Associations of picky eating levels with dietary diversity, nutrient intake, and eating behaviors in preschool children with autism spectrum disorder: a cross-sectional study

Introduction

Background and theoretical basis

Autism spectrum disorder (ASD) is defined by persistent deficits in communication and social interaction, along with rigid, repetitive, and restricted patterns of behavior, activities, and interests, with symptoms typically manifesting in early childhood (1). In recent years, the global prevalence of ASD has been increasing, imposing significant challenges on affected individuals and their families (2). According to the Autism and Developmental Disabilities Monitoring (ADDM) Network report from the U.S. Centers for Disease Control and Prevention (CDC), the overall prevalence of ASD among 4-year-old children in 2020 reached 2.15%, representing a 60% increase compared to 2010 (Christensen et al., 2019; Shaw et al., 2023) (3,4). In Japan, the prevalence of ASD among children rose from 0.21% in 1996 to 1.31% in 2019. Reported prevalence rates in China have generally been lower than those in other countries. A recent large-scale survey indicated an ASD prevalence of 0.7% among children aged 6–12 years (Zhou et al., 2020). Furthermore, the prevalence of ASD among preschool children in China increased from 0.113% in 2019 to 0.181% in 2021, an increase of 60.3%. Nevertheless, these prevalence rates remain substantially lower than findings from recent studies in the United States (Shaw et al., 2023) (5,6). Discrepancies in study methodologies and diagnostic criteria may account for the differences observed across these study outcomes (7). In terms of gender, the incidence of ASD in boys is nearly four times higher than that in girls (8). This demonstrates that ASD has become a significant public health issue affecting the health of children and adolescents. Nutrition may influence the onset or progression of ASD in children, although the underlying mechanisms remain uncertain. Therefore, understanding the nutritional status of children with ASD is essential. Delecato (9) proposed that children with autism may experience significant difficulties with taste and smell, potentially leading to various feeding problems. Among these, picky eating represents the most common feeding issue in children with ASD, characterized by consumption of a limited variety of foods (10). Children with ASD experience picky eating at rates five times higher than typically developing children, partially attributable to restrictive and ritualistic behaviors alongside increased sensory sensitivity. Research indicates that picky eating in adolescents with autism is not associated with poor appetite. Many parents reported that their children exhibit a healthy appetite for preferred foods, which often include highly processed foods. A preference for high-energy, low-nutrient foods and beverages over healthier dietary patterns increases the risk of overweight in children with autism (11). Although picky eating behavior among children with ASD has been well-documented in numerous studies, research on the nutritional status and dietary intake of children with varying degrees of picky eating remains limited. Therefore, in-depth exploration of the above-mentioned issues is of great significance for the early identification of high-risk groups and the implementation of targeted intervention.

Research objectives and hypotheses

This study aims to assess the nutritional status, dietary diversity, dietary intake and eating behavior characteristics of ASD children with different degrees of picky eating. The specific goals are as follows:

• Compare the differences in growth and development indicators [such as height, weight, and body mass index (BMI)] among ASD children with different degrees of picky eating;
• Evaluate the dietary diversity scores of children in each group, as well as the intake of various foods (including staple foods, vegetables, fruits, meats, etc.) and energy and macronutrient intake;
• Analyze the eating behavior characteristics of children with different degrees of picky eating.

Based on the above research purposes, we propose the following hypotheses in advance.

• Hypothesis 1: the higher the degree of picky eating among children with ASD, the poorer their nutritional status (such as an increased risk of low weight, overweight or obesity), and the dietary diversity score significantly decreases.
• Hypothesis 2: ASD children with different degrees of picky eating show significant differences in the intake of specific food categories (such as vegetables, fruits, and processed foods).
• Hypothesis 3: children with different degrees of picky eating exhibit significant differences in eating behavior patterns. Specifically, compared to children with a high level of picky eating, those with a low level of picky eating demonstrate lower scores for picky eating and problematic eating behaviors, but higher scores for satiety responsiveness. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0168/rc).

Methods

Study design and population

This cross-sectional study aimed to investifate the associations between picky eating degree and nutritional status, dietary diversity and eating behavior of preschool children with ASD. The study was conducted at the Department of Pediatric Health Care, The Children’s Hospital, Zhejiang University School of Medicine, between June 2024 and August 2025. All exposure factors (picky eating degree) and outcome measures (nutritional status, dietary intake, and eating behaviors) were assessed within 1 to 2 weeks after enrollment.

• Participants: a total of 130 children aged 3 to 6 years with mild to moderate ASD were enrolled from the outpatient department. Diagnosis of ASD was confirmed by attending physicians according to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, with Childhood Autism Rating Scale (CARS) scores ranging from 30 to 36.
• Inclusion criteria: (I) age between 3 and 6 years; (II) meeting DSM-5 criteria for ASD; (III) CARS score between 30 and 36 (mild to moderate ASD); (IV) diagnosis confirmed by a physician in the Department of Child Health Care; (V) written informed consent obtained from parents or legal guardians.
• Exclusion criteria: (I) acute infection within one month prior to data collection; (II) use of antibiotics, antifungal medications, probiotics, or prebiotics within one month; (III) concurrent or recent (within one month) participation in any dietary intervention trial; (IV) recent brain disorders requiring surgical intervention; (V) recent use of lactulose; or (VI) diagnosis of other inherited metabolic disorders. These exclusion criteria were applied to minimize potential confounders that could independently affect gut microbiota composition, dietary intake, or eating behaviors, thereby ensuring that observed associations could be attributed more specifically to picky eating behaviors rather than to acute illness or medication use.
• Sample size: sample size calculation. Based on a previous study (12) reporting a moderate effect size (Cohen’s d ≈0.5) for differences in eating behavior scale scores between children with ASD and typically developing children, a two-sided significance level (α) of 0.05, and a power (1−β) of 0.80, the minimum required sample size was calculated as 64 participants per group using the formula for comparing two independent sample means. Thus, a total of at least 128 participants was required. This study ultimately included 130 preschool children with ASD, meeting the statistical requirement.

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study protocol was approved by the Ethics Committee of The Children’s Hospital, Zhejiang University School of Medicine (No. 2022-IRB-253). Written informed consent was obtained from all patients’ parents or legal guardians.

Data collection

Demographic and background information. At enrollment, parents completed standardized questionnaires to provide data on child demographics (age, gender, daily outdoor activity time, daily screen time) and parental characteristics (maternal and paternal BMI, self-reported).

The height and weight of each child were measured by trained professionals using standardized instruments. The weight was measured with the child wearing a single garment and having an empty bladder and bowels. The electronic scale was accurate to 0.1 kg. The height was measured using a height measurement board. When standing, the child’s shoulders, hips and heels were in direct contact with the support, and the measurement was accurate to 0.1 cm. BMI was calculated as weight (kg) divided by height squared (m²). WHO Anthro and WHO Anthro Plus software (13) were used to calculate BMI-for-age Z-scores (BAZ). For children aged 2–5 years, nutritional status was classified as: BAZ <−2 (wasting); −2≤ BAZ ≤2 (normal weight); 2< BAZ ≤3 (overweight); BAZ >3 (obesity). For children aged 5–6 years, classifications were: BAZ <−2 (wasting); −2≤ BAZ ≤1 (normal weight); 1< BAZ ≤2 (overweight); BAZ >2 (obesity) (14).

Dietary intake and diversity. Children’s dietary intake was assessed using three non-consecutive 24-hour dietary recalls. Professional dietitians assisted parents in recalling each child’s food intake, using visual aids (food portion photographs) to improve accuracy. Intake data were entered into dietary analysis software (Mint Health App, Shanghai ZhenDing Health Technology Co., Ltd.), which automatically calculated total energy and macronutrient intake as well as consumption of various food groups (grains, vegetables, fruits, meat, eggs, legumes/nuts, dairy, etc.).

Dietary diversity was assessed using the Children’s Dietary Diversity Score (CDDS), constructed according to WHO guidelines (15). Based on foods consumed in the past 24 hours, seven food groups were evaluated: (I) grains/roots/tubers; (II) vitamin A-rich foods (≥120 RE/100 g); (III) other fruits and vegetables; (IV) meat and fish; (V) eggs; (VI) legumes, nuts, and seeds; and (VII) dairy products. One point was assigned for each food group consumed (maximum score =7).

Eating behavior assessment. Two validated instruments were used to comprehensively assess eating behaviors.

Children’s Eating Behavior Questionnaire (CEBQ) (16). The CEBQ is a 35-item parent-reported instrument rated on a 5-point Likert scale (1= “never” to 5= “always”). It assesses eight behavioral dimensions: (I) food enjoyment, (II) emotional overeating, (III) food responsiveness, (IV) desire to drink, (V) food fussiness, (VI) satiety responsiveness, (VII) slowness in eating, and (VIII) emotional undereating. The first four dimensions comprise the ‘food approach’ subscale, and the remaining four comprise the ‘food avoidance’ subscale. A composite picky eating score was created by summing the scores for food fussiness, slow eating, and satiety responsiveness, with reverse scoring applied to the food responsiveness and food enjoyment subscales (13). Based on the distribution of this composite score in the reference population, children were classified into low picky eating (≤3.17) and high picky eating (>3.17) groups (16).

Preschooler’s Eating Behavior Scale (PEBS) (17). The PEBS was developed and validated by Shang et al. (2013) (17) for the Chinese population. The scale comprises 38 items assessing seven dimensions: (I) Picky Eating (e.g., “My child only eats self-selected foods”); (II) Food Responsiveness (e.g., “My child eats whenever food is offered”); (III) Undesirable Eating Habits (e.g., “My child can sit quietly and finish a meal”); (IV) Satiety Responsiveness (e.g., “My child has a good appetite”); (V) External Eating (e.g., “My child eats more at restaurants or others‘ homes than at home”); (VI) Emotional Eating (e.g., “My child eats more when angry”); and (VII) Proactive Eating (e.g., “My child can eat independently”). Each item is rated on a 5-point Likert scale. The average score for each dimension is calculated as the mean of the constituent item scores, with higher scores indicating more problematic eating behaviors. The PEBS was selected to complement the CEBQ because it provides a culturally adapted, multidimensional assessment of eating behaviors specifically validated in Chinese preschool children, including dimensions such as “Proactive Eating” that are not captured by the CEBQ.

Rationale for using two instruments. The CEBQ was used to derive the composite picky eating score for group classification, as this instrument has been widely used internationally for assessing food approach/avoidance behaviors. The PEBS was used to evaluate specific eating behavior dimensions (e.g., satiety responsiveness, undesirable eating habits, external eating, emotional eating, proactive eating) because it has been validated specifically in Chinese preschool populations and captures culturally relevant aspects of eating behavior that complement the CEBQ.

Standardization of PEBS dimension names. To ensure consistency throughout the manuscript, the PEBS dimension names are presented uniformly as: “Picky Eating”, “Food Responsiveness”, “Undesirable Eating Habits”, “Satiety Responsiveness”, “External Eating”, “Emotional Eating”, and “Proactive Eating”.

Outcome and exposure variables

Outcome variables. (I) Nutritional status: BAZ scores calculated from height and weight measurements. (II) Dietary intake: total energy (kcal/day), macronutrient intakes (protein, carbohydrates, fat), polyunsaturated fatty acid (PUFA) intake, dietary fiber intake, and consumption of specific food groups (grains, tubers, fruits, vegetables, meat, eggs, legumes/nuts, snacks, sugar-sweetened beverages, milk). Dietary diversity was assessed using CDDS (range 0–7). (III) Eating behaviors: scores for the seven PEBS dimensions listed above.

Exposure variable. Degree of picky eating was classified as low picky eating (composite picky eating score ≤3.17) or high picky eating (>3.17) based on the CEBQ composite score (16).

Potential confounders. Demographic characteristics (child’s age, gender, daily outdoor activity time, daily screen time) and parental characteristics (maternal and paternal BMI) were considered as potential confounders.

Statistical analysis

Continuous variables (age, BMI, energy and macronutrient intake, CDDS, and PEBS dimension scores) were described as mean ± standard deviation or median (interquartile range), depending on normality of distribution assessed by the Shapiro-Wilk test. Between-group comparisons (low picky eating vs. high picky eating) were performed using independent-samples t-tests for normally distributed continuous variables or Mann-Whitney U tests for non-normally distributed continuous variables. Categorical variables (sex, nutritional status categories) were compared using chi-square tests or Fisher’s exact tests, as appropriate.

All statistical analyses were conducted using (specify software, e.g., SPSS version 26.0 or R version 4.0). A two-tailed P value <0.05 was considered statistically significant.

Bias control. The following measures were implemented to minimize potential bias: (I) anthropometric measurements were performed by uniformly trained professionals using standardized instruments; (II) 24-hour dietary recalls were conducted by professional dietitians with the aid of food portion photographs to reduce recall bias; (III) validated standardized scales (CEBQ, PEBS) were administered under unified guidance; and (IV) group classification was based on a pre-specified cut-off value (3.17) from the literature (13) rather than data-driven thresholds.

Handling of quantitative variables

Group classification was based on the pre-specified cut-off value of the composite picky eating score (3.17), derived from the original validation study (16). No data-driven (e.g., median split or tertile-based) grouping was performed. This threshold was applied consistently to all participants to avoid subjective bias in group assignment.

Results

Basic characteristics of the children

A total of 130 children aged 3 to 6 years with mild to moderate ASD were enrolled in this study (CARS score <30 points or >36 points), and ultimately 130 children with mild to moderate ASD who met the conditions were included. All 130 subjects completed physical measurements, dietary records and questionnaire evaluations, with no loss to follow-up or missing data. The study included 130 children aged 3–6 years (119 males, 11 females) with a mean age of 4.79±1.63 years. The low picky eating group comprised 50 subjects (48 males, 2 females) with a mean age of 5.14±1.55 years. The high picky eating group comprised 80 subjects (71 males, 9 females) with a mean age of 4.58±1.65 years. No statistically significant differences were observed between the two groups in terms of gender, age, outdoor activity time, electronic screen time, WAZ, HAZ, BAZ, or parental BMI values (Table 1).

Outcome data

Nutritional status (physical indicators)

• Weight status: among children in the high-picky-eating ASD group, underweight accounted for 5.0%, normal weight for 87.5%, and overweight or obesity for 10%. In the low-picky-eating ASD group, underweight accounted for 8%, normal weight for 72%, and overweight or obesity for 20%. The difference in weight distribution between the two groups was not statistically significant (Figure 1).
  

  Figure 1 Relative frequencies of (A) age-specific BAZ values (weight status) and (B) age-specific height categories (stunting) in the study population based on the degree of picky eating. BAZ, BMI-for-age Z-scores; BMI, body mass index.
• Height status: among children in the high-picky-eating ASD group, short stature accounted for 2.50%, and normal height for 98.75%. In the low-picky-eating ASD group, short stature accounted for 4%, and normal height for 96%. The difference in height distribution between the two groups was not statistically significant (Figure 1).

Dietary diversity, energy, and macronutrient intake

The total Dietary Diversity Score (DDS) in children with ASD from the low-picky eating group was significantly higher than in the high-picky eating group, and the difference between the two groups was statistically significant (P<0.05). Regarding energy and macronutrient intake, children with ASD in the low-picky eating group exhibited higher total energy intake, polyunsaturated fatty acid (PUFA) intake, and dietary fiber intake compared with those in the high-picky eating group. For food categories, the low-picky eating group showed slightly higher consumption of tubers, fruits, and nuts and soy products than the high-picky eating group. These intergroup differences were statistically significant (P<0.05) (Table 2).

Eating behaviors

Comparison of eating behaviors between the two groups of children

Compared with the high picky eating group, children with ASD in the low picky eating group exhibited a significantly lower mean score of picky eating behaviors and fewer instances of maladaptive eating behaviors. Conversely, the mean score of satiety responsiveness was higher in the low picky eating group than in the high picky eating group. The differences in the aforementioned eating behavior indicators between the two groups were all statistically significant (P<0.05) (Table 3).

Main results

This study found significant differences in dietary nutrient composition, energy and macronutrient intake, and eating behavior patterns among preschool children with ASD exhibiting varying degrees of picky eating. Although no statistically significant differences were observed in macroscopic growth indicators, such as height and weight, between ASD children with different levels of picky eating, those in the low picky eating group demonstrated significantly superior performance in dietary diversity, total energy intake, polyunsaturated fatty acid (PUFA) intake, dietary fiber intake, and consumption of tubers, fruits, nuts, and legumes compared to the high picky eating group. Furthermore, the low picky eating group displayed better outcomes in terms of picky eating behaviors and maladaptive.

Discussion

Key results

This study revealed significant associations among the dietary nutrition structure, specific nutrient intake, and eating behavior patterns of preschool-age children with ASD across varying degrees of picky eating. Although there was no statistical difference in macroscopic growth indicators such as height and weight among ASD children with different degrees of picky eating, children in the low picky eating group were significantly better than those in the high picky eating group in terms of dietary diversity, total energy intake, polyunsaturated fatty acid intake, dietary fiber intake, and intake of tubers, fruits, nuts and soybeans. At the same time, they performed better in picky eating behavior and bad eating behavior.

Causes and determinants of feeding difficulties in children with ASD

Understanding the underlying causes of feeding difficulties in children with ASD is essential for interpreting the findings of the present study. Previous research has identified several interrelated factors contributing to the high prevalence of picky eating and food selectivity in this population. Atypical sensory processing is one of the most frequently reported determinants. Children with ASD often exhibit hyper- or hyposensitivity to food texture, odor, temperature, or appearance, and such sensory aversions may lead to a progressive restriction in food acceptance (18). Cognitive and behavioral factors also play a critical role. For instance, difficulties in cognitive flexibility may manifest as an insistence on sameness and an inability to transition from familiar to novel foods (19). In addition, family- and environment-related factors—including parental feeding practices, mealtime routines, and the home food environment—have been demonstrated to influence the eating behaviors of children with ASD (20). Collectively, these etiological factors suggest that picky eating in children with ASD is not merely a behavioral choice, but rather a complex phenotype shaped by the interplay of sensory, cognitive, communicative, and environmental influences.

Comparison with other studies

Regarding anthropometric measurements in children with ASD, most previous studies have focused on comparisons with typically developing children, and numerous conflicting findings have been reported. Neumeyer et al. assessed children with ASD and typically developing children, documenting similar BMI values in both groups (17). Mari-Bauset et al. found that children with ASD had lower body weight (21). In contrast, Hyman et al. reported a higher prevalence of overweight and obesity among children with ASD aged 2–5 years compared to typically developing children (22). Based on these studies, it appears that children with ASD may exhibit a bidirectional extreme distribution, encompassing both underweight and obesity. In the present study, we stratified children with ASD by degree of picky eating for comparison. The results showed no statistically significant differences in the distributions of height, weight, or BMI categories between the high and low picky eating groups. This finding may seem counterintuitive, as it is generally assumed that a higher degree of picky eating is associated with poorer nutritional status. However, this phenomenon may be explained by several factors. First, anthropometric indicators such as height, weight, and BMI reflect long-term energy balance rather than the quality of nutrient intake or specific micronutrient levels. A child may maintain normal body weight by consuming sufficient or even excessive amounts of energy-dense foods (e.g., refined grains, processed snacks), while simultaneously exhibiting inadequate intake of vegetables, fruits, and micronutrients—a condition often referred to as "hidden malnutrition" or "micronutrient insufficiency in the context of adequate energy intake." The results of this study are consistent with this concept: although children in the high picky eating group showed no significant differences in anthropometric measures compared to those in the low picky eating group, their dietary quality was notably poorer. Second, although not statistically significant, the trend observed in this study—a higher proportion of overweight/obesity in the low picky eating group (20%) than in the high picky eating group (10%)—warrants attention. A possible explanation is that children with lower levels of picky eating may be more exposed to and accepting of a wider variety of foods, including those that are energy-dense but nutrient-poor, such as sugar-sweetened beverages, refined snacks, and processed foods. This pattern has also been reported in typically developing children, where greater dietary diversity does not necessarily equate to better dietary quality (19). This observation further suggests that, in the nutritional assessment of children with ASD, a "low degree of picky eating" should not be directly equated with "healthy dietary habits." Third, the lack of statistically significant differences may be partially attributable to insufficient statistical power due to the relatively small sample size. For instance, the proportion of underweight children was 5.0% in the high picky eating group and 8.0% in the low picky eating group—a difference that may be clinically meaningful but did not reach statistical significance due to sample size limitations. Future studies with larger sample sizes are needed to further validate these intergroup differences.

Picky eating can restrict dietary diversity in children, leading to inadequate nutrient intake and reduced food selectivity. Children exhibiting picky eating often display aversion to novel or familiar foods (19), with those demonstrating severe picky eating typically showing resistance to a wider variety of foods. This aligns with the findings of Metlika et al. (23), indicating that children with high picky eating exhibit lower dietary quality, including reduced total energy intake, dietary fiber intake, and PUFA intake. This is consistent with our study results: compared to children in the low picky eating group, children with ASD in the high picky eating group demonstrated lower intake of total energy, polyunsaturated fatty acids (PUFA), and dietary fiber. According to previous research (23), children with high picky eating consume more fast food, snacks, and sugar-sweetened beverages compared to children with low picky eating. Moreover, their intake of starchy foods (such as bread, rice, and noodles) was lower, resulting in reduced energy intake in children with high picky eating. The systematic review by Taylor et al. (15) indicated that children with picky eating exhibit limited dietary diversity, primarily due to low vegetable and fruits intake. Furthermore, among children with ASD exhibiting varying degrees of picky eating, it was similarly observed that those with high picky eating had lower dietary diversity compared to children with low picky eating. Although no significant association was found between snack and beverage intake and different degrees of picky eating in children with ASD, children with high picky eating demonstrated significantly lower consumption of starchy tubers and fruits. Additionally, a novel finding was their preference for higher intake of legumes and nuts.

Children with ASD often exhibit severe dietary difficulties, characterized by highly limited food selectivity, and it is consistently observed that children with ASD demonstrate selective eating patterns, food neophobia, and sensory issues (12). Eating behaviors constitute a core feature of ASD (24). These characteristics generate substantial familial anxiety and emerge as one of the primary concerns for caregivers and family members (25,26). Our study found that children with ASD exhibiting a high degree of picky eating showed higher scores for picky eating and problematic eating behaviors, while their scores for satiety responsiveness were slightly lower. This suggests that children with a high degree of picky eating may have poorer appetites, tend to become full quickly after only a few bites, are more likely to leave food uneaten, and consume less food compared to their peers. Therefore, they are more likely to have longer mealtimes and tend to play while eating or watch electronic devices during meals (21). Polyunsaturated fatty acids (PUFAs) are a type of fat essential for normal brain development (27). They serve as key structural components of the phospholipid bilayer in neuronal cell membranes and participate in regulating neuroinflammation and synaptic plasticity. The significantly lower PUFA intake observed in the high picky eating group in this study provides clues for exploring the potential link between abnormal neurodevelopment in ASD and deficiencies in specific dietary nutrients. Simultaneously, inadequate dietary fiber intake may affect gut-brain axis function by altering gut microbiota composition and metabolic activity (28,29).

Therefore, picky eating is not only a common manifestation of feeding difficulties but may also serve as an intervenable behavioral factor that potentially exacerbates or influences the risk of comorbidities in ASD by limiting the intake of nutrients crucial for neurodevelopment and gut health.

Clinical implications

The findings of this study have several profound implications for clinical practice. First, the assessment of children with ASD should extend beyond routine anthropometric monitoring to include systematic evaluations of dietary diversity, food group intake, and specific feeding behaviors. Second, interventions targeting picky eating should integrate sensory integration strategies, cognitive flexibility training, and structured mealtime routines. Third, dietary guidance should prioritize improving the intake of commonly underconsumed food groups (e.g., fruits, tubers, legumes, and nuts) and key nutrients (e.g., polyunsaturated fatty acids (PUFAs) and dietary fiber).

Limitations

Several limitations of this study warrant explicit acknowledgment.

First and foremost, the cross-sectional design precludes the inference of causal relationships. Although significant associations were observed between the severity of picky eating and various dietary and behavioral outcomes, the temporal direction of these relationships cannot be determined. While picky eating may lead to reduced dietary diversity and nutrient intake, it is equally plausible that pre-existing nutritional deficiencies or eating behavior patterns contribute to the development or exacerbation of picky eating. Future longitudinal studies are warranted to establish causal pathways. Second, the relatively small sample size and single-center design limit the generalizability of the findings. Third, this study included only children with mild to moderate ASD. Dietary intake and eating behaviors may differ significantly in children with severe ASD or across different levels of ASD severity, and these populations warrant separate investigation.

Fourth, dietary assessment was limited to three non-consecutive 24-hour dietary recalls, a relatively short timeframe, and relied on caregiver reports. Although trained dietitians used visual aids during the recall process to facilitate accuracy, recall bias and information error cannot be entirely excluded. Fifth, this study primarily focused on energy and macronutrient intake, as well as the consumption of various food groups, and did not systematically collect data on micronutrient intake or related laboratory indicators (e.g., serum vitamin and mineral levels). Consequently, a comprehensive assessment of the children’s nutritional status and absorption levels remains challenging.

Sixth, the demographic characterization of the sample was limited to age, sex, outdoor activity time, screen time, and parental BMI. The absence of additional contextual variables (e.g., household income, parental education level, family structure) constrains the interpretability of our findings and limits the ability to evaluate potential confounding effects of socioeconomic factors.

Universality (external validity)

The subjects of this study were children aged 3 to 6 with mild to moderate ASD, derived from a single-center outpatient sample. The research results may not be applicable to children with severe ASD, children with ASD of different age groups, or ASD populations in other medical Settings. However, the assessment tools (CCD, CEBQ, PEBS) adopted in this study are all widely used standardized scales both internationally and domestically. The research results can provide a reference for the clinical assessment and intervention of similar populations.

Comprehensive interpretation

Based on the research purpose, limitations and the results of similar studies, this study suggests that the degree of picky eating is a key factor influencing the dietary quality and eating behavior of preschool children with ASD. Low picky eating habits are associated with more comprehensive nutrient intake, greater dietary diversity and better eating behavior patterns. Early identification and intervention of picky eating behavior are of great significance for improving the nutritional status of children with ASD.

Conclusions

Based on the results of this cross-sectional study, we found that the degree of picky eating was significantly associated with dietary quality. Among preschool-aged children with ASD, a high level of picky eating was significantly correlated with reduced dietary diversity, decreased total energy intake, and inadequate intake of polyunsaturated fatty acids and dietary fiber, suggesting that picky eating is an important behavioral risk factor for qualitative malnutrition in this population. Children with high levels of picky eating exhibited a characteristic pattern of eating behaviors. Compared with those with low levels of picky eating, children with high levels of picky eating scored higher on measures of picky eating behaviors and maladaptive eating behaviors, while scoring lower on satiety responsiveness, indicating potential differences in their intrinsic satiety regulation mechanisms. The cross-sectional design limits causal inference. The observed associations in this study are all correlational, and the causal relationship between picky eating and nutritional outcomes cannot yet be determined. Future studies employing longitudinal designs are needed to clarify the temporal sequence and causal pathways. Systematic assessment and individualized intervention are required in clinical practice. It is recommended that routine systematic evaluations of dietary diversity, food group intake, and eating behaviors be conducted in children with ASD. Based on the assessment results, individualized comprehensive programs integrating nutritional management, behavioral intervention, and sensory integration training should be developed to improve their nutritional health status and long-term prognosis.

Acknowledgments

We are very grateful to all the researchers involved in the data collection, as well as to the children and parents who volunteered to participate in the study.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0168/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0168/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0168/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0168/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study protocol was approved by the Ethics Committee of The Children’s Hospital, Zhejiang University School of Medicine (No. 2022-IRB-253). Written informed consent was obtained from all patients’ parents or legal guardians.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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