Edited by: Kelly Costello Allison, University of Pennsylvania, USA
Reviewed by: Nicholas T. Bello, Rutgers, The State University of New Jersey, USA; Scott Gregory Engel, Neuropsychiatric Research Institute, USA
Specialty section: This article was submitted to Eating Behavior, a section of the journal Frontiers in Nutrition
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Children’s eating behaviors are influenced by parents, who are the first nutritional educators. The comprehensive feeding practices questionnaire (CFPQ) was developed to measure feeding practices among parents, but has not yet been validated in Brazil, where child obesity rates are steeply increasing. The aim of the study was to test the validity of the CFPQ among Brazilian parents of school-aged children and propose a new version of the instrument.
Transcultural adaptation included translation into Portuguese, back translation, content validity, testing for semantic equivalence, and piloting. Questionnaire data were obtained for 659 parents of 5- to 9-year olds. Confirmatory and exploratory factor analyses and psychometric analyses (tests for internal consistency, factor correlations, item-discriminant and convergent validity, and test–retest reliability) were conducted.
Confirmatory factor analysis demonstrated a poor fit of the data to the original 12-factor model. Exploratory factor analysis generated a 6-factor model composed of 42 items: healthy eating guidance, monitoring, restriction for weight control, restriction for health, emotion regulation/food as reward, and pressure. This factor solution was supported by internal consistency tests (α = 0.71–0.91) and factor correlations (ρ = −0.16 to 0.32). Item-discriminant and convergent validity tests showed that parents who used coercive practices had more overweight children and were more concerned about their child’s weight (ρ = 0.09–0.40). Test–retest reliability was acceptable (intraclass correlation coefficient = 0.45–0.77).
Since parental practices are highly culturally and age group sensitive, it is essential to conduct careful evaluations of questionnaires when introduced into specific age groups within new cultural settings. This modified six-factor model of the CFPQ is valid to measure parental feeding behaviors of school-aged children in urban Brazilian settings.
The Brazilian population, like most societies in the world, is experiencing a nutritional transition, characterized by high intake of ultra-processed foods, such as artificial juice, soft drinks, and sugary snacks, over natural food intake, such as rice, beans, fruits, and vegetables (
Overall, children learn very early about the food context and are highly influenced by the family. Parents are the child’s first nutritional educators, and shape children’s food environments, and thereby their eating behavior (e.g., food preferences, food intake self-regulation) via factors such as accessibility and availability of healthy and unhealthy food; modeling and teaching about nutrition; coercive practices, such as excessive control, restriction, pressure to eat; non-nutritive feeding practices such as using food as a reward; and responsiveness to the child’s internal signs of hunger and satiety (
Since 2001, the child feeding questionnaire (CFQ) has been the most widely used instrument to measure feeding practices, assessing parental restriction, monitoring, and pressure to eat (
Despite the importance of understanding feeding practices in Brazil, a young, culturally diverse country where feeding practices may be different than in other countries due to factors, such as tradition, religion practices, and social demands (
The aim of the current study was, therefore, to test the validity of the CFPQ within a large sample of Brazilian parents of 5- to 9-year olds enrolled in private schools, and to derive an optimized version of the instrument. This age group is especially interesting because as the child matures and starts to eat outside the home environment, relationships with parental feeding change. Although these children are more independent than younger ages and more exposed to external influences, such as school, friends, advertisement, and other environment determinants, they are still very affected by parents’ attitudes and practices regarding eating behavior and food choice (
This study of Brazilian parents of 5- to 9-year olds was composed of two phases: (1) transcultural adaptation of the CFPQ and (2) psychometric analyses including confirmatory and exploratory factor analyses, and tests for internal consistency, factor correlations, item-discriminant and convergent validity, and test–retest reliability.
To estimate sample size, we used the Gorsuch (
For practical reasons, participants were recruited from private schools in the cities of Campinas and São Paulo, via email or telephone, followed by a meeting with the schools’ headmaster and/or coordinator. Seventeen of the 48 contacted schools accepted the invitation to participate in the study. Two of these schools participated in a pilot study, and the remaining 15 participated in the main study. One of these 15 remaining schools also participated in a test–retest reliability procedure.
This research received ethical approval from the Federal University of São Paulo (UNIFESP) Ethics Committee.
Study researchers made contact with the corresponding author of the original scale asking for permission to translate and validate it into Portuguese, and agreement was obtained. Transcultural adaptation was initialized with the translation of the CFPQ into Portuguese by three pediatric nutrition researchers fluent in English. A back translation was then made by a translator blind to the original version of the CFPQ. The same three researchers then translated the questionnaire into Portuguese a second time, in order to improve understanding and to reduce confusion regarding terminology (
After this step, the Portuguese version of the CFPQ was emailed to 11 dietitians, to evaluate its content validity. All the comments/suggestions were compiled and discussed in a 2-h expert panel session, resulting in a slightly modified version of the questionnaire (e.g., changes in the order of some sentences, and replacement of specific words, such as “to regulate” for “to control” and “to discuss” for “to talk”). Semantic equivalence of the new version was then tested in 11 parents of index children drawn at random from two classrooms within one of the selected schools, and some items were modified based on parents’ answers/understanding (e.g., replacement of specific words, such as “to ensure” for “to confirm”).
First, in order to expose any difficulties with questionnaire completion and increase data accuracy, we conducted a pilot study in two of the participating schools. This identified several aspects that needed to be changed to increase comprehension and specificity (e.g., changes in the order of some sentences’ and replacement of specific words/expressions, such as “to encourage” for “to promote” and “the food tastes good” for “the food is tasty”).
After piloting, we conducted the main study. Survey packets including information letters, consent forms, and self-administered questionnaires were left in each classroom at each participating school to be distributed to eligible children, with instructions to bring them home to be completed by one of the parents within 2 weeks. In one of the schools, the survey packets were administered and completed by parents before a parents and teachers meeting. Parent-report anthropometric information was obtained within the survey packet. All returned questionnaires were examined for inconsistencies and missing answers using a consistent protocol performed by two trained researchers. Parents were called up to three times to resolve ambiguous responses. In case of missing phone numbers or parents not picking up, the data were entered as “missing” in the database. Missing data in the CFPQ led to child exclusion.
Finally, one of the participant schools was selected to examine test–retest reliability. After 2 weeks, respondent parents received the CFPQ to be answered again. This interval was chosen to limit the likelihood that feeding practices would have changed with child age, and to reduce the chance of participants’ responding primarily based on recall of their first set of answers (
Confirmatory, followed by exploratory factor analysis, was conducted on the 12-factor original model (
Item-discriminant validity was assessed by running Mann–Whitney’s tests, comparing scale means with indices of children’s food intake. For this, we used low and high intakes of ultra-processed food (i.e., fast food, instant noodles, soft drink, artificial juice, chips, sugared snacks, breakfast cereal, chocolate milk, crackers/biscuits/cakes with and without topping, ice cream/popsicles, dairy desserts, and processed meat) as determined by median intake from the food frequency questionnaire (FFQ).
Convergent validity was assessed by running Spearman’s correlations between both original and proposed scales and three related attitude scales derived from Birch et al. (
Finally, test–retest reliability was assessed by calculating intraclass correlation coefficients (ICCs), for each factor within both the original and the proposed factor solution, with scales considered reliable if ICC values were >0.40. Also, Bland–Altman’s graphs were created using MedCalc for Windows, version 15.2.2 (
Data were entered twice and analyzed using Stata version 12.0 (
Of the total of 1430 survey packets distributed, we received 730 completed questionnaires (51.0%). Of the remaining 700, 671 were not returned, 23 had missing data on the CFPQ, and six had essential demographic and anthropometric information missing. Of the completed 730 questionnaires, 34 were excluded due to index children having siblings in the same age group, to avoid sample over-representation of those family units (in case of siblings, the youngest child was included; in case of twins, the child whose name began with the earliest letter in the alphabet was included), 13 for not being within the eligible age group, and 11 for reporting diseases related to nutrition and/or other conditions that might interfere with parental feeding practices, such as lactose intolerance or cow’s milk protein allergy (
Table
Demographic and anthropometric characteristics | Category | |
---|---|---|
Sex | Male | 305 (46.28) |
Female | 354 (53.72) | |
BMI/age |
Extremely underweight | 10 (1.58) |
Underweight | 11 (1.74) | |
Normal weight | 385 (60.82) | |
Overweight | 149 (23.54) | |
Obese | 65 (10.27) | |
Extremely obese | 13 (2.05) | |
Respondent | Mother | 596 (90.44) |
Father | 63 (9.56) | |
Maternal education | College completed | 567 (86.17) |
College incomplete | 44 (6.69) | |
High school completed | 38 (5.78) | |
High school incomplete | 5 (0.76) | |
Middle school completed | 2 (0.30) | |
Middle school incomplete | 2 (0.30) | |
Family’s income | Until 5 minimum wage | 43 (6.91) |
From 6 to 10 minimum wage | 113 (18.17) | |
From 11 to 15 minimum wage | 117 (18.81) | |
From 16 to 20 minimum wage | 117 (18.81) | |
More than 20 minimum wage | 232 (37.30) | |
Maternal BMI | Underweight | 12 (1.84) |
Normal weight | 424 (65.13) | |
Overweight | 172 (26.42) | |
Obese | 43 (6.61) |
Since the initial confirmatory factor analysis did not confirm the factor structure of the original CFPQ’s model in our sample, we conducted an exploratory factor analysis. Both the matrix model and scree plot (data not shown) indicated that six factors should be extracted. The exploratory factor analysis also demonstrated that seven items should be excluded: items 2, 3, 5, 18, and 49 due to factor loadings <0.3, and items 1 and 4 due to negative factor loadings. Amongst these items was the entire “child control” factor from the original model. The final 6-factor model comprised 42 items (Supplementary Material). Factor loadings for all items were higher than 0.3 (0.41–0.88) (Figure
Derived factors were as follows:
Spearman’s correlations revealed low correlations between factors (ρ = −0.16 to 0.32) indicating no overlap (
Item-discriminant validity between factors from the original and proposed scales, and child’s ultra-processed food intake, is represented in Table
Factors | Ultra-processed food | ||
---|---|---|---|
Low intake | High intake | ||
M (SD) | M (SD) | ||
Child control | 2.56 (0.63) | 2.77 (0.69) | < |
Emotion regulation | 1.22 (0.40) | 1.30 (0.50) | |
Encourage balance and variety | 4.76 (0.38) | 4.67 (0.45) | |
Environment | 4.34 (0.62) | 3.95 (0.71) | < |
Food as reward | 1.57 (0.81) | 1.76 (0.95) | |
Involvement | 3.98 (0.93) | 3.72 (0.99) | < |
Modeling | 4.67 (0.46) | 4.57 (0.56) | |
Monitoring | 4.49 (0.67) | 4.31 (0.75) | < |
Pressure | 3.31 (0.97) | 3.30 (1.05) | 0.745 |
Restriction for health | 3.55 (1.27) | 3.82 (1.20) | |
Restriction for weight control | 2.42 (0.91) | 2.50 (0.96) | 0.348 |
Teaching about nutrition | 4.48 (0.64) | 4.47 (0.64) | 0.783 |
Healthy eating guidance | 4.52 (0.41) | 4.38 (0.43) | < |
Monitoring | 4.39 (0.62) | 4.07 (0.70) | < |
Restriction for weight control | 2.25 (0.96) | 2.31 (1.01) | 0.519 |
Restriction for health | 3.57 (1.26) | 3.82 (1.18) | |
Emotion regulation/food as reward | 1.32 (0.44) | 1.45 (0.54) | |
Pressure | 3.31 (0.06) | 3.30 (0.06) | 0.745 |
Table
Factors | Perceived responsibility for feeding | Concern about overweight | Concern about underweight |
---|---|---|---|
ρ ( |
ρ ( |
ρ ( |
|
Child control | − |
− |
− |
Emotion regulation | −0.04 (0.282) | 0.02 (0.595) | −0.01 (0.755) |
Encourage balance and variety | 0.01 (0.726) | 0.03 (0.500) | |
Environment | 0.07 (0.086) | −0.05 (0.224) | |
Food as reward | 0.02 (0.567) | 0.02 (0.642) | −0.03 (0.490) |
Involvement | 0.07 (0.086) | 0.03 (0.460) | |
Modeling | 0.05 (0.234) | 0.05 (0.161) | |
Monitoring | −0.00 (0.932) | ||
Pressure | −0.10 (0.017) | ||
Restriction for health | 0.07 (0.096) | ||
Restriction for weight Control | 0.05 (0.254) | 0.02 (0.681) | |
Teaching about nutrition | −0.00 (0.994) | −0.00 (0.989) | |
Healthy eating guidance | 0.06 (0.105) | 0.05 (0.243) | |
Monitoring | −0.03 (0.475) | ||
Restriction for weight control | 0.03 (0.448) | −0.00 (0.980) | |
Restriction for health | |||
Emotion regulation/food as reward | 0.00 (0.996) | −0.00 (0.971) | −0.03 (0.463) |
Pressure | −0.09 (0.017) |
Test–retest reliability analyses demonstrated ICC values ranging from 0.27 to 0.78 for the original scale and ICCs from 0.45 to 0.77 for the proposed scale. Satisfactory reliability was also verified by Bland–Altman’s graphs, which demonstrated randomness (data not shown).
The present paper presents the adaptation and validation of a Portuguese version of the CFPQ in a large sample of urban Brazilian parents of school-aged children. Transcultural adaptation of the questionnaire led to some small changes in sentence order and in some verbs and food names. Exploratory factor analysis produced a 6-factor model of parental feeding practices (“healthy eating guidance,” “monitoring,” “restriction for weight control,” “restriction for health,” “emotion regulation/food as reward,” and “pressure”) with a better fit for our sample.
Most of the items loaded as expected. For example, “pressure” had exactly the same composition as the original factor. This parental practice is related to lower weight in children and higher parental concern about child weight (
The original factors “emotion regulation” and “food as reward,” with the exception of one excluded item, loaded together in our factor solution, suggesting that these practices tend to cluster together in our population of interest. The use of food to regulate a child’s emotional state may lead the child to learn to use food in order to alleviate or distract from their emotions (
The most widely studied feeding practice, restriction, maintained its original structure such that separate factors emerged for “restriction for weight control” and “restriction for health.” The only exception was item 39, which loaded on the former factor in the original model but on the latter factor in the current analysis. The distinction between these two factors may be important, because, for example, restriction for health may be associated with teaching the child healthy eating habits for the future, while restriction for weight control could potentially engender weight concern and disordered food-related attitudes among children (
“Monitoring” is a practice that could be interpreted as negative, if associated with rigid, authoritarian parental control, or positive, if seen as a more authoritative, flexible way for parents to limit their children’s intake, since young children do not have full autonomy to make wise decisions (
The final extracted factor was “healthy eating guidance” – a combination of the entire original factors “encourage balance and variety,” “involvement,” “modeling,” and “teaching about nutrition” (except one excluded item) and half of the “environment” factor, all of which measure child-centered, positive feeding practices. These kinds of practices, i.e., reasoning, encouraging, complimenting, being a good example, and providing healthy food, allow the child to develop good internal self-regulation of intake (
Seven items loaded below 0.3 in the matrix model, including the entire “child control” (items 1–5) and so, were excluded. A probable explanation for this is that school-aged children become more autonomous through the years, which leads parents to gradually transfer control to them (
Item 18, which assesses the withholding of sweets/dessert from the child in response to bad behavior, was also excluded due to low factor loading, suggesting that this practice does not tend to be paired with offering their child’s favorite food to reward good behavior. Similar to the Malay validation of the CFPQ, item 49 (“I tell my child what to eat and what not to eat without explanation”) also did not load above 0.3 on any factor, including the factor it loaded on in the original CFPQ, “teaching about nutrition.” The low loading we observed may be because this item reflects a rigid form of parental control paired with a lack of concern about involving the child in the feeding interaction, which seems qualitatively different from the other two items from this scale (
Internal consistency testing demonstrated high reliability, with each factor, especially those with few modifications from the original and those with more items, demonstrating high Cronbach’s alpha values. The lowest (but still adequate value) was for “emotion regulation/food as reward” (0.71), which is a combination of two of the original factors each containing five items. In contrast to our findings, Cronbach’s alpha values for some of the original factors and for the factors emerging from other validation studies were lower than desirable (0.70), which reinforces the adequacy of our results for our particular population of interest (
Although parental feeding practices are hypothesized to correlate, correlations between factors were not substantial, indicating that each factor captures specific practices. The highest correlation was found between “restriction for health” and “restriction for weight control.” Both of these factors represent conceptually close practices, since having good health is associated with having a healthy body weight and a correlation was also observed by Musher-Eizenman and Holub (
“Healthy eating guidance” and “monitoring” were also moderately correlated (0.32). This was likely because both factors are characterized by child-centered and positive feeding practices, and parents who use positive practices tend to use them not in isolation (
Unlike some of the previous CFPQ validation studies (
We also tested item-discriminant validity, which evaluates an instrument’s discrimination capability between well-known different groups, using a construct indicator, in this case children’s ultra-processed food intake. As expected, the use of “restriction for health” and “emotion regulation/food as reward” was both related to higher intake of ultra-processed food. Both of these practices may decrease responsivity to internal satiety cues, thereby increasing energy intake, especially from sweet and fatty foods, and potentially leading to excessive weight gain (
Finally, convergent validity analyses demonstrated, as expected, that higher perceived responsibility for feeding was associated with the child-centered and positive parental practices captured by the “healthy eating guidance” and “monitoring” factors. Further, parents who reported more concern about their child being overweight also reported more restrictive feeding practices, whereas those who were concerned about their child being underweight reported more pressure to eat. There were no significant associations, however, between “emotion regulation” and “food as reward” with parental perceived responsibility and concerns. Notably, the same pattern of correlations was largely found for the original scales except that “child control” showed negative correlations with parental responsibility and concern (
We had a response rate of 46.08%, which was adequate for our statistical approach and in the expected range of 38–48% for surveys of this nature (
Our sample was composed of Brazilian families with relative high income and education. This could be seen as a limitation, since it reduces the generalizability of the results to the wider population, which, due to Brazil’s territorial extension and continental features, is largely low in socioeconomic status. However, a significant portion of the Brazilian population earns high incomes and the results of our study are comparable to this sector. Although obesity is more likely in low-income populations, we believe research in relatively high-income communities is also important, because these parents have the possibility of buying and offering whatever they wish to their children, whereas low-income parents have their purchasing power comparatively contained.
Other validations of the CFPQ have been conducted in the USA (English, 2–8 years old,
Notably, all of the validation studies, including our own, resulted in a slightly modified version of the questionnaire, likely due to differences in cultural background and/or age group (
To conclude, the present validation study used multiple methods including transcultural adaptation, test–retest reliability, factor correlations, and internal, item-discriminant, and convergent validity, to derive a modified Portuguese version of the CFPQ into for use with middle- and high-income and well-educated parents of school-aged children. Since the proposed scale was demonstrated to be valid and reliable, we recommend its use to assess parental feeding practices in a Brazilian setting.
LM contributed for the selection of study design, participated in the data gathering and data entering, performed the data analysis and interpretation, wrote the article, and approved the final version to be published. SW contributed for the selection of the study design, participated in the data gathering and data entering, and contributed to the data analysis and interpretation, writing of the article, and approved the final version to be published. ML suggested and supervised the data analysis and interpretation, reviewed the article, and approved the final version to be published. SC contributed to the interpretation of the data, writing and revising the article critically, and approved the final version to be published. JT selected the study design, supervised the data gathering and data entering, contributed to the data analysis and interpretation, reviewed the article, and approved the final version to be published.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Data collection was performed at schools in Campinas and São Paulo, SP, Brazil. The authors thank the participant schools, parents, and children for their valuable contribution. We also thank the CAPES for scholarships for LM and SW, the National Institute of Health (NIH) for research funding for SC (R00DK088360), and the Conselho Nacional de Pesquisa (CNPq) for a productivity scholarship for JT.
The supplementary material for this article can be found online at