DTIC ADA419967: Factors Related to Nonadherence of a Low Sodium Diet in Heart Failure Patients

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Title; Factors Related to Nonndherence of « Low Sodivm Diet in Het Failure Palienls

Runuing Tile: Sodium Nenacherence

Authors:

Brooke Renlley, RN, MSN, ARNP
‘Doctoral Student

University of Kentucky. College of Nuning

Lexington, KY

‘Assistant Professir

astern Kentucky Univesity. College of Health Sciences
Richmond, KY

Marla J. De Tong, RN, MS, Ci
Doctoral Student

Lniversity of Kentucky, College of Nursing / United States Air Force
Texington, KY

[Debra K. Mascr. DNSe. RN, FAN

Professor and Gill Chair of Nursing

University of Kentucky, Collage of Nursing

Lexington, KY

‘Ann K. Peden, DSN, RN, CS

‘Associate Professor

University of Kenweky, College of Nursing.

Lexington. KY

8, CORN, CEN, Major

Contact Author: Brooke Bexley

208 Stonewall Ct
Richmond. KY 40475
Home: 859-623-5935
Work: £59-622-1969
FAX: [phone]
E-mail; Brooke Rentley@EKU HDL

‘Institution Where the Wark Was Performed: University of Kentucky. College of Nursing

Diselaimer Statement: ‘The opisions or wsertioux eoruuined herein are the private views ofthe
authors and are not to be constrved ax aicial or as electing the views of the Department of the

Air Force or the Department of Defense.
Tackgrouns

A lo sodium diet is comerstone af nonphannacologic therapy for het failure
patients, ANough nenaifherence ia cocamon, Title iv kaown about sshy heart faze patoats fail
‘ro adhcor to this del. The purpowe ofthis suudy was In explore tho experience of hear failure
‘alien in Following a low sodium dit.

“Methods: We conducted a qualiltive descriptive siady wilh a convenience sample of 20
participants. Inforviows were conducted and analyed fr themes,

Results: ‘The data reflocted three primary theaes about noandhereuce to the Low sodium dil
luck of knowledge, iatertetence with socializstion. and lack of find sefection. Partin
cexprossod a need for details about dictay information, low sodium food selection, food
reparation, and rationale for the diet, “Lack of knowledge also was manifested as diet eanfusion
for participants who required aciitionsl dictary rstrvtions rated to other disease processes
Tnterference with sovialization was manifested by patients’ experiences with tamily confiet
‘when family members chore and ole high-sodiua foods al home a Family gatherings, ex
<fTicully euting out, The theme of lack of low sodium food selections was teflected hy
‘comments about limited food choices, and lack of paltability.

Conclusions; Researchers and clinicians need to consider patients! peroeptions as they generate

and evalat

tervontions to Source adherence low kiw sium Tie

Key Words: Dicuzy sodium, adherence, qualitative research
‘Over 4,900,000 Amerieans have heart ilure (HE). a chronic illness thet comiribules to
roore than 262,000 deaths anmually:! Rach year approxionately 400,000 10 700.000 neve parieuts
are diagnosed with HF.! The United States spends $24.3 billion annually to care for persis
wilh THE? Approximarcly 60% ofthis ost is lor hospital cate? The njost common eausc of HF
hospitalizations is volume overfoad, and the proximate eause af walume overload in most cases is
excessive dietary sodium intake *

‘Since 1995, much propress has becn made in improvement of pharmacolngie and
snvaphatmacologie therupies for HI Physicians and nuess practitioners often prseribe
roullifazeted medical, dietary, and exercine treatment regimens for individuals with HP. The low
sndium diet isa comerstune of nanphamuacologic thempy.* However, norudheremex tn this
component o HF therapy is extecmsly common.?*"* Despite the low rates of adherence to the
low sodium diel recommendation, little is knovm abwul why patiews Witt TIF fall to ater.

Accordingly, the purpose of this qualitative deseriptive stuly was Ip explore the experience af

FF yuvients.as they attempt to follow a low sodiom diet.
Methods

Design

‘A qualitative deserptive appranch guided this rescench.? This design is appropriate when
the goul isto descuibe a phenomenon using a common Language that clinicians will understand
Qualitative description is especially amenable to obvaintng stsight and largcly
nadomel..answers to questions of spestal elevunce ln pracidaners and policy makers.”
Participants and Setting

Using eouvenienss sampling, 20 patients who met the following criteria were ennulled in
this study: 1) dingnosis of MF dn to let ventricular spsusfie dysfunction with ejeetion fiaetion

les than 50%, 2) healthuure provider's recommendation to follow alow sodium diet, 3) 00
cexiitve impairments timiting the ability ws complete an interview, 4) uot living in an extended

care feility, and 5) on stable medical therapy withoul major recent aljunirents. AN patients

spake English and moccived cure al wT clinie ocated

major Southem aesdenie medical
cents, Table I oonturs information regarding ths charters of the same,

‘The Institwionat Review Hoard approved this dy and thie vestigation conforms with
the principles outlined in the Deslartion of Helsinki, Prior t data collection, participants gave
Jnr, writen consent for this stud.

Data Collection

‘he investigstns collected data regseing demographic aud clniesl characteris by
ptent interview ad metal ord review, The iwentgatons contacted potent partieipans
in person or ty telephone and invited them to participa inthis study. The pent and
investigators scheduled the infeview fr a mca agreesble de, time, and place. Before the
fst iotorview, the tvesigators designe au intervisw gi ha tinted & site
spptoech o each interview: An expert qualitative rscaresr reviewed the inferview guide and
smdy protocol, Ths semi-structured interviews took plein private oom in th sins or atthe

pient’s home, ranged from 20-50 minutes in lem, snd aecurred during the spring aa

suramer of 2008. Reven psticipants were infeviowed st hom and 13 pticpans complet
ther nterciew inthe clinic. Al inferviews were aulotaed cov the investgptors me etd
roles during ind ater each intsrdow,

To estebish rar beeen the investigator and pticut. the investigator began by
stating, “Pease tell me about your heart failure.” Fations were then asked various questions
regneding wat diet wax preseihed for thei HF how ey leamed about alow sodiom dict their

25 in following a low sodium die, and factors that prevented them fiom following a

experi

low sodium dict. Follow-up questions wore aske to early fliemation or to further expfore
pifient-generated comments.

‘The investigators vontinued to interview: patonts unl They achieved saturation of data

and the interviews yielded no nc information. Prior ip coding, an experienced teanscriptionist
Iransetibed each interview verbatir, the investigators emCirmed transcription accuracy by
comparing euch audiotaped inkarview wilh ity corresponding transcript
Data Analysis

The investigators used SPSS software, versinn 115,10 summarize data regarding,
<domographiv und clinical characteristics, These results are prescenod as frequencies and moans 4
standard deviations

The investigators usod content analysia procedures to auatyze interview data with the
goal of accurately dasering putts ar regulatitics within the data,” Prior un unatysis, the

[nvstigators proposed potential eades huned on hele recalt of the interviews. Examples uf these

codes were other dietary testictions. palatability. and Hited food choices. ‘Iwo investigators

(BB end MD independey ended the warps. identifying ecwrent eles and themes hat
focused on description of why patents with HP fl to adhere wo alow sodom dst, During dan
anal theinvesigatoes collaboratively added or refined codes as indicated. ‘The investigators
Anblecoded portions of the manscripis to ensure interrater agement, When the investigators
Aisagroed on code, they reexamined the tamer in detail and discussed the mats nt thoy
ucieved eonscusus, After coding the daa, the investgaorseollepsol similar endes into eer
themes. Analysis procedures were recordin wn wi ail
Results
‘The data reflected thre primary themes reguslng sons for noaadherence to the

preveribed tow sodium dist: Jack of kaowledge interference with socialization, and lack of food

soleations,
Lack of Knowledge
The puticpants expressed a ned for healheure pennnanel to provide them with detailed
Aieury information and wrileniicusions garding low ot food seletion and
preperation, bul the majority sted that cy dd no teceive this information, According toa
piriipant, “they didi’ really cover what wanted w know, Thsy jos discharged ne ard
thoes Other partisipans easily listed high soto fxs, be end a iia

naming tow sodium foods, One perlicipant stated,“ wish it would ive beca like when I was

Asbo. They gave ie a fod list of what contsned a ot of sugar anda diet which had cooking
Instustions, Tryoa would offer some recipes thet would e helpful”

Anche finding emerges it hecarae apparent shat most paticipans taught Phemsefves
about theirlowesodiom diets, Physician, nurs, and dictiians 110 hem to follow a tow
sodium diet: however, according 1 Une paricpants, thee heathen prfessioals provided
sean! dels aout ow som fos and sateen fr fllnsing a ow sadn det, Ava resll,
atic pats tng thanselves how to read fod labels and independently cauird information
abont aTow sodium diet, Sever informants hal proviquly cared fora fanvly memberwho was
‘ov hws det and related that this experience eed sie wi easton o low soon,
sie, Ta site oftheir offre. pactisipan five lo Filly comprchend the invcacies of false
a fow sodium del. One participa stated, “Well, the dietician gove me some prints t follow,
‘ut dida’tunderstaud them that well becouse F dont thin she was hotough wit me, so just
veent with what Lumen” The participant vt on to say, Mg siters a muse sed. she
told me wht to stay aay from... and she ca inform me what 4."

Participants were unaware af he sodium cont ot the “bidden wl”in many fade
Several participants expres pride in pling tei salt shaker way, Yo poks abt routinely

cling high sodium faods such as baon, canned soup, and chavs mien. Ce participant even
ssked, “But al you bave to dois cook and not add any sak to it, isn’t that right?”

Te was evident that the participants failed to undersund Ihe ratiouale behind their dictary

restriction, Aer consuming high sotium fonds, patients woted increased edemu and shortness a

breath, but they did not alibute these symptoms to wortesing cardiac function, Fusthermons,

participants focused their atlenion on these physical discomforts but did nor express worry or
concern about inet heart. A patiut's wile galed, “Ihe goes out and cats something that
somerne else eoaks and itas too much salt ini, you can tell the dillerence. | don’t know if that

has anything to do with him may being dizzy. short of breath, and all that kind of stuf, but that

right have something todo with" This partiipane and his wile never mentioned tat the
higher st nue might he Zaher staining hin ready Failing hear.

Tor those participants with addtional dictary resctions, flowing Tow sodium diet
‘eas confusing, Respondents stroglsd to diferente between low cholesterol and ow sodium
foods and ofan wsumed that ll hear ost as were kw in seus A mile participant
slaed, “Sometimes e can find bologna tat is fow in at” Another said,“ bouehr some new

butter that is sured to have ths healer ta inf.”

Faterference with Social

Partsipants express frustration that their lw sodium diet restrictions permeated theit
avi lifestyle, Nearly all participants idenied ha eating ot was an obstalc to aering to
their prescribed dict, Respondents tamenved that eating out was challenging hecmise many
restourans use excesive sodium in preparing (oad. One participant comuvented, “Yor eat go
anyovhere aly thot they haven't already salted or dumped a bunch of barbeque ont. md
te Finda place to eat,” Fusthermore, participants pureived that tei diet Tinted opportunities
to socialize with fiends and fly, A female putipant stated, “We ad hinds whe used tn

come and ent vith me ul the ine, but they don"t anymore, In their opinion, Pm not as good of a
nk as T used tobe”

‘The diet ls interfered ith Tonystanding church actives, Many patcipenls
consmented ou the hardship of church dinners, One pariipantsned, “We had an anniversary
down st ovr church and they wete fussing and mac ame hecavse 8 woulda’t eat that tu, Lust
cotati”

Friends and family did not always understand the participant's diet restictions and did

not respect dietary needs. Low sodium dict restrictions dirsefly conushuted to confit
within seme faites. Some respondens ll isolated ftom family membors wo coutnued ty cl
ih sodium foods, One participant spoke of having problem with family members who
requested specific foods, “We request hings, You don’t eook them any 9 why dot Sou
cook what you wint ts cock?” Avather expressed biteaess towards her husband, “My husband

makes it ton

ly hard, He doesn consider the ter tat | shoo not ct erkan restaurant
when Cn with Bim,”
Tack of Food Selections

Tmt low sodium food choioes and lack of puloubility were identitied as sigiticant
briny adneruoe, Pantisipans exmesed dismay that most foods coatain more sodium than

they are allowed ro eat, A participa stated, “just overwhelms you because you low sodium

isin everyhing™ Amer infonmane suid that she didnot hink fllewcng low sodium diet
‘would be dificult unt she went shopping, She snd L went into sore and eventing picked
sph satin it and fresked ou, srt of, Teouldebeieve tat so many things hs salt in them.
Wsuntelievable”

Tor many participants, the problom of limite fad choices was confounded by ational

ictary restictions, As resulL, participants could not even eat certain lovr sodium foods,

Panicipans wete challenged to adhere t diet recritinns related to Coumadin therapy and
iabotes, For example, thoy stated that fresh finits and vegetables contain litle sodium but

expressed concems about maintaining eorsact blood levels of Couruadin when eating too much

fresh produce. One perticipant’s wife snmmariveil his concept saying, *...he's u diabetic and.

ia double the woutle." Another diabetic respondent stard “Tean't havea ot of rut on that
limits food cbsices.”

Partisipants complained tht few low sotam foods appsoed wo ther appetite and thus
farther narowed food sees, Palatblliy, or the lak thereof. was a eourrng swe forthe
puricipants. One patent tated, the green beans toms theyre very hard to eat because
Ayre very hard to soason...” Portiaipansdiscusvel the ongoing hardship uf hoki for
something to replace the favor fsa, Foreeample,*._ rc the st sabe but didnot ike
fn trod Mrs, Dash but wasnt slisfed..”” Many times ual replacement wns never found, "1
could do without the buter, but just hve to have a its tse of sat”

“the lack of fund selection as a chronic hardship, Pavticiumls exyresed the nec to
lays plan aheat, Several participants nated thatthe odin content of foods ulayson theie
‘wind and thet meal plating rors consti stention, Severe informants tated about isi
stenggle with keeping an aloqaue inventory of ow sodium foods av home, One informant spk
bout this, ying, “Yeaby that's the problem, AFT don’t uve it inthe honse, that’s the renson i's
all he time on your mind, all ts tying o stay ahead ofits Yow dot get eatin hose
sirustons, nd that’s why it's hard.” The cravings for favorite ih sodtinm foods never
Aiminished. Oue prtsipuntcomunentd, “Tove bot dogs bili dog would tate so good”

Disenssion

The principal fading frown this quatative study ws thal ck of knowledge, interference

‘ith scilizaton, and husk of food sloetions were the major reasons perms with ITF dd aoe

adhere to their low sodium dist. Thi is one ofthe frst quulilative studies to ditcetty explore