Obese Adolescents Have Reduced Mentalizing Ability

Introduction

Obesity is a growing global health crisis, with particularly alarming rates among children and adolescents [1,2]. Adolescence is a critical developmental period characterized by increased vulnerability to mental health issues [3]. Obesity during this stage is linked to numerous psychological challenges, including elevated risks of suicidal ideation and attempts [4,5]. Furthermore, adolescence marks a pivotal phase for body image development, where excess body weight often leads to weight-based teasing, body dissatisfaction, and engagement in health-risk behaviors, such as maladaptive eating patterns [6-9]. Adolescents with obesity frequently exhibit maladaptive eating behaviors, including binge eating, emotional eating, and difficulties in regulating overeating [10-12]. These behaviors may foster an unhealthy dependence on food and are often accompanied by restrictive practices like fasting, laxative misuse, or self-induced vomiting [13,14]. Research suggests that these eating patterns serve as coping mechanisms to manage negative emotions, such as in comfort eating, a key contributor to weight gain [15-19]. Impaired emotional regulation underpins these maladaptive patterns, prompting individuals to adopt ineffective strategies for addressing internal distress or environmental challenges [15,20].

Adolescents with obesity often face neuropsychological vulnerabilities, including lower sensory thresholds, which manifest as patterns of sensory avoidance and sensory sensitivity. These traits complicate their ability to regulate emotions and behaviors, fostering maladaptive eating patterns such as external eating— eating driven by environmental cues rather than internal hunger [21]. Such vulnerabilities underscore the critical need to investigate the psychological mechanisms underlying these behaviors in this population.Mentalization, or reflective functioning (RF), is a promising framework for examining the psychological dimensions of obesity. This ability to interpret and understand one’s own and others’ mental states is crucial for emotional regulation, self-awareness, and adaptive social interactions [22]. Impairments in mentalization are associated with emotional dysregulation and are hypothesized to contribute to maladaptive eating behaviors [23]. Despite the emphasis on emotional dysregulation in obesity research, interventions focusing solely on emotional regulation have yielded mixed results, suggesting that other psychological mechanisms, such as mentalization, deserve further investigation [24-26].

Obesity shares significant psychological overlap with eating disorders (Eds), including emotional dysregulation, unhealthy weight control behaviors, and insecure attachment styles [27-31]. Insecure attachment, more common among obese individuals, is closely tied to impaired mentalization [30,33,65]. Mentalization helps individuals navigate ambiguity and mental strain, potentially protecting them from both physical symptoms, such as somatization, and psychological conditions, including EDs [31,35]. Mentalizing deficits may also hinder individuals' ability to reflect on their condition and its social or personal impact, further complicating obesity management [36]. Research highlights an unexpectedly high prevalence of EDs and disordered eating behaviors among Iranian adolescents and adults [37]. These findings underscore an urgent need to better understand the mechanisms driving these behaviors and to develop conceptual models and targeted treatments for obesity that address these underlying processes.Although impaired RF has been explored in individuals with Eds, and the mentalizing model is recognized as relevant for understanding ED psychopathology and guiding their treatment [23,38-40]. Little is known about its role in non-eating disordered individuals with obesity.Existing studies suggest that maternal RF impairments increase the likelihood of obesity in children, and limited evidence points to reduced RF in overweight women. However, no research has specifically examined RF deficits in non-ED adolescents with obesity. This study aims to address this critical gap by investigating the mentalizing abilities of non-eating disordered obese adolescent females. By shedding light on the potential role of RF in obesity, this research seeks to advance our understanding of the psychological status of obese adolescents and inform more effective prevention and treatment strategies tailored to this vulnerable population.

Materials and Methods

Participants & Procedure

This is acomparative cross-sectional study. Atotal of 380 adolescent girls from 10 single-sex secondary high schools were selected through convenience sampling, and written consent was obtained from each participant and one of their parents.To provide a more accurate measurement, an individual’s body mass index (BMI) is typically adjusted for age and sex. The adjusted BMI (adj-BMI) is calculated by determining an individual’s BMI and then mapping their height and weight against their age and sex on an appropriate BMI chart [44]. Therefore, the height and weight of each participant were measured, and based on their date of birth, the BMI (weight/ height²) was calculated for each individual separately.According to growth reference data approved by WHO [44]. for females aged 15 to 19, a BMI value between the 25th and 75th percentiles is considered within the normal weight (NW) range, while a BMI value in the 95th percentile or above is considered obese (OB) [45,46]. Participants with BMI values falling within the overweight (between the 75th and 95th percentiles) or underweight (below the 25th percentile) categories, as defined by WHO growth reference data, were excluded from the study to ensure methodological accuracy.The remaining participants were divided into two groups: 91 NW adolescent girls (with BMI values between the 25th and 75th percentiles) and 120 adolescent girls with obesity (with BMI values at or above the 95th percentile). The subjects were then provided with the questionnaires. The exclusion criteria included incomplete questionnaires or responses such as "I don’t know" or "approximately" to any question.Ethical approval was obtained from the Ethics Committee of Shahid Beheshti University (ID IR.SBU.REC.1399.022.)

Measures and Instruments

Reflective Functioning Questionnaire (RFQ)

The RFQ is a questionnaire that measures mentalization ability using two subscales: certainty (RFQc) and uncertainty (RFQu), based on a 7-point Likert scale [47]. Certainty is measured by how strongly one opposes propositions. Little agreement with the propositions indicates hyper-mentalization, while frequent agreement suggests a genuine understanding that absolute clarity of mind is impossible. Uncertainty is assessed by the degree to which one agrees with the propositions. A very high score indicates a lack of awareness of internal mental states, while a low score indicates proper mentalization [47,48]. In the Persian version of the questionnaire, Cronbach's alpha for RFQc and RFQu was 0.707 and 0.624, respectively [34]. In the present study, Cronbach's alpha for certainty and uncertainty was 0.661 and 0.668, respectively.

Toronto Alexithymia Scale (TAS)

The TAS is a scale that measures three subscales based on a five-point Likert scale: Difficulty Identifying Feelings (DIF), Difficulty Describing Feelings (DDF), and Externally Oriented Thinking (EOT). In the Persian version of the questionnaire, Cronbach's alpha for overall alexithymia, DIF, DDF, and EOT was reported as 0.85, 0.82, 0.75, and 0.72, respectively [64]. In the present study, Cronbach's alpha for DIF, DDF, and EOT, as well as overall alexithymia, was 0.795, 0.725, 0.616, and 0.823, respectively.

Reading the Mind in the Eyes Test (RMET)

RMET is a psychological test of theory of mind (ToM) in which the respondent must choose the option that best describes the mental state of the person in the picture. In the Persian version of this questionnaire, Cronbach's alpha was reported as 0.72 and in the present study, Cronbach's alpha was 0.641 [49].

Difficulties in Emotional Regulation Scale (DERS)

DERS assesses impairment in emotional regulation based on six subscales: Non-acceptance of Negative Emotions (Non-acceptance), Difficulties Engaging in Goal-Directed Behaviors (Goals), Difficulties Controlling Impulses (Impulse), Lack of Emotional Awareness (Awareness), Lack of Emotional Clarity (Clarity), and Limited Access to Emotion Regulation Strategies (Strategies). In the Persian version, Cronbach's alpha for Non-acceptance ranged from 0.73 to 0.88, Goals from 0.72 to 0.89, Impulse from 0.75 to 0.90, Strategies from 0.76 to 0.85, Awareness from 0.72 to 0.86, Clarity from 0.77 to 0.90, and for overall difficulty, it was reported as 0.79 to 0.92 [63]. In the present study, Cronbach's alpha was 0.848, 0.515, 0.527, 0.699, 0.860, 0.836, and 0.914, respectively.

Results

The results of the multivariate analysis of variance (MANOVA) test, conducted to ensure that the differences in age and height were not imbalanced, showed no significant differences in height (F = 0.107, p = 0.743) and age (F = 3.722, p = 0.055). The mean age of participants in the obese and normal weight (NW) groups was 206.08 months (approximately 17 years and 2 months) and 202.53 months (approximately 16 years and 10 months), respectively. The mean height of participants in the obese and NW groups was 164.20 cm and 164.46 cm, respectively. The mean BMI for the obese and NW groups was 30.03 and 20.89, respectively.Table 1 presents the results for the two groups. Regarding the 12 subscales (DIF, DDF, EOT, Non-acceptance, Goals, Impulse, Awareness, Strategy, Clarity, RFQc, RFQu, and the total score of RMET) and the two-level grouping criteria (obese and NW individuals), the MANOVA was used, and the results are reported below. To assess the homogeneity of the variance-covariance matrix of the research variables, Box’s M test was employed. Since the significance level of this test was less than 0.05 (Box’s M = 203.461, F = 2.448, p = 0.001), Pillai’s trace test was applied. The results of the MANOVA indicated a significant difference between the two groups in terms of the twelve variables (F = 43.143, p < 0.05, η² = 0.723). Table 2 displays the results of the between-subjects effects test, which determined the differences by the dependent variables.

                                        Table 1: Descriptive Statistics of Research Variables for Obese and Normal Weight Groups

TAS, Toronto alexithymia scale; DERS, dificulties in emotional regulation; DIF, dificulty identifying feelings; DDF, dificulty describing feelings; EOT, externally oriented thinking; RFQ, reflective functioning questionnaire; RFQc, certainty; RFQu, uncertainty; RMET, reading the mind in the eyes test.

Table 2: Tests of Between-Subjects Effects on the Scores of DIF, DDF, EOT, Non-acceptance, Goals, Impulse, Awareness, Strategy, Clarity, RFQc, RFQu, and the Total RMET Score Between Obese and Normal Weight Groups

TAS, Toronto alexithymia scale; DERS, dificulties in emotional regulation; DIF, dificulty identifying feelings; DDF, dificulty describing feelings; EOT, externally oriented thinking; RFQ, reflective functioning questionnaire; RFQc, certainty; RFQu, uncertainty; RMET, reading the mind in the eyes test.

RFQc, which measures confidence in judging one's own and others' mental states, was lower in the obese group than in the NW group (0.74 vs 1.15). In contrast, RFQu, which reflects difficulty in perceiving complex internal mental state patterns, was higher in the obese group (1.03 vs 0.54).The obese group showed significantly higher mean scores than the NW group on all three subscales of the TAS, indicating greater difficulty in identifying emotions (DDF), expressing emotions (DIF), and reflecting on emotional experiences (EOT).In terms of Theory of Mind (ToM), the obese group scored lower on the RMET than the NW group, suggesting an impairment in perceiving emotional states.The obese group also exhibited more difficulty in all subscales of DERS compared to the NW group. Specifically, the subscale on Goals, which relates to difficulties in sustaining attention and mentalization as well as the subscales for Emotional Awareness, Clarity, and Non-acceptance, align with findings from the alexithymia and reflective functioning measures.

Discussion

The aim of this study was to compare the mentalizing abilities of non-ED obese adolescent girls with those of normal weight (NW) controls, to explore potential mentalizing impairments in adolescents with obesity. The results indicate that obese adolescents exhibit significantly poorer mentalizing abilities compared to their NW peers. These findings are consistent with prior studies which highlight the difficulties that individuals with obesity experience when reflecting on their condition [36]. A similar pattern of impaired reflective RF in overweight women has been reported in previous research by Maxwelll et al. (2017), further supporting the current results.The lower certainty and higher uncertainty observed in the obese group suggest that individuals with obesity tend to interpret reality more through physical experiences than considering the complexity of mental states. This tendency may contribute to the increased somatization observed in individuals with obesity [36]. Moreover, individuals with obesity often prioritize external cues, such as the appearance of food, over internal cues like hunger [51]. which further points to a lack of self-reflection on their internal states. Our study reveals that individuals with obesity are more prone to hypo-mentalizing—characterized by a reduced ability to perceive mental states and insufficient use of theory of mind (ToM). This is evidenced by the higher uncertainty scores in the obese group compared to their NW peers. Hypo-mentalizing is marked by difficulties in interpreting mental states, whereas individuals with high certainty scores are typically prone to hyper-mentalizing, where they over-interpret mental states and apply excessive ToM [48]. In contrast, the elevated uncertainty scores in the obese group suggest a deficiency in mentalizing abilities, leading to an underestimation of others' and their own mental states.Higher mean scores in the obese group on all subscales of the Toronto Alexithymia Scale (TAS) align with previous studies and reinforce the well-established association between alexithymia and eating disorders (EDs) [15,52,66]. Alexithymia is negatively correlated with certainty and positively correlated with uncertainty which corresponds with the findings of the present study [54,32].

The difficulty in ToM (emotion perception) observed in the obese group, compared to their NW peers, indicates a challenge in understanding others' mental states and external cues. This difficulty may arise from misinterpreting nonverbal cues, such as facial expressions and body language, which are essential for effective social interaction. Limited ability to identify both internal and external stimuli can adversely affect social adjustment. On the other hand, mentalizing enables individuals to navigate social challenges by understanding their own and others' mental states. Effective mentalization is essential for forming and maintaining healthy social relationships, and dysfunction in this area may negatively impact social adjustment [55]. Poor social adjustment can lead to emotional distress, which, in turn, affects mentalizing abilities [53]. One study reported that impairments in ToM and emotion recognition in obese patients are comparable to those in obese patients with binge eating disorder suggesting that these impairments are not solely attributable to Binge Eating Disorder (BED) [57]. Additionally, difficulties in emotional regulation contribute to emotional overeating and the developmentof obesity [20]. In our study, the obese group demonstrated greater emotional regulation difficulties. The DERS subscales, which assess emotional regulation, have been shown to correlate with eating behaviors [58]. Impaired mentalizing may exacerbate emotional regulation difficulties, which is consistent with findings from Sharp et al. who demonstrated an association between mentalizing and emotional regulation difficulties.In conclusion, impaired mentalization may serve as a risk factor for obesity. However, further research is needed to explore additional components of mentalization and their potential impact on the development and persistence of obesity.

Conclusion

This study is the first to specifically compare mentalization abilities between adolescents with obesity and their normal-weight peers. While previous research has primarily focused on RF in individuals with obesity who also experience EDs or in overweight populations, the non-ED obese demographic has been largely overlooked. Our findings suggest that impaired mentalization may serve as a risk factor, a contributing element to the persistence of obesity, or a consequence of the condition itself. Further research is needed to determine the causal relationships among these factors.

Given the link between impaired mentalization and emotional regulation difficulties, both of which are central to Mentalization-Based Therapy (MBT) we propose that MBT could serve as a valuable adjunctive treatment for individuals with obesity [40]. By enhancing their ability to understand and manage their own and others' mental states, MBT could support healthier eating behaviors and improve emotional regulation, ultimately aiding weight management.This study also underscores the broader psychosocial challenges faced by adolescents with obesity [59,60]. Impaired mentalizing not only affects their internal emotional world but may also hinder their social adjustment and relationships [61,62]. Since mentalizing is essential for interpreting nonverbal cues and fostering successful social interactions, therapeutic strategies targeting mentalization could potentially enhance both psychological well-being and social functioning in this population.

Study Limitations and Future Directions

Despite its novel contributions, this study has several limitations. First, the cultural context of the study was limited to a single country, which may affect the generalizability of the findings. Cross-cultural studies are needed to determine whether the observed relationships hold true across diverse populations. Second, the study focused exclusively on psychological factors, without accounting for potential genetic, hormonal, or neurobiological influences that may also impact mentalization and obesity.Third, this study included only female participants. While this decision allowed for a focused exploration of mentalization in adolescent girls, it limits the generalizability of the findings to males. Importantly, our study did not aim to explore whether gender plays a role in the relationship between mentalization and obesity. As a result, we cannot draw any conclusions regarding gender's potential influence in this context. Future research should investigate whether and how gender may affect the interplay between mentalization and obesity, providing a more comprehensive understanding of this relationship.The concept of the "opaque mind" highlights the inherent fallibility of mentalization, even among highly skilled [56]. Nonetheless, our findings indicate that adolescent girls with obesity exhibit significantly impaired mentalizing abilities compared to their NW counterparts. Replicating these results in larger, more diverse samples will be crucial to confirming these observations.

Implications for Prevention and Treatment

These findings have important implications for understanding the etiology, prevention, and treatment of obesity. Impaired mentalization could be a key psychological factor influencing maladaptive eating behaviors and emotional dysregulation, both of which are associated with obesity. Addressing these deficits through targeted interventions, such as MBT, could reduce the psychological barriers to effective weight management and foster improved social and emotional functioning.Additionally, these findings shed light on the potential social challenges faced by individuals with obesity, who may struggle with interpreting others' intentions and emotions, leading to difficulties in social adjustment. Enhancing mentalization skills could help mitigate these challenges, promoting better social integration and quality of life.Future studies should explore the mechanisms linking impaired mentalization to eating behaviors, emotional dysregulation, and psychosocial difficulties. A deeper understanding of these relationships will pave the way for innovative, evidence-based strategies to address the complex interplay of psychological factors in obesity.

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing Interests and Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Statements and Declarations

The authors declared no conflicts of interest with respect to the research, authorship, and/or publication of this article.

Consent to Participate

Written informed consent was obtained from all individual participants included in the study and one of their parents.

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