Assessing Your Health Psychology Paper

Assignment 5: Assessing Your HealthThis assignment is related to Module 9: Research Methods and Health Psychology. This
assignment is about assessing your own health, given the importance of playing an active role in
your own health experiences and healthcare, as well as the importance of being a “smart” patient.
This is in no way meant to provide you with medical information or advice; it is simply a way for
you to assess your health via a method used by Health Psychologists to assess health status
among patients or research participants.
1. Go to the following website to take a standard health survey that is used by many
psychologists to measure health status: https://rand36calculator.com
2. Answer each question on the survey by clicking on the response that is most appropriate for
you. Read all questions and options carefully.
3. As you select answers, your results will populate in the “Results” area after the survey;
complete all questions on the survey so that all areas (e.g., Pain) have a percentage score based
on your answers. Scores represent the percentage of total possible score achieved, and all items
are calculated so that a high score defines a more favorable health state. For example, if
your pain score is 98/100%, that indicates you are mostly pain free, whereas if your pain score is
10/100, you may have high levels of pain; if your general health is 90% out of a possible 100,
that means you are considerably healthy; etc.
4. After you answer all questions, print or save the results for yourself and write a
summary/discussion of your results. Do you agree with some or all of the results? Do you think
the results accurately represent your current state? Did you learn anything about your current
health status that you may not have been aware of or may not have considered? In your
summary, please touch on your results for every category. For each category, discuss your result,
whether or not you agree with it, whether it is something you are or are not surprised by, and
why you think that result might be the case for you (e.g., you are currently injured).
5. At the end of your summary, discuss whether you feel such an assessment could help you or
others feel in control or more prepared when discussing information with healthcare providers.
Why or why not? Where appropriate for points made here, cite course materials.
•
•
•
You do not have to submit your exact test results, but please write your summary of them.
The content of this summary should be 1-2 pages, double-spaced, and clearly address
points 4 and 5 above.
Submit your summary to Blackboard by its due date.
Research Methods and
Health Psychology
1
Health Research Overview
• Health psychology is the scientific study of how our
thoughts, emotions, and behaviors influence health
• Health psychologists focus on behaviors, disease,
preventative health
• Health psychologists use a variety of research
techniques to study health behaviors and interventions
to address health issues
The Basic Research Process
Research Designs
• Research design is about using a framework (e.g.,
methods, techniques) to guide the research process for
a study
• Health psychologists use common research designs:
• Correlational studies
• Experimental studies
• Intervention studies/Randomized controlled trials (RCTs)
2
Health Research Examples
• Society places a lot of value on looks, especially body
weight, which can be stigmatizing:
• Weight Stigma is the social devaluation of a person
because of their weight, typically higher weight
Basic Research Methodology
Correlational Studies
• Correlational studies assess relationships between two
or more variables
• Correlational studies do NOT show causation
• Example research question:
• Are weight stigma and eating
behavior related?
Stigma
Eating
Correlational Example: Variables
• Research Hypothesis: As weight stigma increases,
binge eating will increase, among participants who
consider themselves overweight
• Variables:
• Weight Stigma (higher scores = more weight stigma)
• 7-item survey; “I personally have been a victim of weight
discrimination.” 1(strongly disagree) to 7(strongly agree)
• Binge Eating (higher scores = more binge eating)
• 16-item survey; “I feel utterly helpless when it comes to feeling
in control of my eating urges.” Scored: 0 – 49
Correlational Example: Results
• Weight stigma and binge eating are positively related
Binge Eating
r = .503, p < .05, N = 536 Weight Stigma Correlational Relationships • A familiar problem: Directionality (a) Stigma Eating (b) Eating Stigma Negative Mood (c) Stigma Eating 3 Experimental Studies C a use a nd effect! • Experimental studies manipulate a variable of interest to influence another variable • Experimental studies involve assigning people to groups, applying a treatment/manipulation, and then measuring any response to that treatment/manipulation • Example research question: • Does exposure to weight stigma influence eating behavior? Stigma Eating Experimental Example: Variables • Research Hypothesis: Participants who consider themselves overweight will order more calories on a food-selection task if they are exposed to weight stigma, compared to participants exposed to stigma against a self-irrelevant outgroup (N = 113 college students) • Variables: • Independent variable (IV): Weight-stigma exposure • Dependent variable (DV): Calories ordered on menu task (Araiza & Wellman, 2017) Experimental Example: Procedure • Participants were randomly assigned to read about (1) weight stigma in the workplace or (2) workplace stigma against a self-irrelevant ethnicity outgroup • IV = weight-stigma exposure versus no exposure • Participants then imagined they were going to dinner with a friend, and they ordered any food items they wanted to eat from a menu • DV = mean number of calories ordered on menu task (Araiza & Wellman, 2017) Experimental Example: Result • Among people who consider themselves to be overweight, exposure to weight stigma can lead to ordering more calories at an imagined dinner, compared to exposure to stigma toward a self-irrelevant outgroup (Araiza & Wellman, 2017) 4 Intervention Studies • Health Psychology is very applied, or aimed at addressing real-world health issues • We can use information learned from studies about health behaviors and health outcomes to address problems related to our health • Intervention studies attempt to do just that by implementing different programs or techniques to help people change health behaviors, improve health outcomes, deliver health services, etc. Randomized Controlled Trials • RCTs: Research trial/experiment in which subjects are randomly assigned to one of two groups: one receiving an intervention (experimental group) being tested vs. another receiving an alternative treatment (comparison group) or no treatment (control group) (Kendall, 2003) An RCT Example: Variables • Research Question: Does journaling about gratitude, compared to journaling about everyday events and no journaling (control condition), increase subjective well-being? • Variables: • Independent variable (IV): Intervention type • Dependent variable (DV): Well-being (Jackowska et al., 2016) An RCT Example: Procedure • IV: Participants were randomly assigned to one IV level: • Experimental condition: Instructed to write in a diary expressing gratitude towards three previously unappreciated people or things in their lives • Active control condition: Instructed to write in a diary to record three things that happened to them, or that they noticed each day, whether good, bad, or neutral • No-treatment control condition: Told they would receive their writing task in three weeks, and they should go on about their lives, no daily writing • DV: Self-reported well-being (e.g., optimism, positive emotionality, life satisfaction, emotional distress) (Jackowska et al., 2016) An RCT Example: Results • Well-being results: Gratitude participants reported significantly more positive emotional style and optimism than the no-treatment control group, as well as significantly lower emotional distress than both the no-treatment and active control groups • Bonus results: Sleep quality and blood pressure • Gratitude participants reported better sleep quality (a small but significant effect) and showed a greater decrease in blood pressure, compared to participants in the no-treatment control condition (Jackowska et al., 2016) 5 Health Research Considerations • Who will be your participants? • Participants are often recruited from the general population, hospitals, health clinics • When will you assess them? • Longitudinal studies are common (e.g., chronic illness) • How will you assess them? • Physiological measures (e.g., blood pressure, heart rate) are common for data collection in health psychology Comparing Basic Designs • Correlational designs: • Examine how variables are related to each other • Do not manipulate or control variables, no random assignment • Answer questions like: ”Are stigma and eating related?” • Experimental designs: • Manipulate an independent variable (IV) to determine a causal change in a dependent variable (DV) • Place participants into groups, use random assignment • Answer questions like: “Does exposure to a stigmatizing experience cause people to eat more?” • Randomized controlled trials: • Test interventions, use random assignment and control groups • Answer questions like: ”Does this intervention increase well-being?” DOI: 10.1111/spc3.12378 ARTICLE Stress and eating: Definitions, findings, explanations, and implications Ashley M. Araiza | Marci Lobel Stony Brook University Correspondence Ashley M. Araiza and Marci Lobel, Department of Psychology, Stony Brook University, Stony Brook, NY 11794‐2500, USA. Email: ashley.araiza@stonybrook.edu; marci. lobel@stonybrook.edu Abstract As high stress has become ubiquitous in modern society, so too has the prevalence of overweight and obesity, leading many to question whether these changes are related. Does stress affect eating? In this article, we summarize research investigating associations between stress and eating and describe the mechanisms that may explain Funding information W. Burghardt Turner Fellowship such associations. Our review indicates that regardless of how stress and eating are operationalized, manipulated, or analyzed, and regardless of sample characteristics, associations of stress with eating behavior are observed quite consistently, with some variability due to individual differences. There is also evidence that the link between stress and eating involves both biological and behavioral processes. We discuss the possible longer term implications of stress–eating associations for weight gain, weight stigma, and subsequent health, and we identify specific methodological and conceptual advances needed to improve further research and application. 1 | I N T RO DU CT I O N Stress is pervasive in the United States and exerts pernicious effects on physical and mental health (American Psychological Association [APA], 2015). Some of these effects are explained by the unhealthful practices of people under stress, including inactivity (Ng & Jeffery, 2003), substance use (Sinha, 2001), and other high‐risk behaviors (Lighthall, Mather, & Gorlick, 2009; Porcelli & Delgado, 2009). Eating is also frequently examined in conjunction with high stress. Approximately two thirds of Americans are now considered to be overweight or obese (Ogden, Carroll, Kit, & Flegal, 2014), and eating in response to stress is a likely contributor to this epidemic. In 2015, 41% of American adults ages 18–35, 35% of adults ages 36–49, 29% of adults ages 50–68, and 21% of adults 69 years of age and older reported eating too much or eating unhealthy foods in response to stress (APA, 2015). Yet, there is great variation across studies in the ways that stress and eating have been conceptually and operationally defined. In this article, we describe these definitions and summarize what is known about the effects of stress on eating and the mechanisms posited to explain these effects, and we consider the potential downstream costs of stress‐induced eating, particularly obesity and its social‐ and health‐related consequences. We provide an overview of the range of research topics, methods, and conceptual variations that exist in the literature on stress and eating to inform readers about the current state of the field Soc Personal Psychol Compass. 2018;e12378. https://doi.org/10.1111/spc3.12378 wileyonlinelibrary.com/journal/spc3 © 2018 John Wiley & Sons Ltd 1 of 13 2 of 13 ARAIZA AND LOBEL and to highlight possibilities for future research in this area. Because it is not feasible to provide an exhaustive review of this extensive literature, we sample from the variety of studies that have used methodologically and conceptually robust approaches, as described in each of the subsections of this article, to offer illustrative examples. Studies were selected only if they were peer‐reviewed and used well‐validated and/or frequently utilized manipulations and measures to examine variables of interest. Wherever possible, we recommend relevant review articles or additional empirical work to guide the reader to the larger body of research available on each topic covered in this review. 2 | CONCEPTUALIZING AND OPERATIONALIZING STRESS It is particularly challenging to operationally define stress in humans considering the emotional and cognitive aspects that are unique to psychological stress (Adam & Epel, 2007; Nesse, Bhatnagar, & Young, 2007). Nevertheless, Lazarus and Folkman (1984) offered a definition of psychological stress that has been particularly influential. They defined stress as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well‐being” (p. 19). This definition illustrates the complexity of stress by emphasizing the importance of the individual, the situation, and the individual's appraisal of their situation and their ability to manage it. Numerous studies of stress related to eating have relied on operational definitions of stress that focus only on the individual, the situation, or on appraisal. Correlational studies of stress and eating have largely assessed stress by counting major life events, by assessing chronic stressors, or by focusing on daily hassles (i.e., minor, annoying, day‐to‐day irritations; Kanner, Coyne, Schaefer, & Lazarus, 1981) or perceived stress (O'Connor, Jones, Conner, McMillan, & Ferguson, 2008). Common methods of manipulating stress in experimental studies of stress and eating include having a participant deliver an impromptu speech in front of others (Brochu & Dovidio, 2014) or assigning them an impossible problem to solve (Habhab, Sheldon, & Loeb, 2009). Such studies then typically assess stress using well‐validated self‐report measures such as the Perceived Stress Scale (Cohen & Williamson, 1988) or measures with unknown psychometric properties that are designed or adapted for a particular study (e.g., Wallis & Hetherington, 2009). Some experimental studies examining stress and eating have also assessed biomarkers such as cortisol, a hormone secreted by the adrenal gland in response to stress (Stephens & Wand, 2012). Its biological precursor, corticotrophin releasing hormone (CRH; George, Khan, Briggs, & Abelson, 2010), has also been used to operationally define stress, and there is some research examining cortisol reactivity to stress as an individual characteristic that is differentially associated with eating behavior (Epel, Lapidus, McEwen, & Brownell, 2001). The variety of conceptual and operational definitions of stress that exist across the literature impede definitive conclusions about the impact of stress on eating behavior. It is not clear, for example, whether particular types of stress are more likely to influence eating, nor whether perceptions of stress and biological measures are equally reliable ways to operationalize stress. Experimental research confirms the ordering and causal connection between stress variables and eating, but experimentally induced stress may not be an ecologically valid method to understand the impact of stress on eating. As the number of studies examining stress and eating grows, there is increasing need to resolve these methodological and conceptual issues. 3 | S T R E S S A N D EA T I N G B E H A V I O R There is similarly great variation in the ways that eating has been operationalized across studies. Many investigations have focused on maladaptive behaviors such as “comfort eating,” which involves consuming high‐calorie, high‐sugar, or high‐fat foods (Torres & Nowson, 2007). Finch and Tomiyama (2015), for example, examined the relationship between stress and comfort eating in a sample of 2,379 young adult women. They found that the number of adverse life events experienced in the previous year and self‐reported psychological stress in the previous month were positively correlated with comfort eating, defined by how often participants reported eating when they felt stressed, sad, worried, ARAIZA AND LOBEL 3 of 13 mad, or bored. Similarly, in a sample of 561 community women, Groesz et al. (2012) found that both perceived stress and exposure to chronic stress (i.e., number of endorsed stressors) were associated with greater self‐reported frequency of consumption of appetizing, nonnutritious foods such as chips and burgers. Ng and Jeffery (2003) also examined the relationship between stress and fat intake among 12,110 working adults and found that greater perceived stress (i.e., feeling out of control over life situations) was correlated with self‐reported consumption of high‐fat foods. Some studies have focused on excess consumption of calories, or consuming more calories than are necessary for the body and brain to function properly (McEwen, 2006). Oliver and Wardle (1999) assessed stress‐induced eating among 212 college students by measuring the extent to which participants perceived stress to influence their eating behavior (e.g., snack consumption). Participants reported that experiencing stress led to increases in the overall amount of snack foods consumed, although the number of participants who reported eating more food in response to stress was relatively equal to the number who reported eating less food in response to stress. O'Connor et al. (2008) used a daily diary method over a 7‐day period to obtain reports of daily hassles and several eating indices (e.g., amount of food consumed and intake of high‐sugar snacks) from 422 working adults. At the end of each day, participants recorded each daily hassle experienced and its intensity, as well as food eaten between meals. In this study, experiencing at least one daily hassle was associated with consuming a greater number of snacks between meals, as well as consuming an increased number of snacks high in fat and sugar. Similarly, in a 2‐week daily diary study of 55 premenopausal women, Newman, O'Connor, and Conner (2007) found that a greater number of daily hassles was associated with an increase in number of between‐meal snacks consumed per day. Emotional eating, or eating in response to emotionally arousing states such as sadness or anger (van Strien, Frijters, Bergers, & Defares, 1986), has also been examined in relation to stress. Among 97 freshmen in their first month of college, Wilson, Darling, Fahrenkamp, D'Auria, and Sato (2015) found that the extent to which students viewed events as stressful was positively associated with increased emotional eating. This was observed among those who were average weight and those who were overweight as determined by the body mass index (BMI), a well‐accepted guideline of body weight for height (National Institutes of Health, 2013). Although a substantial amount of research examining the impact of stress uses self‐report methods to assess eating, these have questionable reliability and validity, especially considering the potential for social desirability bias and the tendency to underreport stigmatized behaviors such as overeating (Gorber, Tremblay, Moher, & Gorber, 2007). Evidence of this problem was provided from a sample of 185 male and female non‐insulin‐dependent diabetics who reported their food intake using a daily‐diary method over a 3‐day period (Adams, 1998). Intake was evaluated in comparison to an estimate of each participant's total energy expenditure, determined using well‐established basal metabolic rates based on age and sex (intake should approximate total expenditure). Results indicated that most participants underreported their consumption of food. This was particularly pronounced among women who were considered obese based on their BMI. Relatedly, Gorber et al. (2007) conducted a systematic review of the literature on objectively measured versus self‐reported weight and found that individuals tended to underreport their weight, with the exception of those who were underweight due to anorexia. van de Mortel (2008) reviewed research on assessment of social desirability in health research and found that most studies did not use any measure to assess socially desirable responding. In the studies that did, almost half found that results were influenced by social desirability. Considering the potential for unreliable findings from self‐report measures of eating, assessing actual consumption is especially valuable, which is the norm in most studies of eating associated with experimentally induced stress. Participation in stressful laboratory tasks has been associated with a variety of eating outcomes, especially consumption of unhealthy snack foods. Habhab et al. (2009) examined food intake in 40 female college students who were randomly assigned to complete either an unsolvable (high‐stress) or solvable (low‐stress) puzzle and were provided with M&M's, Teddy Grahams, potato chips, and pretzels to eat freely during the experiment. Participants under high stress consumed a greater amount of food compared to those experiencing low stress. Royal and Kurtz (2010) induced high or low stress using a similar paradigm and examined subsequent snack food intake (M&M's, Reese's Pieces, cheese crackers, and peanuts) in 52 female college students. Highly stressed participants consumed more of these foods than their low‐stress counterparts. In a third study using this type of stress induction, high‐stress participants 4 of 13 ARAIZA AND LOBEL ate significantly more M&M's than low‐stress participants, although there were not differences for two other snack foods, potato chips and peanuts (Zellner et al., 2006). In studies examining biological indicators of stress, women higher in cortisol reactivity to stress have been shown to consume more calories under stress than women with lower cortisol reactivity to stress (Epel et al., 2001). In this study, 59 premenopausal women completed three stressful tasks that involved puzzles, mental math, and speech delivery, during which cortisol levels were assessed via salivary samples. Participants were subsequently left alone in a room with several snacks (chocolate granola bars, potato chips, rice cakes, and pretzels) to eat at their leisure. Women who exhibited higher cortisol reactivity consumed a greater number of calories following the stressful tasks, compared to women lower in cortisol reactivity. Similarly, an increase in CRH, a biological precursor to cortisol, has been linked to higher caloric intake and increased food consumption in men and women who were administered CRH via injection, compared to a placebo, and then given the opportunity to consume prepackaged snacks in the laboratory (George et al., 2010). In addition to being associated with an increase in unhealthy eating, many studies have also shown that there is a relationship between stress and decreased consumption of healthy foods. For example, Zellner et al. (2006) not only found that stressed participants ate more M&M's than non‐stressed participants but also that stressed participants were significantly less likely to consume grapes than non‐stressed participants. Similarly, Groesz et al. (2012) found that stress was associated with a self‐reported decrease in the amount of nutritious foods consumed, such as fruit and vegetables, and Oliver and Wardle (1999) found that college students reported decreased consumption of foods typical of balanced meals, such as vegetables or meat, in response to stress. These studies are particularly important in the larger context of research on stress and eating, as they suggest that the association between stress and eating may not involve greater consumption of food per se, but selective consumption, favoring calorically dense, sweet, and otherwise unhealthful foods. 3.1 | Stress and disordered eating Symptoms commonly associated with eating disorders, particularly binge eating, have also been reported in response to stress. Binge eating involves a disinhibition of eating behavior (Heatherton & Baumeister, 1991) and is characterized in part by a loss of control over eating (Colles, Dixon, & O'Brien, 2008). In addition to the aforementioned findings from the study by Groesz et al. (2012), these researchers also found that perceived stress and chronic exposure to life stressors were correlated with self‐reported frequency of binge eating behaviors. Other studies have observed links between self‐reported perceived stress over the last month and endorsement of binge eating symptoms in community samples (Rosenbaum & White, 2015); between number of self‐reported experiences with common stressors and frequency and severity of binge eating behaviors in female college students (Sulkowski, Dempsey, & Dempsey, 2011); and between self‐reported number of daily stressful events and binge eating episodes among college women with previously existing maladaptive eating patterns (Wolff, Crosby, Roberts, & Wittrock, 2000). A separate literature also exists identifying stress as a trigger of binge eating among individuals with clinically diagnosed eating disorders or who are predisposed to such disorders (Connan & Treasure, 1998). Razzoli, Pearson, Crow, and Bartolomucci (2017) provide a brief, more in‐depth analysis of the association between stress and binge eating. 3.2 | Adolescents and children Most studies examining the effects of stress on eating have been conducted in adult populations; however, associations between stress and eating behavior have also been observed in adolescents (e.g., Nguyen‐Michel, Unger, & Spruijt‐Metz, 2007) and young children (e.g., Michels et al., 2012). Hou et al. (2013) found that unhealthy eating was significantly correlated with the amount of self‐reported life stress, namely, stress due to family, school, relationships, growth, or love/sex, in a sample of 2,885 junior and high school students in China. In 437 young children ages 5–12, stress defined by the number of reported stressful events, emotions, problems, and daily hassles was positively ARAIZA AND LOBEL 5 of 13 associated with emotional eating and with greater intake of high‐fat, sweet foods (Michels et al., 2012). Michels and colleagues also found that when children were stressed, they engaged in more frequent unhealthy eating habits (e.g., decreased consumption of fruits and vegetables), as reported by both the children and their parents. Understanding the stress–eating relationship in childhood is particularly important, as many unhealthy eating patterns, including preferences for high‐fat and high‐sugar foods, are developed very early (Wen, Kong, Eiden, Sharma, & Xie, 2014). 4 | UNDERSTANDING THE RELATIONSHIP BETWEEN STRESS AND EATING 4.1 | Mechanisms underlying the stress–eating relationship Mood, cognition, coping, and hormones have received the most attention as potential mechanisms to explain the association of stress with eating. In a sample of 133 women with bulimia nervosa, for example, Goldschmidt et al. (2014) showed that negative affect mediated the relationship of binge eating with stress, operationalized as the number of stressors and the severity of event‐related stress appraisals. Cognitive load has also been examined as a mediator of the impact of stress on eating. High cognitive load occurs when working memory resources are taxed, subsequently impairing performance on mental tasks (Byrd‐Bredbenner, Quick, Koenings, Martin‐Biggers, & Kattelmann, 2016; Paas, Renkel, & Sweller, 2004). Stressors in general are thought to contribute to higher cognitive load by reducing availability of working memory resources, and cognitive load is proposed to affect eating by monopolizing cognitive resources that may be necessary to engage in desired eating behaviors and avoid undesired eating behaviors (Byrd‐Bredbenner et al., 2016). In a sample of 1,018 undergraduate students, Byrd‐Bredbenner et al. (2016) examined the association between cognitive load and self‐reported eating behavior. High cognitive load was determined using a calculation based on number of self‐reported stressors and various other participant factors related to stress. Participants under high cognitive load had higher scores on self‐report measures of restrained eating including restrictive dieting, which involves limiting calories, externalized eating, which involves eating in response to outside cues related to food, and emotional eating. High cognitive load participants also scored lower in self‐reported regulation of planning, choosing, and assembling healthy meals, compared to participants with low cognitive load. Coping strategies have also been shown to mediate associations between stress and eating (e.g., MacNeil, Esposito‐Smythers, Mehlenbeck, & Weismoore, 2012; Ward & Hay, 2015). In a study of 147 female college students, participants reported whether or not they had encountered several life stressors commonly experienced by undergraduates, the behavioral and/or emotional strategies they utilized in response to such stressors, and the severity and frequency of their binge eating behaviors. The authors found that greater use of emotion‐focused coping (e.g., minimization of or distancing from a stressor) partially mediated the relationship between stress and binge eating (Sulkowski et al., 2011). Closely related to emotion‐focused coping is avoidant coping, which is characterized by withdrawal from a stressor (Herman‐Stahl, Stemmler, & Petersen, 1995). As part of a larger study involving 102 adolescent high school students, Martyn‐Nemeth, Penckofer, Gulanick, Velsor‐Friedrich, and Bryant (2009) assessed stress across six domains: school, parents, friends, romantic interests, self, and future; coping strategies; and how often participants reported eating behaviors considered to be healthy (e.g., regularity of meals) or unhealthy (e.g., skipping breakfast). Greater stress was associated with avoidant coping, which in turn was associated with a higher frequency of unhealthy eating behaviors. Several physiological and biological mechanisms for associations between stress and eating have also been investigated (see Adam & Epel, 2007 for a review). Ghrelin, a hormone that activates appetite (Klok, Jakobsdottir, & Drent, 2007) and has been shown to be released in response to psychological stress (Rouach et al., 2007), has been proposed as a mechanism by which stress may lead to increased appetite and subsequent eating (Diz‐Chaves, 2011; Schellekens, Finger, Dinan, & Cryan, 2012; Sominsky & Spencer, 2014). Conflicting evidence exists, however, about the role of ghrelin in the stress–eating relationship. For example, in one study of mice using a paradigm thought to 6 of 13 ARAIZA AND LOBEL be analogous to long‐term psychosocial stress in humans, ghrelin levels mediated the association between stress, indicated by depressive behaviors exhibited following prolonged interaction with an aggressive mouse, and increased consumption of a high‐fat diet (Chuang et al., 2011). In contrast, ghrelin did not mediate the relationship between stress (speech delivery) and the self‐reported urge to eat uncontrollably in a human sample of 24 individuals with and without binge eating disorder (Rouach et al., 2007). A second hormone, leptin, which signals satiety (Morton, Cummings, Baskin, Barsh, & Schwartz, 2006), has been associated with decreased intake of high‐fat, sweet, comfort, and snack foods and has also been shown to be released in response to stress (Appelhans, 2010; Tomiyama et al., 2012). Tomiyama et al. (2012) investigated whether leptin reactivity could explain the stress–eating relationship in a sample of 29 postmenopausal community women. Participants completed four tasks related to delivering a speech in public and were then left alone in a room and invited to eat available snacks at their leisure. Leptin was assessed using blood samples taken during the stress period. Stress, defined by increases in cortisol, was associated with increased leptin, and the increases in leptin were significantly associated with the consumption of fewer grams of high‐fat and sweet snacks (Tomiyama et al., 2012). This finding suggests that leptin may be another mechanism through which stress affects eating, paradoxically, to decrease consumption of unhealthy foods. The opposing relationships of ghrelin and leptin with eating behaviors have been observed in previous studies, and these relationships exist in the face of stress. Thus, these hormones may offer a biological explanation for variation in eating patterns that occur in response to stress (Stone & Brownell, 1994). This is a particularly intriguing possibility because there is evidence that some individuals eat more in response to stress, whereas others eat less (Appelhans, Pagoto, Peters, & Spring, 2010). 4.2 | Moderators of the stress–eating relationship A large literature also exists on the many variables that may moderate the relationship between stress and eating (e.g., Conner, Fitter, & Fletcher, 1999; van Strien, Herman, Anschutz, Engels, & de Weerth, 2012). These studies indicate that certain individuals may be more likely to engage in maladaptive eating patterns under stress (Torres & Nowson, 2007). For example, people who engage in restrained eating behaviors are more vulnerable to stress‐induced unhealthy eating than non‐restrained eaters (Lattimore & Caswell, 2004; Wardle, Steptoe, Oliver, & Lipsey, 2000). It has been proposed that long‐term rigid restraint of eating is not sustainable and may be counterproductive, leading to increases in eating and subsequent negative health consequences (e.g., Araiza & Wellman, 2017; Wellman, Araiza, Newell, & McCoy, 2017). Increased intake of unhealthy foods in response to stress is also more common among individuals considered to be emotional eaters (Wallis & Hetherington, 2009); individuals who are overweight according to BMI guidelines (O'Connor et al., 2008); younger adults (18–34 years old; Wansink, Cheney, & Chan, 2003); and women (O'Connor et al., 2008; Zellner et al., 2006; Zellner, Saito, & Gonzalez, 2007), than among their respective counterparts. Additionally, White women appear more likely than African American women to engage in binge eating following stress (Harrington, Crowther, Payne Henrickson, & Mickelson, 2006). Last, decreased food consumption in response to stress has been observed to be more common in men than women (Grunberg & Straub, 1992). Other findings suggest that decreased eating in response to stress is more common among unrestrained eaters than among restrained eaters (Rutledge & Linden, 1998). 5 | STRESS, EATING, AND OBESITY An important consequence of stress‐induced eating is the potential for weight gain and obesity (see Torres & Nowson, 2007 for a review of associations among stress, eating behavior, and obesity). Eating more than is metabolically required is the primary contributor to weight gain and subsequent obesity (Tsenkova, Boylan, & Ryff, 2013). Other variables such as stress‐related metabolic changes (Scott, Melhorn, & Sakai, 2012) may also help explain the association of stress with weight gain and obesity, and there is evidence that stress can influence the distribution of weight, ARAIZA AND LOBEL 7 of 13 particularly abdominal adiposity (Wardle, Chida, Gibson, Whitaker, & Steptoe, 2011), which is determined by a high waist‐to‐hip ratio. In a sample of 619 community men and women, Chao, Grilo, White, and Sinha (2015) found that chronic stress, operationalized as endorsement of consistent stressors, problems, and hassles over one's lifetime, was associated with higher BMI and that this association was partially mediated by self‐reported cravings for fats, complex carbohydrates/ starches, sweet foods, and fats from fast foods. Other research by this team examined associations among stress, self‐control, and addiction in a community sample of 320 men and women (Chao, Grilo, & Sinha, 2016). The authors identified a link between self‐reported food cravings and self‐reported binge eating episodes, defined as having at least one binge eating episode in the previous month. Furthermore, there is evidence that binge eating is associated with higher BMI (Adamus‐Leach et al., 2013). Several studies have also observed links between stress‐related eating and other indices of obesity, including research documenting associations of increased cortisol response to stress with distribution of abdominal body fat (Pasquali et al., 1993) and higher waist‐to‐hip ratio (Epel et al., 2000). Taken together, these findings support the notion that there are links from stress to eating to obesity. Epel et al. (2004) assessed self‐reported tendencies to eat more or eat less in response to self‐reported stress among 81 male and female medical students. They examined stress‐related tendencies toward increased eating as a predictor of both BMI and waist‐to‐hip ratio over a 1‐year period, which included baseline measurements and physiological measurements taken during two exam periods throughout the year and then averaged. Students who reported at baseline that they typically ate more in response to stress experienced significant increases in BMI, as they gained an average of 5 lbs over the 1‐year period, compared to those who reported that they typically ate less during stressful periods. Additionally, waist‐to‐hip ratio increased for women who reported a tendency to increase food consumption in response to stress, although this was not observed in male participants. Similarly, Roberts, Campbell, and Troop (2014), as part of a larger 12‐week prospective study, investigated how BMI might be influenced by physiological stress, as defined by cortisol secretion, and psychological stress, as indicated by self‐reported level of distress, in anticipation of a significant end‐of‐period stressor (a university exam) among 71 female students from a university in London. Slightly more than half (56%) of students experienced an increase in BMI in response to stress. Long‐term adverse health consequences may also arise from the stress–eating relationship. People who gain weight from consuming unnecessary calories in response to stress are at risk for health problems related to obesity, including heart disease, stroke, Type 2 diabetes, some forms of cancer, and premature death (Nixon, 2010). Tsenkova et al. (2013) examined relationships among stress, eating, and several early metabolic indicators of diabetes (e.g., fasting glucose and insulin) in a nondiabetic sample of 1,138 adults. The authors found that stress‐induced eating, indicated by the extent to which individuals reported turning to food when stressed, was related to poor glycemic control and an increased likelihood of prediabetes and diabetes and that this relationship was mediated by greater waist circumference. These findings substantiate that stress‐induced eating can lead to poorer health outcomes through weight gain. 6 | S T R E S S, E A T I N G , O B E S I T Y , A N D WE I G H T S T I G M A An additional implication of the link between stress and maladaptive eating patterns is the potential for people to experience weight‐related stigma (refer to Tomiyama, 2014 for a review and proposed theoretical model supporting these associations). Weight stigma refers to the disparagement and social degradation of those who are higher in body weight (Tomiyama et al., 2014), and research indicates that this stigma may lead to further weight gain via increased eating (Tomiyama, 2014). Several studies have shown that weight stigma is associated with intentions to consume increased amounts of food (Araiza & Wellman, 2017), self‐reported increases in eating (O'Brien et al., 2016), and actual increases in food intake (Major, Hunger, Bunyan, & Miller, 2014). The proposed mechanism by which weight stigma leads to increased eating is stress; the predominant theory is that weight stigma is itself stressful and can deplete the resources necessary to regulate eating behavior, leading to increased caloric intake (Major, Eliezer, & 8 of 13 ARAIZA AND LOBEL Rieck, 2012; Major et al., 2014; Tomiyama, 2014). Considering the relevance of the stress–eating relationship in predicting weight gain and obesity, it is likely that stress‐induced eating may create in some individuals a self‐fulfilling cycle of weight gain and subsequent weight stigma (Tomiyama, 2014). Longitudinal studies examining the association between stress and weight gain have shown that stress experienced by individuals who are already higher in body weight is related to long‐term increases in weight gain (Block, He, Zaslavsky, Ding, & Ayanian, 2009). Additional prospective, longitudinal studies investigating the long‐term costs of stress‐induced eating may help inform how this cycle of consequences unfolds not only in people who are already considered to be higher in body weight but also among those who are considered to be average weight. 7 | I M P L I C A T I O N S A N D C O N C L U SI O N S It appears from the extensive literature on the relationship between stress and eating that stress influences eating behavior in a variety of ways. In this review, to illustrate some of the variety that exists in this literature, we presented a collection of studies that highlight the breadth of ways in which stress and eating have been operationalized and examined. Regardless of how stress and eating are operationalized, manipulated, or analyzed, regardless of sample characteristics, and regardless of additional mediator and moderator variables that may help explain the stress–eating relationship, associations of stress with eating behavior are observed quite consistently. Although there is some variation depending on the study, a similar pattern exists: stress influences eating and most often in an unfavorable manner. Thus, it is critical to recognize the stress–eating connection and its potential to act as a contributor to obesity, which may help inform efforts to design and implement both preventive and curative interventions. A variety of interventions have been developed, tested, and implemented to provide people with tools to avoid unhealthy eating in response to stressful life experiences (e.g., Corsica, Hood, Katterman, Kleinman, & Ivan, 2014) or to emotional stress (for a closer look at interventions targeting emotional stress eating, see Frayn & Knäuper, 2017). One recent intervention developed by O'Connor, Armitage, and Ferguson (2015) offers a promising approach. In an experimental study, participants completed a stress management support intervention, based on elements from similar interventions previously used to reduce other unhealthy behaviors (Adriaanse, de Ridder, & de Wit, 2009; Armitage, 2008). Participants listed five stressful situations that elicit negative emotions and identified a healthy snack that they could readily access and eat in each of the five situations (e.g., eating an apple when feeling worried). Participants in the experimental condition were then asked to visualize themselves following through with their plans to choose the healthy snack in the stressful situation. Compared to control participants, those in the experimental condition did eat an increased number of healthy snacks on subsequent stressful days (O'Connor et al., 2015). The goal of such an intervention is not to reduce stress‐induced eating, per se, but rather to help people plan ahead and reduce their likelihood of unhealthy food choices in response to stress. The current state of understanding regarding relationships among stress, eating, and obesity highlights the importance of studying both the mechanisms that underlie these relationships and the implications they have for health. Although a large body of literature exists describing the relationship between stress and eating, more work is needed to discern predictors and outcomes associated with stress and the stress–eating relationship. For example, novel and sophisticated methodological approaches (e.g., ecological momentary assessment) may allow for closer study of the stress–eating relationship and provide increased reliability and validity. Additionally, a clearer understanding of the roles of gender, race, socioeconomic status, and other demographic factors may illuminate characteristics that influence the impact of stress on eating. Finally, delineating the mechanisms underlying the stress–eating relationship would provide crucial information about how to address the role that stress plays in unhealthy eating and subsequent health outcomes. There are likely to be multiple mechanisms underlying the stress–eating relationship, and understanding their additive and interactive processes will require close investigation. Addressing such methodological and conceptual issues can facilitate the development of successful, tailored interventions that target stress, stress‐ induced eating and eating restriction, and relevant health outcomes. 9 of 13 ARAIZA AND LOBEL Forty‐two percent of adults in the United States are unsure about whether they are doing enough to manage stress or feel that their attempts to do so are inadequate (APA, 2015). Simultaneously, we are witnessing an epidemic of overweight and obesity in Americans, with resulting health, social, and economic impacts on individuals, families, and society through a rise in obesity‐related illnesses, effects on the labor market, and strain on our health‐care system (Wang, McPherson, Marsh, Gortmaker, & Brown, 2011). For these and many other reasons, it is important for researchers and clinicians to identify accessible, manageable ways for people to reduce stress or to reduce stress‐ induced unhealthful eating and, thereby, preserve health and well‐being. ACKNOWLEDGEMEN T Ashley M. Araiza was supported by a W. Burghardt Turner Fellowship from the Center for Inclusive Education at Stony Brook University. ORCID Ashley M. Araiza Marci Lobel http://orcid.org/0000-0002-8656-4696 http://orcid.org/0000-0002-7841-2422 RE FE R ENC ES Adam, T. C., & Epel, E. S. (2007). Stress, eating and the reward system. Physiology & Behavior, 91, 449–458. https://doi.org/ 10.1016/j.physbeh.2007.04.011 Adams, S. J. (1998). The dietary intake of people with non‐insulin‐dependent diabetes (NIDDM): How valid is self‐reported intake? Journal of Human Nutrition and Dietetics, 11, 295–306. https://doi.org/10.1046/j.1365‐277X.1998.00110.x Adamus‐Leach, H. J., Wilson, P. L., O'Connor, D. P., Rhode, P. C., Mama, S. K., & Lee, R. 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Predictors of emotional eating during adolescents' transition to college: Does body mass index moderate the association between stress and emotional eating? Journal of American College Health, 63(3), 163–170. https://doi.org/10.1080/07448481.2014.1003374 Wolff, G. E., Crosby, R. D., Roberts, J. A., & Wittrock, D. A. (2000). Differences in daily stress, mood, coping, and eating behavior in binge eating and nonbinge eating college women. Addictive Behaviors, 25(2), 205–216. https://doi.org/10.1016/ S0306‐4603(99)00049‐0 Zellner, D. A., Loaiza, S., Gonzalez, A., Pita, J., Morales, J., Pecora, D., & Wolf, A. (2006). Food selection changes under stress. Physiology & Behavior, 87, 789–793. https://doi.org/10.1016/j.physbeh.2006.01.014 Zellner, D. A., Saito, S., & Gonzalez, J. (2007). The effect of stress on men's food selection. Appetite, 49(3), 696–699. https:// doi.org/10.1016/j.appet.2007.06.013 Ashley M. Araiza is a doctoral student in the Social and Health Psychology graduate program at Stony Brook University, and a recipient of the W. Burghardt Turner Graduate Fellowship. She holds a BA in Biological Psychology and an MA in Experimental Psychology from California State University, San Bernardino. Broadly, her research is focused on the social and cognitive determinants of health‐related behaviors and decisions. Her work is more specifically focused on social and psychological predictors (e.g., weight stigma and stress) of eating behavior and on biases in the processing and acceptance of health information. She has coauthored two empirical articles on the effects of weight stigma on eating behavior. Marci Lobel (AB, Harvard University; PhD, University of California, Los Angeles) is Professor of Psychology, Director of the Stony Brook Pregnancy Project, and Director of the Program in Social and Health Psychology at Stony Brook University. Her research focuses on conceptualization, measurement, and effects of stress on health, particularly women's reproductive health. Additionally, she conducts research to address critical public health problems in the United States, including racial disparities in birth outcomes and rising rates of surgical delivery. Dr. Lobel serves on the editorial boards of several journals, and she teaches courses on Social Psychology and the Psychology of Women's Health. She has received a variety of awards for her research, teaching, and service. How to cite this article: Araiza AM, Lobel M. Stress and eating: Definitions, findings, explanations, and implications. Soc Personal Psychol Compass. 2018;e12378. https://doi.org/10.1111/spc3.12378

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