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

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Background: 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.
Infants, Nutrition, Māori (New Zealand people), Pacific Islanders, Health and hygiene, New Zealand, Iron deficiency anemia in children, Pēpē, Kai tōtika, Hauora whānau, Māori Doctoral Thesis, iron, baby food pouches, feeding methods, baby led weaning, complementary food