Charles P. Vega, MD: Hello and welcome to Critical Issues in Cardiology. My name is Charles Vega, and I am a clinical professor of family medicine at the University of California at Irvine. Today we are going to be talking about heart failure, specifically an important but unfortunately too often ignored concern, and that is nutrition and nutrition supplements for patients with heart failure. To help me with this discussion, I am excited to have Dr Ileana Piña, a professor in the department of medicine, division of cardiology, at the Montefiore Medical Center. Dr Piña is also associate chief for academic affairs there as well. Ileana is a real expert in heart failure, so I am really excited that we could have this conversation. Thank you very much for joining us, Ileana.
Ileana L. Piña, MD, MPH: Thank you for having me.
Dr Vega: I do not have to tell you that the rate of heart failure in the United States is increasing, and it is estimated that by the year 2030, eight million Americans will have heart failure.[1] That is 1 out of every 33 adults. It is certainly something I see in my primary care practice. I know it is a focus of your practice as well. It is a challenge to manage these patients with heart failure. Diagnosis can be challenging, and certainly ongoing management is difficult. We tend to focus on medications—their effectiveness and side effects. But we forget about lifestyle issues. Primary among those is diet and nutrition. I am going to bring up a few issues with you today, Ileana, and want to get your take on them.
What About Sodium?
Dr Vega: First of all, sodium intake. A lot of clinicians recommend 2-3 g of sodium per day for patients.[2] That is about half of what the average US adult consumes on a daily basis. It is a challenge to get patients to adhere to a low sodium diet, but there is also some research showing that a very low sodium diet can produce higher rates of readmission compared with just a low sodium diet.[3] What are you recommending to your patients regarding sodium intake? Secondarily, how do you promote adherence? How do you get patients to stick to that regimen? That is a challenge.
Dr Piña: Those are great questions. I have been doing this for 30 years, and I really have stopped "cantankering" patients about their diet. I try to keep it simple. Patients with heart failure are incredibly challenged. They may have an appointment with me. They may have an appointment with their primary care clinician. Heaven knows how many other clinicians they must see, so they spend their lives with a calendar in front of them trying to figure out where they have to go next and for which clinic. Add to that those with diabetes who may go to a diabetes clinic. It gets pretty complicated. When patients leave the hospital, they leave with 13 drugs, which is ridiculous. No one can take 13 pills a day. By the time they get to us the first time, we can whittle them down to about eight.
There are three basic groups of heart failure meds:
The angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and the angiotensin receptor-neprilysin inhibitor;
Beta blockers and spironolactone; and
Diuretics
The diuretic medications is where I have a little bit of a chance to play with the medications. I say to patients that if they can cut down sodium intake, I may be able to cut down the diuretics. Patients hate their diuretics. That is the one medication they hate.
To keep it simple, I would like patients to be on a 2-g sodium diet. However, there has never been a randomized controlled clinical trial of different levels of sodium in heart failure. Never. But we extrapolated from the hypertension world, where recommendations for low sodium have been present for eons. What I say to patients is that if you cook at home, you can cook with a little bit of salt. No salt shaker at the table. No canned foods. No visits to delis. In the Bronx, where I practice, delis are very popular. Deli foods have tremendous amounts of sodium, even chicken or turkey, which patients think is healthy. It is not. If patients do buy canned vegetables, which by the way are cheaper, I tell them to rinse them to get the sodium off. I have stopped this business of telling folks to look at the sodium content of food and add it up because, if they do, they go crazy.
If I have one bargaining chip with patients, I want to use it to encourage them to take their medications because I do have randomized controlled clinical trials that show that the drugs reduce mortality, reduce morbidity, and can actually make the patients really feel better. Everything else I can work around.
Dr Vega: That is absolutely the same way I approach it. It is really watching prepared foods, fast foods, or any other food that patients themselves are not preparing. That is where a lot of the damage occurs in terms of sodium. That is really what can put patients into the hospital and into crisis.
Dr Piña: There is a way around it for patients who wish to go out to eat. It is very hard to control the sodium in a restaurant. Certainly all of the fast food places have a lot of hidden sodium in the food. If a patient gains 3 lb over a 3-day period, I tell them that they are allowed to take an extra diuretic.
By doing that, I give them back some power and some control over their life simply with a scale. Very simple: 3 lb in 3 days.
Restricting Water Intake: Necessary or Not?
Dr Vega: That is great advice. It is important to think about water intake, too. Again, a common recommendation to patients is a fluid restriction to less than 2 L a day of free liquids. Again, we are not sure how effective that might be. A meta-analysis of randomized trials that examined liberal fluid intake versus a more restricted intake found no difference in terms of mortality or readmission.[4] Is fluid restriction for everyone, or should you reserve it for certain patients? Patients can get very frustrated with fluid restriction.
Dr Piña: I do not restrict fluids at all. If patients follow the reasonable sodium diet you and I have just discussed, the water follows. A lot of the thirst has to do with the disease and the central mechanism of angiotensin II, which causes thirst, and patients think that they need more fluid. If you neurohormonally block that mechanism well, patients will not have that thirst. So I do not restrict fluid at all unless the patient is hyponatremic. That is when you get into trouble, and that is the hardest one to do. Patients who are not neurohormonally blocked, which is usually the reason behind the hyponatremia, are usually undermedicated. Once you medicate them, the thirst gets better. But until then, it is very hard to restrict fluids. These folks will drink from the faucet. They will drink from the bathroom. There is a huge drive to drink that fluid. Those patients need to be handled very carefully.
Dr Vega: Electrolyte management is always a challenge for these patients as well. That is something we need to be working on as a team with primary care, who might be ordering a test and working with nephrology, cardiology, and all of the other important specialists, to be alert. It is important that we are not stepping on each other in dietary or medication management.
What About Supplements?
Dr Vega: The last question I had is a grab bag kind of question. Currently, there are no recommendations from the American College of Cardiology or the Heart Failure Society of America regarding use of supplements in patients with heart failure. Small studies have shown that intake of protein or vitamin D or fish oil may be beneficial. Are you hanging your hat on any of these small studies and actually recommending these products to patients? Is there anything else that you are currently recommending that we did not cover today?
Dr Piña: What I recommend is a healthy diet. I recommend absolutely none of the above. They are more expensive than a 2-week dose of enalapril 10 mg twice a day. My patients in the Bronx do not have the money to do that. What I want my patients to eat is a balanced diet with enough fruits and vegetables. I do want patients to have protein because, at least in my neck of the woods, patients are very overweight. A higher protein intake combined with a lower carbohydrate intake will cause weight loss and may better control diabetes. A good, healthy, balanced diet; eating frequent meals; and not skipping meals is good advice to give any of your patients. People think that when they skip a meal, they are going to lose weight. On the contrary, skipping meals may actually make you gain weight. Small meals, frequently given, are really the best option. Eat healthy. Avoid saturated fats. Avoid sugars. I give very simple instructions that are not very complicated. For patients with alcoholic cardiomyopathy, I want to make sure that they take folate, B vitamins, and a multivitamin may be reasonable. If the patient is cachectic, not eating, and losing weight, a general multivitamin may be fine. The other issue is iron. A lot of my patients in the Bronx are anemic. They may be taking an iron supplement but not absorbing it. We are now studying the effects of intravenous iron. A lot of these anemias that are often overlooked and presumed to be anemia of chronic disease may not be anemia of chronic disease.
Dr Vega: I love this approach. It is holistic and very patient-centered. Both patients that are high functioning as well as those with very low health literacy, whatever resources they have, can follow these kinds of instructions and directions. You are really empowering them to take on their own care. You described a great framework for developing a partnership that really puts the patient in charge and therefore puts her or him on the best path to success.
Dr Piña: You have to engage the patient. If you do not engage the patient, you lost the battle.
Dr Vega: Yes. Let's go out now and win some battles. Hopefully, this information helps everyone to provide patient-centered care. Ileana, thanks for the great insights. I look forward to seeing you again soon.
Medscape Family Medicine © 2018 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Heart Failure: Are Sodium and Fluid Restriction Necessary? - Medscape - Jan 16, 2018.
Comments