Associations between dietary patterns, eating behaviours, and body composition and adiposity in 3‐year‐old children of mothers with obesity

The relationships between eating habits, behaviours, and the development of obesity in preschool children is not well established.

slowness in eating was associated with lower measures of body composition. These novel findings highlight modifiable behaviours in high-risk preschool children which could contribute to public health strategies for prevention of childhood obesity. England suggest that nearly a quarter of preschool children were overweight or had obesity, 1 with one in 40 children being affected by severe obesity. Obesity in early life is a predictor for adolescent and adulthood obesity, 2-4 with a recent meta-analysis of 37 studies reporting that children classified as having obesity using body mass index (BMI) were five times more likely to have obesity as adults compared with their healthy weight counterparts. 5 Worldwide, there is intense focus on reducing rates of childhood obesity. 6,7 The UK government recommend creating healthier food environments in schools, local areas, and providing parents with information on healthy food choices for their families with the aim of halving rates of childhood obesity by 2030. 6 Several studies have independently suggested a relationship between eating behaviours [8][9][10][11] or dietary intake 12,13 and body composition in childhood. Associations between weight status in early life and food approach eating behaviours, such as food responsiveness and emotional overeating and consumption of energy dense foods, have consistently been reported. Longitudinal studies suggest that eating habits and food choices established in childhood are likely to persist into adulthood. [14][15][16][17][18] Therefore, the early years provide a unique opportunity to develop and establish healthy eating habits and behaviours.
Since current guidelines for prevention of childhood obesity recommend identification of populations at risk and early engagement, 6,7 we have addressed relationships between dietary habits and behaviours and childhood adiposity in children born to mothers with obesity.
As recently reported by ourselves in a contemporary cohort, 19 and previously in many mother-child cohort studies, children of mothers with obesity are at high risk of developing obesity themselves. 20 The primary aims of this study were to investigate (a) associations  The intervention had no effect on the primary outcomes of gestational diabetes and large for gestational age infants. However, it was effective at improving maternal dietary intake, reducing gestational weight gain, and sum of skinfolds and increasing self-reported physical activity by 36 weeks gestation (all P ≤ .04). In the infants at 6 months of age, we have reported that the intervention was associated with a reduction in a measure of adiposity; 23   The child's diet was assessed using an 85-item food frequency questionnaire (FFQ). The list of food and drink items were compiled from the 80-item validated Southampton Women's Survey FFQ. 25 In addition, three questions were extended to include culturally appropriate options, eg, "Rice-boiled & fried" extended to "Rice-boiled & fried jollof, rice and peas." Five extra food items were included which were culturally appropriate for the non-white ethnic subgroups in the UPBEAT cohort (black-including Afro Caribbean and African) ( Table S1). The FFQ asked how often in the last 3 months the child had consumed each item with response options including never, less than once per month, one to three times per month, number of times per week (1-7), or more than once per day. If the item was consumed more than once a day, the number of times was recorded. Food and drink items consumed more than once a week which were not included in the FFQ were recorded as additional items. Type of milk consumed as a drink or added to cereal and sugar added to drinks and cereal was also collected.
Dietary patterns of the children were derived using factor analysis.
Food and drink items listed in the FFQ were categorized into 39 groups based on similar nutritional composition. On the basis of frequency consumption, three items recorded as additional foods were also included: porridge/shredded wheat, fast food (McDonalds, Burger King, and KFC), and cereal bars (Table S1). Factor analysis with orthogonal varimax rotation was performed to derive the patterns using the children's weekly  (Table S2); this cut-off was selected so that each dietary pattern had equal distribution of food groups. Food groups with a factor loading coefficient ≥ ±0.32 were considered to have a strong association with that factor. Derived dietary pattern labels were selected based on foods with the highest factor loadings (≥±0.32).

| Children's Eating Behaviour Questionnaire
The Children's Eating Behaviour Questionnaire 26 (CEBQ) is a validated parent-reported psychometric method to assess child's eating style and behaviour. 27 The questionnaire consists of 35 items divided into eight eating behaviours, further subdivided into food approach and food avoidance questions rated on a 5-point Likert scale (Never = 1, Rarely = 2, Sometimes = 3, Often = 4, Always = 5). Seven questions were reverse scored. Food approach behaviours include food responsiveness, emotional overeating, enjoyment of food, and desire to drink; food avoidance behaviours were satiety responsiveness, slowness in eating, emotional undereating, and food fussiness. Higher scores indicate a higher level for the respective eating style.

| Anthropometric measures and body fat percentage
The outcomes of interest for the offspring were measures of body composition and adiposity assessed by sum of skinfold thicknesses (addition of triceps, bicep, subscapular, suprailiac, and abdominal skinfolds, measured in triplicate by trained research staff using children's Holtain skinfold callipers), mid-upper arm and waist circumferences, body fat percentage assessed by ImpediMed Imp SFB7 bioelectrical impedance analysis (BIA) and weight, height, and BMI z scores derived using the World Health Organization (WHO) reference data. 28 Childhood obesity was defined by International Obesity Task Force (IOTF) sex-specific centiles (boys obesity = 98.9th centile and girls obesity = 98.6th centile). 29

| Maternal variables
We also addressed relationships between maternal social and demographic variables (maternal age at trial entry, ethnicity, socio-economic status, years in full-time education, and early-pregnancy BMI) and offspring eating habits.

| Statistical analysis
In this secondary analysis of the UPBEAT study, there was no effect of the intervention on offspring eating patterns or behaviours; therefore, the data were treated as a cohort. Demographic results were expressed as mean ± standard deviation, median, and interquartile range or percent 3 | RESULTS Figure 1 shows a flow chart of participants through the study. Five hundred fourteen children (33.0% of the original UPBEAT cohort) were followed up at age 3 years (3.5 ± 0.28 years). Four hundred ninety (95%) provided complete dietary data (FFQ and CEBQ), eight children were excluded as they were either born ≤34 weeks gestation or were suffering from severe illness; therefore, the study population comprised 482 children. Data for the majority of measures of anthropometry had less than 5% missingness except for BIA (20%) and sum of skinfolds (23%). Of the 482 included children, 243 (50%) were female and 234 (49%) were born to mothers who were randomized to the UPBEAT intervention arm. Mean maternal age was 31.2 ± 5.2 years; 68% were white, 23% were black African/Caribbean, and 9% were from Asian or other ethnic backgrounds. Seventy-six percent were from the index of multiple deprivation quintiles 4 and 5 (most deprived). One hundred sixty-five of the children (34%) were overweight or had obesity, and 6% were morbidly obese (defined using the IOTF sex-specific centiles 29 ). For the WHO z scores, the average height-for-age, weight-for-age, and weight-for-height were above the mean of the reference population 0.38 ± 1.1, 0.83 ± 1.0, and 0.90 ± 1.0, respectively (Table 1).

| Dietary pattern analysis
Factor analysis identified three dietary patterns in the children, summarized in Figure S1 with the full list of factor loadings shown in Table S2. The first dietary pattern was labelled "healthy/prudent" due to high loadings (≥0.32) on brown bread, boiled and baked potatoes, rice and pasta, fish, vegetables, beans and pulses, fruit (fresh, tinned, and dried), and nuts. The second dietary pattern was characterized as a diet high in white bread, crisps and savoury snacks, roast potatoes (including chips), processed foods, quiche and pizza, confectionary, desserts, cakes, biscuits, and low and high sugary drinks, and this pattern was termed "processed/snacking." The third pattern, "African/Caribbean," was characterized by yam/cassava/plantain, red meat, chicken and turkey, soups (including African and Caribbean soups) and rice/pasta, fish, and offal and was low in cheese, yoghurts, and spreads.

| Maternal demographics
In a univariate analysis (model 1), different maternal social and demographic characteristics were associated with the three childhood dietary patterns. A higher number of years in full-time education and a higher maternal age were associated with the child having a higher score on a healthy/prudent dietary pattern. Fewer years in full-time education, lower maternal age, and having a white mother were associated with the child having a higher score on a processed/snacking dietary pattern.
Having a black mother and a greater deprivation defined by index of multideprivation were associated with the child having a high score on an African/Caribbean dietary pattern (Table S3, all P < .05).

| Dietary patterns and anthropometric measures and body fat percentage
In the adjusted regression model (model 2), the healthy/prudent dietary pattern was associated with a −1.76 cm (95% confidence interval, −3.30 to −0.14, P = .03) lower sum of skinfolds. The processed/ snacking pattern was associated with a higher odds of obesity

| Eating behaviour and body composition
There were no differences in the CEBQ scores according to gender or mode of infant feeding (Tables S4 and S5). For the food approach scales, following adjustment for confounders, lower enjoyment of food, and food responsiveness were associated with lower arm and waist circumferences, weight-for-age, weight-for-height, and BMI z scores and obesity (all P < .006, Figures 2 and 3). For the food avoidance scales, greater slowness in eating and satiety responsiveness were associated with a lower BMI z score, a lower odds of obesity, weight-for-age, weight-for-height, and height-for-age z scores and arm and waist circumferences (all P < .009, Figures 2 and 3).
Food fussiness was associated with a lower BMI, odds of obesity, and weight-for-height z score (all P < .002, Figures 2 and 3). Emotional undereating was not associated with any measures of body composition or adiposity; emotional overeating was only associated with weight-for-height z score (P = .02). Body fat percentage and sum of skinfolds were not associated with any of the eating behaviour subscales (data not shown).
Grouping the children by BMI class, an obese BMI (IOTF BMI centile cut-off equivalent to ≥30 kg/m 2 ) vs healthy, after adjustment for confounders, the children with obesity showed higher food approach scales scores for food responsiveness (P = .001), enjoyment of food (P = .02), and desire to drink (P = .03). In contrast, the food avoidance scale, slowness in eating, and satiety responsiveness (P < .008) were inversely associated with obesity (Table 3, Figure S2).

| DISCUSSION
This study uniquely explores associations between dietary patterns and eating behaviours with BMI and measures of adiposity in 3-yearold children born to mothers with obesity from high social deprivation and ethnically diverse backgrounds.
Children with obesity had higher scores on a processed/snacking dietary pattern defined as a diet high in confectionary, crisps, processed foods, cakes, and biscuits and greater food approach and less food avoidance eating behaviours. Dietary intake and body composition analyses in children have hitherto focused on specific food groups, such as sugar-sweetened beverages, 30 high sugar/fat snacks, 31 or fruit and vegetable intake. 32 However, dietary patterns reduces dietary data into fewer variables by combining highly correlated food groups; therefore, they may better define an individual's habitual diet as they attempt to describe the whole diet rather than description of specific nutrients or foods. 33 Whilst several studies have addressed relationships between dietary patterns and obesity in older children, 34     Similarly to dietary patterns, eating behaviours developed in early life track through childhood. 42 The validated CEBQ questionnaire has greatly facilitated studies of relationships between appetite traits and body composition. 18,26,43 Using this questionnaire, food responsiveness and enjoyment of food were associated with higher arm and waist circumferences, weight-for-age, weight-for-height, and BMI z scores and higher odds of obesity. In contrast, slowness in eating and satiety responsiveness were inversely associated with the same measures of body composition, suggesting that these traits are protective against an obesogenic environment. Importantly, slower eating is a modifiable eating style which may reduce excessive weight gain in childhood. The associations between enjoyment of food and food responsiveness and increased body composition and rates of obesity are consistent with previous studies, suggesting that children with overweight or obesity are more responsive to food cues, [44][45][46] but amongst these, the only report of children at a similar age to this study was from an Australian cohort of 2-to 5-year-old children, although the results were based on parent-reported measurements. 46 In agreement with BASELINE, an observational study in 1189 two-year-old children from Ireland, 43 we did not find associations between emotional undereating/overeating and desire to drink and measures of body composition. This could be because the children were too young to display emotion in relation to eating habits.
Although in older children, a similar lack of an association has been found. 47 This may imply that these three measures from the CEBQ do not have a major impact on body composition and adiposity compared with the other subscales.
The offspring of mothers with obesity are particularly at risk of obesity, and this is the first study to address dietary patterns and eating behaviours associated with obesity in such children. As previously described by ourselves 19   Lastly, our study was observational, so causality of the associations cannot be assumed.
In summary, we found that food approach eating behaviours and a diet high in processed and snacking foods were associated with obesity and measures of body composition at 3 years of age in children of mothers with obesity. Conversely slower eating, a "healthy/prudent" or a traditional "African/Caribbean" diet was associated with lower rates of obesity or adiposity. This study provides evidence for potentially modifiable determinants and adds credence to the view that promoting healthy food alternatives and eating behaviours should be

ACKNOWLEDGEMENTS
We thank all staff in the UPBEAT consortium, and we are most grateful to all the women and their children who took part in the UPBEAT study.