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Dietary recommendations can be confusing. Having a heart condition can make it even more challenging. Dr. Amanda Vest, Section Head of Heart Failure and Transplantation Cardiology, has a special interest in making diet and nutrition choices easier for patients with heart failure. She talks about recommended dietary patterns and considerations for weight management.

Interested in working with a Registered Dietician Nutritionist? Find one that specializes in heart health.

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How Should You be Eating if You Have Heart Failure?

Podcast Transcript


Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular, and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic, and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy!

Amanda Vest, MBBS:

Hello, Amanda Vest here, and I'd like to talk with you today about nutrition advice specifically for patients with heart failure and their caregivers. We do want to encourage this whole food approach of thinking about all the nutrients that your overall diet can provide rather than focusing on a single supplement or pill to add to your diet. What we do want to help you to achieve is a dietary pattern where you are able to enjoy your foods and eat very healthful foods that fuel your body and promote your overall cardiovascular health. We endorse dietary patterns such as the Mediterranean, DASH or plant-based patterns and calorie-restricted versions can be appropriate for people who've been recommended to lose weight.

Here are some of the dietary patterns that are considered to be very good for patients with a heart condition. The Mediterranean diet is light on dairy, meats, and sweets but encourages fish, especially those fatty fishes with good heart, healthy oils, olive oils, and maybe some wine in moderation, but speak to your clinicians about this.

Vegetarian diets obviously cut out the meat and focus a lot more on vegetable proteins such as soy products and legumes, and it is important if one is following a vegetarian diet, or even more so a stricter vegan diet, to ensure that you're taking enough protein and/or the micronutrients that your body needs. So do speak to a dietitian on this if you're uncertain.

The DASH diet stands for Dietary Approaches to Stop Hypertension, and it is low in sodium, less than 1,500 milligrams a day. It encourages lean meats, poultries, fish and is very rich in those fruits and vegetables, especially ones that are high in potassium.

Meanwhile, it's always recommended that you think about cutting back on processed meats and saturated fats. That's animal fats in particular. Please do avoid trans fats. They come in fast foods. And be sure to drink water, ideally instead of juice or other sugary beverages. Trying to keep your beverages all to zero calories is a really important piece if you're trying to lose some weight.

Here's a little bit more information about the DASH diet. The plate is rich in fresh fruits and vegetables, with six to eight servings of grains per day, preferably whole grains, that's brown rice and so forth. There are lean proteins, nuts, seeds, and a little bit of low-fat dairy. And the good news is that this DASH diet very much aligns with the recommended heart healthy diet from the American Heart Association shown on the right.

So the ideal dietary pattern for a patient with heart failure is one that promotes heart health with grains, vegetables, and healthy fats. It should be low in sugar, sodium, and the unhealthy animal fats. It prioritizes freshly prepared foods over the highly processed foods and needs to fit into your lifestyle and culture, and importantly, be sustainable for the long term. Now, if finances are a limitation for you being able to eat in a heart healthy way, please do speak to your care providers or social worker about that because there may be ways that they can help.

Now we'll move on to the topic of a weight that is either above or below goal specifically for patients with heart failure. So you may have been told that your weight is currently too high, and specifically for patients with heart failure, we would consider this to be the case if the body mass index is above 35. You can calculate your body mass index online if you're not sure. We set this threshold a little bit higher for our patients with heart failure because it is important to maintain enough weight to have strength and do well physically, and in fact, it's more concerning when patients are losing weight and becoming underweight. The BMI below 20, or an unintentional weight loss of more than 5% of body weight, is actually a very concerning situation for our patients with heart failure. So you should be on the lookout for that as well.

There are many reasons why your clinicians may recommend that you consider losing weight if you are developing obesity. Treating obesity can help your symptom management and potentially reduce heart failure hospitalizations, leads to improvements in the myocardium structure and function. That means the thickness of the heart and its ability to relax between heartbeats. Weight loss can be helpful in managing other related conditions, such as atrial fibrillation and sleep apnea. And importantly, for patients who are in a direction of needing a heart transplantation, many centers have a body mass index threshold for eligibility for heart transplant. So that can be an important reason to lose weight for future health.

Also, very notably, we have several studies that recently alert us to the fact that patients who receive a bariatric surgery to help with weight loss actually do better in terms of survival and hospitalizations than those with a high weight who do not receive a bariatric surgery. So for people with very elevated weights, it may be important to talk to your doctor about how you can best manage that condition. There are three categories of obesity management that may be an option for you. Dietary and physical activity interventions are the cornerstone of any obesity management plan. Increasingly, we may use medications to help support weight loss. Not all of them are appropriate for people with a heart condition, but some may be. And then bariatric surgery is an option for people with a severely elevated body mass index, and we do have some literature published on each of these areas that are specific to patients with heart failure. Although, admittedly, we do not have as many studies as we need to guide our recommendations for patients in this situation.

Now it's become clear that the idea of “calories in, calories out” is not an adequate way to really think about weight loss. So this means that if you're having a hard time losing weight despite trying to limit your calories, that that is not your fault and not a big surprise because there are many other features that affect whether your body holds onto or burns off energy. Some of these are listed on the right-hand side here, but there's clearly a very complicated metabolic pathway or set of pathways that govern weight management in our bodies. And so it may be necessary to move beyond just calorie restriction to some of these other metabolic treatments if you're having a difficult time meeting your weight goals.

So when we're talking to patients about dietary interventions for weight loss, we recommend that you aim for three balanced meals a day, increase fiber because that helps you feel full up and increase protein intake. There should be protein with all meals and snacks because that also increases a sense of fullness and helps to maintain that important muscle mass in the arms and legs even while you're losing weight. Also, as mentioned, it's particularly important to remove sugar-sweetened beverages from your daily diet. So every teaspoon of sugar is equivalent to four grams of sugar. Take a look at any beverages you're drinking to see how many grams of sugar are in there, and try really hard to replace it with a zero-calorie alternate.

In general, patients do the best in their weight loss journey when supported by a registered dietitian nutritionist within a weight management program, and usually it'll be recommended that about one to two pounds of weight loss per week is an acceptable and healthy pace to achieve.

Now, you may have heard things about certain metabolic diets that can, in some situations, help with weight loss. These include things like the low-carbohydrate or ketogenic diet, paleo or whole-food diets, or time-restricted eating. There's much information about these dietary patterns out there on the internet, for example. But please do speak to your clinicians if you're considering pursuing one of these dietary approaches. Some can be useful for kick-starting your weight-loss journey. For example, some patients do well with a low-carbohydrate diet for the first several weeks of their weight loss program, but this should only be pursued if it is agreed by your cardiology clinicians that this is healthy for you, and you may need some extra monitoring of your blood sugar if you have diabetes and of your electrolytes like sodium and potassium if you're using one of these metabolic diets.

We can also harness metabolism to aid with weight loss in other ways, including the sleeve gastrectomy or Roux-en-Y gastric bypass surgeries. Now, these are only considered for patients who have severe obesity and who have tried other methods of lifestyle and medication interventions to lose weight without success. But do speak to your clinicians about bariatric surgery if you have a body mass index, especially above 40, because this may be an option for you that could help both your heart health and even your long-term survival. Increasingly, some newer medications which are injectable, called semaglutide and liraglutide, are used for weight loss. These are FDA-approved indications for these medications, although you may also be aware that these meds are prescribed for type two diabetes as well. For patients with significant obesity who are having a hard time losing weight, these medications may be an option for you. So again, speak to your clinicians if you think that you may qualify for a medication such as semaglutide or liraglutide to help you lose weight.

Now, on the other end of the spectrum, we have to be very careful about malnutrition and unintentional weight loss, which are also quite problematic for patients' wellbeing and survival in the setting of a heart failure syndrome. What we do know from this recent study is that giving good nutrition supplementation and this nutrition support, particularly included extra protein, can help patients survive better. This is actually a study of patients admitted to the hospital who have heart failure, and the researchers found that those who receive nutrition support actually did better in terms of 30-day survival compared to those who just ate the hospital food. So very important to keep up your nutrition intake and work with your dietitian or clinicians about this, especially at times when you're feeling unwell.

 There are a couple of conditions that we describe amongst patients with heart failure that both relate to unintentional weight and muscle loss. So cardiac cachexia is this complex wasting syndrome. It's characterized by unintentional, edema-free weight loss. That means weight loss that isn't just diuresis of fluid, and there are different thresholds that are used. Some people would say 5% or 7.5% of weight loss over the past six to 12 months. It's accompanied by inflammation in the body and some abnormalities of blood tests. Sarcopenia is a related condition.

We all lose some muscle mass and strength as we age, but amongst patients with heart failure, we can see this muscle mass occurring faster and sooner than would be normal in healthy aging. We can measure muscle mass using tools such as a DEXA scan. Images from a participant in one of my research studies, and this individual is being scanned around the time of implantation of a left ventricular assist device that's a surgical heart pump to help their heart pumping function. They have repeated scans at three and six months, and what we learned from this is that actually it is possible to achieve recovery of skeletal muscle mass over that first six months after a left ventricular assist device is implanted. And this was a very important observation, we think, because we were previously uncertain as to whether the muscle wasting seen in chronic conditions like heart failure is irreversible or reversible, and we found that indeed it is reversible when the heart failure syndrome is taken care of. And so this is leading us on to explore other ways in which we can stimulate muscle regain in patients who aren't eligible for or appropriate for left ventricular assist devices. So stay tuned on this area of research.

Now, if you're interested in the topic of nutrition in the setting of heart failure, please do speak to a registered dietitian nutritionist if you have access to one or your cardiology doctors and nurses. I would also be delighted if you would further explore our website and feel free to reach out to me with any questions or comments about your journey in maintaining healthy nutrition in the setting of a heart failure condition. Thank you, and bye for now.


Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts, or listen at clevelandclinic.org/loveyourheartpodcast.

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