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: 3 Date: 07 Sep 2023
Reviewer's report:
PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research
question(s) (brief or other article types: is there a clear objective)?
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are minor issues
EXECUTION - Are the experiments and analyses performed with technical rigor to allow
confidence in the results?
Yes - experiments and analyses were performed appropriately
STATISTICS - Is the use of statistics in the manuscript appropriate?
Yes - appropriate statistical analyses have been used in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
Yes - the author's interpretation is reasonable
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically
sound? If not, can revisions be made to make the work technically sound?
Yes - current version is technically sound
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: In this study, the authors aimed to evaluate the association between
the HEI-2015 score and various cardiometabolic indices in Iranian individuals diagnosed with
ultrasound-determined hepatic steatosis. The authors have addressed some of the concerns raised
in a previous evaluation of the manuscript. The investigation of the relationship between diet
quality and cardiometabolic indices is not a novel line of inquiry. Consequently, these results
are expected to contribute only incrementally to the field.
REQUESTED REVISIONS:
In this study, the authors aimed to evaluate the association between the HEI-2015 score and
various cardiometabolic indices in Iranian individuals diagnosed with ultrasound-determined
hepatic steatosis. The authors have addressed some of the concerns raised in a previous
evaluation of the manuscript. However, the quality of the work would be further improved with
consideration of the following factors:
1.  The study employed a Food Frequency Questionnaire (FFQ) encompassing 130 food items
to assess dietary intake over the past year. Typically, FFQs rely on shorter recall periods, usually
ranging from one week to a month. It's important to acknowledge that using a FFQ with a
one-year recall period may introduce recall bias, potentially affecting the study's results. This
limitation should be mentioned in the discussion.
2. The HEI serves as a tool to gauge diet quality based on alignment with the Dietary Guidelines
for Americans. However, the validity of HEI in the context of the Iranian population has not
been established. To enhance the credibility of the findings, it would be valuable to include
an independent method for assessing diet quality specific to the Iranian population, helping to
validate the study's results.
3. The investigation of the relationship between diet quality and cardiometabolic indices is not a
novel line of inquiry. Consequently, these results are expected to contribute only incrementally
to the field. To strengthen the significance of the study, consider discussing the potential practical
implications or unique insights that the study brings to the existing body of knowledge.
4. HEI scores range from 0 to 100, with higher scores indicating better diet quality. In the context
of Americans, HEI scores above 80 indicate a "good" diet, scores between 51 and 80 suggest a
diet that "needs improvement," and scores below 51 indicate a "poor" diet. In this study's cohort,
the overall diet quality appeared to be suboptimal. For instance, the Q4 total score averaged
57.27 ± 3.30. It seems that none of the participants in this study adhered to a good diet, which
could potentially explain the null findings.
5. There appears to be limited variability in clinical findings among the participants with
NAFLD. Expanding the cohort to encompass a broader spectrum of NAFLD severity could
provide a more meaningful basis for examining diet quality as a predictor of hepatic indices.
This limitation should be acknowledged and discussed in the manuscript.
6. It is essential to consider including individuals without NAFLD as a comparator group. This
is particularly important as it is plausible that individuals with NAFLD may have developed the
condition due to poor dietary habits. The absence of such a group is a limitation that should be
addressed in the study's limitations section.
7. In the Discussion section, consider breaking the second paragraph into multiple paragraphs
to address different topics more clearly. This will enhance the readability and organization of
this section.
8. Throughout the manuscript, the term “patient” should be replaced with “participant”.
9. In the Introduction section of the Abstract, the authors are encouraged to indicate the rationale
for assessing an American eating index in an Iranian population to prepare the reader.
10. In the Introduction, please note what the NAFLD prevalence is in the Middle East.
11. In the Introduction, the sentence “The pathophysiology of NAFLD is multifactorial,
involving various mechanisms such as genetic factors, insulin resistance, obesity, and dietary
factors(4, 5).” These factors are not “mechanisms” and the authors are encouraged to revise this
sentence accordingly.
12. In the second paragraph of the Introduction, “as” needs to be deleted (“Diet may play “as”
a mediating role…”). At the end of the same paragraph, green coffee should be edited to “green
coffee bean extract”.