Edited by: Hana Kahleova, Physicians Committee for Responsible Medicine, United States
Reviewed by: Ertugrul Kilic, Istanbul Medipol University, Turkey; Tianan Alan Jiang, McCormick & Company, Inc., United States
This article was submitted to Clinical Nutrition, a section of the journal Frontiers in Nutrition
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
A 54-year-old female with grade 3 obesity body mass index (BMI 45.2 kg/m2) and type II diabetes (hemoglobin A1c 8.1%) presented to her primary care physician in May 2017 with a chief complaint of left lower extremity edema. Work-up revealed heart failure with depressed left ventricular systolic function. Upon diagnosis, she substantially altered her lifestyle, changing her diet from a “healthy western” one to a whole food plant-based one. Guideline directed medical therapy for heart failure was also utilized. Over five and a half months, she lost 22.7 kg and reversed her diabetes without the use of diabetes medications. Her left ventricular systolic function normalized. Although causality cannot be determined, this case highlights the potential role of a plant-based diet in helping to reverse heart failure with reduced ejection fraction. This article will review how a minimally processed whole food plant-based dietary pattern and similar dietary patterns, such as the Dietary Approach to Stop Hypertension diet, may contribute to the reversal of left ventricular dysfunction.
A 54-year-old female with grade 3 obesity body mass index (BMI 45.2 kg/m2) and type II diabetes (hemoglobin A1c 8.1%) presented to her primary care physician in May 2017 with a chief complaint of left lower extremity edema. Venous duplex revealed no deep venous thrombosis and an X-Ray revealed lower extremity atherosclerosis with no fracture. She was sent to a cardiologist. Electrocardiogram demonstrated normal sinus rhythm and a left bundle branch block. Echocardiography revealed a left ventricular ejection fraction of 25% without significant valvular pathology; heart failure was diagnosed. Renal, liver, and thyroid function, as well as ferritin and potassium levels were within normal limits. HIV was non-reactive. She was not anemic. She was started on a beta-blocker, an ACE inhibitor, and a statin. Cardiac MRI in June 2017, revealed a dilated cardiomyopathy and an ejection fraction of 21%. Coronary CT angiogram revealed an Agatston coronary artery calcium score of 458. Extensive calcification on the CT angiogram precluded assessment of coronary artery stenosis. Hence cardiac catheterization was performed and revealed a cardiomyopathy out of proportion to coronary artery disease with a 30% proximal left anterior descending artery stenosis, a 25% proximal and a 60% distal left circumflex artery stenosis, and a 65% first obtuse marginal artery lesion. The left main and right coronary arteries were without stenosis. She was shaken by her diagnosis and became determined to adopt a more healthful diet. She changed her diet from “healthy western” to whole food plant-based (
Patient's dietary pattern pre- and post-dietary change.
• Chicken (without the skin) |
• |
Health parameters at baseline and after five and a half months on a plant-based diet.
BMI | 45.2 kg/m2 | 35.1 kg/m2 |
Hemoglobin A1c | 8.1% | 5.7% |
Ejection fraction | 25% | 55% |
Although causality cannot be determined, this case highlights the potential role of a plant-based diet in helping to reverse systolic dysfunction, or heart failure with reduced ejection fraction.
This article will review how a minimally processed whole food plant-based dietary pattern and similar dietary patterns, such as the Dietary Approach to Stop Hypertension (DASH) diet and vegetarian diet, may contribute to the reversal of left ventricular dysfunction. For the purposes of this case report and literature review, the term plant-based diet will include dietary patterns that are exclusively plant-based and dietary patterns that are predominantly plant-based, such as the DASH diet and vegetarian dietary patterns.
Heart failure (HF) is a condition in which the heart is unable to provide adequate blood flow to meet the normal metabolic needs of the body and can occur with either a reduced or a preserved left ventricular ejection fraction (
Numerous risk factors for the development and progression of HF are influenced by diet, including inflammation, hypertension, dysbiotic microbiome, hyperlipidemia, obesity, and diabetes (
This focus may occur because cardiologists receive little instruction on either nutrition or nutrition counseling (
This deficit may represent a preventive opportunity lost throughout the lifecycle. The Barker Hypothesis suggests that the intrauterine environment influences cardiovascular health later in life (
Prospective cohort studies support the beneficial impact of plant-based dietary patterns on incident HF (
Elevated serum levels of inflammation increase risk factors for HF, as well as incident HF (
ROS are unstable molecules that promote inflammation and may react with and damage myocardial cells leading to interstitial fibrosis, myocyte hypertrophy, and decreased myocardial contractility (
Moreover, vegetarian versus omnivorous diets are associated with lower plasma levels of the pro-oxidant compound, myeloperoxidase, which promotes atherosclerotic plaque formation, and progression. This promotion may lead to atherosclerotic plaque rupture, myocardial infarction, and HF (
Hypertension (HTN) is a common precursor to HF, increasing its risk by 2–3 fold (
In prospective studies, red meat and poultry increased incident HTN (
The gut microbiome consists of around one hundred trillion microorganisms and impacts our immunologic, cardiovascular, and overall health (
Furthermore, soluble dietary fiber, found exclusively in plant-based foods (
Plant-based diets lower serum lipid levels in part due to their soluble fiber, phytosterols, low saturated fat content, absence of cholesterol, and potentially due to their ability to reduce enterocyte cholesterol biosynthesis (
Furthermore, a PBD may render low-density lipoprotein (LDL) cholesterol particles less prone to oxidation (
While high-density lipoprotein (HDL) levels may decrease on a PBD (
Obesity is a risk factor for HF and may account for approximately 11 and 14 percent of HF cases in men and women, respectively. Increases in BMI are linearly associated with an increase in HF risk, where those with obesity having twice the risk of HF compared to those with a healthy BMI (
This increased risk may occur as obesity is associated with altered left ventricular remodeling (
PBDs have been associated with greater weight loss (
Diabetes Mellitus (DM) is associated with an approximate 400% increase in the incidence of HF (
A PBD results in a lower incidence of diabetes (
Accordingly, in the Seventh-Day Adventist Study, the relationship between Type 2 diabetes and degree of dietary plant consumption appeared to lie on a continuum, with a prevalence of: 2.9% in vegans, 3.2% in lacto-ovo vegetarians, 4.8% in pesco-vegetarian, 6.1% in semi-vegetarians, and 7.6% in non-vegetarians (
Heart failure with preserved ejection fraction (HFpEF), or diastolic heart failure, is common and has similar symptoms and adverse outcomes as heart failure with reduced ejection fraction (
Our patient's improvements were temporally associated with her adoption of a whole food plant-based diet. Plant-based diets are associated with improvements in risk factors for heart failure and with direct benefits on cardiac metabolism and function. Given the burden of heart failure, its adverse prognosis, and the overall evidence to date, a plant-based diet should be considered as part of a multifaceted approach to heart failure care.
Full name of the ethics committee: The Montefiore Einstein Institutional Review Board.
Consent Procedure: Written informed consent was obtained from the patient to publish her identifiable/case report data.
RO identified the case and had sole access to patient information. RO, KA, and DG all performed background research, and contributed both to the writing and editing of the paper.
RO consulted for Better Therapeutics. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Body mass index
Dietary Approach to Stop Hypertension
High density lipoprotein
Heart Failure
heart failure with preserved ejection fraction
Hypertension
Low-density lipoprotein
Plant-based Diet.