Reviewer’s report
Title: 
Retrospective Analysis of a Dedicated Care Pathway for Nonalcoholic
Fatty Liver Disease in an Integrated US Healthcare System Demonstrates
Support of Weight Management and Improved ALT
Version: 
2 
Date: 
13 Sep 2020
Reviewer's report:
Dear Editor, 
Patton et al wrote a paper on a very interesting field of hepatology: the impact of
lifestyle interventions on the NAFLD status and outcomes. To do so, they
performed a retrospective study on a cohort of NAFLD patients (identified by
ICD code for NAFLD/NASH) undergone to a care pathway of the largest
American integrated managed care consortium, based in California. They
enrolled 632 patients, of whom about 28% attended an education program on
NAFLD. They evaluated the changes in liver stiffness measurement and ALT
after one year in those who participated the program and confronted it to the time
period before their participation. They also conducted a weight management
(WM) program in 24 (3.8%) patients of this cohort who accepted and evaluated
the importance of WM in weight loss after 12 months. They found that the
improvements in ALT and liver stiffness measurement were significantly higher
after participating the NAFLD program and that the weight loss was significantly
associated with higher levels of liver stiffness and WM program participation.
They concluded that to construct a care pathway for NAFLD improves the
management of NAFLD patients by improving the referral that, in turn,
ameliorates the outcomes. 
The paper, even if is not based on a very novel approach is very informative and
helpful in providing information on the effects of such cascade of care in
NAFLD patients, in whom the lifestyle interventions are, nowadays, the only
weapon we have. 
The paper already underwent a full revision which improved it, I have no
particular issues to raise. 
kindest regards
Publons Reviewer Recognition
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Yes
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no competing interests
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
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?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Reviewer’s report
Title: 
Retrospective Analysis of a Dedicated Care Pathway for Nonalcoholic
Fatty Liver Disease in an Integrated US Healthcare System Demonstrates
Support of Weight Management and Improved ALT
Version: 
2 
Date: 
13 Sep 2020
Reviewer's report:
Dear Editor, 
Patton et al wrote a paper on a very interesting field of hepatology: the impact of
lifestyle interventions on the NAFLD status and outcomes. To do so, they
performed a retrospective study on a cohort of NAFLD patients (identified by
ICD code for NAFLD/NASH) undergone to a care pathway of the largest
American integrated managed care consortium, based in California. They
enrolled 632 patients, of whom about 28% attended an education program on
NAFLD. They evaluated the changes in liver stiffness measurement and ALT
after one year in those who participated the program and confronted it to the time
period before their participation. They also conducted a weight management
(WM) program in 24 (3.8%) patients of this cohort who accepted and evaluated
the importance of WM in weight loss after 12 months. They found that the
improvements in ALT and liver stiffness measurement were significantly higher
after participating the NAFLD program and that the weight loss was significantly
associated with higher levels of liver stiffness and WM program participation.
They concluded that to construct a care pathway for NAFLD improves the
management of NAFLD patients by improving the referral that, in turn,
ameliorates the outcomes. 
The paper, even if is not based on a very novel approach is very informative and
helpful in providing information on the effects of such cascade of care in
NAFLD patients, in whom the lifestyle interventions are, nowadays, the only
weapon we have. 
The paper already underwent a full revision which improved it, I have no
particular issues to raise. 
kindest regards
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons upon publication of the manuscript. If you have already registered at
Publons, they will notify you of the receipt of this review and update your profile
as per your settings and their policy. If you are not registered with Publons, you
will receive an email from them asking you to register in order for them to be
able to recognize your review on your new profile page. Publons may use the
Review Data to generate derivative metadata for the benefit of Publons and you
as a reviewer, carefully considering the sensitivity of such information. For
example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help
editors to identify candidate reviewers. Please find the details of processing in
Publons’ privacy policy 
https://publons.com/about/terms
Yes
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no competing interests
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
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?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Please review this paper.
user
Reviewer’s report
Title: 
Retrospective Analysis of a Dedicated Care Pathway for Nonalcoholic
Fatty Liver Disease in an Integrated US Healthcare System Demonstrates
Support of Weight Management and Improved ALT
Version: 
2 
Date: 
13 Sep 2020
Reviewer's report:
Dear Editor, 
Patton et al wrote a paper on a very interesting field of hepatology: the impact of
lifestyle interventions on the NAFLD status and outcomes. To do so, they
performed a retrospective study on a cohort of NAFLD patients (identified by
ICD code for NAFLD/NASH) undergone to a care pathway of the largest
American integrated managed care consortium, based in California. They
enrolled 632 patients, of whom about 28% attended an education program on
NAFLD. They evaluated the changes in liver stiffness measurement and ALT
after one year in those who participated the program and confronted it to the time
period before their participation. They also conducted a weight management
(WM) program in 24 (3.8%) patients of this cohort who accepted and evaluated
the importance of WM in weight loss after 12 months. They found that the
improvements in ALT and liver stiffness measurement were significantly higher
after participating the NAFLD program and that the weight loss was significantly
associated with higher levels of liver stiffness and WM program participation.
They concluded that to construct a care pathway for NAFLD improves the
management of NAFLD patients by improving the referral that, in turn,
ameliorates the outcomes. 
The paper, even if is not based on a very novel approach is very informative and
helpful in providing information on the effects of such cascade of care in
NAFLD patients, in whom the lifestyle interventions are, nowadays, the only
weapon we have. 
The paper already underwent a full revision which improved it, I have no
particular issues to raise. 
kindest regards
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons upon publication of the manuscript. If you have already registered at
Publons, they will notify you of the receipt of this review and update your profile
as per your settings and their policy. If you are not registered with Publons, you
will receive an email from them asking you to register in order for them to be
able to recognize your review on your new profile page. Publons may use the
Review Data to generate derivative metadata for the benefit of Publons and you
as a reviewer, carefully considering the sensitivity of such information. For
example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help
editors to identify candidate reviewers. Please find the details of processing in
Publons’ privacy policy 
https://publons.com/about/terms
Yes
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no competing interests
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
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?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
assistant