Heart failure (HF) remains a deadly disease tied to a high risk of hospitalizations, reduced cardiorespiratory fitness and a subsequently reduced quality of life. Targeted treatments and lifestyle interventions continue to show promising results in improving HF outcomes although, there is limited evidence of their role in decompensated patients admitted to the hospital for acute heart failure.
The most common non-pharmacologic therapy for HF patients is dietary sodium restriction, aimed at mitigating excess fluid retention. However, this method is supported by limited and controversial evidence as some studies have shown sodium restriction can even worsen health outcomes by leading to unintended reductions in calorie, macro-, and micro-nutrient intake. Additionally, the effects of sodium restriction as an intervention on quality of life and clinical outcomes remain unknown.
As patients with heart failure commonly present with poor nutritional status – which significantly affects disease progression and prognosis – new research from the University of Michigan in Ann Arbor aims to uncover the clinical implications of dietary patterns on HF. Published in JACC: Heart Failure, the GOURMET-HF trial found that heart failure patients who had an insufficient calorie intake faced an increased risk of hospital readmission and a poor quality of life after being discharged.
Hospitalizations in HF Patients
Led by Feriha Bilgen, MPH, RD, a group of researchers analyzed data gathered from 57 patients – mean age of 70 years, 31% women, mean BMI 32 kg/m2 – hospitalized for decompensated heart failure. To assess nutritional intake, participants completed the Block Food Frequency Questionnaire at baseline and serum albumin and body weight were then used to calculate Nutritional Risk Index. Insufficient calorie intake was defined as meeting less than 90% of estimated nutritional needs; a 15-point deficiency score was developed taking into account the intake of certain micronutrients – such as folate, magnesium, iron, and calcium.
The primary measured outcomes of the study included all-cause hospital readmission and change in Kansas City Cardiomyopathy Questionnaire clinical summary score, which was assessed 12 weeks after hospital discharge.
Importance of Nutritional Patterns
Overall, the median sodium intake of patients in the trial was 2,987 mg per day and the median calorie intake was 1,602 kcal/day. Only 11% were considered malnourished according to the Nutritional Risk Index equation.
Researchers found that patients who consumed less than 2,000 mg of sodium per day – the standard recommendation in heart failure patients – often consumed an insufficient amount of calories overall and had protein and micronutrient deficiencies as well.
At the 12-week point, participants who had insufficient calorie intake were more likely to be readmitted to the hospital and showed less improvement in the Kansas City Cardiomyopathy Questionnaire clinical summary score. These patients were readmitted to the hospital for longer than those who had a sufficient calorie intake during the study.
The latest findings suggest that sodium restriction may not have favorable results in patients with HF. Instead, experts recommend lifestyle interventions aimed at increasing unsaturated fatty acids intake or improving adherence to the DASH diet for patients with chronic and stable HF.
“Of note, both the Mediterranean diet and DASH diet are primarily composed of plant-based foods, suggesting that a prudent plant-based dietary pattern might be beneficial in HF,” Kathleen E. Allen, MS, RD of Dartmouth College Geisel School of Medicine wrote in an accompanying editorial to highlight potential benefits of certain diets.
“The main message of this paper is that patients who are eating low-sodium diets may also have deficiencies in other important dietary components like micronutrients that help with mitochondrial function and protein for building muscle,” Scott L. Hummel, MD, MS, section chief of cardiology at VA Ann Arbor told Healio in an interview.
Researchers hope that the results of their findings raise awareness of the potential adverse consequences of sodium restriction and emphasize the need for lifestyle interventions to be introduced under the supervision of a dietitian. Physicians must exercise caution to help maintain overall nutrition while reducing sodium intake to reduce potential consequences of dietary deficiencies in patients hospitalized with HF.