"Alma" is a 38-year old overweight woman who describes her life as constant turmoil. She lost a significant amount of weight 4 years ago but regained all of it. Her family keeps her busy and her job is stressful and demanding, allowing little time for exercise. She has battled excess weight for years and now shows signs of hypertension and prediabetes. Most NPs and PAs would appropriately recommend a low-calorie diet and regular exercise for this patient. How many would assess her for emotional eating?
Information missing from this history is that the patient eats large quantities of food when in sorrow or celebration. She often relates to comforting memories of foods from her childhood. Her comfort food choices consist of fried chicken, potatoes, corn and cherry pie. These foods remind her of Sunday dinners with her family. Comforting foods tend to be high in fat, which she finds satisfying and soothing, while simple carbohydrates initially give her energy and then produce fatigue.
For some patients, the common weight loss approach of balancing calories in vs. energy expenditure out is effective. Maintenance of weight loss is the more difficult task. Approximately 80% of people who lose weight regain an initial weight loss.1
For patients who are not successful with long-term weight maintenance, additional exploration of emotional eating habits may be the key to treatment. Multiple studies show that emotional eating contributes to years of poor eating habits and the obesity epidemic.2-4
Definition of Emotional Eating
Emotional eating has been described as the use of food to manage emotions that are especially distressing, such as anger and loneliness.5 For some people, emotional eating is often symptomatic of an entrenched unresolved issue. The habits of emotional eaters range from snatching a candy bar to compulsively binging on enormous quantities of food in a short period. Using food to feed emotions rather than to provide sustenance can blind a person to the quantity of food consumed. Some emotional eaters describe a lapse of conscious state sometime after the first bite and lasting until the food is entirely consumed.6
Hunger, social eating, nervous energy, cortisol-linked cravings, buried feelings and childhood food memories may precipitate emotional eating.7 The act of eating is often part of social support sought by people under stress. Social support offers satisfaction in the short term, but long-term negative consequences are associated with excess food consumption. Food choices typically are high in fat and carbohydrates. Eating when stressed or nervous, but without hunger, leads to emotional eating. An oral fixation on food often leads to mindless snacking. Additionally, stress and nervousness elevate cortisol levels,6 stimulating a craving for sweet and salty foods. The result is weight gain.
Some people attempt to bury the emotions that cause discomfort, yet more often food is used temporally to tame uncomfortable feelings. The act of eating is used to modulate these mood states in the absence of more appropriate means of coping.3,8
Finally, childhood food memories facilitate an emotional attachment to certain foods: Favorite foods are used to calm emotions and stress. The healthier action is to turn to predetermined coping strategies.
Adult obesity rates in the United States have been reported at 35.5% among women and 32.2% among men.9 Approximately 18% of obese adults are emotional eaters.4 Emotional eaters tend to be women. Overweight women tend to overeat for nonphysiologic reasons, particularly during negative emotional states.10,11
Evaluation for Emotional Eating
An estimated 75% of all eating is triggered by emotions.12 It is never too soon to evaluate patients' eating habits and offer recommendations for improvement. Years of poor food choices and eating styles are difficult to change, since both a physiologic and psychologic reward response occur. Self-recognition of emotional eating may trigger a behavioral change, while awareness of how stress, depression and emotional eating are intertwined may facilitate the development of an effective treatment plan. In some cases, referrals to a registered dietitian (RD) with specialized training in emotional eating and/or a mental health therapist are necessary so that underlying issues of emotional eating can be adequately addressed.
Stress, Depression and Emotional Eating
Emotional eating and depressive symptoms are correlated.10,13 Nearly half of people with emotional eating meet the criteria for a diagnosis of depression.7 Overweight people sense a greater urge to eat in response to negative situations and emotions compared to people of normal weight.14 Most emotional eaters describe eating large quantities of food when emotional or sad, and many say they feel immediate remorse.
Depressed people also describe appetite changes and the consumption of unhealthy foods.5 Eating in response to emotions has been linked to a psychological eating style in which the person craves highly palatable, calorie-laden foods high in fat and sugar.9 Most people, and especially women, increase their consumption of these palatable foods during stressful times in an effort to relieve specific physiologic symptoms of depression, stress or anxiety.11 Thus, this eating style is used as a physiologic and mental coping mechanism.10
Highly palatable foods generate a neurobiologic alteration that activates the reward system of the brain, signaling a release of opioids, dopamine and endocannabinoids into the limbic system. Opioids mitigate the stress response by producing a physiologic response through a reduction of the hypothalamic-pituitary-adrenal axis. During stress, cortisol is released from the brain, stimulating appetite.6 Repeated stimulation of this reward system leads to learned behaviors of eating to cope, along with a subsequent pattern of overeating that is compulsive in nature. Thus, highly palatable foods have the propensity to be addictive and thereby stimulate a repeated cycle of negative eating behaviors that appear to physiologically and psychologically comforting.6
The identification of patients who are overweight and obese starts with weight measurement at every clinic visit, to look for patterns and trends. For all patients identified as overweight or obese, use of the Eating and Appraisal Due to Emotions and Stress (EADES) Questionnaire during an office visit could identify people who are emotional eaters. The EADES Questionnaire has been preliminarily validated with evident internal consistency.12 An important aspect of the questionnaire is that in addition to assessing whether a patient eats as a result of emotions, it assesses how the patient perceives daily life situations and resources in relation to eating and overall health.
This questionnaire takes about 10 minutes to complete and contains 49 questions that help provide insight about how a person copes with and appraises stress and emotions using food. Questions are written so that patients respond in first person and determine their level of agreement with the questions by answering Strongly Disagree to Strongly Agree on a scale of 1 to 5. Scores are assigned to each construct by adding up Likert Scale numbers; some questions are reverse scored. Lower scores represent greater emotion and stress-related eating and more compromised appraisal skills. Access a copy of the questionnaire at this link: http://www.chhs.niu.edu/about/staff/profiles/EADES%20Questionnaire.pdf.
Some questions that specifically measure emotion and stress-related eating address self-efficacy with regard to eating. These questions try to determine whether or not the patient feels confident about partaking or not partaking in an eating behavior, such as "I am confident I can control my eating when I am tired." In a study of a general university population, researchers found that people who scored lower for emotion and stress-related eating were 13.38 times more likely to be overweight or obese, highlighting the importance of appropriate assessment for emotional eating in people who are overweight and obese.4 Some clinicians have used EADES questions as a discussion point to probe for information related to eating behavior and to gain insight on weight status.
Treatment of Emotional Eating
Few people (an estimated 10%) obtain treatment for emotional eating.4 Therefore, to prevent further dysfunction and promote intuitive eating, it is vital that NPs and PAs explore emotional eating triggers with patients. Intuitive eating is an approach to eating that emphasizes a healthy relationship among mind, body and food. Intuitive eating rejects dieting and promotes eating when hungry and recognizing satiety.
NPs and PAs can also assist patients in selecting effective stress management techniques starting at young ages, to potentially prevent years of emotional eating. Appropriate referral to interdisciplinary team members may be necessary. Skills training may be utilized as an alternative means to cope with emotions, manage stress and self-monitor eating behavior. It is important to identify the types of resources necessary to help decrease stress.
All patients should be screened for depression and treated if necessary; some may need referral to a psychiatric NP or PA.
Interventions should be designed to promote healthy food choices during emotional and stressful times. Choosing high-fiber or crunchy foods may satisfy hunger, since they take longer to eat and promote satiety.
Obesity prevention is a top public health priority. NPs and PAs need to assess overweight and obese patients for emotional eating. The EADES Questionnaire can be used during an office visit to identify emotional eating patterns. Exploring stressful and emotional eating triggers is vital to effective weight loss treatment and can impact chronic medical conditions and the obesity epidemic. Instructions for the questionnaire are at this link: http://www.chhs.niu.edu/about/staff/profiles/EADES_instructions1.pdf. Access the scoring form at this link: http://www.chhs.niu.edu/about/staff/profiles/EADES%20scoring%20form_final.pdf
1. Turk MW, et al. Randomized clinical trials of weight-loss maintenance: a review. J Cardiovasc Nurs. 2009;24(1):58-80.
2. Hernandez-Hons A, Woolley SR. Women's experiences with emotional eating and related attachment and sociocultural processes. J Marit Fam Ther. 2011;38(4):589-603.
3. Konttinen H, et al. Emotional eating, depressive symptoms and self-reported food consumption. A population-based study. Appetite. 2010;54(3):473-479.
4. Ozier AD, et al. Overweight and obesity are associated with emotion and stress-related eating as measured by the eating and appraisal due to emotions and stress questionnaire. J Am Diet Assoc. 2008;108(1):49-56.
5. Heatherton T, et al. Effects of physical threat and ego threat on eating behavior. J Personal Soc Psychol. 1991;60(1):138-143.
6. Adam T, Epel E. Stress, eating and the reward system. Physiol Behav. 2007;91(4):449-458.
7. Scott JG, Schoenberger MR. Affect, Emotions and Mood. In: A Little Black Book of Neuropsychology: A Syndrome Based Approach. New York: Springer; 2010: 249-251.
8. Wallis DJ, Hetherington MM. Emotions and eating. Self-reported and experimentally induced changes in food intake under stress. Appetite. 2009;52(2):355-362.
9. Flegal KM, et al. Prevalence and trends in obesity among US adults. JAMA. 2010;303(3):235-241.
10. Ouwens M, et al. Possible pathways between depression, emotional and external eating. A structural equation model. Appetite. 2009;53(2):245-248.
11. Macht M. How emotions affect eating: a five-way model. Appetite. 2008;50(1):1-11.
12. Ozier A, et al. The eating and appraisal due to emotions and stress (EADES) Questionnaire: Development and validation. J Am Diet Assoc. 2007;107(4):619-628.
13. Dallman M, et al. Chronic stress and obesity: a new view of comfort food. Proc Natl Acad Sci. 2003;100(20):11696-11701.
14. Renfrew Center Foundation. Emotional Eating. http://renfrewcenter.com/services/treatment-tracks/emotional-eating
Joanne Haeffele is a family nurse practitioner who is an assistant professor of nursing at Northern Illinois University in Dekalb. Pat Braun is a pediatric nurse practitioner who is an assistant professor of nursing at the same university. Amy Ozier is a registered dietitian who is an associate professor in the School of Family, Consumer and Nutrition Sciences at Northern Illinois University.