Review for 10.1186/s12876-024-03222-x (2024)

Title: The Association between Healthy Eating Index-2015 with Anthropometric,
Cardiometabolic and Hepatic Indices among Patients with Non-alcoholic Fatty Liver Disease
Version: 2 Date: 30 Sep 2022
Reviewer's report:
In the present study, Hosseini SA et al. aimed to evaluate the anthropometric, hepatic and
cardiometabolic associations associated with the Healthy Eating Index (HEI) score in 664
patients with NAFLD (the diagnosis of NAFLD is likely based on the indices). In this work, the
authors concluded that there is a correlation between lower HEI levels and an increased risk of
steatosis in men with NAFLD, thus highlighting the importance of diet in the management of
this disease, although gender-related differences should be taken into account. However, I have
several comments that I think the authors should address:
1. HEI index is the American index developed in 1995 (and constantly updated). Its values
range from 0 to 100 (where 100 represents the maximum score for adherence to the American
guidelines). Therefore, we believe that this work does not add any novel elements in this field.
2. The authors do not mention how NAFLD was diagnosed in these patients. Also, the lack of
histology data is a limitation of the study. They should add firmly that this data needs to be
confirmed by histology and that the associations that they find are related to the non invasive
markers.
3. In their sample there are patients who consume between 800 and 8500 kcal per day....this
seems too wide a range and without explanation. Authors should include data showing the
average energy intake of these patients.
4. The conclusions should be softened.
5. They should have the paper reviewed by a native English speaker, there are several errors.
Statistical analysis section:
6. It would be preferable to express the data in the tables with the median and the IQR
7. The authors should explain why they divide by sex in table 1 (of the general patient
characteristics) if it appears that there are no significant differences between sexes
They compare the variables with ANOVA without specifying whether the variables are
parametric or not. In case of non-parametric variables it would be preferable to use the Kruskal-
Wallis test
8. Please, the percentage of diabetics in the study population should be added. Also, the
regression model should be adjusted by diabetes
Other comments to address:
Statistical section:
1. Authors used the Kolmogorov-Smirnov test for the evaluation of normality. I would suggest
adding the Shapiro-Wilk test.
2. They do not mention in the biochemical assessment section the measurement of ALT, AST
and MCV.
3. Please, add a reference in the 'Biochemical assessments' section for the calculation of LDL
Tables are somewhat difficult to interpret. Authors should include the average HEI index in the
population
4. Acronyms often do not match or are not introduced. An example, Hepatic Steatosis Index
(HSI) is also written as HIS in the Discussion. Please correct them.
5. When introducing an acronym, they should capitalise the first letter....for example Food
Frequency Questionnaire (FFQ). Please correct them.
How much alcohol do the excluded participants (n=8) consume? How much alcohol
consumption is allowed for participants to be included in the study?