Emotional Eating and Cardiovascular Risk Factors in the Police Force: The Carolina Blue Project

Cardiovascular disease (CVD) remains the most significant cause of mortality in the United States, accounting for 695,000 deaths in 2021 [1]. CVD encompasses a range of disorders affecting the heart and blood vessels, including coronary artery disease, cerebrovascular disease, and hypertension, each contributing to this staggering mortality rate [2]. Law enforcement officers in the United States have the highest CVD mortality rate of all occupations and are particularly vulnerable to CVD, driven by unique occupational stressors and lifestyle challenges [3,4]. Studies have identified a higher prevalence of CVD risk factors in law enforcement officers compared to the general public, including increased rates of obesity, hypertension, and metabolic syndrome [5].

The implications of CVD risk factors in law enforcement officers are far-reaching, impacting not only their personal health but also their professional capabilities and public safety responsibilities [6]. The physical and mental readiness of law enforcement officers is critical for their effective performance in high-stakes situations, with their health directly impacting their ability to respond effectively [7]. Notably, officers with CVD or its risk factors are at an increased risk of on-duty sudden cardiac events, a leading cause of mortality among active-duty law enforcement officers [8]. Nationally, a study of police officers in the Buffalo Cardio-Metabolic Occupational Police Stress study highlighted the significant disparity in CVD risk factors between law enforcement officers and the general employed population [3]. For example, a much higher percentage of officers were found to be obese (40.5% vs. 32.1% in the general population), have metabolic syndrome (26.7% vs. 18.7%), and have higher mean serum total cholesterol levels (200.8 mg/dL vs. 193.2 mg/dL) [3].

In North Carolina (NC), the situation may be exacerbated, as the risk of CVD death (170.9 per 100,000 in 2021) and risk of CVD event (9.8% risk of myocardial infarction or stroke) surpasses the national average (9.1% risk of myocardial infarction or stroke) [9,10]. Unfortunately, the prevalence of CVD risk factors among law enforcement officers in NC is unknown. The most recent study assessing law enforcement officers’ cardiovascular health in NC focused on the impact of air pollution on heart rhythm and non-CVD-related blood biomarkers, such as blood cell counts, but did not explore CVD risk factors in the context of emotional eating behaviors, which is an emerging area of concern [11].

Emotional eating refers to the tendency (or the urgency) of individuals to eat in response to emotions such as stress, sadness, boredom, or anger rather than in response to physical hunger [12]. While not officially recognized as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [13], studies have shown connections between emotional eating and risk factors for CVD [14,15]. For example, more emotional eating was associated with higher body mass index (BMI) in 600 Italian young adults [16]. A longitudinal study suggested that emotional eating was linked to decreased high-density lipoprotein cholesterol (HDL) levels in Korean men and women (n = 1876) [17]. Young adults with higher degrees of emotional eating had a greater incidence of metabolic syndrome in a cross-sectional study (n = 104) [18]. Several studies have evaluated emotional eating among military personnel in the United States (U.S.) [19,20,21]. Emotional eating was associated with higher BMI and lower aerobic activity among U.S. Army and other active duty military service members [19,21]. However, research in military personnel did not explore emotional eating’s impact on CVD risk factors beyond BMI. In addition, prior research on military personnel has measured emotional eating using four different scales: the Motivation for Eating Scale [22], the Intuitive Eating Scale [23], the Three-factor Eating Questionnaire [24], and the Dutch Eating Behavior Questionnaire [25]. However, these scales do not specifically measure the tendency to eat in response to different types of emotion, such as anger, depression, or anxiety, which is measured by the Emotional Eating Scale [26].

To our knowledge, no study has investigated the relationship between emotional eating and CVD risk factors among NC law enforcement officers. The majority of research on law enforcement officers’ eating has focused on dietary composition (i.e., caloric consumption and percentage of dietary fat, carbohydrate, and protein) [27], with very little attention to eating behaviors. Considering the high prevalence of CVD risk factors in the police force and the strong associations between emotional eating and CVD risk factors, understanding emotional eating and its association with CVD risk factors in the police force will help guide future strategies to reduce CVD risk factors in NC law enforcement officers. Thus, the purpose of this study was to explore the relationships between emotional eating in response to various emotions (e.g., anger, depression, and anxiety) and CVD risk factors (i.e., body weight, body mass index, waist and hip circumference, waist-to-hip ratio, systolic and diastolic blood pressure, mean arterial pressure, total cholesterol, high- and low-density lipoprotein cholesterol, and glucose levels) among law enforcement officers in NC. We have also considered the differences in emotional eating and CVD risk factors based on sex. Because men and women may have different responses to emotional eating, and the CVD risk factors also vary between them [28,29], it is important to examine the sex variable. This will help identify any potential disparities that can influence the association between emotional eating and CVD risk factors.

Our findings showed that higher emotional eating in response to anger was associated with higher body weight. This finding is consistent with previous emotional eating studies on U.S. military personnel and the general population [19,48]. Higher self-reported frequency of emotional eating was associated with higher BMI among 1451 soldiers in the U.S. Army (β = 0.65, p = 0.004) [19]. Higher levels of emotional eating were associated with an increase in BMI over time (β = 0.18, p = 0.004), according to a study conducted on a large adult population in the Netherlands (n = 1562) [48]. A plausible explanation accounting for the observed association is that individuals may engage in emotional eating as an adaptive response to mitigate the impact of stress or negative emotional states, thereby potentially contributing to subsequent weight gain [49,50]. For example, emotional eating partially mediated the association between stress and body fat percentage in U.S. military personnel [20] indicating that stress or negative emotions may lead to a cycle of overeating as individuals attempt to cope with or suppress their negative feelings through eating [51]. Over time, this can contribute to a pattern of unhealthy eating habits and weight gain [51]. Furthermore, emotional eating often involves the consumption of high-calorie, comfort foods that are typically rich in sugars and fats, and these foods can contribute to an excess of calorie intake, leading to weight gain over time [52]. Despite the ongoing debate regarding whether the measures of emotional eating can accurately reflect the amount of excess food an individual consumes [53] evidence suggests that emotional eating is linked to higher BMI, increased body fat, and weight gain [15,54]. It is noteworthy that, within our sample comprising law enforcement officers routinely exposed to stressful and life-threatening situations while experience the anti-police climate in recent years [55], only emotional eating related to anger demonstrated a significant association with body weight. However, caution should be exercised when interpreting this result as our current study lacks a specific measure for anger. Additional studies are warranted to further investigate the relationship between the emotion of anger, overeating, and weight gain.

Our data showed that higher emotional eating related to anger was associated with higher diastolic blood pressure and mean arterial pressure. Our findings are consistent with prior studies that reported higher degree of emotional eating was associated with higher diastolic blood pressure after adjusting for age, NSAIDS, antidepressants, and antihypertensive medicines among women (β = 0.29, p = 0.04) [56], and emotional eating was associated with higher systolic blood pressure in a cross-sectional study among adults with type 2 diabetes (β = 0.24, p = 0.04) [57]. It is possible that the high blood pressure we observed may be associated with the emotion of anger. When individuals experience anger, their body’s “fight or flight” response is activated. This results in the release of stress hormones like adrenaline, which constricts blood vessels and increases heart rate to supply more blood to the muscles, preparing the body for physical action [58]. Another possible explanation is that higher emotional eating in response to anger was associated with higher body weight in our sample. Excess body weight is a well-established risk factor for high blood pressure [59]. The additional adipose tissue requires more blood supply, leading to increased demand on the cardiovascular system and contributing to elevated blood pressure [60]. However, our result needs to be interpreted with caution. The Anger subscale of the Emotional Eating Scale only measures the tendency to eat in response to the emotion of anger, including if they feel an urge to eat when experience resentful (item 1), rebellious (item 7), irritated (item 12), jealous (item 13), furious (item 17), and angry (item 21). We did not measure how much food the participants consumed when they were feeling angry. Therefore, our findings can only reflect the association between the urge to eat when experiencing anger and blood pressure levels. In addition, our study did not include a quantitative measure of anger expression (i.e., to hold anger inside without any outlet or express it through verbal or aggressive behaviors) and the association with the urge to eat [61]. It would be valuable for future studies to investigate the association between anger expression, disordered eating behaviors, and CVD risk factors by utilizing measures such as the State-Trait Anger Expression Inventory [62]. Furthermore, the relationships between emotional eating related to anger and blood pressure were no longer significant after separating male (n = 267) and female (n = 136) participants. It is possible that the small sample size in the current study may have limited its statistical power to identify significant relationships between emotional eating and blood pressure.

Our findings show mixed results in the relationships between emotional eating and triglyceride levels. Specifically, triglyceride level was positively associated with emotional eating in response to depression, but negatively associated with emotional eating in response to anxiety in our total sample and male participants, but not female participants. Our result is inconsistent with a previous study showing no statistically significant association between emotional eating and triglyceride level in 200 adults in Istanbul [63]. It is possible that the difference in results between our study and the study conducted in Istanbul can be attributed to the methodology used to measure emotional eating. While the study in Istanbul used the Dutch Eating Behavior Questionnaire, this questionnaire did not distinguish between different types of emotions that may trigger emotional eating [63]. In addition, the mixed results of the triglyceride levels in our findings may be due to the complex interplay of psychological and physiological factors that influence eating behavior as a result of depression and anxiety. Depression and anxiety are two mental health conditions that can affect a person’s appetite in various ways [64]. While they can exist together, either can cause an increase or decrease in appetite [64], which may ultimately impact triglyceride levels. Although our t-tests results show no statistical significance between male and female’s emotional eating and triglycerides levels, further research is needed to explore the complex relationship between male and female’s emotional eating in response to depression and anxiety, coping mechanisms, biological responses, food consumption, and how it affects triglyceride levels. Understanding these connections can contribute to more targeted interventions and personalized approaches to address the impact of emotional eating on metabolic health.

This study should be considered within the context of its limitations. First, because we considered this an exploratory study, we did not determine a minimum sample size through a power analysis before recruitment and data collection. As a result, only 221 of the 405 officers participated in the health assessment and provided CVD related biomarkers, which limits its statistical power to identify significant relationships between emotional eating and CVD risk factors. For example, we performed post hoc power analyses using G*Power (version 3.1) [65] based on multiple linear regression coefficient estimates as effect sizes (Table 3) to evaluate the power of the multiple linear regression models. For the nonsignificant relationships between emotional eating in response to anxiety and waist-to-hip ratio, the power value was only 29% (effect size = 0.02, α = 0.05, n = 221) to analyze the relationships. Second, we did not take into account other important factors that may affect CVD risk, such as diet and physical activity, which may limit our understanding of the comprehensive picture of CVD development and progression. Third, we were not able to conclude temporal causality because the independent (i.e., emotional eating) and dependent variables (i.e., CVD risk factors) were simultaneously measured [66]. Fourth, the findings cannot be assumed to be generalizable to the population of NC law enforcement because most participants were Non-Hispanic White and less than 30% of participants came from NC rural counties. Moreover, our findings cannot speak to clinical levels of emotional eating because the Emotional Eating Scale is not a clinical diagnostic tool and can only indicate the urge to eat in response to a variety of negative emotions [40].