Nutrition and Congestive Heart Failure Introduction Management of Heart Failure Role of Dietitian in Heart Failure Management - PDF

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Nutrition and Congestive Heart Failure Maureen Elhatton, RD, Registered Dietitian, Northern Alberta Cardiac Rehabilitation Program, Glenrose Rehabilitation Hospital Introduction Congestive heart failure
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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 6- month 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 comorbidities -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 Lower sodium Food Sodium Content Food Sodium Content 1 tsp/5 ml salt 2373 mg 1 tsp/5 ml black pepper 1 mg 1 cup/250 ml canned 700 mg 1 cup/250 ml fresh 8 mg mushrooms mushrooms 1 (68 g) pork sausage 533 mg 1 (63 g) pork chop 49 mg 1slice (70 g) of roasted 1053 mg 2 slices (88 g) roast 49 mg ham beef ½ cup/125 ml canned 516 mg 1 breast (115 g) of 69 mg chicken chicken prepared without salt ½ cup/125 ml canned 197 mg ½ cup/125 ml frozen 74 mg peas peas 1 piece (66 g) salt cod 4657 mg 1 piece (90 g) fresh cod 70 mg 1 slice (20 g) smoked 400 mg 1 piece (75 g) Atlantic 43 mg salmon salmon 1 cup/250 ml tomato 931 mg 1 whole tomato 11 mg juice 1 Tbsp. soy sauce 1044 mg 1 clove fresh garlic 9 mg 1 dill pickle 833 mg 10 baby carrots 35 mg 1 piece (20 g) beef jerky 569 mg 1 rice cake 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 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 ( 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. Kostuk, W. J. Congestive heart failure:what can we offer our patients. CMAJ 2001;165(8): 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; Douglas, S. Nutrition guidelines for congestive heart failiure. Heartbeat, Dietitians of Canada National Cardiology Network 2001; Summer: Gibbs, C.R., Jackson, G., and Lip G.Y. ABC of heart failure Non-drug management. BMJ 2000; 320: Health Canada. Nutrient Value of Some Common Foods. Cat No H58-28/1999E Canadian Government Publishing, Public Works and Government Services Canada, Ottawa Ont. 6. 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: Van Bakel AB, Chidsey G. Management of Advanced Heart Failure. Clin Cornerstone (6):42-52, accessed online on March 7, 2003 at 8. 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 The Lancet 360(9326) accessed online on December 12, 2002 as Internet Resources British Columbia Dietetic Association provides nutrition information and diet copies (e.g. low sodium and coumadin) Dietitians of Canada website to help you find a registered dietitian in your area. 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. All rights reserved For more information please contact: the Association Manager CACR, 1390 Taylor Avenue Winnipeg, MB R3M 3V8
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