Eating Behaviors 15 (2014) 403409

Contents lists available at ScienceDirect

Eating Behaviors

The impact of maternal overweight and emotion regulation on early

eating behaviors
Gaia de Campora a,, Luciano Giromini b, Giovanni Larciprete c, Valentina Li Volsi a, Giulio Cesare Zavattini a
a
b
c

Sapienza University of Rome, Department of Dynamic and Clinical Psychology, Via degli Apuli 1, 00185, Italy
Alliant International University, California School of Professional Psychology, 10455 Pomerado Road, San Diego, CA 92131, United States
Fatebenefratelli Hospital, Department of Obstetrics and Gynecology, Piazza Fatebenefratelli 2, Rome, 00186, Italy

a r t i c l e

i n f o

Article history:
Received 7 October 2013
Received in revised form 2 March 2014
Accepted 29 April 2014
Available online 10 May 2014
Keywords:
Emotion regulation
Early eating behaviors
Pregnancy
BMI
Overweight
Risk factors

a b s t r a c t
1
Empirical data indicate that the risk for childhood obesity and overweight increases when one or both parents
are overweight or obese. Such an association, however, cannot be entirely explained only by biological factors.
Based on available literature, we hypothesized that maternal emotion regulation might play a role in explaining
the intergenerational transfer of overweight and obesity. We conducted a quasi-experimental, longitudinal
study: (step I) during the third trimester of pregnancy of 65 Italian women (33 overweight and 32 nonoverweight), the Difculties in Emotion Regulation Scale were administered to assess the quality of their emotion
regulation strategies; and (step II) seven months after the delivery, the feeding interactions between the participants and their babies were evaluated in a 20-minute video-recording, by using the Italian version of the Observational Scale for MotherInfant Interaction during Feeding. When compared to the non-overweight group, the
overweight group had more difculties in emotion regulation, was more psychologically distressed, and had
poorer feeding interactions with their babies. Perhaps more importantly, the extent to which the participants
were suffering difculties in emotion regulation during pregnancy predicted, signicantly, and beyond the effects
of pre-pregnancy maternal weight, the quality of the motherchild feeding interactions 7 months after the
delivery.
2014 Elsevier Ltd. All rights reserved.

1. Introduction
Overweight and obesity consist of an imbalance between calorie
intake and expenditure. Overweight individuals have a Body Mass
Index (BMI; weight in kilograms divided by the square of the height in
meters) between 25 and 30 while obese individuals have a BMI greater
than 30. These rapidly increasing conditions are primarily diet-induced,
resulting from sustained excess of energy dense, high fat, and rened
carbohydrate content foods, as well as insufcient consumption of fruits
and vegetables. The increasingly sedentary lifestyles and changing environments which restrict opportunities for physical activity, also contribute to their development.
Despite the high prevalence of these phenomena, to date the relationship between weight and psychological health remains controversial and poorly understood. A number of risk factors for overweight
and obesity have been linked to demographic aspects, dietary habits,

Corresponding author. Tel.: +39 340 2996770.

E-mail addresses: gaiadecampora@gmail.com (G. de Campora), lgiromini@alliant.edu
(L. Giromini), giovanni.larciprete@fbf-isola.it (G. Larciprete), vale.liv@hotmail.it (V. Li Volsi),
giuliocesare.zavattini@uniroma1.it (G.C. Zavattini).
1
This research is part of a larger and ongoing longitudinal investigation.

http://dx.doi.org/10.1016/j.eatbeh.2014.04.013
1471-0153/ 2014 Elsevier Ltd. All rights reserved.

social/environmental and cognitive factors (Van der Merwe, 2007).

However, the specic psychological mechanisms through which these
risk factors affect the attitude toward food and lifestyle, and consequently behavior and weight, have not been completely claried.
Most of the research efforts are currently directed toward addressing
the complex etiology underlying these conditions, by integrating genetic, physiological and psychological components. A growing body of research, in particular, shows that a central role in the development of
obesity and overweight might be played by the parentchild relationship. Indeed, the risk among children to be overweight when one or
both parents are overweight or obese dramatically increases as compared to peers from non-obesogenic environments, and such an association cannot be entirely explained by biological factors alone. Many
researchers, indeed, have demonstrated that factors such as breast feeding duration (Agras & Mascola, 2005), use and length of bottle feeding,
smoking during pregnancy (Owen, Martin, Whincup, Smith, & Cook,
2005), parental style, and their modeling of eating behaviors constitute
major risk factors in promoting overweight during childhood and in
later ages (Frankel et al., 2012). Furthermore, it has been reported that
the provision, or not, of the emotional context of the feeding interaction
with the baby (as being permissive or demanding, available or poorly
tuned), strongly affects the eating habit of the child (Farrow & Blissett,
2008; Ventura & Birch, 2008).

404

G. de Campora et al. / Eating Behaviors 15 (2014) 403409

1.1. Emotion regulation and early feeding interactions

2. Method

The caregiving system plays an important role in promoting the

physical, emotional and social wellbeing of the baby. The ability to regulate emotions and internal states during the early stages of life is also
linked to the caregiver's capacity to handle the emotional states of the
child. A central role in this process, in particular, is played by what has
been referred to as maternal sensitivity, i.e., the ability to appropriately,
timely, and consistently respond to the baby's signals and needs. As
Schore (2000) pointed out, indeed, during the rst year of life the motherinfant dyad goes on as a mutually regulating biological unit, and the
two elements of the dyad reciprocally affect themselves as a common
system of regulation. Thus, the lack of maternal sensitivity likely undermines the development of emotion regulation skills in the baby.
In studying the process of development in this domain, the role of
both internal and external sources of regulation during infancy and
childhood has been investigated. The transition from using the parents
for regulation of arousal to being able to self-regulate is a process that
begins early and carries on through childhood (Calkins & Fox, 2002).
The caregiver's role in this process is extensive: initially, the provision
of food, clothing, and physical soothing assists the infant in state regulation; later, more complex communications and interactions with the
caregiver teach the child how to manage distress, control impulses,
and delay gratication. The process of developing emotion regulation
skills and strategies, however, is fundamentally an interactive one, and
depends on both infant and caregiver contributions. Its success or failure
likely depends on whether the goals of both participants are in agreement (DiSantis, Collins, Fisher, & Davey, 2011; Velotti, Zavattini, &
Garofalo, 2013).
The complex interplay between mother and child is also important
in the development of the child's eating self-regulation (Anderson,
Gooze, Lemeshow, & Whitaker, 2012). Indeed, because maternal sensitivity largely depends on the mother's ability to regulate her own emotions (Ammaniti, Ambruzzi, Lucarelli, Cimino, & D'Olimpio, 2004;
Mills-Koonce et al., 2006), it has been suggested that the poor emotional
functioning of the mother might in turn lead to the establishment of
early eating problems of the baby, by affecting how much and what children eat during mealtime (Blissett & Farrow, 2007; Farrow & Blisset,
2006; Hughes et al., 2011). For instance, if parentchild exchanges are
inadequate during the feeding interactions, children may learn to use
food as a consolation instrument (Faith, Scanlon, Birch, Francis, &
Sherry, 2004). Similarly, directive/controlling feeding attitudes of the
parents are associated with lower self-regulation in eating and higher
weight status among children (Veugelers & Fitzgerald, 2005). Along
the same line, parents who highly control their children's food intake,
lead them to pay attention to external rather than internal cues in
order to regulate the amount of food, which results in lack of selfregulation and greater eating in the absence of hunger (Hughes et al.,
2011). Thus, by affecting maternal sensitivity, the maternal inability to
regulate emotion likely plays a key role in the overeating behaviors of
the child, and presumably represents an important risk factor for overweight and obesity in developmental age (Farrow & Blisset, 2006).

2.1. Procedure

1.2. Aim of the study

The link between maternal emotion regulation and early eating patterns nds some support in the literature. However, despite the growing body of research related to this topic and the increasing number of
researchers investigating the emotional processes underlying the overweight risk, there is still a lack of longitudinal data in this area. To overcome this lack of empirical data, the current study examined the impact
of overweight and maternal emotion dysregulation on the quality of the
early feeding interactions. Specically, we aimed to evaluate the extent
to which the quality of emotion regulation strategies in overweight
pregnant women, as well as maternal overweight itself, would predict
the subsequent dysfunctional feeding interactions with their babies.

Prospective participants were contacted at the Isola Tiberina,

Fatebenefratelli hospital, in Rome. After the approval from the hospital's
Institutional Review Board was received, all pregnant women who were
referred for assistance to the Department of Obstetrics and Gynecology
were informed by their gynecologist about the possibility to volunteer
for the study. Women willing to participate were given a consent form
and a subject's bill of rights. Condentiality was also reviewed. Though
no monetary compensation was offered in exchange for participation, at
the end of the study participants received a DVD with the video of their
feeding interactions.
During the beginning of the third trimester (2840 gestational
weeks), we conducted the rst screening related to the pre-pregnancy
BMI. Additional medical and bio-psycho-social information was also
collected by a gynecologist and a psychologist, so as to ascertain eligibility. Participants were then assigned to a group based on their BMI: the
overweight group was made up of women with a pre-pregnancy BMI
between 25 and 30, while the non-overweight group was made up of
women with a pre-pregnancy BMI between 20 and 25.
Inclusion criteria required that the participants be (a) primiparous
women with full-term singleton gestations, (b) not experiencing chronic diabetes or hypertension, (c) married or cohabiting, (d) in absence of
any full-blown psychological diagnosis, and (e) between 28 and
38 years old. Women delivering preterm or post term were also excluded, in order to avoid confounds related to stressful reactions to a different medical condition. As a result of these criteria, this investigation
generally included healthy women.
2.2. Research design
A quasi-experimental, longitudinal research design, including two
independent groups and two research steps1, was used. As noted
above, the two groups were composed of overweight vs. nonoverweight pregnant women. The rst step of the research occurred
during the third trimester of pregnancy, and aimed at assessing maternal emotion regulation during pregnancy. The second step occurred at
7-months of age of the baby, and aimed at assessing the motherbaby
mealtime interactions. The choice of 7 months was based on the fact
that babies typically begin to eat solid foods and to more actively participate in the feeding interactions at that age. Observing the feeding interactions at 7 months, thus, allowed for assessing the contribution of both
partners, instead of only focusing on the behavior of the mother.
2.3. Participants
The entire sample was collected at the Obstetrics and Gynecology
Department of Fatebenefratelli Isola Tiberina Hospital in Rome. At step
1, the sample was comprised of 65 Italian women, 33 of whom were
overweight and 32 non-overweight. The mean age was approximately
35 years, and nearly half of the sample had a bachelor's degree or a
higher level of education. The two groups did not signicantly differ in
terms of age, education, and gender of the baby. However, in line with
other studies in the eld (Veugelers & Fitzgerald, 2005), education did
approach signicance when considering an alpha value of .10. A more
detailed description of the sample available at step 1 is presented in
Table 1.
Of the 65 women included in the rst step of the research, 12
discontinued their participation after the rst step, so the second step
of the research only included 53 dyads. Age, education, employment position and gender of the baby did not account for attrition rates. However, it should be pointed out that two-thirds of the women who
discontinued their participation (i.e., 8 out of 12) were in the overweight group.

G. de Campora et al. / Eating Behaviors 15 (2014) 403409

405

Table 1
Composition of the sample at step 1.

Age (t(49) = .80; p = .78)

Mean
SD
Education (phi = .20, p = .11)
High school or less
Bachelor degree or more
Employment (chi2(3) = 5.52, p = .14)
House wife
General employee
Freelance
Other
Gender of the baby (phi = . 14, p = .31)
Male
Female

Overweight group (N = 33)

Non-overweight group (N = 32)

35.2
4.2

35.8
3.6

22 (66.7%)
11 (33.3%)

15 (46.9%)
17 (53.1%)

5 (15.2%)
17 (51.5%)
7 (21.2%)
4 (12.1%)

1 (3.1%)
13 (14.6%)
14 (43.8%)
4 (12.5%)

14 (50%)
14 (50%)

16 (64%)
9 (36%)

2.4. Measures
During the third trimester of pregnancy (step 1) participants were
asked to complete a series of questionnaires. All were handed out personally by the rst author, completed at home, and then handed back
to the rst author. About 7 months after the delivery (step 2), the mealtime interactions between each mother and her baby were videorecorded. The questionnaires collected in step 1, as well as the feeding
interaction measure utilized in step 2, are detailed below.
2.4.1. Step 1 Difculties in Emotion Regulation Scale (DERS; Gratz &
Roemer, 2004; Giromini, Velotti, de Campora, Bonalume, & Zavattini, 2012)
The DERS is composed of 36 items with response options on a 5point Likert scale, ranging from 1 (almost never) to 5 (almost always).
This measure assesses the following dimensions of difculties in emotion regulation: lack of consciousness and understanding of emotions
(awareness); nonacceptance of emotions (nonacceptance); inability to
start goal-oriented behaviors (goals); attitude toward impulsive behaviors to face negative emotions (impulse); inaccessibility toward emotion regulation strategies perceived as suitable (strategies); and lack of
emotional clarity (clarity).
The Italian adaptation of the DERS was performed by Giromini et al.
(2012). By investigating data from three independent Italian samples,
the authors observed that the Italian DERS had good internal consistency (Cronbach's alpha of .92 for the total score and an alpha .77 for the
subscales), correlated signicantly with a number of related constructs,
and produced signicantly different scores when comparing clinical vs.
nonclinical adults.
In the current study, the Italian DERS was administered during pregnancy so as to investigate the hypothesis that the maternal ability to
regulate emotion would predict the quality of the subsequent feeding
interactions with the baby.
2.4.2. Step 1 The Symptom Checklist 90 (SCL-90; Derogatis, 1977;
Magni, Messina, De Leo, Mosconi, & Carli, 1983)
The SCL-90 is a 90-item self report symptom inventory, which provides a measure of the current psychological symptom status. It is
scored on nine subscales Somatization, Obsessivecompulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety,
Paranoid Ideation, Psychoticism and three Global Indices of Distress
(Global Severity Index, Positive Symptom Distress Index, Positive Symptom Total), which indicate the severity and depth of individual psychological distress.
The Italian adaptation of the SCL-90 was performed by Magni et al.
(1983). According to the authors, the adapted version showed satisfactory internal consistency (alpha ranging from .77 to .90), and high levels
of construct and convergent-discriminant validity.
Since in previous studies high levels of distress were associated with
increased emotional eating and eating disorders (GilboaSchechtman,

Avnon, Zubery, & Jeczmien, 2006), we anticipated that the SCL-90-R

Global Severity Index at step 1 might contribute to the predicting of
the quality of the early feeding interactions at step 2. The Italian version
of the SCL-90 was administered so as to test this hypothesis.
2.4.3. Step 1 Center for Epidemiological Studies Depression Scale
(CES-D; Radloff, 1977; Pierfederici et al., 1982)
The CES-D is a 20 item self-report questionnaire on depressive
symptoms. Its internal consistency is considered to be around 0.85 in
community samples and 0.90 in psychiatric samples. Given that depressive symptoms often associate to eating disorders and dysfunctional dyadic interactions (Ammaniti et al., 2004), we used the Italian version of
the CES-D (Pierfederici et al., 1982) to assess the potential role of depression at step 1 in predicting the quality of the subsequent feeding
interactions.
2.4.4. Step 1 Multidimensional Scale for Perceived Social Support (MSPSS;
Zimet, Dahlem, Zimet, & Farley, 1988; Prezza & Pacilli, 2002)
The MSPSS is composed of 12 items with response options on a 7point Likert scale, ranging from 1 (absolutely false) to 7 (absolutely
true). The instrument measures support from family, friends, and significant others.
The Italian adaptation of the MSPSS was carried out by Prezza and
Pacilli (2002). As indicated by the authors, the Italian MSPSS total
score produced a Cronbach's alpha of .88, and a testretest reliability
(over 3 months) of r = .85.
Since social support may play a role in predicting eating behavior
(Stice, 2002), we administered the Italian MSPSS so as to investigate
whether the perceived social support at step 1 might predict the subsequent mealtime dyadic interactions.
2.4.5. Step 2 Observational Scale for MotherInfant Interaction during
Feeding (Chatoor et al., 1997; Lucarelli et al., 2002)
The SVIA is a 20-minute video-taped observation measuring normal
and/or at-risk feeding interactions between mother and child (age
range: 136 months).
The Italian version of the Observational Scale for MotherInfant Interaction during Feeding (SVIA; Lucarelli et al., 2002) has 40 items,
rated by an observer on a four-point Likert Scale, and includes four subscales: Affective State of the mother, Interactional Conict, Food Refusal
Behaviors of the Child, and Affective State of the Dyad. Higher scores in
the Affective State of the Mother refer to greater difculties of the caregiver to show positive affect, and a higher frequency of negative affect,
such as sadness or distress. The subscale Interactional Conict evaluates
both the presence and intensity of exchanges of conict within the dyad
(e.g., the mother directs the meal according to her own emotions and
intentions, rather than following the signals from the child). The subscale Food Refusal Behaviors of the Child explores behavioral and emotional characteristics of feeding patterns of the child (e.g., being easily

406

G. de Campora et al. / Eating Behaviors 15 (2014) 403409

distracted, opposition, and negativity). Higher scores in the Affective

State of the Dyad refer to the difculties of the caregiver in supporting
autonomous initiatives of the child (by means of requests, insistent
orders, and criticism), while the child demonstrates distress and is
oppositional. As for the validity and reliability of the scale, Lucarelli
et al. (2002) reported that the ICC ranged between 0.73 and 0.89
(mean ICC = .83).
In the current study, the SVIA was utilized so as to measure the quality of the mealtime interactions in the second step of the data collection,
i.e., when the baby was about seven month old. All videos were independently coded by two blind reliable SVIA judges. When coding the
videos, the judges were also blind to the results of the questionnaires
at step 1. Two-way random effects model single measures intraclass
correlation coefcients (ICCs) ranged from .68 to .80, thus indicating
good to excellent inter-rater reliability (for criteria for interpreting
ICCs, see Cicchetti, 1994).
2.5. Hypotheses
Based on the available literature, we hypothesized that: (a) at step 1,
overweight women would show a higher tendency toward emotion dysregulation, and possibly also higher psychological distress, higher depression risk, and poorer perceived social support, when compared to the
non-overweight group (H1 overweight and emotion regulation
during pregnancy); (b) dyads with overweight mothers would show
higher difculties in feeding interactions when compared to dyads of
the non-overweight group (H2 overweight and feeding interactions);
and (c) pre-pregnancy maternal BMI and emotion dysregulation strategies, and possibly also general distress, depression risk and perceived
social support (all measured during pregnancy) would predict the quality
of the feeding interactions at 7 months of the baby (H3 predictors of
feeding interactions).
3. Results
3.1. H1 overweight and emotion regulation during pregnancy
As expected, when compared to the non-overweight group, the
overweight group showed higher rates of difculty in emotion regulation, with a large effect size for the total DERS score, and medium to
large effect sizes for the subscales (Table 2). The SCL90 Global Severity
Index also resulted in a signicant difference, with a large effect size,

while the depression scale (CES-D) yielded only marginally signicant

results (although in the expected direction), and there were no signicant differences in terms of perceived social support (MSPSS). Taken together, these results indicate that maternal pre-pregnancy overweight
is associated, during pregnancy, with difculties in emotion regulation
and psychological distress.
3.2. H2 overweight and feeding interactions
As shown in Table 3, the quality of the dyadic feeding interactions at
7 months of age of the baby was signicantly different between the
overweight and the non-overweight groups. More precisely, when
compared to the non-overweight group, the overweight group demonstrated poorer quality of feeding interactions on all the dimensions of
the SVIA. The effect size of these differences was large for Affective
State of the Mother, Interactional Conict, and Affective State of the
Dyad, and medium for Food Refusal Behavior of the Child. Thus, as expected, the overweight group was more distressed and emotionally
dysregulated than the non-overweight group during pregnancy, and
showed poorer quality of feeding interactions at 7 months of age of
the baby.
3.3. H3 predictors of feeding interactions
A third aim of the study was to investigate whether pre-pregnancy
maternal BMI, as well as maternal difculties in emotion regulation,
would predict the quality of the feeding interactions within the dyads
at 7 months of age of the baby. The potential predictive role of psychological distress, depression, and perceived social support during pregnancy was also investigated. As shown in Table 4, a large amount of
signicant correlations were obtained. The pre-pregnancy maternal
BMI, the total DERS score, and the SCL90 Global Severity Index signicantly correlated with all 4 subscales of the SVIA, the CES-D signicantly
correlated with 3 SVIA subscales, and the total MSPSS score signicantly
correlated with the Affective State of the Dyad subscale of the SVIA.
To further investigate the relationship of maternal pre-pregnancy
BMI, difculties in emotion regulation, psychological distress, depression, and perceived social support to the quality of feeding interactions
at 7 months of age of the baby, a series of multiple regressions were
tested. For each model, a stepwise selection method was used, in
order to identify the best predictors. The pre-pregnancy BMI, DERS, SCL90, CES-D, and MSPSS scores were used as predictors, and each SVIA

Table 2
Differences at step 1 in emotion dysregulation, global distress, depression, and perceived social support between overweight and non-overweight groups.
Overweight group
(N = 33)

DERS
Nonacceptance
Goals
Impulse
Awareness
Strategies
Clarity
Total
SCL-90
Global Severity Index
CES-D
Total score
MSPSSb
Signicant others
Family
Friends
Total score
a
b

Non-overweight
group (N = 32)

df

SD

SD

13.2
13.1
12.3
14.1
14.6
8.1
75.4

5.5
5.2
4.5
3.6
5.3
2.4
17.5

10.4
10.9
8.8
12.8
11.1
7.3
61.3

3.7
3.3
2.0
3.0
2.9
1.6
8.3

2.33
2.05
4.07
1.46
3.34
1.65
4.16

55.8a
54.7a
44.2a
63
49.5a
63
46.2a

0.02
0.05
0.00
0.15
b0.01
0.10
b0.01

0.58
0.51
1.00
0.36
0.82
0.41
1.02

0.7

0.5

0.4

0.2

3.75

47.4a

b0.01

0.92

15.1

8.4

11.8

6.6

1.76

63

0.08

0.44

25.5
22.9
22.3
70.8

2.5
6.3
4.7
8.3

26.1
24.4
23.5
74.0

2.7
4.0
3.8
7.8

0.87
1.14
1.08
1.59

62
52.6a
62
62

0.39
0.26
0.28
0.12

0.22
0.28
0.27
0.40

Because homoscedasticity could not be assumed, WelchSatterthwaite method was used to adjust degrees of freedom.
One record in the overweight group was missing MSPSS information.

G. de Campora et al. / Eating Behaviors 15 (2014) 403409

407

Table 3
Differences in feeding interactions between overweight and non-overweight groups.
Overweight group
(N = 25)

Feeding interaction scale

Affective State of the Mother
Interactional Conict
Food Refusal Behavior
Affective State of the Dyad
a

Non-overweight
group (N = 28)

SD

SD

11.6
18.3
10.0
5.0

3.4
5.9
2.8
2.4

8.6
12.7
8.5
2.9

3.4
4.2
2.1
1.3

df

3.25
4.02
2.32
3.96

51.0
51.0
51.0
36.5a

b0.01
b0.01
0.02
b0.01

0.89
1.11
0.64
1.12

Because homoscedasticity could not be assumed, WelchSatterthwaite method was used to adjust degrees of freedom.

subscale as the dependent variable. In order to avoid multicollinearity,

only the total scores were used for the DERS and MSPSS. The resulting
multiple regression models are presented in Table 5. The total DERS
score and the pre-pregnancy maternal BMI were the best predictors for
Affective State of the Mother and for the Interactional Conict, the total
DERS score was the best predictor for Food Refusal Behavior of the
Child; the pre-pregnancy maternal BMI was the best predictor for Affective State of the Dyad. Thus, the DERS measured during pregnancy,
along with the pre-pregnancy BMI, were the best predictors of the quality
of the dyadic feeding interactions at 7 months of age of the baby.

psychologically distressed, and had poorer feeding interactions with

their babies. Perhaps more importantly, the extent to which the
participants were suffering difculties in emotion regulation during
pregnancy predicted, signicantly and beyond the effects of prepregnancy BMI, the quality of the subsequent dyadic feeding interactions, 7 months after the delivery. To the best of our knowledge, this
is the rst study to investigate the predictive role of maternal emotion
regulation during pregnancy on the subsequent feeding interaction.
According to our rst hypothesis (H1 overweight and emotion
regulation during pregnancy) we predicted that overweight mothers
would be more likely than non-overweight mothers to show emotion
regulation difculties, during pregnancy. As shown in Table 2, this hypothesis was fully supported by our results. In particular, not only did
the overweight group show higher difculties in emotion regulation,
but it also showed higher levels of psychological distress and (albeit
only marginally signicantly) higher depression risk. Given the amount
of research indicating that eating disorders associate to decits in the
cognitive processing of emotions (de Groot, Rodin, & Olmsted, 1995),
this nding is perhaps not surprising. Indeed, our suggestion is that
emotion dysregulation and disordered eating are so intrinsically related
to each other, that the ability to regulate the emotion should be assessed
every time an existing overweight condition cannot be explained by
biological factors.
Our second hypothesis (H2 overweight and feeding interactions)
anticipated that the overweight group would show more problematic
dyadic mealtime interactions, when compared to the non-overweight
group. This hypothesis was based on the idea that the overweight condition is thought to be associated with emotion and eating regulation

4. Discussion
Some empirical data indicate that the risk for childhood obesity and
overweight increases dramatically when one or both parents are overweight or obese. However, it has also been shown that such an association cannot be entirely explained only by biological factors (Kral & Faith,
2007). Based on the available literature, we hypothesized that, in addition to a number of other non-biological risk factors (Owen et al., 2005),
the maternal ability to regulate emotions might also play an important
role in explaining the intergenerational transfer of overweight and obesity. Specically, we hypothesized that maternal emotion regulation
would impact the quality of the feeding interactions between the mother and the baby, which in turn is known as an important predictor of
childhood obesity and overweight (Rising & Lifshitz, 2005).
By adopting a quasi-experimental, longitudinal research design, we
showed that, when compared to the non-overweight group, the overweight group had more difculties in emotion regulation, was more

Table 4
Correlation between maternal psychological features during pregnancy and quality of feeding interaction at 7 months of age (N = 53).

BMI
Maternal pre-pregnancy BMI
DERS
Nonacceptance
Goals
Impulse
Awareness
Strategies
Clarity
Total
SCL-90
Global Severity Index
CES-D
Total score
MSPSSa
Signicant Others
Family
Friends
Total score

SVIA

SVIA

SVIA

SVIA

Aff. State Mother

Interactional Conict

Food Refusal Behavior

Aff. State Dyad

0.42

0.55

0.28

0.27
0.34
0.41
0.11
0.49
0.25
0.43

0.34
0.25
0.36
0.04
0.51
0.11
0.44

0.32
0.34
0.32
0.07
0.45
0.05
0.38

0.30
0.11
0.28
0.11
0.40
0.01
0.29

0.36

0.38

0.32

0.34

0.32

0.30

0.30

0.25

0.13
0.17
0.06
0.18

a
One record in the overweight group was missing MSPSS information.
p b 0.05.
p b 0.01.

0.20
0.04
0.16
0.17

0.10
0.12
0.10
0.16

0.55

0.32
0.08
0.25
0.29

408

G. de Campora et al. / Eating Behaviors 15 (2014) 403409

Table 5
Multiple regression models with pre-pregnancy BMI, DERS, SCL90 Global Severity Index, CES-D, and MSPSS as predictors (stepwise method) and each SVIA subscale as criterion (N = 52).
Criterion/predictors entered by step
SVIA Affective State of the Mother
Step 1
Total DERS score
Step 2
Pre-pregnancy BMI
SVIA Interactional Conict
Step 1
Pre-pregnancy BMI
Step 2
Total DERS score
SVIA Food Refusal Behavior
Step 1
Total DERS score
SVIA Affective State of the Dyad
Step 1
Pre-Pregnancy BMI

0.43

0.32

0.31

0.55

0.46

0.27

0.38

0.55

R2

Adj. R2

R2

0.43

0.19

0.17

0.52

0.27

0.24

0.08

0.55

0.31

0.29

0.61

0.37

0.34

0.06

0.38

0.15

0.13

0.55

0.30

0.29

1, 2 = standardized beta coefcients for steps 1 and 2.

p b 0.05.
p b 0.01.

issues (Sim & Zeman, 2005; Whiteside et al., 2007), and that therefore it
should also be characterized by poor maternal sensitivity (Anderson
et al., 2012). As shown in Table 3, this hypothesis was also fully conrmed. In fact, when compared to the non-overweight group, the overweight mothers: (a) showed less positive affect (SVIA Affective State
of the Mother); (b) were more prone to direct the meals according to
their own emotions and intentions, rather than following the signals
from the child (SVIA Interactional Conict); (c) produced more dyadic exchanges characterized by opposition, distraction, and negativity of
the baby (SVIA Food Refusal Behavior of the Child); and (d) showed
greater difculties in supporting autonomous initiatives of the baby
(SVIA Affective State of the Dyad). These ndings are particularly important in terms of understanding the early risk factors for overweight
and obesity. Indeed, a lack of maternal sensitivity during the mealtime
interactions (e.g., lack of sensitivity for the child's choices and preferences, as well as for the child's emotional state) is thought to reduce
the baby's competence to employ its own hunger and satiety cues,
which in turn represents an important risk factor for future eating disorders (Rising & Lifshitz, 2005).
The third aim of the current study (H3 predictors of feeding
interactions) was to investigate whether the quality of emotion regulation strategies measured during pregnancy, as well as the maternal
pre-pregnancy BMI, would predict the subsequent feeding interactions
of the dyads. The results presented in Tables 4 and 5 show that the most
important contributors to the prediction of the SVIA scores (measured
at the second step of the research) were the pre-pregnancy BMI and
the total DERS scores (both measured during the rst step of the research). In fact, when testing a series of multiple regressions with a
stepwise method, part of the variance of the SVIA scores appeared to
be uniquely explained by the maternal pre-pregnancy BMI, and part of
it appeared to be uniquely explained by the maternal ability to regulate
the emotion. Thus, in line with other studies indicating that the intergenerational transfer of overweight and obesity cannot be ascribed
only to biological factors (Agras, Hammer, McNicholas, & Kraemer,
2004; Kral & Faith, 2007), these ndings provide evidence that the maternal ability to regulate emotions, as measured during pregnancy, may
predict the quality of the mealtime interactions seven months after the
delivery.
Many researchers have supported the idea that emotion regulation
problems work as a maintenance factor for eating problems, and that
eating problems work as a means of regulating negative affect (Svaldi,
Griepenstroh, Tuschen-Cafer, & Ehring, 2012). Our suggestion is that
maternal emotion dysregulation might promote and maintain the

overweight of the mothers, and also be transmitted within the feeding

interaction with the baby. As noted above, indeed, a low maternal sensitivity for the child's own choices and preferences, as well as for his or
her emotional states, likely affects the child's ability to develop selfregulation skills, and poses him or her at risk for learning to selfregulate himself or herself through food intake. If the mealtime interactions lack maternal sensitivity, indeed, the children may learn to use
food as a consolation instrument, or may learn to pay attention to external rather than internal cues in order to regulate the amount of food
(Hughes et al., 2011). This, in turn, may constitute a risk factor for eating
(Frankel et al., 2012), and perhaps also for emotion dysregulation.
To date, the great majority of the studies on these topics have
adopted cross-sectional research designs, which do not allow to appropriately investigate causal relationships. In contrast, by adopting a longitudinal research design, the current study has probably provided more
conclusive evidence for the existence of a causal relationship between
certain maternal characteristics and their subsequent dyadic feeding interactions. Nevertheless, it should be noted that a number of limitations
also characterize our work. First of all, the ability to regulate the emotion
a key variable of this investigation was only measured through a
self-report instrument. Although the DERS is fairly consolidated in the
literature as a well validated instrument, social desirability and other
potential biases might still have occurred. Second, while we aimed at
identifying early risk indicators associated with the overweight condition, given the age of the babies we were not able to provide actual outcome measures for the weight of the babies. Future follow-ups might
provide important information, in regard to this aspect. Third, the sample size was relatively small, and some attrition occurred, so that some
of the analyses lacked adequate power to support our conclusions.
Given that about 18% of the participants did not complete the study,
in particular, it is difcult to draw precise conclusions in regard to the
generalizability of our ndings. The fact that none of the demographic
variables under investigation signicantly associated with the attrition
rates, however, suggests that attrition did not act as a confound, in
this study. Fourth, our data do not refer to breastfeeding or the bottle
feeding, while research indicates that being bottle fed may increase
the risk of lower self regulation skills of the baby. Future research should
consider including this measure.
With these limitations in mind, the current study is the rst to
suggest that emotion dysregulation during pregnancy can be predictive of the subsequent development of feeding interaction problems, and paves the way for future follow-ups and replication
studies.

G. de Campora et al. / Eating Behaviors 15 (2014) 403409

Role of funding sources
This research is part of a dissertation study and no funding for this study was provided.
Contributors
Author A designed the study, and wrote the protocol. Author B conducted the statistical analyses. Authors A and B wrote the rst draft of the manuscript. Author C supervised
the inclusion criteria, selected the eligible participants, and provided feedback across
various draft. Author D conducted literature searches and provided summaries of previous
investigations. Author E supervised the research, and provided feedback across the data
collection. All authors contributed to and have approved the nal manuscript.
Conict of interests
None of the authors have any conict of interest to declare.
Acknowledgments
We thank to Dr. Elio Cirese, M.D., Head of the OBGYN Department, for his availability
and support at the beginning of this research; the Department of Dynamic and Clinical
Psychology and the Lab of Couple and Family relationships of Sapienza University of
Rome, for their help and sustain throughout the research; Verdiana Imperio and Vanessa
Palombi, for their help with data collection; and Dr. Cher Raee for proofreading the
manuscript.

References
Agras, W. S., Hammer, L. D., McNicholas, F., & Kraemer, H. C. (2004). Risk factors for
childhood overweight: A prospective study from birth to 9.5 years. Journal of
Pediatrics, 145, 2025.
Agras, W. S., & Mascola, A. J. (2005). Risk factors for childhood obesity. Current Opinion in
Pediatrics, 17, 648652.
Ammaniti, M., Ambruzzi, A. M., Lucarelli, L., Cimino, S., & D'Olimpio, F. (2004). Malnutrition and Dysfunctional MotherChild Feeding Interactions: Clinical assessment and
research implications. Journal of the American College of Nutrition, 23(3), 259271.
Anderson, S. E., Gooze, R. A., Lemeshow, S., & Whitaker, R. C. (2012). Quality of early
maternalchild relationship and risk of adolescent obesity. Pediatrics, 129(1),
132140.
Blissett, J., & Farrow, C. (2007). Predictors of maternal control of feeding at 1 and 2 years
of age. International Journal of Obesity, 31(10), 15201526. http://dx.doi.org/10.1038/
sj.ijo.0803661.
Calkins, S. D., & Fox, N. A. (2002). Self-regulatory processes in early personality development: A multilevel approach to the study of childhood social withdrawal and aggression. Development and Psychopathology, 14, 477498. http://dx.doi.org/10.1017/
S095457940200305X.
Chatoor, I., Getson, P., Menvielle, E., Brasseaux, C., O'Donnell, R., Rivera, Y., et al. (1997). A
feeding scale for research and clinical practice to assess motherinfant interactions in
the rst three years of life. Infant Mental Health Journal, 18(1), 7691.
Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and
standardized assessment instruments in psychology. Psychological Assessment, 6(4),
284.
de Groot, J. M., Rodin, G., & Olmsted, M. P. (1995). Alexithymia, depression, and treatment
outcome in bulimia nervosa. Comprehensive Psychiatry, 36(1), 5360.
Derogatis, L. R. (1977). SCL-90. Administration, scoring & procedures manual I for the
r(evised) version and other instruments of the psychopathology rating scale series.
Baltimore: John Hopkins University Press.
DiSantis, K. I., Collins, B. D., Fisher, J. O., & Davey, A. (2011). Do infants fed directly from the
breast have improved appetite regulation and slower growth during early childhood
compared with infants fed from a bottle? International Journal of Behavioral Nutrition
and Physical Activity, 8, 89.
Faith, M. S., Scanlon, K. S., Birch, L. L., Francis, L. A., & Sherry, B. (2004). Parentchild
feeding strategies and their relationships to child eating and weight status. Obesity
Research, 12, 17111722. http://dx.doi.org/10.1038/oby.2004.212.
Farrow, C., & Blisset, J. (2006). Maternal cognitions, psychopathologic symptoms, and
infant temperament as predictors of early infant feeding problems: A longitudinal
study. International Journal of Eating Disorders, 39(2), 128134. http://dx.doi.org/10.
1002/eat.20220.
Farrow, C. V., & Blissett, J. (2008). Controlling feeding practices: Cause or consequence of
early child weight? Pediatrics, 121(1), e164e169. http://dx.doi.org/10.1542/peds.
2006-3437.

409

Frankel, L. A., Hughes, S. O., O'Connor, T. M., Power, T. G., Fisher, J. O., & Hazen, N. L. (2012).
Parental inuences on children's self-regulation of energy intake: Insights from
developmental literature on emotion regulation. Journal of Obesity. http://dx.doi.
org/10.1155/2012/327259.
GilboaSchechtman, E., Avnon, L., Zubery, E., & Jeczmien, P. (2006). Emotional processing
in eating disorders: Specic impairment or general distress related deciency?
Depression and Anxiety, 23(6), 331339.
Giromini, L., Velotti, P., de Campora, G., Bonalume, L., & Zavattini, G. C. (2012). Cultural
adaptation of the difculties in emotion regulation scale: Reliability and validity of
an Italian version. Journal of Clinical Psychology, 00, 120. http://dx.doi.org/10.1002/
jclp.21876.
Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and
dysregulation: Development, factor structure, and initial validation of the difculties
in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment,
26(1), 4154. http://dx.doi.org/10.1007/s10862-008-9102-4.
Hughes, S. O., Power, T. G., Papaioannou, M. A., Cross, M. B., Nicklas, T. A., Hall, S. K., et al.
(2011). Emotional climate, feeding practices, and feeding styles: An observational
analysis of the dinner meal in head start families. International Journal of Behavioral
Nutrition and Physical Activity, 8(60), 111. http://dx.doi.org/10.1186/1479-5868-8-60.
Kral, T. V., & Faith, M. S. (2007). Child eating patterns and weight regulation: A developmental behaviour genetics framework. Acta Paediatrica, 96(s454), 2934.
Lucarelli, L., Cimino, S., Perucchini, P., Speranza, A. M., Ammaniti, M., & Ercolani, A. P.
(2002). I disturbi alimentari nella prima infanzia: validazione di uno strumento
osservativo dell'interazione madre-bambino. Infanzia e Adolescenza, 2, 113124.
Magni, G., Messina, C., De Leo, D., Mosconi, A., & Carli, M. (1983). Psychological distress in
parents of children with acute lymphatic leukemia. Acta Psychiatrica Scandinavica, 68,
297300.
Mills-Koonce, W. R., Garipy, J. L., Propper, C., Sutton, K., Calkins, S., Moore, G., et al.
(2006). Infant and parent factors associated with early maternal sensitivity: A
caregiver-attachment systems approach. Infant Behavior and Development, 30(1),
114126. http://dx.doi.org/10.1016/j.infbeh.2006.11.010.
Owen, C. G., Martin, R. M., Whincup, P. H., Smith, G. D., & Cook, D. G. (2005). Effect of
infant feeding on the risk of obesity across the life course: A quantitative review of
published evidence. Pediatrics, 115(5), 13671377. http://dx.doi.org/10.1542/peds.
2004-1176.
Pierfederici, A., Fava, G. A., Munari, F., Rossi, N., Baldaro, B., Grandi, S., et al. (1982).
Validazione italiana del CES-D per la misurazione della depressione. In R. Canestrari
(Ed.), Nuovi Metodi in Psicometria (pp. 95103). Firenze: Organizzazioni Speciali.
Prezza, M., & Pacilli, M. G. (2002). Perceived social support from signicant others, family
and friends and several socio-demographic characteristics. Journal of Community &
Applied Social Psychology, 12(6), 422429. http://dx.doi.org/10.1002/casp.696.
Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the
general population. Applied Psychological Measurement, 1(3), 385401. http://dx.doi.
org/10.1177/014662167700100306.
Rising, R., & Lifshitz, F. (2005). Relationship between maternal obesity and infant feedinginteractions. Nutrition Journal, 4(17.2005).
Schore, A. N. (2000). Attachment and the regulation of the right brain. Attachment &
Human Development, 2(1), 2347. http://dx.doi.org/10.1080/146167300361309.
Sim, L., & Zeman, J. (2005). Emotion regulation factors as mediators between body
dissatisfaction and bulimic symptoms in early adolescent girls. The Journal of Early
Adolescence, 25(4), 478496. http://dx.doi.org/10.1177/0272431605279838.
Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta-analytic
review. Psychological Bulletin, 128, 825848.
Svaldi, J., Griepenstroh, J., Tuschen-Cafer, B., & Ehring, T. (2012). Emotion regulation deficits in eating disorders: A marker of eating pathology or general psychopathology?
Psychiatry Research, 197(1), 103111.
Van der Merwe, M. T. (2007). Psychological correlates of obesity in women. International
Journal of Obesity, 31, S14S18. http://dx.doi.org/10.1038/sj.ijo.0803731.
Velotti, P., Zavattini, G. C., & Garofalo, C. (2013). Lo studio della regolazione delle
emozioni: Prospettive future. Giornale Italiano di Psicologia, 2, 247262.
Ventura, A., & Birch, L. (2008). Does parenting affect children's eating and weight status?
International Journal of Behavioral Nutrition and Physical Activity, 5(1), 15. http://dx.
doi.org/10.1186/1479-5868-5-15.
Veugelers, P. J., & Fitzgerald, A. L. (2005). Prevalence of and risk factors for childhood
overweight and obesity. Canadian Medical Association Journal, 173(6), 607613.
Whiteside, U., Chen, E., Neighbors, C., Hunter, D., Lo, T., & Larimer, M. (2007). Difculties
regulating emotions: Do binge eaters have fewer strategies to modulate and tolerate
negative affect? Eating Behaviors, 8(2), 162169.
Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The multidimensional scale
of perceived social support. Journal of Personality Assessment, 52(1), 3041.