Hydrologic and water quality performance of a subsurface gravel wetland treating stormwater runoff.

Subsurface gravel wetlands are an emerging type of green infrastructure that can be used to manage stormwater through the capture and slow release of runoff. They are unique to other types of green infrastructure in that they have a distinct fully saturated gravel layer below an occasionally saturated soil layer that influences pollutant removal processes. While they have been widely applied to treat wastewater, our understanding of their efficiency in treating stormwater with variable pollutant inputs is limited. To fill this gap, this study monitored the flow and water quality (total suspended solids, total nitrogen, total phosphorus, and chloride) in a subsurface gravel wetland in Oshkosh, Wisconsin at the influent, effluent, and in an observation well. Results from nine storm events indicated that the wetland had a median volume reduction of 74% and a median peak flow reduction of 89%. The reduction in pollutant concentrations where highly dependent upon the influent concentration. Average reductions of total suspended solids, total nitrogen, and total phosphorus were 49%, -21% and -0.2%, respectively, indicating an increase in nutrients; however, where influent concentrations were above irreducible levels, total phosphorus was reduced by 45% (influent ≥0.25 mg/L) and total nitrogen was reduced by 38% (influent ≥2.5 mg/L). Overall, this study shows that the subsurface gravel wetland performed similar to other types of green infrastructure and could be a good management practice to mitigate the harmful effects of stormwater runoff.

Welcoming, supportive care in US birthing facilities and realization of breastfeeding goals.

BACKGROUND: Emotional and physical support for birthing parents is positively associated with realization of their breastfeeding goals. However, few studies have investigated maternal descriptions of their postnatal unit experience of these domains. RESEARCH AIM: The objective was to investigate maternal report of their birthing facility experiences and quantify the extent to which accounts of postpartum support were associated with meeting their breastfeeding goals. METHODS: After IRB review, data were obtained through an online survey distributed from November 2016-May 2017. This analysis utilizes data from 2,771 birthing parents who were at least 18 years of age, experienced maternity care in the United States within five years, and reported that they had intended to breastfeed. Bivariate analysis was followed by logistic regression controlling for significant covariates. RESULTS: In this sample of primarily non-Hispanic white birthing parents with intent to exclusively breastfeed, the following postnatal unit variables were associated with higher odds of meeting their breastfeeding goals, birthing parents feeling: welcomed (adjusted OR=1.36), that health care promoted their physical health (adjusted OR=1.41), that care promoted their emotional health (adjusted OR=1.38), that they were supported (adjusted OR=1.56), and that they were recognized by their health care team (adjusted OR=1.30). All the measured postnatal unit support variables were significantly correlated with each other, with correlation coefficients ranging from 0.15 to 0.81. CONCLUSIONS: Before the COVID-19 pandemic, birthing parents' experiences on the postnatal unit were interrelated and associated with meeting their breastfeeding goals. As health care services are reviewed and prioritized during the COVID-19 pandemic and as part of ongoing strengthening of systems, qualitative and observational research can address the mechanisms underlying breastfeeding outcomes to inform the provision of more holistic and effective support.

The adequacy of phosphorus binder prescriptions among American hemodialysis patients.

Because hemodialysis treatment has a limited ability to remove phosphorus, dialysis patients must restrict dietary phosphorus intake and use phosphorus binding medication. Among patients with restricted dietary phosphorus intake (1000 mg/d), phosphorus binders must bind about 250 mg of excess phosphorus per day and among patients with more typical phosphorus intake (1500 mg/d), binders must bind about 750 mg/d. To determine the phosphorus binding capacity of binder prescriptions among American hemodialysis patients, we undertook a cross-sectional study of a random sample of in-center chronic hemodialysis patients. We obtained data for one randomly selected patient from 244 facilities nationwide. About one-third of the patients had hyperphosphatemia (serum phosphorus level > 5.5 mg/dL). Among the 224 patients prescribed binders, the mean phosphorus binding capacity was 256 mg/d [standard deviation (SD) 143]. A total of 59% of prescriptions had insufficient binding capacity for restricted dietary phosphorus intake, and 100% had insufficient binding capacity for typical dietary phosphorus intake. Patients using two binders had a higher binding capacity than patients using one binder (451 vs. 236 mg/d, p < 0.001). A majority of binder prescriptions have insufficient binding capacity to maintain phosphorus balance. Use of two binders results in higher binder capacity. Further work is needed to understand the impact of binder prescriptions on mineral balance and metabolism and to determine the value of substantially increasing binder prescriptions.

Effect of food additives on hyperphosphatemia among patients with end-stage renal disease: a randomized controlled trial.

CONTEXT: High dietary phosphorus intake has deleterious consequences for renal patients and is possibly harmful for the general public as well. To prevent hyperphosphatemia, patients with end-stage renal disease limit their intake of foods that are naturally high in phosphorus. However, phosphorus-containing additives are increasingly being added to processed and fast foods. The effect of such additives on serum phosphorus levels is unclear. OBJECTIVE: To determine the effect of limiting the intake of phosphorus-containing food additives on serum phosphorus levels among patients with end-stage renal disease. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized controlled trial at 14 long-term hemodialysis facilities in northeast Ohio. Two hundred seventy-nine patients with elevated baseline serum phosphorus levels (>5.5 mg/dL) were recruited between May and October 2007. Two shifts at each of 12 large facilities and 1 shift at each of 2 small facilities were randomly assigned to an intervention or control group. INTERVENTION: Intervention participants (n=145) received education on avoiding foods with phosphorus additives when purchasing groceries or visiting fast food restaurants. Control participants (n=134) continued to receive usual care. MAIN OUTCOME MEASURE: Change in serum phosphorus level after 3 months. RESULTS: At baseline, there was no significant difference in serum phosphorus levels between the 2 groups. After 3 months, the decline in serum phosphorus levels was 0.6 mg/dL larger among intervention vs control participants (95% confidence interval, -1.0 to -0.1 mg/dL). Intervention participants also had statistically significant increases in reading ingredient lists (P<.001) and nutrition facts labels (P = .04) but no significant increase in food knowledge scores (P = .13). CONCLUSION: Educating end-stage renal disease patients to avoid phosphorus-containing food additives resulted in modest improvements in hyperphosphatemia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00583570.

Fast food, phosphorus-containing additives, and the renal diet.

OBJECTIVE: Fast food is commonly consumed by hemodialysis patients, but many menu items are not compatible with renal diets because of their sodium, potassium, or phosphorus content. Moreover, the phosphorus content of fast foods is difficult for patients to estimate, because phosphorus-containing additives are commonly added to many fast foods. We sought to determine how many fast-food entrees and side dishes are compatible with renal diets. METHODS: We examined nutrition-facts labels and ingredient lists provided by 15 fast-food chains. Each entree and side dish was first assessed according to traditional criteria (limited sodium, potassium, and naturally occurring phosphorus content), and then according to the presence of a phosphorus -containing additive. RESULTS: Of 804 total entrees across all restaurants, 415 (52%) were acceptable according to traditional criteria, but only 128 (16%) were also free of phosphorus-containing additives. Of 163 total side dishes, 37 (23%) were acceptable according to traditional criteria, and 27 (17%) were also free of phosphorus-containing additives. There were no acceptable entrees at 3 chains, and no acceptable side dishes at 5 chains. CONCLUSION: Only a small proportion of fast-food entrees and side dishes are compatible with renal diets. The widespread use of phosphorus-containing additives is a major impediment to the availability of acceptable fast-food choices for hemodialysis patients. We recommend limiting the use of phosphorus-containing additives, and including phosphorus content in nutrition-facts labels.

Phosphorus-containing food additives and the accuracy of nutrient databases: implications for renal patients.

OBJECTIVE: Phosphorus-containing additives are increasingly being added to food products. We sought to determine the potential impact of these additives. We focused on chicken products as an example. METHODS: We purchased a variety of chicken products, prepared them according to package directions, and performed laboratory analyses to determine their actual phosphorus content. We used ESHA Food Processor SQL Software (version 9.8, ESHA Research, Salem, OR) to determine the expected phosphorus content of each product. RESULTS: Of 38 chicken products, 35 (92%) had phosphorus-containing additives listed among their ingredients. For every category of chicken products containing additives, the actual phosphorus content was greater than the content expected from nutrient database. For example, actual phosphorus content exceeded expected phosphorus content by an average of 84 mg/100 g for breaded breast strips. There was also a great deal of variation within each category. For example, the difference between actual and expected phosphorus content ranged from 59-165 mg/100 g for breast patties. Two 100-g servings of additive-containing products contained, on average, 440 mg of phosphorus, or about half the total daily recommended intake for dialysis patients. CONCLUSIONS: Phosphorus-containing additives significantly increase the amount of phosphorus in chicken products. Available nutrient databases do not reflect this higher phosphorus content, and the variation between similar products makes it impossible for patients and dietitians to accurately estimate phosphorus content. We recommend that dialysis patients limit their intake of additive-containing products, and that the phosphorus content of food products be included on nutrition facts labels.