Effect of Phosphate-Specific Diet Therapy on Phosphate Levels in Adults Undergoing Maintenance Hemodialysis: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Hyperphosphatemia is a persistent problem in individuals undergoing maintenance hemodialysis, which may contribute to vascular and bone complications. In some dialysis centers, dietitians work with patients to help them manage serum phosphate. Given the regularity of hyperphosphatemia in this population and constraints on kidney dietitian time, the authors aimed to evaluate the evidence for this practice. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: There was a systematic review and meta-analysis of clinical trials. MEDLINE, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, and other databases were searched for controlled trials published from January 2000 until November 2019 in the English language. Included studies were required to examine the effect of phosphate-specific diet therapy provided by a dietitian on serum phosphate in individuals on hemodialysis. Risk of bias and certainty of evidence were assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) method. RESULTS: Of the 8054 titles/abstracts identified, 168 articles were reviewed, and 12 clinical trials (11 randomized, one nonrandomized) were included. Diet therapy reduced serum phosphate compared with controls in all studies, reaching statistical significance in eight studies, although overall certainty of evidence was low, primarily due to randomization issues and deviations from protocol. Monthly diet therapy (20-30 minutes) significantly lowered serum phosphate in patients with persistent hyperphosphatemia for 4-6 months, without compromising nutrition status (mean difference, -0.87 mg/dl; 95% confidence interval, -1.40 to -0.33 mg/dl), but appeared unlikely to maintain these effects if discontinued. Unfortunately, trials were too varied in design, setting, and approach to appropriately pool in meta-analysis, and were too limited in number to evaluate the timing, dose, and strategy of phosphate-specific diet therapy. CONCLUSIONS: There is low-quality evidence that monthly diet therapy by a dietitian appears to be a safe and efficacious treatment for persistent hyperphosphatemia in patients on HD.

An Integrated Model of Breastfeeding Peer Counseling Support is Feasible and Associated with Improved Exclusive Breastfeeding.

Background Though in-person contacts in the home have demonstrated efficacy in improving breastfeeding outcomes in peer counseling programs, home contacts are resource-intensive. Objective To compare the feasibility and effectiveness of an Integrated Model of peer counseling breastfeeding support characterized by select home visits augmented with individual WIC clinic visits and group education, in contrast to the Standard Model which includes a standard number of in-person home contacts. Methods Six counties (n = 226 participants) and nine counties (n = 472 participants) were assigned to the Standard Model and the Integrated Model, respectively. Differences in demographic characteristics and breastfeeding outcomes were tested using Chi square tests and Cox proportional hazards regression models. Results Participants in counties where the Integrated Model was implemented had fewer home contacts (p = 0.03) and were more likely to have a hospital (p = 0.03) or group education (p < 0.001) contact, whereas Standard Model participants were more likely to receive an individual WIC clinic contact (p < 0.001). While there was no difference in the hazard of discontinuing any breastfeeding between groups, participants in the Integrated Model group had a lower hazard of discontinuing exclusive breastfeeding by 3 months postpartum (p = 0.02). Among participants within the Integrated Model, group education classes were associated with higher hazard of discontinuation (p = 0.04 and p = 0.003 for any and exclusive breastfeeding, respectively). Conclusions It was feasible for peer counselors to implement changes in program delivery to achieve fewer home visits without a detrimental impact on breastfeeding outcomes. However, group education classes did not appear to be beneficial for improving breastfeeding outcomes in this population.

Self-reported reasons for breastfeeding cessation among low-income women enrolled in a peer counseling breastfeeding support program.

BACKGROUND: Peer counseling programs have demonstrated efficacy in improving breastfeeding rates in the low-income population, but there is little research concerning why women enrolled in these programs ultimately discontinue breastfeeding. OBJECTIVE: This study aimed to describe the self-reported reasons for discontinuing breastfeeding among women who are receiving peer counseling support by participant characteristics and timing of discontinuation. METHODS: This study is a secondary analysis of data collected from 7942 participants who discontinued breastfeeding while enrolled in a peer counseling breastfeeding support program from 2005 to 2011. Reasons for discontinuing breastfeeding were assessed in relation to participant characteristics and weaning age using chi-square analyses and Kruskall-Wallis analyses of variance. RESULTS: The most common reasons reported for discontinuing breastfeeding were mother's preference (39%) and low milk supply (21%), although reasons differed by age of infant weaning (P < .001). Among participants who discontinued the earliest, the most commonly cited reasons were breastfeeding challenges [median duration (interquartile range), 4.7 (2.0, 13.4) weeks], followed by low milk supply [8.9 (4.6, 19.1) weeks] and mother's preference [12.9 (5.0, 25.7) weeks]. Women who were younger, were less educated, were non-Hispanic black, were unmarried, and had no prior breastfeeding experience were the most likely to discontinue breastfeeding due to mother's preference. CONCLUSION: Peer counselors are in a unique position to offer breastfeeding education and encouragement and may be able to use evidence presented here to anticipate specified concerns either prenatally or postpartum, to prevent early breastfeeding discontinuation.

Impact of peer counselling breast-feeding support programme protocols on any and exclusive breast-feeding discontinuation in low-income women.

OBJECTIVE: Peer counselling (PC) programmes have been shown to improve breast-feeding outcomes in populations at risk for early discontinuation. Our objective was to describe associations between programme components (individual and combinations) and breast-feeding outcomes (duration and exclusivity) in a PC programme for low-income women. DESIGN: Secondary analysis of programme data. Multivariable-adjusted Cox proportional hazards models were used to examine associations between type and quantity of peer contacts with breast-feeding outcomes. Types of contacts included in-person (hospital or home), phone or other (e.g. mail, text). Quantities of contacts were considered 'optimal' if they adhered to standard programme guidelines. SETTING: Programme data collected from 2005 to 2011 in Michigan's Breastfeeding Initiative Peer Counseling Program. SUBJECTS: Low-income (n 5886) women enrolled prenatally. RESULTS: For each additional home, phone and other PC contact there was a significant reduction in the hazard of discontinuing any breast-feeding by 6 months (hazard ratio (HR)=0·90 (95% CI 0·88, 0·92); HR=0·89 (95% CI 0·87, 0·90); and HR=0·93 (95% CI 0·90, 0·96), respectively) and exclusive breast-feeding by 3 months (HR=0·92 (95% CI 0·89, 0·95); HR=0·90 (95% CI 0·88, 0·91); and HR=0·93 (95% CI 0·89, 0·97), respectively). Participants receiving greater than optimal in-person and less than optimal phone contacts had a reduced hazard of any and exclusive breast-feeding discontinuation compared with those who were considered to have optimum quantities of contacts (HR=0·17 (95% CI 0·14, 0·20) and HR=0·28 (95% CI 0·23, 0·35), respectively). CONCLUSIONS: Specific components of a large PC programme appeared to have an appreciable impact on breast-feeding outcomes. In-person contacts were essential to improving breast-feeding outcomes, but defining optimal programme components is complex.

Prioritization of resources for participants in a peer counseling breastfeeding support program.

BACKGROUND: Peer counseling (PC) breastfeeding support programs have proven effective in increasing breastfeeding duration in low-income women. OBJECTIVES: This study aimed to describe program participants and breastfeeding duration in a PC program according to (1) timing of enrollment (prenatal vs postnatal) and (2) breastfeeding status at program exit (discontinued breastfeeding, exited program while breastfeeding, and completed 1 year program) to improve understanding of how these groups differ and how services might be optimized when resources are limited. METHODS: This study is a secondary analysis of data from low-income women enrolled in a PC breastfeeding support program. Participant characteristics and breastfeeding duration were described using chi-square tests, analyses of variance, and logistic regression. RESULTS: Postnatal enrollees had longer breastfeeding duration than prenatal enrollees (F < .001) and were more likely to be older, to be married, to be more educated, and to have prior breastfeeding experience (each variable P < .01). Women who withdrew from the program while breastfeeding were more demographically similar to those who discontinued breastfeeding prior to 1 year than to those who continued in the program breastfeeding for 1 year, although they breastfed for significantly longer at exit (mean ± SD = 27.8 ± 14.8 weeks) compared to women who discontinued breastfeeding while in the program (15.7 ± 13.3 weeks) (P < .001). CONCLUSION: It may be advantageous for peer counselors to direct fewer resources to later postnatal enrollees and more to prenatal or early postnatal enrollees. It may also be advantageous to focus on supporting women at high risk of discontinuation rather than on retaining women who choose to withdraw from the program while breastfeeding.

Dietary supplement users vary in attitudes and sources of dietary supplement information in East and West geographic regions: a cross-sectional study.

BACKGROUND: Over 50% of adults currently use dietary supplements (DS) but manufacturers do not have to prove the safety or efficacy of a DS before it is marketed. Therefore, consumers may be exposed to inaccurate DS information, may lack confidence in choosing appropriate DS and may seek advice for usage. The objective of this study was to examine trends in usage, attitudes, and sources of information regarding DS according to geographic location, demographic group, and lifestyle choices. METHODS: Eligible individuals completed a 10-item researcher-developed survey tool to determine DS use, sources of DS information, and DS-related knowledge and attitudes over the previous year. Healthy participants (637 individuals aged 21-75 years) from two population-based cohorts that had been recruited for lipoprotein assessment studies at Tufts University in Boston, Massachusetts and University of California at Davis. Outcome measures included participants' use, beliefs regarding essentiality of DS, confidence in choosing appropriate DS, and sources of information on DS. Univariate and multivariate logistic regression were utilized to examine differences in survey responses between groups. RESULTS: Of the total population 72.7% reported taking dietary supplements in the previous year. Those living on the West Coast (80.3%) had greater use than those living on the East Coast (60.7%). Those on the East Coast were more likely to believe DS were essential to health (48.7%) and to feel confident in choosing DS that were appropriate for them (51.0%). Overall, physicians were the most frequent source of DS information for more than 50% of participants on both coasts. CONCLUSION: Because DS usage is widespread, health care providers and nutrition educators must encourage patients to discuss their DS use and be equipped to provide information conducive to safe, efficacious consumption. Tailoring interventions for healthcare providers, media sources, industry, and the public may allow for dissemination of up-to-date information regarding DS.