Clinical Nutrition Topic of the Day: Congestive Heart Failure

Throughout the past 5 weeks of rotating through the acute, in-patient setting, I have been exposed to the dietary implications of a very common disease state: Congestive Heart Failure or CHF (not to be confused with the abbreviation, CF, or Cystic Fibrosis in my previous post).

The general definition of CHF is when the heart is unable to deliver oxygen-rich blood to the rest of the body. This can be due to:

  1. A weakened heart muscle
  2. Stiffening of the heart muscle
  3. Diseases that increase the body’s oxygen requirements that are beyond the capacity of the heart

Signs & Symptoms

  • Fatigue and reduced activity
  • Fluid overload
  • Edema of the legs and/or lungs – This is caused by inadequate blood flow to the kidneys, resulting in aldosterone and antidiuretic hormone secretion…which both act to conserve fluid.  Aldosterone acts by increasing sodium resorption and antidiuretic hormone acts by conserving fluid in the distal tubules of the nephron.
  • Shortness of breath – Due to fluid overload of the lungs. Shortness of breath usually worsens at night or at rest.
  • Increased urination
  • Mental confusion, memory loss, anxiety, insomnia – Due to decreased blood supply to the brain.
  • Malnutrition, anorexia, decreased appetite, feeling of fullness, nausea, constipation, abdominal pain – Due to fluid overload of the liver. These are some of the most pertinent symptoms to a clinical dietitian because it leads to many nutritional complications and dietary changes.

Risk Factors

  • Gender – During middle age, men are at a higher risk for CHF than women.  However, elderly women are at a higher risk than elderly men.
  • Race – The highest incidence of CHF is as follows: black women > black men > Mexican-American men > white men > white women > Mexican-American women
  • Hypertension
  • Diabetes
  • Coronary Heart Disease
  • Atherosclerosis
  • Obesity
  • Left ventricular hypertrophy (enlargement of the left ventricle of the heart)
  • Myocardial Infarction (a heart attack)
  • Excessive dietary sodium
  • Medication noncompliance
  • Arrhythmias
  • Pulmonary embolism

Nutritional Implications of CHF

Because many CHF patients are malnourished, edema can falsely cause their body weights to appear normal or higher than their true weight. Thus, the dietitian should first determine the dry weight of a CHF patient. Thus, the dietitian should determine a patients weight before eating and before urination at the same time each day.  Other determinants of malnutrition, such as serum prealbumin, albumin, and transferrin may appear low due to dilution of extracellular fluid.

As an overall goal, CHF patients should follow a “heart-healthy diet”. This can either be the DASH diet or a diet that is low in saturated fats, trans fats, and cholesterol, and high in fiber.

Nutrition Prescription:

  • Weigh a patient with CHF regularly – This is to monitor anorexia, weight loss, and excess fluid retention.
  • <2 g or 2000 mg of sodium per day – Sodium is restricted because excess sodium only leads to more fluid retention.
  • Fluid restriction – This is usually determined by the physician, but fluid intake is typically restricted to <2 L/day, <1500 mL/day, or <1 L/day depending on the severity of the disease.
  • Adequate energy intake – One of the common complications of CHF is for patients to lose their appetite quickly or become short of breath, leading to decreased energy intake.  The recommendation is to use 31-35 kcal/kg of body weight to determine energy requirements (CHF patients have higher caloric and protein needs due to increases in energy expenditure typical of the body being in a catabolic state). Thus, dietitians need to encourage the importance of consuming adequate calories to prevent cachexia and weight loss.
  • Potassium, Magnesium, Calcium ,and Vitamin D – CHF puts individual at a higher risk for lower levels of these vitamins and minerals due to low activity levels, impaired kidney functioning, and prescription drugs that alter their metabolism.
  • Limit or avoid alcohol – Not only will alcohol add more fluid to the diet, but it also raises blood pressure. If alcohol cannot be avoided, limit intake to <2 drinks/day for men and <1 drink/day for women.
  • Limit or avoid caffeine

Source: AND Nutrition Care Manual

Beverages may be included with meals unless satiety is a problem. Pudding and milk would count toward the fluid intake. If your doctor has limited your fluid intake, the total fluids you drink must be within the amount allowed for the day.

Approximate Nutrient Analysis

Calories: 1,832
Protein: 93g (19% of Calories)
Carbohydrate: 293g (61% of calories)
Fat: 40g (19% of calories), Saturated Fat: 10g
Sodium: 1,525mg
Potassium: 3,750mg
Cholesterol: 80mg

Recommended foods for CHF patients.
Source: AND Nutrition Care Manual

Foods not recommended for CHF patients.
Source: AND Nutrition Care Manual


L. Kathleen Mahan & Sylvia Escott-Stump. Krause’s Food & Nutrition Therapy, 12th Edition

Academy of Nutrition and Dietetics. Nutrition Care Manual.


Low-Sodium Diet In-Service

This week during my patient services rotation at Mon General Hospital, one of my assignments was to create an in-service presentation for the food service employees.  In-Services are a form of continuing professional education provided by the hospital or employer during working hours in order to improve worker knowledge, education, and attitudes.  Typical in-services are in a sit-down, classroom setting and last anywhere from 15-30 minutes.  Employees are educated on a variety of topics relating to their respective field and are given a quiz at the end to assess what they have learned.

For my in-service presentation, I chose to do low-sodium diets. Low-sodium diets are ordered for patients who have heart failure, cardiovascular disease, heart surgery, high blood pressure, and kidney failure.

What do you think of my Low-Sodium handout??