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Item Feeding and dietary practices of New Zealand infants : an observational study : a thesis presented in the partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nutritional Science at Massey University, Albany, New Zealand(Massey University, 2023) Brown, Kimberley JaneBackground: Nutrition and early-life feeding practices have short and long-term impacts on the quality and longevity of life. The importance of optimal nutrition during infancy is recognised worldwide and evidence-based infant feeding recommendations have been developed to promote infant health, growth, development, and the establishment of healthy eating behaviours. Currently, there is limited evidence on infant nutrition and feeding practices in New Zealand (NZ), with gaps in our knowledge about what infants are being fed, adherence to the Ministry of Health (MoH) ‘Healthy Eating Guidelines for New Zealand Babies and Toddlers (0–2 years old)’, and the prevalence of concerning feeding behaviours (CFB). Aim: To 1) investigate the contributions that key foods and food groups make to the dietary intake of NZ infants, 2) investigate infant adherence to key dietary indicators as recommended by the MoH’s ‘Healthy Eating Guidelines for New Zealand Babies and Toddlers (0–2 years old)’, and 3) determine the prevalence of parent-reported concerning infant feeding behaviours and associated demographic characteristics and feeding practices of NZ infants between 7.0 and 10.0 months of age. Methods: The observational First Foods NZ (FFNZ) study recruited 625 ethnically diverse infants (aged 7.0 to 10.0 months) living in Auckland and Dunedin between July 2020 and February 2022. Caregivers who were 16 years or older, spoke English, and had not recently participated in a nutritional intervention that may have influenced their infant’s diet were invited to attend two study visits. Appointments were conducted in the participant’s home, available research centre, or via Zoom (during Covid19 restrictions for second appointment only) and included two 24-hour diet recalls and demographic and feeding questionnaires. Diet recall data were analysed through FoodWorks (Version 10, Xyris Software, Australia) using the NZ Food Composition Database FOODfiles™ 2018 Version 01, and foods were allocated food and food group codes using the FFNZ coding system. Counts of foods and food groups consumed were analysed for at least one and both diet recall days, where available. Key indicators from the MoH’s ‘Healthy Eating Guidelines for New Zealand Babies and Toddlers (0–2 years old)’ that were measurable from FFNZ data and applied to those aged 7.0 to 10.0 months were extracted from questionnaire data, or where stated from 24-hour recalls. Recommendations analysed included exclusive breastfeeding to ‘around’ six months of age (defined as ‘5 months’ or ‘6 months’, being the age when something other than breast milk, i.e. either another drink, or solid foods, was first introduced); current breastfeeding; the introduction of solid foods ‘around’ six months of age” (defined as ‘5 months’ or ‘6 months’ when the first solid food was introduced); the introduction of puréed foods and spoon-feeding when starting solid foods; offering of iron-rich foods (meat, poultry, fish, seafood, and iron fortified infant cereals), vegetables, and fruit as first foods; the daily offering of MoH food groups (24-hour recall data; vegetables, fruit, grain foods, milk and milk products, and meat and protein-rich foods); no salt and sugar added to meals (specific 24-hour recall question); avoidance of inappropriate drinks (specific 24-hour recall question; beverages other than breast milk, formula, or water such as cow’s milk as a drink, other milk, juice, soft drinks, tea, and alcohol); and use of self-feeding when developmentally appropriate. Logistic regression was then used to estimate odds ratios, 95% confidence intervals, and p-values for associated sociodemographic characteristics and key indicators. After their second appointment, caregivers were emailed a final questionnaire, which included the Paediatric Eating Assessment Tool (PediEAT). Feeding behaviours were categorised according to the total PediEAT and subscale scores (physiologic symptoms, problematic mealtime behaviours, selective/restrictive eating, and oral processing). Scores were categorised as ‘concern’ and ‘no concern’ using the PediEAT scoring system. Unpaired t-tests and the chi-squared tests determined associations between PediEAT scores and infant and caregiver sociodemographic characteristics. Logistic regression, adjusted by infant age and deprivation, determined associations between PediEAT scores and food groups consumed during both diet recalls. Data were analysed using Stata software (StataCorp, Texas) and Microsoft Excel (version 16.66). Results: Written consent was obtained from 625 caregivers. Data from the demographic and feeding questionnaire were available from all infants (n=625). All caregivers completed at least one diet recall. A second diet recall was available from 614 infants. PediEAT results were available for 554 term infants. Most infants consumed vegetables (96.2% of infants), fruit (91.8%), grain foods (90.4%), milk and milk products (64.0%), and meat and protein-rich foods (84.3%) at least once during the two 24-hour diet recall days. Commercial infant foods (CIF) were consumed by 78.1% and discretionary foods by 56.3% of infants at least once. The proportion of infants who consumed vegetables (63.2%), fruit (53.9%), grain foods (49.5%), milk and milk products (38.6%), meat and protein-rich foods (31.8%), CIF (41.8%), and discretionary foods (16.1%) on both diet recall days was lower. Overall, only 6.5% of infants met guidelines for the daily consumption of the MoH food groups. The ten most common foods consumed were carrot, banana, bread, brassicas, kumara, extruded commercial infant snacks, pumpkin, apple, potato, and commercial infant pouches. Breastfeeding was initiated by 97.2% of mothers, and 37.8% of infants were exclusively breastfed to around six months. At the time of participation, 66.2% of infants were breastfed. Most infants met guidelines for introducing solid foods, including the age of introduction (75.4%), offering iron-rich foods as first foods (88.3%), providing puréed textures (80.3%) and spoon-feeding (74.1%). Self-feeding at the time of participation was common (86.9%). Most met guidelines for avoiding inappropriate beverages (93.9%) and adding salt (76.5%) and sugar (90.6%) to foods. Typically, infants with caregivers who were younger, higher educated, not currently working, primiparous, and living in low deprivation were more likely to meet the guidelines. Feeding behaviour scores were higher than PediEAT norm-reference values and 17.3% of infants were categorised with ‘concern’ feeding behaviours. ‘Concern’ scores were highest for selective/restrictive eating (29.2%), problematic mealtime behaviours (21.5%), and physiologic symptoms (13.7%) subscales. Mothers who were primiparous and highly educated caregivers were more likely to report ‘concern’ total PediEAT scores. Primiparous mothers and caregivers with higher education, that did not use early child education centres, and had infants of NZ Asian infant ethnicity were more likely to report problematic mealtime behaviours. Infants characterised as of ‘concern’ had significantly lower odds of consuming ‘vegetables’ and ‘meat and protein-rich foods’ and were more likely to consume ‘CIF’. Infants with problematic mealtime behaviours had a lower odds of consuming ‘discretionary foods’ and were more likely to be still breastfeeding. Conclusion: This research provides evidence on infant food and food group intake, adherence to key MoH infant feeding guidelines, and the prevalence of parent-reported infant feeding behaviours and associated demographic characteristics and feeding practices from an ethnically diverse group of NZ infants from Auckland and Dunedin. Infants were shown to consume a range of foods within the MoH food groups at least once during the study. However, only 6.5% of infants consumed all five food groups during both recalls. Grain foods, milk and milk products, and meat and protein-rich foods were the least commonly consumed food groups when investigating those consumed on both recall days, increasing the risk of nutritional deficiencies. Most infants met guidelines for introducing solid foods and avoiding inappropriate beverages and adding salt and sugar to meals, although the prevalence of exclusive breastfeeding to ‘around’ six months, however, continues to be low, particularly for first-time mothers. As seen previously, sociodemographic characteristics were also associated with adherence, identifying key groups (primiparous mothers, lower educated caregivers, those living with multiple children, and those living in areas of high deprivation) that require additional support. Finally, CFB were prevalent in our study, with higher scores reported by primiparous mothers and caregivers who were highly educated. Infants with CFB were less likely to meet recommendations for ‘vegetables’ and ‘meat and protein-rich foods’ and were more likely to consume ‘CIF’. Further investigation is required to understand parental perceptions of feeding behaviours and the nutritional implications of CFB. Further research will determine the nutritional implications of not meeting the MoH food group guidelines during complementary feeding, investigate what support parents need in NZ to improve adherence to the MoH breastfeeding and food group recommendations, and the impact of CFB on nutrient intake.Item Determining the relative validity and reproducibility of a complementary food frequency questionnaire to assess nutrient intake in New Zealand infants aged 9 to 12 months : 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, 2018) Judd, AmyBackground: Obtaining information on dietary intake in infants is challenging but necessary to help understand the relationship between diet and growth and development. Food frequency questionnaires (FFQ) are commonly used to investigate dietary intake as they are suited for use in large population groups, can determine intake over multiple days and minimise participant and researcher burden, and associated costs. FFQs need to be specific to the population they are to be used in and validated so that their results can be interpreted with greater confidence. There are currently no simple, validated dietary assessment methods that are available to assess nutrient intake for New Zealand infants. Objective: To validate a complementary food frequency questionnaire (CFFQ) against a reference method of a four-day weighed food record (4dWFR) for assessing nutrient intakes of New Zealand infants aged 9 to 12 months. A secondary objective was to assess the reproducibility of the CFFQ by having it completed on two separate occasions, four weeks apart. Methods: A cross-sectional study design was used including ninety-five infants aged 10 ± 1 months and their primary caregiver, who completed the CFFQ twice (CFFQ-1 and CFFQ-2), approximately four weeks apart (to assess reproducibility). Four days of weighed food records (4dWFR) were collected on non-consecutive days between CFFQ administrations (validity). Validity and reproducibility were assessed for intakes of energy, macronutrients and micronutrients using paired t-tests, Pearson’s correlation coefficients, cross-classification and Bland-Altman analysis. Two data sets were created, one that included milk intake (breast milk and formula) and one that excluded milk intake. The data was also adjusted for energy intake, before being reassessed for validity and reproducibility. Results: For validity, most nutrient intakes from the CFFQ were comparable to the 4dWFR (range <1% up to 27% different). The CFFQ produced significantly higher nutrient intakes for fat and saturated fat, but significantly lower nutrient intakes for carbohydrate, fibre, folate, potassium, thiamin, riboflavin, niacin and vitamin C (p<0.01). Correlation coefficients ranged from r=0.18 (saturated fat) to r=0.81 (iron; mean r=0.52). Over half of participants had the same tertile classification by both the 4dWFR and the CFFQ (mean 53.9%, range 39.0% (selenium) to 67.4% (iron)). Between 2.1% (iron and calcium) and 14.7% (saturated fat) of participants (mean 7.1%) were misclassified into opposite tertiles. Most of the nutrients showed acceptable agreement between methods (κ=0.20–0.60). Saturated fat and selenium showed poor agreement (κ<0.20) and iron showed good agreement (κ>0.60). Removing milk intake weakened the correlations (range r=0.21 for vitamin E to r=0.60 for niacin, mean r=0.44) and reduced the agreement between methods (50.3% correctly classified and 9.2% grossly misclassified). Adjustment for energy intake showed comparable correlation coefficients (range r=0.24 for fibre and r=0.78 for calcium and iron, mean r=0.52) and improved the agreement between methods (56.2% correctly classified and 6.8% grossly misclassified). The CFFQ had adequate performance for reproducibility for all nutrients and energy with acceptable correlations (r≥0.20) and good cross-classification (>50% correctly classified and <10% grossly misclassified) apart from fat and saturated fat (40.9% and 47.3% correctly classified, respectively). All nutrients showed acceptable to good agreement between the CFFQ-1 and CFFQ-2 (κ>0.20). When milk intake was excluded and when the data was adjusted for energy intake, there was comparable acceptable to good correlations and cross-classification. Conclusion: Although there were some differences in absolute energy and nutrient intakes between the methods, the CFFQ appears to have acceptable validity for assessing 14 nutrients and good reproducibility for assessing 18 nutrients and energy in infants aged 9-12 months. The CFFQ could be used in future research to investigate infant nutrient intakes where using a simple tool with little participant burden is beneficial.Item The development, validity and reproducibility of a tool (the Athlete Diet Index Questionnaire) to assess the dietary intake of high performing athletes : a thesis presented in partial fulfilment of the requirements for the degree of Masters of Science in Nutrition and Dietetics at Massey University, Albany, New Zealand(Massey University, 2016) Blair, RachelBackground: Well-chosen eating strategies can enhance an athlete’s health and sporting performance. It is important for sports dietitians and nutritionists to have access to accurate and reliable dietary assessment methods. Currently there is no population specific, simple food based dietary index suitable for the examination of diet quality among athletes. This study aimed to develop a diet quality index (the Athlete Diet Index Questionnaire (ADI-Q)) which focusses on the baseline nutrition requirements of high performing New Zealand athletes, and examine the validity and reproducibility of food groups, food variety, fluid consumption and eating habits within the ADI-Q. Methods: The ADI-Q was developed for high performing athletes and was based on dietary components which reflect the Eating and Activity Guidelines for New Zealand Adults (EAGNZA). Athletes who represented their main sport at a regional level or above volunteered to participate in the study. During the first appointment athletes completed the ADI-Q (ADI-Q#1) and an estimated four-day food record (4DFR) (to assess relative validity). The test-retest reliability of ADI-Q#1 was assessed by a second administration of the ADI-Q (ADI-Q#2) four-weeks later. Both relative validity and reliability were assessed using paired-t tests, Pearson’s correlation coefficients, Chi square analysis and Bland-Altman plots. Results: Sixty-eight athletes (26 males, 43 females, 16-71 years) involved in more than 30 different sports completed the study. When assessing relative validity paired t-tests showed good agreement between servings of dried fruit/fruit juice, starchy vegetables, milk and/or milk alternatives, lean meat (beef, lamb, pork) and times treat food were consumed (p>0.05). Food groups found to be significantly different tended to have a lower mean number of servings for the ADI-Q#1 compared with 4DFR. Correlation coefficients ranged from 0.19 (servings of starchy vegetables) (p>0.05) to 0.66 (servings of non-starchy vegetables) (p<0.05) with an average correlation of 0.42. Variety of fruit and vegetables had an average correlation of 0.52. The majority of fluid components had good agreement with only servings of milk and/or milk alternatives and soft drinks/fizzy drinks/carbonated water found to be significantly different (p<0.05). Correlation coefficients ranged from -0.03 (flavoured water/sports water and coconut water) (p>0.05) to 0.77 (herbal tea) (p<0.05) with an average correlation of 0.39. Healthy versus less healthy options showed poor agreement between the ADI-Q#1 and the 4DFR with all components except the use of unsaturated fat being significantly different (p<0.05). Meal frequency showed good agreement with only consumption of morning tea found to be significantly different between methods (p<0.05). When assessing reproducibility, there was no significant difference found between most dietary components with the exception of servings of non-starchy vegetables, breads and cereals, meat alternatives, water and times takeaways were consumed (p<0.05). Significantly different food groups and fluids had a higher mean number of servings/times from ADI-Q#1 compared with ADI-Q#2. Correlation coefficients for food groups ranged from 0.18 (servings of lean meat) (p>0.05) to 0.63 (servings of starchy vegetables) (p<0.05) with an average correlation of 0.46. Variety of fruit and vegetables had an average correlation of 0.56. The correlation coefficients for fluid consumption ranged from -0.02 (servings of flavoured water/sports water) (p>0.05) to 0.91 (servings of coffee) (p<0.05) with an average correlation of 0.52. There was no significant difference between healthy versus less healthy options and meal frequency between the first and second administration of the ADI-Q. Conclusions: The ADI-Q showed reasonable validity for the majority of dietary components when compared with a 4DFR. Reproducibility of the ADI-Q was moderate to high for majority of the dietary components. Further development of the ADI-Q and index score to assess diet quality may help to improve the analysis of dietary intake among high performing athletesItem The use of precoded and open-ended questions for the collection of age and income information : a thesis presented in partial fulfilment of the requirements for the degree of Master of Business Studies at Massey University(Massey University, 1984) Lambourne, Peter WhitleyThe objectives of this research were to determine the following points: 1) what effect the use of an open-ended format had on the reply rates to age and income questions; 2) what effect the method of data collection has on the reply rates to age and income questions; 3) whether any difference that occurs due to the interviewer and/or the contents of the survey; and 4) what factors about the interviewer and/or contents of the survey that may be causing this difference. The research was conducted in three stages. The first stage was the estimating of reply rates for open-ended and precoded age and income questions. These reply rates were estimated using each of the different data collection methods. A split sample design was used for each survey. Eight surveys being conducted by Massey University's Market Research Centre and Marketing Department were used in this stage of the research. Half of each sample received precoded age and income questions; the other half had open-ended questions.