Journal of the Academy of Nutrition and Dietetics - Articles in Press

Intensive Medical Nutrition Therapy: Methods to Improve Nutrition Provision in the Critical Care Setting - Corrected Proof

2012-05-14

Abstract: Patients requiring mechanical ventilation in an intensive care unit commonly fail to attain enteral nutrition (EN) infusion goals. We conducted a cohort study to quantify and compare the percentage of energy and protein received between standard care (n=24) and intensive medical nutrition therapy (MNT) (n=25) participants; to assess the percentage of energy and protein received varied by nutritional status, and to identify barriers to EN provision. Intensive MNT entailed providing energy at 150% of estimated needs, using only 2.0 kcal/cc enteral formula and 24-hour infusions. Estimated energy and protein needs were calculated using 30 kcal/kg and 1.2 g protein/kg actual or obesity-adjusted admission body weight. Subjective global assessment was completed to ascertain admission intensive care unit nutritional status. Descriptive statistics and survival analyses were conducted to examine time until attaining 100% of feeding targets. Patients had similar estimated energy and protein needs, and 51% were admitted with both respiratory failure and classified as normally nourished (n=25/49). Intensive MNT recipients achieved a greater percentage of daily estimated energy and protein needs than standard care recipients (1,198±493 vs 475±480 kcal, respectively, P<0.0001; and 53±25 vs 29±32 g, respectively, P=0.007) despite longer intensive care unit stays. Cox proportional hazards models showed that intensive MNT patients were 6.5 (95% confidence interval 2.1 to 29.0) and 3.6 (95% confidence interval 1.2 to 15.9) times more likely to achieve 100% of estimated energy and protein needs, respectively, controlling for confounders. Malnourished patients (n=13) received significantly less energy (P=0.003) and protein (P=0.004) compared with normally nourished (n=11) patients receiving standard care. Nutritional status did not affect feeding intakes in the intensive MNT group. Clinical management, lack of physician orders, and gastrointestinal issues involving ileus, gastrointestinal hemorrhage, and EN delivery were the most frequent clinical impediments to EN provision. It was concluded that intensive MNT could achieve higher volumes of EN infusion, regardless of nutritional status. Future studies are needed to advance this methodology and to assess its influence on outcomes.

Absorption of Folic Acid from a Softgel Capsule Compared to a Standard Tablet - Corrected Proof

2012-05-14

Abstract: Consumption of 400 μg folic acid per day from fortified foods and/or supplements, plus food folate from a varied diet is recommended for women of childbearing potential to reduce the risk for neural tube defects during fetal development. This randomized crossover study was designed to evaluate the bioavailability of folic acid from a multivitamin softgel capsule vs a folic acid tablet in 16 premenopausal women (18 to 45 years of age). Participants were randomly assigned to receive a single dose of ∼1,000 μg folic acid in two tablets or ∼1,000 μg folic acid in a multivitamin softgel capsule, and then crossed over to receive the other study product ∼1 week later. Products were administered with a low-folate breakfast. Blood samples were collected predose (0 hour) and 1, 2, 3, 4, 6, and 8 hours post-dose for serum folate analysis. Repeated measures analysis of variance was used to compare responses between treatments. Data from the two sequence groups (n=8 per sequence) were pooled. Mean serum folate total and net incremental areas under the curve (AUC0-8 hours) were not significantly different between tablets and softgel capsule (AUC0-8 hours 214.9±11.2 hours×ng/mL [487±25.4 hours×nmol/L] and 191.6±13.3 hours×ng/mL [434.2±30.1 hours×nmol/L]; net incremental AUC0-8 hours 117.3±8.5 hours×ng/mL [265.8±19.3 hours×nmol/L] and 105.8±12.5 hours×ng/mL [239.7±28.3 hours×nmol/L], respectively), nor was maximum folate concentration (45.1±2.5 ng/mL [102.2±5.7 nmol/L] and 42.5±3.8 ng/mL [96.3±8.6 nmol/L], respectively). Time to peak folate concentration was significantly (P<0.001) delayed for the softgel capsule vs tablet (3.9±0.3 vs 1.7±0.2 hours, respectively). In conclusion, apparent bioavailability of folic acid was similar for the folic acid tablets and a multivitamin softgel capsule.

Biomarker and Dietary Validation of a Canadian Food Frequency Questionnaire to Measure Eicosapentaenoic and Docosahexaenoic Acid Intakes from Whole Food, Functional Food, and Nutraceutical Sources - Corrected Proof

Ashley C. Patterson, Ryan C. Hogg, Diane M. Kishi, Ken D. Stark — 2012-05-14

Abstract: Background: Canadian dietary sources of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) include marine and non-marine whole foods, functional foods, and nutraceuticals. Objective/design: In the present study, these sources were incorporated into a nutrient-specific, semi-quantitative food frequency questionnaire (FFQ) and the ability to measure the EPA and DHA intakes of Canadian adults was assessed. Specifically, the EPA and DHA intakes estimated by FFQ of 78 men and women, 20 to 60 years of age, were compared with EPA and DHA measurements from 3-day food records and measures of EPA and DHA in fasting whole blood. Results: Mean (±standard deviation) and median intakes of EPA+DHA were 0.34±0.34 and 0.21 g/day by FFQ and 0.47±0.71 and 0.13 g/day by food record, with no significant differences between mean intakes (P=0.93). The FFQ provided higher estimates than the food record at low intakes of EPA and DHA and lower estimates at high intakes based on Bland-Altman plots. The FFQ was moderately correlated with food record (r=0.31 to 0.49) and with blood biomarker measures of EPA and DHA (r=0.31 to 0.51). Agreement analysis revealed that 42% of participants were classified in the same and 77% into same or adjacent quartile when EPA and DHA intake was assessed by food record and by FFQ. Similar quartile agreement was found for EPA and DHA intakes by FFQ with blood biomarker EPA and DHA. The range of the validity coefficients, calculated using the method of triads, was 0.43 to 0.71 for FFQ measurement of EPA+DHA. Conclusions: The FFQ is an adequate tool for estimating usual EPA and DHA intakes and ranking Canadian adults by their intakes.

The Effects of an Energy Density Prescription on Diet Quality and Weight Loss: A Pilot Randomized Controlled Trial - Corrected Proof

2012-05-10

Abstract: Dietary goals specific for lowering energy density (ED) may promote a nutrient-dense diet and weight loss. This pilot study examined the effects of ED-based diet prescriptions on diet quality and weight loss during a 3-month behavior-based obesity intervention conducted in a research setting. Forty-four adults with overweight/obesity (age 52.1±7.6 years, body mass index [BMI; calculated as kg/m] 34.8±4.8, 81.8% women, and 93.2% white) were recruited between December 2009 and March 2010 and randomly assigned to: Low ED (consume ≥10 foods ≤1.0 kcal/g dietary ED and ≤2 foods ≥3.0 kcal/g dietary ED per day (n=15); Low-Energy, Low-Fat (1,200 to 1,500 kcal/day, ≤30% energy from fat (n=15); or Low-ED, Low-Energy, Low-Fat (n=14). Participants received 12 weekly group sessions led by a research interventionist. Dietary intake (measured by 3-day food records), self-reported physical activity, and weight were measured at baseline and 3 months. Intent-to-treat analyses showed all conditions reduced dietary ED and energy intake (P<0.001). Low-ED and Low-ED, Low-Energy, Low-Fat interventions increased fruit consumption (P<0.05). All conditions increased self-reported physical activity (P<0.001), with no difference between conditions. Although participants in all conditions lost weight (P<0.001), those in the Low-ED condition lost more (P<0.05) than those in the Low-ED, Low-Energy, Low-Fat condition (Low-ED −20.5±7.0 lb, Low-Energy, Low-Fat −16.9±10.1 lb, and Low-ED, Low-Energy, Low-Fat −12.5± 6.5 lb). A diet prescription that lowered ED increased fruit intake and enhanced weight loss compared with other weight loss prescriptions.

Factors that Influence Research Involvement among Registered Dietitians Working as University Faculty: A Qualitative Interview Study - Corrected Proof

Kevin Whelan, Sharon Markless — 2012-05-09

Abstract: Research involvement is fundamental to the practice of dietetics and dietetics faculty should be ideally placed to contribute to this. Studies have identified a range of factors that influence faculty research involvement, many of which are relevant to registered dietitians. The aim of this study was to explore the factors that influence research involvement among dietetics faculty using qualitative semi-structured interviews. Thirteen dietetics faculty members were purposively sampled and participated in semi-structured interviews. Interviews were recorded, transcribed, and analyzed thematically by the same researcher. Eight themes emerged that influenced research involvement among dietetics faculty and these related to the following distinct factors: institution and department (ie, size and structure, research philosophy, being established in research); activities (ie, faculty roles, time and teaching, research and grants); and individuals (ie, significant others, self). There was complex interaction between each of the eight themes. Many of the themes were very specific to the dietetics context, including being a small discipline, being in newer universities without established research portfolios, having greater teaching responsibilities, and the availability of grants in areas related to nutrition. The factors influencing research involvement among dietetics faculty members are complex and interact; therefore, solutions to overcome these barriers will need to account for this. These findings provide understanding that can contribute to this endeavor.

Estrone and Estrone Sulfate Concentrations in Milk and Milk Fractions - Corrected Proof

Ann L. Macrina, Troy L. Ott, Robert F. Roberts, Ronald S. Kensinger — 2012-05-07

Abstract: Dairy products naturally contain estrogens, and some consumer groups contend these estrogens cause adverse health effects. The objectives of this research were to characterize estrone (E1) and estrone sulfate (E1S) concentrations in milk from a large number of individual cows, in skim and fat fractions of milk, and in retail milk to provide food and nutrition practitioners with information to estimate potential consumption. Milk was from Holstein cows. Data are presented as means and standard deviations. Analysis of variance was used to determine differences in E1 and E1S content of whole milk and its skim and fat fractions. Mean E1 and E1S concentrations (n=173 cows) were 7.0±12.7 and 46.7±62.1 pg/mL (25.89±46.96 and 172.74±229.71 pmol/L), respectively. Analysis of milk fractions (n=50 samples) demonstrated that 55% of E1 and 14% of E1S were associated with the fat fraction with the remainder associated with the skim fraction. Concentrations of E1 and E1S in pasteurized-homogenized whole milk (n=8) averaged 10.3±0.6 and 85.9±7.3 pg/mL (38.09±2.22 and 317.74±27.00 pmol/L), respectively. Production rates of E1 plus estradiol in human beings range from 54,000 to 630,000 ng/day. US Food and Drug administration guidelines state that no physiologic effects occur when consumption is ≤1% of the endogenous quantities produced by the segment of the population with the lowest daily production. This threshold value for intake would be 540 ng/day. Estimated total E1 intake from three servings of whole milk was 68 ng/day, which represents 0.01% to 0.1% of daily production rates in human beings. These findings support levels below the current guidelines for safe consumption.

Inadequate Dietary Intake in Patients with Thalassemia - Corrected Proof

2012-05-02

Abstract: Background: Patients with thalassemia have low circulating levels of many nutrients, but the contribution of dietary intake has not been assessed. Objective: Our objective was to assess dietary intake in a large contemporary sample of subjects with thalassemia. Design: A prospective, longitudinal cohort study using a validated food frequency questionnaire was conducted. Participants/setting: Two hundred and twenty-one subjects (19.7±11.3 years, 106 were female) were categorized into the following age groups: young children (3 to 7.9 years), older children/adolescents (8 to 18.9 years), and adults (19 years or older); 78.8% had β-thalassemia and 90% were chronically transfused. This study took place at 10 hematology outpatient clinics in the United States and Canada. Main outcome measures: We conducted a comparison of intake with US Dietary Reference Intakes and correlated dietary intake of vitamin D with serum 25-OH vitamin D and dietary iron with total body iron stores. Statistical analyses performed: Intake was defined as inadequate if it was less than the estimated average requirement. χ2, Fisher's exact, and Student's t test were used to compare intake between age categories and logistic regression analysis to test the relationship between intake and outcomes, controlling for age, sex, and race. Results: More than 30% of subjects consumed inadequate levels of vitamin A, D, E, K, folate, calcium, and magnesium. The only nutrients for which >90% of subjects consumed adequate amounts were riboflavin, vitamin B-12, and selenium. Dietary inadequacy increased with increasing age group (P<0.01) for vitamins A, C, E, B-6, folate, thiamin, calcium, magnesium, and zinc. More than half of the sample took additional supplements of calcium and vitamin D, although circulating levels of 25-OH vitamin D remained insufficient in 61% of subjects. Dietary iron intake was not related to total body iron stores. Conclusions: Subjects with thalassemia have reduced intake of many key nutrients. These preliminary findings of dietary inadequacy are concerning and support the need for nutritional monitoring to determine which subjects are at greatest risk for nutritional deficiency. Future research should focus on the effect of dietary quality and nutritional status on health outcomes in thalassemia.

Changes in Diet Behavior when Adults Become Parents - Corrected Proof

2012-05-02

Abstract: Background: Cross-sectional studies suggest that parents eat more saturated fat than nonparents. Few studies exist on other dietary factors or using longitudinal data. Objective: To compare change in daily dietary intake of selected foods and nutrients across 7 years between adults who have children enter the home and those who do not. Design: Analysis of data from the Coronary Artery Risk Development in Young Adults cohort study. Dietary intake was assessed by the diet history questionnaire used in that study. The main dependent variables were change from baseline (1985-1986) to Year 7 (1992-1993) for intake of percent saturated fat, energy, daily servings of fruits and vegetables and sugar-sweetened beverages, and frequency of fast-food intake. The primary independent variable was whether or not participants had children in their home by Year 7. Participants: Two thousand five hundred sixty-three black and white adults who did not have children at baseline from four urban centers. Statistical analyses performed: Linear regression adjusting for baseline demographics, energy intake, physical activity, and smoking status. Results: Parents were more likely to be women, full-time workers, married, and older. Diet did not differ at baseline. Seven-year change in diet for parents and nonparents did not differ for fruit and vegetable, sugar-sweetened beverages, or fast food. Percent saturated fat decreased among both groups but parents showed a smaller decrease in percent saturated fat (1.59 vs 2.10; P<0.001). Compared with nonparents, parents increased energy intake by 79 kcal/day (P=0.058), but this difference did not reach statistical significance. Conclusions: Parenthood does not have unfavorable effects on parents' diets, but neither does it lead to significant improvements. In fact, parents lag behind their childless counterparts in decreasing intake of saturated fat and overall diets remain poor. Nutrition education programs and food and nutrition practitioners should develop strategies to support and motivate healthy eating habits in parents.

Development, Content Validity, and Piloting of an Instrument Designed to Measure Managers' Attitude toward Workplace Breastfeeding Support - Corrected Proof

Tan Chow, Edward W. Wolfe, Beth H. Olson — 2012-04-30

Abstract: Manager attitude is influential in female employees' perceptions of workplace breastfeeding support. Currently, no instrument is available to assess manager attitude toward supporting women who wish to combine breastfeeding with work. We developed and piloted an instrument to measure manager attitudes toward workplace breastfeeding support entitled the “Managers' Attitude Toward Breastfeeding Support Questionnaire,” an instrument that measures four constructs using 60 items that are rated agree/disagree on a 4-point Likert rating scale. We established the content validity of the Managers' Attitude Toward Breastfeeding Support Questionnaire measures through expert content review (n=22), expert assessment of item fit (n=11), and cognitive interviews (n=8). Data were collected from a purposive sample of 185 front-line managers who had experience supervising female employees, and responses were scaled using the Multidimensional Random Coefficients Multinomial Logit Model. Dimensionality analyses supported the proposed four-construct model. Reliability ranged from 0.75 to 0.86, and correlations between the constructs were moderately strong (0.47 to 0.71). Four items in two constructs exhibited model-to-data misfit and/or a low score-measure correlation. One item was revised and the other three items were retained in the Managers' Attitude Toward Breastfeeding Support Questionnaire. Findings of this study suggest that the Managers' Attitude Toward Breastfeeding Support Questionnaire measures are reliable and valid indicators of manager attitude toward workplace breastfeeding support, and future research should be conducted to establish external validity. The Managers' Attitude Toward Breastfeeding Support Questionnaire could be used to collect data in a standardized manner within and across companies to measure and compare manager attitudes toward supporting breastfeeding. Organizations can subsequently develop targeted strategies to improve support for breastfeeding employees through efforts influencing managerial attitude.

LA Sprouts: A Garden-Based Nutrition Intervention Pilot Program Influences Motivation and Preferences for Fruits and Vegetables in Latino Youth - Corrected Proof

2012-04-20

Abstract: Garden-based approaches to nutrition education may be effective for improving nutrition habits in adolescents. A quasi-experimental, garden-based intervention for Latino youth (LA Sprouts) was piloted and assessed for its influence on behavior associated with dietary intake and psychosocial factors. Study participants were 104 predominately Latino fourth and fifth grade students in Los Angeles (mean age, 9.8±0.7 years; n=70 control subjects, n=34 LA Sprouts participants); more than half (n=61, 59.8%) were overweight or obese (body mass index ≥85th percentile). LA Sprouts participants received an intervention of weekly 90-minute culturally tailored, interactive classes for 12 consecutive weeks at a community garden during the spring of 2010; control participants received an abbreviated delayed intervention. Questionnaire data were obtained before and after the intervention. Compared with control subjects, LA Sprouts participants had an increased preference for vegetables overall, increased preferences for three target fruits and vegetables, as well as improved perceptions that “vegetables from the garden taste better than vegetables from the store.” In the overweight/obese subgroup (n=61), LA Sprouts participants had a 16% greater increase in their preference for vegetables compared with control subjects (P=0.009). Results from this pilot study suggest that a cooking, nutrition, and gardening after-school program in a garden-based setting can improve attitudes and preferences for fruits and vegetables in Latino youth, which may lead to improved nutritional habits and dietary intake and reduced health disparities.

Effect of a Grocery Store Intervention on Sales of Nutritious Foods to Youth and Their Families - Corrected Proof

Ashley S. Holmes, Paul A. Estabrooks, George C. Davis, Elena L. Serrano — 2012-04-18

Abstract: Grocery stores represent a unique opportunity to initiate nutrition interventions. The aim of this study was to develop and evaluate a 12-week, child-focused intervention at one grocery store. An observational uninterrupted time-series design was implemented from May to September 2009. The Healthy Kids campaign consisted of a point-of-purchase kiosk featuring fruits, vegetables, and healthy snacks as well as a sampling pod comprised of food items from the kiosk. Data collection included changes in sales for featured products; observations of customers at the kiosk/intervention; and brief questionnaires for customers who engaged with the kiosk. Descriptive statistics were computed for questionnaire responses and observational data. Correlational analyses were conducted to identify potential predictors of engagement. Sales data were analyzed using analysis of variance. Results showed an overall increase in the proportion of sales of the featured items to total store sales during the intervention period (P<0.05). Individual items that increased sales during the intervention period included whole-wheat bagels, bananas, radishes, honey, sunflower seeds, baked tortilla chips, and almond butter (P<0.05). Almost two thirds (61.7%) of the patrons interviewed noticed the Healthy Kids kiosk, with about one quarter (28.7%) indicating that they purchased at least one item. Fifty-eight percent reported that the kiosk encouraged them to buy healthier foods.

Long-Term Impact of a Chef on School Lunch Consumption: Findings from a 2-Year Pilot Study in Boston Middle Schools - Corrected Proof

2012-04-16

Abstract: School cafeterias can play an important role in providing healthy meals. Although schools participating in the National School Lunch Program are required to meet minimum program standards, advocates recommend that innovations be sought to enhance menu dietary quality. This study evaluated the Chef Initiative, a 2-year pilot study in two Boston middle schools, designed to increase the availability and consumption of healthier school foods. Between 2007 and 2009, a professional chef trained cafeteria staff to prepare healthier school lunches (ie, more whole grains, fresh/frozen fruits and vegetables, and less sugar, salt, saturated fats, and trans fats). Meal nutrient compositions were monitored from 2007 to 2009, and a plate waste study conducted in the spring of 2009 compared food selection and consumption patterns among students at Chef Initiative schools, with students receiving standard school lunches at two matched control schools. Paired t tests and descriptive statistics were used to examine differences in menus and mixed-model analysis of variance was used to analyze differences in students' food selection and consumption between Chef Initiative and control schools. Overall, the Chef Initiative schools provided healthier lunches and the percent of foods consumed at Chef Initiative and control schools were similar (61.6% vs 57.3%; P=0.63). Of the areas targeted, there was greater whole-grain selection and vegetable consumption; 51% more students selected whole grains (P=0.02) and students consumed 0.36 more vegetable servings/day (P=0.01) at Chef Initiative schools. The potential of chefs collaborating with cafeteria staff to improve the availability, selection, and consumption of healthier meals is promising.

The Extent to Which School District Competitive Food and Beverage Policies Align with the 2010 Dietary Guidelines for Americans: Implications for Federal Regulations - Corrected Proof

Linda M. Schneider, Rebecca M. Schermbeck, Jamie F. Chriqui, Frank J. Chaloupka — 2012-04-16

Abstract: The Healthy, Hunger-Free Kids Act of 2010 authorized the Secretary of the US Department of Agriculture to establish science-based nutrition standards for competitive foods and beverages sold in school that are, at a minimum, aligned with the 2010 Dietary Guidelines for Americans (DGA), while still providing districts with discretion in regulating the competitive food and beverage environment. The objective of this study was to examine the extent to which district competitive food and beverage policies had specific and required limits aligned with 2010 DGA recommendations, and to inform US Department of Agriculture efforts as they develop competitive food and beverage standards. Competitive food and beverage policies were compiled for the 2009-2010 school year from a nationally representative sample of 622 districts. Each policy was double-coded for compliance with selected 2010 DGA recommendations (ie, restrictions on sugars, fats, trans fats, and sodium in foods and restrictions on regular soda, other sugar-sweetened beverages, and fat content of milk). Descriptive statistics were computed, clustered to account for the sample design, and weighted to account for districts nationwide. District nutrition policies were strongest for elementary schools. Nationwide, <5% of districts met or exceeded all of the previously mentioned nutrient requirements examined. Fat and sugar content of foods and soda availability were more commonly addressed. Areas that require attention include stronger nutrition standards at the secondary level, limits on trans fats, sodium, sugar-sweetened beverages other than soda, and fat content of milk, and greater availability of produce and whole grains at all sale locations.