Dietary Interventions for Heart Failure: What You Need to Know

According to a review published in the journal Hearts, heart failure (HF) is a global health issue, affecting millions worldwide. While salt restriction to less than 2-3 grams per day is a common dietary recommendation, evidence on its effectiveness remains mixed. Emerging dietary components like medium-chain triglycerides (MCT) oil, beta-hydroxybutyrate salts, and coenzyme Q10 (CoQ10) have shown potential benefits, though more research is needed. Dietary patterns such as the DASH and Mediterranean diets are associated with improved HF outcomes, but the long-term effects of other approaches, like ketogenic diets, remain unclear. HF patients with comorbidities, such as diabetes and chronic kidney disease, require personalized dietary management. Malnutrition and cachexia are prevalent in advanced HF, increasing mortality risk. Nutritional support, including high-protein supplements, may improve outcomes, but larger, well-designed trials are necessary to confirm the efficacy of dietary interventions. Research on personalized approaches and long-term dietary strategies could help optimize HF management.

Key points

1. Sodium restriction is commonly recommended for heart failure (HF), but evidence on its effectiveness is mixed, with guidelines suggesting limits between 2-3 grams per day.

2. Emerging supplements like medium-chain triglycerides (MCT) oil, beta-hydroxybutyrate (BHB) salts, and coenzyme Q10 (CoQ10) show promise for improving heart function, but more research is needed.

3. Dietary patterns, such as the DASH and Mediterranean diets, are associated with improved HF outcomes, reducing risk factors and hospitalizations.

4. Ketogenic diets have the potential for short-term benefits in HF management, but their long-term safety and effectiveness remain uncertain.

5. HF patients often have comorbidities like diabetes, obesity, or chronic kidney disease, requiring personalized dietary strategies to manage both HF and related conditions.

6. Malnutrition and cachexia are common in advanced HF, significantly increasing mortality risk, and nutritional support may help improve outcomes.

7. More research is needed on the long-term efficacy, safety, and personalization of dietary interventions for HF, with a focus on large, well-designed randomized trials.

Heart failure management through diet and nutrition:

Heart failure (HF) is a major global health problem, affecting approximately 64 million people worldwide. It occurs when the heart is unable to pump blood effectively to meet the body's metabolic needs. Despite advances in medications and device therapies, HF remains a significant cause of morbidity and mortality. There is growing interest in exploring dietary interventions as a complementary approach to managing HF.

Current Dietary Guidelines for HF

Currently, the only dietary recommendation consistently included in HF management guidelines is salt restriction, typically to less than 2 g per day. However, the evidence supporting strict sodium restriction is mixed. While some studies have shown benefits in terms of symptoms and quality of life, others have found no reduction in hospitalizations or mortality with low-sodium diets. The SODIUM-HF trial, the largest randomized controlled trial (RCT) on this topic to date, found that sodium restriction to <1500 mg/day did not reduce cardiovascular-related emergency department visits compared to usual care.

There is controversy over the optimal level of sodium restriction, with guidelines recommending anywhere from <1.5 g to <3 g per day. Very low sodium intake (<2000 mg/day) may even lead to increased weight in some HF patients, suggesting fluid retention. Given the conflicting evidence, current recommendations generally align with broader population guidelines of around 2000–2300 mg sodium per day for HF patients.

Emerging Dietary Components and Supplements

Several dietary components and supplements are being investigated for potential benefits in HF management:

1. Medium-chain triglyceride (MCT) oil: MCTs are rapidly metabolized fatty acids that can be converted to ketone bodies. Since failing hearts increase ketone oxidation, MCT oil has been proposed as a potential energy source for HF patients. However, no studies have yet assessed MCT oil specifically in HF patients.

2. Beta-hydroxybutyrate (BHB) salts: BHB is a ketone body that can serve as an energy substrate for the heart. Exogenous BHB supplementation has shown promise in animal models and small human studies, with one trial finding a 40% increase in cardiac output after BHB infusion in HF patients. However, maintaining therapeutic BHB levels may be challenging, and long-term efficacy and safety need further study.

3. Ketone esters: These synthetic compounds can rapidly elevate blood ketone levels when ingested. A recent 14-day RCT in patients with HF with reduced ejection fraction (HFrEF) found improvements in cardiac output and left ventricular ejection fraction with ketone ester supplementation. However, the long-term effects of chronic supplementation are unknown.

4. Coenzyme Q10 (CoQ10): This antioxidant plays a crucial role in mitochondrial energy production. Lower myocardial CoQ10 levels correlate with increased mortality risk in HF. The Q-SYMBIO trial, a large RCT, found that CoQ10 supplementation (300 mg daily) reduced cardiovascular death and all-cause mortality by approximately 40% in HF patients.

5. Resveratrol: This plant-derived polyphenol has shown cardioprotective effects in animal studies. Small clinical trials in HF patients have found improvements in left ventricular function, exercise capacity, and reductions in inflammatory markers with resveratrol supplementation. However, larger trials are needed to confirm these benefits.

Dietary Patterns in HF Management

1. DASH Diet: The Dietary Approaches to Stop Hypertension (DASH) diet, characterized by high intake of fruits, vegetables, and plant proteins, and low intake of sodium and saturated fats, has been associated with reduced risk of HF in observational studies. The GOURMET-HF trial, a small RCT, found that providing DASH-compliant meals to recently hospitalized HF patients led to a 69% decrease in rehospitalizations over 12 weeks.

2. Mediterranean Diet: This diet, rich in fruits, vegetables, whole grains, and olive oil, has well-established cardiovascular benefits. The PREDIMED trial found improvements in HF biomarkers and classical risk factors with Mediterranean diet interventions. However, the effect on HF incidence was non-significant, possibly due to the small number of HF events in the study.

3. Ketogenic Diet: Given the metabolic shift towards increased ketone utilization in HF, ketogenic diets have gained interest as a potential therapeutic approach. Animal studies have shown mixed results, with some indicating improvements in cardiac function and others finding potential adverse effects with long-term use. In humans, short-term ketogenic diets have shown improvements in hemodynamic and metabolic parameters in HF patients, but long-term effects and safety remain unclear.

Comorbidities and Dietary Management

Many HF patients have co-existing conditions that can complicate dietary management. Common comorbidities include:

1. Diabetes Mellitus: For HF patients with diabetes, a Mediterranean-style diet rich in monounsaturated and polyunsaturated fats may be beneficial. The DASH diet has also shown benefits for both conditions. Careful monitoring of blood glucose is essential, especially if ketogenic approaches are considered.

2. Obesity: Weight loss through calorie restriction and increased physical activity is generally recommended for obese HF patients. However, extreme calorie restriction should be avoided due to the risk of muscle wasting.

3. Coronary Artery Disease: Diets low in saturated fats and rich in fruits, vegetables, and whole grains are recommended. Omega-3 fatty acid supplementation may be beneficial.

4. Chronic Kidney Disease: Sodium and fluid restrictions are often necessary, but protein intake should be carefully managed to prevent malnutrition. Potassium and phosphorus restrictions may also be required depending on kidney function.

Malnutrition in Advanced Heart Failure

Malnutrition is a significant concern in advanced HF, affecting up to 65% of patients and associated with increased mortality. Several factors contribute to malnutrition in HF:

• .Gut malabsorption

• Increased energy demand

• .Cytokine-induced anorexia

• .Fatigue and breathlessness

• .Early satiety

• .Taste changes

• Difficulties in food preparation

Severe malnutrition can lead to cardiac cachexia, characterized by substantial weight loss and muscle wasting. Cachexia is associated with a 2-3 fold increase in mortality risk. Sarcopenia, the age-related loss of muscle mass and strength, is also common in HF patients and associated with poor outcomes.

Nutritional screening and assessment are crucial for identifying and managing malnutrition in HF patients. Tools such as handgrip strength measurements, anthropometry, and bioelectrical impedance analysis can help assess nutritional status and body composition. However, care must be taken to account for fluid retention, which can mask weight loss in HF patients.

Nutritional interventions for malnourished HF patients have shown promise in improving clinical outcomes and survival. The PICNIC and EFFORT trials demonstrated benefits of individualized nutritional support. Specific interventions that have shown potential include:

• High-protein, high-energy oral nutritional supplements

• Beta-hydroxy-beta-methylbutyrate (HMB) supplementation

• Omega-3 polyunsaturated fatty acid supplementation

• Essential amino acid supplementation

• However, the optimal approach to nutritional support in HF patients with malnutrition or cachexia remains unclear due to the limited size and quality of existing studies.

Future Directions and Research Needs

While dietary interventions show promise in HF management, several key areas require further research:

1. Long-term studies: Most existing trials on dietary interventions in HF have been relatively short-term. Longer studies are needed to assess the efficacy and safety of various dietary approaches over extended periods.

2. Larger, well-designed RCTs: Many studies to date have been small or observational. Larger, randomized trials are needed to provide more definitive evidence on the effects of specific dietary patterns and supplements in HF.

3. Personalized approaches: Given the heterogeneity of HF and the prevalence of comorbidities, research is needed to determine whether specific dietary interventions are more suitable for different HF subtypes or patient populations.

Conclusion

Diet and nutrition play important roles in the management of heart failure, offering potential to improve symptoms, quality of life, and clinical outcomes. While sodium restriction remains the primary dietary recommendation in current guidelines, emerging evidence suggests that a broader approach to nutritional management may be beneficial.

Promising areas include the use of ketone-based supplements, coenzyme Q10, and dietary patterns such as the DASH and Mediterranean diets. However, the optimal approach likely varies depending on individual patient factors, including the presence of comorbidities and nutritional status.

Malnutrition and cachexia represent significant challenges in advanced HF, requiring careful assessment and targeted interventional strategies. Nutritional support has shown potential to improve outcomes in malnourished HF patients, but more research is needed to determine the most effective approaches.

Future research should focus on conducting larger, long-term randomized trials to provide more definitive evidence on the efficacy and safety of various dietary interventions in HF. Additionally, efforts to develop personalized nutritional strategies that account for individual patient characteristics and comorbidities may help optimize outcomes.

FAQs

1. What is the role of sodium restriction in heart failure management?

• Sodium restriction is commonly recommended for heart failure patients to help manage fluid retention and blood pressure. However, evidence on its impact is mixed, with guidelines suggesting a limit between 2-3 grams per day.

2. Are there any new supplements that might help with heart failure?

• Emerging supplements such as medium-chain triglycerides (MCT) oil, beta-hydroxybutyrate (BHB) salts, and coenzyme Q10 (CoQ10) show potential benefits for heart failure management. However, further research is needed to confirm their efficacy and safety.

3. How do dietary patterns like the DASH and Mediterranean diets impact heart failure?

• The DASH and Mediterranean diets are associated with improved heart failure outcomes. They help reduce risk factors and hospitalizations through their emphasis on fruits, vegetables, whole grains, and healthy fats.

4. What about ketogenic diets for heart failure patients?

• Ketogenic diets might offer short-term benefits by improving metabolic and hemodynamic parameters. However, their long-term safety and efficacy in heart failure management are not well-established and require more study.

5. How should heart failure patients with comorbidities adjust their diets?

• Patients with comorbidities such as diabetes, obesity, or chronic kidney disease need personalized dietary plans. These plans should address both heart failure and the specific comorbidity to optimize overall health.

6. Why is malnutrition a concern in advanced heart failure?

• Malnutrition and cachexia are common in advanced heart failure and significantly increase mortality risk. Nutritional support can improve clinical outcomes, but managing malnutrition requires careful assessment and targeted interventions.

7. What are the current gaps in research on dietary interventions for heart failure?

• Key research gaps include the need for long-term studies, larger randomized trials, personalized dietary approaches, and standardized methods for evaluating interventions. Understanding interactions with medications and cost-effectiveness are also important areas for future research.

Journal Reference

Liao, L. P., Pant, A., Marschner, S., Talbot, P., & Zaman, S. (2024). A Focus on Heart Failure Management through Diet and Nutrition: A Comprehensive Review. Hearts, 5(3), 293-307. https://doi.org/10.3390/hearts5030022

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