Relation of Emotional and Behavioral Problems With Body Mass Index in Preschool Children: The Generation R Study

Objective: Although problem behavior in children and adolescents has frequently been associated with overweight, it is unclear whether this relationship is already present in early childhood. We hypothesized that problem behavior is positively related to body mass index (BMI) in children of preschool age and that eating behavior explains part of this relation. Methods: The study was embedded in the Generation R Study, a population-based cohort with data available on BMI and problem behavior for 3137 children aged 3 to 4 years. Problem behavior was measured with the Child Behavior Checklist (CBCI), and eating behavior was assessed using the Child Eating Behaviour Questionnaire (CEBQ). Linear regression analyses were conducted to assess the association between the CBCI (expressed as z-scores). CEBQ, and BMI standard deviation scores (BMI-SDS), Bootstrapping was used to formally test mediation. Results: Children with higher levels of emotional problems had a lower BMI-SDS after adjustment for relevant covariates (e.g. beta [95% confidence interval {CI}] for mother report of emotional problems = -0.04 [-0.07, -0.001], father report = -0.04 [-0.08, -0.001]). Behavioral problems were not associated with BMI. Emotional and behavioral problems were not associated with underweight or overweight if studied categorically. The effect estimate for the relation of emotional problems with BMI-SDS attenuated to nonsignificance after adjustment for specific eating behaviors, i.e., they were accounted for by satiety responsiveness, fussiness, and emotional undereating. Conclusion: In this population-based study, emotional problems in pre-schoolers were negatively related to BMI, and this relation was fully explained by food avoidant eating behaviors.