Title: Association between different obesity patterns and the risk of NAFLD detected by
transient elastography: A cross-sectional study
Version: 1 Date: 14 Apr 2024
Reviewer's report:
Sun and colleagues explored the association between different obesity patterns (increased BMI
with normal WC; increased WC with normal BMI; increased BMI and WC) in the NHANES
2017-2020 cohort. The topic is well-acknowledged and investigated, since obesity is closely
link to MASLD. Indeed, positive associations were found for different obesity patterns across
multiple adjustments.
Major points:
- BMI and WC cut-offs are described univocally as for Asian individuals, but more ethnicities
are included in the dataset. This datum should be adjusted when considering BMI and WC cut-
offs for the analysis
- This paper holds the outdated nomenclature NAFLD, which should be accommodated to the
novel SLD guidelines with subgroups (MASLD, metALD, ALD). There is a conceptual mistake,
where steatosis is one entity and NAFLD/MASLD a consequence. In the paper it should be clear
that liver fat content is defined by CAP thresholds and that presence of steatosis along with
metabolic co-factors define MASLD (please see the first lines in the introduction, for instance).
Viral infection were excluded: other etiologies including toxic medications or autoimmune/
cholestatic liver diseases were considered?
- In 17.2% of cases, MASLD was present also in lean individuals: I suggest performing an
additional analysis on the variables associated with liver fat content in this population
- It is not clear if WC was evaluated as continuous variable for the regression analysis across
the three models (e.g. WC quartiles were inside the normal ranges? – Table 3)
- I suggest performing a ROC curve also for BMI and for compound obesity and a comparison
of ROC curves (DeLong test); Se, Sp, PPV, NPV and type of cut-off chosen (Youden Index?)
should be reported.
- What do “fibrosis; non-fibrosis” mean in Figure 2 with regard to MASLD risk? Fibrosis is
an intrinsic feature/consequence of MASLD, why was treated as an independent/external co-
factor?
- Since the Authors collected data on LSM (which is stressed also in the title), I would suggest
performing an analysis of obesity patterns and risk for significant fibrosis.
- Why were malignancies excluded for a sensitivity analysis (Table S1)? This is also not clear
from the paper: were hepatic malignancies included in the analysis?
- Why were overweight and general obesity analyzed together? They belong to a different risk
class for MASLD and should be separated for the analysis.
Minor:
- Please report alcohol intake in grams/day or grams/week
- Please correct in the first lines of results: Prevalence, and not incidence of MASLD is examined
here
- The subgroup analysis in the main text does not report any quantitative results, please amend
- In the abstract, types of obesity patterns should be explained
Title: Association between different obesity patterns and the risk of NAFLD detected by
transient elastography: A cross-sectional study
Version: 1 Date: 14 Apr 2024
Reviewer's report:
Sun and colleagues explored the association between different obesity patterns (increased BMI
with normal WC; increased WC with normal BMI; increased BMI and WC) in the NHANES
2017-2020 cohort. The topic is well-acknowledged and investigated, since obesity is closely
link to MASLD. Indeed, positive associations were found for different obesity patterns across
multiple adjustments.
Major points:
- BMI and WC cut-offs are described univocally as for Asian individuals, but more ethnicities
are included in the dataset. This datum should be adjusted when considering BMI and WC cut-
offs for the analysis
- This paper holds the outdated nomenclature NAFLD, which should be accommodated to the
novel SLD guidelines with subgroups (MASLD, metALD, ALD). There is a conceptual mistake,
where steatosis is one entity and NAFLD/MASLD a consequence. In the paper it should be clear
that liver fat content is defined by CAP thresholds and that presence of steatosis along with
metabolic co-factors define MASLD (please see the first lines in the introduction, for instance).
Viral infection were excluded: other etiologies including toxic medications or autoimmune/
cholestatic liver diseases were considered?
- In 17.2% of cases, MASLD was present also in lean individuals: I suggest performing an
additional analysis on the variables associated with liver fat content in this population
- It is not clear if WC was evaluated as continuous variable for the regression analysis across
the three models (e.g. WC quartiles were inside the normal ranges? – Table 3)
- I suggest performing a ROC curve also for BMI and for compound obesity and a comparison
of ROC curves (DeLong test); Se, Sp, PPV, NPV and type of cut-off chosen (Youden Index?)
should be reported.
- What do “fibrosis; non-fibrosis” mean in Figure 2 with regard to MASLD risk? Fibrosis is
an intrinsic feature/consequence of MASLD, why was treated as an independent/external co-
factor?
- Since the Authors collected data on LSM (which is stressed also in the title), I would suggest
performing an analysis of obesity patterns and risk for significant fibrosis.
- Why were malignancies excluded for a sensitivity analysis (Table S1)? This is also not clear
from the paper: were hepatic malignancies included in the analysis?
- Why were overweight and general obesity analyzed together? They belong to a different risk
class for MASLD and should be separated for the analysis.
Minor:
- Please report alcohol intake in grams/day or grams/week
- Please correct in the first lines of results: Prevalence, and not incidence of MASLD is examined
here
- The subgroup analysis in the main text does not report any quantitative results, please amend
- In the abstract, types of obesity patterns should be explained
Please review this paper.
user
Title: Association between different obesity patterns and the risk of NAFLD detected by
transient elastography: A cross-sectional study
Version: 1 Date: 14 Apr 2024
Reviewer's report:
Sun and colleagues explored the association between different obesity patterns (increased BMI
with normal WC; increased WC with normal BMI; increased BMI and WC) in the NHANES
2017-2020 cohort. The topic is well-acknowledged and investigated, since obesity is closely
link to MASLD. Indeed, positive associations were found for different obesity patterns across
multiple adjustments.
Major points:
- BMI and WC cut-offs are described univocally as for Asian individuals, but more ethnicities
are included in the dataset. This datum should be adjusted when considering BMI and WC cut-
offs for the analysis
- This paper holds the outdated nomenclature NAFLD, which should be accommodated to the
novel SLD guidelines with subgroups (MASLD, metALD, ALD). There is a conceptual mistake,
where steatosis is one entity and NAFLD/MASLD a consequence. In the paper it should be clear
that liver fat content is defined by CAP thresholds and that presence of steatosis along with
metabolic co-factors define MASLD (please see the first lines in the introduction, for instance).
Viral infection were excluded: other etiologies including toxic medications or autoimmune/
cholestatic liver diseases were considered?
- In 17.2% of cases, MASLD was present also in lean individuals: I suggest performing an
additional analysis on the variables associated with liver fat content in this population
- It is not clear if WC was evaluated as continuous variable for the regression analysis across
the three models (e.g. WC quartiles were inside the normal ranges? – Table 3)
- I suggest performing a ROC curve also for BMI and for compound obesity and a comparison
of ROC curves (DeLong test); Se, Sp, PPV, NPV and type of cut-off chosen (Youden Index?)
should be reported.
- What do “fibrosis; non-fibrosis” mean in Figure 2 with regard to MASLD risk? Fibrosis is
an intrinsic feature/consequence of MASLD, why was treated as an independent/external co-
factor?
- Since the Authors collected data on LSM (which is stressed also in the title), I would suggest
performing an analysis of obesity patterns and risk for significant fibrosis.
- Why were malignancies excluded for a sensitivity analysis (Table S1)? This is also not clear
from the paper: were hepatic malignancies included in the analysis?
- Why were overweight and general obesity analyzed together? They belong to a different risk
class for MASLD and should be separated for the analysis.
Minor:
- Please report alcohol intake in grams/day or grams/week
- Please correct in the first lines of results: Prevalence, and not incidence of MASLD is examined
here
- The subgroup analysis in the main text does not report any quantitative results, please amend
- In the abstract, types of obesity patterns should be explained
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