The Journal of Nutrition. First published ahead of print May 21, 2014 as doi: 10.3945/jn.114.193177. The Journal of Nutrition Nutritional Epidemiology
The Associations between Emotional Eating and Consumption of Energy-Dense Snack Foods Are Modified by Sex and Depressive Symptomatology1,2 G´eraldine M. Camilleri,3* Caroline M´ejean,3 Emmanuelle Kesse-Guyot,3 Valentina A. Andreeva,3 France Bellisle,3 Serge Hercberg,3,4,5 and Sandrine P´eneau3
Downloaded from jn.nutrition.org at RYERSON UNIVERSITY on June 10, 2014
3 Paris 13 University, Sorbonne Paris Cit´e, Epidemiology and Biostatistics Research Center, Nutritional Epidemiology Research Team (EREN), U1153 National Institute of Health and Medical Research, U1125 National Institute for Agricultural Research, National Conservatory of Arts and Crafts, Paris 7 and 5 Universities, Bobigny, France; 4Nutrition Epidemiology and Surveillance Unit, French Institute for Health Surveillance, Paris 13 University, Sorbonne Paris Cit´e, Bobigny, France; and 5Public Health Department, Avicenne Hospital, Bobigny, France
Abstract In recent years, emotional eating (EmE) has incited substantial research interest as an important psychologic determinant of food intake and overweight. However, little is known about factors that might modulate its relations with dietary habits. The objective was to examine the association between EmE and consumption of energy-dense snack food and assess the 2-way interaction of EmE with sex and depressive symptoms. A total of 7378 men and 22,862 women from the NutriNetSante´ cohort (France, 2009–2013) who completed $6 self-reported 24-h food records were included in this cross-sectional analysis. EmE was evaluated via the revised 21-item Three-Factor Eating Questionnaire. Depressive symptoms were assessed by the Center for Epidemiologic Studies Depression Scale. The associations between EmE and energy-dense food consumption were assessed by multivariable logistic and linear regression models adjusted for sociodemographic and lifestyle factors. Higher EmE was associated with higher consumption of energy-dense snacks and, in particular, with consumption of sweet-and-fatty foods across most categories studied. However, these associations were stronger in women with depressive symptoms (e.g., high consumption of chocolate, OR: 1.77, 95% CI: 1.43, 2.20; cakes/biscuits/ pastries, OR: 1.81, 95% CI: 1.45, 2.26) compared with those without depressive symptoms (e.g., high consumption of chocolate, OR: 1.52, 95% CI: 1.36, 1.69; cakes/biscuits/pastries, OR: 1.44, 95% CI: 1.29, 1.61). In contrast, the significant positive associations observed in men without depressive symptoms (e.g., high consumption of chocolate, OR: 1.33, 95% CI: 1.16, 1.52; cakes/biscuits/pastries, OR: 1.28, 95% CI: 1.11, 1.48) were not found in men with depressive symptoms. In conclusion, in women, EmE was positively associated with consumption of energy-dense snack food, particularly in those with depressive symptoms. For men, the relation between EmE and energy-dense snack foods was found only in those without depressive symptoms. These findings call for consideration of the psychologic state when targeting unhealthy dietary habits, especially in women. This trial was registered at eudract.ema.europa.eu as 2013-000929-31. J. Nutr. doi: 10.3945/jn.114.193177.
Introduction In Western societies, psychologic traits could be 1 explanation for the individual-level differences in susceptibility to an environment characterized by food abundance and promoting intake 1 Supported by the Ministry of Health, French Institute for Health Surveillance, National Institute for Prevention and Health Education, Medical Research Foundation, National Institute of Health and Medical Research, National Institute for Agricultural Research, National Conservatory of Arts and Crafts, and Paris 13 University. 2 ´ Author disclosures: G. M. Camilleri, C. Mejean, E. Kesse-Guyot, V. A. Andreeva, ´ F. Bellisle, S. Hercberg, and S. Peneau, no conflicts of interest. * To whom correspondence should be addressed. E-mail: g.camilleri@uren. smbh.univ-paris13.fr.
of food with high energy density and therefore weight gain. In particular, the theory of emotional eating (EmE)6 implies that overeating can occur in response to negative emotions (1). In experimental studies, emotional eaters were found to consume more high-fat snack foods (2) and more sweet-and-fatty foods (3) in response to stress compared with those not classified as emotional eaters. Some epidemiologic studies showed a positive association of EmE with consumption of energy-dense sweet snacks (4–6), whereas other research showed no consistent association 6 Abbreviations used: CES-D, Center for Epidemiologic Studies Depression Scale; EmE, emotional eating; TFEQ-R21, revised 21-item Three-Factor Eating Questionnaire.
ã 2014 American Society for Nutrition. Manuscript received March 4, 2014. Initial review completed April 2, 2014. Revision accepted May 1, 2014. doi: 10.3945/jn.114.193177.
Copyright (C) 2014 by the American Society for Nutrition
1 of 10
Participants and Methods Study population. NutriNet-Sant´e is an ongoing Web-based prospective observational cohort study launched in France in May 2009 with a scheduled follow-up of 10 y. It aims to investigate the relation between nutrition and chronic disease risk, as well as the determinants of dietary behavior and nutritional status. The study was implemented in the general French population (Internet-using adult volunteers, aged $18y). The rationale, design, and methodology of the study were described in detail previously (21). In brief, to be considered included in the study, participants complete a baseline set of self-administered, Web-based questionnaires assessing dietary intake, physical activity, anthropometric characteristics, lifestyle, socioeconomic conditions, and health status. As part of the follow-up, participants are requested to complete the same set of questionnaires every year. Moreover, each month, participants are invited by e-mail to fill in optional questionnaires related to dietary intakes, determinants of eating behaviors, and nutritional and health status. This study is conducted in accordance with the Declaration of Helsinki, and all procedures were approved by the Institutional Review Board of the French National Institute for Health and Medical Research (No. 0000388FWA00005831) and the French National Commission for Computed Data and Individual Freedom (Nos. 908450 and 909216). All participants provided informed consent with an electronic signature. This study is registered at eudract.ema.europa.eu as 2013-000929-31. Dietary data. At inclusion and once a year thereafter, participants are invited to complete 3 non-consecutive 24-h dietary records, randomly assigned over a 2-wk period (2 weekdays and 1 weekend day). For the 2 of 10
Camilleri et al.
present analysis, among the 9 24-h dietary records completed during the first 2 y of follow-up, we selected participants who completed $6 24-h dietary records. Participants reported all foods and beverages consumed at each eating occasion. They estimated the amounts eaten using validated photographs of portion sizes (22), using household measures or by indicating the exact quantity (grams) or volume (milliliters). Daily mean food intakes were calculated, weighted for the type of day of the week. Nutrient intakes were estimated using the published NutriNet-Sant´e composition table including >2000 foods (23). Dietary underreporting was identified on the basis of the method proposed by Black (24). For the purpose of the study, we selected energy-dense food groups [averaging >225 kcal/100 g (25)] that are also often consumed as snacks and soft drinks. Sweet food groups consisted of sugar/sugary products (candies, honey, jam, dessert toppings, and sugar syrups) and breakfast cereals. Sweet-and-fatty foods were composed of cakes/biscuits/pastries (including croissant-like pastries), chocolate, ice cream/chocolate-based products/ confectionary (chocolate bars, chocolate spread, and marzipan), and sweetened cream desserts (including milkshakes and high-fat and drinking yogurts). Salty and fatty foods consisted of fast food/pizzas/quiches, appetizers (including salted oleaginous plant seeds), cheese, and processed meat. The sweetened cream desserts group averaged 140 kcal/100 g but was retained in the present analysis because its food items contain $12% of added sugars and is considered to be a popular snacking group in France. Finally, soft drinks were composed of artificially sweetened soft drinks (diet drinks) and sugar-sweetened soft drinks (soda, flavored water, and fruit drinks excluding 100% pure fruit juice). ParticipantsÕ reported consumption was divided into ‘‘low’’ and ‘‘high’’ for each energydense food group according to the sex-specific median intake. EmE. EmE was assessed 14 mo after inclusion using the French version of the revised 21-item Three-Factor Eating Questionnaire (TFEQ-R21) EmE scale (26). The TFEQ-R21 covers 3 aspects of eating motivation: 1) cognitive restraint (6 items); 2) EmE (6 items); and 3) uncontrolled eating (9 items). The EmE scale measures the propensity to eat in response to negative emotions and consists of 6 items (e.g., ‘‘I start to eat when I feel anxious’’). These items were rated on a 4-point scale from ‘‘definitely true’’ to ‘‘definitely false.’’ EmE scores range from 0 to 100, and a higher score indicates greater EmE. Because the EmE variable was not normally distributed, the following 3 categories were created on the basis of the sexspecific median values (excluding those with no EmE): 1) no EmE (score = 0); 2) low EmE (score > 0 to < median); and 3) high EmE (score $ median). The EmE items displayed excellent internal consistency (CronbachÕs a = 0.93). Evaluation of depressive symptoms. Depressive symptoms were measured 26 mo after inclusion with the validated French version of the Center for Epidemiologic Studies Depression Scale (CES-D) (27,28). The CES-D assesses depressive symptomatology and consists of 20 items (e.g., ‘‘I thought my life had been a failure’’). These items are rated on a 4-point scale from ‘‘never or rarely’’ to ‘‘most or all of the time.’’ Four items assess positive feelings and are therefore inversely rated. CES-D scores range from 0 to 60, with a lower score corresponding to fewer depressive symptoms. A cutoff of >15, commonly used to identify persons with depressive symptoms (28), was chosen for the present analyses. The CES-D items displayed good internal consistency (CronbachÕs a = 0.74). Sociodemographic, lifestyle, and behavioral data. Potential covariates or moderators were identified based on evidence in the literature: age (years), sex, BMI (kilograms per meter squared), educational level (primary, secondary, or university), and physical activity (low, moderate, or high) (6,15,29), as well as marital status (living alone, married, or living with a partner) (15), smoking status (never, former, or current smoker) (29), and history of dieting (never, former, or current dieter) (29) reported at 12 mo after inclusion or inclusion if data at 12 mo was not available. Physical activity was assessed using a short form of the French version of the International Physical Activity Questionnaire (30). The weekly energy expenditure expressed in metabolic equivalent task minutes per week was estimated, and 3 scores of physical activity were constituted [1) low (
The Associations between Emotional Eating and Consumption of Energy-Dense Snack Foods Are Modified by Sex and Depressive Symptomatology1,2 G´eraldine M. Camilleri,3* Caroline M´ejean,3 Emmanuelle Kesse-Guyot,3 Valentina A. Andreeva,3 France Bellisle,3 Serge Hercberg,3,4,5 and Sandrine P´eneau3
Downloaded from jn.nutrition.org at RYERSON UNIVERSITY on June 10, 2014
3 Paris 13 University, Sorbonne Paris Cit´e, Epidemiology and Biostatistics Research Center, Nutritional Epidemiology Research Team (EREN), U1153 National Institute of Health and Medical Research, U1125 National Institute for Agricultural Research, National Conservatory of Arts and Crafts, Paris 7 and 5 Universities, Bobigny, France; 4Nutrition Epidemiology and Surveillance Unit, French Institute for Health Surveillance, Paris 13 University, Sorbonne Paris Cit´e, Bobigny, France; and 5Public Health Department, Avicenne Hospital, Bobigny, France
Abstract In recent years, emotional eating (EmE) has incited substantial research interest as an important psychologic determinant of food intake and overweight. However, little is known about factors that might modulate its relations with dietary habits. The objective was to examine the association between EmE and consumption of energy-dense snack food and assess the 2-way interaction of EmE with sex and depressive symptoms. A total of 7378 men and 22,862 women from the NutriNetSante´ cohort (France, 2009–2013) who completed $6 self-reported 24-h food records were included in this cross-sectional analysis. EmE was evaluated via the revised 21-item Three-Factor Eating Questionnaire. Depressive symptoms were assessed by the Center for Epidemiologic Studies Depression Scale. The associations between EmE and energy-dense food consumption were assessed by multivariable logistic and linear regression models adjusted for sociodemographic and lifestyle factors. Higher EmE was associated with higher consumption of energy-dense snacks and, in particular, with consumption of sweet-and-fatty foods across most categories studied. However, these associations were stronger in women with depressive symptoms (e.g., high consumption of chocolate, OR: 1.77, 95% CI: 1.43, 2.20; cakes/biscuits/ pastries, OR: 1.81, 95% CI: 1.45, 2.26) compared with those without depressive symptoms (e.g., high consumption of chocolate, OR: 1.52, 95% CI: 1.36, 1.69; cakes/biscuits/pastries, OR: 1.44, 95% CI: 1.29, 1.61). In contrast, the significant positive associations observed in men without depressive symptoms (e.g., high consumption of chocolate, OR: 1.33, 95% CI: 1.16, 1.52; cakes/biscuits/pastries, OR: 1.28, 95% CI: 1.11, 1.48) were not found in men with depressive symptoms. In conclusion, in women, EmE was positively associated with consumption of energy-dense snack food, particularly in those with depressive symptoms. For men, the relation between EmE and energy-dense snack foods was found only in those without depressive symptoms. These findings call for consideration of the psychologic state when targeting unhealthy dietary habits, especially in women. This trial was registered at eudract.ema.europa.eu as 2013-000929-31. J. Nutr. doi: 10.3945/jn.114.193177.
Introduction In Western societies, psychologic traits could be 1 explanation for the individual-level differences in susceptibility to an environment characterized by food abundance and promoting intake 1 Supported by the Ministry of Health, French Institute for Health Surveillance, National Institute for Prevention and Health Education, Medical Research Foundation, National Institute of Health and Medical Research, National Institute for Agricultural Research, National Conservatory of Arts and Crafts, and Paris 13 University. 2 ´ Author disclosures: G. M. Camilleri, C. Mejean, E. Kesse-Guyot, V. A. Andreeva, ´ F. Bellisle, S. Hercberg, and S. Peneau, no conflicts of interest. * To whom correspondence should be addressed. E-mail: g.camilleri@uren. smbh.univ-paris13.fr.
of food with high energy density and therefore weight gain. In particular, the theory of emotional eating (EmE)6 implies that overeating can occur in response to negative emotions (1). In experimental studies, emotional eaters were found to consume more high-fat snack foods (2) and more sweet-and-fatty foods (3) in response to stress compared with those not classified as emotional eaters. Some epidemiologic studies showed a positive association of EmE with consumption of energy-dense sweet snacks (4–6), whereas other research showed no consistent association 6 Abbreviations used: CES-D, Center for Epidemiologic Studies Depression Scale; EmE, emotional eating; TFEQ-R21, revised 21-item Three-Factor Eating Questionnaire.
ã 2014 American Society for Nutrition. Manuscript received March 4, 2014. Initial review completed April 2, 2014. Revision accepted May 1, 2014. doi: 10.3945/jn.114.193177.
Copyright (C) 2014 by the American Society for Nutrition
1 of 10
Participants and Methods Study population. NutriNet-Sant´e is an ongoing Web-based prospective observational cohort study launched in France in May 2009 with a scheduled follow-up of 10 y. It aims to investigate the relation between nutrition and chronic disease risk, as well as the determinants of dietary behavior and nutritional status. The study was implemented in the general French population (Internet-using adult volunteers, aged $18y). The rationale, design, and methodology of the study were described in detail previously (21). In brief, to be considered included in the study, participants complete a baseline set of self-administered, Web-based questionnaires assessing dietary intake, physical activity, anthropometric characteristics, lifestyle, socioeconomic conditions, and health status. As part of the follow-up, participants are requested to complete the same set of questionnaires every year. Moreover, each month, participants are invited by e-mail to fill in optional questionnaires related to dietary intakes, determinants of eating behaviors, and nutritional and health status. This study is conducted in accordance with the Declaration of Helsinki, and all procedures were approved by the Institutional Review Board of the French National Institute for Health and Medical Research (No. 0000388FWA00005831) and the French National Commission for Computed Data and Individual Freedom (Nos. 908450 and 909216). All participants provided informed consent with an electronic signature. This study is registered at eudract.ema.europa.eu as 2013-000929-31. Dietary data. At inclusion and once a year thereafter, participants are invited to complete 3 non-consecutive 24-h dietary records, randomly assigned over a 2-wk period (2 weekdays and 1 weekend day). For the 2 of 10
Camilleri et al.
present analysis, among the 9 24-h dietary records completed during the first 2 y of follow-up, we selected participants who completed $6 24-h dietary records. Participants reported all foods and beverages consumed at each eating occasion. They estimated the amounts eaten using validated photographs of portion sizes (22), using household measures or by indicating the exact quantity (grams) or volume (milliliters). Daily mean food intakes were calculated, weighted for the type of day of the week. Nutrient intakes were estimated using the published NutriNet-Sant´e composition table including >2000 foods (23). Dietary underreporting was identified on the basis of the method proposed by Black (24). For the purpose of the study, we selected energy-dense food groups [averaging >225 kcal/100 g (25)] that are also often consumed as snacks and soft drinks. Sweet food groups consisted of sugar/sugary products (candies, honey, jam, dessert toppings, and sugar syrups) and breakfast cereals. Sweet-and-fatty foods were composed of cakes/biscuits/pastries (including croissant-like pastries), chocolate, ice cream/chocolate-based products/ confectionary (chocolate bars, chocolate spread, and marzipan), and sweetened cream desserts (including milkshakes and high-fat and drinking yogurts). Salty and fatty foods consisted of fast food/pizzas/quiches, appetizers (including salted oleaginous plant seeds), cheese, and processed meat. The sweetened cream desserts group averaged 140 kcal/100 g but was retained in the present analysis because its food items contain $12% of added sugars and is considered to be a popular snacking group in France. Finally, soft drinks were composed of artificially sweetened soft drinks (diet drinks) and sugar-sweetened soft drinks (soda, flavored water, and fruit drinks excluding 100% pure fruit juice). ParticipantsÕ reported consumption was divided into ‘‘low’’ and ‘‘high’’ for each energydense food group according to the sex-specific median intake. EmE. EmE was assessed 14 mo after inclusion using the French version of the revised 21-item Three-Factor Eating Questionnaire (TFEQ-R21) EmE scale (26). The TFEQ-R21 covers 3 aspects of eating motivation: 1) cognitive restraint (6 items); 2) EmE (6 items); and 3) uncontrolled eating (9 items). The EmE scale measures the propensity to eat in response to negative emotions and consists of 6 items (e.g., ‘‘I start to eat when I feel anxious’’). These items were rated on a 4-point scale from ‘‘definitely true’’ to ‘‘definitely false.’’ EmE scores range from 0 to 100, and a higher score indicates greater EmE. Because the EmE variable was not normally distributed, the following 3 categories were created on the basis of the sexspecific median values (excluding those with no EmE): 1) no EmE (score = 0); 2) low EmE (score > 0 to < median); and 3) high EmE (score $ median). The EmE items displayed excellent internal consistency (CronbachÕs a = 0.93). Evaluation of depressive symptoms. Depressive symptoms were measured 26 mo after inclusion with the validated French version of the Center for Epidemiologic Studies Depression Scale (CES-D) (27,28). The CES-D assesses depressive symptomatology and consists of 20 items (e.g., ‘‘I thought my life had been a failure’’). These items are rated on a 4-point scale from ‘‘never or rarely’’ to ‘‘most or all of the time.’’ Four items assess positive feelings and are therefore inversely rated. CES-D scores range from 0 to 60, with a lower score corresponding to fewer depressive symptoms. A cutoff of >15, commonly used to identify persons with depressive symptoms (28), was chosen for the present analyses. The CES-D items displayed good internal consistency (CronbachÕs a = 0.74). Sociodemographic, lifestyle, and behavioral data. Potential covariates or moderators were identified based on evidence in the literature: age (years), sex, BMI (kilograms per meter squared), educational level (primary, secondary, or university), and physical activity (low, moderate, or high) (6,15,29), as well as marital status (living alone, married, or living with a partner) (15), smoking status (never, former, or current smoker) (29), and history of dieting (never, former, or current dieter) (29) reported at 12 mo after inclusion or inclusion if data at 12 mo was not available. Physical activity was assessed using a short form of the French version of the International Physical Activity Questionnaire (30). The weekly energy expenditure expressed in metabolic equivalent task minutes per week was estimated, and 3 scores of physical activity were constituted [1) low (
