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Recommendations Summary

HF: Energy and Protein Intake (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: Individualize Energy Intake 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 individualize energy intake, meeting total estimated energy needs [resting metabolic rate (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 medical nutrition therapy resulted in maintenance of body weight (one of the goals of medical nutrition therapy for heart failure) along with effective management of comorbid conditions, such as hypertension, disorders of lipid metabolism, diabetes mellitus and obesity.

    Rating: Strong
    Imperative

    HF: Intentional Weight Loss in Obesity and 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) who are also obese, once the patient is considered weight-stable and euvolemic (sodium, fluid and medication adherent), the registered dietitian nutritionist (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 heart failure.

    Rating: Weak
    Conditional

    HF: Individualize Protein Intake 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 individualize protein intake, prescribing at least 1.1g protein per kg actual body weight to prevent catabolism. Research reports that in patients with heart failure who are either normally nourished or malnourished, reported protein intakes ranging from 1.1g to 1.4g per kg actual body weight per day resulted in positive nitrogen balance, while protein intakes ranging from 1.0g to 1.1g per kg actual body weight per day resulted in negative nitrogen balance.

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

      Sibutramine or ephedra weight loss preparations are contraindicated in heart failure. Use of ephedra weight-loss preparations may contribute to the development of heart failure and should be avoided.

      If weight loss is started without evidence of weight stability, the following may occur:

      • Worsening of condition
      • Hypercatabolic state
      • Individualized energy intake may be based on improper weight and therefore underestimate or overestimate needs.

    • Conditions of Application

      The recommendation, HF: Purposeful Weight Loss in Obesity and Heart Failure (NYHA Classes I–IV/AHA Stages B and C) applies only to patients with heart failure (NYHA Classes I–IV/AHA Stages B and C) who are also obese, and once the patient is considered weight-stable and euvolemic (sodium, fluid and medication adherent).

      For weight management in other conditions, the registered dietitian nutritionist (RDN) should coordinate care with an inter-disciplinary health care team, especially for patients with the following conditions:

      • Advanced heart failure patients (NYHA Class IV/AHA Stage D) awaiting transplantation
      • Heart failure patients (NYHA Classes I–IV/AHA Stages B, C and D) who have cardiac cachexia.
      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

      Two studies were included in the evidence analysis supporting the recommendations, both conducted in patients with heart failure (NYHA Classes I–IV/AHA Stages B and C) (Aquilani, Opasich et al, 2003; Aquilani, Opasich et al, 2008). None of the studies were conducted in patients with advanced heart failure (NYHA Class IV/AHA Stage D).

      • One positive-quality randomized controlled trial (Aquilani, Opasich et al, 2008)
      • One positive-quality cross-sectional study (Aquilani, Opasich et al, 2003).
      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), measured resting metabolic rate (RMR) ranged from 22kcal per kg actual body weight in normally nourished patients to 24kcal per kg actual body weight in malnourished patients (Aquilani, Opasich et al, 2003). Research is needed regarding measured resting metabolic rate in patients with heart failure
        (Grade III).
      • In patients with heart failure (NYHA Classes I–IV/AHA Stages B and C) that are either normally nourished or malnourished, reported protein intakes ranging from 1.1g to 1.4g per kg actual body weight per day resulted in positive nitrogen balance (Aquilani, Opasich et al, 2008), while protein intakes ranging from 1.0g to 1.1g per kg actual body weight per day resulted in negative nitrogen balance (Aquilani, Opasich et al, 2003). Research is needed regarding the relationship between protein intake and nitrogen balance in patients with heart failure (Grade II).
      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 their measured resting metabolic rate. (Grade V).
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), there were no studies identified that reported on the relationship between protein intake and nitrogen balance. (Grade V).
      From the Evidence Analysis Regarding Medical Nutrition Therapy in Heart Failure:

      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- to 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- to 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 multi-disciplinary intervention group (who received four individualized educational sessions from a registered dietitian nutritionist, as well as individualized dietary counseling 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 two 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).
      From the 2016 ACCF/AHA Scientific Statement for Contributory Risk and Management of Comorbidities of Hypertension, Obesity, Diabetes Mellitus, Hyperlipidemia, and Metabolic Syndrome in Chronic Heart Failure: 

      Recommendations for the Recognition and Treatment of Obesity in Patients at Risk for or With Established HF

      Stages B and C Heart Failure
      • Purposeful weight loss via healthy dietary intervention or physical activity for the purposes of improving health-related QOL or managing comorbidities such as diabetes mellitus, hypertension, or sleep apnea may be reasonable in obese patients with HF. (Class IIb; Level of Evidence C).
      • Sibutramine or ephedra weight loss preparations are contraindicated in HF. Use of ephedra weight-loss preparations may contribute to the development of HF and should be avoided. (Class III: Harm; Level of Evidence C).

    • Recommendation Strength Rationale

      • Conclusion statements in support of these recommendations were given Grade II, Grade III and Grade V.
      • The 2013 ACCF/AHA Guidelines for the Management of Heart Failure received Levels of Evidence A and C.
      • The 2016 ACCF/AHA Scientific Statement for Contributory Risk and Management of Comorbidities of Hypertension, Obesity, Diabetes Mellitus, Hyperlipidemia, and Metabolic Syndrome in Chronic Heart Failure received Levels of Evidence C.

    • Minority Opinions

      Consensus reached.