JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 79, NO.

16, 2022

ª 2022 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER

JACC REVIEW TOPIC OF THE WEEK

Nutrition Assessment and Dietary

Interventions in Heart Failure
JACC Review Topic of the Week

Elissa Driggin, MD,a Laura P. Cohen, MD, MPP,a Dympna Gallagher, EDD,b
Wahida Karmally, DRPH, MS, RDN, CDCES, CLS,c Thomas Maddox, MD, MSC,d Scott L. Hummel, MD, MS,e
Salvatore Carbone, PHD, MS,f,g Mathew S. Maurer, MDa

ABSTRACT

Despite the high prevalence of nutrition disorders in patients with heart failure (HF), major HF guidelines lack specific
nutrition recommendations. Because of the lack of standardized definitions and assessment tools to quantify nutritional
status, nutrition disorders are often missed in patients with HF. Additionally, a wide range of dietary interventions and
overall dietary patterns have been studied in this population. The resulting evidence of benefit is, however, conflicting,
making it challenging to determine which strategies are the most beneficial. In this document, we review the available
nutritional status assessment tools for patients with HF. In addition, we appraise the current evidence for dietary in-
terventions in HF, including sodium restriction, obesity, malnutrition, dietary patterns, and specific macronutrient and
micronutrient supplementation. Furthermore, we discuss the feasibility and challenges associated with the implemen-
tation of multimodal nutrition interventions and delineate potential solutions to facilitate addressing nutrition in patients
with HF. (J Am Coll Cardiol 2022;79:1623–1635) © 2022 by the American College of Cardiology Foundation.

A s the prevalence of heart failure (HF) rises

with time, a multidisciplinary approach to
treatment is paramount. Nutrition disorders,
including abnormalities in body composition such as
obesity and malnutrition and/or macronutrient and
micronutrient deficiencies, are highly prevalent in
HF, with the potential to affect the disease trajec-
tory. 1,2 Despite this, major HF guidelines have very
limited recommendations on nutrition disorders
because of a lack of consensus on how to effectively
treat them.3-6 Accordingly, we reviewed the available
published reports related to nutrition and HF using
an online search strategy outlined in the
Supplemental Appendix. In this review, we discuss
the major assessment tools and focus areas for nutri-
tion in HF. Furthermore, we describe the challenges
associated with implementing nutrition interventions
and offer potential solutions to mitigate these

Listen to this manuscript’s
audio summary by
Editor-in-Chief
Dr Valentin Fuster on
JACC.org.
From the aDivision of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New
York, USA; bInstitute of Human Nutrition, Columbia University Irving Medical Center, New York, New York, USA; cColumbia
University Irving Medical Center, New York, New York, USA; dDivision of Cardiology, Washington University School of Medicine,
St Louis, Missouri, USA; eAnn Arbor Veterans Affairs Health System, University of Michigan Frankel Cardiovascular Center, Ann
Arbor, Michigan, USA; fDepartment of Kinesiology & Health Sciences, College of Humanities & Sciences, Virginia Commonwealth
University, Richmond, Virginia, USA; and the gVirginia Commonwealth University Pauley Heart Center, Division of Cardiology,
Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,
visit the Author Center.

Manuscript received January 5, 2022; revised manuscript received February 15, 2022, accepted February 17, 2022.

ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2022.02.025

1624 Driggin et al
Nutrition Considerations in Heart Failure
ABBREVIATIONS challenges so that nutrition becomes a focus
AND ACRONYMS
area of future attention and research as a
treatment target in HF (Central Illustration).
BMI = body mass index
CRF = cardiorespiratory fitness QUANTIFYING NUTRITIONAL STATUS
DASH = Dietary Approaches to IN HF
Stop Hypertension
The prevalence of malnutrition in HF is
FFM = fat free mass
HF = heart failure estimated at 15% to 90%, depending on the
HFpEF = heart failure assessment method and, when present, is
preserved ejection fraction associated with more than double the risk for
n-3 PUFA = omega-3 mortality.3,7 Given the heterogeneity of
polyunsaturated fatty acids nutrition disorders and limited comprehen-
UFA = unsaturated fatty acids sive head-to-head studies comparing assess-
ment tools, there is no gold standard for assessing
malnutrition in HF.8 In this section, we will outline
and appraise common assessment methods (Table 1).
BODY MASS INDEX. The most common tool to
approximate nutritional status is body mass index
(BMI). Although easy to measure in routine clinical
practice, BMI does not distinguish weight attributable
to excess fluid vs lean and/or fat mass. 9 In this
context, patients with HF who are volume overloaded
may be classified according to the World Health Or-
ganization criteria as having falsely normal or high
BMI yet still have low lean body mass and/or
malnutrition.9 Additionally, a significant proportion
of patients with HF and obesity are malnourished or
at risk of malnutrition, estimated at 10% to 50%,
depending on the population and screening instru-
ment. 10
Furthermore, among patients with excess fat
mass, BMI does not reflect adipose distribution (ie,
visceral vs subcutaneous), which may have prog-
nostic implications in HF. 11 A reliance on BMI alone as
a measure of nutritional status clearly misses patients
at risk for poor outcomes.
BODY COMPOSITION. Body composition analysis is
an important assessment tool in HF that informs the
proportion of body mass that is fat mass vs fat-free
mass (FFM). However, HF-related increases in body
water and reductions in muscle mass violate the un-
derlying assumptions for many body composition
assessment techniques, rendering them inaccurate.9,12
Dual-energy X-ray absorptiometry, though an efficient
and highly accurate technique to assess bone, lean,
and fat mass, assumes minimal effects of hydration on
FFM, which is inaccurate in HF. 12
Although magnetic
resonance imaging and computed tomography are
ideal to quantify muscle and fat mass, their clinical use
is limited by impracticality and cost as well as contra-
indications to magnetic resonance imaging such as
claustrophobia and/or incompatible pacemakers or
defibrillators. Quantitative magnetic resonance tech-
niques with short scan times developed for the
JACC VOL. 79, NO. 16, 2022
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HIGHLIGHTS

Nutritional disorders are often over-
looked in patients with heart failure
because of a paucity of standardized
definitions and accurate tools to assess
nutritional status in this population.

Evidence is controversial for in-
terventions targeting nutrition issues
pertinent to patients with heart failure,
including sodium restriction, obesity,
malnutrition, dietary patterns, and
micronutrient supplementation.

There are several patient, provider, and
societal barriers to the implementation of
effective nutrition interventions in the
management of heart failure.
purpose of body composition analysis may be accurate
in HF, although they are not yet widely available.12
Despite the potentially high discriminatory ability of
these modalities, the lack of diagnostic criteria for
nutrition disorders based on fat and FFM mass quan-
tification limits their clinical utility to date.
BIOMARKERS. There are multiple candidate bio-
markers as surrogates for nutritional status in HF
(Table 1). Serum albumin is a hepatic protein affected
by nutrition that has been studied extensively
regarding HF prognosis. In large HF cohort studies,
hypoalbuminemia (ie, serum albumin of <3.4 g/dL)
was an independent predictor of all-cause mortality.13
Similarly, low prealbumin level, lymphopenia, and
low serum cholesterol level have all been implicated
as poor nutrition-related prognostic indicators in
HF.14-16 Despite these associations, these biomarkers
are affected by comorbidities, medications, volume
status, and inflammation, and they are difficult to
interpret in isolation. Importantly, there are several
candidate biomarkers specific to cardiac cachexia,
such as ghrelin, adiponectin, and myostatin, that are
the subject of future research and may aid in the
diagnosis of this high-risk condition in advanced
HF.17 In addition, metabolomics, including amino
acid profiling, have identified elevated 3-methyl-
histidine (3-Me-His), a histidine derivative, as a
marker of cardiac cachexia that predicts poor prog-
nosis in patients with HF. 18
MULTIDIMENSIONAL ASSESSMENT TOOLS. There
are numerous multidimensional tools to diagnose
malnutrition in HF (Table 1). 8,10 These assessment
methods incorporate several parameters related to
nutrition and often use a scoring system to categorize
JACC VOL. 79, NO. 16, 2022
APRIL 26, 2022:1623–1635
C ENTR AL I LL U STRA T I O N Major Heart Failure Nutrition Domains and Challenges
to Implementation
Driggin E, et al. J Am Coll Cardiol. 2022;79(16):1623–1635.
Schematic representing the major nutrition-related research focus areas in the context of potential challenges to the implementation of
nutrition interventions in heart failure.
the severity of malnutrition. Given the potential con-
founding clinical factors in HF associated with any
individual measurement, these assessment tools are
potentially useful because they take into account
variable combinations of anthropometrics,
markers, and appetite assessments.8 Although there
are limited head-to-head studies that have compared
these assessment methods directly, the Geriatric
Nutritional Risk Index, which assesses current body
weight indexed to ideal body weight and serum albu-
min level, and the Mini Nutritional Assessment, which
assesses dietary intake, mobility, and BMI, have
shown the strongest association with mortality risk in
HF cohort studies.8,10 The Subjective Global Assess-
ment, which incorporates physical examination
Driggin et al 1625
Nutrition Considerations in Heart Failure
findings such as muscle wasting and loss of subcu-
taneous fat, has also been identified as one of the most
specific malnutrition assessments in HF. 19 Notably,
there is no accepted gold standard instrument, and
bio- although these scores are often quick to calculate,
their results may reflect the severity of the patient’s
underlying illness rather than malnutrition directly.
CURRENT FOCUS AREAS IN NUTRITION AND HF
To date, there are several nutrition disorders known
to affect HF incidence, progression, and prognosis. 1,3
Although the evidence to support interventions for
some nutrition disorders is robust, in others it is
lacking, resulting in limited nutrition-related
1626 Driggin et al JACC VOL. 79, NO. 16, 2022

Nutrition Considerations in Heart Failure APRIL 26, 2022:1623–1635

T A B L E 1 Nutritional Status Assessment Methods in Heart Failure

Method Measures Advantages Disadvantages

BMI Weight indexed to height squared (kg/m2) Easy to calculate Does not differentiate lean vs fat vs fluid mass
Routinely measured Does not reflect distribution of adiposity
High clinical awareness
Body composition
DXA Differentiates lean vs fat vs fluid mass Certain measures inaccurate with excess body
analysis
MRI water (ie, DXA, BIA)

CT Certain methods expensive and/or impractical

Quantitative MRI (ie, MRI)

BIA
No established cutoffs for nutritional disorders
Biomarkers Albumin Easy to measure Confounded by comorbidity, hepatopathy,
Prealbumin medication, and inflammation

Lymphocyte count
Total cholesterol
Biomarkers of cardiac cachexia:

Ghrelin

Adiponectin

C-terminal agrin fragment

Growth differentiation factor 15

Atrial natriuretic peptide

N-terminal propeptide of type III
procollagen

Type VI collagen N-terminal globular,
domain epitope

Myostatin

Me-3-His
Multidimensional
CONUT Easy to measure Low clinical awareness
assessment tools
GLIM Incorporate multiple domains of Reflects severity of underlying illness rather than

GNRI nutrition status assessment (ie, malnutrition directly (ie, nonspecific)

NRI anthropometrics, biomarkers,

NRS intake patterns, and so on)

MNA

MSRA

NUTRIC

PNI

SARC-F

BIA ¼ bioelectrical impedance analysis; CONUT ¼ Controlling Nutritional Status score; DXA ¼ dual-energy X-ray absorptiometry; GLIM ¼ Global Leadership Initiative on Malnutrition;
GNRI ¼ Geriatric Nutritional Risk Index; MNA ¼ Mini Nutritional Assessment; MRI ¼ magnetic resonance imaging; MSRA ¼ Mini Sarcopenia Risk Assessment; NRI ¼ Nutritional Risk Index;
NRS ¼ Nutritional Risk Screening; NUTRIC ¼Nutrition Risk in the Critically Ill; PNI ¼ Prognostic Nutritional Index; SARC-F ¼ Strength, Assistance With Walking, Rising From a Chair, Climbing
Stairs, and Falls.

recommendations in the HF guidelines. In this sec-
tion, we summarize the evidence for and contro-
versies related to the major nutrition focus areas in
HF (Table 2).20-43
SODIUM RESTRICTION. The most common dietary
recommendation in HF is sodium restriction. Howev-
er, recent data are conflicting, leading to the down-
grading of this recommendation in the major HF
44,45
guidelines. The data on sodium restriction in HF is
largely observational in nature and varies widely in
study design, patient population, and sodium and/or
fluid restriction strategy, making the results difficult
to interpret in aggregate.44 Some studies to date have
shown potential benefits to reduce congestive symp-
toms, improve functional class, and reduce diuretic
dose.20,46 Contrastingly, other studies have reported
neurohormonal activation in response to sodium
restriction in HF, demonstrating higher levels of hor-
mones associated with renin-angiotensin-aldosterone
system activation and worse renal function compared
to those with more liberalized sodium intake.22,47
Potential mechanisms include intravascular volume
depletion, decreased renal perfusion, and lower so-
dium delivery to nephrons; however, confounding by
medication use cannot be excluded. 44 Regarding hard
outcomes, sodium restriction has been associated with
increased hospitalizations and mortality, which may
be confounded by the lower intake of calorie and
micronutrients associated with the prescription of
low-sodium diets.25,26 SODIUM-HF (Study of Dietary
Intervention Under 100 mmol in Heart Failure) is an
ongoing multicenter trial in ambulatory patients with
chronic HF that will study the impact of a low-sodium
diet on a composite of all-cause mortality, HF
JACC VOL. 79, NO. 16, 2022
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T A B L E 2 Nutrition Domains in Heart Failure: Societal Recommendations, Considerations for Intervention, and Key Areas for Future Research
Nutrition Sodium
Domain Restriction
Society recommendations
HFSA, 2010 Restrict sodium to 2-3 g,
consider <2g in
moderate to severe
HF
ACC/AHA, 2013 Reasonable if
symptomatic
ESC, 2021 None
Considerations with intervention
Potential benefits Improve symptoms20
Lower diuretic doses
Potential mortality
benefit in NYHA classes
III-IV21
Potential harms Neurohormonal
activation22-24
Potential increase in HF
hospitalizations22,23,25
Potential increased Long-term weight regain
mortality, especially
21
in NYHA class I-II HF
Malnutrition attributable
to lower overall intake
with sodium
restriction26
Future research Patient-level factors that
influence sodium
restriction
recommendations
Specific strategies for
HFpEF vs HFrEF
ACC ¼ American College of Cardiology; AHA ¼ American Heart Association; BMI ¼ body mass index; CRF ¼ cardiorespiratory fitness; DASH ¼ Dietary Approaches to Stop Hypertension; ESC ¼ European
Society of Cardiology; HF ¼ heart failure; HFpEF ¼ heart failure preserved ejection fraction; HFrEF ¼ heart failure reduced ejection fraction; HFSA ¼ Heart Failure Society of America; n-3 PUFA ¼omega-3
polyunsaturated fatty acids; NYHA ¼ New York Heart Association; UFA ¼ unsaturated fatty acids.
hospitalization, and/or HF emergency department
visits (NCT02012179).
OBESITY. Obesity, or excess body fat, is an inde-
pendent risk factor for cardiovascular diseases such
as hypertension, diabetes, and coronary artery dis-
ease that, in turn, promote the development of HF.
Driggin et al 1627
Nutrition Considerations in Heart Failure
Dietary Macronutrient and
Obesity Malnutrition Patterns Micronutrient Supplements
BMI of <30 kg/m2 to Caloric supplementation for None Consider n-3 PUFA in NYHA
prevent HF; treat cardiac cachexia class II-IV HFrEF
“severe obesity” in
established HF
Weight loss to prevent None None Intravenous iron in NYHA
HF; unknown efficacy class II-IV HF with iron
for treatment in deficiency
established HF n-3 PUFA reasonable in
NYHA class II-IV HF
Same as ACC/AHA 2013 None None Consider intravenous iron in
HFrEF with symptoms
or recent hospitalization
and iron deficiency
Reduce incidence of HF Potential mortality benefit Reduce incidence of HF with Improved exercise capacity
with weight loss27 with malnutrition plant-based diet35 with intravenous iron38
interventions32-34 Potential mortality benefit in
women with DASH diet36
Improve CRF with weight Fewer HF hospitalizations Improve symptoms with DASH Improved quality of life
loss 28 with malnutrition diet with intravenous iron38
interventions32,34
Improved functional capacity Improve quality of life with Improved quality of life
and quality of life with DASH diet37 with n-3 PUFA39
malnutrition Lower HF hospitalization
interventions33,34 with n-3 PUFA40
Potential mortality benefit
with n-3 PUFA40
Improved exercise capacity
with UFA41
Potential mortality benefit
with coenzyme Q42
Potential for increased Potential for gastrointestinal Potential for malnutrition Potential for
mortality in side effects with attributable to lower gastrointestinal side
established HF, ie, the supplements to treat overall intake with plant- effects with oral iron
obesity paradox29-31 malnutrition33 based diet26 and n-3 PUFA
Lean mass loss with Higher infection risk with
caloric restriction intravenous iron
administration
Increased incidence of atrial
after weight loss fibrillation with n-3 PUFA
supplementation43
Influence of body Ideal method to quantify Impact of the Mediterranean Need for micronutrient
composition on the malnutrition in HF diet in HF supplementation in
obesity paradox context of well-rounded
whole-food diet
Specific strategies for Effective and practical Role for other diets (ie,
HFpEF vs HFrEF malnutrition intervention ketogenic) in HF
strategies in HF
Maintaining a healthy weight across the lifespan
substantially decreases the risk of developing HF
and among patients with obesity, weight loss
through bariatric surgery reduces incident HF by
35%.27 As such, major HF guidelines recommend
intentional weight reduction to reduce adiposity to
1628 Driggin et al JACC VOL. 79, NO. 16, 2022

Nutrition Considerations in Heart Failure APRIL 26, 2022:1623–1635

F I G U R E 1 Pathophysiologic Mechanisms for Malnutrition and Wasting in Heart Failure

HEART FAILURE

Proinflammatory Hyperadrenergic state Increased metabolic Physical

cytokines (ncortisol, nepinephrine, requirements inactivity
(nTNFD, nIL-6, nIL-1) nnorepinephrine)

Renin-angiotensin- Prescription of Inaccurate calculation

aldosterone activation sodium of energy and protein
restricted diets requirements

High catabolic, Poor appetite Vasoconstriction Volume retention pMuscle mass,

low anabolic (altered ghrelin, nfat mass
state (pIGF-1) leptin signaling) Bowel Gut Insufficient
malperfusion edema dietary intake

Muscle wasting pOverall Malabsorption pCardiorespiratory

(nCAF, dietary intake fitness
nGDF-15, nP3NP)
Macronutrient and micronutrient deficiencies

Physical inactivity, HEART FAILURE WASTING

frailty SYNDROMES
pQuality of life
Malnutrition
pFunctional capacity
Cachexia
nMortality
Sarcopenia
Sarcopenic obesity

Schematic representing of the pathophysiologic mechanisms involved in the development and progression of malnutrition and wasting in patients with HF, including
inflammation, neurohormonal activation, and reduced intake and/or physical activity. CAF ¼ C-terminal agrin fragment; GDF ¼ growth differentiation factor;
IL ¼ interleukin; P3NP ¼ N-terminal propeptide of type III procollagen; TNF ¼ tumor necrosis factor.

lower the risk of incident HF. 4-6 In addition, obesity
is thought to play a pathogenic role in heart failure
with preserved ejection fraction (HFpEF) specifically
and is associated with distinct echocardiographic,
hemodynamic, and cardiorespiratory fitness (CRF)–
related attributes that differ from other HFpEF
phenotypes.48 In a randomized trial of 100 patients
with HFpEF and obesity, caloric restriction and/or
aerobic exercise led to significant improvement in
CRF with loss of body weight. 28 However, in this
study, patients had low severity of illness and
impressive adherence to the intervention because
meals were provided by the research team, which
may not be generalizable. Whether these benefits
can be achieved with real-world caloric restriction–
induced weight loss without bariatric surgery re-
mains unclear.
Despite the association between obesity and inci-
dent HF, numerous studies show a protective effect
of class I or II obesity on survival in established HF,
termed the obesity paradox.29 Whether measured by
BMI, percent body fat, or waist circumference, over-
weight and obesity are consistently associated with
improved short-term prognosis compared to normal
or underweight. Even in those patients with HFpEF
for which obesity may be pathogenic, overweight and
obesity (classes I-III) were associated with improved
survival in 2,501 ambulatory patients. 30 Potential
mechanisms include higher metabolic reserve,
increased muscle mass, and improved CRF in those
meeting BMI criteria for overweight or obesity. 31 Of
note, despite the potential benefit for survival,
obesity is still associated with a greater risk for HF
hospitalizations, which is counterintuitive given the
JACC VOL. 79, NO. 16, 2022 Driggin et al 1629
APRIL 26, 2022:1623–1635 Nutrition Considerations in Heart Failure

F I G U R E 2 Approach to the Management of Malnutrition in Heart Failure

Screening Diagnostics Intervention

Multidimensional
History Nutrition Counseling
Assessment Tool

Weight loss Subjective Global Establish protein

Reduced intake Assessment calorie goals
Declining functional Mini Nutrition Liberalize diet
capacity Assessment Refer to registered
Geriatric Nutritional dietitian
Risk Index
Prescribe Nutrition
Physical Exam
Consider Body Supplement
Composition Analysis
Muscle wasting High calorie and high
Loss of subcutaneous Appendicular limb protein
fat DXA Tailor to
Muscle weakness Quantitative MR if comorbidities and
available patient preferences
Laboratory Data

Downtrend in albumin,
prealbumin

Suggested considerations for screening, diagnostics, and intervention with regard to malnutrition in heart failure. DXA ¼ dual-energy X-ray
absorptiometry; MR ¼ magnetic resonance.

association of HF hospitalizations with survival.49
Clearly, further studies are needed to elucidate
these mechanisms.
MALNUTRITION: CARDIAC CACHEXIA AND SARCOPENIA.
In a recent meta-analysis including 12,537 patients,
malnutrition, diagnosed using a variety of multidi-
mensional assessment tools, more than doubled the
risk for all-cause mortality in patients with HF (HR:
2.15; 95% CI: 1.89-2.45). 7 Cardiac cachexia, or the
unintentional loss of >5% of edema-free body weight
over 6 to 12 months, is associated with a particularly
poor prognosis in HF.50 Sarcopenia, or loss of muscle
strength, quantity, and/or physical performance, is
estimated at up to 20% prevalence in patients with
HF and is associated with worse functional class, CRF,
and quality of life.9 Given that sarcopenia may occur
with excess fat mass, termed sarcopenic obesity, this
consequence of malnutrition is highly likely to be
missed. 9 Proposed pathophysiologic mechanisms
linking HF with the development of malnutrition and
wasting are depicted in Figure 1. 50
Several dietary interventions have been trialed in
patients with HF and malnutrition. The PICNIC (Pro-
grama de IntervenCión Nutricional en pacientes hos-
pitalizados por Insuficiencia Cardiaca desnutrido) trial
randomized 120 patients to a 6-month intervention
involving diet optimization and/or nutrition supple-
ment prescriptions, which resulted in a significant
reduction in all-cause death or readmission for HF
(HR: 0.45; 95% CI: 0.19-0.62). 32 The NOURISH (Nutri-
tion effect On Unplanned ReadmIssions and Survival
in Hospitalized patients) trial randomized 652
malnourished hospitalized patients $65 years of age,
25% of whom had HF, to a protein supplement or pla-
cebo for 90 days. 33 Although there was no difference in
the primary endpoint of death or readmission, 90-day
mortality was significantly lower in the supplement
group (RR: 0.49; 95% CI: 0.27-0.90). Most recently, a
secondary analysis of the EFFORT (Effect of early
nutritional support on Frailty, Functional Outcomes,
and Recovery of malnourished medical inpatients
Trial) including 645 hospitalized patients with HF and
1630 Driggin et al JACC VOL. 79, NO. 16, 2022

Nutrition Considerations in Heart Failure APRIL 26, 2022:1623–1635

T A B L E 3 Key Micronutrient Deficiencies With Potential Involvement in HF Pathogenesis and Considerations for Supplementation

Micronutrient Deficiency Significance in HF Evidence for a Direct HF Benefit with Supplementation a

Minerals
Calcium Most common micronutrient deficiency in HF52 Not applicable
Severe hypocalcemia (but not calcium deficiency)
can lead to cardiac dysfunction53
Coenzyme Q Antioxidant activity Reduction in major adverse cardiovascular events (all-cause
Deficiency associated with worse cardiac function mortality, cardiovascular mortality, and hospitalizations for
and worse biomarker profile1 HF) at 2-y follow-up in a randomized trial among patients
with HFrEF and HFpEF42
Folate Common micronutrient deficiency in HF52 May consider supplementation if on diuretic agents and
restricted diets3
Iron Iron deficiency anemia common and compounds Intravenous but not oral iron supplementation improved HF
reduced exercise capacity in HF38 functional status, objective exercise capacity, and quality of
life1,38
Magnesium Common micronutrient deficiency in HF52 May consider in high burden of ventricular arrhythmia or
prolonged QT interval
Selenium Deficiency common in HF52 Some evidence for improvement in cardiac function with
Severe deficiency can lead to reversible supplementation3
cardiomyopathy (Keshan disease)
Zinc Common deficiency in HF52 Trial results pending for a prospective study on zinc
Modulates oxidative stress supplementation in nonischemic cardiomyopathy
(NCT00696410)
Susceptible with angiotensin-converting enzyme
and aldosterone receptor blockers associated
with reduced serum zinc because of increased
urinary excretion3
Water-soluble vitamins
Vitamin B1 (thiamine) Common deficiency in HF52 In select observational (n < 30) and randomized control trials
Severe deficiency can lead to reversible (n < 50), thiamine supplementation improved ejection
cardiomyopathy (wet beriberi) fraction1

Susceptible with renal excretion of water-soluble

vitamins in the setting of diuretic use3
Vitamin B6 (pyridoxine) Less common deficiency May consider supplementation if on diuretic agents and
Susceptible with renal excretion of water-soluble restricted diets3
vitamins in the setting of diuretic use3
Vitamin B12 Less common deficiency May consider supplementation if on diuretic agents and
Increased renal excretion of water-soluble vitamins restricted diets3
in the setting of diuretic use3
Vitamin C Deficiency common in HF52 May improve endothelial function in HF1
Oxidative stress is involved in the pathogenesis of
HF, and vitamin C is an antioxidant1
Fat-soluble vitamins
Vitamin D Lower vitamin D associated with increased mortality No major improvements in symptoms or outcomes with
in HF1 supplementation
Susceptible with decreased exercise tolerance and May increase the incidence of mechanical circulatory support
less sun exposure with supplementation (possible confounding by critical
illness)54
Vitamin E Oxidative stress is involved in the pathogenesis of Possible role in improvements in markers of oxidative stress1
HF, and vitamin E is an antioxidant1
Vitamin K Common deficiency in HF52 Not applicable

a
None of the micronutrients listed in this table are currently recommended for routine use with the exception of intravenous iron in cases of deficiency
HF ¼ heart failure.

malnutrition revealed that a dietitian-led inpatient intervention strategies to date.4-6 A suggested

intervention to reach daily calorie and protein goals
was associated with lower all-cause 30-day mortality
compared to control with a median intervention time
of only 10 days (OR: 0.44; 95% CI: 0.26-0.75).34 Despite
these results, there are no specific recommendations
to treat malnutrition in the major HF guidelines, likely
because of underdiagnosis and heterogeneity of
approach to the diagnosis and treatment of malnutri-
tion in HF is depicted in Figure 2.50
DIETARY PATTERNS. Although there are no guideline
recommendations to endorse a specific diet in the
management of HF, there are data in support of spe-
cific dietary patterns. The most well researched are the
DASH (Dietary Approaches to Stop Hypertension) and
JACC VOL. 79, NO. 16, 2022 Driggin et al 1631
APRIL 26, 2022:1623–1635 Nutrition Considerations in Heart Failure

T A B L E 4 Barriers to Implementation for Nutrition Interventions in Heart Failure and Potential Solutions

Access Adherence Practicality Education

Patient-level Insurance coverage Preference for high-sodium foods Time and financial investment Lack of nutrition education at all
barriers associated with nutrition age levels
Affordability of nutrition Cultural preferences at odds with interventions Lack of culturally sensitive
interventions prescribed nutrition nutrition education
interventions
Potential side effects of nutrition
interventions (ie, nausea or
diarrhea with supplements)
Health care Lack of nutrition-related Lack of adherence measurement Time limits preventing nutrition Lack of nutrition education
provider–level resources techniques counseling
barriers Insufficient number of trained Lack of clear referral patterns to Low awareness of certain
dietitians dietitians nutritional disorders
Societal-level Disparities in access to care for Strong emphasis on Strong emphasis on efficiency in Lack of nutrition-related
barriers those of racial and ethnic pharmacologic and invasive patient-provider interactions guidelines in HF
minorities solutions and lower emphasis on
Disparities in insurance coverage prevention

Low availability of fresh fruit

and vegetables
Neighborhoods and regions
designated as “food deserts”
Potential solutions Programs to reduce racial and Programs to adapt diets consistent Incentives or compensation for Patient education initiatives
ethnic bias in nutrition- with patient preferences physician nutrition regarding the importance of
related HF care counseling nutrition
Increase insurance coverage for Improve technologies to measure Electronic medical record Nutrition education curricula in
effective nutrition adherence prompt for referral to medical school
interventions dietitians
Routine integration of Telehealth dietitian visits Specific nutrition-related HF
registered dietitians into the guidelines
development of HF clinical
programs
Leverage remote delivery of
meals

HF ¼ heart failure.

the Mediterranean diet, which entail a base of fruits,
vegetables, whole grains, unsalted nuts, legumes, and
seafood, as well as low intake of processed foods and
red meats. In a cohort of more than 16,000 healthy
adults enrolled in the REGARDS
Geographic and Racial Differences in Stroke) study,
adherence to a plant-based diet was inversely associ-
ated with HF risk over 8.7 years of median follow-up
(HR: 0.49; 95% CI: 0.41-0.86).35 Among those with
established HF, women enrolled in the Women’s
Health Initiative had lower mortality risk with greater
adherence to the DASH diet in a dose-dependent
manner (most adherent HR: 0.84; 95% CI: 0.70-
36
1.00). In the GOURMET-HF (Geriatric Out-of-Hospi-
tal Randomized Meal Trial in Heart Failure) trial in
which patients $65 years were randomized to 4 weeks
of home-delivered DASH-compliant meals following
an HF hospitalization, those randomized to the inter-
vention experienced benefit with regard to symptoms,
functional capacity, and hospitalizations. 37 It is
notable that in a study examining the impact of several
dietary patterns on HF risk, certain patterns were
associated with the development of heart failure
reduced ejection fraction but not HFpEF (ie, a
“Southern” high–saturated fat/high-sugar diet).35
Whether specific dietary patterns can be used for the
precision prevention of HF based on etiology and other
(REasons for phenotypic features is an important subject for
future research.51
MACRONUTRIENT AND MICRONUTRIENT SUPPLEMENTATION.
Micronutrient supplementation is a subject of great
interest in HF, given the association between micro-
nutrient deficiencies and poor outcomes.52 Micro-
nutrient deficiencies in HF can result from
inadequate dietary intake as well as urinary losses
with diuretic agents. 3,26 Although the quantity and
quality of evidence for micronutrient supplementa-
tion in HF is highly variable, iron supplementation
with iron deficiency is one strategy with a robust
research base to date.38 Although oral iron supple-
mentation does not improve clinical outcomes,
intravenous iron has shown benefit for functional
capacity and quality of life.38 To date, the evidence
for improvement in mortality and hospitalization
rates are less clear, although one trial is ongoing for
these endpoints (FAIR-HF2 [Intravenous Iron in
1632 Driggin et al JACC VOL. 79, NO. 16, 2022

Nutrition Considerations in Heart Failure APRIL 26, 2022:1623–1635

F I G U R E 3 Multidisciplinary Care Team for Nutrition Disorders in Heart Failure

Patient and Caregiver

• Engagement with the
multidisciplinary team to
personalize nutrition
interventions in order to Registered Dietitian
Heart Failure Specialist optimize adherence
• Nutrition assessment,
• HF management,
malnutrition screening,
recognize/treat associated
diet optimization/counseling,
nutrition disorders
supplement prescriptions

Social Worker
Endocrinologist
• Adequate social support, Multidisciplinary Care Team
• Address neurohormonal
insurance coverage, for Nutrition Disorders in
perturbations related to low
transportation to/from Heart Failure appetite in HF
appointments

Exercise Physiologist +
Gastroenterologist
Physical Therapist
• Recognize/treat HF-related
• Address frailty, sarcopenia
gastroenterology issues
related to nutrition disorders,
including malabsorption,
physical inactivity, and reduced
poor appetite
cardiorespiratory fitness

Mental Health Specialist

Primary Care Provider • Address mental health issues
• Comorbidity management, that may contribute to
recognize/treat associated development and progression
nutrition disorders of nutrition disorders
(ie, depression)

Suggested members of the multidisciplinary team and potential contributions for the care of patients with HF and nutritional disorders. HF ¼ heart failure.

Patients With Systolic Heart Failure and Iron Defi-
ciency to Improve Morbidity and Mortality;
NCT03036462). The evidence for other micronutrient
supplementation in HF is limited to date, and further
large-scale trials are needed to establish their partic-
1,3,38,42,52-54
ular role in HF pathogenesis (Table 3).
Overall, it is likely that most micronutrient de-
ficiencies can be mitigated by a well-rounded diet.
In terms of macronutrient supplementation, there
have been data supporting a benefit with unsaturated
fatty acid (UFA) supplementation. Supplementation
with omega-3 polyunsaturated fatty acid (n-3 PUFA)
has been shown to improve CRF, ejection fraction,
and reduced rates of HF hospitalizations compared to
placebo in randomized trials.55 In the GISSI-HF
(Gruppo Italiano per lo Studio della Sopravvivenza
nell'Infarto miocardico-Heart Failure) trial, >7,000
patients with HF were randomized to n-3 PUFA or
placebo with a significant reduction in all-cause
mortality over a mean follow-up of 3.9 years (HR:
0.91; 95% CI: 0.83-1.00).40 However, a recent meta-
analysis demonstrated increased risk for incident
atrial fibrillation with n-3 PUFA in patients with
established or at high risk for cardiovascular disease
(incidence rate ratio: 1.37; 95% CI: 1.22-1.54).43
Therefore, further studies, particularly in patients
with HFpEF at highest risk for atrial fibrillation, are
needed. UFA supplementation through dietary sour-
ces, such as extra-virgin olive oil, canola oil, and nuts,
has also been demonstrated as a feasible and effective
intervention to improve CRF in patients with HFpEF
and obesity in a single-arm pilot study. 41 A
JACC VOL. 79, NO. 16, 2022
APRIL 26, 2022:1623–1635
randomized controlled trial is ongoing (UFA-Pre-
sewrved2 [Unsaturated Fatty Acids to Improve
Cardiorespiratory Fitness in Obesity and HFpEF];
NCT03966755). Finally, supplementation with amino
acids and/or protein has shown modest benefits in
CRF among patients with sarcopenia and/or cardiac
cachexia, although to date this is not recommended
routinely.1
CHALLENGES IN IMPLEMENTATION OF
NUTRITIONAL INTERVENTIONS
As the body of evidence for nutrition interventions in
HF continues to expand over time, it is important to
recognize the challenges in implementation. In this
section, we outline potential barriers and offer po-
tential solutions that may improve the detection and
management of nutrition disorders in HF (Table 4).
Overall, it is likely that involvement of a multidisci-
plinary care team is the best approach to the care of
complex nutrition-related disorders among patients
with HF (Figure 3).
EDUCATION. A lack of population nutrition educa-
tion may hinder the implementation of nutrition in-
terventions in HF. In U.S. schools that offer nutrition
curricula, of which there are few, those with long-
term programs ($1 year) have shown reduction in
overweight/obesity among students.56 Culturally
relevant nutrition education is necessary to make
information more accessible for diverse populations.
Additionally, from a provider standpoint, there is an
overall lack of nutrition education in medical school
and throughout postgraduate training. A meta-
analysis of 24 studies from diverse countries re-
ported that nutrition is insufficiently incorporated
into medical education regardless of country, setting,
or year of medical education, despite students’ desire
to develop their skills in the field. 57 Therefore, edu-
cation reform is necessary from both the patient and
provider standpoint to maximize the effectiveness of
all dietary interventions in HF.
PRACTICALITY. All health-related interventions,
including those for nutrition, require time and
financial investment. Types of interventions that
have been studied to date include intensive inpatient
interventions, meal preparation and distribution,
prescription of supplements, and nutrition education
and/or counseling, all of which vary widely in their
practicality. In the outpatient setting, time con-
straints on provider-patient interactions may limit
the time available to dedicate to nutrition counseling.
Additionally, from a patient standpoint, nutrition
interventions that require meal preparation and/or
Driggin et al 1633
Nutrition Considerations in Heart Failure
repeated in-person visits to the dietitian may be
impractical in the context of other work- and family-
related responsibilities.
ADHERENCE. Measuring adherence is a major
obstacle to determine the efficacy of any nutrition
intervention, and there is no gold standard assess-
ment tool. Methods that involve self-report are used
most frequently, including 24-hour dietary recalls,
3-day food diaries, and food frequency question-
naires; however, these are subject to significant recall
bias. 58 Whether photography methods using mobile
phone capabilities can be used as a more accurate
measure of adherence is a subject of ongoing
research. Measuring biomarkers that reflect recent
intake is another candidate method; however, there
are no validated protocols. In a recent pilot trial
studying UFA supplementation in HFpEF, plasma
UFA were measured to assess compliance and
increased with reported intake of supplemental UFA,
providing both memory-based and objective
operator-independent measures of adherence.41
It is also important to consider patient-related
barriers to adherence with nutrition interventions.
In the NOURISH trial, despite finding a reduction in
all-cause mortality with protein supplementation,
45% of participants self-reported <25% adherence.33
Potential reasons may include cultural and/or per-
sonal preferences that are inconsistent with pre-
scribed diets. HF-related symptoms, such as nausea,
fatigue, and low exercise tolerance, as well as non–
HF-related conditions, such as depression and anxi-
ety, may also contribute.59 Additionally, older pa-
tients with limited functional and/or cognitive
capacity may be unable to acquire or prepare food
that complies with dietary recommendations.
ACCESS. Lack of access to resources that are neces-
sary for a particular nutrition intervention may limit
its efficacy. We must keep in mind disparities in ac-
cess to quality care for racial and ethnic minority as
well as socioeconomically disadvantaged pop-
ulations that may limit access to nutrition-related
resources. Previous studies have shown that
community-level engagement targeting nutrition-
related cardiovascular risk factors such as hyperten-
sion can be highly successful in high-risk minority
populations.60 Other access issues include environ-
mental factors such as neighborhood, which in-
fluences access to fresh fruits and vegetables, with
large disparities in the distribution of such resources
by location. For older adults with mobility disorders,
the inability to travel because of physical or cogni-
tive limitations must be considered. Lack of physi-
cian access to registered dietitians also limits the
1634 Driggin et al JACC VOL. 79, NO. 16, 2022

Nutrition Considerations in Heart Failure APRIL 26, 2022:1623–1635

ability of patients with HF to receive adequate the New York Cardiological Society (May 2021); has received
compensation and travel expense reimbursement for American Col-
nutritional support.
lege of Cardiology leadership roles and meetings; is currently
employed as a cardiologist and vice president of digital products and
CONCLUSIONS innovation at BJC HealthCare/Washington University School of
Medicine, and in this capacity is advising Myia Labs, for which his

Because of a lack of clinically accepted and reliable
measures of nutritional status and ongoing contro-
versy regarding the most effective interventions on a
variety of nutritional disorders, nutrition-related rec-
ommendations are lacking in the current HF guide-
lines. Barriers related to education, practicality,
adherence, and access on the patient, provider, and
societal levels have also contributed. There is a need to
develop multimodal dietary interventions involving
HF, nutrition, metabolism, and implementation sci-
ence so that we can most effectively target nutritional
disorders to affect HF morbidity and mortality.
FUNDING SUPPORT AND AUTHOR DISCLOSURES
Dr Gallagher has received grant support from National Institutes of
Health (UG3 DK128302-01, P30 DK26687-41 and 5T32DK007559-31). Dr
Karmally is a health advisor at Sesame Workshop; and is a member of
Heali Diet Advisory Group and a member of the Abbott Diversity
Council. Dr Maddox has received grant funding from the National
Institutes of Health National Center for Advancing Translational
Sciences (1U24TR002306-01: A National Center for Digital Health
Informatics Innovation); has received honoraria and/or expense
reimbursement in the past 3 years from the Henry Ford health system
(March 2019), the University of California, San Diego (January 2020),
the University of Chicago (January 2021), George Washington Uni-
versity (January 2021), Baylor College of Medicine (April 2021), and
employer is receiving equity compensation in the company (he is
receiving no individual compensation from the company); and is a
compensated director for a New Mexico–based foundation, the J.F.
Maddox Foundation. Dr Hummel has grant support from the National
Institutes of Health (R01-HL39813, R01-AG062582, R61-HL155498),
American Heart Association (20-SFRN35370008), and Veterans Affairs
Clinical Science Research & Development (CARA-009-16F9050); has
received previous grant support from PurFoods, LLC; and has insti-
tutional support in the form of clinical trial funding from Pfizer,
Novartis, Corvia, and Axon Therapeutics. Dr Carbone is supported by
a Career Development Award (19CDA34660318) from the American
Heart Association and by the Clinical and Translational Science
Awards Program (UL1TR002649) from the National Institutes of
Health to Virginia Commonwealth University. Dr Maurer has grant
support from the National Institutes of Health (R01HL139671,
R21AG058348, and K24AG036778); has received consulting income
from Eidos, Prothena, Akcea, Alnylam, Intellia, and GlaxoSmithKline;
and has received institutional support in the form of clinical trial
funding from Pfizer, Ionis, Eidos, and Alnylam. All other authors have
reported that they have no relationships relevant to the contents of
this paper to disclose.
ADDRESS FOR CORRESPONDENCE: Dr Elissa Drig-
gin, Columbia University Irving Medical Center/
NewYork-Presbyterian Hospital, 630 West 168th
Street, Box 93, PH10-203-1, New York, New York
10032, USA. E-mail: ed2761@cumc.columbia.edu.
Twitter: @EDrigginMD.

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KEY WORDS diet, heart failure, nutrition
A PP END IX For supplemental methodology,
please see the online version of this paper.