Barbara Bruemmer

An Introduction to Qualitative Research for Food and Nutrition Professionals

The purpose of this article is to define qualitative research, explain its design, explore its congruence with quantitative research, and provide examples of its applications in dietetics. Also, methods to ensure validity, reliability, and relevance are addressed. Readers will gain increased knowledge about qualitative research and greater competency in evaluating this type of research. The hope is that food and nutrition professionals will be inspired to conduct and publish qualitative research, adding to the body of peer-reviewed dietetics-related qualitative publications. This type of research must be methodically planned and implemented with attention to validity, reliability, and relevance. This rigorous approach boosts the probability that the research will add to the scientific literature and qualify for publication.

Predictors of Oral Mucositis in Patients Receiving Hematopoietic Cell Transplants for Chronic Myelogenous Leukemia

PURPOSE Oral mucositis is a nearly universal and often severe complication following hematopoietic cell transplantation (HCT). The objective of this study was to evaluate factors predicting oral mucositis severity among 133 patients undergoing allogeneic HCT for chronic myelogenous leukemia. PATIENTS AND METHODS All patients were transplanted between 1992 and 1999, were >or= 18 years of age, received either cyclophosphamide/total-body irradiation (TBI) or busulfan/cyclophosphamide conditioning regimens, and received four doses of methotrexate for graft-versus-host disease prophylaxis post-transplant. Oral mucositis was measured by a trained examiner every 2 to 3 days using the Oral Mucositis Index (OMI). Multiple linear regression analysis was used to identify predictors of mean OMI during days 6 to 12, 1 to 18, and the maximum OMI score between days 1 to 18. RESULTS TBI containing conditioning regimens, body mass index >or= 25, and methylenetetrahydrofolate reductase 677 TT genotype were found to be predictive of higher mean OMI scores (P <.05). Pretransplant multivitamin supplement use was associated with lower mean OMI scores compared to those who did not use supplements. Smoking status, race, pretransplant treatment with interferon-alfa or hydroxyurea, and patient/donor ABO compatibility were not associated with mean OMI scores. CONCLUSION Patients who are scheduled to receive conditioning regimens containing TBI, have a pretransplant body mass index >or= 25, or carry the methylenetetrahydrofolate reductase 677 TT genotype should be considered at greater risk of developing oral mucositis following HCT. Future studies should investigate whether multivitamin supplementation before HCT could reduce mucositis severity.

Energy, saturated fat, and sodium were lower in entrées at chain restaurants at 18 months compared with 6 months following the implementation of mandatory menu labeling regulation in King County, Washington.

BACKGROUND Policies on menu labeling have been proposed as a method to improve the food environment. However, there is little information on the nutrient content of chain restaurant menu items and changes over time. OBJECTIVE To evaluate the energy, saturated fat, and sodium content of entrées 6 and 18 months post-implementation of restaurant menu labeling in King County of Washington State for items that were on the menu at both time periods, and across all items at 6 and 18 months and to compare energy content to recommendations provided by the 2005 Dietary Guidelines for Americans. SETTING Eligible restaurants included sit-down and quick-service chains (eg, burgers, pizza, sandwiches/subs, and Tex-Mex) subject to King County regulations with four or more establishments. One establishment per chain was audited at each time period. STATISTICAL ANALYSES Hypothesis one examined entrées that were on the menu at both time periods using a paired t test and hypothesis two compared quartiles at 6 months to the distribution at 18 months using a Mantel-Haentzel odds ratios and 95% CIs, and a Cochrane-Armitage test for trend. The content of entrées at 18 months was compared with one-third (assuming three meals per day) of the nutrient intake recommendations for adults provided by the 2005 Dietary Guidelines for Americans. RESULTS The audit included 37 eligible chains of 92 regulated chains. Energy contents were lower (all chains -41, sit down -73, and quick service -19; paired t tests P<0.0001) for entrées that were on the menu at both time periods. There was a significant trend across quartiles for a decrease in energy, saturated fat, and sodium for all entrées at sit-down chains only. At 18 months entrées not designated for children exceeded 56%, 77%, and 89% of the energy, saturated fat, and sodium guidelines, respectively. CONCLUSIONS Modest improvements in the nutrient content of sit-down and quick-service restaurant entrées occurred but overall levels for energy, saturated fat, and sodium are excessive.

A Double-Blind Randomized Trial Comparing Outpatient Parenteral Nutrition With Intravenous Hydration: Effect on Resumption of Oral Intake After Marrow Transplantation

BACKGROUND Outpatient parenteral nutrition (PN) is often given to marrow transplant recipients after high-dose chemoradiotherapy until the resumption of adequate oral intake; however, it may adversely prolong resumption or oral calorie intake by contributing to early satiety. METHODS A double-blind, randomized study compared standard PN (final concentration 25% dextrose, 5% amino acids) with a hydration solution (5% dextrose) during the first 28 days of outpatient treatment. Patients were eligible for the study if they were > or = 2 years of age, < 65 days posttransplant, had < 70% oral caloric intake at hospital discharge, and required < or = 10 U insulin/L PN. Solutions were provided until the patients oral intake met > or = 85% caloric requirements for 3 consecutive days. RESULTS Two hundred fifty-eight marrow transplant recipients (128, PN and 130, hydration solution) were studied. Age, donor type, and diagnoses were similar in the two groups. Time to resumption of > or = 85% oral caloric intake was 6 days sooner in the hydration group than in the PN group (median 10 vs 16 days, respectively; p = .049). When adjusting for sex, age, donor type, total body irradiation, previous oral intake, acute graft-versus-host disease, and prednisone therapy, the hydration group resumed oral intake sooner than the PN group (relative risk = 1.51; 95% confidence interval [CI] 1.04 to 2.19; p = .029). The percentage of weight change from pretransplant values, adjusted for the above covariates and the number of weeks of treatment, indicated that the hydration solution group lost weight (4.63%) compared with the PN group (1.27%) after 4 weeks of therapy (p = .004). Rates of hospital readmissions, relapse of malignancy, and survival did not differ between the two treatment groups. CONCLUSIONS We conclude that outpatient PN delays resumption of oral intake and that its replacement with hydration solution does not result in adverse patient outcome.

Fluid intake and the incidence of bladder cancer among middle-aged men and women in a three-county area of western Washington.

This population-based case-control study reports on the relationship between fluid intake and the incidence of bladder cancer among 262 bladder cancer cases from Western Washington and 405 controls identified through random-digit dialing Cases were identified from the Surveillance. Epidemiology, and End Results (SEER) registry and were diagnosed between January 1987 and June 1990. All eligible subjects were Caucasian 45- to 65-year-old residents of King, Pierce, or Snohomish counties and completed a structured telephone interview. Analyses were conducted by logistic regression with adjustment for age, county, and smoking (current, former, never). Among women there was a positive association between total fluid intake and the incidence of bladder cancer [p (trend = 0.02] and a moderate positive association between the use of decaffeinated coffee and the incidence of bladder cancer [p (trend) = 0.08]. Among men there was an inverse association between the consumption of regular soft drinks and the incidence of bladder cancer [p (trend) = 0.03]. No association was found between the incidence of bladder cancer and the intake of water, coffee, tea, diet soft drinks, alcohol, or liquids from tap for men or women. This study suggests that the intake of water and specific beverages is overall not associated with risks of bladder cancer. This study provides limited evidence of a positive association between total fluid intake and bladder cancer among women.

Impact of School District Sugar-Sweetened Beverage Policies on Student Beverage Exposure and Consumption in Middle Schools

PURPOSE To determine the associations between 1) exposure to sugar-sweetened beverages (SSB) in middle schools and student consumption of SSB during the school day; and 2) school district policies about SSB and exposure to SSB in schools. METHODS The strength of school district SSB policies was scored on three SSB policy indicators. Student SSB consumption at school was assessed by a self-administered Beverage and Snack Questionnaire. Exposure to SSB at school was defined as the number of vending slots and SSB venues as determined on-site at each school. Multivariate analysis considered the multilevel nature of the data. RESULTS Data from 9151 students in 64 middle schools in 28 districts were used in the analysis. With schools as the unit of analysis, the proportion of students who consumed any SSB at school ranged from 19.2% to 79.8%. SSB exposure was a significant predictor of SSB consumption (beta=.157, p < .001). SSB consumption was not significantly associated with the size of the school, the racial or ethnic composition of the schools students, or the proportion of students eligible for free and reduced price meals. District SSB policy scores ranged from 0 to 6 with a mean score of 3.25 (+/-2.15). District SSB policy was a significant predictor of SSB exposure (beta=-9.50, p < .0002). CONCLUSIONS School district SSB policies and exposure to SSB in middle schools are associated with student SSB consumption. Interventions to improve policies and their implementation may offer opportunities to improve the diets of adolescents.

Worksite Study Promoting Activity and Changes in Eating (PACE) : Design and Baseline Results

Objective: Based on previous worksite‐wide intervention studies and an ecological framework, we created a behavioral intervention program to maintain or reduce weight through healthy eating and physical activity. The design and evaluation plan of the group‐randomized trial and the recruitment of worksites are described. Preliminary results regarding the dietary and physical activity behaviors associated with BMI are discussed.

Methylenetetrahydrofolate reductase genotype affects risk of relapse after hematopoietic cell transplantation for chronic myelogenous leukemia

Purpose: Methylenetetrahydrofolate reductase (MTHFR) directs intracellular folate toward homocysteine metabolism and away from nucleotide synthesis. Two common MTHFR polymorphisms, C677T and A1298C, are associated with reduced enzyme activity. We evaluated the association of these polymorphisms with risk of relapse and bcr-abl mRNA transcript detection among 336 Caucasian patients who underwent allogeneic hematopoietic cell transplantation for chronic myelogenous leukemia. Experimental Design: Data on the transplant course and folate-related exposures were abstracted from medical records. MTHFR C677T and A1298C genotypes were determined using polymerase chain reaction/restriction fragment length polymorphism and TaqMan assays. Qualitative bcr-abl mRNA testing was conducted using a two-step reverse transcription-polymerase chain reaction assay. Cox regression analysis was used to assess the association between MTHFR genotypes and time to relapse and bcr-abl mRNA detection. Results: A statistically significant decreased risk of relapse was observed in patients with the variant A1298C genotype [1298AC, hazard ratio (HR) = 0.48 and 95% confidence interval (CI) = 0.26–0.88; 1298CC, HR = 0.28 and 95% CI = 0.09–0.84; P-trend < 0.01). For the joint C677T/A1298C genotype, variant genotypes were associated with a decreased risk of relapse when compared with the wild-type 677CC/1298AA genotype. This risk was lowest for the 677CC/1298CC genotype (HR, 0.23; 95% CI, 0.08–0.72). MTHFR genotypes were not associated with bcr-abl transcript detection. Conclusions: These findings suggest that individuals with the 677CC/1298AA genotype are at higher risk of relapse after hematopoietic cell transplantation and that the balance of intracellular folate metabolites available for nucleotide synthesis (regulated by the relative activity of the MTHFR enzyme) may affect the progression from bcr-abl positivity to clinical relapse.

Publishing Nutrition Research: Validity, Reliability, and Diagnostic Test Assessment in Nutrition-Related Research

This is the sixth in a series of monographs on research design and analysis. The purpose of this article is to describe and discuss several concepts related to the measurement of nutrition-related characteristics and outcomes, including validity, reliability, and diagnostic tests. The article reviews the methodologic issues related to capturing the various aspects of a given nutrition measures reliability, including test-retest, inter-item, and interobserver or inter-rater reliability. Similarly, it covers content validity, indicators of absolute vs relative validity, and internal vs external validity. With respect to diagnostic assessment, the article summarizes the concepts of sensitivity and specificity. The hope is that dietetics practitioners will be able to both use high-quality measures of nutrition concepts in their research and recognize these measures in research completed by others.

Nutrition-Labeling Regulation Impacts on Restaurant Environments

BACKGROUND Recent attempts to improve the healthfulness of away-from-home eating include regulations requiring restaurants to post nutrition information. The impact of such regulations on restaurant environments is unknown. PURPOSE To examine changes in restaurant environments from before to after nutrition-labeling regulation in a newly regulated county versus a nonregulated county. METHODS Using the Nutrition Environment Measures Survey-Restaurant version audit, environments within the same quick-service chain restaurants were evaluated in King County (regulated) before and 6 and 18 months after regulation enforcement and in Multnomah County (nonregulated) restaurants over a 6-month period. Data were collected in 2008-2010 and analyses conducted in 2011. RESULTS Overall availability of healthy options and facilitation of healthy eating did not increase differentially in King County versus Multnomah County restaurants aside from the substantial increase in onsite nutrition information posting in King County restaurants required by the new regulation. Barriers to healthful eating decreased in King County relative to Multnomah County restaurants, particularly in food-oriented establishments. King County restaurants demonstrated modest increases in signage that promotes healthy eating, although the frequency of such promotion remained low, and the availability of reduced portions decreased in these restaurants. The healthfulness of childrens menus improved modestly over time, but not differentially by county. CONCLUSIONS A restaurant nutrition-labeling regulation was accompanied by some, but not uniform, improvements in other aspects of restaurant environments in the regulated compared to the nonregulated county. Additional opportunities exist for improving the healthfulness of away-from-home eating beyond menu labeling.