Introduction

Intuitive eating is an adaptive eating pattern that has been receiving increasing recognition in the fields of nutrition and psychology recently1. Associated with a healthy lifestyle, it can be defined as consuming food with no restrictions until a feeling of satiety is reached2. Additionally, it involves an element of awareness and consciousness: the person is driven to eat by the physical need of hunger, instead of other emotional motives2. Therefore, the act of eating is motivated by the body’s physiological demands.

Also related to a healthy lifestyle is self-esteem, which has been associated with a lower risk of engaging in maladaptive eating patterns3. Self-esteem can be defined as one’s self-worth and personal view of one’s competence4. Moreover, higher self-esteem was found among those who exhibited healthier eating behaviors in comparison with others5. Similarly, a positive relationship was found between self-esteem and healthy eating behaviors in a sample of college students6. Identified as a healthy eating behavior, intuitive eating also showed a positive association with self-esteem1.

Another factor guiding eating patterns is physical appearance-based social comparison7. Physical appearance comparison is considered a form of social comparison, where an individual contrasts their own physical attributes to that of others8. Research has shown that a high level of physical appearance comparison is significantly related to eating pathology9. Furthermore, physical comparison was associated with variance in maladaptive eating behaviors consistently across genders10. In one study on adolescent girls specifically, comparing one’s appearance to others had a negative relationship with intuitive eating11.

Intuitive eating also had a connection with psychological distress: engaging in intuitive eating was linked to lower psychological distress12. Overall, intuitive eating is positively correlated with positive psychological constructs and negatively correlated with psychological distress1. A study that investigated dieting, unhealthy eating and intuitive eating found that intuitive eating was the least associated with psychological distress2. In addition, concern about one’s appearance and depression were both connected to maladaptive eating patterns2.

According to the literature, psychological distress factors, specifically depression, have played a mediating role between maladaptive eating patterns and other factors, including the relationship between excessive social media use and bulimia nervosa13. Additionally, depression mediated the relationship between externalizing disorders and eating disorders14, as well as emotion regulation and maladaptive eating patterns15. These results further clarify the potential indirect effect of psychological distress on eating patterns. At the same time, some findings have suggested that depressive symptoms do not show a direct relationship with dietary patterns16.

Intuitive eating is relatively novel domain in research, in comparison with that conducted on maladaptive eating patterns or eating pathology. The factors promoting eating pathologies, which are unhealthy eating practices, have been studied extensively over the course of the past few years17, and the investigation is still ongoing18,19. While many studies have established the links between self-esteem19, physical appearance-related variables20and psychological distress21 with eating pathology, these links remain scarce and require further probing when discussing intuitive eating, an adaptive eating pattern.

A scale assessing intuitive eating behaviors was validated in Lebanon recently22, and adaptive eating patterns have been investigated in the Lebanese population as of late23. Many factors are involved in the dietary patterns of Lebanese people including food insecurity that are affected by level of income24, given that Lebanon suffers from many economic crises, which might cause low food intake despite cues of hunger.

Previous evidence suggests that depression and self-esteem mediated the relationship between body dissatisfaction and maladaptive eating behaviors25. These results might drive more research to assess the possible mediating role of psychological distress between positive psychological variables such as self-esteem and intuitive eating. Considering the multiple factors mentioned above, including the associations between intuitive eating and self-esteem and physical appearance comparison, the indirect effect of psychological distress on eating patterns and the lack of research on intuitive eating in Lebanon, the current aims of the study are (1) to clarify the associations between intuitive eating, self-esteem, physical appearance and psychological distress, and (2) to assess the mediating effect of psychological distress on the relationship between self-esteem/physical appearance comparison and intuitive eating. This investigation could help bridge the existing gap in the literature about the potential integration of the variables mentioned, as well as further guide researchers and practitioners towards a holistic approach regarding psychological factors, given that the literature does not present explicit findings about the indirect effect of psychological distress on the relationship between intuitive eating, self-esteem and physical appearance.

Methods

Study design

A total of 359 Lebanese participants were enrolled in this cross-sectional study (mean age: 22.75 ± 7.04 years, 40.1% males), conducted between September and November 2022, through convenience sampling in several Lebanese governorates (Beirut, Mount Lebanon, North Lebanon, South Lebanon, and Bekaa). The survey was a Google form questionnaire that was administered through the internet, using the snowball technique. To reach the largest possible group of subjects, the research team initiated the contact with friends and family members they know; those people were asked to forward the link to their friends and family members, and were asked to forward the link to their contact list via social media applications such as WhatsApp, Facebook Messenger, and Instagram. Before proceeding with the questionnaire, participants were informed of the purpose of the study, assured of the anonymity of their participation and provided with a virtual informed consent form via ‘Google Forms’. The latter had to be ‘signed’, after reading, by clicking the box ‘Yes, I acknowledge having read the above-mentioned information and I agree to participate in this study voluntarily and without any pressure’ to which the answer is required in order to continue with the self-administration. Participants had the right to accept or refuse to respond and no financial compensation was provided in exchange for their submission.

Ethics approval and consent to participate

The Ethics and Research Committee at the Lebanese International University approved this study protocol (2022RC-051-LIUSOP). A written informed consent was considered obtained from each participant when submitting the online form. All methods were performed in accordance with the relevant guidelines and regulations.

Minimal sample size calculation

A minimal sample of 128 was deemed necessary using the formula suggested by Fritz and MacKinnon26 to estimate the sample size: \(\:n=\frac{L}{f2}+k+1\), where f=0.26 for small-medium effect size, L=7.85 for an α error of 5% and power β = 80%, and k=11 variables to be entered in the model.

Questionnaire

The questionnaire used was anonymous and in Arabic, the native language in Lebanon; it required approximately 20 min to complete. The questionnaire consisted of three parts. The first part of the questionnaire included an explanation of the study topic and objective, a statement ensuring the anonymity of respondents. The participant had to select the option stating I consent to participate in this study to be directed to the questionnaire. The second part of the questionnaire contained sociodemographic information about the participants (age, sex, marital status, and Household Crowding Index). The Body Mass Index (BMI) was calculated using the self-reported weight and height27. The strength, frequency, and duration of physical activity were multiplied to create the physical activity index28. The third part included the scales used in this study:

Intuitive Eating Scale‑2 (IES‑2).Validated in Arabic22, the IES-2 consists of 23 items29 such as “If I am craving a certain food, I allow myself to have it” and “I find myself eating when I am stressed out, even when I’m not physically hungry”, rated on a 5-point scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The total score was computed by summing up the answers of all questions. Higher mean values refer to higher levels of adaptive, intuitive eating patterns and behaviors (Cronbach’s α in this study = 0.84).

Depression Anxiety Stress Scale (DASS-8).Validated in Arabic, the DASS-8, a shortened version of the DASS-21, consists of eight items divided into three subscales: depression (3 items), anxiety (3 items), and stress (2 items)30. The items include statements like “I was unable to become enthusiastic about anything” and “I felt down-hearted and blue”. Responses to the items are scored on a 4-point scale, ranging from 0 (did not apply to me at all) to 3 (applied to me very much or most of the time). The scale yields three scores for depression, anxiety and stress respectively, with higher scores equate to a higher level of symptoms in each dimension (Cronbach’s α in this study = 0.91).

Rosenberg Self-Esteem Scale (RSS).The RSS31was used to evaluate trait self-esteem. It is composed of 10 items, in which 5 items are reversed. This scale is scored as a Likert scale, with a 4-point response from Strongly Disagree to Strongly Agree, with higher scores indicating higher self-esteem. Some items from the scale are “On the whole, I am satisfied with myself” and “I certainly feel useless at times”. The Arabic translated version has been used in previous studies32,33,34,35 (Cronbach’s α in this study = 0.83).

Physical Appearance Comparison Scale (PACS-R).The scale, validated in Arabic36, consists of 11 items for unidimensional evaluation of the frequency of comparing one’s own physical appearance with other persons in various social situations8. The response format varies from 0 (never) to 4 (always). The scale presents statements like “When I’m out in public‚ I compare my body fat to the body fat of others” and “When I meet a new person (same sex)‚ I compare my body size to his/her body size”. The scale was recently validated in Arabic among the Lebanese population, showing good psychometric quality (Cronbach’s α = 0.97)37. Higher scores indicate higher physical comparison (Cronbach’s α in this study = 0.97).

Statistical analysis

The SPSS software v.25 was used for the statistical analysis. There were no missing values in our dataset. The intuitive eating score was considered normally distributed since the skewness and kurtosis values varied between − 1 and + 138. The Student t was used to compare two means and the Pearson test was used to correlate two continuous variables. The mediation analysis was conducted using PROCESS MACRO (an SPSS add-on) v3.4 model 439; four pathways derived from this analysis: pathway A from the independent variable (self-esteem/physical appearance comparison) to the mediator (depression/anxiety/stress), pathway B from the mediator (depression/anxiety/stress) to the dependent variable (intuitive eating), Pathways C and C’ indicating the total and direct effects from the independent (self-esteem/physical appearance comparison) to the dependent variable (intuitive eating). Results of the mediation analyses were adjusted over all variables that showed a p < .25 in the bivariate analysis. We considered the mediation analysis to be significant if the Bootstrapped Confidence Interval did not pass by zero. P < .05 was deemed statistically significant.

Results

Sociodemographic and other characteristics of the sample

Three hundred fifty-nine adults were enrolled (mean age = 22.75 years (SD = 7.04) and 59.9% females). Other descriptive statistics of the sample can be found in Table 1.

Table 1 Sociodemographic and other characteristics of the sample (n = 359).
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Bivariate analysis of factors associated with intuitive eating

The results of the bivariate analysis of factors associated with intuitive eating are summarized in Tables 2 and 3. The results showed that higher BMI (r = − .15) and higher physical appearance comparison (r = − .19) were significantly associated with less intuitive eating, whereas higher self-esteem (r = .23) was significantly associated with more intuitive eating.

Table 2 Bivariate analysis of factors associated with intuitive eating. Numbers in bold indicate significant p values.
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Table 3 Correlations of continuous variables with intuitive eating.
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Mediation analysis

The results of the mediation analysis are summarized in Table 4; the analyses were adjusted over the following variables: BMI and marital status. The results of the mediation analysis showed that depression partially mediated the association between self-esteem / physical appearance comparison and intuitive eating (Figs. 1 and 2). Higher self-esteem was significantly associated with lower depression; higher depression was significantly associated with more intuitive eating. Finally, higher self-esteem was directly and significantly associated with more intuitive eating.

On another hand, higher physical appearance comparison was significantly associated with higher depression; higher depression was significantly associated with more intuitive eating. Finally, higher physical appearance comparison was directly and significantly associated with less intuitive eating.

It is noteworthy that anxiety and stress did not mediate the association between self-esteem / physical appearance comparison and intuitive eating (Table 4).

Table 4 Mediation analyses results, taking self-esteem/physical appearance comparison as independent variables, depression/anxiety/stress as mediators and intuitive eating as the dependent variable taking self-esteem/physical appearance comparison as independent variables depression/anxiety/stress as mediators and intuitive eating as the dependent variable. *Indicates significant mediation. Direct effect refers to the direct association between avoidant restrictive eating and wellbeing without the effect of the mediator, whereas the indirect effect refers to the same association through the mediator (psychological distress).
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Fig. 1
figure 1

(a) Relation between self-esteem and depression (R2 = .213); (b) Relation between depression and intuitive eating (R2 = .100); (c) Total effect of self-esteem on intuitive eating (R2 = .079); (c’) Direct effect of self-esteem on intuitive eating. Numbers are displayed as regression coefficients (standard error). **p < .01; ***p < .001.

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Fig. 2
figure 2

(a) Relation between physical appearance comparison and depression (R2 = .213); (b) Relation between depression and intuitive eating (R2 = .100); (c) Total effect of physical appearance comparison on intuitive eating (R2 = .079); (c’) Direct effect of physical appearance comparison on intuitive eating. Numbers are displayed as regression coefficients (standard error). **p < .01; ***p < .001.

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Discussion

The results of the current study show that depression partially mediated the association between self-esteem and intuitive eating. Previous results suggest that other body positive variables impact intuitive eating significantly more than self-esteem40, suggesting that the relationship between self-esteem and intuitive eating might be indirect, or that the relationship is insignificant. On the other hand, there is evidence suggesting that the direction of the relationship is related to depression influencing self-esteem in a negative manner41. Meanwhile, intuitive eating was related to lower depressive symptoms in other studies42,43. Depression is a risk factor for maladaptive eating behaviors44, therefore, it is logical to assume that the absence of depression or lower depressive symptoms could be associated with a higher probability of healthy eating behaviors. The hypothesis that the presence of depressive symptoms affects self-esteem and intuitive eating independently, and subsequently can act as a mediator could explain the present results.

Also, depression partially mediated the association between physical appearance comparison and intuitive eating. Depression was previously associated with higher appearance sensitivities, which is related to social comparison45, within the same domain of physical appearance comparison. There was a direct positive correlation between depression and social appearance anxiety, also related to social comparison46. Moreover, appearance-related anxiety was a contributing factor in developing maladaptive eating patterns as well as depression47. Based on these findings47, we can assume that depression has a significant effect on eating patterns. It can be inferred through the studies mentioned that depression can influence social comparison factors, such as physical appearance comparison, and eating patterns independently. Accordingly, it can be assumed the current finding that depression mediates the relationship between physical appearance comparison and intuitive eating are founded.

It is important to take note that depression was a partial mediator in both mediation models involving intuitive eating. This indicates that the relationship between self-esteem and intuitive eating as well as the relationship between physical appearance comparison and intuitive eating depends partially on depression. To begin with, higher intuitive eating is directly associated with lower depressive symptoms42. We can hypothesize that the effect of depression on intuitive eating extends onto other psychological and physiological factors.

Additionally, higher self-esteem was significantly associated with lower depression and higher depression was significantly associated with more intuitive eating. It has been previously established that lower levels of self-esteem have a strong relationship with the onset of depression48. Having said that, previous investigation has suggested that the association between depression and eating patterns is not general, but specific aspects of depression are related to maladaptive eating patterns49, with lower self-esteem potentially connecting depression and eating patterns. These past findings might explain why the current results connect higher depression with intuitive eating, an adaptive eating pattern. As a possible hypothesis, specific dimensions of depression, such as feeling like a failure, are associated with maladaptive eating patterns49, while other dimensions such as diminished or heightened appetite50, a symptom of depression, can potentially be associated with eating intuitively. As a result, someone with more depression symptomatology might act in accordance with their heightened or reduced appetite, which we can hypothesize could be confounded with elements of intuitive eating such as only eating when one experiences hunger and stopping when feeling satiety cues.

On the other hand, higher self-esteem was directly and significantly associated with more intuitive eating. The current result is supported by another recent study that found that higher self-esteem and higher intuitive eating were significantly correlated51. Moreover, higher intuitive eating decreased the probability of having lower self-esteem in a study conducted over the span of 8 years42. The present findings are validated by the fact that intuitive eating is related to adaptive psychosocial factors and healthy lifestyle52.

Higher physical appearance comparison was directly and significantly associated with less intuitive eating. Previously, body appreciation and intuitive eating were both indicator of healthy eating behavior53. It is important to note that body appreciation can be considered the opposite of body appearance pressure, which could be generated through social physical appearance comparison54. Overall, self-acceptance, good body image, irrespective of contrasting one’s appearance with others’, and intuitive eating are promoters of positive psychological health55.

Practical implications

Given the lack of studies on intuitive eating in Lebanon, the current results are valuable in investigating an adaptive eating pattern. These findings allow practitioners to promote healthy eating behaviors and psychological health by educating patients and clients about intuitive eating. The current results not only could guide dieticians and nutritionists in their practice, but also psychologists and mental health professionals in developing management models for psychological distress and eating behaviors. Furthermore, it prompts action on the public health level to promote awareness regarding intuitive eating and its association with mental health. Finally, the mediating role of depression in the current associations prompts researchers to further assess the relationship in order to identify specific dimensions of depression involved.

Limitations

First, it is most important to mention the limitations of using a mediation model on cross-sectional data, as finding an accurate conclusion from data collected in one instance of time could be misrepresentative. Also, inferences about cause and effect cannot be concluded. Second, the questionnaire was distributed to participants through a snowball sampling technique, which might reduce the probability of the sample being representative. Third, the research about intuitive eating in the Middle East, the region where Lebanon is situated, is relatively limited and therefore no previous results exist to compare and contrast the findings. However, it makes the current results act as important motivators for future investigation about intuitive eating and psychological variables locally and internationally. Moreover, the process of the data collection, which is a self-report questionnaire, could be susceptible for response bias limiting the objectivity of the answers. Finally, it is important to note that the findings should be interpreted with caution, given the small effect sizes despite the significant results.

Conclusion

The present study clarifies the associations between intuitive eating, self-esteem, physical appearance and psychological distress and defines the mediating effect of psychological distress on the relationship between self-esteem/physical appearance comparison and intuitive eating. These results show how significantly intuitive eating, an adaptive eating pattern, and psychological variables are interrelated and possibly affect each other. It helps shed light on the factors involved with intuitive eating in the Lebanese population. In future studies, other mediators could be taken into consideration such as cognitive or personality ones.