Time of Eating and Cardiorespiratory Fitness in Patients with Heart Failure with Preserved Ejection Fraction and Obesity

Abstract

Background and Aims:

Our objective was to examine the impact of caloric intake before or after the mean time of evening meal on cardiorespiratory fitness (CRF) in patients with heart failure with preserved ejection fraction (HFpEF) and obesity.

Methods and Results:

Twelve patients with HFpEF and obesity completed a cardiorespiratory exercise test to measure CRF, defined as peak oxygen consumption (VO₂). Three five-pass 24-hour dietary recalls were performed for each participant and mean evening meal time was determined for each participant individually as well as the group. Participants were divided into those who ate before (Group I) and after (Group II) the mean time of evening meal, 7:25 PM.

Peak VO₂ and exercise time were significantly greater in Group II compared to Group I, moreover, delaying time of evening meal was associated with greater peak VO₂.

Conclusion:

Caloric intake after the mean time of evening meal was associated with better CRF in patients with HFpEF and concomitant obesity. Later nutrient intake may help prevent fasting related stress associated with cardiac metabolic disturbances present in HFpEF. Based on these findings, prospective trials aimed at examining the effects of later evening meal times in patients with HFpEF and obesity are warranted.

Introduction

Reduced cardiorespiratory fitness (CRF) measured by peak oxygen consumption (VO₂) is associated with poor prognosis and quality of life in patients with heart failure with preserved ejection fraction (HFpEF).¹ Obesity further impairs peak VO₂ and intentional weight loss has been shown to improve peak VO₂ in patients with HFpEF.² In patients with obesity alone, time restricted feeding (TRF) proposes that eating most calories earlier in the day within a 8–10-hour window could result in weight loss, however, a recent randomized clinical trial in adults with obesity demonstrated no weight loss benefit with TRF, but reduced lean mass and physical activity, factors which may reduce CRF.³ It is, however, unknown how time of eating may affect CRF in patients with HFpEF and concomitant obesity. We therefore investigated the effect of eating prior to or after the mean time of evening meal on CRF in patients with HFpEF and obesity.

Methods

We prospectively collected data for 12 patients with stable, symptomatic (New York Heart Association Class II-III) HFpEF (left ventricular ejection fraction ≥50%) and obesity (body mass index (BMI) ≥30 kg/m² or fat mass percent (FM%) of body weight ≥25% men or≥35% women). Fat free mass (FFM) and FM were both measured with bioelectrical impedance analysis (RJL Systems). A maximal cardiopulmonary exercise test was conducted using a conservative ramping protocol.^{4, 5} Measurements of CRF collected included peak VO₂ relative to body weight and to FFM (Peak VO_2FFM) (ml•kg⁻¹•min⁻¹), percent predicted peak VO₂ (% peak VO₂), exercise time, oxygen pulse (O₂ pulse), oxygen uptake efficiency slope (OUES) and oxygen uptake efficiency plateau (OUEP).¹ Phlebotomy was performed to obtain N-terminal pro B-type natriuretic peptide (NT-proBNP), a marker of myocardial wall stress. Three consecutive five-pass 24-hour dietary recalls were performed by dietitians,^{4, 5} final evening meal times of the day were averaged together for each participant. Mean time of eating was determined to be normally distributed via Q-Q plots and the Shapiro-Wilk test. Participants were then grouped by having intake prior to (Group I) or after (Group II) the mean of 7:25 (SD = 2.1 hours) post meridiem (_PM). Baseline physical activity and total caloric intake were determined using the International Physical Activity Questionnaire (IPAQ) and baseline dietary recall (Nutrition Data Systems for Research software) for each participant, respectively.^{4, 5}

All other variables are presented as median and interquartile range; significance was defined as P<0.05. Mann-Whitney U test was utilized to examine differences in CRF measures between patients with intake occurring only before and after mean time of eating in the evening. Spearman’s rank correlation coefficients were utilized to examine associations between time of eating and CRF measures.

Results

Baseline characteristics are presented in Table 1. Comparing the differences between Groups I and II, there was a significant difference in peak VO₂, peak VO_2FFM and exercise time, with more favorable performance in Group II (Figure 1A). There was also a trend for greater % peak VO₂ (Group II, 66 [51–80] versus Group I, 46 [39–67]; P=0.082) as well as O₂ pulse in those with later mean meal time (Group II, 11.6 [10.8–16.3] mL/beat versus Group I, 9.7 [7.9–12.5] mL/beat; P=0.062). Physical activity, body composition, age, total daily calories, NT-proBNP, OUEP and OUES did not differ between groups (all P>0.1).

Table 1. Baseline Characteristics.

IQR: Interquartile range; N: number; kg/m²: kilograms/meters, squared; FM (%): percent fat mass of body weight; VO₂: oxygen consumption; ml•kg⁻¹•min⁻¹: milliliters per kilogram body weight per minute; % peak VO₂: percent predicted peak VO₂; VO_2FFM: VO₂ relative to fat free mass; O₂ pulse: oxygen pulse; mL/beat: milliliter/beat; NT-ProBNP: N-terminal pro B-type natriuretic peptide; mg: milligrams

Variable	Median (IQR) or N (%)
Age	64 (52–65)
Female (%)	9 (75%)
Black (%)	7 (58%)
BMI (kg/m2)	36.6 (34.2–41.6)
FM (%)	42.5 (36.1–45.5)
Peak VO2 (ml•kg−1•min−1)	14.6 (11.0–19.6)
% Peak VO2	56.3 (46.9–76.4)
Peak VO2FFM	25.7 (20.5–32.0)
Exercise Time (seconds)	566 (453–786)
O2 pulse (mL/beat)	11.4 (9.8– 15.1)
OUES	1.7 (1.5–2.0)
OUEP	39.5 (35.0–47.7)
NT-ProBNP (pg/mL)	50.0 (39.5–206.5)
Calories	1637 (1309–1792)
% Calories Total Fat (%)	36.5 (29.9–40.9)
% Calories Saturated Fat (%)	10.4 (8.0–14.4)
% Calories Unsaturated Fat (%)	18.9 (13.1–26.2)
% Calories Protein (%)	17.5 (12.1–20.0)
% Calories Carbohydrates (%)	49.2 (41.8–55.6)
% Calories Sugars (%)	20.6 (13.7–26.6)
Sodium (mg)	2315 (1963–3417)

Figure 1. Meal Timing and Cardiorespiratory Fitness.

Patients with heart failure with preserved ejection fraction (HFpEF) who consumed their last evening meal after 7:25 pm (Group II) on average, had greater peak oxygen consumption relative to body weight (peak VO₂) and fat free mass (peak VO_2FFM) as well as exercise time (Panel A). When measured as a continuous variable, mean time of evening meal remained associated with peak VO₂ (Panel B).

On univariate analysis, peak VO₂ (r=0.736, p=0.006) (Figure 1B), peak VO_2FFM (r=0.774, P=0.003), O₂ pulse (r=0.613, P=0.034), exercise time (r=0.767, P=0.004), OUEP (r=0.666, P=0.018) and OUES (r=0.620, P=0.032) demonstrated an association with time of eating, while NT-proBNP demonstrated an inverse association with meal time (r=−0.689, P=0.040). Mean meal time and % peak VO₂ were not associated (P=0.124).

Discussion

In this study we have shown for the first time that participants with HFpEF and obesity who consumed their evening meal after the mean time of eating had better CRF than those who ate prior to the mean. Moreover, increasing lateness of meal was associated with more favorable CRF. Although TRF has been suggested as a beneficial strategy to support weight loss and improve other cardiometabolic parameters in patients with obesity, there is no available data to support its use in patients with HF and the results of this analysis suggest delaying evening meal may, in fact, support fitness in this population. In patients with HF, there is derangement in cardiac as well as whole body metabolism and increased reliance on fatty acids as substrate.^6–8 We speculate that prolonged fasting resulting from TRF may pose an additional stress on the heart by depriving cardiac tissue of its main source of ATP generation, while providing nutrients later in the evening might provide the heart with energetic substrate ultimately avoiding a fasting-related stress.

The current study is limited by the cross-sectional design and small sample size. Although total daily calories, physical activity and age did not differ between the two groups, the sample was not large enough perform a multivariate analysis to fully investigate potential confounding effects of these factors on the relationship between time of eating and CRF. Moreover, Group II had 2 men compared to 1 only man in Group 1, which could have also potentially affected our results.

In conclusion, consumption of the evening meal at a later time was associated with more favorable CRF in patients with HFpEF and obesity. Based on our findings, prospective trials examining the effects of later evening meal time in patients with HFpEF and obesity are warranted. Finally, understanding the potential mechanisms responsible for such effects on CRF (i.e., cardiac and/or peripheral non-cardiac improvements) remains to be elucidated.

Highlights.

• Time of eating has never been explored in heart failure with preserved ejection fraction (HFpEF) and obesity

• Delayed evening meal is associated with better peak VO₂ and longer exercise time in patients with HFpEF and obesity

• Delaying evening meal is also associated with a lower NT-ProBNP in patients with HFpEF and obesity