Encouraging healthier diets and monitoring patient lifestyles outside of the hospital's walls are among the new weapons hospitals are deploying to curb readmissions. The goal is to avoid federally imposed penalties for excess readmissions that went into effect last fall.
Research has connected lower-salt diets with lower blood pressure, which has been proven to reduce the incidence of heart attacks and strokes. But many providers see cutting salt as just part of improving an overall diet. Avoiding saturated fats and cutting caloric intake also help, as does eating more foods with potassium. Consuming more potassium and less sodium was endorsed in the National Heart, Lung and Blood Institute's Dietary Approaches to Stop Hypertension eating plan, or DASH. The diet also limits added sugars, red meats and avoids saturated and trans fats.
A recent paper in the New England Journal of Medicine encouraged a population-wide reduction in salt consumption. If Americans reduced consumption by 3,000 mg a day (average consumption is approximately 3,300 mg), the number of new cases of coronary heart disease could fall to 120,000, a decrease of 60,000 cases, according to research from “Salt in health and disease—a delicate balance.” The same salt reduction could lower the number of strokes cases by 32,000 for 66,000 cases annually.
The paper's lead author, Dr. Theodore Kotchen, of the Medical College of Wisconsin, acknowledges the controversy surrounding salt, but feels enough information is known to take action: “The intent is to step back and take a balanced view, and I hope that's the way this paper comes across,” he said.
About 97% of Americans consume too much salt, according to the FDA. The agency recommends a daily sodium intake of less than 2,300 mg, based on a 2,000-calorie-a-day diet. Those in higher risk groups—adults 51 or older, African-Americans of any age or those who suffer from hypertension, diabetes or chronic kidney disease—should lower their daily intakes to 1,500 mg, the government advises.
Researchers have debated salt's risks for years. Many leading clinicians still have concerns about the data. Dr. Steven Nissen, chairman of cardiovascular medicine for the Cleveland Clinic, said casting salt as a lone villain doesn't make sense. The evidence against salt is “murky,” he said. When it comes to dietary threats to a healthy heart, salt isn't “on the top of the list.”
Nissen pointed to the high-salt Mediterranean diet, which avoids saturated fats and is promoted as heart healthy. “The data suggests the salt is associated with increased blood pressure and reduced salt may reduce blood pressure a little bit in some patients,” he said. “But it's still a big leap of faith if we cut out salt altogether.”
Most of the salt in a typical American's diet is found in processed and prepared foods. While many food companies are now offering low-salt alternatives, the food additives industry continues to question the validity of the research behind efforts to reduce salt intake.
The Salt Institute, for instance, is calling for a large study to definitely measure the impact of dietary salt on cardiovascular health, said Morton Satin, the group's vice president of science and research. Past studies have too narrow of a focus, which produced incomplete results, he said.
Satin also questioned the government using its regulatory power to limit the amount of salt in processed and prepared foods. It's the government's job to ensure consumers have access to all the information and studies available so they can make that decision, Satin said. “If somebody wants to smoke—and knows everything—let them smoke.”
The ongoing controversy hasn't stopped some hospital systems from integrating low-salt diet recommendations into their post-discharge patient management plans. That sometimes takes extraordinary measures, since after undergoing a surgical procedure, grogginess and confusion often prevent cardiovascular patients from listening to a clinician's instructions. Wanting to return home as fast as possible, many patients fail to hear the valuable advice from nurses and physician assistants that is designed to prevent future hospital visits.
That's why a multidisciplinary team of staffers at Froedtert Health in Milwaukee began showing up to warn patients to avoid highly salted prepared and packaged foods, said Dr. Claudius Mahr, medical director of the system's advanced heart failure program. The team included physicians, nurses, social workers, psychologists and nutritionists, who work with patients after surgery on a variety of issues seen as key to reducing readmissions.
“We need to be prepared to treat our patients along the continuum of care for the duration of their lives as opposed to just sending them home with a handout that says you need to cut salt out of your diet,” Mahr said.
Reducing salt intake sometimes provides the patient with an attractive alternative to taking blood pressure meds, said Dr. Daniel Sauri, a cardiologist at Alexian Brothers Health System in Arlington Heights, Ill. Alexian's nursing homes and subacute rehab centers have also altered their menus toward lower- sodium choices and healthier eating in general.
Cutting sodium intake in half could lead to an eight- to 10-point drop in blood pressure, which could significantly reduce the risk of repeat heart attacks or strokes, officials at Alexian said. Staffers bring the discharged patients back to an outpatient setting where Sauri asks them to write down all the foods they've eaten in a day and identify what high-sodium foods need to be eliminated.
“It really makes people think, 'Oh, my God, I am really taking in all this sodium,' ” Sauri said. “They don't realize it.”