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Keywords:

  • alexithymia;
  • binge eating disorder;
  • emotional eating;
  • depression

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References

Objective: To investigate the relationships between alexithymia and emotional eating in obese women with or without Binge Eating Disorder (BED).

Research Methods and Procedures: One hundred sixty-nine obese women completed self-report questionnaires, including the Beck Depression Inventory, the State Trait Anxiety Inventory, the Stress Perceived Scale, the Dutch Eating Behaviour Questionnaire, and the Toronto Alexithymia Scale. The presence of BED, screened using the Questionnaire of Eating and Weight Patterns, was confirmed by interview.

Results: Forty obese women were identified as having BED. BED subjects and non-BED subjects were comparable in age, body mass index, educational level, and socioeconomic class. According to the Dutch Eating Behaviour Questionnaire, BED subjects exhibited higher depression, anxiety, perceived stress, alexithymia scores, and emotional and external eating scores than non-BED subjects. Emotional eating and perceived stress emerged as significant predictors of BED. The relationships between alexithymia and emotional eating in obese subjects differed between the two groups according to the presence of BED. Alexithymia was the predictor of emotional eating in BED subjects, whereas perceived stress and depression were the predictors in non-BED subjects.

Discussion: This study pointed out different relationships among mood, alexithymia, and emotional eating in obese subjects with or without BED. Alexithymia was linked to emotional eating in BED. These data suggest the involvement of alexithymia in eating disorders among obese women.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References

Binge-eating disorder (BED)1 identifies overweight or obese patients who present with recurrent eating of an unusually large amount of food during a short period of time and who do not engage in the characteristic compensatory behaviors of bulimia nervosa. The diagnostic criteria have been included in Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV). BED is a common problem affecting 20% to 30% of obese individuals who seek treatment (1). Binge eating behavior is important to study because of its potential role in the development of obesity or eating disorders (2, 3, 4). Furthermore, BED is present in a distinct subgroup of obese people who report higher degrees of general psychopathology (4, 5, 6).

Emotional eating corresponds to the tendency toward overeating in response to negative emotions. Emotional eating was first reported to be significantly related to bulimia (7), supporting the hypothesis that places the emotions as a factor of overeating in bulimic subjects. The contribution of emotional eating to binge episodes has also been shown: BED subjects have reported a significantly greater tendency to eat in response to negative mood states than controls subjects (8).

Alexithymia, which literally means “no words for emotions,” is a set of cognitive—emotional deficits that includes the inability to identify and express emotions and affects, an impoverished fantasy life, preference for concrete concerns, and avoidance in coping with conflicts or reporting emotions (9). The involvement of alexithymia in eating disorders (anorexia nervosa and bulimia nervosa) has been shown (10, 11, 12).

The relationships between alexithymia and eating behavior in obesity have been sparsely studied and poorly understood. There is empirical evidence suggesting a relationship between alexithymia and obesity (13, 14). Although some studies do not support this hypothesis (15, 16), alexithymia is present in obese or eating-disorder subjects with psychopathological characteristics (16, 17). These studies suggest that alexithymia could be associated with eating disorders in obese subjects.

The aim of this study was to investigate the involvement of alexithymia in emotional eating in a clinical sample of overweight and obese women with or without BED. The first step was to determine the predictors of BED. As expected, emotional eating emerged as a significant predictor. Then, the relationships between alexithymia and BED were assessed. We hypothesized that emotional eating and alexithymia were linked in obese women exhibiting BED. In this way, a moderated regression analysis on emotional eating using alexithymia, depression, perceived stress, the interaction terms of these predictors, and both groups was conducted to determine whether relationships differ between the BED and non-BED groups.

Research Methods and Procedures

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References

Subjects

One hundred seventy-three overweight or obese women willing to lose weight and admitted for outpatient care in the Nutrition departments of the Toulouse area and Strasbourg Hospital were consecutively recruited. Eligibility criteria included an age range of 18 to 60 years, and body mass index (BMI) >25 kg/m2 to <60 kg/m2. The women currently using psychotropic drugs or undergoing psychotherapy were excluded from the study. Four women did not wish to participate in the study. The final group consisted of 169 women. All subjects had experienced diet prescriptions sometime during their lifetimes, but none of them had followed a precise diet prescription 2 to 3 months before the study.

Assessment

A set of self-report questionnaires was given to all subjects in the standard clinical protocol and collected immediately afterward. The subjects were instructed to complete the questionnaires during the morning. The questionnaires were collected and checked by the same investigator (S.P.) after the subjects’ lunch and were then followed by an interview.

The presence of BED was assessed using the Questionnaire for Eating and Weight Patterns Revised proposed by Spitzer et al. (4), a questionnaire that permits screening of patients who have exhibited BED features during the 6 previous months; the questionnaire used a French-validated translation (18). The diagnosis in accordance with DSM IV criteria was then confirmed during an interview conducted by a trained investigator (S.P.).

Alexithymia was investigated using the Toronto Alexithymia Scale-20 (TAS-20) (19), the short form (20 items) of the first scale proposed by Taylor et al. (10). A cutoff score of 61 was used to define alexithymia as recommended. A French-validated translation was used (20).

Eating behavior was investigated using the Dutch Eating Behaviour Questionnaire (33 items) (21). This self-report contains three scales: “restraint eating,” “external eating,” and “emotional eating.” Restraint scale measures intentions to restrict food intake and actual control of food intake. Emotional eating corresponds to the tendency toward overeating in response to negative emotions. External eating corresponds to the tendency toward overeating in response to food-related stimuli. Each of these scales has good internal consistency and accurate factorial analyses (21, 22), which apply to large groups of obese and nonobese French subjects (23).

The Beck Depression Inventory (BDI) (13 items) (24), the State-Trait Anxiety Inventory (40 items, including 2 subscales: state anxiety and trait anxiety) (25), and the Stress Perceived Scale (14 items) (26) were used to assess depression, anxiety, and the severity of perceived stress, respectively. All these questionnaires were applied using French-validated translations (23, 27, 28, 29).

All the subjects completed the questionnaires in the same order during the same morning.

Statistical Analysis

Subjects who met the criteria for BED (BED subjects), as assessed by interview and according to the Questionnaire for Eating and Weight Patterns Revised, were compared with the remaining subjects (non-BED subjects). For categorical variables, χ2 analyses were conducted. For continuous variables, one-way ANOVA was conducted using BED/non-BED as a factor of the analysis and Bonferroni's post hoc test. Internal consistency was assessed using Cronbach's α coefficient. A series of univariate analyses using alexithymia and mood factors as independent variables and using stepwise logistic and multiple linear regressions as appropriate were performed to search for BED and emotional eating predictors. Moderated regression analyses were performed to determine whether relationships differed between the two groups (BED and non-BED subjects).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References

Sample Characteristics

Of the 169 women, 40 were identified as BED subjects and 129 were not. Clinical and socio-demographic characteristics of the patients are presented in Table 1. BED subjects and non-BED subjects were comparable in age, BMI, educational level, and socioeconomic class. A significantly higher number of BED subjects exhibited obesity onset before adulthood (χ2 = 6.982; df = 1, p = 0.007).

Table 1.  Clinical and socio-demographic characteristics of obese women with or without BED (BED and non-BED subjects, respectively)
 Mean [range]
 Non-BED subjects (n = 129)BED subjects (n = 40)
  • *

    Maximal BMI during lifetime.

  • p = .007.

Age (years)40.4 [19 to 60]38.1 [18 to 60]
BMI (kg/m2)35.7 [26.3 to 58.4]36.8 [27.0 to 59.2]
BMI max* (kg/m2)37.1 [27.9 to 66.9]38.9 [27.0 to 88.6]
Onset of obesity (%)  
 childhood34.157.5
 adulthood65.942.5

BED Characteristics and BED Predictors

The scores of the questionnaires on general current psychopathology and eating behavior are presented in Table 2. BED subjects seemed roughly more depressed and more anxious than non-BED subjects. BED subjects exhibited higher scores of emotional and external eating, and the score of restriction was not significantly different between the two groups.

Table 2.  Current psychological traits assessed using self-report questionnaires and eating behavior assessed using the Dutch Eating Behaviour Questionnaire in obese women with or without BED (BED and non-BED subjects, respectively)
 Mean ± SD  
 Non-BED subjects (n = 129)BED subjects (n = 40)Fp
State—Anxiety40.5 ± 12.943.7 ± 13.31.8230.187
Trait—Anxiety46.6 ± 11.053.6 ± 9.312.9600.001
Perceived stress37.9 ± 8.443.3 ± 7.613.1290.001
BDI6.6 ± 6.010.4 ± 5.911.5110.001
Dutch Eating Behaviour Questionnaire    
 Restriction32.4 ± 7.730.8 ± 6.01.3440.248
 Emotional eating35.2 ± 13.549.8 ± 8.142.1070.001
 External eating27.3 ± 5.730.3 ± 4.39.2230.003

To identify the factors predicting the presence of BED, two stepwise logistic regressions considering the presence of BED as the dependent categorical variable were conducted. The first one was performed on the independent variables assessing psychological features (alexithymia, state anxiety, trait anxiety, perceived stress, and depression scores). Perceived stress emerged as the sole significant predictor of BED (R = 0.23, p < 0.001). The second one was performed on the independent variables assessing eating behavior (restraint eating, emotional eating, and external eating). Emotional eating emerged as the sole predictor of BED (R = 0.36, p < 0.001).

BED and Alexithymia

Alexithymia was assessed using the global score and the three subscales of the TAS-20 (Table 3). BED subjects displayed a significantly higher alexithymia global score than non-BED subjects (p = 0.025). The two groups differed for subscales 1 and 2 (i.e., difficulty in distinguishing feelings and bodily sensations and inability to describe feelings, respectively), but not for the subscale 3 (externally oriented thinking). When considering alexithymia as a categorical variable, we found that 88 of the 169 subjects (52%) presented with TAS-20 scores of 61 or greater and were recognized as alexithymic. The number of categorized alexithymic subjects (using this cutoff) was higher in the BED group than in the non-BED group (62.5% vs. 48.8%, respectively), but this difference did not reach significance (χ2 = 2.284, p = 0.09).

Table 3.  The global score and the scores of each of the three subscales of the TAS-20 in obese women with or without BED (BED and non-BED subjects, respectively) and Cronbach's α coefficients of the three subscales in the whole population
 Mean ± SD  
 Non-BED subjects (n = 129)BED subjects (n = 40)pα (n = 169)
  • *

    Subscale 1, difficulty in distinguishing feelings and bodily sensations.

  • Subscale 2, inability to describe feelings.

  • Subscale 3, externally oriented thinking.

Global score60.5 ± 7.663.8 ± 9.60.025 
Subscale 1*19.5 ± 4.321.5 ± 5.20.0160.815
Subscale 215.5 ± 3.316.9 ± 3.30.0180.704
Subscale 325.4 ± 3.125.2 ± 3.80.8900.494

To precisely determine the link between alexithymia and depression, we performed a moderated regression analysis using the TAS-20 score as the dependent continuous variable and the BDI score as the predictor and interacting the presence or absence of BED (BED/non-BED group) with the predictor. The interaction term (BDI score × BED/non-BED group) was significant (F = 6.172, p = 0.014), suggesting that the relationships between alexithymia and depression differ between the two groups. There was a significant positive correlation between the TAS-20 score and the BDI score in the non-BED subjects (Spearman's ρ = 0.449, p < 0.001), whereas no correlation was observed in the BED subjects (Spearman's ρ = −0.017, not significant).

Emotional Eating and Alexithymia

To investigate the links among alexithymia, eating behavior, and mood, stepwise linear regression analyses with the emotional eating score as the dependent variable and the scores of alexithymia, state anxiety, trait anxiety, perceived stress, and BDI as independent variables were performed separately in BED and non-BED subjects. The results are shown in Table 4. In non-BED subjects, a proposed model explained 15.5% of the total variance with the perceived stress and depression score as the independent predictors of the emotional eating score. In BED subjects, the proposed model (explaining 17% of the total variance) included only alexithymia. To determine whether the relationships between these different predictors and emotional eating differed according to the presence of BED, a model of moderated linear regression was tested using emotional eating as the dependent variable and perceived stress, depression score, alexithymia, and the interaction terms (predictor × BED/non-BED group) as the factors of the analysis. The results are shown in Table 5. The interaction term alexithymia × BED/non-BED group was a significant factor of the analysis exhibiting that the links between alexithymia and emotional eating differed between the two groups.

Table 4.  Differences in predictors of emotional eating between obese women with or without BED (BED and non-BED subjects, respectively) using separate stepwise linear regression analyses
 Non-BED subjects (n = 129)BED subjects (n = 40)
Variablesβtpβtp
Intercept9.6521.7630.08033.8656.1660.000
Alexithymia0.0610.6860.4940.3652.2780.005
Perceived stress0.7564.7380.000−0.143−0.9750.336
Depression score−0.466−2.1090.037−0.043−0.2920.772
State anxiety0.1681.6730.097−0.092−0.6230.537
Trait anxiety0.2021.9040.0590.0520.3430.734
Table 5.  Linear regression model of emotional eating and alexithymia, perceived stress, and depression score according to the presence or absence of BED (BED/Non-BED group) in obese women
VariablesFp
  1. Adjusted R2 = 0.285.

Alexithymia3.3700.068
Perceived stress17.249<0.001
Depression score2.3480.128
BED/Non-BED group6.7430.010
Alexithymia × BED/Non-BED group6.9350.009
Perceived stress × BED/Non-BED group6.2650.013
Depression score × BED/Non-BED group0.9820.323

The regression analyses were also performed using each subscale of the TAS-20 as an independent variable, replacing the TAS global score. In the non-BED group, results did not differ from the first analysis. In the BED group, data indicated that only the first subscale (“difficulty in distinguishing feelings and bodily sensations”) was a predictor of emotional eating (β = 0.77; t = 3.565; p = 0.001).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References

The purpose of the present study was to focus on the relationships between alexithymia and emotional eating in obese women according to the presence of BED.

As expected, the BED subjects in our population exhibited higher scores of depression, anxiety, and perceived stress (30). Among these psychological variables, perceived stress was the sole predictor of BED status. Perceived stress, with the self-report questionnaire used, investigates the experiences of loss of control in general situations (26).

With regard to eating behavior, the dimension of emotional eating corresponds to the tendency toward overeating in response to negative or diffuse emotions, and the dimension of external eating corresponds to the tendency toward overeating in the presence of food stimulus (21). In our population of French obese women, BED subjects exhibited higher scores of emotional and external eating than non-BED subjects. Previous investigators have shown similar findings using the Three Factors Eating Questionnaire (15). According to these results, emotional eating was a significant predictor of BED in our study. As expected, the restraint-eating score did not differ between BED and non-BED subjects (15, 31, 32).

When psychological factors were proposed as independent variables, our data indicated differences between BED and non-BED subjects with regard to emotional eating predictors. In the non-BED group, perceived stress and depression emerged as predictors of emotional eating. Numerous studies have proposed a role for stress and negative mood in overeating (33, 34). In the BED group, the predictor of emotional eating was alexithymia.

Alexithymia qualifies a default in the ability to identify and express emotions and a prevalence of externally oriented thinking. Eating-disorder patients are considerably more alexithymic than apparently healthy controls (11, 12, 35). Some studies have specified that alexithymia is more related to the psychological characteristics of patients with eating disorders than to the eating behavior itself (11, 36, 37). With regard to the links between alexithymia and obesity, it has been found that obese subjects are more alexithymic than nonobese subjects (13, 38). When alexithymia was measured in obese subjects without BED, no significant relationships were found between obesity and alexithymia (16), and alexithymia was present in a subgroup of subjects with psychopathological characteristics (16, 17). These studies suggest that alexithymia was specifically associated with eating disorders in obese subjects. Our data agree with this hypothesis.

In the current study, BED subjects reported a significantly higher score of alexithymia than non-BED subjects. In the same way, the relationships between alexithymia and emotional eating in obese subjects differed between the two groups according to the presence of BED (see Table 5). In our population of BED subjects, alexithymia seems to be the sole predictor of emotional eating. This finding indicates that obese women who have difficulty identifying and communicating their feelings also have tendency to eat in response to emotions. Affective deficits and emotional eating were linked. The analyses performed on each subscale of the TAS-20 showed that the first subscale, “difficulty to identify emotion,” is the sole relevant predictor of emotional eating. Of the three factors of the TAS-20, BED is associated with the affective deficits of alexithymia assessed by the two first factors, but not with the cognitive deficits of alexithymia (third factor; see Table 3). This last set of data could be explained by the insufficient internal consistency of the third factor of the TAS-20 (39).

The presence of an alexithymic dimension in eating disorder, especially in emotional eating, is clinically relevant. Sifneos suggested that alexithymic patients demonstrated tendencies to act rather than talk about feelings (9). In accordance with the addiction theory developed by McDougal, the function of acting is to avoid performing psychic work (40). The affective dimension of alexithymia could be a potential target in treatment focused on the improvement of abilities to regulate emotions among obese binge eaters.

The relationships between alexithymia and depression are well known and well documented in the literature (37, 41, 42). We investigated the links between alexithymia and depression according to the presence or absence of BED. Our data suggest that the relationships between alexithymia and depression differ between the two groups. The data from correlation analyses indicate a significant positive correlation between the TAS-20 score and the depression score in the non-BED subjects, whereas no correlation was observed in the BED subjects. A distinction between primary and secondary alexithymia has been proposed by Freyberger (43). The link between alexithymia and depression in non-BED subjects suggests that alexithymia is secondary to depression in this subgroup. The absence of relationships between alexithymia and depression in BED subjects could suggest that alexithymia could be a primary factor (independent of mood factors) in this subgroup. Longitudinal studies are necessary to clarify this hypothesis (43).

In conclusion, this study pointed out different relationships among mood, alexithymia, and emotional eating in a population of obese subjects (willing to lose weight) with or without BED. The data of this study suggest an involvement of alexithymia in eating disorders among obese women.

Acknowledgment

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References

There was no funding/support for this study. We gratefully acknowledge Dr. Frederic Sanguignol and the nursing staff of the Clinique du Chateau de Vernhes for their assistance in the recruitment of some of the patients participating in this study, as well as Joseph Saint-Pierre (Centre Interuniversitaire de Calcul, Toulouse) for his help in statistical analyses.

Footnotes
  • 1

    Nonstandard abbreviations: BED, binge-eating disorder; BMI, body mass index; TAS-20, Toronto Alexithymia Scale-20; BDI, Beck Depression Inventory.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References
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