What Can Nutrition Education Offer To Improve Dietary Sodium Restriction Interventions For Heart Failure Patients?

Heart failure (HF) affects 26 million people worldwide and accounts for over a million hospitalizations annually with 50% of these patients readmitted within six months. A sodium‐restricted diet (SRD) is consistently recommended for HF self‐management to reduce hospitalizations; however, low adherence makes it difficult to test SRD efficacy. This has implications for patient outcomes as well as the quality of evidence used for recommendations. Therefore, interventions that effectively achieve sodium restriction are necessary. Research in the field of nutrition education suggests that effective interventions focus on behavior over information dissemination; operationalize behavior theories and mediators; and attend to social‐ecological influences on behavior at individual, interpersonal, environmental, and policy levels. In this review, we critically examined sodium reduction interventions for HF patients through a nutrition education lens. We queried PubMed, CINAHL, and Cochrane databases with relevant search terms for reports of studies published in English January 2000–October 2015. We included randomized controlled trials of interventions for HF patients that evaluated sodium restriction as a primary or secondary outcome. Of 213 studies initially identified, 174 were excluded by title. 2 reviewers assessed 39 abstracts and included 7 studies in this analysis. Reviewers noted behavior, theory, strategies, levels of influence, setting, methods, and outcomes. 6 interventions reduced dietary sodium intake (n=5) or increased SRD adherence (n=1). Successful interventions had a clear behavioral target, were delivered by an RN or RD, and included counseling and/or feedback based on dietary assessments. The unsuccessful intervention was a mailed DVD with no clear behavior, individualization, or feedback. Half of the successful interventions (n=3) were theory‐based. All studies intervened at the individual level, and 2 (both successful) intervened at the individual and interpersonal levels. No interventions included environmental or policy elements. It is important to note that no interventions achieved the 1500mg/day recommended sodium intake level for adults with HF. Interventions successful in reducing dietary sodium were behaviorally focused and included clinician‐provided nutrition counseling with personalized plans and/or feedback. This is consistent with prior findings that information is not sufficient to influence behavior. To achieve the recommended level of sodium intake, interventions for HF patients must be improved. Future interventions might test the inclusion of environmental or policy strategies that influence food access in patients’ homes and neighborhoods. This review was limited by inconsistency in reporting of behavior change strategies used. For example, interventions reporting patients received counseling did not precisely explain what the counseling entailed (e.g., motivational interviewing, goal setting). Future sodium restriction intervention evaluations should emulate drug treatment trials by carefully presenting the intervention “ingredients” so more precise conclusions can be drawn about what makes interventions successful. Support or Funding Information This study was funded by National Institutes of Health Training Grant #HL007343