Low Carbohydrate Diets for Diabetic Cardiomyopathy: A Hypothesis

Abstract

Elevated blood glucose levels, insulin resistance (IR), hyperinsulinemia and dyslipidemia the key aspects of type 2 diabetes mellitus (T2DM), contribute to the development of a certain form of cardiomyopathy. This cardiomyopathy, also known as diabetic cardiomyopathy (DMCM), typically occurs in the absence of overt coronary artery disease (CAD), hypertension or valvular disease. DMCM encompasses a variety of pathophysiological processes impacting the myocardium, hence increasing the risk for heart failure (HF) and significantly worsening outcomes in this population. Low fat (LF), calorie-restricted diets have been suggested as the preferred eating pattern for patients with HF. However, LF diets are naturally higher in carbohydrates (CHO). We argue that in an insulin resistant state, such as in DMCM, LF diets may worsen glycaemic control and promote further insulin resistance (IR), contributing to a physiological and functional decline in DMCM. We postulate that CHO restriction targeting hyperinsulinemia may be able to improve tissue and systemic IR. In recent years low carbohydrate diets (LC) including ketogenic diets (KD), have emerged as a safe and effective tool for the management of various clinical conditions such as T2DM and other metabolic disorders. CHO restriction achieves sustained glycaemic control, lower insulin levels and successfully reverses IR. In addition to this, its pleiotropic effects may present a metabolic stress defense and facilitate improvement to cardiac function in patients with HF. We therefore hypothesize that patients who adopt a LC diet may require less medications and experience improvements in HF-related symptom burden.

Pathophysiology and Advances in the Therapy of Cardiomyopathy in Patients with Diabetes Mellitus

“…Among these recommendations is an emphasis on properly adjusting caloric intake and eating unprocessed poultry, fresh fish, nuts, legumes and a variety of vegetables. Indeed, the substitution of red and processed meat has been associated with a lower risk of total mortality and cardiovascular deaths [16,44,45]. Two to three servings of fish per week have been shown to be associated with lower mortality from any cause or lower risk of HF [46].…”

“…Two to three servings of fish per week have been shown to be associated with lower mortality from any cause or lower risk of HF [46]. In addition, it is recommended to limit consumption of sweetened beverages and highly processed foods containing high amounts of salt and to reduce or stop alcohol consumption [44,45]. The most common diets considered in patients with DM are the Dietary Approaches to Stop Hypertension (DASH) diet, the Mediterranean diet and the vegetarian/vegan diet.…”

Cardiometabolic Care: Assessing Patients with Diabetes Mellitus with No Overt Cardiovascular Disease in the Light of Heart Failure Development Risk

“…Regarding LC diets, studies have provided controversial results [ 58 ]; however, there is evidence supporting their role in achieving better glycemic control and reduced insulin resistance. These effects contribute to a more favorable metabolic environment that could prevent the development of diabetic cardiomyopathy [ 59 ].…”

“…Therefore, the Mediterranean diet is suggested to play a significant role in reducing risk factors for heart disease, such as obesity, dyslipidemia, hypertension and diabetes [ 6 , 63 ]. For DM, in particular, the adoption of the Mediterranean diet has been linked to a reduction in fasting and postprandial glucose levels [ 58 , 59 ]. At the same time, it has been found that diabetic patients who follow the standard Mediterranean diet show lower levels of hemoglobin A1c (HbA1c) and improved insulin resistance [ 64 , 65 ].…”

Ketogenic diets and Ketone suplementation: A strategy for therapeutic intervention

“…In summary, nutritional ketosis may serve as a cardioprotective alternative energy supply in the failing heart and reduce pathological ventricular remodeling and could serve as a supportive, non-pharmacologic treatment in people with heart failure along current treatments, such as SGLT2 inhibitors ( 103 , 104 ). Long-term use of ketosis should however be tested for safety.…”