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Activity and Nutrition in Heart Failure

Activity and Nutrition in Heart Failure. Biykem Bozkurt, MD, PhD, FHFSA, FACC, FAHA, FESC

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Activity and Nutrition in Heart Failure

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  1. Activity and Nutrition in Heart Failure Biykem Bozkurt, MD, PhD, FHFSA, FACC, FAHA, FESC W.A. “Tex” and Deborah Moncrief, Jr., Chair; Mary and Gordon Cain Chair and Professor of Medicine; Director of the Winters Center for Heart Failure; Associate Director of Cardiovascular Research Institute; Vice-Chair of Medicine at Baylor College of Medicine; and Medical Care Line Executive at the DeBakey VA Medical Center, Houston TX

  2. The Less You Do, The Less You CAN Do Exercise Capacity (L O2/min) Exercise Capacity (L O2/min) Days Middle-Aged Healthy Men for 10 days ~15% reduction Healthy College Kids for 20 days ~30% reduction Modified from Debusk et al. Circ 1983; 68: 245 Modified from Saltin et al. Circ 1968; 5 (S7); 1 Convertino. Med Sci Sports Exer1997; 29: 191

  3. The Time to Get Moving is Now! Change in Exercise Capacity (%) Days of Bed Rest Modified from Convertino. Med Sci Sports Exerc 1997; 29: 191

  4. Inactivity & The Company It Keeps Decreased cognition Depression Decreased Bone Density Reduced muscle strength Falls Hogan, Mata, Carstensen. Psychol Aging 2013; 28: 587 Wagner et al. Annu. Rev. Publ. Health 1992; 13: 451 Buchner et al. Annu. Rev. Publ. Health 1992; 13: 469 http://smartonlinesuccess.com/arnold-schwarzeneggers-six-rules-for-success/ Bone: Dream Designs. Freedigitalphotos.netBrain: Omega1982. Freedigitalphotos.net

  5. Heart Failure Affects the Whole Body! Lungs Poor transfer of oxygen Lungs Heart and Vessels Less output Poor redistribution to muscles Less Ability to Exercise Diaphragm “steal” blood Less flow to the gut Skeletal Muscle Reduced strength More fatigable Less muscle mass Modified from Poole et al. Am J Physiol Heart CircPhysiol 2012; 302: H1050

  6. Impact of Exercise in Heart Failure • Improved ability to exercise! • Heart • Improved structure and function • Blood Vessels: • Improved delivery of blood to muscles • Muscles • Stronger and more efficient • Improved Quality of Life • Fewer Hospitalization and Deaths Haykowsky et al. JACC 2007; 49: 2329 Hambrecht et al. JACC 1995; 25: 1239 Magnusson et al. Eur H J 1996; 17: 1048 Flynn et al. JAMA 2009; 301: 1451 O’Connor et al. JAMA 2009; 310: 1439 Keteyian et al. JACC 2012; 60: 1899 Image from American Council on Science and Health website

  7. Exercise Reduces Bad Outcomes Death or Hospitalization for Any Reason 11% Reduction in Death/Hospitalization for any reason 0.8 0.7 0.6 0.5 The more exercise you did The greater the benefit! 0.4 Event Rate 0.3 0.2 -- Usual Care − Exercise Group 0.1 0 1 2 3 Time, years O’Connor et al. JAMA 2009; 310: 1439 Keteyian et al. JACC 2012; 60: 1899

  8. Exercise and Safety • Safe in stable HF patients • When is it okay to exercise? • Symptoms are under control! • Not when decompensated/extra fluid • Not when feeling worse/different • Stable medications • Listen to your body: slow and steady • Discuss exercise with your provider • Usually starts with an exercise test • Cardiac Rehabilitation O’Connor et al. JAMA 2009; 310: 1439 Pina. CurrCardiol Rep 2010; 12: 223 Ades et al. JACC HF 2013; 1: 540 Accessed on 1/28/18: HFSA.org: http://www.hfsa.org/wp-content/uploads/2014/10/P969-HFSA-Module-5-Exercise-v5.pdf

  9. What is Cardiac Rehab? • Comprehensive program for overall cardiovascular risk reduction • Multidisciplinary: Exercise Physiologists, Nurses, Nutritionists, Physical Therapists, Physician • Cardiac Rehab incorporates: • Exercise Training • Self-Care Balady et al. Circulation 2007; 115: 2675 Ades et al. J Am CollCardiol HF 2013; 1: 540 Moser et al. CurrCardiol Rep 2012; 14: 265

  10. Self-Care Basics • Choice of behaviors to maintain stability • Regular follow-up • Taking medications • Physical Activity • Dietary restrictions • Sodium and fluid vigilance • Prepared foods • Reading food labels • Tobacco Cessation/Alcohol Reduction • Influenza Vaccination • Learning to monitor your symptoms of heart failure • Weights • Swelling • Shortness of breath • Response to symptoms should/when they occur • Having a plan! * Good Self-Care can decrease hospitalizations for heart failure! * Poor Self-Care: increased hospitalizations! Riegel et al. Circ2009; 120: 1141 Ades et al. J Am CollCardiol HF 2013; 1: 540 Chin, Goldman. Am J Public Health 1997; 87: 643 Jovicic, Holroyd-Leduc, Straus. BMC Cardiovascular Disorders 2006; 6:43

  11. Cardiac RehabilitationUnderutilized resource! • Generally: 36 supervised sessions • 3x/week: 30 min of exercise + warm up/cool down • Build confidence, strength • Learn how to incorporate activity into daily living • Increase heart failure education and self-care • Only ~10-15% of patients with HF referred! February 2014: Medicare approves cardiac rehabilitation for heart failure! Golwala et al. JACC 2015; 66: 917 Pina. CurrCardiol Rep 2010; 12: 223 Ades et al. JACC HF 2013; 6: 540

  12. Activity - Conclusions • Activity is good!!! • Listen to your body, notify your provider of changes • Provided that your heart failure is under control… The time to start moving is now!! • Discuss exercise with your provider • Consider cardiac rehab • HFSA Website: http://www.hfsa.org/hfsa-wp/wp/module-5/

  13. Diet in Heart Failure:What Can I Eat?

  14. Adequate Nutrition • Can be challenging in general • Even more challenging when specific dietary restrictions are required • 139 heart failure patients: 71% following >1 diet (low-sodium, low-cholesterol, low fat, and diabetic); 11% following all 4 diets! • For Heart Failure: focus on salt and fluids • Sodium intake of <3000 mg of sodium/day (Goal 2-3g/day) • Avoiding drinking “excessive” fluids • Adequate intake protein, vitamins, and fiber Yancy et al. JACC 2013; 62: e147 (e171) HFSA HF Guidelines, 2010 (section 6, e61) Carlson, Riegel, Moser. Heart Lung 2001; 30: 351

  15. Salt and Water • Both are essential for health and survival • In setting of heart failure, body is unable to effectively get rid of salt • Wherever there’s salt, there’s water Gupta et al. Circulation 2012; 126: 479

  16. Weight Gain and Heart Failure Hospitalizations 134 Hospitalized Weight gain in 7d before 2-5#: 2.8x 5-10#: 4.5x >10#: 7.7x Day of Admission Average Daily Weight Change (lbs) The greater the weight gain, the more likely that patients were admitted! 134 Not Hospitalized Days Before Heart Failure Hospitalization Chaudhry et al. Circulation 2007; 116: 1549

  17. Watch out for Processed/Packaged Foods!! 5% Added at table 6% Home food prep 14% Naturally-occurring in food 71%: Added OUTSIDE home (commercial processing, restaurants) HFSA HF Guidelines, 2010, Section 6, e61 Harnack et al. Circulation 2017; 135: 1775 Image: https://foodnhealth.wordpress.com/2008/06/15/too-much-salt/ (Accessed 1/25/18 )

  18. The Salty 6 • Breads and rolls • Cold cuts and cured meats • Pizza • Poultry • Canned soups • Sandwiches 170 mg 2 bread slices: 340 mg ~10% of daily salt http://www.sparkpeople.com/calories-in.asp?food=wonder+bread (accessed 1/26/18)

  19. HFSA Low-Sodium Module Accessed 1/28/18: HFSA.org: http://www.hfsa.org/patient/patient-tools/educational-modules/module-2/

  20. Watch out for snacks! Medium 3 ¾” Pickle SNYDER’S MINI PRETZELS 833 mg 250 mg http://www.snydersofhanover.com/products/pretzels/pretzel-minis.html https://www.fatsecret.com/calories-nutrition/usda/dill-cucumber-pickles?portionid=35133&portionamount=1.000

  21. Changing Your Salty Ways Regular chicken noodle soup Low-sodium chicken noodle soup • Fresh is best • Read package labels • Don’t cook with salt • Use herbs and spices liberally • NO salt substitute without OK from clinician • When dining out, ask for “no added salt” and avoid dressings or sauces • Review menu in advance and have plan for what to eat 890 mg 140 mg

  22. What About Water? • Really are referring to all fluids • Coffee, jello, soup, etc • No longer restrict fluid intake in most heart failure patients • Drink if thirsty, but not to excess • If worsening symptoms that require increased diuretics, then should reduce fluid intake (<2 Liters/day) Yancy et al. JACC 2013, 62: e190 HFSA HF Guidelines, JCF 2010; 16: e62

  23. Diet Summary • Eat well-balanced meals filled with fresh fruits and vegetables • Limit salt intake to 2-3 grams per day • Read labels, noting serving size and sodium content • Drink when thirsty • Take a multivitamin daily • Take your medications as directed HFSA HF Guidelines, JCF 2010; 16: e61-63

  24. HFSA Patient Tools Available HFSA offers educational resources to patients and families. Visit our website to learn more about our educational materials and our heart failure patient app: Heart Failure Health Storylines

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