Punam Ohri-Vachaspati

Can a Nutrition Intervention Improve Albumin Levels Among Hemodialysis Patients? A Pilot Study

OBJECTIVE To determine the effect of a tailored intervention on albumin levels among hemodialysis patients. DESIGN Randomized controlled trial. SETTING Eight freestanding chronic hemodialysis units in northeast Ohio. SUBJECTS Eighty-three randomly selected adult patients who had been on dialysis for at least 6 months and had a mean albumin <3.7 g/dL (bromcresol green method) or <3.4 g/dL (bromcresol purple method) for the last 3 months. To better elucidate the feasibility and outcomes of the intervention, we selected more intervention than control patients. INTERVENTION Dietitians of the 52 intervention patients determined whether any of the following potential barriers to adequate protein nutrition were present for each patient: (1) poor knowledge of protein-containing foods, (2) poor appetite, (3) needing help shopping or cooking, (4) low fluid intake, and (5) inadequate dialysis. Depending on the specific barriers present, the dietitians (1) educated patients on protein-containing foods, (2) recommended snacks for which patients had preserved appetite, (3) helped set up social supports, (4) provided recommendations on fluid intake, and/or (5) arranged for improved dialysis. Dietitians of the 31 control patients continued to provide usual care. MAIN OUTCOME MEASURES Change in albumin after 6 months, stratified as minimal change (less than.25 g/dL increase or decrease), moderate improvement (.25 to.49 g/dL increase), and large improvement (increase of .50 g/dL or more). To examine the role of inflammatory states, we also determined serum C-reactive protein levels at the beginning and end of the trial. RESULTS Among intervention patients, 29% had a minimal change in albumin, 44% had a moderate improvement, and 27% had a large improvement. Among control patients, 74% had a minimal change in albumin, 19% had a moderate improvement, and 6% had a large improvement (P <.001 for comparison of intervention and control subjects). About 60% of subjects had high baseline C-reactive protein levels (> 10 mg/L). However, there was little relationship between change in albumin and either baseline C-reactive protein levels or changes in C-reactive protein levels (P = .83). CONCLUSION A nutrition intervention tailored to patient-specific barriers resulted in improved albumin levels even among patients with high C-reactive protein levels. Further work is needed to refine and test this intervention on a larger sample.

Measuring food environments: a guide to available instruments.

Purpose. Food environments affect peoples food-related decisions, consumption, and health outcomes. This paper critiques instruments available for assessing food environments to help researchers, practitioners, and community organizations select those that best meet their needs, resources, and level of expertise. Gaps and recommendations for future instrument development are discussed. Method. Instruments were selected by reviewing the literature and contacting researchers and practitioners. Using the social-ecological model, the instruments were classified according to the type of food environments they assess. Each instrument is rated according to criteria for ease of use, detail, resources required, and psychometric testing. Results. Of the 48 instruments identified, only 39% were tested for validity or reliability. Observational tools were the largest category of instruments developed. Fifty-two percent of the instruments provide some level of technical assistance and 37% are considered appropriate for community members. Conclusion. Three distinct groups want to assess food environments: researchers, practitioners, and community organizations. These groups have different information needs and different capacities to undertake assessments. At this time there is a tradeoff between simplicity and low cost on the one hand, and detail and accuracy on the other. To choose the most suitable instrument, users should consider the pros and cons of each instrument and base their selection on purpose of their assessment, resources and expertise at hand, and validity, reliability, and ease of use of the instrument.

Classification bias in commercial business lists for retail food stores in the U.S.

BackgroundAspects of the food environment such as the availability of different types of food stores have recently emerged as key modifiable factors that may contribute to the increased prevalence of obesity. Given that many of these studies have derived their results based on secondary datasets and the relationship of food stores with individual weight outcomes has been reported to vary by store type, it is important to understand the extent to which often-used secondary data correctly classify food stores. We evaluated the classification bias of food stores in Dun & Bradstreet (D&B) and InfoUSA commercial business lists.MethodsWe performed a full census in 274 randomly selected census tracts in the Chicago metropolitan area and collected detailed store attributes inside stores for classification. Store attributes were compared by classification match status and store type. Systematic classification bias by census tract characteristics was assessed in multivariate regression.ResultsD&B had a higher classification match rate than InfoUSA for supermarkets and grocery stores, while InfoUSA was higher for convenience stores. Both lists were more likely to correctly classify large supermarkets, grocery stores, and convenience stores with more cash registers and different types of service counters (supermarkets and grocery stores only). The likelihood of a correct classification match for supermarkets and grocery stores did not vary systemically by tract characteristics whereas convenience stores were more likely to be misclassified in predominately Black tracts.ConclusionResearches can rely on classification of food stores in commercial datasets for supermarkets and grocery stores whereas classifications for convenience and specialty food stores are subject to some systematic bias by neighborhood racial/ethnic composition.

Effects of Serving High-Sugar Cereals on Children's Breakfast-Eating Behavior

OBJECTIVES: To test (1) whether children will consume low-sugar ready-to-eat (RTE) cereals and (2) the effects of serving high- versus low-sugar cereals on the consumption of cereal, refined sugar, fresh fruit, and milk. PARTICIPANTS AND METHODS: Using an experimental design, we randomly assigned children (n = 91) who were attending summer day camp to receive a breakfast that included either the choice of 1 of 3 high-sugar cereals (high-sugar condition) or low-sugar cereals (low-sugar condition), as well as low-fat milk, orange juice, bananas, strawberries, and sugar packets. Participants served themselves and completed a background questionnaire after eating. Researchers measured the amount and calories consumed of each food. RESULTS: In both conditions, children reported “liking” or “loving” the cereal they chose. Children in the low-sugar cereal condition consumed, on average, slightly more than 1 serving of cereal (35 g), whereas children in the high-sugar condition consumed significantly more (61 g) and almost twice the amount of refined sugar in total (24.4 vs 12.5 g). Milk and total calories consumed did not differ significantly between conditions, but children in the low-sugar condition were more likely to put fruit on their cereal (54% vs 8%) and consumed a greater portion of total calories from fresh fruit (20% vs 13%). CONCLUSIONS: Compared with serving low-sugar cereals, high-sugar cereals increase childrens total sugar consumption and reduce the overall nutritional quality of their breakfast. Children will consume low-sugar cereals when offered, and they provide a superior breakfast option.

Fresh Fruit and Vegetable Program Participation in Elementary Schools in the United States and Availability of Fruits and Vegetables in School Lunch Meals

Dietary intake among children in the United States falls short of national recommendations. Schools can play an important role in improving childrens preferences and food consumption patterns. The US Department of Agricultures Fresh Fruit and Vegetable Program (FFVP) aims to improve childrens nutrient intake patterns by offering fresh fruits and vegetables as snacks outside the reimbursable meals programs in elementary schools that serve large numbers of low-income children. Using a nationally representative sample of public elementary schools, this cross-sectional study investigated FFVP participation patterns among schools by demographic and school characteristics. Further, the study investigated the association between FFVP participation and availability of fresh fruits, salads, and vegetables at lunch as reported by school administrators and foodservice staff. Data collected via a mail-back survey from 620 public elementary schools participating in the National School Lunch Program during 2009-2010 were analyzed. Almost 70% of the FFVP-participating schools had a majority of students (>50%) eligible for free and reduced-cost meals. Participating in US Department of Agriculture Team Nutrition Program and having a registered dietitian or a nutritionist on staff were significantly associated with FFVP participation. Based on the results from logistic regression analyses schools participating in the FFVP were significantly more likely (odds ratio 2.07; 95% CI 1.12 to 3.53) to serve fresh fruit during lunch meals. Slightly >25% of public elementary schools across the United States participated in the FFVP, and participation was associated with healthier food availability in school lunches.

Relative and absolute availability of healthier food and beverage alternatives across communities in the United States

OBJECTIVES We examined associations between the relative and absolute availability of healthier food and beverage alternatives at food stores and community racial/ethnic, socioeconomic, and urban-rural characteristics. METHODS We analyzed pooled, annual cross-sectional data collected in 2010 to 2012 from 8462 food stores in 468 communities spanning 46 US states. Relative availability was the ratio of 7 healthier products (e.g., whole-wheat bread) to less healthy counterparts (e.g., white bread); we based absolute availability on the 7 healthier products. RESULTS The mean healthier food and beverage ratio was 0.71, indicating that stores averaged 29% fewer healthier than less healthy products. Lower relative availability of healthier alternatives was associated with low-income, Black, and Hispanic communities. Small stores had the largest differences: relative availability of healthier alternatives was 0.61 and 0.60, respectively, for very low-income Black and very low-income Hispanic communities, and 0.74 for very high-income White communities. We found fewer associations between absolute availability of healthier products and community characteristics. CONCLUSIONS Policies to improve the relative availability of healthier alternatives may be needed to improve population health and reduce disparities.

Development and reliability testing of a food store observation form.

OBJECTIVE To develop a reliable food store observational data collection instrument to be used for measuring product availability, pricing, and promotion. DESIGN Observational data collection. SETTING A total of 120 food stores (26 supermarkets, 34 grocery stores, 54 gas/convenience stores, and 6 mass merchandise stores) in the Chicago metropolitan statistical area. MAIN OUTCOME MEASURES Inter-rater reliability for product availability, pricing, and promotion measures on a food store observational data collection instrument. ANALYSIS Cohens kappa coefficient and proportion of overall agreement for dichotomous variables and intra-class correlation coefficient for continuous variables. RESULTS Inter-rater reliability, as measured by average kappa coefficient, was 0.84 for food and beverage product availability measures, 0.80 for interior store characteristics, and 0.70 for exterior store characteristics. For continuous measures, average intra-class correlation coefficient was 0.82 for product pricing measures; 0.90 for counts of fresh, frozen, and canned fruit and vegetable options; and 0.85 for counts of advertisements on the store exterior and property. CONCLUSIONS AND IMPLICATIONS The vast majority of measures demonstrated substantial or almost perfect agreement. Although some items may require revision, results suggest that the instrument may be used to reliably measure the food store environment.

Quality of life implications of inadequate protein nutrition among hemodialysis patients

OBJECTIVE To determine the quality of life implications of inadequate protein nutrition among hemodialysis patients. DESIGN Cross-sectional study. SETTING All 22 chronic hemodialysis units in northeast Ohio. PATIENTS There were 289 randomly selected patients. INTERVENTION Interview and chart abstraction. MAIN OUTCOME MEASURES Six quality of life subscales related to general health, physical function, social function, symptoms, burden of kidney disease, and employment status. RESULTS Low albumin levels were independently associated with decreased physical function, social function, and burden of kidney disease scores after adjustment for patient age, race, gender, health insurance, cause of renal failure, years on dialysis, and number of comorbid conditions. Low protein catabolic rate was independently associated with decreased physical function scores and with being retired or disabled. CONCLUSION Inadequate protein nutrition is independently associated with poor quality of life. Further study is needed to develop interventions to overcome barriers to protein nutrition and to determine the effect of such interventions on protein nutrition and patient quality of life.

Improving data accuracy of commercial food outlet databases.

Purpose. Assessing food environments often requires using commercially available data. Disparate methods used for classifying food outlets in these databases call for creating a classification approach using common definitions. A systematic strategy for reclassifying food stores and restaurants, as they appear in commercial databases, into categories that differentiate the availability of healthy options is described here. Design and Setting. Commercially available data on food outlets including names, addresses, North American Industry Classification System codes, and associated characteristics was obtained for five New Jersey communities. Analysis. A reclassification methodology was developed using criteria and definitions from the literature to categorize food outlets based on availability of healthy options. Information in the database was supplemented by systematic Internet and key word searches, and from phone calls to food outlets. Results. The methodology resulted in 622 supermarket/grocery stores, 183 convenience stores, and 148 specialty stores in the original data to be reclassified into 58 supermarkets, 30 grocery stores, 692 convenience stores, and 115 specialty stores. Outlets from the original list of 1485 full-service restaurants and 506 limited-service restaurants were reclassified as 563 full-service restaurants and 1247 limited-service restaurants. Reclassification resulted in less than one-seventh the number of supermarkets and grocery stores, more than three times the number of convenience stores, and twice as many limited-service restaurants—a much less healthy profile than the one generated by using exclusively the commercial databases. Conclusion. An explicit and replicable strategy is proposed for reclassifying food outlets in commercial databases into categories that differentiate on the basis of healthy food availability. The intent is to contribute towards building a consensus among researchers on definitions used in public health research for characterizing different types of food outlets.

The relative contribution of layers of the Social Ecological Model to childhood obesity

OBJECTIVE The Social Ecological Model (SEM) has been used to describe the aetiology of childhood obesity and to develop a framework for prevention. The current paper applies the SEM to data collected at multiple levels, representing different layers of the SEM, and examines the unique and relative contribution of each layer to childrens weight status. DESIGN Cross-sectional survey of randomly selected households with children living in low-income diverse communities. SETTING A telephone survey conducted in 2009-2010 collected information on parental perceptions of their neighbourhoods, and household, parent and child demographic characteristics. Parents provided measured height and weight data for their children. Geocoded data were used to calculate proximity of a childs residence to food and physical activity outlets. SUBJECTS Analysis based on 560 children whose parents participated in the survey and provided measured heights and weights. RESULTS Multiple logistic regression models were estimated to determine the joint contribution of elements within each layer of the SEM as well as the relative contribution of each layer. Layers of the SEM representing parental perceptions of their neighbourhoods, parent demographics and neighbourhood characteristics made the strongest contributions to predicting whether a child was overweight or obese. Layers of the SEM representing food and physical activity environments made smaller, but still significant, contributions to predicting childrens weight status. CONCLUSIONS The approach used herein supports using the SEM for predicting child weight status and uncovers some of the most promising domains and strategies for childhood obesity prevention that can be used for designing interventions.