Quick Links

  • Increase Font Size
  • Decrease Font Size
  • View as PDF

Recommendations Summary

HF: Medical Nutrition Therapy (2017)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    HF: Medical Nutrition Therapy in Heart Failure (NYHA Classes I-IV/AHA Stages B, C and D)

    For adults with heart failure (NYHA Classes I - IV/AHA Stages B, C and D), the registered dietitian nutritionist (RDN) should provide medical nutrition therapy (MNT) to treat heart failure and contributing comorbidities, such as hypertension, disorders of lipid metabolism, diabetes mellitus and obesity. Every patient with heart failure 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 medical nutrition therapy resulted in a significant decrease in sodium intake and maintenance of body weight.

    Rating: Strong
    Imperative

    HF: Frequency and Duration of Medical Nutrition Therapy in Heart Failure (NYHA Classes I-IV/AHA Stages B and C)

    For adults with heart failure (NYHA Classes I - IV/AHA Stages B and C), the registered dietitian nutritionist (RDN) should provide an initial medical nutrition therapy (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 medical nutrition therapy resulted in a significant decrease in sodium intake, as well as maintenance of serum sodium levels and body weight.

    Rating: Fair
    Conditional

    HF: Frequency and Duration of Medical Nutrition Therapy in Advanced Heart Failure (NYHA Class IV/AHA Stage D)

    For adults with advanced heart failure (NYHA Class IV/AHA Stage D), the registered dietitian nutritionist (RDN) should provide an initial medical nutrition therapy (MNT) encounter and additional follow-up encounters as often as every two weeks. Research reports that this frequency and duration of medical nutrition therapy resulted in increased exercise tolerance, higher physical component scores on quality of life measures and decreased anxiety, as well as maintenance of body weight.

    Rating: Fair
    Conditional

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      The recommendation HF: Frequency and Duration of Medical Nutrition Therapy in Heart Failure (NYHA Classes I-IV/AHA Stages B and C) applies to patients with heart failure classified as NYHA Classes I-IV/AHA Stages B and C.

      The recommendation HF: Frequency and Duration of Medical Nutrition Therapy in Advanced Heart Failure (NYHA Class IV/AHA Stage D) applies to patients with advanced heart failure classified as NYHA Class IV/AHA Stage D.

      Regarding nutrition practice guidelines for hypertension, the registered dietitian nutritionist (RDN) should refer to the Academy of Nutrition and Dietetics Hypertension Systematic Review and Guideline. 

      Regarding nutrition practice guidelines for disorders of lipid metabolism, the registered dietitian nutritionist (RDN) should refer to the Academy of Nutrition and Dietetics Disorders of Lipid Metabolism Evidence-based Nutrition Practice Guidelines.

      Regarding nutrition practice guidelines for diabetes, the registered dietitian nutritionist should refer to the Academy of Nutrition and Dietetics Diabetes Mellitus Types 1 and 2 Systematic Review and Guideline.

      Regarding nutrition practice guidelines for adult weight management, the registered dietitian nutritionist should refer to the Academy of Nutrition and Dietetics Adult Weight Management Evidence-Based Nutrition Practice Guidelines.

      Regarding nutrition practice guidelines for chronic kidney disease, the registered dietitian nutritionist should refer to the Academy of Nutrition and Dietetics Chronic Kidney Disease Systematic Review and Guideline.

    • Potential Costs Associated with Application

      Costs of medical nutrition therapy (MNT) sessions and reimbursement vary; however, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      A total of three studies were included in the evidence analysis supporting the recommendations. Two studies were conducted in patients with heart failure (NYHA Classes I - IV/AHA Stages B and C) (Arcand et al, 2005; Donner Alves et al, 2012) and one study in patients with advanced heart failure (NYHA Class IV/AHA Stage D) (Kugler et al, 2012):

      • Two neutral-quality randomized clinical trials (Arcand et al, 2005; Donner Alves et al, 2012)
      • One positive-quality non-randomized controlled trial (Kugler et al, 2012)
      Heart Failure (NYHA Classes I - IV/AHA Stages B and C):
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), research reported that despite a significant decrease in sodium intake in the dietitian education group (who received two 30-45 minute individualized nutrition-counseling appointments with a registered dietitian, four to six weeks apart) compared to usual care (who received only a self-help educational package),  serum sodium levels were maintained within normal range before and after the trial in both groups (Arcand et al, 2005). Research is needed regarding the effect of medical nutrition therapy on renal function labs and clinical labs in patients with heart failure. Grade III
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), there were no studies identified that reported on the effect of medical nutrition therapy by a registered dietitian nutritionist on quality measures. Grade V
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), research reported that despite the intensive intervention provided in the dietitian education groups (who received two 30-60 minute individualized nutrition-counseling appointments with a registered dietitian, four to six weeks apart) compared to usual care (who received only a self-help educational package or an initial meeting with the nutritionist to undergo anthropometric evaluation, quality of life and nutritional knowledge questionnaires, and 24-hour dietary recall), there were no significant differences in quality of life or body weight (Arcand et al, 2005; Donner et al, 2012). Research is needed regarding the effect of medical nutrition therapy on quality of life, signs and symptoms. Grade III
      Advanced Heart Failure (NYHA Class IV/AHA Stage D):
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of medical nutrition therapy by a registered dietitian nutritionist on renal function labs and clinical labs. Grade V
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the effect of medical nutrition therapy by a registered dietitian nutritionist on quality measures. Grade V
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), research reported that subjects in the multidisciplinary intervention group (who received four individualized educational sessions from a registered dietitian nutritionist, as well as individualized dietary counselling interventions depending on the patient's body mass index and family's lifestyle and nutrition, and additional follow-up visits via telephone as often as every 2 weeks) had increased exercise tolerance, higher physical component scores on quality of life measures, and decreased anxiety compared to control subjects, who only received standardized recommendations (to stay on a healthy diet, to target the normal BMI ranges, to improve physical fitness by exercising on a routine basis and to seek psychosocial support if needed). In addition, while intervention subjects maintained their weight, control subjects gained significantly more weight after 18 months (Kugler et al, 2012). Grade III
      From the 2013 ACCF/AHA Guideline for the Management of Heart Failure (HF):

      7.1. Stage A: Recommendations

      Class I
      • Hypertension and lipid disorders should be controlled in accordance with contemporary guidelines to lower the risk of HF. (Level of Evidence: A)
      • Other conditions that may lead to or contribute to HF, such as obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents, should be controlled or avoided. (Level of Evidence: C)
      11.1. Coordinating Care for Patients With Chronic HF: Recommendations

      Class I
      • Effective systems of care coordination with special attention to care transitions should be deployed for every patient with chronic HF that facilitate and ensure effective care that is designed to achieve GDMT and prevent hospitalization. (Level of Evidence: B)
      • 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. (Level of Evidence: C)
      • Palliative and supportive care is effective for patients with symptomatic advanced HF to improve quality of life. (Level of Evidence: B)

    • Recommendation Strength Rationale

      • Conclusion Statements in support of these recommendations were given Grades III and V
      • The 2013 ACCF/AHA Guidelines for the Management of Heart Failure received Levels of Evidence A, B and C

    • Minority Opinions

      Consensus reached.