Elsevier

Journal of Psychiatric Research

Volume 97, February 2018, Pages 38-46
Journal of Psychiatric Research

Eating styles in major depressive disorder: Results from a large-scale study

https://doi.org/10.1016/j.jpsychires.2017.11.003Get rights and content

Highlights

  • Major depressive disorder is related to more emotional and external eating.

  • Higher depressive symptoms are associated to more emotional and external eating.

  • Neuro-vegetative depressive symptoms contributed relatively more to eating styles.

  • Results could be relevant for treating patients suffering from atypical depression.

Abstract

Depressed persons have been found to present disturbances in eating styles, but it is unclear whether eating styles are different in subgroups of depressed patients. We studied the association between depressive disorder, severity, course and specific depressive symptom profiles and unhealthy eating styles. Cross-sectional and course data from 1060 remitted depressed patients, 309 currently depressed patients and 381 healthy controls from the Netherlands Study of Depression and Anxiety were used. Depressive disorders (DSM-IV based psychiatric interview) and self-reported depressive symptoms (Inventory of Depressive Symptomatology) were related to emotional, external and restrained eating (Dutch Eating Behavior Questionnaire) using analyses of covariance and linear regression. Remitted and current depressive disorders were significantly associated with higher emotional eating (Cohen's d = 0.40 and 0.60 respectively, p < 0.001) and higher external eating (Cohen's d = 0.20, p = 0.001 and Cohen's d = 0.32, p < 0.001 respectively). Little differences in eating styles between depression course groups were observed. Associations followed a dose-response association, with more emotional and external eating when depression was more severe (both p-values <0.001). Longer symptom duration was also associated to more emotional and external eating (p < 0.001 and p = 0.001 respectively). When examining individual depressive symptoms, neuro-vegetative depressive symptoms contributed relatively more to emotional and external eating, while mood and anxious symptoms contributed relatively less to emotional and external eating. No depression associations were found with restrained eating. Intervention programs for depression should examine whether treating disordered eating specifically in those with neuro-vegetative, atypical depressive symptoms may help prevent or minimize adverse health consequences.

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).

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    Correspondence: Postbus 74077, 1070 BB Amsterdam, The Netherlands.

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