Dietary Considerations

The relationship between proper nutrition and control of heart failure is well understood: low salt intake, reduced alcohol consumption, and a well-balanced diet are the mainstays of helping patients manage HF.¹

When discussing diet and nutrition, it is important to involve the patient’s spouse, family members, and caregivers. In many cases (particularly with men) HF patients are not the primary food preparer in the household and may be unaware of the caloric, salt, and fat content of the foods they’re ingesting. In cases where a patient’s diet must change, involving their family in these changes will promote compliance.

Canada’s Guide to Healthy Eating offers an excellent template for counselling patients about diet. Encouraging patients to eat foods from the four major food groups will ensure they get their daily requirement of essential nutrients and vitamins.

All heart failure patients should receive written dietary guidelines, reinforced orally by the clinic nurse during regular clinic visits. Those with limited reading ability and certain ethnic groups with unique food preferences should receive specialized counselling.¹

Lowering Sodium Intake

Sodium intake should be limited in patients with HF because it is not efficiently excreted
from their system. In patients taking diuretics, the drug is rendered less effective
when sodium intake is not limited.²

The average person requires less than 500 mg/day of sodium, however, most consume between 5-6 grams/day. The optimum daily salt intake for HF patients is 2 grams/day or less, however, some patients find their diet unpalatable at this level. Therefore, depending on their stability, this level of sodium intake may be increased to 3 grams/day.¹ Patients taking large amounts of diuretics (>80 mg/day of furosemide) need to maintain their sodium intake at 2 grams/day or less. However, for patients with mild to moderate, stable heart failure without fluid retention, 3 grams/day is a reasonable target.¹

In order to increase compliance with a low-sodium diet, patients should be advised to:

• Stop using the salt shaker (remove it from the dinner table)
• Not add salt to food during preparation
• Read food labels carefully
• Stop eating processed and high-sodium foods: the greatest source of sodium (up to 80%) is the salt and other sodium compounds added to food during processing
• Be aware of ‘hidden’ sources of sodium: for example, one slice of bread contains only 150 mg of sodium, however, the quantity of bread eaten during one day could cause total daily sodium intake to be high

Assessing your Patient’s Sodium Intake/Setting Goals for Reduction

Questions that will help assess your patients’ sodium intake are:

• Who prepares your food?
• Is salt added during food preparation?
• Do you add salt to your food at the dinner table?
• How much bread do you eat?
• How often do you eat in restaurants?
• Do you request that your food be prepared without salt or monosodium glutamate?
• How often do you eat processed food (frozen dinners, canned soups, salad dressings, luncheon meats, cheese)?

To ensure compliance with a reduced-salt diet, set small, incremental, achievable goals with your patients (i.e. cut out salt during food preparation, take the salt shaker off the dinner table, stop eating fast food or prepared food). To give patients ‘control’ over their health care, allow them to prioritize the changes they need to make, but help them determine which actions will have the greatest impact on lessening sodium in their diet.

Use this chart to discuss common foods and their sodium content:

Alcohol

Acute ingestion of alcohol depresses myocardial contractility in patients with known cardiac disease. If alcoholism is the suspected cause of a patient’s HF, alcohol intake should be strongly discouraged. For patients with Class I or II HF, ingestion of alcohol should not exceed one drink per day, i.e. 30 mL of liquor, or its equivalent in beer or wine.¹

Smoking

Abstinence is recommended for all patients, especially those with ischemic heart disease (IHD).²

Fluid Restrictions

Unstable HF patients should ingest no more than 1 litre of fluid per day. The recommended daily intake for stable HF patients is 2 litres, which is equivalent to about 6 glasses of water. However, patients must be counselled that not all fluid intake comes from drinking liquids, and that fluid contained in foods such as fruit or soups must be factored into their daily calculation.²

Daily Weigh-in/Weight log

Patients’ weight should be taken and recorded during every clinic visit, to determine whether it has remained stable or if they are experiencing undue water retention. Patients should also be encouraged to weigh themselves daily – particularly if they are taking diuretics – to monitor their weight. Specific instructions to patients include: weigh yourself after emptying your bladder, before breakfast, every morning, wearing the same type of clothing, and using the same weigh scale.

Patients must be counselled to seek medical help immediately should they gain or lose weight quickly. A daily weight log will help monitor weight and encourage control over drug (diuretic) therapy.

Vitamin Supplementation

Vitamin supplementation may be considered for severe HF patients, since vitamin loss may occur with marked diuresis.¹

References

1. Dracup K, Baker D, Dunbar SB, et al. Management of heart failure: counselling, education and lifestyle modification. JAMA 1994;272:1443-1446.
2. Uretsky BF, Pina I, Quigg RJ, et al. Beyond drug therapy: nonpharmacologic care of the patient with advanced heart failure. Am Heart J 1998;135(Suppl 2, Part 6):S264-S284.