In order to bring you the best possible user experience, this site uses Javascript. If you are seeing this message, it is likely that the Javascript option in your browser is disabled. For optimal viewing of this site, please ensure that Javascript is enabled for your browser.
Did you know that your browser is out of date? To get the best experience using our website we recommend that you upgrade to a newer version. Learn more.

Prolonged Caloric Restriction in Obese Patients with Type 2 Diabetes Mellitus Decreases Myocardial Triglyceride Content and Improves Myocardial Function

ESC Working Group on Myocardial and Pericardial Diseases


It is well known that obesity is an established risk factor for cardiovascular complications. There are large-scale epidemiologic studies clearly demonstrating that accumulation of excessive amounts of adipose tissue in the body may lead to type 2 diabetes mellitus, hypertension and coronary artery disease – disorders associated with myocardial damage (1, 2). It has also become clear that not every fat location is equally morbid. Both histopathologic studies and clinical observations point to the visceral fat depot with inflammatory infiltration as the most metabolically active one and carrying major responsibility for deleterious effects of increased body weight (3). However, it has been shown that triglyceride (TG) content in obese individuals increases not only in adipose tissue but also ectopically in organs such as the liver, pancreas, skeletal muscles and the heart (4, 5). Lipid accumulation in non-adipose tissues may impair organs’ function and further explain mechanisms underlying detrimental effects of overweight and obesity. The introduction and validation of a reproducible method of in vivo myocardial TG content quantification – proton magnetic resonance spectroscopy (1HMRS) (1), enabled researchers to carry out studies on myocardial lipid accumulation in humans and thus a new fascinating area of clinical research seems to have been opened. A recently published article on the issue at hand is summarized below and followed by a brief contextual comment.

Myocardial Disease

The article summary

The study by Hammer et al. investigates whether prolonged caloric restriction can change myocardial TG content and influence left ventricular function. To answer these questions, 12 obese patients (7 men, mean age 48.3 ± 2.3 yrs) with insulin treated type 2 diabetes mellitus (T2DM) were put on a very-lowcalorie diet (VLCD; 450 kcal/day) for a 16-week time interval. To assess the effects of prolonged caloric restriction in these patients, myocardial TG content (MR spectroscopy), myocardial function (MRI), plasma hemoglobin A1C and body mass index (BMI) were measured 1 week before and directly after the dietary intervention.

Additionally, to evaluate the tissue-specific effects of caloric restriction further, liver TG content was examined during both of the MR studies. As the result of VLCD, the patients’ BMI decreased from 35.6 kg/m2 to 27.5 kg/m2 (p < 0.001) and considerable improvements in glucoregulation and lipid profile were noted. MR spectroscopy showed that prolonged caloric restriction was associated with significant reduction in TG content in the myocardium (from 0.88% at baseline to 0.64% after the intervention, p < 0.019) and even more notably in the liver (from 21.2% to 3.0%, resp., p < 0.001). Interestingly, the diet modification led to improvements in myocardial function with a significant decrease in LV mass (from 118±7g to 99±6g after the VLCD, p<0.001) and improved diastolic function (E/A ratio increased from 1.02±0.08 at baseline to 1.18±0.06 after the VLCD). These data show that myocardial TG stores in obese patients with T2DM are flexible and respond to therapeutic intervention by caloric restriction.

Context of the study:

The summarized paper is the latest report concerning the issue of TG accumulation in the myocardium and shows that myocardial TG stores in obese patients with T2DM are flexible and amenable to dietary intervention (caloric restriction). Previous investigations demonstrated that myocardial TG content increases with older age, in patients with impaired glucose tolerance, type 2 diabetes mellitus and in subjects with visceral obesity (4, 6, 7). Furthermore, clinical observations linked excessive heart TG
accumulation to increased left ventricular (LV) mass and impaired LV function (4, 6, 7).

In rodents obesity and T2DM lead to excessive fatty acids

These data are in agreement with extensive evidence stemming from basic sciences. Experiments in rodents showed that obesity and T2DM led to excessive fatty acids uptake and, in consequence, to an increase in myocardial TG pool, generation of lipotoxic fatty acid intermediates and free radicals. The shift in metabolism causes
apoptosis of cardiac myocytes, increased oxidative stress and eventually non-ischeamic cardiomyopathy (8). Importantly, this pathogenic process could be interrupted, thus preventing or even reversing the development of LV dysfunction (9, 10). It is plausible that at least some of these mechanisms may work in a similar fashion in obese humans.

Dietary intervention can decrease myocardial TG content

The paper by Hammer et al. is the first one to demonstrate the capability of a dietary intervention to decrease myocardial TG content. Furthermore, the study suggests that LV function in obese patients with T2DM is related to myocardial TG accumulation. However, it remains unknown whether this relationship was independent of other metabolic and hemodynamic changes induced by VLCD. Of interest, Sharma et al. showed with analysis of myocardial lipid staining (oil red O) that intramyocardial lipid overload was present in 30% (9 of 27) of non-ischemic failing human hearts.

The highest levels of lipid staining were observed in patients with diabetes and obesity (BMI>30) (11). The potential associations of increased myocardial TG content with heart failure development remain to be elucidated.


To sum up, the article by Hammer et al. has two important merits. First, it demonstrates for the first time that a therapeutic intervention can decrease lipid content in organs, and second, it reinforces the growing body of evidence concerning the relation between increased myocardial fat content and LV dysfunction.


1) Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. Mokdad AH, Ford ES, Bowman BA, et al. JAMA. 2003 Jan 1;289(1):76-9.
2) Association of overweight with increased risk of coronary heart disease partly independent of blood pressure and cholesterol levels: a meta-analysis of 21 cohort studies including more than 300 000 persons. Bogers RP, Bemelmans WJ, Hoogenveen RT, et al.; for the BMI-CHD Collaboration Investigators. Arch Intern Med. 2007 Sep 10;167(16):1720-8. Review.
3) Abdominal visceral and subcutaneous adipose tissue compartments: association with metabolic risk factors in the Framingham Heart Study. Fox CS, Massaro JM, Hoffmann U, et al. Circulation. 2007 Jul 3;116(1):39-48.
4) Cardiac steatosis in diabetes mellitus: a 1H-magnetic resonance spectroscopy study. McGavock JM, Lingvay I, Zib I, et al. Circulation. 2007 Sep 4;116(10):1170-5.
5) Lipotoxic diseases. Unger RH., Annu Rev Med. 2002 ;53:319-36. Review.
6) Myocardial triglycerides and systolic function in humans: in vivo evaluation by localized proton spectroscopy and cardiac imaging. Szczepaniak LS, Dobbins RL, Metzger GJ, et al. Magn Reson Med. 2003 Mar;49(3):417-23.
7) The ageing male heart: myocardial triglyceride content as independent predictor of diastolic function. Van der Meer RW, Rijzewijk LJ, Diamant M, et al. Eur Heart J. 2008 Jun;29(12):1516-22.
8) Lipotoxic heart disease in obese rats: implications for human obesity. Zhou YT, Grayburn P, Karim A, et al. Proc Natl Acad Sci U S A. 2000 Feb 15;97(4):1784-9.
9) Hyperleptinemia prevents lipotoxic cardiomyopathy in acyl CoA synthase transgenic mice. Lee Y, Naseem RH, Duplomb L, et al. Proc Natl Acad Sci U S A. 2004 Sep 14;101(37):13624-9.
10) Echocardiographic assessment of cardiac function in diabetic db/db and transgenic db/dbhGLUT4 mice. Semeniuk LM, Kryski AJ, Severson DL. Am J Physiol Heart Circ Physiol. 2002 Sep;283(3):H976-82.
11) Intramyocardial lipid accumulation in the failing human heart resembles the lipotoxic rat heart.

Notes to editor

by Radoslaw Pracoń MD and Zofia T. Bilińska MD, PhD, Institute of Cardiology, Warsaw, Poland
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.