Heart Failure
Manual of Clinical Nutrition Management III- 43 Copyright © 2013 Compass Group, Inc.
status that evaluates the patient’s weight and/or muscle mass (especially if weight is difficult to assess) by
using skinfold measurements or grip strength evaluation (4). A careful analysis of biochemical parameters
and nutritional intake should assess the adequacy of energy and protein intake, the sodium and fluid balance,
and the adequacy of vitamins and minerals that can be impacted by polypharmacy. Folate, thiamine, vitamin
B 12 , calcium, and magnesium are key nutrients compromised by medications such as diuretics and digoxin
(1,3).
Patients who have heart failure require limited sodium and fluid intake and adequate total energy intake to
meet their increased energy expenditure. Patients who have severe heart failure may develop malnutrition
and cardiac cachexia due to the increased energy requirements associated with the increased lung function
needed to produce oxygen (2,3). Compromised nutritional intake is also related to the fatigue and shortness of
breath associated with fluid retention (2,3). The mechanism of cardiac cachexia includes hypermetabolism,
muscle wasting, altered intake, and functional impairments (4). Involuntary weight loss associated with heart
failure may be masked by chronic fluid retention. The use of weight as the only parameter to diagnosis a
nutrition-related problem may underestimate the incidence of malnutrition (4,5). Intestinal malabsorption,
especially of fat, is common in heart failure as a result of mucosal and intestinal congestion related to edema
in the large intestine (6). Patients should be monitored for signs and symptoms of malabsorption as part of
the nutrition assessment (4).
Nutrition Intervention
Specific nutrition interventions are effective in managing the signs and symptoms of heart failure (Grade II) (1-3).
The primary objective of medical nutrition therapy is to complement pharmacotherapy in maintaining fluid
and electrolyte balance while preventing malnutrition and cardiac cachexia. Nutrition interventions should
be customized based on the patient’s individualized needs and the nutrition diagnoses identified by the
comprehensive nutrition assessment. Refer to Morrison Nutrition Practice Guideline – Heart Failure and
heart failure evidence-based nutrition practice guidelines as needed (3,7). Hypertension is often associated
with heart failure; therefore, dietary and lifestyle management strategies for treating hypertension should be
applied to heart failure patients who have hypertension (1-3,8). (Refer to “Hypertension”, Section III.)
Energy expenditure: Indirect calorimetry is the best method to determine the energy needs of patients who
have heart failure (Grade III) (3). When indirect calorimetry is not possible, the clinician should use predictive
equations based on the patient’s level of care and adjust for an increased catabolic state (Grade III) (3). A primary
goal is to provide enough energy to maintain a reasonable body weight and visceral protein status. In some
cases, the basal metabolic needs may be 18% higher than age-matched controls; this increased metabolic
need can contribute to malnutrition and cardiac cachexia (9). In obese patients, weight loss improves cardiac
output and shortness of breath (4).
Protein: The daily protein intake should be at least 1.37 g/kg in clinically stable depleted patients and 1.12
g/kg in normally nourished patients to preserve their actual body composition or limit the effects of
hypercatabolism (Grade III) (3). The literature suggests that patients with heart failure have significantly higher
protein needs than patients without heart failure, as measured by negative nitrogen balance (Grade III) (3). The
patient’s nitrogen balance should be evaluated if the adequacy of protein intake is in question (3,4).
Sodium: Limit sodium to 2,000 mg/day (Grade III) (3) and do not exceed 3,000 mg/day (1). Severe heart failure
may warrant a lower sodium intake. (Refer to “Sodium-Controlled Diet” in Section I-F.) Sodium restriction
will improve the patient’s quality of life and clinical symptoms such as edema and fatigue (Grade III) (3). Urinary
sodium levels can be assessed to determine the adherence to a low-sodium diet (2). Severely restricted
sodium intake (1,000 mg or less) is discouraged for home use. Dietary restriction at this extreme may be
unrealistic, leading to reduced patient compliance and compromised nutritional intake.
Fluid: Fluid requirements are based on the presence of edema, ascites, shortness of breath, and
hyponatremia and the frequency of weight fluctuations. Fluid restriction improves these clinical symptoms
and the patient’s quality of life (Grade II) (3). For patients with heart failure, daily fluid intake should be between
1.4 and 1.9 L (48 to 64 oz), depending on clinical symptoms (Grade III) (3). Fluid should be restricted if serum
sodium levels fall below 130 mEq/L (1). Sudden increases in body weight of 3 to 5 lb suggest marked fluid
retention (4). (Refer to “Nutrition Management of Fluid Intake and Hydration” in Section IA.)
Alcohol: Alcohol provides limited nutrients and should be avoided or limited to one drink per day for women
and two drinks or less per day for men; each drink is the equivalent of 1 oz of alcohol (Grade II) (3). Research