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Nutrition and Heart Failure: what we know and don’t know

By Audrey Shively, MCHES
Official ACCN16 Blogger
Dr. Scott Hummel’s presentation on heart failure (HF) and nutrition provided great insights in to what research has told us to date and what we still need to learn.
One in five people have congestive heart failure which equates to six million people and one in nine deaths in the United States. It is a large and growing problem defined as the heart not being able to meet the physiologic demands of the body.
The presentation focused on dietary guidelines, malnutrition and frailty, micronutrient deficiencies, and energy interventions. It was full of lots of great data and I strongly encourage you to view this recorded session to see the complete picture. I am only going to be able to address the highlights here.
Nutrition intervention in heart failure encompasses a variety of issues such as diet adherence, neurohormonal affects, metabolic aspects, and the physical effects of malnutrition. We often ask why our HF patients cannot eat a more healthy diet but such things as a decreased sense of smell, early satiety, and medications all affect how patients eat.
There are several comorbidities associated with HF such as cognitive dysfunction, disability, and polypharmacy with studies showing HF patients can easily have five or more comorbidities to be addressed.
Dr. Hummel focused a great deal of his talk on the Academy of Nutrition and Dietetics (AND) guidelines for heart failure. I will share in overview of his remarks here.
Sodium and fluid intake: should be adapted to the patient and should allow for adequate protein in the diet.The dietary sodium debate has not been answered based on both observational and random control studies.
Malnutrition: if a patient is deemed malnourished there are more adverse outcomes; this is true of fragility as well. If one is malnourished most often they are also frail.
Micronutrients: HF patients are encouraged to take folate, vitamin B6, vitamin B12, thiamine, and magnesium; it is felt these prove to be more beneficial when coming from foods rather than supplements.
Energy metabolism: HF patients have impaired energy production and nutrient deficiency can affect this.
Dr. Hummel spent time addressing new mechanisms that may be promising for HF treatment. These include dietary nitrates, metabolic improvements, microbiomes, and vascular salt sensitivity.
There are also many studies still underway that will have an impact on HF treatments including those looking at the effect of calorie restrictions, sodium intake and quality of life, and the correlation between sodium intake and energy.
His overall takeaway messages were:
  1. Heart failure is a large and growing problem
  2. Nutrition is important but is incompletely understood
  3. Sodium intake must be adapted to each patient
  4. New mechanisms may improve our knowledge base
His final message gives us all sound advice about our nutrition and health and that is we should adopt a whole food dietary approach to eating healthy.

High Sodium Warning Labels…New York’s Latest Public Health Policy

By: Mary Scourboutakos

In just a few weeks, New York will be the first city to introduce high sodium warning labels in restaurants. As a result, come December 1st 2015, any menu item that exceeds 2300 mg of sodium will be required to sport the new graphic illustrating a salt shaker inside of a triangle.

The policy, which is an amendment to the New York City Health Code, will affect any chain restaurant with at least fifteen locations, and will affect over 3000 restaurants, or one-third of all restaurant traffic in New York City.

Megan Lent, the Acting Director of Policy at the Bureau of Chronic Disease Prevention and Tobacco Control, who was involved in the background research and development of the policy, said the idea came from research which showed that people are eating more of their meals away from home. Furthermore, she said the rationale also comes from sodium’s effect on blood pressure, and ultimately heart disease—which is the leading cause of death in New York City. Hence, she explained that this policy will “put information back into consumers hands” and thus hopefully foster healthier choices.

While some might argue that 1500 mg—the daily Adequate Intake level—would be a more conservative limit, Lent says they went with 2300 mg—the daily Upper Tolerable intake level—because “this clearly lets people know when they’ve reached that threshold, without making assumptions.”

As for the choice of a pictorial warning label, Lent explained that listing the number of milligrams of sodium is preempted by the federal calorie labeling law that was passed as part of the Patient Protection and Affordable Care Act, back in 2010. Hence, numerical information regarding sodium simply isn’t allowed. Nevertheless, as Lent highlighted, one advantage of the graphic is that it provides an “actionable symbol.”

The implementation of policies such as this one, rarely come without backlash from critics. However, while this policy did receive some comments from the food industry during the public comment period, Lent explained that with regards to the media coverage “a lot has been fairly supportive.” And while some experts have criticized the whole notion of menu-labeling, citing a lack of evidence of effectiveness, Lent says polling has shown that “many New Yorkers think calorie labeling is useful and that these interventions are helpful.”

In a recent article posted on Nation’s Nutrition News, Anita-Jones Mueller, the founder of Healthy Dining and Healthydiningfinder.com, told industry to “just say no” by stating “save money and time, and prevent the risk of disappointed guests, by saying NO to the icon and making sure that most — if not all — of your menu items contain under 2,300 mg of sodium. It’s possible!”

But is it possible? In my own research, I’ve found that 56% of meals from chain, sit-down restaurants would qualify for the warning label, if it was implemented in Canada. However, when menu items are listed individually on the menu (ex. side dishes separate from entrÉes) only 9% would carry the label.

The New York Department of Health plans to evaluate the policy by monitoring changes in sodium levels over time using “Menu Stat”, their free online longitudinal nutrition database containing information for thousands of restaurant foods. But will the policy encourage decreases in sodium, as was seen in King County, Washington after the implementation of their sodium labelling policy? One can only hope!

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Full-Service Restaurant Dining May Be Calorically Expensive

By Sabrina Sales Martinez, MS, RDN

In the United States, more than 35% of the adult population and 17% of children and adolescents are obese [1-2]. Overconsumption of calories has been contributing to the rise in obesity, and fast food restaurants are often mentioned as a possible culprit. Fast food menu items have been shown to be lower in nutritional quality, higher in saturated fat and misaligned with national dietary guidelines. Often, full-service restaurants are thought to offer higher quality foods and healthier menu options. Data on the nutritional quality of foods sold in full-service restaurants, however, is lacking. According to a recent article in the Journal of Nutrition Education and Behavior, there may be a misconception that full-service restaurants are healthier than fast food restaurants.

A recently published article by Auchincloss and colleagues [3] may provide much needed information on full-service restaurants and the nutritional content of their menu items. The researchers at Drexel University and University of Pennsylvania reviewed menus from 21 full-service chain restaurants in Philadelphia at different price points and over 2,600 menu items. Menu items that were labeled as being healthier options were also compared to the US Dietary Guidelines. Restaurants were included if they provided calorie and sodium information for all menu items and if most of their main dishes were single serving entrees. Their results showed that on average a la carte entrees and appetizers were about 800 kcalories and 50% did not meet the healthier criteria set by the authors based on the US Dietary Guidelines. About one-third of the entrees and appetizers exceeded the dietary reference values (DRV) for a 2,000 kcalorie diet for adults and 1,400 kcalorie diet for children for saturated fat and sodium. In addition, only 20% of the items met minimum fiber recommendations. The most astonishing findings from this study was that, on average, a meal that consisted of an adult entrÉe, side dish and shared appetizer provided about 1,495 kcalories, 28 grams of saturated fat, 3,312 mg of sodium and 11 grams of fiber. If a non-alcoholic beverage and dessert was added to the meal, then it totaled 2,020 kcalories, 39 grams of saturated fat, 3,760 mg sodium and 12 grams of fiber. Yes, one meal exceeded the average adult’s energy needs for the day! Other important findings include that menu items targeted to seniors had surpassed the DRV for saturated fat and sodium, and that those mostly targeted to children exceeded calorie and sodium DRVs.

The results from the study by Auchincloss and colleagues [3] are welcomed, because as previously mentioned, data on the nutritional quality of menu items in full-service restaurants are scarce. Considering that full-service chain restaurants control most of the US restaurant market and that almost half of food expenditures are from restaurants [4], this study provides important information that can be translated into nutrition education for the restaurant customer. Most of the healthy labeled items at these restaurants only considered calories as a criterion for being “healthy” and only half of the restaurants offered a healthier option.

This study only provides the starting point in addressing the nutritional quality of meals in restaurants, and the authors hope that these data can be compared to future studies to see whether changes occur in providing healthier options and whether these options are implemented at the request of consumers or due to regulation. As part of the Affordable Health Care Act of 2010 all restaurants with greater than 20 locations will need to provide menu labeling and the customers will need to have the necessary tools to understand the meaning of these labels and its implications for their health. Findings from present and future studies should be used to propose and implement interventions and/or strategies that can be used to bring about awareness to the restaurant industry and its consumers of the recommended dietary intakes and adoption of healthier menu options. Examining the nutritional quality of restaurant meals may be a worthwhile public health endeavor to reduce obesity, its associated health conditions and their financial burden in medical expenses, especially when there is a strong trend towards consuming increased number of meals outside the home, and there is evidence that these meals may be higher in calories, saturated fat and sodium. In these conditions, establishing criteria for healthier options for restaurants may be warranted.

The authors have made recommendations to restaurants based on their findings.

References
1. Centers for Disease and Control (CDC). Overweight and Obesity: Adult Obesity Facts.
2. Centers for Disease and Control (CDC). Overweight and Obesity: Childhood Obesity Facts.
3. Auchincloss AH, Leonberg BL, Glanz K, Bellitz S, Ricchezza A, Jervis A. Nutritional Value of Meals at Full-service Restaurant Chains. J Nutr Educ Behav. 2014 Jan;46(1):75-81. doi: 10.1016/j.jneb.2013.10.008.
4. Industry at a glance. National Restaurant Association website.