1. Salcido, Richard "Sal MD"

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Literature regarding the "hidden diet" is hard to find even with robust search methods. I learned about the phenomena as an intern in general medicine on the gastrointestinal/liver service. In those days, patients could stay in the hospital a lot longer than in today's compressed admission and discharge tempos. As an intern, my purpose in life was, first, to do no harm, and second, to review and to prepare the laboratory data for the attending professor to review on a daily basis. The medical students, interns, and senior residents were perplexed about a persistently high potassium level in a male patient. We, of course, consulted the "book of lists,"1 which was replete with causes of hyperkalemia. My most important task was to monitor the potassium levels, monitor the well-known complications such as cardiac dysrhythmias, and give sorbitol and furosemide to remove the excessive potassium. One early morning while making rounds, the attending physician happened to be leaning against the patient's window sill and felt something behind the curtain that caused him to open it. There, he discovered to everyone's surprise 2 shakers of salt substitutes! Low-salt preparations contain high levels of potassium salts. Certain comorbid factors preclude the use of potassium because of the type of patients who are at risk for wounds who have impaired ability to excrete potassium normally because of renal failure, congestive heart failure, and diabetes.2

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Other Hidden Culprits

Other common foods or supplements that may show up in the patient's room should be monitored, especially in patients with renal disease. This includes the restriction of foods that are high in phosphate, such as flavored waters, sodas, cereal bars, and nondairy creamers.3 When it comes to congestive heart failure, sodium retention is a major contributor to fluid overload and edema-truncal, sacral, and peripheral. Some of the obvious foods you would not want to see in the patient's room are potato chips, salted peanuts, and other salt-laden foods and snacks.4 Even "healthy foods," such as the Mediterranean Diet pyramid, may have high levels of sodium that are added during the processing of foods such as cheese, whole wheat, and bread.5


Special Populations

Notwithstanding the emphasis on cultural sensitivities and provider competencies related to patient food preferences, there is a paucity of research to show that that "ethnic nutrition" makes a positive impact on patient outcomes. Many studies underscore the negative effects of chronic nutritional inadequacy of African Americans, Mexican Americans, and American Indians.6 Nutritional factors contribute to at least 4 of the 10 leading causes of death in studies of Native American populations (such as heart disease, cancer, cirrhosis, and diabetes). The use of traditional foods has declined, and a dependency on purchased staples has increased.6


Persons with spinal cord injuries (SCIs) need special considerations for diet management. They are at significant risk for truncal obesity and cardiometabolic impairments, such as syndrome X (metabolic syndrome). Syndrome X is a constellation of comorbid factors, including increased lipids, hypertension, insulin resistance, and pertubations in metabolic function. They are at significant risk for skin manifestations including acanthosis nigricans. In a recent study, body fat mass index was greater in the SCI group. Many patients with SCI do not appear to be obese, yet they carry large amounts of fat tissue. Body mass index is widely used to estimate adiposity, but it may underestimate body fat in men with SCI.7


This month's continuing education activity on page 128 focuses on nutritional strategies for frail older adults. As clinicians, we must assess our patient's nutritional status and also beware of any "hidden dangers" in his/her diet.




1. Dhariwal MS. Handbook of Differential Diagnosis in Internal Medicine: Medical Book of Lists. Ann Intern Med 1999; 130: 168. [Context Link]


2. Greenberg A. Hyperkalemia: treatment options. Semin Nephrol 1998; 18 (1): 46-57. [Context Link]


3. Kalantar-Zadeh K, Gutekunst L, Mehrotra R, et al.. Understanding sources of dietary phosphorus in the treatment of patients with chronic kidney disease. Clin J Am Soc Nephrol 2010; 5: 519-30. [Context Link]


4. Magriplis E, Farajian P, Pounis GD, Risvas G, Panagiotakos DB, Zampelas A. High sodium intake of children through "hidden" food sources and its association with the Mediterranean diet: the GRECO study. J Hypertens 2011; 29: 1069-76. [Context Link]


5. Jackson MY. Nutrition in American Indian health: past, present, and future. J Am Diet Assoc 1986; 86: 1561-5. [Context Link]


6. Bentley B, De Jong MJ, Moser DK, Peden AR. Factors related to nonadherence to low sodium diet recommendations in heart failure patients. Eur J Cardiovasc Nurs 2005; 4: 331-6. [Context Link]


7. Jones LM, Legge M, Goulding A. Healthy body mass index values often underestimate body fat in men with spinal cord injury. Arch Phys Med Rehabil 2003; 84: 1068-71. [Context Link]