Advertisement

Heart Failure Reviews

, Volume 24, Issue 4, pp 565–573 | Cite as

Nutrition intervention in heart failure: should consumption of the DASH eating pattern be recommended to improve outcomes?

  • Renad Abu-Sawwa
  • Sandra B. Dunbar
  • Arshed A. Quyyumi
  • Elisabeth L. P. SattlerEmail author
Article
  • 300 Downloads

Abstract

Heart failure (HF) is a chronic, systemic disorder that presents a serious and growing public health problem due to its high prevalence, mortality, and cost of care. Due to the aging of the population and medical advances that prolong the life of HF patients, more effective, widespread strategies for improved HF management in this rapidly growing patient population are needed. While the prevalence of malnutrition in HF patients has been well characterized, evidence is limited regarding the effects of specific macro- and micronutrient deficiencies on HF outcomes and their interaction with other aspects of HF management, including pharmacotherapy. There is a mounting appreciation for the effects of nutritional intervention on pathophysiology, treatment, and outcomes in patients with HF. Heart-healthy dietary patterns, such as the Dietary Approaches to Stop Hypertension (DASH), carry importance for the prevention and treatment of hypertension. While preliminary evidence looks promising regarding effects of DASH eating pattern consumption on ventricular function and 30-day hospitalizations in HF patients, more research is needed to confirm its effects on short-term and long-term HF outcomes while better understand underlying mechanisms in the context of HF pharmacotherapy.

Keywords

Heart failure Nutrition Intervention DASH Malnutrition 

Notes

Acknowledgements

Supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Numbers UL1TR002378 and KLTR002381. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with ethical standards

Financial disclosures

Drs. Abu-Sawwa, Sattler, Dunbar, and Quyyumi have no conflicts of interest or financial ties to disclose.

Ethical standards

The manuscript does not contain clinical studies or patient data.

References

  1. 1.
    Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jimenez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, UKA S, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P, American Heart Association Council on E, Prevention Statistics C, Stroke Statistics S (2018) Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation 137(12):e67–e492.  https://doi.org/10.1161/CIR.0000000000000558 Google Scholar
  2. 2.
    Russo CA, Elixhauser A (2006) Hospitalizations in the elderly population, 2003: statistical Brief #6. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. RockvilleGoogle Scholar
  3. 3.
    Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M (2006) Burden of valvular heart diseases: a population-based study. Lancet 368(9540):1005–1011.  https://doi.org/10.1016/S0140-6736(06)69208-8 Google Scholar
  4. 4.
    Heidenreich PA, Albert NM, Allen LA, Bluemke DA, Butler J, Fonarow GC, Ikonomidis JS, Khavjou O, Konstam MA, Maddox TM, Nichol G, Pham M, Pina IL, Trogdon JG, American Heart Association Advocacy Coordinating C, Council on Arteriosclerosis T, Vascular B, Council on Cardiovascular R, Intervention, Council on Clinical C, Council on E, Prevention, Stroke C (2013) Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail 6(3):606–619.  https://doi.org/10.1161/HHF.0b013e318291329a Google Scholar
  5. 5.
    Gupta D, Georgiopoulou VV, Kalogeropoulos AP, Dunbar SB, Reilly CM, Sands JM, Fonarow GC, Jessup M, Gheorghiade M, Yancy C, Butler J (2012) Dietary sodium intake in heart failure. Circulation 126(4):479–485.  https://doi.org/10.1161/CIRCULATIONAHA.111.062430 Google Scholar
  6. 6.
    Konerman MC, Hummel SL (2014) Sodium restriction in heart failure: benefit or harm? Curr Treat Options Cardiovasc Med 16(2):286.  https://doi.org/10.1007/s11936-013-0286-x Google Scholar
  7. 7.
    Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, Gonzalez-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P, Group ESCSD (2016) 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 37(27):2129–2200.  https://doi.org/10.1093/eurheartj/ehw128 Google Scholar
  8. 8.
    Mimran A, Guiod L, Hollenberg NK (1974) The role of angiotensin in the cardiovascular and renal response to salt restriction. Kidney Int 5(5):348–355Google Scholar
  9. 9.
    Masson S, Solomon S, Angelici L, Latini R, Anand IS, Prescott M, Maggioni AP, Tognoni G, Cohn JN, Val-Heft I (2010) Elevated plasma renin activity predicts adverse outcome in chronic heart failure, independently of pharmacologic therapy: data from the Valsartan Heart Failure Trial (Val-HeFT). J Card Fail 16(12):964–970.  https://doi.org/10.1016/j.cardfail.2010.06.417 Google Scholar
  10. 10.
    Aliti GB, Rabelo ER, Clausell N, Rohde LE, Biolo A, Beck-da-Silva L (2013) Aggressive fluid and sodium restriction in acute decompensated heart failure: a randomized clinical trial. JAMA Intern Med 173(12):1058–1064.  https://doi.org/10.1001/jamainternmed.2013.552 Google Scholar
  11. 11.
    Damgaard M, Norsk P, Gustafsson F, Kanters JK, Christensen NJ, Bie P, Friberg L, Gadsboll N (2006) Hemodynamic and neuroendocrine responses to changes in sodium intake in compensated heart failure. Am J Phys Regul Integr Comp Phys 290(5):R1294–R1301.  https://doi.org/10.1152/ajpregu.00738.2005 Google Scholar
  12. 12.
    Paterna S, Parrinello G, Cannizzaro S, Fasullo S, Torres D, Sarullo FM, Di Pasquale P (2009) Medium term effects of different dosage of diuretic, sodium, and fluid administration on neurohormonal and clinical outcome in patients with recently compensated heart failure. Am J Cardiol 103(1):93–102.  https://doi.org/10.1016/j.amjcard.2008.08.043 Google Scholar
  13. 13.
    Paterna S, Fasullo S, Parrinello G, Cannizzaro S, Basile I, Vitrano G, Terrazzino G, Maringhini G, Ganci F, Scalzo S, Sarullo FM, Cice G, Di Pasquale P (2011) Short-term effects of hypertonic saline solution in acute heart failure and long-term effects of a moderate sodium restriction in patients with compensated heart failure with New York Heart Association class III (Class C) (SMAC-HF Study). Am J Med Sci 342(1):27–37.  https://doi.org/10.1097/MAJ.0b013e31820f10ad Google Scholar
  14. 14.
    Mahtani KR, Heneghan C, Onakpoya I, Tierney S, Aronson JK, Roberts N, Hobbs FDR, Nunan D (2018) Reduced salt intake for heart failure: a systematic review. JAMA Intern Med 178(12):1693–1700.  https://doi.org/10.1001/jamainternmed.2018.4673 Google Scholar
  15. 15.
    Arcand J, Floras JS, Azevedo E, Mak S, Newton GE, Allard JP (2011) Evaluation of 2 methods for sodium intake assessment in cardiac patients with and without heart failure: the confounding effect of loop diuretics. Am J Clin Nutr 93(3):535–541.  https://doi.org/10.3945/ajcn.110.004457 Google Scholar
  16. 16.
    Arcand J, Ivanov J, Sasson A, Floras V, Al-Hesayen A, Azevedo ER, Mak S, Allard JP, Newton GE (2011) A high-sodium diet is associated with acute decompensated heart failure in ambulatory heart failure patients: a prospective follow-up study. Am J Clin Nutr 93(2):332–337.  https://doi.org/10.3945/ajcn.110.000174 Google Scholar
  17. 17.
    Spaderna H, Zahn D, Pretsch J, Connor SL, Zittermann A, Schulze Schleithoff S, Bramstedt KA, Smits JM, Weidner G (2013) Dietary habits are related to outcomes in patients with advanced heart failure awaiting heart transplantation. J Card Fail 19(4):240–250.  https://doi.org/10.1016/j.cardfail.2013.02.004 Google Scholar
  18. 18.
    Lennie TA, Song EK, Wu JR, Chung ML, Dunbar SB, Pressler SJ, Moser DK (2011) Three gram sodium intake is associated with longer event-free survival only in patients with advanced heart failure. J Card Fail 17(4):325–330.  https://doi.org/10.1016/j.cardfail.2010.11.008 Google Scholar
  19. 19.
    Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, de Simone G, Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L, Zanchetti A, Kerins M, Kjeldsen SE, Kreutz R, Laurent S, Lip GYH, McManus R, Narkiewicz K, Ruschitzka F, Schmieder RE, Shlyakhto E, Tsioufis C, Aboyans V, Desormais I, Group ESCSD (2018) 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 39(33):3021–3104.  https://doi.org/10.1093/eurheartj/ehy339 Google Scholar
  20. 20.
    Rahman A, Jafry S, Jeejeebhoy K, Nagpal AD, Pisani B, Agarwala R (2016) Malnutrition and cachexia in heart failure. JPEN J Parenter Enteral Nutr 40(4):475–486.  https://doi.org/10.1177/0148607114566854 Google Scholar
  21. 21.
    Levitan EB, Wolk A, Mittleman MA (2009) Consistency with the DASH diet and incidence of heart failure. Arch Intern Med 169(9):851–857.  https://doi.org/10.1001/archinternmed.2009.56 Google Scholar
  22. 22.
    Jefferson K, Ahmed M, Choleva M, Mak S, Allard JP, Newton GE, Arcand J (2015) Effect of a sodium-restricted diet on intake of other nutrients in heart failure: implications for research and clinical practice. J Card Fail 21(12):959–962.  https://doi.org/10.1016/j.cardfail.2015.10.002 Google Scholar
  23. 23.
    Poehlman ET, Scheffers J, Gottlieb SS, Fisher ML, Vaitekevicius P (1994) Increased resting metabolic rate in patients with congestive heart failure. Ann Intern Med 121(11):860–862Google Scholar
  24. 24.
    Dunn SP, Bleske B, Dorsch M, Macaulay T, Van Tassell B, Vardeny O (2009) Nutrition and heart failure: impact of drug therapies and management strategies. Nutr Clin Pract 24(1):60–75.  https://doi.org/10.1177/0884533608329299 Google Scholar
  25. 25.
    Anker SD, Sharma R (2002) The syndrome of cardiac cachexia. Int J Cardiol 85(1):51–66Google Scholar
  26. 26.
    Kalantar-Zadeh K, Anker SD, Horwich TB, Fonarow GC (2008) Nutritional and anti-inflammatory interventions in chronic heart failure. Am J Cardiol 101(11A):89E–103E.  https://doi.org/10.1016/j.amjcard.2008.03.007 Google Scholar
  27. 27.
    Jimenez Jimenez FJ, Cervera Montes M, Blesa Malpica AL, Metabolism, Nutrition Working Group of the Spanish Society of Intensive Care M, Coronary u (2011) Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: cardiac patient. Nutr Hosp 26(Suppl 2):76–80.  https://doi.org/10.1590/S0212-16112011000800017 Google Scholar
  28. 28.
    Ceconi C, Curello S, Bachetti T, Corti A, Ferrari R (1998) Tumor necrosis factor in congestive heart failure: a mechanism of disease for the new millennium? Prog Cardiovasc Dis 41(1 Suppl 1):25–30Google Scholar
  29. 29.
    Anker SD, Ponikowski P, Varney S, Chua TP, Clark AL, Webb-Peploe KM, Harrington D, Kox WJ, Poole-Wilson PA, Coats AJ (1997) Wasting as independent risk factor for mortality in chronic heart failure. Lancet 349(9058):1050–1053.  https://doi.org/10.1016/S0140-6736(96)07015-8 Google Scholar
  30. 30.
    Kistorp C, Faber J, Galatius S, Gustafsson F, Frystyk J, Flyvbjerg A, Hildebrandt P (2005) Plasma adiponectin, body mass index, and mortality in patients with chronic heart failure. Circulation 112(12):1756–1762.  https://doi.org/10.1161/CIRCULATIONAHA.104.530972 Google Scholar
  31. 31.
    Szabo T, Scherbakov N, Sandek A, Kung T, von Haehling S, Lainscak M, Jankowska EA, Rudovich N, Anker SD, Frystyk J, Flyvbjerg A, Pfeiffer AF, Doehner W (2014) Plasma adiponectin in heart failure with and without cachexia: catabolic signal linking catabolism, symptomatic status, and prognosis. Nutr Metab Cardiovasc Dis 24(1):50–56.  https://doi.org/10.1016/j.numecd.2013.04.015 Google Scholar
  32. 32.
    Narumi T, Arimoto T, Funayama A, Kadowaki S, Otaki Y, Nishiyama S, Takahashi H, Shishido T, Miyashita T, Miyamoto T, Watanabe T, Kubota I (2013) Prognostic importance of objective nutritional indexes in patients with chronic heart failure. J Cardiol 62(5):307–313.  https://doi.org/10.1016/j.jjcc.2013.05.007 Google Scholar
  33. 33.
    Shirakabe A, Hata N, Kobayashi N, Okazaki H, Matsushita M, Shibata Y, Nishigoori S, Uchiyama S, Asai K, Shimizu W (2018) The prognostic impact of malnutrition in patients with severely decompensated acute heart failure, as assessed using the Prognostic Nutritional Index (PNI) and Controlling Nutritional Status (CONUT) score. Heart Vessel 33(2):134–144.  https://doi.org/10.1007/s00380-017-1034-z Google Scholar
  34. 34.
    Sze S, Zhang J, Pellicori P, Morgan D, Hoye A, Clark AL (2017) Prognostic value of simple frailty and malnutrition screening tools in patients with acute heart failure due to left ventricular systolic dysfunction. Clin Res Cardiol 106(7):533–541.  https://doi.org/10.1007/s00392-017-1082-5 Google Scholar
  35. 35.
    Lourenco BH, Vieira LP, Macedo A, Nakasato M, Marucci Mde F, Bocchi EA (2009) Nutritional status and adequacy of energy and nutrient intakes among heart failure patients. Arq Bras Cardiol 93(5):541–548Google Scholar
  36. 36.
    Sargento L, Longo S, Lousada N, dos Reis RP (2014) The importance of assessing nutritional status in elderly patients with heart failure. Curr Heart Fail Rep 11(2):220–226.  https://doi.org/10.1007/s11897-014-0189-5 Google Scholar
  37. 37.
    Tevik K, Thurmer H, Husby MI, de Soysa AK, Helvik AS (2015) Nutritional risk screening in hospitalized patients with heart failure. Clin Nutr 34(2):257–264.  https://doi.org/10.1016/j.clnu.2014.03.014 Google Scholar
  38. 38.
    Gastelurrutia P, Lupon J, Domingo M, Ribas N, Noguero M, Martinez C, Cortes M, Bayes-Genis A (2011) Usefulness of body mass index to characterize nutritional status in patients with heart failure. Am J Cardiol 108(8):1166–1170.  https://doi.org/10.1016/j.amjcard.2011.06.020 Google Scholar
  39. 39.
    Casas-Vara A, Santolaria F, Fernandez-Bereciartua A, Gonzalez-Reimers E, Garcia-Ochoa A, Martinez-Riera A (2012) The obesity paradox in elderly patients with heart failure: analysis of nutritional status. Nutrition 28(6):616–622.  https://doi.org/10.1016/j.nut.2011.10.006 Google Scholar
  40. 40.
    Lennie TA, Andreae C, Rayens MK, Song EK, Dunbar SB, Pressler SJ, Heo S, Kim J, Moser DK (2018) Micronutrient deficiency independently predicts time to event in patients with heart failure. J Am Heart Assoc 7(17):e007251.  https://doi.org/10.1161/JAHA.117.007251 Google Scholar
  41. 41.
    Sciatti E, Lombardi C, Ravera A, Vizzardi E, Bonadei I, Carubelli V, Gorga E, Metra M (2016) Nutritional deficiency in patients with heart failure. Nutrients 8(7).  https://doi.org/10.3390/nu8070442
  42. 42.
    Arcand J, Floras V, Ahmed M, Al-Hesayen A, Ivanov J, Allard JP, Newton GE (2009) Nutritional inadequacies in patients with stable heart failure. J Am Diet Assoc 109(11):1909–1913.  https://doi.org/10.1016/j.jada.2009.08.011 Google Scholar
  43. 43.
    McKeag NA, McKinley MC, Harbinson MT, McGinty A, Neville CE, Woodside JV, McKeown PP (2017) Dietary micronutrient intake and micronutrient status in patients with chronic stable heart failure: an observational study. J Cardiovasc Nurs 32(2):148–155.  https://doi.org/10.1097/JCN.0000000000000322 Google Scholar
  44. 44.
    d'Almeida KS, Rabelo-Silva ER, Souza GC, Trojahn MM, Barilli SL, Mansson JV, Biolo A, Rohde LE, Clausell N, Beck-da-Silva L (2014) Effect of fluid and dietary sodium restriction in the management of patients with heart failure and preserved ejection fraction: study protocol for a randomized controlled trial. Trials 15:347.  https://doi.org/10.1186/1745-6215-15-347 Google Scholar
  45. 45.
    Jacobsson A, Pihl-Lindgren E, Fridlund B (2001) Malnutrition in patients suffering from chronic heart failure; the nurse’s care. Eur J Heart Fail 3(4):449–456Google Scholar
  46. 46.
    Akashi YJ, Springer J, Anker SD (2005) Cachexia in chronic heart failure: prognostic implications and novel therapeutic approaches. Curr Heart Fail Rep 2(4):198–203Google Scholar
  47. 47.
    Rifai L, Silver MA (2016) A review of the DASH diet as an optimal dietary plan for symptomatic heart failure. Prog Cardiovasc Dis 58(5):548–554.  https://doi.org/10.1016/j.pcad.2015.11.001 Google Scholar
  48. 48.
    Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement D, Coca A, De Simone G, Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L, Zanchetti A, Kerins M, Kjeldsen S, Kreutz R, Laurent S, Lip GYH, McManus R, Narkiewicz K, Ruschitzka F, Schmieder R, Shlyakhto E, Tsioufis K, Aboyans V, Desormais I (2018) 2018 Practice Guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC). Blood Press 27(6):314–340.  https://doi.org/10.1080/08037051.2018.1527177 Google Scholar
  49. 49.
    Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement D, Coca A, De Simone G, Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L, Zanchetti A, Kerins M, Kjeldsen S, Kreutz R, Laurent S, Lip GYH, McManus R, Narkiewicz K, Ruschitzka F, Schmieder R, Shlyakhto E, Tsioufis K, Aboyans V, Desormais I, List of authors/Task Force m (2018) 2018 Practice Guidelines for the management of arterial hypertension of the European Society of Hypertension and the European Society of Cardiology: ESH/ESC task force for the management of arterial hypertension. J Hypertens 36(12):2284–2309.  https://doi.org/10.1097/HJH.0000000000001961 Google Scholar
  50. 50.
    Cohen JB, Townsend RR (2018) The ACC/AHA 2017 hypertension guidelines: both too much and not enough of a good thing? Ann Intern Med 168(4):287–288.  https://doi.org/10.7326/M17-3103 Google Scholar
  51. 51.
    Greenland P, Peterson E (2017) The new 2017 ACC/AHA guidelines “up the pressure” on diagnosis and treatment of hypertension. JAMA 318(21):2083–2084.  https://doi.org/10.1001/jama.2017.18605 Google Scholar
  52. 52.
    Lloyd-Jones DM, Larson MG, Leip EP, Beiser A, D'Agostino RB, Kannel WB, Murabito JM, Vasan RS, Benjamin EJ, Levy D, Framingham Heart S (2002) Lifetime risk for developing congestive heart failure: the Framingham Heart Study. Circulation 106(24):3068–3072Google Scholar
  53. 53.
    Sanches Machado d'Almeida K, Ronchi Spillere S, Zuchinali P, Correa Souza G (2018) Mediterranean diet and other dietary patterns in primary prevention of heart failure and changes in cardiac function markers: a systematic review. Nutrients 10(1).  https://doi.org/10.3390/nu10010058
  54. 54.
    Rifai L, Pisano C, Hayden J, Sulo S, Silver MA (2015) Impact of the DASH diet on endothelial function, exercise capacity, and quality of life in patients with heart failure. Proc (Bayl Univ Med Cent) 28(2):151–156Google Scholar
  55. 55.
    Levitan EB, Lewis CE, Tinker LF, Eaton CB, Ahmed A, Manson JE, Snetselaar LG, Martin LW, Trevisan M, Howard BV, Shikany JM (2013) Mediterranean and DASH diet scores and mortality in women with heart failure: the Women’s Health Initiative. Circ Heart Fail 6(6):1116–1123.  https://doi.org/10.1161/CIRCHEARTFAILURE.113.000495 Google Scholar
  56. 56.
    Hummel SL, Seymour EM, Brook RD, Kolias TJ, Sheth SS, Rosenblum HR, Wells JM, Weder AB (2012) Low-sodium dietary approaches to stop hypertension diet reduces blood pressure, arterial stiffness, and oxidative stress in hypertensive heart failure with preserved ejection fraction. Hypertension 60(5):1200–1206.  https://doi.org/10.1161/HYPERTENSIONAHA.112.202705 Google Scholar
  57. 57.
    Hummel SL, Seymour EM, Brook RD, Sheth SS, Ghosh E, Zhu S, Weder AB, Kovacs SJ, Kolias TJ (2013) Low-sodium DASH diet improves diastolic function and ventricular-arterial coupling in hypertensive heart failure with preserved ejection fraction. Circ Heart Fail 6(6):1165–1171.  https://doi.org/10.1161/CIRCHEARTFAILURE.113.000481 Google Scholar
  58. 58.
    Hummel SL, Karmally W, Gillespie BW, Helmke S, Teruya S, Wells J, Trumble E, Jimenez O, Marolt C, Wessler JD, Cornellier ML, Maurer MS (2018) Home-delivered meals postdischarge from heart failure hospitalization. Circ Heart Fail 11(8):e004886.  https://doi.org/10.1161/CIRCHEARTFAILURE.117.004886 Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Clinical and Administrative Pharmacy, College of PharmacyUniversity of GeorgiaAugustaUSA
  2. 2.Nell Hodgson Woodruff School of NursingEmory UniversityAtlantaUSA
  3. 3.Division of Cardiology, School of MedicineEmory UniversityAtlantaUSA
  4. 4.Department of Foods and Nutrition, College of Family and Consumer SciencesUniversity of GeorgiaAthensUSA

Personalised recommendations