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    Request for Comment on Sodium Reduction in Long Term Care, Adult Medical Day Care, and Assisted Living Facilities
    Approximately 9 out of 10 Americans consume an unhealthy amount of sodium.[1] The 2010 Dietary Guidelines for Americans from the United States Department of Agriculture (USDA) and Department of Health and Human Services (HHS) recommend a maximum of 2,300 mg of sodium per day. Despite these recommendations, the average sodium intake for Americans age 2 and older is roughly 3,400 mg/day.[2] Data shows that dietary sodium is derived largely from processed and restaurant foods, while salt added at the table appear to account for an estimated 11% of total sodium intake.[3] Excess sodium intake has been shown to be the primary modifiable risk factor for hypertension.[4]  Hypertension, or high blood pressure, is the single largest modifiable risk factor for cardiovascular mortality in the United States, affecting 68 million Americans or 31% of all Americans.[5]
    There are an estimated 1.4 million adults in Maryland with hypertension.[6]  Hypertension prevalence rises with age, with an estimated 7% prevalence of hypertension in 18-24 year olds, compared to 34% in 45-54 year olds, and 65% in those aged 75 or older. Thus, the elderly are at greatest risk for hypertension, and a reduction in sodium intake by the elderly may result in measurable improvements in health. Scientific evidence reviewed in the 2013 Sodium Intake In Populations: Assessment of Evidence IOM report consistently associated excessive dietary sodium with an increased risk of CVD stroke outcomes, CVD mortality, and elevated blood pressure as a surrogate indicator of CVD risk.[7]  In addition to discrepancies in prevalence based on age, there exist wide disparities in the prevalence of hypertension by race and location. African Americans are at higher risk for hypertension (39.2%) compared to the average risk (28.4%) across the entire population. Geography also appears to be a factor, suggested by the fact that the highest rates of hypertension in Maryland among age and race controlled populations are found in Baltimore City, Somerset County, and Allegany County.[8]  It is estimated that an incremental reduction of sodium intake of 4% annually for 10 years until recommended levels are reached would result in 380,000 fewer deaths from CHD and 80,000 fewer deaths from stroke annually.[9] 
    The impact of excess sodium consumption on blood pressure may pose a particular risk for elderly Marylanders residing in Long Term Care (LTC) and Assisted Living Facilities (ALFs) or attending Adult Medical Day Care Centers (AMDCCs). This population is at high risk for hypertension due to advanced age and may be offered meals in facilities with sodium amounts exceeding 2,300 mg per day. Currently in Maryland, there are 232 LTC facilities with a resident capacity of 27,299; 1,384 ALFs with a resident capacity of 20,032; and 118 AMDCCs with a capacity of 8,550 residents – a total population of 50,000 or more elderly residents who may benefit from reduced sodium intake.[10] 
    At the same time, if sodium reduction makes food for the elderly less palatable, there is a potential risk of reduction in intake, which poses a different type of health risk.
    The Department’s regulations currently address nutrition and dietary services in LTCs, ALFs and AMDCCs. COMAR states that, in the LTCs food services, “[t]o the extent medically possible, the current ‘Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences’, adjusted for age, sex, and activity shall be observed.” COMAR directs ALFs to ensure that “[m]eals and snacks are . . .  of sufficient quality and quantity to meet the daily nutritional needs of each resident.”  Under COMAR, AMDCCs are required to provide minimum numbers of meals and snacks to meet certain percentages of the recommended dietary allowance of the Food and Nutrition Board of the National Research Council, depending on how many hours the adult is present at the facility. 
    Request for Comments
    The Department of Health and Mental Hygiene, pursuant to §§14-206(a) and 19-308(a)(7) of the Health-General Article, seeks comment from members of the public, interested parties, health professionals, and persons knowledgeable about sodium reduction in long term care, adult medical day care, and assisted living facilities. 
    The Secretary requests comment specifically addressing (a) the risks of excess sodium consumption, particularly by residents of the facilities and participants in the programs identified above; (b) whether there are potential unforeseen consequences to reducing sodium consumption, and if so, whether and how adverse consequences can be mitigated; (c) whether the Department should take steps, such as encouraging voluntary action or enhancing regulatory requirements, to support recommended levels of sodium intake in programs and facilities for the elderly.
    In addressing the above issues, the Department encourages commenters to identify any studies of the risks or benefits of reducing sodium consumption of individuals residing in LTCs or ALFs or participating in AMDCCs. The Secretary may appoint an advisory panel to review comments and to recommend what action, if any, should be taken. Comments should be submitted by December 16, 2013. 
    Comments may be submitted by mail to Michele Phinney, Director, Office of Regulation and Policy Coordination, Department of Health and Mental Hygiene, 201 W. Preston St., Room 512, Baltimore, MD, 21201; by email to mdh.regs@maryland.gov; or by fax to (410) 767-6483.
    40:23 Maryland Register November 15, 2013
    Pages 1999-2000

    1. Centers for Disease Control and Prevention. Where’s the Sodium? CDC Vital Signs. February 2012.
    2. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Sodium Fact Sheet.
    3. Mattes R, Donnelly D. Relative contributions of dietary sodium sources. Journal of the American College of Nutrition 1991 Aug;10(4):383-93.
    4. National Heart, Lung, and Blood Institute Statement on Sodium Intake and High Blood Pressure.
    Online at: http://www.nhlbi.nih.gov/news/pressreleases/1998/statement-on-sodium-intake-and-high-blood-pressure.html
    5 Vital Signs: Prevalence, Treatment, and Control of Hypertension --- United States, 1999--2002 and 2005—2008.
    Online at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6004a4.htm
    6 Maryland Behavioral Risk Factor Surveillance System (BRFSS), 2011
    7 Institute of Medicine (IOM): “Sodium Intake in Populations: Assessment of the Evidence” May 14, 2013.
    Online at: http://www.iom.edu/Reports/2013/Sodium-Intake-in-Populations-Assessment-of-Evidence.aspx
    8 Maryland Assessment Tool for Community Health (MATCH).
    9 Ibid.
    10 Figures taken from Maryland Department of Health and Mental Hygiene Office of Health Care Quality Licensee Directory.