An overview of heart failure and nutrition

Heart failure is a syndrome defined by the heart’s inability to pump blood effectively and can be due to structural or functional impairments. Heart failure is a prominent cause of morbidity and mortality globally, affecting 26 million individuals with a huge financial burden, with costs greater than $200 billion annually. It’s a progressive condition that advances through multiple stages.  

With each stage, there is an associated increase in metabolic and oxygen needs. As cardiac function declines, physiological changes alter energy requirements and overall nutritional needs. Proper medical nutrition therapy can help manage and reduce heart failure-related symptoms, and when implemented in early stages, may slow condition progression. Nutrition intervention plays a pivotal role in improving clinical outcomes and quality of life for individuals with heart failure.  

How is heart failure diagnosed? 

The diagnosis of heart failure is made largely based on symptoms and physical exam. One commonly used diagnostic tool is the Framingham Diagnostic Criteria for Heart Failure. Several labs and tests are used for the monitoring and evaluation of heart failure. Examples include complete blood count, renal profile, serum B-type natriuretic peptide, electrocardiogram, chest radiographs, and echocardiography.  

Ejection fraction (EF) refers to the percentage of blood pumped through the heart’s left ventricle, indicating the heart’s effectiveness in pumping blood. The normal EF range is 50-70%. An EF <50% indicates abnormalities in the heart’s function. EF is used to differentiate four classifications of heart failure: heart failure with reduced EF, heart failure with mildly reduced EF, heart failure with preserved EF, and heart failure with improved EF.  

The most common causes of heart failure are ischemic heart disease, chronic obstructive pulmonary disease (COPD), hypertensive heart disease, and rheumatic heart disease. Risk factors include advancing age, African American race, metabolic risk factors, and a sedentary lifestyle. Signs of heart failure include elevated jugular venous pressure, third heart sounds, cardiomegaly, and hepatojugular reflux. Common symptoms experienced by individuals with heart failure include shortness of breath, fatigue, edema, and reduced exercise tolerance.  

How does heart failure progress? 

As H heart failure progresses, physiological compensations occur that try to maintain the heart’s function. Compensations include increased heart rate, vasoconstriction, and fluid and sodium retention. These compensation mechanisms cause hypertrophy and eventual myocardial cell death, which contributes to decreased ejection fraction. 

Per the American College of Cardiology and American Heart Association, there are four stages of heart failure. These stages are A, B, C, and D. 

• Stage A: At-risk for heart failure 
• Stage B: Pre-heart failure 
• Stage C: Heart failure with current or prior symptoms of heart failure 
• Stage D: Advanced heart failure 

Nutrition priorities in each stage 

Throughout the various stages of heart failure, nutritional needs vary. In stages A and B, the focus is on preventing progression. The focus in stages A and B includes “Life’s Essential 8”, which was updated in 2022 by the American Heart Association (AHA) for improving and maintaining cardiovascular health. These include healthy eating, physical activity, tobacco cessation, healthy sleep, healthy weight, blood lipids management, blood sugar management, and blood pressure management.  

For healthy eating guidelines, focus should be on heart-healthy guidelines, such as those outlined by the AHA and the Dietary Approaches to Stop Hypertension (DASH) diet. This dietary pattern emphasizes vegetables, fruits, whole grains, low-fat dairy, lean proteins, and unsaturated fats, while limiting added sugars, saturated fats, and highly processed foods, and avoiding trans fats and excessive caloric intake. 

As progression into stage C and D, patient nutritional needs may be higher due to increased metabolic demands, catabolism, and inflammation. For stages C and D, prioritizing maintenance of nutritional status is essential to preventing exacerbations with a focus on consuming adequate energy and protein, as well as an appropriate level of salt intake. 

Malnutrition in heart failure 

Malnutrition is common in later stages of heart failure. This is driven by increased metabolic demands and catabolic activity. As heart failure progresses, chronic inflammation, decreased nutrient intake, and impaired nutrient absorption contribute to nutritional decline. 

Cardiac cachexia, a severe form of malnutrition in heart failure, results from an increase in proinflammatory cytokines, malabsorption, anorexia, and prolonged activation of the renin-angiotensin-aldosterone system. These physiological changes promote catabolic pathways while inhibiting anabolic pathways, leading to loss of fat-free mass and ultimately poorer clinical outcomes. 

Addressing malnutrition through nutritional intervention is critical. Malnutrition in heart failure is associated with increased mortality and worsened prognosis. During this phase, nutrition therapy should prioritize adequate energy and protein intake to meet increased metabolic demands. 

Nutrition strategies to support intake may include: 

• Encouraging small, frequent meals 
• Liberalization of sodium restrictions when appropriate to increase intake, while individualizing and utilizing clinical judgement 
• Considering oral nutrition supplements to help meet needs, if needs are inadequate from food alone 

What are the goals of MNT in heart failure? 

Medical nutrition therapy goals should be individualized for each patient. The primary goals will highlight avoiding further complications, such as exacerbations, maintaining and optimizing nutritional status, and focusing on quality of life. 

Energy needs 

Determination of energy needs should consider the patient’s heart failure stage and nutritional status. When available, indirect calorimetry should be used to determine a patient’s resting metabolic rate (RMR). In the absence of indirect calorimetry, predictive weight-based equations may be used to estimate RMR. Apply clinical judgement to adjustments for individualized activity and stress factors. 

In 2017, the Academy of Nutrition and Dietetics updated the heart failure section of its Evidence Analysis Library. They suggested estimating RMR in heart failure stages B and C by using 22 kcal/kg and 24 kcal/kg for normally nourished patients and malnourished patients, respectively. Additionally, for heart failure stage D, they suggested 18 kcal/kg. RMR calculations require the multiplication of an appropriate physical activity factor.  

Generally speaking, there is an indication for calorie reduction for individuals with overweight or obesity, as well as increased calories for those who are underweight or malnourished. There’s some variance in the literature regarding appropriate caloric goals. For example, a systematic review from 2020 in Heart failure Reviews suggested stratifying calorie goals by body mass index (BMI). A 30% calorie reduction was suggested for patients with a high BMI. In comparison, for those with a normal BMI, it was suggested to reduce calories by 15%, and for those with a low BMI to increase calories by 30%.  

Protein needs 

Patients with heart failure have increased protein requirements due to increased protein catabolism. Adequate protein intake is essential to preserve fat-free mass, reduce the risk of malnutrition, and support overall functional status. 

Current protein recommendations for adults with heart failure include: 

• Normally nourished, clinically stable: 1.2 g/kg/day 
• Clinically stable, depleted patients: at least 1.37 g/kg/day 

Some evidence suggests up to 1.5 g/kg for those with malnutrition. Protein needs should be individualized based on nutritional status, comorbidities, and overall clinical condition. 

Sodium restriction 

Heart failure leads to compensatory mechanisms that promote sodium and fluid retention. Excessive sodium intake can further increase fluid retention, requiring the heart to work harder to circulate blood. The Dietary Guidelines for Americans and the American Heart Association recommend limiting sodium intake below 2,300 mg/day. 

In patients with malnutrition, a liberalized sodium intake may be appropriate to support overall intake; however, sodium recommendations should be individualized based on the patient’s needs and clinical judgement. 

Fluid restriction 

Fluid restriction with heart failure may contribute to improved quality of life and managing clinical symptoms. Fluid restrictions should be discussed with the medical team and are based on the measurements of fluid intake and output. Careful monitoring is essential to ensure the patient maintains adequate hydration while avoiding excess fluid accumulation. 

A dietitian’s role 

Medical nutrition therapy is essential in the management of heart failure by slowing syndrome progression, improving symptom management, and meeting increased metabolic demands. Providing personalized nutrition care for heart failure, prioritizing appropriate energy, protein, sodium, and fluid needs while emphasizing heart-healthy dietary guidelines, prevents further complications and enhances quality of life. Registered dietitians are crucial in their role of managing heart failure and have a direct impact on patients’ health. 

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References:  

Shams P, Malik A, Chhabra L. Heart failure (Congestive Heart failure) [Updated 2025 Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Accessed December 31, 2025. https://www.ncbi.nlm.nih.gov/books/NBK430873/ 

Bianchi VE. Nutrition in chronic heart failure patients: A systematic review. Heart Fail Rev. 2020;25(6):1017–1026. https://link.springer.com/article/10.1007/s10741-019-09891-1. doi: 10.1007/s10741-019-09891-1. 

Academy of Nutrition and Dietetics. Nutrition Care Manual®. Heart failure (2023). Accessed December 31, 2025. https://www-nutritioncaremanual-org.uab.idm.oclc.org/topic.cfm?ncm_category_id=1&lv1=272984&lv2=275292&lv3=275293&ncm_toc_id=275293&ncm_heading=Nutrition%20Care.  

Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of Cardiovascular Disease: A report of the american college of cardiology/american heart association Task Force on Clinical practice guidelines. Journal of the American College of Cardiology. 2019;74(10):e177. https://www.ncbi.nlm.nih.gov/pubmed/30894318. doi: 10.1016/j.jacc.2019.03.010. 

Bozkurt B, Coats AJS, Tsutsui H, et al. Universal definition and classification of heart failure: A report of the heart failure society of america, heart failure association of the european society of cardiology, japanese heart failure society and writing committee of the universal definition of heart failure. European journal of heart failure. 2021;23(3):352–380. https://www.ncbi.nlm.nih.gov/pubmed/33605000. doi: 10.1002/ejheart failure.2115. 

Kida K, Miyajima I, Suzuki N, Greenberg BH, Akashi YJ. Nutritional management of heart failure. Journal of Cardiology. 2023;81(3):283–291. https://www.clinicalkey.com/#!/content/1-s2.0-S0914508722002726. doi: 10.1016/j.jjcc.2022.11.001. 

Recommendations Summary HEART FAILURE: Assessment of Energy Needs (2017). AND Evidence Analysis Library. 2017. Accessed January 7, 2026. https://www.andeal.org/template.cfm?template=guide_summary&key=4582#:~:text=Supporting%20Evidence