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Nutritional issues in obese patients submitted to bariatric surgery. Re. “Bariatric surgery may not achieve intended outcomes in all patients”
Letters to the Editor / Nutrition 31 (2015) 1182–1186
To the Editor: Since the obesity epidemic has been increasing worldwide, the World Health Organization has emphasized the importance of lifestyle; that is, healthy eating habits and regular physical activity [1]. Despite the importance of these measures for obtaining good health, it is becoming common in clinical practice to identify severely obese patients as those with a body mass index of 40. In an attempt to provide more effective treatment for severely obese patients, there has been an increase in the number of bariatric surgeries [2]. Among the main reasons for this procedure are: the correction of body weight to within the normal range, control other chronic diseases, and achievement of a more satisfying self-image. New bariatric surgery techniques have been emerging in recent decades. However, in evident paradox with nutritional issues, some investigators have reported that the most effective surgical techniques are those that promote greater weight loss within a shorter period of time [3]. Information concerning the safety of the surgical procedure is mainly related to the dumping syndrome, vomiting, and the mortality rate. In the Editorial “Bariatric surgery may not achieve intended outcomes in all patients”, Crook and Sriram [4] raise necessary and important issues regarding the possibility of severe malnutrition in obese patients undergoing bariatric surgery [5]. Specific nutritional deficiencies reported in severely obese patients during the preoperative period have also been described after performing bariatric surgery. On the basis of these considerations, guidelines recently published by ASPEN [6] recommend that hospitalized obese patients submitted to malabsorptive or restrictive surgical procedures for weight loss should take multiple vitamin/mineral supplements daily, as well as specific nutrients (vitamin D, calcium, copper, iron, vitamin B12). Some nutrients must be evaluated annually (folic acid, iron, 25-hydroxyvitamin D), and others should be measured when patients show clinical signs suggestive of deficiency (copper, zinc, selenium, thiamine). The intact human gastrointestinal tract exhibits a proximal-todistal anatomic absorptive gradient. The functional capacity of the gastrointestinal tract is directly related to this anatomic gradient. The digestion process, which is initiated by mechanical forces and acidic secretions of the stomach, is completed by pancreatic digestive enzymes, and bile present in the small intestine. After digestion, absorption of nutrients continues throughout the small and large intestine. Several lines of evidence have demonstrated the important trophic effects of food/nutrients on the intestinal mucosa [7]. The usual functions of the normal gastrointestinal tract, as well as the anatomical specificities of the intestinal segments concerning the absorption of specific nutrients, have rarely been considered in scientific texts that address the techniques of bariatric surgery. It is a concern that some investigators have reported an average 72% loss of excess body weight after laparoscopic duodenojejunal bypass with sleeve gastrectomy during a mean follow-up period of 17 months. These investigators have also reported a very favorable result, i.e., a 92% reduction of clinical cases of diabetes mellitus [8]. However, relevant nutritional issues were not addressed.
As warned by Crook and Sriram [4], specialized outpatient clinical follow-up before and after bariatric surgery is essential to identify nutritional diseases. Particularly important is the duration of outpatient follow-up during the postoperative period. Specific nutrient deficiency has been reported to occur a very long time after bariatric surgery (e.g., more than 10 years for copper deficiency) [9]. In light of current knowledge, one can infer that more effective weight loss is associated with greater nutritional damage. Thus, when considering adaptations of surgical bariatric techniques in an attempt to increase the efficacy of excess weight loss and to reduce the usual complications, questions should also be raised regarding the specificity of nutrient absorption sites in different intestinal segments in order to reduce nutritional deficiencies. An additional consideration is that the usual doses of medications may be less effective for the treatment of various diseases after bariatric surgery. Since most drugs are absorbed in the small intestine, the reduction of serum levels in patients undergoing the surgical procedure may mean that the normally prescribed dosages of different medications may be ineffective for patients with intestinal malabsorption after bariatric surgery. In addition, despite the decrease in prescriptions of antidiabetic and cardiovascular medications after bariatric surgery, the authors reported increased prescription of paracetamol, opioids, antimicrobials, and proton pump inhibitors/histamine H2- receptor antagonists during the postoperative period [9]. In summary, despite the benefits recently reported in the Literature [10,11], bariatric surgery may have important consequences for the patient, including relevant nutritional issues and modifications of the therapeutic response to the usual doses of medications. References [1] World Health Organization (WHO). Global Strategy on Diet, Physical Activity and Health. Available at: http://www.who.int/dietphysicalactivity/en/. Accessed June 9, 2015. [2] Mechanick JI, Youdim A, Jones BD, Garvey T, Hurley DL, McMahon MM, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient d 2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis 2013;9:159–91. [3] Baptista V, Wassef W. Bariatric procedures: an update on techniques, outcomes and complications. Curr Opin Gastroenterol 2013;29:684–93. [4] Crook MA, Sriram K. Bariatric surgery may not achieve intended outcomes in all patients. Nutrition 2015;31:1181–2. [5] Martins TCP, Duarte TC, Mosca ERT, Pinheiro CF, Marc¸ola MA, De-Souza DA. Severe protein malnutrition in a morbidly obese patient who underwent bariatric surgery. Nutrition 2015;31:535–8. [6] Choban P, Dickerson R, Malone A, Worthington P, Compher CThe American Society for Parenteral and Enteral Nutrition. A.S.P.E.N.. Clinical guidelines: nutrition support of hospitalized adult patients with obesity. J Parenter Enteral Nutr 2013;37:714–44. [7] Tappenden KA. Pathophysiology of short bowel syndrome: considerations of resected and residual anatomy. J Parenter Enteral Nutr 2014;38:14S–22S. [8] Raj PP, Kumaravel R, Chandramaliteeswaran C, Vaithiswaran V, Palanivelu C. Laparoscopic duodenojejunal bypass with sleeve gastrectomy: preliminary results of a prospective series from India. Surg Endosc 2012;26:688–92. [9] Stein J, Stier C, Raab H, Weiner R. The nutritional and pharmacological consequences of obesity surgery. Aliment Pharmacol Ther 2014;40:582–609. [10] Miras AD, Roux CW. Metabolic surgery: shifting the focus from glycaemia and weight to end-organ health. Lancet Diabetes Endocrinol 2014;2:141–51. [11] Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Brethauer SA, Navaneethan SD, et al. Bariatric surgery versus intensive medical therapy for diabetes– 3- year outcomes. N Engl J Med 2014;370:2002–13.
Daurea Abadia De-Souza, M.D., Ph.D. Department of Internal Medicine Faculty of Medicine Federal University of Uberlandia Uberlandia, Minas Gerais, Brazil ˇ
Nutritional issues in obese patients submitted to bariatric surgery. Re. “Bariatric surgery may not achieve intended outcomes in all patients”
ˇ
1184
Letters to the Editor / Nutrition 31 (2015) 1182–1186
Lewis Joel Greene, Ph.D. Protein Chemistry Center ~o Preto and the Regional Center for Hemotheraphy of Ribeira Department of Cellular and Molecular Biology and Pathogenic ~o Preto Bioagents, Faculty of Medicine of Ribeira ~o Paulo University of Sa ~o Preto, SP, Brazil Ribeira http://dx.doi.org/10.1016/j.nut.2015.06.003
Re: “Dietary fatty acids intake and mortality in patients with heart failure” To the Editor: We read with great interest the recently published article by Colin-Ramirez et al. [1] in which the authors aimed to evaluate the association of macro- and micronutrients intake on 1-y of mortality in patients with heart failure (HF). The authors concluded that intake of polyunsaturated fatty acids (PUFAs) and saturated fatty acids (SFAs) was independently associated with 1-y of all-cause mortality in patients with chronic HF. Limiting dietary SFAs and increasing PUFA intake might be advisable in this population [1]. However, we think that there are some points that should be emphasized about this study. First, in the original study, it was indicated that dietary intake of participants was estimated by using a 3-d food record, which has been shown to have a higher validity and agreement than the 103-item food frequency questionnaire compared with 9-d food record. However, this 3-d record is not of long enough duration for an opinion to be formed about the pathogenesis of cardiovascular disease (CVD) or HF. Although, the importance of fatty acids (FAs) in cellular homeostasis demands an efficient uptake system, their metabolism in cells and tissues still plays the most important role in the pathogenesis of diseases like CVD [2]. Therefore, quantitating the level of FAs in plasma, erythrocyte membrane, and even tissues, particularly of essential FAs, in addition to assessing dietary intake, can provide more accurate results about the processes leading to the pathogenesis of HF and can provide valuable information in the management of dietary strategies in HF, which are deficient and blamed for the pathogenesis of CVD. Second, to date, there have been several studies evaluating the influence of intake of PUFAs on risk for coronary heart disease and on mortality in patients with chronic HF [3–5]. In the original study, intake of total fat was broken down into monounsaturated, PUFAs, and SFAs. PUFAs include both u-3 and u-6 FAs and a healthy diet contains a balance of both FAs. This balance is essential for cardiovascular health because, as is known, u-6 PUFAs may compete with u-3 PUFAs for common metabolic enzymes and thereby increase the production of prothrombotic rather than antithrombotic and inflammatory leukotrienes, thromboxanes, and prostaglandins [6,7]. However, exploratory analyses of dietary PUFAs subtypes were not performed in the original analysis, and this may lead to underestimation and undertreatment of the current patient group. Therefore, it would have been better to evaluate different patterns of u-3 and u-6 PUFA intake and ratios of intake in the original study [8].
1185
In conclusion, measurement of the level of FAs in plasma, erythrocyte membrane, and even tissues, and evaluation of dietary PUFAs subtypes are critical to assess patients with HF. References [1] Colin-Ramirez E, Castillo-Martinez L, Orea-Tejeda A, Zheng Y, Westerhout CM, Ezekowitz JA. Dietary fatty acids intake and mortality in patients with heart failure. Nutrition 2014;30:1366–71. [2] Øie E, Ueland T, Dahl CP, Bohov P, Berge C, Yndestad A, et al. Fatty acid composition in chronic heart failure: Low circulating levels of eicosatetraenoic acid and high levels of vaccenic acid are associated with disease severity and mortality. J Intern Med 2011;270:263–72. [3] Mozaffarian D, Ascherio A, Hu FB, Stampfer MJ, Willett WC, Siscovick DS, et al. Interplay between different polyunsaturated fatty acids and risk of coronary heart disease in men. Circulation 2005;111:157–64. [4] Virtanen JK, Mursu J, Tuomainen TP, Voutilainen S. Dietary fatty acids and risk of coronary heart disease in men: the Kuopio Ischemic Heart Disease Risk Factor Study [E-pub ahead of print]. Arterioscler Thromb Vasc Biol; 2014. pii: ATVBAHA.114.304082. [5] Schwingshackl L, Hoffmann G. Dietary fatty acids in the secondary prevention of coronary heart disease: a systematic review, meta-analysis and metaregression. BMJ Open 2014;4:e004487. [6] Gibson RA, Cleland LG. Dietary polyunsaturated PUFAs and inflammatory mediator production. Am J Clin Nutr 2000;71:343S–8S. [7] Blau N, Duran M, Gibson KM. Laboratory guide to the methods in biochemical genetics. Berlin: Springer; 2008:207–19. [8] Deckelbaum RJ. n-6 and n-3 Fatty acids and atherosclerosis: ratios or amounts? Arterioscler Thromb Vasc Biol 2010;30:2325–6.
Erdim Sertoglu, M.D. Biochemistry Laboratory, Anittepe Dispensary, Ankara Mevki Military Hospital, Ankara, Turkey Metin Uyanik, M.D. Biochemistry Laboratory, Corlu Military Hospital Tekirdag, Turkey Huseyin Kayadibi, M.D. Biochemistry Laboratory, Adana Military Hospital Adana, Turkey http://dx.doi.org/10.1016/j.nut.2014.10.005
Re. “Dietary fatty acids intake and mortality in patients with heart failure”: Authors’ response To the Editor: We thank Sertoglu et al. for their interest in our work, their insightful comments, and the opportunity to clarify relevant aspects from our work. Sertoglu et al. [1] pointed out that the self-reported dietary method we used in our study, the 3-d food record, is not enough to justify an opinion about the pathogenesis of cardiovascular disease (CVD) or heart failure (HF), and that metabolism of fatty acids (FAs) in cells and tissues plays the most important role in the pathogenesis of CVD. They further suggested that quantifying the level of FAs in plasma erythrocyte membrane and tissues, particularly essential fatty acids, can provide more accurate results than dietary information regarding the processes leading to HF. Although our work [2] was designed to evaluate the association of dietary intake and 1-y mortality in patients with HF, we
To the Editor: Since the obesity epidemic has been increasing worldwide, the World Health Organization has emphasized the importance of lifestyle; that is, healthy eating habits and regular physical activity [1]. Despite the importance of these measures for obtaining good health, it is becoming common in clinical practice to identify severely obese patients as those with a body mass index of 40. In an attempt to provide more effective treatment for severely obese patients, there has been an increase in the number of bariatric surgeries [2]. Among the main reasons for this procedure are: the correction of body weight to within the normal range, control other chronic diseases, and achievement of a more satisfying self-image. New bariatric surgery techniques have been emerging in recent decades. However, in evident paradox with nutritional issues, some investigators have reported that the most effective surgical techniques are those that promote greater weight loss within a shorter period of time [3]. Information concerning the safety of the surgical procedure is mainly related to the dumping syndrome, vomiting, and the mortality rate. In the Editorial “Bariatric surgery may not achieve intended outcomes in all patients”, Crook and Sriram [4] raise necessary and important issues regarding the possibility of severe malnutrition in obese patients undergoing bariatric surgery [5]. Specific nutritional deficiencies reported in severely obese patients during the preoperative period have also been described after performing bariatric surgery. On the basis of these considerations, guidelines recently published by ASPEN [6] recommend that hospitalized obese patients submitted to malabsorptive or restrictive surgical procedures for weight loss should take multiple vitamin/mineral supplements daily, as well as specific nutrients (vitamin D, calcium, copper, iron, vitamin B12). Some nutrients must be evaluated annually (folic acid, iron, 25-hydroxyvitamin D), and others should be measured when patients show clinical signs suggestive of deficiency (copper, zinc, selenium, thiamine). The intact human gastrointestinal tract exhibits a proximal-todistal anatomic absorptive gradient. The functional capacity of the gastrointestinal tract is directly related to this anatomic gradient. The digestion process, which is initiated by mechanical forces and acidic secretions of the stomach, is completed by pancreatic digestive enzymes, and bile present in the small intestine. After digestion, absorption of nutrients continues throughout the small and large intestine. Several lines of evidence have demonstrated the important trophic effects of food/nutrients on the intestinal mucosa [7]. The usual functions of the normal gastrointestinal tract, as well as the anatomical specificities of the intestinal segments concerning the absorption of specific nutrients, have rarely been considered in scientific texts that address the techniques of bariatric surgery. It is a concern that some investigators have reported an average 72% loss of excess body weight after laparoscopic duodenojejunal bypass with sleeve gastrectomy during a mean follow-up period of 17 months. These investigators have also reported a very favorable result, i.e., a 92% reduction of clinical cases of diabetes mellitus [8]. However, relevant nutritional issues were not addressed.
As warned by Crook and Sriram [4], specialized outpatient clinical follow-up before and after bariatric surgery is essential to identify nutritional diseases. Particularly important is the duration of outpatient follow-up during the postoperative period. Specific nutrient deficiency has been reported to occur a very long time after bariatric surgery (e.g., more than 10 years for copper deficiency) [9]. In light of current knowledge, one can infer that more effective weight loss is associated with greater nutritional damage. Thus, when considering adaptations of surgical bariatric techniques in an attempt to increase the efficacy of excess weight loss and to reduce the usual complications, questions should also be raised regarding the specificity of nutrient absorption sites in different intestinal segments in order to reduce nutritional deficiencies. An additional consideration is that the usual doses of medications may be less effective for the treatment of various diseases after bariatric surgery. Since most drugs are absorbed in the small intestine, the reduction of serum levels in patients undergoing the surgical procedure may mean that the normally prescribed dosages of different medications may be ineffective for patients with intestinal malabsorption after bariatric surgery. In addition, despite the decrease in prescriptions of antidiabetic and cardiovascular medications after bariatric surgery, the authors reported increased prescription of paracetamol, opioids, antimicrobials, and proton pump inhibitors/histamine H2- receptor antagonists during the postoperative period [9]. In summary, despite the benefits recently reported in the Literature [10,11], bariatric surgery may have important consequences for the patient, including relevant nutritional issues and modifications of the therapeutic response to the usual doses of medications. References [1] World Health Organization (WHO). Global Strategy on Diet, Physical Activity and Health. Available at: http://www.who.int/dietphysicalactivity/en/. Accessed June 9, 2015. [2] Mechanick JI, Youdim A, Jones BD, Garvey T, Hurley DL, McMahon MM, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient d 2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis 2013;9:159–91. [3] Baptista V, Wassef W. Bariatric procedures: an update on techniques, outcomes and complications. Curr Opin Gastroenterol 2013;29:684–93. [4] Crook MA, Sriram K. Bariatric surgery may not achieve intended outcomes in all patients. Nutrition 2015;31:1181–2. [5] Martins TCP, Duarte TC, Mosca ERT, Pinheiro CF, Marc¸ola MA, De-Souza DA. Severe protein malnutrition in a morbidly obese patient who underwent bariatric surgery. Nutrition 2015;31:535–8. [6] Choban P, Dickerson R, Malone A, Worthington P, Compher CThe American Society for Parenteral and Enteral Nutrition. A.S.P.E.N.. Clinical guidelines: nutrition support of hospitalized adult patients with obesity. J Parenter Enteral Nutr 2013;37:714–44. [7] Tappenden KA. Pathophysiology of short bowel syndrome: considerations of resected and residual anatomy. J Parenter Enteral Nutr 2014;38:14S–22S. [8] Raj PP, Kumaravel R, Chandramaliteeswaran C, Vaithiswaran V, Palanivelu C. Laparoscopic duodenojejunal bypass with sleeve gastrectomy: preliminary results of a prospective series from India. Surg Endosc 2012;26:688–92. [9] Stein J, Stier C, Raab H, Weiner R. The nutritional and pharmacological consequences of obesity surgery. Aliment Pharmacol Ther 2014;40:582–609. [10] Miras AD, Roux CW. Metabolic surgery: shifting the focus from glycaemia and weight to end-organ health. Lancet Diabetes Endocrinol 2014;2:141–51. [11] Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Brethauer SA, Navaneethan SD, et al. Bariatric surgery versus intensive medical therapy for diabetes– 3- year outcomes. N Engl J Med 2014;370:2002–13.
Daurea Abadia De-Souza, M.D., Ph.D. Department of Internal Medicine Faculty of Medicine Federal University of Uberlandia Uberlandia, Minas Gerais, Brazil ˇ
Nutritional issues in obese patients submitted to bariatric surgery. Re. “Bariatric surgery may not achieve intended outcomes in all patients”
ˇ
1184
Letters to the Editor / Nutrition 31 (2015) 1182–1186
Lewis Joel Greene, Ph.D. Protein Chemistry Center ~o Preto and the Regional Center for Hemotheraphy of Ribeira Department of Cellular and Molecular Biology and Pathogenic ~o Preto Bioagents, Faculty of Medicine of Ribeira ~o Paulo University of Sa ~o Preto, SP, Brazil Ribeira http://dx.doi.org/10.1016/j.nut.2015.06.003
Re: “Dietary fatty acids intake and mortality in patients with heart failure” To the Editor: We read with great interest the recently published article by Colin-Ramirez et al. [1] in which the authors aimed to evaluate the association of macro- and micronutrients intake on 1-y of mortality in patients with heart failure (HF). The authors concluded that intake of polyunsaturated fatty acids (PUFAs) and saturated fatty acids (SFAs) was independently associated with 1-y of all-cause mortality in patients with chronic HF. Limiting dietary SFAs and increasing PUFA intake might be advisable in this population [1]. However, we think that there are some points that should be emphasized about this study. First, in the original study, it was indicated that dietary intake of participants was estimated by using a 3-d food record, which has been shown to have a higher validity and agreement than the 103-item food frequency questionnaire compared with 9-d food record. However, this 3-d record is not of long enough duration for an opinion to be formed about the pathogenesis of cardiovascular disease (CVD) or HF. Although, the importance of fatty acids (FAs) in cellular homeostasis demands an efficient uptake system, their metabolism in cells and tissues still plays the most important role in the pathogenesis of diseases like CVD [2]. Therefore, quantitating the level of FAs in plasma, erythrocyte membrane, and even tissues, particularly of essential FAs, in addition to assessing dietary intake, can provide more accurate results about the processes leading to the pathogenesis of HF and can provide valuable information in the management of dietary strategies in HF, which are deficient and blamed for the pathogenesis of CVD. Second, to date, there have been several studies evaluating the influence of intake of PUFAs on risk for coronary heart disease and on mortality in patients with chronic HF [3–5]. In the original study, intake of total fat was broken down into monounsaturated, PUFAs, and SFAs. PUFAs include both u-3 and u-6 FAs and a healthy diet contains a balance of both FAs. This balance is essential for cardiovascular health because, as is known, u-6 PUFAs may compete with u-3 PUFAs for common metabolic enzymes and thereby increase the production of prothrombotic rather than antithrombotic and inflammatory leukotrienes, thromboxanes, and prostaglandins [6,7]. However, exploratory analyses of dietary PUFAs subtypes were not performed in the original analysis, and this may lead to underestimation and undertreatment of the current patient group. Therefore, it would have been better to evaluate different patterns of u-3 and u-6 PUFA intake and ratios of intake in the original study [8].
1185
In conclusion, measurement of the level of FAs in plasma, erythrocyte membrane, and even tissues, and evaluation of dietary PUFAs subtypes are critical to assess patients with HF. References [1] Colin-Ramirez E, Castillo-Martinez L, Orea-Tejeda A, Zheng Y, Westerhout CM, Ezekowitz JA. Dietary fatty acids intake and mortality in patients with heart failure. Nutrition 2014;30:1366–71. [2] Øie E, Ueland T, Dahl CP, Bohov P, Berge C, Yndestad A, et al. Fatty acid composition in chronic heart failure: Low circulating levels of eicosatetraenoic acid and high levels of vaccenic acid are associated with disease severity and mortality. J Intern Med 2011;270:263–72. [3] Mozaffarian D, Ascherio A, Hu FB, Stampfer MJ, Willett WC, Siscovick DS, et al. Interplay between different polyunsaturated fatty acids and risk of coronary heart disease in men. Circulation 2005;111:157–64. [4] Virtanen JK, Mursu J, Tuomainen TP, Voutilainen S. Dietary fatty acids and risk of coronary heart disease in men: the Kuopio Ischemic Heart Disease Risk Factor Study [E-pub ahead of print]. Arterioscler Thromb Vasc Biol; 2014. pii: ATVBAHA.114.304082. [5] Schwingshackl L, Hoffmann G. Dietary fatty acids in the secondary prevention of coronary heart disease: a systematic review, meta-analysis and metaregression. BMJ Open 2014;4:e004487. [6] Gibson RA, Cleland LG. Dietary polyunsaturated PUFAs and inflammatory mediator production. Am J Clin Nutr 2000;71:343S–8S. [7] Blau N, Duran M, Gibson KM. Laboratory guide to the methods in biochemical genetics. Berlin: Springer; 2008:207–19. [8] Deckelbaum RJ. n-6 and n-3 Fatty acids and atherosclerosis: ratios or amounts? Arterioscler Thromb Vasc Biol 2010;30:2325–6.
Erdim Sertoglu, M.D. Biochemistry Laboratory, Anittepe Dispensary, Ankara Mevki Military Hospital, Ankara, Turkey Metin Uyanik, M.D. Biochemistry Laboratory, Corlu Military Hospital Tekirdag, Turkey Huseyin Kayadibi, M.D. Biochemistry Laboratory, Adana Military Hospital Adana, Turkey http://dx.doi.org/10.1016/j.nut.2014.10.005
Re. “Dietary fatty acids intake and mortality in patients with heart failure”: Authors’ response To the Editor: We thank Sertoglu et al. for their interest in our work, their insightful comments, and the opportunity to clarify relevant aspects from our work. Sertoglu et al. [1] pointed out that the self-reported dietary method we used in our study, the 3-d food record, is not enough to justify an opinion about the pathogenesis of cardiovascular disease (CVD) or heart failure (HF), and that metabolism of fatty acids (FAs) in cells and tissues plays the most important role in the pathogenesis of CVD. They further suggested that quantifying the level of FAs in plasma erythrocyte membrane and tissues, particularly essential fatty acids, can provide more accurate results than dietary information regarding the processes leading to HF. Although our work [2] was designed to evaluate the association of dietary intake and 1-y mortality in patients with HF, we