Determination of distress, emotional eating and internalized weight bias levels of Turkish pregnant women

Abstract This study was conducted to determine the stress, emotional eating and weight bias levels of Turkish pregnant women. The study sample was composed of 210 pregnant women, who met the research inclusion criteria and admitted to the obstetrics and gynaecology outpatient clinics of Bingol Hospital for Obstetrics and Gynaecology. Research data were collected between December 2018 and June 2019, using face-to-face interview technique. Personal Information Form, Tilburg Pregnancy Distress Scale (TPDS), Internalised Weight Bias Scale (IWBS), and Emotional Eating sub-scale items of the Netherlands Eating Behaviour Questionnaire used to collect data. In our study, 47.9% of pregnant women were found to be overweight or obese according to the pre-pregnancy body mass index (BMI) average. Pregnant women experience a moderate level of stress, emotional eating and weight bias. It was found that there was a statistically significant relationship between the weight bias score averages and the emotional eating and stress score averages of the pregnant women (p < .05). In our study, stress, emotional eating and weight bias score averages of pregnant women in the 3rd trimester were found to be higher than that of the pregnant women in the 2nd trimester (p < .05). It has been determined that nearly 1in 2 pregnant women was overweight or obese, when BMI level of the women increased, weight stigma and emotional eating of them also increased. IMPACT STATEMENT What is already known on this subject? To be overweight or obese pre-pregnancy is risk for pregnancy complications and adverse birth outcomes. What do the results of this study add? It is important to inform nurses about the relationship between stress, weight bias, eating disorders, and obesity; moreover, care should be providing with the awareness that pregnant women with obesity are at greater risk in terms of these factors. It is of great importance to provide the necessary training and counselling by nurses to ensure the psychological adaptation of pregnant women to childbirth and the postpartum period. Besides, any disadvantage or disparity between overweight and obese pregnant women in the care process should be eliminated, and all pregnant women, regardless of their body size, should have equal access to supportive prenatal and postnatal care. What are the implications of these findings for clinical practice and/or further research? It is of great importance to providing training and consultation by nurses on coping with stress and stigma and eating during pregnancy in order to ensure psychological adjustment of the pregnant women to childbirth and the postpartum period, which are at risk in terms of stress, emotional eating and weight bias factors.


Introduction
Many factors that occur during pregnancy, such as social, physical and psychological changes, deterioration in body image, anxiety about new roles and responsibilities, taking care of the baby, lack of social support, low socioeconomic status, less than 20 years of age, being single, have less than grade 11 educations increase the risk of psychological distress (C¸apik et al. 2015).Different from the general stress, the stress experienced during the pregnancy covers not only the pregnancy-specific conditions and stress but also anxiety and depression (Mulder et al. 2002).Pregnancy-specific stress refers to maternal fears and concerns about the health of the foetus, physical symptoms associated with pregnancy, parental relationships, relationships with others, changes in the body, delivery, and the health of the infant.Studies reported that the prevalence of stress during pregnancy range from 5.5 to 78% (Iranzad et al. 2014, Vijayaselvi 2015, Ahmed et al. 2017, Pais and Pai 2018).The prevalence of stress during pregnancy reported by the studies conducted in Turkey was between 11.9% and 33% (Bacaci and Apay 2018, C¸apik et al. 2015, Yildiz C¸i _ltas ¸ 2019).Many characteristics of Turkish society such as becoming pregnant during adolescence, frequently becoming pregnant, inadequate prenatal care, unemployment, low educational level, lack of health insurance, living in an extended family, economic problems and domestic violence can cause stress (Karac¸am and Anc ¸el 2009).Providing appropriate and supportive care is of importance due to increased risk of pregnancy and birth complications because of the stress experienced in pregnancy, and the adverse effects of both mother and foetus/ newborn (Claesson et al. 2010).There is evidence that the stress experienced in pregnancy has unintended consequences, such as premature birth and a low-weight baby.It is noteworthy that studies highlight the physiological threats of stress in pregnancy for the mother and baby, but ignore the psychological problems.Stress in pregnancy leads to eating disorders, low energy, and negative mood (Mulder et al. 2002, Ahmed et al. 2017).Eating disorders are one of the psychiatric disorders with increasing prevalence in the world and are defined as abnormal eating habits that can threaten health and life (Watson et al. 2013).Eating disorders are seen between 5% and 7% in women of childbearing age, and recent studies highlight the incidence and risks during the pregnancy and the postpartum period (Kimmel et al. 2016).Pregnancy has the potential to raise issues for psychology of eating disorders including 'fear of pregnancy and motherhood for their negative consequences ranging from loss of control one's body and life (Brownell et al. 2005).Diagnosing eating disorders in the pre-pregnancy period and during the pregnancy is of importance for the health of the mother and foetus/newborn because of the negative effects eating disorders to the health of the mother and foetus (abortus, low Apgar score and low birth weight newborn, premature birth, hyperemesis and postpartum depression) (Watson et al. 2013).It is known that pregnant women are inclined to an emotional eating disorders to cope with the negative emotional stimulation they experience due to the change in their body image.One of the factors affecting emotional eating is the societal pressures that occur related to the ideal physical appearance, i.e. weight bias (Pearl and Puhl 2014).Internalised weight bias, expressed as accepting society's negative stereotypical judgments about weight, causes emotional and restrictive eating behaviour disorder, depression, and low self-esteem in individuals (Pearl and Puhl 2016).Weight bias is defined as displaying prejudicial attitudes and discriminatory behaviours to the individual due to his/ her weight, which affects physiological and especially psychological health.Weight bias is more common during the pregnancy when the body undergoes rapid and intense changes (Watson et al. 2013, Incollingo Rodriguez et al. 2019).
Experiencing weight bias negatively affects the mental health of health these women, who are already fragile and experience psychological changes during the pregnancy.Researchers in Australia found a relationship between obese pregnant women and weight bias.It was found that health professionals had a greater negative attitude towards obese pregnant women and that they believe that obesity was entirely the result of individuals' laziness and lack of will (Mulherin et al. 2013).Women experiencing weight stigma from more sources (family, community, healthcare professionals) reported more depressive symptoms, maladaptive dieting behaviour and perceived stress contribute to unfavourable physical and mental health outcomes for pregnant and postpartum women (Incollingo Rodriguez et al. 2020).Altinayak et al. (2017) revealed that the vast majority of midwifery students are prone to prejudice against obese pregnant women.
The pregnant women must have good physiological and psychological health.For this purpose, distress and possible mental complications in pregnancy should not be ignored in the treatment plan.Our study aims to determine the distress, emotional eating and weight bias levels of pregnant women due to inadequate studies on this subject and the significant impact of this issue on maternal and newborn health.

Research questions
1. Were there differences in personal and pregnancyrelated characteristics and weight bias, distress, emotional eating in Turkish pregnant women? 2. What are weight bias, prenatal distress and emotional levels in Turkish pregnant women?3. Is there any relationship between weight stigma, distress and emotional eating in Turkish pregnant women.

Design and sample
This descriptive and cross-sectional study was conducted at obstetrics and gynaecology outpatient clinics of Hospital for Obstetrics and Gynaecology in Bingol, Turkey within 12months.G Power 3.1 at the stage of determining sufficient sample volume in the study package program is used.Type 1 margin of error when calculating the sample size (a) ¼ 0.05, test power (1-b) ¼ 0.80, effect size ¼ 0.222 were calculated and the sample size was determined as a minimum of 172.Criteria for the inclusion of pregnant women were as follows: 1) Those who have the ability to speak, read and write in Turkish, able to provide consent to participate in the research, 2) be 18 years old or older those at the 12 th gestational week and above, 3) those who haven't any risk factor either regarding herself or her baby, 4) those who know her weight and height before the pregnancy (at the time of her pregnancy diagnosed by obstetrician), 5) no history of chronic diseases and the absence of multiple pregnancies.210 participants were eligible for inclusion in the sample and agreed to participate in the study.The pregnant women were approached directly by the researchers while waiting for their prenatal care appointment.The completion of the questionnaires took about 15 minutes.

Data collection tools
Data were collected using four data collection tools and their pregnancy health records.The data collection tools were Pregnancy Information Form, Internalisation Weight Bias Scale (WBIS), Dutch Eating Behaviour Questionnaire/ Emotional eating subscale: and Tilburg Pregnancy Distress Scale (TPDS).Pregnancy Information Form; included questions about women and her partners' characteristics and pregnancyrelated characteristics (age, marital status, education level, financial level, obstetric history etc.) Tilburg Pregnancy Distress Scale (TPDS) which was developed by Pop, Pommer, Purceleanu, Wijnen, Bergink, and Power to determine the distress in pregnancy (stress, anxiety, depression) and adapted to Turkish by C¸apık and Pasinlio� glu ( 2015) by conducting a validity and reliability study was used (Pop et al. 2011, C¸apik andPasinlioglu 2015).The scale consists of 16 items.It has two subscales, 'Negative Affect' and 'Partner Involvement'.The lowest score that can be obtained from the whole scale is 0 and the highest score is 48.The scale is applied to those who are pregnant for 12 weeks or over.The Cronbach's Alpha value was found as 0.83 in the validity reliability study of the scale.In this study, Cronbach's a internal consistency coefficient for the scale was 0.78.

Internalised Weight Bias Scale (IWBS)
The scale was developed by Pearl and Puhl (2014) and it evaluates the 'internal stigma' reflecting the internal experiences of individuals in different weight categories related to stigma (e.g.I feel anxious about my weight because of what people might think of me).Weight bias, defined as negative attitudes directed towards individuals who are perceived to have excess body weight, experience weight bias in social, professional, and health care settings and, consequently, are 'anti-fat' stigmatising stereotypes and beliefs into their selfevaluation (Durso and Latner 2008).Scale including 11 items, the latest form of the scale is a 7-point Likert type scale, with higher scores indicating higher stigma.The scale adapted to Turkish by Apay et al. (2017) and the internal consistency coefficient of the scale's original English version was found to be 0.94 Cronbach's a internal consistency coefficient for the scale was 0.92.

Dutch eating behaviour questionnaire/emotional eating subscale
This is at 33-item scale measuring restraint, emotional and external eating adapted to Turkish by Bozan et al. 2011).In this study, we used only the 'emotional eating' subscale which included 13 items relating to eating in response to emotional difficulties/inconvenience rather than physical hunger (e.g.'Do you have a desire to eat when you are irritated?').A higher score indicated a higher prevalence of emotional eating.In this study, Cronbach's a internal consistency coefficient for the scale was .72.

Data analysis
SPSS (Statistical Package for the Social Sciences) 25.0 package program was used for the statistical evaluation of the data.Kolmogrov-Smirnov test was used to examine whether the parameters used in the study showed normal distribution and its value was determined as p < 0.05.Categorical measurements are shown as numbers and percentages, continuous measurements as mean/standard deviation and min-max.Since the parameters used in the research show Normal distribution; Student's T test in paired group analyses; One Way Anova tests were used in the analysis of more than two groups.In case of a significant difference between more than two groups, the Post Hoc test (Bonferroni test due to the homogeneous distribution of variances) was used to determine between which groups the significance was.Pearson correlation test was used to determine the relationship between scale scores.

Ethical considerations
The Institutional Ethics Committee of University approved this study before implementation.All study participants gave informed verbal and written consent before participation in this study.The researcher guaranteed that the data would be kept confidential.

Results
The aim of study was conducted to determine internalised weight bias, emotional eating, and stress levels of pregnant women.The study findings revealed that mean age of the pregnant women was 29.72 ± 5.64, and 71.4% was a housewife, 45.3% was primary school graduate, 51.7% had medium financial level (no one good level, 62.0% was living in the city centre, and 31% had a university graduate husband.Of the women, 77.5% was in the 2 nd trimester, 31.4% was primiparous, all of them was married and 47.9% was overweight or obese according to the pre-pregnancy body mass index average. According to comparison the scales with descriptive characteristics of the pregnant women, there was a statistically significant difference between the current trimester of the pregnant women and their mean stress, emotional eating and internalised weight bias scores; and, it was found that mean stress, emotional eating and weight bias scores of the pregnant women in the 3 rd trimester were higher than that of the pregnant women in the 2 nd trimester (p < .05).When the scale score averages were examined about to with concerning the previous pregnancies, it was found that the stress score averages of those who had a first pregnancy were significantly lower than who had 1-2 or above children (p < .05).No significant relationship was found between internalised weight bias, emotional eating, stress scale score averages and other sociodemographic characteristics (age, education, place of residence,etc.) of the pregnant women (Table 1).
Their mean internalised weight bias score was 30.93 ± 10.92, the mean stress score was 19.64 ± 10.57, the mean spouse-participation sub-scale score was 3.39 ± 3.59, the mean negative-self sub-scale score was 16.25 ± 6.22, and the mean emotional eating sub-scale score was 44.08 ± 15.94 (Table 2).
According to the examination of the relationship between BMI, stress, weight bias and emotional eating score averages, a positive, statistically significant and moderate relationship was found between BMI, weight bias and emotional eating score average (r weightbias ¼ .681,r emotionaleating ¼ .490,p ¼ .001);however, the relationship with the stress score average was not statistically significant (r stress ¼.103, p ¼ .138).
When the relationship between stress, emotional eating and weight bias scores of pregnant women was examined, a statistically significant, positive and weak relationship was found between stress and weight bias total scores of pregnant women (r stress ¼ .305,p ¼ .001);also, there was a positive, significant and moderate relationship between emotional eating and weight bias score averages (r emotionaleating ¼ .624�� , p ¼ .001).A statistically significant and positive, but weak correlation was found between emotional eating and stress total score averages (r ¼ .224� , p ¼ .014)(Table 3).

Discussion
In this study, 47.9% of pregnant women were found to be overweight or obese according to their pre-pregnancy body mass index averages.BMI before conception according to Turkey Nutrition Guide (2016) is below 18.5 kg/m2 pregnant women with low birth weights, 18.5-24.9kg/m2 normal, 25.0-29.9kg/m2 pregnant women who are pregnant are overweight, and expectant mothers with 30.0 kg/m2 or more are obese.In a study in the U.S., more than half of all women of childbearing age were reported to be obese, while 8% were reported to be extremely obese (Vahratian 2009).In the UK, however, one out of every 20 pregnant women was found to be obese (Charnley et al. 2021).The prevalence of obesity in pregnant women in Turkey was reported in the range of 27.2% to 33% (Irge et al. 2005 no date; Kaya et al. 2012, Kaya et al. 2012, Koc¸ak et al. 2021).Atalay and Derin (2020) reported 49.2% of pregnancy women obese and slightly obese.Being pregnant as overweight or obese increased risk of complications during pregnancy and childbirth (Despite all efforts to reduce obesity and minimise its risk factors, obesity can lead to unwanted complications for the mother and baby during the prenatal period, pregnancy, and postpartum period) (Kimmel et al. 2016, Charnley et al. 2021).Pregnant women with obesity have a risk of gestational diabetes, hypertension, preeclampsia, emergency caesarean section, foetal growth abnormalities, intrauterine development retardation, and intrauterine mortality compared to non-obese pregnant women (Hildingsson and Thomas 2012).
In our study, the stress, internalised weight bias, and emotional eating score averages of pregnant women in the 3 rd trimester were found to be higher than that of the pregnant women in the 2 nd trimester (p < .05).Yıldız (2015) has found that there was no significant difference in stress levels in terms of trimesters.In their study, Khashan et al. (2014) found that mean stress score of pregnant women at the 20 th week of gestation was higher than that of the 15 th week of gestation.Pregnant women may experience stress due to trimester-specific psychological and physiological changes.Causes such as the fear of childbirth and the burden of new roles and responsibilities of parenthood may increase the stress seen during the pregnancy in the third trimester (C ¸apik et al. 2015(C ¸apik et al. , Barton et al. 2017)).During pregnancy women experience physiological changes in terms of hormones, body weight and fat disposition.Similarly, as the gestational week progresses, weight gain increases, the body image of the pregnant woman changes more rapidly, internalised weight biases increase so that resort to harmful coping methods in the face of these stigmatised experiences like emotional eating, experienced weight discrimination more frequently were associated with higher and oxidative stress (Atalay Z and Derin D € O, no date; Tomiyama et al. 2014).In our study, it was found that the stress score averages of those who had first pregnancy statistically significantly lower than who had 1-2 -3 or above children (p < .05).There are studies in the literature (Akbas et al. 2020(Akbas et al. , G€ oz€ uyes ¸il et al. 2008) ) showing that psychological symptoms increases as the number of pregnancies increases.Conditions such as complications in a previous pregnancy difficult and painful labour, physiological changes in the postpartum period, baby care and parenting role have been proven to increase the stress experienced by those who had a previous pregnancy.
The average Tilburg Pregnancy Distress Scale (TPDS) score was 19.64 ± 10.57, and it was found that 11.1% experiences stress, According to the score averages, it was determined that pregnant women experience a moderate level of stress, emotional eating and weight bias.Reported moderate psychological stress in pregnancy (Yuksel et al. 2014).Yildiz C ¸i _ltas ¸ 2019) reported that the stress levels of pregnant women were moderate This variation could be due to all of the pregnant women were living with their husband.Social support could reduce stress, hiding the effects of stress and protect pregnant women from the harmful effects of stressful situations.Most of the Turkısh society is more supportive of pregnant women.When the national and international literature was reviewed, it was seen that the stress level in pregnancy was between 9.9% and 35.8% (Rubertsson et al. 2014, C ¸apik et al. 2015, Barton et al. 2017).In this study, it was found that individuals who were pregnant had the medium of weight bias and the mean emotional eating.Incollingo Rodriguez et al. (2020) reported nearly 1 in 5 pregnant and postpartum women's women (n ¼ 92) experiencing weight stigma in healthcare settings.Of the 501 women who were pregnant or up to 1 year postpartum 157 indicated experiencing weight stigma from close relations (Nagpal et al. 2021).Weight stigma in pregnancy are weight-based judgement due to physical changes as a result of gestational weight gain and comparisons made to social ideals of pregnant bodies.Hence, the increased focus on weight during pregnancy positions women at risk for experiencing weight stigma from a variety of sources (healthcare, media, family) as women reported negatively judging themselves (Incollingo Rodriguez et al. 2019).Pregnant women also commonly identify both emotional, hormonal and social factors as influencing their eating behaviour (Broussard 2012).
In this study, a positive relationship was found between stress, weight bias and emotional eating.It is reported in the literature that weight bias increases the level of depression in individuals, leading to low self-esteem (Pearl andPuhl 2016, Emmer et al. 2020).Pregnant women with eating disorders had high levels of depression (Santos et al. 2017).In their study, (Stevens et al. 2018) stated that internalised weight bias causes depression.Similarly, in our study, it was found that pregnant women's stress levels increased as their weight biases increased.The social identity of an individual who internalises society's weight bias is negatively affected, and therefore his/ her level of anxiety and stress increases (Ashmore et al. 2008).Research has consistently found a link between internalised weight stigma and increased psychological distress (Durso and Latner 2008).Internalised weight bias causes emotional eating (Thompson et al. 2017).In another study, internalised weight bias was found to cause eating disorders such as emotional eating, restrictive eating, and night eating in individuals (O' Brien et al. 2016).According to this study, it can be said that weight bias affects eating behaviour and increases the individual's predisposition to emotional eating.
In our study, it was found that weight bias and emotional eating levels increase as the body mass index of pregnant women increases, and that internalised weight bias and emotional eating behaviours increase as negative emotions and stress increase.Studies have shown that BMI affects levels of emotional eating and weight bias (Pearl and Puhl 2016).Emotional eating can become a learned behaviour that is used to control negative emotions, response to stress involves increased food intake, especially unhealthy foods that are high in fat and sugar (Schvey et al. 2011).Pregnant women exhibit more emotional eating behaviour as their internalised weight biases increase.The internalised weight bias, which is fed by society's negative bias towards weight, causes physiological and mental distress for the pregnant woman and foetus (Mulherin et al. 2013).Pregnant women with obesity were found to be subjected to discrimination by medical staff because of their weight during the perinatal period (Hildingsson and Thomas 2012).Studies have found a significant relationship between eating disorder, unhealthy weight control, and body dissatisfaction in individuals who feel stigmatised because of their weight.Perinatal counselling and obstetric care are important since impaired eating behaviours and attitudes during the pregnancy can affect pregnancy outcomes and neonatal health.In our study, it was found that weight bias and emotional eating levels increase as the body mass index of pregnant women increases, and that internalised weight bias and emotional eating behaviours increase as negative emotions and stress increase.

Implications for psychiatric nursing practice
In conclusion, it was found that the majority of pregnant women were overweight or obese, that pregnant women experience moderate stress, emotional eating and internalised weight bias, and that the levels of stress, emotional eating and internalised weight bias of pregnant women in the third trimester were higher than those in the second trimester.Also, the stress, weight bias, BMI and eating disorder factors were found to be related to each other.
It is important to inform nurses about the relationship between stress, weight bias, eating disorders, and obesity; moreover, care should be providing with the awareness that pregnant women with obesity are at greater risk in terms of these factors.Pregnancy is a critical period.Nurses should be vigilant and routinely assess for eating pathology and attitudes, as reduce associated negative outcomes.In this direction, more studies and larger sample groups are needed to determine the weight stigma experienced in pregnant women and to reveal the relationship between stigma and the symptoms experienced.If the relationship between the level of stigmatisation of pregnant women and symptoms in the care provided by health professionals during pregnancy is determined, the care given to pregnant women can be provided in a more planned, detailed and effective way.To mitigate weight stigma related to pregnancy and its deleterious maternal and infant consequences, nurses and health care providers are urged to offer patient education and health behaviour counselling void of biases.Future research should corroborate these associations using prospective measures of weight stigma and its potential consequences throughout the pregnancy and the postpartum period.Future qualitative work is needed to better understand how pregnant women with overweight or obesity experience, perceive, and internalise weight-based discrimination.

Table 1 .
The comparison of Internalisation Weight Bias Scale (IWBS), and Tilburg Pregnancy Distress Scale (TPDS) Dutch Eating Behaviour Questionnaire/ Emotional eating subscale with personal and pregnancy-related characteristics of women (n ¼ 210).Boldface values represent the significance level as p < .05.