Comments by Susan Carnell, Ph.D., Sarah Ann Duck, B.S., and Elena Jansen Ph.D. (May, 2024)

The Child Eating Behavior Questionnaire (CEBQ)¹ was developed by Jane Wardle and colleagues to measure individual differences in eating style in children, and to facilitate further exploration of a behavioral susceptibility model of obesity^2,3. Building on the theories of Stanley Schacter⁴ (Ingestive Classic #16) and pioneering behavioral observational research by Leann Birch and colleagues (e.g.⁵), this 35-item parent-report questionnaire contains eight sub-scales measuring different appetitive behaviors in children. Four sub-scales assess ‘food avoidant’ traits: Satiety Responsiveness (e.g. “My child has a big appetite”), Slowness in Eating (e.g. “My child eats slowly”), Emotional Undereating (e.g. “My child eats less when s/he is tired”) and Food Fussiness (e.g. “My child refuses new foods at first”). The CEBQ additionally contains four sub-scales assessing ‘food approach’: Food Responsiveness (e.g. “My child is always asking for food”), Enjoyment of Food (e.g. “My child loves food”), Desire to Drink (e.g. “My child is always asking for a drink”), and Emotional Overeating (e.g. “My child eats more when worried”). Parents respond to each question using a 5-point Likert scale (Never, Rarely, Sometimes, Often, Always) with responses scored from 1 to 5.

Critical to the value of the CEBQ as a tool for ingestive behavior research, appetitive traits as reported by parents on the CEBQ were subsequently shown to capture eating behaviors elicited during standardized behavioral tests of appetite, with one study that incorporated measures of caloric compensation and eating in the absence of hunger as well as eating rate and ad libitum intake showing that these tests in combination could explain 56% of variance in Satiety Responsiveness, 33% of variance in Food Responsiveness, and 40% of variance in Enjoyment of Food⁶. Early and more recent work has also shown that CEBQ sub-scales demonstrate continuity throughout childhood^7-9, providing support for their trait-like quality. Further, multiple studies of children have demonstrated cross-sectional and prospective associations of CEBQ sub-scales with weight/adiposity, with the strongest positive relationship apparent for Food Responsiveness, and the strongest negative relationship for Satiety Responsiveness¹⁰.

A major advantage of the CEBQ has been its ease of use for data collection on eating behavior in large population samples, enabling well-powered tests of genetic contributions to appetitive responses. For example, early analyses of CEBQ data in a large cohort of 8–11 y old twins (Twins Early Development Study, TEDS) demonstrated that 75% of the variation in Enjoyment of Food, and 63% of the variation in Satiety Responsiveness was attributable to genetic influences¹¹. Subsequent studies using the CEBQ in the Gemini twin cohort then went on to demonstrate that Food Fussiness was 78% heritable when assessed at 3y¹². However, analyses in both Gemini and TEDS have demonstrated much greater environmental than genetic contributions for Emotional Overeating and Emotional Undereating, with the important implication that the home environment could be a promising intervention target for these behaviors^13,14. Notably, studies measuring common obesity-associated genetic variants have also demonstrated associations with appetite as assessed by the CEBQ, with one early study showing that high risk genotypes on FTO SNP rs9939609 were associated with lower Satiety Responsiveness scores in children¹⁵. Subsequent studies have also demonstrated associations between higher polygenic risk scores created by summing an individual’s number of risk alleles on multiple obesity-associated variants and lower Satiety Responsiveness¹⁶ and Slowness in Eating¹⁷ in children.

Other applications of the CEBQ to date have included its use as a tool to probe the neural underpinnings of appetite variation in children using neuroimaging (e.g.^18-20) as well as to explore the role of epigenetics^21,22 in appetite development. Alongside this work, the CEBQ has been incorporated in obesity intervention studies²³, with some emergent evidence that CEBQ sub-scale scores may moderate intervention impacts²⁴. The CEBQ is also being investigated as a potential clinical instrument to assess feeding problems in normative samples^25-27 or children showing neurodevelopmental diversity^28,29, and may also be of use in clinical conditions in which eating behavior can be affected, with consequences for disease outcomes30,31. In addition, some studies suggest that CEBQ sub-scale scores could serve as early indicators of eating disorder risk³². However, perhaps the commonest and most influential application of the CEBQ has been as a survey tool within observational studies of population samples. This work is helping to advance understanding of how socioeconomic conditions might influence eating behavior33. Further, prospective studies using the CEBQ have allowed investigation of dynamic relationships among appetite, weight, and family environment factors. Such research has been critical to advance understanding of reciprocity in parent-child feeding dynamics, such that parents not only impact child outcomes, but also adjust their feeding practices based on their child’s eating behaviors^34,35.

Demonstrating the CEBQ’s value for advancing research on ingestive behavior, on the date when this article was submitted the manuscript describing the development of the CEBQ¹ had accumulated a total of 1939 citations, creating a legacy the authors believe that its creator Jane Wardle (d. 20 October 2015), an inspirational mentor and leading behavioral scientist in multiple fields³⁶, would have been very excited to see.

References

1. Wardle, J., Guthrie, C. A., Sanderson, S. & Rapoport, L. Development of the children’s eating behaviour questionnaire. J Child Psychol Psychiatry 42, 963–970 (2001).

2. Carnell, S. & Wardle, J. Appetite and adiposity in children: evidence for a behavioral susceptibility theory of obesity. Am J Clin Nutr 88, 22–9 (2008).

3. Llewellyn, C. H. et al. Behavioural susceptibility theory: the role of appetite in genetic susceptibility to obesity in early life. Philos Trans R Soc Lond B Biol Sci 378, 20220223 (2023).

4. Schachter, S. Obesity and eating. Internal and external cues differentially affect the eating behavior of obese and normal subjects. Science 161, 751–6 (1968).

5. Birch, L. L. & Sullivan, S. A. Measuring children’s food preferences. J Sch Health 61, 212–4 (1991).

6. Carnell, S. & Wardle, J. Measuring behavioural susceptibility to obesity: Validation of the child eating behaviour questionnaire. Appetite 48, 104–113 (2007). 7. Ashcroft, J., Semmler, C., Carnell, S., van Jaarsveld, C. H. M. & Wardle, J. Continuity and stability of eating behaviour traits in children. Eur J Clin Nutr 62, 985–990 (2008).

8. Jansen, E. et al. The Development of Appetite: Tracking and Age-Related Differences in Appetitive Traits in Childhood. Nutrients 15, (2023).

9. Farrow, C. & Blissett, J. Stability and continuity of parentally reported child eating behaviours and feeding practices from 2 to 5 years of age. Appetite 58, 151–156 (2012).

10. Kininmonth, A. et al. The association between childhood adiposity and appetite assessed using the Child Eating Behavior Questionnaire and Baby Eating Behavior Questionnaire: A systematic review and meta-analysis. Obesity Reviews vol. 22 Preprint at https://doi.org/10.1111/obr.13169 (2021).

11. Carnell, S., Haworth, C. M. A., Plomin, R. & Wardle, J. Genetic influence on appetite in children. Int J Obes 32, 1468–1473 (2008).

12. Fildes, A., Van Jaarsveld, C. H. M., Cooke, L., Wardle, J. & Llewellyn, C. H. Common genetic architecture underlying young children’s food fussiness and liking for vegetables and fruit. American Journal of Clinical Nutrition 103, 1099–1104 (2016).

13. Herle, M., Fildes, A. & Llewellyn, C. H. Emotional eating is learned not inherited in children, regardless of obesity risk. Pediatr Obes 13, 628–631 (2018).

14. Herle, M., Fildes, A., Rijsdijk, F., Steinsbekk, S. & Llewellyn, C. The Home Environment Shapes Emotional Eating. Child Dev 89, 1423–1434 (2018).

15. Wardle, J. et al. Obesity associated genetic variation in FTO is associated with diminished satiety. Journal of Clinical Endocrinology and Metabolism 93, 3640–3643 (2008).

16. Llewellyn, C. H., Trzaskowski, M., Van Jaarsveld, C. H., Plomin, R. & Wardle, J. Satiety mechanisms in genetic risk of obesity. JAMA Pediatr 168, 338–344 (2014).

17. Steinsbekk, S., Belsky, D., Guzey, I. C., Wardle, J. & Wichstrom, L. Polygenic risk, appetite traits, andweight gain in middle childhood a longitudinal study. JAMA Pediatr 170, (2016).

18. Bohon, C. Brain response to taste in overweight children: A pilot feasibility study. PLoS One 12, (2017).

19. English, L. K. et al. Food portion size and energy density evoke different patterns of brain activation in children. American Journal of Clinical Nutrition 105, 295–305 (2017).

20. Chen, L., Thapaliya, G., Papantoni, A., Benson, L. & Carnell, S. Neural correlates of appetite in adolescents. Appetite 191, (2023).

21. Harris, H. A. et al. An epigenome-wide association study of child appetitive traits and DNA methylation. Appetite 191, 107086 (2023).

22. Gardner, K. R., Sapienza, C. & Fisher, J. O. Genetic and epigenetic associations to obesity-related appetite phenotypes among African-American children. Pediatr Obes 10, 476–82 (2015).

23. Boutelle, K. N. et al. Role of appetitive phenotype trajectory groups on child body weight during a family-based treatment for children with overweight or obesity. Int J Obes 43, 2302–2308 (2019).

24. Ruggiero, C. F., Hohman, E. E., Birch, L. L., Paul, I. M. & Savage, J. S. INSIGHT responsive parenting intervention effects on child appetite and maternal feeding practices through age 3 years. Appetite 159, (2021).

25. Rendall, S., Dodd, H. & Harvey, K. Behavioural validation of a parent-report measure of child food fussiness. Appetite 154, 104796 (2020).

26. Piloquet, H., Berge, B., Maigret, P. & Hospital, V. Food fussiness is associated with family environmental factors in 1-3-year-old children: A large-scale cross-sectional study. Appetite 192, 107043 (2024).

27. Steinsbekk, S., Sveen, T. H., Fildes, A., Llewellyn, C. & Wichstrøm, L. Screening for pickiness - a validation study. Int J Behav Nutr Phys Act 14, 2 (2017).

28. Calisan Kinter, R. et al. The Sensory Profiles, Eating Behaviors, and Quality of Life of Children with Autism Spectrum Disorder and Avoidant/Restrictive Food Intake Disorder. Psychiatric Quarterly 95, 85–106 (2024).

29. Dovey, T. M., Kumari, V. & Blissett, J. Eating behaviour, behavioural problems and sensory profiles of children with avoidant/restrictive food intake disorder (ARFID), autistic spectrum disorders or picky eating: Same or different? European Psychiatry 61, 56–62 (2019).

30. Papantoni, A. et al. Appetitive characteristics in children with cystic fibrosis: Questionnaire validation and associations with nutritional status. Appetite 139, 90–94 (2019).

31. Duck, S. A. et al. Parental perceptions of body weight and appetite in infants and toddlers with cystic fibrosis. Appetite 198, 107357 (2024).

32. Derks, I. P. M. et al. Early childhood appetitive traits and eating disorder symptoms in adolescence: a 10-year longitudinal follow-up study in the Netherlands and the UK. Lancet Child Adolesc Health (2024) doi:10.1016/S2352-4642(23)00342-5.

33. Jansen, E., Williams, K. E., Mallan, K. M., Nicholson, J. M. & Daniels, L. A. Bidirectional associations between mothers’ feeding practices and child eating behaviours. Int J Behav Nutr Phys Act 15, 3 (2018).

34. Mallan, K. M. et al. Feeding a Fussy Eater: Examining Longitudinal Bidirectional Relationships Between Child Fussy Eating and Maternal Feeding Practices. J Pediatr Psychol 43, 1138–1146 (2018).

35. Kininmonth, A. R., Smith, A. D., Llewellyn, C. H. & Fildes, A. Socioeconomic status and changes in appetite from toddlerhood to early childhood. Appetite 146, 104517 (2020).

36. The Guardian. Jane Wardle obituary. The Guardian (2015).