Development of a preliminary diabetes dietary satisfaction and outcomes measure for patients with type 2 diabetes.

Adopting dietary lifestyle changes for diabetes management is often difficult for patients; yet the health-related quality of life (HRQOL) outcomes of dietary management for the patient are not extensively developed in the HRQOL assessments now widely used in diabetes research. This study developed a preliminary instrument, the diabetes dietary satisfaction and outcomes measure, to assess outcomes of individuals' experiences in following a meal plan for the treatment of type 2 diabetes. A theoretical framework and preliminary focus group data guided the design of a 47-item questionnaire, administered to 239 patients with type 2 diabetes. Medical file data was obtained on 180 of these patients. Fifty-four percent of respondents were women, with mean age of 64 +/- 12 years and diabetes duration of 10 +/- 8 years. Scores for the satisfaction and other outcome measures discriminated between patient groups by age, gender, medication use, depression diagnosis, meal plan status, and employment status. Significant correlations also occurred with diet adherence, number of co-morbidities, and glycemic control as measured by glycolated hemoglobin (HbA1c). Future research with additional patient samples is needed to refine the measure for use in diabetes education programs.

Oxalate content of soybean seeds (Glycine max: Leguminosae), soyfoods, and other edible legumes.

Consumption of soybeans and food products made from them is increasing because of their desirable nutritional value. However, the oxalate content of seeds from 11 cultivars of soybean showed relatively high levels of total oxalate from 0.67 to 3.5 g/100 g of dry weight. Oxalate primarily was found as calcium oxalate crystals. Thirteen tested commercial soyfoods contained between 16 and 638 mg of total oxalate per serving. These values compare to those of three other legume foods, peanut butter, refried beans, and lentils, which contained 197, 193, and 100 mg of total oxalate per serving, respectively. After oxalate has been absorbed from the diet, it cannot be metabolized and is excreted by the kidney into urine, where it binds to calcium forming an insoluble salt that may precipitate to form kidney stones. The amounts of total oxalate in soybean seeds, soy foods, and other common legume foods exceed current recommendations for oxalate consumption by individuals who have a history of calcium oxalate kidney/urinary stones. This study serves as the basis to find soybean cultivars lower in oxalate, which will have lower risk for kidney stone formation after human consumption.

Dairy food consumption, blood pressure and stroke.

Recent clinical and biochemical evidence supporting the hypothesis that consumption of dairy products may be associated with reduced blood pressure and risk of stroke is reviewed. The two prospective studies of dairy food consumption and stroke incidence both indicate that a higher intake of dairy foods reduces risk. It is difficult to associate any one mineral in dairy products to reduction in blood pressure or stroke incidence because an appropriate metabolic balance of all three is important and because of the strong correlations among Ca, Mg and K intakes when dairy products are consumed. In fact, the evidence reviewed indicates that although K apparently has the greatest effect, all three minerals potentially contribute to blood pressure and stroke reduction, i.e., a dietary balance of all three is recommended. Milk and food products such as yogurt made from milk, which retain substantial amounts of K, Ca and Mg, are important dietary sources of all three of these minerals. In addition, milk is a low Na food, which, as seen in Dietary Approaches to Stop Hypertension (DASH) II, provides further benefit in blood pressure reduction. New studies have associated dairy food consumption with other potential mechanisms affecting stroke, mainly reduction of platelet aggregation and insulin resistance. Further research is required to explore the relationship of dairy food consumption and stroke.

Diets with either beef or plant proteins reduce risk of calcium oxalate precipitation in patients with a history of calcium kidney stones.

OBJECTIVE: To determine the effect of substituting equal amounts of dietary protein as animal protein (beef) for plant protein (legumes, seeds, nuts, and grains) on urinary components associated with calcium oxalate precipitability risk. DESIGN: Randomized crossover trial. SUBJECTS: Twenty-three normocalciuric patients with a history of calcium kidney stones (8 women and 15 men, mean age 50.7+/-14.6 years) with 24-hour urinary calcium < or =10.3 micromol, 24 hour urinary oxalate excretion between 228 and 963 micromol, and a urinary calcium increase of < or =1.0 micromol in 4 hours after a 25 micromol oral calcium load. SETTING: Four-day, free-living adaptation period, followed by 2-day metabolic unit study. INTERVENTION: The study compared consumption of 2 servings of beef (43 g protein for women and 50 g for men) daily with an equal amount of protein from plant foods including legumes, nuts, and grains. MAIN OUTCOME MEASURES: Tiselius risk index (TRI) for calcium oxalate precipitability calculated from urinary calcium, oxalate, magnesium, citrate, and volume. STATISTICAL ANALYSES: Paired t tests. RESULTS: Urinary calcium, oxalate, magnesium, citrate, phosphorus, volume, and TRI did not differ between diets. Urinary sodium and potassium were higher for patients on the plant protein diet. After correcting for variations in urinary sodium and potassium between diets, the difference in urinary calcium remained insignificant. TRI was lower on both beef- and plant-protein diets compared with self-selected prestudy diets for all participants. CONCLUSION/APPLICATIONS: Balanced diets containing moderate amounts of either beef or plant protein are equally effective in reducing calcium oxalate kidney stone risk based on changes in urinary composition.

Barriers to nutrition care for nursing home residents.

The prevalence of protein-calorie malnutrition (PCM) in nursing home residents has reached 85% in some nursing homes and is linked to increased mortality among residents. Separate survey questionnaires were developed and administered to 99 nursing assistants and 44 nurses (35 RNs, 9 LPNs) from five eastern Washington nursing homes. The purpose was to assess nurse (RN, LPN) and nursing assistant perceived beliefs and views related to nutritional needs of nursing home residents that have a potential impact on PCM of residents. Experienced nursing assistants did not view the nurse as an active participant during mealtime. Specific barriers such as a lack of time and training, too many residents, working short staffed, poor food quality, and a lack of nurse-nursing-assistant teamwork may contribute to residents not getting enough food to eat. An education program addressing staff relationships and nutrition training of nursing assistants could improve the ability of nursing staff to ensure residents' food intake and improve the quality of life for residents in nursing homes.

Nutrition knowledge of nurses in long-term care facilities.

BACKGROUND: The purpose of this study was to determine knowledge-based nutrition competencies of nurses and describe needed nutrition education relative to reducing protein-calorie malnutrition (PCM) in nursing home residents. METHOD: A sample of 44 nurses (35 RNs, 9 LPNs) from five eastern Washington nursing homes completed a 50-item questionnaire that measured nutrition knowledge based on Benner's Novice to Expert Model. RESULTS: Nurses scored an average 65% +/- 11% on the nutrition examination. CONCLUSION: An educational program addressing the identified deficient areas could improve the ability of nursing staff to assess and monitor resident food intake, thereby reducing the prevalence of PCM of residents in nursing homes.

Caffeine and the elderly.

The most common source of dietary caffeine among the elderly is coffee, with consumption averaging about 200 mg/day. Because of the greater proportion of adipose tissue to lean body mass in older humans, and because caffeine is distributed essentially only through lean body mass, a dose of caffeine expressed as mg/kg total bodyweight may result in a higher plasma and tissue concentration in elderly compared with younger individuals. The metabolism of, and physiological responses to, caffeine is similar in elderly and younger individuals. However, there is a limited amount of evidence that responses to caffeine in some physiological systems may be greater in the elderly at doses in the 200 to 300 mg range. Although caffeine consumption increases urinary calcium levels similarly in both younger and older individuals, the preponderance of data suggest that caffeine has a greater impact on calcium metabolism and bone in older people. Evidence also suggests that increasing age is associated with increasing sensitivity to the pressor effects of caffeine. Caffeine appears to affect metabolic and neurological responses similarly in both young and elderly individuals, when differences in baseline performance are taken into account.

Excess dietary protein can adversely affect bone.

The average American diet, which is high in protein and low in fruits and vegetables, generates a large amount of acid, mainly as sulfates and phosphates. The kidneys respond to this dietary acid challenge with net acid excretion, as well as ammonium and titratable acid excretion. Concurrently, the skeleton supplies buffer by active resorption of bone. Indeed, calciuria is directly related to net acid excretion. Different food proteins differ greatly in their potential acid load, and therefore in their acidogenic effect. A diet high in acid-ash proteins causes excessive calcium loss because of its acidogenic content. The addition of exogenous buffers, as chemical salts or as fruits and vegetables, to a high protein diet results in a less acid urine, a reduction in net acid excretion, reduced ammonium and titratable acid excretion, and decreased calciuria. Bone resorption may be halted, and bone accretion may actually occur. Alkali buffers, whether chemical salts or dietary fruits and vegetables high in potassium, reverse acid-induced obligatory urinary calcium loss. We conclude that excessive dietary protein from foods with high potential renal acid load adversely affects bone, unless buffered by the consumption of alkali-rich foods or supplements.

Substituting milk for apple juice does not increase kidney stone risk in most normocalciuric adults who form calcium oxalate stones.

OBJECTIVE: Increasing intake of dietary calcium from less than 400 mg to 800 mg daily may decrease the absorption of dietary oxalate, which in turn would decrease urinary oxalate excretion. The effect of substituting milk for apple juice on urine composition and risk of calcium oxalate precipitability was studied. SUBJECTS: Twenty-one normocalciuric adults with a history of at least 1 calcium oxalate stone and urinary oxalate excretion exceeding 275 micromol/day on their self-selected diet. DESIGN: Randomized crossover trial. INTERVENTION: Each participant consumed two moderate-oxalate (2,011 micromol/day) study diets, which were identical except that one contained 360 mL milk and the other contained 540 mL apple juice as the beverage with meals. SETTING: Four days free-living then 2 days in the metabolic unit of a university nutrition department. MAIN OUTCOME MEASURE: Tiselius risk index for calcium oxalate precipitability calculated from urine composition. STATISTICAL ANALYSES: Paired t tests. RESULTS: Twenty-four hour urinary oxalate excretion was 18% lower (P<.0001) on the milk diet vs the juice diet: 423 vs 514 micromol, respectively. Calcium excretion was 17% higher (P<.05) on the milk vs juice diet: 4.7 vs 3.9 mmol, respectively. Urinary magnesium and citrate excretion, volume, and Tiselius risk index did not differ between diets. APPLICATIONS: Substituting 360 mL milk daily for apple juice with meals in a diet containing moderate amounts of dietary oxalate from whole grains, legumes, fruits, and vegetables does not increase the risk index of calcium oxalate precipitability in most normocalciuric adults who form stones.

Interactions between dietary calcium and caffeine consumption on calcium metabolism in hypertensive humans.

Abnormal calcium metabolism has been implicated in human hypertension. Caffeine consumption may contribute to hypertension since it increases urinary calcium excretion. Nineteen hypertensive subjects (HTN) and nineteen age and gender matched normotensive controls (NTC) who habitually consumed at least 175 mg caffeine daily were studied before and after abstinence from all caffeine (CAF) consumption for 2 weeks. Caffeine abstinence (CAF-) increased fasting serum ultrafiltrable calcium in HTN and NTC, but not serum total calcium. Parathyroid hormone (PTH) levels decreased after CAF abstinence in 14 of 18 HTN subjects, including all seven subjects consuming less than 700 mg calcium daily. Three day dietary calcium intakes and 72 h urinary excretion of calcium were not different between CAF+ and CAF- or between HTN and NTC. A morning caffeine dose of 6 mg/kg lean body mass increased urinary Ca/creatinine ratios similarly for 2 h after beverage consumption in both HTN and NTC. Caffeine consumption stresses calcium metabolism in hypertensive individuals, especially those consuming less than 700 mg calcium daily.

Dietary salt, urinary calcium, and kidney stone risk.

Both salt-loading studies and reports of free-living populations find that urinary calcium excretion increases approximately 1 mmol (40 mg) for each 100 mmol (2300 mg) increase in dietary sodium in normal adults. Renal calcium stone-formers with hypercalciuria appear to have greater proportional increases in urinary calcium (approximately 2 mmol) per 100 mmol increase in salt intake. Thus, reduction of dietary NaCl may be a useful strategy to decrease the risk of forming calcium-containing kidney stones.

Effects of acute caffeine ingestion and menopause on sulfate homeostasis in women.

Inorganic sulfate is a physiological anion which is utilized in the metabolism of both endogenous compounds and xenobiotics. Its homeostasis is maintained predominantly by facilitated reabsorptive processes in the kidneys. The objectives of the present investigation were to evaluate the effects of menopausal status and caffeine ingestion on the serum concentrations and clearance of inorganic sulfate. Thirty-nine women who were classified as premenopausal, postmenopausal with or without estrogen treatment, and postmenopausal with osteoporosis participated in the study. The women were studied on two separate occasions following the ingestion of a decaffeinated beverage to which 6 mg caffeine/kg lean body mass or no caffeine was added. All women were habitual caffeine users (mean ingestion of 588 mg caffeine per day) but abstained from all caffeine sources for 2 weeks prior to the control study day. Postmenopausal women with estrogen supplementation exhibited significantly lower sulfate serum concentrations (0.24 +/- 0.02 mM vs. 0.32 +/- 0.04 mM in premenopausal women, mean +/- SD, p < 0.05) and a decreased renal reabsorption of sulfate for the control (no caffeine) period. There was no difference in serum sulfate or sulfate reabsorption in estrogen supplemented postmenopausal women, compared with women not taking estrogen. Postmenopausal women with osteoporosis had significantly lower creatinine and sulfate clearances than postmenopausal women with estrogen supplementation which may be related to their older age, or factors related to the disease process. The 6 mg/kg dose of caffeine caused a diuresis, but no change in GFR, as indicated by urine volume and creatinine clearance values, respectively. Caffeine administration resulted in an increase in the sulfate excretion rate; there was no change in sulfate serum concentrations. The results of this investigation indicate that menopause results in decreased sulfate serum concentrations that may be the consequence of a decreased renal reabsorption of sulfate. Secondly, this investigation demonstrated that caffeine ingestion increases the urinary excretion of sulfate, an effect that may be related to the diuretic effect of caffeine or due to a caffeine-induced alteration in the renal reabsorption of sulfate.

Interactions between dietary caffeine and calcium on calcium and bone metabolism in older women.

OBJECTIVE: Our purpose was to determine the effect of 2 weeks of caffeine abstinence on calcium (Ca) and bone metabolism in women habitually consuming caffeine and either low or moderate amounts of Ca. METHODS: Participants were 25 women, aged 39-76 years (mean 65 years, median 57 years) habitually consuming at least 200 mg caffeine daily. Three days of dietary records and 24-hour urine collections were made immediately prior to collection of fasting blood and 1-hour urine in a metabolic unit. Women were classified as low Ca consumers (414-584 mg daily) or moderate Ca consumers (662-1357 mg daily) based on 6 days of diet records. RESULTS: Women in the low Ca group had higher levels of serum ultrafiltrable Ca (UFCa) after caffeine abstinence (1.40 mmol/L CAF+ vs 1.52 mmol/L CAF-, p < 0.01), while there were no differences between experimental periods for UFCa in the moderate Ca group (1.35 mmol/L CAF+ vs 1.38 mmol/L CAF-, ns). Women in the low Ca group also had lower serum bone isoenzyme alkaline phosphatase levels after caffeine abstinence (9.3 U/L CAF+ vs 8.8 U/L CAF-, p < 0.05), while no significant changes were seen in bone alkaline phosphatase in the moderate Ca consumers (8.7 U/L CAF+ vs 8.9 U/L CAF-, ns). Fasting total serum Ca, urinary hydroxyproline/creatinine, and Ca/creatinine ratios were unchanged in both dietary groups. Three-day mean 24-hour urinary Ca excretion decreased after caffeine abstinence in the moderate Ca group only. There were no differences in dietary intakes of Ca from dairy products between CAF+ and CAF- in either the low or moderate Ca groups. CONCLUSION: Abstinence from moderate caffeine intake (mean 5.8 mg/kg lean body mass, 383 mg/day caffeine) raises ultrafiltrable Ca and decreases bone alkaline phosphatase in older women consuming < 600 mg Ca daily.