Journal of Cardiovascular Nursing

Vol. 30, No. 1, pp 58Y65 x Copyright B 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Association Between Self-reported Adherence to

a Low-Sodium Diet and Dietary Habits Related
to Sodium Intake in Heart Failure Patients
Eloisa Colin-Ramirez, PhD; Finlay A. McAlister, MSc; Elizabeth Woo, RD; Nellie Wong, RD;
Justin A. Ezekowitz, MBBCh, MSc
Background: Sodium restriction is the primary dietary therapy in heart failure (HF); however, assessing sodium
intake is challenging to clinicians, who commonly rely on patients self-report of following a low-sodium diet
to determine adherence. It is important to further explore the utility of self-reported adherence to a low-sodium diet
in patients with HF. Objectives: The objective of this study was to evaluate the association between patients
self-reported adherence to a low-sodium diet and dietary habits related to sodium intake in patients with chronic HF.
Methods: Patients with HF seen in a tertiary care Heart Function Clinic and who have been taught on a low-sodium diet
with a target of less than 2300 mg/d were included. Self-perception of compliance and dietary habits related to
sodium intake was evaluated by using a dietary questionnaire. Patients were divided into 3 groups according to
self-reported adherence to a low-sodium diet: never, sometimes, and always. Results: Overall, 237 patients (median age,
66 years, 72.6% men) were included. Compared with the other 2 groups, patients who stated always following a
low-sodium diet were less likely to use salt in cooking or at the table. However, 4.2% of the patients in the always group
reported eating canned or package soups every day. Moreover, the highest proportion of patients eating fast foods
1 to 3 times a week was found among those in the sometimes group (22.9%) compared with the never (9.1%) and
always (6.7%) groups (P = .002). Importantly, the rest of the food items did not show any significant differences between
self-reported adherence groups. Conclusion: Self-report of adherence to a low-sodium diet is not reliable among
patients with HF, who associate the idea of following a low-sodium diet mainly with not using salt for cooking or at
the table but not with reducing frequency of intake of high-sodium processed foods.
KEY WORDS:

dietary adherence, heart failure, nutrition, salt intake, sodium

Eloisa Colin-Ramirez, PhD

Postdoctoral Fellow, Medicine Department, University of Alberta,
Edmonton, Canada.

Finlay A. McAlister, MSc

Professor, Division of General Internal Medicine, University of
Alberta, Edmonton, Canada.

Elizabeth Woo, RD
Clinic Dietitian, Heart Function Clinic, Division of Cardiology,
University of Alberta Hospital, Edmonton, Canada.

Nellie Wong, RD
Clinical Dietitian for Heart Function and EASE Clinic and Outpatient
Cardiology Dietitian at the Mazankowski Alberta Heart Institute.
University of Alberta Hospital, Edmonton, Canada.

Justin A. Ezekowitz, MBBCh, MSc

Director, Heart Function Clinic, Division of Cardiology, University of
Alberta, Edmonton, Canada.
E.C.R. is supported by a postdoctoral fellowship from Alberta
Innovates-Health Solutions (AIHS) and the National Council of Science
and Technology (CONACYT), Mexico. J.A.E. holds a Population
Health Investigator award from AIHS and a grant from the University
of Alberta Hospital Foundation for research on sodium restriction in
heart failure. F.A.M. holds the Capital Health Chair in Cardiology
Outcomes Research and an AIHS Senior Health Scholar Award.
The authors have no conflicts of interest to disclose.

Correspondence
Justin A. Ezekowitz, MBBCh, MSc, 2C2 Cardiology, Walter Mackenzie Centre,
8440 112 Street, Edmonton, Alberta T6G 2B7, Canada (jae2@ualberta.ca).
DOI: 10.1097/JCN.0000000000000124

iven that heart failure (HF) is associated with neurohormonal activation and abnormalities in autonomic control that lead to sodium and water retention,
clinicians have focused on strategies to mitigate these
physiological processes to realize improved patient outcomes. Recognizing the importance of sodium balance
in HF, it has been presumed that reducing exogenous
sodium intake in clinical situations characterized by an
overtly fluid overloaded state would be an appropriate
intervention. Therefore, nutritional strategies in patients
with HF are focused on self-care, including sodium and
fluid restriction, to minimize the risk of acute volume overload episodes.1 Importantly, many urgent clinical visits,
emergency department visits, and acute care hospitalizations continue to be linked to dietary salt indiscretion,
and nonadherence to diet was reported as a precipitating
factor for HF admission in 5.2% in a HF population.2
Despite the importance of following a low-sodium
diet in patients with HF, there is no agreement about
the best method to measure dietary sodium intake and,
therefore, adherence to a sodium-restricted diet in HF.
Measurement approaches have ranged from objective
measures such as a 24-hour urine sodium to subjective

58
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Dietary Habits and Sodium Intake in HF Patients 59

ones such as patients self-report of following a lowsodium diet.3Y5 Adherence to a sodium-restricted diet
as evaluated by objective (24-hour urine sodium)6,7 and
subjective (3-day food records)8 methods has been shown
to be associated with better clinical outcomes in patients with HF in prospective studies. However, even
though assessment of adherence to a low-sodium diet
is an important component of the management of HF,
evaluation of adherence in clinical practice, where an
easily administrated and reliable method is required, is
still challenging.
Clinicians commonly rely on patients self-report of
following a low-sodium diet to determine adherence
because this approach is the most convenient method
available in the clinical setting; however, it has been
suggested that the accuracy of this self-reported method
to evaluate adherence may be affected by several factors, including patients lack of knowledge about what
constitutes adherence and it may not be reflecting actual adherence4; in consequence, dietary counseling decisions made based on this self-reported method may
be misguided. Therefore, it is important to further explore the utility of self-reported adherence to a lowsodium diet in the clinical setting in patients with HF.
The objective of this study was to evaluate the association of patients self-reported adherence to a lowsodium diet and dietary habits related to sodium intake
in the clinical setting in patients with chronic HF.

Methods
Clinical Setting
This retrospective study was conducted at the Heart
Function Clinic (HFC) of the Mazankowski Alberta
Heart Institute. Details on the HFC cohort have been
previously described,9 but in brief, all patients undergo a structured history and physical examination and
systematic collection of demographic, clinical, and laboratory data. In addition to assessment by physician, nursing, and pharmacy health professionals, patients have
access to and are assessed by a registered dietician and
are exposed to an initial dietary teaching on a low-sodium
diet and its importance in controlling fluid balance in HF.
Patients are taught a low-sodium diet with a target of less
than 2300 mg/d and to consume less processed,
packaged, or restaurant foods. Label reading is often
discussed to assist in choosing lower sodium packaged
foods and reading materials are also given to reinforce
information.
Assessments
Self-reported Adherence to a Low-Sodium Diet
Patients were asked to complete a self-administrated
questionnaire adapted from the Dietary Sodium Re-

striction Questionnaire (Supplement)10 as part of their

routine dietary assessment during the initial and follow-up
clinical visits to evaluate self-reported adherence to a
low-sodium diet and dietary habits related to sodium
intake to guide dietary counseling. Patients were asked
to rate how often they followed a low-sodium diet, and
the response options were never, sometimes, and always.
Dietary Habits Related to Sodium Intake
The dietary questionnaire also includes questions about
use of salt in cooking or at the table and frequency of
intake of common high-sodium foods. Patients were
asked to specify how often they consumed the listed
high-sodium foods (less than once a week, 1 to 3 times
a week, or every day). This questionnaire also includes
a section (open question) to have patients write down
what they think can help them to follow a low-sodium
diet more closely.
Demographic and clinical data were also collected.
Study Population
For the purpose of this study, patients attending a
follow-up clinical visit at the HFC between May and
October 2012 and who therefore had been exposed to
an initial dietary teaching session were included. When
more than 1 dietary questionnaire was available for the
same patients, only the first questionnaire completed
during a follow-up clinical visit was included, and patients were excluded if that first questionnaire was
incomplete.
Study Groups
Patients were divided into 3 groups according to the degree of self-reported adherence to a low-sodium diet: never
adherent, sometimes adherent, and always adherent.
In addition, patients were further classified into
2 groups according to the current use of salt in cooking:
(1) patients using salt and (2) patients not using salt.
This secondary classification was intended to estimate
the probability (odds ratio [OR]) of increased frequency
of each 1 of the selected high-sodium foods among
patients who do not use salt for cooking in comparison
with those who use salt for cooking.
The study was approved by the Health Research
Ethics Board of the University of Alberta.
Statistical Analysis
Results were expressed as median (25thY75th percentile)
when the variables were continuous and in relative frequencies when they were categorical. For the comparison of continuous variables between the primary study
groups, the Kruskal-Wallis test was used, and for

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

60 Journal of Cardiovascular Nursing x January/February 2015

categorical variables, the Pearson # 2 test was used. In
addition, the association between use of table salt and
intake of high-sodium foods was studied using a multivariable logistic regression analysis to estimate the
probability of eating at least once a week each 1 of
the high-sodium food included in the questionnaire
among patients who do not use salt for cooking compared with those who do use salt, adjusting for age,
gender, and New York Heart Association functional
class. This analysis was intended to test the robustness
of the observed associations when primary study groups
(self-reported adherence groups) were compared due to
imbalance groups were expected (sensitivity analysis).
Data were analyzed using the SPSS statistical program
(SPSS 17.0 for Windows; SPSS, Inc, Chicago, Illinois).
All statistical tests were considered statistically significant when P G .05.

Results
Overall, a total of 299 patients with chronic HF attending a follow-up clinical visit at the HFC between May
and October 2012 were identified. Of these, 62 were
excluded because of incomplete dietary questionnaires,
and therefore, 237 patients were included in the analysis. Of these, 4.6% (11), 44.7% (106), and 50.6% (120)
self-reported that they were never, sometimes, or always
adherent with a low-sodium diet, respectively. Demographic and clinical characteristics for the overall population and by study groups are shown in Table 1.
Significant differences between groups were found for
age, New York Heart Association class, and use of loop
diuretics and anticoagulants.
When self-reported use of salt was compared among
these groups, there was a significant association between

TABLE 1 Patients Characteristics According to Self-perception of Current Adherence to a

Low-Sodium Dieta
Characteristics
Demographic
Age, y
Gender (male)
Weight, kg
Body mass index, kg/m2
Heart failure related
NYHA class
I
II
IIIYIV
Ischemic etiology
SBP, mm Hg
DBP, mm Hg
Ejection fraction, %
Creatinine, 6mol/L
GFR, mL/min/1.73 m2
Comorbidities
Coronary artery disease
Cerebrovascular disease
Diabetes mellitus
Dyslipidemia
Hypertension
Cardiac medications
ACE inhibitors or ARB
"-blockers
Calcium channel blockers
Digoxin
Antiarrhythmic
Loop diuretics
Nonloop diuretics
Nitrates
MR antagonist
ASA
Clopidogrel
Anticoagulants

Overall
(n = 237)

Never Adherent
(n = 11)

Sometimes Adherent
(n = 106)

Always Adherent
(n = 120)

66 (56Y75)
172 (72.6)
87.7 (75Y102)
30 (26Y34)

67 (60Y85)
6 (54.5)
94.5 (54Y103)
29.8 (23Y33)

63 (52Y72)
72 (67.9)
88.7 (72Y104)
30.1 (26Y35)

69
94
85.8
29.7

(61Y78)
(78.3)
(76Y101)
(26Y34)

.007
.084
.93
.86

67 (29)
96 (41.6)
68 (29.4)
92 (39.1)
116 (100Y126)
66 (60Y74)
35 (25Y50)
97 (81Y131)
64.3 (43Y81)

1 (9.1)
9 (81.8)
1 (9.1)
5 (45.5)
112 (94Y128)
64 (60Y68)
30 (20Y33)
91 (78Y117)
63.8 (51Y82)

38 (36.2)
39 (37.1)
28 (26.7)
38 (36.2)
116 (102Y129)
68 (60Y79)
35 (30Y50)
93 (79Y125)
66 (44Y81)

28
48
39
49
114
64
35
103
59

(24.3)
(41.7)
(33.9)
(41.2)
(98Y125)
(60Y74)
(25Y50)
(81Y145)
(39Y80)

.02

.68
.52
.37
.06
.29
.47

Pb

107
19
79
164
129

(45.5)
(8.1)
(33.6)
(69.8)
(54.9)

5
0
6
10
5

(45.5)
(0)
(54.5)
(90.9)
(45.5)

47
9
34
73
52

(44.8)
(8.6)
(32.4)
(69.5)
(49.5)

55
10
39
81
72

(46.2)
(8.4)
(32.8)
(68.1)
(60.5)

.98
.6
.32
.29
.21

212
219
31
32
11
163
31
41
115
133
18
98

(90.2)
(93.2)
(13.2)
(13.6)
(4.7)
(69.4)
(13.2)
(17.4)
(48.9)
(56.6)
(7.7)
(41.7)

10
11
1
1
0
9
0
2
8
6
2
3

(90.9)
(100)
(9.1)
(9.1)
(0)
(81.8)
(0)
(18.2)
(72.7)
(54.5)
(18.2)
(27.3)

99
100
13
11
4
64
16
14
45
61
4
36

(94.3)
(95.2)
(12.4)
(10.5)
(3.8)
(61)
(15.2)
(13.3)
(42.9)
(58.1)
(3.8)
(34.3)

103
108
17
20
7
90
15
25
62
66
12
59

(86.6)
(90.8)
(14.3)
(16.8)
(5.9)
(75.6)
(12.6)
(21)
(52.1)
(55.5)
(10.1)
(49.6)

.15
.27
.84
.35
.58
.039
.35
.32
.10
.92
.09
.042

Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blockers; ASA, acetyl salicylic acid; DBP, diastolic blood pressure;
GFR, glomerular filtration rate; MR, mineralocorticoid-receptor; NYHA, New York Heart Association; SBP, systolic blood pressure.
a
Values are median (25thY75th percentile) and n (%) for continues and categorical variables, respectively.
b
Data with median (25thY75th percentile): P values determined by Kruskal-Wallis test between adherence groups. Data with n (%): P values
determined by # 2 tests between adherence groups.

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Dietary Habits and Sodium Intake in HF Patients 61

this practice and self-reported adherence to a lowsodium diet. The lowest proportion of patients using
salt in cooking or at the table was found in the always
adherent group (Figure 1).
A high proportion of patients in the overall population reported a high intake of processed meats at least
once a week (30%); cottage, feta, or parmesan cheese
(21%); other processed and spread cheeses (35%); and
condiments such as ketchup, BBQ sauce, oxo cubes,
soy sauce, and salad dressings (52%). When groups of
self-reported adherence were compared, a statistically
significant difference was found for intake of soups
(canned or package). The highest proportion of patients
eating this product 1 to 3 times per week was found in
the never adherent group, compared with the other
2 groups. However, it is important to note that 4% of
the patients who said always being adherent with a lowsodium diet reported to eat this type of processed food
every day (Table 2).
Frequency of intake of fast food was also significantly different between groups, with the highest proportion of patients eating this kind of food 1 to 3 times
per week among those who stated sometimes being adherent with a low-sodium diet. Moreover, frequency of
consumption of processed meat tended to be higher
among patients in this same group compared with the
never and always adherent groups; however, and most
importantly, the rest of the food items did not show any
statistically significant differences among groups of selfreported adherence (Table 2).
When patients were reclassified in 2 groups according to the current use of salt in cooking, those reporting
not using salt in cooking were less likely to eat at least
once per week foods such as processed meats (OR, 0.48;
95% confidence interval [CI], 0.26Y0.90; P = .02);
salted nuts or salted crackers (OR, 0.23; 95% CI,
0.09Y0.60; P = .003); chips, pretzels, or nachos (OR,
0.42; 95% CI, 0.19Y0.91 P = .03); and seasonings such
as garlic salt, sea salt, onion salt, or seasoning salt
(OR, 0.17; 95% CI, 0.09Y0.34, P G .001), after
adjusting for key variables. However, these patients

FIGURE 1. Use of salt in cooking or at the table by study group.

did not show a significantly lower risk of eating at

least once per week any of the remaining high-sodium
foods included in the questionnaire (eg, canned/packaged
soups and rice, frozen dinners, canned products, processed cheeses, fast food) in comparison with patients
who reported using salt for cooking regularly.
Finally, the most frequent comments received from
the patients when they were asked about what would
help them to follow a low-sodium diet were more selfdiscipline, eating at home more or homemade meals,
and having more access to low-sodium processed foods
(Figure 2).

Discussion
The findings of this study conducted in a clinical setting
showed that self-report of following a low-sodium diet
is not associated with frequency of intake of highsodium processed foods in patients attending a specialized clinic who have received dietary counseling on
restricting sodium intake. A lack of consistency between
self-reported adherence to a low-sodium diet and dietary habits related to sodium intake was found. Patients
who stated always being adherent with a low-sodium
diet were less likely to use salt either in cooking or at
the table, compared with the other 2 groups. However,
a number of patients in the always adherent group reported to eat canned or package soups every day and
processed meats or fast foods at least once a week.
These results suggest that patients associate the idea of
following a low-sodium diet mainly with avoiding salt
in cooking or at the table but not with reducing frequency of intake of high-sodium processed foods. These
findings were confirmed in the sensitivity analysis,
which showed that patients who do not use salt in
cooking were less likely to eat at least once per week
foods such as processed meats; salted nuts or salted
crackers; chips, pretzels, or nachos; and salt seasonings
but were just as likely to consume products such as
canned/packaged soups and rice, frozen dinners, canned
products, processed cheeses, fast food, and others.
A previous study demonstrated that patients ability
to estimate how well they follow a low-sodium diet is
not accurate when compared with an objective method
such as 24-hour urinary sodium excretion. The 24-hour
urine sodium levels of patients who self-reported that
they were adherent to a low-sodium diet were similar
to the levels of patients who indicated that they did not
consistently follow a low-sodium diet (4560 vs 4333 mg;
P = .59).4 Authors suggested that the inability to estimate low-sodium diet adherence may be the result of
gaps in patients knowledge that preclude accurate
self-assessment. In this sense, Lennie et al11 reported
that among patients with HF who had received recommendations to follow a low-sodium diet, 31.5% could
not remember the instructions received when they

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62 Journal of Cardiovascular Nursing x January/February 2015

TABLE 2

Frequency of Intake of Common High-Sodium Foods by Study Groupa

Processed Foods
Soups (canned or package)/ramen/
instant noodle soup
Less than once/week
1Y3 times/week
Every day
Canned products
Less than once/week
1Y3 times/week
Every day
Frozen diners
Less than once/week
1Y3 times/week
Every day
Processed meats (hot dog, luncheon meat,
bacon, sausage, ham)
Less than once/week
1Y3 times/week
Every day
Package pasta/rice
Less than once/week
1Y3 times/week
Every day
Tomato sauce or pasta
Less than once/week
1Y3 times/week
Every day
Tomato juice/vegetable juice/
clamato juice
Less than once/week
1Y3 times/week
Every day
Cottage cheese/feta cheese/parmesan
Less than once/week
1Y3 times/week
Every day
Other processed and spread cheeses
Less than once/week
1Y3 times/week
Every day
Fast food (burgers/fried chicken/pizza/fries)
Less than once/week
1Y3 times/week
Every day
Salted nuts/salted crackers
Less than once/week
1Y3 times/week
Every day
Chips/pretzels/nachos
Less than once/week
1Y3 times/week
Every day
Ketchup, BBQ sauce, oxo cubes,
soy sauce, salad dressings
Less than once/week
1Y3 times/week
Every day
Garlic salt/sea salt/onion salt/seasoning salt
Less than once/week
1Y3 times/week
Every day

Overall
(n = 237)

Never Adherent
(n = 11)

Sometimes Adherent
(n = 106)

Always Adherent
(n = 120)

81.8
16.1
2.1

63.6
36.4
0

80.2
19.8
0

84.9
10.9
4.2

.02

84.7
14.8
0.4

90.9
9.1
0

84.0
16
0

84.9
14.3
0.8

.8

91.5
7.7
0.9

90.9
9.1
0

91.3
8.7
0

91.6
6.7
1.7

.7

69.9
27.1
3

81.8
9.1
9.1

63.2
34.9
1.9

74.8
21.8
3.4

.09

88.9
11.1
0

90.9
9.1
0

86.4
13.6
0

90.8
9.2
0

.6

84.2
15.8
0

90.9
9.1
0

81.7
18.3
0

85.7
14.3
0

.6

86.9
10.9
2.2

90.9
0
9.1

83.5
13.6
2.9

89.6
9.6
0.9

.2

79.1
20.5
0.4

90
10
0

77.9
22.1
0

79.2
20
0.8

.8

65.4
32.1
2.6

90.9
9.1
0

59.6
36.5
3.8

68.1
30.3
1.7

.2

86
14
0

90.9
9.1
0

77.1
22.9
0

93.3
6.7
0

.002

91.1
6.8
2.1

90
10
0

85.7
10.5
3.8

95.8
3.3
0.8

.1

86.3
12.4
1.3

90.9
9.1
0

80.6
17.5
1.9

90.8
8.4
0.8

.3

48.5
46
5.5

45.5
54.5
0

42.5
51.9
5.7

54.2
40
5.8

.4

77.1
19.1
3.8

63.6
27.3
9.1

73.3
20
6.7

81.7
17.5
0.8

.1

Pb

(continues)

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Dietary Habits and Sodium Intake in HF Patients 63

TABLE 2

Frequency of Intake of Common High-Sodium Foods by Study Groupa, continued

Processed Foods
Pickles, olives, sauerkraut
Less than once/week
1Y3 times/week
Every day

Overall
(n = 237)

Never Adherent
(n = 11)

Sometimes Adherent
(n = 106)

Always Adherent
(n = 120)

82.6
15.7
1.7

81.8
18.2
0

77.1
19
3.8

87.5
12.5
0

Pb
.1

Data reflect proportion of patient (%) per study group.

For comparison of frequency of intake between study groups by # 2 test between adherence groups.

underwent a recall about the instructions by healthcare

providers regarding a low-sodium diet, and only 49%
of patients in another study reported that they understood or knew how to follow a sodium-restricted diet.12
Other authors5,13,14 have also reported that HF patients
identified lack of knowledge as an important factor
limiting their adherence to a sodium-restricted diet. In
addition, it is important to note that interviewer bias is
another factor that might also affect patients self-report
of adherence to a low-sodium diet and lead patients to
report more favorable sodium intake.
The results of this study extend the existing evidence
base by reporting a lack of association between selfreported adherence to a low-sodium diet and dietary
habits related to sodium intake in patients with HF,
who associated the idea of following a low-sodium diet
mainly with not using salt for cooking or at the table
but not with reducing frequency of intake of highsodium processed foods, which are the main source
of sodium in the diet, accounting for 77% of average
daily sodium intake.15 Similar results were found in the
national survey examining Canadians concern, actions,
barriers, and support for dietary sodium reduction intervention. Forty-six percent of participants admitted limiting sodium intake but not avoiding high-sodium foods
and thought their sodium intake was low because they
do not add salt to their food.16 These data point out an

important misconception about a low-sodium diet and

support the need for further clinical and population
interventions targeting high-sodium processed foods to
help HF patients in lowering their sodium intake.
Currently, there are insufficient data to endorse any
specific level of sodium intake with certainty in HF patients. The recent American Heart Association17 recommendations of 1500 mg/d sodium for the general
population appears to be applicable for HF patients.1
However, even HF patients who have received specialized
nutritional advice continue to consume large quantities
of sodium daily. In a recent study among HF patients
who have been advised to limit their sodium intake to
2000 mg/d, the estimated compliance rate was only
33% as noted by 3-day food diaries,18 whereas based
on 24-hour urinary sodium excretion, compliance to
this same level of sodium restriction was estimated to
be only 15% in another HF population.6 Therefore,
there is an undeniable need to identify strategies to improve adherence to this dietary treatment in HF. In this
sense, the adoption of a better method of monitoring
adherence in clinical practice, other than self-report of
following a low-sodium diet, that provides timely feedback for the clinician to better guide dietary counseling
for sodium reductions is needed.
Monitoring the frequency of intake of high-sodium
foods may help clinicians qualitatively evaluate adherence

FIGURE 2. Most frequent comments from patients with heart failure about what would help them improve their adherence
to a low-diet.

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64 Journal of Cardiovascular Nursing x January/February 2015

Whats New and Important

h Patients with HF associate the idea of following a
low-sodium diet mainly with not using salt for cooking
or at the table but not with reducing frequency of intake
of high-sodium processed foods, the main source of
sodium in the diet. Therefore, self-report of adherence
to a low-sodium diet is not reliable among patients
with HF.
h Evaluation of frequency of intake of high-sodium
foods may help clinicians more effectively evaluate adherence
to a low-sodium diet and guide dietary counseling by
the identifying main sources of sodium intake and
misconceptions regarding a low-sodium diet.
h Development of new quantitative methods for sodium
intake assessment in HF that fit the pragmatic needs
of clinical setting and that provide timely feedback for
clinicians to guide dietary counseling is needed.

to a low-sodium diet by identifying main sources of

sodium intake to guide dietary counseling in HF. In addition, the clinical relevance of frequent intake of highsodium foods in HF has been reported in a recent study
showing that frequent intake of salty foods was associated with heart transplantation in high-urgency status
(hazard ratio, 2.9; 95% CI, 1.55Y5.42) in patients with
advanced HF.19
However, a valid quantitative method for sodium
intake assessment in HF that fits the pragmatic needs
of a clinical setting is still needed. Traditional methods
for quantification of sodium consumption are complex
and do not necessarily provide timely feedback to guide
dietary counseling. The gold standard 24-hour urine collection is time-consuming and cumbersome and requires
laboratory analysis. Dietary methods, including food records, can be relatively time-consuming to complete and
require specialized software to be analyzed, which hinders
their usefulness in the clinical setting. An emerging
online tool intended to provide instant personalized
feedback to the patient and clinician on the sources of
sodium in the diet and the amount of sodium habitually
consumed appears to address these issues; however, its
validity in the clinical setting of HF needs to be evaluated.20
Finally, it is worthy to note that 13.3% of the study
patients reported more and better low-sodium processed foods as a factor that might help them follow a
low-sodium diet; however, because sodium is used as
a preservative by the food industry, this represents a
challenge. Salt and other sodium-containing preservatives are being partially replaced by compounds based
on potassium to reduce sodium content in the foods
without affecting preservation.21 However, a great proportion of HF patients may also need to reduce potassium intake sometime during the disease course because
of the use of potassium-sparing cardiac medications
and/or to the coexistence of renal disease.

Limitations
The present study has 4 main limitations. First, the
sample size in 1 of the 3 study groups was small (n = 11)
and type II error could have occurred in the estimates.
Second, actual sodium intake was not assessed other
than by self-report. This is a study in the clinical setting,
and data regarding other methods to estimate sodium
intake, such as 24-hour urinary sodium excretion or
food records, were not available. In addition, previous
studies have raised concerns regarding the utility and
accuracy of 24-hour urine sodium excretion for patients
with HF on diuretics.22 Third, there might be other
common high-sodium foods that were not included in
this questionnaire, such as bread and restaurant meals.
Fourth, if anything, our results likely underestimate the
extent to which HF patients consume high-sodium foods
because we studied patients with chronic HF followed
in a specialized clinic who had already undergone extensive dietary teaching.

Conclusion
Self-report of adherence to a low-sodium diet is not
reliable among patients with HF, who associate the idea
of following a low-sodium diet mainly with not using
salt for cooking or at the table, but not with reducing
frequency of intake of high-sodium processed foods,
which are the main source of sodium in the diet. These
results also suggest that evaluating frequency of intake
of high-sodium foods may help clinicians more effectively evaluate adherence to a low-sodium diet and
guide dietary counseling by identifying main sources of
sodium intake and misconceptions regarding a lowsodium diet.
Acknowledgments
We thank the University of Alberta HFC patients and
staff for their support on this study, as well as Marilou
Isla for administrative support.
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