Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. Investigating eating behaviours as predictors of body composition and dietary intake in New Zealand European, Māori and Pacific women – the women’s EXPLORE study. A thesis presented in partial fulfilment of the requirements for the degree Master of Science in Nutrition and Dietetics Massey University, Albany New Zealand Katrina Jade Shepherd 2018 1 Abstract Background/Aim: Internationally, eating behaviour has been linked with an optimal and adverse body composition in women. However no study to date has examined eating behaviour in female New Zealand ethnic groups. Therefore, the aim of this study was to investigate eating behaviours as predictors of different body composition factors and dietary intake in New Zealand European (NZE), Māori and Pacific women, aged 16-45 years, participating in the women’s EXPLORE study. Methods: Women (N=368) were assessed for basic anthropometry, total adiposity, regional adipose distribution and lean mass using height, weight, circumferences, dual x-ray absorptiometry and air- displacement plethysmography. Body composition profiles (normal-fat, hidden-fat and apparent-fat) were established using parameters of body mass indices and body fat percentages. The validated Three-Factor Eating Questionnaire (TFEQ) and New Zealand Women’s Food Frequency Questionnaire were both used to examine eating behaviour and dietary intake, respectively. The TFEQ examined Restraint (Flexible and Rigid), Disinhibition (Habitual, Emotional and Situational) and Hunger (Internal and External). Combinations of behaviour (sub-groups) were established from the main categories and also examined. Results: Restraint was significantly higher in NZE than Pacific women (p = 0.015). Disinhibition) was significantly higher in the apparent-fat profile than normal-fat profile (p < 0.001). Likewise, Hunger was significantly higher in Pacific (p < 0.001) and the apparent-fat profile (p = 0.034) than NZE women and women with normal-fat profile, respectively. Adverse tendencies of Habitual Disinhibition, and External Hunger were more prominent in Pacific and the apparent-fat profile than NZE women and normal-fat profile, respectively (all p < 0.05). External Hunger was more prominent in the hidden-fat profile than normal-fat profile (p = 0.001). When accounting for age and ethnicity the most significant predictors of BMI and BF % were Restraint (p = 0.007 and p = 0.005 respectively), Disinhibition (both p < 0.001), Habitual Disinhibition (both p < 0.001) and Emotional Disinhibition (both p < 0.001). Non- ideal behaviour combinations (Low Restraint High Disinhibition and High Hunger High Disinhibition) generally corresponded to significantly higher body composition markers and dietary intake (p < 0.05). Pacific women were three times more likely to have High Hunger High Disinhibition than NZE women (p = 0.004). Low Restraint High Disinhibition and High Hunger High Disinhibition increased by 12% and 11%, respectively from the normal-fat profile to hidden-fat profile (both p < 0.001). Conclusions: The TFEQ eating behaviour categories, sub-categories and sub-groups can significantly vary between ethnicities and body composition groups. Tailored interventions to promote Restraint 2 (particularly Flexible Restraint) and counteract Disinhibition (particularly Habitual Disinhibition and Emotional Disinhibition), Hunger (particularly External Hunger), Low Restraint High Disinhibition and High Hunger High Disinhibition could enhance eating behaviour and dietary intake and help optimise weight management in young New Zealand women. Key words: Eating behaviour, body composition profiles, New Zealand women 3 Acknowledgements There are many people I would like to acknowledge that have enabled me to complete this thesis. Firstly, thank you to the women who participated in the EXPLORE study. There would be no results to examine without the generous donation of your time. Secondly, thank you to wonderful EXPLORE team (Rozanne Kruger, Pamela Von Hurst, Cathryn Conlon, Kathryn Beck, Maralize Richter, Sarah Philipsen, Owen Mudridge, PC Tong, Wendy O’Brien, Shakeela Jayasinghe, Richard Swift, Andrea Fenner, Adrianna Hepbrun, Ridvan Firestone, Welma Stonehouse and Lily George, Sara Bodel, Maria Casale, Alexandra Lawn and Jenna Schrijvers) who worked tirelessly on the study design, recruitment, screening, data collection and data processing. I do not take for granted the amount of work that went into the data set that I was provided with. Thank you to my supervisors Rozanne Kruger and Marilize Richter for the countless hours you have spent reviewing my work. Your dedication and support has been outstanding and it has been great working with you both. Thank you to my parents (Alison and David), sister (Rebecca) and boyfriend (Aaron) for your unconditional love, patience, and encouragement throughout my Masters. You have been the most incredible support system in your own ways, and I could not have gotten through any of this without you four. Also, thank you to my cat Heidi who sat with me nearly every single day, and kept me company, while I wrote this. To Beatrice Drury, we started our Massey journey together as teenagers in 2013. Thank you for your friendship and being there for me every step of the way. Finally, thank you to all of my wonderful friends who have been exceptionally understanding and supportive during my Masters. You all inspire me and I am truly grateful each and every one of you. 4 Table of Contents Abstract .................................................................................................................................................. 1 Acknowledgements ................................................................................................................................ 3 List of Tables ........................................................................................................................................... 6 List of Figures .......................................................................................................................................... 7 List of Appendices .................................................................................................................................. 7 List of Abbreviations .............................................................................................................................. 7 Chapter 1 .............................................................................................................................................. 10 Introduction .......................................................................................................................................... 10 1.1 Background ........................................................................................................................... 10 1.2 Justification and statement of the research problem .......................................................... 12 1.3 Purpose of the research study .............................................................................................. 14 1.3.1 Aim ................................................................................................................................ 15 1.3.2 Objectives ...................................................................................................................... 15 1.3.3 Hypothesis ..................................................................................................................... 15 1.4 Structure of the thesis .......................................................................................................... 16 1.5 Researchers contribution ...................................................................................................... 17 Chapter 2 .............................................................................................................................................. 18 Literature review .................................................................................................................................. 18 2.1 Obesity .................................................................................................................................. 18 2.2 Measuring body composition ............................................................................................... 21 2.3 Measuring eating behaviour ................................................................................................. 29 2.4 The relationship between eating behaviour, body composition, dietary intake and ethnicity 36 2.4.1 Restraint ........................................................................................................................ 38 2.4.2 Disinhibition .................................................................................................................. 41 2.4.3 Hunger ........................................................................................................................... 46 2.4.4 Sub-groups of Restraint, Disinhibition and Hunger ...................................................... 49 2.5 Conclusion ............................................................................................................................. 50 Chapter 3 .............................................................................................................................................. 52 Research Study Manuscript ................................................................................................................. 52 Abstract ............................................................................................................................................. 52 3.1 Introduction .......................................................................................................................... 53 3.2 Materials and methods ......................................................................................................... 54 3.2.1 EXPLORE Study design................................................................................................... 54 3.2.2 Study participants and screening procedures .............................................................. 54 5 3.2.3 Measures ............................................................................................................................ 55 3.2.4 Statistical analysis ......................................................................................................... 58 3.3 Results ................................................................................................................................... 59 3.3.1 Participant characteristics in relation to ethnicity and BCP.......................................... 59 3.3.2 TFEQ categories and sub-categories influence on body mass index and body fat percentage .................................................................................................................................... 65 3.3.3 Sub-groups of Restraint and Disinhibition .................................................................... 68 3.3.4 Sub-groups of Hunger and Disinhibition ....................................................................... 70 3.4 Discussion .................................................................................................................................... 74 3.4.1 Restraint ........................................................................................................................ 74 3.4.2 Disinhibition .................................................................................................................. 76 3.4.3 Hunger ........................................................................................................................... 78 3.4.4 Sub-groups of Restraint and Disinhibition ................................................................... 80 3.4.5 Sub-groups of Hunger and Disinhibition ...................................................................... 80 3.4.6 Recommendations, strengths and weaknesses ........................................................... 81 3.5 Conclusion ................................................................................................................................... 82 Chapter 4 .............................................................................................................................................. 83 Conclusions and Recommendations .................................................................................................... 83 4.1 Overview ............................................................................................................................... 83 4.2 Aims and objectives .............................................................................................................. 83 4.3 Strengths and weaknesses of the study ............................................................................... 88 4.4 Recommendations ................................................................................................................ 89 4.4.1 Recommendations for improving eating behaviour ..................................................... 89 4.4.2 Recommendations for future research ......................................................................... 91 References ............................................................................................................................................ 93 Appendix ............................................................................................................................................. 103 6 List of Tables Table 1.1 Researcher’s contributions to the thesis .............................................................................. 17 Table 2.1 Body mass index categories and the associated risks of morbidity (World Health Organisation, 2017)............................................................................................................................... 18 Table 2.2 The prevalence of overweight and obesity in New Zealand women, in relation to age and ethnicities (Ministry of Health, 2018a). ................................................................................................ 20 Table 2.3 The purpose, strengths and weaknesses of laboratory-based body composition assessments (Lee and Nieman, 2007, Gibson, 2005)............................................................................ 22 Table 2.4 The purpose, strengths and weaknesses of manual anthropometric assessment methods of body composition (Gibson, 2005, Lee and Nieman, 2007). .................................................................. 25 Table 2.5 Body fat percentage categories, for women > 18 years, in relation to health (Shuster et al., 2012). .................................................................................................................................................... 27 Table 2.6 Body composition profiles and their associated body mass indices and body fat percentages (Kruger et al., 2015). ........................................................................................................ 28 Table 2.7 Metabolic biomarkers and measurements, across different body composition profiles, in young women (Oliveros et al., 2014). ................................................................................................... 28 Table 2.8 Dietary behaviour assessment methods used in epidemiological studies (Hunot et al., 2016, Framson et al., 2009, Clementi et al., 2017, James et al., 2017, Schembre et al., 2009, Schembre and Geller, 2011, Kliemann et al., 2016, Van Strein et al., 1986, Gormally et al., 1982, Herman and Mack, 1975, Pudel et al., 1975)........................................................................................ 30 Table 2.9 A summary of the Three Factor Eating Questionnaire categories and sub-categories (Bond et al., 2001, Westenhoefer, 1991). ....................................................................................................... 34 Table 2.10 Studies investigating the relationship between Restraint and body composition in normal weight, overweight and obese adults. .................................................................................................. 39 Table 2.11 Studies investigating the relationship between Disinhibition and body composition in normal weight, overweight and obese adults. ..................................................................................... 42 Table 2.12 Studies investigating the relationship between Hunger and body composition in normal weight, overweight and obese adults ................................................................................................... 47 Table 3.1 Participant characteristics in terms of demographic, anthropometric and body composition data. ...................................................................................................................................................... 60 Table 3.2 Participant characteristics in terms of dietary intake and TFEQ scores. .............................. 63 Table 3.3 Linear regression for Three Factor Eating Questionnaire main categories correlation to body mass index and body fat percentage. .......................................................................................... 65 Table 3.4 Linear regression for Three Factor Eating Questionnaire sub-categories correlation to body mass index and body fat percentage. ................................................................................................... 66 Table 3.5 Sub-groups of Restraint and Disinhibition in relation to participant characteristics. .......... 69 Table 3.6 Sub-groups of Hunger and Disinhibition in relation to participant characteristics. ............. 73 Table 4.1 Recommendations for improving eating behaviour in relation to ethnicity and body composition profiles ............................................................................................................................. 90 7 List of Figures Figure 2.1 Potential complications and diseases associated with increased adiposity (Rochester Medical Weight Loss Center, 2018). ..................................................................................................... 19 Figure 3.1 Flow diagram of the EXPLORE sub-study participants, procedures and measures ............. 57 Figure 3.2 Sub-groups of Restraint and Disinhibition in relation to body composition profiles. ......... 68 Figure 3.3 Sub-groups of Hunger and Disinhibition in relation to ethnicity. ........................................ 71 Figure 3.4 Sub-groups of Hunger and Disinhibition in relation to body composition profiles. ............ 72 List of Appendices Appendix A. Participant personal health, demographics and screening questionnaire .................... 103 Appendix B. New Zealand Women’s Food Frequency Questionnaire ............................................... 107 Appendix C. Three Factor Eating Questionnaire ................................................................................ 137 Appendix D Correlations between air displacement plethysmography and dual x-ray absorptiometry for fat mass and body mass percentage ............................................................................................. 146 Appendix E Scatter plot of air displacement plethysmography and dual x-ray absorptiometry fat mass for women with a normal body mass index, in relation to ethnicity. ....................................... 146 Appendix F Scatter plot of air displacement plethysmography and dual x-ray absorptiometry fat mass for women with a high body mass index, in relation to ethnicity. ............................................ 147 Appendix G Scatter plot of air displacement plethysmography and dual x-ray absorptiometry body fat percentage for women with a normal body mass index, in relation to ethnicity. ........................ 148 Appendix H Scatter plot of air displacement plethysmography and dual x-ray absorptiometry body fat percentage for women with a high body mass index, in relation to ethnicity. ............................. 149 Appendix I Linear Regression for Three Factor Eating Questionnaire main categories correlation to body mass index and body fat percentage ......................................................................................... 149 Appendix J Linear Regression for Three Factor Eating Questionnaire sub-categories correlation to body mass index and body fat percentage ......................................................................................... 151 Appendix K.1 Sub-groups of Restraint and Disinhibition in relation to ethnicity .............................. 153 Appendix L.2 Sub-groups of Restraint and Disinhibition in relation to demographic information ... 153 Appendix M Sub-groups of Hunger and Disinhibition in relation to demographic information ....... 154 List of Abbreviations ADP Air displacement plethysmography AEBQ Adult Eating Behaviour Questionnaire AT Adipose tissue 8 BCP Body composition profile BD Body density BF Body fat BF % Body fat percentage BIA Bioelectrical impedance analysis BMD Bone mineral density BMI Body mass index BV Body volume CT Computerised tomography DEBQ Dutch Eating Behaviour Questionnaire DXA Dual x-ray absorptiometry EAT Eating Attitude Test EDI Eating Disorder Inventory EXPLORE Examining Predictors Linking Obesity Related Elements FFM Fat-free mass FFQ Food Frequency Questionnaire FPS Food Pleasure Scale G Gram HC Hip circumference HDL-C High density lipoprotein cholesterol IES Intuitive Eating Scale IL-6 Inflammatory marker 6 KG Kilogram LBM Lean body mass LDL-C Low density lipoprotein cholesterol M Metre MEQ Mindful Eating Questionnaire Mrem Millirem MRI Magnetic resonance imagine N Number NZ New Zealand 9 NZE New Zealand European NZWFFQ New Zealand Women’s Food Frequency Questionnaire OGTT Oral glucose tolerance test PET Positron emission tomography PSS Perceived Stress Scale rEI Reported energy intake RMR Resting metabolic rate SAT Sub-cutaneous adipose tissue SEIC Satter Eating Competency Inventory SREBQ Self-Regulation Eating Behaviour Questionnaire STAI State Trait Anxiety Inventory TAC Tissue time activity curves TBW Total body water TEE Total energy expenditure TEF Thermic effect of food TFEQ Three Factor Eating Questionnaire VAS Visual Analogue Scale WC Waist circumference WHR Waist to hip ratio WREQ Weight Related Eating Questionnaire WTHR Waist to height ratio YFAS Yale Food Addiction Scale