1. INTRODUCTION
Heart failure (HF) has developed into a global pandemic, affecting about 64 million humans and costing $346.17 billion [1]. Chronic heart failure (CHF) is a complex clinical condition that represents the final evolution of all cardiac ischemic disease. It has a tremendous economic impact on the public healthcare system, with an incidence of approximately 5.8 million in the United States alone, costing $39 billion/year [2], and is steadily increasing in prevalence. The prognosis among individuals diagnosed with HF remains dismal, and there are few dietary interventions that have proved an improvement in clinical outcomes, as seen by the scarcity of evidence-based nutrition recommendations from major HF guidelines. Nutrition management for HF has traditionally centered on a balanced diet, salt, and fluid restriction, but in recent years, overall dietary patterns, as well as particular micro- and macronutrients, have attracted researchers’ interest [3].
Nutrition in cardiovascular care focuses on reducing hypertension and diabetes in HF patients. Food not only expresses personal ideals but also provides enjoyment and support [4].
Behavioral and lifestyle modifications are critical for avoiding cardiovascular illnesses, including HF. Dietary patterns that protect against HF have recently received attention, such as the Dietary Approaches to Stop Hypertension (DASH) diet, which emphasizes fruits, vegetables, whole grains, and lean meats while restricting sugar, saturated, and trans fats [5].
The DASH diet lowers the probability of coronary artery disease and stroke by decreasing low-density lipoprotein cholesterol and saturated fat [6]. It, along with the Mediterranean and low-carbohydrate diets, is advised for controlling chronic illnesses such as diabetes and hypertension [7].
Changing diet in individuals with various chronic diseases might be difficult due to inconsistent findings about salt and fluid consumption [8], processed meats rich in salt may raise the risk of heart disease by raising blood pressure [9]. Proteins like arginine contained in the DASH diet can help lower blood pressure [10]. Patients with chronic disease may intake excessive amount of meat instead of more nutritious meals such as fruits and vegetables [11]. However, nutritional recommendations seek to lower hypertension, lipidemia, and obesity while also including non-pharmacological methods to HF care, such as low-sodium diets [12]. The DASH diet has been found to reduce blood pressure in people with hypertension, which is a major risk factor for HF [13]. Eggs, while high in cholesterol, provide high-quality protein and other nutrients at a reasonable cost, prompting controversy about their association with cardiovascular disease (CVD) [14], [15]. Incorporating plant-based proteins, seafood, and less processed diets can help reduce CVD risk. Excess sodium consumption should be limited to (2,000 mg) per day for HF patients, since it might increase fluid retention and exacerbate the condition [16].
Whole grains, such as brown rice, which are high in vital nutrients and fiber, have been related to lower inflammation and improved glucose management, but white rice, which has a higher glycemic index, may raise the risk of Type 2 diabetes [17]. The Canada’s food guide recommends a balanced meal containing vegetables, protein, and whole grains to promote weight control and general health [18].
Patients with HF should check their weight on a regular basis since variations might indicate fluid imbalances and an increased risk of hospitalization [19]. Sudden weight fluctuations require medical care [20]. Dietitians propose that patients monitor their food and fluid consumption to better understand how their diet affects salt and fluid retention [21].
Nursing interventions make a big difference in patient outcomes. Nurses are in charge of executing initiatives targeted at disease prevention, health promotion, and patient care. Implementing nurse interventions is critical for improving patient outcomes and providing superior patient-centered care [22].
Individuals with HF require a balanced diet due to diuretic-induced electrolyte, vitamin, and micronutrient imbalances [23]. Nutritional standards highlight the need for dietary diversity for optimal health since eating a diverse range of foods helps avoid chronic illnesses [24]. However, increasing dietary diversity has been associated with an increased risk of adverse events and poorer clinical outcomes for hospitalized HF patients [25]. According to research, concentrating on nutritional treatment with nursing care can enhance food consumption in hospitalized HF patients [26]. Therefore, the purpose of this study was to investigate the impact of an educational program on nutritional status among patients with HF at Sulaimani Cardiac Hospital.
2. PATIENTS AND METHODS
2.1 Design of the Study
A quantitative approach (quasi-experimental study) was utilized to evaluate the efficacy of a nursing teaching program on the nutritional status of HF patients at Sulaimani Cardiac Hospital in Sulaimani City. The investigation was conducted between August 2nd, 2021, and February 8th, 2024.
2.2. Administrative Approval
The study protocol was approved by the College of Nursing-University of Sulaimani, and an official agreement letter from the College of Nursing-University of Sulaimani was sent to the Directorate of Health (Sulaimani Cardiac Hospital) to facilitate and ensure cooperation during the implementation of the Nursing education program.
2.3. Study Setting
This study was done at the Coronary Care Unit at Cardiac Hospital, which considered as the top hospitals for managing heart illness.
2.4. The Study Sample
A non-probability purposive sampling was used as a method for selecting samples in this study. Patients who were admitted to the Cardiac Hospital were diagnosed with HF by the cardiologists and were invited to participate in the study. Two hundred patients participated in this study. The participants were divided into two groups (100) recruited for the interventional and (100) for the control group. However, after implementing the nursing educational program, the intervention group decreased to (94) patients and the control group to (90) patients due to mortalities.
2.5. Inclusion and Exclusion Criteria
The study included adults aged (20) years and older diagnosed with HF with reduced ejection fraction, approved by a cardiologist team at least 3 months prior. Moreover, the patients had a right to refuse or withdraw from the study in any time they want. Exclusion criteria encompassed severe mental health issues, end-stage liver or renal failure, pregnant women, asthma, or chronic obstructive pulmonary disease, due to potential health impediments during the study period.
2.6. Instruments of the Study
The study tool was composed of three parts that represent demographic data of patients with HF such as (age, gender, marital status, educational level, residential area, and economic state). The second part deals with some clinical data such as (number of times admitted to hospital, body mass index, waist-hip ratio (WHR), and lipid profile, serum electrolyte, and, renal function test). Third part is previous medical history such as (Diabetes Mellitus, hypertension, and dyslipidemia).
2.7. Pilot Study
It was conducted with (20) patients from the initial study sample during the period of January (15th 2022) and then they excluded from the study sample.
2.8. Reliability of the Study Sample
The reliability was determined by the Cronbach Alpha Correlation Coefficient and Stability (test-retest) approach, producing a strong association (r = 0.85).
2.9. Approaches of Data Collection
All patients diagnosed with HF and admitted to the Cardiac Hospital in Sulaimani City were included in this study sample. Data were collected through face-to-face interviews with the patients for their information. The data collection period spanned from March 26th, 2022. Completing the questionnaire about HF took approximately 15 min. Two hundred patients participated with HF for both intervention and control groups. The researchers measured patient’s blood pressure, body weight, body high, and recorded their investigations such as lipid profiles, serum electrolyte, and renal function test before and after the nursing educational program.
2.10. Statistical Analysis of the Study Sample
Version (26) of the Statistical Package of the Social Science (SPSS) was used to code and organize the data into computer files. (The inferential data analysis, frequency and percentage computation Chi-square, and independent t-test) were used to process the data.
3. RESULTS
Table 1 demonstrated that the total number of HF patients was 200, their mean age (±standard deviation) was 68.3 ± 11.2 years and the age range was between 38 and 100 years. No significant differences were detected in the age distribution or the mean age of the two study groups (P = 0.23 and 0.11 respectively). More than half of the intervention and control group (72% and 69%), respectively, were males. Half of intervention and control group (52%, 50%), respectively, were widower, and they live alone or with their children. While others were married and live with their wives or their husbands, the proportion of illiterate patients was higher in the control group than the intervention group (65% and 59%), respectively, while the proportion of secondary school and college graduates was higher in the intervention than the control group (14%, 7%). In the control group, housewife was slightly more than interventional group (25%, 29%). Almost all of the patients of the intervention group (95%) were living in urban areas compared to (87%) of patients of the control group. More than half of both group’s incomes were insufficient (63%, 68%). This table showed that there were no significant differences between both groups in all items of socio-demographic and clinical data at P value more than 0.05 except residential area.
TABLE 1: Participants’ sociodemographic and clinical characteristics (the own numbers are percentages)
Table 2 demonstrated the consumption status of various food items such as red meat, milk and dairy products, white rice, fruit, and drinking coffee that showed significant differences before and after the educational program between the two groups. In addition, the consumption status of fish and seafood, bread, nuts and seeds, fizzy drink, butter, cream and margarine, hydrogenated fat, lard, and skin also showed significant differences after the nursing educational program (P ≤ 0.001).
TABLE 2: Comparisons between both groups related to dietary pattern before and after the nursing educational program
Table 3 showed that before implementing the nutritional educational program, there were no significant differences observed between the intervention and control groups in laboratory investigations except high-density lipoprotein (HDL) and random blood (RB) glucose levels at (P ≤ 0.001). However, the results after the educational program showed a significant difference between both groups in cholesterol, HDL, hemoglobin A1c, and RB Glucose levels (P ≤ 0.001).
TABLE 3: Comparisons between both groups regarding laboratory investigation before and after the nursing educational program
Table 4 documented that (48%, 57%) of intervention and control groups had a past medical history of Diabetes Miletus (DM), and (73% and 82%) of them had hypertension, respectively. (59% and 63%) of intervention and control groups had dyslipidemia, respectively.
TABLE 4: Participant’s previous medical history for other disease
The electrolyte results of the participants are presented in Table 5. Before the educational program, there were no significant differences in serum creatinine, serum sodium, serum potassium, and serum chloride between the control and intervention groups. However, post-educational program results indicated significant differences in serum creatinine, serum sodium, serum potassium, and serum chloride between the intervention and control groups (P ≤ 0.001).
TABLE 5: Comparisons between both groups related to electrolyte before and after the nursing educational program
Table 6 indicated that there was no significant difference was observed in body mass index (BMI) before and after the educational program between the two groups; however, there was an improvement in decreasing the BMI.
TABLE 6: Comparisons between both groups concerning body mass index before and after the nursing educational program
Table 7 indicated that those male patients that falling within the normal range for WHR were (29.2% and 40.6%) in the intervention and control groups, respectively. Conversely, (70.8% and 59.4%) of individuals in both groups had WHR values in the abnormal range. Notably, there were no statistically significant differences between the two groups, with a P-value of (0.180) before the educational program.
TABLE 7: Comparisons between both groups related to waist and hip circumference before and after the nursing educational program
Following the educational program, there was a notable shift in WHR values. The percentage of individuals within the normal range increased from intervention group to (54.4%) but decreased from the control group to (38.1%). Meanwhile, the percentage of individuals with abnormal WHR values decreased to (45.6%) from the intervention group but from control group increased to (61.9%). Despite these changes, there were no significant differences between the intervention and control groups, as indicated by a P-value of 0.086. However, when comparing the pre- and post-program values within the intervention group, a significant difference emerged with a P-value of (0.001). This contrasted with the control group, there were no significant difference observed, as reflected by a P-value of (0.521).
The same table illustrates the WHR findings for the female gender in both intervention and control groups. Initially, (57.1% and 35.4%) of females in the intervention and control groups, respectively, had a normal WHR, while (42.9% and 64.6%) had an abnormal WHR, with no significant differences between the two groups (P = 0.214). Following the educational program, there was a noteworthy shift in WHR values among patients in the intervention group. The percentage of females within the normal range increased to (88.5%) in intervention group, and (51.9%) in the control group. Conversely, the percentage of females with abnormal WHR values decreased to (11.5%) and (48.1%) in the intervention and control groups, respectively. Importantly, a significant difference between the two groups emerged (P = 0.004) after the implementation of the dietary educational program.
Table 8 compares hospital admission frequencies between an interventional group and a control group over the last 12 weeks, both before (pre-test) and after (post-test) an intervention. It presents the number and percentage of participants in each category, including “Zero,” “1 time,” “2 times,” and “≥3 times,” along with the corresponding p-values for group differences. Key findings include:
TABLE 8: Comparisons between both groups regarding numbers of admitting hospital during the past 3 months
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Pre-test: No significant difference between groups in admission frequencies (P = 0.555).
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Post-test: A trend toward reduced admissions in the interventional group, though not statistically significant (P = 0.059).
This suggests a potential effect of the intervention on reducing hospital admissions.
Table 9 demonstrated that before implementing the nursing educational program, there were no significant differences observed in systolic and diastolic blood pressure, between the control and intervention groups. The only significant difference was found in diastolic blood pressure at (P ≤ 0.006) after dietary educational program.
TABLE 9: Comparisons between both groups related to systolic and diastolic blood pressure before and after the nursing interventional program
4. DISCUSSION
Nutritional care of HF clients includes screening for nutritional hazards, providing information, conducting evaluations, designing tailored programs, tracking progress, and keeping ongoing communication with patients [27]. Nurses are essential in supporting HF patients with meals, monitoring intake, and working with dietitians. However, there is minimal research on nursing care quality in this area, and tailored nutritional therapy is frequently constrained in practice [28]. The demographic data from the study indicated that the average age of participants in both groups was (68.3) years. This is consistent with findings by (McMurray et al., 2021) [29], who reported that more than half of their cases were aged between 50 and 60. No studies included participants under (60) years old, except for (Mohamed et al., 2017) [30], who reported that Egyptians are more prone to cardiac conditions at a younger age. In the current study, younger patients in both groups made up about one-tenth of the total. This rise in cases may be attributed to population aging, dietary changes, and increasingly sedentary lifestyles. In addition, the majority of cases in this study were male, representing nearly three quarters of the participants. This finding is come along with the study of (Awoke et al., 2019) [31], who emphasized similar trends. However, it contrasts with the results of (Elmaghraby et al., 2023) [32]. HF is more common in rural areas due to insufficient medical education on disease risk factors, clinical symptoms, and treatment options, but this result is contrast with the current outcome because the majority of the present sample were lived in urban region, the researchers returned this outcome to background of that more than half of the HF patients in the current study were illiterate with bad economic state. The study showed a marked improvement in patients’ vital signs and BMI after the program, compared to pre-program levels. This is consistent with (Walters et al., 2020) [33], who found that regular physical activity, exercise, a healthy diet, weight management, and avoiding tobacco are key factors for cardiovascular health. Similarly with the study of (Beauchamp et al., 2020) [34] highlighted the importance of health behavior modification and education, aligning with the current study’s focus on addressing individual needs in cardiovascular prevention and rehabilitation.
Adopting healthy habits is essential for both preventing and managing CVDs. The current research identified hypertension as the most prevalent condition associated with HF, as nearly three-quarters of the intervention group and the majority of the control group had a history of hypertension. In addition, over half of both groups experienced DM and dyslipidemia, respectively. This finding is consistent with (Anker et al., 2021; Bachmann et al., 2021) [35], [36], who identified hypertension and diabetes mellitus as primary risk factors for HF. Concerning edema, both in the feet and abdominal bloating – which contributes to overweight – over half of the patients exhibited ankle edema, and all cases experienced abdominal bloating. This study revealed that nearly half of both groups were obese before the educational program. However, post-program, the intervention group showed a slight reduction in obesity rates compared to the control group. The study of (Cleland et al., 2021) [37] found that half of their study participants had edema, which is a marker of clinical HF. Edema, caused by fluid retention often due to excessive fluid intake, frequently signals worsening cardiac function. The study of (Koikai and Khan, 2023) [38] described their educational program as covering topics such as HF, complications related to seeking treatment, dry weight monitoring, signs of fluid overload, and the benefits of self-care and nutrition. They employed a teach-back approach to ensure comprehension. The interventional group in their study showed lower rates of cardiac deaths compared to the control group, which aligns with our findings. Before the last (12) weeks of the nursing educational program, nearly half of the intervention group and less than half of the control group had been hospitalized twice. However, the frequency of hospital admissions decreased more significantly in the intervention group compared to the control group. This outcome is consistent with the study of (Tsutsui et al., 2019) [39], who observed a reduction in hospital readmissions following an educational program. Conversely, the study of (Halliday et al., 2019) [40] did not find statistically significant results regarding rehospitalization rates but noted that the educational intervention reduced the risk of readmission after 12 months. This discrepancy may be due to the high standard of care already provided by the hospitals involved in these studies, even without an educational program. The study of (Cui et al., 2019) [41] conducted a randomized controlled trial on a nurse-led structured education program aimed at improving self-management skills and reducing hospital readmissions among patients with HF. The intervention group in their study showed lower readmission rates compared to the control group. In addition, a study of (Mizukawa et al., 2019) [42] demonstrated the feasibility and benefits of self-management and collaborative management techniques, suggesting that further investigation with a larger sample is warranted. This discrepancy may be due to the high standard of care already provided by the hospitals involved in these studies, even without an educational program. Regarding WHR for males and females in the current study, nearly three-quarters of males in the intervention group and more than half in the control group had abnormal WHR levels. Before the nursing educational program, there were no statistically significant differences between the two groups (P = 0.180). However, after the program, the intervention group showed a significant improvement in WHR levels compared to the control group, with a significant difference noted in the intervention group (P = 0.001). For females, more than half of those in the intervention group and nearly half in the control group had abnormal WHR levels before the educational program. There were no significant differences in WHR levels between the two groups before the program (P = 0.214). However, after the program, there was a significant change in WHR levels between the groups, with notable improvements in the intervention group (P = 0.004 and P = 0.006). The researcher noted that participants had long histories of unhealthy eating, multiple health issues, various treatments, and high-stress levels. Despite these challenges, the results of the study were considered valid, particularly given the short duration (only 3 months) of the nursing dietary educational program. This outcome contrasts with the study of (Ballin, 2023) [43] who stated that altering abdominal or visceral fat within a short intervention period is unlikely, especially for patients with CVD who are physically inactive and follow an unhealthy diet. Despite this, the current study found that the nursing educational program led to significant improvements in various aspects related to quality of life (QoL), such as dietary patterns, in the intervention group compared to the control group. This finding is consistent with studies by (Akbari et al., 2019; Stavrianopoulos, 2016; Liou et al., 2015; Al-Hchaim and Hamza,2012; Harris, 2012; Ali et al., 2019; and Świątoniowska-Lonc et al., 2020) [44], [45], [46], [47], [48], [49] and [50], all of which reported that improvements were predominantly observed in the intervention group compared to the control group after their respective programs. Furthermore, the study by (Kakabra and Abdulsahib, 2021) [51] in China and (Lainscak et al., 2011) [52] in Sulaimani City aligns with recent findings because their program was associated with improvements in dietary practices, monitoring recommendations, and social support and the nutritional regimen significantly influences dietary habits and effectively regulates blood pressure in the participants. Most notably, it led to a reduction in the readmission rate within the first (12) months post-discharge. Patients with HF encounter difficulties in self-care due to personal, illness-related, and support-related factors. Healthcare professionals can influence this understanding to develop personalized education programs, offer psychological support, and provide financial assistance. These measures aim to enhance self-care and improve treatment outcomes for HF patients (Cui et al., 2019) [41].
5. CONCLUSION
The intervention group experienced more significant improvements in nutritional status than the control group. The (12-week) educational program resulted in better eating habits, lower hypertension, reduced diabetes and lipids levels, decreased body weight and hospital readmissions, and greater awareness of healthier food choices. These outcomes indicate that similar programs can enhance QoL, improve dietary habits, and potentially lower mortality rates among participants compared to those in the control group.
This educational programs are recommended to be available in every coronary care unit enhance the knowledge of nurses concerning health education related to healthy nutrition and the consequences of a healthy diet on heart failure disease patients.
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