Title: The impact of diabetes, anemia, and renal function in the relationship between
osteoporosis and fasting blood glucose among Taiwanese women: a cross-sectional study
Version: 2 Date: 19 Nov 2023
Reviewer:  Phuc Nhon Nguyen
Reviewer's report:
Dear authors,
Thank you for your great work to the literature. This topic is  interesting.  The study found the
relationship among factors diabetes, anemia, renal dysfuction,  and osteoporosis.  The study
had a tool to measure and classify the osteoporosis according  to T-score of WHO. This is
potential point.  I’m very impressive with the data presentation in Tables and mechanism-
described Figures. To be honest, I understand that data acquisition through a restrospective study
is difficult to obtain all the necessary variables, particularly, by electronic patient’file. However,
some points needed to be clarified before publication to readers:
- A study flowchart should be added.
-     How the authors decided to enroll 11,872 Taiwanese women? This number  of participants
was based on calculated sample size  or probability  sample size during this period?
- The study was conducted between 2014 and 2020. The COVID-19 pandemic should be
mentioned and discussed. Since this contaminated disease and vacination influences to many
issues. Even, quarantine may interupt the re-checked examination of all diseases in the
author’s study. (Hampson G, Stone M, Lindsay JR, Crowley RK, Ralston SH. Diagnosis and
Management of Osteoporosis During COVID-19: Systematic Review and Practical Guidance.
Calcif Tissue Int. 2021;109(4):351-362. doi:10.1007/s00223-021-00858-9; Yu EW, Tsourdi E,
Clarke BL, Bauer DC, Drake MT. Osteoporosis Management in the Era of COVID-19. J Bone
Miner Res. 2020;35(6):1009-1013. doi:10.1002/jbmr.4049)
- The patient age and BMI are the important factors affecting to osteoporosis concentration. But
it is significantly different between decreased and normal renal function groups. I thought that
postmenopausal women has a higher risk of bone fracture compared to premenopausal women
or reproductive-age women. Thus, classification of age group is more necessary.
- The type I, type II of diabetes, and duration time of diabetes are also important factors to
be discussed. Since it will impact on renal function. The treatment by insuline injection or
medicament or changes in life-style therapy may result to the other diseases.
- Level of anemia should be mentioned.
- Chronic renal dysfunction is in association with the anemia. Were chronic or acute renal
dysfunction, or any kind of renal diseases analyzed?
- The gravida, parity is also necessary. Did the team concern to this factor?. Moreover, pregnant
women and non-pregnant women has a different risk of bone fracture.
- Some diseases related to thyroids surgery which lead to hypothyroidism and causes the
hypocalcemia, then affecting to osteoporosis. Did thyroid-related disease be excluded?
- The study should give a modeling formula to estimated the risk of bone-fracture based on the
revealed findings.
- The strength and other limitations needed to be addressed in more detailed.
After revision, I believe this great paper can be published in BMC Women’ s Health.
Best regards,
Phuc Nhon Nguyen MD,
Tu Du Clinical Research Unit (TD-CRU)
Tu Du Hospital, Ho Chi Minh City, Vietnam