Patient-Reported Barriers to Dietary Adherence in Heart Failure: A Qualitative Substudy of the Pro-HEART Trial

Abstract Aims Dietary interventions can improve outcomes for individuals with heart failure and cardiometabolic comorbidities, yet long-term adherence remains difficult and contributes to high attrition in nutrition trials. Understanding participants’ lived experiences is essential for designing sustainable, patient-centered interventions. This qualitative substudy of the registered Pro HEART randomized controlled trial explored participants’ reported barriers to adherence to high-protein or standard-protein dietary prescriptions during a 12-week intensive weight-loss phase and 12-month maintenance phase. Methods Twenty-four participants from the parent trial who completed the parent trial participated in semi-structured interviews conducted immediately after the intensive phase. Two researchers conducted reflexive thematic analysis using an inductive approach until thematic saturation was reached. Results Participants encountered several interrelated challenges, which were categorized into six key themes: (1) psychological distress, stemming from guilt and fear of failure; (2) tracking burden from extensive weighing and logging; (3) technological stress related to rigid or unintuitive digital tools; cultural dissonance, particularly the mismatch between prescribed meal plans and participants’ traditional food practices; (5) social pressures stemming from family dynamics and social events; and (6) a decrease in motivation, as initial enthusiasm waned throughout the intervention. Conclusion Participant experiences demonstrate the need for culturally inclusive, emotionally supportive, and behaviorally feasible heart failure nutrition therapies. Future nutrition trials may improve adherence and retention by addressing psychological distress, fatigue, cultural dissonance, and social pressure. Registration (ClinicalTrials.gov: NCT1423266)