5. Effective Lifestyle Changes

Based on the evidence collected from your medical history, physical exam, and diagnostic tests, your cardiologist will design a treatment plan for your level of heart failure or likelihood to develop it.

If you do not have heart failure symptoms, treatment will focus on preventing structural changes in your heart, slowing or stopping the development of symptoms, and minimizing risk factors of heart failure. If you already have symptoms, the treatment plan will be to improve your quality and length of life.

Some of the components of treatment are under your control—and taking responsibility for improving your health can help you psychologically as well as physically. While medications and surgery may slow the progression of heart failure, it is up to you to provide a healthy environment for your overworked heart. It starts with making heart-healthy decisions about your lifestyle.

Lifestyle Changes

Making changes in daily, health-related, lifestyle behavior is challenging and requires support, says the American Psychological Association (APA). Committing to a change is one thing, but following through on a long-term basis is even more difficult.

A meta-analysis of 27 weight-loss programs, for example, found that the overall adherence rate was 60.5 percent. The 2016 study was published in the journal Patient Preference Adherence.

The APA provides five suggestions that may help you make lasting and life-saving lifestyle changes.

  • Start small. Identify manageable things you can do and that can be measured. Want to lose 20 pounds in five months? Start with a goal of one pound a week.
  • Be specific. Write down the details of your plan. If more exercise is a goal, specify which days, what kind of workout, where you’ll do it, and how long you will exercise. Don’t plan to do it when you have time. Make it a priority in your daily or weekly routine.
  • Change one behavior at a time. You may not have a choice on this one, depending on your condition and your doctor’s instructions, but many of us have problems when we try to do too much, too fast. As one behavior becomes a habit, add another goal.
  • Involve a family member, friend, or co-worker. You are more likely to stay with a program if you participate with another person or in a group.
  • Ask for support. If you are overwhelmed or unable to meet your goals, talk with a friend, family member, or psychologist who is trained to understand the connection between the mind and body, as well as the factors that promote behavior change.

Don’t Smoke

Cigarette smoking has fallen to its lowest point in recorded history—14 percent of adults in the U.S. (In 1965, 42 percent of adults smoked.)

But if you are in that 14 percent who stills smokes and either have heart failure or don’t want it, you’d better stop smoking. It remains the leading preventable cause of death in the United States, and smoking-associated deaths often are caused by heart attack.

Tobacco in any form (cigarettes, e-cigarettes/vaping, cigars, pipes, and chewing tobacco) wreaks havoc on the cardiovascular system. Smokers are two to three times more likely to die from a heart attack. But when most smokers quit, their risk of heart attack drops by as much as 50 percent after one year. After 15 years, their risk reaches that of a never-smoker.

The news isn’t that good for formerly heavy smokers (a pack a day). After having quit for 15 years, their risk of heart failure and death is still elevated. Their risk of death, but not heart failure, will be lower than that of current smokers. However, quitting does have significant overall health benefits, including improvements in circulation and lung function. After five years of not smoking, the risk of cancers of the mouth, throat, esophagus, and bladder is cut in half. Cervical cancer risk falls to that of a non-smoker. And stroke risk can drop to that of a non-smoker as well.

Most people find it extremely difficult to stop smoking on their own or to quit “cold turkey.” The average person tries to quit seven times before succeeding. Using proven stop-smoking aids—nicotine-replacement therapy (patch, gum, spray, lozenges, or inhaler), cessation programs incorporating hypnosis or acupuncture, or prescription oral medications, such as varenicline (Chantix) or buproprion (Zyban)—can reduce the number of unsuccessful attempts.

Smoking-cessation experts say that a combination of methods—for example, the nicotine patch, a prescription medication, and counseling—increases the likelihood of success. It also is important to try to avoid worrying about gaining weight after quitting. The few extra pounds are often temporary and less of a health risk than smoking.

Take a Break, Get Some Rest

Ensuring that you get enough rest may not be difficult, because heart failure causes fatigue. You may have to adjust your work schedule or activities to accommodate the extra rest time. Plan activities ahead of time, and don’t schedule too many activities in one day. Also, do not push, pull, or lift heavy objects that require you to strain or that quickly tire you. Learn to ask for help.

On some days you may have more energy, but if you are more active on one day, you may feel more tired the next. When you wear out, simply stop and rest. It’s okay to nap, but try not to nap too often or too long, or you may not be able to sleep well at night. It is important to sleep as well as possible. Good sleep practices include:

  • Avoiding caffeine and alcohol before bedtime.
  • Restricting strenuous activity just before bedtime.
  • Reserving your bed for sleeping, not for watching television, reading, or eating.
  • Developing specific bedtime rituals and sticking to them.
  • Going to bed and getting up at approximately the same time every day.
  • Aiming for seven to eight hours of sleep every night.
  • Asking your doctor to adjust your medications so that you can get uninterrupted sleep.

If you still have difficulty sleeping, ask your doctor if a sleep medication would help. Suvorexant (Belsomra), eszopiclone (Lunesta), zolpidem (Ambien), and temazepam (Restoril) are examples, but there are many others. Non-medicine choices include sipping on chamomile tea, relaxing stretches, and calming deep breathing exercises. Mindfulness meditation can help you learn to relax and stress less, which can assist with falling asleep.

Ask Your Doctor

Many people with heart failure are surprised to hear that exercise is beneficial, because they think that exerting themselves is the last thing they should do.

Exercise can improve quality of life and reduce heart failure symptoms, cardiac mortality, and hospital readmissions. It even may ward off heart failure death (see “Lifestyle Modifications Help Prevent and Manage Heart Failure”).

Even minimal exercise produces modest reductions in heart failure risk, but the more exercise you get, the lower your risk will drop. When you are active, you may have more energy, be less irritable, sleep better, and be better able to keep your weight under control.

Inactivity can cause your physical condition to deteriorate because your muscles will lose their ability to function and your bones will weaken. When this happens, the heart must pump more blood to the muscles to produce the necessary energy, which in turn stresses the heart. Exercise also improves blood flow to the arms and legs.

Check with Your Cardiologist. You should not start an exercise program without asking your cardiologist how much exercise you can do each day and what kind of activities are right for you. Your efforts should match your capacity, and as your capacity improves, so can your effort.

Even if you can’t exercise on your own, you can participate in cardiac rehabilitation. These programs are monitored and adjusted to help patients exercise safely. Active participation in a cardiac rehabilitation program is associated with better outcomes in heart failure patients. Medicare and many insurance companies now pay for cardiac rehabilitation. If your doctor does not refer you to a program, request a referral.

If the thought of a formal exercise program overwhelms you, keep in mind that any exercise is better than no exercise at all, and exercise does not have to be intense to be beneficial. Healthy choices include walking, bicycling, or practicing tai chi, the Chinese modality that combines gentle movement and meditation.

An exercise test can help determine your exercise capacity. Based on the test results, an exercise physiologist will prepare an individual exercise prescription. That prescription initially may be for as little as five to 10 minutes on a stationary bicycle or walking a few times a week at a relatively slow pace. The intensity and duration of exercise will be gradually increased.

Lose Weight, Avoid Fad Diets

Excess weight is a major risk factor for heart failure (see “Lifetime Obesity Risk”). The (AHA) reports that 69 percent of U.S. adults are overweight or obese. If you fall into one of these two categories, or your doctor recommends that you lose weight, make an effort to shed the excess pounds. Preparing fresh foods—or purchasing prepared meals that are low in sodium and contain the right balance of fat, protein, and carbohydrates for someone with heart disease—will help you lose weight.

Although it may be tempting to try fad diets, registered dietitians do not recommend them. Many diets promote drinking large quantities of water, which can be detrimental in heart failure. You may lose weight rapidly on certain popular diets, but the limited choice of foods makes them difficult to follow for very long, and 90 percent of people regain the lost weight after they stop.

The Ornish diet is safe for people with heart failure, but it is highly restrictive. The South Beach Diet is not considered a fad diet, because it is scientifically sound. You also may find it easier to follow than the Ornish diet.

It may be helpful to consult with a registered, licensed dietitian (RD, LD) to plan a healthful diet that includes foods you enjoy.

If you are finding it difficult to lose weight, discuss with your doctor whether bariatric surgery might be an option for you. Recent research suggests that the surgery may benefit people with heart failure.

Eat Heart-Friendly Foods

Maintaining a balanced, heart-healthy diet is essential to ensure your body gets the nutrients it needs. A diet high in omega-3 fatty acids (the kind found in fish and fish oil supplements) has been shown to help prevent body wasting, a risk factor for death from heart failure. A diet high in whole grains may lower the risk of heart failure. Variety also is highly recommended to help ensure you are getting all the needed nutrients (see “Diet Monotony Could Lead to Hospitalization, Earlier Death”). Consulting with a registered dietitian can help you create an eating plan that is both delicious and nutritious.

Following a heart-healthy diet that limits fat intake may help prevent a heart attack or stroke. In addition, everyone with heart failure should limit their intake of salt and fluids. Sodium causes water retention, and drinking excessive amounts of fluid increases blood volume. Your kidneys may not eliminate water and salt as efficiently as healthy kidneys.

In people with heart failure, the body makes more renin, vasopressin, and aldosterone, which are hormones that increase salt and water retention. The result is high blood volume, swelling, shortness of breath, and a heart that works harder than it should.

The Dietary Approaches to Stop Hypertension (DASH) diet and a Mediterranean-style diet are both good choices for patients with heart failure. When researchers looked at the effects of these diets on participants in the long-running Women’s Health Initiative study, both diets were found to offer protection against death from heart failure.

Cut Back on Salt

Limiting salt in your diet is one of the most effective ways you can manage heart failure, as well as your overall heart health. Salt contains sodium, which causes cells to retain water and raises blood pressure, neither of which is desirable.

A review of salt studies suggests the tasty seasoning may harm other organs, as well. Various studies concluded that consuming large amounts of salt affects the lining of arteries and makes them stiff, harms the kidneys, blunts the effects of our “fight-or-flight” response, and may even impact the brain.

Sodium is found in many foods, most often in the form of sodium chloride (table salt). The average American consumes two to three teaspoons of sodium a day, much of it in prepared or processed foods. Your doctor will tell you how much sodium you can safely consume each day. The Heart Failure Society of America recommends that consumption stay below one teaspoon a day.

Following a low-sodium diet requires more effort than merely avoiding adding salt. It’s important to learn how much sodium is in the foods you buy and order in restaurants, and which foods are naturally low in sodium. It is equally important to learn which foods are very high in sodium and should be avoided. Understanding the following terms found on food labels will help:

  • Sodium-free: Less than 5 milligrams (mg) of sodium per serving.
  • Very low sodium: 35 mg or less per serving.
  • Low sodium: 140 mg or less per serving.
  • Unsalted/no salt added: Made without added salt but may still contain sodium that is naturally present in the food.

Table salt isn’t the only source of dietary sodium. Other salts are used in cooking and food preparation. Baking soda and baking powder contain sodium bicarbonate. Some artificial sweeteners contain sodium saccharin. Many food preservatives and antioxidants are sodium-containing salts, such as sodium benzoate, sodium propionate, sodium ascorbate, and sodium erythorbate. Food thickeners and stabilizing agents used in ice cream, coffee creamers, and other foods include sodium caseinate and sodium carboxymethylcellulose. A teaspoon of soy sauce contains 700 mg of sodium.

“Lite” salt substitutes include sodium in reduced amounts, but those amounts are still too high for people with heart failure. Ask your physician about whether you can use salt substitutes.

To lower your sodium intake:

  • Reduce salt use gradually to allow your taste buds to adjust.
  • Use herbs and spices rather than salt to flavor your food, and consider using onion, garlic, lemon juice, and vinegar for added flavor.
  • When you dine out, ask your server to make sure that salt, monosodium glutamate (MSG, which is a flavor enhancer commonly used in Chinese food), and seasoned salt are omitted.

Other Sodium-Heavy Products. Many over-the-counter products contain sodium, including medications for colds, headaches, upset stomach, and other ailments; vitamins and mineral supplements; food supplements; and nutraceuticals.

Sodium compounds found in such products include sodium ascorbate, sodium bicarbonate, sodium phosphate, sodium biphosphate, sodium citrate, sodium fluoride, sodium saccharin, and sodium salicylate.

If you see the word “sodium” anywhere on the label, look for a comparable product with less sodium or no sodium. If no substitute is available, it’s advisable to avoid the product altogether.

Limit Fluids

Heart failure is one of the few conditions when a doctor will tell you to limit fluid intake. Too much contributes to congestion and swelling, increasing your heart’s workload. Your physician will tell you whether you need to restrict fluids—if so, follow your fluid-management guidelines carefully.

As a rule, fluid intake should be limited to less than eight cups per day (including coffee and tea). This is equivalent to about two liters, two quarts, or one-half gallon. Keep a daily record of your fluid intake until you feel comfortable with your restrictions and can accurately determine your fluid intake. It helps to learn the fluid volumes (cups, fluid ounces, or liters) in a serving of your favorite foods.

Ice is a fluid, so it counts. Include foods that are considered fluids (such as soup, pudding, frozen yogurt, applesauce, and all fruits, particularly citrus) against your total daily fluid allowance.

Instead of drinking a beverage, quench your thirst by nibbling on frozen grapes or strawberries, or by eating sugarless hard candy or chewing sugarless gum. Covering your lips with lip balm also may help. Milk and ice cream products increase thirst.

Avoid or Limit Alcohol. Alcohol weakens the heart’s pumping ability and may make you more likely to develop arrhythmias. Limiting alcohol consumption to no more than one drink daily (or not drinking at all) is recommended. One drink means 12 ounces of beer, four to five ounces of wine, or one ounce of 80-proof liquor. If your doctor tells you that you can safely have one daily drink, remember to count it against your total daily fluid allowance.

Watch for Signs of Fluid Retention. Although the most obvious sign of fluid retention is weight gain, there may be other clues:

  • Your belt seems tighter.
  • Your belly appears more swollen.
  • Your clothes don’t fit as well.
  • Your feet and ankles become swollen.
  • Your shoes become tight.
  • Your shoelaces seem shorter.
  • You are short of breath.
  • You cough, especially when lying down.
  • You wake at night with difficulty breathing.
  • You feel full after eating only a small amount of food.

Weigh Yourself Daily

Weigh yourself every day at the same time, using the same scale and wearing clothing of similar weight (or none). Record your weight daily in a diary or on a calendar.

If you have symptoms of congestion, especially if you feel more fatigued than usual or have shortness of breath along with weight gain, call your doctor. Otherwise, for two days try eliminating 500 mg of sodium from your diet and decrease your fluid intake by one-and-a-half cups (12 oz). If your swelling and weight do not go down after two days, call your doctor. Your medications may need some adjustment.

To track of your daily sodium and fluid intake, see the Sodium and Fluid Intake Record Form at the end of this report.

Stress Management

Recognizing stress and learning how to manage it can improve your quality of life and benefit your heart. About half of people with heart failure experience depression. In people with heart failure, mild depression increases the risk of death by 60 percent and moderate-to-severe depression quadruples the risk. If you think you may be depressed, talk with your doctor. Medications and therapies can help you restore a healthier outlook and may even save your life.

Different stress-management techniques work for different people. Often, a combination of methods is best. Some things you can do to reduce stress include:

  • Following an exercise program and remaining as active as possible.
  • Performing relaxation exercises or yoga to calm the body and mind.
  • Praying, meditating, or practicing tai chi.
  • Joining a support group—talking to others can help.
  • Seeking one-on-one counseling for guided support.
  • Participating in social activities and spending time with friends.
  • Volunteering in faith-based or community public service.

Guard General Health

Minor illnesses that most people shrug off can seriously affect people with heart failure. Call your doctor if you have symptoms of a respiratory infection (sore throat, runny nose, persistent cough, fever, and general achiness). Avoid contact with anyone who has a cold, the flu, or bronchitis. Get a flu shot every year. The benefits of flu shots far outweigh the risks (see “Flu Shots May Reduce the Risk of Death”).

  • Get a pneumonia vaccination. The CDC recommends two vaccines for adults 65 and older. You should receive a dose of PCV13 first, followed by a dose of PPSV23 at least a year later.
  • If you feel faint or lose consciousness, your family or friends should call 911. It may indicate a life-threatening arrhythmia or low blood pressure (hypotension). Report the incident to your cardiologist, and discuss it with your doctor as soon as possible.
  • Avoid temperature extremes, and stay indoors when it is very hot or very cold outside. High humidity levels may cause you to become fatigued more easily.
  • If you become fatigued or experience shortness of breath during any activity, slow down, or stop and rest. Be sure to tell your doctor about it. You may need changes in your medications, diet, or fluid consumption.
  • Avoid lifting or pushing heavy objects or doing strenuous chores, such as raking, mowing, shoveling, or scrubbing. If you find household chores exhausting, ask for help or hire someone.
  • If you develop a rapid or irregular heartbeat or palpitations, check your pulse. If your heart rate is higher than 120 beats per minute, call your doctor or go to the emergency department.
  • If you have shortness of breath at night, try sleeping in a recliner chair, or use more pillows or a supportive wedge cushion to elevate your upper body.

What’s Next?

Lifestyle modifications can alleviate symptoms, but they cannot not cure or reverse heart failure. At some point, you will need medications, which are discussed in Chapter 6.

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