Accepted Manuscript

A multidimensional approach to understanding the potential risk factors and

covariates of adult picky eating

Jordan M. Ellis, Rebecca R. Schenk, Amy T. Galloway, Hana F. Zickgraf, Rose Mary
Webb, Denise M. Martz

PII: S0195-6663(17)30836-X
DOI: 10.1016/j.appet.2018.01.016
Reference: APPET 3755

To appear in: Appetite

Received Date: 11 June 2017

Revised Date: 13 January 2018
Accepted Date: 15 January 2018

Please cite this article as: Ellis J.M., Schenk R.R., Galloway A.T., Zickgraf H.F., Webb R.M. & Martz
D.M., A multidimensional approach to understanding the potential risk factors and covariates of adult
picky eating, Appetite (2018), doi: 10.1016/j.appet.2018.01.016.

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A Multidimensional Approach to Understanding the Potential Risk Factors and Covariates of

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Adult Picky Eating

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Jordan M. Ellisa, Rebecca R. Schenkb, Amy T. Gallowayb, Hana F. Zickgrafc, Rose Mary Webbb

and Denise M. Martzb

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a
Department of Psychology, East Carolina University, East Fifth Street, 104 Rawl Building,

Greenville, NC 27858-4353 USA, Tel. # 1-(828)-772-8746, ellisjo15@students.ecu.edu

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Department of Psychology, Appalachian State University, P.O. Box 32109, 222 Joyce Lawrence
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Ln. Boone, NC, 28608, USA

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Department of Psychology, University of Pennsylvania, 425 S. University Ave

Philadelphia, PA, 19104, USA

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Correspondence concerning this article should be addressed to Jordan M. Ellis

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This research was funded by the Creating a Healthy, Just and Sustainable Society Student

Research Grant awarded to the first author by the Appalachian State University Office of Student

Research.
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Running Head: POTENTIAL RISK FACTORS OF ADULT PICKY EATING 1

A Multidimensional Approach to Understanding the Potential Risk Factors and Covariates of

Adult Picky Eating

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POTENTIAL RISK FACTORS OF ADULT PICKY EATING 2

Abstract

Objective: Adult picky eating (PE) has received increased attention in the eating behavior

literature due to its important association with adult avoidant-restrictive food intake disorder

(ARFID). The current study tested a model of potential risk factors of adult PE behavior,

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including perceived early parental feeding practices. An exploratory model was also utilized to

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understand associations with different aspects of adult PE behaviors. Methods: A sample of

1,339 US adults recruited through Amazon’s MTurk completed an online survey that included

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the recently developed Adult Picky Eating Questionnaire (APEQ), retrospective reports of

parental feeding practices, and other measures of eating behavior and demographic variables. A

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structural equation modeling procedure tested a series of regression models that included BMI
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and disordered eating behaviors as covariates. Results: SEM modeling indicated that

retrospective reports of greater parental pressure to eat, higher disgust sensitivity, lower PE age
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of onset, and experiencing an aversive food event were associated with general adult PE
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behavior. Results also indicated parental encouragement of healthy eating may be a protective
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factor, and that men endorsed higher levels of adult PE. Exploratory analyses indicated that

cross-sectional predictors and covariates were differentially related to specific aspects of PE as

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measured by the APEQ subscales. Conclusions: Early experiences, including parental

approaches to feeding, appear to be potential risk factors of PE behavior in adults. A nuanced

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understanding of adult PE is important for the prevention and treatment of severe PE behaviors,
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related psychosocial impairment, and ARFID.

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POTENTIAL RISK FACTORS OF ADULT PICKY EATING 3

A Multidimensional Approach to Understanding the Potential Risk Factors and Covariates of

Adult Picky Eating

Picky eating (PE) is characterized by the consumption of a limited variety of food,

through the avoidance or rejection of both familiar and unfamiliar foods (Dovey, Staples,

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Gibson, & Halford, 2008; Taylor, Wernimont, Northstone, & Emmett, 2015). PE that persists

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and causes significant distress or impairment related to the consequences of PE can now be

diagnosed as Avoidant/Restrictive Food Intake Disorder (ARFID), a new entry to the Diagnostic

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and Statistical Manual of Mental Disorders, fifth addition (DSM-5, APA, 2013). Most PE

research has focused on children, but with the recent addition of ARFID to DSM-5, there has

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been a shift in focus to the understudied concern of adult PE. The ARFID diagnosis is intended
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to identify individuals from infancy to adulthood with clinically significant restrictive eating

problems that result in persistent failure to meet nutritional and/or energy needs and are not
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driven by a desire to lose weight or associated with distorted body image. The DSM-5 describes
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three types of eating disturbances that can lead to ARFID symptoms: PE, low appetite/interest in
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eating, and fear of negative consequences from eating, although other eating restrictions can lead

to an ARFID diagnosis (APA, 2013). Research relating to PE in adults and potential implications
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of PE as a contributing factor to ARFID in adulthood is extremely limited, despite evidence

suggesting that some degree of adult PE is fairly common (Ellis, Galloway, Webb, & Martz,
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2016; Zickgraf, Franklin, & Rozin, 2016). The purpose of this paper is to use a cross-sectional
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design to identify potential predictors of general PE and to explore differential predictors of four

empirically-derived facets (i.e., rigid attitudes and behaviors around food

presentation/preparation; low dietary variety; disengagement and avoidance during mealtimes;

aversion to bitter and sour tastes) of PE behavior in adulthood using a large non-clinical sample.
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POTENTIAL RISK FACTORS OF ADULT PICKY EATING 4

There has been extremely little research on the relationship between PE and the formal

ARFID diagnosis. However, PE has consistently been linked to nutritional, weight, and

psychosocial outcomes across the lifespan. PE is associated with slow growth, underweight, and

delayed development in children, and has been shown to have relationships with reduced fruit

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and vegetable consumption, functional constipation, internalizing and externalizing

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psychopathology symptoms, and increased family stress and conflict (Cano et al., 2016; Cooke,

Carnell, & Wardle, 2006; Coulthard & Blissett, 2009; Ekstein, Laniado, & Glick, 2010;

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Galloway, Fiorito, Lee, & Birch, 2005; Goh & Jacob, 2012; Jacobi, Schmitz, & Agras, 2008;

Mascola, Bryson, & Agras, 2010; Micali et al., 2011; Ramos-Paúl, Marriage, Debeza, Leal, &

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Ros, 2014; Tharner et al., 2014; Zucker et al., 2015). In adulthood, PE has been associated with
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symptoms of depression, social eating anxiety, obsessive-compulsive disorder (OCD) symptoms,

psychological inflexibility, lower eating-related quality of life, reduced fruit and vegetable
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consumption, and report of lower dietary variety. (Ellis et al., 2016; Kauer, Pelchat, Rozin, &
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Zickgraf, 2015; Wildes, Zucker, & Marcus, 2012; Zickgraf et al., 2016; Zickgraf & Schepps,
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2016). PE has not been linked to clinically significant underweight in school-aged children or

adults, but PE appears to be a common precursor to ARFID symptoms. In eating disorder clinics
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ARFID is associated with underweight to the same extent as AN in these settings (e.g., Forman

et al., 2014). When PE is measured continuously, it is often negatively associated with BMI,
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leading some to suggest that it might be protective against the development of overweight
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(Berge, Tate, Trofholz, Conger, & Neumark-Sztainer, 2016; Galloway et al., 2005).

Picky eating is common in both childhood and adulthood, and although it has consistently

been associated with negative nutritional, developmental, and psychosocial correlates, it is likely

that only higher levels of PE are associated with negative outcomes and ARFID symptoms. A
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POTENTIAL RISK FACTORS OF ADULT PICKY EATING 5

limited body of research in adolescents and adults indicates that individuals with severe PE or

diagnoses of ARFID show levels of psychological distress and eating-related impairment

comparable to those of individuals diagnosed with or screened at risk for an eating disorder

(Strandjord, Sieke, Richmond, & Rome, 2015; Wildes et al., 2012; Zickgraf et al., 2016).

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PE behavior includes food neophobia, sensory food aversions, and rejection of familiar

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foods, and is closely associated with rigidity around food preparation/presentation. Given the

heterogeneity of eating behaviors associated with PE, multidimensional measures of this

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construct may shed more light on the relationships between PE behaviors and clinical outcomes.

Previous research has described some of the social, dietary, and clinical implications of adult PE

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but has not investigated potential predictors of specific PE behaviors. The current study
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attempted to bridge the gap in the literature by exploring common and specific predictors of

various adult PE behaviors.

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Previous research suggests that there are several demographic variables that may relate to
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the development of PE. Picky eaters are known to have younger mothers (Dubois, Farmer,
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Girard, Peterson, & Tatone-Tokuda, 2007; Hafstad, Abebe, Torgersen, & Soest, 2013; Tharner et

al., 2014), lower socioeconomic status as children (Dubois et al., 2007; Tharner et al., 2014), and
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to be less-educated as adults (Wildes et al., 2012). In two recent studies of children, parent-

reported picky eaters were more likely to come from non-Western backgrounds (Cano et al.,
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2015; Tharner et al., 2014), although other studies have not found demographic differences
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among picky eaters (Carruth, Ziegler, Gordon, & Barr, 2004). Sex findings have been

inconsistent within the literature, some studies reporting no sex differences in PE among children

and adults (Dovey et al., 2008; Fisher et al., 2014; Jacobi et al., 2008; Kauer, Pelchat, Rozin, &

Zickgraf, 2015), but other findings suggest a higher prevalence of male picky eaters (Cano et al.,
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2016; Tharner et al., 2014). In addition to demographics, there are other likely predictors of PE,

such as the extent to which picky eaters were pressured or forced to eat disliked food (Tharner et

al., 2014), or the degree to which they were encouraged to eat a variety of healthy food during

childhood (Steinsbekk, Sveen, Fildes, Llewllyn & Wichstrom, 2017; Vaughn et al., 2016).

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Moreover, negative experiences with food, such as choking or vomiting after eating, have been

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linked to ARFID symptoms (Fisher et al., 2014), and individual differences in sensitivity to

disgust may be associated with domains of adult PE (Dovey et al., 2008; Kauer et al., 2015).

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Given the mixed findings linking PE to outcomes, it is possible that various domains of

PE differentially relate to ARFID outcomes. In order to understand the relationship between PE

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and ARFID, a more refined measure of PE that enables the identification of the common and
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unique predictors of distinct aspects of adult PE is needed (Ellis et al., 2016). Previous research

supports the expectation that lower income, lower educational levels, and younger maternal age,
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will likely predict adult PE. In support of previous research, it was hypothesized that
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retrospective reports of higher levels of parental pressure to eat and lower levels of parental
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encouragement to eat certain foods would also be associated with adult PE. Finally, it was

hypothesized that disgust sensitivity and recollections of early negative experience with food
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would be associated with overall PE. The model described below also investigated maternal and

paternal age, sex, race, and self-reported age of PE onset as potential predictors. In addition to
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examining a composite measure of PE, exploratory analyses were employed to determine

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predictors of different aspects of PE behaviors. It should be emphasized that the aim of the study

was to examine potential predictors of adult PE, not ARFID. The models and measures

employed do not clearly distinguish between subclinical PE and eating behaviors that would

cross the threshold of severity of an ARFID diagnosis.

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Methods

Participants

A sample of Mechanical Turk (MTurk) workers, from the US and over the age of 18,

were recruited to complete an online survey about adult development, with no indication the

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survey would be assessing eating behaviors. No exclusion criteria beyond age and US residence

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was employed. Amazon’s MTurk is an online interface for recruiting and paying participants to

complete tasks, and can be more representative of the US population than in-person convenience

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samples (Berinsky, Huber, & Lenz, 2012). The sample included 1,339 MTurk workers (804

women, 535 men; 80% White, 10% Black, 5% Asian, 3% Hispanic; mean age 40.39, SD =

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13.39). The mean BMI of the sample was 27.67 (SD = 7.18) and 53.0% of the sample had
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completed at least a 4-year college degree (see Table 1). The university’s Institutional Review

Board approved the study’s procedure.

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Measures
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Participants were first asked to respond to a series of questions about demographic

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factors, including age, sex, race, educational attainment, family income, and their mother’s and

father's ages at their birth. Participants were asked to self-report their height and weight, from
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which Body Mass Index (BMI) was calculated. Given that having an aversive food experience

has been associated with childhood PE (Fisher et al., 2014), and PE attitudes and behaviors
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appear to manifest early in life (Mascola et al., 2010), a series of specific questions about PE
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were also presented. If participants answered "yes" to being unusually picky/selective about the

foods they eat, they were also asked, “At what age did you become a picky eater?” They were

also asked to respond “yes,” “maybe,” or “not applicable” to the question, “Before you became a

picky/selective eater, did you have a bad experience with food?” Participants were then asked if
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they did have a bad experience involving food to provide an open-ended response describing the

experience.

Adult Picky Eating Questionnaire (APEQ). The APEQ is a 15-item self-report

measure that assesses multiple aspects of adult PE, and its factor structure was confirmed in the

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present sample (Ellis et al., 2016). The APEQ has fours subscales: Meal Presentation, which

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assesses rigid preferences around food preparation and presentation; Food Variety, which

assesses a restricted dietary range across foods and food groups; Meal Disengagement, which

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assesses avoidant behaviors around mealtimes; and Taste Aversion, which assesses the rejection

of bitter and sour foods. A composite score can also be calculated by averaging the 15-items, and

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the measure is scored on a five-point Likert scale ranging from 1 = “Never” to 5 = “Always.”
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Parental Feeding Practices. A modified version of the "Pressure" and "Encourage

Balance and Variety" subscales from the Comprehensive Feeding Practices Questionnaire
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(CFPQ; Musher-Eizenman & Holub, 2007) was utilized to assess retrospective parental feeding
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practices. The CFPQ was developed as a multi-factor parent self-report measure that assesses a
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variety of practices used to feed their children, and has shown validity and adequate

psychometric properties across a range of age and ethnic groups (Melbye, Øgaard, & Øverby,
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2011; Musher-Eizenman & Holub, 2007).

As there is currently no retrospective measure of college student perceptions of their

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parents feeding practices during childhood, items from the CFPQ were slightly modified for use
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with a college sample. Previous researchers have modified another measure of parental feeding,

the Child Feeding Questionnaire (CFQ; Francis, Hofer, & Birch, 2001), to assess child and

college student perceptions of parental pressure, but the CFQ does not assess encouragement for

healthful eating (Carper, Orlet Fisher, & Birch, 2000; Galloway, Farrow, & Martz, 2010);
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therefore, we similarly modified the CPFQ for the current study. For example, one CPFQ item

asks parents to respond to “My child should always eat all of the food on his/her plate,” on a 5-

point Likert scale (1 = “Disagree” to 5 = “Agree”). The item in the current study was modified to

state, “Your parents believed you should eat all of the food on your plate.” The Pressure subscale

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measures the extent to which parents pressured the college student, as a child, to consume more

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food at meals, with higher scores indicating greater pressure. The Encourage Balance and

Variety Subscale measures the extent to which college students recall their parents promoting a

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well-balanced food intake, including encouraging the consumption of a variety of foods and

healthy foods. Higher scores indicate greater parent encouragement. Both the Pressure (α = .86)

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and Encourage Balance and Variety (α = .87) subscales showed good internal consistency in the
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present sample.

Disgust Sensitivity. The Core Disgust subscale from the Disgust Scale was utilized to
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measure disgust sensitivity (Rozin, Haidt, & McCauley, 2008; Olatunji et al., 2007). The Core
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Disgust subscale is a 12-item subscale that is based on a general sense offensiveness and
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contamination towards a variety of disgust eliciting stimuli. The scale is rated on a 5-point Likert

scale ranging from “0 = No disgust or repugnance at all” to “4 = Extreme disgust or

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repugnance.” The subscale has demonstrated good psychometric properties (Olatunji et al., 2007;

Van Overveld, de Jong, Peters, & Schouten, 2011). This subscale demonstrated satisfactory
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internal consistency in the current study (α= .81).

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Disordered Eating Symptoms. The Eating Disorder Diagnostic Scale (EDDS) was

utilized to assess disordered eating behaviors. It is a 22-item measure that has demonstrated

evidence for good reliability and validity and can be used to support clinical diagnoses, as it can

provide diagnostic cutoffs for specific eating disorders (Stice, Fisher, & Martinez, 2004). Given
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that the present study did not include a clinical population, our analytic approach included

calculating a continuous eating disorder symptom composite score by standardizing item scores

and averaging them together to assess symptom severity, as opposed to using diagnostic cutoffs

(Stice, Telch, & Rizvi, 2000). The EDDS composite score demonstrated satisfactory internal

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consistency in the present study (α = .71).

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Data Analysis

Structural equation modeling (SEM) procedures were employed to assess the

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hypothesized predictors of adult PE. The first model assessed predictors of the composite APEQ

latent variable, which was identified within a second order model with 15-item indicators and the

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four primary latent subscale factors. Latent variable predictors included pressure to eat (4-item
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indicators), encouragement to eat (4-item indicators), and core disgust (12-item indicators).

Manifest predictors included sex, race, BMI, the age at which PE developed, aversive experience
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related to PE onset, family income, education, mother’s age at birth, and father’s age at birth.
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Race was coded as a binary variable, representing majority (i.e., white) and minority subsets of
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the sample. Family income was coded as a binary variable to categorize participants into groups

with family income less than or greater than $50,000. Education was also coded as a
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dichotomous variable, capturing whether or not participants had attained a four-year degree or

greater, or less than a four-year degree. Having a bad experience related to PE onset was also
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coded as a dichotomous variable as a way to categorize participants who endorsed “yes” or

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“maybe” versus those who replied, “not applicable.” Open ended responses from participants

who endorsed “yes” to having had a bad experience with food were coded as: 1) pressure to eat

or forced consumption experience; 2) choking or food related sickness; 3) medical problem; or 4)

weight concerns. While a causal model could not be proposed because the present data set is
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cross-sectional and not longitudinal, the current literature suggests that treating most of the

predictor variables as temporally distinct is justified in that they likely occurred before the

current adult PE behaviors. BMI was included as a covariate to control for weight related

influences, but is not necessarily temporally distinct from PE. Finally, the EDDS was added as a

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stepwise covariate to examine and control for possible distortions caused by more traditional

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eating disorder symptomatology.

For the SEM procedure, the measurement model, including all of the latent variables, was

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estimated using confirmatory factor analysis procedures (CFA). A robust maximum likelihood

(MLR) estimator was employed for the measurement model, as all of the latent variables were

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continuous data. Because ordinal predictors were included in the measurement model, a diagonal
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weighted least squares (DWLS) estimator was employed. The DWLS is a robust weighted least

squares estimator that can analyze both continuous and non-continuous variables and has
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performed well in computer simulations (Muthén, du Toit, & Spisic, 1997). If the measurement
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model demonstrated acceptable fit, the structural model was then estimated. Non-significant
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regression paths were then trimmed to produce a more parsimonious model.

Model fit was assessed using the Comparative Fit Index (CFI), the Tucker Lewis Index
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(TLI), the root mean square residual (RMSEA) and the standardized root mean square residual

(SRMR). Values at or above .90 on the CFI and TLI have been advised as a cutoff that represents
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an acceptable fitting model, and values at or above .95 represent a good fitting model. Values at
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or below .06 for the RMSEA and .08 for the SRMR further represent a good model fit (Hu &

Bentler, 1999).

The final SEM procedure included an exploratory approach to examine the relationship

between the predictors from the trimmed model and each of the APEQ latent subscale factors, to
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assess the relationship between predictors and specific aspects of adult PE. The subscales were

modeled as correlated factors, without the general PE factor.

Results

Correlations between the APEQ subscales and continuous predictor variables are

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presented in Table 2. The measurement model demonstrated acceptable model fit, χ2 (584) =

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1950.93, p < .001, CFI = .91, TLI = .90, RMSEA = .04, SRMR = 0.05, and loadings across all

latent factors were in an acceptable range (.36 - .92). Modification indices and residuals from the

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model were examined to determine if minor adjustments could further improve model fit. They

suggested that two items from the pressure subscale and two items from the encouragement

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subscale were highly correlated. Item content within each item pair was similar, thus two
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residual covariance pathways were added to the measurement model. Model fit improved

following the modifications, χ2 (582) = 1733.90, p < .001, CFI = .92, TLI = .92, RMSEA = .04,
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SRMR = 0.05. The structural model with all predictors of PE was then estimated and resulted in
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a mediocre fit, χ2 (987) = 2336.74, p < .001, CFI = .89, TLI = .88, RMSEA = .05, SRMR = 0.07.
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Figure 1 presents the conceptual progression of models 1 through 3. As shown in Table 3 (see

Model 1), all of the statistically significant pathways were in the expected direction. However,
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race, education, income, mother’s age, and father’s age all fell short of significance as predictors

of PE in the model. After trimming these non-significant pathways, Model 2 demonstrated

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acceptable model fit, χ2 (722) = 1671.60, p < .001, CFI = .92, TLI = .91, RMSEA = .05, SRMR
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= 0.06. These results indicate that adult PE is positively associated with parental pressure to eat

in childhood, disgust sensitivity, the presence of a negative experience with food, and BMI. The

results also suggest that the earlier PE behaviors start, the more likely they are to persist into
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adulthood, and encouragement to eat during childhood was negatively related to adult PE.

Finally, men reported higher scores on the general PE subscale.

The EDDS was added in Model 3 as a covariate to control for possible distortions caused

by more traditional eating disorder symptomatology, χ2 (757) = 1793.74, p < .001, CFI = .92,

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TLI = .91, RMSEA = .05, SRMR = 0.06. All of the pathways except for BMI remained

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significant and of similar magnitudes. BMI was no longer significant with the addition of the

EDDS, but BMI was retained in the exploratory model to determine if different facets of PE

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were related to BMI.

Figure 2 shows a conceptual presentation of the following exploratory models. The

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model examining predictor relationships with each of the APEQ subscales also demonstrated
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acceptable model fit, χ2 (699) = 1364.14, p < .001, CFI = .92, TLI = .94, RMSEA = .05, SRMR

= 0.06. Standardized beta weights are presented in Table 4, Model 4. Results indicate that all
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variables, except for BMI, were significant in predicting the Meal Presentation subscale, and in
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the expected direction. All of independent variables significantly predicted the Food Variety
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subscale, in the expected directions. Results also showed that disgust sensitivity, age of PE onset,

and BMI were not significant predictors of the Meal Disengagement subscale. Finally, parental
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pressure to eat, sex, and age of PE onset were not significant predictors of the Taste Aversion

subscale. Parental encouragement to eat and the presence of a negative food experience were
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both significant predictors for all four facets of the APEQ.

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Again, the EDDS was added into the model as a covariate to control for possible

distortions caused by more traditional eating disorder symptomatology, χ2 (731) = 1452.23, p <

.001, CFI = .94, TLI = .93, RMSEA = .04, SRMR = 0.06 (see Model 5 in Table 4). All of the

pathways remained significant and of similar magnitudes, except the relationship between Taste
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Aversion and BMI became nonsignificant, suggesting that the only subscale significantly related

to BMI when controlling for disordered eating was the Food Variety subscale. Overall, these

exploratory results suggest that while certain aspects of PE share predictors, some predictors are

specific to certain types of PE behaviors.

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Discussion

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Currently, there is a paucity of research on adult PE. Given recent findings that suggest

PE is related to significant psychosocial impairment and distress in adulthood (Ellis et al., 2016,

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Kauer et al., 2015, Zickgraf et al., 2016), it is important that researchers continue to work toward

a better understanding of how these eating behaviors may affect physical and mental well-being.

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Moreover, it is important that researchers explore demographic and environmental factors that
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may contribute to the maintenance of PE from childhood to adulthood. The purpose of the

current study was to identify self-reported potential risk factors of adult PE and to examine
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whether there are different predictors for specific PE behaviors and attitudes. Findings from this
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study may also aid in understanding the etiology and maintenance of ARFID, an understudied
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eating disorder new to the DSM-5, as severe PE can be a core feature of the disorder in both

children and adults (APA, 2013).

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In this study, the predictive value of several demographic variables was tested, including

race, education, income, parent age, and participant sex for general PE and specific PE
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behaviors. Of these, only sex was related to general adult PE, in that males were more likely to
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report higher PE behaviors related to Food Variety, Meal Presentation, and Meal

Disengagement. This conflicts with one previous study in adults that found women were more

likely than men to identify as severely picky (Zickgraf et al., 2016); although, many participants

in that study were recruited from an online support group for adult picky eaters and may not be
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representative of the demographics of severe adult picky eaters. Interestingly, other studies of

children and adults report no sex differences in PE (Kauer et al., 2015; Fisher et al., 2014; Jacobi

et al., 2008); however, several reports have found that school-aged and younger boys are more

likely than girls to be picky eaters (Cano et al., 2015; Tharner et al., 2014). These inconsistent

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findings in the past may be attributed to differences in measurement of PE (i.e., maternal vs. self-

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report, single item measurement), particularly considering that different dimensions of PE have

not been previously considered. Surprisingly, several other demographic variables including

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race, education, income, and parent age were not associated with adult PE. It is possible that the

measure of participants’ current family income did not consistently represent childhood income

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status, when this variable is presumed to have had its effect on adult eating behavior. Although
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some previous studies report that older maternal age and higher educational attainment may be

protective factors against the development of PE in childhood (Hafstad et al., 2013; Tharner et
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al., 2014), results from this study did not replicate that finding for adults.
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Body size as measured by BMI was included in each model as a covariate to account for
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weight-related influences on the APEQ subscales. In this study, BMI was not directly correlated

with overall PE or any of the aspects of PE; however, when entered in the multiple regression,
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higher BMI was a significant covariate with overall PE, suggesting a potential suppressor effect.

However, it was no longer significantly related when the EDDS was entered into the model. This
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difference may be due to the higher prevalence of eating disorders in high-weight individuals
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(Duncan, Ziobrowski, & Nicol, 2017). BMI was differentially associated with the various aspects

of PE; higher BMI was positively associated with PE related to low Food Variety and negatively

associated with Meal Disengagement. In other words, participants with higher weight status were

more likely to eat from a limited selection of foods and participants with lower weight status
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POTENTIAL RISK FACTORS OF ADULT PICKY EATING 16

were more likely to report being disengaged with food. The relationship between BMI and Food

Variety may reflect the tendency for picky eaters to consume more palatable, energy-dense

foods; adult and child picky eaters have been found to be more likely to restrict their variety of

fruits and vegetables more than other food groups, and adult picky eaters are more likely to omit

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fruits and vegetables completely (Galloway et al., 2005; Zickgraf & Schepps, 2016). The

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negative relationship between Meal Disengagement and BMI might suggest that individuals who

are disengaged from meals consume fewer overall calories because they are avoiding all types of

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food rather than specific types of food. Future research should examine the dietary patterns of

individuals who endorse the various aspects of PE. It should be noted that the causal direction of

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the relationship between adult PE and BMI is currently unclear. PE behavior could influence
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BMI, but it is also possible that early experiences, such as childhood food allergies, a history of

vomiting/choking, or gastrointestinal reflux (Fisher et al., 2014) might influence weight as well
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as an individual’s relationship with food.

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Results from this study showed clear patterns in how parental pressure to eat and
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encouragement to eat certain foods in childhood is related to picky eating in adulthood. The

recollection of being pressured to eat as a child was associated with higher levels of PE across
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subtypes and the recollection of being encouraged to eat as a child was associated with lower

levels of PE across subtypes. Results from this study align with a recent prospective study
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showing that parental feeding practices, such as the use of pressure and encouragement, may
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have long-term implications for the development of children’s eating behavior (Steinsbekk,

Belsky, & Wichstrom, 2016). However, because the current data are cross-sectional and

retrospectively reported, it cannot be concluded that parental feeding practices caused or even

preceded the development of PE. In fact, it is likely that the relationship between PE and parental
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POTENTIAL RISK FACTORS OF ADULT PICKY EATING 17

use of pressure and encouragement is bidirectional (Berge et al., 2016). Children who are picky

eaters are probably more challenging for parents to feed than children who are open to eating a

variety of foods, hence shaping parental behaviors over time. One cross-sectional study has

suggested that parents use pressure or encouragement in response to their child’s eating behavior

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and/or weight (Francis, Hofer, & Birch, 2001). Other findings indicate that the use of pressure

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has the potential to exacerbate PE (Galloway, Fiorito, Francis, & Birch, 2006) whereas the use of

encouragement has been shown to predict more positive eating behaviors in children (Ventura &

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Birch, 2008).

In a recent study, adult picky eaters scored higher on disgust sensitivity than non-picky

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eaters (Kauer et al., 2015). Results from the current study corroborated this finding in general,
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but also indicated that disgust sensitivity is associated with particular aspects of PE. Perhaps this

represents a response to the characteristics of the food itself that may be explained by an
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underlying biological predisposition of disgust sensitivity (Sherlock, Zietsch, Tybur, & Jern,
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2016); however, more research is needed to understand these differential relationships. Early
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experiences are also thought to be important for shaping the development of eating behavior

(Dovey et al., 2008; Fisher et al., 2014). Results indicated that recollections of early negative
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experiences with food consistently predicted adult PE for all of the subtypes. It is also possible

that factors such as childhood PE, disgust sensitivity, and early aversive experiences with food
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could be part of a single phenomenon associated with adult eating behavior. The effect of early
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aversive food experiences was stronger for Meal Presentation and Food Variety, suggesting that

some types of PE might be influenced by environmental circumstances, including important

early experiences, whereas others might more strongly reflect biological predisposition (e.g.,
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POTENTIAL RISK FACTORS OF ADULT PICKY EATING 18

Taste Aversion) or comorbid psychopathology or the effects of PE on psychosocial functioning

(e.g., Meal Disengagement).

Corroborating this hypothesis is that the age of PE onset was not associated with these

same two subtypes. It should be noted that the mean age of onset was 14 years of age, which was

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unexpected given that PE incidence has been reported as less than 5% per year after age six, and

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most studies that explore PE longitudinally, or cross-sectionally across age groups in childhood,

suggest that PE prevalence and severity decrease with age (Mascola et al., 2010; Pelchat &

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Pliner, 1995). It may be the case that many of the negative eating experiences reported by

participants were associated with pre-existing PE rather than causal (e.g., forced consumption of

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an already-disliked food). It is possible that our participants were more able to remember
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experiences in early adolescence than experiences earlier in childhood, and were reporting the

first incident they could clearly remember rather than the first incident they experienced. The
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salience of this time period could be due to the increasing importance of peer relationships at this
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age, greater autonomy about eating choices, or the development of cognitively sophisticated
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decision-making around eating. Of course, this discrepant age-related finding may represent a

limitation to the generalizability of findings between age of onset and other variables, but also
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highlights the need for future studies that explore PE incidence in late adolescence and

adulthood.
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Interestingly, being pressured to eat was not associated with PE related to Taste
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Aversion. It is possible that this facet of PE is the result of more biologically-based taste aversion

and that is less related to negative social experiences with food. This possibility suggests parental

pressure as a potential causal or maintenance factor. If the current findings were driven by PE
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POTENTIAL RISK FACTORS OF ADULT PICKY EATING 19

leading to parental pressure, the different aspects of PE may not be predicted to differ in their

relationship with parental feeding practices.

Strengths of this study include a relatively large and representative sample. In addition,

the inclusion of a multi-dimensional scale with good psychometrics to measure PE provides a

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more comprehensive understanding of this behavior. The study has several limitations including

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the use of self-report measures, some of which were retrospective in nature. Furthermore, all of

the variables in the current study were measured cross-sectionally, and some had stronger

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evidence for temporal precedence in the predictive model than others (e.g., disgust sensitivity vs.

current family income). The finding that 8.7% of individuals who reported aversive events

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associated with their PE described the aversive event as being related to weight concerns limits
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the generalizability of some results, given that PE is typically not thought to be a response to

weight concerns. However, this finding also stresses the importance of continued refinement in
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the comprehensive measurement and operationalization of PE. It should also be noted that the
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APEQ was developed for the purpose of understanding a range of PE behaviors in adulthood, but
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it is not yet validated at a diagnostic screener for the more severe pathology related to individuals

who meet DSM-5 criteria for ARFID.

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The current study provided evidence for several potential risk factors of adult PE, using a

series of SEM regression models. Importantly, potential risk factors included parental feeding
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practices and disgust sensitivity, which could serve as future intervention targets. In addition,
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models examining multiple aspects of PE showed that some potential risk factors consistently

related across all facets (e.g., variety of food intake), whereas other variables were more strongly

related to a specific aspect of PE. These findings suggest that understanding the nuanced

attitudes, aversions, and behavioral sets that may have different developmental trajectories is
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POTENTIAL RISK FACTORS OF ADULT PICKY EATING 20

important for generating effective clinical treatments for severe PE behaviors and ARFID. These

findings also suggest that early experiences may be important predictors for whether PE

continues into adulthood. Specifically, the results suggest the importance of developing and

testing interventions to help parents moderate their negative responses to PE behavior that may

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have unintended consequences. Specifically, parents could learn positive approaches to child

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feeding (e.g., encouragement, modeling, and repeated exposure to foods) that have been

demonstrated to foster healthy eating behaviors in children (Johnson, 2016).

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Table 1 Demographic Characteristics of the Participants (n = 1339)

Variable Mean SD
Pressure 3.26 0.87
Encouragement 3.50 0.96
Core Disgust 28.75 8.54
PE Age 14.03 14.34
Mother’s age 26.71 6.50

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Father’s age 29.34 7.88
EDDS (standardized) 0.00 0.61
APEQ Total 2.30 0.68
APEQ Meal Presentation 2.35 0.74

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APEQ Food Variety 2.32 0.85
APEQ Meal Disengagement 2.05 0.86
APEQ Taste Aversion 2.44 1.08

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Variable n Percentage
PE Experience
Yes 117 8.7
Maybe 225 16.8
NA 997 74.5

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PE Experience Code for “Yes”
Pressure to Eat 27 26.0
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Choking/Food Sickness 40 38.5
Medical Problem 28 26.9
Weight Concern 9 8.7
Income
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Less than $20,000 207 15.5

$20-35,000 295 22.0
$35-50,000 292 21.8
Over $50,000 545 40.7
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Education
< High School/GED 5 0.4
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High School/GED 146 10.9

Some College 311 23.2
2-year College Degree 167 12.5
4-year College Degree 505 37.7
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Master’s Degree 151 11.3

Doctoral Degree 24 1.8
Professional Degree 20 1.5
Technical or Vocational 10 0.7
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School
Race
White 1070 79.9
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Black 129 9.6

Hispanic 46 3.4
Asian 66 4.9
Native American 10 0.7
Pacific Islander 1 0.1
Other 17 1.3
Note: APEQ = Adult Picky Eating Questionnaire; PE Age = self-reported age of picky eating onset; PE Experience
= Aversive food experience related to picky eating; BMI = Body Mass Index. EDDS = Eating Disorder Diagnostic
Scale standardized composite socre; PE Experience Code for “Yes” = coded open-ended response for those who
marked yes to experiencing an aversive food experience related to their picky eating.
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Table 2 Two-tailed Correlations Between APEQ Subscales and Continuous Predictors (n = 1339)
PE Subscale Pressure Encouragement Disgust PE Age Father’s Age Mother’s Age EDDS BMI

APEQ-Total .19** -.08** .23** -.11* -.05 -.06* .31** .01

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APEQ- Meal Presentation .20** .02 .28** -.11* -.03 -.06* .28** -.02

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APEQ- Food Variety .16** -.17** .17** -.11* -.06* -.06* .23** .05

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APEQ- Meal Disengagement .12** -.07* .00 -.02 -.02 -.01 .29** -.03

APEQ-Taste Aversion .10** -.08** .20** -.05 -.05 -.03 .19** .05

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Note: ** = correlation is significant at the 0.01 level; * = correlation is significant at the 0.05 level.

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Figure 1: Conceptual representation of Models 1 through 3. Circles represent latent variables. Boxes represent manifest variables. The
dashed box represents variables trimmed from Model 1 due to insignificant path weights. Dashed arrow from BMI shows
nonsignificance in Model 3 after controlling for EDDS. APEQ = Adult Picky Eating Questionnaire. PE Age = self-reported age of
picky eating onset. PE Experience = Aversive food experience related to picky eating. BMI = Body Mass Index. EDDS = Eating
Disorder Diagnostic Scale. Full reporting of standardized regression weights can be found in Table 3.
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POTENTIAL RISK FACTORS OF ADULT PICKY EATING 32

Table 3 Standardized Regression Weights of Predictors of the APEQ Composite Score

Model 1 Model 2 (Trimmed) Model 3 (EDDS covariate)
Predictors Loadings Loadings Predictors Loadings
Pressure 0.172 0.175 Pressure 0.175
Encouragement -0.256 -0.255 Encouragement -0.255
Disgust 0.289 0.288 Disgust 0.286

PT
Sex -0.115 -0.114 Sex -0.160
PE Age -0.139 -0.134 PE Age -0.127
PE Experience 0.277 0.281 PE Experience 0.245
BMI 0.109 0.115 BMI 0.015

RI
Race 0.001 EDDS 0.317
Education 0.001
Income -0.001

SC
Mother’s age -0.129
Father’s age 0.052

U
Note: Nonsignificant paths were trimmed from Model 2 and the Eating Disorder Diagnostic
Scale (EDDS) was added as a covariate to Model 3 to control for disordered eating symptoms
AN
related to shape and weight; PE = picky eating; PE Age = self-reported age of picky eating onset;
PE Experience = Aversive food experience related to picky eating; BMI = Body Mass Index; Sex
was coded as 1 = men and 2 = women; Bolded standardized regression paths indicate p < .05.
M
D
TE
C EP
AC
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POTENTIAL RISK FACTORS OF ADULT PICKY EATING 33

PT
RI
U SC
AN
M
D
TE
C EP
AC

Figure 2: Conceptual representation of Models 4 and 5. Circles represent latent variables. Boxes represent manifest variables. The
Eating Disorder Diagnostic Scale (EDDS) was added to Model 5 as a covariate. APEQ = Adult Picky Eating Questionnaire. PE Age =
self-reported age of picky eating onset. PE Experience = Aversive food experience related to picky eating. BMI = Body Mass Index.
Full reporting of standardized regression weights can be found in Table 4.
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POTENTIAL RISK FACTORS OF ADULT PICKY EATING 34

Table 4
Standardized Regression Weights of Predictors of the APEQ Subscale Scores
Model 4 Model 5 (EDDS Covariate)
Subscale and Predictors Subscale and Predictors
Meal Presentation Loadings Meal Presentation Loadings
Pressure 0.152 Pressure 0.151
Encouragement -0.115 Encouragement -0.115

PT
Disgust 0.369 Disgust 0.368
Sex -0.075 Sex -0.117
PE Age -0.139 PE Age -0.134

RI
PE Experience 0.264 PE Experience 0.231
BMI 0.062 BMI -0.029
EDDS 0.289

SC
Food Variety Food Variety
Pressure 0.171 Pressure 0.171
Encouragement -0.360 Encouragement -0.361
Disgust 0.165 Disgust 0.164

U
Sex -0.149 Sex -0.169
PE Age -0.157 PE Age -0.155
AN
PE Experience 0.264 PE Experience 0.248
BMI 0.187 BMI 0.144
EDDS 0.139
M

Meal Disengagement Meal Disengagement

Pressure 0.126 Pressure 0.125
Encouragement -0.166 Encouragement -0.166
Disgust 0.011 Disgust 0.011
D

Sex -0.096 Sex -0.150

PE Age -0.027 PE Age -0.020
TE

PE Experience 0.161 PE Experience 0.118

BMI -0.020 BMI -0.137
EDDS 0.376
EP

Taste Aversion Taste Aversion

Pressure 0.043 Pressure 0.043
Encouragement -0.132 Encouragement -0.132
Disgust 0.255 Disgust 0.255
C

Sex -0.004 Sex -0.025

PE Age -0.053 PE Age -0.050
AC

PE Experience 0.107 PE Experience 0.090

BMI 0.111 BMI 0.065
EDDS 0.145
Note: The Eating Disorder Diagnostic Scale (EDDS) was added as a covariate to Model 5 to
control for disordered eating symptoms related to shape and weight; PE = picky eating; PE Age
= self-reported age of picky eating onset; PE Experience = Aversive food experience related to
picky eating; BMI = Body Mass Index; Sex was coded as 1 = men and 2 = women; Bolded
standardized regression paths indicate p < .05.