This is the first study to use the CEBQ instrument in a preschool sample including children as young as 1 year old, offering unique opportunities to measure eating behaviours very early in life and to analyse their variation with age in the age bracket 1-6 years. We have shown that the Swedish version of the CEBQ has good psychometric properties in terms of factor structure, internal reliability and correlations between subscales, similar to the original UK study and two other validation studies on Dutch and Portuguese samples [18, 19, 22].
The factor analysis showed that a seven factor structure was the best solution in our sample, combining two of the 'food-approach' scales, 'emotional overeating' and 'food responsiveness' into one ('overeating'), confirming the factor structure of the previous Dutch study . Several items that originally belonged to the 'food responsiveness' scale had loadings above 0.4 on both the 'overeating' and 'food responsiveness' scales, but these were retained on the 'overeating' scale, optimizing the internal reliability. The single item that loaded onto a separate factor was disregarded since one item is not sufficient to describe a dimension of eating behaviour. We chose to use the resulting seven-factor structure in the statistical analyses, rather than the original structure, since it fitted our sample the best and comparisons with other validation studies were still applicable. However, using the original structure would have been an option as the internal reliability was only marginally lower.
Since this study included children as young as 1 year old up to 6 years old, we found age effects for several of the scales that interestingly differed for some of the eating behaviours compared to previous studies. The 'food-approach' behaviours 'overeating' and 'enjoyment of food' was less present in the older preschool children, whereas these scales previously have been seen to increase with age from 2-3 years of age [18, 23]. We also observed that 'food fussiness' was more present in older children, whereas this eating behaviour did not vary by age in the original study (study population 3-9 years) and in general is thought to decrease with age after the preschool period [18, 23]. As previous studies did not include children as young as 1 year old this may explain our results. Food neophobia, which is described as the reluctance to eat new food, normally starts to develop in children from the age of 18 months, reaches a peak between 2 and 6 years of age and then gradually decreases with age (and with repeated food exposures) [26, 32, 33]. Food neophobia is measured as part of the CEBQ scale 'food fussiness', which has been shown to be negatively correlated with both 'enjoyment of food' and 'food responsiveness' [18, 19]. It would be logical that these eating behaviours have opposite patterns also in variation with age. Since our study did not include school-age children, we suggest that the youngest children might have a lower neophobic behaviour as well as the highest scores for 'enjoyment of food'. A higher presence of 'overeating' in younger children may seem somewhat surprising though, since in theory children's ability to self-regulate how much to eat normally decreases with age . However, the 'overeating' scores were quite low for all children in our sample, and thus the identified difference with regard to age may be of less importance. Similar to previous findings, we could report that the behaviour 'emotional undereating' decreased with age, implying that as children grow older the negative effect of emotions, such as anger and tiredness, on how much the children eat gradually diminishes.
Boys and girls did not differ in eating behaviours, which was comparable with the original study that only saw minimal gender differences . In older (adolescent) children, it has been reported that boys and girls have different eating styles, however it is not known at what age these differences start to develop .
Our study could not identify any associations between eating behaviours and the children's relative weight (BMI SDS) - in contrast to previous research [18–20, 22]. A plausible explanation is a lack of power, our sample was quite small and weight homogeneous. Other studies analysing associations between relative weight and eating behaviours have had a reasonable share of overweight/obese children in their study samples [19–22, 35]. On the other hand we found a significantly higher relative weight among children having one obese or two overweight parents. This result is not surprising since parental weight has been identified as a dominating risk factor for obesity in children and weight is highly heritable [1, 2, 36, 37], but it is in contrast to the previous CEBQ studies [18–20, 22]. However, the associations between eating behaviours and the children's relative weight have not been controlled for parental weight in several of the previous studies [19, 20, 22].
Interestingly, the parents' BMI correlated with certain eating behaviours. Mothers with higher BMI had children with lower scores for the 'food avoidant' scales 'emotional under-eating' and 'food fussiness' and fathers with higher BMI had children showing higher 'overeating' scores. This confirms previous research on the effect of parental weight on children's eating behaviours. In one study, comparing eating behaviours in preschool children to lean and obese parents, children with obese parents showed higher emotional overeating and food responsiveness . The relation between maternal BMI and their sons emotional eating has been seen to be mediated by maternal eating behaviour in a German population of preschool children . There are additional evidence for associations between different aspects of parental behaviour (parents' own eating behaviours, parental feeding practises and parenting style) and children's eating behaviours [13, 39]. The identified association between parental and child relative weight could as suggested above partly be explained by genetic factors where one possible pathway is through inherited appetitive traits, which also could explain our associations between parental relative weight and children's eating behaviours . In measuring children's eating behaviours it thus appears to be important to take into account both familial predisposition to obesity as well as parental behavioural influence .
This study has some limitations that should be acknowledged. The parents' weight and height were self-reported. Self-reports are known to underestimate BMI, especially among females, but there are epidemiological studies showing that self-reported weight and height in adults has been reliable for recognizing associations . The sample of children for which relative weight was available was small and weight homogeneous, with a negative impact on the possibility to detect associations between eating behaviours and child weight. The external validity may also be limited to a high SES population, due to a large share of parents with high educational level in our sample. Finally, regarding the applicability of the questionnaire for children under 2 years of age, there is a possibility that parents with younger children may have found some items less relevant when describing their child's eating behaviour, with a potential effect on their responses. We chose to use the CEBQ even though it was originally developed and validated on children above 2 years old since we found it to be the most suitable tool available . In addition, approval to use the questionnaire and confirmation that it could be applicable for children under 2 years of age was obtained from the developer of the instrument (prof. Wardle). Our study also confirmed that the factor structure of the CEBQ was unaffected by the youngest children. However, as this study has been completed the authors have become aware that a CEBQ version for toddlers is being developed by the same group (unpublished).
In this study the eating behaviours were assessed among young children only at one occasion. However, the outcome in terms of overweight can only be detected in longitudinal studies, where eating behaviours are measured repeatedly. Eating behaviours would also be an applicable outcome in interventional studies, where parents' knowledge about children's eating behaviours and parents' feeding practices can be targeted. Future research will focus on longitudinal associations between parental feeding behaviour and child eating behaviours in groups with different predisposition to obesity.