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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.