Eating styles in major depressive disorder: Results from a large-scale study
Introduction
In the modern Western society, depression is the most frequently diagnosed mental disorder (Kessler et al., 2003, Steel et al., 2014). While associations between depression and somatic and biological health have been recognized earlier (Penninx et al., 2013), only recently there has been attention for the link between depression and food-related behavior. This is a relevant topic to examine as well, as unhealthy diet and eating styles can contribute to depression's negative health consequences such as increased morbidity and mortality (Penninx et al., 2013). One of these consequences of depression is obesity (Luppino et al., 2010), for which diet is notoriously important.
Depressed persons have been found to present both disturbances in dietary patterns (Jacka et al., 2011, Quirk et al., 2013) as well as in eating styles (Brechan and Kvalem, 2015, Clum et al., 2014, Goldschmidt et al., 2014, Konttinen et al., 2010a, Konttinen et al., 2010b, Lazarevich et al., 2016, Ouwens et al., 2009, van Strien et al., 2016a, Werrij et al., 2006). Eating styles refer to a complex interplay amongst physiological, psychological, social and genetic factors that influence food preferences and quantity of food intake (Grimm and Steinle, 2011). Eating styles can influence depression indirectly by inducing unhealthy dietary patterns and obesity (Keskitalo et al., 2008, Konttinen et al., 2010a, Macht, 2008), which have shown to increase the risk of subsequent depression (Jacka et al., 2011, Luppino et al., 2010, Quirk et al., 2013). In addition, a few cross-sectional studies show high depressive symptoms to be associated to unhealthy eating styles (Brechan and Kvalem, 2015, Clum et al., 2014, Goldschmidt et al., 2014, Konttinen et al., 2010a, Konttinen et al., 2010b, Lazarevich et al., 2016, Ouwens et al., 2009, van Strien et al., 2016a, Werrij et al., 2006). There seems to be a vicious circle, possibly going both ways, in which a systematic understanding of the important direct association from clinical depression to eating styles is lacking.
Three different eating styles, based on three psychological theories, have been identified over the past decades. The psychosomatic theory on emotional eating assumes that some people are unable to distinguish hunger from other bodily arousal (e.g. emotions) (Bruch, 1961), while the externality theory on external eating suggests that exposure to attractive food and food-related external stimuli triggers eating (Schachter, 1964). The restrained theory on restrained eating assumes individuals with overweight and obesity to be chronic dieters, who constantly try to cognitively regulate their eating. However at some point this control breaks down due to “emotional turmoil”, and they start to overeat again (Herman and Mack, 1975).
Previous studies that showed cross-sectional associations between depressive symptoms and eating styles (Brechan and Kvalem, 2015, Clum et al., 2014, Goldschmidt et al., 2014, Konttinen et al., 2010a, Konttinen et al., 2010b, Lazarevich et al., 2016, Ouwens et al., 2009, van Strien et al., 2016a, Werrij et al., 2006), all operationalized depression by using one overall severity of symptoms score in general populations, and thereby have limited generalizability to clinical samples. Two studies only included females (Clum et al., 2014, Ouwens et al., 2009), and one only investigated adolescents (Lazarevich et al., 2016). Also, in three studies, the participants’ mean body mass index was above 30 kg/m2 (indicating obesity (Clum et al., 2014, Goldschmidt et al., 2014, Ouwens et al., 2009);). None of these studies actually investigated patients with major depressive disorder as established by formal psychiatric diagnostic criteria. Furthermore, symptom heterogeneity among individuals diagnosed with major depressive disorder is well-established, and some clear subtypes of depression (e.g. atypical versus melancholic symptom profiles) have been successfully verified (Fried and Nesse, 2015, Lamers et al., 2012). The atypical symptom profile is characterized by increased appetite (Lamers et al., 2010, Milaneschi et al., 2015), a heightened risk of obesity (Levitan et al., 2012) and subsequent weight gain (Lasserre et al., 2014), and consequently likely represents a group of patients who are at risk for unfavorable eating styles. Moreover, studies show depression to be related to disturbances in neurobiological appetite-related processes (Milaneschi et al., 2014, Penninx et al., 2013, Zupancic and Mahajan, 2011). Associations are found with metabolic disturbances (Penninx et al., 2013) like the functioning of the hormone leptin, which is involved in appetite regulation. Increasing evidence indicates that depression is associated with reduced leptin signaling to the central nervous system (Milaneschi et al., 2014, Zupancic and Mahajan, 2011), specifically within the atypical depression subtype. This work indicates that depression might be associated with eating styles by affecting appetite-regulating processes. However, due to the lack of studies relating specific depressive symptoms to eating styles, it remains unclear whether depression is consistently associated with emotional, external and restrained eating, and whether different associations with eating styles exist between different subgroups of depression.
Since depressive symptoms and unhealthy eating styles are shown to be associated, and eating styles can also induce unfavorable health outcomes like unhealthy dietary patterns and obesity, it is crucial to have a thorough understanding of the associations between depression and unhealthy eating styles. Therefore, this study investigates the cross-sectional and longitudinal associations between depression disorders in their full clinical heterogeneity and three disordered eating styles; emotional, external and restrained eating. In a large cohort, we will examine if and how participants with a diagnosis of current or remitted depression disorders differ in eating styles as compared to healthy controls. In addition we will examine which specific depression characteristics (severity, symptom profiles, individual symptoms), and changes in depressive disorder characteristics (course, duration) are associated with emotional, external and restrained eating.
Section snippets
Study sample
Data from the Netherlands Study of Depression and Anxiety (NESDA), an ongoing cohort study of people with depressive and anxiety disorders and healthy controls were used. In order to represent diverse settings and developmental stages of psychopathology, 2981 adults (18-65 year) from the community (19%), general practice (54%) and specialized mental health care (27%) were included at baseline. Exclusion criteria were a primary clinically overt diagnosis of other psychiatric disorders such as
Descriptives
Participants’ mean age was 51.2 (sd = 13.0), and almost two-third of the total sample was female (Table 1). The three groups had a similar mean BMI, current patients smoked the most cigarettes, and drank the least alcohol per week. Those in the current patient group showed, as expected, the highest scores on overall depression severity and depressive symptom clusters.
Depression diagnosis, depression severity and eating styles
Patients with a remitted depressive disorder as well as with those with a current depressive disorder showed higher levels of
Discussion
Using a large cohort of depressed patients and healthy controls, the current study is the first to examine the associations of depressive disorder and individual depressive symptoms, with three disordered eating styles; emotional, external and restrained eating. Results showed that patients with a current and remitted depressive disorder reported significantly more emotional and external eating, but not restrained eating. Differences in eating styles were found between healthy controls and
Conflicts of interest
Tatjana van Strien has a copyright and royalty interest in the Dutch Eating Behavior Questionnaire (DEBQ) and manual. The other authors report no conflict of interest.
Role of the funding source
Funding for this paper was provided by the Geestkracht program of the Netherlands Organisation for Health Research and Development (Zon-Mw, grant number 10-000-1002) and the European Union FP7 MooDFOOD Project ‘Multi-country cOllaborative project on the rOle of Diet, FOod-related behaviour, and Obesity in the prevention of Depression’ (grant agreement no. 613598).
References (60)
- et al.
Dopamine polymorphisms and depressive symptoms predict foods intake: results from a nationally representative sample
Appetite
(2011) - et al.
Relationship between body dissatisfaction and disordered eating: mediating role of self-esteem and depression
Eat. Behav.
(2015) - et al.
An open trial of an acceptance-based behavioral intervention for weight loss
Cogn. Behav. Pract.
(2009) - et al.
The Three-Factor Eating Questionnaire, body mass index, and responses to sweet and salty fatty foods: a twin study of genetic and environmental associations
Am. J. Clin. Nutr.
(2008) - et al.
Emotional eating, depressive symptoms and self-reported food consumption. A population-based study
Appetite
(2010) - et al.
Emotional eating and physical activity self-efficacy as pathways in the association between depressive symptoms and adiposity indicators
Am. J. Clin. Nutr.
(2010) - et al.
Relationship among obesity, depression, and emotional eating in young adults
Appetite
(2016) How emotions affect eating: a five-way model
Appetite
(2008)- et al.
The association between leptin and depressive symptoms is modulated by abdominal adiposity
Psychoneuroendocrinology
(2014) - et al.
Relations between negative affect, coping, and emotional eating
Appetite
(2007)
Emotional eating as a mediator between depression and weight gain
Appetite
Intake of energy is best predicted by overeating tendency and consumption of fat is best predicted by dietary restraint: a 4-year follow-up of patients with newly diagnosed Type 2 diabetes
Appetite
The mediation effect of emotional eating between depression and body mass index in the two European countries Denmark and Spain
Appetite
Emotional eating in adolescents : a gene ( SLC6A4/5-HTT ) e Depressive feelings interaction analysis
J. Psychiatr. Res.
The structure and dimensionality of the Inventory of Depressive Symptomatology Self Report (IDS-SR) in patients with depressive disorders and healthy controls
J. Affect. Disord.
Overweight and obesity: the significance of a depressed mood
Patient Educ. Couns.
Reliability and validity studies of the who-composite international diagnostic interview (CIDI): a critical review
J. Psychiatr. Res.
The transformation of oral impulses in eating disorders: a conceptual approach
Psychiatr. Q.
Associations between depressive symptoms, self-efficacy, eating styles, exercise and body mass index in women
J. Behav. Med.
Weight and shape overconcern and emotional eating in binge eating disorder
Int. J. Eat. Disord.
Depression sum-scores don't add up: why analyzing specific depression symptoms is essential
BMC Med.
An initial evaluation of a weight loss intervention for individuals who engage in emotional eating
J. Behav. Med.
Affect and eating behavior in obese adults with and without elevated depression symptoms
Int. J. Eat. Disord.
DSM-IV psychiatric disorder comorbidity and its correlates in binge eating disorder
Int. J. Eat. Disord.
Genetics of eating behavior: established and emerging concepts
Nutr. Bull. Londen
Emotion regulation. Conceptual foundations
Do emotional eating urges regulate affect? Concurrent and prospective associations and implications for risk models of binge eating
Int. J. Eat. Disord.
Binge eating as escape from self-awareness
Psychol. Bull.
The Fagerstrom test for nicotine dependence: a revision of the Fagerstrom tolerance questionnaire
Br. J. Addict.
Cited by (43)
Association between periodontitis and depression severity – A cross-sectional study of the older population in Hamburg
2023, Brain, Behavior, and Immunity - HealthThe relationship between nutrition and depression in the life process: A mini-review
2023, Experimental GerontologyThe conscientiousness-health link in depression: Results from a path analysis
2021, Journal of Affective DisordersCitation Excerpt :On the global level, depressive disorder is ranked as the single largest contributor to non-fatal health loss (World Health Organization, 2017). Depressive symptoms have been associated with health risk behaviors such as smoking, physical inactivity, and unhealthy eating habits including overweight and obesity (Paans et al., 2018; Rahe et al., 2016; Schuch et al., 2017). In addition, personality traits have been indicated as meaningful constituents of health.
- 1
Correspondence: Postbus 74077, 1070 BB Amsterdam, The Netherlands.