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Appetite in patients with heart failure: Assessment, prevalence and related factors
Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0002-1482-767X
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Appetite is an important component in nutrition for maintaining the food intake needed by the body. Decreased appetite is a common clinical problem in patients with heart failure. It has a negative impact on food intake and possibly on malnutrition and health outcomes. There is a lack of evidence on how to assess appetite in heart failure. Furthermore, there are knowledge gaps about factors associated with appetite and which role appetite plays for health status in heart failure.  

Aim: The overall aim of the thesis was to investigate appetite in patients with heart failure. Four studies were conducted with the goal to evaluate the psychometric properties of the Council on Nutrition Appetite Questionnaire (CNAQ) (I) and to explore the prevalence of decreased appetite and related factors associated with appetite in patients with heart failure (II-IV).  

Methods: A multicenter study was conducted in three outpatient heart failure clinics in the center of Sweden during 2009-2012. Data were collected through a baseline measurement (I-IV) and an 18-month follow-up (IV). The first study was a psychometric evaluation study (I), while the other studies had an observational cross-sectional design (II-III) and an observational prospective design (IV). One hundred and eighty-six patients diagnosed with heart failure and experiencing heart failure symptoms participated at baseline. At the 18-month follow-up study (IV), one hundred and sixteen participants from the baseline participated. Data were collected from medical records (pharmacological treatment, comorbidity, left ventricle ejection fraction, time of diagnosis), self-reported questionnaires (demographic background data, appetite, symptoms of depression, health status, sleep, self-reported physical activity), objective measurements (anthropometric assessment of body size, blood samples, six minutes’ walk test, and physical activity measured with an actigraph) and clinical assessment (New York Heart Association (NYHA) functional classification, and cognitive assessment). The main outcome variables included appetite (I, II and IV) and health status (III). Descriptive and inferential statistics were used in the studies (I-IV).  

Results: The majority of the participants had moderate heart failure symptoms, i.e., NYHA class II (n=114, 61%). Most of the participants were men (n=130, 70%). Mean age was 70,7 years, (SD=11,0), and mean BMI was 28.7 (SD=5.3). The CNAQ showed acceptable psychometric properties for assessing appetite in patients with heart failure (I). This thesis shows that 38% of the participants experienced an appetite level that put them at risk of weight loss (I). It was shown that factors such as biological, medical, psychological (II) and physical activity/exercise capacity (IV) are associated with appetite. Also, appetite was associated with impaired health status. However, this association was found to be moderated by symptoms of depression (III). Neither appetite nor physical activity changed during the 18-month follow-up (IV).  

Conclusion: Decreased appetite is a serious phenomenon that needs attention in the care of patients with heart failure. Health care professionals can now use a validated and simple appetite instrument to assess appetite in heart failure. In addition, attention should be paid to elderly patients and those who have symptoms of depression, sleep problems, impaired cognitive function and impaired physical activity, as well as to patients on suboptimal medical treatment. Higher appetite was shown to contribute to a better health status, but this was only evident in patients without symptoms of depression. Therefore, special attention should be paid to symptoms of depression, as this risk factor affected the association between appetite and health status. This thesis enhances the understanding of the magnitude of the problem with decreased appetite in heart failure both in numbers and factors. New priorities in nutrition care and new ideas can be established, both in practice and in research, in order to improve a nutrition care that is vital for patients with heart failure.  

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2018. , p. 87
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1606
Keywords [en]
Appetite, Age, Cognitive function, Depression, Health status, Heart failure, Malnutrition, Physical activity, Psychometrics, Pharmacotherapy, Sleep
National Category
Nursing Cardiac and Cardiovascular Systems
Identifiers
URN: urn:nbn:se:liu:diva-145533DOI: 10.3384/diss.diva-145533ISBN: 9789176853733 (print)OAI: oai:DiVA.org:liu-145533DiVA, id: diva2:1187519
Public defence
2018-04-20, Berzeliussalen, Ingång 65, Campus US, Linköping, 09:00 (English)
Opponent
Supervisors
Available from: 2018-03-14 Created: 2018-03-05 Last updated: 2018-04-26Bibliographically approved
List of papers
1. Psychometric Evaluation of Two Appetite Questionnaires in Patients With Heart Failure
Open this publication in new window or tab >>Psychometric Evaluation of Two Appetite Questionnaires in Patients With Heart Failure
2015 (English)In: Journal of Cardiac Failure, ISSN 1071-9164, E-ISSN 1532-8414, Vol. 21, no 12, p. 954-958Article in journal (Refereed) Published
Abstract [en]

Background: Decreased appetite in heart failure (HF) may lead to undemutrition which could negatively influence prognosis. Appetite is a complex clinical issue that is often best measured with the use of self-report instruments. However, there is a lack of self-rated appetite instruments. The Council on Nutrition Appetite Questionnaire (CNAQ) and the Simplified Nutritional Appetite Questionnaire (SNAQ) are validated instruments developed primarily for elderly people. Yet, the psychometric properties have not been evaluated in HF populations. The aim of the present study was to evaluate the psychometric properties of CNAQ and SNAQ in patients with HE Methods and Results: A total of 186 outpatients with reduced ejection fraction and New York Heart Association (NYHA) functional classifications II-IV were included (median age 72 y; 70% men). Data were collected with the use of a questionnaire that included the CNAQ and SNAQ. The psychometric evaluation included data quality, factor structure, construct validity, known-group validity, and internal consistency. Unidimensionality was supported by means of parallel analysis and confirmatory factor analyses (CFAs). The CFA results indicated sufficient model fit. Both construct validity and known-group validity were supported. Internal consistency reliability was acceptable, with ordinal coefficient alpha estimates of 0.82 for CNAQ and 0.77 for SNAQ. Conclusions: CNAQ and SNAQ demonstrated sound psychometric properties and can be used to measure appetite in patients with HF.

Place, publisher, year, edition, pages
CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS, 2015
Keywords
Appetite; heart failure; outpatient; psychometrics
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-123773 (URN)10.1016/j.cardfail.2015.10.006 (DOI)000366230900004 ()26497759 (PubMedID)
Note

Funding Agencies|Center for Clinical Research and Sormland County Council, Sweden; Swedish Heart and Lung Foundation; King Gustaf V and Queen Victorias Freemason Foundation; Medical Research Council of Southeast Sweden; Canadian Institutes of Health Research

Available from: 2016-01-11 Created: 2016-01-11 Last updated: 2018-03-14
2. Prevalence and associated factors for decreased appetite among patients with stable heart failure
Open this publication in new window or tab >>Prevalence and associated factors for decreased appetite among patients with stable heart failure
2016 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 25, no 11-12, p. 1703-1712Article in journal (Refereed) Published
Abstract [en]

Aims and objectivesTo explore the prevalence of decreased appetite and factors associated with appetite among patients with stable heart failure. BackgroundDecreased appetite is an important factor for the development of undernutrition among patients with heart failure, but there are knowledge gaps about prevalence and the factors related to appetite in this patient group. DesignObservational, cross-sectional study. MethodsA total of 186 patients with mild to severe heart failure were consecutively recruited from three heart failure outpatient clinics. Data were obtained from medical records (heart failure diagnosis, comorbidity and medical treatment) and self-rated questionnaires (demographics, appetite, self-perceived health, symptoms of depression and sleep). Blood samples were taken to determine myocardial stress and nutrition status. Heart failure symptoms and cognitive function were assessed by clinical examinations. The Council on Nutrition Appetite Questionnaire was used to assess self-reported appetite. Bivariate correlations and multivariate linear regression analyses were conducted to explore factors associated with appetite. ResultsSeventy-one patients (38%) experienced a loss of appetite with a significant risk of developing weight loss. The final multiple regression model showed that age, symptoms of depression, insomnia, cognitive function and pharmacological treatment were associated with appetite, explaining 27% of the total variance. ConclusionIn this cross-sectional study, a large share of patients with heart failure was affected by decreased appetite, associated with demographic, psychosocial and medical factors. Relevance to clinical practiceLoss of appetite is a prevalent problem among patients with heart failure that may lead to undernutrition. Health care professionals should routinely assess appetite and discuss patients experiences of appetite, nutrition intake and body weight and give appropriate nutritional advice with respect to individual needs.

Place, publisher, year, edition, pages
WILEY-BLACKWELL, 2016
Keywords
age; appetite; cognitive function; depression; heart failure; insomnia; outpatient; pharmacological treatment
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-128929 (URN)10.1111/jocn.13220 (DOI)000375866200022 ()26879764 (PubMedID)
Note

Funding Agencies|Centre for Clinical Research Sormland, Uppsala University, Eskilstuna, Sweden; Swedish Heart and Lung Foundation; King Gustaf V and Queen Victorias Freemason Foundation; Medical Research Council of Southeast Sweden

Available from: 2016-06-09 Created: 2016-06-07 Last updated: 2018-03-14
3. Depressive Symptoms Moderate the Association Between Appetite and Health Status in Patients With Heart Failure
Open this publication in new window or tab >>Depressive Symptoms Moderate the Association Between Appetite and Health Status in Patients With Heart Failure
Show others...
2018 (English)In: Journal of Cardiovascular Nursing, ISSN 0889-4655, E-ISSN 1550-5049, Vol. 33, no 2, p. E15-E20Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Decreased appetite and depressive symptoms are clinical problems in patients with heart failure. Both may result in impaired health status.

OBJECTIVE: The aims of this study were to investigate the association between appetite and health status in patients with heart failure and to explore whether depressive symptoms moderate this association.

METHODS: In this cross-sectional study, patients with heart failure (n = 186; mean age, 71 years), New York Heart Association class II to IV, participated. Data on appetite (Council of Nutrition Appetite Questionnaire), depressive symptoms (Patient Health Questionnaire-9), and health status (EQ-5D 3-level scale [EQ-5D-3L] descriptive system, EQ-5D-3L index, and EQ Visual Analog Scale) were collected by self-rating questionnaires. Pearson correlation was used to investigate the association between appetite and health status. Multiple regression was performed to examine whether depressive symptoms moderate the association between appetite and health status.

RESULTS: There was a significant association between appetite and health status for EQ-5D-3L descriptive system, mobility (P < .001), pain/discomfort (P < .001), and anxiety/depression (P < .001). This association was also shown in EQ-5D-3L index (P < .001) and EQ Visual Analog Scale (P < .001). Simple slope analysis showed that the association between appetite and health status was only significant for patients without depressive symptoms (B = 0.32, t = 4.66, P < .001).

CONCLUSIONS: Higher level of appetite was associated with better health status. In moderation analysis, the association was presented for patients without depressive symptoms. Decreased appetite is an important sign of poor health status. To improve health status, health professionals should have greater attention on appetite, as well on signs of depressive symptoms.

Place, publisher, year, edition, pages
Wolters Kluwer, 2018
Keywords
appetite, association, depression, health status, heart failure, nutritional status
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-139105 (URN)10.1097/JCN.0000000000000428 (DOI)000440241700003 ()28574973 (PubMedID)2-s2.0-85020167287 (Scopus ID)
Available from: 2017-07-01 Created: 2017-07-01 Last updated: 2018-09-27Bibliographically approved

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