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Increasing Fiber Intakes of Patients with Chronic Kidney Disease: Impact on Gastrointestinal Function and Nutrient Intakes

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Title:
Increasing Fiber Intakes of Patients with Chronic Kidney Disease: Impact on Gastrointestinal Function and Nutrient Intakes
Creator:
Watson, Jessica
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Language:
English

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Subjects / Keywords:
Cholesterols ( jstor )
Diet ( jstor )
Dietary fiber ( jstor )
Energy intake ( jstor )
Fats ( jstor )
Food ( jstor )
Micronutrients ( jstor )
Nutrition ( jstor )
Vitamin D ( jstor )
White people ( jstor )
Chronic renal failure
Chronic renal failure--Nutritional aspects
Fiber in human nutrition
Food--Fiber content
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Undergraduate Honors Thesis

Notes

Abstract:
As today’s population strays further from wholesome foods to the fast food Western diet, the consumption of the Adequate Intake of fiber, set by the National Academies Institute of Medicine (21 to 25 g for women and 30 to 38 g for men), is rarely met. Current estimation of dietary fiber intake in the general population is half of the Adequate Intake (AI) recommendation (5). Individuals with Chronic kidney disease (CKD) may have even further reduced dietary fiber intake due to diet restriction and/or poor appetite. CKD may lead to serious co-morbidities and side effects such as constipation and inadequate nutrient intake. The purpose of this study was to determine the impact of individual-packaged, commercial-available cookies, snack bars and cereal foods with added fiber on patients’ bowel movement frequency and nutrient intake. Consenting adults with CKD (n = 15; 9F, 6M; 66 ± 15 y) were provided with cereal, cookies and snack bars without added fiber for 2 weeks, followed by similar foods providing 23 g/d of fiber (pea hull, inulin, and soluble corn fiber) for 2 weeks. Control and treatment 3-day food records (analyzed using Food Processor®) were collected. Mean fiber intake increased from 11.8 ± 3.2 to 22.4 ± 7.0 g/d (p < 0.001) with no change in energy or protein intake. However, a decrease in fat (p < 0.01) and an increase in vitamin D (p < 0.05) were seen with added fiber. Daily bowel movement frequency increased from 1.2 ± 0.7 to 1.5 ± 0.7 (p < 0.05). Providing foods with added functional fiber effectively increases fiber intake as well as bowel movement frequency in individuals with CKD without impacting energy intake. ( en )
General Note:
Awarded Bachelor of Science; Graduated May 3, 2011 summa cum laude. Major: Food Science and Human Nutrition, Emphasis/Concentration: Nutritional Sciences
General Note:
Advisor(s): Dr. Wendy Dahl
General Note:
College/School: College of Agricultural and Life Sciences

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University of Florida
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Copyright Jessica Watson. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.

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Increasing Fiber Intakes of Patie nts with Chronic Kidney Disease: Impact on Gastrointestinal Function and Nutrient Intakes Student: Jessica Watson UFID: 1116-1911 Food Science and Human Nutrition: Nu trition Major and CLAS Biology Major International Development and Humanitarian Assistance Minor Phone: 561-308-6517 Email: jhwatson@ufl.edu Faculty Mentor: Wendy Dahl, PhD Assistant Professor Food Science and Human Nutrition Depa rtment and Center for Nutritional Sciences University of Florida Phone: 352-392-1991 ext. 224 Email: wdahl@ufl.edu Honors Coordinator: Anne Kendall, PhD Senior Lecturer Food Science and Human Nutrition Department University of Florida Email: kendall@ufl.edu

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Abstract As today's population strays further from w holesome foods to the fast food Western diet, the consumption of the Adequate Intake of fiber, set by the National Academies Institute of Medicine (21 to 25 g for women and 30 to 38 g fo r men), is rarely met. Current estimation of dietary fiber intake in the gene ral population is half of the Ad equate Intake (AI) recommendation (5). Individuals with Chronic ki dney disease (CKD) may have even further reduced dietary fiber intake due to diet restriction and/or poor appetite. CKD may l ead to serious co-morbidities and side effects such as constipation and inadequate nutrient intake. Th e purpose of this study was to determine the impact of indivi dual-packaged, commercial-avail able cookies, snack bars and cereal foods with added fiber on patients' bow el movement frequency and nutrient intake. Consenting adults with CKD (n = 15; 9F, 6M; 66 15 y) were provided with cereal, cookies and snack bars without added fiber for 2 weeks, fo llowed by similar foods providing 23 g/d of fiber (pea hull, inulin, and soluble corn fiber) for 2 weeks. Control and treatment 3-day food records (analyzed using Food Processor¨) were collected. Mean fiber in take increased from 11.8 3.2 to 22.4 7.0 g/d (p < 0.001) with no change in en ergy or protein intake. However, a decrease in fat (p < 0.01) and an increase in vitamin D (p < 0.05) were seen with added fiber. Daily bowel movement frequency increased from 1.2 0.7 to 1.5 0.7 (p < 0.05). Providing foods with added functional fiber effectively increases fiber in take as well as bowel movement frequency in individuals with CKD without impacting energy intake.

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Table of Contents Introduction a. Defining Fiber 1 b. Fibers Role in Maintaining Health 1 c. Adequate Intake of Fiber 2 d. Chronic Kidney Disease 3 e. Study Aims 4 Methods and Materials a. Participants 5 b. Study Protocol 5 c. Diet Treatment 6 d. Assessment Tools 6 Results 6 Discussion 7 References 11 Table 1. Participant Demographics 12 Table 2. Macronutrients baseline and treatment 13 Table 3. Micronutrients baseline and treatment 14 Table 4. Bowel movement frequency per day 15 Appendix A. Food Record 16 Appendix B. Daily Diary 17

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Introduction a. Defining Fiber Fiber could be defined as the substance in plants that is indi gestible by the human enzymes. However, the Dietary Guidelines from 2010 more specifically de fines dietary fiber as the non-digestible form of carbohydrates and lignin in plants that helps provide a feeling of fullness and promotes healthy laxation (1). In addition, the Institute of Medicine defines total fiber as the sum of dietary and a dded fiber. Dietary fiber consists of indigestible carbohydrates and lignin present naturally in plants while a dded fiber consists of isolated, indigestible carbohydrates with beneficial physio logical effects in humans (1). Fiber exists in two forms: soluble and insoluble, each with separate, yet similar benefits. Soluble fiber forms a gel-like substance when bound to water. It binds to fat an d slows gastric emptying. Soluble fiber includes pectin and gums (2) and can be found in oat bran beans, fruit and vegetables. Insoluble fiber decreases transit time and increases fecal bulk, promoting healthy bowel movements. Insoluble fiber includes cellulose, hemicellulose, and lingin. These are found in wheat, whole grains, beans and vegetables, especially skins (2). In addition to dietary fiber, supplemental fiber is now commonly found in food. This "functional" fiber is added to naturally found nutri ents in food. It is unkn own if added fiber has the same effects as dietary fi ber (1). Some known added fibe rs are pea hull, inulin, and polydextrose. Studies have shown an increase in fecal bulk with the use of pea hull fiber (3). This has been used to increase bowel freque ncy in individuals suffe ring from constipation. Similarly, inulin and polydextrose are on the rise as supplementa l fibers demonstrating many of the same functionalities of gr ain fiber, such as being fermentable and laxatives (4).

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! Role in Maintaining Health Fiber has been the focus of many recent studie s due to its contributions to health. Fiber has been associated with reduc tion in cholesterol levels (5), lowering blood pressure (6), improved blood glucose control in di abetics (7), and promotion of re gularity (8). The viscosity of fiber, increasing the excretion of cholesterol and bile salts, works to lower cholesterol, thus lowering the risk of coronary heart disease (9,10 ). Soluble fiber can pr omote the integrity and immunity of the intestine by providing resident inte stinal bacteria with nut rients to produce short chain fatty acids (11). In addition, non-fermentable fiber adds to f ecal bulk and decreased transit time that contributes to bowel movement frequency. A diet high in fibe r can help improve the common complaint of constipation. In addi tion, bowel movement frequency is associated with a decrease risk in colon cancer, constip ation, and hemorrhoids (2). Fibrous foods, such as fruits, vegetables, a nd whole grains, are usually low-calorie dense and can improve weight loss, weight maintenance, and may be associated with a decreased risk of type 2 diabetes (1). Reduction in caloric intake caused by longer f eelings of satiety and glucose regulation is also associ ated with fighting obesity and t ype 2 diabetes (12). It is not difficult to see how fiber acts thr ough co-morbidities to affect va rious realms of health. Obesity, high cholesterol, type 2 diabetes and other associations of a lo w fiber diet contribute to comorbidities. Clearly the appropriate intake of fi ber is important in maintaining a healthy diet, gastrointestinal tract and life. c. Adequate Intake of Fiber Current dietary intakes of individuals in th e United States rarely meet the necessary intake of fiber. The AMA most recent 2010 Di etary Recommendations state that the daily

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! # recommended intake of fiber for an adult consum ing 2000 calories is 25 grams. The Institute of Medicine Adequate Intake (AI) recommendation is 14 grams per 1000 calories consumed (1). This corresponds to approximately 38 grams a day for men and 25 grams a day for women (13). Current estimation of dietary fiber intake in the general population is half of the AI recommendation (14). The commonly found refined grains consumed in the Western diet, now enriched with some vitamins, still lack the enrich ment of fiber. The fiber content of a food is listed in grams and as a percentage of the daily value on nutrition labels. Sp ecial attention should be paid to nutrition labels, as even foods market ed to have "grains" don't always contain fiber. Eating a diet high in fruits, vegetables, beans, and whole grains will help raise the amount of fiber obtained in the diet (1). d. Chronic Kidney Disease One of the most costly co-morbidities of diab etes and hypertension, in terms of health care expenditures and patient quality of life, is th at of chronic kidney disease (CKD). With the progression of CKD, abnormalities in fluid and electrolyte balance develop as well as uremic syndrome, where patients have high levels of blood urea (and other waste products from protein metabolism). Symptoms of uremic syndrome incl ude fatigue, intense itching, anorexia (loss of appetite) and slowed thinking. Th e current nutrition therapy for CKD has serious limitations and patient compliance with the diet is poor. The recommended diet for CKD focuses on moderate protein intake and recommends pr otein of high biological valu e to reduce blood urea nitrogen levels. However, this recommendation may cont ribute to the malnutrition seen in many individuals, as they progress to end-stage renal failure. Restricted sodium, restricted phosphorus and high calcium inta ke are required, since with the loss of kidney function, electrolyte, minera l and fluid balance are disrupted. High phosphorus

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! $ foods must be restricted. These include primaril y dairy products, beans, bran cereals and whole grains. Limitations on potassium intake for some patients necessitate the exclusion of beans and milk, as well as nuts and many fr uits and vegetables. The restrict ion of beans, whole grains and many fruits and vegetables leaves a diet seriously depleted of diet ary fiber, potentially leading to constipation and inadequate fermentable substrat e for colonic and general health. Although it is recommended that CKD patients consume diet s high in fiber, no kidney disease diet recommendations provide guidelines as to how to achieve this recommendation. Little research has been carried out on fiber supplementation of patient s with CKD. Isolated fiber fractions, unlike wheat bra n, are low in phosphorous (and pot assium) and would, therefore, be appropriate fiber sources for those prescr ibed a diet for the management of CKD. e. Study Aims Research questions: 1. Does providing usual foods with added fiber result in increase fiber intakes in chronic kidney disease patients? 2. Does providing usual foods with added fi ber result in increased bowel movement frequency? 3. Does providing usual foods with added fiber affect energy, macronutrient and micronutrient intake in chroni c kidney disease patients? If there is participan t compliance, it is anticipated th at providing fiber-supplemented food will be matched with an increase in fiber f ound in dietary intake. In accordance with the functions of fiber, it is anticipated that an increase in fiber will result in an increase in bowel movement frequency in patients with CKD. It is not known if added fiber will decrease energy and nutrient intake of patients with CKD.

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! % Methods and Materials a. Participants Patient with Chronic Kidney Di sease participated in this st udy. Due to their condition, they have diets lacking in fiber. Particip ants were 18 and older, with GFR of 50 mL/min/1.73 m 2 (stage 3 through 5 but who are not on dialysis), are not diagnosed with acute kidney injury (AKI) or glumerulonephritis (GN), a nd are not on immunosuppressant medications. Participants must be able to understand, verbalize, and sign the in formed consent (in Eng lish). Patients who are scheduled to have transplant or dialysis in 3 months of the st udy initiation, history of liver disease, dialysis, have undergone renal transpla ntation, are taking probio tic supplements and are unwilling to discontinue, lactating, active gastrointe stinal bleeding, on steroids, or had a change in medications over the past 4 weeks were not able to particip ate in the study. b. Study Protocol The methods followed the protocol of the "An investigation into pulse fiber fermentation and nitrogen excretion in patients with chr onic renal failure" (IRB1 # 16-2010). Research volunteers were asked to complete a 3-day food r ecord in week 1 of the study and during week 6 of the study. Food records were analyzed for fi ber and other nutrients using Food Processor. Study volunteers completed a daily questionnaire with questions regarding such aspects of gastrointestinal health such as bowel movement frequency and occurrence of diarrhea. Relationships among fiber intake, gastrointestinal health and overall nutrient intake will be assessed. Participants consumed the control (baked goods and cereals with no added fiber) or fiber treatment (baked goods and cereals with added fi ber). The study consisted of two phases. Phase 1 was the control period in whic h 20 participants consumed the baked goods and cereals with no

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! & added fiber for 2 weeks, which will serve as a ba seline period for all participants. Participants attended clinic visits two times during each pha se. Phase 2 started immediately after Phase 1 with the introduction of fiber supplemented (treat ment) foods. Foods were given to patients at the clinic during weeks 2 and 4. c. Diet Treatment For the control periods, individual-packaged, commercial-available cookies, snack bars and cereal (4 servings/day) were provided to the participants. For the treatment period, individual-packaged, commercial-available cookies, snack bars and cereal (4 servings/day), containing 23 g of isolated fiber per day, were provided to the partic ipants. Foods to be used in this study were fortified with pea hull, inulin, and corn soluble fiber. d. Assessment Tools Daily Journal A daily journal was used to assess bowel fre quency and changes in patients' medications. (Appendix A) Food records Participants were provided a food diary to record their 3-day in takes. (Appendix B) Three-day food records were assessed (using Fo od Processor¨, ESHA Research Inc., Salem, OR) for nutrients and energy intake according to study design. Results Demographics Table 1 shows the demographics of study partic ipants. Seventeen indivi duals were consented for the study with 15 completing the study. There were 6 males and 9 females between the ages of 31 to 86 years. Of these fifteen, onl y twelve completed dietary recalls.

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! Macronutrient and Micronutrient Baseline vs. Treatment Table 2 shows the macronutrient intakes (mean SD) of participants before and after fiber treatment. Energy, protein and carbohydrate intakes did not ch ange (NS). However, fiber increased (p < 0.001) and fat decreased (p < 0.01) with the fiber inte rvention. Table 3 shows micronutrient intakes of participants before and after fiber treatment. The figure shows the mean SD for iron, calcium, phosphorus, potassium, and vitamin D. Significant changes in micronutrient intakes before and after fiber tr eatment were not found, with the exception of vitamin D that showed an increase du ring the fiber treatment period (p < 0.05). Bowel Movement Frequency Table 4 represents the amount of bowel moveme nt frequencies recorded before and after fiber treatment. Daily bowel movement frequency increased from 1.2 0.7 to 1.5 0.7 (p < 0.05). Discussion In previous studies, an increase in certain fi ber types has shown a ch ange in energy intake. This could be harmful or helpful to an individu al depending on their needs. While a decrease in the consumption of energy could pr ove beneficial to an obese patient, it could also be detrimental to a sick patient needing to main tain a high caloric intake. Indivi duals with CKD, at a high risk of malnutrition, require a need to benefit from th e addition of added fiber without a decrease in energy. The fiber-containing foods administered to the participants contained pea hull, inulin, and corn soluble fiber. This composition of fiber in cluded not only the bulking component of pea hull but also inulin, which has been seen to increase satiety. Sati ety was not measured, however, no decrease in average energy in take was found indicating sati ety may be been unaffected.

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! () However, as seen in Table 4, an overall increase in added fiber did correspond to increase in bowel movement frequency. Bowel movement fre quency while maintaining energy intake shows the beneficial impact for individuals with CKD that may suffer from constipation and high risk for malnutrition. The administered added fiber during treatment pha se increased fiber intake in the diet of participants. Of the 12 food-recall participants, none had met the AI for fiber before treatment. After the treatment phase, eight participants met th e AI for fiber. This was seen with an absence in energy and protein change, but a decrease in fat intake. Of the micronutrients analyzed, only vitamin D had a significant change before and after treatment. Conclusion The noticeable jump in fiber during the treatme nt phase proves that reaching the AI's is attainable. Just by eating the administered 4 serv ings of fiber added f oods a day, participants' fiber jumped drastically. More research and tech nology should be applied to the creation of fiber rich foods in order to make them available to al l individuals. Fiber is an important component of every persons diet and results in positive impacts on daily life as well as disease reduction. This is reason enough to gain more know ledge in the realm of dietary and added fiber. The additional potential benefits seen from this study also require more research. Although an increase in fiber dur ing the treatment phase was not seen to affect energy intake, it impacted other aspects of diet specifically vitamin D and fat. Individuals with CKD need to maintain their energy intakes and may have difficu lties maintaining other necessary nutrients. It is advantageous that these indi viduals are able to improve sy mptoms without affecting other intakes. The increase in vitamin D found with an increase in fiber could be beneficial to some individuals (those with low bone density). More research regard ing the affect of fiber on fat

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! (( intake as well as vitamin D intake could prove us eful. The types of fiber used in treatment could have unknown impacts on these nutrients that coul d aid in designing dietar y intakes of not only individuals with CKD, but other diseases as well. The overall increase in fiber with treatment re sulted in an increase in bowel movement frequency proving that providing foods with a dded fiber improves bowel function. Increased bowel movement frequency is bene ficial to individuals with C KD that frequently suffer from constipation. An increase in fiber may also lowe r the risk for common co -morbidities of CKD. Limitations The sample size of the study was relatively sma ll. In addition, only a certain criteria of individuals were allowed to pa rticipate in this sp ecific study design. Diets of other types of individuals should also be resear ched. Diets with known basal levels of fat and vitamin D intake and close attention to the change s in dietary intake during trea tment phase could prove useful. Individuals with CKD require speci al dietary attention and due to their strict intakes could also make superior participants for other studies regarding fiber. Diet recalls were returned a week after completion leaving room for error in measurements and room for discrepancies of amounts and types of food actually consumed. Therefore, participant cooperation and error could have resulted in inaccuracies of the actual amount of fiber that could have been consumed. However, this f actor could have been controlled since each individual likely made similar estimates or errors during baseline and treatment periods of their own consumption. More information should be sought regarding th e different types of fibers (soluble vs. insoluble) as well as different forms of fiber (dietary vs. added) affect on gastrointestinal functioning and metabolism. The selection of fibe r type could result in different findings of

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! (* bowel frequency, as well macronutrients and micronut rients interactions. Th erefore, more studies focusing on different types of fiber in addition to using different tech niques for dietary recall could prove beneficial. Overall, the impacts of fiber cl early need more research. As fiber is found to change even more macronutrient and micronutrient intakes, it is obvious it has a profound affect on consumption and metabolism. Simultaneously, as fiber found naturally in foods is decreasing, research and creation of fiber al ternatives (as found in added fi ber foods) will be indispensable.

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! (+ References 1. Institute of Medicine (IOM). (2002). Dietary Re ference Intakes for Energy, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. The National Academies Press: Washington, DC. 2. J. Anderson, Colorado State University Extensi on foods and nutrition specialist and professor; S. Perryman, Extension foods and nutrition specia list; and L. Young, former foods and nutrition graduate student.12/98. Reviewed and revised by K. Topham, CSU food science and human nutrition graduate student. 12/10. 3. W. Dahl, S. Whiting, A. Healey, et al. Increas ed stool frequency occurs when finely processed pea hull fiber is added to usual foods consumed by elderly resident in long-term care. J Am Diet Assoc; 103:1199-1202 (September, 2003). [Corresp ondence: Susan J. Whiting PhD, Professor, College of Pharmacy and Nutrition, University of Saskatchewan, 110 Science Place, Saskatoon SK S7N 5C9 Canada. 4. Raninen K, Lappi J, MykkŠnen H, Poutanen K. Dietary fiber type reflects physiological functionality: comparison of grain fiber, inulin, and polydextrose. Nutr Rev. 2011 Jan;69(1):9-21. doi: 10.1111/j.1753-4887.2010.00358.x. Review. PubMed PMID: 21198631. 5. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. Am J Clin Nutr 1999;69:30-42. 6. Keenan JM, Pins JJ, Frazel C, Moran A, Turnquis t L. Oat ingestion reduces systolic and diastolic blood pressure in patients with mild or border line hypertension: a pilot trial. J Fam Pract 2002;51:369. 7. Anderson JW, Randles KM, Kendall CW, Jenkins DJ Carbohydrate and fiber recommendations for individuals with diabetes: a quantitative assess ment and meta-analysis of the evidence. J Am Coll Nutr 2004;23:5-17. 8. Mitch WE. Dietary protein restriction in chronic renal failure: nutritional efficacy, compliance, and progression of renal insufficiency J Am Soc Nephrol 1991;2:823-31. 9. Romero AL, Romero JE, Galaviz S, Fernandez ML Cookies enriched with psyllium or oat bran lower plasma LDL cholesterol in normal and h ypercholesterolemic men from Northern Mexico. J Am Coll Nutr. 1998 Dec;17(6):601-8. PubMed PMID: 9853540. 10. National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Report of the National Cholesterol Education Program Expert Panel on detection, evaluation and treatme nt of high blood cholesterol in adults. Arch Intern Med 148: 3669, 1993. 11. Jenkins DJ, Vuksan V, Kendall CW, WŸrsch P, Jeffcoat R, Waring S, Mehling CC, Vidgen E, Augustin LS, Wong E. Physiological effects of resistant starches on fecal bulk, short chain fatty acids, blood lipids and glycemic index. J Am Coll Nutr. 1998 Dec;17(6):609-16. PubMed PMID: 9853541 12. de Munter JS, Hu FB, Spiegelman D, Franz M, van Dam RM. Whole grain, bran, and germ intake and risk of type 2 di abetes: a prospective cohort study and systematic review. PLoS Med. 2007 Aug;4( 8):e261. PubMed PMID: 17760498; PubMed Central PMCID: PMC1952203. 13. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Mactronutrients). Washingt on, D.C.: The National Academies Press, 2005. 14. Moshfegh AJ, Friday JE, Goldman JP, Ahuja JK. Pr esence of inulin and oligofructose in the diets of Americans. J Nutr 1999;129:1407S-11S.

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! (" Table 1. Participant Demographics ID Gender (F/M) Ethnicity Race Age (yrs) FS001 F Non-Hispanic White 70 FS002 M Black 54 FS003 M White 65 FS004 F Non-Hispanic White 66 FS005 M Polish-Ukrainan White 86 FS006 M Black 80 FS007 F Black 75 FS008 F Non-Hispanic White 31 FS009 F Non-Hispanic White 41 FS010 M Non-Hispanic White 70 FS011 F White 79 FS012 F White 61 FS013 M Non-Hispanic White 75 FS016 F White 72 FS017 F Non-Hispanic Black 62 6615

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! (# Table 2. Macronutrients baseline and treatment Baseline Energy Treatment Energy Baseline Carbohydrates Treatment Carbohydrates Baseline Protein Treatment Protein Baseline Fat Treatment Fat Baseline Fiber Treatment Fiber FS001 1295126 1303132 18515 2171248174214431376 7.8229.82 FS002 18671165 1494597 203109 173918563793569125110 1512149 FS003 1759196 1854361 21283 268126772568469446227 813718 FS004 1361353 1666463 22946 229463216281241214732 81264 FS005 1722252 1975543 18053 2514160291113474206529 137334 FS006 1531102 1381192 18039 1932556762136334417 83302 FS007 1774334 1917143 20783 294357215484758693 122364 FS008 2185569 1945282 293144 275265229663483256911 1310256 FS010 1579587 941339 21657 1559450242694318184 1322018 FS011 1717992 1489273 244136 23053362034467445419 99205 FS013 1819553 1594706 23131 249101683060407441 97189 FS016 1372345 1350131 18333 193336817442144174716 137294 Mean SD 1665253 1576313 21433 227435916562457214720 113267 P value 0.28 0.29 0.62 0.005 4.67E-05 ! !

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! ($ Table 3. Micronutrients baseline and treatment Baseline Phosphorous Treatment Phosphorous Baseline Vitamin D (IU) Treatment Vitamin D (IU) Baseline Iron Treatment Iron Baseline Calcium Treatment Calcium Baseline Potassium Treatment Potassium FS001 37965 430165 18315 37907.41 .116.41.436711340642 898136 1235570 FS002 895652 817402 15023 282713 815727975426163 1205746 815310 FS003 1047134 1815219 147117 26424313.51. 413.78.5840182564349 1815219 1406613 FS004 456169 243119 8431 111967.7 2.17.93.828058299160 1256284 640231 FS005 843352 124847 67112 15579.34 .015.31.83391941078134 23562 31021 FS006 50077 703100 8340 27121518.65. 411.11.02515346943 918131 1535422 FS007 1064129 54332 32362 2182715.9 2.710.8.5110266602145 14428 658 FS008 630521 1096610 4754 1211777.06. 011.95.4261255680438 599511 1711544 FS010 887349 32266 332123 33017911.5 2.211.7.9864342454111 29161524 1040521 FS011 410125 612288 6217 115438.5 6.87.91.342511069670 880689 834176 FS013 749215 978761 17395 4663612.92. 725.07.5525183684177 19571507 13431038 FS016 52890 668267 8874 345812.73. 617.11.636195912 15459 14328 Mean SD 699236 790442 14596 23413111.53.6 13.64.7464312535251 1081826 923551 P value 0.44 0.04 0.22 0.50 0.47 !

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! (% Table 4. Bowel Movement Frequency per day Baseline Treatment Bowel movements/dayBowel movements/day FS001 0.81.8 FS002 1.81.6 FS003 1.21.3 FS004 0.71.0 FS005 2.12.3 FS006 Not reportedNot reported FS007 0.50.9 FS008 1.1Not reported FS009 1.41.1 FS010 0.91.2 FS011 1.42.4 FS012 Not reportedNot reported FS013 0.70.7 FS014 1.1Not reported FS015 Not reportedNot reported FS016 2.83.2 FS017 0.50.6 Average SD 1.2 0.7 1.5 0.7

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! (& Appendix A Food Record Please be as specific as possible when recording foods and beverage s. Include types of breads (wheat, rye, etc), preparations of foods (grilled, raw, canne d, etc), any added dressings or condiments, or brand names when applicable. A meal will require more than one entry if multiple foods were eaten. Date Time Type of Meal or Snack Food Eaten (include preparation, brand names, or specific types of bread where applicable) Amount of Food Eaten (cups, ounces, number of items, etc) Additional Notes or Comments

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! (' Appendix B Daily Diary Date:_________________ Study #___________ 1. How many bowel movements did you have today? 0 1 2 3 4 5 >6 2. Did you experience diarrhea today? yes no 3. Did you take laxative today? yes no 4. Are you currently taking antibiotics? yes no 5. Did your medication change? yes no 6. How many servings of study foods did you consume today? 0 1 2 3 4 5 >6 7. Did you consume a fiber supplement today? If so, what did you take?



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Increasing Fiber Intakes of Patients with Chronic Kidney Disease: Impact on Gastrointestinal Function and Nutrient Intakes Student: Jessica Watson UFID: Food Science and Human Nutrition: Nutrition Major and CLAS Biology Major International Development and Humanitarian Assistance Minor Phone: 561-308-6517 Email: jhwatson@ufl.edu Faculty Mentor: Wendy Dahl, PhD Assistant Professor Food Science and Human Nutrition Department and Center for Nutritional Sciences University of Florida Phone: 352-392-1991 ext. 224 Email: wdahl@ufl.edu Honors Coordinator: Anne Kendall, PhD Senior Lecturer Food Science and Human Nutrition Department University of Florida Email: kendall@ufl.edu

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Abstract As todays population strays further from wholesome foods to the fast food Western diet, the consumption of the Adequate Intake of fiber, set by the National Academies Institute of Medicine (21 to 25 g for women and 30 to 38 g for men), is rarely met. Current estimation of dietary fiber intake in the general population is half of the Adequate Intake (AI) recommendation (5). Individuals with Chronic kidney disease (CKD) may have even further reduced dietary fiber intake due to diet restriction and/or poor appetite. CKD may lead to serious co-morbidities and side effects such as constipation and inadequate nutrient intake. The purpose of this study was to determine the impact of individual-packaged, commercial-available cookies, snack bars and cereal foods with added fiber on patients bowel movement frequency and nutrient intake. Consenting adults with CKD (n = 15; 9F, 6M; 66 15 y) were provided with cereal, cookies and snack bars without added fiber for 2 weeks, followed by similar foods providing 23 g/d of fiber (pea hull, inulin, and soluble corn fiber) for 2 weeks. Control and treatment 3-day food records (analyzed using Food Processor) were collected. Mean fiber intake increased from 11.8 3.2 to 22.4 7.0 g/d (p < 0.001) with no change in energy or protein intake. However, a decrease in fat (p < 0.01) and an increase in vitamin D (p < 0.05) were seen with added fiber. Daily bowel movement frequency increased from 1.2 0.7 to 1.5 0.7 (p < 0.05). Providing foods with added functional fiber effectively increases fiber intake as well as bowel movement frequency in individuals with CKD without impacting energy intake.

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Table of Contents Introduction a. Defining Fiber 1 b. Fibers Role in Maintaining Health 1 c. Adequate Intake of Fiber 2 d. Chronic Kidney Disease 3 e. Study Aims 4 Methods and Materials a. Participants 5 b. Study Protocol 5 c. Diet Treatment 6 d. Assessment Tools 6 Results 6 Discussion 7 References 11 Table 1. Participant Demographics 12 Table 2. Macronutrients baseline and treatment 13 Table 3. Micronutrients baseline and treatment 14 Table 4. Bowel movement frequency per day 15 Appendix A. Food Record 16 Appendix B. Daily Diary 17

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Introduction a. Defining Fiber Fiber could be defined as the substance in plants that is indigestible by the human enzymes. However, the Dietary Guidelines from 2010 more specifically defines dietary fiber as the non-digestible form of carbohydrates and lignin in plants that helps provide a feeling of fullness and promotes healthy laxation (1). In addition, the Institute of Medicine defines total fiber as the sum of dietary and added fiber. Dietary fiber consists of indigestible carbohydrates and lignin present naturally in plants while added fiber consists of isolated, indigestible carbohydrates with beneficial physiological effects in humans (1). Fiber exists in two forms: soluble and insoluble, each with separate, yet similar benefits. Soluble fiber forms a gel-like substance when bound to water. It binds to fat and slows gastric emptying. Soluble fiber includes pectin and gums (2) and can be found in oat bran, beans, fruit and vegetables. Insoluble fiber decreases transit time and increases fecal bulk, promoting healthy bowel movements. Insoluble fiber includes cellulose, hemicellulose, and lingin. These are found in wheat, whole grains, beans and vegetables, especially skins (2). In addition to dietary fiber, supplemental fiber is now commonly found in food. This functional fiber is added to naturally found nutrients in food. It is unknown if added fiber has the same effects as dietary fiber (1). Some known added fibers are pea hull, inulin, and polydextrose. Studies have shown an increase in fecal bulk with the use of pea hull fiber (3). This has been used to increase bowel frequency in individuals suffering from constipation. Similarly, inulin and polydextrose are on the rise as supplemental fibers demonstrating many of the same functionalities of grain fiber, such as being fermentable and laxatives (4).

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! Role in Maintaining Health Fiber has been the focus of many recent studies due to its contributions to health. Fiber has been associated with reduction in cholesterol levels (5), lowering blood pressure (6), improved blood glucose control in diabetics (7), and promotion of regularity (8). The viscosity of fiber, increasing the excretion of cholesterol and bile salts, works to lower cholesterol, thus lowering the risk of coronary heart disease (9,10). Soluble fiber can promote the integrity and immunity of the intestine by providing resident intestinal bacteria with nutrients to produce short chain fatty acids (11). In addition, non-fermentable fiber adds to fecal bulk and decreased transit time that contributes to bowel movement frequency. A diet high in fiber can help improve the common complaint of constipation. In addition, bowel movement frequency is associated with a decrease risk in colon cancer, constipation, and hemorrhoids (2). Fibrous foods, such as fruits, vegetables, and whole grains, are usually low-calorie dense and can improve weight loss, weight maintenance, and may be associated with a decreased risk of type 2 diabetes (1). Reduction in caloric intake caused by longer feelings of satiety and glucose regulation is also associated with fighting obesity and type 2 diabetes (12). It is not difficult to see how fiber acts through co-morbidities to affect various realms of health. Obesity, high cholesterol, type 2 diabetes, and other associations of a low fiber diet contribute to comorbidities. Clearly the appropriate intake of fiber is important in maintaining a healthy diet, gastrointestinal tract and life. c. Adequate Intake of Fiber Current dietary intakes of individuals in the United States rarely meet the necessary intake of fiber. The AMA most recent 2010 Dietary Recommendations state that the daily

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! # recommended intake of fiber for an adult consuming 2000 calories is 25 grams. The Institute of Medicine Adequate Intake (AI) recommendation is 14 grams per 1000 calories consumed (1). This corresponds to approximately 38 grams a day for men and 25 grams a day for women (13). Current estimation of dietary fiber intake in the general population is half of the AI recommendation (14). The commonly found refined grains consumed in the Western diet, now enriched with some vitamins, still lack the enrichment of fiber. The fiber content of a food is listed in grams and as a percentage of the daily value on nutrition labels. Special attention should be paid to nutrition labels, as even foods marketed to have grains dont always contain fiber. Eating a diet high in fruits, vegetables, beans, and whole grains will help raise the amount of fiber obtained in the diet (1). d. Chronic Kidney Disease One of the most costly co-morbidities of diabetes and hypertension, in terms of health care expenditures and patient quality of life, is that of chronic kidney disease (CKD). With the progression of CKD, abnormalities in fluid and electrolyte balance develop as well as uremic syndrome, where patients have high levels of blood urea (and other waste products from protein metabolism). Symptoms of uremic syndrome include fatigue, intense itching, anorexia (loss of appetite) and slowed thinking. The current nutrition therapy for CKD has serious limitations and patient compliance with the diet is poor. The recommended diet for CKD focuses on moderate protein intake and recommends protein of high biological value to reduce blood urea nitrogen levels. However, this recommendation may contribute to the malnutrition seen in many individuals, as they progress to end-stage renal failure. Restricted sodium, restricted phosphorus and high calcium intake are required, since with the loss of kidney function, electrolyte, mineral and fluid balance are disrupted. High phosphorus

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! $ foods must be restricted. These include primarily dairy products, beans, bran cereals and whole grains. Limitations on potassium intake for some patients necessitate the exclusion of beans and milk, as well as nuts and many fruits and vegetables. The restriction of beans, whole grains and many fruits and vegetables leaves a diet seriously depleted of dietary fiber, potentially leading to constipation and inadequate fermentable substrate for colonic and general health. Although it is recommended that CKD patients consume diets high in fiber, no kidney disease diet recommendations provide guidelines as to how to achieve this recommendation. Little research has been carried out on fiber supplementation of patients with CKD. Isolated fiber fractions, unlike wheat bran, are low in phosphorous (and potassium) and would, therefore, be appropriate fiber sources for those prescribed a diet for the management of CKD. e. Study Aims Research questions: 1. Does providing usual foods with added fiber result in increase fiber intakes in chronic kidney disease patients? 2. Does providing usual foods with added fiber result in increased bowel movement frequency? 3. Does providing usual foods with added fiber affect energy, macronutrient and micronutrient intake in chronic kidney disease patients? If there is participant compliance, it is anticipated that providing fiber-supplemented food will be matched with an increase in fiber found in dietary intake. In accordance with the functions of fiber, it is anticipated that an increase in fiber will result in an increase in bowel movement frequency in patients with CKD. It is not known if added fiber will decrease energy and nutrient intake of patients with CKD.

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! % Methods and Materials a. Participants Patient with Chronic Kidney Disease participated in this study. Due to their condition, they have diets lacking in fiber. Participants were 18 and older, with GFR of 50 mL/min/1.73 m2 (stage 3 through 5 but who are not on dialysis), are not diagnosed with acute kidney injury (AKI) or glumerulonephritis (GN), and are not on immunosuppressant medications. Participants must be able to understand, verbalize, and sign the informed consent (in English). Patients who are scheduled to have transplant or dialysis in 3 months of the study initiation, history of liver disease, dialysis, have undergone renal transplantation, are taking probiotic supplements and are unwilling to discontinue, lactating, active gastrointestinal bleeding, on steroids, or had a change in medications over the past 4 weeks were not able to participate in the study. b. Study Protocol The methods followed the protocol of the An investigation into pulse fiber fermentation and nitrogen excretion in patients with chronic renal failure (IRB1 # 16-2010). Research volunteers were asked to complete a 3-day food record in week 1 of the study and during week 6 of the study. Food records were analyzed for fiber and other nutrients using Food Processor. Study volunteers completed a daily questionnaire with questions regarding such aspects of gastrointestinal health such as bowel movement frequency and occurrence of diarrhea. Relationships among fiber intake, gastrointestinal health and overall nutrient intake will be assessed. Participants consumed the control (baked goods and cereals with no added fiber) or fiber treatment (baked goods and cereals with added fiber). The study consisted of two phases. Phase 1 was the control period in which 20 participants consumed the baked goods and cereals with no

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! & added fiber for 2 weeks, which will serve as a baseline period for all participants. Participants attended clinic visits two times during each phase. Phase 2 started immediately after Phase 1 with the introduction of fiber supplemented (treatment) foods. Foods were given to patients at the clinic during weeks 2 and 4. c. Diet Treatment For the control periods, individual-packaged, commercial-available cookies, snack bars and cereal (4 servings/day) were provided to the participants. For the treatment period, individual-packaged, commercial-available cookies, snack bars and cereal (4 servings/day), containing 23 g of isolated fiber per day, were provided to the participants. Foods to be used in this study were fortified with pea hull, inulin, and corn soluble fiber. d. Assessment Tools Daily Journal A daily journal was used to assess bowel frequency and changes in patients' medications. (Appendix A) Food records Participants were provided a food diary to record their 3-day intakes. (Appendix B) Three-day food records were assessed (using Food Processor, ESHA Research Inc., Salem, OR) for nutrients and energy intake according to study design. Results Demographics Table 1 shows the demographics of study participants. Seventeen individuals were consented for the study with 15 completing the study. There were 6 males and 9 females between the ages of 31 to 86 years. Of these fifteen, only twelve completed dietary recalls.

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! Macronutrient and Micronutrient Baseline vs. Treatment Table 2 shows the macronutrient intakes (mean SD) of participants before and after fiber treatment. Energy, protein and carbohydrate intakes did not change (NS). However, fiber increased (p < 0.001) and fat decreased (p < 0.01) with the fiber intervention. Table 3 shows micronutrient intakes of participants before and after fiber treatment. The figure shows the mean SD for iron, calcium, phosphorus, potassium, and vitamin D. Significant changes in micronutrient intakes before and after fiber treatment were not found, with the exception of vitamin D that showed an increase during the fiber treatment period (p < 0.05). Bowel Movement Frequency Table 4 represents the amount of bowel movement frequencies recorded before and after fiber treatment. Daily bowel movement frequency increased from 1.2 0.7 to 1.5 0.7 (p < 0.05). Discussion In previous studies, an increase in certain fiber types has shown a change in energy intake. This could be harmful or helpful to an individual depending on their needs. While a decrease in the consumption of energy could prove beneficial to an obese patient, it could also be detrimental to a sick patient needing to maintain a high caloric intake. Individuals with CKD, at a high risk of malnutrition, require a need to benefit from the addition of added fiber without a decrease in energy. The fiber-containing foods administered to the participants contained pea hull, inulin, and corn soluble fiber. This composition of fiber included not only the bulking component of pea hull but also inulin, which has been seen to increase satiety. Satiety was not measured, however, no decrease in average energy intake was found indicating satiety may be been unaffected.

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! () However, as seen in Table 4, an overall increase in added fiber did correspond to increase in bowel movement frequency. Bowel movement frequency while maintaining energy intake shows the beneficial impact for individuals with CKD that may suffer from constipation and high risk for malnutrition. The administered added fiber during treatment phase increased fiber intake in the diet of participants. Of the 12 food-recall participants, none had met the AI for fiber before treatment. After the treatment phase, eight participants met the AI for fiber. This was seen with an absence in energy and protein change, but a decrease in fat intake. Of the micronutrients analyzed, only vitamin D had a significant change before and after treatment. Conclusion The noticeable jump in fiber during the treatment phase proves that reaching the AIs is attainable. Just by eating the administered 4 servings of fiber added foods a day, participants fiber jumped drastically. More research and technology should be applied to the creation of fiber rich foods in order to make them available to all individuals. Fiber is an important component of every persons diet and results in positive impacts on daily life as well as disease reduction. This is reason enough to gain more knowledge in the realm of dietary and added fiber. The additional potential benefits seen from this study also require more research. Although an increase in fiber during the treatment phase was not seen to affect energy intake, it impacted other aspects of diet, specifically vitamin D and fat. Individuals with CKD need to maintain their energy intakes and may have difficulties maintaining other necessary nutrients. It is advantageous that these individuals are able to improve symptoms without affecting other intakes. The increase in vitamin D found with an increase in fiber could be beneficial to some individuals (those with low bone density). More research regarding the affect of fiber on fat

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! (( intake as well as vitamin D intake could prove useful. The types of fiber used in treatment could have unknown impacts on these nutrients that could aid in designing dietary intakes of not only individuals with CKD, but other diseases as well. The overall increase in fiber with treatment resulted in an increase in bowel movement frequency proving that providing foods with added fiber improves bowel function. Increased bowel movement frequency is beneficial to individuals with CKD that frequently suffer from constipation. An increase in fiber may also lower the risk for common co-morbidities of CKD. Limitations The sample size of the study was relatively small. In addition, only a certain criteria of individuals were allowed to participate in this specific study design. Diets of other types of individuals should also be researched. Diets with known basal levels of fat and vitamin D intake and close attention to the changes in dietary intake during treatment phase could prove useful. Individuals with CKD require special dietary attention and due to their strict intakes could also make superior participants for other studies regarding fiber. Diet recalls were returned a week after completion leaving room for error in measurements and room for discrepancies of amounts and types of food actually consumed. Therefore, participant cooperation and error could have resulted in inaccuracies of the actual amount of fiber that could have been consumed. However, this factor could have been controlled since each individual likely made similar estimates or errors during baseline and treatment periods of their own consumption. More information should be sought regarding the different types of fibers (soluble vs. insoluble) as well as different forms of fiber (dietary vs. added) affect on gastrointestinal functioning and metabolism. The selection of fiber type could result in different findings of

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! (* bowel frequency, as well macronutrients and micronutrients interactions. Therefore, more studies focusing on different types of fiber in addition to using different techniques for dietary recall could prove beneficial. Overall, the impacts of fiber clearly need more research. As fiber is found to change even more macronutrient and micronutrient intakes, it is obvious it has a profound affect on consumption and metabolism. Simultaneously, as fiber found naturally in foods is decreasing, research and creation of fiber alternatives (as found in added fiber foods) will be indispensable.

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! (+ References 1. Institute of Medicine (IOM). (2002). Dietary Reference Intakes for Energy, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. The National Academies Press: Washington, DC. 2. J. Anderson, Colorado State University Extensi on foods and nutrition specialist and professor; S. Perryman, Extension foods and nutrition specialist; and L. Young, former foods and nutrition graduate student.12/98. Reviewed and revised by K. Topham, CSU food science and human nutrition graduate student. 12/10. 3. W. Dahl, S. Whiting, A. Healey, et al. Increased stool frequency occurs when finely processed pea hull fiber is added to usual foods consumed by elderly resident in long-term care. J Am Diet Assoc; 103:1199-1202 (September, 2003). [Correspondence: Susan J. Whiting PhD, Professor, College of Pharmacy and Nutrition, University of Saskatchewan, 110 Science Place, Saskatoon SK S7N 5C9 Canada. 4. Raninen K, Lappi J, Mykknen H, Poutanen K. Dietary fiber type reflects physiological functionality: comparison of grain fiber, inulin, and polydextrose. Nutr Rev. 2011 Jan;69(1):9-21. doi: 10.1111/j.1753-4887.2010.00358.x. Review. PubMed PMID: 21198631. 5. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. Am J Clin Nutr 1999;69:30-42. 6. Keenan JM, Pins JJ, Frazel C, Moran A, Turnquist L. Oat ingestion reduces systolic and diastolic blood pressure in patients with mild or borderline hypertension: a pilot trial. J Fam Pract 2002;51:369. 7. Anderson JW, Randles KM, Kendall CW, Jenkins DJ Carbohydrate and fiber recommendations for individuals with diabetes: a quantitative assessment and meta-analysis of the evidence. J Am Coll Nutr 2004;23:5-17. 8. Mitch WE. Dietary protein restriction in chronic renal failure: nutritional efficacy, compliance, and progression of renal insufficiency J Am Soc Nephrol 1991;2:823-31. 9. Romero AL, Romero JE, Galaviz S, Fernandez ML. Cookies enriched with psyllium or oat bran lower plasma LDL cholesterol in normal and hypercholesterolemic men from Northern Mexico. J Am Coll Nutr. 1998 Dec;17(6):601-8. PubMed PMID: 9853540. 10. National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Report of the National Cholesterol Education Program Expert Panel on detection, evaluation and treatment of high blood cholesterol in adults. Arch Intern Med 148: 3669, 1993. 11. Jenkins DJ, Vuksan V, Kendall CW, Wrsch P, Jeffcoat R, Waring S, Mehling CC, Vidgen E, Augustin LS, Wong E. Physiological effects of resistant starches on fecal bulk, short chain fatty acids, blood lipids and glycemic index. J Am Coll Nutr. 1998 Dec;17(6):609-16. PubMed PMID: 9853541 12. de Munter JS, Hu FB, Spiegelman D, Franz M, van Dam RM. Whole grain, bran, and germ intake and risk of type 2 diabetes: a prospective cohort study and systematic review. PLoS Med. 2007 Aug;4(8):e261. PubMed PMID: 17760498; PubMed Central PMCID: PMC1952203. 13. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Mactronutrients). Washington, D.C.: The National Academies Press, 2005. 14. Moshfegh AJ, Friday JE, Goldman JP, Ahuja JK. Presence of inulin and oligofructose in the diets of Americans. J Nutr 1999;129:1407S-11S.

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! (" Table 1. Participant Demographics ID Gender (F/M) Ethnicity Race Age (yrs) FS001 F Non-Hispanic White 70 FS002 M Black 54 FS003 M White 65 FS004 F Non-Hispanic White 66 FS005 M Polish-Ukrainan White 86 FS006 M Black 80 FS007 F Black 75 FS008 F Non-Hispanic White 31 FS009 F Non-Hispanic White 41 FS010 M Non-Hispanic White 70 FS011 F White 79 FS012 F White 61 FS013 M Non-Hispanic White 75 FS016 F White 72 FS017 F Non-Hispanic Black 62 6615

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! (# Table 2. Macronutrients baseline and treatment Baseline Energy Treatment Energy Baseline Carbohydrates Treatment Carbohydrates Baseline Protein Treatment Protein Baseline Fat Treatment Fat Baseline Fiber Treatment Fiber FS001 1295126 1303132 18515 2171248174214431376 7.8229.82 FS002 18671165 1494597 203109 173918563793569125110 1512149 FS003 1759196 1854361 21283 268126772568469446227 813718 FS004 1361353 1666463 22946 229463216281241214732 81264 FS005 1722252 1975543 18053 2514160291113474206529 137334 FS006 1531102 1381192 18039 1932556762136334417 83302 FS007 1774334 1917143 20783 294357215484758693 122364 FS008 2185569 1945282 293144 275265229663483256911 1310256 FS010 1579587 941339 21657 1559450242694318184 1322018 FS011 1717992 1489273 244136 23053362034467445419 99205 FS013 1819553 1594706 23131 249101683060407441 97189 FS016 1372345 1350131 18333 193336817442144174716 137294 Mean SD 1665253 1576313 21433 227435916562457214720 113267 P value 0.28 0.29 0.62 0.005 4.67E-05 ! !

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! ($ Table 3. Micronutrients baseline and treatment Baseline Phosphorous Treatment Phosphorous Baseline Vitamin D (IU) Treatment Vitamin D (IU) Baseline Iron Treatment Iron Baseline Calcium Treatment Calcium Baseline Potassium Treatment Potassium FS001 379 430 183 3797.4.116.4.4367406 898 1235 FS002 895 817 150 2813815279426 1205 815 FS003 1047 1815 147 26413.5.413.7.5840564 1815 1406 FS004 456 243 84 1117.72.17.9.8280299 1256 640 FS005 843 1248 67 1559.3.015.3.83391078 235 310 FS006 500 703 83 27118.6.411.1.0251469 918 1535 FS007 1064 543 323 21815.92.710.8.51102602 144 65 FS008 630 1096 47 1217.0.011.9.4261680 599 1711 FS010 887 322 332 33011.52.211..9864454 2916 1040 FS011 410 612 62 1158.56.87.9.3425696 880 834 FS013 749 978 173 46612.9.725.0.5525684 1957 1343 FS016 528 668 88 34512.7.617.1.63659 154 143 Mean SD 699 790 145 23411.5.613.6.7464535 1081 923 P value 0.44 0.04 0.22 0.50 0.47 !

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! (% Table 4. Bowel Movement Frequency per day Baseline Treatment Bowel movements/dayBowel movements/day FS001 0.8 1.8 FS002 1.8 1.6 FS003 1.2 1.3 FS004 0.7 1.0 FS005 2.1 2.3 FS006 Not reported Not reported FS007 0.5 0.9 FS008 1.1 Not reported FS009 1.4 1.1 FS010 0.9 1.2 FS011 1.4 2.4 FS012 Not reported Not reported FS013 0.7 0.7 FS014 1.1 Not reported FS015 Not reported Not reported FS016 2.8 3.2 FS017 0.5 0.6 Average SD 1.2 0.7 1.5 0.7

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! (& Appendix A Food Record Please be as specific as possible when recording foods and beverages. Include types of breads (wheat, rye, etc), preparations of foods (grilled, raw, canned, etc), any added dressings or condiments, or brand names when applicable. A meal will require more than one entry if multiple foods were eaten. Date Time Type of Meal or Snack Food Eaten (include preparation, brand names, or specific types of bread where applicable) Amount of Food Eaten (cups, ounces, number of items, etc) Additional Notes or Comments

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! (' Appendix B Daily Diary Date:_________________ Study #___________ 1. How many bowel movements did you have today? 0 1 2 3 4 5 >6 2. Did you experience diarrhea today? yes no 3. Did you take laxative today? yes no 4. Are you currently taking antibiotics? yes no 5. Did your medication change? yes no 6. How many servings of study foods did you consume today? 0 1 2 3 4 5 >6 7. Did you consume a fiber supplement today? If so, what did you take?