Heart Failure and Plant-Based Diet: A Mini-Review
Syed Adeel Hassan1*, Umar Farooque2, Ali Choudhry3, Fahad Nawaz Sheikh4, Somia Jamal5, Naresh Kumar6, Komal Girdhari7, Tooba Hussain6, Yusra Minahil Nasir8
1Department of Internal Medicine, Dow University Hospital, Karachi, Pakistan
2Department of Neurology, Dow University of Health Sciences, Karachi, Pakistan
3Department of Internal Medicine, Lahore Medical and Dental College, Karachi, Pakistan
4Department of Pathology, University of Illinois at Chicago, Chicago, USA
5Department of Internal Medicine, Abbasi Shaheed Hospital, Karachi, Pakistan
6Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
7Department of Internal Medicine, Civil Hospital, Sukkur, Pakistan
8Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
*Corresponding author: Syed Adeel Hassan, Department of Internal Medicine, Dow University Hospital, Karachi, Pakistan
Received: 24 August 2020; Accepted: 29 August 2020; Published: 03 September 2020
Syed Adeel Hassan, Umar Farooque, Ali Choudhry, Fahad Nawaz Sheikh, Somia Jamal, Naresh Kumar, Komal Girdhari, Tooba Hussain, Yusra Minahil Nasir. Heart Failure and Plant-Based Diet: A Mini-Review. Archives of Internal Medicine Research 3 (2020): 191-194.Share at Facebook
The role of diet in the development and prevention of heart disease has gained much attention. This is due to the rapidly growing evidence that supports the efficacy of nutrition in attenuating the incidence and severity of heart failure. Herein, we review current clinical studies that support the efficacy of a plant-based diet in patients with heart failure. Furthermore, we also outline the effectiveness of plant-based diets in the reduction of cardiovascular risk factors.
Heart Failure, Plant-Based Diet, Risk Factors
Heart Failure (HF) is defined as the reduced ability of the heart to pump or fill with blood leading to unmatched metabolic demands . It usually presents with a complex constellation of symptoms such as dyspnea, bilateral lower limb swelling, and orthopnea . Furthermore, patients also present with clinical signs such as elevated jugular venous pressure and pulmonary congestion . The clinical signs and symptoms are usually seen once the compensatory neurohormonal activation is ineffective in maintaining a normal cardiac output. For clinical purposes, HF is subdivided on the basis of echocardiogram derived ejection fraction. Therefore, the clinical subtypes of HF include HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), and HF mid-range ejection fraction (HFmrEF). HF accounts for one of the leading causes of hospitalization and mortality worldwide. Currently, In the United States, 5.7 million people have HF . This figure is projected to increase to more than 8 million by the year 2030 . This accounts for a 46% increase in the prevalence of HF patients. Annually, > 550,000 are diagnosed with HF in the US alone . These worrisome figures warrant an alternative approach and strategy to treat and prevent cardiovascular diseases. Risk factors leading to the development of heart failure are multi-factorial. These risk factors include diet, diabetes mellitus, hypertension, hyperlipidemia, and obesity . In turn, most of the risk factors leading to the development of heart disease are influenced by the patient’s dietary routine. Most of the current research pertaining to HF focuses on the clinical utility of various drugs and devices . Therefore, data regarding the role of nutrition in the pathogenesis and prevention of HF is scarce. Exploring nutritional therapy as an alternative means provides us with low risk and low-cost options to reduce the incidence and severity of HF. Therefore, we assess the possible efficacy of plant-based diets in HF patients and risk factor prevention.
2.1 Supporting clinical studies
Relevant to the context of our discussion, a plant-based diet refers to the intake of plant foods coupled with a reduction in the intake of animal-based foods. Several studies have indicated that plant-based diets reduce the risk of cardiovascular risk factors such as ischemic heart disease, obesity, diabetes mellitus, and hypertension [6, 7]. In an interventional study, Najjar, and Montgomery initialized plant-based diets in three heart failure (HF) patients as an adjunct to standard HF therapy . The diet based regime was instituted for an average of 79 days. Clinical improvement in various cardiac parameters of all patients was noted in this study. A cardiac magnetic resonance revealed a 92% increase (22.0?±?6.9% vs 42.2?±?18.4%) in ejection fraction . A 21% reduction in left ventricular mass (214?±?90?g vs 170?±?102?g), 62% increase (55.8?±?24.3 cc vs 90.3?±?30.6 cc) in stroke volume and 17% increase (3.6?±?1.2?L/min vs 4.2?±?1.6?L/min) in cardiac output were duly noted . Furthermore, in one of the study participants, 90-95% of ostial stenosis of the left anterior descending artery nearly regressed . Therefore, results from this interventional study support the clinical efficacy of a plant-based diet as an adjunct in the care of HF patients. Furthermore, a plant-based diet may reverse and attenuate the functional and morphological features of HF.
Choi et al. reported an interventional study, where a patient with left ventricular systolic dysfunction and low ejection fraction was placed on a whole food plant-based diet . At the 2 months follow up, an echocardiogram revealed an increase in baseline ejection fraction from 35% to 50% . Furthermore, other cardiac disease risk factors improved drastically over a period of 2 months . Therefore, in conclusion, 60 days of whole food plant-based diet improves ejection fraction significantly. In 2007, Pischke et al. conducted an interventional study comprising of 46 participants with left ventricular dysfunction and reduced ejection fractions . All patients were initiated on plant-based diets for a period of 90 days . Follow up revealed a decrease in cardiovascular disease risk factors (P <0.05) such as body weight, body fat, blood pressure, resting heart rate, total cholesterol, and low-density lipoprotein cholesterol .
2.2 Mechanistic insight
The clinical efficacy of plant-based diets may be due to several underlying pathophysiological mechanisms. They work specifically to mitigate the development of various cardiovascular disease risk factors. Recent studies have implied the importance of the gut microbiome in the maintenance of cardiovascular health. The gut microbiome metabolizes various dietary nutrients such as l-carnitine and choline to yield the pro-atherogenic molecule trimethylamine N-oxide (TMAO) . TMAO is known to impede reverse cholesterol transport . Furthermore, it may also exacerbate vascular inflammation and platelet reactivity . Several clinical studies have indicated that elevated levels of TMAO are associated with worsening rates of HF and overall mortality [11, 12]. Institution of a plant-based diet ensures that the microflora produces less TMAO as compared to when a animal-based diet is consumed . This may account for the association between plant-based diets and fewer cardiovascular events. Furthermore, plant-based diets contain soluble fiber, which improves the health of the gut bacteria. As a consequence, gut bacteria tend to produce more short-chain fatty acids (SCFA) . SCFA is associated with the repression of enterocyte genes involved in cholesterol synthesis . Therefore, reduced cholesterol synthesis may translate to a reduced risk of HF. Plant-based diets are also known to reduce total LDL-C molecules . This may in turn aid to reduce the progression of atherosclerosis. Furthermore, such diets are also high in antioxidants and help neutralize reactive oxygen species (ROS) . This helps alleviate ROS induced myocyte hypertrophy, aortic stiffness, and interstitial fibrosis . Finally, plant-based diets may also help alleviate inflammation by decreasing the plasma concentrations of inflammatory molecules such as soluble intercellular adhesion molecule-1, and interleukin-6 .
From the results of the above discussed literature, plant-based diets can be useful as an adjunct to standard heart failure treatment. When used in adjunct for a period of 60 days or more, they possess the capability to improve functional and morphological disturbance in heart failure. Further large trials and interventional studies are needed to explore plant-based diets as a therapeutic option in heart failure patients. This sets up a precedent for a multifaceted clinical approach to such patients in the future.
- Kurmani S, Squire I. Acute Heart Failure: Definition, Classification and Epidemiology. Curr Heart Fail Rep 14 (2017): 385-392.
- Savarese G, Lund LH. Global Public Health Burden of Heart Failure. Card Fail Rev 3 (2017): 7-11.
- Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (2009): e391-e479.
- Bui AL, Horwich TB, Fonarow GC. Epidemiology and risk profile of heart failure. Nat Rev Cardiol 8 (2011): 30-41.
- Rich MW, Hauptman PJ. Nutrition in heart failure: more than drugs and devices. J Card Fail 21 (2015): 943-944.
- Marsh K, Zeuschner C, Saunders A. Health Implications of a Vegetarian Diet: A Review. American Journal of Lifestyle Medicine 6 (2012): 250-267.
- Tonstad S, Butler T, Yan R, et al. Type of vegetarian diet, body weight, and prevalence of type 2 diabetes. Diabetes Care 32 (2009): 791-796.
- Najjar RS, Montgomery BD. A defined, plant-based diet as a potential therapeutic approach in the treatment of heart failure: A clinical case series. Complement Ther Med 45 (2019): 211-214.
- Choi EY, Allen K, McDonnough M, et al. A plant-based diet and heart failure: case report and literature review. J Geriatr Cardiol 14 (2017): 375-378.
- Pischke CR, Weidner G, Elliott-Eller M, et al. Lifestyle changes and clinical profile in coronary heart disease patients with an ejection fraction of 40% in the Multicenter Lifestyle Demonstration Project. Eur J Heart Fail 9 (2007): 928-934.
- Li XS, Obeid S, Klingenberg R, et al. Gutmicrobiota-dependent trimethylamine N-oxide in acute coronary syndromes: a prognostic marker for incident cardiovascular events beyond traditional risk factors. Eur Heart J 38 (2017): 814-824.
- Tang WHW, Wang Z, Levison BS, et al. Intestinal microbial metabolism of phosphatidylcholine and cardiovascular risk. N Engl J Med 368 (2013): 1575-1584.
- Koeth RA, Wang Z, Levison BS, et al. Intestinal microbiota metabolism of L-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med 19 (2013): 576-585.
- Desai MS, Seekatz AM, Koropatkin NM, et al. A dietary fiber-deprived gut microbiota degrades the colonic mucus barrier and enhances pathogen susceptibility. Cell 167 (2016): 1339-1353.e1321.
- Alvaro A, Sola R, Rosales R, et al. Gene expression analysis of a human enterocyte cell line reveals downregulation of cholesterol biosynthesis in response to short-chain fatty acids. IUBMB Life 60 (2008): 757-764.