1. Kim La Croix, MPH, RD Juliana Pearl-Beebe, RD Oregon State Hospital Marci Brown-McMurphy, CAPECO AAA

2.  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

3.  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

4.  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

8.  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

9.  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.

10. Juliana Pearl-Beebe, RDN Clinical Dietitian at Oregon State Hospital

11.  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

12.  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

13. Dietary Approaches to Stop Hypertension Aka: high blood pressure

14.  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

15. 1 Daily 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)

16.  Fruit  Vegetables  Whole grains  Low fat dairy/soy  Lean meats  High in:  Fiber  Low in:  Sodium  Added fat & saturated fat  Added sugar

17. At the time of the DASH Studies, the food guide pyramid was is use:

19. When providing diet education, patients are taught the Plate Method or, MyPlate:

20.  Higher rates of Metabolic syndrome in the mentally ill. Why? 1. 1 Increased cortisol levels in Schizophrenia  Higher stress and inflammatory response 2. 2 Higher cravings for carbohydrates and sugars in Bipolar Disorder 3. Side effects of antipsychotic medications 4. 3 High prevalence of unhealthy lifestyle behaviors:  3 Smoking, low physical activity, poor diet, alcohol and substance abuse  3 Reduces 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

21. 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!

22.  Metabolic syndrome is a clustering of risk factors 1. Obesity 2. Hypertension 3. Glucose intolerance 4. High triglycerides 5. Low HDL  3 or more = metabolic syndrome  Strong relationship to disease  It’s a matter of WHEN, not if

23.  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).

24.  2008 deep fat fryers removed  Can cuttings for lower sodium products  Began reducing added sugar tor recipes  Discussed strategies to reduce sodium  And…

25. 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)

26.  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*

27.  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

28.  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

29.  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

30.  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

31.  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

32.  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.

33.  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

34.  Meat  Purchase meats which are not injected  Beef  Poultry  No Ham: Turkey ham  Cured differently and low in sodium  Pork loin

35. Azadbakht, 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 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.

36.  Tips for reducing sodium intake in older adults, “Savor the Flavor with Less Sodium”  http://www.cdc.gov/salt/pdfs/sodium_tips_older _adults.pdf. http://www.cdc.gov/salt/pdfs/sodium_tips_older _adults.pdf  Provider resources for reducing sodium, “Online Resources: Reducing Sodium in Congregate and Home Delivered Meals”  http://www.cdc.gov/salt/pdfs/sodium_resources_ older_adults.pdf. http://www.cdc.gov/salt/pdfs/sodium_resources_ older_adults.pdf