Effect of Educational Program on Dietary Diversity and Nutritional Status among Heart Failure Patients

Background: Heart failure represents a clinical condition, characterized by cardiac damage, altered systolic and diastolic function, exercise intolerance as well as fluid retention. Foodstuffs are classified into several classes based on the variation in nutritional density. Aim: this work was aimed at identifying the effect of educational program on dietary diversity and nutritional status among heart failure patients. Subject & Methods: A quasi-experimental study. A purposive sample was 50 adult HF cases. Data were collected from cardiology department. Tanta University Hospital. Tools, three tools utilized within our research ; Tool (1) Structured Interview Questionnaire it involved three parts. Part (A): Socio-demographic data. Part (B): Health relevant assessment sheet. (C): Laboratory investigation. Tool (2) Household Dietary Diversity Score. Tool (3) The Stanford Nutrition Action Program questionnaire: Part (1): The nutrition knowledge evaluation was determined utilizing a survey tool. Part (2): The nutrition self-efficacy scale. Results: It was revealed that score of nutrition related self-efficacy scale (100%) of study group stronger belief immediate and after three months implementation of program and a highly significant difference was documented in study group before and after implementation program (P=0.000). Conclusion: Our study addressed that HF cases exhibited low dietary diversity pre implementing the program and improved after implementation. Recommendations: The study’s replication on a larger population. Applying educational dietary diversity program for HF cases rather than the traditional care, following the guidelines of care as well as illustrated patient education


Introduction:
Heart failure (HF) represents a clinical condition that are characterized by cardiac damage, altered systolic and diastolic function, exercise intolerance, and fluid retention.Individuals diagnosed with HF have significant symptoms that affect their quality of life and are at a heightened risk of hospitalization and death (McDonagh et. al (2021).It is a prominent reason for hospitalization among patients, and it has an unfavorable prognosis, addressing a mortality rate of 50% within four years after diagnosis (Bragazzi et al (2021).
It has become more prevalent and results in significant costs, affecting both the quality and duration of life, as wit ell as having social and economic consequences.
Initiating prognostic treatment earlier in the illness progression aims to prevent the expenses associated with emergency hospitalization and the negative consequences of the disease, Heart failure has a significant socioeconomic influence and requires continued focus on its care (Fernandes et. al 2020).
Dietary diversity refers to a variety of meals or dietary types ingested during a certain timeframe.Foodstuffs are classified into several classes based on the variation in nutritional density.Some foodstuffs are high in energy, while others are rich in protein, minerals, or vitamins.Classifying food based on these criteria helps to find alternative options with comparable nutritional supplies.

(Balestracci 2018)
The Dietary Diversity Score (DDS) is an important metric used to determine nutritional adequacy.Dietary diversity represents a qualitative measurement of food intake that considers a household's access to a range of foods.It also serves as an indication of the nutritional sufficiency of people' diets (Farhangi & Jahangiry 2018).
Dietary diversity significantly affects nutrition and vitamin supply in a healthy diet.Increasing variation in daily food intake is linked to higher consumption of both macro and micronutrients.Dietary diversity score (DDS) may be associated with the occurrence of some noncommunicable chronic diseases, involving cardiovascular diseases, malignancies, as well as metabolic syndrome (Wawrzeńczyk et.al 2019).Increased nutritional variety may provide higher protection against several chronic conditions.(SarrafzadeganN, Mohammmadifard 2019).
Nurses in cardiology wards must be cautious for ensuring proper nutrition levels for admitted cases and managing their dietary regimens.Monitoring client conditions involving vomiting, inputoutput, and electrolyte levels to adjust food components and maintain proper hydration, is crucial. .

(Roshan et. al 2021)
A nutrition education program provides information and assistance on the types and quantities of food needed to achieve daily nutritional requirements, (Roshan et.al 2021).
The Nutritional Educational Program should aim to enhance knowledge and, crucially, to rebuild confidence and promote a heightened feeling of perceived personal control.The approach should be tailored for the individual, after a dialogue between the nurse and the patient.Education must be offered through a discursive manner not a didactic one wherever feasible.Only providing information during scheduled educational sessions is insufficient.It is important to evaluate current knowledge levels and identify learning requirements for individuals and groups in order to customize content accordingly.Scoring system: The HDDS variable is computed for every household.This variable will have a value between 0 and 12. HDDS (0-12).Total food groups' number ingested by the household's members.Values for A through L will be either "0" or "1".Sum

3-Validity of tools:
A panel of 10 experts in the fields of medical-surgical nursing, at the faculty of Nursing, cardiology field professor at the faculty of medicine, and public health at the faculty of medicine, assessed and confirmed the tools' content validity.The calculated content validity was found to be 98%.A code number was utilized as an alternative to a name.

4-Reliability of the tools
The tool (2) reliability: tested utilizing Alpha Crombachs factor as well as the result =0.Planning Phase: -Each session began with a recap of the previous session's content and an outline of the next session's goals, utilizing basic language appropriate for the patients' level.Motivation and reinforcement were implemented in the educational sessions to improve learning.The booklets were given to the patients who were part of the study at the conclusion of the sessions.
-The program's primary objectives involve enhancing patients knowledges, with special focus on problems associated with nutrition.Health teaching was employed for the study 10 group within 8 sessions; each session took twenty to thirty mins in five patients.The health teaching was created and delivered in Arabic.This phase was developed using information gathered during the assessment phase and related literature study.During this phase, the teaching session was implemented.The teaching style involved group talks, demonstrations, as well as re-demonstrations.The teaching materials contained video tapes, PowerPoint presentations, and colorful handouts created by the researchers in Arabic language.These were provided to the patients as a guide and reference to help them understand all components of the education program.

Implementation phase:
Educational program was implemented by the researchers which were divided into 8 educational training sessions as following.During the first session, an introduction to the health guideline and its objective was provided.

Session 1.
Researchers talked about prevalent problems associated with nutrition, involving overweight/obesity as well as cardiovascular disease.
They also examined the vulnerability and severity of various health issues, as well as the advantages of proper nutrition for health.Furthermore, the researchers discussed barriers and several methods for avoiding detected barriers.Finally, the researchers discussed attitudes toward dietary change.Session 2.
The researchers deliberated on foods categories, foods to restrict, as well as the foods they should consume more.Furthermore, they focused on the specifics of the dietary sugar as well as sodium, including secret sugar as well as sodium, along with their impact on health, and the ideal salt consumption.Furthermore, they spoke about choosing healthy options among the most suitable ones.Session 3. The researchers provided information about vegetable, fruits, potassium, fibers, vitamin A, vitamin C, cleaning techniques, storage, as well as cooking veges as well as fruits, alongside with suggested consumption quantities.The researcher examined the correlation between veges as well as fruits and health as a DASH diet principles' component aimed at reducing BP.They also addressed obstacles to consuming the appropriate amount of veges as well as fruits, providing strategies to deal with them.Furthermore, the researchers examined the phases of change readiness as regards increasing veges as well as fruits intake.

Session 4:
The researchers provided information about the types of whole grain foods, their significance, containing B vitamins, fiber, mostly iron-fortified, and others), storage safety, label identification, nutritional guidelines.Also, the researchers were discussed the whole grains' importance for health according to DASH dietary guidelines for reducing BP, and obstacles against obtaining optimum consumption, along with stating phases of change readiness as regards transition from favoring white-flour products towards whole grains' consumption.

Session 5:
The researchers provided information on meat, dairy products, beans, safety of food, preparing meals, calcium, iron, recommended caloric intake per day, fish, as well as lipids.The researchers spoke on the need of including dairy products containing low fats as well as others containing lean proteins into the diet to promote health, following the DASH dietary guidelines for managing hypertension.They also emphasized the distinction between dietary good as well as bad fats.The researchers examined obstacles to obtaining the necessary lean proteins along with strategies for dealing with them, as well as the phases of change involved in selecting low-fat choices.

Session 6:
The researchers provided information on facts about nutrition shown on labels, guidelines for interpreting labels, allergic foods, salt content, trans fats, and other related topics.They also reviewed the impacts of salt and trans fats on health and how to make optimal decisions by reading labels.The researchers also examined obstacles to reading and comprehending labels, as well as strategies for dealing with them.The researchers examined the phases of change readiness to be considered for food labels.

Session 7:
The researchers provided information on meal planning, shopping, food safety, conserving money, and foods from community resources, including shopping to buy large amounts with and to other people.The researchers also spoke about creating menus that prioritize health, diversity, and attractiveness, as well as selecting healthier choices in fast food restaurants and convenience stores.Furthermore, the researchers were discussing obstacles to obtaining nutritious diets and strategies for dealing with them.The researchers examined the levels of change readiness regarding meal planning as well as food budgeting.

Session 8:
The researchers spoke on health promotion, illness prevention, adequate diet, obstacles, and behavior changes.The researchers received the assessment for their knowledge about nutrition and a selfefficacy survey at the start of the program for data collection.Evaluation phase: -Evaluation was done for patients three times before implementing the program by used all tools, at the end of the program and 3months used tool 1, part B, tool 2 and tool 3.

Statistical analysis of the data:-
The data went through organization, tabulation as well as statistical analysis utilizing statistical package for social studies (SPSS) version 23.As regards categorical data the number as well as percent were measured.Additionally, subcategories' variations underwent testing utilizing chi square X 2 through Friedman test.As regards numerical data the range, mean as well as SD were measured.While comparing between more than 2 means the F variance of repeated measures analysis was employed.Also, while comparing 2 means paired sample t test was employed.Association among variables underwent an assessment utilizing Pearson's correlation coefficient (r).Significance level deemed to be set to p < 0.05 while interpreting tests' results of significance.

Results
Table (1) Illustrate distribution of the patients based on their socio-demographic characteristics.It reveals, near three quarters (72%) were in age of group 51-60 years, as well as (78%) were male and (84%) married.With regards to educational attainment and socioeconomic status, it was found that (60%) had diploma degree, while (64%) had low socioeconomic status.Table (2): This table demonstrates, the studied cases based on the previous hospital admission, surgical history, and heart failure duration (years), it reveals that the majority (90%) had previous hospital admission, (76%) had no Previous surgical history, (40%) had history of hypertension, and (66%) had heart failure since from 3 to 5 years.Table (3): Illustrate distribution of the cases based on the health assessment of vital signs and body mass index (BMI) pre, immediate and 3 months following the program intervention.This table reveals, there were significant and highly statistical significant variations were documented between groups as regards, temperature, blood pressure, and body mass index in pre, immediate and 3 months (P= 0.018*, 0.000*, 0.000*) respectively.Table (4): Illustrate distribution of the cases based on their clinical data about signs of heart failure pre, immediate and three months post program intervention.A highly statistical highly significant variation was documented as regards signs of, swelling in feet or ankles, socks or shoes fit's, swelling go away by the next morning, abdomen is bloated, daily weight changed and patient's look frail (P= 0.000 **) Table ( 5): Shows distribution of the cases based on the Personal barriers to healthy eating prior, immediate as well as 3 months following intervention.There were highly statistical significant difference within study group pre, immediate and post three months in low income, dislike of the taste of healthy food, cooking for one person and missing teeth ( P= 0.000) ** Table ( 6): Distribution of the cases based on the Laboratory investigation related to heart failure prior, immediate as well as 3 months following intervention, revealing that, a highly statistical significant variation was documented in study group before, immediate and post three months of implementation program intervention according to fasting blood sugar, serum cholesterol, HDL, LDL, serum triglycerides, ejection fraction.P= 0.000.Table (7): Illustrate mean as well as SD of Household Dietary Diversity Score of the cases' prior, immediate as well as 3 months following intervention.The mean score was for the study group (7.088± 1.206) (12 ± 0.000) (12 ± 0.000) respectively before, immediate and post three months after implemented program, indicating highly statistical significant variation (P= 0.000).Table (8) Illustrate distribution of the cases' prior, immediate as well as 3 months following intervention as regards their total knowledge score about nutrition.It reveals (100%) of study group exhibit low levels of knowledge before implementing program while (100%) of the study group develop good knowledge after implementing program in immediate and after three months.A highly statistical significant variation was documented in study group before and after implementing program (P =0.000).Also, it represented in the Mean ± SD, before, immediate and after three months.(0.98 ± 1.220) (9.98 ± 0.141) (9.98 ± 0.141) respectively.Table ( 9) Illustrate distribution of the cases based on total score of Nutrition-Related Self-Efficacy scale prior, immediate as well as 3 months following intervention.This table showed, score of nutrition related self-efficacy scale, (100%) of study group stronger belief immediate and after three months of program implementation and a highly significant difference was documented within study group before and following program implementation ( P=0.000*), also represented Range in pre, immediate and 3 months after implementing program 10-11, 30-40, 35-40 respectively and also the Mean ± SD = 10.34 ± 0.479, 38.96± 1.124, 35.42 ± 4.238 respectively.Table ( 10): Shows association between total household dietary diversity Score (HDDS), total knowledge and total selfefficacy scores as well as the sociodemographic characteristics of the cases' preprogram intervention.
Regarding, education a significant negative association was documented between education as well as Total household dietary diversity Score r = -0.403& P = 0.004 ** , Additionally, a significant positive association was documented between Socio-economic status, smoking and total household dietary diversity score with Total knowledge P= 0.002**, 0.002 ** and 0.000 ** respectively.

Items
The studied patients (n =50)

Barriers for healthy eating
The studied patients (n = 50)   There is little research on the nursing care quality as well as organization as regards food service and assisting HF cases in meal selection.Therefore, it has been emphasized that HF cases should have adequate understanding of dietary risk screening and status assessment.
It should also demonstrate cultural sensitivity.Patients along with supporters should actively participate in the educational process by exchanging information to enhance knowledge acquisition.(World Health Organization 2018) Significant of Study:Dietary diversity is linked to longer life expectancy and a lower risk of degenerative conditions, involving cardiovascular diseases, diabetes, and cancer.In the hospitals setting, lack of knowledge among patients especially heart failure patients, such as the lack of specific guidelines, are obstacles against delivering effective nutritional therapy.This research was the first study at Tanta University Hospital addressing this subject to assist those patients.Heart failure has a significant socioeconomic influence and requires continued focus on its care.Heart failure rates in Egypt are increasing by 15.2% yearly, thus, it is recommended that comprehensive patient education sessions be conducted by heart failure nurses or clinical pharmacists.(Hassanein et.al 2023) The patients' knowledge greatly improved after the nutritional health education program was implemented, confirming the program's efficacy in enhancing patients' awareness regarding HF.Illiterate HF patients lack illness information and struggle with self-care due to low education levels.This results in worsened symptoms, reduced quality of life, and higher risks of hospitalization and mortality.Therefore, this work was aimed at identifying the effect of educational program on dietary diversity and nutritional status among heart failure patients.Aim of the study: -Identifying the effect of educational program on dietary diversity and nutritional status among heart failure patients.Research Hypothesis: -The patients with heart failure who are given the nutritional educational program on dietary diversity is expected to exhibit improvement in their nutritional status.Subjects and Methods: Design: A quasi-experimental was utilized for achieving the study's aim.Setting: Tanta University Hospitals' cardiology department, contains six rooms, the rooms contain eight beds in every room.Subjects: A purposive sample of (n=50) adult HF cases selected from previous setting depending on Epi-info program in accordance with the inclusion and exclusion criteria.The sample size was determined utilizing Epi Info 7 statistical program according to patients' admission within hospital at 95% confidence power of the study and accepted error 5%.(n=1308) patients annually.nonverbally.-BMI was ranged between 18.5 to 30 Exclusion criteria: -Impaired mental functions patients -Morbid obesity patients.-Underweight patients.-Defensive hearing alterations.Tools of data collection: Three tools utilized for gathering relevant information, thus obtaining the study's aim, they involve the following.data, involving patients' Code, age, sex, marital status, educational level as well as employment, socioeconomic status determined by family monthly income, smoking history.Part (B): Health relevant assessment sheet that included clinical information about medical history, vital signs, previous hospitalization, and past surgical history.Anthropometric profile, involving weight, height, and BMI was measured.Heart failure duration years.Part (C): Laboratory investigation: CBC, FBS (mg/dl), TC (mg/dl), TG (mg/dl), HDL (mg/dl), LDL (mg/dl), and Ejection fraction (%).Tool (2) Household Dietary Diversity Score (HDDS) This tool was introduced through (Swindale & Bilinsky, 2006) which was adopted and translated into Arabic by the researchers.The HDDS was introduced in 2006 as a component of the FANTA II Project as a population-level measure of household food availability.Household dietary diversity refers to the food groups' number ingested by a household within a certain timeframe, and serves as a crucial measure of food security for several causes.A more diversified household diet is linked to caloric as well as protein sufficiency, protein percentage from animal sources, as well as household income (Swindale & Bilinsky, 2006).The HDDS indicator offers insight into a household's food access and socioeconomic level during the last 24 hours.The following set involves 12 dietary groups: A. Cereals, B. Root and tubers, C. Vegetables, D. Fruits, E. Meat, poultry, offal, F. Eggs, G. Fish and seafood, H. Pulses/legumes/nutsI. Dairy products J. Oil/fats K. Sugar/honey L. Miscellaneous) are utilized for the HDDS calculation.
(A + B + C + D + E + F + G + H + I + J + K + L) Second, the average HDDS indicator is determined for the sample population.The closer the dietary diversity score to 12, and the total score presented in percentage as the following: Average HDDS Sum (HDDS) Total Number of Household -Very good equal to or more 85% -Fairly good equal to 75% to less than 85% -Fairly bad equal to 65% to less than 75% -Very bad equal less than 65% Tool (3) The Stanford Nutrition Action Program questionnaire The Stanford Nutrition Action Program questionnaire developed by Howard et.al 1997.The questions involved components evaluating knowledge of nutrition, as well as self-efficacy.Part (1): The nutrition knowledge evaluation was determined utilizing a survey tool comprising of ten true and false item.Scoring system; The items were scored as 1=correct, and 0 =incorrect.It possessed a possible total score falling between zero and ten, undergoing scoring prior to educational intervention as well as following them.Total level of patients' knowledge score.Low level is below sixty percent Moderate level falls between sixty and seventy-five percent High level is above seventy-five percent Part (2): The nutrition self-efficacy scale utilized while collecting data prior to and after intervention involves ten questions with Likert-like response choices comprising of five points.ach answer option regarding every question was rated over the scale from 1 (not at all certain) to 5 (extremely certain).The score range might vary from 1 to 50.Scoring system: Categorized as the following: Low level: less than 15 score.Moderate level: 16-25 score.High level: 26-50 score Methods of data collection.Ethical consideration: -Approval was granted by the faculty authorities to perform this research.-Ethical permission was granted by the ethics committee of the Faculty of Nursing, Tanta University, with the code 300-9-2023.-The study's nature did not cause any type of harm or pain to participants.-Confidentiality as well as Privacy were considered while collecting data.-All participants were asked to fill an informed consent after explaining the study's aim as well as their right to withdraw from participating at any point.-Tools development: The researchers introduced all the study's tools following the revision of related literature with tools being utilized for gathering data except tool (2 & 3) which were introduced by (Swindale & Bilinsky, 2006 & Howard et.al 1997) respectively.
91. the tool (3) reliability underwent testing utilizing Alpha Crombachs factor as well as the result =0.820.5-A pilot study was carried out for testing the tools' practicality as well as applicability along with detecting any issues which could be faced during the data collection timeframe, being performed on a ten percent from patients accordingly, required modification was employed.Pilot study from patients was not included within the study sample.-Duration of data collection from September 2023 to December 2023 6-Educational training program was conducted utilizing 4 phases involving; (assessment, planning, implementation and evaluation):-I.Assessment phase: In this tool used tools 1, 2 and 3, each patient was individually interviewed.The average time required for completing the questionnaire fell between ten to twenty mins, starting with the sheets' distribution along with explaining the research's purpose as well as clarifying any questions-related issues, three assessments, before implementing the program, at the end of the program, and 3 month after the program.

*
Significant at (p < 0.05) ** Highly Significant at (p < 0.01).Table (6): Distribution of the cases based on theLaboratory investigation related to heart failure pre, immediate and three months post program intervention.Significant at (p < 0.001)

*
Correlation is significant at the 0.05 level (2-tailed( **Correlation exhibits a highly significance at the 0.001 level (2-tailed( Discussion Proper diet is crucial for HF cases due to electrolyte and vitamin imbalances and micronutrient deficiencies induced by diuretics usage (Roshan et.al 2021).nutritional recommendations state that nutritional diversity represents a key aspect of a healthy diet.Consuming a diverse range of meals is the greatest defense against chronic conditions.(Schuetz et al 2020) Alliterated in dietary diversity consumption is linked to a higher likelihood of adverse events as well as worse clinical results among HF cases when hospitalized (Farhangi & Jahangiry 2018).The nutrition process involves screening for nutritional risk, doing a nutritional assessment, creating a nutrition plan, monitoring progress, and communicating with the individual (Motoki et al 2019).Nursing duties include serving meals and preparing patients for eating by ensuring they are adequately positioned.Nurses are responsible for monitoring food intake, evaluating it, and trying to enhance oral intake.They also assess resistance to eating, either alone or in cooperation with dieticians and doctors.Research has shown that focusing on nutritional treatment and receiving support from nurses may boost food consumption in hospitalized HF cases (Rossello et al 2019).
Despite meticulous nutrition assessments and planning, the direct nutritional treatment along with serving for individual patients may be restricted in practice.(Hassanein et.al 2023) Therefore this study aimed to, identifying the effect of educational program on dietary diversity and nutritional status among heart failure patients.The study's demographic data revealed that almost two-thirds of the cases examined were between 50 and 60 years old.This research aligned with McMurray et al (2020), who found that over 50% of their studied cases were between 50 and 60 years old.Bozkurt B et al (2021) found that most of the samples were over sixty years old and widowed, which contradicts the current research.No research included cases under 60 years old, except for a study by Mohamed M. G et al (2017) which found that Egyptians are more susceptible to cardiac conditions at a younger age.Possible explanations of this growth involve the gradual aging of the population, dietary changes, sedentary lifestyles, smoking, as well as stress.This research found that most cases were male, comprising almost three quarters of the total.This finding aligns with the research conducted by Awoke et al (2019) that highlighted the previous sentences.The current study aligns with Elmaghraby et al.'s (2023) findings, indicating that in Egypt, HF is more prevalent in rural areas due to a lack of medical education on disease risk factors, clinical manifestations, as well as treatment.The study demonstrated a significant improvement in patients' vital signs and BMI after the program compared to before.This aligns with Walters et al (2020), who found that physical activity, exercise, a healthy diet, avoiding obesity, and staying away from all forms of tobacco are linked to good cardiovascular health.In line with the current research, Beauchamp et al. (2020) emphasize that health behavior modification and education are crucial aspects of cardiovascular prevention and rehabilitation, particularly in addressing,individual requirements.Embracing healthy habits is crucial for preventing along with managing CVDs.In this research, involving HF cases, a significant number of them exhibited a poor Household Dietary Diversity Score (HDDS) before the program commenced, with a mean HDDS of 7.088 ± 1.206.This conclusion is consistent with the findings of Wawrzeńczyk et al. (2019).research assessing the relationship of HDDS with CVDs risk factors was found lower than this study.Geographical and cultural factors significantly influence dietary and nutritional habits and should be taken into consideration.The recent research found a significant correlation between the, period developing HF, hypertension, smoking habits, as well as dietary diversity.Cases having hypertension along with those developing prolonged history of HF exhibited a less diverse diet, but former smokers exhibited more family dietary diversity as opposed to non-smokers.Our findings indicated that those with elevated cholesterol levels and reduced ejection fraction were prone to have a less diverse diet.This conclusion is consistent with the findings of Vaccaro et al. (2019), who also obtained similar outcomes.The research found that hypertension is the most frequent medical condition linked to the HF occurrence.This finding aligns with the research of Anker et al. (2021) and Bachmann et al. (2021), which identified hypertension as well as DM as the predominant risk factors among HF cases.Regarding the feet edema as well as bloating in the belly, over half of the patients exhibited ankle edema and all cases developed abdominal bloating along with a fragile appearance.Cleland et al. (2021) found that 50% of the study participants had edema, which is an indicator for clinical HF.Edema results from fluid retention in the body, often indicating deteriorating cardiac function.A larger proportion of cases post-program implementation exhibited no edema as opposed to most cases tested pre-program implementation who developed edema.Koikai and Zahid Khan (2023) addressed that their educational program included topics such as HF, obstacles to seeking treatment, dry weight review, indications of fluid overload, as well as the advantages of self-care and nutrition.The teach-back approach was implemented for verifying comprehension.The examined group exhibited lower cardiac death rates as opposed to controls.This outcome aligns with our findings.Virani el al (2020) observed that a crucial aspect of the proposed criteria for clinical stability in chronic HF is the lack of congestion symptoms, involving orthopnea as well as edema.The majority of the individuals investigated had prior hospital admissions.Tsutsui et al. (2019) observed that following recommendations led to a reduction in hospital readmissions from 5 to 0, reduced the duration of hospital stay from 15 to 3 days, and cut hospitalization costs by $7,264 US.Halliday et al. (2019) contradicted this finding by reporting that the studies did not show statistically significant results regarding rehospitalization.However, they did find that the educational intervention decreased the risk of readmission by forty percent after twelve months.This might be attributed to the fact that the hospitals where these studies took place were already providing excellent treatment even without the use of an Educational Program.In China, Cui et al. (2019) conducted an RCT on a nurse-led structured education program to enhance self-management skills along with decreasing hospital readmissions among chronic HF cases.The intervention group exhibited lower readmission rates as opposed to controls .A pilot how to proceed?Eur Heart J, 42:2331-43.-Cui X, X., Sun, T., Bishop, L., Gardiner, F., & Wang, L., (2019).A nurse-led structured education program improves self-management skills and reduces hospital readmissions in patients with chronic heart failure: a randomized and controlled trial in China.Rural Remote Health, 19:5270.10.22605/RRH5270 -Elmaghraby, M. , Demitry, S., Hasaballah, E., & Razik, N., (2023).Multi-slice CT coronary angiography versus invasive coronary angiography in the assessment of graft patency after coronary artery bypasses graft surgery.The Egyptian Heart Journal, 75:100 https://doi.org/10.1186/s43044-023-00424-8-Farhangi, A., & Jahangiry, L.,(2018).Dietary diversity score is associated with cardiovascular risk factors and serum adiponectin concentrations in patients with metabolic syndrome.BMC Cardiovasc Disord, 18(1):68.https://doi.org/10.1186/s12872-018-0807-3. -Fernandes,.F., Fernandes, G., Mazza, M., Knijnik, L., Fernandes, G., de Vilela, A., Badiye, A., & Chaparro, S., (2020).A 10-Year Trend Analysis of Heart Failure in the Less Developed Brazil.Arq.Bras.Cardiol, 114, 222-231.-Fernández, A., Rodríguez, G., Castro, I., Cantón, A., Seoane, M., Casanueva, F., Crujeiras, B., & Martínez, M., (2021).Relevance of Nutritional Assessment and Treatment to Counteract Cardiac Cachexia and Sarcopenia in Chronic Heart Failure.Clin.Nutr, 40, 5141-5155.-Gastelurrutia, P., Lupon, J., & Moliner, P., (2018).Comorbidities, fragility, and quality of life in heart failure patients with midrange ejection fraction.Mayo Clin Proc Innov Qual Outcomes, 2: 176-85.-Halliday, P., Wassall, R., Lota, S., (2019).Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF): an open-label, pilot, randomised trial.Lancet, 393:61-73.-Hashad, M., & Mohamed, M.,(2022).Student nutritional knowledge and dietary behavior: The mediating role of students' self-efficacy and the moderating role of nutrition education.Journal of the Faculty of Tourism and Hotels-University of Sadat City, 6, 109 -Hassanein, M., Tageldien, A., Badran, H., Elshafey, W., Hassan, M., Magdy, M., Louis, O., Abdel-Hameed, T., (2023).Current status of outpatient heart failure management in Egypt and recommendations for the future, ESC Heart Fail, 10 (5):2788-2796.doi: 10.1002/ehf2.14485.-Howard, B. , Winkleby, M. , Albright, C., Bruce, B., Fortmann, S.,(1997).The Stanford Nutrition Action Program: a dietary fat intervention for low-literacy adults.Am J T., & Metra, M.,(2021).ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.Eur Heart J, 42:3599-726.10. 1093\eurheartj\ehab368 -McMurray, V., Solomon, D., Docherty.K., Jhund, S., (2020).The chronic heart failure-a systematic review.Heart Fail Rev,24(5):671-700.https://doi.org/10.1 007/s10741-019-09793-2. -World Health Organization WHO., (2018).The state of food security and nutrition in the world 2018: building climate resilience for food security and nutrition: Food & Agriculture Org.; Available at htt:\\www.apps,who.Int\iris\bitstream\doi\10665\201 8\85839\3 WHO_NMH_NHD_MNM_11.1_eng.pdf