Review for 10.1186/s12876-023-02785-5 (2023)

Title: Fatty liver index relationship with bio markers and lifestyle: Result from RaNCD cohort
study
Version: 1 Date: 21 Dec 2022
Reviewer's report:
This is an observational study on how lifestyle risk factors were associated with NAFLD defined
by Fatty Liver Index among Middle Eastern population. In relation to NAFLD, FLI had been
utilized in other ethnicities but no studies involved Middle Eastern population with a large
sample size. More research is needed in terms of risk factors for FLI and the current research
adds an evidence to the existing body of literatures.
Thoroughly go over your English grammar in the paper. To name a few, page 4, line 11, a Cross-
sectional study and page 5, line 1, rheumatoid arthritis. There are too many grammatical errors
in the paper. Consider using English proofreading services if possible.
In the results section of the Abstract, please report the OR, CI as well (ex: OR 1.493; 95% CIs
1.41–1.581)
Page 3, line 9-11, Consider using the following sentence instead. “As a treatment for NAFLD,
clinicians emphasize the importance of an active lifestyle which includes regular exercise, a
balanced diet, and weight reduction.”
Page 3, line 28-29, I do not understand what this sentence means. If you intended to suggest
NAFLD patients were more likely to be depressed than other liver disease patients, then please
include the reference(s).
Page 4, line 1-6, shorten this paragraph and instead include any evidence(s) where a successful
adherence to lifestyle changes resulted in an improved quantitative scale of Depression than in
nonadherent group. Line 6 remove survival, you are not studying any mortality rates here.
Page 5, line 24, “conversely, a higher HEI 2015 score indicates..” I assume you meant say a
lower HEI. If not, you should correct line 21-22.
Page 4, line 7-8, rephrase your hypothesis. Since your design is a cross-sectional study, you
can only test the association between lifestyle risk factors with FLI. No causal effect can be
established from the current design. Also, the same goes for page 9, line 13-14.
Page 4, line 28, you mentioned “A total of 2933 people were initially eliminated owing to
potential dietary changes”, what do you mean by this statement? Please elaborate.
In the Methods, please explain how you divided the HEI quartiles and their definitions. It is
unclear from how you described in the Results section. Is quartile 1 is the highest HEI points?
And I don’t understand the sentence, “most of participants was in 1st Quartile”. Please explain
further in the Methods section.
Page 8, line 14-16, omit the statement with a nonsignificant p-value.  “Participants with a FLI
<60 had a higher intake for daily carbohydrate intake compare to participants with FLI #60, (P
= 0.735)”
Page 8, line 2 and page 7 line 6-7, the definition of low physical activity is different. Could
you explain?
It is known that omega 3 fatty acids are cardioprotective and anti-inflammatory and a few past
studies have indicated that omega 3 may reverse hepatic steatosis and ALT levels. But your
result in Table 2 shows that higher amount of omega-3 fat was found in FLI>60 group. Include
an explanation in this regard in the Discussion.
Page 9, line 13, please remove the word “prospective research”. The main design of the article
is a cross-sectional study.
Page 9, line 10-11, please elaborate on this sentence. “In all the analyzes of model 2, we also
performed the analyzes with daily energy intakes adjustment, there was no change in the results."
Page 10, line 10-13, remove the sentences. It is too lengthy.
Page 10, line 21, instead of “When NAFLD risk ORs were calculated”, please use “when the
ORs of NAFLD were calculated..”
Page 12, line 9, Instead of “Finally, we discovered that sadness raises the ORs for NAFLD risk”,
consider using “In women, depression defined with medication use was associated with higher
odds of NAFLD.”
Page 12, line 9-17, is there a possibility that BMI was an effect modifier in the association
between depression and FLI>60? Table 3 shows that among NAFLD patients, only women had
a significantly higher odds of being depressed. Could you show more data on how BMI interacts
with the relationship between depression and FLI in women?
Page 13, line 1, the gold standard of diagnosing NAFLD is a tissue biopsy.
In general, with regards to the discussion on PA, diet, SES, and depression the authors spend
a great length on how their results are in line with the previous studies but the authors do not
emphasize how their work is superior in relation to prior studies. Please include how the results
go beyond the prior studies (i.e. a large cohort of Middle East population). Consider reading the
paper: https://dx.doi.org/10.20517/mtod.2021.08