Rethinking Nutrition in Heart Failure: Beyond Calories and Salt

For years, nutritional advice in cardiology has followed a simple script: eat less, cut calories, and reduce salt. This advice was grounded in the fight against hypertension, diabetes, and obesity—important risk factors for heart disease. But when it comes to heart failure, the story is far more complex.

A review in the Journal of Cardiology (2023) highlights how our traditional approach to nutrition in heart failure may be outdated, even harmful. It introduces the concept of “Heart Nutrition”—a stage-specific, patient-centered approach to eating that prioritizes resilience, not restriction.

The Obesity Paradox and the Real Risk: Undernutrition

In early cardiovascular disease, weight loss and calorie restriction can be helpful. But in symptomatic heart failure (Stage C/D), the opposite is true: being underweight predicts worse outcomes. This is known as the “obesity paradox.”

Why? Because in heart failure, patients are at high risk of sarcopenia (loss of muscle mass) and cardiac cachexia (wasting syndrome). Losing muscle, not just fat, reduces strength, lowers immunity, and worsens survival.

Here’s the key shift:

• Early disease → “Nutrition for weight loss” (calorie control, salt restriction).

• Advanced disease → “Nutrition to prevent weight loss” (protein, energy balance, and nutrient adequacy).

Protein First, Not Calories Alone

The review points out that heart failure is marked by an imbalance of protein catabolism (breakdown) and anabolism (building). Inflammation, reduced appetite, and poor nutrient absorption all accelerate muscle loss.

This means protein prioritization becomes central:

• Adequate protein intake helps preserve muscle mass.

• Protein supports recovery after hospitalization.

• Combined with physical activity, protein prevents frailty.

Calories still matter, but simply “eating more” or “cutting back” misses the point. What matters is quality and balance, with protein as the anchor.

The Salt Paradox

Salt restriction is another area where dogma meets new evidence.

For decades, patients with heart failure were told to avoid salt. While excess sodium can worsen fluid retention, strict uniform restriction (<3.8 g/day) has not been shown to improve prognosis. In fact, overly aggressive restriction may reduce appetite, worsen malnutrition, and lower quality of life.

Physiologically, the renin–angiotensin–aldosterone system (RAAS) normally regulates sodium. Only in patients with compromised adrenal/RAAS function does strict salt control clearly help. For many others, moderate salt intake—balanced with fluid management and diuretics—may be safer than rigid restriction.

The real priority is to match nutrition with the patient’s adaptive capacity, not enforce blanket rules.

Heart–Gut Axis: Why Digestion Matters

The review also highlights the heart–gut axis: reduced intestinal blood flow, congestion, and microbiome changes in heart failure. These lead to malabsorption, inflammation, appetite loss, and worsening cachexia. Supporting gut health—with balanced nutrients, fiber, and sometimes probiotics—may help break this cycle.

Toward “Heart Nutrition”

The authors propose a new concept: Heart Nutrition—a framework that integrates protein, calories, salt, and gut health into a stage-specific plan:

• Stage A/B (at-risk or early disease): Prevent obesity and lifestyle-related disease with calorie balance, modest salt control, and healthy diet quality.

• Stage C/D (symptomatic disease): Prevent muscle loss with adequate protein and energy, and avoid excessive restriction that worsens frailty.

• End-of-life care: Prioritize comfort and enjoyment of food, rather than strict diet rules.

This approach requires multidisciplinary care, with dietitians playing a central role in tailoring interventions.

An ERM Perspective: Nutrition as Energy Allocation

From the lens of Exposure-Related Malnutrition (ERM), these insights reflect a deeper principle: nutrition is not about restriction, but allocation.

• Calories represent energy supply.

• Protein supports structural resilience.

• Salt reflects endocrine regulation.

When adaptive systems (like RAAS or muscle protein turnover) are intact, the body balances these inputs. But under chronic stress and disease, these systems falter. At that point, rigid restriction can push patients into maladaptation, whereas targeted support (especially protein and nutrient adequacy) restores resilience.

Takeaway

Heart failure nutrition is not just about eating less salt or fewer calories. It’s about preserving muscle, supporting digestion, and respecting the body’s adaptive systems.

The shift from restriction to resilience—from calorie/salt limits to protein- and function-centered care—isn’t just a change in guidelines. It’s a paradigm shift that aligns with how the body truly adapts under stress.

In short: Heart nutrition means feeding resilience, not enforcing restriction.

Kida, K., Miyajima, I., Suzuki, N., Greenberg, B. H., & Akashi, Y. J. (2023). Nutritional management of heart failure. Journal of Cardiology, 81(4), 283–291. https://doi.org/10.1016/j.jjcc.2022.11.001

#Heart failure nutrition, #Protein prioritization, #Sarcopenia and cachexia, #Salt restriction, #Heart–gut axis