Introduction
Heart failure (HF) is a prevalent and progressive condition characterized by the heart’s reduced ability to pump blood effectively. Alongside other clinical challenges, malnutrition emerges as a common and clinically relevant complication in HF patients. Malnutrition in this population is not merely a consequence of reduced intake; it results from a complex interplay of metabolic, inflammatory, psychosocial, and care-related factors that collectively influence prognosis and quality of life. This article synthesizes the main determinants of malnutrition in HF and highlights implications for clinical practice and future research.
Key physiological and disease-related factors
HF triggers a catabolic state where energy expenditure often exceeds intake. Chronic inflammation, neurohormonal activation, and oxidative stress contribute to muscle wasting (sarcopenia) and cachexia in a subset of patients. Altered protein turnover, impaired anabolism, and poor appetite further worsen nutritional status. In advanced HF, gastrointestinal edema and reduced gastric motility can impede nutrient absorption and contribute to early satiety, limiting meal size and frequency.
Inflammation and metabolic derangements
Systemic inflammation, commonly present in HF, drives muscle protein breakdown and reduces nutrient efficiency. Pro-inflammatory cytokines disrupt appetite signals and insulin sensitivity, promoting a negative nitrogen balance even in the presence of adequate caloric intake. Understanding these pathways helps explain why some patients become malnourished despite seemingly sufficient energy supply.
Sarcopenia, cachexia, and functional decline
Muscle wasting is a hallmark of malnutrition in HF. Loss of lean mass compromises mobility, exercise tolerance, and daily functioning, creating a vicious cycle where reduced activity further lowers caloric needs but worsens nutritional risk due to frailty and fatigue. Detecting sarcopenia early can guide targeted interventions to preserve muscle and improve outcomes.
Nutritional intake, appetite, and feeding difficulties
Appetite suppression, early satiety, and dietary restrictions common in HF contribute to insufficient nutrient intake. Concurrent comorbidities such as renal impairment or diabetes complicate diet planning, especially when sodium, potassium, and fluid restrictions are required. Behavioral factors, mood disorders, and caregiver support also influence meal patterns and overall energy balance.
Comorbidity, polypharmacy, and treatment effects
HF often coexists with chronic kidney disease, chronic obstructive pulmonary disease, diabetes, and liver disease, each adding nutritional risk through altered metabolism and treatment burdens. Polypharmacy can cause adverse effects (nausea, dysgeusia, mouth mucositis) that reduce appetite or food enjoyment. Some HF therapies may affect weight and nutrient absorption, underscoring the need for comprehensive medication reviews in nutritional assessments.
Sociodemographic and psychosocial influences
Socioeconomic status, education, social isolation, and food insecurity are linked to poor nutritional status in HF. Access to nutrient-rich foods, transportation to appointments, and caregiver support shape a patient’s ability to maintain adequate intake. Psychological distress, depression, and anxiety can diminish motivation to prepare meals and adhere to dietary recommendations, amplifying malnutrition risk.
Clinical implications and management implications
Early identification of malnutrition in HF requires systematic screening using validated tools that capture weight history, muscle mass, appetite, and functional status. Multidisciplinary care teams—cardiologists, dietitians, nurses, pharmacists, and social workers—can tailor nutrition plans, address barriers to intake, and adjust medications with nutritional considerations in mind. Interventions may include anti-catabolic nutritional support, resistance exercise to combat sarcopenia, and psychosocial resources to mitigate barriers such as food insecurity and depression.
Gaps and directions for future research
There is a need for standardized, HF-specific malnutrition definitions and outcome measures to harmonize research. Longitudinal studies should clarify causal pathways between HF progression, nutritional status, and clinical outcomes, while randomized trials can evaluate targeted nutrition and rehabilitation programs. Understanding patient-centered factors—preferences, cultural influences, and care settings—will improve acceptability and effectiveness of nutritional strategies.
