Welcome, this is Rhonda Monroe, and I'm going to be your moderator today for the HFSA and NEEDyMeds patient education webinar. I'm a member of the Heart Failure Society of America patient committee, and I'm also a heart attack survivor. I've recovered from congestive heart failure, but I still follow the protocol that keeps my heart healthy, and we're going to talk a lot about what that entails today. Our presentation is titled Physical Activity and Diet in Heart Failure, and we'll provide an in-depth discussion of the importance of exercise and diet in the well-being of heart failure patients. Topics to be covered include an overview of heart failure in the body, the benefits of exercise and a balanced diet, understanding sodium intake, safety for heart failure patients, and the importance of cardiac rehab. I'm a big proponent of cardiac rehab, and you'll learn why. It's Heart Failure Awareness Week 2020, and I'm so glad that all of you joined us. As a heart attack survivor, I'm so thrilled to be able to participate in this education on heart failure, and especially on the importance of exercise and diet and successfully managing this condition, which you can thrive with, and I'm living proof. We'd like to take a moment to thank Abbott, Amgen, AstraZeneca, and Cytokinetics, which provide educational grants to support the development and dissemination of these patient and caregiver webinars. I want you to know that today you're in for a real treat. Our speaker is Dr. Laura Peters. She's a board-certified family nurse practitioner and an assistant professor of medicine in the advanced heart failure and cardiac transplant section. She works in the Division of Cardiology in the Department of Medicine at the University of Colorado. Additionally, she's a senior clinical instructor in the University of Colorado College of Nursing. She is the director of the Children's Hospital Colorado and UC Health Heart Transplant Transition Program. Dr. Peters is passionate about the impact of mental health and healthy lifestyle habits in patients with chronic disease state, and we're so happy to hear from her today. We want today's webinar to really be interactive, and so we're encouraging you to submit your questions to our presenter using the questions tab on the left side of your screen. Feel free to submit your questions at any time. The question and answer portion of this program will immediately follow the presentation. I'd also like to point out there's a great feature for those of you who wish to take notes during this presentation, and it'll be a lot of good information for you to take in, and so you might just want to take some notes on that so you can refer to it later. When you click on the notes tab on the right side of the screen, you'll see a white text box where you can take notes on today's webinar. These notes will be emailed to you automatically at the end of the presentation. And now, without further ado, I'd like to present to you Dr. Laura Peters for today's feature presentation. Hello, everyone. Thank you for joining Rhonda and I today for this webinar. I'd also like to thank the Heart Failure Society of America for putting together this opportunity during the 2020 Heart Failure Awareness Week. As Rhonda said, I'm Laura Peters, an Assistant Professor and Nurse Practitioner on the Advanced Heart Failure Team at the University of Colorado. Today we're going to spend some time discussing the ways that physical activity and diet can benefit heart failure management. We will go through specific recommendations for diet and exercise and how following these recommendations can improve heart failure symptoms, increase muscle strength and endurance, result in fewer hospital admissions, and improve quality of life. Let's start with physical activity. There are a number of studies that have researched the impact of bed rest on exercise capacity. This is a graph from a study done by Convertino and colleagues that looked at the physiological effects of bed rest. They found that averaged over a 30-day period every day in bed resulted in about a 1% reduction per day in what you can do. There have been other studies looking at the same effect in healthy individuals and the studies show that even a healthy individual will have less capacity to exercise the longer they remain on bed rest. In addition to decrease in exercise ability, inactivity has some other unfortunate companions. Inactivity is associated with decreased cognition or the ability to think clearly as well as depression. Remaining inactive also results in muscle loss, meaning your muscles do not have as much strength. This loss of muscle strength can impact balance and result in an increased risk of falling. Additionally, inactivity results in a decrease in bone density, meaning that if you do fall, it may result in a fracture. Another complicating factor is that heart failure affects the whole body, not just the heart. This means that heart failure makes you less able to exercise. It affects the heart and blood vessels, making the system less efficient at getting blood from the heart and redistributing it to where it needs to go, like the muscles when you want to exercise. There are changes in the lungs, leading to poor transfer of oxygen from the air around you into the blood. The respiratory muscles are working overtime. We know that for any amount of work, patients with heart failure have to breathe more. That means that blood must go to the diaphragm to supply that respiratory muscle and it means less for your legs. Additionally, there's often swelling in the gut, leading to feeling full early, poor absorption of nutrients, abdominal bloating, which means that you may not be taking in as many calories and be more fatigued. And finally, the muscles are abnormal. They are weaker, they tend to get tired more quickly, and in general, they have less muscle mass than someone without heart failure. The good news, after all that bad news, is that exercise is possible in heart failure and that exercising with heart failure can help to counteract some of the negative things that we have just discussed. When you start to exercise, you will find that over time you are able to improve your ability to exercise. This is because exercise improves cardiac function. Your heart is a muscle and while heart failure is making it sick, exercise can counteract some of the damage from heart failure. Exercise improves muscular structure and the ability of your heart to squeeze and it strengthens your blood vessels so that they do a better job of delivering oxygen-rich blood to your muscles. This results in improved muscular strength and bone density, which improves your gait, balance, and decreases your risk for falling. It can also improve your heart failure symptoms, which would improve your New York Heart Association functional class. In addition to the physiological benefits that we just discussed, regular exercise results in improved quality of life. In fact, one study showed that even just 15 minutes of bike riding led to improvements in cognition and positive feelings. Finally, exercise decreases your risk of hospitalization and death. In 2018, a large study looked at over 17,000 women who wore devices to measure physical activity for a one-week period. They found that the group who had the most physical activity had a significant decrease in mortality. This is a graph from the HF Action Study, which was a study that looked at over 2,000 heart failure patients. These patients were randomized to either exercise therapy or usual care and followed for an average of 30 months. The study endpoints looked at death for any reason or being admitted to the hospital for any reason. When they analyzed the results and adjusted for important differences in the groups, they found an 11% reduction in these bad outcomes in the groups that were assigned to exercise therapy. What's even more interesting is that they also took a deeper look into the exercise group. Those individuals that did the most exercise had the most benefit. Now that we've identified the benefits of exercise and heart failure, it's important to discuss when it is safe to exercise. Exercise has been proven safe when heart failure symptoms are stable. If you have shortness of breath at rest, chest pain, fatigue, have a fever or other signs of infection, that is not the time to start exercising. Additionally, if you have too much fluid or if you are in the process of changing your medications with your provider, you will want to wait to start an exercise program. However, if your symptoms are under control, you're feeling well, that's a great time to discuss exercise with your provider. Generally, when beginning an initial exercise routine, your provider will want to obtain an exercise stress test to see how your body responds to exercise. They may also refer you to cardiac rehab. The important thing to remember when starting exercising is to go slow and steady. You may find that you can comfortably walk for just a few minutes before you need to rest. You may decide to do this for a couple of days and then slowly add a few minutes every couple days until you are at 20 to 30 minutes at a comfortable pace while you're feeling well. Once you and your provider have decided that exercise is safe and is a good thing for you to begin, you may discuss cardiac rehab. Cardiac rehab is a carefully monitored comprehensive program that seeks to improve cardiovascular health. It is run by a multidisciplinary team of experts consisting of exercise physiologists, nurses, nutritionists, physical therapists, and a provider. It incorporates exercise training with self-care. Participants attend 36 supervised sessions, which are generally split up into three sessions per week for three months. These sessions have an aerobic exercise component, generally on a treadmill or a bicycle. Participants start at 15 to 30 minutes at 60% of reserve three times a week. After six weeks, participants have home sessions added in with the goal to be at 40-minute sessions at 60 to 70% of reserve five times a week by the end of the program. There are a number of benefits to cardiac rehab. These include an increase in confidence and strength. Cardiac rehab can prevent the worsening of heart failure symptoms. It provides a safe environment where participants are able to have support and education on diet, exercise, and self-care, and it improves the quality of life and reduces risk of death. Unfortunately, very few heart failure patients are referred. Historically, part of this may have been due to funding, but in February 2014, Medicare approved cardiac rehab for patients with heart failure. So, ask your provider if you qualify for cardiac rehab. Another question often asked is if it is safe to exercise with a pacemaker or defibrillator. The answer is yes. These devices should not limit your ability to exercise. They are actually designed to function appropriately during exercise. As always, it is important to discuss exercise with your provider to make sure it is safe, as there are lots of individual reasons to consider. While cardiac rehab is a great way to begin regular exercise routine and one of my favorites, it's not the only way. Physical activity can come in many forms. You do not have to work out at a gym. You can be active by doing everyday activities, such as vacuuming your house, walking in the mall, or walking your dog. I think it's important to choose physical activity, though, that you enjoy, and it can also be helpful to find people to be active with. Doing something you like with people you enjoy spending time with will help you be consistent with physical activity, and you'll have fun doing it. Now I want to briefly talk about self-care. Self-care is the choice of behaviors to promote and maintain stability. These choices can include making sure you attend clinic on a regular basis, taking your medications as prescribed, and engaging in regular physical activity. It also means making sure you don't smoke or that you quit smoking, and limiting alcohol intake. It is also important to get an annual influenza vaccine and follow a healthy diet with appropriate restrictions, such as watching sodium and fluid intake, limiting processed foods, and eating more home-cooked meals, and reading food labels. It also means learning to monitor your symptoms of heart failure and developing a plan with your provider should your symptoms worsen. Good self-care can reduce hospitalizations. Learning to monitor heart failure symptoms includes watching for changes in your breathing, changes in your daily weight, observing for swelling in your legs or abdomen, and noticing changes in your ability to do daily activities. Any of these changes should have some sort of plan of action. Here is an example of a plan that highlights symptoms in the middle column and action items in the far right column. You can see the green zone has stable symptoms, such as no shortness of breath and no weight gain. Action items for the green zone include continuing the good work of taking care of yourself and weighing yourself every day. The yellow and red zones note changes in symptoms along with action items. For example, in the yellow zone, if you have a weight gain of three pounds overnight, this should prompt you to call your doctor or nurse. If you are in the red zone, such as having a hard time breathing, even at rest, or having chest pain, you should get help immediately and go to an emergency room. So, as we wrap up the physical activity portion of this presentation, a couple of final thoughts. Physical activity is good and it results in improved heart failure outcomes. It is very important to pay attention to your body and let your health care team know if something changes. Talk with your health care team to learn about safe exercise for you and ask your provider if you qualify for cardiac rehab. Now let's shift gears to food and talk about the impact of diet on heart failure symptoms. Dietary changes can be challenging and even more challenging when multiple specific dietary restrictions are required. A study of over 130 heart failure patients looked at dietary compliance to four different diets, low sodium, low cholesterol, low fat, and diabetic. The study found that 71% of patients were able to follow at least one dietary restriction. However, only 11% of study participants acknowledged being able to follow all four diets. The American College of Cardiology heart failure guidelines note that a target of less than 3,000 milligrams of sodium per day is reasonable. You should also avoid drinking excessive fluids, but there's no clear guidance on fluid restriction except in stage D heart failure where 1.5 to 2 liters is suggested. There is also a recommendation for 2 liter fluid restriction for patients that are hospitalized. Finally, you should aim to have an adequate intake of protein, vitamins, and fiber. So why the focus on salt and water? Both are essential for health and survival. But in heart failure, the body has a decreased ability to effectively get rid of salt. And wherever salt is, water will follow. So if you have extra salt because your body can't effectively get rid of it, you will begin to retain water. This results in excess fluid in your legs, lungs, and belly. And this looks like swelling in your legs and abdomen, shortness of breath, and a decrease in appetite from swelling in your GI tract. You will also notice that your weight will increase. Paying attention to your weight is important as it is a good indicator of fluid retention, and it often changes before you may have other signs. This study looked at 260 individuals who were part of a monitored program where they did daily weight. The far right shows day of admission, and to the left of that shows days before heart failure hospitalization. You will notice that the dark line that stays flat are patients who are not hospitalized. You will also notice that their weight stayed fairly stable. The lighter line shows patients who are hospitalized, and you can see that in the week before they were hospitalized, there was a steady increase in their weight. Weight gain in the seven days prior to admission of two to five pounds, they had about a three-fold chance of getting admitted. And for those patients that had a 10 or more pound weight gain, they had an eight-fold chance of being admitted. Where do we get the salt in our diet? There was a study published in 2017 of 450 adult participants across the U.S. who measured sodium intake and where it came from. They found that over 70% of sodium intake comes from food prepared outside the home, including anything that comes in a package or that is eaten at a restaurant. 14% of sodium was from sodium that occurs naturally in food. 6% was from home food preparation. And then 5% was from salt that was added to food once it's on the table. The best way to watch your sodium intake is to pay attention to that 71% and to limit the amount of processed foods or meals eaten at a restaurant. Here are some common foods that have high sodium levels. Bread, cold cuts, pizza, poultry, canned soup, and sandwiches. On the left, you will note that one slice of Wonder Bread has 170 milligrams of sodium. If you make a sandwich with two slices of bread, you are already over 10% of the daily recommended amount of sodium. And that's before you even put anything else on the sandwich. This is why it's important to pay attention to food items and to think of ways to eat differently with foods that have less sodium content. Here's a slide from the HFSA website taken from the low sodium module. It highlights the sodium content of different types of common foods on the left. For example, a large cheeseburger has over 1200 milligrams of sodium in it. The right table offers examples of high sodium foods with low sodium alternatives. If you have a recipe that calls for one teaspoon of garlic salt, that will add almost 1500 milligrams of sodium to the food. However, if you substitute that garlic salt with garlic powder, you will only add one milligram of sodium. A small order of French fries can have as much as 700 milligrams of sodium. But if you ask for unsalted French fries, you may only get 10 to 20 milligrams of sodium. And finally, if you enjoy corned beef, this contains approximately 800 milligrams of sodium. But switching to roast beef cuts the sodium to 60 milligrams. This table can be a really good reference and help give you alternatives. Another area where sodium can creep in is through snacks. You will notice that a serving of mini pretzels, which is about 20 mini pretzels, contains 250 milligrams of sodium, and that's one serving. A medium pickle can contain over 800 milligrams of sodium. So it's important to pay attention to food labels and check the sodium content, as well as check the serving size when deciding what snack choices to take in. So how can we change what we eat and limit sodium? The absolute best way is to eat fresh foods. Foods that do not come in a package. One way to do this is to focus on shopping the perimeter of a grocery store, focusing on fresh whole foods. Also, as mentioned several times, it's important to read food labels. Look for alternatives and low sodium options. It's also good to avoid salt when cooking, but liberally use spices and herbs for taste. Steer clear of no salt substitutes unless you have been given permission by a clinician. It is also possible to go out to eat, but you will be more successful if you can do a little bit of planning before. Ask for your food item with no extra salt and avoid dressings and sauces, or ask for them on the side so you can control the amount that you use. Oil and vinegar is a great alternative for salad dressings. Another tip is to review the menu beforehand and have a plan for what to eat. Some restaurants even post their nutritional information online so you can see approximations of sodium in the foods you are deciding between. Now let's talk about water, or really we're going to talk about all fluids. There's no clear evidence that there is a reason to restrict fluid intake in most heart failure patients. Often, if you are thirsty, you should drink. This is your body saying that it needs fluid. But be careful and don't drink to excess and don't drink for no reason. If you are having worsening symptoms, if you are gaining weight, or if you are requiring higher doses of diuretics, this is a time you should work to limit your fluid intake to less than two liters a day. As we wrap up the discussion on diet, it's important to remember to focus on eating a well-balanced meal that is full of fresh fruits and vegetables. Eating meals made at home with whole ingredients and limiting processed foods is a good choice. You should aim to limit your salt to two to three grams a day using labels and serving size to follow your sodium intake. You should drink when you are thirsty, but not in excess or not if instructed to limit by your provider. And finally, a multivitamin can supplement a healthy balanced diet, but it should not be used instead of it. Most nutrients are best gained and absorbed directly from food. The Heart Failure Society of America website offers many different educational resources for patients and families. The website is listed here and please visit it if you have additional questions after this webinar or if you want to reference things that were discussed today. I'd like to thank our sponsors who have helped make this webinar possible. Now, we'd like to move into the question portion. Thank you so much, Dr. Peters. That was really informative. And even for me, I found fascinating the fact that you said, shop the perimeter of the store. And I actually never really thought about it, but thank you so much for that. I never really thought about it, but that's where all the fresh food is in the perimeter of the store. And I thought that was a good tip. So, thank you. Now, we're going to turn to Dr. Peters for the question that you may have. So, feel free, type away, submit your questions. You can submit them using the question tab on the left side of your screen. Are there any questions out there? Okay, well, I'll ask the question. You said that you can look ahead if you're going out to eat, when you're trying to dine out, that you can look ahead and think about what you're going to eat. You can look ahead and plan your meal. Do you have any tips or suggestions for how to do that? I'm asking, is there a particular website that you may send some of your patients to where they can go in and get information? Or do you just send them to the restaurant website for their menu information, nutrition information? That's a great question, Rhonda. There are some apps that have some nutritional information, but my favorite is just using Google. So if you know that you're going to go out to dinner at a particular restaurant, oftentimes you can just type in that restaurant and the menu will come up. There are some, it's not, sometimes it requires a little bit of digging, so if you're going to go on and you may look at the menu and find a couple food options that you are interested in, you can typically then take that meal option and Google, like for example, Del Frisco's is a restaurant here in Colorado and it's a steak place, so you could pick a menu, put in Del Frisco's steak and it nutritional information and then it will generally populate. The other thing that I think patients have had some success with, and I have a few dietary restrictions myself, is to call the restaurant directly and say, I'm coming for dinner, I'd like a couple of these options, but I have a few dietary restrictions, are you able to accommodate? And most times they are more than happy to have you kind of talk to their chef and work directly, but I do think that Google is probably my best used tool. Thank you so much, that's an excellent idea and I'm going to be using that going forward. Sometimes I just opt to cook and stay in because I don't want to take the risk of eating the wrong thing. So we have a couple questions and Michael Lynch submitted a question, he wants to know about the potential problems with hypotremia due to excessive fluid intake. He wants you to comment on that, potential problems with hypotremia due to excessive fluid intake. Sure, thank you so much for that question Michael. So I think there is some risk that you can have too much water and what that does then it can lower the amount of sodium that's in your blood, it sort of dilutes your blood if you will, and that can lead to a rare complication as water intoxication where you have different problems such as GI discomfort, nausea, vomiting, you can have swelling in your brain, lethargy and confusion. But I think and I hope I'm answering your question correctly Michael, the concern is that if we are saying there's not a fluid restriction, are we at risk for getting hyponatremia if we take in too much fluid? And I see below Michael there's another question regarding the restriction of fluid and I think these kind of go hand in hand. I am not advocating that you drink water excessively throughout the day, but it's really to thirst. So if you're drinking to thirst and paying attention to your fluid intake, then I think you're going to be able to kind of avoid that hyponatremia or excessive fluid. For example, I think we're conditioned sometimes to have a glass of water and finish the whole glass, but I would encourage a patient to have a glass of water and drink until they felt like their thirst was quenched and if that was half a glass of water, I would encourage them not to feel like they had to finish that second half. Not sure if that answered the question. And Karen did comment, Karen Potenza did comment that at her surprise about not necessarily needing to restrict the fluids. So thank you for commenting on that as well. And I have to admit as a heart failure patient or having been a heart failure patient, I was a bit surprised by that too because there was always a big that had been a big push for fluid restriction. I'm going to move on and ask Kathleen, can't actually say, Ramsey's question, is the pneumococcal vaccine also advised for this population? So for heart failure patients, are you advising a pneumococcal vaccine? Yes, so there's two different ones. I would say the CDC has recommendations for the two different variations. But in general, yes, the heart failure population would be candidates for the pneumococcal conjugate vaccine or the PCV 13. Again, I would always recommend to discuss this with your provider. But this is a population that would benefit from this. Yes, excellent. And always as with anything, even if there is a recommendation from an organization, check with your provider, your personal provider, because they know your personal heart health history. We have another question. What's the best plan for someone who is completely unable to prepare their own food? What's the best low-sodium fast food if such a thing exists? Great question. I think we are lucky to live in 2020 and we have so many resources now in regards to healthy food options. I would say in regards to fast food options, there are things. It may not just be the restaurant of choice, but it may be what's chosen off the menu. For example, we had talked about the cheeseburger that had a lot of sodium, but having a fresh salad and then choosing a salad dressing such as oil and vinegar or choosing a salad dressing and then using a portion of it as opposed to the whole packet are great options. The other thing is there's a lot of meal preparation services that are available. So there's a lot of healthy fresh food that can be made and ordered online and then delivered to the home and it's low sodium and you can sort of pick what you want. So those are two great options. I think it really comes down to the choices of food. I see a question too about a reference book for diet that can help with food exchanges for sodium. I would refer to the HFSA website. I'm not aware of a specific book, but I will say that there is a lot of information on the internet looking at trying to figure out some salt substitutions and changes in the foods that we've discussed. Great, and I was going to say for the meal prep, I would even try to engage people maybe in the community because I know a lot of people who meal prep themselves and then go an extra step to supplement their income and meal prep for others. So in addition to bigger services, maybe locally, there are some people who also will provide that service. That's a great recommendation, Rhonda. So Erica Bernard wants to know what are some strategies to get patients motivated to exercise? That is a good one. Some of my favorite things to encourage people are to think about exercise as play or to think of exercise as investing in yourself. I think if we also think about exercise sort of as taking a medication, oftentimes you wake up and you look at your pill box and you know you have to take those, so you just do it. I like to tell people exercise should be the same thing. It should be on your to-do list and it should be something you do sort of regarding a side of the emotions that you feel for it. Now I'm not advocating that if you wake up and you feel poorly, if you're ill, if you're more short of breath. I'm not saying that then you should exercise regardless of how you feel. I'm talking a little bit more about the emotional component that maybe you don't want to do it or you feel unmotivated, but if you can just sort of add it in as sort of a to-do, that it's something that you must complete just like taking your medication aside from sort of that emotional whether or not you want to, it can take some of that pressure off. Another thing is that people should do what they enjoy and so I think people should be moving their bodies every day, but it doesn't have to be a chore. So if you're somebody that really likes yoga or you're not sure what you like, it may be fun to try a gym and try all sorts of different things. There's recumbent bikes, there's elliptical machines, we have treadmills, there's pools, we have a ton of snow right now in Colorado, so there's cross-country skiing or snowshoeing. There's all sorts of different physical activities that people should do and then I also think it's really fun to involve people in your community. So whether that's your spouse or a family member that lives with you, whether that's a good friend or maybe it's somebody else that you met in cardiac rehab that you want to help keep each other accountable. But when you can really kind of have somebody else or a few people and create a group, it's more motivating and I happen to think it's more fun because you're hanging out with people that you enjoy and there's somebody there that says, oh it's 10 o'clock, we're going to go for our walks now. That's great Dr. Peters and also I think accountability is a huge component of it and the companionship because then you don't feel so isolated and then also doing something that you like to do. You know, not being compelled to do one activity over another and then finally as a patient, I hear a lot of other patients who say, well I can't exercise because my heart is bad and they don't make the correlation that it's just like a prescription and it's something that they will, that will strengthen their heart because when they hear heart failure, they think their heart is failing and that it's over with. And so just knowing that exercise is a possibility. You know that you, yes, you've been diagnosed with this disease state but it is also possible for you to exercise. It may not be to the magnitude that you once could have but you can and not to compare yourself to others but just to go at your own pace and to do something that you enjoy. We have another question. Patients often say that the Lasix makes them thirsty and they'll drink more because of that. Would you still advise them to have, to drink when they're thirsty? I always fear that they're going to overdo it. Any thoughts? Great question. I would say that Lasix does tend to make people feel thirsty and in those instances, I think it's helpful for patients to pay attention to how much they're drinking. So often I think heart failure patients should have a bottle, a water bottle that has marks on it so that you know kind of how much you're taking in throughout the day. If you are on Lasix and your weight is staying the same and your Lasix dose is staying the same and you are drinking to thirst and not excessively, I think that is still reasonable. However, if you are drinking to thirst and your weight is going up and your Lasix dose is needing to be increased regularly, I would say that is a great example of a time when a fluid restriction would be helpful. It may also be helpful to note that when you're drinking to thirst, you may only be drinking one, one and a half liters or you may note that if your Lasix dose is going up, you may note that you're drinking three and a half liters. So it does help to to kind of have an idea of how much fluid you're taking in. I just think that the guidelines of sticking to a hard and fast rule are not necessarily validated yet, but I do think there is a lot of data surrounding volume and diuretics and trying to manage that balance and I think it's a balance that's individual. And so it's really good to be doing your daily weights, knowing how much fluid you're taking in, and then being in contact with your provider and having those discussions. Carl has a question. So is there a test to determine how much salt we have in our system and if there is, what are the tolerances? So the way that we measure patients' sodium is through a basic metabolic panel and this would be drawn routinely through your provider's office and then this is a test that we use when we are looking at diuretic dosing as well as fluid restrictions. And so this goes back to the question I think earlier where kind of the concern for hyponatremia. We are particularly in hospitalized patients and heart failure patients worried about your sodium level in your blood and we do have a blood test that we can use to follow that and then we have things that we can do to sort of adjust through medications and your fluid intake and your diet to kind of get that into a stable healthy range. Great. Vivian Ehrlich submitted a question. Do you have any suggestions for what you can do if you are thirsty but you need to restrict your liquids? Yes. So oftentimes it helps to suck on candy. I do see somebody I think Vivian you commented that you don't want to suck on candy as it's not good for the teeth which I appreciate. I think it can be helpful to occupy yourself with something else. It could be that could be the time when you go for a walk or when you find a puzzle or a crossword puzzle or ways to distract yourself. I think sucking on candy again can be helpful and you can use options like sugar-free candy. I also think that it can be helpful to have a small amount of liquid and so I think we're used to in our culture sometimes having if we're thirsty to having a huge amount of liquid to kind of quench that thirst but you may find that even a small amount may help quench that thirst. I also think that sucking on ice can be it's fluid but it's less fluid and it will help stimulate some saliva and help kind of your brain think that you're getting more fluid than maybe you're actually taking in. I have a question. Do you think that the volume the size of drinks now compared to what they were say 25 years ago has contributed to people's belief that they're more thirsty because now when you order a meal you get this huge gallon of fluid you know as your drink option whereas before it would be eight ounces or maybe a large with 16 ounces. Do you think that people have been conditioned maybe to think that they need more to drink because of that? Yes, I think that's a great comment and I think that kind of goes back to what I was saying even like if you fill a glass of water I feel like we are conditioned to drink that entire glass of water as quenching our thirst then but it may be that you only need three sips to quench your thirst. So I think there's an element with some of this heart failure self-care is learning your body and and then also learning how to listen to your body. So I think that it's important to learn how to listen to your body. I also think that it depends on what fluid we are taking in. If we are drinking soda for example that's going to not quench your thirst over time and it's going to make you want to take in more fluid whereas switching to a mainly water-based fluid intake people find I think that they need less water and they their thirst quenched. Can you comment on coffee? Because I'm a coffee drinker and coffee dehydrates you. You drink it and then you feel thirstier after you drink you know one or two cups of coffee then you still feel thirsty. Can you comment on the impact that that has on heart failure patients and then in addition to making you feel thirsty it also increases your need to relieve yourself and go to the bathroom which tends to be a side effect of Lasix of your diuretic and so and so I'm asking for a friend. Do you think that coffee has an impact on what do you recommend in terms of coffee for heart failure patients who may be on a diuretic? That is a good question. I think it comes back to That is a good question. I think it comes back to moderation. So there have been concerns about caffeine consumption particularly with coffee but there has not been a lot of data that's actually shown it to be detrimental. There are some concerns I would say so again this is always in context of talking with your specific provider that caffeine may contribute to an irregular heartbeat but that's pretty, they found pretty significant levels of caffeine. So I think moderate coffee intake is very reasonable in the heart failure patient. Again knowing that and it should know how your body responds to coffee. If you have a cup of coffee you know it may have a mild diuretic effect that may actually augment your Lasix if you're trying to pull some fluid off. On the flip side it may cause you to have increased thirst so you're taking in more water than you maybe normally would or if you're on a fluid restriction that is added into that fluid restriction. I do think in general caffeine and coffee can be okay in patients with heart failure but I would say it should be a moderate consumption and it should definitely be discussed with your provider. Great. Are there any more questions? I think we've been through all of the questions that were submitted to this point. If you have an additional question, any additional questions, feel free to submit them right now. I think we're done. Laura would you like to add any additional comments before we move on? I don't think so. I think I would just refer patients that HFSA website has a wealth of patient resources and references and this webinar will be available and so I would send patients there and I just am so thankful that people took the time today and I hope that they found this meaningful and helpful. Great. Thank you. So before we move on, in the interest of time in the beginning, I didn't really share much of my personal story because I wanted to leave ample time for the presentation and for all of the questions and answers but the reason this particular webinar was near and dear to my heart is because I've had three heart attacks and two strokes and three open heart surgeries and part of my heart cut off and 15 laser holes drilled in my heart and a pericardial window and angioplasty and stents and I had my third defibrillator placed in 2018 and just a host of heart health issues and I am an avid exerciser. In fact, it keeps me going and so I just want to say for those who are on the line who are wondering if and how and should they exercise and will it improve their heart function and an ability to thrive with this disease state, I say absolutely yes. I walk, I don't really run and that's not due to my heart, that's because of my knee but I ride bikes, I do exercise classes, I belong to a gym, I do spin class, I'm going to do two classes this evening, I went yesterday morning and then back again in the evening and my digestion fraction had been 21% and now it's in the lower limits of normal and I'm thriving with heart disease and so I just encourage you to try it, to start slowly and I remember I started, I did start with cardiac rehab and then once I graduated from cardiac rehab, I just continued to go to the gym and exercise and there were times when I didn't feel as well as others or times where my heart may have relapsed or I had additional issues and then I would just simply walk at a slow pace but just continue to keep moving, one so my muscles wouldn't atrophy in my legs and the rest of my body but remember your heart is a muscle and so you need to use it to build it up and so I just encourage you to take in all the information that's on HFSA's website, join the Heart Failure Society of America as a patient and I'll talk to you about that in a moment but really love yourself, love your heart, invest in your body, in your heart, in your future, do it for yourself and then do it for your loved ones and so we do have a new patient membership for 2020 and this partnership with clinicians and patients, the goal is really to provide interested patients with leadership, collaboration, and advocacy opportunities. HFSA will follow up with you after the webinar and provide more information if you want to join. I'm obviously a member and I'm a member of their newly formed patient committee and then we're going to have opportunities in the future for you to become a part of the organization in an even greater way. You can serve on committees and task force, collaborate, participate in patient surveys, panel discussions, and interact with heart failure leaders and really become a heart failure leader yourself from a patient perspective and then advocate, volunteer, and help others with heart failure, help those who may be newly diagnosed and then you can advocate in your local community or at a state or federal level. I want you to know that a recording of this webinar is going to be available and there are others as well in the patient and caregiver education series and you can find those on hfsa.org and finally I'm going to ask that you would just fill out an evaluation of this session. If you found it useful, it's going to appear, the evaluation will appear immediately after this but it's also going to be available on the website after the webinar concludes and so it's really important to us that we know if we're meeting your needs and one of the ways that you can let us know is just taking a few minutes and filling out this evaluation. Again, it's going to automatically appear on your screen at the end of the live session but if you have to jot off to another meeting, it'll be available on the event registration page so you can come back to it and really your feedback is invaluable to us. If there's more that you would like to see or hear or topics that you're interested in being covered, please provide your feedback. Again, thank you so much. Thank you Dr. Peters for participating and giving us all of that excellent information. Thank you for taking time out of your busy day to join us to participate in this important session on physical activity and diet and heart failure. Thank you for considering becoming a member and please take advantage of the resources that we've provided for you on the Heart Failure Society of America. It is Heart Failure Awareness Week 2020 and we are taking control. Thank you so much for joining us. Please fill out the evaluation. Keep loving your heart and we'll be here advocating for you. Thank you so much.

Physical Activity

Diet

Heart Failure

Exercise

Cardiac Rehabilitation

Sodium Intake

Fluid Restriction

Self-care

Heart Failure Symptoms