Eating Behaviour among Multi-Ethnic Adolescents in a Middle-Income Country as Measured by the Self-Reported Children’s Eating Behaviour Questionnaire

Mohamed Z (2013) Eating Behaviour among Multi-Ethnic Adolescents in a Middle-Income Country as Measured by the Self-Reported Children's Eating Behaviour Questionnaire. PLoS ONE 8(12): e82885. doi:10.1371/journal.pone.0082885 Eating Behaviour among Multi-Ethnic Adolescents in a Middle-Income Country as Measured by the Self-Reported Children's Eating Behaviour Questionnaire Debbie Ann Loh 0 Foong Ming Moy 0 Nur Lisa Zaharan 0 Zahurin Mohamed 0 Mari Alemany, University of Barcelona, Faculty of Biology, Spain 0 1 Julius Centre University of Malaya, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, 2 Department of Pharmacology, Faculty of Medicine, University of Malaya , Kuala Lumpur , Malaysia Background: Escalating weight gain among the Malaysian paediatric population necessitates identifying modifiable behaviours in the obesity pathway. Objectives: This study describes the adaptation and validation of the Children's Eating Behaviour Questionnaire (CEBQ) as a self-report for adolescents, investigates gender and ethnic differences in eating behaviour and examines associations between eating behaviour and body mass index (BMI) z-scores among multi-ethnic Malaysian adolescents. Methodology: This two-phase study involved validation of the Malay self-reported CEBQ in Phase 1 (n = 362). Principal Axis Factoring with Promax rotation, confirmatory factor analysis and reliability tests were performed. In Phase 2, adolescents completed the questionnaire (n = 646). Weight and height were measured. Gender and ethnic differences in eating behaviour were investigated. Associations between eating behaviour and BMI z-scores were examined with complex samples general linear model (GLM) analyses, adjusted for gender, ethnicity and maternal educational level. Results: Exploratory factor analysis revealed a 35-item, 9-factor structure with 'food fussiness' scale split into two. In confirmatory factor analysis, a 30-item, 8-factor structure yielded an improved model fit. Reliability estimates of the eight factors were acceptable. Eating behaviours did not differ between genders. Malay adolescents reported higher Food Responsiveness, Enjoyment of Food, Emotional Overeating, Slowness in Eating, Emotional Undereating and Food Fussiness 1 scores (p<0.05) compared to Chinese and Indians. A significant negative association was observed between BMI z-scores and Food Fussiness 1 ('dislike towards food') when adjusted for confounders. Conclusion: Although CEBQ is a valuable psychometric instrument, adjustments were required due to age and cultural differences in our sample. With the self-report, our findings present that gender, ethnic and weight status influenced eating behaviours. Obese adolescents were found to display a lack of dislike towards food. Future longitudinal and qualitative studies are warranted to further understand behavioural phenotypes of obesity to guide prevention and intervention strategies. - Funding: This study was supported by the High Impact Research (HIR) Grant from the Ministry of Higher Education, Malaysia (HIR MOHE E000049-20001) and the University of Malaya Research Grant (RG466/12HTM) from University of Malaya. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Countries across the spectrum of development are grappling with burgeoning rates of childhood obesity [1,2] although recent evidence of plateauing prevalence in few countries has emerged [3]. Chronic obesity-related diseases previously diagnosed among adults have now emerged among paediatric populations [1,4,5]. Malaysia, a developing, middle-income and ethnically diverse country situated in South-East Asia, is likewise experiencing a concomitant rise in paediatric obesity [6,7]. The National Health and Morbidity Survey (NHMS IV) in 2011 reported that on a national level, 6.1% of Malaysian children and adolescents aged below 18 years were obese [8]. While eating is a necessity for survival, food intake beyond energy requirements in todays obesogenic environment is common, leading to consumption largely stimulated by pleasure (hedonic hunger) rather than physiological hunger [9]. Interestingly, not all individuals become obese, some remain lean despite increased food intake. Differences in heritable neurobehavioural and psychological traits affecting eating behaviours may explain a greater predisposition or resistance to weight gain observed among individuals [10]. Eating behaviour is influenced by both internal and external determinants including food availability, knowledge, attitudes, emotional state and experiences of the individual [11]. Profiles of eating behaviours that predict weight status is a growing area of research. Although experimental laboratory studies are objective measures of eating behaviour, it is often impractical for large-scale research due to external factors present during the test, a limited number of participants allowed and the cost of setup [12]. The development of several psychometric tools has made epidemiological studies on eating behaviour possible. The most comprehensive tool currently identified is the Childrens Eating Behaviour Questionnaire (CEBQ) developed by Wardle and colleagues [13]. The CEBQ is a 35-item questionnaire, originally designed as a parent-report to measure eating behaviour traits related to obesity risk among children aged below 12 years old. All items were developed from a combination of literature review and interviews with parents [13]. The CEBQ contains eight dimensions of eating styles; four subscales that measure foodapproach behaviours [Food Responsiveness (FR), Enjoyment of Food (EF), Emotional Overeating (EOE), Desire to Drink (DD)] and another four subscales that reflect food-avoidant behaviours [Satiety Responsiveness (SR), Slowness in Eating (SE), Emotional Undereating (EUE) and Food Fussiness (FF)]. FR reflects response to environmental food cues while EF refers to a general interest in food, traits strongly observed in overweight or obese children [12,13]. EOE and EUE represent fluctuating food intake during negative emotional states. BMI in children has been positively associated with EOE and negatively associated with EUE [14-17]. DD represents the desire to drink liquids, particularly sugar-sweetened beverages (SSBs) [13]. Frequent consumption of SSBs have shown strong positive associations with BMI [18]. SR reflects the ability to regulate food intake according to internal satiety cues. Overweight and obese individuals tend to allow external food cues to override internal satiety signals [12]. A reduced eating speed due to a lack of enjoyment and decreased interest in food characterises SE. Obese children tend to eat faster towards the end of a meal [19]. FF is described as being highly selective of foods resultin (...truncated)