Review for 10.1186/s12876-025-04161-x (2025)

Title: METS-VF as a Novel Predictor of Gallstones in U.S. Adults: A Cross-Sectional Analysis
(NHANES 2017-2020)
Version: 0 Date: 23 Jun 2025
Reviewer:  Amira A. A. Othman
Reviewer's report:
First of all
I want to congratulate the authors on their work, "Association between Visceral Fat Metabolism
Score and Gallstone." In this study, Yang et al. aimed to investigate the relationship between the
Metabolic Score for Visceral Fat (METS-VF) and gallstones, leveraging data from the NHANES
2017–2020 cohort. With obesity and gallstones posing significant public health challenges,
the authors aim to identify METS-VF as a superior predictor of gallstone risk compared to
traditional obesity indicators like waist circumference (WC), lipid accumulation product (LAP),
and visceral adiposity index (VAI). The findings could offer clinicians a practical tool for early
risk stratification and personalized interventions..
The authors tried to contribute to this field of research with new findings; nevertheless, there is
an observation for which sufficient justification must be obtained.
In general:
1. The language is generally clear, but some minor grammatical errors and awkward phrasings
could be improved.
- Avoid passive voice (e.g., "was observed" # "we observed").
- 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.
In Title:
1. The title should indicate the age and locality of the study population at which the National
Health and Nutrition Examination Survey (NHANES) was performed. The title is informative,
but could be more concise. I suggest “ METS-VF as a Novel Predictor of Gallstones in U.S.
Adults: A Cohort Study (NHANES 2017-2020).”.
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.
- Briefly contextualize the clinical significance of gallstones and the limitations of existing
obesity metrics.
3. In the method subsection in the abstract :
-  The type of study: a population-based study.
- Nothing was mentioned about the participant's age, sex, ethnicity, etc.
- It would help if you described the aim of your statistical analysis.
- Clarify study design and analysis techniques: “This cross-sectional study analyzed NHANES
data (2017–2020) using …….. analysis.”
4. In the results subsection in the abstract :
-   Specify the demographic scope (e.g., "U.S. adults") and highlight key metrics (e.g., "METS-
VF had the highest AUC [0.712]").
5. In the conclusion subsection in the abstract :
- Emphasize the clinical significance of your study: (e.g., "METS-VF may enhance early
gallstone screening in clinical practice").
In the Introduction section:
6. Try to provide a summarized description of the National Health and Nutrition Examination
Survey (NHANES) in the background section. You may use the following: “NHANES
(www.cdc.gov/nchs/nhanes) is designed to assess the health and nutritional status of adults
and children in the United States. The survey is distinctive in that it incorporates both
physical examinations and interviews. Several cross-sectional, nationally representative health
examination surveys are part of the NHANES program. Questions about demographics,
health insurance status, dietary habits, acute and chronic medical issues, mental health, and
prescription drug use are all included in the health interview. Exam components can change
between survey cycles but typically include blood pressure, dental exams, vision, hearing,
dermatology, fitness, balance and strength testing, respiratory testing, taste and smell, and
body measurements (weight, height, skin folds, body composition scans). Hematology, organ
and endocrine function (e.g., thyroid, kidney), environmental exposure, dietary biomarkers,
metabolic and cardiovascular health, and infectious disease are a few examples of laboratory
components.
7. Improve logical progression from gallstone epidemiology to the rationale for METS-VF.
The link between visceral fat’s metabolic activity and gallstone pathogenesis needs clearer
elaboration.
8. Study gap: how this study advances prior work (e.g., "While BMI and WC are widely used,
METS-VF integrates metabolic markers, offering a holistic risk assessment").
In the Methods section:
9. Please move the sentences defining the NHANES to the introduction section rather than the
methodology section.
10. The study utilized the 2017-2020 NHANES survey cycle. why did you choose the study
survey cycle? The survey includes study cycles from 2001 to 2023.
11. Please provide the participants' sociodemographic data.
12. How the sample size was calculated.
13. Mention ethical approval earlier in the methodology to emphasize compliance.
14. Clarify exclusion criteria (e.g., "Participants missing gallstone status or METS-VF data were
excluded"). The flow chart (Fig. 1) should be referenced earlier.
15. Simplify the description of models (e.g., "Three adjusted models were used: crude,
demographically adjusted, and fully adjusted").
16. Provide METS-VF calculation details in the main text, not just the supplement, for
readability.
In the Results section:
17. In all tables, please explain the abbreviations under the tables.
18. Ensure that table captions succinctly describe the content for standalone clarity.
19. Table 2’s ORs should align with the narrative (e.g., "Q4 METS-VF showed a 7.3-fold higher
gallstone risk").
20. In Subgroup Analysis, highlight the alcohol interaction finding earlier, as it’s clinically
intriguing.
21. Ensure axis labels in Fig. 2 (RCS plot) and Fig. 4 (ROC curves) are legible and units are
specified.
22. Table 1: Use consistent formatting (e.g., decimals, % symbols) and clarify abbreviations in
footnotes.
23. Table 3/4: Merge redundant AUC comparisons or streamline into one table.
24. Add captions explaining key takeaways (e.g., "Fig. 5: METS-VF ranked highest in XGBoost
feature importance").
In the Discussion section:
25. 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.
26. Expand on how METS-VF’s components (e.g., WHtR, METS-IR) mechanistically link to
gallstones.
27. Discuss potential biological reasons for males’ higher AUCs (e.g., hormonal influences on
fat distribution).
28. Address cross-sectional design’s inability to infer causality and potential unmeasured
confounders (e.g., dietary habits).
The manuscript presents a compelling case for METS-VF’s utility in gallstone prediction.
Strengthening methodological clarity, mechanistic explanations, and narrative flow would
enhance its impact. With minor revisions, this study could significantly influence both research
and clinical practice in metabolic health. With minor refinements to clarity, focus, and visual
presentation, it could better highlight its contributions to both science and clinical practice.