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Validation of the Child Feeding Questionnaire among Saudi
pre-schoolers in Jeddah city
Rana H Mosli*
Clinical Nutrition Department, Faculty of Applied Medical Sciences, King Abdulaziz University, PO Box 80215,
Jeddah 21589, Kingdom of Saudi Arabia
Submitted 18 October 2018: Final revision received 6 May 2019: Accepted 4 June 2019: First published online 13 September 2019
Abstract
Objective: To examine the psychometric properties of an Arabic version of the
Child Feeding Questionnaire (CFQ-A) in a sample of Saudi pre-schoolers and their
mothers.
Design: Cross-sectional study. Mothers completed questionnaires over the tele-
phone and child anthropometry was measured objectively using standardized
procedures; BMI Z-scores (BMIZ) were calculated based on the age- and sex-
specific WHO growth standards and reference data. Confirmatory factor analysis
was used to examine the original seven-factor CFQ model, as well as a modified
nine-factor model. Cronbach’sαwas calculated to examine the internal consis-
tency of each factor; Spearman correlation was used to examine 2-week retest
reliability. Factor–factor and factor–child BMIZ correlations were examined.
Setting: Jeddah, Kingdom of Saudi Arabia.
Participants: A total of 209 mothers and children were recruited from eight differ-
ent pre-schools.
Results: Both the original seven-factor and modified nine-factor CFQ-A exhibited
good fit (root-mean-square-error of approximation <0·05). Six out of nine factors
had excellent internal consistency and all factors showed excellent 2-week
test–retest reliability. There were significant correlations between child BMIZ
and five out of the nine factors; Perceived Child Weight, Perceived Parent
Weight, Restriction and Monitoring were each positively correlated with child
BMIZ, while Concern about Child’s Diet was negatively correlated with child BMIZ.
Conclusions: The study provided evidence supporting the validity and reliability of
the original seven-factor and modified nine-factor CFQ-A. Future studies are
needed to further establish the psychometric properties of the CFQ-A in addition
to other feeding assessment tools.
Keywords
Validation
Maternal feeding
Pre-schoolers
BMI Z-score
Globally, the troubling burden of obesity continues to be
evident among both children and adults(1) as the preva-
lence of elevated BMI and its associated morbidity and
mortality continue to soar(1,2). Since childhood is a critical
period for shaping lifelong obesity risk(3), identifying modi-
fiable risk factors at an early age is vital for the promotion
and maintenance of a healthy weight status(4).
Characteristics of the mealtime environment and the
behaviour of family members around food have been asso-
ciated with child eating behaviours and weight status in sev-
eral predominantly developed countries, including the USA,
the UK and Australia(5–10). For example, overly demanding
maternal feeding behaviours and restriction, such as use
of punishments and rewards, were found to be inversely
associated with children’s ability to self-regulate food intake,
which can lead to overeating and weight gain(11–14).
Indulgent feeding behaviours and low involvement in child
feeding have also been associated with higher weight status
among children(6,15). Although evidence supporting causal
associations between maternal feeding behaviours and child
obesity is lacking(16), results from several studies show that
the association between maternal feeding and child eating
behaviours is bidirectional; mothers may adjust and adapt
the way they approach feeding in response to the child’s
temperament, behaviour and weight status(9,17,18) and the
mother’s approach to feeding can in turn influence the
child’s counter-response and behaviour around food(19).
Therefore, maladaptive feeding and eating behaviours of
Public Health Nutrition: 23(4), 599–608 doi:10.1017/S1368980019002581
*Corresponding author: Email aimuwseli@kau.edu.sa, ranamosli@gmail.com © The Author 2019
https://doi.org/10.1017/S1368980019002581 Published online by Cambridge University Press
mothers and their children may be described as a viscous
cycle of obesogenic events that can ultimately promote an
unhealthy weight status. Hence, validated instruments that
aid in the evaluation of both maternal feeding and child
eating behaviours are needed in order to efficiently identify
maladaptive behaviours and subsequently promote a
healthier mealtime environment.
As seen in many countries around the world, the preva-
lence of obesity and obesity-related diseases (e.g. type 2
diabetes) in the Kingdom of Saudi Arabia (KSA) has been
increasing alarmingly(20). The prevalence of overweight
and obesity among children is concerning, where about
32 % of children were found to be overweight or obese(21).
Moreover, KSA is classified as a country experiencing
advanced nutrition transition, such that dietary patterns
are changing rapidly and drastically to mimic those seen
in Western countries(22,23). It is hypothesized that these
changes in dietary intake are secondary to changes in
socio-economic status and social and familial norms(24).
Although these sociocultural adaptations are likely to be
accompanied by changes in the family mealtime environ-
ment, family mealtimes and the behaviour of family mem-
bers around food in Saudi society have not been efficiently
explored. Although one study found that Saudi mothers of
pre-school children may use restriction and pressure to eat
in feeding(25), we were unable to identify any other studies
evaluating maternal feeding behaviours and practices as
they relate to child weight status. Additionally, we were
able to identify only one study that evaluated initial validity
of a child feeding assessment tool in a convenience sample
of highly educated Saudi mothers living in the USA(25).
The Child Feeding Questionnaire (CFQ) is a feeding
behaviour assessment tool that was first developed by
Birch et al. in 2001 to assess parental beliefs, attitudes and
practices relating to child feeding in a US cohort of parents
of 2–11-year-old children(26). The questionnaire consists of
thirty-one items with 5-point Likert response scales and gen-
erates seven factors: Perceived Responsibility; Perceived
Parent Weight; Perceived Child Weight; Concern about
Child Weight; Restriction; Pressure to Eat; and Monitoring.
Although some studies involving CFQ subscales have shown
poor or mediocre model fit(27) and problematic structure of
some factors (mainly Restriction)(27–30), several studies have
reported evidence of validity and reliability in US(26,31,32) and
non-US samples(10,29,30,33,34).
Given the immediate need for valid and reliable, cultur-
ally sensitive instruments to assess feeding in KSA, the
objective of the present study was to examine the psycho-
metric properties of an Arabic version of the CFQ (CFQ-A)
in a sample of Saudi pre-schoolers and their mothers by: (i)
testing the original seven-factor CFQ-A model in addition to
a modified nine-factor CFQ-A model and examining model
fit and internal reliability of subscales; (ii) examining
test–retest reliability of CFQ-A factors; and (iii) examining
intercorrelations among CFQ-A factors as well as
correlations with child BMI Z-score (BMIZ).
In developing the modified nine-factor CFQ-A model, we
hypothesized that Saudi mothers are more invested and
indulgent in feeding and that they like to ensure that their
children are ‘eating enough food’and that they are at the
heavier end of the normal weight range(25,35,36).Wetherefore
added the two additional factors, Use of Food as a Reward
and Concern about Child’s Diet. Moreover, we hypothesized
that Perceived Child Weight, Concern about Child Weight
and Concern about Child’s Diet are correlated with feeding
practices including Restriction, Pressure to Eat, Monitoring,
Perceived Responsibility and Use of Food as a Reward,
and that these maternal perceptions and practices are also
correlated with child BMIZ(37). Results from the present study
can help provide evidence regarding the appropriateness of
use of an Arabic version of the CFQ in Saudi Arabia. Findings
can also help identify and inform future work needed for
further development of efficient feeding assessment tools
among Saudi/Arab populations.
Methods
Sample and procedures
A total of 209 mothers and children were included in the
present study. Participants were recruited from eight different
pre-schools around the city of Jeddah, KSA. Schools were
randomly selected based on location; two schools were
located in the northern area, two in the southern area, two
in the eastern area and two in the western area. Of the eight
pre-schools, four were public (government-subsidized) and
four were private pre-schools. A description of the study and
consent forms were placed in the backpacks of all students
enrolled in the pre-schools. Research assistants contacted
mothers who returned signed consent forms and completed
the study questionnaire with them over the telephone.
The study questionnaire included the CFQ-A, questions that
assessed use of food as a reward and concern about
child’s diet, and questions that assessed demographic
characteristics.
Within 1 week of completing the questionnaire, the
study team performed school visits in order to obtain
weight and height measurements of participating children.
Study inclusion criteria were as follows: child is Saudi or a
permanent resident of KSA; between 3 and 5 years old;
resides with his/her mother and is healthy with no serious
medical problems or history of food allergies; and mother is
an Arabic speaker. In order to examine test–retest reliabil-
ity, forty randomly selected mothers (19 %) completed the
questionnaire for a second time approximately 2 weeks
after the initial telephone call.
Measures
Demographic characteristics
Mothers were asked questions that assessed demographic
characteristics including the child’s sex, birthdate and
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nationality; the mother’s birthdate, educational level,
employment status, marital status and nationality; as well
as the family’s total monthly income. Birthdates and dates
of interviews were used to calculate child and maternal age.
The Arabic version of the Child Feeding Questionnaire
Mothers completed the CFQ-A in Arabic language, following
aforward–backward translation process conducted by bilin-
gual professionals(10,38). The final version of the CFQ-A was
pretested using a different sample consisting of sixty mothers
of pre-school children and was reviewed by an expert com-
mittee of four health-care professionals. Clarifications were
made to wording of questions and response options based
on comments from mothers and expert committee members.
Use of food as a reward and concern about child’s diet
Saudi mothers may be more indulgent in feeding, tradition-
ally use food as a reward to encourage desirable behaviours
and may consciously or subconsciously follow the tradi-
tional belief that heavier children are healthier(25,35,36).
We therefore elected to evaluate a modified CFQ-A model
that assessed Use of Food as a Reward as a separate
construct, rather than including these items with the
Restriction subscale, as employed in the original question-
naire(26). This approach yielded satisfactory results among
a sample of Chinese mothers(33).Furthermore,weincluded
a separate subscale for assessing Concern about Child’sDiet.
Mothers completed questions that were adapted from
the Meals in Our Household Questionnaire, a question-
naire developed to assess family meals in the households
of 3–11-year-old children(40). Questions included six items
that assessed Use of Food as a Reward (FR; response
options ranging from 1 =‘never’to 5 =‘always’)(39).
These items were: FR1, ‘I give my child food to keep
him/her quiet when shopping or travelling’; FR2, ‘I give
my child food to reward him/her for good behaviour’;
FR3, ‘I withhold a food my child likes as a consequence
for bad behaviour’; FR4, ‘My child expects to be given a
favourite food as a reward’; FR5, ‘I give my child a special
food to celebrate an achievement’; and FR6, ‘I give my child
food to persuade him/her to do something he/she does not
really want to do’. In addition, mothers completed seven
out of seventeen items that assessed Concern about
Child’s Diet (CD; response options ranging from 1 =‘not
at all concerned’to 6 =‘extremely concerned’)(39).We
selected items that reflected concern about child’s diet in
general, rather than those that measured concern about
child’s consumption of specific food types (e.g. CD14
and CD17 concerning eating vegetables and meat).
These items were: CD1, ‘Child is not eating enough’;
CD2, ‘Child is eating too much’; CD3, ‘Child eats a lot of
junk food’; CD4, ‘Child eats only a few types of food’;
CD5, ‘Child is not getting good nutrition’; CD6, ‘Child has
poor eating habits’; and CD7, ‘Child will not try new foods’.
The same translation and pretesting process was utilized
with these items, which were used to construct a modified
nine-factor CFQ-A model as described in following
sections.
Child BMI Z-score
Trained staff members followed standardized procedures
to measure children’s weights and heights. Calibration of
the instruments was checked periodically. Shoes and heavy
clothing were removed and the child was asked to stand
still on a digital scale, with his/her weight equally distrib-
uted on both feet. Each child was weighed twice and if
the two readings were inconsistent by more than 0·1 kg,
the child was weighed two more times and the average
of the two measurements was calculated. Similarly, height
was measured twice and if the measurements differed by
more than 0·5 cm, two more measurements were taken
and the average of the two measurements was calculated.
BMI was calculated for each child by dividing weight (in
kilograms) by the square of height (in metres)(40). BMIZ
were calculated based on the age- and sex-specific WHO
growth standards for children aged ≤5 years and the
WHO growth reference data for children who were
between 5 and 6 years old(41,42). Two children had missing
weight and height data due to transferring to other schools
and were therefore excluded from analyses involving child
BMI data.
Statistical analysis
Analyses were conducted using the statistical software pack-
age IBM SPSS Statistics version 21.0. Descriptive statistics
were used to examine sample characteristics, as well as
the distribution of questionnaire factors, maternal BMI and
child BMIZ.
To examine internal reliability, Cronbach’sαwas calcu-
lated for each factor in the seven- and nine-factor CFQ-A
models. A Cronbach’sαvalue of 0·70 or higher is consid-
ered favourable(43,44). Spearman correlation coefficients
were calculated to examine the 2-week test–retest reliabil-
ity of the CFQ-A factors.
To assess validity of the seven- and nine-factor models,
confirmatory factor analysis was performed using lavaan
version 0.5-23(45) in R version 3.3.1. Diagonally weighted
least squares was used to estimate model parameters.
Diagonally weighted least squares was specifically
designed for ordinal data and is more appropriate/recom-
mended for use with Likert-type scales(46,47).
Fit indices were estimated for each of the models by cal-
culating the root-mean-square error of approximation,
Tucker–Lewis index, comparative fit index, standardized
root-mean-square residual, and the likelihood ratio test
or the minimum sample discrepancy function/df(48,49).
The suitability of confirmatory factor analysis was assessed
prior to conducting the analysis, and inspection of the
correlation matrix showed that all variables in both the
seven-factor and nine-factor models had correlation
coefficients greater than 0·30.
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Table 1 summarizes factors and subscales of the original
seven-factor CFQ-A, as well as the modified nine-factor
CFQ-A. The modified nine-factor CFQ-A model includes
two additional factors: Use of Food as a Reward and
Concern about Child’sDiet
(39). As described earlier, items
relating to using food as a reward were removed from the
Restriction subscale and were included only in the Use of
Food as a Reward subscale in the modified nine-factor
model. These items were RST3A and RST3B. Scores for all
factors were calculated as the mean of contributing items,
with higher scores reflecting more of the given behaviour(26).
Intercorrelations among the modified CFQ-A factors as
well as correlations with child BMIZ were examined.
Interpretation of the correlation coefficients were based
on Cohen’s guidelines(50); correlations between 0·5 and
1·0 were considered large, correlations between 0·3 and
0·5 as medium and correlations between 0·1 and 0·3 as
small. Only children with complete BMIZ data (n207)
were included in the correlation analysis between CFQ-A
factors and child BMIZ. For all statistical analyses, the
significance level was set at 0·05.
Results
Sample characteristics
Mean child age was 4·79 years (
SD
=0·79 years), and about
half of the sample (51·7 %) was male. The majority
(approximately 70 %) of children and mothers were
Saudi. Of the sixty-four non-Saudi children, about half
(n29, 45·3 %) were Egyptian, ten (15·6 %) were Syrian,
eight were Yemeni (12·5 %), six were Jordanian (9·4 %),
five (7·8 %) were Lebanese, five (7·8 %) were Palestinian
and one (1·6 %) was Sudanese. In addition, the majority
Table 1 Summary of factors and subscales of the original seven-factor and modified nine-factor Arabic version of the Child Feeding
Questionnaire (CFQ-A)
Original seven-factor CFQ-A Modified nine-factor CFQ-A
Perceived Responsibility (PR) Perceived Responsibility (PR)
Items: PR1, PR2, PR3 Items: PR1, PR2, PR3
Response options: 1 =never; 2 =seldom; 3 =half of the time;
4=most of the time; 5 =always
Response options: 1 =never; 2 =seldom; 3 =half of the time;
4=most of the time; 5 =always
Perceived Parent Weight (PPW) Perceived Parent Weight (PPW)
Items: PPW1, PPW2, PPW3, PPW4 Items: PPW1, PPW2, PPW3, PPW4
Response options: 1 =markedly underweight;
2=underweight; 3 =normal; 4 =overweight; 5 =markedly
overweight
Response options: 1 =markedly underweight; 2 =underweight;
3=normal; 4 =overweight; 5 =markedly overweight
Perceived Child Weight (PCW) Perceived Child Weight (PCW)
Items: PCW1, PCW2, PCW3, PCW4 (PCW5 and PCW6 not
included due to sample age)
Items: PCW1, PCW2, PCW3, PCW4 (PCW5 and PCW6 not
included due to sample age)
Response options: 1 =markedly underweight;
2=underweight; 3 =normal; 4 =overweight; 5 =markedly
overweight
Response options: 1 =markedly underweight; 2 =underweight;
3=normal; 4 =overweight; 5 =markedly overweight
Concern about Child Weight (CN) Concern about Child Weight (CN)
Items: CN1, CN2, CN3 Items: CN1, CN2, CN3
Response options: 1 =unconcerned; 2 =a little concerned;
3=concerned; 4 =fairly concerned; 5 =very concerned
Response options: 1 =unconcerned; 2 =a little concerned;
3=concerned; 4 =fairly concerned; 5 =very concerned
Restriction (RST) Restriction (RST)
Items: RST1A, RST1B, RST1C, RST2, RST3A, RST3B,
RST4A, RST4B
Items: RST1C, RST2, RST4A, RST4B
Response options: 1 =disagree; 2 =slightly disagree;
3=neutral; 4 =slightly agree; 5 =agree
Response options: 1 =disagree; 2 =slightly disagree; 3 =neutral;
4=slightly agree; 5 =agree
Pressure to Eat (PE) Pressure to Eat (PE)
Items: PE1, PE2, PE3, PE4 Items: PE1, PE2, PE3, PE4
Response options: 1 =disagree; 2 =slightly disagree;
3=neutral; 4 =slightly agree; 5 =agree
Response options: 1 =disagree; 2 =slightly disagree; 3 =neutral;
4=slightly agree; 5 =agree
Monitoring (MN) Monitoring (MN)
Items: MN1, MN2, MN3 Items: MN1, MN2, MN3
Response options: 1 =never; 2 =rarely; 3 =sometimes;
4=mostly; 5 =always
Response options: 1 =never; 2 =rarely; 3 =sometimes;
4=mostly; 5 =always
Use of Food as a Reward (FR)
Items: FR1, FR2, FR3, FR4, FR5, FR6
Response options: 1 =never; 2 =rarely; 3 =sometimes;
4=often; 5 =very often
Concern about Child’s Diet (CD)
Items: CD1, CD2, CD3, CD4, CD5, CD6, CD7
Response options: 1 =not at all concerned; 2 =a little concerned;
3=somewhat concerned; 4 =quite concerned; 5 =very
concerned; 6 =extremely concerned
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of mothers (80 %) had a college education or higher, and
about half (51·2 %) reported that they were housewives
(Table 2).
Table 3 shows the distribution (including mean,
SD
and
range) of questionnaire factors.
Internal and test–retest reliability
Table 3 shows the respective Cronbach’sαfor each factor of
the seven- and nine-factor CFQ-A models. For the seven-
factor CFQ-A model, three factors fell below the 0·70
threshold: Perceived Parent Weight (Cronbach’sα=0·67),
Restriction (Cronbach’sα=0·60) and Pressure to Eat
(Cronbach’sα=0·49). These same factors were also
below the 0·70 threshold for the nine-factor CFQ-A
model: Perceived Parent Weight (Cronbach’sα=0·67),
Restriction (Cronbach’sα=0·62) and Pressure to Eat
(Cronbach’sα=0·49). All factors showed excellent 2-week
test–retest reliability, with Spearman correlations >0·70
(all P<0·05).
Confirmatory factor analysis
The seven-factor CFQ-A model
Forced extraction of seven factors explained 19·53, 13·71,
10·17, 9·12, 7·10, 6·07 and 4·84 % of the total variance,
respectively. The seven-factor solution explained 70·5 %
of the total variance. The root-mean-square error of approxi-
mation of 0·02 indicates good fit(51). The Tucker–Lewis index
and comparative fit index were calculated to be 0·96 and
0·97, respectively. The seven-factor model is illustrated in
Fig. 1.
The nine-factor CFQ-A model
Forced extraction of nine factors had explained 15·42, 13·43,
11·84, 7·57, 6·79, 5·01, 4·16, 3·62 and 3·59 % of the total
variance, respectively. The nine-factor solution explained
71·4 % of the total variance. The root-mean-square error
of approximation of 0·04 indicates good fit(51).The
Tucker–Lewis index and comparative fit index were
estimated to be 0·90 and 0·88, respectively. The nine-factor
model is illustrated in Fig. 2. A comparison of fit indices of
the seven- and nine-factor models is shown in Table 4.
Factor–factor and factor–child BMI Z-score
correlations
As shown in Table 5, the highest correlations between
factors were between Restriction and Monitoring (r=0·50,
P<0·001), Perceived Responsibility and Monitoring
(r=0·40, P<0·001) and Perceived Responsibility and
Restriction (r=0·30, P<0·001). There were small
positive correlations between Perceived Child Weight
and Restriction (r=0·20, P<0·001) and Perceived Child
Weight and Monitoring (r=0·17, P=0·01), as well as
between Concern about Child’s Diet and Concern about
Child Weight (r=0·18, P<0·001) and Concern about
Child’s Diet and Use of Food as a Reward (r=0·16,
P=0·01). Although marginally significant, Perceived
Responsibility was also positively correlated with
Perceived Child Weight (r=0·13, P=0·06) and Pressure
to Eat (r=0·12, P=0·07).
We detected negative correlations between Perceived
Responsibility and Concern about Child’s Diet (r=−0·24,
P<0·001) and between Perceived Responsibility and Use
of Food as a Reward (r=−0·19, P<0·001). Furthermore,
Concern about Child’s Diet was negatively correlated with
Perceived Parent Weight (r=−0·15, P=0·03) and
Perceived Child Weight (r=−0·23, P=0·001). Concern
about Child Weight was negatively correlated with
Pressure to Eat (r=−0·14, P=0·04).
There were significant correlations between child
BMIZ and five out of the nine factors; Perceived Child
Weight (r=0·49, P<0·001), Perceived Parent Weight
(r=0·30, P<0·001), Restriction (r=0·21, P<0·001)
and Monitoring (r=0·16, P=0·02) were each positively
correlated with child BMIZ, while Concern about Child’s
Diet was negatively correlated with child BMIZ (r=−0·18,
P=0·01; Table 5).
Discussion
Our study including 209 Saudi mothers and their pre-school
children provides initial evidence of the validity and
reliability of a modified nine-factor CFQ-A model. Our
Table 2 Characteristics of the sample of pre-schoolers and their
mothers (n209) recruited from eight different pre-schools in
Jeddah city, Kingdom of Saudi Arabia, October 2017–April 2018
Variable Mean or n
SD
or %
Child age (years) 4·79 0·79
Child sex
Male 108 51·7
Female 101 48·3
Child nationality
Saudi 145 69·4
Non-Saudi 64 30·6
Child BMI Z-score 0·17 1·34
Total monthly income
<5000 SR 21 10·0
5000–10 000 SR 74 35·4
>10 000 SR 114 54·5
Maternal age (years) 33·05 4·98
Maternal nationality
Saudi 140 67·0
Non-Saudi 69 33·0
Maternal education
Middle school 3 1·4
High school 39 18·7
College 142 67·9
Postgraduate 24 12·0
Maternal employment
Employed 84 40·2
Housewife 107 51·2
Student 15 7·2
Other 3 1·4
Data are presented as mean and
SD
for continuous variables or as nand % for
categorical variables.
Child Feeding Questionnaire–Arabic validation 603
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results suggest that modifying the restriction subscale and
including a separate subscale to assess using food as a
reward may be suitable for Saudi mothers. This approach
has previously provided satisfactory results among a sample
of Chinese mothers of pre-schoolers(33),suggestingthat
parenting/feeding strategies among Middle-Eastern and
Asian families might be comparable. Indeed, when compar-
ing our restriction factor mean with that of the study involving
Chinese mothers(33) (total mean scores out of 5), we observed
that they are almost similar (mean =4·40,
SD
=0·94 and
mean =4·18,
SD
=0·80, respectively), whereas a larger
difference is seen when comparing with Western samples
of pre-school (mean =2·72,
SD
=0·99)(10) and school-age
children (mean =2·50,
SD
=0·95)(26). Likewise, perceived
responsibility was higher among our Saudi mothers
(mean =4·23,
SD
=0·93), as well as Chinese (mean =4·26,
SD
=0·71) and Turkish mothers (mean =4·14,
SD
=0·67),
compared with US (mean =3·40,
SD
=0·95) and Swedish
(mean =4·02,
SD
=0·69) mothers. Interestingly, monitoring
among our sample of Saudi mothers (mean =4·44,
SD
=0·80) was noticeably higher than that of other samples
of Chinese (mean =3·68,
SD
=1·12), Turkish (mean =2·96,
SD
=0·70), US (mean =3·60,
SD
=0·90) and Swedish
(mean =3·87,
SD
=0·88) mothers. These cross-cultural
similarities/differences might be attributed to societal norms
regarding the role and responsibility of mothers in feeding
Table 3 Distribution and internal consistencies of factors of the Arabic version of the Child Feeding Questionnaire
(CFQ-A) in the sample of pre-schoolers and their mothers (n209) recruited from eight different pre-schools in
Jeddah city, Kingdom of Saudi Arabia, October 2017–April 2018
Minimum Maximum Mean
SD
Cronbach’sα
Seven-factor
model
Nine-factor
model
Perceived Responsibility 1·00 5·00 4·23 0·93 0·74 0·74
Perceived Parent Weight 2·00 5·00 3·20 0·47 0·67 0·67
Perceived Child Weight 2·00 4·75 2·90 0·35 0·70 0·70
Concern about Child Weight 1·00 5·00 1·62 1·17 0·88 0·88
Restriction 1·00 5·00 4·40 0·94 0·60 0·62
Pressure to Eat 1·00 5·00 3·91 1·14 0·49 0·49
Monitoring 1·00 5·00 4·44 0·80 0·86 0·86
Use of Food as a Reward 1·00 5·00 2·22 1·01 –0·73
Concern about Child’s Diet 1·00 5·00 2·26 1·14 –0·82
Perceived
Responsibility
PR1
PR2
PR3
0·74
PPW1
PPW2
0·83
PPW3
PPW4
PCW1
PCW2
PCW3
PCW4
CN1
CN2
CN3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
0·31
0·58
0·47
0·32
0·34
0·30
0·30
0·32
1·04
1·13
1·12
Monitoring
Restriction
Pressure to
Eat
RST1A
RST1B
RST1C
RST2
RST3B
MN1
MN2
MN3
PE1
PE2
PE3
PE4
RST4A
RST4B
0·50
1·03
0·36
0·42
0·69
0·67
0·85
0·53
0·30
0·73
0·98
0·30
RST3A
0·24
0·74
0·68
0·84
Perceived
Parent Weight
Perceived
Child Weight
Concern
about Child
Weight
Fig. 1 Seven-factor model of the Arabic version of the Child Feeding Questionnaire (CFQ-A), with the factors Perceived
Responsibility, Perceived Parent Weight, Perceived Child Weight, Concern about Child Weight, Restriction, Monitoring and
Pressure to Eat (see Table 1 for a description of the factors and subscales). Fit indices: root-mean-square error of approximation
=0·02 (95 % CI 0·00, 0·04), Tucker–Lewis index =0·96, comparative fit index =0·97, standardized root-mean-square residual
=0·07, χ2=267·7 (P<0·001), minimum sample discrepancy function/df =1·10 (ε
1
–ε
29
are error terms)
604 RH Mosli
https://doi.org/10.1017/S1368980019002581 Published online by Cambridge University Press
their children, as well as availability and access to quality
early childhood care centres (e.g. daycare centres and
pre-schools), which affects the amount of time mothers
spend being in charge of feeding their children.
Both the original seven-factor model as well as the modi-
fied nine-factor model showed good fit to data (root-mean-
square error of approximation <0·05)(52).Furthermore,our
findings suggest adequate internal reliability for six out of the
nine factors in the modified nine-factor CFQ-A model. The
three factors with Cronbach’sαthat fell below the 0·70
cut-off were: Perceived Parent Weight, Restriction, and
Pressure to Eat. This is consistent with results from other val-
idation studies that also found lower internal reliability for
the Restriction and Pressure to Eat factors(10,27).Onepossible
explanation for the less satisfactory estimates for the
Restriction and Pressure to Eat subscales could be the varia-
tion between mothers in defining some phrases used in
questionnaire items, such as ‘Ihavetobesurethatmychild
does not eat too many high-fat foods’. For example, while
one mother might define ‘being sure’as actively or
physically removing food items from the child’sreach,
another might define this as more subtle behaviours such
as stating the harms of high-fat foods in front of the child.
In line with previous studies, ours showed evidence of
adequate test–retest reliability(10).
Overall, intercorrelations between factors in the modi-
fied model were in the expected direction and give support
to our hypothesis that perceived child weight and concern
about child weight and diet are each associated with feed-
ing practices among Saudi mothers. Results suggest that
mothers who apply higher restriction may monitor their
children’s eating to a greater extent. Mother who perceive
that they are highlyresponsible for their children’seatingmay
apply greater restriction. Although the original CFQ study by
Birch et al. did not find a correlation between perceived
responsibility and restriction(26), our findings are consistent
with those of a study involving Turkish mothers(53).Inline
with our findings, both the original CFQ study and the
Turkish study reported a positive correlation between
perceived responsibility and monitoring(26,53). Additionally,
Perceived
Responsibility
Perceived
Parent Weight
Perceived
Child Weight
Concern
about Child
Weight
RST1C
RST2
MN1
MN2
MN3
PE1
PE2
PE3
PE4
RST4A
RST4B
1·22
0·66
0·31
0·42
0·69
0·76
0·75
1·26
1·33
0·47
0·56
1·05
1·15
0·79
1·25
1·49
1·38
1·14
0·53
1·08
0·79
Use of Food as
a Reward
FR1
FR2
FR3
Concern about
Child’s Diet
FR4
CD1
CD3
CD4
CD5
CD6
CD7
PR1
PR2
PR3
PPW1
PPW2
PPW3
PPW4
PCW1
PCW2
PCW3
PCW4
CN1
CN2
CN3
0·89
0·75
0·32
0·55
0·45
0·31
0·39
0·30
0·30
0·39
0·95
1·06
1·29
0·75
Monitoring
Restriction
Pressure to
Eat
ε
1
ε
2
ε
3
ε
4
ε
5
ε
6
ε
7
ε
8
ε
9
ε
10
ε
11
ε
12
ε
13
ε
14
ε
17
ε
18
ε
21
ε
22
ε
23
ε
24
ε
25
ε
26
ε
27
ε
28
ε
29
ε
30
ε
31
ε
32
ε
33
ε
34
ε
35
ε
36
ε
37
ε
38
ε
39
Fig. 2 Nine-factor model of the Arabic version of the Child Feeding Questionnaire (CFQ-A), with the factors Perceived Responsibility,
Perceived Parent Weight, Perceived Child Weight, Concern about Child Weight, Restriction, Monitoring, Pressure to Eat, Use of Food
as Reward and Concern about Child’s Diet (see Table 1 for a description of the factors and subscales). Fit indices:
root-mean-square error of approximation =0·04 (95 % CI 0·03, 0·05), Tucker–Lewis index =0·88, comparative fit index =0·90,
standardized root-mean-square residual =0·07, χ2=694·0 (P<0·001), minimum sample discrepancy function/df =1·41
(ε
1
–ε
18
and ε
21
–ε
39
are error terms)
Table 4 Comparison of fit indices between the seven-factor and nine-factor models of the Arabic version of the Child
Feeding Questionnaire (CFQ-A) in the sample of pre-schoolers and their mothers (n209) recruited from eight different
pre-schools in Jeddah city, Kingdom of Saudi Arabia, October 2017–April 2018
Model CMIN/df χ2Pvalue TLI CFI SRMR RMSEA 95 % CI
Seven-factor 1·10 256·7 <0·001 096 0·97 0·07 0·02 0·00, 0·04
Nine-factor 1·41 694·0 <0·001 0·89 0·90 0·07 0·04 0·03, 0·05
Δχ²–437·3 ––––––
CMIN, minimum sample discrepancy function; χ2, chi-square statistic; TLI, Tucker–Lewis index; CFI, comparative fit index; SRMR, standardized-
root-mean square residual; RMSEA, root-mean-square error of approximation.
Child Feeding Questionnaire–Arabic validation 605
https://doi.org/10.1017/S1368980019002581 Published online by Cambridge University Press
our findings suggest that mothers who perceive their children
to have a higher weight status may apply higher restriction
and monitoring, and mothers who are more concerned about
their children’s weight may be more concerned about
their diet.
Furthermore, we found that mothers who perceive that
they are highly responsible for their children’s eating also
reported lower concern about their child’s diet. This is
probably due to these mothers exerting higher restriction
and monitoring, leading them to feel more in control of
what their children eat. Additionally, some of the
Concern about Child’s Diet items were related to the child
receiving ‘good nutrition’and him/her having ‘poor eating
habits’, which can be relevant to both underweight and
overweight children. This might explain the negative
correlation between Concern about Child’s Diet and
Perceived Child Weight. Our results showed a negative
correlation between Concern about Child Weight and
Pressure to Eat, which is consistent with results from
previous studies in Western samples(10,11,26).
Correlations detected between the modified CFQ-A
factors and child BMIZ also give support to our hypothesis
that maternal perceptions and practices around feeding are
associated with child BMIZ in a sample of Saudi mothers
and pre-schoolers. While some studies did not detect an
association between restriction and child BMI(33,37) consis-
tent with our results, others have reported a link with over-
eating and obesity risk(13,14,54). Furthermore, although only
marginally significant, our finding of a negative correlation
between pressure to eat and child BMIZ is consistent with
those of previous studies(33,55) suggesting that mothers may
pressure their children to eat more when they are thinner.
Since the present analyses did not take potential
confounders into account, further studies that test adjusted
statistical models are needed to further establish the
association between maternal feeding behaviours and
child BMI in a Saudi sample. Our findings, in addition to
evidence from previous studies(25,36), suggest that Saudi
mothers may feel great responsibility towards their role
in feeding their families. Future studies that characterize
feeding behaviours and examine associations with weight
status are needed to help inform intervention studies
aiming to enhance adaptive feeding practices and promote
healthy eating behaviours among children in Saudi
Arabia(56).
Our study was the first to evaluate validity and reliabil-
ity of an Arabic version of the CFQ in a cohort residing in
KSA. We were able to slightly modify the CFQ in order to
better capture traditional feeding practices among Saudi
mothers. Child anthropometry was objectively measured,
and the sample was recruited from eight different pre-
schools with varying degrees of socio-economic status.
Limitations of the study included that our sample size
was relatively small. Mothers were recruited through an
opt-in approach by placing consent forms in children’s
backpacks. This might have increased the likelihood of
Table 5 Factor–factor and factor–child BMI Z-score (BMIZ) correlations of the modified nine-factor model of the Arabic version of the Child Feeding Questionnaire (CFQ-A), October 2017–April 2018
Perceived
Responsibility
Perceived Parent
Weight
Perceived Child
Weight
Concern about
Child Weight Restriction
Pressure
to Eat Monitoring
Use of Food as a
Reward
Concern about
Child’sDiet
Child BMIZ
(n207)
Perceived
Responsibility
1
Perceived Parent
Weight
−0·02 1
Perceived Child
Weight
0·13* 0·09 1
Concern about
Child Weight
−0·03 0·09 0·05 1
Restriction 0·30*** 0·03 0·20*** −0·009 1
Pressure to Eat 0·12* −0·12* −0·20*** −0·14** 0·06 1
Monitoring 0·40*** −0·07 0·17** −0·09 0·50*** 0·08 1
Use of Food as a
Reward
−0·19*** −0·12* −0·009 −0·07 −0·03 −0·03 −0·09 1
Concern about
Child’s Diet
−0·24*** −0·15** −0·23*** 0·18*** −0·09 −0·09 −0·11* 0·16** 1
Child BMIZ (n207) 0·11* 0·30*** 0·49*** 0·02 0·21*** −0·12* 0·16** 0·05 −0·18** 1
n209 unless otherwise specified.
*P<0·10, **P<0·05, ***P<0·01.
606 RH Mosli
https://doi.org/10.1017/S1368980019002581 Published online by Cambridge University Press
self-selection bias, such that mothers who were more
interested in the topic of feeding might have been more
inclined to participate. Administration of the question-
naire over the telephone might have increased the likeli-
hood that mothers will give socially desirable responses,
although this approach can help minimize missing data.
Furthermore, since the majority of mothers in our study
had a college degree or higher, our results may not be gen-
eralizable to other population groups with lower educa-
tional levels.
Future studies with larger sample sizes that include moth-
ers with different educational backgrounds and studies that
employ different recruitment strategies are warranted.
Longitudinal designs are also needed in order to evaluate
the effect of feeding behaviours over time and draw infer-
ences regarding causal associations. Additionally, qualitative
studies and those that include direct observation of mother–
child interactions during mealtimes may be useful in identi-
fying unique feeding behaviours among Saudi and Arab
families.
Conclusion
Identifying characteristics of the mealtime environment
and how they relate to child eating behaviours and weight
status can help inform effective prevention and interven-
tion strategies among Saudi families. Culturally sensitive
assessment tools are needed in order to evaluate feeding
behaviours among Saudi mothers. Our study provides
evidence that supports the validity and reliability of the
original seven-factor CFQ-A as well as a modified nine-
factor CFQ-A model. Future larger studies are needed to
further establish the psychometric properties of the
CFQ-A as well as other feeding assessment tools.
Acknowledgements
Financial support: This project was funded by the
Deanship of Scientific Research (DSR) at King Abdulaziz
University, Jeddah (grant number J-734-142-38). The
author acknowledges and thanks DSR for technical and
financial support. Conflict of interest: The author has no
financial relationships relevant to this article to disclose.
Authorship: R.H.M. designed the study, oversaw data col-
lection, analysed the data, wrote the manuscript and
approved final the version as submitted. Ethics of human
subject participation: This study was conducted according
to the guidelines laid down in the Declaration of Helsinki
and all procedures involving research study participants
were approved by the Unit of Biomedical Ethics at King
Abdulaziz University. Written informed consent was
obtained from all participants.
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