Journal Articles
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Item Testing and adapting dietary habits and food security questions for a national nutrition survey using cognitive interviews and expert consultation(Cambridge University Press on behalf of The Nutrition Society, 2025-10-06) Follong B; Haliburton C; Grey J; Maiquez M; Mackay S; Te Morenga L; Mhurchu CNObjective: To cognitively test questions for inclusion in a national nutrition survey, ensuring the questions are interpreted as intended and to inform further improvements. Design: A draft nutrition survey questionnaire was developed based on existing questionnaires and expert input. Twelve questions on dietary habits and food security were selected for cognitive testing as these were newly developed, amended from existing questions, or identified to no longer reflect the current food environment or concepts. Cognitive interviews were conducted using both think-aloud and probing techniques to capture respondents’ thought processes used to arrive at an answer. Interviews were audio recorded and transcribed verbatim. Qualitative data were analysed for recurring patterns and unique discoveries across the survey questions. Setting: New Zealand. Participants: Sixty-eight participants aged 11 years and older representing diverse sociodemographics including gender, ethnicity, and education level. Results: Three main cognitive challenges were identified: 1) interpreting ambiguous terms, 2) understanding of dietary or technical terms, and 3) following complex or unclear instructions. Questions were refined based on the study findings and further advice from experts in nutrition and survey design to enhance participant understanding and accuracy. Conclusion: The cognitive testing findings and expert input led to the refinement and potential improvement of selected questions for inclusion in a national nutrition survey. Changes included simplified terminology, clearer instructions, improved examples, and better question order. Our methodological approach and findings may be valuable for those designing similar questions for dietary surveys.Item “The Fact [Is] That There Is No Easy Way”. A Qualitative Study of the Experiences of Aotearoa New Zealand Clinicians with Opioid Tapering for Chronic Non-Cancer Pain(Dove Medical Press Limited, 2025-11-18) Fu R; Bean D; Te Morenga L; Frei D; Devan H; Atkinson TObjective: Opioid tapering is a complex process for both clinicians and patients with chronic pain. This qualitative study explored the experiences of Aotearoa New Zealand clinicians in managing opioids for patients with chronic non-cancer pain. Methods: Purposive and snowball sampling were used to interview nineteen health professionals including general practitioners (n=5), pain medicine specialists (n=5), addiction medicine specialists (n=4), pain fellows (n=3), addiction medicine registrar (n=1) and a pain nurse practitioner (n=1). Data were collected using a face-to-face focus group and fourteen individual interviews conducted via Zoom. The data were analysed using a Reflexive Thematic Analysis approach. Independent parallel coding was done by members of our research team, and the final themes were iteratively developed by mutual consensus. Results: This qualitative study suggests that meaningful opioid tapering requires a patient-centred approach that considers the individual’s unique sociopsychobiomedical context. Clinicians emphasised the importance of building trust, addressing fears, and tailoring tapering regimens to patients’ needs and motivations. While opioid tapering is a complex process for all patients, participants acknowledged unique considerations for supporting people living in rural areas – Māori and Pasifika and their whānau (families and significant others) addressing social determinants of health. There were overwhelming accounts of clinician distress from all participants especially for rural general practitioners due to the lack of support, conflicting practices, limited resourcing, and time constraints. Conclusion: These findings call for a co-ordinated, multidisciplinary approach to opioid tapering that addresses systemic inequities and prioritises patient and clinician well-being.Item Call for emergency action to restore dietary diversity and protect global food systems in times of COVID-19 and beyond: Results from a cross-sectional study in 38 countries(Elsevier Ltd, 2023-11-07) Hoteit M; Hoteit R; Aljawaldeh A; Van Royen K; Pabian S; Decorte P; Cuykx I; Teunissen L; De Backer C; Bergheim I; Staltner R; Devine A; Sambell R; Wallace R; Allehdan SS; Alalwan TA; Al-Mannai MA; Ouvrein G; Poels K; Vandebosch H; Maldoy K; Matthys C; Smits T; Vrinten J; DeSmet A; Teughels N; Geuens M; Vermeir I; Proesmans V; Hudders L; De Barcellos MD; Ostermann C; Brock AL; Favieiro C; Trizotto R; Stangherlin I; Mafra AL; Correa Varella MA; Valentova JV; Fisher ML; MacEacheron M; White K; Habib R; Dobson DS; Schnettler B; Orellana L; Miranda-Zapata E; Wen-Yu Chang A; Jiao W; Liu MT; Grunert KG; Christensen RN; Reisch L; Janssen M; Abril-Ulloa V; Encalada L; Kamel I; Vainio A; Niva M; Salmivaara L; Mäkelä J; Torkkeli K; Mai R; Risch PK; Altsitsiadis E; Stamos A; Antronikidis A; Henchion M; McCarthy S; McCarthy M; Micalizzi A; Schulz PJ; Farinosi M; Komatsu H; Tanaka N; Kubota H; Tayyem R; Al-Awwad NJ; Al-Bayyari N; Ibrahim MO; Hammouh F; Dashti S; Dashti B; Alkharaif D; Alshatti A; Al Mazedi M; Mansour R; Naim E; Mortada H; Gutierrez Gomez YY; Geyskens K; Goukens C; Roy R; Egli V; Te Morenga L; Waly M; Qasrawi R; Hamdan M; Sier RA; Al Halawa DA; Agha H; Liria Domínguez MR; Palomares L; Wasowicz G; Bawadi H; Tayyem R; Othman M; Pakari J; Abu Farha A; Abu-El-Ruz R; Petrescu DC; Petrescu Mag RM; Arion F; Vesa SC; Alkhalaf MM; Bookari K; Arrish J; Rahim Z; Kheng R; Ngqangashe Y; Mchiza ZJ-R; Gonzalez-Gross M; Pantoja-Arévalo L; Gesteiro E; Ríos Y; Yiga P; Ogwok P; Ocen D; Bamuwamye M; Al Sabbah H; Taha Z; Ismail LC; Aldhaheri A; Pineda E; Miraldo M; Holford DL; Van den Bulck HBackground: The COVID-19 pandemic has revealed the fragility of the global food system, sending shockwaves across countries' societies and economy. This has presented formidable challenges to sustaining a healthy and resilient lifestyle. The objective of this study is to examine the food consumption patterns and assess diet diversity indicators, primarily focusing on the food consumption score (FCS), among households in 38 countries both before and during the first wave of the COVID-19 pandemic. Methods: A cross-sectional study with 37 207 participants (mean age: 36.70 ± 14.79, with 77 % women) was conducted in 38 countries through an online survey administered between April and June 2020. The study utilized a pre-tested food frequency questionnaire to explore food consumption patterns both before and during the COVID-19 periods. Additionally, the study computed Food Consumption Score (FCS) as a proxy indicator for assessing the dietary diversity of households. Findings: This quantification of global, regional and national dietary diversity across 38 countries showed an increment in the consumption of all food groups but a drop in the intake of vegetables and in the dietary diversity. The household's food consumption scores indicating dietary diversity varied across regions. It decreased in the Middle East and North Africa (MENA) countries, including Lebanon (p < 0.001) and increased in the Gulf Cooperation Council countries including Bahrain (p = 0.003), Egypt (p < 0.001) and United Arab Emirates (p = 0.013). A decline in the household's dietary diversity was observed in Australia (p < 0.001), in South Africa including Uganda (p < 0.001), in Europe including Belgium (p < 0.001), Denmark (p = 0.002), Finland (p < 0.001) and Netherland (p = 0.027) and in South America including Ecuador (p < 0.001), Brazil (p < 0.001), Mexico (p < 0.0001) and Peru (p < 0.001). Middle and older ages [OR = 1.2; 95 % CI = [1.125–1.426] [OR = 2.5; 95 % CI = [1.951–3.064], being a woman [OR = 1.2; 95 % CI = [1.117–1.367], having a high education (p < 0.001), and showing amelioration in food-related behaviors [OR = 1.4; 95 % CI = [1.292–1.709] were all linked to having a higher dietary diversity. Conclusion: The minor to moderate changes in food consumption patterns observed across the 38 countries within relatively short time frames could become lasting, leading to a significant and prolonged reduction in dietary diversity, as demonstrated by our findings.Item ‘Let us enjoy the fruits of our own labour, we have our own solutions’ Creative co-design methods and narratives of Māori whānau with chronic pain(Taylor and Francis Group on behalf of the Royal Society of New Zealand, 2025-07-07) Davies C; Devan H; Kokiri Whānau; Te Morenga LChronic or persistent pain disproportionately affects Māori and their whānau (family and significant others). Our previous engagement with Māori living with persistent pain has identified significant barriers for Māori to accessing primary, secondary, and tertiary services. This paper describes the insights obtained from Māori living with persistent pain by using a creative art-based data collection method as part of a co-design process to understand how they would like to be supported in their pain management journey. We used brainstorming discussion sessions and a creative art session to encourage divergent thinking and to stimulate innovative ideas for better pain management support for Māori. The creations showed a deep connection to taiao (nature) and the support of whānau as sources of strength. Connecting with other whānau living with pain in a safe space (i.e. community setting or a marae (community meeting place)) was an aspiration. Existing mainstream services were viewed as deficit-focused with an overwhelming support for Māori-led solutions delivered kanohi-ki-te-kanohi (face-to-face). Creative activities can be used as a culturally appropriate research method for both generating rich insights into the lived experiences of Māori living with persistent pain and how to deliver culturally responsive pain services.Item Insights on wellbeing and society from a Taulasea/traditional healer perspective(Taylor and Francis Group on behalf of the Royal Society of New Zealand, 2025-06-18) Firestone R; Hitti P; Latu L; Brown B; Te Morenga L; Aitaoto NUnquestionably there is a need for more Indigenous and traditional knowledge to understand better the link between ‘culture and food systems, diet and traditional practices’ and ‘diet-related diseases’ (e.g. diabetes), particularly from a Pacific worldview. In this study, we explored the role of Samoan traditional healers or Taulasea with the research question: ‘What insights are contained in Indigenous and traditional knowledge systems that can be used to design new ways to prevent diet-related diseases among Samoans (and Pacific peoples in general) in NZ?’ Fourteen Taulasea participated in semi-structured narrative interviews (talanoa methodology) from June 2022 to October 2023. Transcribed interviews were coded and analysed using thematic analysis. Four major themes were revealed that examined the sacredness of their knowledge and practice, Taulasea specialisation, treatment methods and holistic views that impact health. These insights highlight why Samoans continue to use traditional healing as the first port of call for their health needs.Item Is a voluntary healthy food policy effective? evaluating effects on foods and drinks for sale in hospitals and resulting policy changes(BioMed Central Ltd, 2025-12-01) Ni Mhurchu C; Rosin M; Shen S; Kidd B; Umali E; Jiang Y; Gerritsen S; Mackay S; Te Morenga LBackground: Healthy food and drink guidelines for public sector settings can improve the healthiness of food environments. This study aimed to assess the implementation and impact of the voluntary National Healthy Food and Drink Policy (the Policy) introduced in New Zealand in 2016 to encourage provision of healthier food and drink options for staff and visitors at healthcare facilities. Methods: A customised digital audit tool was used to collate data on foods and drinks available for sale in healthcare organisations and to systematically classify items as green (‘healthy’), amber (‘less healthy’), or red (‘unhealthy’) according to Policy criteria. On-site audits were undertaken between March 2021 and June 2022 at 19 District Health Boards (organisations responsible for providing public health services) and one central government agency. Forty-three sites were audited, encompassing 229 retail settings (serviced food outlets and vending machines). In total, 8485 foods/drinks were classified according to Policy criteria. The primary outcome was alignment with Policy guidance on the availability of green, amber, and red category food/drink items (≥ 55% green and 0% red items). Secondary outcomes were proportions of green, amber, and red category items, promotional practices, and price. Chi-square tests were used to compare results between categorical variables. Results: No organisation met the criteria for alignment with the Policy. Across all sites, 38.9% of food/drink items were rated red (not permitted), 39.0% were amber, and 22.1% were green. Organisations that adopted the voluntary Policy offered more healthy foods/drinks than those with their own organisational policy, but the proportion of red items remained high: 32.3% versus 47.5% (p < 0.0001). About one-fifth (21.3%) of all items were promoted, with red (24.6%) and amber (22.2%) items significantly more likely to be promoted than green items (14.0%) (p < 0.001). Green items were also significantly more costly on average (NZ$6.00) than either red (NZ$4.00) or amber (NZ$4.70) items (p < 0.0001). Conclusions: Comprehensive and systematic evaluation showed that a voluntary Policy was not effective in ensuring provision of healthier food/drink options in New Zealand hospitals. The adoption of a single, mandatory Policy, accompanied by dedicated support and regular evaluations, could better support Policy implementation.Item Impact of unhealthy food/drink marketing exposure to children in New Zealand: A systematic narrative review(Oxford University Press, 2025-04-03) Frost H; Te Morenga L; MacKay S; McKerchar C; Egli VUnhealthy food and drink marketing exposure to children is known to influence children's dietary choices and the World Health Organization recommends governments protect children from the marketing of unhealthy commodities. This study aims to explore and synthesize children's unhealthy food and drink marketing exposure in New Zealand. A systematic search strategy was undertaken following the PRISMA guidelines. Eight databases were searched for studies from inception to January 2024 on marketing exposure of unhealthy food and drink to children aged 2-17 years. A deductive coding analysis was used, with codes sourced from a modified coding framework developed using a diagram sourced from the ASEAN and UNICEF (2023) report. The diagram demonstrates the pathway from marketing exposure to unhealthy food- and drink-related diseases. A total of 1019 studies were screened for eligibility. Forty-five studies met the inclusion criteria - five qualitative, 34 quantitative and four mixed-method studies. The results are presented in a narrative review format. Findings demonstrated children's exposure to unhealthy food/drink marketing is ubiquitous with clear links to dietary preference and consumption. To improve child health now and over the life course, unhealthy food/drink marketing needs to be subjected to greater restriction with enforceable legislation to protect children from exposure to unhealthy marketing, breaking the chain from exposure to ill health.Item Māori food culture and wellbeing on TikTok: a content and thematic analysis(Taylor and Francis Group, 2024-12-17) Renall N; Te Morenga LWe examined content posted on TikTok on the topic of kai Māori (traditional food and associated customs of the indigenous people of Aotearoa New Zealand) to inform strengths-based approaches to health promotion in Māori communities. We conducted a content analysis of 100 unique TikTok videos labelled with the hashtags #kai and #Maori and coded content characteristics and viewer engagement for each video. Twenty foods were determined to be key Māori identity foods from this analysis. We also undertook a reflexive thematic analysis of the content of all videos and user engagement from a sample of 40 videos. Three themes relating to the value of kai Māori were identified: Mauri ora (kai as an expression of pride in Māori identity), Ahikā kai (a means of keeping traditions alive) and Tūhononga (a means of connecting with Te Ao Māori). Māori used TikTok to celebrate Māori identity by sharing and discussing content about kai Māori that was informative and often humorous or self-deprecating. Health promotion in Māori communities should draw on the values of kai as more than food. Kai has an important role in strengthening wellbeing through facilitating cultural connections and linking healthy lifestyles with traditional practices like collecting seafood. Glossary of Māori words: Ahikā kai: keeping Māori traditions alive; Ahuriri: Napier, Aotearoa New Zealand; Aotearoa NZ: Aotearoa New Zealand; aroha: love; atua: deity, ancestor; ehe: e hē: an expression of no in Ngāi Tūhoe Iwi [tribe] dialect; hāngī: food cooked in an earth steam oven or gas steamer; he kai reka tenei: this food is yum or sweet; he tīno reka: very yummy; he reka: yum, sweet; huhu: huhu grub, Prionoplus reticularis; kai: food; kai Māori: traditional food and associated customs; kaimoana: food from the sea including fish and shellfish; kaitiaki: custodians, guardians; kānga wai/ kānga pirau: fermented ‘rotten’ corn; kamokamo: squash, vegetable marrow; kao: no; karakia: blessing, giving thanks; kare: an endearment; karengo /parengo: seaweed; kaupapa Māori: a Māori approach, Māori philosophy and principles guide practice; kia ora: hello, greetings, thank you; kina: sea urchin; koro:grandfather; kumara: sweet potato; kupu: word; kūtai: mussels; inanga: whitebait; mahinga kai: traditional food gathering place; mana whenua: Māori people who have customary authority and rights over identified land; manaakitanga: the act of showing support, caring for others; Māoritanga: Māori culture, way of life; mātua: parents; marae: a place of cultural significance to gather and meet; mauri: spirit, life essence; mauri ora: strong pride in having a unique Māori identity; meke: too much, good; mirimiri: to rub; moana: ocean; Ngāpuhi: northern iwi [tribe] of Aotearoa; noa: ordinary, unrestricted; ora: to be alive, healthy and well; Pākehā: New Zealanders of European descent; paraoa: fry bread; patu: traditional club used in warfare; paua: abalone; pikopiko: young fern shoots; pipi: shellfish, clam; puha: a sow thistle green; Rakiura: Stewart Island; rangatahi: Māori youth; rawe: excellent; reka: sweet; rēwana: fermented bread made with potato; Tā: Sir, Knight; tamariki Māori: Māori children; Tangaroa: the Māori atua (god) for the oceans; tapu: restricted, to be sacred, under atua protection; tautoko: show support; Te Ao Māori: the Māori world and its traditions; te taiao: the natural world; Te Whare Tapa Whā: a model of Māori health developed by Tā Professor Mason Durie; tēnā koe: greetings (speaking to an individual); tikanga: traditional customs or practices; tinana: body, physical self; tino reka: an expression of deliciousness; tino reka te kai: the kai is yum; tītī: mutton bird Puffinus griseus; toa: brave, accomplished, competent; toheroa: large clam;f toroi / whakamara: a fermented dish of cooked mussels and puha; tuatua: shellfish, clam; tūhononga: connecting with Te Ao Māori; tuna: eel; tūpuna / tīpuna: ancestors, grandparents; wahine: woman; Whaea: Mother, Aunty; whakaiti: look down on; whakapapa: lineage, genealogy, ancestry; a central concept in Māori culture of identity, relation and connection to people, place, and culture; whānau: family group, including extended family; whanaunga: relative, kin; whanaungatanga: relationship building; whenua: land, ground.Item Dietary Fibre Intake, Adiposity, and Metabolic Disease Risk in Pacific and New Zealand European Women(MDPI (Basel, Switzerland), 2024-10-07) Renall N; Merz B; Douwes J; Corbin M; Slater J; Tannock GW; Firestone R; Kruger R; Te Morenga L; Brownlee IA; Feraco A; Armani ABACKGROUND/OBJECTIVES: To assess associations between dietary fibre intake, adiposity, and odds of metabolic syndrome in Pacific and New Zealand European women. METHODS: Pacific (n = 126) and New Zealand European (NZ European; n = 161) women (18-45 years) were recruited based on normal (18-24.9 kg/m2) and obese (≥30 kg/m2) BMIs. Body fat percentage (BF%), measured using whole body DXA, was subsequently used to stratify participants into low (<35%) or high (≥35%) BF% groups. Habitual dietary intake was calculated using the National Cancer Institute (NCI) method, involving a five-day food record and semi-quantitative food frequency questionnaire. Fasting blood was analysed for glucose and lipid profile. Metabolic syndrome was assessed with a harmonized definition. RESULTS: NZ European women in both the low- and high-BF% groups were older, less socioeconomically deprived, and consumed more dietary fibre (low-BF%: median 23.7 g/day [25-75-percentile, 20.1, 29.9]; high-BF%: 20.9 [19.4, 24.9]) than Pacific women (18.8 [15.6, 22.1]; and 17.8 [15.0, 20.8]; both p < 0.001). The main source of fibre was discretionary fast foods for Pacific women and whole grain breads and cereals for NZ European women. A regression analysis controlling for age, socioeconomic deprivation, ethnicity, energy intake, protein, fat, and total carbohydrate intake showed an inverse association between higher fibre intake and BF% (β= -0.47, 95% CI = -0.62, -0.31, p < 0.001), and odds of metabolic syndrome (OR = 0.91, 95% CI = 0.84, 0.98, p = 0.010) among both Pacific and NZ European women (results shown for both groups combined). CONCLUSIONS: Low dietary fibre intake was associated with increased metabolic disease risk. Pacific women had lower fibre intakes than NZ European women.Item Slow and steady-small, but insufficient, changes in food and drink availability after four years of implementing a healthy food policy in New Zealand hospitals(BioMed Central Ltd, 2024-12) Mackay S; Rosin M; Kidd B; Gerritsen S; Shen S; Jiang Y; Te Morenga L; Ni Mhurchu CBACKGROUND: A voluntary National Healthy Food and Drink Policy (the Policy) was introduced in public hospitals in New Zealand in 2016. This study assessed the changes in implementation of the Policy and its impact on providing healthier food and drinks for staff and visitors in four district health boards between 1 and 5 years after the initial Policy introduction. METHODS: Repeat, cross-sectional audits were undertaken at the same eight sites in four district health boards between April and August 2017 and again between January and September 2021. In 2017, there were 74 retail settings audited (and 99 in 2021), comprising 27 (34 in 2021) serviced food outlets and 47 (65 in 2021) vending machines. The Policy's traffic light criteria were used to classify 2652 items in 2017 and 3928 items in 2021. The primary outcome was alignment with the Policy guidance on the proportions of red, amber and green foods and drinks (≥ 55% green 'healthy' items and 0% red 'unhealthy' items). RESULTS: The distribution of the classification of items as red, amber and green changed from 2017 to 2021 (p < 0.001) overall and in serviced food outlets (p < 0.001) and vending machines (p < 0.001). In 2021, green items were a higher proportion of available items (20.7%, n = 815) compared to 2017 (14.0%, n = 371), as were amber items (49.8%, n = 1957) compared to 2017 (29.2%, n = 775). Fewer items were classified as red in 2021 (29.4%, n = 1156) than in 2017 (56.8%, n = 1506). Mixed dishes were the most prevalent green items in both years, representing 11.4% (n = 446) of all items in 2021 and 5.5% (n = 145) in 2017. Fewer red packaged snacks (11.6%, n = 457 vs 22.5%, n = 598) and red cold drinks (5.2%, n = 205 vs 12.5%, n = 331) were available in 2021 compared to 2017. However, at either time, no organisation or setting met the criteria for alignment with the Policy (≥ 55% green items, 0% red items). CONCLUSIONS: Introduction of the Policy improved the relative healthiness of food and drinks available, but the proportion of red items remained high. More dedicated support is required to fully implement the Policy.
