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. Author manuscript; available in PMC: 2017 Feb 1.
Published in final edited form as: Rehabil Nurs. 2015 Mar 14;41(3):149–157. doi: 10.1002/rnj.205

Uptake of Dietary Sodium Restriction by Overweight and Obese Patients After Cardiac Revascularization

Lufei Young 1, Susan Barnason 1
PMCID: PMC5111900  NIHMSID: NIHMS827965  PMID: 25772478

Abstract

Purpose

High sodium intake increases the risk of cardiovascular diseases. Cardiac patients are recommended a daily sodium restriction of ≤1,500 mg. The purpose of this article is to describe daily sodium intake and sodium restriction adherence and its correlates in cardiac rehabilitation (CR) program participants following cardiac revascularizations.

Design

This is a descriptive correlational study.

Methods

A subanalysis was performed using the data collected from a randomized controlled trial to determine the effect of a 12-week weight management intervention.

Findings

The average daily sodium intake was 3,020 mg ± 1,134 at baseline, 4,047 mg ±1,517 at 4 months, and 4,399 mg ± 1,722 at 6 months. The adherence rates were 4.8% at baseline and zero at 4 and 6 months. The factors influencing daily sodium intake were identified.

Conclusion

The CR program participants failed to adhere to the sodium restriction guidelines.

Clinical relevance

Rehabilitation nurses need to identify effective strategies to educate CR participants and their family members regarding dietary sodium adherence in CR participants.

Keywords: Cardiac, rehabilitation, older adults

Background

The adverse effects of high sodium intake on morbidity and mortality in people with established cardiovascular disease (CVD) is well documented (Celermajer & Neal, 2013; Mc Causland, Waikar, & Brunelli, 2012; Strazzullo, D’Elia, Kandala, & Cappuccio, 2009; Taylor, Ashton, Moxham, Hooper, & Ebrahim, 2011). Decreased sodium intake reduces subsequent cardiovascular events by as much as 25% (Cook et al., 2007). In a long-term clinical trial, a low sodium intake independently reduced cardiovascular morbidity and mortality (Middeke, 2012). Experimental studies have demonstrated an independent dose–response relationship between sodium intake and blood pressure, a leading risk factor for CVD (Cook, Kumanyika, Cutler, Whelton, & Trials of Hypertension Prevention Collaborative Research Group 2005; Lin et al., 2007; Rambod & Tolouian, 2012; Sacks et al., 2001). When patients with hypertension and prehypertension decreased daily sodium intake to less than 2,300 mg over a 12- to 48-month period, they reduced their systolic blood pressure by 1.2–3.7 mmHg and diastolic blood pressure by 0.7–2.0 mmHg (Trials of Hypertension Prevention Collaborative Research Group, 1997; Appel et al., 2001; China Salt Substitute Study Collaborative Group, 2007; Kumanyika et al., 1993; Lasser et al., 1995).

The prior research supports the association between sodium intake and CVD and the recommended diet modification for patients with known heart disease to restrict dietary sodium intake to ≤1,500 mg/day (Appel et al., 2011; Balady et al., 2011; Lloyd-Jones, Adams, Brown, & Carnethon, 2010; McGuire, 2011). Modification of CVD risk is dependent on patient adherence to specific guideline recommendations. Unfortunately, adherence to sodium restriction guidelines by patients at risk for or with known CVD is low. On the basis of the National Health and Nutrition Examination Survey (NHANES), 69.2% of adult Americans should follow the recommended daily sodium intake of 1,500 mg or less (Centers for Disease Control and Prevention [CDC], 2009); however, 98.8% of adults (N = 12,581) surveyed consumed daily sodium >1,500 mg per day; and 60.4% consumed >3,000 mg per day (Cogswell et al., 2012). There has been little information about the adherence to heart-healthy diet, specifically related to recommended dietary sodium intake guidelines among cardiac patients following cardiac revascularization. Therefore, the purpose of this study was to describe daily sodium intake and explore the correlates of adherence with sodium restriction guidelines in patients following cardiac revascularization and participating in rural cardiac rehabilitation (CR) programs.

The following aims were addressed in this study:

  1. Describe rural CR participants’ average of daily sodium intake at baseline, 4, and 6 months after cardiac revascularization.

  2. Determine the proportion of rural CR participants who adhered to the sodium restriction of 1500 mg or less at baseline, 4, and 6 months after cardiac revascularization.

  3. Examine the factors related to the daily sodium intake in rural CR participants.

Sodium restriction adherence was defined as the ability to initiate and sustain the behavioral change to follow the sodium restriction guideline of daily sodium intake ≤1500 mg. The factors related to daily sodium intake were identified based on Hibbard’s patient activation theory (Hibbard, Stockard, Mahoney, & Tusler, 2004) and Bandura’s social cognitive theory (Bandura, 1997). Hibbard defined patient activation as the degree to which the person is ready, willing, and able to engage in health behavior change and manage his or her own health (Lubetkin, Lu & Gold, 2010). Both Hibbard’s and Bandura’s theories delineate the relationships among behavioral change capabilities (i.e., knowledge, skills, and activation), outcome expectations for behavioral change, self-efficacy for behavioral change, behavioral changes, and the associated health outcomes. These concepts were used to describe and examine the factors influencing sodium restriction adherence.

Methods

Study Design, Setting, and Sample

This was a subanalysis of a study using data collected from a repeated measure experimental study aimed at testing the efficacy of a weight management intervention on weight reduction over time in overweight and obese CR participants following cardiac revascularizations. In the parent study, a sample of 43 adult subjects who had undergone cardiac revascularization were recruited from two Midwestern tertiary hospitals. Subjects recruited were overweight and obese patients who underwent cardiac revascularization (coronary artery bypass surgery [CABS] of percutaneous coronary intervention [PCI]) and were referred to rural community CR programs. For this subanalysis, only subjects from the control group (n = 21) were included to prevent the potential confounding effect of the weight management intervention on daily sodium intake. Data collection took place over a 6-month period. All study procedures were approved by the respective Institutional Review Boards. Subjects gave written informed consent.

Measurements and Instruments

Demographic and Clinical Characteristics

Demographical and clinical information for subjects was obtained at baseline from the medical records and subject interview. Data were comprised of demographic variables (i.e., age, gender, educational level, working status, and marital status), clinical variables (i.e., weight, height, body mass index [BMI], comorbidity), and other variables related to self-management adherence (e.g., health promotion behaviors such alcohol use and smoking).

Daily Sodium Intake

Daily sodium intake, the primary outcome variable, was measured using 3-day food record at baseline (discharge from hospital), 4 and 6 months following the cardiac revascularization procedures. Subjects completed a 3-day food record, a tool commonly used to assess dietary information in cardiac patients (Buscemi et al., 2009; Dunbar et al., 2013; Harton, Narojek, & Solik-Tomassi, 2005; Jungert & Neuhauser-Berthold, 2013; McNeil et al., 2013; Murray et al., 2013; Thiengwiboonwong, Chongsuwat, Temcharoen, Pandii, & Pavadhgul, 2013; Thomas, Ziogas, Yan, Schmitz, & LaFontaine, 1998; Watson et al., 2002). Then the daily sodium intake based on the food diaries was analyzed and computed using the Minnesota Nutrition Data System (V 5.0/35; Center, 1992).

Variables Related to Daily Sodium Intake

Patient activation

Patient activation was measured at baseline, 4, and 6 months following cardiac revascularization, using the Patient Activation Measure (PAM), with a reported reliability (Skolasky et al., 2011) content and construct validity (Hibbard, Mahoney, Stockard, & Tusler, 2005). PAM consists of 13 items (Hibbard et al., 2005). Each item is rated on a four-point Likert response scale ranging from “strongly disagree” to “strongly agree.” The raw scores are summed continuous measure ranging from 13 to 52 (13 = lowest activation, 52 = highest activation). Higher scores are associated with higher level of activation (Hibbard et al., 2004).

Self-Efficacy and Outcome Expectation

Self-efficacy for diet change and outcome expectations were assessed by the Heart-Healthy Eating Self-Efficacy (HHESE) scale at 4 months. The HHESE scale is a 43-item self-report questionnaire. It contains subscales measuring self-efficacy for healthy eating and outcome expectations for healthy eating (Gaughan, 2003). Each item can be rated on a 6-point Likert scale from “least confidence” to “most confidence.” The scale has reported internal consistency of subscales (0.89–0.91) and test–retest reliability with coefficients ranging from 0.85–0.90 (Gaughan, 2003).

Use of Weight Management Strategies

The use of weight management strategies was examined by the Diet and Exercise Self-Management survey at 4 months. The survey is a 43-item questionnaire (Nothwehr, Dennis, & Wu, 2007; Nothwehr & Peterson, 2005), consisting of nine subscales: (1) self-monitoring of diet, (2) food planning strategies, (3) food preparation and buying, (4) portion control, (5) diet management in social interactions, (6) cognitive strategies for maintaining diet behaviors, (7) self-monitoring of activity, (8) activity management in social interactions, and (9) cognitive strategies for maintaining activity behaviors (Nothwehr & Peterson, 2005; Nothwehr et al., 2007). Subjects are asked to recall the frequency of engaging in the weight management strategies using a four-point Likert scale ranging from “almost never” to “almost always.” The overall score and the score for each subcategory were included in the final analysis. This questionnaire has established reliability and validity (Nothwehr & Peterson, 2005; Nothwehr et al., 2007).

Statistical Analyses

Descriptive statistics were used to characterize the sample, evaluate the average sodium daily intake, as well as the adherence rates for sodium restrictions at baseline, 4, and 6 months. Bivariate correlation analyses were conducted to examine relationships between sodium restriction adherence and its correlates outlined in the conceptual framework. IMB SPSS Version 19 software (Chicago, IL) was used for data management and analysis.

Results

Sample Demographical and Clinical Characteristics

Of the 21 subjects included in this subanalysis study, the average age was 63.95 ± 2.38 years. The majority were male (62%), White (100%), and married (81%), with approximately half (52%) retired. The average BMI was 32.77 ± 4.03. The majority of subjects presented one or more of risk factors associated with CVD (Table 1).

Table 1.

Demographic and clinical characteristics of the participants

Demographic Variable
Age in years, M ± SD 63.95 ± 2.38
Years of education, M ± SD 12.85 ± 0.49
Male, n (%) 13 (62)
White, n (%) 21 (100)
Married, n (%) 17 (81)
Retired, n (%) 11 (52)
Clinical Variable
Type of cardiac revascularization procedures
 PCI, n (%) 17 (81)
 CABG, n (%) 4 (19)
CVD risk factors
 Hypercholesterolemia, n (%) 18 (86)
 Hypertension, n (%) 14 (67%)
 Obese, n (%) 13 (62%)
 BMI, M ± SD 32.77 ± 4.03
 Metabolic syndrome, n (%) 7 (33%)
 Diabetes, n (%) 7 (33%)
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Daily Sodium Intake and Adherence to Recommended Sodium Intake

The average and standard deviation for the average daily sodium intake levels are shown in Table 2. The average daily sodium intake was 3,020 mg ± 1,134 at baseline, 4,047 mg ± 1,517 at 4 months, and 4,399 mg ± 1,722 at 6 months (Figure 1). Given the sodium restriction guideline for postcardiac procedural patients is 1,500 mg or less per day, the proportion of subjects that adhered to this recommendation was 4.8%, 0%, and 0%, respectively, at baseline, 4, and 6 months (Figure 2).

Table 2.

Baseline and follow-up testing of daily sodium intake and adherence rate

Variables Baseline 4 months 6 months
Daily sodium intake 3,020 mg ± 1,134 4,047 mg ± 1,517 4,399 mg ± 1,722
Adherence rate to sodium restriction guideline of 1,500 mg or less 4.8% 0% 0%
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Figure 1.

Figure 1

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Sodium restriction adherence rate over time. *The Dietary Guidelines for Americans, 2010 recommends the daily sodium intake <2,300 mg for the general population. **The Dietary Guidelines for Americans, 2010 recommends the daily sodium intake <1,500 mg for people 51 and older, those of any age who are African Americans, who have hypertension, diabetes, or chronic kidney disease.

Figure 2.

Figure 2

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Sodium daily intake over time.

Correlates Related to Daily Sodium Intake

Descriptive statistics were conducted to calculate the average and standard deviation of correlates examined in this study based on patient activation and self-efficacy concepts (Table 3). The participants in this subanalysis study were above the 80th percentiles for both patient activation level and outcome expectations for healthy eating measures.

Table 3.

Variables related to sodium restriction adherence

Variables Mean ± SD Normal Score Range
Patient activation measure at baseline 42.48 ± 4.81 13–52
Outcome expectation 4.67 ± 0.453 1–6
Overall use of weight management strategies at 4 months 2.13 ± 0.28 1–3
 Self-monitoring of diet 1.95 ± 0.51 1–3
 Diet management in social interactions 1.64 ± 0.33 1–3
 Using cognitive strategies for maintaining diet behaviors 1.69 ± 0.46 1–3
 Using cognitive strategies for maintaining activity behaviors 1.67 ± 0.37 1–3
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Second, bivariate correlations were conducted to examine the relationships between the average daily sodium intake at 4 months and the selected variables: patient activation, self-efficacy for healthy eating, outcome expectations for healthy eating, and the use of overall and specific weight management strategies. There were significant correlations between the average daily sodium intake at 4 months and baseline patient activation level (r = −.45, p = .04), outcome expectations for healthy eating (r = −.63, p = .004). There were also significant relationships between daily sodium intake at 4 months and overall weight management strategy use at 4 months (r = −.49, p = 0.03) and the following subcategories: self-monitoring of diet (r = −.45, p = .05), diet management in social interactions (r = −.62, p = .004), using cognitive strategies for maintaining diet behaviors (r = −.47, p = .03), and using cognitive strategies for maintaining activity behaviors (r = −.61, p = .005; Table 4). There were no significant associations between average daily sodium intake and self-efficacy for healthy eating and other weight management strategy subcategories (e.g., food planning strategies, food preparation and buying, self-monitoring of activity).

Table 4.

Correlates of the average daily sodium intake

Daily Sodium Intake at 4 months Patient Activation Level at Baseline Outcome Expectation at 4 months Self-Monitoring Diet at 4 months Overall Cognitive Behavioral Strategies at 4 months Diet Management in Social Interactions at 4 months Using Strategies Maintaining Diet Behaviors at 4 months Using Strategies for Maintaining Activity at 4 months
Pearson Correlation −.450* −.633** −.455* −.494* −.623** −.478* −.615**
p value .046 .004 .05 .031 .004 .039 .005
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*

Correlation is significant at the 0.05 level (two-tailed).

**

Correlation is significant at the 0.01 level (two-tailed).

In summary, results support that participants with lower daily sodium intake are more likely to: (1) have a higher activation level (e.g., more ready, willing, and capable of making behavioral changes to improve health), (2) have more positive outcome expectations for healthy eating, and (3) use weight management strategies (e.g., self-monitoring diet and physical activity, using strategies to promote healthy eating and physical activity, and use diet management during social interactions).

Discussion

Study findings reinforce the challenges to engage cardiac patients in diet modification to reduce secondary coronary artery disease risk factors after cardiac revascularization procedures. Study findings demonstrated the low adherence rate to dietary sodium restriction (1,500 mg or less/day) in the participants of rural CR programs following cardiac revascularization. Furthermore, the average daily sodium intake of the participants in this subanalysis was higher than the national average daily sodium intake (Cogswell et al., 2012). These findings may be attributed to the participants in this study who were overweight or obese as other researchers have demonstrated that overweight people are more likely to consume both more calories and salt compared to people who were normal weight (Burke et al., 2005). Thus, portion control may be a key strategy to assist in both sodium reduction and weight management since sodium and calorie contents of food are closely correlated (Alderman, Cohen, & Madhavan, 1998).

In addition, we also conducted correlation analysis to examine the potential correlates to daily sodium intake. Data collected at 4 months showed the significant correlations between the daily sodium intake, patient activation levels, outcome expectations for healthy eating, and the use of weight management strategies. However, self-efficacy for healthy eating was not significantly related to daily sodium intake. This reflects that subjects in this study with higher self-efficacy for healthy eating did not necessarily reduce the daily sodium intake, which echoes with other similar studies examining the impact of self-efficacy on behavioral changes in cardiac populations (Hyde, Hankins, Deale, & Marteau, 2008; Mansyur, Pavlik, Hyman, Taylor, & Goodrick, 2013).

Key Practice Points.

  • A low sodium intake independently reduces the cardiovascular morbidity and mortality.

  • It is challenging for overweight and obese patients following cardiac revascularizations to follow the sodium intake guideline of less than 1,500 mg daily.

  • Daily sodium intake is not significantly associated with self-efficacy for healthy eating in this study. Therefore, there is a need to identify the additional mechanisms and strategies to increase adherence to a low sodium diet in this population.

  • Rehabilitation nurses play an important role in assisting cardiac patients to modify their sodium consumption and augment the benefits of cardiac procedures.

Implications for Research

Research interventions designed to target self-efficacy alone may not be sufficient to overcome the challenges and barriers encountered by postcardiac revascularization patients with respect to following sodium restriction guidelines. Intervention research aimed to improve postcardiac revascularization outcomes should consider a holistic approach by targeting multiple mechanisms (e.g., outcome expectations and patient activation) in addition to self-efficacy. Furthermore, the conflicting results about the relationship between self-efficacy and behavioral change call for more vigorous studies with larger, fully powered studies to determine the effect of self-efficacy on behavioral change. The significant interrelation between daily sodium intake and use of multiple weight management strategies implies that CR participants are likely to engage in multiple behavioral changes (e.g., reduced daily sodium intake, exercise and healthy eating) following cardiac revascularization rather than only single behavioral changes. This finding may direct future interventions designed to target multiple healthy behavior changes instead of single behavior changes alone to improve the adherence to risk behavioral modification guideline in postcardiac revascularization patients.

Implications for Practice

Following a low sodium diet is critical to reducing cardiovascular disease risk. The prevalence of nonadherence to sodium restriction guidelines among the overweight and obese CR participants in this study has implications for further research and evidence-based practice to develop effective nutrition education and cognitive behavioral interventions to improve adherence to sodium restriction guidelines. Due to limited resources, the barriers and challenges to promote sodium restriction adherence may be more prevalent in rural CR programs, such as limited resources for dietary consultation to deliver and intervene with patients during CR to promote healthy cardiac diet recommendations. (Agostini et al., 2008; Beswick et al., 2004; Cavallaro et al., 2004; Pomeroy & Worsley, 2008; Uzun, 2007). To fill these gaps, nurses working in the rural CR programs can expand their roles and facilitate innovative interventions to improve cardiac patients’ adherence to sodium restriction guidelines.

Limitations

There are several inherent limitations in this study. The small convenience sample, and subanalysis limits the generalizability of the study. The sodium daily intake was measured by 3-day food record that is not designed to provide precise measurements of sodium (Appel et al., 1995). The parent study was to test the effect of a weight management intervention in obese and overweight CR patients. Therefore, sodium measure was not the main focus of the parent study. The variables, such as self-efficacy for diet change, outcome expectation, and risk modification behaviors, were measured at 4 months only, limiting further understanding of the changes in these variables over time in this cardiac population. Furthermore, using self-report measures introduces measurement bias. The enrolled CR participants reported high activation level and outcome expectation (both were above 80th percentile, respectively), however, their adherence to the sodium restriction guideline was poor, which indicated the self-ported measure could overestimate the participants’ activation level and outcome expectation. In the future, the use of objective methods should be used to increase reliability of the measures, decrease subject burden.

Conclusion

To achieve and maintain significant health benefits following cardiac revascularization, it is essential that cardiac patients adhere to the recommended heart-healthy diet including the sodium restriction guideline. This study indicates that it is difficult for cardiac patients to adhere to sodium restriction guidelines. The patients who reduced sodium consumption were likely to engage in multiple behavioral changes for weight loss, thus resulting in the reduction of cardiac risk factors after PCI or CABS. Further studies are needed to identify the effective strategies and approaches that can be utilized in cardiac rehabilitation to promote multiple behavioral changes, including the dietary sodium restriction, in the context of improving secondary CVD risk reduction.

Acknowledgments

This study was supported by the grant NR011404 P20 from National Institute of Nursing Research, NIH (PI: Susan Barnason, PhD, RN, APRN-CNS).

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