ABC | Volume 112, Nº2, February 2019

Original Article d’Almeida et al Cut-point for Dietary Sodium Restriction Questionnaire Arq Bras Cardiol. 2019; 112(2):165-170 Regarding the scores and the cut-point identified for the subscale perceived behavioral control (≤8, a total of 20 points), the main barriers – for both compensated and decompensated patients – are the palatability of foods with little salt, food preferences of patients, and less significantly, the willpower to change their diets, factors already described previously. Palatability of foods with low sodium content has been referred as one of themain barriers to adherence. 26,27 Furthermore, when compared to healthy individuals, patients with HF have a preference for highly salted foods. 28 This can be explained largely by changes in the renin-angiotensin-aldosterone system, which promotes a higher desire for salt. 29 The low scores observed in the dependent behavior subscale influenced the determination of a low cut-point (≤ 3, of a total of 15 points). In a study conducted with a sample of 225 patients with decompensated HF, 12 decision-making situations that occur outside the home – going to restaurants and the supermarket – did not influence significantly adherence in this population, possibly due to the limitations imposed by the severity of the disease. In addition, the trip to the supermarket and the choice of food is often performed by a family member or the person responsible for their care, which may explain the small impact caused by this factor. 6 In the comparative analysis of patients by functional class to determine the cutoff point for satisfactory adherence, it was observed that both sensitivity and specificity values were lower than those obtained in the comparison between compensated and decompensated patients. Thus, our findings indicated that adherence was higher in outpatients compared with patients hospitalized for decompensated HF. Limitations Other factors other than sodium restriction may affect HF decompensation, which can lead to a small bias in the determination of the cut-point. Although it was a case-control study, matching was not sufficient to minimize discrepancies between the two groups (compensated and decompensated). Other studies with the same designmay contribute to elucidate the findings of this study. Another limitation refers to the inexistence of national and international studies on specific cut-points in the evaluation of adherence using the QRSD, which makes comparisons with other investigations impossible. Conclusions Assessment of knowledge, barriers and attitudes towards dietary sodium among patients with HF in two different scenarios – outpatient and emergency services – allowed the determination of cut-points for satisfactory adherence to dietary sodium reduction. Countries with similar cultures may use this cut-point, as other researchers could also use it as reference in further studies. We suggest this cut-point to identify facilitators and barriers related to reduction of dietary sodium intake in HF patients in Brazil, and be used to guide strategies, seeking better results. Author contributions Conception and design of the research, analysis and interpretation of the data, obtaining funding and critical revision of the manuscript for intellectual content: d’Almeida KSM, Barilli SLS, Souza GC, Silva ERR; acquisition of data, statistical analysis and writing of the manuscript: d’Almeida KSM, Barilli SLS. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding This study was funded by Fundo de incentivo à pesquisa e eventos do Hospital de Clínicas de Porto Alegre. Study Association This study is not associatedwith any thesis or dissertationwork. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Hospital de Clínicas de Porto Alegre under the protocol number 130343 and Hospital Nossa Senhora da Conceição/Grupo Hospitalar Conceição under the protocol number 13-049. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study. 169