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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 159

Revising the comprehensive feeding practices questionnaire used in planning preventive overweight, obesity, and underweight programs for 2–5-year-old children


1 Department of Community Nutrition, School of Nutritional Sciences and Dietetics, International Campus, Tehran University of Medical Sciences (IC-TUMS), Tehran, Iran
2 Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
3 Chronic Disease Research Centre, Endocrinology and Population Sciences Research Institute, Tehran University of Medical Sciences, Tehran, Iran
4 Department of Nutrition, Science and Research Branch, Islamic Azad University, Tehran, Iran
5 Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
6 Department of Clinical Nutrition, Deputy of Curative Affaires, Birjand University of Medical Sciences, Birjand, Iran

Date of Submission15-Jan-2018
Date of Acceptance24-Jan-2018
Date of Web Publication09-Oct-2019

Correspondence Address:
Abolghasem Djazayery
Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpvm.IJPVM_34_18

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  Abstract 


Background: Overweight, obesity, and underweight are common child health problems in Iran. Child-feeding practices are one of the major factors affecting children's weight through eating behavior and dietary intake. The Comprehensive Feeding Practices Questionnaire (CFPQ), a 49-item measure comprising 12 subscales, assesses parental child-feeding practices. It is used to determine factors that may affect the development of overweight, obesity, and underweight and therefore, helps us plan appropriate preventive action. The aim of this study was to revise and adapt CFPQ to be used for 2–5-year-old children. Methods: This study including, 300 mothers selected by simple systematic random sampling, was conducted in the rural and urban areas of Birjand city, Iran. Health workers interviewed the mothers and completed questionnaire according to the standard protocol. Exploratory factor analysis (EFA), tests for internal consistency, and test–retest reliability were conducted. Results: EFA resulted in a final questionnaire with 39 items distributed over seven factors, including Healthy Eating Guidance, Modeling, Parent Pressure, Monitoring, Emotion Regulation, Child Control, and Restriction. The internal consistency reliability for the proposal scales was acceptable for five out of the seven factors and all of the seven factors demonstrated excellent test–retest reliability. Conclusions: The revised CFPQ is a valid tool for determining the various aspects of parental feeding practices aiming to prevent overweight, obesity, and underweight among 2–5-year-old children.

Keywords: Comprehensive Feeding Practices Questionnaire, feeding behaviors, feeding practices, validation studies


How to cite this article:
Minaie M, Mirzaei K, Heshmat R, Movahedi A, Motlagh AD, Parsaeian M, Raghebi SS, Djazayery A. Revising the comprehensive feeding practices questionnaire used in planning preventive overweight, obesity, and underweight programs for 2–5-year-old children. Int J Prev Med 2019;10:159

How to cite this URL:
Minaie M, Mirzaei K, Heshmat R, Movahedi A, Motlagh AD, Parsaeian M, Raghebi SS, Djazayery A. Revising the comprehensive feeding practices questionnaire used in planning preventive overweight, obesity, and underweight programs for 2–5-year-old children. Int J Prev Med [serial online] 2019 [cited 2019 Oct 15];10:159. Available from: http://www.ijpvmjournal.net/text.asp?2019/10/1/159/268745




  Introduction Top


Overweight, obesity, and underweight are common children's nutritional issues in some provinces of Iran.[1] Parental feeding practices, especially pressure to eat and restriction to food intake, can influence weight outcomes (over- or under-weight) through eating behavior and dietary intake.[2],[3],[4]

The Comprehensive Feeding Practices Questionnaire (CFPQ) is an instrument that can determine many new aspects of parental feeding practices. The CFPQ is used for assessing feeding practices of parents of 2–8-year-old children. It consists of a 49-item measure comprising 12 subscales that is completed with using a 5-point Likert response scale. The CFPQ subscales include child control, emotion regulation, encourage balance and variety, environment, food as reward, involvement, modeling, monitoring, pressure, restriction for health, restriction for weight control, and teaching about nutrition subscales.[5]

Understanding the factors that can influence a child's weight, dietary intake, and eating behaviors is very important for planning preventive overweight, obesity, and underweight programs for 2–5-year-old children. The aim of this study was to revise and adapt CFPQ to be used for 2–5-year-old children.


  Methods Top


Translation and content validity of the CFPQ was done in a previous study in Iran, so we used the translated CFPQ in our study.[6] The study was conducted in rural and urban areas of Birjand city, capital city of the South Khorasan province in Iran. An acceptable sample size for doing factor analysis (300 mothers with 2–5-year-old children) was selected with simple systematic random sampling.[7]

Trained local health workers, after obtaining mothers' agreement and signature of written consent, interviewed them and filled the CFPQ according to the standard protocol. In order to determine test–retest reliability of CFPQ, after 2 weeks, fifty mothers were interviewed again. This research received ethical approved from Tehran University of Medical Sciences' research ethical review board (Ethical Approval code: 9313475003).

Statistical analysis

IBM SPSS Statistics Software (V.23, Chicago, IL, USA) was used for conducting exploratory factor analysis (EFA). A combination of the Kaiser criterion (the eigenvalues >1.5) and scree plots was used to determine the number of factors that should be extracted.[8],[9] Items with loading >0.4 were initially included in a factor.[9] Unrelated items that do not belong together and do not determine the construct should be deleted.[10]

The internal consistency of items within each identified factor and all the proposed factor items were tested using Cronbach's alpha, with values >0.7 considered acceptable.[9] Finally, test–retest reliability was tested by calculating Intraclass correlation coefficients (ICCs), for each factor of the proposed factor solution, with scales considered reliable if ICC values were >0.75.[11]


  Results Top


EFA with Varimax rotation determined seven factors that explained 50% of the variance. This resulted in a final questionnaire with 39 items distributed to the seven factors. The factors, items, and loadings from exploratory factor analysis are shown in [Table 1]. Five excluded items were with a loading of <0.4 and five items were excluded because they did not belong to factor structure. The extracted factors were as follows:
Table 1: Factors, items, and loading from exploratory factor analysis

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Restriction

This factor demonstrates how much a parent controls a child's food intake and weight gain.

Healthy eating guidance

This factor determines how much a parent models, teaches and encourages healthy eating for the child.

Modeling

This factor assesses how much parents show healthy eating for the child.

Parent pressure

This factor determines how much parents use pressure in order to increase their child's food intake.

Monitoring

This factor indicates how much parents follow the child's consumption of unhealthy food.

Emotion regulation

This factor determines how much parents use food in order to regulate the child's emotional condition.

Child control

This factor determines how much parents let the child control eating behavior.

The excluded items from original factors were as follows:

Items with a loading factor less than 0.4

43. I have to be sure that my child does not eat too many sweets (candy, ice cream, cake, or pastries) (Restriction health).

36. I withhold sweets/dessert from my child in response to bad behavior (Food as reward).

42. I tell my child what to eat and what not to eat without explanation (Teaching about nutrition).

11. Do you allow this child to eat snacks whenever s/he wants? (Child control).

10. If this child does not like what is being served, do you make something else? (Child control).

Items with less meaningful construct

16. I keep a lot of snack food (potato chips, Doritos, cheese puffs) in my house (Environment).

23. I offer sweets (candy, ice cream, cake, pastries) to my child as a reward for good behavior (Food as reward).

19. I offer my child his/her favorite foods in exchange for good behavior (Food as reward).

37. I keep a lot of sweets (candy, ice cream, cake, pies, and pastries) in my house (Environment).

13. Do you encourage this child to eat healthy foods before unhealthy ones? (Encourage balance and variety).

Reliability

[Table 2] shows that the internal consistency reliability for the proposal scales was acceptable for five factors (0.727–0.882). The internal consistency for all the proposed factors was acceptable factors (0.873). All the seven factors demonstrated excellent test–retest reliability (correlations above 0.7, all P = 0.0001).
Table 2: Internal consistency and test–retest reliability on the Comprehensive Feeding Practices Questionnaire

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  Discussion Top


This CFPQ validation study showed a final questionnaire with seven factors. The results of this study, such as other results of CFPQ validation studies did in New Zealand and Brazil, could not confirm the original CFPQ subscales.[12],[13],[14] The New Zealand's version consisted of five factors with 32 items and Brazilian version included six factors with 43 items.[12],[13],[14]

It can be clearly observed that the social and cultural differences can lead to producing different results in CFPQ validation studies so that we determined some noticeable differences between ours and the original scale structure.[15]

In our study, four of the seven proposed factors were similar to factors in original model that included monitoring, modeling, emotion regulation, and parent pressure.[5] Healthy eating guidance was a new factor proposed in the New Zealand and Brazil CFPQ validation studies.[12],[13],[14] Healthy eating can affect a child's dietary intake and dietary behavior.[16],[17]

Restriction was a combination of restriction for weight control and for health subscales. Restriction for weight control and restriction for health subscales have similar constructs, so that in a previous study, parents could not determine the differences between these two subscales.[5]

Restrictive child-feeding practice is one of the important practices that can affect children's weight.[18] Decreasing in restrictive parent feeding practices during child obesity treatment could improve a child's body mass index; therefore, modification in restrictive feeding practices is one of the good approaches in child treatment obesity program.[19]

Child control did not include all items from the original CFPQ.[5] Child control was not one of the proposed subscales in Brazilian validation studies.[13],[14]

Food as reward and environment subscales could not be extracted in this study. In the Norwegian validation study, environment factor was divided into a separate factor. The first factor reflected availability of healthy foods in the home environment and the second factor reflected availability of unhealthy foods in the home environment.[20] Two items of the environment subscale showing availability of healthy foods in the home environment were included in the healthy eating guidance subscale and two items showing availability of unhealthy foods in the home environment were not in relevant subscale (monitoring) and were excluded from the monitoring subscale.

Food as reward was not extracted in this study. Today's parents are aware that rewarding children with food is not a good recommendation. Considering the role of teaching parents through the health system and the media about child healthy feeding behavior, it is apparent that mothers do not use low food as reward in feeding practice. In our study, most of the mothers disagreed with the food reward practice.

Decreasing the number of questions from 49 to 39, by removing 10 items that did not belong to any of the proposed factors, has the potential to drop the response burden. Considering the role of proposed factors in a child's weight status and dietary intake, we recommend its use for determining parental feeding practices.


  Conclusions Top


A revised version of the CFPQ is a valid tool for assessing child-feeding practices for 2–5-year-old children in Iran. Determining child-feeding practices through nutrition service package in the health system and taking suitable actions can improve a child's weight and dietary intake in preventive underweight, overweight, and obesity prevention program.

Acknowledgments

We would like to thank the Nutrition Community Department of Ministry of Health and Medical Education for their great financial support. We also are grateful of Birjand health center workers for facilitating and enabling data gathering.

Financial support and sponsorship

This study was financially supported by the Nutrition Community Department of Ministry of Health and Medical Education.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Siassi F, Djazayery A, Pouraram H, Abdollahi Z. National Integrated Micronutrient Survey 2012 (NIMS II). 1st ed. Tehran: Ministry of Health and Medical Education; 2015.  Back to cited text no. 1
    
2.
Rodgers RF, Paxton SJ, Massey R, Campbell KJ, Wertheim EH, Skouteris H, et al. Maternal feeding practices predict weight gain and obesogenic eating behaviors in young children: A prospective study. Int J Behav Nutr Phys Act 2013;10:24.  Back to cited text no. 2
    
3.
Tschann JM, Martinez SM, Penilla C, Gregorich SE, Pasch LA, de Groat CL, et al. Parental feeding practices and child weight status in Mexican American families: A longitudinal analysis. Int J Behav Nutr Phys Act 2015;12:66.  Back to cited text no. 3
    
4.
Yee AZ, Lwin MO, Ho SS. The influence of parental practices on child promotive and preventive food consumption behaviors: A systematic review and meta-analysis. Int J Behav Nutr Phys Act 2017;14:47.  Back to cited text no. 4
    
5.
Musher-Eizenman D, Holub S. Comprehensive feeding practices questionnaire: Validation of a new measure of parental feeding practices. J Pediatr Psychol 2007;32:960-72.  Back to cited text no. 5
    
6.
Doaei S, Kalantari PN, Gholamalizadeh PM, Rashidkhanip PB. Validating and investigating reliability of comprehensive feeding practices questionnaire. Zahedan J Res Med Sci 2013;15:42-5.  Back to cited text no. 6
    
7.
Tabachnick BG, Fidell LS. Using Multivariate Statistics. 5th ed. Boston, MA: Pearson Education; 2007.  Back to cited text no. 7
    
8.
Schönrock-Adema J, Heijne-Penninga M, Van Hell EA, Cohen-Schotanus J. Necessary steps in factor analysis: Enhancing validation studies of educational instruments. The PHEEM applied to clerks as an example. Med Teach 2009;31:e226-32.  Back to cited text no. 8
    
9.
Field A. Discovering Statistics Using SPSS: Book Plus Code for E Version of Text. London: SAGE Publications Ltd.; 2009.  Back to cited text no. 9
    
10.
Parsian N, Dunning T. Developing and validating a questionnaire to measure spirituality: A psychometric process. Glob J Health Sci 2009;1:2-11.  Back to cited text no. 10
    
11.
Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 2016;15:155-63.  Back to cited text no. 11
    
12.
Haszard JJ, Williams SM, Dawson AM, Skidmore PM, Taylor RW. Factor analysis of the comprehensive feeding practices questionnaire in a large sample of children. Appetite 2013;62:110-8.  Back to cited text no. 12
    
13.
Warkentin S, Mais LA, Latorre Mdo R, Carnell S, Taddei JA. Validation of the comprehensive feeding practices questionnaire in parents of preschool children in Brazil. BMC Public Health 2016;16:603.  Back to cited text no. 13
    
14.
Mais LA, Warkentin S, Latorre Mdo R, Carnell S, Taddei JA. Validation of the comprehensive feeding practices questionnaire among Brazilian families of school-aged children. Front Nutr 2015;2:35.  Back to cited text no. 14
    
15.
Wehrly SE, Bonilla C, Perez M, Liew J. Controlling parental feeding practices and child body composition in ethnically and economically diverse preschool children. Appetite 2014;73:163-71.  Back to cited text no. 15
    
16.
Mais LA, Warkentin S, Latorre MD, Carnell S, Taddei JA. Parental feeding practices among Brazilian school-aged children: Associations with parent and child characteristics. Front Nutr 2017;4:6.  Back to cited text no. 16
    
17.
Haszard JJ, Skidmore PM, Williams SM, Taylor RW. Associations between parental feeding practices, problem food behaviours and dietary intake in New Zealand overweight children aged 4-8 years. Public Health Nutr 2015;18:1036-43.  Back to cited text no. 17
    
18.
Couch SC, Glanz K, Zhou C, Sallis JF, Saelens BE. Home food environment in relation to children's diet quality and weight status. J Acad Nutr Diet 2014;114:1569-790.  Back to cited text no. 18
    
19.
Holland JC, Kolko RP, Stein RI, Welch RR, Perri MG, Schechtman KB, et al. Modifications in parent feeding practices and child diet during family-based behavioral treatment improve child zBMI. Obesity (Silver Spring) 2014;22:E119-26.  Back to cited text no. 19
    
20.
Melbye EL, Øgaard T, Øverby NC. Validation of the comprehensive feeding practices questionnaire with parents of 10-to-12-year-olds. BMC Med Res Methodol 2011;11:113.  Back to cited text no. 20
    



 
 
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