Review for 10.1186/s12876-025-04060-1 (2025)

Title: Association between dietary flavonoids intake and metabolic dysfunction-associated
steatotic liver disease especially in non-smokers: A cross-sectional study in US adults
Version: 0 Date: 26 Apr 2025
Reviewer:  Bryan Adrian Priego-Parra
Reviewer's report:
I appreciate the invitation to review this manuscript in which the authors evaluate the relationship
between dietary flavonoid intake and smoking on metabolic dysfunction-associated steatotic
liver disease (MASLD) using the NHANES cohort. The authors conducted a thorough statistical
approach through logistic regressions, multivariate analysis, restricted cubic spline analysis,
weighted quantile sum analysis, mediation analysis, and performed various sensitivity analyses
to validate the robustness of their results.
The authors highlight a U-shaped association between flavonoids and MAFLD/MASLD
mediated by low-grade inflammation, finding a protective factor specifically among non-
smokers. I find this an interesting article, generally well-written and with a logical sequence.
However, there are several parameters that could be improved, which I list below:
MAJOR CORRECTION:
* MASLD stands for metabolic dysfunction-associated steatotic liver disease, while MASH
refers to metabolic dysfunction-associated steatohepatitis. Their article is conducted on subjects
with MASLD, not MASH; therefore, the title should be changed to:
"Interaction between dietary flavonoid intake and smoking on metabolic dysfunction-associated
steatotic liver disease in US adults: A cross-sectional study."
Similarly, this correction should be made throughout the entire text and keywords.
P-values should be written in lowercase.
General comments:
• Replace the word "race" with "ethnicity" throughout the text and tables.
• Replace "female" and "male" with "men" and "women," respectively.
Abstract:
• Page 2, line 3: Add a space after the period, before "This study investigated."
• Line 5: Correct the MASLD nomenclature.
• Line 11: Add a space after the period, before "The fully adjusted."
• "Introduction:
• Line 10: Remove the space before "FDA-approved."
• Line 12: Specify the type of diet associated with MAFLD/MASLD (e.g., Westernized, high-
fructose, etc.).
Methods:
• Line 53: Change "follows" to past tense: "this study followed."
• Line 116: Replace "poverty income ratio" with "low income ratio."
• Line 130: Remove the extra parenthesis after "IQR."
Results:
• Line 178: Of the 5,645 adults, how many had MAFLD and how many had MASLD? Please
specify.
• Lines 184-185: Replace "fatty liver" with "steatotic liver."
• Line 186: Replace "were more obese" with "had more obesity."
• Line 202: The authors mention a negative association of MAFLD/MASLD with ln flavanones
(OR, 0.99; 95% CI, 0.98–1.00, P = 0.018) and ln isoflavones (OR, 0.99; 95% CI, 0.98–1.00, P
= 0.008); however, the confidence intervals reach 1.00, suggesting that this association is not
statistically significant.
• Line 211: Change to past tense: "A unit increase in ln flavonoids was associated with a
21%..." (same in Line 214).
• Line 269: In "Then the Healthy Eating Index-2020 was further adjusted based on Model 4, a
significant negative correlation between ln flavonoids and MAFLD (OR, 0.91; 95% CI, 0.84–
0.99)/MASLD (OR, 0.92; 95% CI, 0.85–1.00) was also exhibited," the significant association
was found only with MAFLD, not with MASLD. This should be discussed.
Discussion:
• Line 284: Change "is also observed" to "was also observed."
• Line 300: Replace "fatty liver disease" with "steatotic liver disease."
• Line 302: Write in past tense: "Our analysis showed a linear..."
• Line 305: Again, replace "fatty liver" with "steatotic liver."
Limitations:
• I believe an important limitation is the inclusion of both MAFLD and MASLD within the same
group, since MAFLD involves individuals with other causes of steatosis, whereas MASLD does
not. This could introduce bias.
Thank you again for the invitation, Good work!