Review for 10.1186/s12876-022-02353-3 (2022)

Title: The Association between Dietary Inflammation Scores and Non-alcoholic Fatty Liver
Diseases in Iranian Adults
Version: 2 Date: 28 Apr 2022
Reviewer's report:
The authors have done significant work compiling their responses and revising the manuscript.
Well done!
However, some points were not addressed, and a few additional issues to consider. Kindly see
them below;
1. C4: Line 15-16: The authors mentioned tertiles but only presented a single OR and 95% CI.
Where are the OR for the other tertiles?
R: Given that, our main aim was to compare the odds of NAFLD in the highest tertile of EDIP and
LIS compared to the first tertile of EDIP and LIS (reference group), so only the OR of the third
tertile of LIS and EDIP was reported in the Results section (Abstract). It is worth mentioning
that all the findings were reported in detail in Table 3, but according to the author guideline of
BMC gastroenterology journal, we have reported only the most important findings in the Results
section of Abstract (, Page 2, Lines 20-24) to avoid duplication of descriptions of findings.
Reviewer’s comments/reply
The OR and 95% confidence intervals of NAFLD odds in all tertiles should be included in the
abstract. By that, the results would be clear to all readers at first glance in the abstract.
2. C12: Line 71: what is the difference between excluded and replaced? How was the
replacement carried out?
R: Thank you for your comment. It seems necessary to explain the following to clarify the
ambiguities: After exclusion of a number of participants due to non-fulfillment of the conditions
for staying in the study, to reach the required sample size, we selected new cases by considering
the inclusion and exclusion criteria mentioned among the individuals referred to the selection
center and replaced the people who were excluded.
However, now, in reviewing the text of the manuscript, we found that it was not necessary
to mention these items (because this is a common action in the selection process of study
participants), and it causes confusion to readers. Therefore, we removed the phrase "were
replaced" from the text in this section.
Reviewer’s comments/reply
It is necessary to summarize the details of your reply in the revised manuscript. Kindly
summarize this as part of lines 72-79 of the revised manuscript.
3. C17: Line 119: is smoking status current or lifetime use? This should be clearly defined.
R: Thanks for your attention. We used the current smoking status in this study. The word
"current" was added to clear up the ambiguity. Also, we have provided more explanation on the
classification of participants based on smoking status as follows:
Method section, Pages 8-9, Lines 149-151: “In the current study, smoking was classified into
yes/no groups; ‘yes’ defined subjects who smoked cigarettes as daily or occasionally or ex-
smokers and ‘no’ defined the individuals who are non-smokers.”
Reviewer’s comments/reply
Current smoking might not be the best for evaluating smoking in this kind of study. Ever smoked
would be more reliable as the impact of smoking even after cessation is usually. Please include
this as a limitation in the discussion section of the revised manuscript.
4. There was no appropriate citation for factors included in lines 138 – 158 of the revised
manuscript.
5. C21: Lines 152-170: it might be useful if some of the critical summary estimates could be
included in the narrative without reverting to the table.
R: Thank you for your valuable suggestion. In the Results section, we tried to express the main
points related to Tables 1 and 2 (reporting the possible difference of variables according to DIS
and EDIP) according to the journal author guideline. As the reviewer suggested, we have added
more explanation for the findings of the study in the Results section based on Table 1 and Table
2 content. P values for each comparison of one of the variables according to DIS (Table 1) and
EDIP (Table 2) were added to this part of the Results section (Page 10-11, Lines 184-204) and
highlighted.
Reviewer’s comments/reply
By including critical summary estimates, I meant including the exact; means/SD, n(%) or
median (IQR) for the descriptions itemized and not the p-values. The p-values do not necessarily
make any significant sense as they are unadjusted. Kindly revise this section of the manuscript
carefully. Thank you.
6. C22: Line 171-174: the details of the OR for the tertiles were omitted. For example, which
tertile was used as a reference for comparison? Also, the OR presented belonged to which tertile.
It will be vital to include the entire spectrum of OR across the tertile in a consecutive manner.
R: As we explained in response to the previous comment, considering that, our main aim was
to compare the odds of NAFLD in the highest tertile of EDIP and LIS compared to the first
tertile of EDIP and LIS (reference group), so only the OR of the third tertile of LIS and EDIP
was reported in the Results section. It is worth mentioning that all the findings were reported
in detail in Table 3, but according to the author guideline of BMC gastroenterology journal, we
have reported only the most important findings in the Results section to avoid duplication of
descriptions of findings as follows:
Results section, Page 11, Lines 206-212: “In the age and sex-adjusted model, individuals in the
highest tertile of EDIP score (OR= 1.54; 95% CI: 1.04-2.28, P for trend=0.029) and DIS score
(OR=2.83; 95% CI: 1.84-4.37, P for trend <0.001) had higher odds of NAFLD compared to
lowest tertile. Also, in the final model, after additional adjusting for physical activity, smoking,
marital status, WHR, and dietary energy intake, the odds of NAFLD in the highest tertile of
EDIP score [(OR: 1.82, 95% CI: 1.02–3.23), (P for trend =0.031)] and DIS score [(OR: 2.54,
95% CI: 1.39–4.63), (P for trend =0.003)] was higher than the lowest tertile of EDIP and DIS.”
Reviewer’s comments/reply
Again, the author did not consider my comments abnicio. All tertiles ORs and 95% should be
included in the result narrative. There is not need reading your results description if we can
as well read the tables only. Also, the conventional standards from presenting results like this
involves include the OR in each tertile and the P for trend. A P-trend would not be applicable
without details of quantiles making the trend. The authors should kindly include the all results
of the OR for tertiles both in the abstract and this section of the manuscript. Thank you.
7. I have yet to see a paragraph on the pathophysiology of NAFLD scores. Perhaps you might
want to consider discussing the significance of your findings in public health implications.
8. Also, I am curious about the relevance of the statements in lines 248-255 in discussing your
findings. It is well known that poor dietary choices are critical to CVD manifestations, but what
is the uniqueness of these predicted scores in NAFLD events, and why is it useful?