Title: High-Protein Diet Scores, Macronutrient Substitution, and Breast Cancer Risk: Insights
from Substitution Analysis
Version: 0 Date: 27 Dec 2023
Reviewer's report:
Dear
-Make the title clearer. For example:
High-Protein Diet Variations, Macronutrient Substitution, and Breast Cancer Risk: Insights from
Substitution Analysis".
-Extensive English editing is essential
Abstract
Provide a brief background of the title and variables of the article.
Briefly explain using substitution analysis
Briefly explain using substitution analysis
The conclusion is to repeat the findings
Keywords should be based on mesh
Introduction
The article provides a comprehensive overview of breast cancer, its prevalence in Iranian society,
and the impact of dietary protein intake on its risk. However, it could benefit from more precise
and concise language in certain areas to enhance readability.
-   Consider breaking down the information into more structured sections to make it easier
for readers to follow. For example, you could have distinct sections discussing breast cancer
prevalence, risk factors, impact of dietary protein intake, previous research findings, and the
purpose of your study.
- Some sentences might benefit from restructuring for better clarity and flow. Here's an example
of a sentence that could be revised: "In Iranian society, BC is the third cause of death among
women, with a ten-year survival rate equal to 58.1 percent." Consider rephrasing for better
readability, such as: "In Iran, breast cancer ranks as the third leading cause of death among
women, with a ten-year survival rate of 58.1 percent."
- Consider incorporating statistical or empirical data related to the impact of dietary protein
intake on breast cancer risk. It could strengthen the argument and provide more concrete
evidence for your assertions.
Method
Here are a few suggestions for improving this section:
- You could have separate subsections detailing the inclusion and exclusion criteria for both the
case and control groups.
-It might be beneficial to briefly justify the exclusion criteria chosen for both groups. For
instance, why were individuals with specific dietary habits or those on hormone replacement
therapy excluded?
- You've mentioned that seven participants were excluded due to reported energy intakes that
deviated significantly from the mean energy intakes of the population. Adding a sentence or two
explaining why such extreme deviations were considered exclusion criteria could enhance the
clarity of this decision.
-You might consider briefly explaining how energy intakes were calculated, why extreme
deviations could affect the analysis, and how this could potentially impact the study outcomes.
-You've mentioned the study period as September 2015 to February 2016. Adding this
information at the beginning of the section or providing it alongside the study population details
could be helpful for readers to understand the timeframe of data collection.
-Consider briefly describing the rationale for choosing this specific questionnaire and its
advantages in assessing dietary intake in large-scale studies. Highlighting its validity and
reliability could strengthen the methodology.
-The breakdown of dietary subgroups (refined vs. non-refined carbohydrates, animal vs. plant
protein and fat sources) is beneficial. However, you may want to include a brief rationale for this
categorization and its relevance to breast cancer risk. Explaining why these distinctions were
made and their potential impact on health outcomes can add depth to the methodology.
- Mentioning the use of the Iranian Food Composition Table for traditional Iranian food items
not present in the USDA database is essential. Consider briefly discussing any adjustments
or considerations made when using this database for the analysis to ensure transparency in
methodology.
- It was mentioned that data on alcohol consumption were not collected due to cultural beliefs.
You might want to briefly explain how this decision was made and its potential impact on the
study.
-Please explain how portion sizes were standardized or how any variations in reporting were
addressed to maintain consistency in the estimation of daily grams and nutrient intake from the
reported frequencies.
- Ensure consistent use of terms throughout the section. For instance, if you refer to animal fat,
maintain this terminology across the entire article to avoid confusion.
-Consider adding a sentence or two about the relevance of examining these dietary subgroups
in relation to breast cancer risk based on previous research or
- it might be beneficial to add a brief rationale for choosing these specific instruments
(digital scale and tape meter) and highlight their accuracy and reliability in capturing these
measurements.
- You've mentioned instructions for participants regarding clothing and footwear during weight
measurement. Consider mentioning if there were any specific protocols followed to ensure
consistency in measurements, especially if multiple individuals were involved in data collection.
-  Providing a brief explanation for choosing these specific questionnaires and their relevance
to breast cancer risk or their validation status can add value to the methodology description.
- cite the sources that validate the questionnaires or methods used for assessment to establish
their reliability and validity in this context.
-if certain information relied on self-reporting, discuss the potential for recall bias and how it
was minimized.
Statistical analysis
-Briefly mentioning the results of this normality assessment for transparency in the analysis.
- Providing a rationale for the selection of these tests and how they suit the data characteristics
can strengthen the methodological clarity.
- Why these increments or tertiles were chosen and how they aid in interpreting the association
with breast cancer risk
- Please mentioning why these specific confounders were chosen and their relevance to breast
cancer risk based on prior literature or hypotheses
Results
- You've highlighted significant findings, particularly that individuals in the third tertile of high-
protein-low-CHO and fat diet score had lower odds of breast cancer compared to those in the
first tertile. However, for the other high-protein scores, there were no statistically significant
associations found after adjustment for various confounders.
-Discussing the effect sizes can be beneficial. For instance, mentioning the magnitude of the
observed associations (e.g., a 29% decrease in breast cancer odds with each SD increase in high-
protein-low-CHO and fat diet score) helps readers understand the practical implications of the
findings.
-Highlight the key findings of the substitution analysis, such as the percentage decrease in breast
cancer odds associated with each 50 or 100 kcal replacement of fat by protein. This helps
emphasize the practical implications of dietary changes on breast cancer risk.
-Clarify the observed effects of replacing macronutrients. For instance, mention the notable
decrease in breast cancer odds associated with replacing fat by protein or plant protein instead
of refined carbohydrates.
Discussion
- Elaborate on the observed associations, especially the inverse relationships between specific
high-protein diet scores (like high-protein-low-CHO and fat diet, high-protein and CHO-low-
fat diet) and breast cancer risk. Discuss the potential mechanisms or biological pathways behind
these associations, referencing relevant literature.
-Clearly explain the implications of substituting macronutrients in the context of breast
cancer risk reduction. Emphasize the practical significance of these findings and how dietary
modifications could potentially lower the risk of breast cancer.
-Highlight the importance of plant-based protein sources in reducing breast cancer risk. Discuss
the potential beneficial effects of these proteins, their associated nutrients, and anti-carcinogenic
properties.
-Conclude with recommendations for further research in this area, emphasizing the need for
prospective studies, dietary intervention trials, or longitudinal studies to validate and expand
upon your findings. Discuss the potential implications for public health or dietary guidelines.