake in dieters, in part due to abandonment of restraint (disinhibition) and consumption of forbidden items including alcohol exacerbates attempts to resist temptation. Paradoxically, links between binge drinking or increased drinking frequency to overweight and obesity may be mediated by dietary restraint. Efforts to limit food and alcohol intake for weight control appear to be unsuccessful and have the net effect of promoting overconsumption. The potential role of restrained eating in the association between alcohol, appetite and obesity has been overlooked by much of the current research and further investigation of this is therefore warranted.
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Affiliation(s)
- Samantha J Caton
- School of Health and Related Research, University of Sheffield, S1 4DA, Sheffield, UK.
| | - Laurence J Nolan
- Department of Psychology, Wagner College, Staten Island, NY, 10301, USA
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Rieber N, Giel KE, Meile T, Enck P, Zipfel S, Teufel M. Psychological dimensions after laparoscopic sleeve gastrectomy: reduced mental burden, improved eating behavior, and ongoing need for cognitive eating control. Surg Obes Relat Dis 2012; 9:569-73. [PMID: 22784946 DOI: 10.1016/j.soard.2012.05.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 05/02/2012] [Accepted: 05/24/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Obesity as a chronic disease has spread worldwide. Conservative treatment, especially with severe obesity, often fails. Obesity surgery has been shown to be an effective treatment. Laparoscopic sleeve gastrectomy (LSG), as a restrictive procedure, has low risks and results in good weight loss outcomes. However, to date, no studies have investigated the changes in psychological dimensions-especially concerning eating behavior and cognitive restraint-after LSG. The present study investigated, for the first time, eating behavior (cognitive restraint, disinhibition, hunger), depression, and perceived stress before and 1 year after LSG. The setting was a university hospital, comprehensive obesity center. METHODS Of 59 patients who had undergone LSG from 2008 to 2010, 40 patients were evaluated using questionnaires on eating behavior, depression, and stress, with measurements made before and 1 year after surgery. RESULTS The body mass index had decreased, on average, by 15.5 kg/m(2) 1 year after LSG (62.7% excess weight loss). The eating behaviors had changed, with patients experiencing less hunger, fewer food cravings, and decreased disinhibition. Depressive symptoms and perceived stress improved. However, the results showed high levels in the dimension of cognitive restraint of eating 1 year after LSG. CONCLUSIONS Most psychological dimensions improved as expected. The patients were less distracted by food, experienced less hunger, and were less disturbed by emotional distress. However, we found persistent cognitive restraint, reflecting an ongoing need for central eating control. Additional investigations are needed to describe the communication between the gut and brain after surgery.
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Affiliation(s)
- Nicole Rieber
- Department of Internal Medicine, Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
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