Introductıon
Childhood obesity and overweight is considered an important public
health problem due to its increasing prevalences in many low and middle
income countries (1). Many psychiatric factors such as internalizing and
externalizing symptoms are found to be associated with childhood obesity
(2).
Alexithymia is defined as inability to find words to describe one’s own
feelings (3). As a way of coping with emotions, several studies suggest
that the alexithymic patients might develop negative eating behaviors
(4)(5)(6). Although there are many studies showing that alexithymic
features are more common in obese individuals (7), studies that show no
significant relationship between body mass index (BMI) and alexithymic
characteristics are also reported (8)(9). Therefore, the role of
alexithymia in the development of obesity is not fully understood (7).
Emotion recognition or regulation problems may increase emotional eating
which can be defined as increased amount of eating in negative affective
situations such as stress. Therefore this mechanism may also cause
obesity (10)(11). People with high alexithymic properties are reported
to be more prone to relieve their emotional tension by excessive eating
(12).
Insulin resistance, known as impaired function of insulin in balancing
plasma and hepatic glucose levels (13), is considered as a risk factor
for many health problems such as essential hypertension (14) and Type 2
Diabetes Mellitus (15), and is frequently associated with obesity (16).
It is known that insulin resistance can cause increased food consumption
and disinhibition of eating (17).
Studies examining the relationship between alexithymia and eating
behaviour in obese people have been reported mostly in the adult age
group. In children and adolescents, the relationship between alexithymia
levels and effect of emotional and external factors on the amount of
food consumption is less investigated (18). Also, to our knowledge,
there are no studies conducted in Turkish population. Understanding the
relationship between emotional eating and alexithymia can be a guide for
psychosocial interventions in the treatment process of obese youth. We
predict that obese adolescents or overweight adolescents (O+OW) have
more alexithymic features than normal weight adolescents (N). Therefore,
O+OW are more prone to have problematic eating behaviours. Main
objective of this study is to investigate the relationship between
alexithymia levels and problematic eating behaviours such as emotional,
restrained and external eatings in obese and overweight adolescents.
Possible predictors of obesity/overweight among these factors are
determined. To reveal effect of insuline resistance on eating behaviour,
the association between insulin resistance and emotional, restrained and
external eating levels is investigated.
Method
The data used in this study is obtained from Zehra Koyuncu’s doctoral
thesis (referanslara ekleyebilirsiniz). Cases with subtreshold
depression and anxiety symptoms are used in the analysis.
Participants:
A hundred and four adolescents (11-16 years old) with a BMI percentile
above 85 were recruited from Department of Pediatrics, Adolescent
Outpatient Clinic Unit, Cerrahpaşa Medical School. The reference values
determined by Neyzi et al. (19) for Turkish children were used to
determine the percentile of the BMI. Patients with BMI above 95 were
considered Obese (O) and those between 85 and 95 were assumed Overweight
(OW) (20). Adolescents who had antipsychotic or corticosteroid medicine
in the last 6 months, who were diagnosed with mental retardation, autism
spectrum disorder and schizophrenia spectrum disorder and who were
illiterate were not included. Participants with depression/anxiety
scores higher than clinical treshold were excluded from the statistical
analysis due to the reported relationship between alexithymia and
depression/anxiety disorder (21)(22). Seventeen adolescents were
excluded because of using antipsychotic drugs, missing data and having
RCADS-CV score above clinical treshold (70). Therefore, statistical
analysis was conducted with 87 patients.
Comparison group were recruited from middle and high schools in
Istanbul. Adolescents with a BMI percentile between 5 and 85 with
similar sociodemographic characteristics were enrolled in as the
comparison group. The objective of the study and the tests were
explained to the adolescents and their parents. Those who accepted were
included in the study. One hundred and fifty two adolescents were tested
for the purpose of creating the comparison group. 51 members of the
tested adolescents were removed because of missing forms (n=25),
inappropriate BMI (n=16), being diagnosed with a psychiatric disorder
during the study (n=1), having RCADS-CV t score above the clinical
treshold (n=9). As a result, the comparison group was formed with 101
adolescents. Permissions were obtained from relevant educational
institutions and written consent was obtained from each participants and
their parents. The participants were asked to fill in surveys which
lasted about 30 minutes. In addition, HOMA-IR value, which is a reliable
method to evaluate insulin resistance, was calculated in obese
adolescents. The formula for the HOMA-IR value is\(\frac{\text{fasting\ insulin\ concentration\ x\ fasting\ glucose\ concentration}}{22.5}\)(23).
The Declaration of Helsinki was used as the standard of medical ethics
in the study design. The Istanbul University-Cerrahpasa, Cerrahpasa
Medical School Ethics Committee reviewed and approved all study
materials (83045809-604.01.02-).
Instruments:
The Sociodemographic Data Form was created by researchers to
record information on age, gender, number of siblings, number of
children, presence of chronic diseases, psychiatric disease history,
weight and height, family income, family integrity, parental loss, age,
educational level and occupation of parents.
Alexithymia Questionnaire for Children (AQC) was developed by
Rieffe et al.(24) to measure children’s alexithymia levels. The scale
consists of 20 items (24). Koçak et al. (25) adapted this scale to
Turkish and conducted a reliability study. Reliability coefficient
values was very close to the original scale. The Cronbach alpha internal
consistency coefficient of the scale was .78. Higher total score from
the scale indicates more alexithymic properties (24).
The Dutch Eating Behavior Questionnaire (DEBQ) was developed in
1986 by Van Strien et al. (26). The DEBQ is used to identify external
stimuli and internal stimuli other than fasting, that affect eating
behavior. In addition to the ’Restrained Eating’ scale which
assesses food intake restriction, a new questionnaire was developed by
adding the ’Emotional Eating’ scale and the ’External
Eating’ scale which asseses eating in response to food-related stimuli
(26). The questionnaire was adapted to Turkish and the validity and
reliability study was performed by Bozan (27). The internal consistency
coefficient of the whole scale was found to be .94 (27).
Revised Child Anxiety and Depression Scale- Child Version
(RCADS-CV) was developed in 2000 by Chorpita et al. (29) based on the
Spence Children’s Anxiety Scale (28). The Turkish validity study was
carried out by Gormez et al.(30). Cronbach alfa value was calculated as
95 (30). A T score of 70 was reported as clinical treshold (31).
Statistical Analysis
All data were analyzed using SPSS software package 22.0. Mean, standard
deviation, median, lowest, highest, frequency and ratio values were used
in descriptive statistics of the data. The distribution of variables was
measured by the Shapiro Wilk test. In the analysis of quantitative
independent data, Student t test and Mann-Whitney test were used.
Chi-square test was used for the analysis of qualitative independent
data and fischer test was used when the chi-square test conditions were
not satisfied. Spearman correlation analysis was used in the correlation
analysis. Lastly, potential predictors of obesity and overweight were
determined by Multiple Linear Regression Analysis. Statistically, values
of p <0.05 were considered significant.
Results
4.1 Comparison of Obese+Overweight with Normal
The mean age of the O+OW was 13.5 ± 1.2 years and the mean age of the
control group was 13.6 ± 1.3 year (p> 0.05). When O+OW were
compared with N, weight and BMI were significantly higher in O+OW
(p< 0,001). There was no significant difference
(p> 0.05) between the height, parental education, family
income and integrity between N and O+OW (Table 1). AQC scores
were significantly higher in O+OW than N (p:0.009). The DEBQrestrained eating and emotional eating subscale scores of
O+OW were significantly higher than the scores of N (p<0,001
for both). The DEBQ external eating subscale score did not differ
significantly between O+OW and N (p> 0.05). (Table
2).