Medical nutrition therapy in incretin-treated obesity-related heart failure with preserved ejection fraction

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  Figure 1. Beyond-the-scale framework for high-quality weight loss in obesity-related HFpEF during incretin-based therapy. High-quality weight loss is conceptualized as preferential reduction in excess adiposity with preservation of metabolic and physical function rather than reduction in scale weight alone. Incretin-based therapy may promote preferential fat loss, but fat-loss quality requires beyond-the-scale assessment of fat mass, visceral or ectopic fat, waist circumference, body composition, regional adiposity, inflammation, muscle quality, and functional reserve. Fat-free mass, lean soft tissue, skeletal muscle, myosteatosis, and strength and function represent related but noninterchangeable domains; therefore, body-composition findings should be interpreted together with direct functional measures. Preferential fat loss may reduce hemodynamic load, while high-quality weight loss and preserved functional reserve are linked to clinical benefit, including lower symptom burden and improvements in KCCQ-CSS and 6MWD. Durable HFpEF benefit represents the longitudinal clinical goal. Arrows indicate conceptual treatment, assessment, or outcome pathways; the arrow from preferential fat loss…

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  Figure 2. Relationships among body composition, skeletal muscle metabolism, nutrition–exercise co-therapy, and functional outcomes during incretin-based therapy in obesity-related HFpEF. The N, C, M, and F callouts denote nutrition and intake regulation, body composition and adiposity, skeletal muscle, and functional capacity or HFpEF outcomes, respectively. The left panels summarize changes in appetite and food intake, body composition, exercise exposure, and muscle metabolism. Body-composition changes are shown separately from strength and walking performance because these measures may not change in parallel. MNT includes amino acid and protein planning, meal distribution, satiety-aware eating, and diet quality, coordinated with resistance and aerobic exercise. The lower sequence links muscle glucose uptake and lipid oxidation with strength, 6MWD, peak VO2, KCCQ-CSS, NYHA functional class, symptoms, and HRQoL. Arrows denote proposed biological or clinical associations and do not establish causality. Tissue and circulation elements are schematic. The figure was created using Figdraw. 6MWD, 6-min walk distance; C, body composition and adiposity; F, functional capacity and HFpEF outcomes;…

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  Figure 3. Proposed phase-based medical nutrition therapy pathway for incretin-treated obesity-related HFpEF. The sequence follows common clinical decision points in HFpEF care and obesity pharmacotherapy: pretreatment assessment, dose escalation, maintenance or plateau, dose reduction or discontinuation, and long-term follow-up. Pretreatment assessment covers HFpEF stability, patient-prioritized goals, nutritional status, selected laboratory measures, body composition, and functional capacity. During dose escalation, monitoring focuses on gastrointestinal tolerance, food and protein intake, micronutrient adequacy, hydration, blood pressure, renal function, and volume status. Micronutrient supplementation is considered when dietary assessment, clinical findings, or laboratory results indicate a need. Maintenance and plateau care include reassessment of diet and protein adequacy, physical activity, weight and body composition, function, symptoms, and treatment goals before any attempt to intensify therapy solely to restart weight loss. Subsequent treatment decisions may include continuation, dose reduction, or discontinuation according to access, tolerability, treatment burden, clinical…