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Emotional eating is a common behavioral phenomenon that involves eating in response to emotional impulses rather than physical hunger and is believed to be a form of affect regulation (Ball and Lee, 2002). While emotional eating occurs within the symptomatology of eating disorders it also occurs independently (Benett, Greene, and Schwartz-Barcott, 2012). Further, a pattern of emotional eating can lead to weight gain and the development of eating disorders (Grant and Boersma, 2005). Currently, research is limited in terms of smart practice treatment recommendations for emotional eating. In order to address this gap in research, the Delphi method was utilized in order to gain consensus from a panel of nine experts regarding treatment recommendation specific to emotional eating. These panelists identified 47 treatment interventions that will be discussed. / Master of Science

Prevalence rates of overweight and obesity in Maltese adolescents are amongst the highest in the world. Stress-induced eating and dysfunctional coping skills have been linked to overeating and obesity. This study was undertaken in two phases. Phase 1 examined the relationship between perceived stress, coping and eating behaviours in Maltese adolescents and devised a model to guide the development of an effective Internet-based intervention. Based on the findings, Phase 2 developed ACES – a novel online intervention for the reduction of perceived stress and emotional eating in Maltese adolescents – and assessed its feasibility. In Phase 1, cross-sectional data were gathered from 79 Maltese adolescents using an online questionnaire with 6 self-report measures examining perceived stress, coping responses, eating behaviours, self-efficacy, physical exercise and social support. Findings suggested that emotional eating behaviours can be decreased by reducing perceived stress and dysfunctional coping strategies (self-controlling and escape-avoidance) and increasing self-efficacy and functional coping strategies (seeking social support and planful problem solving). In Phase 2, ACES was developed and a feasibility study, with a one-group pretest-posttest design, carried out to assess the functionality, usability, perceived utility and acceptability of ACES and to test the design of a definitive randomized controlled trial. Forty-six out of 125 participants completed ACES. Findings suggested that ACES is feasible and well-received by participants. Preliminary effectiveness results provide additional support for the Phase 1 findings concerning the variables that need to be taken into account to decrease emotional eating behaviours. This study has made significant contributions to the literature and offered insights into specific functional and dysfunctional coping strategies impacting perceived stress and eating behaviours. It has produced an online intervention, which is a feasible avenue for the reduction of perceived stress and emotional eating, that could be built upon by practitioners and researchers, with potential implications for obesity prevention.

Attentional bias (AB) refers to the tendency to selectively attend to (orientation towards) and/or hold attention on (slowed disengagment from) disorder-relevant stimuli. Females with eating-related concerns are thought to preferentially process threatening stimuli, which in turn is thought to maintain and exacerbate eating concerns. The aim of the present thesis was to explore AB for threatening stimuli in females characterised by restrained, external or emotional eating, and those with high levels of (non-clinical) eating psychopathology. This was carried out with the intention of identifying cognitive processes that contribute to eating behaviours in females, in order to assess the relevance of an attention training (AT) programme for reducing such biases. A pilot study assessed orientation/slowed disengagement, for mood and food words amongst females with high/low levels of restraint. Forty females completed a modified Stroop task with three conditions. Food and mood conditions included sequences of five words ( target food/mood followed by four neutral). The neutral condition consisted of all neutral words. Performance did not significantly differ according to high/low restraint groups. All participants took longest to colour-name word position 2 (demonstrating slowed disengagement lasting one consecutive trial). However, this pattern was also found in the neutral condition. Methodological limitations were then addressed in study one. High/low restrained eaters (n=48) completed a modified Stroop where targets (food, interpersonal threat, animal) were presented prior to four neutral words. Participants were slow to disengage from targets (slowest for word position 2) in all conditions. Patterns of responding indicated that restrained eaters might take longer to disengage (i.e. the carry-over effect from the food word seemed to last longer than one trial). However, more neutral words in the sequence were needed to assess this. As slowed disengagement from animals also arose, a categorical effect may have occurred. Study two explored attention processing of food using modified Stroop and dot probe tasks. In the Stroop task targets (food, interpersonal threat, household objects) were presented prior to six matched neutral words. This task revealed no evidence of AB. No significant pattern of differences between restrained (n=29)/unrestrained eaters (n=31) emerged; however, binge eating scores were significantly negatively correlated with response times. A dot probe task with food/neutral picture pairs also revealed no evidence of AB. Both restrained/unrestrained eaters had negative mean interference scores indicating avoidance of food. None of the following eating behaviours significantly correlated with AB: restraint, disinhibition, external eating, emotional eating and non-clinical eating psychopathology. Study three employed a further modified dot probe task based on image ratings. There was no evidence of AB, and no significant relation between task performance and restrained, emotional or external eating. 2000ms bias scores (assessing disengagement) were significantly negatively correlated with eating psychopathology and age, suggesting that those with high levels of non-clinical eating psychopathology attentionally avoid food stimuli and that younger females are slower to disengage attention from food (although found within a limited age range). Study four employed further modified Stroop and dot probe tasks, and assessed whether AB mediates the negative mood-eating relationship. Participants were allocated to negative or neutral mood conditions. No evidence of AB was found with the dot probe, but greater levels of emotional eating were associated with slower responding. In the Stroop task, all participants displayed an orientation bias towards food. Emotional eating and drive for thinness (DFT) scores were significantly positively correlated with food word colour-naming times but only amongst participants in a negative mood. However, those with high levels of external eating showed greater AB towards food when in a neutral mood. Highly emotional eaters in a negative mood showed a greater desire to eat than those in a neutral mood but did not increase in food intake. Furthermore, those with a high DFT (in a negative mood) showed no evidence of increased desire to eat or food intake. AB was not significantly related to subjective appetite or food intake. Therefore, AB does not seem to mediate the negative-mood eating relationship. The present thesis provides important suggestions for modifications of Stroop and dot probe tasks targeting orientation and disengagement. A modified Stroop has been more sensitive at detecting food AB than the dot probe. Implications of biased attention processing are discussed in relation to the development of harmful eating behaviours, and the present findings have important implications for developing programmes to prevent eating disorders amongst at-risk females (e.g. through AT or training at-risk females how to effectively cope with negative mood).

Obesity is a major health epidemic, impacting many people worldwide. Bariatric surgery is a common treatment for severe obesity and generally leads to improved overall health, remission of comorbid disease, and improved quality of life. Despite positive postsurgical results, many patients regain some to most of their weight following the procedure. Guidelines for presurgical psychological assessments have been developed to assist healthcare professionals in predicting outcomes for patients. Previous studies have focused on the impact of psychological illness on surgical outcomes, with mixed results. The current study aimed to assess the influence that difficulties in emotion regulation has on eating patterns in bariatric surgery patients. A total of 144 patients seeking bariatric surgery were included in the study. Results indicated no difference in severity of eating patterns among restricted, emotional, and external eating; though difficulties in emotion regulation was only significantly related to emotional (r = .427, p < .001) and external (r = .275, p < .001) eating patterns. Regression analyses indicated significant models for the impact of difficulties in emotion regulation on emotional (R2 = .254 F(5, 135) = 9.180, p < .001) and external (R2 = .094, F(5, 135) = 2.811, p = .019) eating. Specific predictors of emotional eating were discussed. Outcomes of this study highlight the importance of considering difficulties in emotion regulation in bariatric surgery patients due to the impact emotional dysregulation may have on eating patterns.

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.

This thesis investigates a contextual behavioral approach for obesity surgery patients. In a contextual approach a behavior is interpreted as inseparable from its current and historical context. Candidates for bariatric surgery often have a history of self-stigma, body dissatisfaction and eating for emotional relief. Despite losing a large amount of weight post surgery, psychological problems may still be present for some patients. One possible common underlying process observed in body concerns and eating patterns is experiential avoidance. Experiential avoidance is defined as; any attempt to avoid, change, or control unwanted thoughts and feelings when so doing causes harm. Though a multidisciplinary team is recommended for post-surgical care, there are few studies evaluating the psychological treatment of patients undergoing bariatric surgery. In this thesis a protocol based on Acceptance and Commitment Therapy (ACT), was developed and implemented, partly via the Internet, in a clinical setting. In an acceptance-based approach to obesity, psychological well-being is the main outcome. ACT was significantly more effective than ‘treatment as usual’ in terms of body dissatisfaction and quality of life after surgery. Both groups improved in eating disordered attitudes and behaviors. Predictions based on the underlying treatment model were also investigated. Positive treatment outcomes were found to be associated with increased psychological flexibility.  Despite some methodological limitations, the results are promising and future studies should further evaluate ACT in the context of bariatric surgery. This thesis also acknowledges the need for clinical assessment tools appropriate for the bariatric surgery context. The Acceptance and Action Questionnaire for Weight (AAQ-W) is a measure of experiential avoidance, and was evaluated in the present thesis. The AAQ-W was found to be a reliable and valid measure for people undergoing bariatric surgery. Another measure, Disordered Eating in Bariatric Surgery (DEBS) was developed and evaluated. The DEBS was found to posses satisfactory psychometric properties in terms of reliability and validity.  The AAQ-W and the DEBS may facilitate both systematic clinical evaluation and future research within the area of bariatric surgery.

Abstract Eighty percent of all black women are overweight or obese which can lead to greatly increased morbidity and mortality, increasing healthcare costs and loss of healthy years of life. While multiple factors may contribute to obesity in black women, the cultural persona of the Strong Black Woman (SBW), an ideology that promotes unflagging toughness and denial of self-needs, may be the basis for behaviors that contribute to steady state obesity in this group. The purpose of this study was to investigate the relationships between the SBW persona, depression, and emotional eating. Two predominately black churches in Florida were approached concerning this research. A total of sixty-six women consented to participate during their monthly women's fellowship meeting. Each woman was asked to complete a packet of three instruments. The Strong Black Woman Cultural Construct Scale, a 22-item instrument was scored on a 5-point Likert-like scale with possible scores on the inventory ranging from 22 to 110. The mean score for this inventory was high (M=74.62; SD= 8.700. The SBWCCS has 3 subscales, measuring Affect Regulation (7 items), Caretaking (8 items), and Self-Reliance (7 items). Affect Regulation scores may range from 7 to 35. The mean score for Affect Regulation was moderately high (M=21.35; SD = 4.39). Caretaking scores could range from 8 to 40 points. The mean score for Caretaking was moderately high (M=25.11; SD = 4.47). Self-Reliance scores could range from 7 to 35, and had the highest mean score (M= 28.17; SD = 3.31). The Emotional Eating scale, a 25 item inventory rated on a five-point Likert-like scale, has a score range of 25 to 125 points. The mean score for Emotional Eating was low (M=49.36; SD = 19.42). The Center for Epidemiological Study-Depression Scale, a 20-item inventory has scores that range from 0-60 points. The mean score for this inventory was low (M=14.06; SD = 9.05). Pearson Product Moment Correlations were run to determine if there were any relationships among the three variables and the subscales. No relationships were found between SBW and Depression, or between SBW and Emotional Eating. However the relationship between Depression and Emotional Eating was statistically significant (r=0 .27, p<.05). No relationships were found between the three subscales and emotional eating, nor was there a relationship between depression and caretaking or depression and self-reliance. However, the relationship between Depression and Affect Regulation was statistically significant (r=0.28, p<.05). The findings regarding the relationships between SBW and depression, and also SBW and Emotional Eating were inconsistent with the current literature, suggesting that either response bias or some other source of bias interfered with the relationships. However, the significant relationships between Depression and Emotional Eating, along with Depression and Affect Regulation, were consistent with previous studies. Further research is needed to determine if there is response bias due to questions on the instruments being at odds with strong identification with the SBW persona and also to determine levels of depression in this population. A more complete understanding of these relationships is needed before culturally specific interventions for psychosocial factors supporting obesity in black women may be developed.