Screening and Referral
- The registered dietitian nutritionist (RDN) plays an integral role in the interdisciplinary healthcare team by designing the optimal nutrition prescription that complements drug therapy, physical activity, and behavioral therapy.
- Based on the client’s treatment plan and comorbid conditions, other nutrition practice guidelines may be needed in order to provide optimal treatment.
HF: Medical Nutrition Therapy (MNT)
- For adults with heart failure (HF) (NYHA Classes I–IV/AHA Stages B, C and D), the RDN should provide MNT to treat HF and contributing comorbidities, such as hypertension, disorders of lipid metabolism, diabetes mellitus and obesity. Every patient with HF should have a clear, detailed, and evidence-based plan of care that ensures the achievement of guideline determined medical therapy (GDMT) goals, effective management of comorbid conditions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. Research reports that MNT resulted in a significant decrease in sodium intake and maintenance of body weight. (Strong, Imperative)
HF: Frequency and Duration of MNT
- For adults with HF (NYHA Classes I–IV/AHA Stages B and C), the RDN should provide an initial MNT encounter lasting 30–60 minutes, with a follow-up encounter four to six weeks later, and determine if and when additional MNT encounters are needed. Research reports that this frequency and duration of MNT resulted in a significant decrease in sodium intake, as well as maintenance of serum sodium levels and body weight. (Fair, Conditional)
HF: Frequency and Duration of MNT in Advanced HF
- For adults with advanced HF (NYHA Class IV/AHA Stage D), the RDN should provide an initial MNT encounter and additional follow-up encounters as often as every two weeks. Research reports that this frequency and duration of MNT resulted in increased exercise tolerance, higher physical component scores on quality of life measures and decreased anxiety, as well as maintenance of body weight. (Fair, Conditional)
Nutrition Assessment
HF: Nutrition Assessment
- The RDN should assess the following (Table 1) in adults with HF (NYHA Classes I–IV/AHA Stages B, C and D), to formulate the nutrition care plan:
Table 1. Nutrition Assessment and Monitoring and Evaluation
New York Heart Association (NYHA) functional classification, which describes the severity of symptoms and exercise intolerance as follows: |
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Biochemical data, medical tests and medication usage: |
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Nutrition-focused physical findings: |
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Client history: |
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Food and nutrition-related history: |
Every patient with HF should have a clear, detailed, and evidence-based plan of care that ensures the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. (Strong, Imperative) |
HF: Measure Resting Metabolic Rate (RMR) in Adults
- If indirect calorimetry is available, the RDN should use a measured RMR, which is then multiplied by a physical activity factor to estimate total energy needs in adults with HF (NYHA Classes I–IV/AHA Stages B, C and D). Measurement of RMR using indirect calorimetry is more accurate than estimating RMR using predictive equations. (Consensus, Conditional)
HF: Estimate RMR in Adults
- If indirect calorimetry is not available, the RDN should use 22 kcal per kg
actual body weight (for normally nourished patients) to 24 kcal per kg actual body weight (for malnourished patients) to estimate RMR, which is then multiplied by a physical activity factor to estimate total energy needs in adults with HF (NYHA Classes I–IV/AHA Stages B and C). In these patients, measured RMR ranged from 22 kcal per kg actual body weight in normally nourished patients to 24 kcal per kg actual body weight in malnourished patients. (Fair, Conditional)
HF: Estimate RMR in Adults with Advanced HF
- If indirect calorimetry is not available, the RDN should use 18 kcal per kg actual body weight to estimate RMR, which is then multiplied by a physical activity factor to estimate total energy needs in adults with advanced HF (NYHA Class IV/AHA Stage D). In these patients, the average measured RMR using indirect calorimetry was 1,610 kcal per day (17.69 kcal per kg actual body weight). (Consensus, Conditional)
HF: Estimate Total Energy Needs Using RMR and Activity Factors in Adults
- The RDN should multiply the RMR (RMR, measured or estimated) by one of the following physical activity factors to estimate total energy needs in adults with HF (NYHA Classes I–IV/AHA Stages B, C and D):
- Sedentary: ≤1.0 – <1.4
- Low active: ≥1.4 – <1.6
- Active: ≥1.6 – <1.9
- Very active: ≥1.9 – <2.5
The Dietary Reference Intakes (DRI) Physical Activity Levels (PAL) represent the ratio of total energy expenditure to basal energy expenditure and are defined as sedentary, low active, active or very active. (Consensus, Imperative)
Nutrition Intervention
HF: Individualize Energy Intake
- For adults with HF (NYHA Classes I–IV/AHA Stages B, C and D), the RDN should individualize energy intake, meeting total estimated energy needs (RMR, measured or estimated), which is then multiplied by a physical activity factor] for weight maintenance, the prevention of further weight gain or loss, and the prevention of catabolism. Research reports that MNT resulted in maintenance of body weight (one of the goals of MNT for HF along with effective management of comorbid conditions, such as hypertension, disorders of lipid metabolism, diabetes mellitus and obesity. (Strong, Imperative)
HF: Intentional Weight Loss in Obesity and HF
- For adults with HF (NYHA Classes I–IV/AHA Stages B and C) who are also obese, once the patient is considered weight-stable and euvolemic (sodium, fluid and medication adherent), the RDN may or may not consider intentional weight loss. Purposeful weight loss via healthy dietary intervention or physical activity for improving health-related quality of life or managing comorbidities such as diabetes mellitus, hypertension or sleep apnea may be reasonable in obese patients with HF. (Weak, Conditional)
HF: Individualize Protein Intake
- For adults with HF (NYHA Classes I–IV/AHA Stages B, C and D), the RDN should individualize protein intake, prescribing at least 1.1 g protein per kg actual body weight to prevent catabolism. Research reports that in patients with HF who are either normally nourished or malnourished, reported protein intakes ranging from 1.1–1.4 g per kg actual body weight per day resulted in positive nitrogen balance, while protein intakes ranging from 1.0–1.1 g per kg actual body weight per day resulted in negative nitrogen balance. (Fair, Imperative)
HF: Individualize Sodium and Fluid Intake
- For adults with HF (NYHA Classes I–IV/AHA Stages B, C and D), the RDN should individualize sodium and fluid intake, within the ranges of 2000–3000 mg sodium per day and 1–2 L fluid per day. Research reports that a sodium intake of 2000–3000 mg per day and fluid intake of 1–2 L
per day resulted in improvements in quality measures (readmissions rate, length of stay and mortality rate), renal function and clinical laboratory measures (blood urea nitrogen, creatinine, BNP and serum sodium), symptom burden (shortness of breath, difficulty breathing when lying flat, swelling of legs or ankles, lack of energy, and lack of appetite) and body weight. (Fair, Imperative)
HF: Encourage Individualized Physical Activity Plan for Adults
- Unless medically contraindicated, the RDN should encourage an individualized physical activity plan for adults with HF (NYHA Classes I–IV/AHA Stages B, C and D). Regular physical activity is recommended as safe and effective for patients with HF who are able to participate to improve functional status and cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, health-related quality of life and mortality. (Strong, Conditional)
HF: Educate on Self-Care for Adults
- For adults with HF (NYHA Classes I–IV/AHA Stages B, C and D), the RDN should educate on self-care, on topics such as, but not limited to:
- Appropriate eating plan based on stage and class of HF, as well as other comorbidities
- Energy and protein intake
- Sodium and fluid intake
- Physical activity
- Self-monitoring of weight and symptoms
Adults with HF should receive specific education to facilitate HF self-care. (Fair, Imperative)
HF: Coordination of Care for Adults
- For adults with HF (NYHA Classes I–IV/AHA Stages B, C and D), the RDN should implement MNT for HF and coordinate care as part of an interdisciplinary health care team. Every patient with HF should have a clear, detailed, and evidence-based plan of care that ensures the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. This plan of care should be updated regularly and made readily available to all members of each patient’s healthcare team. (Fair, Imperative)
HF: Consult with Interdisciplinary Health Care Team Regarding Vitamin, Mineral and Herbal Supplementation
- For adults with HF (NYHA Classes I–IV/AHA Stages B, C and D), the RDN should consult with others on the interdisciplinary health care team regarding vitamin, mineral and herbal supplementation. Due to the many interactions between various supplements and common medications, it is unclear whether certain supplements, such as omega-3 fatty acids, coenzyme Q10, vitamin D, iron and thiamin, are appropriate for patients with HF. (Weak, Imperative)
