'Fussy eating' in children 'increases risk of eating disorders' – but increase is very low

"Children who overeat, pick at meals or are fussy when it comes to food may be more at risk of eating disorders as teenagers," the Mail Online reports. The news website reports on a new study based on data of a long-running research project looking at parents and children in the UK.

Researchers asked parents to record their child's eating patterns; specifically looking for undereating, overeating, or fussy eating (defined as a child preferring to eat only certain foods while being reluctant to try anything new).

They then looked at whether these types of patterns were linked with teen-reported eating disorders, at age 16 years.

While researchers found an increased risk with certain child eating habits, children only had a 1% risk of developing an eating disorder to start with. Fussy eaters and overeaters then had only a 1 to 2% higher risk. There was a slightly higher increase in anorexia risk specifically for girls who persistently under ate (6%). But all of these remain very low risks.

Parents and carers should not be overly concerned by this news story and periods of disrupted eating in childhood are common.

Where did the story come from?

This study was conducted by researchers from University College London, King's College London and other institutions in the UK, Sweden, Switzerland and the US. The study was funded by the Medical Research Council and Medical Research Foundation and published in peer-reviewed The British Journal of Psychiatry.

The Mail coverage may cause unnecessary alarm. The coverage does not highlight how uncommon diagnosed eating disorders were during the study, or the various limitations when using observational data.

What kind of research was this?

This study used data collected as part of the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort study, which recruited pregnant women from the southwest of England in 1991-92, and has since followed the family's health.

This study has used information collected on parent-reported child eating habits and looked at whether this was linked with any subsequent eating disordersin the teenager.

Prospective cohorts can look at links between a risk factor or exposure and later health outcomes. However, they cannot prove direct cause and effect, as many other influences may be involved. This is particularly the case in a study that was not designed to look at this specific question.

There are additional limitations from the low numbers with eating disorders as this makes any association more likely to be the result of chance.

What did the research involve?

The ALSPAC cohort initially recruited 14,451 pregnant women, with 13,988 resulting live births.

Parent reports of child fussy eating, overeating or undereating, were assessed on 8 occasions between child ages of 1 and 9 years.

For fussy eating the researchers describe questioning parents about their child "being choosy", "refusing food" or "having general feeding disorders" – with response options of "did not happen", "happened but not worried" and "a bit/greatly worried". These were then split into patterns of:

• no fussy eating
• low transient fussy eating (low levels within the first 5 years)
• low increasing fussy eating (low levels increasing over time)
• early and decreasing fussy eating (high levels in first year of life, gradually decreasing)
• rapidly increasing fussy eating (rapidly increasing after age 1)
• high persistent fussy eating (persistent across all assessments)

Overeating and undereating were also assessed. The researchers split the response patterns into similar categories as above. However, the study does not describe the specific questions or answer options that parents were given to assess these patterns.

Eating disorders were assessed by teenager self-report at age 16 years, using an adapted version of a validated questionnaire (Youth Risk Behaviour Surveillance System).

They were defined as:

• binge eating – eating a large amount of food at least once a week and having a feeling of loss of control during that episode
• purging behavior – use of laxatives or self-induced vomiting to lose weight or avoid gaining weight
• fasting – not eating at all for at least a day, to lose weight or avoid gaining weight
• excessive exercise – exercise for weight loss purposes with feelings of guilt if missing exercise, or finding it hard to meet other obligations because of fitting in exercise

Of the original sample, only 4,760 children had information reported on both child eating patterns and teen eating disorders.

The researchers looked for links between the 2, taking into account potential confounders of gender, maternal educational level, maternal age at pregnancy, birthweight and prematurity.

What were the basic results?

Fussy eating

Some level of fussy eating was fairly common:

• 15% of children were low transient fussy eaters
• 26% of children were low increasing fussy eaters
• 9% of children were persistent fussy eaters

The only significant risk increases were for anorexia. Those who weren't fussy eaters had a 1% baseline risk of anorexia. Those in the "early decreasing" and "high persistent" groups both had 2% higher risk of anorexia than children who were not fussy eaters.

Undereating

Child undereating was also common:

• 38% of children were low transient undereaters
• 19% of children were low and decreasing undereaters
• 2% of children were high persistent undereaters

Those who didn't under eat had a 15% risk of fasting, 6% risk of excessive exercise and 2% risk of anorexia. The main findings were actually risk decreases: children who underate at low levels had 3% lower chance of fasting and 2% lower risk of excessive exercise. Researchers found no link between undereating and anorexia; however, when they only looked at girls they found a 6% increase risk compared with those who did not undereat.

Overeating

Overeating was not so common. 70% never overate, while 13% had low transient overeating. Progressively increasing overeating was only reported for 6%.

Those who didn't overeat had a 10% risk of reporting binge eating, and 1% risk of actual diagnosis. Late increasing overeating was linked with 6% higher risk of reporting binge eating and 1% higher risk of binge eating diagnosis. "Early increasing" overeating was also linked with a 7% higher risk of reporting binge eating.

How did the researchers interpret the results?

The researchers conclude: "Our results suggest continuities of eating behaviours into eating disorders from early life to adolescence… Findings have the potential to inform preventative strategies for eating disorders."

Conclusion

Research looking into the risk factors for eating disorders in young people is valuable.

However, it's very common for young children to go through periods of fussy eating or undereating, and the media coverage may cause considerable and unnecessary alarm for many parents and carers.

It's important to realise that the baseline level of risk of eating disorders such as anorexia, purging or diagnosed binge eating was extremely low, at only 1 or 2%. As so few children had these outcomes, there's higher likelihood of finding chance associations or inaccurate links when looking at links with individual child eating patterns.

Only a random scattering of significant links were seen, and then the risk increases remained small. For example, fussier eaters had a 2% increased risk of anorexia (upon only a 1% baseline risk); some over-eaters had a 1% higher risk of binge eating disorder (again upon only a 1% baseline risk). Therefore the absolute risk of an eating disorder, even for children with the highest level of, or persistence of, fussy eating or overeating remains very low.

There are several other limitations to be aware of:

• the study cannot prove cause and effect. Several confounding factors were taken into account, but the factors contributing to development of eating disorders are likely to be complex and varied. Many other health, lifestyle, personal and environmental factors could be influencing the links
• parent reports of child eating habits are likely to be highly subjective, and may mean different things to different people. We cannot be sure all children in the same category have identical habits
• eating disorders were assessed by self-report at 16 years. As this is a sensitive topic, there is a possibly of under-reporting.

Overall these limitations do not undermine the importance of eating disorders such as anorexia, binge eating and purging. They highlight the need for those who are involved with young people – families, teachers, social groups – to be aware of signs that teens may be experiencing difficulties with mental health, wellbeing and esteem and body image, to ensure they access the support they need.

The study should not cause concern for the many parents whose young children go through periods of disrupted eating. However, if it is persistent, increasing or causing them concern, contact a health professional.

The eating disorder charity Beat has more advice about supporting somebody with an eating disorder.