The Multifaceted Interplay Between COVID-19-Induced Psychological Stress, Cognitive Flexibility, Emotional Overeating, and Physical Activity Patterns in Adult Women: A Mediated Path Analysis

The Multifaceted Interplay Between COVID-19-Induced Psychological Stress, Cognitive Flexibility, Emotional Overeating, and Physical Activity Patterns in Adult Women: A Mediated Path Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Multifaceted Interplay Between COVID-19-Induced Psychological Stress, Cognitive Flexibility, Emotional Overeating, and Physical Activity Patterns in Adult Women: A Mediated Path Analysis Siavash Naddafha, Robabeh Shanahad, Mandana Sangari, Zohreh Eskandari, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5761175/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Sep, 2025 Read the published version in Sport Sciences for Health → Version 1 posted 8 You are reading this latest preprint version Abstract Purpose This study investigated the impact of COVID-19-related stress on food consumption and emotional overeating in adult women, with cognitive flexibility and physical activity as mediating factors. Methods A descriptive-analytical, correlational, and applied research design was employed. The study population included adult women aged 20–50 in an urban area. Using Cochran's formula, a sample size of 300 was determined. Data were collected using validated tools: COVID Stress Scale (CSS-18(2021), AEBQ(2016),SREBQ), Cognitive Flexibility Scale, and Rapid Assessment of Physical Activity (RAPA). Chi-square tests and Spearman's correlation were applied at a significant level of p = 0.05. Results COVID-19-related stress significantly reduced cognitive flexibility (p 0.05). Conclusion Increased stress negatively affected cognitive flexibility and physical activity in adult women, highlighting the need for interventions to enhance resilience and promote healthier behaviors. stress nutrition emotional overeating cognitive flexibility physical activity Figures Figure 1 Figure 2 Introduction In December 2019, a severe acute respiratory syndrome caused by the novel coronavirus (COVID-19) rapidly spread worldwide, leading to an unprecedented global pandemic (Hossain et al., 2020). The COVID-19 pandemic significantly increased stress and anxiety among many adults (Chen et al., 2020). Factors such as concerns about personal health or the health of loved ones affected by the virus, financial stress due to lost income or economic downturns caused by the pandemic, disruptions to daily life, childcare, and education due to quarantine restrictions, as well as uncertainty about the future and feelings of helplessness, have all contributed to increased stress in individuals (Cooke et al., 2020). Stress refers to a state in which an individual is excessively worried or distressed about the occurrence of a catastrophic event in the future (Cooke et al., 2020). In the short term, fear and stress activate the hypothalamus in the brain, which leads to an increase in cortisol secretion from the adrenal cortex and sympathetic nerve stimulation throughout the body, aiding the body's response to stressors. However, if fear and stress, along with the body's response of increased cortisol levels and sympathetic stimulation, persist in the long term, they can be harmful, weakening the immune system and reducing the body's ability to fight diseases (Genet & Siemer, 2011). These stressors have elicited diverse behavioral and physiological responses, including changes in dietary habits (S. Murata et al., 2021) While the majority of the global population has experienced environmental stressors related to the pandemic, there are significant individual variations in the intensity and duration of the stress experienced, as well as in behavioral and physiological responses to these stressors (Stephen Murata et al., 2021). One potential behavioral response to environmental stress is increased food consumption (Oliver & Wardle, 1999), particularly highly palatable and energy-dense foods (Tryon et al., 2013). Consuming "comfort" foods in response to chronic stress may mitigate its negative effects, specifically by reducing cortisol levels, especially in women and individuals predisposed to high stress (Dubé et al., 2005). Early evidence suggests that the COVID-19 pandemic has been associated with changes in self-reported food consumption, with individuals reporting increased intake of sweets, desserts, salty snacks, and other palatable foods (Robinson et al., 2021). These findings suggest that psychological factors, such as cognitive flexibility and appetite factors, such as emotional overeating, may influence the likelihood of either increasing or decreasing food consumption in response to acute and chronic stress related to the pandemic. Psychological characteristics such as cognitive flexibility may help reduce stress responses (A. Park et al., 2020). Cognitive flexibility is an individual's ability to modify thinking patterns and behaviors in response to challenges and is associated with high cognitive abilities. Cognitive flexibility makes individuals resilient in the face of stress (Genet & Siemer, 2011). Cognitive flexibility, the ability to adapt thoughts and behaviors to changing demands, has been linked to resilience under stress (Genet & Siemer, 2011). During the COVID-19 pandemic, greater psychological flexibility, or the ability to recognize and adapt to situational demands, has been associated with less pandemic-related worry and distress (David L Dawson & Nima Golijani-Moghaddam, 2020). Higher cognitive or psychological flexibility may help individuals respond to pandemic-related stressors with more adaptive behavioral responses. In general, preliminary research during the COVID-19 pandemic indicates that individual characteristics, such as cognitive flexibility, may affect susceptibility to pandemic-related stress (Jennifer R Sadler et al., 2021). Studies have shown that women under 29 years of age with low cognitive flexibility are more likely to report higher consumption of high-calorie foods than others (Buckland et al., 2021). A positive coping strategy to manage stress is the consumption of healthy foods, which not only reduces stress but also strengthens the immune system, helping the body fight against COVID-19 (Stephen Murata et al., 2021). Studies have also demonstrated a positive correlation between stress and increased food consumption during the pandemic (David L Dawson & Nima Golijani-Moghaddam, 2020). However, to date, no study has examined whether cognitive flexibility may alter sensitivity to stress-induced dietary changes during the pandemic. Despite these insights, no study has specifically examined whether cognitive flexibility moderates the relationship between stress and dietary behaviors during the pandemic. Understanding who is vulnerable to overeating during the pandemic is critical for targeting public health interventions. Therefore, in addition to examining food consumption during the COVID-19 pandemic, we aim to explore how cognitive flexibility may exacerbate or protect against stress-related overeating during the pandemic. This study addresses this gap by investigating how cognitive flexibility influences stress-related overeating in adult women during the COVID-19 pandemic. Understanding these dynamics is critical for developing targeted interventions to mitigate health risks associated with chronic stress. Methods Demographic Information Questionnaire The Demographic Information Questionnaire was developed by the research team to gather detailed social and demographic data from women aged 20 to 50 years residing in XXX. The questionnaire was structured into multiple sections, each targeting specific aspects of the participants' demographic, health, and lifestyle profiles to provide a comprehensive understanding of their background. These sections included personal demographics such as age, marital status (e.g., single, married, divorced, or widowed), educational attainment (e.g., primary school, high school, undergraduate, or postgraduate), and employment status (e.g., employed full-time, part-time, unemployed, homemaker, or student). The health-related information section captured self-reported height and weight (used to calculate BMI), the presence of chronic illnesses or health conditions (e.g., diabetes, hypertension), smoking and alcohol consumption habits (yes/no and frequency), and history of mental health issues or psychological stress. COVID-19-specific information was also collected, including the history of COVID-19 infection (self-reported diagnosis or symptoms), COVID-19 vaccination status (e.g., unvaccinated, partially vaccinated, or fully vaccinated), the impact of the pandemic on personal and family health (e.g., financial strain, health complications), and access to COVID-19-related healthcare services. Socioeconomic background details included monthly household income (categorized into income ranges), the number of dependents in the household, and access to essential resources such as healthcare, education, or transportation. Information about physical activity and daily routines was also gathered, covering the level of physical activity (sedentary, light, moderate, or vigorous), time spent on work-related and caregiving responsibilities, and regularity of exercise or recreational activities. Finally, the questionnaire addressed psychological and social stress factors, including major life changes during the pandemic (e.g., job loss, relocation, caregiving challenges), the availability of social support networks (e.g., family, friends, or community resources), and self-reported stress levels and coping mechanisms. Each section provided critical data to enable a thorough analysis of the relationship between COVID-19-related stress and its effects on emotional, cognitive, and physical well-being. COVID-19-Related Stress Questionnaire The 18-item COVID Stress Scales (CSS-18) was used to assess individuals' stress and related literature. This scale includes 18 items divided into three subscales: psychological stress (10 items), physical stress symptoms (5 items), and stress-related behaviors (3 items). The overall COVID stress score is obtained by summing all questions, with higher scores indicating greater stress. The scale is scored on a 5-point Likert scale, ranging from "never" (score 0) to "always" (score 4). The validity and reliability of this questionnaire have been reported as satisfactory in XXX studies (Salimi et al., 2021) Adult Eating Behavior Questionnaire (AEBQ) The Adult Eating Behavior Questionnaire (AEBQ) is widely used to measure individual differences in eating behaviors, including enjoyment of food, emotional overeating, emotional undereating, food fussiness, responsiveness to food cues, slowness in eating, hunger, and satiety responsiveness. The questionnaire comprises 35 items across eight subscales (each consisting of 3–5 items). Responses are rated on a 5-point Likert scale, ranging from "strongly disagree" (1) to "strongly agree" (5), with subscale averages calculated accordingly. The questionnaire's validity and reliability have been reported as satisfactory (Cohen et al., 2021). Self-Regulation of Eating Behavior Questionnaire (SREBQ) The Self-Regulation of Eating Behavior Questionnaire (SREBQ) is designed for individuals striving to achieve or maintain a healthy diet. The scale uses general terms such as "tempting foods" to allow respondents to answer based on their dietary intentions. Scoring is based on a 5-point Likert scale, from "never" to "always." A mean score below 2.8 indicates low self-regulation, scores between 2.8 and 3.6 reflect moderate self-regulation, and scores above 3.6 signify high self-regulation. The validity and reliability of this scale have been reported as satisfactory (Kliemann et al., 2016) Cognitive Flexibility Questionnaire The Cognitive Flexibility Scale was employed to assess participants' self-efficacy in adapting to added information. This 12-item scale measures agreement with statements such as "My actions are the result of conscious decisions I make" and "I can find workable solutions to seemingly unsolvable problems," rated on a 6-point scale from "strongly disagree" to "strongly agree." The total cognitive flexibility score ranges from 12 to 72, with higher scores indicating greater cognitive flexibility (Cronbach's alpha = 0.87)(Kalia et al., 2020). International Physical Activity Questionnaire (RAPA) Physical activity levels were measured using the Rapid Assessment of Physical Activity (RAPA) questionnaire. Participants were categorized as sedentary, lightly active, moderately active, or highly active. The first page of the questionnaire provided explanations of light, moderate, and vigorous activities, and the second page included questions about their weekly activity levels. The highest-scoring response was used to determine their activity level, with scores below 6 considered suboptimal and scores above 6 classifieds as active. (Daga et al., 2022) Procedure The questionnaire, consisting of six sections—1) demographic information, 2) COVID-19-related stress questionnaire, 3) Adult Eating Behavior Questionnaire, 4) Self-Regulation of Eating Behavior Questionnaire, 5) Cognitive Flexibility Questionnaire, and 6) International Physical Activity Questionnaire—was designed on the Press Line platform. The questionnaire link was distributed via social media (WhatsApp, Telegram, email, LinkedIn, and ResearchGate) until the target sample size was reached. Once completed, the data were exported from Press Line as an Excel file, coded, and analyzed using SPSS software. Ethical Considerations To ensure ethical and humane treatment, all participants were assured that their information would remain confidential and only aggregate results would be utilized. The demographic questionnaire and consent form avoided private or sensitive questions. Participation was voluntary, with written consent obtained from both participants and their families IR.QUMS.REC.1401.063 All procedures were in accordance with the declaration of Helsinki. Statistical Procedures Descriptive statistics were used to calculate means and standard deviations for the study variables, and tables and graphs were generated. Using SPSS version 19 (IBM, Armonk, NY, USA), inferential statistics first tested data normality with the Shapiro-Wilk test. Then, a series of Chi-square distributions and Spearman's rank correlation coefficient were used to examine relationships between variables, with a significance level of p = 0.05. Results The study involved 303 women with a mean age of 34.48 ± 9.77 years, mean weight of 67.82 ± 12.88 kg, mean height of 165.99 ± 6.92 cm, and mean BMI of 24.61 ± 4.37 kg/m². Figure 1 illustrates the scores on the CSS-18 questionnaire and its subscales. The psychological stress subscale included 10 questions with a range of 10–50, the physical stress subscale had five questions with a range of 5–25, and the stress-related behaviors subscale contained three questions with a range of 3–15. As shown in Fig. 1 , the participants' overall stress score was 45.3, indicating a moderate level of COVID-19 stress. Additionally, 15.84% of the women reported elevated levels of COVID-19-related stress. Participants were classified into high and low stress groups based on their CSS-18 scores. Scores exceeding 45 were designated as high stress, while scores at or below 45 indicated low stress. This threshold was determined based on the distribution of CSS-18 scores within the sample, with 45 representing the upper quartile, consistent with prior research identifying this range as indicative of clinically significant stress levels. The results of the Chi-square test showed no significant difference between COVID-19-related stress (low-high) and food consumption in adult women, X2(1, N = 303) = 0.99, p = 0.317X^2(1, N = 303) = 0.99, p = 0.317X2(1, N = 303) = 0.99,p = 0.317. Additionally, the results of the Spearman correlation test indicated no significant relationship between COVID-19-related stress (low-high) and food consumption in adult women (r = 0.07, p = 0.206, r = 0.07, p = 0.206, r = 0.07, p = 0.206; Table 1 ). As a result, it appears that COVID-19-related stress did not significantly affect emotional eating behavior in adult women. The results of the Spearman correlation test showed no significant relationship between COVID-19-related stress and emotional eating behavior (r s (301) = 0.07, p = 0.206, r s (301) = 0.07, p = 0.206, r s ​(301) = 0.07, p = 0.206) or self-regulation of eating behavior (r s (301) = − 0.09,p = 0.106, r s (301) = -0.09, p = 0.106, r s ​(301) = − 0.09, p = 0.106). However, there was a strong negative and significant correlation between COVID-19-related stress and cognitive flexibility (r s (301) = − 0.91, p < 0.001, r s (301) = -0.91, p < 0.001, r s 301) = − 0.91, p < 0.001), indicating that higher stress levels were associated with lower cognitive flexibility. Additionally, a moderate negative and significant correlation was found between COVID-19-related stress and physical activity (r s (301) = − 0.46, p = 0.005, r s (301) = -0.46, p = 0.005, r s ​(301) = − 0.46, p = 0.005), suggesting that increased stress was linked to reduced physical activity levels in adult women. Table 1 Spearman Correlation Test Results Variable Emotional Eating Behaviour Self-Regulation of Eating Behaviour Cognitive Flexibility Physical Activity COVID-19 Stress r s = 0.07, p = 0.206 r s = -0.09, p = 0.106 r s = -0.91, p < 0.001 r s = -0.46, p = 0.005 Discussion Research has confirmed the positive impact of physical activity on COVID-19-related stress (Vogel et al., 2022). The results of the Spearman correlation analysis revealed no significant association between COVID-19-related stress and emotional eating behavior (r = 0.07, p = 0.206) or self-regulation of eating behavior (r = -0.09, p = 0.106), consistent with previous findings (MacBlane, 2024). The COVID-19 pandemic has imposed unprecedented psychological and physiological stress on individuals worldwide, particularly affecting eating behaviors, physical activity, and cognitive function. Several studies have explored how pandemic-induced stress has led to emotional eating, physical inactivity, and disruptions in mental health (Cecchetto et al., 2021a; Jennifer R Sadler et al., 2021). Emotional eating, characterized by increased consumption of high-sugar or high-fat foods in response to stress, has been shown to correlate with heightened levels of anxiety and depression during the pandemic (Dakanalis et al., 2023). Similarly, reductions in physical activity were commonly reported as individuals faced lockdowns and restricted access to exercise facilities (Sara Al-Musharaf, 2020; Violant-Holz et al., 2020). Despite extensive research on pandemic-related stress and its effects on behaviors like emotional eating and physical inactivity, there remains a critical gap in understanding the cognitive mechanisms—specifically cognitive flexibility—that underpin these stress-induced behaviors. Cognitive flexibility refers to an individual’s ability to adapt thoughts and behaviors in response to changing environments, making it a key factor in coping with prolonged stress. While individuals with higher cognitive flexibility are generally better equipped to manage stress and avoid maladaptive behaviors like emotional overeating or reduced physical activity, few studies have examined how cognitive flexibility moderates or mediates the relationship between pandemic stress and these behaviors. Moreover, inconsistent findings in the literature underscore the need for further exploration. For example, while some studies (Cecchetto et al., 2021a) found a direct correlation between stress and emotional eating, others (e.g., Oor et al., 2022) did not (Orr et al., 2022), highlighting the need for a more nuanced understanding of how cognitive and behavioral factors interact under stress. Additionally, while prior research (Meiling Qi et al., 2020) has examined the pandemic's effects on emotional eating and physical activity, much of it has focused on short-term behavioral responses. There has been limited attention given to the long-term cognitive adaptations, particularly in populations experiencing chronic stress, such as women during the COVID-19 pandemic. Our study aims to fill these gaps by investigating the relationship between COVID-19-related stress, cognitive flexibility, and key behaviors such as emotional eating and physical activity in adult women. By incorporating cognitive flexibility as a central variable, our research seeks to clarify how this trait may mediate or moderate the effects of stress on eating and exercise habits. Understanding these cognitive mechanisms is crucial for developing targeted interventions aimed at enhancing cognitive resilience and promoting healthier coping strategies during prolonged stress periods, such as during global crises. This study offers a unique perspective by placing cognitive flexibility at the center of the stress-behavior relationship, which has often been overlooked in prior research. By examining how cognitive flexibility influences both emotional eating and physical activity, our findings will contribute to a more comprehensive understanding of the complex interplay between stress, cognition, and behavior. Ultimately, this research has significant public health implications, particularly for designing interventions that foster cognitive resilience and help individuals maintain healthier lifestyle behaviors amid ongoing stressors. The present study sought to clarify whether COVID-19-related stress would influence emotional eating behavior, physical activity, and cognitive flexibility in adult women, with particular attention to whether cognitive flexibility could mitigate stress-induced changes. Contrary to some prior research (Cecchetto et al., 2021b; Rogers et al., 2021) our findings indicated that COVID-19-related stress did not significantly affect emotional overeating (i.e., self-regulation of eating behavior). Although this result aligns with several studies (S. Al-Musharaf, 2020); Orr et al., 2022), the discrepancy with other investigations (Cecchetto et al., 2021b) may stem from differences in sample demographics, stress levels, and methodological designs. In this study, only 15% of participants reported high levels of stress, suggesting that the majority of women were either resilient or had other protective factors that attenuated the impact of stress on overeating behaviors (J. R. Sadler et al., 2021) Despite the lack of a direct association between stress and emotional overeating, a strong negative correlation emerged between COVID-19-related stress and both cognitive flexibility and physical activity. Participants with higher stress reported lower cognitive flexibility and reduced physical activity, confirming earlier work that underscores stress as a hindrance to adaptive behaviors (S. Al-Musharaf, 2020; M. Qi et al., 2020; Violant et al., 2020) Elevated stress levels may deplete cognitive resources, making it more challenging to maintain healthy routines such as exercise (Violant et al., 2020). Conversely, higher cognitive flexibility—an individual’s capacity to adapt to changing demands—seemed to buffer against the deleterious effects of stress. These findings support previous research indicating that psychological flexibility enables more effective coping strategies and stress management (D. L. Dawson & N. Golijani-Moghaddam, 2020; Tudi et al., 2021). Notably, the inconclusive evidence across studies regarding stress and overeating behaviors highlights the complexity of these relationships. Factors such as heterogeneity in study populations, self-reported measures, gender imbalances, and different tools for assessing emotional eating may all contribute to inconsistent findings. Moreover, most existing studies—including the present one—are cross-sectional, limiting inferences about causality. Future longitudinal or interventional research could offer deeper insights into how COVID-19-related stress interacts with cognitive and behavioral pathways over time, particularly in populations at risk for chronic stress or maladaptive eating behaviors. Our results also emphasize the need to explore how heightened cognitive flexibility can serve as a protective factor. Women with greater cognitive flexibility may be more capable of adapting their eating behaviors and maintaining physical activity, even under pandemic-related stress. This adaptability is particularly important when designing public health interventions aimed at fostering long-term resilience. Interventions that enhance cognitive flexibility, perhaps through mindfulness training or stress management programs, could potentially reduce the negative impact of stress on physical activity and eating behaviors (Champion & Skinner, 2008; A. L. Park et al., 2020). Conclusion and Future Directions Overall, the study underscores that while COVID-19-related stress was not significantly associated with emotional overeating among the majority of adult women in this population, it did correlate with reduced cognitive flexibility and physical activity. High cognitive flexibility appeared to buffer the adverse effects of stress, suggesting that interventions aimed at bolstering adaptability and resilience may be key in mitigating long-term health risks. 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Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Sep, 2025 Read the published version in Sport Sciences for Health → Version 1 posted Editorial decision: Revision requested 24 Jun, 2025 Reviews received at journal 23 Jun, 2025 Reviewers agreed at journal 23 Jun, 2025 Reviewers agreed at journal 29 May, 2025 Reviewers invited by journal 31 Mar, 2025 Editor assigned by journal 06 Jan, 2025 Submission checks completed at journal 06 Jan, 2025 First submitted to journal 03 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5761175","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":398276909,"identity":"9b54dfeb-6df8-4342-9e0c-1f31d5301cfc","order_by":0,"name":"Siavash Naddafha","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYJACiQoGuQR+JAEDwlrOMBgnSDaQrMXgALFa5Gc3P7xxoMYgz/h4j9kHhgq7xAb25m0SDDWHcWoxuHPM2OLAMYNiszNnjGcwnElObOA5VibBcAyPFokEM+kPbH8St93IMWZgbDuQ2CCRYybBwIZbi/yM9G8SB/4ZJG6eAdLyD6hF/g1Qyz/cWhhuAM082GaQuEECpKUBZAuPmQRjGx6H3cgptjjYZ5A448yxYoaEY8nGbTxpxRaJfen4HLbxxoFvBon97c2bGT7U2Mn2sx/eeOPDN2vcDkMBCUDMBmOMglEwCkbBKCAfAABO4lXsfWjlewAAAABJRU5ErkJggg==","orcid":"","institution":"Edith Cowan University","correspondingAuthor":true,"prefix":"","firstName":"Siavash","middleName":"","lastName":"Naddafha","suffix":""},{"id":398276910,"identity":"881dae78-5a8d-4e7a-9fac-20205276f9ab","order_by":1,"name":"Robabeh Shanahad","email":"","orcid":"","institution":"Raja University","correspondingAuthor":false,"prefix":"","firstName":"Robabeh","middleName":"","lastName":"Shanahad","suffix":""},{"id":398276912,"identity":"7edea7e4-2cab-4c55-a651-ef013a5e349a","order_by":2,"name":"Mandana Sangari","email":"","orcid":"","institution":"Islamic Azad University","correspondingAuthor":false,"prefix":"","firstName":"Mandana","middleName":"","lastName":"Sangari","suffix":""},{"id":398276914,"identity":"b0fc5b7b-bcf5-4f8f-b123-6a0163405b83","order_by":3,"name":"Zohreh Eskandari","email":"","orcid":"","institution":"Raja University","correspondingAuthor":false,"prefix":"","firstName":"Zohreh","middleName":"","lastName":"Eskandari","suffix":""},{"id":398276916,"identity":"7162ddeb-df49-4306-9015-f68d12879dd2","order_by":4,"name":"Christopher B. Taber","email":"","orcid":"","institution":"Sacred Heart University","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"B.","lastName":"Taber","suffix":""}],"badges":[],"createdAt":"2025-01-04 03:53:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5761175/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5761175/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11332-025-01490-y","type":"published","date":"2025-09-03T15:57:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73285074,"identity":"98eb61a3-bc3b-49e8-b03c-804dc717e4a1","added_by":"auto","created_at":"2025-01-08 13:14:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":29036,"visible":true,"origin":"","legend":"\u003cp\u003eThis figure visually depicts the relationship between stress levels (low vs. high) and the cognitive flexibility categories (low, moderate, and high) expressed as percentages\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5761175/v1/3156fde74dc5bd1533e2026c.png"},{"id":73285075,"identity":"6f0db00c-8e8b-4e35-8bf4-23fb591dd2c9","added_by":"auto","created_at":"2025-01-08 13:14:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":39893,"visible":true,"origin":"","legend":"\u003cp\u003eDescriptive statistics showing the relationship between COVID Stress Scale (CSS) scores and self-regulation of eating behavior among women participants categorized by high and low stress levels. The figure highlights a negative correlation between stress and self-regulation, as well as the frequency distribution of cognitive flexibility and physical activity\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5761175/v1/4d9200d946920fb4fd8f836c.png"},{"id":90827965,"identity":"20e89998-05bf-4b1a-8e3b-6cb7f752716a","added_by":"auto","created_at":"2025-09-08 16:04:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":678946,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5761175/v1/ec48d400-1298-4e98-ade9-467dae4824ad.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Multifaceted Interplay Between COVID-19-Induced Psychological Stress, Cognitive Flexibility, Emotional Overeating, and Physical Activity Patterns in Adult Women: A Mediated Path Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn December 2019, a severe acute respiratory syndrome caused by the novel coronavirus (COVID-19) rapidly spread worldwide, leading to an unprecedented global pandemic (Hossain et al., 2020). The COVID-19 pandemic significantly increased stress and anxiety among many adults (Chen et al., 2020). Factors such as concerns about personal health or the health of loved ones affected by the virus, financial stress due to lost income or economic downturns caused by the pandemic, disruptions to daily life, childcare, and education due to quarantine restrictions, as well as uncertainty about the future and feelings of helplessness, have all contributed to increased stress in individuals (Cooke et al., 2020). Stress refers to a state in which an individual is excessively worried or distressed about the occurrence of a catastrophic event in the future (Cooke et al., 2020). In the short term, fear and stress activate the hypothalamus in the brain, which leads to an increase in cortisol secretion from the adrenal cortex and sympathetic nerve stimulation throughout the body, aiding the body's response to stressors. However, if fear and stress, along with the body's response of increased cortisol levels and sympathetic stimulation, persist in the long term, they can be harmful, weakening the immune system and reducing the body's ability to fight diseases (Genet \u0026amp; Siemer, 2011).\u003c/p\u003e \u003cp\u003eThese stressors have elicited diverse behavioral and physiological responses, including changes in dietary habits (S. Murata et al., 2021) While the majority of the global population has experienced environmental stressors related to the pandemic, there are significant individual variations in the intensity and duration of the stress experienced, as well as in behavioral and physiological responses to these stressors (Stephen Murata et al., 2021). One potential behavioral response to environmental stress is increased food consumption (Oliver \u0026amp; Wardle, 1999), particularly highly palatable and energy-dense foods (Tryon et al., 2013). Consuming \"comfort\" foods in response to chronic stress may mitigate its negative effects, specifically by reducing cortisol levels, especially in women and individuals predisposed to high stress (Dub\u0026eacute; et al., 2005). Early evidence suggests that the COVID-19 pandemic has been associated with changes in self-reported food consumption, with individuals reporting increased intake of sweets, desserts, salty snacks, and other palatable foods (Robinson et al., 2021). These findings suggest that psychological factors, such as cognitive flexibility and appetite factors, such as emotional overeating, may influence the likelihood of either increasing or decreasing food consumption in response to acute and chronic stress related to the pandemic. Psychological characteristics such as cognitive flexibility may help reduce stress responses (A. Park et al., 2020).\u003c/p\u003e \u003cp\u003eCognitive flexibility is an individual's ability to modify thinking patterns and behaviors in response to challenges and is associated with high cognitive abilities. Cognitive flexibility makes individuals resilient in the face of stress (Genet \u0026amp; Siemer, 2011). Cognitive flexibility, the ability to adapt thoughts and behaviors to changing demands, has been linked to resilience under stress (Genet \u0026amp; Siemer, 2011). During the COVID-19 pandemic, greater psychological flexibility, or the ability to recognize and adapt to situational demands, has been associated with less pandemic-related worry and distress (David L Dawson \u0026amp; Nima Golijani-Moghaddam, 2020). Higher cognitive or psychological flexibility may help individuals respond to pandemic-related stressors with more adaptive behavioral responses. In general, preliminary research during the COVID-19 pandemic indicates that individual characteristics, such as cognitive flexibility, may affect susceptibility to pandemic-related stress (Jennifer R Sadler et al., 2021). Studies have shown that women under 29 years of age with low cognitive flexibility are more likely to report higher consumption of high-calorie foods than others (Buckland et al., 2021). A positive coping strategy to manage stress is the consumption of healthy foods, which not only reduces stress but also strengthens the immune system, helping the body fight against COVID-19 (Stephen Murata et al., 2021). Studies have also demonstrated a positive correlation between stress and increased food consumption during the pandemic (David L Dawson \u0026amp; Nima Golijani-Moghaddam, 2020). However, to date, no study has examined whether cognitive flexibility may alter sensitivity to stress-induced dietary changes during the pandemic. Despite these insights, no study has specifically examined whether cognitive flexibility moderates the relationship between stress and dietary behaviors during the pandemic. Understanding who is vulnerable to overeating during the pandemic is critical for targeting public health interventions. Therefore, in addition to examining food consumption during the COVID-19 pandemic, we aim to explore how cognitive flexibility may exacerbate or protect against stress-related overeating during the pandemic. This study addresses this gap by investigating how cognitive flexibility influences stress-related overeating in adult women during the COVID-19 pandemic. Understanding these dynamics is critical for developing targeted interventions to mitigate health risks associated with chronic stress.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDemographic Information Questionnaire\u003c/h2\u003e \u003cp\u003eThe Demographic Information Questionnaire was developed by the research team to gather detailed social and demographic data from women aged 20 to 50 years residing in XXX. The questionnaire was structured into multiple sections, each targeting specific aspects of the participants' demographic, health, and lifestyle profiles to provide a comprehensive understanding of their background. These sections included personal demographics such as age, marital status (e.g., single, married, divorced, or widowed), educational attainment (e.g., primary school, high school, undergraduate, or postgraduate), and employment status (e.g., employed full-time, part-time, unemployed, homemaker, or student).\u003c/p\u003e \u003cp\u003eThe health-related information section captured self-reported height and weight (used to calculate BMI), the presence of chronic illnesses or health conditions (e.g., diabetes, hypertension), smoking and alcohol consumption habits (yes/no and frequency), and history of mental health issues or psychological stress. COVID-19-specific information was also collected, including the history of COVID-19 infection (self-reported diagnosis or symptoms), COVID-19 vaccination status (e.g., unvaccinated, partially vaccinated, or fully vaccinated), the impact of the pandemic on personal and family health (e.g., financial strain, health complications), and access to COVID-19-related healthcare services.\u003c/p\u003e \u003cp\u003eSocioeconomic background details included monthly household income (categorized into income ranges), the number of dependents in the household, and access to essential resources such as healthcare, education, or transportation. Information about physical activity and daily routines was also gathered, covering the level of physical activity (sedentary, light, moderate, or vigorous), time spent on work-related and caregiving responsibilities, and regularity of exercise or recreational activities.\u003c/p\u003e \u003cp\u003eFinally, the questionnaire addressed psychological and social stress factors, including major life changes during the pandemic (e.g., job loss, relocation, caregiving challenges), the availability of social support networks (e.g., family, friends, or community resources), and self-reported stress levels and coping mechanisms. Each section provided critical data to enable a thorough analysis of the relationship between COVID-19-related stress and its effects on emotional, cognitive, and physical well-being.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCOVID-19-Related Stress Questionnaire\u003c/h3\u003e\n\u003cp\u003eThe 18-item COVID Stress Scales (CSS-18) was used to assess individuals' stress and related literature. This scale includes 18 items divided into three subscales: psychological stress (10 items), physical stress symptoms (5 items), and stress-related behaviors (3 items). The overall COVID stress score is obtained by summing all questions, with higher scores indicating greater stress. The scale is scored on a 5-point Likert scale, ranging from \"never\" (score 0) to \"always\" (score 4). The validity and reliability of this questionnaire have been reported as satisfactory in XXX studies (Salimi et al., 2021)\u003c/p\u003e\n\u003ch3\u003eAdult Eating Behavior Questionnaire (AEBQ)\u003c/h3\u003e\n\u003cp\u003eThe Adult Eating Behavior Questionnaire (AEBQ) is widely used to measure individual differences in eating behaviors, including enjoyment of food, emotional overeating, emotional undereating, food fussiness, responsiveness to food cues, slowness in eating, hunger, and satiety responsiveness. The questionnaire comprises 35 items across eight subscales (each consisting of 3\u0026ndash;5 items). Responses are rated on a 5-point Likert scale, ranging from \"strongly disagree\" (1) to \"strongly agree\" (5), with subscale averages calculated accordingly. The questionnaire's validity and reliability have been reported as satisfactory (Cohen et al., 2021).\u003c/p\u003e\n\u003ch3\u003eSelf-Regulation of Eating Behavior Questionnaire (SREBQ)\u003c/h3\u003e\n\u003cp\u003eThe Self-Regulation of Eating Behavior Questionnaire (SREBQ) is designed for individuals striving to achieve or maintain a healthy diet. The scale uses general terms such as \"tempting foods\" to allow respondents to answer based on their dietary intentions. Scoring is based on a 5-point Likert scale, from \"never\" to \"always.\" A mean score below 2.8 indicates low self-regulation, scores between 2.8 and 3.6 reflect moderate self-regulation, and scores above 3.6 signify high self-regulation. The validity and reliability of this scale have been reported as satisfactory (Kliemann et al., 2016)\u003c/p\u003e\n\u003ch3\u003eCognitive Flexibility Questionnaire\u003c/h3\u003e\n\u003cp\u003e The Cognitive Flexibility Scale was employed to assess participants' self-efficacy in adapting to added information. This 12-item scale measures agreement with statements such as \"My actions are the result of conscious decisions I make\" and \"I can find workable solutions to seemingly unsolvable problems,\" rated on a 6-point scale from \"strongly disagree\" to \"strongly agree.\" The total cognitive flexibility score ranges from 12 to 72, with higher scores indicating greater cognitive flexibility (Cronbach's alpha\u0026thinsp;=\u0026thinsp;0.87)(Kalia et al., 2020).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eInternational Physical Activity Questionnaire (RAPA)\u003c/h2\u003e \u003cp\u003ePhysical activity levels were measured using the Rapid Assessment of Physical Activity (RAPA) questionnaire. Participants were categorized as sedentary, lightly active, moderately active, or highly active. The first page of the questionnaire provided explanations of light, moderate, and vigorous activities, and the second page included questions about their weekly activity levels. The highest-scoring response was used to determine their activity level, with scores below 6 considered suboptimal and scores above 6 classifieds as active. (Daga et al., 2022)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eThe questionnaire, consisting of six sections\u0026mdash;1) demographic information, 2) COVID-19-related stress questionnaire, 3) Adult Eating Behavior Questionnaire, 4) Self-Regulation of Eating Behavior Questionnaire, 5) Cognitive Flexibility Questionnaire, and 6) International Physical Activity Questionnaire\u0026mdash;was designed on the Press Line platform. The questionnaire link was distributed via social media (WhatsApp, Telegram, email, LinkedIn, and ResearchGate) until the target sample size was reached. Once completed, the data were exported from Press Line as an Excel file, coded, and analyzed using SPSS software.\u003c/p\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003eTo ensure ethical and humane treatment, all participants were assured that their information would remain confidential and only aggregate results would be utilized. The demographic questionnaire and consent form avoided private or sensitive questions. Participation was voluntary, with written consent obtained from both participants and their families IR.QUMS.REC.1401.063 All procedures were in accordance with the declaration of Helsinki.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Procedures\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to calculate means and standard deviations for the study variables, and tables and graphs were generated. Using SPSS version 19 (IBM, Armonk, NY, USA), inferential statistics first tested data normality with the Shapiro-Wilk test. Then, a series of Chi-square distributions and Spearman's rank correlation coefficient were used to examine relationships between variables, with a significance level of p\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study involved 303 women with a mean age of 34.48\u0026thinsp;\u0026plusmn;\u0026thinsp;9.77 years, mean weight of 67.82\u0026thinsp;\u0026plusmn;\u0026thinsp;12.88 kg, mean height of 165.99\u0026thinsp;\u0026plusmn;\u0026thinsp;6.92 cm, and mean BMI of 24.61\u0026thinsp;\u0026plusmn;\u0026thinsp;4.37 kg/m\u0026sup2;. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the scores on the CSS-18 questionnaire and its subscales. The psychological stress subscale included 10 questions with a range of 10\u0026ndash;50, the physical stress subscale had five questions with a range of 5\u0026ndash;25, and the stress-related behaviors subscale contained three questions with a range of 3\u0026ndash;15. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the participants' overall stress score was 45.3, indicating a moderate level of COVID-19 stress. Additionally, 15.84% of the women reported elevated levels of COVID-19-related stress.\u003c/p\u003e \u003cp\u003eParticipants were classified into high and low stress groups based on their CSS-18 scores. Scores exceeding 45 were designated as high stress, while scores at or below 45 indicated low stress. This threshold was determined based on the distribution of CSS-18 scores within the sample, with 45 representing the upper quartile, consistent with prior research identifying this range as indicative of clinically significant stress levels.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe results of the Chi-square test showed no significant difference between COVID-19-related stress (low-high) and food consumption in adult women, X2(1, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;303)\u0026thinsp;=\u0026thinsp;0.99, p\u0026thinsp;=\u0026thinsp;0.317X^2(1, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;303)\u0026thinsp;=\u0026thinsp;0.99, p\u0026thinsp;=\u0026thinsp;0.317X2(1, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;303)\u0026thinsp;=\u0026thinsp;0.99,p\u0026thinsp;=\u0026thinsp;0.317. Additionally, the results of the Spearman correlation test indicated no significant relationship between COVID-19-related stress (low-high) and food consumption in adult women (r\u0026thinsp;=\u0026thinsp;0.07, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.206, r\u0026thinsp;=\u0026thinsp;0.07, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.206, r\u0026thinsp;=\u0026thinsp;0.07, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.206; Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). As a result, it appears that COVID-19-related stress did not significantly affect emotional eating behavior in adult women.\u003c/p\u003e \u003cp\u003eThe results of the Spearman correlation test showed no significant relationship between COVID-19-related stress and emotional eating behavior (r\u003csub\u003es\u003c/sub\u003e(301)\u0026thinsp;=\u0026thinsp;0.07, p\u0026thinsp;=\u0026thinsp;0.206, r\u003csub\u003es\u003c/sub\u003e(301)\u0026thinsp;=\u0026thinsp;0.07, p\u0026thinsp;=\u0026thinsp;0.206, r\u003csub\u003es\u003c/sub\u003e​(301)\u0026thinsp;=\u0026thinsp;0.07, p\u0026thinsp;=\u0026thinsp;0.206) or self-regulation of eating behavior (r\u003csub\u003es\u003c/sub\u003e(301)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.09,p\u0026thinsp;=\u0026thinsp;0.106, r\u003csub\u003es\u003c/sub\u003e(301) = -0.09, p\u0026thinsp;=\u0026thinsp;0.106, r\u003csub\u003es\u003c/sub\u003e​(301)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.09, p\u0026thinsp;=\u0026thinsp;0.106). However, there was a strong negative and significant correlation between COVID-19-related stress and cognitive flexibility (r\u003csub\u003es\u003c/sub\u003e(301)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.91, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, r\u003csub\u003es\u003c/sub\u003e(301) = -0.91, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, r\u003csub\u003es\u003c/sub\u003e301)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.91, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that higher stress levels were associated with lower cognitive flexibility. Additionally, a moderate negative and significant correlation was found between COVID-19-related stress and physical activity (r\u003csub\u003es\u003c/sub\u003e(301)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.46, p\u0026thinsp;=\u0026thinsp;0.005, r\u003csub\u003es\u003c/sub\u003e(301) = -0.46, p\u0026thinsp;=\u0026thinsp;0.005, r\u003csub\u003es\u003c/sub\u003e​(301)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.46, p\u0026thinsp;=\u0026thinsp;0.005), suggesting that increased stress was linked to reduced physical activity levels in adult women.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSpearman Correlation Test Results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotional Eating Behaviour\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-Regulation of Eating Behaviour\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCognitive Flexibility\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePhysical Activity\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOVID-19 Stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003csub\u003es\u003c/sub\u003e = 0.07, p\u0026thinsp;=\u0026thinsp;0.206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u003csub\u003es\u003c/sub\u003e = -0.09, p\u0026thinsp;=\u0026thinsp;0.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003er\u003csub\u003es\u003c/sub\u003e= -0.91, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er\u003csub\u003es\u003c/sub\u003e = -0.46, p\u0026thinsp;=\u0026thinsp;0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eResearch has confirmed the positive impact of physical activity on COVID-19-related stress (Vogel et al., 2022). The results of the Spearman correlation analysis revealed no significant association between COVID-19-related stress and emotional eating behavior (r = 0.07, p = 0.206) or self-regulation of eating behavior (r = -0.09, p = 0.106), consistent with previous findings (MacBlane, 2024). The COVID-19 pandemic has imposed unprecedented psychological and physiological stress on individuals worldwide, particularly affecting eating behaviors, physical activity, and cognitive function. Several studies have explored how pandemic-induced stress has led to emotional eating, physical inactivity, and disruptions in mental health (Cecchetto et al., 2021a; Jennifer R Sadler et al., 2021). Emotional eating, characterized by increased consumption of high-sugar or high-fat foods in response to stress, has been shown to correlate with heightened levels of anxiety and depression during the pandemic (Dakanalis et al., 2023). Similarly, reductions in physical activity were commonly reported as individuals faced lockdowns and restricted access to exercise facilities (Sara Al-Musharaf, 2020; Violant-Holz et al., 2020). Despite extensive research on pandemic-related stress and its effects on behaviors like emotional eating and physical inactivity, there remains a critical gap in understanding the cognitive mechanisms—specifically cognitive flexibility—that underpin these stress-induced behaviors. Cognitive flexibility refers to an individual’s ability to adapt thoughts and behaviors in response to changing environments, making it a key factor in coping with prolonged stress. While individuals with higher cognitive flexibility are generally better equipped to manage stress and avoid maladaptive behaviors like emotional overeating or reduced physical activity, few studies have examined how cognitive flexibility moderates or mediates the relationship between pandemic stress and these behaviors. Moreover, inconsistent findings in the literature underscore the need for further exploration. For example, while some studies (Cecchetto et al., 2021a) found a direct correlation between stress and emotional eating, others (e.g., Oor et al., 2022) did not (Orr et al., 2022), highlighting the need for a more nuanced understanding of how cognitive and behavioral factors interact under stress. Additionally, while prior research (Meiling Qi et al., 2020) has examined the pandemic's effects on emotional eating and physical activity, much of it has focused on short-term behavioral responses. There has been limited attention given to the long-term cognitive adaptations, particularly in populations experiencing chronic stress, such as women during the COVID-19 pandemic. Our study aims to fill these gaps by investigating the relationship between COVID-19-related stress, cognitive flexibility, and key behaviors such as emotional eating and physical activity in adult women. By incorporating cognitive flexibility as a central variable, our research seeks to clarify how this trait may mediate or moderate the effects of stress on eating and exercise habits. Understanding these cognitive mechanisms is crucial for developing targeted interventions aimed at enhancing cognitive resilience and promoting healthier coping strategies during prolonged stress periods, such as during global crises. This study offers a unique perspective by placing cognitive flexibility at the center of the stress-behavior relationship, which has often been overlooked in prior research. By examining how cognitive flexibility influences both emotional eating and physical activity, our findings will contribute to a more comprehensive understanding of the complex interplay between stress, cognition, and behavior. Ultimately, this research has significant public health implications, particularly for designing interventions that foster cognitive resilience and help individuals maintain healthier lifestyle behaviors amid ongoing stressors.\u003c/p\u003e\n\u003cp\u003eThe present study sought to clarify whether COVID-19-related stress would influence emotional eating behavior, physical activity, and cognitive flexibility in adult women, with particular attention to whether cognitive flexibility could mitigate stress-induced changes. Contrary to some prior research (Cecchetto et al., 2021b; Rogers et al., 2021) our findings indicated that COVID-19-related stress did not significantly affect emotional overeating (i.e., self-regulation of eating behavior). Although this result aligns with several studies (S. Al-Musharaf, 2020); Orr et al., 2022), the discrepancy with other investigations (Cecchetto et al., 2021b) may stem from differences in sample demographics, stress levels, and methodological designs. In this study, only 15% of participants reported high levels of stress, suggesting that the majority of women were either resilient or had other protective factors that attenuated the impact of stress on overeating behaviors (J. R. Sadler et al., 2021)\u003c/p\u003e\n\u003cp\u003eDespite the lack of a direct association between stress and emotional overeating, a strong negative correlation emerged between COVID-19-related stress and both cognitive flexibility and physical activity. Participants with higher stress reported lower cognitive flexibility and reduced physical activity, confirming earlier work that underscores stress as a hindrance to adaptive behaviors (S. Al-Musharaf, 2020; M. Qi et al., 2020; Violant et al., 2020) Elevated stress levels may deplete cognitive resources, making it more challenging to maintain healthy routines such as exercise (Violant et al., 2020). Conversely, higher cognitive flexibility—an individual’s capacity to adapt to changing demands—seemed to buffer against the deleterious effects of stress. These findings support previous research indicating that psychological flexibility enables more effective coping strategies and stress management (D. L. Dawson \u0026amp; N. Golijani-Moghaddam, 2020; Tudi et al., 2021).\u003c/p\u003e\n\u003cp\u003eNotably, the inconclusive evidence across studies regarding stress and overeating behaviors highlights the complexity of these relationships. Factors such as heterogeneity in study populations, self-reported measures, gender imbalances, and different tools for assessing emotional eating may all contribute to inconsistent findings. Moreover, most existing studies—including the present one—are cross-sectional, limiting inferences about causality. Future longitudinal or interventional research could offer deeper insights into how COVID-19-related stress interacts with cognitive and behavioral pathways over time, particularly in populations at risk for chronic stress or maladaptive eating behaviors.\u003c/p\u003e\n\u003cp\u003eOur results also emphasize the need to explore how heightened cognitive flexibility can serve as a protective factor. Women with greater cognitive flexibility may be more capable of adapting their eating behaviors and maintaining physical activity, even under pandemic-related stress. This adaptability is particularly important when designing public health interventions aimed at fostering long-term resilience. Interventions that enhance cognitive flexibility, perhaps through mindfulness training or stress management programs, could potentially reduce the negative impact of stress on physical activity and eating behaviors (Champion \u0026amp; Skinner, 2008; A. L. Park et al., 2020).\u003c/p\u003e"},{"header":"Conclusion and Future Directions","content":"\u003cp\u003e\u0026nbsp;Overall, the study underscores that while COVID-19-related stress was not significantly associated with emotional overeating among the majority of adult women in this population, it did correlate with reduced cognitive flexibility and physical activity. High cognitive flexibility appeared to buffer the adverse effects of stress, suggesting that interventions aimed at bolstering adaptability and resilience may be key in mitigating long-term health risks. Future research employing longitudinal designs, larger and more diverse samples, and standardized measures of stress, eating behaviors, and cognitive flexibility is necessary to advance our understanding of how best to support women’s health behaviors in prolonged or recurring stressful conditions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAl-Musharaf S. Prevalence and predictors of emotional eating among healthy young Saudi women during the COVID-19 pandemic. \u003cem\u003eNutrients\u003c/em\u003e. 2020;12(10):2923. https://doi.org/10.3390/nu12102923.\u003c/li\u003e\n\u003cli\u003eBuckland NJ, Swinnerton LF, Ng K, Price M, Wilkinson LL, Myers A, et al. Susceptibility to increased high energy dense sweet and savoury food intake in response to the COVID-19 lockdown: The role of craving control and acceptance coping strategies. \u003cem\u003eAppetite\u003c/em\u003e. 2021;158:105017.\u003c/li\u003e\n\u003cli\u003eCecchetto C, Aiello M, Gentili C, Ionta S, Osimo SA. Increased emotional eating during COVID-19 associated with lockdown, psychological and social distress. \u003cem\u003eAppetite\u003c/em\u003e. 2021;160:105122. https://doi.org/10.1016/j.appet.2021.105122.\u003c/li\u003e\n\u003cli\u003eChampion VL, Skinner CS. The health belief model. In: Glanz K, Rimer BK, Viswanath K, editors. \u003cem\u003eHealth behavior and health education: Theory, research, and practice\u003c/em\u003e. 4th ed. San Francisco: Jossey-Bass; 2008. p. 45\u0026ndash;65.\u003c/li\u003e\n\u003cli\u003eChen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. \u003cem\u003eLancet\u003c/em\u003e. 2020;395(10223):507\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eCohen TR, Kakinami L, Plourde H, Hunot-Alexander C, Beeken RJ. Concurrent validity of the adult eating behavior questionnaire in a Canadian sample. \u003cem\u003eFront Psychol\u003c/em\u003e. 2021;12:779041.\u003c/li\u003e\n\u003cli\u003eCooke JE, Eirich R, Racine N, Madigan S. Prevalence of posttraumatic and general psychological stress during COVID-19: A rapid review and meta-analysis. \u003cem\u003ePsychiatry Res\u003c/em\u003e. 2020;292:113347.\u003c/li\u003e\n\u003cli\u003eDaga FA, Agostino S, Peretti S, Beratto L. Correction to: COVID‑19 nationwide lockdown and physical activity profiles among North‑western Italian population using the International Physical Activity Questionnaire (IPAQ). \u003cem\u003eSport Sci Health\u003c/em\u003e. 2022;18(1):287.\u003c/li\u003e\n\u003cli\u003eDakanalis A, Mentzelou M, Papadopoulou SK, Papandreou D, Spanoudaki M, Vasios GK, et al. The association of emotional eating with overweight/obesity, depression, anxiety/stress, and dietary patterns: A review of the current clinical evidence. \u003cem\u003eNutrients\u003c/em\u003e. 2023;15(5):1173.\u003c/li\u003e\n\u003cli\u003eDawson DL, Golijani-Moghaddam N. COVID-19: Psychological flexibility, coping, mental health, and wellbeing in the UK during the pandemic. \u003cem\u003eJ Contextual Behav Sci\u003c/em\u003e. 2020;17:126\u0026ndash;34. https://doi.org/10.1016/j.jcbs.2020.07.010.\u003c/li\u003e\n\u003cli\u003eDub\u0026eacute; L, LeBel JL, Lu J. Affect asymmetry and comfort food consumption. \u003cem\u003ePhysiol Behav\u003c/em\u003e. 2005;86(4):559\u0026ndash;67.\u003c/li\u003e\n\u003cli\u003eGenet JJ, Siemer M. Flexible control in processing affective and non-affective material predicts individual differences in trait resilience. \u003cem\u003eCogn Emot\u003c/em\u003e. 2011;25(2):380\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eHossain MM, Sultana A, Purohit N. Mental health outcomes of quarantine and isolation for infection prevention: a systematic umbrella review of the global evidence. \u003cem\u003eEpidemiol Health\u003c/em\u003e. 2020;42:e2020038.\u003c/li\u003e\n\u003cli\u003eKalia V, Knauft K, Hayatbini N. Cognitive flexibility and perceived threat from COVID-19 mediate the relationship between childhood maltreatment and state anxiety. \u003cem\u003ePLoS One\u003c/em\u003e. 2020;15(12):e0243881.\u003c/li\u003e\n\u003cli\u003eKliemann N, Beeken RJ, Wardle J, Johnson F. Development and validation of the self-regulation of eating behaviour questionnaire for adults. \u003cem\u003eInt J Behav Nutr Phys Act\u003c/em\u003e. 2016;13:1\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eMacBlane M. COVID-19 Fear, Self-Regulation, Coping, and Eating Behaviors. \u003cem\u003eWalden University\u003c/em\u003e; 2024.\u003c/li\u003e\n\u003cli\u003eMurata S, Rezeppa T, Thoma B, Marengo L, Krancevich K, Chiyka E, et al. The psychiatric sequelae of the COVID‐19 pandemic in adolescents, adults, and health care workers. \u003cem\u003eDepress Anxiety\u003c/em\u003e. 2021;38(2):233\u0026ndash;46. https://doi.org/10.1002/da.23120.\u003c/li\u003e\n\u003cli\u003eOliver G, Wardle J. Perceived effects of stress on food choice. \u003cem\u003ePhysiol Behav\u003c/em\u003e. 1999;66(3):511\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003ePark AL, Velez CV, Kannan K, Chorpita BF. Stress, functioning, and coping during the COVID-19 pandemic: Results from an online convenience sample. \u003cem\u003eBehav Ther\u003c/em\u003e. 2020;43:210\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eQi M, Li P, Moyle W, Weeks B, Jones C. Physical activity, health-related quality of life, and stress among the Chinese adult population during the COVID-19 pandemic. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e. 2020;17(18):6494. https://doi.org/10.3390/ijerph17186494.\u003c/li\u003e\n\u003cli\u003eRobinson E, Boyland E, Chisholm A, Harrold J, Maloney NG, Marty L, et al. Obesity, eating behavior and physical activity during COVID-19 lockdown: A study of UK adults. \u003cem\u003eAppetite\u003c/em\u003e. 2021;156:104853.\u003c/li\u003e\n\u003cli\u003eRogers AM, Lauren BN, Woo Baidal JA, Ozanne EM, Hur C. Persistent effects of the COVID-19 pandemic on diet, exercise, risk for food insecurity, and quality of life: A longitudinal study among U.S. adults. \u003cem\u003eAppetite\u003c/em\u003e. 2021;167:105639. https://doi.org/10.1016/j.appet.2021.105639.\u003c/li\u003e\n\u003cli\u003eSadler JR, Thapaliya G, Jansen E, Aghababian AH, Smith KR, Carnell S. COVID-19 stress and food intake: Protective and risk factors for stress-related palatable food intake in US adults. \u003cem\u003eNutrients\u003c/em\u003e. 2021;13(3):901. https://doi.org/10.3390/nu13030901.\u003c/li\u003e\n\u003cli\u003eTryon MS, Carter CS, DeCant R, Laugero KD. Chronic stress exposure may affect the brain\u0026apos;s response to high calorie food cues and predispose to obesogenic eating habits. \u003cem\u003ePhysiol Behav\u003c/em\u003e. 2013;120:233\u0026ndash;42.\u003c/li\u003e\n\u003cli\u003eViolant-Holz V, Gallego-Jim\u0026eacute;nez MG, Gonz\u0026aacute;lez-Gonz\u0026aacute;lez CS, Mu\u0026ntilde;oz-Violant S, Rodr\u0026iacute;guez MJ, Sansano-Nadal O, et al. Psychological health and physical activity levels during the COVID-19 pandemic: A systematic review. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e. 2020;17(24):9419. https://doi.org/10.3390/ijerph17249419.\u003c/li\u003e\n\u003cli\u003eVogel EA, Zhang JS, Peng K, Heaney CA, Lu Y, Lounsbury D, et al. Physical activity and stress management during COVID-19: A longitudinal survey study. \u003cem\u003ePsychol Health\u003c/em\u003e. 2022;37(1):51\u0026ndash;61.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sport-sciences-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssfh","sideBox":"Learn more about [Sport Sciences for Health](http://link.springer.com/journal/11332)","snPcode":"11332","submissionUrl":"https://submission.nature.com/new-submission/11332/3","title":"Sport Sciences for Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"stress, nutrition, emotional overeating, cognitive flexibility, physical activity","lastPublishedDoi":"10.21203/rs.3.rs-5761175/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5761175/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study investigated the impact of COVID-19-related stress on food consumption and emotional overeating in adult women, with cognitive flexibility and physical activity as mediating factors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA descriptive-analytical, correlational, and applied research design was employed. The study population included adult women aged 20\u0026ndash;50 in an urban area. Using Cochran's formula, a sample size of 300 was determined. Data were collected using validated tools: COVID Stress Scale (CSS-18(2021), AEBQ(2016),SREBQ), Cognitive Flexibility Scale, and Rapid Assessment of Physical Activity (RAPA). Chi-square tests and Spearman's correlation were applied at a significant level of p\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCOVID-19-related stress significantly reduced cognitive flexibility (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and negatively impacted physical activity (p\u0026thinsp;=\u0026thinsp;0.005). No significant associations were found with emotional overeating (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIncreased stress negatively affected cognitive flexibility and physical activity in adult women, highlighting the need for interventions to enhance resilience and promote healthier behaviors.\u003c/p\u003e","manuscriptTitle":"The Multifaceted Interplay Between COVID-19-Induced Psychological Stress, Cognitive Flexibility, Emotional Overeating, and Physical Activity Patterns in Adult Women: A Mediated Path Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-08 13:06:02","doi":"10.21203/rs.3.rs-5761175/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-24T14:46:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-23T18:52:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5926821501190183645720671852646606933","date":"2025-06-23T18:35:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123528756555945212080079476330895091766","date":"2025-05-29T22:03:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-31T10:58:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-06T12:19:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-06T12:17:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Sport Sciences for Health","date":"2025-01-04T03:37:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sport-sciences-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssfh","sideBox":"Learn more about [Sport Sciences for Health](http://link.springer.com/journal/11332)","snPcode":"11332","submissionUrl":"https://submission.nature.com/new-submission/11332/3","title":"Sport Sciences for Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"15385416-f6f6-4163-b28a-2b3ad5e3c0a2","owner":[],"postedDate":"January 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T16:00:29+00:00","versionOfRecord":{"articleIdentity":"rs-5761175","link":"https://doi.org/10.1007/s11332-025-01490-y","journal":{"identity":"sport-sciences-for-health","isVorOnly":false,"title":"Sport Sciences for Health"},"publishedOn":"2025-09-03 15:57:37","publishedOnDateReadable":"September 3rd, 2025"},"versionCreatedAt":"2025-01-08 13:06:02","video":"","vorDoi":"10.1007/s11332-025-01490-y","vorDoiUrl":"https://doi.org/10.1007/s11332-025-01490-y","workflowStages":[]},"version":"v1","identity":"rs-5761175","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5761175","identity":"rs-5761175","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}