Dietary Patterns and Incident Heart Failure

Study Questions:

Is there an association between dietary patterns and incident heart failure (HF) among participants without known coronary artery disease (CAD)?


This was a prospective observational study using the REGARDS (Reasons for Geographic and Racial Differences in Stroke) cohort. REGARDS is a national, prospective cohort of 30,329 participants over age 45 years recruited between 2003 and 2007, and aimed at assessing risk factors for incident stroke and mortality. The study design included in-home visit for physical evaluation with 6 monthly follow-ups and completion of a validated food frequency questionnaire at the time of enrollment, completed by 72% of participants. Five dietary patterns were identified including convenience (loaded on fast food, meat, and pasta), plant-based (loaded on fresh fruits, vegetables, and fish), sweets/fats (loaded on desserts, bread, and sugar), southern (loaded on fried food, processed meats, added fats, and sugar-sweetened beverages), and alcohol/salads (loaded on wine, liquor, beer, greens, and salad dressings). Each participant received a score based on how their diet was loaded and subsequently divided into quartiles of lowest to highest adherence to each dietary pattern. The primary outcome of interest was incident HF defined as incident hospitalization for HF until December 2014 or death. The secondary outcome included incident HF stratified as systolic or diastolic HF.


A total of 16,068 participants without known HF/CAD were included in this study, with a mean age of 64 ± 9.1 years, 58.7% women, and 33.6% blacks. Participants in the highest quartile of plant-based diet were more likely to be women who smoked less compared to the lowest quartile of plant-based diet. Participants in the highest quartile of southern pattern were more likely to be males, black, smokers with hypertension, and have diabetes compared to the lowest quartile of this diet. Over a median follow-up of 8.7 years, there were 363 new HF hospitalizations. After multivariable adjustment for known HF risk factors, among participants in the highest quartile of plant-based diet, the hazard for new HF hospitalization was 41% lower (hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.41-0.86) compared to those in the lowest quartile of plant-based diet. An association was noted between greater adherence to southern diet and higher incident HF risk (HR, 1.72; 95% CI, 1.20-2.46), which was statistically nonsignificant after multivariable adjustment for diabetes, hypertension, and other HF risk factors. Other dietary patterns were not significantly associated with incident HF. No significant differences were noted in association of dietary patterns by subtype of HF based on ejection fraction.


In a national, prospective, well-represented, contemporary registry, higher adherence to a plant-based diet was associated with a 41% lower hazard for incident HF hospitalization. While greater adherence to a southern diet was associated with a 72% increased hazard for incident HF, this association did not persist after adjustment for other HF risk factors.


HF is a growing epidemic, projected to have a prevalence of over 8 million by 2030, making preventative measures imperative. Cardioprotective benefits of a Mediterranean diet (rich in fruits, vegetables, nuts, with minimal red meat, poultry, and eggs) have been previously described in patients with established CAD. In this study, among patients without known CAD, a plant-rich dietary pattern was associated with a lower risk for incident HF. While the association between greater adherence to a southern diet and increased HF incidence was attenuated upon adjustment for other HF risk factors such as diabetes and hypertension among others, these risk factors may act as mediators explaining the association between this dietary pattern and incident HF. The impact of diet on hypertension and diabetes has been extensively studied, both of which are well-known HF risk factors. Other potential mechanisms include abundance of anti-inflammatories and antioxidants in plant-rich diets.

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Diet, Hypertension, Smoking

Keywords: Beer, Bread, Coronary Artery Disease, Diabetes Mellitus, Diet, Diet, Vegetarian, Diet, Mediterranean, Fast Foods, Fruit, Heart Failure, Hypertension, Meat, Primary Prevention, Risk Factors, Smoking, Sweetening Agents, Vegetables, Wine

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