MNT for Heart Failure MNT for Heart Failure and Transplantand Transplant

Congestive Heart Congestive Heart Failure (CHF)Failure (CHF) A clinical syndrome characterized A clinical syndrome characterized

by progressive deterioration of by progressive deterioration of left ventricular function, left ventricular function, inadequate tissue perfusion, inadequate tissue perfusion, fatigue, shortness of breath, and fatigue, shortness of breath, and congestioncongestion

Gradual failure of heartGradual failure of heart

1.1. Compensated—Lack of OCompensated—Lack of O22 to to tissues causes increase in heart tissues causes increase in heart rate and enlargement of heartrate and enlargement of heart

2.2. Decompensated—Heart no Decompensated—Heart no longer adjustslonger adjusts

Gradual failure of heartGradual failure of heart

1.1. Compensated—Lack of OCompensated—Lack of O22 to to tissues causes increase in heart tissues causes increase in heart rate and enlargement of heartrate and enlargement of heart

2.2. Decompensated—Heart no Decompensated—Heart no longer adjustslonger adjusts

Congestive Heart Failure (CHF) —cont’dCongestive Heart Failure (CHF) —cont’d

Causes of Heart Causes of Heart FailureFailure Diseases of the heart (valves, muscle, Diseases of the heart (valves, muscle,

vessels, arteries) and vasculature vessels, arteries) and vasculature (hypertension) cause left ventricular (hypertension) cause left ventricular systolic dysfunctionsystolic dysfunction

Once established, myocardial infarction, Once established, myocardial infarction, dietary sodium excess, medication dietary sodium excess, medication noncompliance, arrhythmias, pulmonary noncompliance, arrhythmias, pulmonary embolism, infection, anemia can embolism, infection, anemia can precipitate complete CHFprecipitate complete CHF

Prevalence and Prevalence and IncidenceIncidence Unlike other cardiovascular Unlike other cardiovascular

diseases, CHF is on the increasediseases, CHF is on the increase Number of CHF-related discharges Number of CHF-related discharges

increased 174% from 1979-2003increased 174% from 1979-2003 4.8 million Americans have CHF; 4.8 million Americans have CHF;

overall prevalence 2-6%overall prevalence 2-6%

Krummel DA in Krause, 12th ed., 2008

Prevalence and Prevalence and IncidenceIncidence Prevalence increases with age, Prevalence increases with age,

especially after age 55especially after age 55 Black women have the highest Black women have the highest

rates, followed by black men, rates, followed by black men, Latino men, white men, white Latino men, white men, white women, and Latino womenwomen, and Latino women

More Medicare dollars are spent on More Medicare dollars are spent on CHF than on any other diagnosisCHF than on any other diagnosis

Prevalence and Prevalence and IncidenceIncidence Incidence has risen in last 20 years Incidence has risen in last 20 years

because of aging population, increased because of aging population, increased number of people being saved from number of people being saved from premature death secondary to MI, premature death secondary to MI, increase in obesity and associated increase in obesity and associated hypertensionhypertension

Incidence of CHF approaches 10 per Incidence of CHF approaches 10 per 1000 people over 65 years1000 people over 65 years

Median survival of men and women is Median survival of men and women is 1.7 years and 3.1 years respectively1.7 years and 3.1 years respectively

One in five persons with CHF will die One in five persons with CHF will die within a year of diagnosiswithin a year of diagnosis

Risk FactorsRisk Factors

Hypertension (91% of Framingham Hypertension (91% of Framingham cohort had hypertension before cohort had hypertension before CHF)CHF)

Left ventricular hypertrophyLeft ventricular hypertrophy Coronary heart disease (causes 60-Coronary heart disease (causes 60-

65% of cases)65% of cases) DiabetesDiabetes Mean age of onset is 70 yearsMean age of onset is 70 years

Stages of Heart FailureStages of Heart Failure

AA High risk of HF High risk of HF because of presence because of presence of risk factors but of risk factors but without syx or without syx or structural damagestructural damage

HBP, CAD, diabetes, alcohol HBP, CAD, diabetes, alcohol abuse, hx rheumatic fever; abuse, hx rheumatic fever; family hx cardiomyopathy, family hx cardiomyopathy, using cardiotoxins, metabolic using cardiotoxins, metabolic syndromesyndrome

BB Structural heart Structural heart disease associated disease associated with HF but no with HF but no signs/syxsigns/syx

LVH or fibrosis, left ventricular LVH or fibrosis, left ventricular dilatation; low EF; dilatation; low EF; asymptomatic valve disease, asymptomatic valve disease, previous MIprevious MI

CC Structural heart Structural heart disease with current disease with current or prior syx of HFor prior syx of HF

Dyspnea or fatigue due to LV Dyspnea or fatigue due to LV dysfunction; reduced exercise dysfunction; reduced exercise tolerancetolerance

DD Advanced structural Advanced structural damage, refractory damage, refractory symptomssymptoms

Frequently hospitalized; Frequently hospitalized; awaiting transplantawaiting transplant

Krummel in Krause, 12th Ed.

Classifications of Heart Classifications of Heart FailureFailure

Class IClass I No undue symptoms associated No undue symptoms associated with ordinary activity; no with ordinary activity; no limitationslimitations

Class IIClass II Slight limitation of physical Slight limitation of physical activity; patient comfortable at activity; patient comfortable at restrest

Class Class IIIIII

Marked limitation of physical Marked limitation of physical activity; patient comfortable at activity; patient comfortable at restrest

Class Class IVIV

Inability to carry out physical Inability to carry out physical activity without discomfort; activity without discomfort; symptoms of cardiac symptoms of cardiac insufficiency or chest pain at insufficiency or chest pain at restrest

Congestive Heart Failure Congestive Heart Failure SymptomsSymptoms

DyspneaDyspnea

OrthopneaOrthopnea

NauseaNausea

FullnessFullness

Pulmonary edemaPulmonary edema

Cardiac edemaCardiac edema

Cardiac cachexiaCardiac cachexia

CHF DIAGNOSISCHF DIAGNOSIS

EKG or electrocardiogramEKG or electrocardiogram– measures the rate and regularity of measures the rate and regularity of

the heartbeatthe heartbeat– May indicate whether there has been May indicate whether there has been

heart damage or changes in anatomyheart damage or changes in anatomy Chest X-rayChest X-ray

– Shows whether heart is enlarged, fluid Shows whether heart is enlarged, fluid in lungs, pulmonary diseasein lungs, pulmonary disease

CHF DIAGNOSISCHF DIAGNOSIS

EchocardiogramEchocardiogram– Most useful test in diagnosis of heart Most useful test in diagnosis of heart

failurefailure– Uses sound waves to create a Uses sound waves to create a

picture of the heartpicture of the heart– Evaluates heart function: cardiac Evaluates heart function: cardiac

output and areas of the heart that output and areas of the heart that are not contracting normallyare not contracting normally

Other Cardiac TestsOther Cardiac Tests

Holter Monitor: ambulatory Holter Monitor: ambulatory electrocardiographyelectrocardiography– Worn for 24 hours and provides a Worn for 24 hours and provides a

continuing recording of heart rhythm continuing recording of heart rhythm during normal activityduring normal activity

Cardiac Blood Pool Scan (radionuclide Cardiac Blood Pool Scan (radionuclide ventriculography or nuclear scan)ventriculography or nuclear scan)– Uses radioactive imaging agent injected Uses radioactive imaging agent injected

into a vein to outline chambers of the into a vein to outline chambers of the heart and blood vesselsheart and blood vessels

– Shows how well heart is pumping blood to Shows how well heart is pumping blood to the rest of the bodythe rest of the body

Other Cardiac TestsOther Cardiac Tests

Cardiac CatheterizationCardiac Catheterization– Flexible tube passed through vein in the Flexible tube passed through vein in the

groin or arm to reach the coronary arteriesgroin or arm to reach the coronary arteries– Allows physician to visualize the arteries, Allows physician to visualize the arteries,

check pressure and blood flow in coronary check pressure and blood flow in coronary arteries, collect blood samplesarteries, collect blood samples

Coronary angiography: usually done Coronary angiography: usually done along with cardiac catheterizationalong with cardiac catheterization– Dye injected into coronary arteries and/or Dye injected into coronary arteries and/or

chambers of the heartchambers of the heart– Allows angiographer to visualize flow of Allows angiographer to visualize flow of

blood blood

Cardiac TestsCardiac Tests

Exercise Stress TestExercise Stress Test– EKG and blood pressure readings are EKG and blood pressure readings are

taken before, during, and after taken before, during, and after exercise to determine how the heart exercise to determine how the heart responds to exerciseresponds to exercise

– Patient exercises on a treadmill or Patient exercises on a treadmill or stationary bike until reaches a stationary bike until reaches a heartrate established by the physicianheartrate established by the physician

– Echocardiogram often included Echocardiogram often included

BNP and NT-proBNP BNP and NT-proBNP Blood TestBlood Test Measure the concentration of BNP Measure the concentration of BNP

(hormone made by the heart) or NT-(hormone made by the heart) or NT-proBNP (both formed when pro-BNP is proBNP (both formed when pro-BNP is cleaved into two fragments)cleaved into two fragments)

Released as a natural response to Released as a natural response to heart failure, to hypotension, and to heart failure, to hypotension, and to LVHLVH

Used to grade the severity of heart Used to grade the severity of heart failurefailure

Cachectic HeartCachectic Heart

A soft, flabby heart characterized A soft, flabby heart characterized by loss of myocardial mass as by loss of myocardial mass as the result of extreme the result of extreme malnutritionmalnutrition

Congestive Heart Congestive Heart Failure Failure TreatmentTreatment Goal: Goal: decrease work of heartdecrease work of heart

DietDiet

1.1. Na restriction (500 to 1000 mg)Na restriction (500 to 1000 mg)

2.2. Monitor serum K—hypokalemia Monitor serum K—hypokalemia possible with diuretics and digoxin)possible with diuretics and digoxin)

3.3. Fluid restrictionFluid restriction

4.4. Alcohol—none to moderateAlcohol—none to moderate

5.5. Caffeine—can cause MI or cardiac Caffeine—can cause MI or cardiac arrhythmiaarrhythmia

Medications Used in Medications Used in Heart FailureHeart Failure DiureticsDiuretics help reduce fluid buildup in lungs and help reduce fluid buildup in lungs and

peripheral edema peripheral edema ACE inhibitorsACE inhibitors lower blood pressure and reduce lower blood pressure and reduce

the strain on the heart. These medications also the strain on the heart. These medications also may reduce the risk of a future heart attack. may reduce the risk of a future heart attack.

Beta blockersBeta blockers slow heart rate and lower blood slow heart rate and lower blood pressure to decrease the workload on the heart. pressure to decrease the workload on the heart.

DigoxinDigoxin makes the heart beat stronger and pump makes the heart beat stronger and pump more blood. more blood.

Vasodilators: reduce blood pressure and stress Vasodilators: reduce blood pressure and stress on the hearton the heart

MNT in HFMNT in HF

Fluid restriction Fluid restriction Sodium restrictionSodium restriction Meet energy/protein needsMeet energy/protein needs Prevent cardiac cachexiaPrevent cardiac cachexia Small frequent mealsSmall frequent meals

Fluid RestrictionFluid Restriction

If hyponatremia occurs (serum If hyponatremia occurs (serum sodium <130 mEq/L)sodium <130 mEq/L)

Limit total fluids to <2000 mlLimit total fluids to <2000 ml In severe decompensation, limit to In severe decompensation, limit to

1000-1500 ml1000-1500 ml Maintain restricted sodium diet even Maintain restricted sodium diet even

if serum sodium depleted; sodium if serum sodium depleted; sodium has moved from blood to tissueshas moved from blood to tissues

Fluid Status and Fluid Status and AssessmentAssessment Patients should record daily Patients should record daily

weights and advise care providers weights and advise care providers if weight gain exceeds 2-3 lb a if weight gain exceeds 2-3 lb a day or 5 lb in a weekday or 5 lb in a week

Restricting sodium and fluids Restricting sodium and fluids (decreasing by 1 to 1.5 cups) may (decreasing by 1 to 1.5 cups) may prevent complete HFprevent complete HF

Fluid CalculationsFluid Calculations

Hospitalized patients may be Hospitalized patients may be limited to 500-2000 ml dailylimited to 500-2000 ml daily

Foods having a high fluid content Foods having a high fluid content may also be limitedmay also be limited

Foods that are liquid at room Foods that are liquid at room temperature such as ice cream, temperature such as ice cream, yogurt, gelatin, popsicles count yogurt, gelatin, popsicles count towards fluid allotmenttowards fluid allotment

Living with Fluid Living with Fluid RestrictionsRestrictions Freezing fruit or sucking on sugar Freezing fruit or sucking on sugar

free hard candy may helpfree hard candy may help Fluid status monitored by measuring Fluid status monitored by measuring

urine specific gravity and serum urine specific gravity and serum electrolyte values and observing for electrolyte values and observing for clinical signs of edemaclinical signs of edema

Restrictions often discontinued when Restrictions often discontinued when patients leave the hospitalpatients leave the hospital

Cardiac CachexiaCardiac Cachexia

Involuntary weight loss of >6% of Involuntary weight loss of >6% of nonedematous body weight over a 6-nonedematous body weight over a 6-month periodmonth period

Significant loss of lean body mass: Significant loss of lean body mass: exacerbates HFexacerbates HF

Cachectic heart: soft and flabbyCachectic heart: soft and flabby Structural, circulatory, metabolic, Structural, circulatory, metabolic,

inflammatory, and neuroendocrine inflammatory, and neuroendocrine changes in skeletal musclechanges in skeletal muscle

Serious complication of HFSerious complication of HF

Cardiac CachexiaCardiac Cachexia

Patients with cardiac cachexia may lose Patients with cardiac cachexia may lose 10-15% of their body weight (dry weight)10-15% of their body weight (dry weight)

Other markers (serum prealbumin and Other markers (serum prealbumin and transferrin) may be disproportionately transferrin) may be disproportionately low because of the dilutional effect of low because of the dilutional effect of excess fluidexcess fluid

Use anthropometrics (measurement of Use anthropometrics (measurement of calf and thigh circumference, MUAC) and calf and thigh circumference, MUAC) and diet historydiet history

Cardiac CachexiaCardiac Cachexia

Proinflammatory state in which cytokines Proinflammatory state in which cytokines (TNF, IL-1 and I-6) are elevated in the (TNF, IL-1 and I-6) are elevated in the blood and myocardial tissueblood and myocardial tissue

Reduced blood flow to the gut may Reduced blood flow to the gut may reduce gut integrity leading to entry of reduce gut integrity leading to entry of bacteria and endotoxinsbacteria and endotoxins

High TNF associated with reduced BMI, High TNF associated with reduced BMI, lower skinfolds, reduced visceral proteinslower skinfolds, reduced visceral proteins

Krummel in Krause, 12th ed., 2008

Energy Needs in HFEnergy Needs in HF

For obese patients, hypocaloric diets For obese patients, hypocaloric diets (1000-1200 kcals) will reduce the (1000-1200 kcals) will reduce the stress on the heartstress on the heart

In undernourished patient, energy In undernourished patient, energy needs are increased by 30-50% above needs are increased by 30-50% above basal levels; 35 kcals/kg often usedbasal levels; 35 kcals/kg often used

Patients with cardiac cachexia may Patients with cardiac cachexia may require 1.6-1.8 times resting energy require 1.6-1.8 times resting energy expenditure for repletionexpenditure for repletion

SodiumSodium

Impaired cardiac function Impaired cardiac function → → inadequate inadequate blood flow to the kidneys blood flow to the kidneys → → aldosterone aldosterone and antidiuretic hormone secretionand antidiuretic hormone secretion

Aldosterone promotes sodium resorption Aldosterone promotes sodium resorption and ADH promotes water conservationand ADH promotes water conservation

Even patients with mild heart failure can Even patients with mild heart failure can retain sodium and water if consuming a retain sodium and water if consuming a high salt diet (6 g or 250 mEq/day)high salt diet (6 g or 250 mEq/day)

Sodium in Patients with Sodium in Patients with

Heart FailureHeart Failure Recommendations vary between Recommendations vary between

1200 to 2400 mg/day (adequate 1200 to 2400 mg/day (adequate intake 1200 mg/d)intake 1200 mg/d)

Patients on high dose lasix (>80 Patients on high dose lasix (>80 mg/day) <2000 mgmg/day) <2000 mg

Severe restrictions are unpalatable Severe restrictions are unpalatable and nutritionally inadequateand nutritionally inadequate

Ethnic differences in sodium intakeEthnic differences in sodium intake Use least restrictive diet that Use least restrictive diet that

achieves clinical goalsachieves clinical goals

Dietary Sources of Dietary Sources of SodiumSodium Salt used at the tableSalt used at the table Salt or sodium compounds added during Salt or sodium compounds added during

preparation or processingpreparation or processing Inherent sodium in foodsInherent sodium in foods Chemically softened waterChemically softened water Average American consumes 4 to 6 g Average American consumes 4 to 6 g

sodium/day; 80% from processed foodssodium/day; 80% from processed foods Minimum to maintain life is 250 mg/dayMinimum to maintain life is 250 mg/day Salt substitutes, herbs, spices and other Salt substitutes, herbs, spices and other

seasoningsseasonings Drugs and antacids may contain sodiumDrugs and antacids may contain sodium Kosher foodsKosher foods

Characteristics of Characteristics of Common Sodium Common Sodium RestrictionsRestrictions3 g (131 mEq)3 g (131 mEq)

No added saltNo added saltHigh sodium foods are limited; no more High sodium foods are limited; no more than ½ t of table salt allowedthan ½ t of table salt allowed

2 g (87 mEq)2 g (87 mEq)

Mild restrictionMild restrictionHigh sodium foods are eliminated; High sodium foods are eliminated; moderate sodium foods are limited; no moderate sodium foods are limited; no more than ¼ t of table salt allowedmore than ¼ t of table salt allowed

1 g (43 mEq)1 g (43 mEq)

ModerateModerateHigh and moderate sodium foods High and moderate sodium foods eliminated; table salt not allowed; eliminated; table salt not allowed; canned/processed foods containing salt canned/processed foods containing salt omitted; frozen peas, lima beans, omitted; frozen peas, lima beans, mixed veg and corn omitted d/t brine in mixed veg and corn omitted d/t brine in processing; regular bread and baked processing; regular bread and baked goods limited. Difficult to maintain at goods limited. Difficult to maintain at homehome

500 mg Sodium Diet500 mg Sodium Diet

High sodium, moderate sodium foods High sodium, moderate sodium foods eliminated. Table salt not allowed. Canned or eliminated. Table salt not allowed. Canned or processed foods containing salt omittedprocessed foods containing salt omitted

Frozen vegetables (peas, lima beans, mixed Frozen vegetables (peas, lima beans, mixed vegetables, corn) omitted due to brinevegetables, corn) omitted due to brine

High sodium vegetables beets, beet greens, High sodium vegetables beets, beet greens, carrots, kale, spinach, celery, white turnips, carrots, kale, spinach, celery, white turnips, rutabagas, mustard greens, chard, dandelion rutabagas, mustard greens, chard, dandelion greens omittedgreens omitted

Low sodium bread instead of regular breadLow sodium bread instead of regular bread Meat limited to 6 ouncesMeat limited to 6 ounces

High Sodium FoodsHigh Sodium Foods

Food Servings for Food Servings for Sodium-Controlled Sodium-Controlled DietsDiets

Food Servings for Food Servings for Sodium Controlled Sodium Controlled Diets, contDiets, cont

Food Labeling Guide Food Labeling Guide (standard serving)(standard serving)

Sodium FreeSodium Free Less than 5 mg Less than 5 mg

Very Low SodiumVery Low Sodium 35 mg or less 35 mg or less

Low SodiumLow Sodium 140 mg or less140 mg or less

Reduced SodiumReduced Sodium At least 25% less sodium At least 25% less sodium than than regular foodregular food

Light SodiumLight Sodium 50% less sodium50% less sodium

Unsalted,Unsalted, No salt added during No salt added during processing processing Without Added Salt, Without Added Salt, No Salt AddedNo Salt Added

Lightly SaltedLightly Salted 50% less added sodium than 50% less added sodium than normally added (product normally added (product

must must state “not a low-sodium food”)state “not a low-sodium food”)

Nondietary Sources of Nondietary Sources of SodiumSodium Medications: barbiturates, Medications: barbiturates,

sulfonamides, antibiotics, cough sulfonamides, antibiotics, cough medications, stomach alkalizers, medications, stomach alkalizers, laxatives, mouthwasheslaxatives, mouthwashes

Chewable antacid tablet can add Chewable antacid tablet can add 1200 to 7000 mg of sodium daily 1200 to 7000 mg of sodium daily

Aspirin: 50 mg sodium per tabletAspirin: 50 mg sodium per tablet

PotassiumPotassium

Potassium wasting diuretics Potassium wasting diuretics (hydrochlorthiazide, furosemide) increase (hydrochlorthiazide, furosemide) increase potassium excretion which may lead to potassium excretion which may lead to digitalis toxicitydigitalis toxicity

Some patients will need potassium Some patients will need potassium supplementssupplements

Salt substitutes can provide 500-2000 mg Salt substitutes can provide 500-2000 mg of potassium per teaspoon; of potassium per teaspoon; contraindicated in renal failure and with contraindicated in renal failure and with certain other medicationscertain other medications

Sodium and Salt Gram Sodium and Salt Gram and Milliequivalent and Milliequivalent MeasuresMeasures

1 mEq Na = 23 mg NA

Other Dietary Factors Other Dietary Factors in in Heart FailureHeart Failure

Alcohol and caffeineAlcohol and caffeine Weight maintenanceWeight maintenance Calcium and vitamin DCalcium and vitamin D MagnesiumMagnesium Thiamin supplementationThiamin supplementation Small frequent feedingsSmall frequent feedings SupplementsSupplements

Other Nutritional Other Nutritional IssuesIssues Calcium and Vitamin D: half of patients Calcium and Vitamin D: half of patients

with severe HF have osteopenia or with severe HF have osteopenia or osteoporosis, especially cachectic osteoporosis, especially cachectic patients; use calcium supplements patients; use calcium supplements with caution w/ cardiac arrhythmiaswith caution w/ cardiac arrhythmias

Magnesium: diuretics may increase mg Magnesium: diuretics may increase mg excretion; measure blood mg levelsexcretion; measure blood mg levels

Thiamin status should be evaluated in Thiamin status should be evaluated in HF patients on loop diureticsHF patients on loop diuretics

Cardiac Assist DevicesCardiac Assist Devices

Mechanical heart pumpsMechanical heart pumps May be helpful in pre-transplant May be helpful in pre-transplant

HF patients or in those for whom HF patients or in those for whom transplant is not an optiontransplant is not an option

Heart TransplantHeart Transplant

Only cure for refractory CHFOnly cure for refractory CHF In 2003, 2000 cardiac In 2003, 2000 cardiac

transplants in the U.S. transplants in the U.S. Highest number in white Highest number in white

men 50-64 years of agemen 50-64 years of age

Pretransplant MNT Pretransplant MNT GoalsGoals Body weight 90-110% of ideal body Body weight 90-110% of ideal body

weightweight Extremes of weight (<80% or >140% Extremes of weight (<80% or >140%

IBW predict poor outcomeIBW predict poor outcome Pretransplant comorbidities Pretransplant comorbidities

(hypertension, hyperlipidemia, diabetes) (hypertension, hyperlipidemia, diabetes) reduce survival ratesreduce survival rates

Survival 83% at 1 year, 72% at 5 years, Survival 83% at 1 year, 72% at 5 years, 50% at 9 years50% at 9 years

CardiomyopathyCardiomyopathy

Post-Transplant MNT Post-Transplant MNT GoalsGoals Adequate support to promote healing Adequate support to promote healing

and fight infectionand fight infection Monitor and correct electrolyte Monitor and correct electrolyte

abnormalitiesabnormalities Achieve optimal blood glucose controlAchieve optimal blood glucose control Provide energy for ambulation and Provide energy for ambulation and

physical therapyphysical therapy Energy: 1.3-1.5 times REE; protein 1.5-2 Energy: 1.3-1.5 times REE; protein 1.5-2

grams/kg body weight; Na 2-4 g/daygrams/kg body weight; Na 2-4 g/day

Hasse in Krause, 12th Ed., p. 896

Post-Transplant MNT Post-Transplant MNT Issues Long TermIssues Long Term Immunosuppressants can cause weight gain Immunosuppressants can cause weight gain

and hyperlipidemiaand hyperlipidemia Risk factors are prednisone dose, baseline Risk factors are prednisone dose, baseline

cholesterol level, blood glucose levels, and cholesterol level, blood glucose levels, and weight gainweight gain

Graft atherosclerosis is the leading cause of Graft atherosclerosis is the leading cause of death in long-term survivorsdeath in long-term survivors

TLC diet with 2-4 gram sodium; optimal TLC diet with 2-4 gram sodium; optimal calcium and vitamin D to prevent steroid-calcium and vitamin D to prevent steroid-induced osteoporosisinduced osteoporosis

ADA Nutrition Care ADA Nutrition Care Manual Education Manual Education ResourcesResources

http://nutritioncaremanual.org/univerhttp://nutritioncaremanual.org/universi13si13

Heart failure Nutrition TherapyHeart failure Nutrition Therapy Hypertension Nutrition TherapyHypertension Nutrition Therapy DASH Diet guidelinesDASH Diet guidelines

SummarySummary CHF—most common reason for CHF—most common reason for

long lengths of stay in the elderlylong lengths of stay in the elderly Prevention and management is Prevention and management is

key as prognosis is poorkey as prognosis is poor Aggressive nutritional Aggressive nutritional

interventions are important.interventions are important.