Exploring the emotional and behavioral dimensions of childhood obesity: the role of shame, guilt, and eating patterns

Abstract

Purpose

Childhood obesity is a growing public health concern, associated with severe physical and psychological consequences. This study investigates the relationship between self-conscious emotions, specifically shame and guilt, and their impact on eating behaviors, physical activity levels, and screen time in children aged 10–18 years. Understanding these relationships may help design more effective obesity management strategies.

Methods

The study included 100 children with obesity and 90 children without obesity. Participants were evaluated using the Test of Self-Conscious Affect for Adolescents (TOSCA-A), the Dutch Eating Behavior Questionnaire (DEBQ), the Physical Activity Questionnaire for Children (PAQ-C), and the Revised Children’s Anxiety and Depression Scale (RCADS). Comparative analysis was conducted between the two groups to assess emotional and behavioral patterns.

Results

Children with obesity reported higher levels of anxiety, depression, emotional eating, and restrictive eating, along with lower physical activity levels and increased screen time compared to children without obesity. While guilt was positively correlated with emotional eating in both groups, shame was significantly associated with problematic eating patterns only in children without obesity. The relationship between physical activity and these emotions was minimal, with only guilt showing a modest negative association with school-based activity in the control group.

Conclusions

These findings highlight the need to address emotional well-being as part of childhood obesity interventions. Psychological approaches focusing on guilt and emotional eating may improve the effectiveness of treatment strategies. Future research is warranted to explore developmental variations in the impact of shame and guilt on children’s behaviors.

Level of Evidence: Level III, well-designed cross-sectional analysis.

Introduction

The World Health Organization (WHO) defines obesity as “abnormal or excessive fat accumulation that presents a risk to health” Globally, the rates of overweight and obesity have been steadily increasing in both adults and children. From 1990 to 2022, the proportion of adults aged 18 and over classified as obese increased from 7 to 16%, representing more than a twofold rise. However, the increase has been even more dramatic among younger populations: the global rate of children and adolescents aged 5–19 with obesity increased from 2 to 8%, representing a fourfold rise that underscores the critical nature of this public health challenge [1]. The early stages of life represent a critical period for obesity development, with childhood-onset obesity significantly increasing risks for metabolic disorders, cardiovascular diseases, and type 2 diabetes in adulthood [2, 3].

Beyond the well-established medical risks, childhood obesity is accompanied by significant psychosocial consequences that profoundly affect children’s emotional and behavioral development. Children and adolescents with obesity experience higher rates of low self-esteem, depression, anxiety, eating-related disorders, and body dissatisfaction compared to their normal-weight peers [3]. Recent comprehensive studies involving over 114,000 individuals reveal that mental health comorbidities affect approximately 35% of children and adolescents with obesity, with anxiety disorders (31.3%), depression (24.3%), and eating disorders (12.9%) being most prevalent [4]. The bidirectional relationship between childhood obesity and eating disorders is particularly concerning, with bulimia nervosa and binge eating disorders being most frequently observed in children with obesity, both characterized by abnormal eating or weight-control behaviors [5]. Furthermore, childhood trauma significantly compounds these psychological challenges, with food addiction accounting for up to 45% of the variance in the relationship between childhood trauma and body mass index, suggesting that maladaptive coping mechanisms through eating behaviors serve as responses to psychological distress [6].

Shame and guilt are emotions that arise in social contexts and regulate individuals’ thoughts and behaviors. They serve to discourage socially unacceptable actions and promote morally appropriate behaviors [7]. These emotions are directly linked to a person’s self-perception and social relationships, and are referred to as self-conscious emotions [8]. Shame, in particular, is associated with a negative evaluation of the self as a whole and is described as a painful emotion. This leads to the perception of the self as inadequate, unsuccessful, and worthless, often prompting reactions, such as the desire to shrink away or hide in social situations [9]. In contrast, guilt focuses more on an individual’s actions and triggers remorse for wrongdoing. The feeling of guilt encourages individuals to correct their mistakes and avoid similar errors in the future [10]. Understanding these emotions requires distinguishing between momentary emotional experiences and stable personality characteristics, as both play distinct roles in chronic conditions, such as obesity. State shame and guilt refer to situation-specific emotional experiences, whereas shame-proneness and guilt-proneness represent stable traits reflecting individual differences in responses to transgressions [9, 11]. Shame-proneness involves global negative self-evaluations, while guilt-proneness focuses on evaluations of specific behaviors [9]. Such trait-level predispositions are particularly relevant in chronic conditions like obesity, where repeated social evaluations may activate these emotional tendencies.

These trait-level predispositions become particularly salient during adolescence, a developmental period marked by heightened self-consciousness and social evaluation. During this phase, shame shows strong associations with depression and anxiety disorders and can lead to social phobia, social isolation, and avoidance behaviors [9, 12]. The mechanisms underlying these associations have been well-articulated; according to Lewis’ emotional displacement theory, individuals manage shame by shifting it to more manageable emotions, such as sadness and anger, which, over time, can evolve into depression [13]. Reimer suggests that individuals prone to shame are more vulnerable to psychopathology, as shame triggers feelings of hopelessness and heightened self-consciousness, thereby increasing the risk of internalizing disorders [14]. Empirical evidence supports these theoretical models. Research by Muris and Meesters (2012) demonstrates that guilt and shame in adolescents are associated with trauma, internalizing problems, anxiety, and risky behaviors, with shame showing positive relationships with both internalizing and externalizing symptoms [15]. A recent meta-analysis found that when controlling for their shared variance, only shame-proneness remained significantly associated with anxiety symptoms, whereas guilt-proneness showed no significant association, suggesting that guilt’s maladaptive effects may stem primarily from its overlap with shame [16, 17]. Shame-proneness has also been linked to eating disorder pathology, with clinical samples showing significantly higher levels of shame-proneness compared to non-clinical samples, and shame-proneness demonstrating strong associations with body dissatisfaction, low self-esteem, and psychological maladjustment in both eating disorder patients and at-risk populations [18]. In contrast, guilt appears to be protective against externalizing problems in adolescents, with a lack of guilt contributing to increased behavioral issues [19, 20].

In relation to obesity, weight-related shame can lead individuals to self-criticism, social isolation, and inward coping responses, such as avoidance of problems [21, 22]. As a result, shame may have a significant impact on the emotional well-being of individuals with obesity. In contrast, weight-related guilt may promote more proactive and corrective coping strategies [23]. These strategies may involve problem-solving behaviors, such as weight control and changes in eating habits, making weight management more achievable [21, 22]. While this theory has been supported by some studies in adult populations [24, 25], and recent systematic reviews have documented the psychological correlates of shame and guilt in pediatric obesity [26], to our knowledge, there are no studies in the existing literature that have evaluated the relationship between shame and guilt with physical activity and eating behaviors in children with obesity.

The aims of this study are: (a) to compare feelings of shame and guilt between children with and without obesity, (b) to evaluate the relationship between shame and guilt with physical activity levels, and (c) to determine the relationship between shame and guilt with eating behaviors. Understanding how coping responses through shame and guilt influence individuals with obesity could provide valuable insights for therapeutic interventions aimed at improving emotional well-being and promoting effective weight management strategies.

Materials and methods

Study design and participants

This case–control study was conducted through face-to-face surveys among children aged 10–18 years at the pediatric endocrinology clinic from January 2023 to July 2023. Obesity group inclusion criteria comprised children aged 10–18 years with BMI > 2 SDS according to Neyzi [27] reference charts for Turkish children who were treatment-naive, having received no prior formal interventions for obesity management. While participants presented to the pediatric endocrinology clinic for various reasons, we did not specifically assess their motivation for seeking obesity treatment or their readiness to engage in weight management interventions. In addition, a comparison group was formed with children aged 10–18 years who were typically developing and did not meet criteria for obesity. General inclusion criteria required participants to be between 10 and 18 years of age and possess adequate reading skills and language comprehension necessary to complete the self-report questionnaires independently. All children and their legal guardians were comprehensively informed about the study purpose, procedures, and their rights as participants, and written informed consent was obtained from all participants and their legal guardians prior to study participation. Participants did not receive any financial incentives or awards for their participation. The study was conducted in accordance with the Declaration of Helsinki and received approval from the Ethics Committee of Basaksehir Cam and Sakura City Hospital (Decision Number 57, 2023).

Procedure

Data collection was conducted between January and July 2023 at the Pediatric Endocrinology Department of Istanbul Basaksehir Cam and Sakura City Hospital. Potential participants with obesity were identified during routine clinical visits to the pediatric endocrinology clinic, while control group participants were recruited from children accompanying patients or through hospital staff referrals. Initial screening was performed to assess eligibility criteria including age range, BMI status and cognitive capacity for questionnaire completion.

Data collection sessions were conducted in a private room within the clinic to ensure confidentiality and minimize distractions. Each session lasted approximately 45–60 min and was supervised by research personnel. Participants completed the questionnaires in the following standardized order: demographic information form, Test of Self-Conscious Affect for Adolescents (TOSCA-A), Dutch Eating Behavior Questionnaire (DEBQ), Physical Activity Questionnaire for Children (PAQ-C), and Revised Children’s Anxiety and Depression Scale (RCADS). Research staff were available to clarify questions and provide assistance while maintaining neutrality to avoid influencing responses.

Measures

Demographic and clinical variables

A comprehensive demographic questionnaire collected information on participant age, gender, family income level (categorized as low, middle, or high income), family structure (living together vs. separated parents), BMI standard deviation scores (SDS), psychiatric referral status, and average daily screen time in hours.

Test of self-conscious affect for children (TOSCA-A)

The TOSCA-A consists of 15 scenarios (10 negative and 5 positive) depicting everyday situations that adolescents might encounter. Each scenario is followed by response options that assess various self-conscious emotions, including guilt-proneness, shame-proneness, detachment, externalization, alpha pride, and beta pride [9]. In the current study, only the response items assessing guilt and shame were utilized for analysis. Participants rate each response option using a five-point Likert scale ranging from 1 (not likely) to 5 (very likely) to indicate the likelihood of responding in the depicted manner. For example, a scenario might describe a social mistake, with shame responses reflecting global negative self-evaluation and guilt responses focusing on remorse about the specific behavior. Scores for shame and guilt subscales are calculated by summing ratings across relevant items for each emotion, with higher scores indicating greater proneness to these specific emotional responses. No total composite score is calculated as each subscale represents a distinct emotional construct. The validity and reliability study of the Turkish translation of TOSCA-A was undertaken by Algedik et al. [28]. Cronbach’s α for the Turkish version were 0.81 for Shame, 0.88 for Guilt. In the current study, Cronbach’s α values were 0.88 for Shame and 0.87 for Guilt, indicating good internal consistency.

Physical activity questionnaire for older children (PAQ-C)

The PAQ-C is a self-reported instrument used to assess general levels of physical activity in children and adolescents. The questionnaire consists of ten items, of which nine are utilized to calculate the overall physical activity score. The tenth item assesses whether the child engaged in normal activity during the previous week despite being sick or experiencing other interference, but this item is not included in the activity score calculation. The first item presents a checklist of physical activities along with an “Other” category, rated on a five-point scale ranging from 1 (no activity) to 5 (7 times or more per week). The remaining eight items assess physical activity participation across various time periods throughout the week, including physical education classes, recess activities, lunch-time activities, after-school activities, evening activities, weekend activities, general self-assessment of activity level compared to peers, and daily activity frequency for each day of the previous week. Each item is scored on a five-point scale, with higher scores indicating greater physical activity levels. The total PAQ-C score represents the arithmetic mean of the nine items used for scoring, where 1 indicates low physical activity levels and 5 indicates high physical activity levels [29]. The validity and reliability study of the Turkish translation of PAQ-C was undertaken by Erdim et al. [30]. Cronbach’s alpha for the Turkish version was 0.77. In the current study, Cronbach’s α was 0.91, demonstrating excellent internal consistency.

Dutch eating behavior questionnaire (DEBQ)

The Dutch Eating Behavior Questionnaire (DEBQ) was developed by Van Strien and colleagues in 1986 [31]. The instrument comprises 33 items distributed across three subscales: emotional eating (eating in response to negative emotions), external eating (eating triggered by food-related external cues), and restrained eating (conscious restriction of food intake for weight control purposes). Items are rated on a five-point Likert scale ranging from 1 (never) to 5 (very often), with an additional “not applicable” option. The DEBQ demonstrates good psychometric properties, including adequate internal consistency and construct validity. The validity and reliability of the scale for adolescent populations in Turkey were specifically established by Demirdogen et al. [32]. Cronbach’s alpha values for the Turkish version range from 0.86 to 0.95. In the current study, Cronbach’s α values ranged from 0.83 to 0.94 across subscales, indicating good to excellent internal consistency.

Revised Children’s Anxiety and Depression Scale (RCADS)

The Revised Children’s Anxiety and Depression Scale (RCADS) is a 47-item scale that evaluates anxiety and depressive disorder symptoms [33]. It has 5 sub-dimensions. There are 7 items addressing separation anxiety disorder, 9 items addressing social phobia, 6 items addressing generalized anxiety disorder, 9 items addressing panic disorder, 6 items addressing obsessive–compulsive disorder, and 10 items addressing major depression. Questions are scored using 4 points (0 = never, 1 = sometimes, 2 = often, 3 = always). A study of its validity and reliability in a clinical sample in Turkey was conducted in 2017 by Gormez et al. [34]. Cronbach’s alpha for the Turkish version was 0.95. In the current study, Cronbach’s α values ranged from 0.73 to 0.89 across subscales, indicating acceptable to good internal consistency.

Statistical analysis

Statistical evaluation of the data was performed using SPSS (Statistical Package for the Social Sciences) version 26 (IBM Corp., Armonk, NY, USA). Frequency and percentage values were provided for categorical variables, while descriptive statistics including mean, standard deviation, minimum, and maximum values were calculated for continuous variables.

Data normality was assessed using the Shapiro–Wilk test for all continuous variables in the study. Based on normality test results, parametric tests were applied for normally distributed data, while non-parametric tests were used for data that did not follow normal distribution. Group comparisons and demographic characteristics were analyzed using the independent sample t test for normally distributed data and the Mann–Whitney U test for non-normally distributed data.

Correlation analyses between continuous variables were performed using Spearman's Rho test due to the ordinal nature of the scale measurements. Chi-square tests were utilized for categorical variable comparisons between groups. A p value of less than 0.05 was considered statistically significant for all analyses. All primary outcome measures (TOSCA-A, DEBQ, PAQ-C, and RCADS) were complete for all 190 participants. One participant had missing data for family income and was excluded only from the family income comparison (Table 1).

Table 1.

Demographic, socioeconomic, and clinical characteristics of control and participants with obesity

	Control (n = 90)	Child with obesity (n = 100)	χ2/Z	p value
Age
Mean ± SD	13.32 ± 2.17	13.97 ± 2.19	− 1.850	.064
M (Min–max)	13(10–18)	14(10–18)
Sex
Girl n (%)	67 (74.4)	74 (74.0)	.005	.944
Boy n (%)	23 (25.6)	26 (26.0)
Family income
Low income n (%)	14 (15.7)	20 (20.0)	3.733	.292
Middle income n (%)	64 (71.9)	75 (75.0)
High income n (%)	11 (12.4)	5 (5.0)
Family status
Separated n (%)	4 (4.4)	12 (12.0)	3.506	.061
Living together n (%)	86 (95.6)	88 (88.0)
BMI sds
Mean ± SD	− 0.14 ± 0.87	2.97 ± 0.67	− 11.890	.000*
M (Min–max)	− 0.14 (− 2.39 to 1.71)	2.94 (2–4.72)
Screen time
Mean ± SD	3.80 ± 2.59	5.3 ± 3.3	− 3.884	.000*
M (Min–max)	3 (0.5–18)	5 (0–20)
Psychiatric referral status
No n (%)	78 (86.7)	83 (83.0)	.492	.483
Yes n (%)	12 (13.3)	17 (17.0)

Mean refers to the average, SD stands for standard deviation, Min indicates the minimum value, Max represents the maximum value, and M corresponds to the median. The p value (p) is derived from the Mann–Whitney U test

*p < 0.05 denotes a statistically significant difference between the groups

Results

The demographic characteristics of the participants and the comparison between the control group and the group of children with obesity are presented in Table 1. The study included 100 children with obesity and 90 children without obesity as the control group. A chi-square test was used to analyze differences in demographic characteristics between the groups.

In terms of gender, 74% of the children in both the control and the group with obesity were female, and 26% were male, with no significant difference between the groups (p = 0.944). The children’s ages ranged from 10 to 18 years in both groups, with a mean of 13.32 ± 2.17 years in the control group and 13.97 ± 2.19 years in the group with obesity, showing no significant difference (p = 0.064).

Family income levels also showed no significant difference between the groups (p = 0.292). In the control group, 15.7% had low incomes, 71.9% had middle incomes, and 12.4% had high incomes. In the group with obesity, 20% had low incomes, 75% had middle incomes, and 5% had high incomes.

Regarding family structure, 4% of the children in the control group had separated parents, compared to 12% in the group with obesity. Most children in both groups lived with both parents (96% in the control group and 88% in the group with obesity), with no significant difference in family structure between the groups (p = 0.061).

There was a significant difference in BMI SDS between the two groups, with a mean of −0.14 ± 0.87 in the control group and 2.97 ± 0.67 in the group with obesity (p < 0.001).

Screen time was also significantly different between the groups. The control group had a mean screen time of 3.80 ± 2.59 h per day, while the group with obesity reported 5.3 ± 3.3 h per day (p < 0.001).

Table 2 presents a comparison of the TOSCA-A, DEBQ, PAQ-C, and RCADS scores between children with obesity and the control group. No significant differences were found for shame and guilt scores between the group with obesity and the control group (p > 0.05).

Table 2.

Comparison of emotional, behavioral, and physical activity measures between control and groups with obesity

	Control (n = 90)		Child with obesity (n = 100)
	Mean ± SD	M (Min–max)	Mean ± SD	M (Min–max)	Z/t (df)	p
TOSCA-A
Shame	58.22 ± 10.60	60 (30–74)	56.14 ± 12.25	59 (23–74)	− 1.019	.308
Guilt	30.67 ± 11.08	28 (13–57)	32.94 ± 11.28	31 (13–60)	− 1.586	.113
Dutch eating behavior questionnaire (DEBQ)	84.34 ± 27.01	84 (36–156)	97.22 ± 24.94	98 (49–182)	− 3.416 (188)	.001*
Emotional eating	29.68 ± 16.14	24 (13–78)	36.55 ± 16.69	38 (13–78)	− 2.878 (188)	.004*
Restrictive eating	23.14 ± 9.16	21 (10–48)	27.21 ± 8.16	27 (10–47)	− 3.236 (188)	.001*
External eating	31.52 ± 9.87	32 (10–55)	33.46 ± 9.27	34 (10–57)	− 3.216 (188)	.165
Physical activity questionnaire for children (PAQ-C)	2.56 ± 0.86	2.5 (1.1–4.4)	2.11 ± 0.72	2.03 (1–3.9)	− 3.502	.000*
Out-of-school activity	2.41 ± 0.97	2.4 (1–4.9)	2.03 ± 0.82	2 (1–4)	− 2.733	.006*
School	2.86 ± 0.96	2.7 (1–5)	2.27 ± 0.84	2.3 (1–4.7)	− 4.290	.000*
Revised child anxiety and depression scale (R-CADS)	46.24 ± 28.59	45(0–118)	58.40 ± 30.5	53(3–132)	− 2.693	.007*
Total anxiety	37.74 ± 22.26	34(0–95)	46.26 ± 24.14	41(0–105)	− 2.293	.022*
Separation anxiety	5.09 ± 4.22	4(0–19)	5.73 ± 4.38	4(0–18)	− 1.085	.278
Social phobia	11.16 ± 6.58	11(0–27)	13.42 ± 7.40	13(0–27)	− 1.908	.046*
Obsessive–compulsive	5.88 ± 4.23	5(0–18)	7.78 ± 4.34	7(0–18)	− 3.046	.002*
Panic disorder	7.89 ± 7.32	5(0–26)	10.08 ± 7.80	8(0–27)	− 2.115	.034*
Generalized anxiety	7.73 ± 4.89	7(0–17)	9.25 ± 4.56	8(0–18)	− 2.076	.038*
Major depression	9.88 ± 7.35	9(0–28)	13.58 ± 7.73	13(0–30)	− 3.413	.001*

^*A p value less than 0.05 (p < 0.05) denotes a statistically significant difference between the groups

Emotional eating scores were significantly higher in the group with obesity (p = 0.004), as were restrictive eating scores (p = 0.001). No significant difference was found in external eating scores (p = 0.165). The total DEBQ score also showed a significant difference between groups (p = 0.001), with higher scores in the group with obesity.

Physical activity scores showed significant differences between groups (p < 0.001), with lower physical activity levels in children with obesity both overall and in school and out-of-school contexts.

Anxiety and depression scores, including total anxiety and depression scores, were significantly higher in the group with obesity (p < 0.05).

Table 3 illustrates the relationship between the TOSCA-A and DEBQ scores in both the group with obesity and the control group. In the control group, both shame and guilt were significantly associated with DEBQ scores (p < 0.05). A positive, moderate correlation was found between shame and the total DEBQ score (r = 0.430). Similarly, shame was positively correlated with emotional eating (r = 0.313), restrictive eating (r = 0.257), and external eating (r = 0.378).

Table 3.

Correlation between shame, guilt, and eating behaviors in control and groups with obesity

	Control (n = 90)				Child with obesity (n = 100)
	Shame		Guilt		Shame		Guilt
	r (%95CI)	p	r (%95CI)	p	r (%95CI)	p	r (%95CI)	p
Dutch Eating Behavior Questionnaire (DEBQ)	.430 (.239; .586)	.001	.419 (.226; .580)	.001	.124 (− .080; .318)	.219	.284 (.087; .460)	.004
Emotional eating	.313 (.107; .493)	.003	.350 (.148; .524)	.001	.078 (− .126; .276)	.440	.282 (.084; .458)	.005
Restrictive eating	.257 (.046; .445)	.015	.389 (.192; .556)	.001	.095 (− .110; .291)	.349	.060 (− .144; .259)	.553
External eating	.378 (.180; .547)	.001	.257 (.046; .445)	.015	.083 (− .121; .280)	.411	.187 (− .016; .375)	.063

p < 0.05 indicates a statistically significant difference between the groups

A positive, moderate correlation was also found between guilt and the total DEBQ score (r = 0.419). Guilt was positively associated with emotional eating (r = 0.350), restrictive eating (r = 0.389), and external eating (r = 0.257). These results indicate that as guilt scores increase, DEBQ scores also increase.

In the group with obesity, no significant correlation was found between shame and any of the DEBQ scores (p > 0.05). However, guilt was positively correlated with the total DEBQ score (r = 0.284) and emotional eating (r = 0.282), though these correlations were low. No significant association was found between guilt and restrictive or external eating scores in the group with obesity (p > 0.05).

Table 4 illustrates the relationship between the TOSCA-A and PAQ-C scores in both the group with obesity and the control group. In the control group, there was no statistically significant relationship between shame and physical activity levels (p > 0.05). However, a negative, low-level correlation was found between guilt and physical activity in school settings (r = − 0.233). No significant relationship was observed between guilt and total physical activity or out-of-school physical activity levels (p > 0.05).

Table 4.

Correlation between shame, guilt, and physical activity contexts in control and groups with obesity

	Control (n = 90)				Child with obesity (n = 100)
	Shame		Guilt		Shame		Guilt
	r (%95CI)	p	r (%95CI)	p	r (%95CI)	p	r (%95CI)	p
Physical activity questionnaire for children (PAQ-C)	− .009 (− .222; .204)	.933	− .178(− .377; 036)	.093	.052 (− .151; .252)	.604	.002 (− .200; .204)	.986
Out-of-school activity	.028 (− 186; .239)	.796	− .121 (− .326; 094)	.254	.070 (− .134; .269)	.486	.070 (− .134; .269)	.482
School	− 054 (− .264; .161)	.612	− .233 (− .425; − .021)	.027	.050 (− .154; .249)	.624	.050 (− .154; .249)	.364

p < 0.05 indicates a statistically significant difference between the groups

In the group with obesity, no statistically significant correlations were found between either shame or guilt and any of the physical activity levels (p > 0.05).

Discussion

The study examined the relationship between feelings of shame and guilt with physical activity levels, eating attitudes, and screen time in individuals aged 10–18. It was found that individuals in the group with obesity, compared to the control group, exhibited more problematic eating behaviors (greater emotional eating, external eating, and restrictive eating), lower levels of physical activity, longer screen time, and higher levels of anxiety and depressive symptoms. In terms of eating behaviors, there was a significant relationship between feelings of shame and guilt and eating behaviors (emotional eating, external eating, and restrictive eating) in the control group. However, in the group with obesity, only guilt was found to be associated with emotional eating behavior. No significant relationship was found between feelings of shame and guilt and physical activity levels among children with obesity.

Studies evaluating shame and guilt emotions in children with obesity remain limited, yet consistently demonstrate that individuals with obesity experience higher levels of these emotions. In a qualitative study by Øen et al., the majority of adolescents with obesity reported experiencing shame and self-blame emotions, which the authors interpreted as barriers that hindered adolescents from seeking help and making lifestyle changes [35]. Research from Sweden involving adolescents aged 15–17 found that individuals with obesity experienced significantly more shame compared to their normal-weight and overweight peers [36]. Adult population studies have yielded similar results, demonstrating that individuals with obesity report elevated shame and guilt levels, though effect sizes were small [37]. Kirk et al.’s qualitative research emphasized the complexity of weight loss efforts among adults with obesity and the cultural, social, and institutional barriers they encountered. Particularly noteworthy was that participants attributed their weight status to personal responsibility despite these external obstacles, expressing profound guilt and shame emotions [38]. Although the literature generally shows that individuals diagnosed with obesity experience higher levels of shame and guilt, this study found that children with obesity did not report significantly higher levels of shame or guilt compared to their non-obese peers. This finding aligns with recent systematic evidence from Czepczor-Bernat et al., who demonstrated that relationships between body- and weight-related emotions in pediatric obesity populations are complex and influenced by multiple contextual factors rather than obesity status alone [26]. We believe there may be several reasons for the divergence of our results from previous studies. First, while other studies have assessed self-conscious emotions using body-focused scales, we evaluated general feelings of shame and guilt in this study. Obesity affects individuals not only through body image perceptions. Friedman and Brownell identified several factors that may determine the negative psychological outcomes for individuals with obesity, including social class, degree of obesity, and body image dissatisfaction [39]. Body image is the psychological experience of an individual regarding the appearance and function of their body, and it represents one aspect of a person’s mental representation of themselves [40, 41]. Second, the literature shows that individuals with obesity who are seeking treatment tend to experience higher rates of psychopathologies compared to those who are not seeking treatment [42–45]. We did not assess participant’ motivation for seeking treatment or their readiness for weight management, which may vary considerably among individuals presenting to clinical settings. The lack of distinction between individuals in our obesity group based on whether they were actively seeking treatment may have hindered our ability to differentiate between the groups.

While evaluating the association between physical activity levels, screen time, and obesity, a study conducted among young adolescents in Poland demonstrated that low levels of physical activity and high screen time increase the likelihood of being overweight or obese [46]. Similarly, a study in Iran involving adolescents aged 12–16 found that a lack of moderate and high physical activity was significantly associated with a higher likelihood of overweight and obesity [47]. This study aligns with these findings, showing that physical activity levels in the children with obesity were significantly lower, while screen time was higher compared to the control group. These results provide strong evidence that low physical activity and higher screen time increase the risk of obesity in adolescents, even across different geographical and cultural contexts [48].

Despite these clear behavioral differences between groups, the relationship between self-conscious emotions and physical activity patterns revealed unexpected findings. It has been theorized that individuals experiencing feelings of shame may engage in more avoidance behaviors, leading to lower levels of physical activity, while those experiencing guilt may exhibit higher levels of physical activity as a “compensatory behaviour” [20, 35]. There are limited studies that evaluate the relationship between physical activity and feelings of shame and guilt in adults diagnosed with obesity. Research conducted with adults diagnosed with obesity has shown that shame is associated with a tendency to avoid social contexts, which may lead individuals experiencing shame to avoid physical activity. In contrast, guilt has been linked to an increase in physical activity as individuals attempt to “correct” poor weight control efforts [24, 25]. Contrary to the findings from studies on adults, this study did not find a significant relationship between feelings of shame or guilt and physical activity levels in the children with obesity group. This inconsistency suggests that developmental or contextual differences may influence how children and adults experience and respond to these emotions. The lack of a significant relationship between shame, guilt, and physical activity in children may be due to differences in cognitive and emotional processing or the various social and environmental factors that shape these behaviors in different age groups.

The findings indicate that feelings of shame in children within the comparison group are moderately and positively associated with general eating behaviors and their subdimensions. This result aligns with the findings of Nechita et al. (2021), whose meta-analysis reported that self-evaluative negative emotions, such as shame and guilt, are significantly associated with eating disorder symptoms. Specifically, shame has been observed to contribute to maladaptive eating behaviors, such as emotional eating and external eating [49]. This suggests that shame is a significant emotional factor influencing eating behaviors and disorders in children and adolescents. In this study, shame scores in the comparison group were found to have significant positive correlations with the total score and subscales of the Dutch Eating Behavior Questionnaire (emotional eating, restrictive eating, and external eating). This indicates that shame may play a role in regulating eating behaviors, and as feelings of shame increase, maladaptive eating behaviors may also intensify. These findings support Goss and Gilbert’s model, which explores the role of shame in eating disorders. Goss and Gilbert propose that shame, particularly shame related to eating and body image, can lead to negative self-evaluations that drive individuals to control their eating behaviors, ultimately contributing to the persistence of eating disorders [50]. This theoretical framework is further supported by recent longitudinal evidence from Uddenberg et al., who demonstrated through network analysis that shame, guilt, and pride show distinct and stable associations with different patterns of disordered eating behaviors in youth, with shame uniquely associated with weight concerns and guilt more closely linked to binge-eating-related behaviors [51]. Emotional experiences such as shame and guilt provide important insights into how children regulate their eating behaviors. Our findings reveal that as shame scores increase, both emotional eating and external eating scores rise as well. This suggests that when children experience shame, they are more likely to engage in emotional eating and become more sensitive to external cues that trigger eating. Similarly, guilt was found to be positively associated with eating behaviors, particularly with emotional and restrictive eating. These findings can be explained by the notion that guilt serves a socially adaptive function [9], where individuals may attempt to engage in corrective behaviors, such as restricting their eating, when they feel guilty.

In this study, children with obesity showed no significant relationship between shame and eating behaviors, while guilt demonstrated only a modest positive association with emotional eating. This pattern partially aligns with previous literature and warrants theoretical consideration. The systematic review by Blythin et al. on shame and guilt demonstrated that shame is more strongly associated with the severity of eating behaviors, while the impact of guilt remains more limited [52]. Similarly, Gupta et al. suggested that chronic shame is more strongly associated with eating disorder symptoms than general negative emotions, emphasizing the distinct and more significant role that long-term feelings of shame play in the development and persistence of disordered eating behaviors [53]. According to Tangney and Dearing's theory, shame is an emotion in which a person negatively evaluates their entire self, leading them to internalize the feeling rather than express it outwardly. As a result, individuals may develop defense mechanisms such as social isolation, avoidance, or other coping strategies to deal with the emotional distress [9]. This theoretical framework may explain why shame was not directly reflected in eating behaviors among children with obesity in this study, as individuals might use avoidance or internalization as coping mechanisms, preventing an immediate or overt connection between shame and their eating habits. This interpretation is supported by research demonstrating that immature defense mechanisms, including avoidance and dissociation, can mediate the relationship between shame and psychopathological outcomes, suggesting that these defensive strategies may alter how shame-related emotions are expressed behaviorally [54].

In this study, it was found that anxiety and depression levels in children with obesity were significantly higher compared to non-obese children. This result aligns with the existing literature, which suggests that obesity in children is associated with increased psychosocial difficulties [3]. Factors such as social stigma, body dissatisfaction, and peer bullying may contribute to the development of anxiety and depression in children with obesity [55]. Therefore, to support the mental health of children with obesity, it is crucial to implement psychosocial interventions alongside multidisciplinary approaches.

Strengths and limitations

This study has several limitations. First, the sample size is limited, which may affect the generalizability of the findings. In addition, the cross-sectional design of the research makes it difficult to determine causal relationships; longitudinal studies could provide better insights into changes and interactions over time. This study included treatment-naive participants with obesity who had not previously received formal obesity interventions. However, we did not assess participants’ motivation for seeking treatment or their readiness for weight management, which may vary considerably among individuals presenting to clinical settings. This heterogeneity in treatment motivation may have influenced psychological variables, such as shame and guilt, potentially affecting the relationships observed in this study. Variables such as eating behaviors, physical activity levels, and emotional states were assessed through self-report, which carries the risk of being influenced by factors, such as social desirability and bias. Furthermore, the cultural and social context in which the study was conducted may affect the validity of the findings, as perceptions of shame and guilt can vary across cultures. These limitations should be considered in future research, and more comprehensive studies are necessary.

Despite these limitations, this study fills an important gap in the literature by investigating the impact of shame and guilt on eating behaviors, physical activity levels, and screen time among children aged 10–18. Through comparisons between groups with obesity and non-obese groups, the study provides an opportunity to examine the effects of different eating behaviors and psychological conditions. Moreover, exploring the relationships between various eating behaviors (emotional, external, and restrictive eating) and feelings of shame and guilt helps deepen our understanding of how these emotions influence eating habits. In addition, examining the connection between physical activity levels and shame and guilt offers a new perspective to the existing body of research in this area.

Conclusion

This study highlights the complex interplay between emotions, eating behaviors, physical activity, and screen time in children with and without obesity. Key findings indicate that while shame and guilt influence eating behaviors differently in children with obesity and non-obese children, these emotions showed minimal associations with physical activity, except for a negative relationship between guilt and school-based activity in controls.

These results suggest that emotional well-being should be a central focus of interventions targeting childhood obesity. Psychological approaches that address guilt and emotional eating may enhance the effectiveness of obesity management programs. Future research is needed to better understand how developmental and contextual factors shape the role of shame and guilt in adolescents’ behaviors and to explore strategies that effectively address emotional challenges in children with obesity.

What is already known on this subject?

Previous research has identified that children and adolescents with obesity often experience higher rates of self-conscious emotions, particularly shame and guilt, which are linked to maladaptive coping strategies and problematic eating behaviors. In addition, low physical activity and high screen time have been established as risk factors contributing to obesity in young populations.

What this study adds?

This study uniquely explores the differential associations of shame and guilt with eating patterns and physical activity in children with obesity and without obesity, suggesting that while guilt correlates with emotional eating in children with obesity, shame plays a more significant role in children without obesity. The findings underscore the necessity of integrating psychological support targeting these emotions into childhood obesity interventions.

Author contributions

Yasin Caliskan: Project administration, conceptualization, funding acquisition, original draft writing, reviewing and editing, resources, statistical analysis. Zumrut Kocabey Sutcu: Conceptualization, funding acquisition, resources. Emel Hatun Aytaç Kaplan: Original draft writing, statistical analysis.

Funding

The authors received no financial support for the research, authorship, or publication of this article.

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval

The study was conducted following the Declaration of Helsinki and was approved by the Ethics Committee of Basaksehir Cam and Sakura City Hospital (Decision Number 57, 2023).

Consent to participate

Informed consent to participate in the study was obtained in writing from all participants and their legal guardians.

Consent for publication

Consent for publication has been obtained in writing from all participants (or from a legal parent or guardian in the case of children).

Competing interests

The authors declare no competing interests.