Nutritional status and adequacy of energy and nutrient intakes among heart failure patients

Abstracts

SUMMARY: Increased knowledge about nutritional status and energy and nutrient intakes is required to improve the treatment of patients with heart failure (HF). OBJECTIVES: To verify the nutritional status and evaluate the adequacy of energy, macronutrient and micronutrient intakes in patients with HF in outpatient clinical settings. METHODS: We collected anthropometric and habitual dietary intake data of 125 patients (72% men, 52.1 ± 9.8 years, BMI 26.9 ± 4.4 kg/m2). Anthropometric variables were compared between genders, and the adequacy of energy and nutrient intakes was analyzed according to current recommendations. RESULTS: Muscle depletion or risk of depletion was present in 38.4% of patients (association with male gender, p <0.0001). In 69.6% of cases the mean energy intake was lower than the one required (p <0.0001). Among the micronutrients evaluated in this study, there was an important prevalence of inadequacy in magnesium, zinc, iron and thiamine intakes, and most patients had calcium and potassium intakes below the adequate levels, and sodium intake above the adequate levels. CONCLUSIONS: Outpatients with HF showed muscle depletion, and inadequate energy and nutrient intakes. There was no significant association between habitual dietary energy intake and nutritional status. Multidisciplinary care should be encouraged to better assess the general condition of these patients.

Heart failure; nutritional status; energy intake; nutrients; adequacy

FUNDAMENTO: Maior conhecimento sobre o estado nutricional e a ingestão de energia e nutrientes é necessário para auxiliar no tratamento de pacientes com insuficiência cardíaca (IC). OBJETIVO: Verificar o estado nutricional e analisar a adequação da ingestão de energia, macro e micronutrientes de pacientes com IC em atendimento ambulatorial. MÉTODOS: Foram coletados dados antropométricos e de ingestão alimentar habitual de 125 pacientes (72% homens, 52,1±9,8 anos, IMC 26,9±4,4 kg/m²). As variáveis antropométricas foram comparadas entre os sexos, e analisou-se a adequação da ingestão de energia e nutrientes perante as recomendações. RESULTADOS: Depleção ou risco de depleção das reservas musculares estava presente em 38,4% dos pacientes (associação com sexo masculino; p < 0,0001). Em 69,6% dos casos, a ingestão média de energia foi menor que as necessidades energéticas (p < 0,0001). Entre os micronutrientes analisados, magnésio, zinco, ferro e tiamina apresentaram prevalências de inadequação importantes, e a maioria dos pacientes teve consumo de cálcio e potássio abaixo da ingestão adequada e consumo de sódio acima. CONCLUSÃO: Pacientes ambulatoriais com IC apresentam depleção de reservas musculares, com ingestão inadequada de energia e diversos nutrientes. Não se observou associação significante entre quantidade de energia proveniente da dieta habitual e o estado nutricional. O acompanhamento multiprofissional deve ser estimulado para avaliar melhor o estado geral desses pacientes.

Insuficiência cardíaca; estado nutricional; ingestão energética; nutrientes; adequação

FUNDAMENTO: Para ayudar en el tratamiento de pacientes con insuficiencia cardiaca (IC) es necesario un mayor conocimiento sobre el estado nutricional y la ingesta de energía y nutrientes. OBJETIVO: Verificar el estado nutricional y analizar la adecuación de la ingesta de energía, macro y micronutrientes de pacientes con IC en atención ambulatoria. MÉTODOS: Se recolectaron datos antropométricos y de la ingesta alimentaria habitual de 125 pacientes (72% hombres, 52,1±9,8 años, IMC 26,9±4,4 kg/m²). Se compararon las variables antropométricas de ambos sexos y se analizó la adecuación de la ingesta de energía y nutrientes frente a las recomendaciones. RESULTADOS: En el 38,4% de los pacientes (asociación con sexo masculino; p < 0,0001) se presentó depleción o riesgo de depleción de las reservas musculares. En el 69,6% de los casos, la ingesta promedio de energía fue menor que las necesidades energéticas (p < 0,0001). Entre los micronutrientes analizados, magnesio, zinc, hierro y tiamina tuvieron una importante prevalencia de ingesta inadecuada, y la mayoría de los pacientes tuvo ingesta de calcio y potasio por debajo y de sodio por encima de la adecuada. CONCLUSIÓN: Pacientes ambulatorios con IC presentan depleción de las reservas musculares, con ingesta inadecuada de energía y diversos nutrientes. No se observó asociación significativa entre cantidad de energía proveniente de la dieta habitual y el estado nutricional. Para evaluar mejor el estado general de esos pacientes debe estimularse su acompañamiento multidisciplinario.

Insuficiencia cardiaca; estado nutricional; ingesta energética; nutrientes; adecuación

ORIGINAL ARTICLE

Nutritional status and adequacy of energy and nutrient intakes among heart failure patients

Bárbara Hatzlhoffer Lourenço^I; Lis Proença Vieira^II; Alessandra Macedo^II; Miyoko Nakasato^II; Maria de Fátima Nunes Marucci^III; Edimar Alcides Bocchi^II

^ICurso de Nutrição da Faculdade de Saúde Pública da Universidade de São Paulo, São Paulo, SP - Brazil

^IIInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil

^IIIDepartamento de Nutrição da Faculdade de Saúde Pública da Universidade de São Paulo, São Paulo, SP - Brazil

Mailing address

SUMMARY

BACKGROUND: Increased knowledge about nutritional status and energy and nutrient intakes is required to improve the treatment of patients with heart failure (HF).

OBJECTIVES: To verify the nutritional status and evaluate the adequacy of energy, macronutrient and micronutrient intakes in patients with HF in outpatient clinical settings.

METHODS: We collected anthropometric and habitual dietary intake data of 125 patients (72% men, 52.1 ± 9.8 years, BMI 26.9 ± 4.4 kg/m2). Anthropometric variables were compared between genders, and the adequacy of energy and nutrient intakes was analyzed according to current recommendations.

RESULTS: Muscle depletion or risk of depletion was present in 38.4% of patients (association with male gender, p <0.0001). In 69.6% of cases the mean energy intake was lower than the one required (p <0.0001). Among the micronutrients evaluated in this study, there was an important prevalence of inadequacy in magnesium, zinc, iron and thiamine intakes, and most patients had calcium and potassium intakes below the adequate levels, and sodium intake above the adequate levels.

CONCLUSIONS: Outpatients with HF showed muscle depletion, and inadequate energy and nutrient intakes. There was no significant association between habitual dietary energy intake and nutritional status. Multidisciplinary care should be encouraged to better assess the general condition of these patients.

Key words: Heart failure; nutritional status; energy intake; nutrients; adequacy.

Introduction

Heart failure (HF) is a complex and progressive clinical syndrome, which has limited prognosis and often evolves to cardiac cachexia^1,2. From 2000 to 2007, circulatory system diseases were the third most important cause of hospitalization by the Unified Health System in Brazil, and HF was the most frequent condition, which accounted for more than 2.7 million hospitalizations, corresponding to 29.3% of all cardiovascular diseases and 3.0% of all hospitalizations³.

The non-pharmacological and non-surgical approaches in the treatment of patients with HF have been very useful to help manage symptoms, reduce the number of readmissions and improve quality of life⁴. Among the factors associated with the development and progression of HF, energy and nutrient intakes and nutritional status of the patients are of major importance^5,6. However, prior investigations suggested that body mass index (BMI), a parameter routinely used to determine nutritional status, has reduced sensitivity to detect severe malnutrition among patients with heart disease⁷.

A more complete understanding of the factors involved in HF may improve the treatment results, minimize complications and ensure greater compliance with therapeutic measures⁸. Therefore, the objectives of this study were to verify the nutritional status and to evaluate the adequacy habitual dietary energy, macronutrient and micronutrient intakes (calcium, phosphorus, magnesium, iron, sodium, potassium, zinc and thiamine) of HF outpatients referred for nutrition care.

Methods

Patients

This was a cross-sectional study involving 125 patients with HF (72% of them men) referred for treatment by a multidisciplinary team. Participants were consecutively seen by the nutrition team of a cardiology institution, from October 1999 to May 2006. The criteria used for the diagnosis of HF were those of the Review of the II Guidelines of the Brazilian Society of Cardiology for the Diagnosis and Treatment of Heart Failure⁹. Clinical characteristics of patients are shown in Table 1.

The inclusion criteria included a written consent to participate in the study and complete anthropometric and dietary data regarding the first nutritional consultation. Two patients with incomplete data were excluded, yielding a response rate of 98.4%.

This study is part of a research protocol that has been reviewed and approved by the Ethics Committee for Analysis of Research Projects of the Hospital das Clínicas of the Medical School, University of São Paulo, number 827/99. The patients received information about the project, its objectives, procedures and potential risks, and signed the written informed consent.

Anthropometric assessment

Weight and height were measured on 0.1kg and 0.1cm scales, respectively, for the measurement and diagnosis of the nutritional status of the patients according to BMI, based on WHO guidelines¹⁰. On the right side of the patients' bodies, the triceps skinfold was measured with an adipometer, and the arm circumference was measured with a non-extensible measuring tape, for the calculation of the arm muscle circumference and the arm muscle area (AMA)¹¹. The AMA was corrected according to gender, by subtracting the arm bone area¹². For the diagnosis of the nutritional status of the patients according to the AMA, we used the values of Frisancho¹³.

Evaluation of the estimated energy and nutrient intakes

Trained nutritionists collected qualitative and quantitative data regarding the habitual diet of the participants, using a diet history interview¹⁴. Self-reported intake of commonly consumed foods and beverages and food preparation practices were systematically assessed, and the amounts were provided in portion sizes. Additionally, the amounts of salt and oil consumed by the patients over a period of one month were estimated to determine with greater accuracy the consumption of these food items. We used the Nutrition Support Program – NUTWIN, version 1.5¹⁵, to calculate the amounts of energy, carbohydrates, proteins, lipids and micronutrients. We quantified calcium, phosphorus, magnesium, iron, sodium, potassium, zinc and thiamine for their relationship with HF^5,6.

Adequacy of the estimated energy and nutrient intakes

For the assessment of habitual dietary energy intake, we used body weight and BMI (biological markers of energy intake-expenditure balance or imbalance) and determined the proportions of low-weight, healthy weight and overweight individuals¹⁰. The estimated energy intake was compared to the specific energy requirements in patients with HF¹⁶.

In the absence of specific recommendations for consumption of macronutrients and micronutrients for individuals with HF, we used the recommendations proposed by the Food and Nutrition Board (FNB)¹⁷.

For the analysis of macronutrients, we observed the acceptable distribution ranges for adults¹⁷, and we estimated the proportions of individuals on diet classified as adequate, above or below the recommended. In the assessment of the intake of micronutrients, the prevalence of inadequacy was observed when comparing the distribution of nutrient intake in the group with the estimated average requirement (EAR)¹⁸.

Phosphorus, magnesium, iron, zinc and thiamine have EARs, and the prevalence of inadequacy was measured using this formula: z = (EAR - mean intake) / standard deviation¹³. Mean and standard deviation of intake do not need adjustments according to intrapersonal variability, as the diet history accesses the habitual diet and eliminates this variability because it accesses daily changes¹⁴. After calculating the value of z, we determined the proportion of participants in a state of inadequacy.

Calcium, potassium and sodium do not have established EARs, so we determined the proportions of patients with intakes above or below the adequate intake (AI) values according to gender and age. Whenever the mean intake of the nutrient exceeds the AI, a low prevalence of inadequacy is expected¹⁸.

Statistical analysis

Age and anthropometric variables were tested for normality and homoscedasticity, and transformed to the logarithmic scale, when these assumptions were rejected. Then, they were compared between genders through the non-paired t test.

The relationships among energy intake, BMI and AMA were analyzed by the construction of dispersion graphs and by Pearson's correlation test. We applied the paired t test and the Wilcoxon signed-rank test to compare the dietary energy intake with the calculated energy requirements. Qualitative variables were compared using the chi-square test. P-values <0.05 were considered significant. The statistical analysis was performed in SPSS software version 13.0 (Statistical Package for Social Science Inc., Chicago, Illinois, USA). The results were presented as mean and standard deviation (SD).

Results

Anthropometric data of patients

Anthropometric data of the patients are shown in Table 2. Age groups did not differ significantly by gender (chi-square = 6.028, p = 0.110). Four individuals (3.2%) had low weight, 35 (28.0%) had healthy weight, 57 (45.6%) had risk of obesity, 25 (20.0%) had grade I obesity, three patients (2.4%) had grade II obesity, and one patient (0.8%) had grade III obesity. There was no association with gender (chi-square = 2.84, p = 0.725).

The AMA assessment showed that 21 patients (16.8%, all men) had muscle depletion and other 27 (21.6%, 22 men) were at risk of depletion. Muscle reserves within the average for age and gender were observed in 58 subjects (46.4%, 41 men), and 19 (15.2%, six men) were above average or in 'good nutrition' condition . The AMA classification showed a significant association with gender (chi-square = 28.670, p <0.0001). Table 3 shows the mean values of BMI, according to AMA classification groups.

Adequacy of the estimated energy intake

The Pearson's correlation test showed no significant association between the habitual dietary energy intake and the BMI or the AMA (Figure 1).

The AMA assessment of the nutritional status indicated risk of depletion or depletion of muscle reserves in 38.4% of cases. The mean energy intake among the patients (1545.3 ± 626.9 kcal) was significantly lower than the energy requirements of the group (1817.4 ± 299.8 kcal, p <0.0001), and the Wilcoxon signed-rank test identified 87 individuals (69.6%, and 59 men) with habitual intake below the estimated energy requirement. The remaining 38 participants (31 men) had a habitual intake above the requirement. There was no association between energy intake below or above the requirements and gender (chi-square = 2.485, p = 0.115).

Adequacy of the estimated macronutrient and micronutrient intakes

Figure 2 shows the proportions of individuals with adequate, above or below the recommended intakes of macronutrients. The average carbohydrate content in the diet was 52.2 ± 9.4%, the average protein content was 20.9 ± 5.9%, and the average lipid content was 26.9 ± 7.9%. There was no association between these ratios and gender.

Probabilities of inadequate intake of phosphorus, magnesium, iron, zinc and thiamine are shown in Table 4. As to magnesium, only two participants were in the age range of 19-30 years. Therefore, the calculation of inadequate intake of this mineral was possible only for patients above 30 years of age. The proportions of subjects with calcium, potassium and sodium intakes above and below the AI are shown in Figure 3.

Discussion

This study observed that the mean BMI of patients provides their classification of risk of obesity, which is consistent with previous results^19,20. The increase in BMI is known to raise the risk for the development of HF in both genders, regardless of other risk factors^21,22, and yet it is also associated with a better prognosis in patients with chronic and acute decompensated HF^{20, 23,24}, which characterizes the obesity paradox^19,25.

It should be noted that, despite the fact that only 3.2% of patients had low weight, approximately 40% were at risk of depletion or had depletion of muscle reserves. Disproportionate mobilization and deposition of muscle and adipose tissues may occur²⁶, and it is noteworthy that protein degradation plays an important role in the progression of HF^6,26,27.

The use of BMI alone, which has low sensitivity for predicting severe malnutrition among cardiac patients⁷, may not confirm the adequacy of the energy intake in patients with HF. In addition to the considerable proportion of participants with values of AMA indicating risk of depletion or depletion, we observed that almost 70% of patients did not meet the energy requirement with the habitual intake of food. Aquilani et al²⁶ identified a similar proportion (70.1%) of HF patients (52 men and five women, 52.0 ± 3.0 years) with a negative energy balance, though they had normal total energy expenditure, measured by indirect calorimetry, as reported in a daily food intake log²⁶. Recently, Catapano et al²⁸ observed a dietary energy intake below the required in 72% of HF patients aged over 60 years²⁸, and Price et al²⁹ observed the same in 64% of individuals aged 80.8 ± 6.8 years²⁹. To complement these results, we found no significant correlation among energy intake, BMI and AMA, which indicates that the nutritional status of patients with HF is influenced by other variables beside energy consumption^6,26,28.

Most patients had an adequate intake of macronutrients¹⁷, in accordance to the recommendations. In the study of Price et al²⁹, they found that all patients had an adequate intake of protein, in accordance to the recommendations, and more than 60% of them had the recommended intake of lipids²⁹. The average carbohydrate and protein contents were higher than those observed by Aquilani et al²⁶, but both met the parameters established by the FNB¹⁷. However, a significant proportion of patients had depleted muscle reserves. Therefore, it is noteworthy that the acceptable distribution range of proteins is broad (10-35% of total energy intake)¹⁷ and HF is characterized by catabolism⁶. In addition, Aquilani et al²⁶ found a negative balance of nitrogen in approximately 60% of their patients, suggesting that the ingestion of normal amounts of protein may not be appropriate for individuals with HF²⁶.

Among the micronutrients, we observed a low proportion of individuals with inadequate intake of phosphorus, and there are no previous studies showing a direct relationship between HF and the intake of this nutrient, which is abundant in many foods and has a specific relationship with cardiac energy metabolism³⁰. Furthermore, there was a high prevalence of inadequate intake of magnesium, which has been reported in patients with HF. The hypomagnesaemia, which usually results in arrhythmia, which is common in these individuals, has a relationship with the aldosteronism that is observed in HF and with worse prognosis, and may be aggravated by the action of diuretics^25,31.

The proportion of individuals with inadequate intake of iron was higher among women aged 50 years, due to their greater iron intake requirement¹⁷. Iron deficiency can lead to anemia, which has been associated with HF³². A multicenter study found that anemia is an independent prognostic factor and it is significantly associated with mortality rate (RR = 3.1)³³. Regarding zinc, an inadequate intake was observed in approximately 40% of men and women. Reductions in serum concentrations of zinc are associated with the development of HF, and its urinary excretion increases with the use of diuretics. Moreover, zinc has an antioxidant function and its deficiency causes changes in taste and may affect the normal food intake³¹. The consumption of thiamine was inadequate in more than 30% of the group. This vitamin acts as a coenzyme in energy metabolism and its deficiency is detected in patients with HF, particularly in undernourished elderly patients, when in use of diuretics and in more severe forms of the disease^5,25,31,34.

Price et al showed a high proportion of patients with potassium intake below 3,500 mg/day²⁹, in agreement with these results. It was also noted that almost all patients did not meet the AI for calcium. It was observed that HF patients have deficient dietary intake of calcium and its absorption is impaired by vitamin D deficiency, age and the use of diuretics. The aldosteronism increases the losses, leading to hypocalcemia, osteoporosis and osteopenia, which are common in HF patients^5,25,31.

Thus, the deficiency of several micronutrients may be related to the development and progression of HF. Although there is no consensus established, all these evidences corroborate the need for supplementary feeding for these patients, since the usual food intake may be affected and the loss of nutrients may be increased^5,25,31.

Finally, 84% of patients had sodium intakes above the AI of 1500 mg/day. In the study by Price et al²⁹, 82% of the patients had sodium intakes above 2000 mg/day, and 44% of them had sodium intakes above 3000 mg/day²⁹. Restriction of sodium is a vital component of the treatment of patients with HF, and currently there is no consensus on the maximum intake. It can be said that an intake of 2-3 g sodium meets the recommendations of organizations such as AHA/ACC and HFSA²⁵, and that these values exceed the proposed AI¹⁷. It is well established that an excessive consumption of sodium exacerbates the symptoms of HF, increasing fluid retention²⁵.

This study has some limitations. The habitual diet was accessed by the retrospective method, which requires an individual to record and quantify commonly consumed foods¹⁴. Moreover, the self-reported food consumption may be underestimated. The nutritional status of patients was identified only by anthropometric variables, and considering the complexity of HF and the results above, other measures, such as biochemical variables have proven useful in assisting the diagnosis.

Conclusion

We concluded that part of HF outpatients display depletion of muscle reserves, especially among men. These individuals do not meet their energy requirements and have inadequate dietary intake of various nutrients, especially magnesium, zinc, iron, thiamine, calcium, potassium and sodium. There was no significant association between total dietary energy intake and nutritional status, assessed by BMI and AMA. We emphasize the necessity and importance of encouraging multidisciplinary monitoring, which may help the management of this complex syndrome³⁵, considering the frequent comorbidities which affect the correct diagnosis of the nutritional status, the treatment of cachexia, the correction of nutritional deficiencies and the best assessment of the patient's general condition.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Sources of Funding

There were no external funding sources for this study.

Study Association

This study is not associated with any post-graduation program.

References

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Publication Dates

• Publication in this collection
  06 Jan 2010
• Date of issue
  Nov 2009

History

• Accepted
  15 Dec 2008
• Reviewed
  09 Dec 2008
• Received
  20 Oct 2008