Training and Caloric Restriction in Patients With HFpEF and Obesity

Resistance training added to caloric restriction plus aerobic exercise training results in improved leg strength and muscle quality among older patients with heart failure with preserved ejection fraction (HFpEF) and obesity. These findings were published in Circulation: Heart Failure.

Previous research has shown improvement in peak exercise O₂ consumption (VO₂peak) and quality of life (QOL) among older patients with HFpEF and obesity who participate in caloric restriction plus aerobic exercise training. In this population, skeletal muscle mass represents approximately 35% of weight lost during caloric restriction plus aerobic exercise training. Researchers sought to investigate whether resistance training added to caloric restriction plus aerobic exercise training would improve outcomes and reduce skeletal muscle loss. The primary outcome was VO₂peak. Secondary outcomes included leg muscle mass strength and quality, QOL, and arterial function and left ventricular (LV) structure/function.

This 20-week, randomized, controlled, single-blind trial (ClinicalTrials.gov Identifier: NCT02636439) was conducted at Wake Forest University School of Medicine from 2015 to 2021. It included 88 patients (77 of whom completed the trial) at least 60 years of age with chronic HFpEF (LVEF ≥50%) and body mass index (BMI) of at least 28. Patients were randomly assigned into treatment groups stratified by sex, resistance training plus caloric restriction plus aerobic exercise training (N=44; 86% women) and caloric restriction plus aerobic exercise training (N=44; 84% women). Exclusion criteria included significant ischemic or valvular heart disease, or history of reduced LVEF. Prior to enrollment, regular exercise or dieting was not part of participant’s daily routine.

The researchers noted hypertension was a common comorbidity (95% in both cohorts). In the resistance training plus caloric restriction plus aerobic exercise training group 45% of patients had diabetes mellitus, 9% had history of atrial fibrillation, and current medications included ACE inhibitors (27%), β-blockers (40%), and antidepressant (26%). The caloric restriction plus aerobic exercise training group had similar or slightly lower percentages. Overall, diet adherence was 99±1% and exercise attendance was 82±8%.

Participants were prescribed a hypocaloric diet for lunch, dinner, and snacks under direction of a registered dietitian. Both groups exercised 3 times per week for 20 weeks, with a total stimulus time per session for both groups of about 60 minutes with 5- to 10- minute warm-up and cool-down. Both groups experienced an identical aerobic exercise training component.

The researchers found resistance training plus caloric restriction plus aerobic exercise training (48% White) and caloric restriction plus aerobic exercise training (46% White) resulted in nonsignificant differences in weight loss between the 3 treatment group and the 2 treatment group (mean -8 kg; 95% CI, -9 to -7 vs -9 kg; 95% CI, -11 to -8; P =.21). They observed similar nonsignificant differences in skeletal muscle (-2.1 kg; 95% CI, -2.7 to -1.5 vs -2.1 kg; 95% CI, -2.7 to -1.4; P =.23) and in body fat reduction (-6.5 kg; 95% CI, -7.2 to -5.8 vs -7.4 kg; 95% CI, -8.1 to -6.7; P =.20).

Both the resistance training plus caloric restriction plus aerobic exercise training group and caloric restriction plus aerobic exercise training group had improvements in VO₂peak (108 ml/min; 95% CI, 58-157 vs 80 ml/min; 95% CI, 30-130; P =.001 and P =.002, respectively) and in Kansas City Cardiomyopathy Questionnaire scores (17; 95% CI, 12-22 vs 23; 95% CI, 17-28; P =.001 for both). The researchers noted no significant between-group differences.

They found significantly greater increases in leg muscle strength with resistance training plus caloric restriction plus aerobic exercise training (4.9 knee extensor strength [Nm]; 95% CI, 0.7-9.0 vs -1.1Nm; 95% CI, -5.5 to 3.2; P =.05) and leg muscle quality (0.07 Nm/cm²; 95% CI, 0.03-0.11 vs 0.02 Nm/cm²; 95% CI, -0.02 to 0.06; P =.04).

The researchers noted both resistance training plus caloric restriction plus aerobic exercise training and caloric restriction plus aerobic exercise training resulted in significantly reduced LV mass and arterial stiffness. No serious study-related adverse events were reported.

Study limitations include the underpowered sample size and that the researchers did not test the effects of resistance training alone. Additionally, there is exclusion of patients with lower BMIs and the study is not generalizable to patients who are not being compensated.

“In older patients with obese HFpEF, combined CR +AT [caloric restriction plus aerobic exercise training] produced robust weight loss and improvements in physical function (including the primary outcome of VO2peak), QOL, body composition, as well as cardiac and arterial function,” the study authors wrote.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.