672661

research-article2016
WJNXXX10.1177/0193945916672661Western Journal of Nursing ResearchWu et al.

Article
Western Journal of Nursing Research
1­–14
Does the Theory of © The Author(s) 2016
Reprints and permissions:
Planned Behavior Predict sagepub.com/journalsPermissions.nav
DOI: 10.1177/0193945916672661
Dietary Sodium Intake wjn.sagepub.com

in Patients With Heart

Failure?

Jia-Rong Wu1, Terry A. Lennie2, Sandra B. Dunbar3,

Susan J. Pressler4, and Debra K. Moser2

Abstract
Sodium intake in heart failure (HF) is a crucial but poorly understood
phenomenon. Theoretical models promote understanding and provide a
context for rational appraisal of complex situations. The purpose of this
study was to determine which factors were associated with sodium intake in
HF patients using theory of planned behavior (TPB). In this study, patients’
(N = 244) attitudes, subjective norms, and perceived behavioral control
(tenets of the TPB) were assessed using the Dietary Sodium Restriction
Questionnaire. Sodium intake was estimated objectively by 24-hr urinary
sodium excretion (UNa). The average UNa was 3,811 mg. Subjective norms,
gender, and New York Heart Association functional class were associated
with sodium intake (p < .001). Thus, it is important for health care providers
to clearly express their approval of following low-sodium diet to their HF
patients, and include significant others in interventions to help patients
develop/maintain a positive subjective norm to decrease sodium intake and
reduce HF exacerbations.

1Universityof North Carolina at Chapel Hill, Chapel Hill, NC, USA

2Universityof Kentucky, Lexington, KY, USA
3Emory University, Atlanta, GA, USA
4Indiana University, Indianapolis, IN, USA

Corresponding Author:
Jia-Rong Wu, School of Nursing, University of North Carolina at Chapel Hill, 435 Carrington
Hall, CB # 7460, Chapel Hill, NC 27599-7460, USA.
Email: jiarongw@email.unc.edu

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

2 Western Journal of Nursing Research 

Keywords
low-sodium diet, heart failure, determinant, adherence

Heart failure (HF) is a chronic condition with high prevalence and mortality
that currently afflicts about six million people, and about 915,000 new cases
are diagnosed each year in the United States (Mozaffarian et al., 2016). In
2012, total medical costs for HF were about 30.7 billion, and 68% of these
costs were attributed to direct medical cost, mostly for hospitalization
(Mozaffarian et al., 2016). Fluid overload secondary to excessive dietary
sodium intake has been reported as one of the most common reasons for hos-
pitalization related to acute exacerbation of HF (Riegel et al., 2009). However,
despite the long-standing recommendation that patients with HF limit the
amount of sodium in their diets (Yancy et al., 2013, 2016), high sodium
intake remains common (Basuray et al., 2015; Dunbar et al., 2013; Hunt
et al., 2009; Lemon et al., 2010; Song, Cho, & Lee, 2013).
A better understanding of the factors associated with sodium intake in patients
with HF is needed to develop effective interventions that help patients limit
sodium intake and reduce rehospitalization. A theoretical model enhances under-
standing of complex situations, and provides context for a full and rational
appraisal of the problem (Corvellec, 2013). In the HF literature, male gender,
overweight, lower education, lower income, higher body mass index, and no
reported diagnosis of hypertension have been found to be associated with higher
sodium intake (Basuray et al., 2015; Dolansky et al., 2016; Hwang & Kim, 2016;
Lemon et al., 2010; Song et al., 2013). However, some important sociodemo-
graphic and clinical factors of sodium intake (e.g., financial status, comorbidities)
have not been studied. Also, most studies of sodium intake to date have not used
a theoretical model for variable selection (Basuray et al., 2015; Dolansky et al.,
2016; Hwang & Kim, 2016; Lemon et al., 2010; Lennie et al., 2008; Song et al.,
2013) or considered multivariate relationships (Hwang & Kim, 2016; Lennie
et al., 2008; Song et al., 2013). Therefore, many important predictors of dietary
sodium intake likely remain unknown or underappreciated.
The theory of planned behavior (TPB) is commonly used in studies to
improve health behaviors (Glanz, Rimer, & Viswanath, 2008), and research to
date supports TPB constructs in predicting behavior change (Maleki, Hosseini
Nodeh, Rahnavard, & Arab, 2016), including many self-care behaviors (e.g.,
adherence to low-sodium diet, medication adherence) in patients with HF
(Welsh et al., 2013; Wu, Corley, Lennie, & Moser, 2012). According to the
TPB, attitudes, subjective norm, and perceived behavioral control are the
three main constructs underlying behavior change (e.g., dietary sodium intake;
Glanz et al., 2008). Attitude is determined by the patient’s beliefs about the

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

Wu et al. 3

outcomes of reducing sodium intake (behavior beliefs) and the value of those
outcomes (Glanz et al., 2008). A patient’s subjective norm is determined by his
or her normative beliefs—whether significant others and health care providers
approve or disapprove of reducing sodium intake—and the patients’ motiva-
tion to follow his or her significant others and health care providers’ expecta-
tion (Glanz et al., 2008). Perceived behavioral control is determined by beliefs
about the presence or absence of resources for, and impediments to, reducing
sodium intake. Perceived behavioral control beliefs are weighted by the per-
ceived impact of resources and impediments (Glanz et al., 2008). Therefore,
we hypothesized that patients with positive attitudes, positive subjective
norms, and higher perceived behavioral control had less dietary sodium intake.
It is imperative that dietary sodium intake be studied using an appropriate
model and multivariate approach to obtain comprehensive information. Once
this information is obtained, it can be used to identify those patients at risk for
high sodium intake and develop interventions to reduce sodium intake,
thereby improving morbidity and mortality in patients with HF. Accordingly,
the purpose of this study was to determine which factors predict sodium
intake in patients with HF using the TPB.

Method
Study Design
This was a cross-sectional study, a secondary data analysis of an observa-
tional study in which patients’ sociodemographic (e.g., age, gender, race/eth-
nicity) and clinical (e.g., comorbidity) data were collected by patient interview
and medical record review. Sodium intake was assessed objectively using
24-hr urinary sodium excretion (UNa).

Samples and Setting

Patients were recruited from clinics associated with three large community
hospitals or academic medical centers in three Midwestern states. Patients
were included if they had a confirmed diagnosis of chronic HF. Patients were
excluded if they had a terminal illness or obvious cognitive impairment that
precluded provision of informed consent.

Measures
Independent variable.  The Dietary Sodium Restriction Questionnaire (DSRQ)
was designed to measure factors related to following a low-sodium diet

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

4 Western Journal of Nursing Research 

recommendation. The DSRQ is composed of three subscales that correspond

to the three major components of the TPB: (a) Attitudes, (b) Subjective
Norm, and (c) Perceived Behavioral Control toward the behavior (following
low-salt diet; Bentley, Lennie, Biddle, Chung, & Moser, 2009). The DSRQ is
a psychometrically sound instrument with acceptable internal consistency
(Cronbach’s α = .62-.77 for three subscales) and supportive construct valid-
ity, and has been used in patients with HF (Bentley et al., 2009). In this study,
the Cronbach’s alpha was .91, .71, and .87, respectively, for the Attitude,
Subjective Norm, and Perceived Behavioral Control subscale.

Attitude. The Attitude subscale is a six-item, self-rated, 5-point Likert-

type scale, with 1 corresponding to strongly disagree and 5 to strongly agree.
Patients are instructed to rate how much they agree or disagree with state-
ments related to attitudes toward following a low-sodium diet such as “It is
important for me to follow my low-salt diet.” Total scores on this subscale
range from 6 to 30, and higher scores indicate more positive attitudes toward
following a low-sodium diet.

Subjective Norms.  The four-item Subjective Norm subscale is based on the

same self-rated, 5-point Likert-type scale. Total scores on this subscale range
from 4 to 20. Patients are instructed to rate how much they agree or disagree
with statements related to subjective norms such as “My spouse or other fam-
ily members think I should follow a low-salt diet.” Higher scores indicate
stronger agreement with subjective norm beliefs.

Perceived Behavioral Control.  The seven-item Perceived Behavioral Con-

trol subscale is also self-rated, 5-point Likert-type scale, with 1 correspond-
ing to not at all and 5 to a lot. All seven items on this subscale are reverse
coded. The scores on this subscale range from 7 to 35. Patients are instructed
to indicate how much they agree with statements related to barriers to fol-
lowing a low-salt diet such as “I can read the nutrition labels on foods to
figure out how much salt is in a food.” Higher scores indicate higher level of
perceived behavior control.

Dependent variable. In the TPB, attitudes, subjective norm, and perceived

behavioral control are thought to predict intentions to engage in a behavior,
which then predicts engagement in the behavior. Many researchers measure
intention to engage in a behavior as an outcome as it is usually easier to mea-
sure. We, however, did not measure intention, rather, we directly measured
engagement in the behavior, the ultimate outcome of interest because inten-
tions commonly do not translate into behavior change.

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

Wu et al. 5

Sodium intake. In this study, dietary sodium intake was measured using
24-hr UNa. Twenty-four-hour UNa is an objective measure of dietary sodium
intake (Lennie et al., 2011). It significantly correlated with reported dietary
sodium intake levels from 3 days (Xu et al., 2014), 4 days (Korhonen et al.,
1999), and 7 days (McKeown et al., 2001) food diaries. Twenty-four-hour UNa
captures all sources of sodium intake (e.g., foods, salt added, and medications),
and is therefore a better measure of sodium intake than self-reported measures
(Centers for Disease Control and Prevention, 2014). We gave written and ver-
bal instructions regarding procedures for urine collection and provided all col-
lection materials to patients. Twenty-four-hour UNa (mmol) was converted to
milligrams by multiplying millimoles × 22.99 (McKeown et al., 2001).

Covariates.  Age, gender, race/ethnicity, education, financial status, left ven-

tricular ejection fraction (LVEF), New York Heart Association (NYHA)
functional class, and comorbidity, which might influence sodium intake,
were collected as covariates (Lennie et al., 2011; Xu et al., 2014; Zhang et al.,
2014). Patients’ sociodemographic (i.e., age, gender, ethnicity, education,
financial status) and clinical (i.e., NYHA class, LVEF, comorbidity) charac-
teristics were collected from the medical record and patient interview.
Patients’ NYHA functional class was determined by patient interview based
on how patients were able to perform activities (Mills & Haught, 1996).

Procedure
Permission to conduct the study was obtained from the institutional review
board at all sites. A trained research nurse visited patients in their home to
explain the study and obtain informed, written consent. Patients were then
given urine collection equipment, and detailed written and verbal instructions
for collecting 24-hr urine. Patients were also instructed to record volume and
time of each void in a urine collection log. The morning before urine collec-
tion began, a research assistant called patients to remind them of the urine
collection and review the collection procedure. When urine collection was
completed, patients brought the urine container and log to the General Clinical
Research Center. Research nurses verified completeness of 24-hr urine collec-
tion and collected sociodemographic and clinical data by interview and medi-
cal record review. Patients were then asked to complete the DSRQ scale.

Data Management and Analysis

All data analyses were done using SPSS version 23.0; a significance level of
.05 was used throughout. Data analysis began with a descriptive examination

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

6 Western Journal of Nursing Research 

of all variables, including frequency distributions, means, standard devia-

tions, medians, and interquartile ranges, as appropriate to the level of mea-
surement of the variables.
A multiple regression with backward selection was used to determine pre-
dictors of sodium intake in patients with HF. We chose backward selection
because it allowed us to enter all covariates of interest initially. Then, the least
significant covariate was dropped until all remaining variables in the model
were statistically significant. Sociodemographic factors (i.e., age, gender, eth-
nicity, education, financial status) were entered first into the model followed
by clinical factors (i.e., age, gender, ethnicity, education, financial status) and
scores of the three DSRQ subscales (Attitudes, Subjective Norm, and
Perceived Behavioral Control). The assumptions of multiple linear regres-
sions (linearity, homoscedasticity, multicollinearity) were tested and met.

Results
Patient Characteristics
We recruited 244 patients for this study (Tables 1 and 2). The mean age of
patients was 62 years with a range from 24 to 97 years. The average LVEF
was 34.4%, 37% had preserved ejection fraction, and 73% had reduced ejec-
tion fraction. The most common HF etiology was ischemic heart disease. The
majority of patients were male, Caucasians, and married. More than one
quarter of patients reported not having enough income to make ends meet.

Sodium Intake
The average 24-hr sodium excretion was 3,811 mg (± 1,924 mg), which is
27% higher than the recommended sodium intake (Lennie et al., 2011; Yancy
et al., 2013). Only 38% of patients had UNa of 3,000 mg or less, indicating a
high number of patients with poor adherence to low-sodium diet. Male
patients consumed more sodium than female patients (4,039 vs. 3,353 mg; t
= 2.655; p = .008). Patients in NYHA Class I had the lowest sodium intake
(3,478 ± 1,920 mg), followed by those in NYHA Class II (3,606 ± 1,852 mg),
Class III (4,018 ± 1,874 mg), and Class IV (4,205 ± 2,248 mg); however,
these differences were not statistically significant (p = .241).

Description of Items From the DSRQ

The mean scores for Attitude of the DSRQ was 25.2 (± 5.3), which was
close to highest possible score of 30, indicating positive attitudes toward

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

Wu et al. 7

Table 1.  Demographic and Clinical Characteristics of Participants—Frequency

(N = 244).

Characteristics n (%)
Female gender 81 (33.2)
Race
 Caucasian 177 (72.5)
Marital status
 Married/cohabitate 142 (58.2)
Financial status
 Comfortable 55 (22.5)
  Enough to make ends meet 119 (48.8)
  Not enough to make ends meet 70 (28.7)
Etiology
 Ischemic 116 (48.3)
 Idiopathic 45 (18.8)
 Hypertensive 38 (15.8)
  Other (e.g., alcoholic) 41 (17.1)
NYHA functional classification
  Class I/II 130 (53.5)
  Class III 80 (32.9)
  Class IV 33 (13.6)

Note. NYHA = New York Heart Association.

following a low-sodium diet. The mean subjective norm scores of the

DSRQ was 12.7 (± 2.4). When each item of the Subjective Norm subscale
was examined, the majority of patients strongly agreed/agreed that their
health care providers and significant other think they should follow a low-
sodium diet. Most of the patients would like to do what their health care
provider and spouse/significant other want them to do to lower dietary
sodium intake (Table 3). The average scores for Perceived Behavioral
Control of the DSRQ was 12 (±3), which was far away from the full score
of 35, indicating low perceived behavioral control of following low-
sodium diet.

Predictors of UNa
The multiple regression model for prediction of UNa is shown in Table 4. The
subjective norm subscale of the DSRQ, gender, and NYHA functional class
predicted UNa (F = 5.330, p = .001). Specifically, lower scores on subjective
norm (meaning less agreement with items suggesting the beliefs of significant

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

8 Western Journal of Nursing Research 

Table 2.  Demographic and Clinical Characteristics of Participants—Mean

(N = 244).

Characteristics M (SD)
Age 61.5 (11.6)
Education (years) 13.8 (3.2)
LVEF (%) 34.4 (13.3)
aCharlson comorbidity index 3.2 (2.0)
DSRQ—Attitude score (range = 6-30) 25.2 (5.3)
DSRQ—Subjective Norm score (range = 4-20) 12.7 (2.4)
DSRQ—Perceived Behavioral Control score 12.0 (3.0)
(range = 7-35)

Note. LVEF = left ventricular ejection fraction; DSRQ = Dietary Sodium Restriction
Questionnaire.
a. Charlson comorbidity index: Higher score reflects greater comorbidity burden.

Table 3.  Descriptive Statistics for Subjective Norm Subscale of the DSRQ
(N = 244).

Patients Who Agree/

Items of the Subjective Norm Subscale of the DSRQ Strongly Agree, n (%)
1.   My doctor thinks I should follow a low-salt diet 194 (79.5)
2.  My spouse or significant others think I should 164 (67.2)
follow a low-salt diet
3.   I want to do what my doctor thinks I should do 226 (92.6)
4.  I want to do what my spouse or significant others 168 (68.8)
think I should do

Note. DSRQ = Dietary Sodium Restriction Questionnaire.

others and health care providers are important to guiding patients’ behavior),
male gender, and worse NYHA class predicted higher UNa.

Discussion
This is the first study in patients with HF in which the factors hypothesized in
the TPB, a well-known model that has been used to explain behavior change,
were tested. The findings of this study supported only one tenet of the TPB, the
subjective norm, but not attitudes or perceived behavioral control as a predictor
of sodium intake. Specifically, in this study, we demonstrated that after control-
ling for relevant sociodemographic (i.e., age, gender, race/ethnicity, education,

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

Wu et al. 9

Table 4.  Predictors of Dietary Sodium Intake in Patients With HF (N = 244).

Variables Standardized β p
Gender −.169 .010
NYHA .153 .019
DSRQ—Subjective Norm −.140 .032

Note. F = 5.330; p = .001. HF = heart failure; NYHA = New York Heart Association;
DSRQ = Dietary Sodium Restriction Questionnaire.

financial status) and clinical (i.e., LVEF, NYHA, comorbidity) characteristics,

higher scores on Subjective Norm (greater agreement that the opinions of oth-
ers about the behavior were important to the patient) were predictive of lower
sodium intake.
The findings of this study are consistent with the current literature demon-
strating that health care provider(s) and significant others are two important
groups who can have an impact on patients’ health behaviors (including
sodium intake; Bentley, De Jong, Moser, & Peden, 2005; Evans et al., 2007).
In a qualitative study, Evans and colleagues interviewed 43 male cancer
patients to determine how they acquired and evaluated complementary and
alternative medicine (CAM) information before deciding which CAM thera-
pies to try (Evans et al., 2007). The majority of the participants expressed a
preference for CAM information to be provided via their health care provid-
ers because they considered information from their health care providers as a
trusted source of care and a “stamp of approval” (Evans et al., 2007).
The majority (93%) of patients in this study reported wanting to follow
their health care providers’ recommendation to limit daily sodium intake.
Bentley and colleagues (2005) interviewed 20 patients with HF to explore
patients’ experiences of following low-sodium diet. One of the major barriers
identified was that HF patients received little/no information from their
health care professionals regarding following low-sodium diet (Bentley et al.,
2005). Therefore, the findings from these studies and the current study sug-
gest that it is important that patients with HF receive confirmation and sup-
port from their health care providers in terms of reducing sodium intake.
Such support can increase patient’s subjective norm, which is associated with
following the low-sodium diet (Bentley et al., 2005; Graven & Grant, 2014;
Riegel & Carlson, 2002). Also, provision of this information to the patient’s
significant others will increase their ability to provide positive support for the
patient.
It is equally important to note that significant others play a crucial role in
supporting patients in reducing daily sodium intake. In this study, we found

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

10 Western Journal of Nursing Research 

that more than two thirds of patients believed that their significant others
thought they should follow a low-sodium diet and they wanted to do what
their significant others thought they should do. Patients have previously
reported that significant others who did not understand or respect their need
for dietary restrictions limited their ability to reduce sodium intake (Bentley
et al., 2005). Results from the Lung Health Study, a large clinical trial of
smoking cessation intervention, provided further evidence of the importance
of a significant other in behavior change. First, married participants and those
who had a family member at the time of the start of the smoking cessation
intervention were more likely to quit smoking at 1 year after the intervention
(Murray et al., 2000; Murray, Johnston, Dolce, Lee, & O’Hara, 1995).
Second, participants had the highest rates of successful smoking cessation
and abstinence when their family members were ex-smokers and attended the
smoking cessation intervention with the participants 3 or more times (showed
support/approval for the participants’ smoking cessation; Murray et al.,
1995). In this study, we add to this literature by revealing that positive subjec-
tive norms from both health care providers and significant others affect HF
patients’ willingness to follow low-sodium diet and reduce dietary sodium
intake, and thus are a target for intervention to increase providers and family
members’ awareness about reducing sodium intake.
Furthermore, we demonstrated that male gender was a predictor of higher
sodium intake in multivariate analysis. Male patients with HF tend to con-
sume more sodium, a finding that has been demonstrated in prior studies
(Basuray et al., 2015; Chung et al., 2006; Dunbar et al., 2013; Hwang & Kim,
2016; Lemon et al., 2010). A number of possible explanations might be that
males had less knowledge and negative attitudes related to reducing sodium
intake, perceived more barriers to reducing sodium intake, and were not the
main person for grocery shopping and meal preparation (Chung et al., 2006;
Dolansky et al., 2016). For example, Chung and colleagues (2006) found that
female HF patients recognized signs of excess sodium intake such as fluid
buildup and edema more often than male HF patients. Female patients had
better understanding of appropriate actions to take related to reducing sodium
intake (Chung et al., 2006). However, in the same study, the investigators did
not find gender differences in perceived barriers to following low-sodium
diet recommendations (Chung et al., 2006). It is important to note that even
though female patients had greater knowledge about reducing sodium intake
than male patients, knowledge is not sufficient for reducing sodium intake. It
is also possible that men simply eat more than women and therefore con-
sumed more sodium.
We demonstrated that NYHA class was predictive of higher sodium
intake. The mechanism underlying the relationship between NYHA class and

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

Wu et al. 11

sodium intake in HF is not known. However, one possible explanation for

this finding is that patients were more symptomatic due to higher sodium
intake resulting in worse functional class. This study is a cross-sectional
design meaning causality cannot be assumed. Therefore, a longitudinal study
is needed to examine whether high sodium intake is causally related to worse
functional class or patients who have worse functional class tend to consume
more sodium.
It is not clear why the other two components of the TPB—attitudes toward
reducing sodium intake and perceived behavioral control—did not predict
sodium intake as we hypothesized. Several reasons can be suggested for
these findings. It is possible that the TPB theory is not appropriate for pre-
dicting dietary sodium intake in patients with HF, our measure did not fully
reflect the theoretical constructs of attitude and perceived behavioral control
in the TPB, there was not enough variance in scores of these two constructs
on dietary sodium intake, or other factors not measured in this study affected
the results. However, there is evidence to support the reliability and validity
of the DSRQ as a measure factor related to following low-sodium diet based
on the TPB (Bentley et al., 2009). Thus, further research is needed to verify
the findings of this study.
Our study has several limitations. First, this is a cross-sectional study and
causality cannot be assumed. Second, our sample was mostly White, male,
and married patients. Therefore, our findings warrant further study to confirm
these results in a more diverse sample of HF patients. Third, the level of
dietary sodium intake was estimated by one-time measurement of 24-hr UNa
that may not reflect habitual dietary sodium intake. However, 24-hr UNa was
significantly correlated with dietary sodium intake from 3-day, 4-day, and
7-day food diary (Korhonen et al., 1999; McKeown et al., 2001; Xu et al.,
2014), and has been used widely to assess dietary sodium intake (Dunbar
et al., 2013; Lennie et al., 2011).
In conclusion, approval from health care providers and significant others
for following the low-sodium diet is associated with reduced sodium intake
among patients with HF. Interventions aimed at decreasing sodium intake
should include a focus on patients and significant others as well health care
providers to enhance patient’s subjective norm regarding reducing sodium
intake.

Authors’ Note
The content is solely the responsibility of the authors and does not necessarily rep-
resent the official views of the National Institute of Nursing Research, National
Institutes of Health, National Center for Research Resources, or Veterans
Administration.

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

12 Western Journal of Nursing Research 

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, author-
ship, and/or publication of this article: This study was supported by funding from the
National Institute of Nursing Research of the National Institutes of Health under Awards
K23NR014489 (Jia-Rong Wu, principal investigator [PI]) and NR009280 (T. Lennie,
PI). It is also funded in part by Public Health Service (PHS) Grant M01 RR000039 from
the General Clinical Research Center program and PHS Grant UL1 RR025008 from the
Clinical and Translational Science Award program, National Center for Research
Resources, and the Atlanta Veterans Administration Medical Center.

References
Basuray, A., Dolansky, M., Josephson, R., Sattar, A., Grady, E. M., Vehovec, A.,
. . . Hughes, J. W. (2015). Dietary sodium adherence is poor in chronic heart
failure patients. Journal of Cardiac Failure, 21, 323-329. doi:10.1016/j.card-
fail.2014.12.016
Bentley, B., De Jong, M. J., Moser, D. K., & Peden, A. R. (2005). Factors related
to nonadherence to low sodium diet recommendations in heart failure patients.
European Journal of Cardiovascular Nursing, 4, 331-336. doi:10.1016/j.ejc-
nurse.2005.04.009
Bentley, B., Lennie, T. A., Biddle, M., Chung, M. L., & Moser, D. K. (2009).
Demonstration of psychometric soundness of the Dietary Sodium Restriction
Questionnaire in patients with heart failure. Heart Lung, 38, 121-128.
doi:10.1016/j.hrtlng.2008.05.006
Centers for Disease Control and Prevention. (2014). The use of urine biomarkers to
estimate population sodium intake. Retrieved from http://www.cdc.gov/salt/pdfs/
sodium_reduction_biomarkers.pdf
Chung, M. L., Moser, D. K., Lennie, T. A., Worrall-Carter, L., Bentley, B., Trupp,
R., & Armentano, D. S. (2006). Gender differences in adherence to the sodium-
restricted diet in patients with heart failure. Journal of Cardiac Failure, 12, 628-
634. doi:10.1016/j.cardfail.2006.07.007
Corvellec, H. (2013). What is theory? Answers from the social and cultural sciences.
Stockholm, Sweden: Copenhagen Business School Press.
Dolansky, M. A., Schaefer, J. T., Hawkins, M. A., Gunstad, J., Basuray, A., Redle, J.
D., . . . Hughes, J. W. (2016). The association between cognitive function and objec-
tive adherence to dietary sodium guidelines in patients with heart failure. Journal of
Patient Preference and Adherence, 10, 233-241. doi:10.2147/ppa.s95528
Dunbar, S. B., Clark, P. C., Reilly, C. M., Gary, R. A., Smith, A., McCarty, F.,
. . . Ryan, R. (2013). A trial of family partnership and education interventions
in heart failure. Journal of Cardiac Failure, 19, 829-841. doi:10.1016/j.card-
fail.2013.10.007

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

Wu et al. 13

Evans, M., Shaw, A., Thompson, E. A., Falk, S., Turton, P., Thompson, T., & Sharp,
D. (2007). Decisions to use complementary and alternative medicine (CAM) by
male cancer patients: Information-seeking roles and types of evidence used. BMC
Complementary and Alternative Medicine, 7, Article 25. doi:10.1186/1472-6882-7-25
Glanz, K., Rimer, B. K., & Viswanath, K. (2008). Health behavior and health educa-
tion: Theory, research, and practice (4th ed.). San Francisco, CA: Jossey-Bass.
Graven, L. J., & Grant, J. S. (2014). Social support and self-care behaviors in individ-
uals with heart failure: An integrative review. International Journal of Nursing
Studies, 51, 320-333. doi:10.1016/j.ijnurstu.2013.06.013
Hunt, S. A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats,
T. G., . . . Yancy, C. W. (2009). 2009 focused update incorporated into the ACC/
AHA 2005 guidelines for the diagnosis and management of heart failure in
adults: A report of the American College of Cardiology Foundation/American
Heart Association Task Force on practice guidelines: Developed in collaboration
with the International Society for Heart and Lung Transplantation. Journal of
the American College of Cardiology, 53, e1-e90. doi:10.1016/j.jacc.2008.11.013
Hwang, S. Y., & Kim, J. (2016). An examination of the association of cognitive func-
tioning, adherence to sodium restriction and Na/K ratios in Korean heart failure
patients. Journal of Clinical Nursing, 25, 1766-1776. doi:10.1111/jocn.13198
Korhonen, M. H., Litmanen, H., Rauramaa, R., Vaisanen, S. B., Niskanen, L., &
Uusitupa, M. (1999). Adherence to the salt restriction diet among people with mildly
elevated blood pressure. European Journal of Clinical Nutrition, 53, 880-885.
Lemon, S. C., Olendzki, B., Magner, R., Li, W., Culver, A. L., Ockene, I., & Goldberg, R.
J. (2010). The dietary quality of persons with heart failure in NHANES 1999-2006.
Journal of General Internal Medicine, 25, 135-140. doi:10.1007/s11606-009-1139-x
Lennie, T. A., Song, E. K., Wu, J. R., Chung, M. L., Dunbar, S. B., Pressler, S. J., &
Moser, D. K. (2011). Three gram sodium intake is associated with longer event-
free survival only in patients with advanced heart failure. Journal of Cardiac
Failure, 17, 325-330. doi:10.1016/j.cardfail.2010.11.008
Lennie, T. A., Worrall-Carter, L., Hammash, M., Odom-Forren, J., Roser, L. P.,
Smith, C. S., . . . Moser, D. K. (2008). Relationship of heart failure patients’
knowledge, perceived barriers, and attitudes regarding low-sodium diet recom-
mendations to adherence. Progress in Cardiovascular Nursing, 23, 6-11.
Maleki, F., Hosseini Nodeh, Z., Rahnavard, Z., & Arab, M. (2016). Effectiveness
of training on preventative nutritional behaviors for type-2 diabetes among the
female adolescents: Examination of theory of planned behavior. Medical Journal
of The Islamic Republic of Iran, 30, Article 349.
McKeown, N. M., Day, N. E., Welch, A. A., Runswick, S. A., Luben, R. N., Mulligan,
A. A., . . . Bingham, S. A. (2001). Use of biological markers to validate self-reported
dietary intake in a random sample of the European Prospective Investigation into
Cancer United Kingdom Norfolk cohort. American Journal of Clinical Nutrition,
74, 188-196.
Mills, R. M., Jr., & Haught, W. H. (1996). Evaluation of heart failure patients: Objective
parameters to assess functional capacity. Clinical Cardiology, 19, 455-460.
Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman,
M., . . . Turner, M. B. (2016). Heart disease and stroke statistics—2016 update:

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016

14 Western Journal of Nursing Research 

A report from the American Heart Association. Circulation, 133, e38-e360.

doi:10.1161/cir.0000000000000350
Murray, R. P., Gerald, L. B., Lindgren, P. G., Connett, J. E., Rand, C. S., & Anthonisen,
N. R. (2000). Characteristics of participants who stop smoking and sustain absti-
nence for 1 and 5 years in the Lung Health Study. Preventive Medicine, 30, 392-
400. doi:10.1006/pmed.2000.0642
Murray, R. P., Johnston, J. J., Dolce, J. J., Lee, W. W., & O’Hara, P. (1995). Social
support for smoking cessation and abstinence: The Lung Health Study. Lung
Health Study Research Group. Addictive Behaviors, 20, 159-170.
Riegel, B., & Carlson, B. (2002). Facilitators and barriers to heart failure self-care.
Patient Education & Counseling, 46, 287-295.
Riegel, B., Moser, D. K., Anker, S. D., Appel, L. J., Dunbar, S. B., Grady, K. L.,
. . . Whellan, D. J. (2009). State of the science: Promoting self-care in persons
with heart failure: A scientific statement from the American Heart Association.
Circulation, 120, 1141-1163. doi:10.1161/CIRCULATIONAHA.109.192628
Song, H. J., Cho, Y. G., & Lee, H. J. (2013). Dietary sodium intake and preva-
lence of overweight in adults. Metabolism, 62, 703-708. doi:10.1016/j.
metabol.2012.11.009
Welsh, D., Lennie, T. A., Marcinek, R., Biddle, M. J., Abshire, D., Bentley, B., &
Moser, D. K. (2013). Low-sodium diet self-management intervention in heart
failure: Pilot study results. European Journal of Cardiovascular Nursing, 12, 87-
95. doi:10.1177/1474515111435604
Wu, J. R., Corley, D. J., Lennie, T. A., & Moser, D. K. (2012). Effect of a med-
ication-taking behavior feedback theory-based intervention on outcomes in
patients with heart failure. Journal of Cardiac Failure, 18, 1-9. doi:10.1016/j.
cardfail.2011.09.006
Xu, J., Wang, M., Chen, Y., Zhen, B., Li, J., Luan, W., . . . Ma, G. (2014). Estimation of
salt intake by 24-hour urinary sodium excretion: A cross-sectional study in Yantai,
China. BMC Public Health, 14, Article 136. doi:10.1186/1471-2458-14-136
Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Jr., Colvin, M. M.,
. . . Westlake, C. (2016). 2016 ACC/AHA/HFSA Focused Update on New
Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/
AHA Guideline for the Management of Heart Failure: A Report of the American
College of Cardiology/American Heart Association Task Force on Clinical
Practice Guidelines and the Heart Failure Society of America. Circulation, 134,
e282-293. doi: 10.1161/cir.0000000000000435
Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Jr., Drazner, M. H.,
. . . Wilkoff, B. L. (2013). 2013 ACCF/AHA guideline for the management of
heart failure: Executive summary: A report of the American College of Cardiology
Foundation/American Heart Association Task Force on practice guidelines.
Circulation, 128, 1810-1852. doi: 10.1161/CIR.0b013e31829e8807
Zhang, J. Y., Yan, L. X., Tang, J. L., Ma, J. X., Guo, X. L., Zhao, W. H., . . . Bi, Z.
Q. (2014). Estimating daily salt intake based on 24 h urinary sodium excretion in
adults aged 18-69 years in Shandong, China. BMJ Open, 4(7), Article e005089.
doi:10.1136/bmjopen-2014-005089

Downloaded from wjn.sagepub.com at University Library Utrecht on October 31, 2016