Reviewer’s report
Title: 
Ketogenic diet may be a new approach to treatment stress urinary
incontinence in obese elderly women: Report of five cases.
Version: 
1 
Date: 
06 Jan 2022
Reviewer's report:
"PEER REVIEWER ASSESSMENTS: 
RELEVANCE - Does this case report make a contribution to medical
knowledge, have educational value, or highlight the need for a change in clinical
practice or diagnostic/prognostic approaches? 
Yes, this report contributes to medical knowledge
CASE DESCRIPTION - Are the details of the case sufficiently well described to
understand the patient's symptoms and course of treatment? 
No - there are major issues
DIAGNOSIS/INTERPRETATION - Based on the facts presented, are the
diagnosis, interpretation, and course of treatment medically sound?
No, based on information contained in the report, the authors' interpretation of
this case is unsound
DISCUSSION OF THE CASE - Does the discussion appropriately analyse the
importance of the findings and their relevance to future understanding of disease
processes, diagnosis or treatment? Has an adequate literature review pertinent to
the case been included?
Yes, the case is discussed fully in the context of the literature
OVERALL MANUSCRIPT POTENTIAL - Could an appropriately REVISED
version of this work represent a technically sound contribution?
Maybe - with major revisions
PEER REVIEWER COMMENTS: 
GENERAL COMMENTS: This is an interesting case series exploring using
ketogenic diet to achieve weight loss and improve on symptoms of Stress urinary
incontinence (SUI). Excellent results were reported by the authors but additional
clarifications are needed to interpret the report properly.
If the findings in this report is true, the use of the ketogenic diet could be a novel
non invasive way to address a common gynecologic problem in clinical practice.
REQUESTED REVISIONS: 
-5 case report of ketogenic diet to treatment stress urinary incontinence-
limitation of low number of participant needs to be acknowledged
-Line 21 : Need rewording. The mechanism of Stress urinary incontinence (SUI)
had been clearly studied with multiple identified causes.
-Please clarify : How are these patients get selected to be reviewed/studied ?
What was their incontinence work up besides clinical presentation ? Any
urodynamic tests performed before and after intervention to confirm the
diagnosis ?
-Expand on ""pad test"" as an objective evaluation end point - how reliable is
this and is this validated in the literature ?
-Limitations of non randomized nature of the study and subjective assessment of
urine leakage needs to be acknowledged.
-In result section : BMI decrease of 2-3 points in these 5 patients are quite
minimal. Any hypothesis how this can lead to a MARKED improvement in
SUI/menopausal symptoms as reported ?
-Line 29-33 page 9: ""In combination with the results of our previous study
about the intervention of ketogenic diet for the treatment of fat polycystic female
patients, it was suggested that the ketogenic diet could improve ovarian
function"", all 5 patients are more than 50 yo in this series and likely post
menopausal. How can ketogenic diet improve ovarian function in these patients
resulting in their symptomatic improvements as reported ??
-Line 58-61 page 9 : ""we believe that the ketogenic diet can effectively reduce
the body fat rate and improve the muscle content of skeletal muscle"" - please
clarify what authors means by muscle content ?
ADDITIONAL REQUESTS/SUGGESTIONS: 
See my suggestions above"
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