Association of Depressive Symptoms and Micronutrient Deficiency With Cardiac Event-Free Survival in Patients With Heart Failure

The Impact of Inadequate Energy Intake on Readmission Burden of Patients With Heart Failure

BACKGROUND

Adequate energy intake is essential for good clinical outcomes. The association between energy intake and readmission burden of patients with heart failure (HF) still needs to be clarified.

OBJECTIVE

In this study, our aim was to determine the association between energy intake and readmission in patients with HF.

METHODS

A total of 311 inpatients with HF were recruited. Demographic and clinical information were collected during hospitalization; the daily diets of the participants were collected in the second week after discharge using the 3-day diet record, and the energy intake was calculated using a standardized nutrition calculator. The inadequate energy intake was defined as <70% × 25 kcal/kg of ideal body weight. The participants were followed up for 12 weeks after discharge. The number, reasons, and length of stay of unplanned readmissions were collected. Regression analyses were used to evaluate the associations between inadequate energy intake, and readmission rate and readmission days.

RESULTS

The median of the energy intake of participants was 1032 (interquartile range, 809-1266) kcal/d. The prevalence of inadequate energy intake was 40%. Patients with inadequate energy intake had a higher risk of unplanned readmission (odds ratio, 5.616; 95% confidence interval, 3.015-10.462; P < .001) and more readmission days (incidence rate ratio, 5.226; 95% confidence interval, 3.829-7.134, P < .001) after adjusting for potential confounders.

CONCLUSIONS

Patients with HF had a high incidence of inadequate dietary energy intake, and it increases the burden of readmission.

Bee Pollen as Functional Food: Insights into Its Composition and Therapeutic Properties

Bee pollen is a hive product made up of flower pollen grains, nectar, and bee salivary secretions that beekeepers can collect without damaging the hive. Bee pollen, also called bee-collected pollen, contains a wide range of nutritious elements, including proteins, carbs, lipids, and dietary fibers, as well as bioactive micronutrients including vitamins, minerals, phenolic, and volatile compounds. Because of this composition of high quality, this product has been gaining prominence as a functional food, and studies have been conducted to show and establish its therapeutic potential for medical and food applications. In this context, this work aimed to provide a meticulous summary of the most relevant data about bee pollen, its composition—especially the phenolic compounds—and its biological and/or therapeutic properties as well as the involved molecular pathways.

Relationships between Depressive Symptoms, Appetite, and Quality of Life in Heart Failure

This analytical, cross-sectional study aimed to analyze the relationship between depressive symptoms, appetite, and quality of life (QoL) in 86 patients hospitalized with heart failure. Patients were assessed for depressive symptoms, appetite, and QoL using the Beck Depression Inventory-II, the Simplified Nutritional Appetite Questionnaire, and the Minnesota Living with Heart Failure Questionnaire, respectively. Relationships between sociodemographic and clinical variables, depressive symptoms, appetite, and QoL were analyzed using bivariate tests and linear regression models, with p < .05 considered significant. The factors associated with QoL were dependence for four activities of daily living (ADLs) (estimate = 15.4, 95% CI = 0.23 to 30.64, p = .046), minor depressive symptoms (estimate = –20.0, 95% CI = –28.3 to −11.73, p < .001), and appetite (estimate = –11.08, 95% CI = –20.5 to −1.62, p = .022). These results can support multi-professional assessment and development of interventions to promote better QoL, including addressing impaired appetite and food intake, the presence or increased intensity of depressive symptoms, especially in patients dependent for ADLs.

Impaired intestinal function is associated with lower muscle and cognitive health and well-being in patients with congestive heart failure

BACKGROUND

Small- and large-intestinal perturbations have been described as prevalent extracardiac systemic manifestations in congestive heart failure (CHF), but alterations in protein digestion and absorption and plasma short-chain fatty acid (SCFA) concentrations and the potential link with other systemic effects (muscle and cognitive health) have not been investigated in CHF.

METHODS

We analyzed protein digestion and absorption with dual stable tracer method in 14 clinically stable, noncachectic CHF outpatients (mean left ventricular ejection fraction: 35.5% [95% CI, 30.9%-40.1%]) and 15 controls. Small-intestinal non-carrier-mediated permeability and active carrier-mediated glucose transport were quantified by sugar permeability test. Plasma SCFA (acetate, propionate, butyrate, isovalerate, valerate) concentrations were measured as intestinal microbial metabolites. Muscle function was assessed by isokinetic dynamometry, cognition by a battery of tests, and well-being by questionnaire.

RESULTS

Protein digestion and absorption were impaired by 29.2% (P = .001) and active glucose transport by 38.4% (P = .010) in CHF. Non-carrier-mediated permeability was not altered. Whereas plasma propionate, butyrate, and isovalerate concentrations were lower in CHF (P < .05), acetate and valerate concentrations did not differ. Overall, intestinal dysfunction was associated with impaired leg muscle quality, emotional distress, and cognitive dysfunction (P < .05).

CONCLUSIONS

We identified impaired protein digestion and absorption and altered SCFA concentrations as additional intestinal dysfunctions in CHF that are linked to reduced muscle and cognitive health and well-being. More research is needed to implement strategies to improve intestinal function in CHF and to investigate the mechanisms underlying its link with other systemic manifestations.

Insufficient Calorie Intake Worsens Post-Discharge Quality of Life and Increases Readmission Burden in Heart Failure

OBJECTIVES

The purpose of this study was to evaluate the relationship between calorie intake and post-discharge outcomes in hospitalized patients with heart failure (HF).

BACKGROUND

Malnutrition increases adverse outcomes in HF, and dietary sodium restriction may inadvertently worsen nutritional intake.

METHODS

In a dietary intervention trial, baseline nutritional intake in HF inpatients was estimated using the Block Food Frequency Questionnaire (FFQ), and the Nutritional Risk Index (NRI) was calculated. Insufficient calorie intake was defined as <90% of metabolic needs, and a 15-point micronutrient deficiency score was created. Adjusted linear, logistic, and negative binomial regression were used to evaluate associations between insufficient calorie intake and quality of life (using the Kansas City Cardiomyopathy Questionnaire Clinical Summary [KCCQ-CS]), readmission risk, and days rehospitalized over 12 weeks.

RESULTS

Among 57 participants (70 ± 8 years of age; 31% female; mean body mass index 32 ± 8 kg/m²); median sodium and calorie intake amounts were 2,987 mg/day (interquartile range [IQR]: 2,160 to 3,540 mg/day) and 1,602 kcal/day (IQR: 1,201 to 2,142 kcal/day), respectively; 11% of these patients were screened as malnourished by the NRI. All patients consuming <2,000 mg/day sodium had insufficient calorie intake; this group also more frequently had dietary micronutrient and protein deficiencies. At 12 weeks, patients with insufficient calorie intake had less improvement in the KCCQ-CS score (β = -14.6; 95% confidence interval [CI]: -27.3 to -1.9), higher odds of readmission (odds ratio: 14.5; 95% CI: 2.2 to 94.4), and more days rehospitalized (incident rate ratio: 31.3; 95% CI: 4.3 to 229.3).

CONCLUSIONS

Despite a high prevalence for obesity and rare overt malnutrition, insufficient calorie intake was associated with poorer post-discharge quality of life and increased burden of readmission in patients with HF. Inpatient dietary assessment could improve readmission risk stratification and identify patients for nutritional intervention. (Geriatric Out of Hospital Randomized Meal Trial in Heart Failure [GOURMET-HF] NCT02148679).

Combined Depression and Malnutrition As an Effective Predictor of First Fall Onset in a Chinese Community-Dwelling Population: A 2-Year Prospective Cohort Study

This study aims to explore the single and joint effects of depression and malnutrition on the incidence of first fall onset in a Chinese community-dwelling elderly population. This cohort study consisted of 739 residents without a history of falls who were aged 60 years and older (mean age: 67.08 ± 5.79 years, female: 58.2%). Depression was defined with the Geriatric Depression Scale (GDS)-30; a score of ≥11 was considered to be depressed, while malnutrition was defined with the Mini Nutritional Assessment where a score <17 was defined as malnourished. Over a 2-year follow-up period, older adults who experienced at least one fall were allocated to the first fall onset group. The prevalence of baseline falls was 21.36%. During the 2-year follow-up, incidence of first fall onset was 13.13%. After adjusting for all confounders, depression alone (adjusted odds ratio [OR] = 3.545, 95% confidence interval [CI] = 1.318-9.535) and malnutrition alone (adjusted OR = 2.204, 95% CI = 1.183-4.108) were observed to be independent risk factors for first fall onset, while comorbidity of depression and malnutrition showed progressively increased risk of promoting first fall (adjusted OR = 8.161, 95% CI = 3.591-18.545) than those with only depression or malnutrition or without both depression and malnutrition. Malnutrition mediated 56% effects in the association between depression and first fall onset, while depression mediated 76% effects in the promoting role of malnutrition in first fall. Depression and malnutrition were found to be independent causes for promoting first fall, while mental health and nutrition should be treated as commonly prior interventions to delay first fall onset. Meanwhile, for malnourished Chinese community-dwelling older adults, avoidance or treatment of depression should be addressed at first.

Clinical significance of nutritional status in patients with chronic heart failure-a systematic review

Chronic heart failure (CHF) and nutritional disorders are recognized as major challenges for contemporary medicine. This study aims to estimate the role of nutritional disorders as risk factors for CHF development and prognostic factors for CHF patients and the outcome of nutritional intervention in CHF. Full-text English articles published between January 2013 and February 2019 available in the PubMed and Scopus databases were considered. Seventy-five prospective, retrospective, and cross-sectional studies as well as meta-analyses on patients with CHF, reporting correlation of their nutritional status with the risk and prognosis of CHF and the outcome of nutritional interventions in CHF were all included. Higher BMI increases the risk of CHF by 15-70%, especially when associated with severe, long-lasting and abdominal obesity. Overweight and obesity are associated with the reduction of mortality in CHF by 24-59% and 15-65%, respectively, and do not affect the outcome of invasive CHF treatment. Malnutrition increases the risk of mortality (by 2- to 10-fold) and the risk of hospitalization (by 1.2- to 1.7-fold). Favorable outcome of nutritional support in CHF patients was reported in a few studies. Nutritional disorders are prevalent in patients with CHF and play a significant role in the incidence, course, and prognosis of the disease. The existence of an "obesity paradox" in patients with CHF was confirmed. Further studies on the effect of nutritional support and body weight reduction in patients with CHF are necessary.

Benefits of multiple micronutrient supplementation in heart failure: A comprehensive review

BACKGROUND

Multiple micronutrient supplementation has been suggested to have a role on health outcomes in patients with heart failure (HF), but the evidence is inconclusive.

OBJECTIVE

To elucidate the role of multiple micronutrient supplementation in heart failure we performed a comprehensive review of the literature.

METHODS AND RESULTS

The search in databases included PUBMED (until June 2018) to detect randomized controlled trials (RCTs) and meta-analyzes that investigated the impact of micronutrient supplementation in HF.

RESULTS

With more than 2357 titles and abstracts reviewed, we included only the studies suitable for the final review. Whether alone or in combination, micronutrients have been found to improve the health outcomes of patients with HF by improving symptoms, work capacity and left ventricular ejection fraction (LVEF), thus increasing the quality of life in these patients.

CONCLUSION

Future studies are needed to document the effects of multiple micronutrient associations in order to include them in nutritional guidelines to increase survival and to improve quality of life in patients with heart failure.

Micronutrient Deficiency Independently Predicts Time to Event in Patients With Heart Failure

Background Dietary micronutrient deficiencies have been shown to predict event-free survival in other countries but have not been examined in patients with heart failure living in the United States. The purpose of this study was to determine whether number of dietary micronutrient deficiencies in patients with heart failure was associated with shorter event-free survival, defined as a combined end point of all-cause hospitalization and death. Methods and Results Four-day food diaries were collected from 246 patients with heart failure (age: 61.5±12 years; 67% male; 73% white; 45% New York Heart Association [NYHA] class III / IV ) and analyzed using Nutrition Data Systems for Research. Micronutrient deficiencies were determined according to methods recommended by the Institute of Medicine. Patients were followed for 1 year to collect data on all-cause hospitalization or death. Patients were divided according to number of dietary micronutrient deficiencies at a cut point of ≥7 for the high deficiency category versus <7 for the no to moderate deficiency category. In the full sample, 29.8% of patients experienced hospitalization or death during the year, including 44.3% in the high-deficiency group and 25.1% in the no/moderate group. The difference in survival distribution was significant (log rank, P=0.0065). In a Cox regression, micronutrient deficiency category predicted time to event with depression, NYHA classification, comorbidity burden, body mass index, calorie and sodium intake, and prescribed angiotensin-converting enzyme inhibitors, diuretics, or β-blockers included as covariates. Conclusions This study provides additional convincing evidence that diet quality of patients with heart failure plays an important role in heart failure outcomes.

Dietary patterns and components to prevent and treat heart failure: a comprehensive review of human studies

Growing evidence has emerged about the role of dietary patterns and components in heart failure (HF) incidence and severity. The objective here is to provide a comprehensive summary of the current evidence regarding dietary patterns/components and HF. A comprehensive search of online databases was conducted using multiple relevant keywords to identify relevant human studies. The Dietary Approaches to Stop Hypertension (DASH) and Mediterranean diets have consistently been associated with decreased HF incidence and severity. Regarding specific dietary components, fruit, vegetables, legumes and whole grains appear beneficial. Current evidence suggests that red/processed meats, eggs and refined carbohydrates are harmful, while fish, dairy products and poultry remain controversial. However, there is a notable lack of human intervention trials. The existing but limited observational and interventional evidence from human studies suggests that a plant-based dietary pattern high in antioxidants, micronutrients, nitrate and fibre but low in saturated/trans-fat and Na may decrease HF incidence/severity. Potential mechanisms include decreased oxidative stress, homocysteine and inflammation but higher antioxidant defence and NO bioavailability and gut microbiome modulation. Randomised, controlled trials are urgently required.

Home-Delivered Meals Postdischarge From Heart Failure Hospitalization

Background In patients with heart failure (HF), malnutrition and dietary sodium excess are common and may worsen outcomes. No prior studies have provided low-sodium, nutritionally complete meals following HF hospitalization. Methods and Results The GOURMET-HF study (Geriatric Out-of-Hospital Randomized Meal Trial in Heart Failure) randomized patients discharged from HF hospitalization to 4 weeks of home-delivered sodium-restricted Dietary Approaches to Stop Hypertension meals (DASH/SRD; 1500 mg sodium/d) versus usual care. The primary outcome was the between-group change in the Kansas City Cardiomyopathy Questionnaire summary score from discharge to 4 weeks postdischarge. Additional outcomes included changes in the Kansas City Cardiomyopathy Questionnaire clinical summary score and cardiac biomarkers. All patients were followed 12 weeks for death/all-cause readmission and potential diet-related adverse events (symptomatic hypotension, hyperkalemia, acute kidney injury). Sixty-six patients were randomized 1:1 at discharge to DASH/SRD versus usual care (age, 71±8 years; 30% female; ejection fraction, 39±18%). The Kansas City Cardiomyopathy Questionnaire summary score increased similarly between groups (DASH/SRD 46±23-59±20 versus usual care 43±19-53±24; P=0.38), but the Kansas City Cardiomyopathy Questionnaire clinical summary score increase tended to be greater in DASH/SRD participants (47±22-65±19 versus 45±20-55±26; P=0.053). Potentially diet-related adverse events were uncommon; 30-day HF readmissions (11% versus 27%; P=0.06) and days rehospitalized within that timeframe (17 versus 55; P=0.055) trended lower in DASH/SRD participants. Conclusions Home-delivered DASH/SRD after HF hospitalization appeared safe in selected patients and had directionally favorable effects on HF clinical status and 30-day readmissions. Larger studies are warranted to clarify the effects of postdischarge nutritional support in patients with HF. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02148679.

Self-Care for the Prevention and Management of Cardiovascular Disease and Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association

Self-care is defined as a naturalistic decision-making process addressing both the prevention and management of chronic illness, with core elements of self-care maintenance, self-care monitoring, and self-care management. In this scientific statement, we describe the importance of self-care in the American Heart Association mission and vision of building healthier lives, free of cardiovascular diseases and stroke. The evidence supporting specific self-care behaviors such as diet and exercise, barriers to self-care, and the effectiveness of self-care in improving outcomes is reviewed, as is the evidence supporting various individual, family-based, and community-based approaches to improving self-care. Although there are many nuances to the relationships between self-care and outcomes, there is strong evidence that self-care is effective in achieving the goals of the treatment plan and cannot be ignored. As such, greater emphasis should be placed on self-care in evidence-based guidelines.

Depressive Symptoms among Patients with Heart Failure in Korea: An Integrative Review

This integrative review was conducted to examine studies reporting depressive symptoms among patients with heart failure (HF) in Korea. An extensive search with both English and Korean search terms was conducted using six electronic databases. Publications were screened by both authors independently, and 10 articles meeting the inclusion criteria were reviewed. All 10 studies were data-based, quantitative, and descriptive in nature. In all studies, depressive symptoms were measured at only one point in time. The prevalence of depression reported in these studies ranged from 24% to 68%. Heterogeneity in the study samples and measures of depression was noted. Depressive symptoms have received limited attention in research with HF patients in Korea. Additional studies, especially longitudinal studies and intervention studies, are needed to assess depressive symptoms and to test the effects of pharmacological and non-pharmacological interventions on depression among patients with HF in Korea. Clinicians need to screen patients with HF for depressive symptoms using validated measures and provide proper treatment for those who are depressed.