SAVOR THE FLAVOR WITH LESS SODIUM: REDUCING SODIUM IN HOME

DELIVERED AND CONGREGATE MEALS. Kim La Croix, MPH, RD

Juliana Pearl-Beebe, RD Oregon State HospitalMarci Brown-McMurphy, CAPECO AAA

Outline

Overview of sodium and health National and state requirements for

sodium intake in home delivered and congregate meal settings

Tips for successful implementation of sodium reduction strategies

Case examples: OSH, CAPECO

Sodium Reduction: A Public Health Imperative

Excess sodium intake leads to hypertension Nearly 1 in 3 U.S. adults has hypertension (68 million

people) Middle-aged and older men and women have a 90%

lifetime risk of developing hypertension More than 1 in 2 people with hypertension do not

have it under control In observational studies, the rise in blood

pressure in response to higher sodium intake increases with age and older adults have been found to be more responsive to changes in sodium intake

Vital Signs: MMWR 2011; 60(4):1-3–8 Vasan, et al. JAMA 2002;287:1003–1010

Sodium Guidelines

Dietary Guidelines for Americans 1,500 mg sodium per day (500 mg/meal)

for individuals age 70 and older Oregon Congregate and HDM

FY 2015 = an average of 1200 mg/meal FY 2015 is from July 1, 2014 through June 30,

2015 FY 2013 was 1500 mg/meal FY 2014 is 1350 mg/meal

44% of U.S. Sodium Intake,10 Types of Food

Sodium Levels for the Same FoodCan Vary Widely

Schenectady County, NY

Menu Planning Tips

Prepare foods without adding salt in the cooking process Use herbal seasoning to replace salt Encourage using oil and vinegar as the preferred salad

dressing Provide at least one low-sodium salad dressing option Establish policies and procedures for purchasing

healthful foods that incorporate the sodium guidelines Working with food purveyors to purchase lower sodium

foods. If a menu item is high in sodium, the rest of the menu

items for the day are “fresh cooked food” items vs. processed food. For example: fresh fruit for dessert

Supporting Tips

Provide nutrition education on the health impact of sodium intake on older adults

Place an icon denoting a high sodium ingredient or item on the menu

Employing a “stealth health” approach to sodium reduction and balancing flavors

Shared Goal: Reducing sodium with no change or minimal change to consumer food experiences or choices.

DASH AT THE STATE HOSPITAL,

REDUCING SODIUM IN A RESIDENTIAL MEDICAL HOME

MODEL Juliana Pearl-Beebe, RDN

Clinical Dietitian at Oregon State Hospital

Oregon State Hospital

Aka: OSH Forensic Psychiatry

Majority of our patients fall under this category

1. not stable enough to go to court, or:2. have been found Guilty Except Insanity for a

crime Civil Commitments

Danger to self or others Court order for psychiatric care

Meals at OSH

Production kitchen begins preparation Satellite kitchens in the living areas finish

cooking No tray service

Exception: medical unit Patients go to their area dining center for

meals Cafeteria style with some choice Portion controlled

DASH

• Dietary• Approaches to• Stop• Hypertension• Aka: high blood pressure

DASH Studies

Reducing sodium = lowered blood pressure The lower the sodium = the lower the blood pressure Blood pressures were lowest on the DASH Eating plan

Most dramatic results:DASH eating plan with a 1,500 mg sodium limit

DASH Studies:

1Daily Nutrient Goals for a 2,100 calorie plan• Total fat: 27% of calories• Saturated fat: 6%

• Protein: 18% of calories• Carbohydrates: 55% of calories• Cholesterol: 150 mg max• Fiber: 30 g

• Sodium: 2,300 mg• Potassium: 4,700 mg• Calcium: 1,250 mg• Magnesium: 500 mg 1, Your Guide to Lowering Your Blood Pressure

With DASH, DASH Eating Plan, U.S. Department of Health and Human Services (2006), (page 5)

We could get complicated but,

DASH is simply… Fruit Vegetables Whole

grains Low fat

dairy/soy Lean meats

High in:Fiber

Low in: SodiumAdded fat &

saturated fat

Added sugar

USDA Food Guide Pyramid

At the time of the DASH Studies, the food guide pyramid was is use:

Compare to DASH Studies Food Guide Pyramid:

Plate Method/MyPlate

When providing diet education, patients are taught the Plate Method or, MyPlate:

Physical Illness in Mental Illness

Higher rates of Metabolic syndrome in the mentally ill. Why?

1. 1Increased cortisol levels in Schizophrenia Higher stress and inflammatory response

2. 2Higher cravings for carbohydrates and sugars in Bipolar Disorder

3. Side effects of antipsychotic medications 4. 3High prevalence of unhealthy lifestyle behaviors:

3Smoking, low physical activity, poor diet, alcohol and substance abuse

3Reduces life expectancy by up to 30 years

1, 2, Toalson, P., R.Ph., Ahmed, S, M.D., Hardy, T, M.D.,, Ph.D., Kabinoff, G., M.D., The Metabolic Syndrome in Patients with Severe Mental Illnesses, Primary Care Companion Journal of Psychiatry 2004;6:152–158 3, Scott, D. BHM, PhD, Happell, B., Ph.D., RN, The High Prevalence of Poor Physical Health and Unhealthy Lifestyle Behaviors in Individuals with Severe Mental Illness

The move towards DASH

Beginning in 2006 Department of Justice expressed concern

over the high number of OSH patients with Metabolic Syndrome. Other concerns led to a plan for a new hospital…

New kitchen plans did not include a tray-line Plan to have buffet service lines How to meet patient’s dietary needs without a tray

line? Patients can see all food options but may not be

allowed to have all of them Potential for conflict and bodily harm!

Metabolic syndrome

Metabolic syndrome is a clustering of risk factors1. Obesity 2. Hypertension3. Glucose intolerance4. High triglycerides 5. Low HDL

3 or more = metabolic syndrome

Strong relationship to disease It’s a matter of WHEN, not if

DASH & Metabolic Syndrome

Example study-three groups Group 1: Control group Group 2: Weight loss diet group

same diet as control (-)500 calories Group 3: DASH group

RESULTS: Per Azadbakht, L., MSC, et al. (2005) “The DASH

diet changed the mean of all components of metabolic syndrome, significantly in both men and women” (pgs. 2826-2827).

Early Response at OSH

2008 deep fat fryers removed Can cuttings for lower sodium products Began reducing added sugar tor recipes Discussed strategies to reduce sodium And…

DASH Plus Choices

In response to Dept. of Justice concerns: March 2010, DASH Plus Choices approved June 21, 2010, DASH Plus Choices became the

standard menu

Regular menu meets therapeutic needs of 95% of

patients at OSH

Estimated total calories: 2200 /day

All areas of the hospital

(except cash for service: café and coffee shop)

DASH Plus Choices

DASH Eating Plan…

Plus Non-DASH holiday meals Weekly dessert at HS snack Additional 1-7 ounces of protein per day

Choices: Patients can choose from all foods on service line Weekly “cheat” meal (w/ DASH available) Weekly dessert with meal Choice to add salt at table*

*New Salt Program

In response to new CMS guidelines: Salt shakers phased out Salt packets available, 1 per meal Each packet = 275 mg of sodium

POSH (OSH-Portland) has been using salt packets for over 1 year Average use of 8 packets per meal for a

census of around 60

DASH Challenges

Before OSH had Computrition-could only follow DASH Eating Plan Adequate for majority of population Meets RDA’s Had to estimate fat, carbs, sodium, etc.

With Computrition: Goal to decrease disease risk in high risk population

Switch from eating plan to meeting actual DASH nutritional goals

Suppliers Challenges Example: we are still looking for a natural peanut butter

which is affordable, acceptable to our population, and not in glass

Results

Initial results in June 2011: Food expenditures decreased by 5%

From 2011 Food Satisfaction Survey Compared with previous surveys: % of

dissatisfaction dramatically decreased Appearance Taste Nutrition Menu Presentation Temperature Variety

Other results

Current trays in February 2014: <35 Majority for geriatrics/neuro 1-2 renal diets 2 gluten free diets

BMI studies demonstrate overall health improvement throughout OSH

Problem #1: Low sodium products are not very good.

Solution: Make entrees and soups from scratch with low sodium/no sodium base products. Example: Soup full of vegetables, protein, and whole

grains made with a low sodium broth base. Bonus: even when labor is calculated in, this solution saves

OSH money (when compared with cost of premade, bought in items)

Warning: many “low sodium” products use potassium chloride in place of sodium chloride: NOT appropriate for dialysis patients

Problem #2: Salt is flavor.

Solution: salt is not a spice. Add spices, herbs, zest, and no salt added

blends to kick up the flavor without salt.

When food is fresh and made from scratch, it doesn’t need a lot of extras to make it taste good.

Working with suppliers

Mostly, OSH purchases ingredients, not products

Legumes are a product OSH must buy in: Truitt Bros. in Salem, Oregon

Available through Food Service of America Locally sourced, sustainable legumes Lower in sodium Rinse legumes after opening to reduce sodium

even more

More on suppliers:

Meat Purchase meats which are not injected

Beef Poultry No Ham: Turkey ham

Cured differently and low in sodium Pork loin

ResourcesAzadbakht, L., MSC. Mirmiran, P., MSC, Esmaillzadeh, A. , MSC, Azizi, T., MD, Azizi, F., MD (2005).

Beneficial Effects of a Dietary Approaches to Stop Hypertension Eating Plan on Features of the Metabolic Syndrome. Diabetes Care, 28(12), 2823-2831.

Co-Occurring Diagnosis. In Psychology Today Diagnosis Dictionary. Retrieved from: http://www.psychologytoday.com/conditions/co-occurring-disorders

Park, T. RN, RM, BNSc, Usher, K. RN, BA, PhD, Foster, K. RN, BN, MA, PhD, (2011). Description of a Healthy Lifestyle Intervention for People with Serious Mental Illness Taking Second-generation Antipsychotics. International Journal of Mental Health Nursing, 20, 428-437.

Scott, D., BHM, PhD, Happell, B., PhD, RN, (2011). The High Prevalence of Poor Physical Healthy and Unhealthy Lifestyle Behaviors in Individuals with Severe Mental Illness. Issues in Mental Health Nursing, 32, 589-597.

Toalson, P., R.Ph., Ahmed, S., MD, Hardy, T. MD, PhD, Kabinoff, G. MD, (2004). The Metabolic Syndrome in Patients with Severe Mental Illnesses. Primary Care Companion Journal of Clinical Psychiatry, 6(4), 152-158.

U.S. Department of Health and Human Services. (2006). Your Guide to Lowering Your Blood Pressure with DASH, DASH Eating Plan. (NIH Publication No. 06-4082). National Institutes of Health, National Heart, Lung and Blood Institute.

Resources

Tips for reducing sodium intake in older adults, “Savor the Flavor with Less Sodium” http://www.cdc.gov/salt/pdfs/sodium_tips_olde

r_adults.pdf.

Provider resources for reducing sodium, “Online Resources: Reducing Sodium in Congregate and Home Delivered Meals” http://www.cdc.gov/salt/pdfs/sodium_resource

s_older_adults.pdf.