Abstract
Background and aims
Stress-related to self-isolation during the COVID-19 pandemic has shown a strong correlation with issues in the diet and health of the population. In this study, we aimed to relate the perceived stress of a group of Ecuadorian adults with emotional eating.
Methods
Cross-sectional design study. We applied validated questionnaires of perceived stress and emotional eating to adults of both sexes who virtually completed a form between the months of January and March 2021. The analyzes were carried out using Chi2 statistical tests, Student's t-tests and a multiple linear regression model., the analyzes were performed using the statistical software R.
Results
The sample was composed of 2333 participants, the median age was 25 years (interquartile range 21–37 years). Females reported more perceived stress than males (77.91% vs. 22.09%). Nearly 64% of participants who displayed perceived stress were emotional eaters. A statistically significant association was found between the emotional eating score and perceived stress (p < 0.001), the effect was an elevation of 0.44 points in the emotional eating score for each stress point perceived. For each unit increase in BMI the emotional eating score increased 0.26 units (p < 0.001) and for each unit increase in age the emotional eating score decreased by 0.27 units (p = 0.03).
Conclusions
It is concluded that stress is associated to emotional eating. Dietary intake that responds to emotions and not to physiological hunger may have long-term problems related to unhealthy diet. It is recommended to consider stress and emotional eating in the nutritional care process of people.
Keywords: Emotional eating, Perceived stress, COVID-19, Ecuadorian adults
1. Introduction
SARS-CoV-2, the novel coronavirus responsible for COVID-19, was identified in China at the end of 2019. Due to its high transmissibility and infectivity, on the 11th of March 2020, the World Health Organization (WHO) declared COVID-19 a pandemic [1]. After this declaration, a large part of the nations around the world implemented measures of social isolation as a measure to stop the spread of SARS-CoV-2 [2]. Social distancing and home isolation can produce changes in eating behaviors, food intake, and physical activity patterns, thus influencing body weight and overall health and wellbeing [3].
Ecuador culminated its first year of the pandemic with around 60,000 excess deaths and 340 deaths per 100,000 inhabitants, positioning it as the second South American country most affected by the pandemic only behind Peru, which registered 560 deaths per 100,000 inhabitants [4,5]. The full morgues and the oversaturation of the health system was soon a cause for concern in all the inhabitants [[6], [7], [8]].
As with any global catastrophe, one area of impact that requires special attention is mental health. Several studies have concluded the deleterious effects on the mental health of citizens subjected to the stress of the pandemic, but also social distancing [9,10]. During quarantine, people have been found to experience twice the rate of mild to severe mental health disorders compared to rates reported prior to quarantine [11]. In addition, a considerable increase in anxiety rates has been reported in countries such as China [12]. However, according to the authors, this information was not enough to conclude that the presence of psychological symptoms is a product of confinement, and that it is necessary to evaluate the general population to reach such conclusions [13].
In this sense, a recent meta-analysis concluded that stress can lead to the interruption of normal eating behaviors, although the strength of this association is unknown. This same study concluded that stress increases the consumption of unhealthy foods [14]. Thus, lack of sleep, decreased physical activity, and eating in response to stress are behaviors related to weight gain during quarantine [15]. Therefore, eating habits driven by emotions and stress, which resemble addictive behaviors, are considered a risk factor for overweight and obesity [16]. In this context, the terms “emotional eating” (EE) (or “comfort eating”) have been used to reflect the tendency to eat in response to emotions rather than feelings of hunger or satiety [17].
Obesity is considered a biological determinant of EE. In a recent study conducted in the USA During COVID-19 (n = 123), respondents who reported weight gains of 2.3–4.5 kg (22% of the sample) also suffered emotional eating behaviors [18]. In a study made up of a sample of Mexican youth, depressive symptoms were associated with higher levels of EE, and higher emotional eating predicted a higher body weight [19].
For healthcare personnel, it is very important to study the relationship between stress and emotional eating [18] since the consequences of excess weight are related to a deterioration of the immune system, which in turn is produced for chronic diseases, inflammation, endothelial dysfunction and mitochondrial dysfunction. The vulnerability to infections and inflammation in the adipose tissue generates metabolic alterations that can cause comorbidities such as dyslipidemia, hypertension, cardiovascular diseases, and diabetes. These comorbidities increase the risk of SARS-CoV-2 infection, as well as its severity and mortality [20].
The purpose of this cross-sectional study is to provide information on the relationship between perceived stress and emotional eating in a sample of Ecuadorian adults. The results gathered in this study will serve as the basis for further research.
2. Materials and methods
2.1. Study design and setting
The present study uses an observational, cross-sectional approach. Data was collected through an online survey questionnaire consisting of multiple-choice questions. Data collection took place between January 2021 and February 2021. During this time confinement was mandatory in Ecuador.
2.2. Participants and sampling
The sample consisted of 752 male and 1581 female adults (over 18 years old), totaling 2333 individuals. Participants were recruited through social networks such as Facebook, Instagram, Twitter, and WhatsApp, and by official email from the universities participating in the study. Non-probability convenience sampling was used for recruitment. The survey questionnaire was voluntary [21] and it was requested that it be answered by adults of both sexes over 18 years of age. 2870 surveys were complete (3.000 survey were sent, survey responsum rate: 95.6%), of which 2333 were selected after excluding surveys that contained information inconsistencies and those that were completed by minors.
2.3. Survey questionnaire
An online survey questionnaire designed to be completed by the participants was designed by four health and nutrition experts from two Ecuadorian universities (Escuela Superior Politécnica de Chimborazo and Universidad Estatal de Milagro). A pilot test was conducted where the survey was taken by 30 Ecuadorian adults (15 males and 15 females) aged 18–64 years old. The survey questionnaire was then reviewed and revised by the same four experts. After changes were implemented, the survey was loaded onto Google Forms and shared through different social networks. The survey consisted of four sections: Section 1, which included an introduction, objectives and an informed consent form; Section 2, which contained questions regarding socio-demographic information; Section 3, which included questions regarding health habits; and Section 4, which contained questions that aimed to assess emotional eating and perceived stress.
The socio-demographic variables considered for this study were sex (male, female), marital status: single (including divorced and widowed participants) and accompanied (including individuals who were married or had a cohabiting partner), education level (primary, secondary, higher), and ethnicity (white, mestizo, black, indigenous). The body mass index (BMI) was described through measures of central tendency.
2.4. Variables
2.4.1. Dependent variable
Emotional eating (EE) was considered as the main dependent variable. EE was assessed in the third section of the online survey using a validated questionnaire developed by Garaulet [22]. The EE questionnaire included 10 questions with four possible answers: 1) Never, 2) Sometimes, 3) Frequently, and 4) Always. The answers were assigned a score of 0, 1, 2, and 3 respectively, therefore, participants could obtain a total score between 0 and 30, which corresponded to the sum of the scores of the 10 questions. A lower score was considered representative of a healthier behavior, and vice versa. For descriptive purposes and in line with the author's methodology; EE was categorized into 4 different groups based on total score: 1) 0–5 as non-emotional eater 2) 6–10 as low emotional eater, 3) 11–20 as emotional eater, and 4) 21–30 as very emotional eater). For the statistical analysis, EE was operationalized as a continuous variable [22].
2.4.2. Independent variable
Perceived stress (PS) was considered as the main independent variable. Perceived stress was estimated using the Perceived Stress Scale (PSS), which assesses the degree at which a specific situation is seen as stressful by an individual [23]. The PSS consists of 14 items, with possible answers ranging from 0 (never) to 4 (very often). Individuals who undergo this assessment instrument can get a score ranging from 0 to 56, the higher the overall score, the higher the level of perceived stress [24]. For descriptive purposes, the variable PS was classified into two categories: stress and no stress. The median of PSS was used as the cut point to identify two groups: one without perceived stress (<median), and one with perceived stress (> or = median). For the statistical analysis, PS was operationalized as a continuous variable.
2.5. Statistical analyses
A descriptive analysis was performed based on the independent variable and the general characteristics of the study group. The statistical significance (p < 0.05) of the proportional difference in the univariate analysis was established using the chi2 tests for the categorical variables and the Mann Whitney U test for the continuous variables.
In order to assess the relationship between the dependent and independent variable, a multiple linear regression model was developed, including the emotional eating score as the dependent variable and the perceived stress score as the independent variable. To better understand the association between emotional eating and perceived stress we implemented a logistic regression model, using emotional eating and perceived stress as categorical variables. In order to include in the logistic model an outcome with two levels we grouped together individuals who were non or low emotional eaters and those who were emotional or very emotional eaters. Both models were adjusted for age (years), sex (male and female), marital status (single and accompanied), BMI (kg/m2) and ethnicity (white, black, mestizo and indigenous).All analyzes were performed using R version 4.0.1 and related packages [24].
2.6. Ethics approval and related considerations
The present study was carried out following the Declaration of Helsinki for working with humans and in accordance with the “Singapore Declaration on Research Integrity”. It was approved by the Ethics Committee in Human Research of the University of Cuenca, with an approval code 2019-232EO-I. All participants accepted and completed an informed consent form included at the beginning of the survey. Participants' responses were anonymous and confidential in accordance with Google's privacy policy, which can be found in English at https://policies.google.com/privacy?hl=en [25]. Participants were not allowed to provide their names or contact information. In addition, participants were able to stop participating in the study and leave the questionnaire at any stage before the submission process, their responses were not saved. Responses were saved only by clicking the “submit” button provided.
3. Results
2333 volunteers participated in the study, the population consisted for the most part of female participants (n = 1581, 67.8%), single (n = 1585, 67.9%), of mestizo ethnicity (n = 2173, 93.1%) and with more than 12 years of formal education (n = 1859, 79.7%). The median age was 25 years (interquartile range = 21–37) and the median BMI was 25.50 kg/m2 (interquartile range = 22.06–27.59). Female participants reported higher perceived stress (77.91%) than males (22.09%). Accompanied participants (74.09%) reported higher perceived stress in comparison with single, widowed, and divorced participants (25.91%). Finally, the mean age (23 years) of subjects who displayed perceived stress was lower than that of the subjects who did not show perceived stress (28 years). These differences were statistically significant (test: chi2, p < 0.001). Education level (test: chi2, p < 0.17), ethnicity (test: chi2, p < 0.051) and Body Mass Index did not show statistically significant differences (Table 1 ).
Table 1.
Socio-demographic characteristics of the study population according to perceived stress.
| Population description | Perceived stress |
Test stat. | P value | ||
|---|---|---|---|---|---|
| n (%) |
n (%) |
||||
| No | Yes | ||||
| 1183 (50.71) | 1150 (49.29) | Chi2 | <0.001 | ||
| Sex | n (%) | n (%) | n (%) | Chi2 | <0.001 |
| Female | 1581 (67.8) | 685 (57.9) | 896 (77.91) | ||
| Male | 752 (32.2) | 498 (42.1) | 254 (22.09) | ||
| Marital Status | n (%) | n (%) | n (%) | Chi2 | <0.001 |
| Single, widow, divorced | 748 (32.1) | 450 (38.04) | 298 (25.91) | ||
| Married | 1585 (67.9) | 733 (61.96) | 852 (74.09) | ||
| Education level | n (%) | n (%) | n (%) | Chi2 | 0.1737 |
| Primary | 39 (1.7) | 14 (1.18) | 25 (2.17) | ||
| Secondary | 435 (18.6) | 223 (18.85) | 212 (18.43) | ||
| University | 1859 (79.7) | 946 (79.97) | 913 (79.39) | ||
| Ethnicity | n (%) | n (%) | n (%) | Chi2 | 0.0516 |
| White | 67 (2.9) | 43 (3.63) | 24 (2.09) | ||
| Indigenous | 49 (2.1) | 22 (1.86) | 27 (2.35) | ||
| Mestizo | 2173 (93.1) | 1091 (92.22) | 1082 (94.09) | ||
| Afro-descendant | 44 (1.9) | 27 (2.28) | 17 (1.48) | ||
| Emotional eaters | n (%) | n (%) | n (%) | Chi2 | <0.001 |
| Non emotional eaters | 854 (36.6) | 582 (49.2) | 272 (23.65) | ||
| Low emotional eaters | 741 (31.8) | 387 (32.71) | 354 (30.78) | ||
| Emotional eaters | 561 (24.0) | 178 (15.05) | 383 (33.3) | ||
| High emotional eaters | 177 (7.6) | 36 (3.04) | 141 (12.26) | ||
| Perceived stress | Median (IQR) | Median (IQR) | Median (IQR) | Mann–Whitney U test | <0.001 |
| 18 (15,22) | 15 (11,17) | 22 (20,25) | |||
| Emotional eaters | Median (IQR) | Median (IQR) | Median (IQR) | Mann–Whitney U test | <0.001 |
| 8.93 (8,12) | 6 (3,9) | 10 (6,16) | |||
| Body Mass Index | Median (IQR) | Median (IQR) | Median (IQR) | Mann–Whitney U test | 0.823 |
| Median (IQR) | 25.40 (22.06, 27.59) | 24.56 (22.09,27.41) | 24.58 (22.04,27.7) | ||
| Age | Median (IQR) | Median (IQR) | Median (IQR) | Chi2 | <0.001 |
| Median (IQR) | 25 (21, 37) | 28 (21,40.5) | 23 (20,33) | ||
Legend: n = absolute frequency; % = relative frequency; IQR = interquartile range; p = p-value for significance level. Source: prepared by the authors, 2021.
Approximately half of the participants presented stress (50.71%) while 49.29% did not present stress (test: chi2, p < 0.001). The population was mostly classified as non-emotional eater (36.6%) or low emotional eater (31.8%) (test: chi2, p < 0.001). When it comes to perceived stress, the majority of non-stressed participants were non-emotional eaters and low emotional eaters, whereas the majority of stressed participants were emotional or highly emotional eaters (test: chi2, p < 0.001). See Table 1.
In the multiple linear regression model, a statistically significant association was found between the emotional eating score and perceived stress (F = 417, gl = 1, p < 0.001), the effect was an elevation of 0.44 points in the score of emotional eating for each perceived stress point. See Fig. 1. Analysis of outcome and exposure as categorical showed similar results. In this case, emotional eating was also significantly associated with perceived stress (Chi2 = 172.60, df = 1, p < 0.001). The odds of being emotional eater among stressed individuals was 3.75 (95%CI, 3.09:4.58) times the odds of being emotional eater among non-stressed individuals.
Fig. 1.
Association between perceived stress and emotional eating in the study population. Multiple linear regression model between the emotional eating scale and the perceived stress score.
The variables BMI (F = 112, gl = 1, p < 0.001) and age (F = 4.48, gl = 1, p = 0.03) were statistically significantly associated with the emotional eating score. For each unit increase in BMI the emotional eating score increased 0.26 units and for each unit increase in age the emotional eating score decreased by 0.27 units (See Supplementary graphs 1 and 2). The variables marital status (F = 1.2, gl = 1, p = 0.27), ethnicity (F = 1.1, gl = 1, p = 0.34), sex (F = 1.9, gl = 1, p = 0.16), and education (F = 2, gl = 1, p = 0.13) did not show a statistically significant relationship with the emotional eating score.
4. Discussion
The COVID-19 pandemic has brought significant changes in the lives of the world's population. The repercussions of self-isolation are being reflected with greater force every day on people's mental health [26]. In this research article the relationship between perceived stress and emotionality when eating was studied. It was found that subjects who displayed perceived stress were more influenced by their emotions when eating, which over a period of time can present a problem in people's dietary intake and therefore their nutritional status [27].
4.1. Perceived stress and emotional eaters
According to De Pasquale et al., the fear of infection during the COVID-19 pandemic has been a significant cause of stress for the population. Food represents a compensating experience, distracting from feelings of uncertainty, fear and despair, causing alterations in eating habits and behaviors [28].
Stress has been associated with eating habits, in some cases decreasing dietary intake, but in most of the population increasing caloric intake [29]. A study by Konttinen et al. offers support for the hypothesis that emotional eating is a behavioral mechanism between depression and development of obesity and abdominal obesity. Moreover, adults with higher emotional eating may be particularly vulnerable to weight gain [30]. This situation represents a serious problem due to its association with overweight and obesity, arterial hypertension, and other cardio-metabolic diseases [31] since excessive dietary intake usually happens due to the consumption of foods rich in fat, sugar or salt, and the deficient consumption of foods rich in fiber vitamins and minerals [32].
In this study it was found that subjects who display perceived stress have a higher risk of being emotional eaters, which is consistent with previous studies that show that stress and emotional situations such as depression can also condition an individual's dietary intake [30,32].
According to Van Strien (2018), previous studies have described that emotional eating can be caused by several mechanisms, such as eating to cope with negative emotions like stress and depression, or confused internal states of hunger and satiety with physiological changes associated with emotions [33].
The immediate effect of consuming palatable foods from emotional eating can bring a certain satisfaction to the individual [22]. However, it is often a maladaptive emotional regulation strategy as it is unlikely to result in long-term improvements in mood. The consequences of this, as stated above, are an excessive dietary intake of poorly nutritious foods, and the subsequent appearance of negative emotions (e.g. feelings of guilt) [33].
Therefore, it is urgent to implement programs that help people manage their perceived stress and, in particular, programs associated with resilience to the stress of confinement or the conditions associated with the COVID-19 pandemic. It is important to teach people to address their emotions and stress problems; in order to prevent perceived stress from being responsible for unhealthy diets.
It is known that in stressful situations, a greater amount of cortisol is released through the hypothalamic–pituitary–adrenal axis [34]. Continued exposure to stressors and the accompanying hormonal imbalances trigger an increase in appetite [35]. The relationship between stress, cortisol, and high food intake has visceral adiposity and insulin resistance as predisposing factors for a metabolic disruption with significant consequences for human health [35].
In this study it was observed that female individuals presented higher percentages of perceived stress than males, which is in accordance with previous studies, where it is mentioned that women are risk groups for presenting greater problems of anxiety, depression [36], and emotional eating [34]. It is also known that women tend to be more likely to have a need to incorporate compensatory substances to emotional states, such as sweet foods and foods rich in fat. In the short term, these substances could allow a greater release of neurotransmitters such as serotonin and dopamine at the level of the reward system, specifically on the NAc Nucleus Accumbens-NAc, however in the long term they could generate a compulsive and uncontrolled consumption of palatable foods [37].
5. Study strengths and limitations
The main weakness of this study, due to the properties of this method, was the non-probability sampling that was carried out. Nonetheless, it was possible to achieve a high response rate from the participants, which allowed us to obtain practical conclusions. In addition, it should be noted that the variables analyzed were self-reported by the participants, however, in order to minimize bias, validated virtual questionnaires were used.
6. Conclusion
Perceived stress is associated with people's eating behaviors. A dietary intake that responds to emotions and not to physiological hunger can have long-term repercussions. The impact on the health status and body weight of the participants in this study. Further research should be carried out on the association between stress and emotional eating in order to issue more precise recommendations to the general population and to prevent health and nutritional problems.
Authors’ contributions
TVCA conceived of the idea at the basis of the article, collected and interpreted the data, designed the study, was responsible for submitting the project to the Ethics Committee, prepared and revised the manuscript; AMS, VS interpreted the data and revised the manuscript; MFVV processed the data; ARB prepared and revised the manuscript; SLBO interpreted the data, prepared and revised the manuscript. All authors approved the final manuscript.
Formatting of funding sources
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
All authors declare that they have no conflict of interests.
Acknowledgment
The authors are grateful for people's participation in this study. The research team appreciates the support of the Research Institute - ESPOCH.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.clnesp.2022.03.030.
Appendix A. Supplementary data
The following are the supplementary data to this article:
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