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Item The feasibility of a nutrition screening tool to improve food habits of Pacific pre-schoolers : a co-designed study : a thesis presented for the partial fulfilment of the requirements for the degree of Master of Science in Nutrition and Dietetics at Massey University, Albany Campus, Auckland, New Zealand(Massey University, 2024) Ngawhika, AimeeAim: To collaborate with stakeholders (Pacific Heartbeat and parents/care givers of Pacific pre-schoolers) in a co-designed feasibility study to assess the acceptability and use of the NutriSTEP nutrition screening tool to improve Pacific pre-schooler eating habits. The aim was to assess the appropriateness of the NutriSTEP questionnaire items with end-users’, to discuss potential adaptations, scoring methods and recommendations for use of the NutriSTEP tool in the community. Methods/Design: The co-design method involved extensive discussions with the Pacific Heartbeat stakeholder team to plan the engagement with end-user groups (Pacific communities). Five focus groups were undertaken across communities in Auckland (N=38 participants, mean age 38±10.9 years, 36 females, 2 male) who were parents/carers of Pacific children between the ages of 2-5 years old. Participants completed and provided feedback on the NutriSTEP tool in focus group discussions. Key findings were collated and presented in a final focus group with representatives from the previous round of focus group participants. Discussions enabled the approval of recommended changes for use of the NutriSTEP tool prior to community implementation. Results: Half of the participants were born in New Zealand with the remaining half born in various Pacific countries, nine participants had a tertiary education while 15 participants preferred not to comment, and over half (58%) of the participants used a first language other than English. Focus group discussions revealed six main themes: 1) The NutriSTEP tool is exposing and eye opening and raised awareness of daily habits, highlighting areas for improvement. 2) The opportunity for parents/carers to self-score the tool to clearly identify nutrition risk level outcomes was preferred. 3) Several proposed wording changes were needed to improve the clarity of questionnaire items. 4) Food group items were ambiguous and needed inclusion of cultural foods in item examples (e.g. taro and cassava in vegetable group). 5) Items related to food habits created a sense of embarrassment and judgement and highlighted the importance of community screening in a supportive group environment. 6) Physical activity, weight and growth items needed reframing to encompass a cultural perspective. Conclusions: The NutriSTEP tool was acceptable for the most part by the end-user groups. Amendments were needed for specified items to improve cultural acceptability and understanding. Groups sessions for completion of the tool was recommended for successful implementation in the Pacific community. The tool increased parent/carers awareness of nutrition related habits, and highlighted areas for improvement. The development of culturally appropriate resources to enable improved eating habits for Pacific pre-schoolers at all levels of health literacy was identified. Post tool completion resources will include material suggested in this co-designed study to increase knowledge around nutrition related topics.Item Teacher perceptions of the school food environment : has the Healthy Active Learning (HAL) initiative made a positive impact? : a thesis presented in partial fulfilment of the requirements of the degree of Master of Science in Nutrition and Dietetics at Massey University, Auckland, New Zealand(Massey University, 2024) Young, MaeBackground: Childhood obesity is a growing concern. Eating patterns are carried through from childhood to adulthood making the school food environment a key setting to influence healthy eating. The 5-year long Healthy Active Learning (HAL) initiative aims to increase wellbeing in primary and intermediate students (5-13 years old) through physical activity and healthy eating. Teachers play a key role in facilitating a healthy school environment and school-based nutrition programmes. However, there is a limited understanding of teachers’ perceptions of the school food environment, and the perceived roles they play in this. This study assessed teachers’ perceptions of the school food environment throughout the HAL initiative. Aim: To assess primary and intermediate schoolteachers’ perceptions on the school food environment over the course of the HAL initiative, specifically from evaluation data collected from 2020/21 and 2022/23. Methods: This mixed methods study used HAL evaluation data from 2020/21 and 2022/23. A survey to assess teachers’ engagement with health topics, perceptions of school food policies, promotion, and provision was sent to primary and intermediate school teachers from participating HAL schools via email using Qualtrics (2020). Survey responses (n = 1728) were analysed using Pearson’s Chi-square and Fisher's exact tests. Qualitative focus groups were undertaken to better understand survey responses and reveal nuanced themes. Teacher focus group transcripts (n = 538) were thematically analysed using NVivo. Results: In both surveys 86% of teachers reported enjoying teaching health (p = 0.96) and ≥84% agreed healthy eating was key to student wellbeing (p = 0.66). Confidence in teaching nutrition decreased from 83% in 2020/21 to 78% in 2022/23 (p = 0.02). Food policies were upheld by ≥60% (p = 0.56) of teachers and ≥56% for external activities (p = 0.76). Schools providing milk and water decreased from 69% in 2020/21 to 58% in 2022/23 (p =<0.001). Most ≤78% teachers agreed healthy food was promoted at their schools (p = 0.22). More than half of schools worked with food providers (68% in 2020/21 to 63% in 2022/23 p = 0.05). Focus groups revealed teachers believed schools are trying to create a healthy school food environment. Concerns were raised about food insecurity in students’ homes and access to unhealthy foods from external food environments. Food promotion from external providers such as Fruit in Schools were highly valued. Teachers expressed a need for professional development in nutrition education as they were not trained for this role. Conclusions: Overall, teachers perceive schools were doing enough to create a healthy school food environment and are engaged with health topics. Some took on the responsibility of nutrition educators if they value nutrition and health. External providers, such as Fruit in Schools, Breakfast Club, and Food for Thought, were valued by teachers and the school community. The school food environment does not operate in a silo and is influenced by the community and home environment. Teachers perceives children’s experience of food security at home impacts the school food environment, through what type of food students bring to school, or impacting their attendance. So, what? Efforts to create a healthy school food environment need to consider the role of teachers and the external influences within the community and home environments. Teachers need more professional development opportunities to feel confident and supported in teaching nutrition topics to students.Item Investigation of the food environment surrounding primary schools in New Zealand : a thesis presented in partial fulfilment of the requirements of the degree of Master of Science in Nutrition and Dietetics(Massey University, 2024) Nicholls, KateBackground: Childhood obesity is a prominent issue in New Zealand (NZ). Children's daily exposure to their food environment significantly influences their health, dietary patterns, and preferences. With children spending a substantial portion of their time on school grounds, the quality of the food environment within and around schools emerges as a crucial factor. Efforts have been made to enhance the food environment within schools. However, limited action has been taken to improve the food environment surrounding schools. Therefore, a comprehensive understanding of the food environment surrounding schools, encompassing both advertisements and stores and exploring correlations with internal food environments, is needed. This knowledge is paramount for informing policymakers and catalysing targeted actions to address childhood obesity comprehensively. Aims: To investigate food and beverage advertising and stores surrounding NZ primary schools and to explore correlations between the external food environment (food and beverage advertisements) and the internal food environment (Healthy Active Learning food menu and policy data) for these schools. Methods: Food and beverage advertisements (n=479) and stores (n=215) within 800 m of 18 primary schools were collected via Google Street View in August 2023. Advertisement and store characteristics were compared across different school deciles (low, medium and high). To determine the healthiness of the advisement, food and beverage advertisements were separated into ‘core’ and ‘non-core’ depending on whether they are considered part of the everyday diet. Results: ‘Non-core’ advertisements (n=426, 89.0%) outnumbered ‘core’ advertisements (n=53, 11.0%), with sugar-sweetened beverages (n=192, 40.1%) the most common category, and Coca-Cola the most common brand (n=158, 33.0%). The majority of advertisements were found near low (n=406, 43.0%) and medium (n=208, 43.4%) decile schools, with low decile schools having more nearby (0-400 m) advertisements (n=111, 57.5%). Advisement characteristics varied by school decile including; distance from school, brand and secondary marketing classifications. The number of advertisements strongly correlated with the number of stores (rs=0.879, n=18, p<0.001), with most advertisements (97.1%) located on food stores. The most common food and beverage stores near schools were local fast-food restaurants (44.7%) and convenience stores (24.2%). Low and medium-decile schools have more convenience stores, fast food outlets and bakeries within 800 m, while high-decile schools have more supermarkets and cafés. Conclusions: ‘Non-core’ food and beverage advertising, fast food stores, and convenience stores are highly prevalent surrounding primary schools, particularly surrounding low and medium-decile schools.Item Dietary intake, household food insecurity, and their associations with anthropometric status and sociodemographic factors amongst young New Zealand children : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nutritional Science, Massey University, Auckland, New Zealand(Massey University, 2024-04-08) Jupiterwala, Rosario Pillar MonzalesBackground: Household food insecurity is a serious public health concern that may impact young children's dietary intake. In New Zealand (NZ), there are limited studies on young children’s dietary intake. However, comprehensive dietary data is crucial to ensure that young NZ children obtain adequate energy and nutrient intakes to support their optimal growth and development. Certain sociodemographic groups are disproportionately affected by household food insecurity, which may have been reflected by the high proportion of obesity in NZ compared to other high-income countries and poor dietary consumption indicative of suboptimal nutrition. Aim: Therefore, this thesis aims to describe the energy and nutrient intakes, food group consumption, and household food security status of young NZ children, their relationship, and associated correlates such as anthropometric status, ethnicity, socioeconomic status, sex, age, caregiver characteristics, and household size and structure. Methods: Two 24-hour food recalls from 289 children aged 1-3 years participating in the Young Foods NZ (YFNZ) study were analysed to obtain energy, nutrient, and food group intake data. YFNZ is an observational cross-sectional study of children living in Auckland, Wellington, and Dunedin, NZ. Household food security status was measured using the NZ food security scale, a NZ-specific and validated questionnaire. NZ Index of Deprivation was utilised as a proxy measure of socioeconomic status. Anthropometric status was measured using the Body Mass Index (BMI) z-score. Data on other sociodemographic characteristics such as ethnicity, sex, age, caregiver characteristics, household size and structure were collected through online and interviewer-assisted questionnaires. Results: Overall, most nutrient intake recommendations were met except for fibre, iron, calcium, and vitamin C, with a proportion of inadequacy at 54.0%, 15.2%, 3.8%, and 4.8% respectively. Additionally, high protein and saturated fat intakes were observed. Māori, Pacific, Asian, and children living in areas of high deprivation were more at risk of lower fibre intakes than their counterparts, whilst children living in areas of high deprivation had a higher fat intake than those living in low-deprived neighbourhoods. Grains and pasta (n=276 participants), fruits (n=266), and biscuits, crackers, cakes, and desserts (n=242) were most commonly consumed. Formulae (i.e., infant and follow-on formula mixes) and mixed dishes primarily contributed to the intake of energy and most nutrients. Children who were more likely to consume dairy products and dairy-alternative products were children with healthy weight compared to those who were overweight (p=0.036), NZ European compared to Māori, Asian and Pacific children (p=0.005), and children living in areas of low deprivation compared to those who live in highly deprived areas (p=0.014). Food insecure children were more likely to consume pies and pasties (p=0.013), potatoes, kūmara and taro (p=0.040), and beverages (i.e., all fluids except for milk and water) (p=0.011) but less likely to consume biscuits, crackers, cakes and desserts (p=0.001), vegetables (p=0.005), and nuts and seeds (p=0.004). Energy-dense and nutrient-poor foods such as sausages and processed meats; sugar, confectionery, sweet spreads; and pies and pasties were the primary contributors to Pacific children's energy intake and those living in areas of higher deprivation and food insecure households. Over a third of young children experienced food insecurity in the past year. Being overweight, Māori or Pacific, living in areas of high deprivation; having a caregiver who was younger, not in paid employment, or had low educational attainment; living with at least two other children in the household, and living in a sole parent household were associated with household food insecurity. Compared to food-secure children, moderately food-insecure children had higher fat and saturated fat intakes, consuming 3.0 (0.2, 5.8) g/day more fat, and 2.0 (0.6, 3.5) g/day more saturated fat (p<0.05). Moderately and severely food insecure children had lower fibre intake, consuming 1.6 (2.8, 0.3) g/day and 2.6 (4.0, 1.2) g/day less fibre, respectively, compared to food secure children. Severely food-insecure children had three times the prevalence of inadequate calcium intakes and over three times the prevalence of inadequate vitamin C intakes compared to food-secure children. Conclusion: Young NZ children consume a diet that is mostly adequate in terms of most nutrients with the exception of fibre, iron, calcium, and vitamin C. High intakes of nutrients of concern (i.e., saturated fat and protein) were detected and reported to be commonly sourced from low-cost, energy-dense, and nutrient-poor foods. The consumption of these foods mirrors the high prevalence of household food insecurity and obesity amongst young NZ children. Other sociodemographic factors closely related to poverty or low income were associated with food insecurity. Therefore, targeted policies and programmes are imperative, particularly for the most vulnerable groups, to ensure young children's optimal growth and development and attain more equitable health outcomes in NZ.Item Crohn's Disease and environmental factors in the New Zealand context : a thesis presented in partial fulfilment of the requirements for the degree of Doctoral of Philosophy in Nutritional Science at Massey University, Manawatū, New Zealand(Massey University, 2023) Morton, HannahBackground: Inflammatory bowel disease (IBD), consisting of Crohn’s disease (CD) and ulcerative colitis (UC), are lesser-known chronic diseases of the gastrointestinal tract. The causes of IBD are unknown, although research indicates an interplay of genetic, immunological, and environmental factors. The incidence and prevalence of CD in New Zealand (NZ) are among the highest worldwide, and unlike many other Western countries, evidence suggests the incidence rate is still increasing. Objective: The objective was to investigate the involvement of environmental factors in the aetiology, pathogenesis, and symptomatology of CD in NZ. Specifically, pathogenic bacterium Mycobacterium avium subspecies paratuberculosis (MAP), vitamin D, diet, and urbanisation. Methods: Patients with IBD and controls from around NZ completed a questionnaire on environmental factor exposure. Foods implicated in symptom triggering or exacerbation, the possible mechanism(s) involved, and whether vitamin D can confer protection, were investigated using an in vitro digestion method and in vitro model of the intestinal barrier. Serum vitamin D concentrations were measured and compared in patients and controls in order to explore a possible association between vitamin D and IBD. Lastly, the incidence and prevalence of IBD in the Manawatū region was determined, and the urban and rural incidence were compared. Results: Questionnaire derived data showed significant associations between CD and exposure to rural sources of microorganisms, and a major urban birthplace (≥100,000 residents), while rainwater for drinking and cooking during childhood was protective. No associations were observed between CD and MAP exposure. Over 50% of patients implicated dietary elements in symptom onset and/or exacerbation. The in vitro investigation findings suggest this may result from tight junction damage. Vitamin D concentrations did not differ between patients and controls, however, were significantly lower in CD patients that reported recent disease activity. In the Manawatū region, the mean annual incidence and 2013-point prevalence of CD were 17.7 and 250.4 per 100,000, respectively, and urban residence at diagnosis was associated with a six-fold greater IBD incidence compared to rural residence. Conclusions: The findings demonstrate that vitamin D, diet, and urbanisation are involved in CD. A greater understanding of environmental factors, especially modifiable factors, could provide opportunities for reducing CD risk, managing symptoms, or slowing disease progression.Item A systematic literature review of unhealthy food and beverage sport sponsorships in New Zealand : examining what existing discourse can tell us about the future : a thesis presented in partial fulfillment of the requirements for the degree of Master of Science in Nutrition and Dietetics at Massey University, Albany, Auckland, New Zealand(Massey University, 2023) Stevenson, Sumithrie SashaBackground: Obesity and its related diseases are trending upward in New Zealand exacerbated by unhealthy food environments, overconsumption of unhealthy food and beverages, and pervasive marketing that promotes unhealthy food and drinks. Such marketing is frequently sought in the form of sport sponsorship and marketing through sport. Aim: This systematic literature review investigated the discourse in academic and grey literature from 1997-2022 regarding unhealthy food and beverage companies' sport sponsorships in New Zealand. Methodology: Literature searches were conducted in Google, Google Scholar, Discover, PubMed, Scopus, SPORTDiscus, Newztext, Factiva, Radio New Zealand, 1News, The New Zealand Herald, Stuff, Sport New Zealand, National Sport Organizations, New Zealand Legislation, the Advertising Standards Authority, and various websites using key search terms. Identified literature was documented according to those containing sport sponsorship (and associated) terms. The literature was analyzed and synthesized. Results: Sport sponsorships offered by unhealthy food and beverage companies are exacerbating the rising obesity rates in New Zealand. Opposition to unhealthy food and beverage company advertising, and sport sponsorships has increased in the last 25 years. New Zealand’s neoliberal government opposed marketing regulations favoring nutrition education, physical activity promotion, and unhealthy food and beverage company self-regulation via the Advertising Standards Authority voluntary codes. Studies found government and food and beverage companies’ anti-obesity measures ineffective and inadequate to curb unhealthy food and beverage marketing, including sponsorships. Such sport sponsorships normalize and promote unhealthy food and beverage consumption leading public health experts to recommend the regulation of these sponsorships. Conclusion: A multi-focused approach which includes government regulation of unhealthy food and beverage advertising, marketing and sport sponsorships is recommended. In the absence of such regulations, sport sponsorships seem likely to continue promoting unhealthy food and beverage consumption contributing to obesity in New Zealand.Item Complementary feeding practices, nutrient intake, and iron status of Māori, Pasifika, and other infants in Aotearoa New Zealand : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nutritional Science, Massey University, Albany, Aotearoa New Zealand(Massey University, 2023-09-09) Casale, MariaBackground: The period of transition from a solely milk-based diet to sharing family foods at around 12 months of age is a critical time for infants. Complementary feeding practices, from the age of introduction to complementary foods, method of feeding (baby-led weaning vs. traditional spoon-feeding), use of the novel baby food pouches, use of traditional cultural foods and practices, and the characteristics and nutrient density of first foods offered support the healthy growth and development of the infant, as well as shape long term dietary patters and food preferences. Additionally, iron status is crucial for healthy infant growth and development, and while this is impacted by myriad maternal, genetic, and environmental factors, complementary feeding practices and the characteristics of foods offered are key modifiable practices that influence infant iron status. Aims and objectives: The overall aim of this study was to investigate and describe early infant feeding practices, key nutrient intake and density, and the iron status of Māori, Pasifika and other infants living in Aotearoa New Zealand, using an observational cross-sectional study design. The primary objective was to conduct an intra-ethnic analysis of infant complementary feeding practices, nutrient intake and density from complementary foods, and iron status between Māori, Pasifika, and ‘other’ infants. ‘Other’ refers to any infants who were not self-identified by the adult respondent as Māori or Pasifika. Methods: Infants aged 7.0–10.0 months along with their primary caregiver participated in an observational cross-sectional study, with 625 infant–caregiver dyads recruited from Auckland and Dunedin, New Zealand. Participants were recruited from a range of ethnic groups and deprivation statuses. Infants were stratified by ethnicity using total response for Māori and Pasifika, with all non-Māori, non-Pasifika infants categorised into a single ‘others’ group. Demographic and feeding practices data were collected via questionnaire. Nutrient intake from complementary food was measured using the multiple-source method from two multiple-pass 24-hour diet recalls. Nutrient density of complementary food was calculated as the concentration of selected nutrients per 418 kJ (100 kcal) of energy. For iron status, haemoglobin, plasma ferritin, soluble transferrin receptor, C-Reactive protein, and alpha-glycoprotein were obtained from a venous blood sample. Inflammation was adjusted for using the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anaemia (BRINDA) method. Body iron concentration (mg/kg body weight) was calculated using the ratio of sTfR and ferritin. Results: A total of 1424 infant-caregiver dyads were assessed for eligibility, and 625 eligible dyads were enrolled in the study, all of whom provided written consent. Data for complementary feeding practices and nutrient intake were analysed for all 625 infants, with blood samples obtained from 365 of these infants for the assessment of iron status. Within the cohort 131 infants were identified by their caregiver as Māori, and 82 as Pasifika. The remaining infants are allocated into a single ‘others’ group as the primary focus of this manuscript is Māori and Pasifika infants. The mean (SD) infant age was 8.4 (0.8) months for Māori, 8.5 (0.9) months for Pasifika, and 8.4 (0.8) months for ‘other’ infants. Over half of all ethnicities introduced CF at around six months of age (56.5% of Māori, 62.2% of Pasifika, and 80.9% of ‘others’). BLW prevalence increased from 11.5% of Māori, 3.7% of Pasifika, and 12.4% of ‘other’ infants at the time of introducing CF to 29.2% of Māori, 17.1% of Pasifika, and 27.3% of ‘others’ currently. Baby food pouches were used at least once by 89.3% of Māori, 85.4% of Pasifika, and 75.6% of ‘other’ infants. Of those who always or frequently were fed pouches, 27.1% of Māori, 25% of Pasifika, and 12% of ‘other’ infants always or mostly sucked directly from the nozzle. Vegetables and ‘pureed’ were the most common first food and texture offered, respectively, for all ethnic groups. At six months red meat was consumed by 54.6% of Māori infants, 63.4% of Pasifika infants, and 61.8% of ‘other’ infants, and approximately half had iron-fortified baby rice (Māori 57.3%, Pasifika 56.1%, ‘other’ 48.7%). Age-inappropriate drinks were currently given to 17.6% of Māori, 20.7% of Pasifika, and 3.8% of ‘other’ infants. In total, 9.1% of Māori and 20.7% of Pasifika respondents reported offering traditional cultural foods to their infants. Energy intake increased with age for all ethnic groups and was higher for boys than girls. Protein as a percentage of energy intake from CF was significantly lower for Māori compared to ‘others’. Fat as a percentage of energy intake from CF was significantly lower for both Māori and Pasifika than ‘others’, whereas carbohydrate as a percentage of energy intake from CF was significantly higher. Sugar intake in grams from CF was significantly higher for Pasifika when compared to ‘others’, and sugar as a percentage of energy intake from CF was significantly higher for Māori than ‘others’. Iron, zinc, and calcium density of the complementary diet was inadequate for all groups: Māori and ‘others’ had an iron density of 0.8 mg/418 kJ, and Pasifika 0.9 mg/418 kJ. Zinc density was 0.5 mg/418 kJ for all groups. Calcium density was 37 mg/418 kJ for Māori, 40 mg/418 kJ for Pasifika, and 38 mg/418 kJ for ‘others’. In total, 96.4% of Pasifika infants were iron sufficient, compared to 82.5% of Māori and 76% of ‘other’ infants. ‘Other’ infants had the highest prevalence of iron deficiency overall, with 3% categorised with iron-deficiency anaemia, 12% with early functional iron deficiency, and 9% with iron depletion. For Māori infants, 4.7% had iron-deficiency anaemia and early functional iron deficiency, respectively, and 8% were iron depleted. One (3.6%) Pasifika infant was iron depleted, and the remainder were iron sufficient. Mediation analysis suggested that the difference in body iron concentration between Pasifika and ‘others’ was partially explained by the frequency of their higher consumption of baby food pouches. Conclusions: The high prevalence of Māori and Pasifika infants feeding directly from baby food pouch nozzles is concerning in light of the increasing popularity and prevalence of this novel feeding device, with concerns for both the safety and impact on development of this way of feeding. The low density of iron, zinc, and calcium in the complementary diet warrants further investigation into feeding and fortification strategies, due to the key role these nutrients play in the growth and development of infants. The rate of iron deficiency was very low for Pasifika infants despite little iron intake from complementary food, indicating non-dietary factors as the likely cause for this group.Item Do primary schools in New Zealand promote a positive food environment? : a menu analysis of primary schools participating in the Healthy Active Learning initiative : a thesis presented in partial fulfilment of the requirements for the degree of Master of Science in Nutrition and Dietetics, Massey University, Albany, New Zealand(Massey University, 2023) Piddington, MarshaBackground: Childhood nutrition is key to developing positive health outcomes that persist into adulthood. The school food environment represents an important setting to direct public health interventions. There is limited data on how New Zealand (NZ) primary school menus contribute to the availability of healthy food to improve the school food environment. This study seeks to fill this knowledge gap by examining the alignment of primary school menus with current Ministry of Health (MoH) guidelines. Aim: This study aims to assess the alignment of NZ primary school menus to the MoH Healthy Food and Drink Guidance and explore their contribution to healthy food availability within primary schools in Aotearoa, NZ. Methods: Quantitative assessment of primary school menus using a quick menu analysis to determine alignment with the MoH guidelines and exploring associations with seven school characteristics (school type, decile, equity index, size, area, region, and deprivation level). In the context of this research, a menu is defined as all foods available for purchase by students at a school on a regular basis. Results: School menus (n=133) had a low alignment to guidelines with 12.8% ‘green’, 41% ‘amber’ and 40% ‘red’ items. Wellington and Auckland had higher percentages of ‘green’ items compared to other regions (Auckland against Northland (p=0.046), Bay of Plenty (p=0.002) and South Island (p=0.026), Wellington against Bay of Plenty (p=0.043)). Wellington had the lowest percentage of ‘red’ items compared to Auckland (p=0.037), Bay of Plenty (p=0.048) and South Island (p=0.041). Schools in urban areas had a higher alignment than rural, 36.9% and 50% of ‘red’ items, respectively (p<0.001) and a higher percentage of ‘green’ items (p=0.006). Small schools had less 'green' items and more ‘red’ items than medium (p=0.002, p<0.001) and large schools (p<0.001, p=0.020). Socioeconomic measures were related to a lower percentage of ‘green’ menu items in schools with low decile compared to high decile p=0.011), a high and medium equity index compared to low (p=0.02 and p<0.001), respectively and medium and high deprivation compared to low, p=0.046 and p<0.007, respectively. Conclusion: Primary schools in NZ do not align with MoH guidelines, with rural schools facing greater challenges. Public health interventions could drive change by engaging schools and food suppliers to limit 'red' items and increase 'green' items. This study shows the need for strategies to reduce the availability of ‘red’ menu items in primary schools, as this poses an increased risk for unhealthy eating in children.Item An exploration of the overall quality of care of Home Enteral Nutrition (HEN) patients in the Counties Manukau district : a thesis in partial fulfilment of requirement for the degree of Master of Science in Nutrition and Dietetics at Massey University, Albany, New Zealand(Massey University, 2023) Pattison, SallyThe overall quality of care is multifaceted, with quality of life, patient satisfaction, and equity of care all important aspects of the patient experience. Previous research internationally has shown that patients receiving HEN may experience lower QoL and frustrations with HEN services, however the current situation in NZ remains unknown. Therefore, understanding the patient’s overall experience of HEN care is essential for improving health outcomes for this patient group in NZ. This study aimed to explore the experiences of patients receiving HEN care from the Counties Manukau community health teams, firstly by conducting patient surveys assessing QoL, HEN-specific QoL, patient equity and experience data, and collecting demographic data. Secondly, by conducting patient interviews to better understand the patient experience. Finally, by conducting staff focus groups with the dietitians and nurses involved in HEN care to better understand the staff’s perception of life with HEN, and HEN care services . . . This is the first research of its kind in NZ and contributes to filling the research gap in terms of understanding the impact of HEN on patient’s QoL and enabling assessment of patient QoL versus the general NZ population and other HEN populations. This research is also the first in NZ to assess the patient experience within the community setting. It highlights the importance of monitoring outpatient and community patient experiences along with in-patient and primary care patients. These research findings have the potential to enhance service delivery and care for this patient group and can serve as a reference point for future studies on QoL in HEN patients in NZ--From Chapter 4.Item Intermediate and secondary school food environment in New Zealand : lunch food and drink menu assessment : a thesis presented in partial fulfilment of the requirements for the degree of Master of Science in Nutrition and Dietetics at Massey University, Albany, New Zealand(Massey University, 2023) Green, ShannonIntroduction: The combination of food insecurity and the increase in nutrition-related obesity among adolescents in New Zealand creates a need for collaborative action to improve the food environment. The school environment is ideal for encouraging a healthy lifestyle; however, the healthiness of food available to intermediate and secondary school students (years seven-13) is unknown. This study assessed how food and drink menus from a convenience sample of schools align with the Ministry of Health Food and Drink Guidance for Schools. Methods: New Zealand intermediate, composite, senior, and secondary schools' (years seven-13) food and drink menus were collected in 2020. Menus were classified using the traffic light criteria ('green', 'amber', and 'red'). A toolkit was developed by three nutritionists and one dietitian (with trained staff support) to aid with menu classification. Menu quality was evaluated against school characteristics and policy use. Results: Of the school menus assessed (n=60), 3.3% met the recommendation for the provision of 75% 'green' items. 'Red' items were the main contributors (mean=53.6%). Schools with high socioeconomic status (deciles 8-10; 14.3%; p<0.05) and of small school size (<749 students; 14.1%; p<0.025) were associated with a higher proportion of 'green' items. Community (19.3%) and in-house school (25.9%) food providers provided a lower percentage of 'amber' items than school providers (39.3%; p<0.001). In-house school providers (64.6%) had a greater percentage of 'red' items than contracted school providers (48.2%; p<0.017). Community providers had the highest proportion of 'green' items (16%; p>0.017). Conclusion: The food available in schools (years seven-13) tended to be unhealthy. A national nutrition policy could improve the school food environment, especially in schools with large populations and of low socioeconomic status. So what? Menu quality is a complex socioeconomic issue, and additional support should be considered in intermediate and secondary schools to improve equitable outcomes within school food environments.