Cardiac Nutrition

Julia ShihVMD, DACVIM (Cardiology)

Healthy eating for a strong heart beating

Key Topics

• Role of Nutrition

• Optimal Weight

• Important Nutrients

• Restricted Nutrients

• Supplements

The Individual –Body Composition

• Obesity– Increased work

– Oxidative stress

– Contributes to CHF signs

• Cardiac Cachexia– Inflammatory cytokines

• TNF-α, IL-1

– Anorexia

– Increased energy requirements

– Loss of lean body mass

– Cardiac myocyte hypertrophy

– Fibrosis

– Negative inotropy

Protein

Protein

• Avoid Protein Restriction– Promotes lean body mass loss and malnutrition

• Maintenance Protein Requirements

• Preclinical Heart Disease– Canine: 45g/1000kcal (AAFCO minimum requirements)

– Feline: 65g/1000kcal

• Heart Failure– Canine: 61g/1000kcal

– Feline: 75g/1000kcal

Protein - CanineDry 41g/1000kcalCan 38g/1000kcal

Dry 60g/1000kcal

Dry 46g/1000kcalCan 48g/1000kcal

Dry 33g/1000kcalCan 32g/1000kcal

Protein - Feline

Dry 82g/1000kcalCan 79g/1000kcal

Dry 65g/1000kcalCan 66g/1000kcal

Fat

Fat – Omega-3 Fatty Acids

• Decrease inflammatory cytokine production– TNF-α

– IL-1

– Improves cardiac cachexia

• Improves muscle mass

• Improves appetite

• Improves myocyte energy metabolism

• Suppresses arrhythmias– Omega-3 fatty acids in Boxer dogs with arrhythmogenic right

ventricular cardiomyopathy. Smith et al, JVIM 2007;21(2).

– Fish oil supplementation for 6 weeks reduced median number ofventricular premature complexes

Omega-3 Fatty Acids

• Dosing– Avoid n-6:n-3 ratio

– EPA 40mg/kg/day

– DHA 25mg/kg/day

• Avoid– Alpha‐linolenic acid

• Found in plant products (flaxseed oil, linseed oil, canola oil)

• Not well converted to EPA and DHA

– Cod Liver Oil, Krill Oil

• Contain fat soluble vitamins (Vit A, Vit D)

Fat - Omega-3 Fatty Acids

• Potential Concerns– Altered platelet function

– Diarrhea

– Pancreatitis

– Altered immune function

– Impaired wound healing

– Lipid peroxidation

– Potential for toxin exposure and nutrient excess

– Hyperglycemia/Insulin sensitivity

– Nutrient-drug interactions

Salt Restriction

• Decrease waterretention

• Allow use of lowerdiuretic doses

• Help control bloodpressure

Salt Restriction

Heart Disease CategoryAllowable 

sodium as a % of DRY matter

Mg of Sodium per 100 kcal of

food

Asymptomatic patient(No active heart failure, At risk of heart failure)

Mild sodium restriction

0.3‐0.4 80 ‐ 100

Symptomatic patient(History of heart failure)

Moderate sodium restriction

0.2‐0.3 50 ‐ 80

Symptomatic patient with refractory heart failure

Marked sodium restriction

< 0.2 < 50

Salt Restriction

• Educate clients on salt content in foods and treats• Avoid

– Baby food– Bread– Canned vegetables (unless no salt added)– Cheeses (unless labeled low sodium)– Condiments– Lunch meat/Cold cuts– Many pet treats– Pickled foods– Pizza– Processed foods (potato mixes, macaroni and cheese, rice mixes)– Snack foods (potato chips, packaged pop corn, crackes)– Soups (unless home made without salt)

• Teach clients how to administer medication without food

Salt Restriction

• Acceptable treats and foods– Plain pasta

– Plain rice

– Lean cooked meat (chicken, turkey, beef, fish)

– Low sodium cheese

– Low salt breakfast cereal

– Fresh vegetables/fruit (carrots, green beans, apple, banana)

– Cooked eggs

– Honey or maple syrup

• Tufts Heart Smart Website– http://vetmed.tufts.edu/heartsmart/

Taurine - Cats

• Essential amino acid in cats

• Taurine-deficiency induced myocardial failure

• Suspect in cats with homemade or vegetarian orotherwise unbalanced diet

• Supplementation– Taurine 250mg PO BID

Taurine - Dogs

• Non-essential amino acid• Cocker Spaniels

– Other: Newfoundland, Golden Retrievers, Portuguese Water Dogs

• Associations– Lamb & Rice Diets– High Fiber diets– Cystinuria

• Causes– Inadeqate intake or limited bioavailablity of precursor amino acids– Higher nutritional requirement for precursor amino acids– Increased fecal taurine loss

• Supplementation– Taurine 30mg/kg PO BID– L-Carnitine 50mg/kg PO TID

BEG Diets & Cardiomyopathy

• BEG Diets– Boutique, Exotic ingredient, Grain-free

• Types of DCM– Diet-associated DCM with normal taurine levels– Diet-associated DCM with taurine deficiency– Primary (idiopathic DCM)

• Theories– Low concentrations of sulfur based amino acids

• Plant-based proteins (Legumes)• Less organ meat

– High fiber• Increased fecal clearance of taurine

– Exotic proteins– Other nutritional deficiencies or toxicities

BEG Diets & Cardiomyopathy BEG Diets & Cardiomyopathy

• What to do for an affected patient– Taurine levels– +/- ECG, radiographs– Echocardiogram– Treatment:

• Diet Change• Taurine & L-Carnitine• Cardiac medications

– Report to FDA• Recommended Diets

– WSAVA Recommendations on Selecting Pet Foods

• Outcome– Variable– Gradual improvement over months

• Essential amino acid• Fatty acid metabolism and energy production• Myocardial Carnitine Deficiency

– 1 family of Boxers

• Supplementation• Dose:

– Systemic deficiency• 50mg/kg PO TID

– Myocardial deficiency• 200mg/kg PO TID

• Side Effects– Diarrhea

L-Carnitine Coenzyme Q10 & Antioxidants

Coenzyme Q10• Cofactor in energy production pathways• Antioxidant• Need controlled prospective studies to judge efficacy• Dose: 30-90mg PO BID• Sensitive to UV Light

– Use oil based emulsion in amber colored capsule

Antioxidants• CHF causes elevated oxidative stress and reduced Vit E• Antioxidant supplementation reduces oxidative stress

– Superoxide dismutase, catalase, glutathione peroxidase, Vitamin C, Vitamin E, beta-carotene

• Long-term benefits in dogs and cats with CHF unknown

Potassium

• Hypokalemia– Diuretics

– Inadequate intake

• Hyperkalemia– ACE Inhibitors

– Spironolactone

Magnesium

• Hypomagnesemia– Diuretics

– Digoxin

Electrolytes Feeding Practices

• Offer multiple choices of appropriate pet foods

• Palatability enhancers– Cooked meat, low sodium tuna, cooked fish (Cats)

– Cooked meat, yogurt, applesauce, maple syrup (Dogs)

• Food Temperature

• Omega-3 Fatty acids

• More frequent, smaller meals

Treats

• Salt content

• Medication administration

Feeding Practices Key Points

• Feed the individual! – Severity of cardiac disease

– Body condition

– Concurrent disease

Questions?