Opposite ends of the spectrum: Is emotional eating present more barriers to applying mindful eating and intuitive eating strategies for females?

Background: There are few studies in the literature examining the role of gender in the relationships between intuitive eating, mindful eating, dietary restraint, and emotional eating. It is important to reveal the role of gender in these relationships. Therefore, in this study, we aimed to evaluate the relationship between intuitive eating, mindful eating, emotional eating and restraint eating behaviors and the role of gender in these relationships. Methods:This study was conducted with 522 participants aged 18-65. Questionnaire about sociodemographic characteristics and general eating habits, Intuitive Eating Scale-2 (IES-2), Mindful Eating Questionnaire-30 (MEQ-30), and Emotional Eating and Restraint Eating Subscale of Dutch Eating Behavior Questionnaire (DEBQ) were applied to the participants. Results: DEBQ Restraint Eating, and Emotional Eating subscale scores were found to be higher in females. The total scores of IES-2 and MEQ-30 were found to be higher in the group with Body Mass Index (BMI)<25, and the DEBQ Emotional Eating subscale score was found to be higher in the group with BMI ≥ 25. The negative correlation between DEBQ Emotional Eating subscale score and IES-2 total score was weak in males and strong in females. The negative relationship between MEQ-30 total score and DEBQ Emotional Eating subscale score was moderate in males and strong in females. It was determined that gender explained 27.7% of the relationship between the total score of IES-2 and the total score of MEQ-30, and 37.9% of the relationship between the total score of MEQ-30 and DEBQ Emotional Eating score. Conclusions:


Introduction
In recent years, it has been reported that eating disorders have increased with obesity and this situation is associated with increased mortality (1,2).It is important to investigate the mechanisms behind eating disorders and to offer solutions.
The role of restraint eating, emotional eating, intuitive eating, and mindful eating in this pathology is discussed in the current literature.The concept of intuitive eating, introduced by Tribole and Resch in 1995 (3), is de ned as feeding in response to hunger and satiety by adhering to internal signals (4).Mindful eating expresses the state of eating by being aware of internal cues and emotional states and perceiving these hunger and satiety signals given by the body (5).While studies emphasize the role of mindful eating and intuitive eating strategies in the prevention and treatment of both eating disorders and obesity (6-8), they report that emotional eating and restraint eating may also be risk factors for these pathologies (9,10).
When these eating behaviors are evaluated on the basis of gender it is reported that males are more dependent on their internal signals than females, that is, they are more prone to intuitive eating behavior, while females show more restraint eating and emotional eating behavior than males (11)(12)(13).
It is important to evaluate these relationships on the basis of gender in order to evaluate the relationship between these eating behavior patterns and to give more speci c recommendations.
The aim of this study is to evaluate the relationship between intuitive eating, mindful eating, restraint eating and emotional eating.It is also aimed to evaluate the moderator role of gender in these relations in order to give more speci c suggestions on the basis of gender.

Participants
This cross-sectional study was conducted between March 26, 2021 and April 12, 2021.The study was conducted online and participants were invited to the study via social networks.Participants aged 18-65 years and volunteered to participate in this study were included in the study.The sample size was calculated as 262 with 95% test power, α = 0.05 margin of error, considering the studies on this issue in order to reveal the relationship between the scale scores (14,15) and was completed with 522 participants.The Ethics Committee on Medical Research of Acibadem Mehmet Ali Aydinlar University approved the study (ATADEK 2021/05) and informed consent was obtained from participants before starting the research.

Study Design
A questionnaire about sociodemographic characteristics and general eating habits, IES-2, MEQ-30 and Emotional Eating and Restraint Eating Subscale of the DEBQ was used.

Sociodemographic Characteristics
A questionnaire was used to obtain information about sociodemographic characteristics general eating habits and anthropometric measurements.Body weight and height information were obtained from the participants and BMI (kg/m²) was calculated using these data.BMI was categorized using the World Health Organization's BMI classi cation (16).
Intuitive Eating Scale-2 (IES-2) IES-2 was used to evaluate participants' intuitive eating levels.IES-2 is an improved version of the Intuitive Eating Scale previously prepared by Tylka (17).It consists of four subscales: eating for physical rather than emotional reason, reliance on hunger and satiety cues, unconditional permission to eat, and body food choice congruence (18).The Turkish validity and reliability study of IES-2 was conducted by Baş et al.As in the original scale, this scale consists of 23 items and 4 subscales.The questions are scored as a 5-point Likert type scale ranging from "Strongly Disagree" to "Strongly Agree".The higher the total score and the subscale scores, the higher the intuitive eating level (19).
Mindful Eating Questionnaire-30 (MEQ-30) MEQ-30, developed by Framson et al. (20), was used to assess participants' mindful eating levels.The Turkish adaptation of MEQ was carried out by Köse et al.This 30-item adapted scale includes 7 subfactors: mindfulness, conscious nutrition, eating control, eating discipline, disinhibition, emotional eating, and interference.Each item in this questionnaire is evaluated on a 5-point Likert-type scale ranging from Never (1) to Always (5).An increase in the questionnaire score indicates an increase in the level of mindful eating (21).

Dutch Eating Behavior Questionnaire (DEBQ)
Emotional eating and restraint eating behaviors of the participants were evaluated with DEBQ, developed by Van Strien et al. (22).The Turkish validity and reliability study of this questionnaire was conducted by Bozan et al.The adapted scale consists of 33 items, and 3 factors: external eating, restrictive eating, and emotional eating, as in the original.Scale scoring is done on a 5-point Likert type scale ranging from 'Never (1) to 'Very often (5)'.Although there is no scoring for the total score of the scale, the increase in each subscale score shows that the person re ects that feature (23).

Statistical analysis
Statistical analyzes were performed with the IBM Statictical Package for Social Sciences (SPSS) version 26.0 (SPSS, 2019) and PROCESS MACRO was used to test for moderator effects.The categorical data obtained were summarized with numbers and percentages, and quantitative variables were summarized with mean, standard deviation, minimum and maximum statistics.Two independent group comparisons were tested with the t-test, more than two independent group comparisons were tested with variance analysis (ANOVA) and Welch ANOVA in cases where the homogeneity of variance assumption was not provided.The relationships between quantitative variables were measured with the Pearson Correlation coe cient.Estimation models for scale scores were constructed as interactive models with moderator effects.Statistical signi cance level was accepted as 5% in all analyzes.

Results
Of the participants, 24% (n = 125) were male and 76% (n = 397) were female.While the mean BMI of females was 23.47 ± 4.38, it was 26.15 ± 4.76 for males.56.8% of males and 28.2% of females were in the group with BMI ≥ 25 (Table 1).The genders were found to be similar in terms of IES-2 (p = 0.197) and MEQ-30 (p = 0.847) total scores.
However, it was found that restraint eating and emotional eating scores of females were higher than those of males.(Table 2).Participants with BMI < 25 had higher IES-2 and MEQ-30 total scores than participants with BMI ≥ 25.On the other hand, DEBQ emotional eating subscale score was found to be lower in participants with BMI < 25 (Table 3).When the relationships examined for males, it was found that there was a weak positive correlation between the IES-2 total score and the MEQ-30 total score, and a weak negative correlation between the IES-2 total score and the DEBQ emotional eating subscale score.In addition, a moderately inverse relationship was found between the MEQ-30 total score and the DEBQ Emotional Eating subscale score.
When the relationships examined for females, it was found that there was a strong positive correlation between the IES-2 total score and the MEQ-30 total score, and a strong negative correlation between the IES-2 total score and the DEBQ Emotional Eating subscale score.There was strong negative correlation was found between the MEQ-30 total score and the DEBQ Emotional Eating subscale score (Table 4).The interaction effect was found to be signi cant when the moderation analysis was performed with MEQ-30 total score and gender for estimation of the IES-2 total score (p = 0.013).It was determined that gender explained 27.7% of the relationship between mindful eating and intuitive eating (R-sq = 0.277) (Table 5).
While the effect of the low levels of the MEQ-30 total score on the IES-2 total score was lower in females than in males, the effect at moderate levels was similar, and the effect of high levels was higher in females than in males (Fig. 1).
The interaction effect was found to be signi cant when the moderation analysis were performed with DEBQ Emotional Eating score and gender for estimation of the MEQ-30 total score (p = 0.013).It was determined that gender explained 37.9% of the relationship between MEQ-30 total score and DEBQ Emotional Eating score (R-sq = 0.379) (Table 5).While the effect of DEBQ Emotional Eating at low levels on the total score of MEQ-30 is higher in females than in males, the difference between genders decreases at moderate levels and decreases to almost similar levels at high levels (Fig. 2).

Discussion
This study showed that the relationship between intuitive eating, mindful eating, dietary restraint, and emotional eating and the differences in scale scores in terms of sociodemographic characteristics in participants aged 18-65.When intuitive eating is evaluated according to gender it is reported that males are more dependent on internal signals than females (13,15).However, in our study, no signi cant difference was found between the genders in terms of the IES-2 total score, and it was found that males and females were similar in terms of their intuitive eating orientation.When the genders are compared in terms of mindful eating, it is reported that the genders have similar predispositions (24).The ndings in literature and our study show that the genders have a similar predisposition in terms of mindful eating.
The tendency of the genders to restraint eating and emotional eating is also an important issue.Studies reported that females showed higher dietary restraint than males (11,25).As it has been shown in the literature that females tend to have more restraint eating behavior compared to males, an expected situation was observed in our study as well.In addition, studies reported that females eat more in response to their mood than males (12,15).The ndings of our study is in line with the literature.It is thought that females' tendency to emotional eating is higher than males, showing more depressive symptoms and being more expressive emotionally.
Mindful eating and intuitive eating approaches are associated with lower BMI and it is emphasized that they are effective in reducing body weight in obese people in several studies (26,27).Contrary to mindful eating and intuitive eating, adopting emotional eating and restraint eating behaviors are associated with increased BMI and adiposity (28, 29).We found that the IES-2 total score and the MEQ-30 total score were signi cantly higher in participants with BMI < 25, while the DEBQ Emotional Eating subscale score was signi cantly higher in obese or overweight (BMI ≥ 25).In addition, we found that there was a weak negative correlation between IES-2 and MEQ-30 total score, MEQ-30 Disinhibition and Eating Control subscales and BMI, and a very weak positive correlation between DEBQ Restraint Eating and Emotional Eating subscale scores and BMI (unshown data) (see Additional le 1).Studies in the literature and the results of our study suggest that intuitive eating and mindful eating approaches may be an alternative in the prevention and treatment of obesity, and maladaptive behaviors such as restraint eating and emotional eating may be risk factors.
Positive relationships between mindful eating and intuitive eating are reported in the literature (14).The literature and the signi cant relationships in our study showed that as the level of intuitive eating increased, mindful eating also increased and proved that intuitive eating and mindful eating approaches conceptually overlap with each other.
Mindful eating and intuitive eating approaches do not adopt the idea of using foods to cope with situations such as sadness and anxiety, instead they are based on the idea of getting to the root of the problem and being aware of individual's internal signals (4,30).Studies on this subject report that intuitive eating and mindful eating are inversely related to emotional eating (14,31).Smith et al. reported that the inverse relationship between emotional eating and the IES-2 total score was strong in females (r=-0.78),while it was moderate in males (r = − 0.54) (15).In our study, there was a weak negative correlation (r=-.284) between DEBQ Emotional Eating subscale and IES-2 total score in male participants, and a strong negative correlation (r=-.611) in females.This nding supported the nding reported by Smith et al. (15).Similarly, there was a moderate negative correlation (r=-0.405,p < 0.01) in males, and a strong negative correlation (r=-0.647,p < 0.01) in females, between MEQ-30 total score and DEBQ Emotional Eating subscale.In general, the studies in the literature and the ndings of our study showed that as the level of intuitive eating and mindful eating increased, people's emotional eating levels decreased, and provided a basis that these adaptive eating behavior approaches could be effective in reducing maladaptive eating behaviors such as emotional eating.However, due to the strong relationships found in females, it is thought that emotional eating may be an obstacle especially for females when applying these approaches.
Studies in the literature evaluating the relationship between dietary restraint and intuitive eating, which have different effects on health parameters report an inverse relationship between intuitive eating and strict dietary control (32,33).In addition to these studies, Smith et al., who examined the relationship between restraint eating behavior and intuitive eating on the basis of gender, reported that this inverse relationship was moderate in females, but weak in males.Our study also supported the literature.These ndings showed that as individuals' intuitive eating level increased, their orientation towards restricted eating behaviors decreased, and that intuitive eating represented the other end of a spectrum re ecting the opposite of restriction.
In the literature, the role of mindful eating in reducing restraint eating behaviors, which is reported to be a risk factor in the pathophysiology of eating disorders, has been evaluated.In a systematic review of 15 studies that used mindfulness approaches to change eating behaviors and treat eating disorders in adolescents, it was reported that mindfulness approach was positively associated with reduced dietary restriction (34).In the study conducted by Anderson et al. (35), it was reported that there was no signi cant relationship between the total score of MEQ and the Cognitive Restraint of Eating subscale of the Three-Factor Eating Questionnaire.Similarly, in our study, no signi cant relationship was found between the MEQ-30 total score and the DEBQ Restraint Eating subscale when evaluated both in all participants and on the basis of gender, and the ndings of our study could not provide a basis for the effectiveness of the mindful eating approach in reducing restraint eating behaviors.However, considering the ndings on the effectiveness of mindfulness practices reported by intervention studies in reducing restricted eating behaviors, it is thought that more studies are needed to explain the role of mindfulness in this regard.
When the moderation analysis was performed in our study, it was found that gender did not have a moderator role in the relationship between the IES-2 total score and the DEBQ Emotional Eating score, and the IES-2 total score and the DEBQ Restraint Eating score.In relation to this, in the study examining the psychometric properties of IES-2, no gender differences were found for the other subscales, except for the Eating For Physcical Rather Than Emotional Reasons subscale (36).Smith et al. (15), determined that gender had a moderator role in the relationship between intuitive eating and emotional eating, and between intuitive eating and restraint eating behavior.As a result, in this study, it was reported that restraint eating and emotional eating may be an obstacle for intuitive eating strategy, especially in females.Despite having a similar participant pro le in terms of gender, contrary to this study, the reason why we did not nd any signi cant results in our study is thought to be because Smith et al. conducted a moderation analysis in a model in which BMI was controlled, while we were working in a model in which BMI was not controlled.
To our knowledge, this is the rst study to investigate the moderator role of gender in the relations between the total score of IES-2 and the total score of MEQ-30, and the total score of MEQ-30 and DEBQ Emotional Eating score.Our study revealed that gender explained 27.7% of the relationship between the total score of IES-2 and the total score of MEQ-30, and 37.9% of the relationship between the total score of MEQ-30 and the DEBQ Emotional Eating score.Our ndings also showed that there were different effects according to gender at different levels of scale scores.While the effect of the low level of MEQ-3O total score on the IES-2 total score was lower in females than in males, the effect at medium levels was similar, and the effect at high levels was higher in females than in males.It was found that the effect of DEBQ Emotional Eating on the total score of MEQ-30 at low levels was higher in females than in males, while the difference between genders decreased at moderate levels and decreased to almost similar levels at high levels.

Limitations
Limitation of our study is that all the data obtained due to the online conduct of the research are based on the participants' own statements.

Conclusion
In conclusion, our results suggest that intuitive eating and mindful eating approaches can be effective methods in the prevention and treatment of obesity.
We found that females tended to restraint eating and emotional eating behaviors more than males.In addition, our study supported that intuitive eating and mindful eating strategies can be effective practices in reducing emotional eating.For this reason, it is thought that the dissemination of intuitive eating and mindful eating practices can be effective strategies for both improving eating behaviors and preventing obesity.However, it is a fact that should not be ignored that emotional eating behaviors can be an obstacle when applying these strategies, especially in females.In addition, in our study, we showed that

Table 4
Correlations Between Scale Scores in All Participants, Males and Females

Table 5 Moderation
Analysis for the Estimation of Intuitive Eating and Mindful EatingWith Mindful Eating and Gender for the Estimation of Intuitive Eating