Using a latent profile approach to identify eating behavior profiles based on the Child Eating Behavior Questionnaire (CEBQ)  in 4 year-olds, we found a distinct fussy eating behavior profile characterized by a pattern of low scores on the food approach scales and high scores on the food avoidance scales. The fussy eating behavior profile was found in 5.6% of children, similar to Micali and colleagues  who report a prevalence of 7.3% in 5–7 year-olds also using a data-driven approach, defining a “picky eating” score by factor analysis. By contrast, studies using a single item approach to assign picky eater status (e.g. “Is your child a picky eater?”) found much higher prevalences, e.g. 21% in a study in 3–5 year-olds  and up to 50% of 2 year-olds . Similarly, Dubois and colleagues  found that 30% of preschoolers were picky eaters, based on a 3-item assessment.
Besides differences in assessment methods, these differences in prevalence might be partly due to the age of assessment of eating behavior. Previous studies have indicated that the highest incidence of picky eating occurs around the age of 2 years . Most likely, fussy eating behavior at this age is driven by food neophobia, i.e. unwillingness to eat new foods, which is often considered to be a part of fussy/picky eating. For example, the CEBQ includes three (out of six) questions about food neophobia in the FF subscale. Food neophobia prevalence rates are known to peak around the age of 2 years, when children become increasingly mobile, and it is beneficial for them to be suspicious towards new foods, from an evolutionary perspective . For most of the children displaying fussy eating behavior at 2 years of age, this will only be a transient phase in normal development. Although our assessment of eating behavior at age 4 years misses the peak incidence of food fussiness, it is more likely to pick up those children with more persistent eating problems. Beyond the specific differences in eating behavior, fussy eaters also differed from non-fussy eaters in several child and family characteristics. For example, indices of low socio-economic status, i.e. below modal household income and lower maternal educational level, were more common the group of fussy eaters than in non-fussy eaters. There were more boys in the fussy eater group (56%) than in the non-fussy eater group (50%).
The validity of the fussy eater profile is supported by differences in the intake of certain food groups when children were 14 months of age. Fussy eaters consumed less foods that are generally not very popular with children such as vegetables, wholegrain products, fish and meat, which has also been reported by previous studies [6, 12, 34, 35]. By contrast, the intake of food groups that are generally liked by children, including refined grain products such as soft buns and cornflakes, dairy products such as yoghurt, and fruits was similar in fussy and in non-fussy eaters. Interestingly, fussy eaters consumed more confectionary such as cookies and also more savory snacks such as potato-chips and fast food than non-fussy eaters. Similar findings were reported by previous studies that assessed food intake and food fussiness at the same time point . Possibly mothers of fussy eaters are more permissive in letting their children eat palatable but unhealthy foods to compensate for the lower intake of other foods. This may account for the finding that fussy eaters did not have a lower total energy intake than non-fussy eaters at 14 months of age. Nevertheless, when they reached the age of four years, fussy eaters had a lower BMI and were more often underweight than non-fussy eaters, which has also been shown in previous studies [10, 12, 42]. Differences in the intake of certain food groups at 14 months might be explained by early differences in preference indicating that fussy eaters were already more picky at the age of 14 months. Alternatively, difference in intake might be due to the lack of access to some food groups such as vegetables and whole grain products, especially in lower SES families, or simply that these foods are not offered to the child by the parents. Together, findings indicate that fussy eaters have a (history of) more unhealthy diet and body weight than non-fussy eaters, although we could not test whether the difference we found when children were 14 months old actually persisted because food intake was not assessed again till the age four years.
We also found differences in maternal feeding behavior between fussy and non-fussy eaters. Mothers of fussy eaters used less monitoring of their child’s eating behavior, and applied more pressure to eat, which also suggests that these children are not eating well by themselves. As also pointed out by Jansen and colleagues  parental pressure may be a reaction to children’s difficult eating behavior, but may at the same time also have counterproductive effects on child eating behavior such as lowering the child’s enjoyment of food. The associations between maternal feeding behavior and child eating behavior therefore probably represent bi-directional effects on behavioral patterns that have developed in the course of early childhood . Differences between fussy and non-fussy children in BMI cannot be explained solely by extreme opposite scores of the potentially overeating children at the other end of the continuum, because these differences were also apparent when we compared the fussy eaters to the moderate eaters only.
Our study confirmed the good psychometric properties of the CEBQ (14) and replicated the eight factors of the original questionnaire. These factors accounted for about 68% of the total variance, which is very similar to previous findings [14, 21]. The eight subscales showed good internal consistency. The correlational structure was generally as expected, with food approach subscales correlating positively with each other, and food avoidance subscales correlating positively with each other, but negatively with the food approach scales. One exception was the positive correlation between emotional undereating and emotional overeating that has been previously reported within the Generation R Study . Other studies also reported inconsistent findings concerning these two scales. For example, in a study by Micali and colleagues , eating more or less in response to emotional distress did not load on any of the five factors they identified in a factor analysis concerning child eating style. A possible explanation is that these two scales describe an emotional eating dimension, which is not part of the food approach - food avoidance continuum. Further research is needed to confirm this hypothesis.
Some limitations of this study should be mentioned. Information about child eating behavior was only available for 67% of the participants who gave consent for the preschool phase of Generation R. As expected and typical in population-based studies, non-responders were potentially more problematic families with lower SES, younger mothers, and more single mothers, which may reduce generalizability of our findings. Most importantly, the eating behavior profiles we identified might be typical for our low risk sample. Future studies should examine, if similar patterns can be identified in different groups.
It is well known that FFQs are not reliable in assessing the exact amount of dietary intake and total energy intake in particular , which usually leads to an underestimation of the true association with diet. However, FFQs have been proven suited to assess the relative intake, and conclusions may be drawn concerning higher or lower intake of a certain foodgroup, for example by using standardized scores. For the current study, the exact intake of each food or foodgroup was not relevant, as we aimed to describe differences in preferences between the different eating behavior groups which is based on relative differences. However, results should be interpreted with caution, because the FFQ used in this study was only validated for the Dutch population and not for the ethnic minorities included in this cohort . Also, dietary data was only available for 60% of the participants included in the LPA. Additional analyses showed that again data was more often missing for potentially problematic families with lower income, lower educational level, and more often a non-Western origin. This selection-bias indicates caution in generalizing the differences in dietary intake between fussy and non-fussy eaters to other populations.
In summary, in a large population-based study we identified a fussy eating behavioral profile in 5.6% of 4-year olds, characterized by high food fussiness, high satiety responsiveness and slowness in eating in combination with low enjoyment of food and low responsiveness to food. This fussy eater profile provides a more detailed eating behavior profile than single items and at the same time distinguishes different potentially problematic eating behavioral groups. Although the single item approach to ask mothers if they consider their child a picky eater has been shown to predict observed eating behavior to some extent  factor analytic approaches indicate that fussy/picky eating is a rather complex combination of different behaviors . Multi-item scales assessing fussy/picky eating behavior provide more detailed information about the specific behaviors that are measured, but the lack of a validated cut-off to classify fussy/picky and non-fussy/picky children limits interpretability of results and clinical implications. This profile approach may be used in future studies to better understand child eating and feeding problems and how they develop and predict later eating behavior. Also, it may eventually lead to a better tool in the diagnosis of eating problems, as fussy/picky eating might be reflected not only by high food fussiness, but rather a combination of worrisome eating behaviors, such as low enjoyment of food, slowness in eating and quickly being full. Future studies might also examine how the eating behavior profiles relate to Avoidant/Restrictive Food Intake Disorders, i.e. non-eating disorder eating disturbances characterized by food avoidance and restriction of the amount or range of food intake, which are proposed to be included in the DSM-5 . Finally, a more detailed profile of problematic eating behaviors also provides a better base for the development of prevention and intervention programs for children with feeding and eating problems that can target more specific eating behaviors which may decrease the risk of nutrient deficiencies.