Quality and adequacy of dietary intake in a southern urban heart failure population

Patients' Perceptions of Hybrid and Virtual-Only Care Models During the Cardiac Rehabilitation Patient Journey: A Qualitative Study

BACKGROUND

The COVID-19 pandemic initially led to discontinuation of the "traditional" center-based cardiac rehabilitation (CR) model. Virtual models emerged as an opportunity to deliver care, with many programs continuing to offer these models.

OBJECTIVE

The aim of this study was to explore patients' perceptions of virtual models of either hybrid (combining center-based and virtual) or virtual-only CR since the pandemic.

METHODS

Men and women who chose to participate in hybrid or virtual CR models between January 2022 and January 2023 were invited to attend 1 of 8 focus group sessions. Focus groups were conducted online until thematic saturation was reached. Transcripts were analyzed using thematic analysis.

RESULTS

Twenty-three patients (48% female; 83% attending hybrid CR) participated in the study. Analysis revealed 12 overarching themes associated with the CR patient journey: pre-CR, namely, (1) importance of endorsement from healthcare providers and (2) need for education/communication while waiting for program initiation; during CR, namely, (3) preference for class composition/structure, (4) need to enhance peer support in the virtual environment, (5) convenience and concerns with virtual sessions, (6) necessity of on-site sessions, (7) safety of the exercise prescription, (8) requirement/obligation for allied health offerings, (9) satisfaction with virtual education, and (10) use of technology to facilitate CR participation; and post-CR, namely, (11) acknowledgment of program completion and (12) need for support/education after program graduation.

CONCLUSIONS

Patients require ongoing support from time of referral to beyond CR program completion. Physical, psychosocial, nutritional, and educational supports are needed. Perceptions expressed by patients related to the program model are modifiable, and strategies to address these perceptions should be explored.

Heart failure self-management: a scoping review of interventions implemented by allied health professionals

BACKGROUND

Heart failure (HF) is typically managed using both medical and patient self-management interventions. Individuals with HF often have frequent readmissions to hospital for medical management. Effective self-management can help to reduce the exacerbation of HF symptoms and the frequency of readmissions.

METHODS

A scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review (PRISMA-ScR) guidelines was conducted to identify literature on the interventions used by allied health professionals to promote HF self-management. A search strategy was implemented, and articles were reviewed by two independent reviewers.

RESULTS

Twenty articles met the inclusion criteria. Articles included interventions from physical therapy, nutrition, social work, and occupational therapy, as well as other health professions in team-based programs. The most common interventions were verbal education, textual information, monitoring resources, and skills practice. Interventions addressed diet/fluid control, exercise and activity, symptom monitoring, medication management, cardiovascular disease knowledge, and mental health. Many interventions were theory informed.

CONCLUSION

There is nascent evidence that interventions promoting HF self-management positively impact health and quality of life outcomes. HF self-management is multi-faceted and requires interprofessional collaboration. Further work is warranted exploring the impact of theory-informed interventions, and the effectiveness of interventions on self-management competence and desired health outcomes.

Cardiovascular Diseases and Zinc

Zinc is structurally and functionally essential for more than 300 enzymes and 2000 transcription factors in human body. Intracellular labile zinc is the metabolically effective zinc and tiny changes in its concentrations significantly affect the intracellular signaling and enzymatic responses. Zinc is crucial for the embrionic and fetal development of heart. Therefore, it is shown to be related with a variety of congenital heart defects. It is involved in epithelial-to-mesenchymal transformation including endocardial cushion development, which is necessary for atrioventricular septation as well as the morphogenesis of heart valves. In atherosclerosis, monocyte endothelial adhesion, and diapedesis, activation and transformation into macrophages and forming foam cells by the ingestion of oxidized LDL are monocyte related steps which need zinc. Intracellular zinc increases intracellular calcium through a variety of pathways and furthermore, zinc itself can work as a second messenger as calcium. These demonstrate the significance of intracellular zinc in heart failure and arterial hypertension. However, extracellular zinc has an opposite effect by blocking calcium channels, explaining decreased serum zinc levels, contrary to the increased cardiomyocyte and erythrocyte zinc levels in hypertensive subjects. These and other data in the literature demonstrate that zinc has important roles in healthy and diseased cardiovascular system but zinc-cardiovascular system relationship is so complex that, it has not been explained in all means. In this article, we try to review some of the available knowledge about this complex relationship.

Which nutritional prognosis is better? comparison of the three most commonly performed bariatric surgeries: A systematic review and network meta-analysis

Background

Obesity is one of the most important public health conditions in the world, and surgical intervention is the only medical treatment recognized by the medical community as a complete and permanent cure for morbid obesity and its complications. The choice of surgical modality is also based more on the experience of the physician or the requirements of people with obesity, rather than on scientific data. In this issue, a thorough comparison of the nutritional deficiencies caused by the three most commonly used surgical modalities is needed.

Objectives

We aimed to use the network meta-analysis to compare the nutritional deficiencies caused by the three most common BS procedures in many subjects who underwent BS to help physicians determine the best BS surgical approach to apply to their clinical people with obesity.

Setting

A systematic review and network meta-analysis of world literature.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, systematically reviewed the literature, and conducted a network meta-analysis using R Studio.

Results

For the four vitamins calcium, vitamin B12, iron and vitamin D, the micronutrient deficiency caused by RYGB is the most serious.

Conclusions

RYGB causes slightly higher nutritional deficiencies in Bariatric surgery, but RYGB remains the most commonly used modality for Bariatric surgery.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022351956, identifier: CRD42022351956.

Health-related information needs and preferences for information of individuals with cardiovascular disease from underserved populations: A systematic review

OBJECTIVE

This systematic review aimed to identify the information needs and preferences of individuals with CVD from underserved populations.

METHODS

Five databases were searched from data inception to February 2022. Pilot and case report studies, non-peer-reviewed literature, and studies published in a language other than English, Portuguese, or Spanish were excluded. Structured and thematic analysis of all included studies were performed. The Critical Appraisal Skills Program and the Downs and Black Checklist were used to assess the quality of the qualitative and quantitative studies, respectively.

RESULTS

Of 35,698 initial records, 19 studies were included, most in observational design and classified as "fair" quality. Underserved populations - women, people living in rural areas, ethnic minority groups, older people, and those with low socioeconomic status - presented unique needs in four main groups, with some similarities across them: information about CVD, primary and secondary prevention of CVD, CVD management, and health care, policies and practices. Across the studies there was a lack of standardization on how individuals' needs were assessed and reported.

CONCLUSION

Underserved populations with CVD have unique information needs and preferences that should be address during their care.

PRACTICAL IMPLICATION

Information from this study may assist health care professionals with the development of comprehensive strategies to improve their provision of care for specific CVD patient groups.

Psychosocial Risk and Health Behaviors as Predictors of Clinical Events in Patients Wait-Listed for a New Heart: Results from 7 Years of Follow-Up

We examined the long-term relationship of psychosocial risk and health behaviors on clinical events in patients awaiting heart transplantation (HTx). Psychosocial characteristics (e.g., depression), health behaviors (e.g., dietary habits, smoking), medical factors (e.g., creatinine), and demographics (e.g., age, sex) were collected at the time of listing in 318 patients (82% male, mean age = 53 years) enrolled in the Waiting for a New Heart Study. Clinical events were death/delisting due to deterioration, high-urgency status transplantation (HU-HTx), elective transplantation, and delisting due to clinical improvement. Within 7 years of follow-up, 92 patients died or were delisted due to deterioration, 121 received HU-HTx, 43 received elective transplantation, and 39 were delisted due to improvement. Adjusting for demographic and medical characteristics, the results indicated that frequent consumption of healthy foods (i.e., foods high in unsaturated fats) and being physically active increased the likelihood of delisting due improvement, while smoking and depressive symptoms were related to death/delisting due to clinical deterioration while awaiting HTx. In conclusion, psychosocial and behavioral characteristics are clearly associated with clinical outcomes in this population. Interventions that target psychosocial risk, smoking, dietary habits, and physical activity may be beneficial for patients with advanced heart failure waiting for a cardiac transplant.

Barriers and facilitators to participant adherence of dietary recommendations within comprehensive cardiac rehabilitation programmes: a systematic review

OBJECTIVE

To identify individual-, provider- and system/environmental-level barriers and facilitators affecting cardiac rehabilitation (CR) participants' adherence to dietary recommendations.

DESIGN

A systematic review of the medical literature was conducted. Six databases were searched from inception through March 2021: APA PsycInfo, CINAHL, Embase, Emcare, Medline and PubMed. Only those studies referring to barriers and facilitators reported by CR participants were considered. Pilot and case report studies, non-peer-reviewed literature and studies published in a language other than English, Portuguese or Spanish were excluded.

RESULTS

Data were extracted and analysed on the basis of individual-, provider- and system/environmental-level factors. Of 2083 initial citations, sixteen studies were included, with nine being qualitative and seven observational in design. From these, ten multi-level barriers and seven multi-level facilitators were identified. Dietary recommendations included developing healthy eating habits, transitioning to vegetarian-rich diets and increasing fish oil and n-3 intake. Only one study reported on all of the nutrition education programme factors recommended by the Workgroup for Intervention Development and Evaluation Research.

CONCLUSION

To the best of our knowledge, this review is the first to summarise specific barriers and facilitators to recommendation adherence among CR participants. Few of the studies offered any conclusions regarding programme design that could facilitate improved dietary adherence practices. Future studies should aim to explore patient perspectives on the nutritional patterns and recommendations outlined in the Mediterranean Diet, the Dietary Approaches to Stop Hypertension Diet, Vegetarian or Vegan diets and the Portfolio Diet.

Nutrition as Treatment Modality in Heart Failure

PURPOSE OF REVIEW

This review aims to discuss recent evidence and controversies regarding nutrition as a treatment modality for heart failure (HF) patients.

RECENT FINDINGS

Adequate nutrition is known to promote health-related quality of life by addressing malnutrition and promoting optimal functioning among older adults and has an established role in the prevention of HF; however, evidence is limited on the effects of nutrition as a treatment modality in HF. While guidance of sodium restriction to address fluid overload is an ongoing debate among experts, evidence from case studies and small clinical trials suggest a positive impact of plant-based and Dietary Approaches to Stop Hypertension (DASH) dietary patterns on HF-related pathophysiology, quality of life, hospital admissions, and mortality. More clinical trials are needed to establish an evidence base to support dietary management strategies for patients with HF. Clinical and Translational Science Alliances (CTSAs) may provide infrastructure to overcome enrollment barriers.

Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study ( Data Supplement ) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

The Relationship between Illness Perception and Self-Care Behaviors among Hemodialysis Patients

Objective: Illness perception and self-care behaviors can result in higher levels of health behavior among hemodialysis patients. The present study aimed to assess the relationship between illness perception and self-care behaviors among hemodialysis patients who referred to the hospitals affiliated to Shiraz University of Medical Sciences in 2017. Method : In this descriptive cross sectional study, 216 hemodialysis patients who referred to the hemodialysis wards of the hospitals affiliated to Shiraz University of Medical Sciences were selected via convenience sampling. The study data were collected using a demographic information form, Brief Illness Perception Questionnaire (9 items), and a 15-item Self-care Behavior of Hemodialysis Patients Questionnaire. Then, the data were analyzed using independent t test and one-way ANOVA. Also, significance level was set at P < 0.05. Results: The mean age of the study participants was 30.15+6.65 years. Also, most of the participants were female (n = 125, 58%). The results revealed a significant relationship between illness perception and self-care behaviors among hemodialysis patients. A significant relationship was observed between the following items: daily weight control and perception of consequences (r = 0.200, p = 0.001), between contacting the physician at the time of shortness of breath and consequences (r = 0.209, p = 0.001), between weight control according to the physician's order and consequences (r = 0.763, p = 0.001), and between adherence to fluids restriction and identity(r = 0.149, p < 0.05). Conclusion: Considering the relationship between illness perception and self-care, beliefs as illness perception have to be incorporated into self-care programs designed for hemodialysis patients so as to promote their self-care behaviors. These findings can be used for planning and implementing care for hemodialysis patients.

Zinc Deficiency and Heart Failure: A Systematic Review of the Current Literature

Zinc is an essential micronutrient that impacts the cardiovascular system through modulation of oxidative stress. It is unknown whether zinc levels are affected in heart failure (HF), and whether the association, if present, is causal. A systematic search for publications that report coexisting zinc deficiency in patients with HF was performed to provide an overview of the pathophysiological and epidemiological aspects of this association (last search April 2019). Review of the literature suggests multiple potential pathophysiologic causes for zinc deficiency in HF as a result of impaired micronutrient consumption, hyper-inflammatory state, upregulation of the renin-angiotensin-aldosterone axis, diminished absorption, and hyperzincuria from HF medications. In a longitudinal study of patients with HF in the setting of intestinal malabsorption, there was partial cardiomyocyte and left ventricular ejection fraction recovery with intravenous selenium and zinc supplementation. Two randomized double-blind control trials evaluating micronutrient and macronutrient supplementation including zinc in patients with HF found improvement in echocardiographic findings compared with placebo. Two recently completed studies evaluated the role for zinc supplementation in 2 different HF populations: a trial of zinc supplementation in patients with non-ischemic HF, and a trial of micronutrient supplementation (including B vitamins, vitamin D, and zinc) in veterans with systolic dysfunction; the results of which are still pending. Several pathobiological pathways to link zinc deficiency with the development and deterioration of HF are presented. Preliminary clinical data are supportive of such an association and future studies should further investigate the effects of zinc supplementation on outcomes in patients with HF.

Salt, No Salt, or Less Salt for Patients With Heart Failure?

Restricting dietary sodium is a common recommendation given by clinicians to patients with heart failure and is one supported by current guidelines. However, the quality of evidence for this recommendation is suboptimal, and there is no consensus on the optimal level of sodium intake. Though excessive sodium intake is associated with left ventricular hypertrophy and hypertension, recent data have suggested that very low sodium intake is paradoxically associated with worse outcomes for patients with heart failure. This is possibly explained by the association between low sodium intake and activation of the sympathetic and renin-angiotensin-aldosterone systems. Nevertheless, sodium restriction is routinely recommended and remains a cornerstone of heart failure and blood pressure therapy. In this review we discuss the pros and cons of sodium restriction for patients with heart failure from the current literature.

Design and Region-Specific Adaptation of the Dietary Intervention Used in the SODIUM-HF Trial: A Multicentre Study

Background

Restricting dietary sodium consumption has been considered a major component of self-care management in heart failure (HF); however, the evidence supporting this recommendation has not been conclusive. The Study of Dietary Intervention Under 100 MMOL in Heart Failure (SODIUM-HF) trial aims to assess the effects of dietary sodium reduction on clinical outcomes in a HF population using a pragmatic design to provide empirical evidence to guide dietary sodium intake recommendations in patients with chronic HF.

Methods

SODIUM-HF is a multicentre, open-label, blinded adjudicated endpoint, randomized controlled trial in ambulatory patients with chronic HF. This trial involves participants recruited from sites in Canada, Australia, New Zealand, Mexico, Colombia, and Chile, who are followed up to 24 months. Rationale and methods of the SODIUM-HF trial were published elsewhere. As an international pragmatic dietary trial, SODIUM-HF was designed to address several challenges, such as defining the most suitable intervention to account for country-specific variations in food intake and availability. In SODIUM-HF, we implemented the Nutrition-Care Model to provide a comprehensive intervention delivered directly to patients, focusing on modifying the nutrient composition of the diet (sodium restriction), using a personalized counselling and close follow-up.

Results

Available upon completion of the trial.

Conclusions

This long-term dietary trial is one of the first in its type in the HF field. This article describes in detail the rationale and methods for the dietary intervention employed and the region-specific adaptation of the SODIUM-HF intervention, so that the learning and processes taken in this trial can be applied to future multicountry dietary clinical trials.

Adherence to diet and medication and the associated factors among patient with chronic heart failure in a multi-ethnic society

OBJECTIVE

To investigate diet adherence, medication adherence and self-care behaviour among patients with chronic heart failure (CHF) in a multi-ethnic society and identify the significant factors associated with their diet and medication adherence.

METHODS

A cross-sectional descriptive correlational study was conducted with a convenience sample of 107 patients with CHF recruited from two cardiology wards of a public tertiary hospital in Singapore. Study variables were measured using the Dietary Sodium Restriction Questionnaire, the Medication Adherence Rating Scale-5 items and the European Heart Failure Self-care Behaviour Scale-12 items.

RESULTS

Our sample reported positive attitudes towards diet adherence, poor self-care behaviour, and good medication adherence. The multiple linear regression results indicated that lower income, Chinese ethnicity, diabetic complications, current smoking, lower New York Heart Association classification I and II, and poorer self-care behaviour predicted poorer diet adherence. In addition, absence of hypertension, having non-myocardial infarction as a cause of CHF, and moderately diminished ejection fraction were identified as significant predictors of poorer medication adherence.

CONCLUSION

The findings from this study have established the need to improve current education and rehabilitation programmes for patients with CHF by addressing those factors significantly influencing their adherence to diet and medication.

Association between the Prognostic Nutritional Index and Dietary Intake in Community-Dwelling Older Adults with Heart Failure: Findings from NHANES III

The objective of this study was to examine the association between nutritional status and dietary intake in community-dwelling older adults with heart failure (HF). A cross-sectional analysis of NHANES III data was conducted. The analytic sample was comprised of n = 445 individuals aged 50+ years with congestive HF (54.4% male, 22.9% non-Hispanic Black, 43.8% low-income). Nutritional status was measured using the Prognostic Nutritional Index (PNI). Participants were classified by PNI quintiles with lower PNI scores indicating lower nutritional status. Participants in quintile 5 showed significantly greater intakes of energy, protein, vegetables, magnesium, zinc, copper, potassium, red meat, saturated fat, and sodium. In multivariate analyses, increased intake of red meat (β = 0.253, p = 0.040) and vegetables (β = 0.255, p = 0.038) was associated with significantly better nutritional status. In the absence of comprehensive nutritional guidance for HF patients, it appears that small increases in energy, protein (red meat), and vegetable consumption are associated with improved nutritional status.

Patterns of adherence to diuretics, dietary sodium and fluid intake recommendations in adults with heart failure

BACKGROUND

Three behaviors advocated to minimize fluid-related hospitalizations in patients with heart failure (HF) are restricted sodium and fluid intake and consistent oral diuretic use. Adherence to behaviors intended to decrease risk of hospitalization is believed to vary over time, but surprisingly little research has addressed patterns of adherence in HF patients.

OBJECTIVE

To describe patterns over time of 3 recommended self-care behaviors (i.e., diet, fluid intake, and diuretic dosing) in adults with HF and to determine how time and behavior influenced adherence rates.

METHODS

We enrolled 24 adults hospitalized for a HF exacerbation and discharged on a loop diuretic into a descriptive, longitudinal pilot study. Over 3-months, diuretic use was measured using electronic event monitoring, and participants were telephoned regularly to assess sodium and fluid intake. Data were summarized for each 2-week intervals.

RESULTS

The overall adherence rates were 42.4% for low sodium diet, 96.4% for fluid restriction, and 84.7% for the diuretic regimen. Early after hospital discharge, medication adherence was the highest, and dietary adherence was the lowest, but adherence to diet and diuretic use decreased significantly over time.

CONCLUSION

Although participants were just discharged from the hospital after an acute exacerbation of HF, all three behavioral patterns decreased markedly over the 3-month follow-up period.

Rationale and design of the Study of Dietary Intervention Under 100 MMOL in Heart Failure (SODIUM-HF)

BACKGROUND

Patients with heart failure (HF) remain at high risk for future events despite medical and device therapy. Dietary sodium reduction is often recommended based on limited evidence. However, it is not known whether dietary sodium reduction reduces the morbidity or mortality associated with HF.

METHODS

The SODIUM study is a pragmatic, randomized, open-label trial assessing the efficacy of dietary sodium reduction to <1500 mg daily counseling compared to usual care for patients with chronic HF. The intervention is provided by trained personnel at the site and uses 3-day food records for directing counseling. The primary outcome is an intention-to-treat analysis on the time to first cardiovascular event or death measured at 12 months. Secondary end points include the change in quality of life (using the Kansas City Cardiomyopathy Questionnaire), change in New York Heart Association class, and change in 6-minute walk test. The first patient was enrolled in March 2014, and subsequently, 27 sites in 6 countries enrolled patients.

CONCLUSIONS

The SODIUM-HF trial will provide a robust evaluation of the effects of dietary sodium reduction in patients with HF. Results are expected in 2020.

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.

Micronutrient Deficiency Independently Predicts Adverse Health Outcomes in Patients With Heart Failure

BACKGROUND

Despite growing evidence on the important role of micronutrients in prognosis of heart failure (HF), there has been limited research that micronutrient deficiency predicts health outcomes in patients with HF.

PURPOSE

The aim of this study was to determine whether micronutrient deficiency independently predicts adverse health outcomes.

METHODS

A total of 113 consecutive outpatients with HF completed a 3-day food diary to measure intake of 15 micronutrients. The Computer Aided Nutrition Analysis Program for Professionals was used to analyze the food diaries and determine dietary micronutrient deficiencies. Patients completed the Minnesota Living With HF Questionnaire to assess health-related quality of life (HRQoL) and were followed up for 1 year to determine cardiac-related hospitalization or cardiac death. Hierarchical multiple linear regressions and Cox proportional hazard regressions were used to determine whether micronutrient deficiencies predicted health outcomes.

RESULTS

Fifty-eight patients (51%) had at least 3 micronutrient deficiencies (range, 0-14). Calcium, magnesium, and vitamin D were the most common micronutrient deficiencies. Micronutrient deficiency was independently associated with worse HRQoL (β = .187, P = .025) in hierarchical multiple linear regression. Thirty-nine patients were hospitalized or died during 1-year follow-up because of cardiac problems. The number of micronutrient deficiencies independently predicted cardiac event-free survival (hazard ratio, 1.14; 95% confidence interval, 1.02-1.28).

CONCLUSIONS

These findings show that micronutrient deficiency independently predicted poor HRQoL and earlier cardiac event-free survival in patients with HF. Further research is needed to provide for specific dietary guidelines for better health outcomes in HF patients.

Associations between copper and zinc intakes from diet and mortality from cardiovascular disease in a large population-based prospective cohort study

Several studies have related cardiovascular disease (CVD) to serum concentrations of copper and zinc but not to their dietary intakes. We thought to examine the association between dietary intakes of copper and zinc with risk of mortality from CVD in a prospective study encompassing 58,646 healthy Japanese men and women aged 40-79 years. The intakes of copper and zinc were determined by a validated self-administered food frequency questionnaire, and their associations with risk of mortality from CVD were evaluated by Cox proportional hazard modelling. During 965, 970 person-years of follow-up between 1989-2009, we documented 3,388 CVD deaths [1,514 from stroke, 702 from coronary heart disease (CHD) and 1,172 from other CVD]. Copper intake was not associated with CHD mortality; however, the multivariable hazard ratios (HRs) with 95% confidence intervals (CIs) for mortality from stroke, other CVD and total CVD in the highest versus the lowest quintiles of copper intake among men were 1.78 (1.16-2.77; P-trend=0.007), 1.61 (1.01-2.81; P-trend =0.03) and 1.63 (1.21-2.33; P-trend=0.001), respectively, and those among women were 1.49 (1.00-2.19; P-trend=0.04), 1.59 (1.09-2.55; P-trend =0.02) and 1.36 (1.06-1.69; P-trend=0.01), respectively. Higher intakes of zinc was inversely associated with mortality from CHD in men; 0.68 (0.58-1.03; P-trend=0.05) but not women; 1.13 (0.71- 1.49; P-trend=0.61). No associations were observed with other mortality endpoints. In conclusion, dietary copper intake was positively associated with mortality from CVD in both genders; whereas, higher dietary zinc intake was inversely associated with mortality from CHD in men but not women.

Self-Care Behaviors in Heart Failure

OBJECTIVE

To identify self-care behaviors, instruments, techniques, parameters for the assessment of self-care behaviors in people with heart failure, compare these behaviors with the indicators of the Nursing Outcomes Classification outcome, Self Management: Cardiac Disease.

METHOD

Integrative literature review performed in Lilacs, Medline, CINAHL, and Cochrane, including publications from 2009 to 2015. One thousand six hundred ninety-one articles were retrieved from the search, of which 165 were selected for analysis.

RESULTS

Ten self-care behaviors and several different assessment instruments, techniques, and parameters were identified. The addition and removal of some indicators are proposed, based on this review. The data provide substrate for the development of conceptual and operational definitions of the indicators, making the outcome more applicable for use in clinical practice.

Dietary Self-management in Heart Failure: High Tech or High Touch?

OPINION STATEMENT

Dietary management of heart failure (HF) has largely been focused on sodium and fluid restrictions. Although safety and efficacy of these interventions in HF remain unclear, a daily sodium intake between 2000 and 3000 mg/day appears to be safe in these patients. Ongoing clinical research will inform on the safety and efficacy of a more restrictive sodium intake to less than 1500 mg/day. Data shows that routine fluid restriction in HF regardless of symptoms may be unnecessary; however, in patients with signs of congestion, fluid restriction to 2.0 L/day may be advisable. Recently, more attention has been paid to other nutritional aspects of HF beyond sodium and fluid intake, although there is still little evidence available to guide nutritional management of HF. Assuring that patients meet daily requirements for key micronutrients, such as calcium, magnesium, potassium, folate, vitamin E, vitamin D, zinc, and thiamine, is essential in order to prevent deficiencies. More appropriate macronutrient composition of the diet is still to be determined; however, a diet containing 50-55% carbohydrates, 25-30% fat, and 15-20% protein seems acceptable for patients with HF with or without non-end-stage renal disease. Additionally, increased protein intake may be considered in malnourished/cachectic patients. Consulting a registered dietitian is especially helpful for patients with recent HF exacerbations or for patients with multiple comorbidities who may need to follow several dietary restrictions and may benefit of individualized dietary counseling in order to ensure appropriate intake of energy, protein, and micronutrients. Today, there are still several knowledge gaps in guiding the dietary management of HF. In this article, we review current recommendations for the dietary management of HF and the evidence supporting this practice.

The association between cognitive function and objective adherence to dietary sodium guidelines in patients with heart failure

BACKGROUND

Although cognitive impairment is common in heart failure (HF) patients, its effects on sodium adherence recommendations are unknown.

PURPOSE

Our aim is to examine if cognitive function is associated with patient sodium adherence.

METHODS

Sodium collection/excretion and cognitive function were assessed for 339 HF patients over a 5-8-week period. Neuropsychological testing was performed at baseline (Visit 1), whereas two 24-hour urine samples were collected within 7 weeks postbaseline. The ability to collect two 24-hour urine samples and the estimation of sodium excretion levels from these samples were used to estimate sodium adherence recommendations.

RESULTS

Nearly half (47%) of the study participants (n=159) were unable to give two valid 24-hour urine samples. Participants who were unable to adhere to two valid 24-hour urine samples had significantly poorer attention and global cognition tests (P<0.044), with a trend for poorer executive function (P=0.064). Among those with valid samples, urine sodium level was not associated with global cognitive function, attention, executive function, or memory after adjusting for covariates. Female sex was associated with lower sodium excretion (all P<0.01); individuals with knowledge of sodium guidelines had less intake of sodium, resulting in excretion of less sodium (all P≤0.03). Conversely, higher socioeconomic status (SES) and body mass index (BMI) were associated with greater sodium (all P≤0.02 and P≤0.01).

CONCLUSION

Adherence to urine sodium collection was poor, especially among those with poorer cognitive function. Sodium consumption exceeded recommended amounts and was unrelated to cognitive function. Interventions for improving sodium adherence should focus on at-risk groups (high SES and BMI) and at improving knowledge of recommended salt intake.

Changes in dietary intake and nutritional status associated with a significant reduction in sodium intake in patients with heart failure. A sub-analysis of the SODIUM-HF pilot study

BACKGROUND & AIMS

Concerns have been raised about the impact of dietary sodium restriction on the overall dietary intake and nutritional status in patients with heart failure (HF). The objective of this study was to evaluate the association between a significant reduction in sodium intake and dietary changes and nutritional status in patients with chronic HF.

METHODS

This is a secondary analysis of 38 patients enrolled in a pilot study of dietary sodium reduction. Patients were classified into two groups according to a level of sodium reduction achieved (≥25% [n = 21 patients] and <25% [n = 14 patients]) at 6 months. Between group changes in energy, nutrient intake, weight loss, and hand grip strength from baseline to 6 months were compared.

RESULTS

Patients had a median age of 65 years, 51% were male, median body mass index was 30.7 kg/m² and median ejection fraction was 39%. Over 6 months, the group with ≥25% sodium reduction exhibited a greater increase in folate intake [median change 50 mcg/day (25th-75th percentiles: -101, 167) vs. -31 mcg/day (25th-75th percentiles: -221, 51), p = 0.04 between groups] and a larger reduction in calcium intake [median change -262 (25th-75th percentiles: -585, -9) vs. 91 (25th-75th percentiles: -114, 210), p = 0.01 between groups], and were more likely to meet the parameters of the DASH diet compared to the <25% sodium reduction group. No significant differences between groups were seen for caloric intake and other relevant nutrients and no significant weight loss was found in either group.

CONCLUSIONS

Dietary sodium reduction may be achieved without compromising overall dietary intake and nutritional status in patients with HF when an individualized and comprehensive dietary approached is used.

CLINICAL TRIAL IDENTIFIER

Clinicaltrials.gov identifier: NCT01480401.

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

BACKGROUND

Depressive symptoms and malnutrition independently predict cardiac events in heart failure (HF) patients. However, the relationships among depressive symptoms, nutritional intake, and cardiac event-free survival have not been examined.

METHODS AND RESULTS

A total of 232 patients with HF completed the Patient Health Questionnaire 9 (PHQ-9) to measure depressive symptoms and a 3-day food diary to determine the number of micronutrient deficiencies. Patients were followed for 2 years to collect data on cardiac event-free survival. Patients were divided into 4 groups by a PHQ-9 score of 10 and the median value of micronutrient deficiencies. Cox regressions were used to determine the relationships among depressive symptoms, micronutrient deficiency, and cardiac event-free survival. Depressive symptoms conferred greater risk of cardiac events in patients with a high number of micronutrient deficiencies than in those with a low number of micronutrient deficiencies. Patients with a PHQ-9 score ≥10 and number of micronutrient deficiencies >5 had 2.4 times higher risk for cardiac events compared with patients with a PHQ-9 score <10 and micronutrient deficiency ≤5 (P = .005).

CONCLUSIONS

There was a synergistic effect on the association of depressive symptoms with cardiac event-free survival in HF patients that differed by micronutrient deficiency.

Association between self-reported adherence to a low-sodium diet and dietary habits related to sodium intake in heart failure patients

BACKGROUND

Sodium restriction is the primary dietary therapy in heart failure (HF); however, assessing sodium intake is challenging to clinicians, who commonly rely on patients' self-report of following a low-sodium diet to determine adherence. It is important to further explore the utility of self-reported adherence to a low-sodium diet in patients with HF.

OBJECTIVES

The objective of this study was to evaluate the association between patients' self-reported adherence to a low-sodium diet and dietary habits related to sodium intake in patients with chronic HF.

METHODS

Patients with HF seen in a tertiary care Heart Function Clinic and who have been taught on a low-sodium diet with a target of less than 2300 mg/d were included. Self-perception of compliance and dietary habits related to sodium intake was evaluated by using a dietary questionnaire. Patients were divided into 3 groups according to self-reported adherence to a low-sodium diet: never, sometimes, and always.

RESULTS

Overall, 237 patients (median age, 66 years, 72.6% men) were included. Compared with the other 2 groups, patients who stated always following a low-sodium diet were less likely to use salt in cooking or at the table. However, 4.2% of the patients in the always group reported eating canned or package soups every day. Moreover, the highest proportion of patients eating fast foods 1 to 3 times a week was found among those in the sometimes group (22.9%) compared with the never (9.1%) and always (6.7%) groups (P = .002). Importantly, the rest of the food items did not show any significant differences between self-reported adherence groups.

CONCLUSION

Self-report of adherence to a low-sodium diet is not reliable among patients with HF, who associate the idea of following a low-sodium diet mainly with not using salt for cooking or at the table but not with reducing frequency of intake of high-sodium processed foods.

Dietary sodium adherence is poor in chronic heart failure patients

BACKGROUND

We sought to determine the rates and predictors of dietary sodium restriction and to evaluate the reliability of 24-hour urine collection as a tool to estimate dietary sodium intake in heart failure (HF) patients.

METHODS AND RESULTS

We evaluated the 24-hour urinary sodium excretion of 305 outpatients with HF and reduced ejection fraction who were educated on following a <2 g sodium diet. The mean sodium excretion according to a single sample from each participant was 3.15 ± 1.58 g, and 23% were adherent to the <2 g recommendation. One hundred sixty-eight participants provided 2 samples with urinary creatinine excretion within normative range. Averaging both resulted in a mean sodium excretion of 3.21 ± 1.20 g and lower adherence rates to the <2-gram diet: 14% versus 23% (P = .019). Multivariate logistic regression showed only male sex and higher body mass index (BMI) to be associated with nonadherence (male: odds ratio [OR] 2.20, 95% confidence interval [CI] 1.25-3.88; 1 unit BMI: OR 1.05, 95% CI 1.01-1.10). Bland-Altman plots of urinary sodium and creatinine showed poor reproducibility between samples.

CONCLUSIONS

In this chronic HF population, sodium consumption probably exceeds recommended amounts, particularly in men and those with higher BMI. Urine analyses were not highly reproducible, suggesting variation in both diet and urine collection.

Identifying predictors of high sodium excretion in patients with heart failure: a mixed effect analysis of longitudinal data

BACKGROUND

A low-sodium diet is a core component of heart failure self-care but patients have difficulty following the diet.

AIM

The aim of this study was to identify predictors of higher than recommended sodium excretion among patients with heart failure.

METHODS

The World Health Organization Five Dimensions of Adherence model was used to guide analysis of existing data collected from a prospective, longitudinal study of 280 community-dwelling adults with previously or currently symptomatic heart failure. Sodium excretion was measured objectively using 24-hour urine sodium measured at three time points over six months. A mixed effect logistic model identified predictors of higher than recommended sodium excretion.

RESULTS

The adjusted odds of higher sodium excretion were 2.90, (95% confidence interval (CI): 1.15-4.25, p<0.001) for patients who were obese; 2.80 (95% CI: 1.33-5.89, p=0.007) for patients with diabetes; and 2.22 (95% CI: 1.09-4.53, p=0.028) for patients who were cognitively intact.

CONCLUSION

Three factors were associated with excess sodium excretion and two factors, obesity and diabetes, are modifiable by changing dietary food patterns.

Sodium restriction in heart failure: benefit or harm?

OPINION STATEMENT

Current guidelines vary in the recommended amount of dietary sodium intake for heart failure (HF) patients. Observational studies and the hypertension literature support the concept that sodium restriction improves HF outcomes. In contrast, several randomized controlled trials imply that dietary sodium restriction can cause harm through hypovolemia and increased neurohormonal activation. Data from hypertensive animal models and humans suggest that dietary sodium intake may need to be individually tailored based on HF severity and the physiologic response to sodium loading. Future studies must assess interactions between sodium intake, fluid intake, and diuretics to match clinical practice and improve safety. More information is needed in multiple areas, including accurate measurement of sodium intake, implementation of dietary changes in HF patients, and establishment of biomarkers that predict response to changes in sodium intake. Additional research is urgently needed to determine the true impact of the most commonly recommended self-care strategy in HF.