Emotional availability, understanding emotions, and recognition of facial emotions in obese mothers with young children☆
Introduction
Obesity is associated with considerable morbidity and mortality and has been identified as one of the most demanding challenges for society and for current public health policies [1]. However, the aetiology of obesity is complex and not yet fully understood. Hence, understanding the role of potentially modifiable aspects of experience in the development of obesity is of the utmost importance for prevention and intervention programmes. Therefore, Davison and Birch [2] have demonstrated the contextual influences on childhood obesity: the child's behaviour, parenting styles and family characteristics and community and demographic factors. Consequently, interest in obesity within the context of the family and the role of parents and parental characteristics have increased in recent years. For example, it appears that positive parental emotions and the emotional climate parents create significantly contribute to the way children are socialised around eating, which may in turn affect their eating behaviours, the development of healthy eating habits, and their weight status [3], [4].
Hilde Bruch [5] was among the first researchers to stress the role of early mother–child interaction and — resulting thereof — the incorrect perception of one's own emotional and physical states in the aetiology of eating disorders and obesity. She hypothesized that the child's perception of hunger develops in a transactional process. During this learning process, the child depends on appropriate reactions by the caregiver (mother). If there is a mismatch between the child's signals or needs and the caregiver's reaction (e.g. food is provided with no consideration of the child's needs), the learning process fails. This in turn leads to confusion in the child and a diminished capacity to correctly identify and differentiate bodily sensations such as hunger from other emotional states.
Although Bruch's observations emphasize the role of early mother–child interaction in the aetiology of obesity, only a few studies have explicitly focused on this point so far. The existing findings suggest that certain aspects of the mother–child relationship in early childhood — namely insecure attachment [6], [7] and low maternal sensitivity [7], [8], [9] — might be risk factors for the development of obesity in later childhood [6], [7], [8], [9] or adolescence [7]. How a mother's own weight status impacts interactions with her child and subsequently her child's weight status remains unclear.
As a second aspect, Bruch [5] suggested the diminished capacity to correctly identify bodily and emotional states to play an important role in the aetiology of disordered eating and obesity. Deficiencies in the correct identification of physical cues and emotional states may be due to a problem in emotion processing or recognition and may precede the development of eating disorders or obesity. There is some evidence coming from research on emotional competencies as represented by Emotional Intelligence (EI) and recognition of facial emotions supporting these assumptions: the model of EI as proposed by Salovey and Mayer [10] consists of four abilities (the abilities to perceive, use, understand, and regulate emotions) and has not explicitly been studied in obese subjects. But it seems to indirectly affect the BMI [11]: when EI was high, subjective food-related knowledge was a significant predictor of lower BMI whereas when EI was low, actual and subjective knowledge was significantly associated with higher BMI. Also, an increase in EI (after training sessions) resulted in a reduction of calorie intake [11]. More specifically, the ability to understand emotions (referring to the ability to analyse emotions, to understand their blends and transitions and probable changes over time as well as their outcomes [12], [13]), seems to be important in the context of disordered eating. It has been shown to be negatively associated with the maintenance of compensatory behaviour in relation to bulimic symptoms [14] and to be lower in women with anorexia nervosa compared with healthy controls [15].
The ability to recognize facial expressions of emotions in others, which also describes part of EI [13], is of utmost importance in comprehending the self and others. It has been studied in obese subjects, with inconsistent findings: Baldaro and colleagues [16], [17] investigated the ability to decode emotions in children aged eight to 15 and 16 years, respectively. Obese compared with normal-weight or moderately overweight children showed a diminished ability to decode facial expressions of emotions presented in pictures and nonverbal expressions of emotions presented in videos. However, no such difference was observed in another study with a sample of obese versus normal-weight adolescents and preadolescents [18]. This inconsistency in results might be due to a lack of power in the latter study due to its small sample size (n = 30 per group) as there was at least a trend (p = .08) for the hypothesized group difference.
Based on Bruch's assumptions, investigating the quality of mother–child relationships in the context of maternal obesity and the role of maternal emotional competencies seem crucial as they may pertain to prevention of overweight and obesity development in the child. In this context, the extent of Emotional Availability (EA) in the mother–child relationship can be considered to be important. EA is defined as a dyadic construct to symbolize ‘a global way of summarizing the overall quality of the affective relationship’ [19, p. 112] and is associated with attachment security [20], [21], [22], [23]. It depends on contributions from both partners in the interaction, i.e. the contributions of the adult (sensitivity, structuring, nonintrusiveness, nonhostility) are considered by taking into account the contributions of the child (child responsiveness, child involvement of the adult) and vice versa [19], [24].
Children's experience of a relationship with an emotionally competent mother characterized by high EA may be a protective factor towards the development of childhood obesity. However, deficits in maternal emotional competencies which may be associated with maternal obesity could impair EA in mother–child relationships as the correct identification of the child's signals and cues goes along with higher EA [19], [24]. When young children experience high EA with their mother who acknowledges emotions and supports the child to regulate them adequately if needed, children themselves are likely to develop a greater regulatory capacity [25], [26], which has been shown in various contexts [e.g. 27, 28] and even in association with lower physiological stress responses [29]. The capacity of emotion regulation has been discussed as a potential protective factor against the development of childhood obesity as it helps the child to cope with and moderate her responses to internal stimuli such as stress [6], [7]. Stress increases food consumption and a preference for food containing high levels of fat and sugar [30], [31], and is associated with emotional eating (i.e. the tendency to overeat in response to negative emotions) [32], which in turn is related to weight gain [33]. Prevalence rates for overweight and obesity are low in infancy and increase with increasing age of the child. Hence, exploring the quality of mother–child relationships in children at risk of obesity (due to maternal obesity) and exploring contributions of maternal emotional competencies during the first three years of life might be crucial for prevention. Prevention could then address a period of time before maladaptive eating behaviours in children may occur and the risk for developing obesity may increase. Since maternal depression has been shown to be related to lower EA [34], [35], obesity [36], and poor understanding [37] and recognition of emotions [38], [39], it should be considered as a potential confounding factor in this context.
To summarize, it remains unclear whether maternal obesity might be a risk for the quality of the mother–child relationship and whether obese mothers have more difficulties in understanding emotions and recognizing facial emotions. As far as we know, understanding emotions (along with other dimensions of performance-based EI) has been examined in the context of anorexia or bulimia nervosa but not in the context of obesity. Studies on the recognition of facial emotions yielded inconsistent results. Furthermore, there is a lack of research on how maternal capacities of understanding emotions and recognizing facial emotions influence mother–child EA in the context of maternal obesity. Such knowledge might be helpful in the context of obesity prevention in childhood.
This study aimed to investigate whether obese and normal-weight mothers differ in mother–child EA and emotional competencies (i.e. understanding emotions, recognition of facial emotions). Specifically, we hypothesized that obese mothers would show lower mother–child EA and lower abilities to understand emotions and to recognize facial emotions. Furthermore, we aimed to explore how maternal weight status and emotional competencies interact with each other in predicting EA, i.e. is the effect of maternal weight status on EA mediated by maternal emotional competencies or does the strength of the associations between emotional competencies and EA differ between obese and normal-weight mothers? Due to the general lack of research in this field, these analyses were exploratory.
Section snippets
Participants
The sample consisted of 73 normal-weight (BMI ≤ 24.9) and 73 obese (BMI ≥ 30) mothers and their children (80 girls, 66 boys) aged 6 to 47 months (Mchild age = 24.49, SDchild age = 11.49). The two groups did not differ in age of mother (p = .21) and child (p = .13), maternal education (p = .28) or child sex (p = 1.00). However, they differed significantly in the level of maternal depressive symptoms (p = .002). Obese mothers showed a higher level of depressive symptoms than normal-weight mothers. Therefore we
Differences in mother–child EA
To test our hypothesis that obese mothers and their children would exhibit lower EA, we conducted a MANCOVA revealing a significant multivariate effect of maternal weight status on the EA scales, F (6, 138) = 3.56, p = .003, ηp² = .13. As reported in Table 2, obese mothers received significantly lower scores than normal-weight mothers for the dimensions sensitivity, structuring, nonintrusiveness and nonhostility in the univariate analyses, whereas no significant differences emerged for the child
Discussion
Former research had shown that the mother–child relationship of low quality represents a risk factor for childhood obesity [6], [7], [8], [9], but remained incomplete or inconsistent with respect to the role of mothers' own obesity and their emotional competencies. Moreover, the interrelation of maternal emotional competencies and mother–child EA has not been investigated so far. Therefore, we conducted a study which aimed to investigate associations between maternal obesity, maternal emotional
Competing interest statement
The authors have no competing interests to report.
Acknowledgements
This work was supported by the Federal Ministry of Education and Research (BMBF), Germany, FKZ: 01EO1001. We wish to thank all the families who participated in this study. Moreover, we would like to thank the members of our research team: Katharina Herfurth-Majstorovic, Stefan Peuker, Sabine Thomassen, Natascha Weinberger and notably Eva Luft for their assistance and support. Special thanks are due to Christoph Becker for his help with implementing the recognition of facial emotion task.
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This work was conducted at: Leipzig University Medical Center, IFB Adiposity Diseases, Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics.