Title: Association between glycated hemoglobin/high-density lipoprotein ratio and
nonalcoholic fatty liver disease in a U.S. nondiabetic population: a cross-sectional study based
on NHANES 2017-2020 data
Version: 0 Date: 11 Jun 2025
Reviewer's report:
This manuscript evaluates the cross-sectional association between the HbA1c/HDL-C ratio and
non-alcoholic fatty liver disease (NAFLD) in non-diabetic adults using data from the NHANES
2017–2020 survey. The topic is interesting and potentially valuable for identifying novel non-
invasive indicators of NAFLD risk. However, several methodological concerns need to be
addressed. My comments are as follows:
1. The manuscript refers to "NAFLD," despite recent consensus recommending a shift toward
the term "metabolic dysfunction-associated steatotic liver disease (MASLD)." The rationale for
maintaining the outdated terminology is unclear. The authors should clarify their choice and
consider updating the terminology to align with current classification standards, unless there is
a compelling reason to retain NAFLD in the context of this dataset.
2. Methods (Line 88). The authors state that participants with heavy alcohol consumption
were excluded, but the cut-off values used to define "heavy" drinking are not reported. This
information should be explicitly stated.
3. Methods (Lines 100–101). The manuscript categorizes liver stiffness into stages (F2, F3,
F4), presumably based on the METAVIR score. This should be explicitly stated for clarity.
Furthermore, Reference 18 does not appear to support the liver stiffness cut-off values used for
staging fibrosis. The authors should provide an appropriate and validated reference to justify
the thresholds applied.
4. Methods (Line 109). The authors refer to "moderate activity" but do not explain how this
was defined or quantified. A clear operational definition, along with an appropriate reference,
should be added.
5. While the HbA1c/HDL-C ratio is the primary independent variable of interest, the rationale
for not including HbA1c and HDL-C as separate covariates in the statistical model is unclear.
It would be helpful to know whether the association between the ratio and NAFLD remains
significant when HbA1c and HDL-C are included individually in the model. The current
analysis does not address whether the observed association is driven primarily by one of the
components of the ratio. The authors should consider additional models that include these
covariates separately to clarify this point.
Title: Association between glycated hemoglobin/high-density lipoprotein ratio and
nonalcoholic fatty liver disease in a U.S. nondiabetic population: a cross-sectional study based
on NHANES 2017-2020 data
Version: 0 Date: 11 Jun 2025
Reviewer's report:
This manuscript evaluates the cross-sectional association between the HbA1c/HDL-C ratio and
non-alcoholic fatty liver disease (NAFLD) in non-diabetic adults using data from the NHANES
2017–2020 survey. The topic is interesting and potentially valuable for identifying novel non-
invasive indicators of NAFLD risk. However, several methodological concerns need to be
addressed. My comments are as follows:
1. The manuscript refers to "NAFLD," despite recent consensus recommending a shift toward
the term "metabolic dysfunction-associated steatotic liver disease (MASLD)." The rationale for
maintaining the outdated terminology is unclear. The authors should clarify their choice and
consider updating the terminology to align with current classification standards, unless there is
a compelling reason to retain NAFLD in the context of this dataset.
2. Methods (Line 88). The authors state that participants with heavy alcohol consumption
were excluded, but the cut-off values used to define "heavy" drinking are not reported. This
information should be explicitly stated.
3. Methods (Lines 100–101). The manuscript categorizes liver stiffness into stages (F2, F3,
F4), presumably based on the METAVIR score. This should be explicitly stated for clarity.
Furthermore, Reference 18 does not appear to support the liver stiffness cut-off values used for
staging fibrosis. The authors should provide an appropriate and validated reference to justify
the thresholds applied.
4. Methods (Line 109). The authors refer to "moderate activity" but do not explain how this
was defined or quantified. A clear operational definition, along with an appropriate reference,
should be added.
5. While the HbA1c/HDL-C ratio is the primary independent variable of interest, the rationale
for not including HbA1c and HDL-C as separate covariates in the statistical model is unclear.
It would be helpful to know whether the association between the ratio and NAFLD remains
significant when HbA1c and HDL-C are included individually in the model. The current
analysis does not address whether the observed association is driven primarily by one of the
components of the ratio. The authors should consider additional models that include these
covariates separately to clarify this point.
Please review this paper.
user
Title: Association between glycated hemoglobin/high-density lipoprotein ratio and
nonalcoholic fatty liver disease in a U.S. nondiabetic population: a cross-sectional study based
on NHANES 2017-2020 data
Version: 0 Date: 11 Jun 2025
Reviewer's report:
This manuscript evaluates the cross-sectional association between the HbA1c/HDL-C ratio and
non-alcoholic fatty liver disease (NAFLD) in non-diabetic adults using data from the NHANES
2017–2020 survey. The topic is interesting and potentially valuable for identifying novel non-
invasive indicators of NAFLD risk. However, several methodological concerns need to be
addressed. My comments are as follows:
1. The manuscript refers to "NAFLD," despite recent consensus recommending a shift toward
the term "metabolic dysfunction-associated steatotic liver disease (MASLD)." The rationale for
maintaining the outdated terminology is unclear. The authors should clarify their choice and
consider updating the terminology to align with current classification standards, unless there is
a compelling reason to retain NAFLD in the context of this dataset.
2. Methods (Line 88). The authors state that participants with heavy alcohol consumption
were excluded, but the cut-off values used to define "heavy" drinking are not reported. This
information should be explicitly stated.
3. Methods (Lines 100–101). The manuscript categorizes liver stiffness into stages (F2, F3,
F4), presumably based on the METAVIR score. This should be explicitly stated for clarity.
Furthermore, Reference 18 does not appear to support the liver stiffness cut-off values used for
staging fibrosis. The authors should provide an appropriate and validated reference to justify
the thresholds applied.
4. Methods (Line 109). The authors refer to "moderate activity" but do not explain how this
was defined or quantified. A clear operational definition, along with an appropriate reference,
should be added.
5. While the HbA1c/HDL-C ratio is the primary independent variable of interest, the rationale
for not including HbA1c and HDL-C as separate covariates in the statistical model is unclear.
It would be helpful to know whether the association between the ratio and NAFLD remains
significant when HbA1c and HDL-C are included individually in the model. The current
analysis does not address whether the observed association is driven primarily by one of the
components of the ratio. The authors should consider additional models that include these
covariates separately to clarify this point.
assistant