Reviewer’s report
Title: 
Factors associated with health-related quality of life in women using path
analyses: Mediation effect of the adiposity traits
Version: 
2 
Date: 
26 May 2021
Reviewer's report:
"STATISTICAL REVIEWER ASSESSMENT: 
Is the study design appropriate for the research question (considering whether the
analyzed population accurately reflects the design and whether you see any
problems with control/comparison groups, e.g., likely confounders)?
No - there are major issues
Are methodologies adequate and well implemented (considering whether
assumptions are addressed and whether analyses are robust)?
No - there are major issues
Are the analyses adequately communicated (considering whether reporting
details are adequate and whether figures and tables are well labeled and
described)?
No - there are major issues
Does the interpretation accurately reflect the analyses without overstatement
(considering whether limitations/bias are acknowledged and whether accurate
descriptors, e.g., 'significant', are used)?
No - there are major issues
Could an appropriately REVISED version of this work represent a statistically
sound contribution? 
Maybe - with major revisions
STATISTICAL REVIEWER COMMENTS:
1. First and foremost, a fundamental and fairly critical issue -- The authors
mistakenly used scores (e.g., TEF-E; Three Eating Factor Questionnaire-
emotional score), instead of variables (e.g., age), in their statistical analyses. 
To
put it another way, the authors are conceptually wrong. 
Hence, the relatively
important Figure 2 is erroneous.
2. For the revised manuscript, the authors carried out path analysis which was
recommended by the prior statistical reviewer. 
Path analysis is a subset of
Structural Equation Modeling (SEM). 
Specifically, SEM is a combination of
multiple regression and factor analysis, while path analysis deals with measured
variables only. 
The authors had also responded to my previous comments as
regards a couple of inappropriate/misleading statements relating to SEM and
path analysis. 
Nonetheless, the authors failed to pay attentions to all needed
revisions in the paper. 
For instance, on page 5, starting on line 91, "Structural
equation modeling (SEM) unlike regression methods, explore the complex
interrelationships … In fact, SEM is an extension of path analysis which allows
us to test the associations among both latent, which was not applicable for
present study, and measured variables (47) … So, the aim of our study was to
apply path analysis in overweight and obese women to determine the direct and
indirect associations ...".
It is obvious that in the above-quoted text the authors firstly praised the
advantages of conducting SEM (over regression methods and path analysis), and
then rather unexpectedly, they declared that they would carry out path analysis
instead. 
The key issue of why the authors could not perform SEM was
mentioned in passing -- "In fact, SEM is an extension of path analysis which
allows us to test the associations among both latent, which was not applicable for
present study (emphasis added), and measured variables (47)." (p. 5, lines 94-
95).
3. Another example of confusing writing. 
In this investigation, the authors used
the 36-Item Short Form Survey (SF-36) to assess health-related quality of life
(HRQoL). 
In the footnotes of Table 2, it revealed "QOL [sic]: computed by
summing up the scores of the eight SF-36 domain [sic]". 
It is reasonable that the
reader would interpret it as there was a SF-36 overall score produced from the
eight domains to indicating the quality-of-life variable. 
However, the SF-36
Scoring Manual does not provide support to calculate a single measure of health-
related quality of life, such as a "SF-36 Total/Global/Overall Score." 
According
to the developers of SF-36 at the RAND Corporation, it is pointless trying to
produce an overall score of health-related quality of life -- "The components
analyses showed that there are two distinct concepts measured by the SF-36® - a
physical dimension and a mental dimension. 
Therefore, it is not appropriate to
try and come up with one overall score; thus instead the two summary scores are
used." (SF-36.org. FAQ: is there one summary score that is a combined score for
the various subscales in the SF-36® so that a single score could be used for each
patient? http://www.webcitation.org/6cfeefPkf ) (accessed May 25 2021).
Indeed, the authors used the physical and mental dimensions separately, and thus
correctly, in both Table 3 and Figures 2. 
In sum, the authors need to avoid
confusing, even incorrect, statements, as pointed out above.
4. In response to my previous comment — "'Among socio-demographic
parameters, age was found to be indirectly and negatively associated with MCS
(B=-0.040; P= 0.050)'. 
It should be statistically insignificant." — the authors
revised the p-value slightly -- P = 0.049. 
It does not make much sense since the
revised p-value of 0.049 is marginally significant only. 
A similar concern for
"education was seen to be indirectly and positively related to MCS (B=0.529; P=
0.045) (p. 9, lines 187-188). 
All in all, it would be much better to provide 95%
CI statistics as well.
5. In response to my previous comment — "The survey of the study was done by
performing face-to-face interviews. 
However, authors did not provide evidence
of the inter-rater reliability (i.e., the kappa statistics)." — the authors declared
that "all of information was collected by a trained dietitian". 
The rebuttal is fairly
amazing to me, considering the fact that the sample size was 278. 
Meanwhile, in
the paper the authors did not indicate the study period, a fundamental piece of
information. 
Finally, employing a single interviewer has its own drawback --
interviewer bias. 
Interviewer bias is "(a) distortion of response related to the
person questioning informants in research. The interviewer's expectations or
opinions may interfere with their objectivity or interviewees may react
differently to their personality or social background. Both mistrust and over-
rapport can affect outcomes." (The Oxford Reference Database;
https://www.oxfordreference.com/view/10.1093/oi/authority.2011080310000873)
(accessed May 25 2021).
6. Table 1 was evidently not professionally constructed.
7. Table 2: Firstly, "scores" are not "variables" (indicated in the table title). 
The
authors are conceptually wrong, as pointed out previously. 
In addition, I could
not comprehend the logic of the order of the acronyms in the footnotes. 
Lastly,
in the last row of the table, "00.00" is markedly inadequate.
8. The revised manuscript title: It is not "Pathway analyses", but "Path analyses".
Throughout the entire manuscript the authors used pathway analysis and path
analysis interchangeably and thus incorrectly.
9. The Abstract: "Three eating factor [sic; emphasis added] questionnaire
(TFEQ)-18" is an incorrect descriptor. 
Rather, it should be "the Three-Factor
Eating Questionnaire-R18 (TFEQ-R18)". 
Moreover, the authors used the
acronyms of MCS and PCS in the Abstract without spelling them out at first use.
10. There are still numerous English writing anomalies throughout the entire
revised manuscript, including the rather important paper title ("Pathway
analyses", as pointed out previously), albeit the authors had declared in their
rebuttal letter that "we did our best to edit and improve the quality of the
manuscript". 
Take the Conclusion of the Abstract, "Conclusion: obesity [sic]
seems to mediate the effects of socio-demographic parameters on HRQoL. Poor
sleep quality was also related to impairment of HRQoL." 
The present and past
tenses were both used, inappropriately. 
In addition, "Age (B=-0.065; P=0.036)
and education (B =0.870; P=0.019) were also directly associated with obesity."
(the Abstract, Results) and "obesity seems to mediate the effects of socio-
demographic parameters on HRQoL." (the Abstract, Conclusion). 
The two
assertions cannot be true simultaneously ("directly associated with" vs. "mediate
the effects").
11. Lastly, and rather fundamentally, I assume that after reading the revised
manuscript, the reader might ask: What is the causal relationship the authors
intended to appraise, exactly? 
Simply comparing two statements: "Pathway
analyses for the association between adiposity traits, eating behavioral, sleep
quality and quality of life among women" (the paper title) vs. "The current work
aimed to investigate the association between sleep quality, quality of life, eating
behaviors and adiposity traits by path analysis" (the Abstract, Background).
What is the outcome measure and what's the main predicting variable, then?
Plus, the context of the quite important Figure 2 may add more confusion -- the
authors inaccurately used scores rather than variables, as aforementioned.
REQUESTED REVISIONS: 
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes