Title: Association between Dietary Insulin Index and Postmenopausal Osteoporosis in Iranian
Women: A Case-Control Study
Version: 2 Date: 20 Jun 2024
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (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 sufficient technical rigor to
allow confidence in the results?
No - there are minor issues
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?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Probably - with minor revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: This is an interesting manuscript in which authors aimed to find a
correlation between dietary insulin index and osteoporosis in Iranian postmenopausal women.
While the authors have requested help with English grammar and answered most of the questions
raised by the reviewers, I still find things that could be improved for clarity and interpretation.
The main suggestion would be to revise some parts in the Discussion. For example authors are
pointing out that the control subjects (lines 220-221) who had the control subjects who had the
highest DII and no osteoporosis, will eventually develop insulin resistance that is correlated
with low bone density so it seems like they are contradicting their main findings. I had a lot of
trouble with that paragraph, I was not sure then what the authors were trying to confirm. It seems
like they were trying to say that one would expect that, however,  their findings contradict that
statement. So I suggest to remove that confusing paragraph. Authors also say that those in the
highest tertile of DII (line 242) ahd higher intake of protein and carbohydrate to explain their
findings but they also had higher intake of total fat, saturated fat and polyunsaturated fat. Overall
I believe that they need to talk more in their discussion about Tables 3 and 4 and what is the
major differences in nutrients between control and osteoporosis and among the different tertiles.
I have other concers about English grammar and interpretation that I will address in detail later
in this review
REQUESTED REVISIONS:
Here are my detailed comments/suggestions
1. Abstract lines 16-17 ""the main aim of this research was to study the connection........
2. Lines 30-31 ""compared to the case group
3. Introduction, line 40 remove the word ""globally"". It is redundant.
4. Lines 63-64 ""while the positive association of IR with BMD has been shown is some studies,
others have either not found.......
5. Line 73: ""foods high in insulin"" is incorrect, it should say foods with high insulin index.
6. Methods. Line 103 ""use of oral contraceptives""
7. Lines 107-108 ""and the validity and dependability has been confirmed in Iranian women""
8. Line 137 ""to account for a 10% dropout""
9. Line 152 ""not significant"", insignificant is not the correct term.
10. Line 160 ""the main intak of nutrients between the two groups""
11. Table 1. although the weight is lower in the control group, BMI is not different.
12. Table 2 indicates that the baseline characteristics were not different amonb DII tertiles.
13. According to Table 3, nutrient intake is substantailly different between the control and
the case group to the point that it merits discussion both in macronutrients and specific
micronutrients that can contribute to the reduction of osteoporosis and this is another point that
should be added to the discussion although Vitamin D is not different. However, magnesium,
selenium, Vitamin E, calcium to mention a few are significantly different between groups. So
this can indeed be a confounding variable
14. Table 3 and 4, it should be ""phosphorus not phosphore""
15. Table 4: The nutrient differences among tertiles needs also to be part of the discussion for
the same reasons.
16. Line 259 ""to our knowledge, previous studies have not examined.....
17. Line 278 consuming foods that ""increase insulin index""
18. in Conclusions line 284 foods that have higher insulin index, not ""elevated insulin
sensitivty"" since that is not an accurate statement since insulin sensitivity was never measured
ADDITIONAL REQUESTS/SUGGESTIONS:
I find interesting that there are so many grammatical errors (I just corrected some) after it has
undergone English checking by experts. Also authors use the term foods with high insulin or
increases in insulin sensitivity observed that are incorrect and I hope this part is corrected because
it is really misleading."