Download Nutrition and Congestive Heart Failure

Nutrition and Congestive Heart Failure
Maureen Elhatton, RD, Registered Dietitian, Northern Alberta Cardiac Rehabilitation
Program, Glenrose Rehabilitation Hospital
Introduction
Congestive heart failure (CHF ) is a complex clinical syndrome with typical symptoms
such as shortness of breath, fatigue and edema associated with evidence of impaired
cardiac function. Individuals often initially present with vague symptoms of fatigue,
cough or dyspnea and general feelings of malaise. CHF affects more than 400,000
Canadians a year and is increasing in incidence with over 50,000 new cases annually. The
annual rate of hospital admission between 1990 and 1997 increased by 35% and the 6month readmission rate increased to 50%. After the initial diagnosis the one- year
mortality rate is 25-40% with a five- year mortality of 50%. (1)
Management of Heart Failure
Treatment models consist not only of symptom control but strongly emphasize steps to
delay the progression of CHF and prevent new cardiac events. Preventative treatment
programs begin with family physicians who need to identify patients in the early stages of
CHF. The treatment of hypertension in the Systolic Hypertension in the Elderly Program
decreased the risk for development of heart failure by 81% (2). In addition to
pharmacological treatment, patients diagnosed with CHF should receive therapeutic
intervention from a variety of multi-disciplinary health care professionals (dietitians,
social workers, exercise specialists, etc.) to improve quality of life and reduce hospital
admissions (3,4).
Role of Dietitian in Heart Failure Management
Registered dietitians (RD) not only provide therapeutic diet counseling but they also act
as patient resources. Table 1.0 provides an overview of the dietitians’ role in patient care.
Table 1 Dietitians Role in Patients with Congestive Heart Failure (4)
1. Reduce myocardial workload
-reduce sodium intake
-achieve/maintain healthy body weight
-fluid restriction
2. Dietary management of other comorbid ities
-e.g. control diabetes
3. Improve nutrition status of individual
-dietary evaluation for nutrition supplementation
4. Food and drug interaction education
5. Patient resource
- community resources
(for example meals on wheels)
Reduction in Dietary Sodium
A major emphasis on the individual’s diet is a reduction in sodium to reduce fluid
retention, improve diuretic response and control blood pressure (3). Sodium intakes less
than 3000 mg per day are generally advised. One level teaspoon of salt, which is the
chemical compound sodium chloride, contains 2373 mg of sodium (6). The easiest way
to remember this is just to think of the millennium year as being the year 2000 and on
average this is what is contained in one teaspoon of salt. Many patients think eliminating
the salt shaker is the only dietary measure needed to achieve these reduced sodium levels.
However, sodium can be found in many food sources. Table 2.0 compares some popular
high sodium foods with lower sodium alternatives. Patients are also shown how to label
read and a restricted sodium diet similar to the DASH diet (Dietary Approaches to Stop
Hypertension) is counseled (7).
Table 2 Dietary sources of sodium (6)
High sodium
Food
Sodium
Content
1 tsp/5 ml salt
2373 mg
1 cup/250 ml canned
700 mg
mushrooms
1 (68 g) pork sausage
533 mg
1slice (70 g) of roasted
1053 mg
ham
½ cup/125 ml canned
516 mg
chicken
½ cup/125 ml canned
peas
1 piece (66 g) salt cod
1 slice (20 g) smoked
salmon
1 cup/250 ml tomato
juice
1 Tbsp. soy sauce
1 dill pickle
1 piece (20 g) beef
jerky
197 mg
4657 mg
400 mg
931 mg
Lower sodium
Food
Sodium
Content
1 tsp/5 ml black pepper
1 mg
1 cup/250 ml fresh
8 mg
mushrooms
1 (63 g) pork chop
49 mg
2 slices (88 g) roast
49 mg
beef
1 breast (115 g) of
69 mg
chicken prepared
without salt
½ cup/125 ml frozen
74 mg
peas
1 piece (90 g) fresh cod
70 mg
1 piece (75 g) Atlantic
43 mg
salmon
1 whole tomato
11 mg
1044 mg 1 clove fresh garlic
833 mg 10 baby carrots
569 mg 1 rice cake
9 mg
35 mg
29 mg
People with CHF often have multiple medical problems that require them to follow
several therapeutic diets. This can lead to frustration on the part of the patient when the
same food might be recommended for one medical condition and not for the other. For
example canned mushrooms are an excellent low calorie vegetable choice on a diabetic
food or weight loss program however with 700 mg of sodium in a one cup serving it is
not advised for CHF patients. Better to consume the fresh mushrooms at 8 mg of sodium
in a one cup serving (6). Consulting with a dietitian can assist the patient in prioritizing
their dietary needs.
Weight Control & Fluid Restriction
A healthy body weight can also minimize the workload on the heart. With reduced
physical activity weight gain is a real concern. Weight control programs may prevent
weight gain and start the patient on a healthy weight control program. Patients should be
advised to avoid weight loss methods that use herbal products or fad diets. Patients
should be instructed to self-weigh daily using the SAME approach – same scale, same
time, same amount of clothing. Daily weights can warn of any excessive fluid weight
gains, thus averting a hospital admission. Weight gains of over 1 kg/2 lb in a 48-hour
period or 2.5 kg/5 lb in one week should be reported, so early interventions might be
initiated (4). The cause of the increase in weight should also be investigated. Has the
person been taking their prescribed medication, have they been following their restricted
sodium diet, have they been drinking too much fluid? Fluid guidelines are applied to any
food item that is liquid at room temperature. Soup, tea, juice, milk etc are all included in
this calculation.
Potassium Intake
Imbalances in serum potassium through medication use e.g. diuretics (non-potassium
sparing) or pre-existing renal problems can lead to cardiac dysrhythmia. Potassium is
found abundantly in the food program specifically in fruits and vegetables (Table 3.0).
While the typical diet contains 2000-4000 mg of potassium, consuming an additional
2000 mg in situations requiring supplementation would be advised. Potassium
supplements are also available by prescription. It is important to monitor a patient’s
potassium level, as excesses of the mineral may be just as harmful as deficiencies.
Potassium based salt substitutes are not advised for CHF patients as they contain
excessive amounts (2000-2500 mg) of potassium in relatively small amounts (5 ml -1
tsp.) of product.
Table 3 Better food sources of potassium (5)
Food item
Potassium content
Banana, 1 medium
454 mg
Tomato, 1 medium
273 mg
Raisins, ½ cup
575 mg
Orange juice, 1 cup
500 mg
Baked potato, 1 medium 844 mg
Food & Drug Interactions
Medications such as coumadin also have potentially hazardous food-drug interactions
that the patient should be thoroughly familiar with. Foods high in Vitamin K can reduce
the effectiveness of the drug while alcohol can increase its effectiveness. Generally
patients on coumadin are advised to avoid alcohol and to balance their intake of leafy
green vegetables which are one of the highest sources of Vitamin K. In addition many
CHF patients turn to over the counter supplements/herbal remedies not realizing these
products may contain ingredients that can affect the method of action of medications
especially coumadin. One patient recently brought in a dietary supplement containing
seaweed and others greens. For someone on coumadin it was not advised due to the high
Vitamin K content of seaweed. Another common patient concern is taking too many
prescribed medications, yet one patient recently seen was taking nine different
vitamin/herbal supplements. These supplements are often unneeded (8), costly and in
some situations dangerous. At this point in time there are no vitamin/mineral supplements
that are advised to reduce the risk of congestive heart failure.
Community Resources
Registered dietitians can also provide patients with information on community resources
such as meal delivery systems, grocery shopping services etc. For patients receiving
provincial financial assistance additional funding may be available with a dietitian’s
referral if the medical condition requires the individual to make therapeutic adjustments
to their diet.
Dietary indiscretion (e.g. excessive sodium intake) is one of the precipitating patientrelated factors contributing to heart failure exacerbation. Other precipitating factors
include medication non-compliance, alcohol consumption and substance abuse. With a
one billion-dollar price tag for Canadian hospital admissions any precipitating factor for
CHF that can be addressed in the community should help to control health care costs
(1,7).
Conclusion
During the past ten years, treatment of heart failure has evolved to a preventative and
progression approach. As with any chronic disease, self- management techniques through
patient education can improve the course of congestive heart failure. Patients can be
educated to become aware of these symptoms and early medical intervention can prevent
many hospital admissions. Dietitians have a valuable role in assisting the patient with
CHF manage their health care.
References
1.
2.
3.
4.
5.
6.
7.
8.
Kostuk, W. J. Congestive heart failure:What can we offer our patients. CMAJ 2001;165(8):1053-5
Gomberg-Maitland M., Baran, D.A., Fuster, V. Treatment of congestive heart failure:Guidelines for
the primary care physician and the heart failure specialist. Archives of Internal Medicine 2001;161
Douglas, S. Nutrition guidelines for congestive heart failiure. Heartbeat, Dietitians of Canada National
Cardiology Network 2001; Summer: 2-3
Gibbs, C.R., Jackson, G., and Lip G.Y. ABC of heart failure Non-drug management. BMJ 2000;
320:366-9
Health Canada. Nutrient Value of Some Common Foods. Cat No H58-28/1999E Canadian
Government Publishing, Public Works and Government Services Canada, Ottawa Ont.
http://publications.pwgsc.gc.ca
Appel LJ, Moore TJ, Obarzanek E, et al, for the DASH Collaborative Research Group. A clinical trial
of the effects of dietary patterns on blood pressure. N Eng J Med. 1997;336:1117-1124
Van Bakel AB, Chidsey G. Management of Advanced Heart Failure. Clin Cornerstone 2002 4(6):4252, accessed online on March 7, 2003 at www.medscape.com
Heart Protection Study Collaborative Group. MRC/BHF Heart protection Study of cholesterol
lowering with simvastatin in 20,536 high risk individuals: a randomized control trial. 2002 The Lancet
360(9326) accessed online on December 12, 2002 as www.thelancet.com
Internet Resources
www.dialadietitian.org British Columbia Dietetic Association provides nutrition information and diet
copies (e.g. low sodium and coumadin)
www.dietitians.ca Dietitians of Canada website to help you find a registered dietitian in your area.
www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm DASH diet copy is available at this website.
This diet incorporates low sodium along with higher intakes of fruit/ vegetables, low fat dairy products.
Copyright © 2003 Canadian Association of Cardiac Rehabilitation.
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For more information please contact: the Association Manager
CACR, 1390 Taylor Avenue Winnipeg, MB R3M 3V8