9/12/2016
Nutrition and Heart Failure
Raquel Thomas MS, RD, LMNT, CNSC
Presentation Objectives
Describe and review a low sodium diet
Describe the American Heart Association guidelines for
diet restrictions in the heart failure patient and diet
appropriateness for different populations
Discuss research that demonstrates effectiveness of
nutrition interventions for heart failure patients
– Compliance through behavior change
– Health literacy
– Moderators of patient-provider communication
Discuss and describe ways to implement motivational
interviewing
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Diet Restrictions
Determine HF classification and diet appropriateness
AHA 2013 recommendations:
– Stage A and B HF - restrict sodium to 1500 mg/day
– Stage C and D HF - currently insufficient data to endorse
a specific level of sodium restriction
Consider: sodium intake is typically high (>4 g/d) in the
general population; therefore, clinicians should consider
some degree (e.g., <3 g/d) of sodium restriction in
patients with stage C and D HF for symptom
improvement
Most common diet prescription = 2,000 mg Sodium/day
Sodium limits 2000 mg per day:
• Limiting sodium of food and drink
helps prevent and control the buildup
of fluids in the heart and in the legs
• Salt is the main source of sodium in
food
• Food labels list the amount of sodium
in one serving of food in the package
• Avoid table salt** (always start here!)
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Common sources of sodium:
• Snacks: chips, pretzels, popcorn, crackers, peanuts
• Smoked meats & fish: bacon, chipped or corned
beef, cold cuts, ham, hot dogs
• Sauerkraut: & other foods preserved with brine,
such as pickles, pickled beets, herring
• Sodium processed cold cuts: bologna, ham
• Condiments/Sauces: ketchup, mayo, mustard,
gravy, BBQ sauce
Nutrition Facts Label
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Sodium limits: 2000 mg per day:
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Check serving sizes on the food label
Select foods < 140 mg per serving size
Avoid foods > 300 mg per serving size
Teach family members to use caution
when supplying food to their loved
ones
• Avoid fast food restaurants**
• Avoid highly processed foods
How much sodium in a Big Mac
meal (sandwich, small fry, 20 oz
diet soda)?
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How much sodium in Panera’s Turkey
Bacon Bravo meal (sandwich, apple
and water – no pickle)?
Tips for dining out:
•Utilize online resources
• Panera: Roasted Turkey & Avocado BLT = 980mg sodium
•Ask for no added salt
• Fries, veggies, baked potato, etc
•Bring your own seasonings, sauces, etc
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Fluid Restrictions
Commonly restricted to 2L daily
If fluids are restricted, and patient feels thirsty, try:
– Chewing gum
– Sucking on hard candy
– Sipping cold water
– Sucking on ice cubes or popsicles
– Eating frozen fruits such as grapes
Multidisciplinary Education
Interdisciplinary care (Anyone in healthcare)
……..a collaborative approach to improving information exchange
among the healthcare professions and patients.
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Multidisciplinary Education
As patient understanding increases, memory of
medical information increases and this promotes
patient satisfaction, which leads to diet compliance
(Glanz et al., 2008).
Multidisciplinary Education
Study involving multidisciplinary care consisted of
interventions including comprehensive education
with the patient and family, prescribed diet and
medication review, and a social-service
consultation. This study incorporates social
support by including family in the patient’s
education process. With the extensive education
and follow up interdisciplinary care provided in the
study, health literacy showed improvement as
well as healthcare costs by reducing hospital
readmission rates in this population by 56%. It
also reduced healthcare costs by ~$460 per
patient in the treatment group (Rich et al., 1995).
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Health Literacy
More than one’s ability to comprehend
information, but rather the ability to
comprehend, interpret and apply changes to
their health behaviors
Enabling patient self-management
Allows the patient to take control of their
health and find information on their own
with the help and support of their provider
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Moderators of Patient-provider Communication
Incorporates the perceptions and beliefs of both the
patient and the provider, or clinician, and their
impact on communication.
– Study on elderly heart failure patients found that “80% (of
patients) reported that they received a recommendation to
follow a low sodium diet and that they understood their
diet”, but in this same study an objective measure of urine
sodium levels showed that only 25% of patients were
compliant. (Lennie et al., 2008)
Motivational Interviewing
• Method that works on facilitating and
engaging intrinsic motivation within the
client in order to change behavior. MI is
a goal-oriented, client-centered
counseling style for eliciting behavior
change by helping clients to explore
and resolve ambivalence.
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Motivational Interviewing
• Readiness for change:
• Importance
• What will I gain or lose if I change
• Confidence
• How will I do it and can I?
Motivational Interviewing
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Positive
Empathetic
Non confrontational
Encouraging
Respectful
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Motivational Interviewing
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Open-ended Questions
Affirm efforts and strengths
Mirror/Reflect
Summarize
Motivational Interviewing
Open-ended
questions:
• What has your
experience been with
diet restrictions in the
past?
• Where do you think the
majority of your sodium
intake comes from?
• What benefits do you
think you would see if
you followed your diet?
Closed ended
questions:
• Do you eat low
sodium foods?
• Do you salt your
foods at the table?
• Do you know how to
label read?
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Conclusion
Most common diet prescription = 2,000 mg sodium/day
Modify for HF classification
– Stage A and B HF - restrict sodium to 1500 mg/day
– Stage C and D HF - currently insufficient data to endorse a specific level of
sodium restriction (~2,000-3,000mg/day)
Diet compliance comes through behavior change
– Assessing Health literacy
– Improve patient-provider communication
Utilize motivational interviewing techniques
References
Glanz K, Rimer BK, Viswanath K, eds. 2008. Health Behavior and Health Education: Theory,
Research, and Practice (4th ed). San Francisco: Jossey-Bass
Go, A.S., Mozaffarian, D., Roger, V.L., Benjamin, E.J., Berry, J.D., Borden, W.B., … Turner, M.B.
(2013). Heart disease and stroke statistics – 2013 update. Circulation, 127, e6-e245. doi:
10.1161/CIR.0b013e31828124ad
Rosamond, W., Flegal, K., Friday, G., Furie, K., Go, A., Greenlund, K., … Hong, Y. (2007). Heart
disease and stroke statistics – 2007 update. Circulation, 115, e69-e171. doi:
10.1161/CIRCULATIONAHA.106.179918
Bhimaraj, A. (2013). Remote monitoring of heart failure patients. The Methodist DeBakey
Cardiovascular Journal, 9(1), 26-31.
Kimmelstiel, C., Levine, D., Perry, K., Patel, A.R., Sadaniantz, A., Gorham, N., … Konstam, M.A.
(2004). Randomized, controlled evaluation of short- and long-term benefits of heart failure
disease management within a diverse provider network. Circulation, 1450-1455.
doi10.1161/01.CIR.0000141562.22216.00
Kollipara, U.K., Jaffer, O., Amin, A., Toto, K.H., Nelson, L.L., Schneider, R., … Drazner, M.H.
(2008). Relation of lack of knowledge about dietary sodium to hospital readmission in patients with
heart failure. The American Journal of Cardiology, 102, 1212-1215.
Evangelista, L., Doering, L., Dracup, K., Westlake, C., & Hamilton, M. (2003). Compliance
behaviors of elderly patients with advanced heart failure. The Journal of Cardiovascular Nursing,
18(3), 197-206
Cardiovascular Nursing, 23(Winter), 6-11.
Rich, M. W. (1997). Epidemiology, pathophysiology and eitiology of congestive heart failure
In older adults. Journal of the American Geriatic Society, 45(8), 968-974.
Rich, M. W., Beckham, V., Wittenberg, Carol., Leven, Charles., Freedland, Kenneth., Carney,
Robert. (1997). A multidisciplinary intervention to prevent the readmission of elderly patients
with congestive heart failure. The New England Journal of Medicine, 333(18), 1190-1195.
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QUESTIONS??
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