What Facets of Picky Eating Relate To Eating Concerns in Undergraduate Students?: The Moderating Effects of Inexible Eating and Mental Health Concerns

Purpose: Picky eating (PE) can occur in adulthood and is associated with mental health concerns. PE is often conceptualized as distinct from disordered eating, but recent research maps positive relationships between these maladaptive eating phenotypes. Relatedly, recent research suggests PE is more strongly related to eating concerns, a facet of disordered eating, via inexible eating and mental health concerns, but precisely what PE facets explain these relations remain unknown. Methods: A large, undergraduate sample (N=509) completed an online survey assessing PE facets (Adult Picky Eating Questionnaire; meal presentation, food variety, meal disengagement, and taste aversion), disordered eating (Eating Disorder Examination Questionnaire), specically eating concerns, mental health concerns (Depression, Anxiety and Stress Scale - 21 Items), and inexible eating (Inexible Eating Questionnaire). Results: Positive relationships emerged between PE facets, eating concerns, inexible eating, and mental health concerns. Meal disengagement was more strongly associated with eating concerns when inexible eating was higher, whereas food variety and meal presentation were more strongly associated with eating concerns when mental health concerns was higher. Inexible eating and mental health concerns did not signicantly interact with taste aversion to explain variance in eating concerns. Conclusions: Considering PE multidimensionally may yield important insights beyond the broader construct. Mental health concerns and inexible eating may be treatment and research targets in addressing the overlap between PE facets such as meal presentation, meal disengagement, and food variety and eating concerns. Likert scale (0=Did not apply to me at all; 3=Applied to me very much, or most of the time). This study averaged scores from the three subscales for a total score, titled mental health concerns. Example items are “I experienced trembling (anxiety),” “I felt that I had nothing to look forward to (depression),” and “I found it hard to wind down (stress).” The DASS-21 has shown strong psychometric properties, including internal consistency [27] and convergent validity [28]. Higher scores indicate greater mental health concerns.


Introduction
Picky eating (PE) is often a vexing behavior present across the lifespan. Indeed, while some research suggests that PE is con ned by age (i.e., only present in younger populations) [1], other research suggests that PE persists over time [2][3][4][5] and that approximately 35% of adults engage in PE [6]. Adult PE is associated with poor dietary quality [7][8] and signi cant psychological impairment including a range of mental health concerns and disordered eating [9][10][11] (e.g., dietary restraint, eating concerns, binge eating, and overall eating pathology) [9]. Recent research suggests that relationships between adult PE and disordered eating, speci cally eating concerns, are strengthened by mental health concerns and in exible eating in undergraduate students [9]. A critical piece missing from this research is precisely which facets of PE explain these relationships.
Picky Eating: De nitions, Multidimensional Structure, and Correlates PE includes di culty trying new foods, eating a limited range of foods, and marked rigidity and sensory sensitivity around food presentation and preparation [12]. PE also includes the rejection of familiar foods -when an individual refuses to eat or rejects a food they have consumed before -which distinguishes it from related constructs like food neophobia, or the avoidance of only novel foods that have never been consumed [13]. Because PE in adults is less understood than PE in children, a multidimensional tool was created to assess four distinct facets of adult PE [14]: (1) meal presentation, or strong preferences regarding food preparation and presentation; (2) food variety, or restricted dietary intake across food groups; (3) meal disengagement, or avoidant behavior around mealtimes; and (4) taste aversion, or rejection of bitter or sour foods [14][15]. This multidimensional approach to assessing PE has been identi ed as a key area of future research to de ne and elaborate on the nuances of adult PE [16], including the overlap between PE, disordered eating, and relevant correlates across these two eating phenotypes such as in exible eating and mental health concerns.
Some research has examined PE in relation to disordered eating, with mixed results. Importantly, PE and disordered eating have been considered distinct eating phenotypes such that PE attitudes, cognitions, and behaviors are thought to persist in the absence of shape and weight concerns [17].
Unlike PE, disordered eating includes shape and weight concerns (i.e., body dissatisfaction), with some research suggesting such concerns drive the development and maintenance of eating pathology (e.g., tripartite in uence model) [18]. That said, some research suggests that PE and disordered eating relate and co-occur [9][10][11]. For example, one study found that a comorbid class (high PE and disordered eating symptoms) was the largest class via latent class analysis, and was associated with psychosocial impairment and poor mental health outcomes [10]. Other research found that all PE facets were related to social anxiety around eating as well as anxiety sensitivity when controlling for disordered eating symptoms [14]. In another study [16] using latent pro le analysis, picky eaters emerged as a pro le of participants that endorsed less disordered eating (including shape and weight concern behaviors) compared to a pro le of participants called "approaching" eaters, or participants who self-reported higher food approach (e.g., high responsiveness and enjoyment of food) and lower traits of food avoidance. However, picky eaters also endorsed more eating-related impairment and depressive symptoms than "moderate" eaters, or eaters with a moderate food approach and avoidance [16]. Related to this is research suggesting that childhood PE did not predict disordered eating in adulthood [19]. These mixed ndings and others [9,[20][21][22][23] suggest unclear relationships between PE and disordered eating, warranting further research mapping these relationships.
Relationships between PE and mental health concerns are clearer. For example, adult picky eaters endorse more obsessive-compulsive disorder and depressive symptoms than non-PE adults [10,21]. Relatedly, positive relationships have been identi ed between PE and anxiety symptoms [14,24], and preliminary evidence suggests that adult PE is positively associated with stress symptoms [9]. Another relevant correlate of PE is in exible eating. For example, picky eaters with Avoidant Restrictive Food Intake Disorder (ARFID) reported elevated eating in exibility (rigidity around eating rules) [23].
Using a multidimensional approach to PE, one study found that meal presentation and meal disengagement predicted psychological in exibility and psychosocial impairment [14]. Furthermore, meal disengagement predicted depressive symptoms [14], suggesting that meal disengagement may be a more proximal predictor of poor mental health than other facets of PE. Taken together, while PE is consistently associated with psychological impairment, there is mixed evidence regarding relationships with disordered eating, and little is known about which speci c facets of PE are associated with in exible eating, mental health concerns, and disordered eating.

In exible Eating and Mental Health Concerns as Moderators of Relationships Between Picky Eating and Disordered Eating
Recently, Barnhart and colleagues [9] explored a range of psychological correlates as moderators of relationships between broad PE behavior and binge eating, dietary restraint, eating concerns, and overall eating pathology in undergraduate students. Mental health concerns (e.g., anxiety, depression, and stress symptoms) and in exible eating moderated relationships between broad PE and eating concerns such that PE was more strongly associated with eating concerns when mental health concerns and in exible eating were higher [9]. As it is measured on the Eating Disorder Examination-Questionnaire, eating concerns captures a range of disordered eating attitudes and cognitions including the fear of loss of control during eating, social aspects of eating such as eating in secrecy and guilt about eating, and a preoccupation with eating, food, calories [25]. The PE literature suggests some overlap with eating concerns, especially in terms of the social aspects of eating [10,14,26]. However, it remains unclear precisely what it is about PE that may relate to in exible eating and mental health concerns in relation to variance in eating concerns. It may be the case that more control-and anxiety-based picky eating facets (e.g., meal presentation and meal disengagement) may be more closely related to eating concerns than food exposure-based picky eating facets (e.g., eating from a limited range of food groups; food variety). To this end, Barnhart and colleagues [9] outlined the need to examine these research questions with a focus on speci c PE facets.

The Present Study
The present study builds on previous research demonstrating positive relationships between PE and disordered eating [10][11], speci cally eating concerns [9], by examining relationships between PE facets and eating concerns. Given recent research pointing to overlap between broad PE, disordered eating, mental health concerns, and in exible eating [9], this study had two exploratory hypotheses. First, we hypothesized that positive, bivariate relationships will emerge between PE facets, eating concerns, in exible eating, and mental health concerns. Second, we explored in exible eating and mental health concerns as moderators of relationships between PE facets and eating concerns. Based on previous research [9], we hypothesized that, overall, in exible eating and mental health concerns will strengthen relations between picky eating facets and eating concerns.

Height and Weight
Body mass index (BMI; kg/m 2 ) was calculated using self-reported height in feet and inches and weight in pounds.

Demographics
Participants self-reported demographic characteristics including age, gender, socioeconomic status, year in school, race, and sexual orientation. Data were also collected on current and past eating disorder diagnosis, current and past PE, and adherence to a particular eating style (e.g., vegetarian, vegan, etc.).

Adult Picky Eating Questionnaire (APEQ)
Adult PE was examined using the APEQ [14]. The questionnaire yields four subscales that are typically averaged to create a total score: meal presentation, food variety, meal disengagement, and taste aversion. This study focused on the subscales, not the total score. Example items are "I have a strong preference toward speci c food presentation (meal presentation)," "I eat a limited number of items from each food group (food variety)," "I usually feel that I have something better to do than eating (meal disengagement)," and "I reject bitter foods, even if they are only slightly bitter (taste aversion)." Participants completed 16 items, on a ve-point Likert scale (1=Never, 5=Always). The APEQ has shown strong psychometric properties, including internal consistency and convergent validity [14]. Higher scores indicated greater PE.

Eating Disorder Examination Questionnaire (EDE-Q)
Disordered eating was self-reported using the EDE-Q [25]. The 28-item scale assesses attitudes, cognitions, and behaviors relating to restraint, weight, shape, and eating concerns on a seven-point Likert scale (1=No days; 7=Everyday). This study focused on the eating concerns subscale. Each of the 28 items is preceded with "on how many of the past 28 days" and followed by the statements such as "Have you gone for long periods of time (8 waking hours or more) without eating anything at all in order to in uence your shape or weight?" The mean is calculated across all items in each scale, and higher scores indicate greater disordered eating.

Depression, Anxiety and Stress Scale -21 Items (DASS-21)
Mental health concerns were assessed using the DASS-21, a short version of the 42-item instrument [27]. The DASS-21 measures depression, anxiety, and stress symptoms on a four-point Likert scale (0=Did not apply to me at all; 3=Applied to me very much, or most of the time). This study averaged scores from the three subscales for a total score, titled mental health concerns. Example items are "I experienced trembling (anxiety)," "I felt that I had nothing to look forward to (depression)," and "I found it hard to wind down (stress)." The DASS-21 has shown strong psychometric properties, including internal consistency [27] and convergent validity [28]. Higher scores indicate greater mental health concerns.
In exible Eating Questionnaire (IEQ) In exible eating was assessed using the IEQ [29]. The 11-item scale assesses engagement in in exible and rigid eating rules on a ve-point Likert scale (1=Fully disagree; 5=Fully agree). This study used the scale's total score with items such as, "To manage my eating through rules gives me a sense of control" and "not following my eating rules makes me feel inferior." The IEQ has high internal consistency, construct and temporal stability [29], and higher scores indicate greater in exible eating.

Procedure
Procedures were approved by the Institutional Review Board prior to data collection (IRB protocol #1530232). University instructors shared a recruitment script about the survey with their students. Interested students then provided informed consent and accessed the survey on Qualtrics. Participants provided demographic information followed by previously described self-report measures; median survey completion time was approximately 27 minutes. Participants received course credit or extra credit following survey conclusion and were asked to recruit their parents to complete a similar survey. However, only student responses were used in the present study.
Two multiple regressions were calculated in SPSS 27. Across both regression analyses, predictor variables were mean centered. In step 1 across both models, BMI (mean centered) and gender (0=men, 1=women) covariates were entered given they are related to primary study variables [30][31]. In step 2, nine predictor variables were entered: picky eating facets (meal presentation, meal disengagement, taste aversion, and food variety), in exible eating total score or mental health concerns score, and four interaction terms created between in exible eating or mental health concerns and each picky eating facet. Across both regression models, eating concerns was the outcome variable. See Table 2 for more information.

Preliminary Results
See Table 1 for descriptive statistics and bivariate correlations. There were signi cant positive bivariate correlations between each facet of PE, eating concerns, in exible eating, and mental health concerns ( Table 1). Assumptions of multiple regression were con rmed via visual inspection of histograms, Q-Q plots, and scatterplots. Diagnostics con rmed there were no issues of multicollinearity (e.g., tolerance and variance in ation factors within acceptable ranges; [32]).
When examining interaction terms, which examined the interaction of in exible eating and each picky eating facet, the interaction between meal disengagement and in exible eating was associated with signi cant variance in eating concerns ( =.10, t=2.25, p = .03; see Table 2). More speci cally, meal disengagement was more strongly associated with eating concerns when in exible eating was higher. No other interaction terms were signi cantly related to variance in eating concerns (see Table 2).

Picky Eating Facets and Mental Health Concerns as Correlates of Eating Concerns
The overall model assessing picky eating facets and mental health concerns contributed signi cant variance in eating concerns (F(11, 469) = 25.52, p < .001, R 2 =.38; see Table 2). When examining main effects (i.e., relations between picky eating facets/mental health concerns and eating concerns), higher mental health concerns ( =.31, t=6.80, p < .001) and meal disengagement ( =.24, t=4.73, p < .001) were associated with higher eating concerns (see Table 2).
When examining interaction terms, which examined the interaction of mental health concerns and each picky eating facet, the interaction between meal presentation and mental health concerns was associated with signi cant variance in eating concerns ( =.13, t=2.38, p = .02; see Table 2). More speci cally, meal presentation was more strongly associated with eating concerns when mental health concerns were higher. Also, the interaction between food variety and mental health concerns was associated with signi cant variance in eating concerns ( =-.10, t=-2.25, p = .03; see Table 2). More speci cally, food variety was more strongly associated with eating concerns when mental health concerns were higher. Neither the interaction between meal disengagement and mental health concerns, nor taste aversion and mental health concerns were signi cantly related to variance in eating concerns (see Table 2).

Discussion
In the present study, we explored relationships between PE facets, eating concerns, in exible eating, and mental health concerns. Eating concerns and PE facets such as meal presentation and meal disengagement were positively related with medium strength, whereas eating concerns and food variety and taste aversion had small positive relations. Thus, some PE facets were more strongly related to eating concerns than others, a nding that is complemented by bivariate results that suggest that meal presentation and meal disengagement were also more strongly related to mental health concerns and in exible eating. These ndings map onto previous research suggesting that PE, speci cally meal presentation and meal disengagement, is positively associated with signi cant psychological impairment [9-10, 14, 21, 23-24].
Building on this, moderation analyses examined in exible eating and mental health concerns as moderators of relationships between PE facets and eating concerns. Overall, ndings suggested that PE attitudes and behaviors such as strong preferences for speci c food presentation, negative affect when food is not prepared/cooked the "right" way (meal presentation), avoiding mealtime and disengagement while sitting down for mealtime (meal disengagement), and eating from a limited number of food groups (food variety) were more strongly associated with eating concerns in undergraduates who self-reported higher mental health concerns and in exible eating. These ndings expand on previous research [9] by demonstrating that speci c facets of PE such as meal presentation, meal disengagement, and food variety may be especially relevant in these relationships. Importantly, meal presentation should be distinguished from food variety in terms of how it may in uence eating concerns via mental health concerns. Meal presentation appears to hinge on control of eating behaviors, including affective responses to eating when food rules are not met [14], whereas food variety emphasizes the food itself, including eating from a limited range of food groups [14]. Despite these unique features, ndings suggest mental health concerns act as a mutual positive correlate that strengthens relations between these PE facets and eating concerns. Importantly, food variety often sits at the center of PE conceptualizations [e.g., 12,13], both in popular and academic thought, which might explain a bias toward a unidimensional conceptualization of PE. The present ndings caution against this approach, emphasizing the role of more internal, control-based PE facets, including affective responses and rigidity around food, that may relate to eating concerns via mental health concerns and in exible eating. Importantly, conclusions drawn from this research may bene t both researchers and clinicians through a more nuanced understanding of the complex links between PE facets, disordered eating, in exible eating, and mental health concerns.

Limitations And Future Directions
Of course, this study is not without limitations and future directions. First, cross-sectional data do not allow us to make causal attributions across study variables. While the statistical analyses, speci cally moderation analyses, allow us to discern the role of both moderators on the relationship between PE facets and eating concerns, it is important for future research to con rm these exploratory ndings with both experimental and experience sampling (e.g., ecological momentary assessment) methods to better map the temporal order and mechanistic links between PE, in exible eating, mental health concerns, and eating concerns. Second, though large and well-powered, the sample is convenient and primarily WEIRD (i.e., Western, Educated, Industrialized, Rich, and Democratic [33]); thus, ndings are bound to undergraduate participants. Still, these effects suggest several important research avenues to build on constraints on generality [34], including how these effects unfold in more severe presentations of PE, disordered eating, and mental health concerns, as well as how these effects unfold across development (e.g., from childhood to adulthood). Third, the present study focused on eating concerns to build on the parent study; still, some recent research has called into question the psychometric strength of this subscale [see 35]. To this end, ndings from this study should be interpreted in light of these data. Finally, data collected in the present study were self-reported; thus, concerns common to descriptive, survey-based research such as social desirability and recall biases may compromise the validity of these ndings. Future research using diverse methods to probe these constructs (e.g., behavioral) may build and substantiate observed effects.

Conclusions
Understanding precisely which PE facets interact with in exible eating and mental health concerns in relation to eating concerns provides useful information to researchers interested in targeting mutual mechanisms of PE and disordered eating, speci cally eating concerns. The present study suggests that PE facets such as meal presentation, meal disengagement, and food variety were more strongly associated with eating concerns when mental health concerns and in exible eating were higher. These data inform clinical practice through knowledge of mental health concerns and in exible eating as correlates that may worsen relationships between PE facets and disordered eating, speci cally eating concerns, which in turn may provide information about potential therapeutic targets in concurrent PE and disordered eating presentations.

Declarations
Con icts of Interest: None of the authors have potential con icts of interest to disclose.