Magnitude and factors associated with emotional eating among pre-university students: a cross-sectional study in urban Mysuru, Karnataka

INTRODUCTION

Adolescence is the stage of development between 10-19 years of age, characterized by several physical, physiological, and psychological changes. Some of the most neglected issues among adolescents are mental health and nutritional health.¹ College life encourages the development of unhealthy habits such as a sedentary lifestyle, poor diet, and substance abuse that, if left unaddressed may lead to increased morbidity and mortality in the future. Some contributory factors include increased autonomy, ineffective coping strategies for managing stressful situations, and increased susceptibility to peer influence.²

The ecological system theory proposed by Bronfenbrenner gives an all-inclusive approach to the network of relationships that could impact the level of stress and overall well-being of adolescents. These extend to various levels: from more direct factors at the microsystem level, including family, friends, and college environment, to factors from the macrosystem level, including wider social structures, cultural ideologies, attitudes, and economic conditions. This heterogeneity of forces will either serve as a source of stress or a potential source of strength and resilience for adolescents going through the rigors of higher education.³

Emotional eating is a phenomenon in which individuals use food as a way of coping with negative emotions such as depression, anxiety, and stress.⁴ It is not an eating disorder in itself but rather a behaviour that falls into the broader array of eating patterns that is influenced by emotions, habits, and personal attitudes to food. It is subject to the influence of various factors. Classical conditioning, or learning to attribute specific foods to specific emotional states may result in the appearance of automatic processes, such as reaching for comfort foods when one is down. Reduced inhibitory control and an impaired capacity to distinguish between internal physiological cues of hunger and emotional hunger also contribute to emotional eating. Perceived stress can act as a trigger for emotional eating by making individuals turn to food for comfort or to distract themselves from emotional turmoil. Persons engaged in intuitive eating or eating in response to hunger and fullness will be more prone to emotional eating since they are unlikely to detect when their hunger is actually driven by emotional suffering. Finally, people with problems or no strategies for emotion regulation may more frequently engage in emotional eating as a way of dealing with their negative emotions.⁵

People under chronic stress tend to consume more during acute episodes of stress and prefer highly palatable, energy-dense foods rich in sugar and fat content. The consumption of hyperpalatable food is associated with short-term pleasure and relief of discomfort and thus may lead an individual to use these foods as a source of comfort during stress.⁶ Secondly, the consumption of energy-dense foods daily is likely to desensitize the brain’s reward system over time. Larger portions will be required to experience the same rewarding effect, thereby strengthening the food craving and eventually leading to more craving episodes. In the long term, this vicious circle will continue since individuals become more fixated on consuming these foods to quench their overwhelming urges.⁷

Despite various studies indicating the prevalence of stress-related health problems in adolescents, little has been done to investigate the implications of chronic stress, and the effects of their coping strategies, on academic achievement.⁸ The research findings also indicate mixed conclusions, where some studies have been unable to find a clear relationship between emotional eating and weight gain measured by body mass index.⁹ Since emotional eating appears to be a relatively common occurrence during childhood and adolescence, identifying its determinants in adolescents can contribute to its effective prevention. Hence, it is important to study emotional eating in the critical years of adolescence.¹⁰

Thus, this study aimed to estimate the magnitude of emotional eating among pre-university students of urban Mysuru, assess the factors associated with it, and evaluate its relationship with their anthropometric parameters and academic performance.

METHODS

Study setting and participants

A cross-sectional study was conducted in JSS Pre-University Colleges of urban Mysuru from September 2023 to January 2024. The study sample included adolescents enrolled in the first and second years of pre-university colleges. The eligibility criteria included students of selected JSS Pre-University Colleges who assent to participate in the study. Students diagnosed with and/or treated for eating disorders such as anorexia nervosa, bulimia nervosa and any neurotic psychiatric disorders were excluded.

Sample size

Aneesh et al reported an overall magnitude of emotional eating of 11.7%, which was used to determine the sample size for the study.¹¹ Assuming a confidence level of 95% and an absolute precision of 3%, the sample size was calculated using the following formula: n=4*p*q/d², where Z=1.96 (for 95% confidence level), p=11.7, q=88.3 (calculated as 100-11.7), and d=3. Substituting these values, the final sample size was estimated to be 460 participants.

Sampling technique and data collection

Five colleges were selected from the list of Pre-University Colleges under the administration of JSS Mahavidyapeeta using simple random sampling through a lottery method. The number of students required to be included from each college was determined using the probability proportionate to size technique. At the college level, the study participants were chosen by simple random sampling, using the attendance register through the lottery method (Figure 1).

Students who met the inclusion and exclusion criteria were identified from each of the five colleges and their written informed assent was obtained. Information regarding sociodemographic characteristics, dietary practices, physical activity, screen time, academics, and stressors were collected using a pre-tested questionnaire. Emotional Eater Questionnaire (EEQ) was employed to collect data on emotional eating. Following that, their height, weight, waist, and hip circumference were measured.

Ethical considerations

Ethical clearance was obtained from the Institutional Ethical Committee of JSS Medical College and Hospital, Mysuru. Informed consent was obtained from the principals of the colleges.

Statistical analysis

The collected data was entered and coded in Microsoft Excel 2021 and then analysed using SPSS version 25 (licensed to JSS AHER). Descriptive statistical measures were expressed as mean and standard deviation for continuous data, and as frequencies and percentages for categorical data respectively. Cross-tabulations were constructed, and inferential statistics such as the Chi-square test and Fisher’s exact test were applied to categorical variables. Normality was checked using Shapiro-Wilk’s test. Non-parametric tests such as Spearman’s rank correlation test were used for continuous variables. Data were presented as tables and graphs as appropriate. P value less than 0.05 was considered statistically significant.

RESULTS

The majority of the participants in the study, 235 (51.1%) were 16 years old with females having a higher representation [304 (66.1%)]. Hindus formed the vast majority of the religion at 94.3%. 237 (51.5%) participants were in their first year of Pre-University. 341 (74.1%) belonged to nuclear families and 300 (65.2%) hailed from urban areas. 279 (60.7%) of them stayed at home. 139 (30.2%) participants’ fathers had completed secondary school, 117 (25.4%) were skilled agricultural and fishery workers, and 32 (7%) had expired. 194 (42.2%) participants’ mothers had completed secondary school, 307 (66.7%) were unemployed and 7 (1.5%) had expired. 375 (81.5%) participants were Below Poverty Line (BPL) with 175 (38%) receiving 100 Rupees or less as a monthly allowance (Table 1).

229 (49.8%) participants were identified as emotional eaters with 121 (26.3%) being low emotional eaters, 103 (22.4%) being emotional eaters, and 5 (1.1%) being very emotional eaters (Figure 2).

The factors associated with emotional eating were gender (p value 0.022), monthly allowance (p value 0.027), frequency of skipping meals (p value 0.002), daily consumption of sweets, snacks, ice-cream, chocolates, and fast food (p value <0.001), stressors such as relations with people, personal, academic and environmental factors (p value <0.001), and screen time (p value <0.001). 163 (53.6%) females and 66 (42.3%) males were identified as emotional eaters with 41 (61.2%) receiving a monthly allowance of 501 to 1000 rupees and 31 (64.6%) receiving 1001 to 5000 rupees. 43 (59.7%) students who skipped meals 3 to 5 times a week, and 19 (73.1%) skipped 6 to 7 times a week were emotional eaters. 11 (68.8%) participants who consumed sweets, 109 (59.6%) consumed snacks, 51 (62.2%) consumed ice-cream and chocolates, and 21 (72.4%) consumed fast-food daily were found to be emotional eaters. 105 (68.2%) participants experienced severe stress concerning their relations with people, 90 (66.2%) participants concerning their personal factors, 110 (61.5%) participants concerning their academic factors, and 68 (65.4%) participants concerning their environmental factors and were identified as emotional eaters. 110 (61.1%) had a screen time of two to four hours and 19 (63.3%) had five to seven hours and were also emotional eaters (Table 2).

79 (50.6%) underweight, 99 (48.5%) normal weight, 24 (50%) overweight, and 27 (51.9%) obese participants were identified as emotional eaters. The mean BMI of emotional and non-emotional eaters was 20.80±5.4 and 20.51±3.7 respectively. 20 (51.3%) out of 39 males who had a waist-hip ratio of more than or equal to 0.90, and 99 (52.1%) out of 190 females who had a waist-hip ratio of more than or equal to 0.85, indicating a substantially higher risk of metabolic complications, were identified as emotional eaters. The mean waist-hip ratio of male emotional and non-emotional eaters was 0.87±0.05 and 0.84±0.07 respectively, and of female emotional and non-emotional eaters was 0.857±0.05 and 0.859±0.05 respectively. 35 (57.4%) students secured distinction, 71 (44.4%) secured first class, 35 (44.3%) secured second class, 62 (57.4%) secured third class, and 26 (50%) failed their recent examination and were identified as emotional eaters. The mean percentage of examination results of emotional and non-emotional eaters was 59.43±20.57 and 59.49±20.23 respectively (Table 3).

*Fisher’s Exact Test

Spearman’s rank correlation test revealed no correlation between emotional eating and body mass index (r=-0.016, p value 0.735), waist-to-hip ratio among females (r=-0.075, p value 0.191), and academic performance (r=-0.052, p value 0.264). In contrast, a weak positive correlation (r=0.105, p value 0.193) was found between emotional eating and waist-to-hip ratio among males, indicating that the higher the EEQ scores, the higher the waist-to-hip ratio.

DISCUSSION

Emotional eating is one of the escape mechanisms whereby food is used to suppress negative emotions. The stress response is suppressed and feelings of pleasure are derived from eating highly palatable, calorie-dense foods through its action on dopamine, which mediates the rewarding effect. This creates a vicious cycle by positively reinforcing the behavior with food to deal with emotions.¹²

The total magnitude of emotional eating in the present study was determined to be 49.8% among which 121 (26.3%) were classified as low emotional eaters, 103 (22.4%) as emotional eaters, and 5 (1.1%) as very emotional eaters. A high prevalence of 73.1% emotional eating was also found in a study by Skolmowska et al conducted among 1126 Polish adolescents.⁹ Radzi et al found a prevalence of 47.5% among pre-university and undergraduate students.¹³ The difference in the prevalence rates could be attributed to variations in factors such as regional demographics, year of study, and sample size.

In the current study, females had a higher tendency of emotional eating than males. This finding has been supported by many previous studies by Radzi et al.¹³, Mohapatra et al and Skolmowska et al.^14,9 Females reported more stress, exhibited more negative feelings, and had less impulsive control over their food choices, making them more likely to use emotional eating as a coping mechanism during stressful situations.¹³ This may also be due to the significant difference in the number of male and female participants in this study.

Our study revealed that nearly one-third of emotional eaters received a monthly allowance ranging between 500 to 5000 rupees. Al-Musharaf reported that emotional eating was highly prevalent in those with high family income.⁴ Receiving a monthly allowance provides students the financial freedom to purchase unhealthy foods. This in turn increases the likelihood of emotional eating.

The current study found a significant association between emotional eating and the frequency of skipping meals, where the majority of emotional eaters skipped meals at least 3 to 5 times a week. Chavez-Hernandez reported that meal skipping was positively correlated with ultra-processed food intake which in turn had a significant positive correlation with emotional overeating.¹⁵ Choi et al also reported that highly stressed college students had a tendency to skip meals and overeat snacks, fast food, and ready-to-eat meals.¹⁶

In the present study, daily and weekly consumption of sweets, snacks, ice cream, chocolates, and fast food were significantly higher in emotional eaters. Frequent consumption of hyperpalatable foods during negative emotions brings about a positive feedback loop and reinforces eating to distract from these emotions.¹² Such foods are often seen as comfort foods which emphasize on mood, sensory appeal, convenience, price, and familiarity while disregarding the aspect of nutrition and health.¹⁷ These foods were often seen being sold near the colleges at low prices. Gemesi et al identified chocolate and coffee as the two favourite comfort foods among adults.¹⁸ Caso et al reported that university students consumed sweets and junk food once a week while snacks were consumed more than once a week.¹⁹ Yang et al also found a positive association between perceived stress and unhealthy food preferences of salty snacks, fast food, and soft and sugary drinks.²⁰

The current study found a significant association between stressors such as relations with people, personal, academic, and environmental factors with emotional eating. This finding is consistent with the stressors identified in the study by Yumba et al.²¹ Radzi et al also determined that academic stress was positively correlated with emotional eating.¹³

More than half of the participants had a screen time of more than 2 hours a day. Screen time was found to be significantly associated with emotional eating. This can be related to boredom eating which is used as a way to pass unengaged time. It was the most significant emotion associated with eating in a study by Guerrero Hreins et al.¹² Shaikh and Bellare reported that boredom eating constituted 19% of all the types of emotional eating.²²

While many studies conducted on adults have confirmed the association between emotional eating and increased BMI, very few studies have been conducted on adolescents and their findings have been contradictory. Our study too did not find a significant association between emotional eating and anthropometric measurements such as body mass index and waist-to-hip ratio. This has been supported by a systematic review that found no association between emotional eating and increased or decreased weight status in adolescents.²³ One possible explanation for this finding could be that more than half of the emotional eaters in the present study engaged in regular physical activity. However, Skolmowska et al and Chavez-Hernandez reported higher emotional overeating among overweight and obese adolescents and university students in their studies respectively.^9,15 Shaikh and Bellare found a significant positive correlation between emotional eating, perceived stress, and BMI among adults.²² Hence, it can be concluded that emotional eating may have an impact on weight status in adulthood.

Not many studies have been conducted to find the relationship between emotional eating and its impact on academic performance in adolescents. Our study did not find a statistical difference in the examination results of emotional and non-emotional eaters. This finding is consistent with the study by Chamberlin et al and Schraml et al who found no statistical difference in the GPA among emotional and non-emotional eaters, although the chronically stressed group achieved worse grades.^10,8 Contrary to our study, Chamberlin et a reported that as academic stress increased, emotional eating increased, and so did the GPA while Pascoe et al reported that poorer academic performance is linked with higher levels of perceived stress.^10,24

However, the current study was limited by its cross-sectional design which could not establish causal relationships between the variables and the unequal gender distribution of participants.

CONCLUSION

The present study concluded that emotional eating is distinctly prevalent among pre-university students of urban Mysuru. Therefore, students must be educated on identifying their stress triggers and how to manage them with positive coping techniques to establish healthy relationships with food since eating behaviors established in this crucial stage will likely be carried over to young adulthood and consequently to adulthood. Longitudinal studies would be beneficial in assessing the development of obesity among emotional eaters during adulthood.

ACKNOWLEDGEMENTS

We would like to thank all the participants and college principals for their support of this research.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of JSS Medical College and Hospital, Mysuru (Approval Number-JSS/MC/PG/91/2022-23) on 24-03-2023

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