The influence of early and current feeding practices, eating behaviors, and screen time on dietary patterns in Polish toddlers - A cross-sectional study

Early nutrition has an important influence on a child ’ s proper health and development, and understanding factors that may be related to desirable dietary patterns is key to improving the diet of future generations. The aim of this study was to assess whether early and current feeding practices, eating behaviors, and screen time viewing are associated with toddlers ’ dietary patterns. A cross-sectional sample of 467 mothers of toddlers (aged 1 year to 3) was surveyed between 2020 and 2022. Food consumption was evaluated by the Food Frequency Questionnaire (FFQ). The k-means algorithm was used to define dietary patterns on the basis of data collected from the FFQ and mealtime environment patterns, based on the data about practices during meals consumption. The odds of following a prohealth dietary pattern among early feeding factors were lower when infants ate commercial complementary foods more often. Distracted mealtime environment pattern increased the odds of following a non-eaters pattern, and commercial complementary foods pattern increased the odds of following a processed pattern. Currently, the odds of following a processed dietary pattern were higher when children were not breastfed and had higher screen time. Toddlers who ate during distraction and were more fussy had lower odds of following a prohealth dietary pattern, whereas higher enjoyment of food and satiety responsiveness increased the odds. The results indicate the need to increase parents ’ awareness about the importance of early factors in establishing dietary patterns.


Introduction
Dietary patterns, food repertoire, and eating behaviors acquired in the first years may track into childhood and beyond, and thus influence later food choices (Ares et al., 2023;Farrow & Blissett, 2012;Haines et al., 2019;Mikkilä et al., 2005;Nicklaus, 2009;Nicklaus et al., 2005;Nicklaus & Remy, 2013;Rose et al., 2017).Therefore, optimal nutrition in early life is an important determinant of a child's health and development and may impact further dietary habits (Hamulka et al., 2020;Manohar et al., 2021;Nicklaus & Remy, 2013;Schwartz et al., 2011;Schwarzenberg & Georgieff, 2018).Rose et al. (Rose et al., 2017) have observed that infants who had a dietary pattern higher in fruits and vegetables or followed a dietary pattern characterized by foods high in energy density had a higher intake of these products at the age of 6 years.Moreover, in a 21-year follow-up study, authors observed tracking of dietary patterns and food choices, suggesting that childhood diet may determine adult diet even after 21 years (Mikkilä et al., 2004(Mikkilä et al., , 2005)).Nonetheless, in a study from the United States, the authors did not find a significant association between early life feeding practices and dietary patterns at the age of 10 (Sitarik et al., 2021).
Previous studies have shown an association between breastfeeding and dietary patterns and intake, which suggests the important role of breastfeeding in healthy eating in toddlerhood and beyond (Abraham et al., 2012;Grieger et al., 2011;Hamulka et al., 2020;Jackson & Johnson, 2017;Jones et al., 2015;Kheir et al., 2021;Kim & Shin, 2022;Scott et al., 2012;Vieira et al., 2019).Less is known about associations between type of solid foods (commercial/homemade) and later dietary patterns.Moreover, these studies regarded fruit and vegetable intake or variety as the outcome and results are inconsistent.In one study, at 12 months of age infants fed with commercial meals got a higher vegetable variety vs those fed with homemade meals (Mesch et al., 2014).In another study, higher percentage of commercial complementary food was associated with lower vegetable intake in infancy (both in girls and boys) and lower fruit and vegetable intake in preschool and school age (observed in boys), but no association with fruit and/or vegetable variety was found (Foterek et al., 2015).
Children's eating behaviors may also influence their dietary intake.Higher food fussiness in infants and toddlers was related to a lower increase in vegetable intake during a learning trial (Caton et al., 2014).Increasing diet variety (from 4 to 7 years of age) was inversely associated with desire to drink, food fussiness, and satiety responsiveness subscales and positively with enjoyment of food (Vilela et al., 2018).Moreover, children with higher diet quality at the age of 7 scored lower in food fussiness and satiety responsiveness subscale 3 years later (da Costa et al., 2022).In addition, 5-year-old children with higher picky eating measured with the CEBQ consumed less vegetables, but not other food groups (Sandvik et al., 2019).However, less is known about these associations in younger children.
Feeding and mealtime practices, eating behaviors, and screen time viewing in the first years seem to be important determinants of dietary patterns.Considering the role of diet in the development of obesity and non-communicable diseases (Budreviciute et al., 2020), it is essential to understand factors that may influence and establish healthy eating patterns early in life.Each of these factors (breastfeeding, complementary feeding, mealtime environment, eating behaviors, and screen time) may affect dietary outcomes around the same time and none of the studies have yet looked at these factors simultaneously.Most of previous studies have investigated the above factors separately or were limited only to early feeding practices (Abraham et al., 2012;Barbosa et al., 2022;Hillesund et al., 2021;Kheir et al., 2021;Morison et al., 2018;Scott et al., 2012;Vieira et al., 2019).To the best of our knowledge, this is the first study to examine all of these factors (breastfeeding, type of complementary foods, mealtime environment, eating behaviors and screen time) concurrently.Thus, the aim of this study was to check possible links between early (exclusive breastfeeding duration, complementary foods and mealtime environment patterns) and current (breastfeeding, mealtime environment pattern, eating behaviors, screen time) factors and dietary patterns in children aged 1-3 years old.We hypothesized that desirable feeding practices both in the first and last 3 months (longer breastfeeding, homemade complementary foods patterns, eating meals with family) would be related with a positive dietary pattern.Undesirable feeding practices (shorter breastfeeding, commercial complementary foods pattern, eating meals during distraction or separately) and screen time exposure, on the other hand, would be related with a negative dietary pattern.At the same time, eating behaviors, measured by the CEBQ, would also show associations with dietary patterns.As well we assumed that the strength of early and current feeding practices may not be equal.

Study design and participants
The study was a cross-sectional study of Polish children aged 1-3 years old conducted in 2020-2022 with the use of the CAWI (Computer-Assisted Web Interview) method.The project was reviewed and approved by the Ethics Committee of the Faculty of Human Nutrition and Consumer Sciences, Warsaw University of Life Sciences (resolution no.45/2019) and followed the ethical standards recognized by the Declaration of Helsinki.All data were collected anonymously.Detailed study design, methods, and sample selection data have been previously published (Masztalerz-Kozubek et al., 2022).
The link to the online survey was published on social media (mainly on Facebook, and Instagram, also was shared by personal contacts of the research group members).Mothers were informed about the scientific purpose of the study, its anonymity, voluntary, and the possibility of resigning from the participation at any stage.A total of 603 mothers completed the online survey.Some of them were excluded from the final analysis due to: toddlers outside the age range (n = 45), missing or incomplete data about early feeding (n = 46) or maternal anthropometry (n = 6), living abroad (n = 37), and gestational age lower than 23 weeks/higher than 44 weeks (n = 2).467 of them were included in the final analysis (Fig. 1).

Questionnaire
The questionnaire consisted of questions regarding early and current feeding practices, eating behaviors, children and maternal anthropometry, birth-related data, toddlers' health and development, and sociodemographic data.

Early feeding practices
We gathered information about milk feeding practices (breastfeeding/formula feeding), types of complementary foods (homemade/commercial), and mealtime environment in the first 3 months of complementary feeding (consuming meals with family/separately/ during distraction, such as watching TV or during playtime).Based on this data, in our previous paper (Masztalerz-Kozubek et al., 2022) we created two patterns regarding type of consumed complementary foods, and mealtime environment.Firstcomplementary foods pattern, where two clusters were selected: homemade (presented by 55.0% of study population), characterized by more frequent consumption of family foods adjusted for babies, and homemade meals cooked especially for babies, and commercial (45.0%), characterized by more frequent consumption of commercial baby foods.Secondmealtime environment pattern in the first 3 months with three clusters: distracted (11.8%),where infants ate more often during distraction; separated (24.6%), in which infants ate more often at different times than the rest of family members and family (63.6%),characterized by more frequent meals with other family members (Masztalerz-Kozubek et al., 2022).

Current feeding practices and eating behaviors
In order to investigate current feeding practices, mothers were asked to relate to the last 3 months of children's nutrition.Information about frequency of consumption of 23 food items was collected according to the following categories: (1) never or almost never, (2) less than once per week, (3) 1 time per week, (4) at least 2-4 times per week, (5) 1 time per day, (6) several times per day, using the adapted Food Frequency Questionnaire (FFQ) (Masztalerz-Kozubek et al., 2020;Wądołowska & Niedźwiedzka).Additionally, we asked about the mealtime environment in the last 3 months (frequency of meal consumption with family, peers, separately, during watching TV, distraction, playtime).To assess parental perceptions of their child's eating, mothers were asked to D. Masztalerz-Kozubek et al. complete the Children's Eating Behavior Questionnaire (CEBQ) which is a 35-item tool (Wardle et al., 2001).CEBQ contained the original eight eating behaviors subscales that represent four food approach behaviors (food responsiveness (FR), enjoyment of food (EF), emotional overeating (EOE), and desire to drink (DD)) and four food avoidance behaviors (satiety responsiveness (SR), food fussiness (FF), slowness in eating (SE) and emotional undereating (EUE)).The questionnaire has been used and validated in a population of Polish children (Czepczor--Bernat & Brytek-Matera, 2019;Malczyk et al., 2022) as well as in our study population.Originally, mothers rated each of the 35 items on a 5-point Likert scale, ranging from never to always, where higher scores reflect a higher intensity of the specific eating behaviors.The scores for 5 of the opposite phrasing items were reversed.However, in our analysis two items were eliminated (My child finishes his/her meal quickly from the SE subscale and My child eats more when s/he has nothing else to do from the EOE subscale) what increased internal consistency measured with Cronbach's alpha reliability for these subscales.

Toddlers' health, development and lifestyle
Mothers were asked about toddlers' health conditions, sleep duration, maternal concerns about children's weight, and whether toddlers attend daycare/preschool.We also asked about screen time, which was formulated as how much during the day a toddler uses a smartphone or tablet or watches TV.We gathered data according to the following categories: (1) child doesn't use such devices, (2) less than 30 min, (3) 30-60 min, (4) 60-120 min, (5) more than 120 min.Due to the small number of answers obtained in some categories, we aggregated them as follows: (1) child doesn't use such devices, (2) less than 30 min, (3) 30-60 min, (4) more than 60 min.

Sociodemographic and lifestyle data
We collected data about parental age and education level, living area (size of place of residence and region of the country, further categorized according to the percentage of EU-27 average gross domestic product (GDP) per capita), number of adults and children living in the household.We also asked about children's sex, age, and birth outcomes (e.g.pregnancy duration, birth anthropometry), maternal weight and height (used to calculate BMI) and smoking status.The socioeconomic and lifestyle status (SLES) was calculated as the sum of the values assigned to the response categories for each of the ten single SLES factors (Supplementary Table 1).The sum of points was calculated, and the tertiles of the SLES were then created.Potential confounders were preselected based on the current understanding of common and possible factors influencing children's diets (Fernández-Alvira et al., 2014;Francis et al., 2001;Koivuniemi et al., 2022;Moore et al., 2023;Rasmussen et al., 2006;Rogers & Emmett, 2003;Santos et al., 2016;Sotos-Prieto et al., 2015).

Statistical analysis
For nominal variables, results were presented as a percentage, and chi-square test was performed.Comparisons of quantitative variables were performed using the U Mann-Whitney test due to non-parametric distribution (confirmed by using the Shapiro-Wilk test) and were summarized by means and standard deviations (SD).
Mealtime environment pattern in the last 3 months was determined with the use of k-means algorithm and three clusters were selected, similarly like regarding the first 3 months of complementary feeding in our previous study (Masztalerz-Kozubek et al., 2022): (1) family, characterized by more frequent meals consumption with family members and with peers; (2) distracted, where toddlers ate more often during watching TV, playtime, or when distracted by parents; (3) separated, characterized by more frequent meals consumption at different times than other family members (Supplementary Table 2).
Dietary patterns were determined using the k-means algorithm, based on the data from FFQ, and three separate clusters were obtained: (1) prohealth, characterized by more frequent intake of fresh fruits, vegetables, natural grain and milk products, fish, legumes, plant oils, unsweetened/unsalted nuts and seeds, water; (2) non-eaters, characterized by one of the less frequent intake of analyzed food items; (3) processed, characterized by more frequent intake of sweetened grain and flavored milk products, red meat, poultry, processed meat, sweetened/salted nuts and seeds, juices, sweets, and salted snacks (Supplementary Table 3).The assessment of the selection of clusters was conducted using ANOVA (analysis of variance) statistics (p < 0.05 for all variables).
Factors associated with dietary patterns were investigated using univariate and multivariate adjusted for key covariates (child's age, sex, and socioeconomic and lifestyle status) logistic regression analysis.Separate models included independent variables such as early feeding factors (exclusive breastfeeding duration, complementary foods, and mealtime environment patterns) and current factors (current breastfeeding, mealtime environment pattern, eating behaviors -CEBQ and screen time) and assessed them in relation to three dietary patterns (each pattern as a dependent variable).In the combined model we included factors which were significant in adjusted models for early and current factors.Thus, we did not include some of the subscales from CEBQ (FR, EOE, DD, SE, EUE).In order to meet the criteria for logistic regression, we aggregated some categories when necessary.Results were presented as odds ratio (OR) or adjusted odds ratio (aOR) and confidence intervals (CI) of 95% were calculated.The level of significance of the odds ratio was assessed with a Wald test.Good fit of the models was confirmed by the Hosmer and Lemeshow Goodness-of-Fit Test (p > 0.05).Receiver Operating Characteristic (ROC) analysis was used to assess the quality of the classifications, providing a combined description of its specificity and sensitivity.Subsequently, the area under the ROC curve was calculated (AUC).AUC index can be interpreted as the model's ability to accurately classify classes.The value of the AUC index assumes in the range [0,1].The AUC = 1 means that the model is perfect in classify, while AUC = 0 means that the model incorrectly classify classes (Kleinbaum & Kleim, 2010).AUC index of 0.5 implies that the model is only as good as random choice.Therefore, the minimum AUC should be considered a chance level i.e., AUC = 0.5.In our study AUC for all models ranges from 0.645 to 0.801.Results of logistic regression analyses conducted separately for early and current factors are presented in Supplementary Tables 4-7.
Statistical analysis was conducted in Statistica 13.3 software (TIBCO Software Inc., StatSoft, Cracow, Poland).A p-value of ≤0.05 was considered to indicate statistical significance.

Results
Almost 50% of the mothers were 30-34 years, most of them had university education (85.2%) and half of the children were boys (50.1%).Nearly half of the children were exclusively breastfed for 5-7 months, and most of them received first solids between 4 and 6 months (81.4%).Currently, nearly 40% of children were breastfed and almost half of them ate most meals with other family members.No significant differences were found for analyzed variables between girls and boys (Table 1).

Associations of feeding practices, eating behaviors, and screen time with children's dietary patterns
Results from univariate and adjusted logistic regression for associations between early (exclusive breastfeeding duration, mealtime environment, and complementary foods patterns), current feeding practices (breastfeeding, mealtime environment pattern), eating behaviors (CEBQ), and screen time and dietary patterns are presented in Tables 2  and 3.
In univariate analysis (Table 2), among children who were breastfed for 1-4.9 months, the odds of following a prohealth dietary pattern were decreased by 71% when compared to those who were breastfed for 5-7 months.These odds were also decreased when children in the first 3 months ate separately or during distraction vs with family and followed a commercial complementary foods pattern when compared to homemade pattern.Regarding the last 3 months, children who were not currently breastfed had reduced by half the odds of following a prohealth dietary pattern when compared to those who were currently breastfed.Among children who had screen time, the odds were decreased by 46% and 81% in comparison to children who had no screen time, depending on the exposure.Regarding eating behaviors, children who scored higher in the food fussiness subscale had lower odds of following a prohealth dietary pattern, whereas higher score in the enjoyment of food subscale increased the odds.In the adjusted model commercial complementary foods pattern (aOR 0.42, 95%CI: 0.27-0.67),eating meals during distraction in the last 3 months (aOR 0.42, 95% CI: 0.22-0.83),higher score in food fussiness subscale (aOR 0.70, 95% CI: 0.50-0.99)and screen time higher than 30 min (aOR 0.44, 95% CI: 0.24-0.82)remained significant.The odds of following this pattern were higher when children scored higher in the enjoyment of food (aOR 1.52, 95% CI: 1.00-2.30)and satiety responsiveness (aOR 1.80, 95% CI: 1.19-2.73)subscales (Table 3).
In a univariate model (Table 2), the odds of following a non-eaters pattern were higher among children who ate commercial complementary foods more often vs homemade, had distracted or separated mealtime environment patterns in the first and last 3 months when compared to family mealtime environment pattern and scored higher in food fussiness subscale.These odds were lower when children scored higher in the enjoyment of food subscale.In the adjusted model associations persisted when children ate meals during distraction in the first 3 months of complementary feeding, separately in the last 3 months (aOR 2.35, 95% CI: 1.18-4.65;aOR 1.89, 95% CI: 1.12-3.19,respectively) and scored higher in food fussiness subscale (aOR 1.77, 95% CI: 1.24-2.48;Table 3).
Regarding a processed dietary pattern, univariate analysis revealed that children who were exclusively breastfed for 1-4.9 months had higher odds of following this pattern when compared to children who were exclusively breastfed for 5-7 months.Children who in the first 3 months of complementary feeding ate more often commercial complementary foods vs homemade had doubled the odds of following a processed dietary pattern.Among children who followed a distracted mealtime environment pattern, both in the first and last 3 months, these odds were around twice as high compared to children in a family pattern.Lack of current breastfeeding increased the odds of following a processed dietary pattern when compared to group of children who were still breastfed.Also children who scored higher score in food fussiness subscale had these odds increased by around 30%.Screen time substantially increased the odds of following this pattern, by 3-11 times, depending on the exposure, when compared to group of children without screen time exposure.The odds of following a processed dietary pattern were lower when children ate separately in the last 3 months when compared to having meals with the family and scored higher in the enjoyment of food subscale (Table 2).In adjusted model, the following variables remained significant: commercial complementary foods pattern (aOR 2.07, 95% CI: 1.26-3.41),lack of current breastfeeding (aOR 1.96, 95% CI: 1.10-3.50),screen time (<30 min -aOR 2.27, 95% CI: 1.05-4.93;30-60 min -aOR 4.14, 95% CI: 1.89-9.06;>60 min -aOR 5.46, 95% CI: 2.03-14.69)and enjoyment of food subscale (aOR 0.60, 95% CI: 0.39-0.94;Table 3).

Discussion
Establishing dietary patterns may be affected by many factors that influence the first months of life as well as later on.In univariate analysis we observed that both early feeding practices such as exclusive breastfeeding duration, complementary foods pattern, and mealtime environment pattern, and current factors -breastfeeding, mealtime environment pattern, screen time, and some eating behaviors were related to at least one of the analyzed patterns.However, some of these associations were attenuated in the combined analysis of early and current factors.This may suggest that some factors affect toddler's dietary patterns to a lesser extent, as well as that this influence may be time-dependent.
Many previous studies have suggested positive associations between breastfeeding and diet (Abraham et al., 2012;Barbosa et al., 2022;Grieger et al., 2011;Hamulka et al., 2020;Husk & Keim, 2016;Jones et al., 2015;Kheir et al., 2021;Nicklaus & Remy, 2013;Scott et al., 2012;Vieira et al., 2019).Exclusive breastfeeding was associated with a greater dietary variety for vegetables, meat/fish, and grain/starch foods in toddlerhood and healthy dietary patterns in children aged 6 (Husk & Keim, 2016;Santos et al., 2016).Longer breastfeeding duration was related to a higher frequency of vegetable consumption for breakfast and dinner among children aged 7-12 (Hamulka et al., 2020), lower levels of junk food consumption (Jackson & Johnson, 2017), and higher intake of fruit and vegetables (Kim & Shin, 2022).Additionally, children who were breastfed for a shorter time scored lower in a fish-based dietary pattern (Barbosa et al., 2022) and those who were ever breastfed compared with never breastfed had higher odds of belonging to a positive eating pattern (Abraham et al., 2012).Observed associations between breastfeeding and healthier dietary habits or greater foods acceptance could be explained by the fact that breast milk exposes infants to a variety of flavors (Beauchamp & Mennella, 2009;Robinson & Fall 2012).Breastfeeding was also pointed out as a promising strategy for promoting the consumption of fruits and vegetables among toddlers, especially if mothers eat fruits and vegetables while breastfeeding (Nicklaus, 2016).These observations were partly confirmed in our study, as we noticed that children who were not currently breastfed had almost two-times higher odds of following a processed dietary pattern.In Sitarik et al. (Sitarik et al., 2021) study, breastfeeding was initially associated with a healthier dietary pattern at the age of 10 years.However, after adjustment, this association was no longer significant (confounded by demographic and maternal characteristics).Similarly, in our adjusted model, exclusive breastfeeding duration was no longer related to a prohealth and processed dietary patterns and current breastfeeding to a prohealth dietary pattern.These results suggest that in terms of decreasing the odds of following a processed dietary pattern, longer any breastfeeding duration seems to be more important than exclusive breastfeeding duration, whereas in increasing the odds of following a prohealth dietary pattern other factors may be meaningful.Another possible explanation is that mothers who are breastfeeding longer may follow the guidelines regarding healthy eating more strictly, as in the study of Khalessi and Reich, the authors observed that women who breastfed for more weeks made better nutrition choices for their infants (Khalessi & Reich, 2013).
In our study, children who were fed with commercial complementary foods more often had the odds of following a prohealth dietary pattern reduced by more than half, whereas the odds of following a processed dietary pattern were 2-times higher.This finding is partly similar to Foterek et al. (Foterek et al., 2015) results.They noticed that the proportion of commercial complementary foods in infancy was associated with lower vegetable intake in the same age (but not with fruit and vegetables variety).A possible explanation seems to rather hypothetical in this context.It could be due to a higher dietary variety in homemade vs commercial complementary foods which increased the

Table 3
Multivariate logistic regression analysis of combined early and current feeding practices, eating behaviors and screen time influencing dietary patterns in children aged 1-3 (adjusted for child's age, sex, and SLES).intake of certain food groups later on.However, another study observed that infants fed with commercial meals had higher vegetable variety than those who received homemade meals (Mesch et al., 2014).Besides, in our study, we investigated the influence on dietary patterns which included many food items, not a single food group.This observation could be also partly explained by the fact that homemade foods are usually characterized by a more complex texture and taste and thus may increase the preference and frequency of intake for products which are considered as more challenging to accept, such as green vegetables, as some of them have a bitter taste (Mennella, 2014).Our results emphasize the importance of giving homemade foods without the addition of salt and sugar, as in homemade complementary foods pattern such meals were served more frequently.Thus, offering well-prepared homemade complementary foods may be a strategy for creating desirable dietary patterns.As complementary feeding pattern remained significant in two out of three patterns (except for a non-eaters pattern), it seems to be one of the most important factors associated with infants' diet.Regarding an association with other early feeding practices and a non-eaters pattern, another factordistracted mealtime environment pattern in the first months of complementary feeding seems to be more important, as only this association was still observed in a multivariate model.Hence, mealtime practices rather than type of complementary foods may play a role in the development of a non-eaters pattern.
The role of the mealtime environment was also highlighted in relation to the last 3 months of infant's feeding practices.The abovementioned distracted mealtime environment pattern in the first 3 months of complementary feeding increased the odds of following a non-eaters pattern almost 2.5 times.In the last 3 months, eating meals separately increased the odds of following a non-eaters pattern almost two times, whereas eating meals during distraction decreased by more than half the odds of following a prohealth pattern, when compared to eating meals with family.The fact that we observed associations between mealtime practices both in infancy and toddlerhood can be supported by Dallacker et al. findings (Dallacker et al., 2018), who noticed that association between family meals frequency and nutritional health was independent of children's age.A similar trend was observed in Hillesund et al. study (Hillesund et al., 2021), who noticed beneficial associations between family meals and child dietary intake at the age of 12 months.Mou et al. (Mou et al., 2021) also found that less frequent family meals at the age of 4 were associated with lower overall diet quality 4 years later.Additionally, studies conducted among adolescents showed that eating alone was associated with less healthy dietary intake, whereas watching TV even during family meals was related to lower dietary quality (Feldman et al., 2007;Reicks et al., 2019).The positive influence of family meals frequency on dietary outcomes has been also supported in a few reviews that represented a wide age range of study subjects -2-18 years (Ares et al., 2023;Dallacker et al., 2018;Hammons & Fiese, 2011;Robson et al., 2020;Snuggs & Harvey, 2023;Verhage et al., 2018).Moreover, Haines et al. in their position statement identified eating together as one of the four key themes that encourage and support healthy eating practices among children (Haines et al., 2019).Possible mechanisms underlying these associations might be nutritional and social (Dallacker et al., 2018).Previous studies have shown that family meals can improve diet quality, as they were associated with more nutrient-dense food intake (Verhage et al., 2018).Other explanation arises from parent-child interaction and learning mechanisms during family meals, like modeling eating behaviors or food choices (Dallacker et al., 2018;Mou et al., 2021;Verhage et al., 2018).Our results regarding distracted mealtime environment patterns are especially important as parents usually use distractors (such as watching TV) as an encouraging strategy to consume the meal, whereas presented results have shown the opposite effect of such an approach.
In this study, a higher score in the enjoyment of food subscale increased 1.5 times the odds of following a prohealth dietary pattern and decreased the odds of following a processed pattern by 40%.It may suggest a beneficial role of higher general interest in food in children's nutrition, especially that Haines et al. mentioned the pleasure of eating among key themes that encourage and support healthy eating practices (Haines et al., 2019).Similarly, higher satiety responsiveness also increased the odds of following a prohealth dietary pattern.Food fussiness, in turn, decreased the odds of following this pattern and increased the odds of following a non-eaters patterns.These trends are in line with other authors' findings, who noticed a positive role of higher enjoyment of food on dietary outcomes, such as dietary variety (Vilela et al., 2018) and healthy eating index (da Costa et al., 2022).One of the possible explanation of the enjoyment of food role is that this subscale was also associated with fruit and vegetable liking/intake (Carnell et al., 2016;Fildes et al., 2015).Food fussiness has been previously negatively related to diet variety (Vilela et al., 2018).Additionally, higher ultra-processed food consumption at 4 years was associated with food fussiness at the age of 7 (Vedovato et al., 2021) and 7 year old children with higher diet quality were more likely to have lower food fussiness (also 3 years later; da Costa et al., 2022).Moreover, Sandvik et al. (Sandvik et al., 2022) suggest that decreasing food fussiness may lead to developing healthier dietary patterns.The role of food fussiness subscale may arise from the fact that fussy children more often reject food groups, like vegetables, and thus have lower fruit and vegetable intake/liking (Fildes et al., 2015;Sandvik et al., 2019).Furthermore, it could be also explained by the fact that children in non-eaters pattern are perceived by their parents as more fussy.Observations related to the enjoyment of food and food fussiness are supported by Gregory et al. (Gregory et al., 2010) findings, as they noticed that modeling of healthy eating predicted lower food fussiness and higher interest in food.Results regarding satiety responsiveness are less consistent with other authors' findings.Carnell et al. (Carnell et al., 2016) observed that 4-5 years old children who scored higher in the satiety responsiveness subscale ate less fruits and vegetables.In previous studies, authors observed the same trends for food fussiness as for satiety responsivenesshigher healthy eating index and fruit and vegetable liking were inversely associated with satiety responsiveness (da Costa et al., 2022;Fildes et al., 2015).Additionally, increasing healthy diet variety index (4-7 years) was inversely associated with satiety responsiveness (Vilela et al., 2018).Our previous study highlighted possible associations between early feeding factors and eating behaviors and could partially explain the indirect effect of early feeding practices on dietary patterns through modeling eating behaviors (Masztalerz-Kozubek et al., 2022).
Even though associations between screen time viewing and dietary patterns were attenuated in multivariate analysis, still remained significant, which suggest an important role of this lifestyle component in dietary patterns.Screen time viewing increased the odds of following a processed dietary pattern from 2.3 to 5.5 times, depending on daily exposition, and decreased the odds of following a prohealth pattern by 50%.Our observations confirm previous studies.Lloyd et al. (Lloyd et al., 2014) have found child screen time to be inversely associated with the intake of core foods (nutrient-dense food groups) and in another study, longer screen time increased the odds of unhealthy dietary habits and decreased the odds of healthy dietary habits (Tambalis et al., 2020).Additionally, television viewing negatively influenced the frequency of consumption of fruits, vegetables and green vegetables and increased the frequency of consumption of processed foods, like sweets, pastries, ice cream, and fast food in 9-11 year old children (Borghese et al., 2014).Moreover, two systematic reviews have found the evidence for an association between screen time and adverse dietary outcomes such as less healthy diet quality, higher consumption of unhealthy foods and lower of fruits and vegetables (Shqair et al., 2019;Stiglic & Viner, 2019).Screen time can disturb physiological perceptions of hunger and satiation cues and thus lead to undesirable food choices (Shqair et al., 2019;Tambalis et al., 2020).Our findings are especially worrisome due to the age of the children in the study (1-3 years old), whereas most of the above studies focused on older children.This emphasizes that excessive screen time, except for many adverse effects on children's health and development, also negatively affects children's diet even since D. Masztalerz-Kozubek et al. toddlerhood and should be limited (WHO, 2019).

Strengths and limitations
A notable strength of this study is its complexity as we performed the analysis of early and current feeding practices, current eating behaviors, and screen time viewing what enabled us to indicate the most significant factors influencing the diet of children aged 1-3 years.Moreover, some variables such as mealtime environment pattern were assessed in reference to both early and current feeding and thus strengthened the importance of this factor and provided a better understanding of the development of children's dietary patterns.Another strength of the study is the use of dietary patterns as the outcome.As suggested by Mou et al. (Mou et al., 2021), studies should be cautious in the use of single food groups as an index of diet quality.The strengths of our study also include the fact that we made considerable efforts to validate CEBQ in the group of Polish children aged 1-3 years and to ensure equal access to the survey for participants despite differences in backgrounds due to the internet-based character of the study.The value of our work also lies in large sample size.
However, some limitations of our study should be considered.Exposures and outcomes were reported by mothers, so reported bias could occur.Nonetheless, it was minimized by relatively short recall time, which was less than 36 months (Amissah et al., 2017;Li et al., 2005).High sociodemographic status (e.g.education, GDP) of mothers and the potential risk that the questionnaire could only reach mothers with social media exposure and those who were especially interested in their child's nutrition prompted that the generalizability of our results may be limited.Future studies should target a larger cohort.Besides, we could not assess changes in analyzed factors over the time, however, previous studies showed good stability and continuity of parental feeding practices, eating behaviors, or dietary patterns (Eichler et al., 2019;Farrow & Blissett, 2012;Rose et al., 2017).Another limitation lies in the fact that we gathered information only about the frequency of food items consumption, without specifying the amount of consumed products.

Conclusions
To our knowledge, this is the first study assessing concurrently early, current feeding practices, eating behaviors, screen time viewing, and dietary patterns.In our study, we demonstrated that factors such as higher enjoyment of food and satiety responsiveness increased the odds of following a prohealth dietary pattern and commercial complementary food pattern (vs homemade), eating meals during distraction, higher food fussiness and screen time decreased these odds.Distracted mealtime environment pattern in the first months of complementary feeding and separated in the last months as well as higher score in the food fussiness subscale increased the odds of following a non-eaters pattern, whereas commercial complementary foods pattern, lack of current breastfeeding, and screen time exposure increased the odds of following a processed dietary pattern.
The present study reinforces the concept that first years of life are important in shaping dietary patterns.Offering homemade complementary foods more often than commercial ones, longer breastfeeding duration, creating a pleasant mealtime environmentwithout distractors and more frequent family meals, modeling eating behaviors traits such as higher enjoyment of food, satiety responsiveness and lower food fussiness as well as limiting screen time exposure may be helpful in establishing healthy dietary patterns early in life.Toddlerhood in this context seems to be an especially important period.New foods are more likely to be accepted in this time compared with older ages, as after the age of 3-4 years dietary patterns seems to be quite stable (Mennella, 2014).Increasing parents' awareness of the potential long-term impacts of feeding practices and lifestyle may be beneficial in improving children's diets (Bell et al., 2021;Haines et al., 2019;Nicklaus, 2016).

Ethical statement
The study was approved by Ethics Committee of the Faculty of Human Nutrition and Consumer Science, Warsaw University of Life Sciences, Poland (n.45/2019) and was conducted in compliance with the Declaration of Helsinki.Respondents' consent was waived due to the anonymous nature of the online survey and impossibility of tracking sensitive personal data.No personal or contact information were required.

Funding sources
This research was financed by the Polish Ministry of Science and Higher Education with funds from the Institute of Human Nutrition Sciences of the Warsaw University of Life Sciences (WULS), for scientific research.

Table 1
Maternal and child characteristics.