0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letters |

Evaluation of Sodium Levels in Hospital Patient Menus FREE

JoAnne Arcand, PhD, RD; Katherine Steckham; Roula Tzianetas, MSc, RD; Mary R. L’Abbe, PhD; Gary E. Newton, MD
[+] Author Affiliations

Author Affiliations: Department of Nutritional Sciences, Faculty of Medicine, University of Toronto (Drs Arcand and L’Abbe), and Departments of Medicine (Ms Steckham and Dr Newton) and Nutrition and Food Services (Ms Tzianetas), Mount Sinai Hospital, Toronto, Ontario, Canada.


Arch Intern Med. 2012;172(16):1261-1262. doi:10.1001/archinternmed.2012.2368.
Text Size: A A A
Published online

Population-wide sodium reduction is a public health priority to address chronic diseases associated with excess sodium consumption.1 For such strategies to be effective, sodium reduction will need to occur in every segment of the food supply, including foods sold in grocery stores and restaurants as well as food served in public institutions such as hospitals.2,3 Guidelines for lowering sodium levels in hospital settings have recently been published but largely focus on consumer food service outlets rather than on foods served to inpatients.4,5 There are few published data describing sodium levels in hospital patient menus and determining whether these levels fall within recommended guidelines. The objectives of this study were to quantify the amount of sodium in commonly prescribed hospital patient menus and to determine whether these levels are in agreement with established sodium recommendations.

The sodium content of standard-unselected menus and consecutive patient-selected menus for regular, diabetic, and 3000- and 2000-mg sodium-restricted diet prescriptions at 3 acute care hospitals in Ontario, Canada (N = 1935 beds), was analyzed between November 2010 and August 2011. Assessment of patient-selected menus allowed us to evaluate the variations in sodium levels that occurred when patients self-select their foods. Combined diets (eg, diabetic and 2000-mg sodium restriction) and other diet types, such as texture modifications and kosher meals, were excluded. Nutritional analysis, which was conducted using manufacturer-specified data, included any ordered salt, snacks, and nutritional supplements. Research ethics board approval was obtained at each institution.

Sodium levels in regular and diabetic menus were compared with the adequate intake (AI) level of 1500 mg/d and the tolerable upper level (UL) of 2300 mg/d.6 Therapeutic sodium-restricted menus were compared with their respective cut points. Unpaired t tests and χ2 tests were used for comparisons between the standard and the patient-selected menus.

The final analysis included 84 standard-unselected menus for the 4 diet prescriptions and 633 regular, 628 diabetic, 630 3000-mg, and 343 2000-mg sodium patient-selected menus. Most menus came from general medical (27%), surgical (24%), and cardiology (20%) wards.

The mean (SD) sodium level in standard-unselected regular menus was 2896 (606) mg. Of these menus, 100% and 86% exceeded the AI and the UL, respectively (Table). Among patient-selected regular menus, 97% and 79% exceeded the AI and the UL, respectively. The mean (SD) sodium level in standard-unselected diabetic menus was 3406 (544) mg; 100% of the menus exceeded both the AI and the UL for sodium. Patient-selected diabetic menus contained similar sodium levels, with 99% of the menus exceeding the AI and 95% of the menus exceeding the UL.

Table Graphic Jump LocationTable. Sodium Content of Menus for Regular, Diabetic, and 3000- and 2000-mg Sodium-Restricted Hospital Dietsa

For the 3000-mg sodium-restricted diet, standard-unselected and patient-selected menus contained similar levels of sodium, with the majority falling within prescribed levels (Table). For the 2000-mg sodium-restricted diet, the mean sodium level in patient-selected menus was significantly higher than that in the standard-unselected menus (2041 [887] mg vs 1504 [296] mg; P < .001). The proportion of menus exceeding the 2000-mg prescription cut point was also significantly higher in patient-selected menus than in the standard-unselected menus (47% vs 10%; P < .001).

We demonstrated that hospital patient menus contain excessive levels of sodium: 86% of regular and 100% of diabetic standard-unselected menus exceeded the UL of 2300 mg of sodium, and 100% of these menus exceeded the AI of 1500 mg. Sodium levels in the 2 sodium-restricted diets typically fell within prescribed levels; however, approximately half of all 2000-mg sodium-restricted menus exceeded that prescribed level when patients self-selected their food. This observation could have important clinical implications given the therapeutic necessity of sodium restriction in conditions such as decompensated heart failure.

There are very few published data on the sodium content of hospital patient menus. One small study from Switzerland found an average of 3760 mg of sodium in a standard menu.7 In another, 20% of renal menus contained sodium levels exceeding the prescribed 2300 mg.8 These studies, however, only assessed 1 type of menu and were conducted in a single center. Although in a different setting, sodium levels in long-term care facilities may contain up to 4390 mg/d.9 Taken together, these findings are explained by the fact that hospitals as well as other public institutions are increasingly serving prepared foods rather than preparing foods from unprocessed ingredients.

All hospitals studied used rethermalization technologies and menus largely composed of outsourced prepared foods. Although these are common elements of food service systems, our data may or may not be applicable to other hospitals. Furthermore, we chose to assess sodium levels in patient menus, although actual sodium consumption will vary with food intake.

The menus studied serve a large group of hospitalized individuals, many of whom are nutritionally vulnerable and/or have cardiovascular diagnoses for which sodium intake regulation is essential. Based on the growing reliance on prepared and processed foods in the hospital setting, our findings highlight the need for sodium-focused food procurement and menu-planning policies to lower sodium levels in hospital patient menus.

Correspondence: Dr Arcand, Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, 150 College St, FitzGerald Bldg, Toronto, ON M5S 3E2, Canada (joanne.arcand@utoronto.ca).

Published Online: July 16, 2012. doi:10.1001 /archinternmed.2012.2368

Author Contributions: Dr Arcand had full access to all of the data in the study and takes full responsibility for the integrity of the accuracy of the data analysis. Study concept and design: Arcand, Tzianetas, and Newton. Acquisition of data: Steckham. Analysis and interpretation of data: Arcand, Steckham, Tzianetas, L’Abbe, and Newton. Drafting of the manuscript: Arcand. Critical revision of the manuscript for important intellectual content: Arcand, Steckham, Tzianetas, L’Abbe, and Newton. Statistical analysis: Arcand and Tzianetas. Obtained funding: Newton. Administrative, technical, and material support: Arcand, Steckham, Tzianetas, and Newton. Study supervision: Arcand, Tzianetas, and L’Abbe.

Financial Disclosure: Dr Arcand receives fellowship funding from the Canadian Institutes of Health Research Program in Public Health Policy.

Funding/Support: This study was conducted with internal research funds.

Additional Contributions: We thank Lori Klin, RD, Jaclyn Nairn, RD, Heather Oliphant, BASc, Linda Stoyanoff, RD, and Heather Fletcher, RD, for their significant contributions to data collection and analysis.

Beaglehole R, Bonita R, Horton R,  et al; Lancet NCD Action Group; NCD Alliance.  Priority actions for the non-communicable disease crisis.  Lancet. 2011;377(9775):1438-1447
PubMed   |  Link to Article
Sodium Working Group.  Sodium Reduction Strategy for Canada: Recommendations of the Sodium Working Group. Ottawa: Health Canada; 2010
Institute of Medicine.  Strategies to Reduce Sodium Intake in the United States. Washington, DC: National Academies Press; 2010
 Under pressure: strategies for sodium reduction in the hospital environment. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/salt/pdfs/sodium_reduction_in_hospitals.pdf. Accessed April 15, 2012
 Healthy hospital food initiative: a survey and analysis of food served at hospitals. Physicians Committee for Responsible Medicine Web site. www.pcrm.org/search/?cid=618. Accessed April 15, 2012
Institute of Medicine.  Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: National Academies Press; 2005
Iff S, Leuenberger M, Rösch S, Knecht G, Tanner B, Stanga Z. Meeting the nutritional requirements of hospitalized patients: an interdisciplinary approach to hospital catering.  Clin Nutr. 2008;27(6):800-805
PubMed
Rai EM, Hartley GH. An evaluation of renal inpatient meals against Renal Nutrition Group standards.  J Hum Nutr Diet. 2006;19(5):369-374
PubMed
Wright-Thompson A, Piché L. Nutritional analysis of a long-term care menu before and after an increase in the raw food cost allowance.  Can J Diet Pract Res. 2011;72(3):141-145
PubMed

Figures

Tables

Table Graphic Jump LocationTable. Sodium Content of Menus for Regular, Diabetic, and 3000- and 2000-mg Sodium-Restricted Hospital Dietsa

References

Beaglehole R, Bonita R, Horton R,  et al; Lancet NCD Action Group; NCD Alliance.  Priority actions for the non-communicable disease crisis.  Lancet. 2011;377(9775):1438-1447
PubMed   |  Link to Article
Sodium Working Group.  Sodium Reduction Strategy for Canada: Recommendations of the Sodium Working Group. Ottawa: Health Canada; 2010
Institute of Medicine.  Strategies to Reduce Sodium Intake in the United States. Washington, DC: National Academies Press; 2010
 Under pressure: strategies for sodium reduction in the hospital environment. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/salt/pdfs/sodium_reduction_in_hospitals.pdf. Accessed April 15, 2012
 Healthy hospital food initiative: a survey and analysis of food served at hospitals. Physicians Committee for Responsible Medicine Web site. www.pcrm.org/search/?cid=618. Accessed April 15, 2012
Institute of Medicine.  Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: National Academies Press; 2005
Iff S, Leuenberger M, Rösch S, Knecht G, Tanner B, Stanga Z. Meeting the nutritional requirements of hospitalized patients: an interdisciplinary approach to hospital catering.  Clin Nutr. 2008;27(6):800-805
PubMed
Rai EM, Hartley GH. An evaluation of renal inpatient meals against Renal Nutrition Group standards.  J Hum Nutr Diet. 2006;19(5):369-374
PubMed
Wright-Thompson A, Piché L. Nutritional analysis of a long-term care menu before and after an increase in the raw food cost allowance.  Can J Diet Pract Res. 2011;72(3):141-145
PubMed

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 5

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles