Obesity is a heterogeneous condition that can seriously impact the degree to which one is healthy and socially accepted. It is generally considered to be greatly influenced by genetic factors. Given that we cannot change our genes, it was the purpose of this study to try to further understand the variables related to obesity that are not genetic. Specifically, the purpose of this study was to investigate the impact of certain family systems variables and childhood feeding practices on Body Mass Index (BMI). The family variables of interest were intergenerational intimacy, intergenerational differentiation, intergenerational triangulation, spousal intimacy, spousal differentiation, nuclear family triangulation, and the relationship between eating and sex. The childhood feeding variables of interest related to the use of food as a reward, coercive use of food, parental disagreement about feeding, the expression of love through food, and feeding enmeshment (i.e., the perception of parental overcontrol in feeding). Because certain eating styles have been found to be related to obesity, further investigation revolved around the impact of the family and feeding variables on eating styles. The eating styles of interest were restrained eating, emotional eating, external eating, and binge eating. The variables were studied by surveying employees of a school system in southwest Virginia. Body Mass Index was found to be significantly positively correlated with feeding enmeshment, weight as a means of sexual avoidance, and eating in response to a lack of physical affection. Restrained eating was not found to be significantly related to any family or childhood feeding variable. Emotional eating, external eating, and binge eating were all significantly negatively correlated with intergenerational intimacy, spousal differentiation, and nuclear family triangulation health, significantly positively correlated with sexual avoidance and deprivation of affection. In addition, emotional eating and binge eating were significantly negatively correlated with intergenerational differentiation, while external eating and binge eating were significantly negatively correlated with spousal intimacy. Emotional eating was positively correlated with all of the childhood feeding practices, while external eating and binge eating were correlated with four and three, respectively, of the feeding practices. While there were many significant correlational findings, there were few significant coefficients in the hierarchical regression analyses, presumably because of the high intercorrelations between the predictor variables (the family and feeding variables). In general, it can be said that family functioning and childhood feeding behaviors are relevant to overeating and overweight. The family and feeding variables are better predictors of eating styles that can lead to obesity than of obesity per se. High levels of dysfunction in families and frequent use of food in non-nutritional ways are associated with high levels of emotional, external, and binge eating. These findings may have implications for physicians and therapists. / Ph. D.

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Approximately one-third of U.S. adults are at increased risk for life-threatening diseases such as atherosclerosis and type 2 diabetes mellitus. Such individuals are considered healthy without any diagnosed cardiometabolic conditions but may have a constellation of cardiometabolic complications that include obesity, glucose intolerance, hyperinsulinemia, dyslipidemia, hypertension, insulin resistance, and hypertriglyceridemia. When most of these preclinical conditions comorbidly occur, the condition has been referred to as metabolic syndrome (MetS). MetS is considered to reflect one or more early pathophysiological processes in cardiometabolic disease; however, the extent to which these complications and their underlying pathophysiology interact with behavioral factors such as stress, diet, and physical activity have not been clearly established. For example, diet consisting of high total caloric intake and high fat composition is posited to contribute to obesity and other cardiometabolic risk factors, but research is inconsistent regarding the effect of psychological distress (i.e., anxiety, stress, depression, anger) on dietary intake and whether dietary intake mediates a relationship between distress and preclinical cardiometabolic disease risk. One factor that has been suggested to play a role in the distress – dietary intake relationship is eating style. Research on eating styles has identified four main types that may be related to distress and dietary intake: restrained, disinhibited, emotional, and external eating. Restrained eaters consciously restrict food intake to control body weight and body shape. Disinhibited eating refers to overeating that occurs following failure of restraint. Emotional eaters consume foods to reduce and alleviate negative emotions, such as anxiety. External eating occurs in response to immediate food-related external stimuli, regardless of internal physiological cues of hunger. Current evidence suggests each of these eating styles moderates the relationship between distress and dietary intake. There is also some research to suggest a relationship between eating styles and weight gain, body mass index (BMI), and development of obesity. However, no study has examined the interrelationships among psychological distress, eating style, and central obesity, and whether these relationships differ according to gender. Moreover, the extent to which distress and eating style may be associated with cardiometabolic risk beyond obesity is unknown. Thus, the main aim of the present study was to test a model of mediation and moderation to evaluate how psychological distress, eating styles, dietary intake, and gender are associated with measures of cardiometabolic risk in healthy individuals (Figure 1). Four hundred sixty-four participants contributed data from two different studies: Obesity, Metabolic Syndrome, and Meal-Related Glycemia (SUGAR) and Markers Assessing Risk for Cardiovascular Health (MARCH). All participants were aged 18-55 years, had no major systemic disease, were not using medications having a cardiovascular, carbohydrate, endocrine, or psychiatric effect, and had no history of substance or alcohol abuse or dependence. The study employed a structural equation modeling (SEM) approach to assess the following aims: 1) to develop composite, latent factors to reflect psychological distress, eating style, and dietary intake using confirmatory factor analysis (CFA) and to develop a hybrid model of cardiometabolic risk; and 2) to simultaneously test the interrelationships among factors in a comprehensive model so that the strength of direct and indirect effects can be evaluated while statistically controlling for the other factors and covariates in the model. Latent factor models of psychological distress and eating style fit the data and were statistically acceptable, and a hybrid model of cardiometabolic risk fit the data and its CFA components were acceptable. A latent factor model of dietary intake would have likely fit the data and been statistically acceptable given the high intercorrelations among dietary variables, but no such factor was created because dietary variables failed to confirm the hypothesized associations with other model components (e.g., waist girth, eating styles); thus, these measures were excluded from further SEM analyses. Final model results showed that psychological distress was positively related to restrained, emotional, and external eating styles, but only restrained eating was directly associated with greater waist girth. Distress was not directly related to cardiometabolic risk, but an indirect effect was found in which higher levels of distress led to greater waist girth via higher levels of restrained eating. Waist girth, in turn, served as a significant mediator between restrained eating and worse insulin sensitivity, higher blood pressure, diminished glucose tolerance, and greater dyslipidemia. These effects were significant when controlling for age, gender, education, and physical activity, and when analyzed in a comprehensive SEM model simultaneously including distress, eating style, and cardiometabolic risk variables. Of note, results suggest the possibility for a reversed effect such that waist girth leads to restrained eating. Findings also suggest that emotional eating may lead to distress. In contrast, the relationship between distress and the other two eating styles, restrained and external eating, appeared unidirectional such that distress leads to restrained and external eating but not the reverse. Future studies using longitudinal data are needed to better understand these relationships in regards to causality. Data from the MARCH subsample was excluded from the above final modeling analyses because eating style data were only available for the SUGAR subsample. Thus, the role of gender in how distress, eating styles, and cardiometabolic risk are interrelated could not be examined due to the small number of women in the SUGAR study (n = 38). It remains unknown whether the significant effect of distress on each of the eating styles found in the current study was driven primarily by men, women, or both equally. Similarly, the sample size would not permit the evaluation of whether gender moderated the effect of restrained eating on central obesity. Given that women in the current study reported more restrained, emotional, and external eating than men, future studies with larger samples should follow-up by assessing for potential moderating effects of gender. The present findings suggest that decreasing restrained eating style may lead to less central fat deposition and hence reduced cardiometabolic risk. Such “non-diet” interventions show potential for improved cardiometabolic health, but more research is needed. Particularly needed are studies examining prevention and intervention outcomes based on type of restrained eating – flexible versus rigid – to better understand how these different subtypes operate and how they can be altered effectively to improve health.

abstract: Lay theories of healthy eating are a potentially important consideration for public health and nutrition efforts as perceptions and beliefs about “healthiness” are key determinants of dietary choices (Furst et al. 1996; Grunert, 2007). A rich body of social science literature has examined how people across cultures decide what counts as healthy eating, yet such work has focused mainly on what people think is good and bad to consume, overlooking another important aspect- how one eats. The ways one eats can include patterns and timing of meal intake, as well as mental and emotional states during eating (henceforth, “eating styles”). This dissertation aims to 1) examine whether beliefs on eating styles constitute a separate category of healthy eating perceptions, 2) describe American and Eastern European lay models of how both food characteristics and styles of eating shape health outcomes, and 2) investigate cross-cultural variation in the endorsement of eating styles as important for health in the United States and Eastern Europe. Aims 1 and 2 use pile sorts (n=48), in-person interviews (n=49), and online surveys (n=283) to elicit subjective perspectives on how different eating considerations impact health, and aim 3 involves two sets of questionnaires collected in the U.S. (n=50; n=42) and Eastern Europe (n=42; n=35) to test the hypothesis that levels of collectivism influence variation in endorsement of eating styles for health. Results demonstrate that “eating styles” is a separate category of beliefs in people’s models of healthy eating and individuals in both cultures perceive a variety of important health outcomes from how one eats- weight management, energy levels, digestive health, and overall feeling of wellbeing. These perceptions are not uniform, as participants held contrasting models of how styles of food consumption can influence weight control, and Eastern European respondents held additional views on how aspects of food timing can affect long-term health. Finally, results show that individual level of collectivism, not differences in nationality, accounts for variation in endorsement of eating styles for health. These results suggest that the holistic pattern of attention characteristic of the collectivist social orientation extends to the domain of diet. / Dissertation/Thesis / Doctoral Dissertation Anthropology 2017

The World Health Organisation ([WHO], 2007) declared obesity as the public health threat of the 21st century. Currently, the Maltese adult population ranks as the heaviest in the Euro‐Mediterranean region. In response to a gap in Maltese research on the area of obesity and food consumption, this PhD aimed to gather local data to unearth behavioural‐psychological factors that could be implemented in local interventions. The focus of the PhD was narrowed to women with families based on literature that has identified motherhood as a salient point of transition that amplifies the weight trajectories for adult women. A mixed‐methods approach guided the methodology of the PhD programme with four studies carried out sequentially in two phases. The findings of the qualitative phase revealed that weight management for Maltese mothers was enmeshed with gender norm expectations surrounding motherhood. For mothers with a higher BMI, their relationship to food was a significant barrier to weight loss maintenance. Mothers with a lower BMI or who maintained their weight pointed at their food planning ability to manage their diet. The quantitative phase extended literature on the dimensional validity of the Dutch Eating Behaviour Questionnaire (DEBQ) (Van Strien et al., 1986) by reproducing its factor structure and ascertaining its reliability among Maltese women. This was the first validation of an eating behaviours assessment tool in Maltese and the first validation of the DEBQ in a Semitic language. Finally, Structured Equation Modelling revealed how food planning could act as a mediator to restrained and external eating styles to increase fruit and vegetable snacking and decrease high calorie snacking. In addition to the implications to theory, it is believed that these findings have worthy practical implications through tailored eating behaviour interventions, by targeting food planning to counterbalance the impact of external eating among Maltese mothers.