Review for 10.1186/s12876-025-04087-4 (2025)

Title: TyG-BMI as a Superior Predictor of MAFLD and Pre-MAFLD in Chinese Adults: A
Cross-Sectional Study
Version: 0 Date: 18 May 2025
Reviewer:  Amira A. A. Othman
Reviewer's report:
First of all
I want to congratulate the authors on their work. In this study, Huang et al. aimed to explores
the predictive efficacy of triglyceride-glucose (TyG) index and its derivatives—TyG-BMI,
TyG-WC, and TyG-WHtR—for identifying metabolic-associated fatty liver disease (MAFLD)
and its precursor state (pre-MAFLD) in a Chinese population from the Yangtze River Delta
region. With MAFLD emerging as a global health burden, early detection is critical to prevent
progression to severe outcomes like cirrhosis and hepatocellular carcinoma. The authors aim to
validate TyG-related indices as non-invasive, cost-effective tools, comparing their performance
to traditional anthropometric measures. Their focus on pre-MAFLD adds novelty, addressing a
gap in early risk stratification.
Non-alcoholic fatty liver disease (NAFLD) is recognized as the most prevalent chronic liver
disease, impacting about 30% of global individuals, with the potential to progress to advanced
hepatic fibrosis and end-stage liver diseases eventually [*]. In June 2023, a multi-society
committee of international experts was gathered, and new terminology was adopted to reduce
stigma and increase disease awareness [**]. A new terminology, Steatotic liver disease (SLD),
replaces “fatty liver disease” as the umbrella term. Under subgroups of SLD, NAFLD has been
renamed as metabolic dysfunction-associated Steatotic liver disease (MASLD) [**]. NAFLD/
MASLD is closely related to metabolic syndrome (MetS) and its associated components of
hypertension, type 2 diabetes mellitus, dyslipidemia, and obesity[***].
(*:doi: 10.1097/HEP.0000000000000004, **: doi: 10.1016/j.jhep.2023.06.003, ***  doi:
10.1111/apt.17308).
The authors handled the reviewer comments satisfactorily, nevertheless, there is an observation
for which sufficient justification must be obtained.
In general:
1. The language has some minor grammatical errors, and awkward phrasings could be improved.
Consider having the manuscript proofread by a native English speaker or a professional editing
service.
2. Abbreviations must be fully written at their first appearance.
3. Avoid redundancy (e.g., "ultrasound findings of hepatic steatosis" vs. "hepatic steatosis on
ultrasound").
4. Replace passive constructions (e.g., "It was found that" # "We found").
In Title:
1. The title should be concise, I suggest “ TyG-BMI as a Superior Predictor of MAFLD and Pre-
MAFLD in Chinese Adults: A Cross-Sectional Study”.
In the Abstract section
2. The background subsection in the abstract :
-  Should be the shortest part of the abstract. It should briefly outline the following information:
What is already known about the subject, related to the paper in question. What is not known
about the subject, and hence what the study intended to examine (or what the paper seeks to
present)? Please reconstruct it properly.
- The background is lengthy; condense to one sentence on MAFLD’s global impact.
3. In the method subsection in the abstract :
- The type of study: a Cross-Sectional Study.
- Nothing was mentioned about the participant's age, sex, ethnicity, etc.
- It would help if you described the aim of your statistical analysis.
4. In the results subsection in the abstract :
-   Improve numerical clarity and conciseness: “Include specific AUC values for TyG-BMI
upfront (e.g., "TyG-BMI had the highest AUC [0.874] for MAFLD".
5. In the conclusion subsection in the abstract :
- Emphasize the clinical significance of your study: "TyG-BMI could serve as a first-line
screening tool."
In the Introduction section:
6. MAFLD must replace NAFLD:
“In contrast to NAFLD, MAFLD does not necessitate ruling out other liver disease causes, such
as viral hepatitis or heavy alcohol use*. The new name chosen to replace NAFLD reflected the
disease etiology better and conveyed a more practical approach in daily clinical practice than
NAFLD, considering its close association with metabolic syndrome**. Please discuss the new
nomenclature in more detail.
(*: Doi: 10.1016/j.jhep.2020.03.039, **: doi: 10.1097/HEP.0000000000000520)
7. Improve transition from NAFLD to MAFLD by briefly explaining the diagnostic shift (e.g.,
metabolic criteria).
8. Why pre-MAFLD is understudied and how this work addresses it?
9. why TyG derivatives (vs. TyG alone) might better capture MAFLD risk, linking IR and
obesity synergistically.
In the Methods section:
10. Please provide the participants' sociodemographic data.
11. How the sample size was calculated.
12. Mention ethical approval earlier in the methodology to emphasize compliance.
13. Provide more details on the exclusion criteria to ensure reproducibility
14. Figure 1 is referenced but not provided; ensure it’s included or described in detail.
15. Justify ultrasound’s limitations (e.g., sensitivity for mild steatosis) and how this might affect
pre-MAFLD classification.
16. How were confounders (e.g., alcohol use, medications) addressed in regression models?
In the Results section:
17. In all tables, please explain the abbreviations under the tables. Table 1’s footnotes need
expansion (e.g., define "non-MAFLD" vs. "pre-MAFLD" criteria).
18. You can title the statistical test column as “Test of significance” and use U= for the Mann–
Whitney U test, T= for the T-test, and #2 = for the Chi-square test, etc...
19. Ensure that table captions succinctly describe the content for standalone clarity.
20. Figure 3’s "S-shaped" curve is pivotal; label phases (e.g., "low-risk plateau") to aid
interpretation.
21. Contrast TyG-BMI’s performance with traditional metrics (e.g., BMI alone) to underscore
its added value.
22.  Include units in the main text (e.g., "TyG = ln[TG (mg/dL) × FPG (mg/dL)/2]") for clarity.
23. Add clinical context (e.g., "TyG-BMI >202.54 may prompt lifestyle intervention").
In the Discussion section:
24. The discussion section is one of the final parts of a research paper, in which an author
describes, analyzes, and interprets their findings. They explain the significance of those results
and tie everything back to the research question(s). In this manuscript, there is confusion between
what should be written in the introduction and discussion sections. Please reconstruct the
discussion section: Highlight how defining pre-MAFLD advances early intervention paradigms.
25. Discuss the novelty of your study regarding previously published papers.
26. Discuss potential selection bias (regional focus) and ultrasound’s false negatives. Propose
liver biopsy/FibroScan validation in future work.
27. Discuss applicability to non-Chinese populations or those with comorbid metabolic
disorders.