“Hedonic hunger” describes increased appetite when metabolic needs are absent. This increased appetite is brought on by the urge to consume despite the inaccessibility of certain foods in connection with the expectation of food-related pleasure (1). Hedonic food consumption leads to excessive eating behaviors that exceed the body’s requirements, often as a means to suppress or respond to emotional states. This phenomenon is characterized by the enjoyment of palatable foods and is influenced by motivational factors or reward-punishment dynamics (2). Foods that are commonly consumed have a high energy density, along with higher amounts of salt, sugar, and fat (3). Numerous factors, including physiological differences, dietary habits, sensitivity to environmental, nutritional cues, perceived food rewards, food availability, cravings for food, emotional eating, sleep, physical activity, social media, and individual self-esteem, influence hedonic hunger (4–6).

Another factor that may be related to hedonic hunger is premenstrual syndrome (PMS). PMS is defined by a range of emotional symptoms, such as depressed mood, irritability, and anger outbursts, alongside physical symptoms, including muscle and joint pain, headaches, indigestion, and breast tenderness. Additionally, it encompasses behavioral changes like changes in eating habits, social withdrawal, and impaired concentration, primarily affecting young and middle-aged women (7, 8). Research indicates that the prevalence of PMS ranges from 24.6 to 53%. This variation predominantly results from differing diagnostic criteria, study populations, and socio-cultural factors (9–13). The worldwide incidence of PMS has been reported at 47.8% (14). The precise mechanisms underlying the pathophysiology of PMS remain unclear. Variations in sex steroid levels such as elevated estrogen levels, alterations in the estrogen-progesterone ratio, and excessive prolactin release, along with modifications in central neurotransmitters such as serotonin, gamma-aminobutyric acid, glutamate, and beta-endorphins, as well as genetic origins, biological variables, and psychological difficulties, significantly contribute to the pathogenesis of PMS (15–17). According to previous research, women with severe PMS are more prone to overeat during the luteal phase and consume high-calorie food, which may serve as a coping strategy for psychological stress (18–20). PMS influences eating behaviors, characterized by symptoms including mood fluctuations, decreased energy levels, and increased appetite (18).

Dietary patterns and nutritional status are regarded as crucial components and represent the most modifiable factor in the management of PMS (21, 22). Studies showed that increased consumption of energy-dense, fatty, and salty foods has been associated with more significant onset and exacerbation of PMS symptoms (23, 24). Carbohydrate consumption peaks during the premenstrual phase (25), alongside an increase in cravings for sweet and fatty foods (26). Furthermore, lifestyle variables and nutritional deficiencies, including sleep duration, caffeine and alcohol consumption, smoking, and elevated body mass index (BMI), are significantly correlated with PMS (10, 27). During the premenstrual phase, women are more sensitive to food stimuli, suggesting that it may be difficult to maintain regulated eating (28). Cravings for foods that release serotonin and premenstrual cravings may be exacerbated by elevated metabolism, highest progesterone and estrogen levels, and lowered serotonin levels (29). A different explanation is that women desire prohibited foods that they perceive as unhealthy and are limited to a healthy feminine diet (26). Menstrual hormonal fluctuations and physiological and neurochemical factors are associated with increased food consumption and elevated food cravings in the premenstrual phase (29, 30).

Hedonic hunger demonstrates theoretical and empirical connections with other recognized eating variables, including uncontrolled eating, which reflects opportunistic consumption when palatable food is accessible, and food craving, which signifies reward reactivity to external stimuli (5). For these reasons, determining a balanced relationship between hedonic hunger, food cravings, emotional eating, and PMS is significant, especially for university students. Extensive studies have explored the individual relationships among personality traits, PMS, nutrition intake, and eating behaviors; however, a scarcity of research has collectively examined these variables within a comprehensive model. This study aims to improve understanding of the complex interactions among variables, including menstrual cycle characteristics, anthropometric measures, hedonic hunger, food cravings, emotional eating, and PMS in university students. It aims to contribute to the literature on the diverse factors influencing eating behaviors in female university students.

Table 1 presents students’ general and menstrual cycle characteristics as shown by PMSS scores. The mean age of students without PMS was 21.03 ± 4.60 years, whereas for those with PMS, it was 21.10 ± 1.57 years (p < 0.05). Most students are in the second and third grades (29.0 and 28.0%, respectively). A significant number of students (83.6%) live in dormitories. Approximately two-thirds of students’ income equals their expenses (p < 0.05). The mean age of menarche among students was 13.08 ± 1.17 years, and they had a regular menstrual cycle with periods ranging from 22 to 34 days [PMS (−), 84.20%; PMS (+), 79.30%]. The duration of menstruation ranged from 3 to 7 days [PMS (−), 92.10%; PMS+, 92.30%]. Students with PMS reported a greater incidence of menstrual pain during their menstrual cycle (p < 0.05). No significant differences were observed among students regarding the number of main meals and snacks, smoking status, and alcohol consumption (p > 0.05). The mean BMI of the students was 23.3 ± 4.07 [PMS (−), 24.15 ± 4.81; PMS (+), 23.06 ± 3.87, respectively] (p > 0.05). There was no statistically significant difference between the students with PMS (−) and PMS (+) in terms of fat mass, total body water, and fat-free mass (p > 0.05).

Figure 1 details the PFS-Tr, FCQ-T, and EEQ scores among students with PMS (−) and PMS (+). The PFS-Tr and subscales were significantly higher in the PMS (+) group (p < 0.001), except for the food presence subscale. In students with PMS (+), the FCQ-T and sub-factor scores were significantly higher (p < 0.001; p < 0.05). The emotional eating behaviors of students analysis revealed statistically significant increases in disinhibition, food type, and EEQ score among students with PMS (+). Compared to PMS (−) students, PMS (+) students had statistically higher EEQ, food type, and disinhibition scores (p < 0.05).

There was a positive correlation between the PFS-Tr total score and the total score of the PMSS, sub-factor scores of anxiety, fatigue, irritability, depressive thoughts, pain, appetite changes, and bloating. A positive correlation was observed between the total score of the FCQ-T and the total score of the PMSS, as well as the sub-factor scores for anxiety, fatigue, irritability, depressive thoughts, pain, appetite changes, sleep changes, and bloating. A positive correlation was found between the total score of the EEQ and the total score of the PMSS, the sub-factor scores for anxiety, fatigue, irritability, and bloating (p < 0.05; p < 0.001; Table 2).

When the factors (BMI, PMSS, FCQ-T, and EEQ total scores) related to PFS-Tr total scores were evaluated with multiple linear regression analysis, the model was significant (R²: 0.426, p < 0.001). FCQ-T was related to the PFS-Tr total score (p < 0.001). Higher cravings for food predicted increased hedonic hunger tendencies (Table 3). When the factors (BMI, PMSS, PFS-Tr, and EEQ total scores) related to FCQ-T total scores were evaluated with multiple linear regression analysis, the model was significant (R²: 0.614, p < 0.001). FCQ-T total score was related to PMSS, PFS-Tr, and EEE-Q total scores; however, BMI was unrelated (p > 0.05) (Table 4). A higher PMSS, increased craving for food, and emotional eating predicted increased craving (p < 0.05).

To the best of our knowledge, this is the first study to evaluate the relationship between hedonic hunger, food cravings, emotional eating, and PMS among Turkish nursing students. Our main findings were: (i) 81.6% of the female nursing students experienced PMS, (ii) students with PMS had significantly higher overall scores in PFS-Tr, FCQ-T, and EEQ compared to PMS (−) students, (iii) a positive and significant correlation was observed between PMSS and PFS-Tr scores, (iv) there was a positive and significant correlation between PMSS and FCQ-T scores, (v) the PMSS and EEQ scores were positively and significantly correlated.

The majority of students in this research experienced PMS (81.6% of 207 participants). A study by Gürkan and Bilgili (41) of university students in Türkiye found the prevalence of PMS was 34.2, 47.3% by Çelik and Uskun (42), 49.2% by Turan et al., (43). Further research indicated higher rates: 70.7% by Çağlar and Oskay (44), 72.4% by Yılmaz (45), 80.5% by Akın and Erbil (46), 83.7% by Arslan et al. (22). A recent systematic review and meta-analysis carried out in Türkiye revealed that PMS affected 52.2% of women of reproductive age, with 50.3% of those being university students (13). A study by Nandakumar et al. (47) of health professional undergraduate and postgraduate students in India found the prevalence was 76.4%, while Al-Shahrani et al. (48) reported 64.9% in Saudi Arabia, Rezende et al. found (11) 46.9% in Brazil. The prevalence of PMS in women of reproductive age was 47.8% globally (49). These outcomes result from various factors, such as living in a dormitory, academic challenges, sleep habits, stress levels, financial situations, and dietary and lifestyle choices. The variations in prevalence observed across studies can be attributed to factors such as cultural and regional differences, differing exclusion criteria, study design, and methods of sample selection.

Some research have examined the correlation between PMS symptoms and lifestyle factors (50, 51). Family history, age, oral contraceptive use, stress, smoking, eating habits, BMI, and physical activity may influence menstruation symptoms (52–54). Studies indicated a link between high BMI and menstruation problems, and disordered eating was found to be much more prevalent in the PMS (+) group compared to the PMS (−) group (16, 55). Our study indicated that there were no significant differences between PMS (+) and PMS (−) individuals for any general or menstrual cycle features of students, except for monthly income status and menstrual pain. The PMS (+) group had a significantly greater number of females reporting menstrual pain compared to the PMS (−) group. Variations in methodologies, sample sizes, hormonal variations during PMS, alterations in neurotransmitter systems, inflammatory responses, and the interplay of individual psychosocial variables are believed to have impacted the research outcomes.

During the luteal phase and the initial few days of menstruation, many women have food cravings, and changes in appetite and eating behaviors are found between healthy women and those with PMS (56–59). Previous studies have indicated that females experience increased appetite, especially for sweets, with an increase in the consumption of various food types throughout all menstrual phases. Notably, there was a significant rise in cravings for sweets and junk foods during the premenstrual period (60, 61), a positive association between PMSS scores and high-calorie diets, sweets, and salty and fried snacks (24), a significant association between high FCQ-T scores and PMS symptoms (62), and food cravings and PMS symptoms and changes in appetite were higher in the PMS group (63). As expected in this study, PFS-Tr and FCQ-T scores were shown to positively correlate with PMSS total and several subscale scores. Our findings indicate that students with PMS exhibited significantly higher total scores in the PFS, as well as increased scores in the food available and food tasted subscales. Furthermore, the total score and subscale scores of the FCQ-T were observed to be significantly higher in students with PMS compared to those without PMS. The results of our study coincide with previous research, indicating that increased food cravings and hedonic hunger are prevalent during PMS, with a more pronounced relationship observed between excessive food cravings and PMS compared to hedonic hunger.

Studies have shown that eating disorders are associated with PMS, with notable differences in appetite and dietary behaviors between healthy women and those having PMS (59, 64). PMS is significantly linked to impaired eating behaviors, particularly among female university students (65, 66). A study of adolescents revealed that disordered eating was significantly more prevalent in the PMS group compared to the non-PMS group, with higher scores for emotional and uncontrolled eating observed in the PMS group (67). In another study, the premenstrual dysphoric disorder group, severe form of PMS, showed higher mean scores for emotional eating compared to those without PMS (19). Consistent with these studies, it was determined that there is a positive correlation between EEQ scores and PMSS scores among nursing students. Students with PMS exhibited higher total EEQ scores, as well as elevated mean scores for disinhibition and food type-the sub-dimensions of emotional eating-compared to non-PMS students. The biopsychosocial characteristics of PMS require the use of several methods of treatment for symptom management (68). In this context, several psychological intervention programs have been established for reducing emotional eating behavior, with certain methods demonstrating efficacy. A research by Başoğul and colleagues shown that cognitive behavioral therapy significantly reduced both psychological and physical symptoms in women with PMS. Mindfulness-based therapies have been substantially correlated with PMS symptoms and may effectively decrease these symptoms (69, 70). Cognitive behavioral therapy and mindfulness-based therapies are considered helpful psychological interventions for mitigating emotional eating behaviors in women with PMS.

Hormone fluctuations during the menstrual cycle have a major impact on the hedonic aspect of eating behavior. Cyclical variations in estrogen and progesterone, essential hormones regulating the female reproductive system and menstrual cycle, are believed to significantly influence this process (71, 72). Estradiol, a steroid hormone classified as an estrogen, influences serotonin levels through modifications in the expression of 5-HT 2A receptors and serotonin transporter genes in brain areas linked to behavior and emotion (73). Women experiencing PMS exhibit serotonin deficits during the luteal phase of the menstrual cycle, coinciding with a decline in estradiol levels, which indicates a potential heightened sensitivity to the influence of estradiol on serotonin regulation (74). Changes in progesterone and allopregnanolone, the primary metabolite of progesterone, have also been associated with PMS. preliminary research suggest that decreasing progesterone levels in the late luteal phase correlate with elevated anxiety and changes in γ-aminobutyric acid (GABA) receptor function. In women experiencing PMS, it is suggested that a reduction in GABA (A) receptor sensitivity to neuroactive steroids, such as progesterone, and/or diminished levels of allopregnanolone could lead to symptoms of depression and anxiety (75, 76). Recent studies suggest a connection between brain-derived neurotrophic factor (BDNF) and the development of PMS, though its precise function remains to be clarified. While BDNF levels vary over the menstrual cycle, women with PMS have a declining trend in plasma BDNF throughout the ovarian cycle, contrasting with the rising trend seen in women without PMS (77–79).

The two primary phases of the menstrual cycle in women are the luteal and follicular. Increased homeostatic (related to energy demands) and hedonic (related to pleasure) hunger determinants may be implicated in the decrease of oestrogen levels during the luteal phase (80). Women exhibit distinct brain activity patterns in response to dietary cues across various periods of the menstrual cycle. It has been demonstrated that the orbitofrontal cortex is more activated during the luteal phase than during the late follicular phase. As we all know, palatable food is a natural reward. This has been identified as significantly influencing energy intake and food cravings during the luteal phase through the activation of reward system pathways (81–83).

The present study had several strengths. Pregnant or breastfeeding individuals, those outside the menstrual cycle such as in early menopause, those with irregular menstrual cycles, those with physical or mental health issues, any confirmed psychiatric disorders, or women prescribed psychiatric medication by a physician were excluded from the study. The accuracy of the data obtained, together with the low risk of bias, is a notable strength when considering the exclusion criteria. According to the existing literature, an initial study of the relationship between hedonic hunger, food cravings, emotional eating, and PMS was conducted among nursing students. This study has some limitations. First, the cross-sectional study design complicates the determination of cause-effect relationships between independent and dependent variables. Second, the participants consist only of nursing students from one university, hence constraining generalizability. Third, data collection included self-reporting, which introduces the potential for recall bias and inaccurate reporting. Finally, there is a lack of confounder information.

Our study assessed the prevalence of PMS, menstrual cycle features, and anthropometric measures among university students, and elucidated the correlation between hedonic hunger, food cravings, emotional eating, and PMS. PMS was a problem experienced by most of the students (81.6%). Hedonic hunger, food cravings, emotional eating, and overall PMSS scores, along with many sub-scores, exhibited a significant correlation among nursing students. Food cravings were the most strong indicator of hedonic hunger, while hedonic hunger, PMS, and emotional eating all had important roles in predicting food cravings. According to the findings, nursing students who have PMS are more likely to have increased hedonic hunger, desires for food, and emotional eating tendencies. The intricate interplay among these factors indicates that strategies aimed at encouraging healthy eating behaviors should take into account the diverse aspects of these correlations. Further studies should concentrate on investigating more mediating factors that might affect the correlation between PMS and eating habits. More research on strategies for managing eating habits during PMS might be beneficial. Furthermore, replicating these findings across many populations may enhance their generalisability and facilitate the development of similar interventions for various demographic groups.