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Attachment & Human Development
ISSN: 1461-6734 (Print) 1469-2988 (Online) Journal homepage: http://www.tandfonline.com/loi/rahd20
Maternal mentalization affects mothers’ – but not
children’s – weight via emotional eating
Anja Keitel-Korndörfer, Sarah Bergmann, Tobias Nolte, Verena Wendt, Kai
von Klitzing & Annette M. Klein
To cite this article: Anja Keitel-Korndörfer, Sarah Bergmann, Tobias Nolte, Verena Wendt,
Kai von Klitzing & Annette M. Klein (2016): Maternal mentalization affects mothers’ – but
not children’s – weight via emotional eating, Attachment & Human Development, DOI:
10.1080/14616734.2016.1196376
To link to this article: http://dx.doi.org/10.1080/14616734.2016.1196376
Published online: 23 Jun 2016.
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Maternal mentalization affects mothers’–but not children’s
–weight via emotional eating
Anja Keitel-Korndörfer
a,b
, Sarah Bergmann
a,b
, Tobias Nolte
c
, Verena Wendt
a,b
,
Kai von Klitzing
b
and Annette M. Klein
b
a
University Medical Center IFB Adiposity Diseases, Leipzig, Germany;
b
Department of Child and Adolescent
Psychiatry, Psychotherapy, and Psychosomatics, University of Leipzig, Leipzig, Germany;
c
Research
Department of Clinical, Educational and Health Psychology, University College London, London, UK
ABSTRACT
Previous research on childhood obesity has shown that maternal
obesity is an important risk factor for this malady. Because biological
and environmental factors are able to explain the transgenerational
transmission of obesity only in part, psychological risk factors (e.g.,
emotional eating) have become more important in recent research.
As maternal mentalization –which lays the foundation for the child’s
ability to regulate his/her emotions –has not yet been investigated, we
examined the effects of mentalization on maternal and childhood
obesity. By investigating groups of obese (n=30)andnormal-weight
(n= 30) mothers and their children aged 18 to 55 months, we found,
contrary to our expectations, that obese mothers’mentalization
(Reflective Functioning Scale) was similar to that of mothers with
normal weight and that mentalization showed no direct effect on the
child’s weight. However, we found hints of an indirect influence of
mentalization via emotional eating on mothers’but not on children’s
weight and via mother–child attachment (Attachment Q-Set) on chil-
dren’s weight. Possible reasons for these inconclusive effects are
discussed.
ARTICLE HISTORY
Received 28 December 2015
Accepted 28 May 2016
KEYWORDS
Reflective Functioning;
mentalization; maternal
obesity; childhood obesity;
attachment
“Ce qui me manque c’est ce moi que tu vois.”(“What I lack is the self that you see.”)
Paul Valery (as cited by Broome, 1999, p. 474)
Overweight, and obesity in particular, has become a major public health problem around the
world (World Health Organization, 2013). Recent research has revealed dramatic prevalence
rates (Janssen et al., 2005;Ogden,Carroll,Kit,&Flegal,2014;Zaninotto,Head,Stamatakis,
Wardle, & Mindell, 2009). For example, 34.9% of adults and 16.9% of 2–19-year-olds in the
United States are obese (Ogden et al., 2014). The perspective on the future is even more
alarming: According to the Trust for America’sHealth(2012), 50–67% of adults in the United
States will be obese by 2030. As obesity can cause serious illnesses (e.g., diabetes, cancer,
depression), leading to a large financial burden on the health care system, governmental and
societal institutions have a major interest in halting the development of obesity through well-
CONTACT Annette M. Klein annette.klein@medizin.uni-leipzig.de Department of Child and Adolescent
Psychiatry, Psychotherapy, and Psychosomatics, University of Leipzig, Liebigstraße 20a, 04103, Leipzig, Germany
ATTACHMENT & HUMAN DEVELOPMENT, 2016
http://dx.doi.org/10.1080/14616734.2016.1196376
© 2016 Informa UK Limited, trading as Taylor & Francis Group
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directed and evidence-based intervention programs (Gray, Kahhan, & Janicke, 2009;
Kopelman, 2000; Reilly et al., 2003; Wyatt, Winters, & Dubbert, 2006). This holds in particular
for children because overweight frequently persists between childhood and adulthood
(Ferraro, Thorpe, & Wilkinson, 2003;Guo,Roche,Chumlea,Gardner,&Siervogel,1994;
Whitaker, Wright, Pepe, Seidel, & Dietz, 1997). Thus, it is crucial to understand the etiological
factors underpinning the development of this problem.
Etiology of obesity and emotional eating
Researchers from different fields agree that obesity is multicausal and can be viewed as a
result of the complex interplay between biological, environmental, and psychological
aspects (Demerath et al., 2007; Dubois et al., 2007). In the context of childhood obesity,
parental overweight, especially maternal overweight, has been identified as a key risk factor
(Agras, Hammer, McNicholas, & Kraemer, 2004; Keitel-Korndörfer et al., 2015;Kimbro,
Brooks-Gunn, & McLanahan, 2007; Linabery et al., 2013). Certainly, this association can be
explained by the heredity of obesity-related genes (Chagnon et al., 2000; Mammes et al.,
2000) and environmental factors such as unfavorable eating habits in the family (Anzman,
Rollins, & Birch, 2010; Davison & Birch, 2002). However, according to resent research, those
aspects can explain only a small portion of the variance (Yiannakouris et al., 2001). As a
result, psychological risk factors are now considered to be more critical than previously
thought. For example, it has been demonstrated that both obese adults and obese children
have a lower ability to regulate emotional states (Graziano, Kelleher, Calkins, Keane, & Brien,
2013; for detailed reviews, see Dallman, 2010;Frankeletal.,2012) and, as a result, are more
likely to use food for affect regulation (Harrist, Hubbs-Tait, Topham, Shriver, & Page, 2013;
Vandewalle, Moens, & Braet, 2014). This unhealthy eating behavior described as “emotional
eating”occurs even in the absence of hunger and can be seen as a maladaptive coping
mechanism in an attempt to escape from negative emotions (see also Vandewalle et al.,
2014). Emotional eating, of course, is associated with a higher calorie intake and constitutes
one crucial cause of weight gain (Braet & van Strien, 1997; Kaplan & Kaplan, 1957).
The roles of mother–child attachment and emotional eating in the
development of obesity
In addition to deficits in emotion regulation, family interactions, particularly mother–
child attachment, are considered to be important psychological risk factors. The basis
of the attachment system is an inherent mechanism that enables the infant to seek
proximity with a caregiver in times of uncertainty and distress. In response to early
interpersonal experiences, the child develops an internal working model, which
reflects a cognitive and relational framework including mental representations for
understanding the world, the self, and others (Bowlby, 1980; Bretherton &
Munholland, 1999). Within a relationship characterized by secure attachment, an
emotionally available caregiver coregulates the levels of the child’s high arousal
and helps him/her to acquire the capacity to self-regulate his/her emotional condi-
tions (Nolte, Guiney, Fonagy, Mayes, & Luyten, 2011). Conversely, an insecurely
attached child does not experience this secure relational base and, therefore, is less
flexible and adaptive in times of distress and perceived threat (Bowlby, 1980;Nolte
2A. KEITEL-KORNDÖRFER ET AL.
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et al., 2011). In this case, it is supposed that food –as it may be soothing –may
become one possible strategy for the child to use to deal with negative emotions
(Bowlby, 1969). Bornstein, Wong, and Licinio (2006) further argued from a neuropsy-
choanalytical perspective: “We seem to have not only an obesogenic modern envir-
onment, but also obesogenic early programming of our brain”(p. 1071). That is, they
suggest that the causes of weight problems lie in key events in early life, which lead
to psychological maladaptation.
These theoretical assumptions have been corroborated by recent empirical research. In
our own study (Keitel-Korndörfer et al., 2015), we found an association between mother–
child attachment and the child’s weight. That is, children who were less likely to use their
mothers as a secure base had higher Body Mass Index (BMI) percentiles. It is interesting to
note that children of obese mothers showed more deficits in their mother–child attachment
than children of mothers with normal weight. A longitudinal study by Anderson and
Whitaker (2011) also assessed the influence of mother–child attachment on the child’s
weight. They found that children with an insecure attachment in early childhood had a
1.3 times higher risk of becoming obese at preschool age than securely attached children.
Another longitudinal study of 977 individuals demonstrated even stronger effects of
attachment insecurity on obesity for the period of adolescence (Anderson, Gooze,
Lemeshow, & Whitaker, 2012), thus stressing the increasing risk across the lifespan. In
response to these findings, Bost, Wiley, Fiese, Hammons, and McBride (2014) investigated
whether parents’own attachment style impacts the child’s eating behavior and emotion
regulation among 2.5–3.5-year-olds. Indeed, the authors found that insecure mothers used
more negative emotion regulation strategies in response to their children. Most important,
insecure attachment in the mother affected children’s unhealthy food consumption.
The role of mentalization
Bruch (1973) speculated that mothers who feel insecure (e.g., as a result of being
rejected by their child) tend to react inappropriately by overprotecting the child and
feeding the child to excess. Food appears to be a substitute for closeness and safety and,
consequently, the child is unable to differentiate between their biological and emotional
needs and instead learns to use eating as a proxy for regulating affect. The mechanisms
behind this early “misunderstanding”between a caregiver and the child and negative
compensatory eating behavior remain poorly understood. The concept of mentalization
may shed light on some aspects of maladaptive parent–child interactions. Mentalization
(operationalized as Reflective Functioning; RF) can be defined as “[. . .] a form of mostly
preconscious imaginative mental activity, namely, perceiving and interpreting human
behavior in terms of intentional mental states (e.g., needs, desires, feelings, beliefs, goals,
and reasons)”(Fonagy, Gergely, & Target, 2007, p. 288). According to Fonagy and Target
(2005), the mentalizing capacity of the mother allows her to feel and understand her
child’s distress and to treat the child as an intentional agent. Consequently, she is able to
react sensitively and empathically, to mirror the child’s mental state in a marked and
contingent way, and, therefore, to regulate the child’s emotions (Fonagy, Gergely, &
Jurist, 2004). Thus, she is a secure base for her infant. Infants of mothers with high RF will
subsequently be less likely to resort to “eating their feelings”and may be at lower risk
for developing obesity.
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Mentalizing, however, is not limited to mirroring the child’s emotional states. Rooted
in their own relationship history, mothers may also differ in their abilities to self-
mentalize (Suchman, DeCoste, Leigh, & Borelli, 2010). Difficulties in maternal self-men-
talization might lead to an impaired capacity to regulate not only the child’s emotional
states but also the mother’s own emotions –so that she herself may use food to deal
with negative emotions. Such negative cascades have been shown, for example, in
research on substance-abusing mothers (Suchman et al., 2010).
In the context of obesity, studies have yet to examine the role of mentalization in
explaining unhealthy emotional eating behavior in adults or the potential role of
parental mentalization in the child’s emotional eating behavior. However, there is
some research on eating disorders and mentalization. For example, Fonagy et al.
(1996) found lower levels of mentalization in a group of patients suffering from anorexia
nervosa. It is interesting that in a later study, even the mothers of these patients showed
an impaired capacity to mentalize in comparison with a control group (Ward, Turnbull, &
Steele, 2001). In a recent study from Denmark, Pedersen, Lunn, Katznelson, and Poulsen
(2012) did not find significant differences between bulimic patients and healthy controls
in terms of RF. Nevertheless, the results showed that the capacity was more polarized
within the group that suffered from bulimia. That is, bulimic patients achieved very high
as well as very low levels of mentalization.
Taken together, previous research indicates that (1) obese people are characterized by a
lower capacity to regulate their emotions and, as a consequence, show more emotional
eating, (2) deficits in emotion regulation result from a lower quality of mother–child
attachment and deficits in maternal mentalization, and (3) it is still unclear whether this
deficit might be a factor that contributes to the intergenerational transmission of obesity.
The present research
Drawing on these findings, the present study aimed to investigate the role of mentaliza-
tion in the complex development of maternal and childhood obesity. That is, by
examining obese mothers and their children as well as mothers with normal weight
and their children, we were able not only to focus on parental generation but also to
investigate how mentalization might explain the transgenerational transfer of obesity.
To do so, we extended our previous research on the role of maternal attachment in the
development of obesity published in this journal (Keitel-Korndörfer et al., 2015). This
previous study did not address the question of which mechanism might explain the
finding that deficits in mother–child attachment are associated with higher weight in
children. Knowing that maternal mentalization predicts attachment quality as well as the
child’s emotion regulation, the goal of the current study was to explore whether
mentalization would be found to be associated with maternal obesity and child obesity
and whether these relations would be found to be mediated by emotional eating. Using
the same sample as before, we hypothesized that (1) obese mothers would show a lower
capacity to mentalize than mothers of normal weight, (2) the effect of mentalization on
the mother’s weight group (obese vs. normal weight) would be mediated by the
mother’s emotional eating, (3) maternal mentalization would impact the child’s weight,
and (4) the effect of maternal mentalization on the child’s weight would be mediated by
the child’s emotional eating.
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As previous research has indicated that maternal mentalization predicts the quality of
mother–child attachment (Benoit & Parker, 1994; Fonagy, Steele, & Steele, 1991; Slade,
Grienenberger, Bernbach, Levy, & Locker, 2005; Ward & Carlson, 1995) and that deficits in
mother–child attachment are a critical risk factor for childhood obesity, we also con-
ducted an exploratory analysis to determine whether the effect of mentalization on the
child’s weight would be mediated by the quality of mother–child attachment.
Methods
Study design and participants
We analyzed data from a community sample of 60 mothers (age in years: M= 31.71,
SD = 4.32) and their children (33 girls, 27 boys) aged 18 to 55 months (M= 34.22,
SD = 10.76; for the current study, we used a subsample from our previous research;
Keitel-Korndörfer et al., 2015). Half of the sample consisted of obese mothers (BMI ≥30);
the other half consisted of mothers of normal weight (BMI < 25). Mothers and children
took part in a research project at the Integrated Research and Treatment Center (IFB)
“AdiposityDiseases”of the University Medical Center Leipzig (for more details, see Grube
et al., 2013) and were recruited via kindergartens, healthcare professionals, and public
services for families in and around Leipzig, Germany. In order to avoid any bias due to
socioeconomic disparities between obese families and families of normal weight (Shih,
Dumke, Goran, & Simon, 2013), we matched the groups (frequency matching) on
mother’s age, mother’s educational and relationship status, as well as child’s age and
gender (for a full description of the sample, see Table 1).
As can be seen in Table 1, the children of obese mothers already showed a signifi-
cantly higher weight (BMI percentile) compared with the children of mothers of normal
weight (M
obese
= 75.83, SE
obese
= 19.30, M
normal weight
= 60.24, SE
normal weight
= 25.34), t
(58) = 2.66, p= .01, but no differences in emotional eating (Emotional overeating;
M
obese
= 1.28, SE
obese
= 0.45, M
normal weight
= 1.31, SE
normal weight
= 0.42), t(58) = 0.30,
p= .77. By contrast, obese mothers had significantly higher levels of emotional eating
compared with mothers of normal weight (M
obese
= 2.29, SE
obese
= 0.86, M
normal
weight
= 1.71, SE
normal weight
= 0.58), t(58) = 3.04, p< .01.
Procedure
We invited the mothers and their children to our lab. They received a short introduction
in which detailed information was provided about the study and the families’rights
(verbal and written), and the mothers gave written informed consent to participate in
the study. After allowing time for the child to settle in, we assessed the anthropometric
data (weight and height) of both the mother and child. In addition, we interviewed the
mother (Adult Attachment Interview; George, Kaplan, & Main, 1985) separately from her
child who was in a playroom with one of the research team members during this time.
The mother also provided self-reported demographic information and her own and the
child’s eating behaviors. In addition, mothers completed a questionnaire for assessing
depressive symptoms and were tested on intelligence. During the assessment in our lab,
we asked each mother if she would agree to a home visit in which we videotaped the
ATTACHMENT & HUMAN DEVELOPMENT 5
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mother and child for two hours to assess the quality of mother–child attachment.
Assessments were conducted between March 2012, and October 2013. Mothers again
gave written informed consent prior to the home visit.
Our study was approved by the ethics committee of the University of Leipzig,
Germany (case number 177–12-21052012).
Measures
Maternal mentalization
Mentalization, operationalized as RF, is measured with verbatim transcripts of the Adult
Attachment Interview (AAI; George et al., 1985) and coded according to the Reflective
Functioning Scale (RF-S; Fonagy, Target, Steele, & Steele, 1998). The AAI is a semistructured
interview that includes 20 questions about childhood experiences and childhood relation-
ships, notably with the parents. These questions stimulate the interviewees to reflect on
their parents’behavior and on the influence this might have had on them. In particular,
eight so-called “demand questions”(e.g., “Who did you feel closest to, and why?”) are used
for the probing and scoring of RF. Thus, the RF-S assesses mentalizing as a cognitive capacity
paired with an affective component due to specific reactions elicited in the emotionally
charged context of the AAI (e.g., stress responses; Roisman, Tsai, & Chiang, 2004).
The coding captures whether an awareness of mental states exists and whether the
interviewee explains his/her behavior from a mental-state perspective or by taking into
account the developmental characteristics of mental states (Fonagy et al., 1998). RF is coded
on an 11-point scale ranging from −1(antireflective)to9(exceptionally reflective). RF scores
up to 3 are considered to indicate a negative or limited RF and a score of 5 or above to
Table 1. Descriptive statistics for the two groups including test statistics for group differences.
Variables
Obese mothers
(n= 30)
Mothers of normal weight
(n= 30) Test statistics
Mother characteristics
Age in years, M(SD) 30.94 (4.51) 32.48 (4.05) t= 1.39
BMI, M(SD) 37.47 (5.64) 22.37 (1.86) t= 13.91***
School education
a
10 years of school or less
(primary & secondary school level)
15 13 u= 412.50
12 years of school
(high school level)
15 16
Relationship status with the father
In relationship 21 24 χ
2
= 0.80
Not in relationship 9 6
Emotional eating, M(SD) 2.29 (0.86) 1.71 (0.58) t= 3.04**
Child characteristics
Age in months, M(SD) 34.37 (10.11) 34.07 (11.56) t= 0.11
Sex
Girls 15 18 χ
2
= 1.09
Boys 15 12
Current BMI percentile, M(SD) 75.83 (19.30) 60.24 (25.34) t= 2.66*
Emotional overeating, M(SD) 1.28 (0.45) 1.31 (0.42) t= 0.30
ttests were used to test for differences between the two groups in mother’s and child’s age, mother’s BMI, and child’s
BMI percentile. χ
2
tests were used to test for group differences in mother’s relationship status and child’s sex. A
Mann-Whitney U test was used to examine the difference between groups in mother’s education.
a
One mother did not report her educational status (N= 59).
*p< .05. ** p< .01. *** p< .001.
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indicate an ordinary to high RF. A person’s RF has been shown to be stable over time, and
good interrater reliability for the scale has been reported (Taubner et al., 2013).
In the current study, two coders who were independent and blind to the hypotheses
and groups rated the AAI transcripts. Both coders were trained and reliable assessors. To
control for interrater reliability, 20% of the sample was rated twice. The statistical
calculations yielded excellent interrater reliability (ICC = .90, p< .001).
Emotional eating of the child
The child’s emotional eating was measured with the Emotional Overeating subscale
from the Children’s Eating Behaviour Questionnaire (CEBQ; Wardle, Guthrie, Sanderson,
& Rapoport, 2001). A German version of the CEBQ was developed in accordance with
standard translation-back-translation procedures. The Emotional Overeating subscale
contains four items describing different emotional situations in a child’s life and possible
reactions to these situations regarding food intake (e.g., “My child eats more when
anxious”). Respondents can choose between 1 (never), 2 (seldom), 3 (sometimes), 4
(often), and 5 (always). The CEBQ is valid for children aged two years and older. The
CEBQ has been shown to successfully capture children’s eating styles and their connec-
tions with child weight (Webber, Hill, Saxton, van Jaarsveld, & Wardle, 2009).
Furthermore, good psychometric properties were shown with regard to internal consis-
tency and test-retest reliability (Wardle et al., 2001). In our sample, reliability was
marginal (α= .57).
Emotional eating of the mother
Mothers’emotional eating was assessed with a subscale from the Dutch Eating
Behaviour Questionnaire (DEBQ; van Strien, Frijters, Bergers, & Defares, 1986; German
translation by Grunert, 1989). The Emotional Eating subscale consists of 13 items (e.g.,
“When I feel blue I often overeat”). The items have to be answered by choosing one of
five categories: 1 (never), 2 (seldom), 3 (sometimes), 4 (often), and 5 (very often).
Consequently, a higher score indicates a higher level of emotional eating. The DEBQ is
often used as a screening instrument to reveal maladaptive eating styles in adults and
has shown high internal consistency (α= .95 for the Emotional Eating subscale; Braet
et al., 2007), high factorial validity, and high categorical stability (van Strien et al., 1986;
Wardle, 1987). In our sample, its reliability was excellent (α= .92).
Mother–child attachment
The quality of mother–child attachment was measured with the Attachment Q-Set (AQS;
Waters, 1995; German version by Ahnert, Eckstein, Supper, Harwardt, & Milatz, 2012). The
AQS is based on the idea that a securely attached child is able to use a caregiver as a
secure base in everyday circumstances and that this secure base behavior can be
observed. A trained observer rates the mother–child interaction observed in the families’
homes. The AQS can be applied to children aged 1–5 years.
The assessment at home lasts at least two hours, and the mother is instructed to
behave as she would every day and to try to ignore the observer. After the visit, a
trained person (after one week of training) rates the interaction on video and
completes the Q-Sort, which consists of 90 items for the mother–child interaction
and the child’s behavior. The AQS score ranges from −1.0to+1.0anddisplaysa
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correlation with a hypothetically ideally attached child, sorted by experts. Children
with high total scores are able to use the mother as a secure base, and children with
lower scores are less likely to do so (Waters, 1995;Waters&Deane,1985). If sorted by
a trained observer, the AQS shows convergent validity (r= .31) for attachment
security measured by the Strange Situation procedure, as well as very good predictive
validity with maternal sensitivity (r= .39; van IJzendoorn, Vereijken, Bakermans-
Kranenburg, & Riksen-Walraven, 2004).
In the current study, a second coder (after one week of training) scored 20% of the
videotapes for interrater reliability. The statistical calculations revealed a good to very
good interrater reliability (ICC = .79).
Anthropometric data
The weight and height of both mother and child were obtained by trained pediatricians
or psychologists. We used calibrated scales with a reading accuracy of ±0.1 kg and a
stadiometer with a reading accuracy of ±0.5 cm. Using the anthropometric data, we
determined the mothers’BMI as well as the age- and sex-specific BMI percentiles of the
children.
Control variables
The German version of the Patient Health Questionnaire (PHQ; Löwe, Spitzer, Zipfel, &
Herzog, 2002), a self-screening instrument for mental health problems, provided a
continuous measure of the severity of mothers’depression. Maternal intelligence was
assessed with the 37-item multi-vocabulary-intelligence-test (MWT-B; Lehrl, 2005). On
the basis of the number of correct answers, a score for the intelligence quotient (IQ) can
be derived.
Statistical analyses
First, we compared the RFs of the groups (obese vs. normal-weight mothers) by
computing a ttest. In the next step, to test for the hypothesized associations and
mediations, we computed bias-corrected bootstrap mediation analyses (5000 bootstrap
samples) using the SPSS macro “Indirect”(Preacher & Hayes, 2008). Due to directional
hypotheses testing, a 90% CI was deemed sufficient. We tested three mediations: (1)
with mother’s RF as the predictor variable, mother’s emotional eating as the mediator
variable, and mother’s BMI group as the dependent variable, (2) with mother’s RF as the
predictor variable, child’s emotional overeating as the mediator variable, and child’s BMI
percentile as the dependent variable, and (3) with mother’s RF as the predictor variable,
the AQS as a mediator variable and, again, child’s BMI percentile as the dependent
variable. For the intercorrelations of these variables, see Table 2.
In supplementary exploratory analyses, we controlled for mother’s IQ and mother’s
depression in our mediation analyses. However, the mediation results with these cov-
ariates were no different from those without the covariates. Therefore, we decided to
present the results of the analyses that did not include mother’s IQ or mother’s
depression.
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Results
Group difference in mothers’Reflective Functioning (Hypothesis 1)
The RF means of both groups were at an average level (M
obese
= 4.51, SE
obese
= 0.25,
M
normal weight
= 4.85, SE
normal weight
= 0.21) with no statistically significant group differ-
ences, t(58) = −1.05, p= .15 (one-tailed), r= .14. Thus, we did not find support for
Hypothesis 1.
Mediation analyses
Effects of maternal mentalization on mother’s BMI group (Hypothesis 2)
We first tested the total effect of mentalization on mothers’BMI group. In accordance with
the previous analysis that was computed to test Hypothesis 1, this effectwasnotstatisti-
cally significant (B= -.224, SE = .213, p= .15, one-tailed). At this point, researchers typically
assume that no mediation is at play due to the lack of a significant total effect (see Baron &
Kenny, 1986). However, according to recent research (Hayes, 2013; Zhao, Lynch, & Chen,
2010), mediation can exist even in the absence of a statistically significant total effect. We
therefore investigated the proposed mediation further. As Figure 1 shows, we did not find a
significantdirecteffect of mentalization on mother’s BMI group (B= -.086, SE =.233,p=.36,
one-tailed). Nevertheless, our analyses revealed statistically significant effects of mentaliza-
tion on emotional eating (B=-.160,SE =.079,p< .05, one-tailed) and of emotional eating
on mother’s BMI group (B=1.062,SE =.415,p< .01, one-tailed). Taking the product of these
two effects in 5000 bootstrap samples to examine the indirect effect, we found a 90% CI for
this product of -.021 to -.451. This revealed a significant mediation effect, that is, an indirect-
only mediation, according to Zhao et al. (2010). Thus, we could conclude that (1) mothers
with lower RF scores showed more emotional eating, (2) mothers who engaged in more
emotional eating were almost three times more likely (per unit on the emotional eating
scale; OR = 2.986) to belong to the obese group than to the group of normal-weight
mothers, and (3) mothers’emotional eating mediated the association between mothers’
ability to mentalize and mothers’BMI group, confirming Hypothesis 2.
Table 2. Intercorrelations of the variables used in the mediation analyses (N= 60).
Mother’s BMI
group
Mother’s
emotional eating
Mother–child
attachment
Child’s BMI
percentile
Child’s emotional
overeating
Mother’s RF .14 −.26* .30* −.02 .38**
Mother’s BMI
group
−.37** .58*** −.33* .04
Mother’s
emotional
eating
−.22
†
.05 .06
Mother–child
attachment
−.23
†
.21
Child’s BMI
percentile
.02
Mother’s BMI group is a dummy variable (1 = obese mothers, 2 = normal-weight mothers).
†
p< .10. * p< .05. ** p< .01. *** p< .001.
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Effects of maternal mentalization on children’s BMI percentile
Mediator: child’s emotional overeating (Hypotheses 3 and 4). As shown in Figure 2,
neither the total effect of maternal mentalization on the child’s BMI percentile (B= -.343,
SE = 2.495, p= .45, one-tailed) nor the direct effect of maternal mentalization on the
child’s BMI percentile when the child’s emotional overeating was additionally entered
Figure 1. Mediation model of the effect of RF on mother’s BMI group via mother’s emotional eating.
The figure shows the unstandardized B coefficients. The standardized βcoefficients for the effects on
emotional eating and Odds Ratios for the effects on mother’s BMI group are presented in parenth-
eses.
a
Current maternal BMI group (1 = mothers of normal weight; 2 = obese mothers).
* p < .05. ** p < .01 (one-tailed).
Figure 2. Mediation model of the effect of maternal RF on child’s BMI percentile via child’s
emotional overeating. The figure shows the unstandardized B coefficients. The standardized β
coefficients are given in parentheses.
** p < .01 (one-tailed).
10 A. KEITEL-KORNDÖRFER ET AL.
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into the model (B= -.538, SE = 2.718, p= .42, one-tailed) reached statistical significance.
According to this, and contrary to our Hypothesis 3, the mother’s ability to mentalize
was not directly associated with the child’s weight. However, as can be seen for the
indirect path, maternal mentalization influenced the child’s emotional overeating such
that higher mentalization increased the child’s emotional overeating (B= .129, SE = .042,
p< .01, one-tailed). By contrast, the child’s emotional overeating did not affect the
child’s BMI percentile (B= 1.507, SE = 7.946, p= .43, one-tailed). Thus, the overall indirect
effect was also not significant, 90% CI [−1.251, 1.804]. In contradiction to our Hypothesis
4, the child’s emotional overeating, therefore, did not function as a mediator of the
effect of mother’s mentalization on child’s weight.
Mediator: mother–child attachment (exploratory analysis). In the second mediation
analysis involving the effect of maternal mentalization on the child’s BMI percentile, we
examined whether mother–child attachment would function as a mediator of this relation.
As can be seen in Figure 3 and similar to the previous analysis, the direct effect of maternal
mentalization on the child’s BMI percentile was not statistically significant when mother–
child attachment was additionally entered into the model as a mediator (B=1.084,
SE =2.562,p= .34, one-tailed). However, our analysis revealed an indirect effect such that
maternal mentalization showed a significant positive effect on mother–child attachment
(B=.053,SE =.022,p< .01, one-tailed), and mother–child attachment negatively influenced
the child’s BMI percentile (B=−27.160, SE =14.631,p< .05, one-tailed). This indicates that
the higher the level of maternal mentalization, the higher the degree of mother–child
attachment; and the higher the degree of mother–child attachment, the lower the child’s
BMI percentile. Furthermore, the overall indirect effect was significant (90% CI [−3.559;
−0.235]), indicating an indirect-only mediation (Zhao et al., 2010) of the effect of maternal
mentalization on the child’s BMI percentile via mother–child attachment.
Figure 3. Mediation model of the effect of maternal RF on child’s BMI percentile via mother–child
attachment. The figure shows the unstandardized B coefficients. The standardized βcoefficients are
given in parentheses.
* p < .05. ** p < .01 (one-tailed).
ATTACHMENT & HUMAN DEVELOPMENT 11
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Discussion
The present research aimed to examine whether the transgenerational transmission
of obesity (Agras et al., 2004; Kimbro et al., 2007; Linabery et al., 2013)mightbe
influenced in part by reduced mentalization in obese mothers. A comparison of obese
mothers and their children with mothers of normal weight and their children showed
that the children of obese mothers had higher BMI percentiles than the children of
mothers with normal weight (Keitel-Korndörfer et al., 2015;seealsoTable 1 in the
current study). This can be seen as particularly alarming given that overweight
frequently persists or even increases over the years (Ferraro et al., 2003; Guo et al.,
1994;Whitakeretal.,1997). Affected children are therefore at a higher risk of
developing obesity themselves. This difference in child’s weight, however, could not
be reproduced for the emotional overeating construct as there was no difference
between children of obese mothers and children of normal-weight mothers (see
Table 1). By contrast, obese mothers showed significantly higher levels of emotional
eating than mothers of normal weight.
In the current study, we expected obese mothers to be characterized by a lower
capacity to mentalize than normal-weight mothers. However, our analyses did not
confirm this hypothesis –there was no difference between normal-weight and obese
mothers, and there was no direct effect of RF on maternal weight status in the first
mediation analysis. We found mean RF scores of between 4.51 and 4.81 for both groups.
These scores can be considered to be at an average level of RF and were similar to
community samples (Fonagy et al., 1998). Lower RF scores have been reported for
subjects with psychiatric disorders, e.g., substance-use disorders (mean RF score 3.13;
Suchman et al., 2010) and anorexia nervosa (mean RF scores 2.4–3.8; Fonagy et al., 1996;
Rothschild-Yakar, Levy-Shiff, Fridman-Balaban, Gur, & Stein, 2010; Ward et al., 2001). This
is the first study to report RF scores for subjects with obesity which is viewed as a
medical disorder rather than a psychiatric disorder.
In our sample, the mentalizing capacity of obese mothers does not appear to deviate
from scores reported for community samples. However, this may also have been due to
a selection effect in that obese mothers who are willing to take part in a study on
childhood obesity may be more reflective and aware of their child’s health risks than
those who did not participate. On the other hand, this explanation can also be applied
to the normal-weight control group –so selection effects could have been expected for
both groups, and we can only speculate about whether the prevalence of mothers with
a high mentalization capacity is lower in the group of obese mothers than in the group
of normal-weight mothers.
In our second and third mediation analyses, we were unable to corroborate the direct
influence of maternal mentalization on children’s BMI percentiles. It might be the case
that the influence increases with the child’s age due to the small variance in child’s
weight at that early age. If this is the case, it would be interesting to acquire data at later
points in development (e.g., in 5–10 years). On the basis of the present study, we were
inclined to state that in the intricate etiology of childhood obesity maternal mentaliza-
tion does not appear to play a relevant role in the early years of life. Alternatively, it
might be the case that the influence of mentalization is more complex.
12 A. KEITEL-KORNDÖRFER ET AL.
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As mothers with a lower mentalizing capacity cannot adequately understand and
react to their own distress (Fonagy et al., 2004; Fonagy & Target, 2005), and they need to
find other strategies to escape from negative emotions –such as the regulatory use of
food (Harrist et al., 2013; Vandewalle et al., 2014)–we also expected to find a mediation
of mothers’RF on their own weight via emotional eating. Indeed, our data supported
this pathway –in the form of an indirect-only mediation. Mothers with lower RF might
misinterpret their own feelings (e.g., hunger vs. satiety) and, moreover, they might use
food to deal with emotional distress. This in turn may lead to higher weight.
We expected children of mothers with a low mentalizing capacity to use (over)eating
as a regulative strategy as their mothers cannot adequately understand and react to
their distress. Yet, we found no effect of maternal mentalization on children’s weight via
emotional eating, a finding that contradicts previous research (Braet & van Strien, 1997;
Kaplan & Kaplan, 1957). The children’s BMI percentiles were not influenced by their
emotional eating. It is interesting, however, to note that we found an effect of maternal
mentalization on the child’s emotional eating but in the opposite direction from what
we expected. This means that mothers with higher maternal mentalization have children
with higher emotional eating. It is conceivable that the mother’s high RF, which is
associated with a more sensitive perception of the child, might even lead her to observe
the child’s eating behavior and hold it in mind more accurately –including problematic
aspects. It might be the case that those mothers’answers reflected a different point of
view of their child and, therefore, such mothers rated their child higher on emotional
eating (e.g., child eats more when anxious).
In our third mediation analysis, we explored whether mentalization would demon-
strate an indirect effect on the child’s BMI percentile via the level of security in the
mother–child relationship. As previous research has pointed out, mentalization and the
mother–child relationship are closely connected (Slade, Grienenberger, et al., 2005).
Moreover, mentalization is considered to be a vehicle for the intergenerational transmis-
sion of attachment (Benoit & Parker, 1994; Fonagy et al., 1991; Ward & Carlson, 1995).
Our own preceding study also demonstrated that the quality of the mother–child
attachment impacts the child’s BMI percentile (Keitel-Korndörfer et al., 2015). Indeed,
our present results reveal that with higher maternal RF, the likelihood for secure
attachment increases, which goes hand in hand with a reduced BMI percentile for the
child. Thus, even though mentalization showed no direct effect on the child’s BMI
percentile, improving maternal RF may be effective at reducing childhood obesity by
improving the attachment quality of the mother–child relationship.
However, an open question remains: Why did mother–child attachment but not
maternal mentalization affect child’s weight when there was a considerable association
between attachment and mentalization? In our view, there are two possible explana-
tions for this pattern of results. First, it might be the case that the part of the variance
that is shared between attachment and mentalization is different from the part that is
shared between attachment and child’s weight. Mentalization is considered to be the
very basis for a secure mother–child attachment and is, besides some genetic factors
(Gillath, Shaver, Baek, & Chun, 2008), largely responsible for the transmission of attach-
ment patterns from one generation to the next (van IJzendoorn, 1995). Therefore, it is
not surprising that these constructs are associated. However, attachment patterns and
maternal mentalization are also formed by unshared and different environmental
ATTACHMENT & HUMAN DEVELOPMENT 13
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experiences. So one environmental experience may influence mother–child attachment
but, by contrast, might have no impact on maternal mentalization (which is influenced
by other environmental experiences). In the context of the present work, this could
mean that the part of the variance of mother–child attachment that was influenced by
environmental experiences (one might think of breastfeeding) was the part that influ-
enced the child’s weight, whereas the same environmental experiences had no effect on
maternal mentalization and, therefore, no part of the variance in mentalization influ-
enced the child’s weight.
Second, it is doubtful whether the part of the variance of maternal mentalization that
influenced the child’s feeding and eating could be accurately measured with the RF-S.
To assess RF, mothers take the AAI and reflect on their parents’behavior and on the
influence this might have had on them. Therefore, maternal RF is also a cognitive ability,
and it is not yet clear how this cognitive ability is manifested in concrete behavior
(especially in the feeding situation, which could be considered very specific). Measuring
mothers’mentalizing capacities regarding their child or even by observing mother–child
interactions while the child is eating might be promising approaches for answering this
question. In this respect, two scientific approaches should be mentioned: RF derived
from the Parent Development Interview (PDI; Slade, Aber, et al., 2005; Slade, Bernbach,
Grienenberger, Levy, & Locker, 2005) and the construct Mind-Mindedness (Meins et al.,
2003). In contrast to the AAI, the PDI elicits parents’representations of their current,
ongoing relationship with their child. Mind-Mindedness can be assessed by observing
interactions between the mother and child and identifying discourse in which the
mother comments on the child’s supposed internal state (Meins, Fernyhough, Fradley,
& Tuckey, 2001). Thus, both instruments might be helpful for future research on the
association between the mother’s RF and the child’s eating behavior.
New developments in RF research point toward the assessment of symptom-specific
RF. For example, in their study, Kullgard, Persson, Möller, Falkenström, and Holmqvist
(2013) used an interview for measuring specific RF in the group of patients with
obsessive-compulsive disorder. This could also be a promising approach for the eat-
ing-related assessment of RF.
Limitations and future directions
Although the present study used state-of-the-art instruments to assess mentalization as
well as mother–child attachment, there are at least four limitations to our research that
should be addressed in the future. First, due to the use of time-consuming and very
expensive instruments (AAI, coded with the RF-S; AQS), only a relatively small number of
participants were included. However, the sample was large enough to create groups
that were matched on critical variables (mother’s educational and relationship status,
child’s age and gender). Notably, socioeconomic aspects such as education are impor-
tant to control for in obesity research (cf. Stamatakis, Wardle, & Cole, 2010).
Second, emotional eating within the group of very young children –especially those
who were not able to eat by themselves –was difficult to assess. Due to a lack of
alternatives (e.g., experimental procedures), we used a questionnaire –the Emotional
Overeating subscale from the CEBQ (Wardle et al., 2001)–which has been validated for
children two years of age and older. However, at such early ages, mealtimes, and often
14 A. KEITEL-KORNDÖRFER ET AL.
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the size of the meal, are regulated and prescribed by parents (which might, at least in
part, explain the critical internal consistency of α= .57 in our sample). Hence, future
research should assess emotional eating in young children, for example, by observing an
actual family meal at home or under experimental conditions.
Third, as in previous studies in mentalization research, we concentrated on maternal,
and not paternal, mentalization. However, it is conceivable that mentalizing by the
father has an influence on the child’s mental development and behavior and might
compensate for the mother’sdeficits in RF. Hence, future research should include an
assessment of the reflective capacities of both parents and take into account whether
both parents were available for the child –particularly in the child’sfirst years of life as a
sensitive period during which the child acquires the ability to regulate affect (Schore,
2001).
Fourth, owing to the cross-sectional design, we are not in a position to provide
information on the direction of the mediation effects. However, our hypotheses and
the interpretations of our findings were based on previous research in this field that
indicated that maternal mentalization is an important precondition for the mother to be
able to regulate her own and her child’s emotions (Fonagy et al., 2004; Fonagy & Target,
2005; Suchman et al., 2010,2010), that emotional eating leads to increases in body
weight (Braet & van Strien, 1997; Kaplan & Kaplan, 1957), and that maternal mentaliza-
tion is the basis for mother–child attachment (Benoit & Parker, 1994; Fonagy et al., 1991;
Slade, Grienenberger, et al., 2005; Ward & Carlson, 1995). Therefore, in our view, the
effects we reported are less likely to go in the opposite direction. Nevertheless, the
present results would benefit from a replication using a longitudinal design.
Summary
In conclusion, research has revealed that maternal obesity seems to be a risk factor for
children’s negative weight development. However, on the basis of the present study, the
role of maternal mentalization in the intergenerational transmission of obesity is unclear.
Obese mothers did not differ from mothers with normal weight in their capacity to
mentalize, and mentalization did not affect the child’s BMI percentile. However, mothers
with a reduced capacity to mentalize showed more emotional eating and were, in turn,
more likely to belong to the group of obese mothers than to the group of mothers with
normal weight. On the other hand, we did not find this mediation via emotional eating
among children. Thus, all in all, in our one-shot cross-sectional design, mentalization did
not play the relevant role in children’s weight in the early years that we expected.
Possibly, the fact that there are multiple heterogeneous factors which play a role in the
pathogenesis of obesity, might explain these unexpected results.
However, the present study gives reason to believe that RF may be more important in
general terms, irrespective of maternal obesity. That is, maternal mentalizing affects the
child’s BMI percentile by influencing the attachment relationship between the mother
and the child. Improving maternal mentalization via prevention programs could there-
fore be fruitful in two ways: It might prove pivotal for enhancing the child’s attachment
quality and might thereby reduce the child’s risk for developing obesity. Furthermore,
improving the mother’s mentalizing might be a useful approach for interventions in
mothers with unhealthy eating behavior.
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Last, mentalization and attachment are very important variables for the subsequent
development of the child. Former research has indicated that these aspects are risk
factors for many health problems and psychopathologies (Agrawal, Gunderson, Holmes,
& Lyons-Ruth, 2004; Antonsen, Johansen, Rø, Kvarstein, & Wilberg, 2016; Fonagy &
Bateman, 2008; Zachrisson & Skårderud, 2010). That is, they seem to be global vulner-
ability factors. Therefore, future research should address the question of specifically how
these factors influence the child’s future overweight or obesity.
Acknowledgements
The authors would like to thank all the families that participated in our study. Moreover, we
gratefully acknowledge the members of our research team, Katharina Herfurth-Majstorovic,
Natascha-Alexandra Weinberger, David Bruckmüller, Elisa Schneiderheinze, Anja Löschcke,
Sabine Thomassen, Eva Luft, Stefan Peuker, Matthias Grube, and especially Lars White, for their
enormous support. We also would like to thank Susan Sierau and Christina Regenbogen for coding
attachment security and mentalization, respectively. We thank the kindergartens and the health
professionals for allowing us to contact the families. Special thanks go to Ruth Gausche (CrescNet
gGmbH) for calculating the children’s BMI percentiles.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This study is part of the Integrated Research and Treatment Center “IFB AdiposityDiseases”and
was funded by the Federal Ministry of Education and Research, Germany [BMBF, number:
01EO1001]. The first author holds a PhD scholarship from the “Evangelisches Studienwerk
Villigst”. This study was also conducted with the help of funds from the “Heidehof Stiftung
GmbH”. We would like to extend our gratitude to both foundations.
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