Time Since Bariatric and Metabolic Surgery Is Associated with Ultra-Processed Food Intake and Food Addiction but Not with Culinary Abilities in Adults

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The methodological part of the paper is well presented .

The conclusions are adequate, the claims are fully supported by the experimental data.

The statistical analyses are appropriate. The manuscript is clearly written.

There are no ethical concerns regarding the use of human subjects.

Author Response

Reviewer #1

“The methodological part of the paper is well presented.

The conclusions are adequate, the claims are fully supported by the experimental data.

The statistical analyses are appropriate. The manuscript is clearly written.

There are no ethical concerns regarding the use of human subjects.”

               

Authors’ response:

                        Thank you for comments.

Reviewer 2 Report

Comments and Suggestions for Authors

This study explores how time since bariatric surgery (BMS) relates to patients’ intake of ultra-processed foods (UPFs), food addiction (FA), and cooking skills. Conducted via a cross-sectional online survey in Brazil with 1,525 post-bariatric adults (mean age ~38, 96% women), it assessed dietary intake using food frequency markers and a NOVA-UPF screener, measuring FA with the modified Yale Food Addiction Scale 2.0 and culinary skills with a Cooking Skills Index (CSI). Participants were grouped by time since surgery: 0–6 months, 6–12 months, 12–48 months, and >48 months.

Major Concerns

• A central limitation is the cross-sectional nature of the study, which the authors acknowledge. Patients at different post-op times were compared, but they were not the same individuals over time. Therefore, it cannot be concluded that increasing time causes higher UPF intake or lower FA; other cohort differences or secular trends might contribute. The manuscript should emphasize even more clearly that associations with “time since surgery” do not establish causality. For example, patients >4 years post-op may differ in unmeasured ways (e.g., received surgery under older guidelines or experienced different follow-up care) compared to recent patients. Strengthening the caution in the Abstract and Conclusions about this point would improve the scientific soundness. The title and text do use the phrase “associated with,” which is appropriate. Still, any language implying a trajectory or causal effect of time (e.g., “each year since surgery increased NOVA-UPF score by 0.67…”) should be interpreted carefully. Consider explicitly stating that these are correlations and that longitudinal studies would be needed to confirm causation.
• The recruitment via social media and the sample characteristics raise concerns about the generalizability of the results. The authors note that the sample likely overrepresents individuals who are active on the internet and social networks. This could skew the results toward younger or more health-conscious patients, possibly underestimating problems in less engaged populations. Moreover, the sample was overwhelmingly female (95.6%). While females do constitute a majority of bariatric patients, the extreme gender imbalance limits the applicability of findings to male patients. The authors should discuss whether any gender-specific analyses were attempted or feasible; if not, it’s worth noting that the conclusions primarily apply to female post-bariatric patients. Similarly, over half of the participants resided in the Southeast region of Brazil, and most were from a middle-class background (economic class B2). These demographic skews could influence dietary habits (e.g., regional food availability or cultural differences in cooking). I recommend that the authors temper their conclusions by acknowledging these biases and limited representativeness. Additional details on how recruitment was conducted (including which social media platforms and any targeting strategies employed) and the inclusion criteria (e.g., minimum age, specific types of surgery included) would also help assess sampling bias. Currently, the inclusion/exclusion criteria are only briefly implied (adults with BMS, with no personal identifiers collected). Clarifying these in the Methods could help readers understand who was eligible and how the 399 excluded cases failed to qualify (presumably due to incomplete responses or not meeting the criteria).
• All data (dietary intake, addiction symptoms, cooking skills, and weights) were self-reported via an online questionnaire. This method is prone to recall and reporting biases. The authors acknowledge the possibility of under- or overestimation in self-reported data. It is a major concern because individuals who regained weight or returned to unhealthy eating might under-report problematic foods, and those who are early after surgery might over-report compliance. The Discussion could elaborate on how recall bias might specifically impact the key findings. For instance, could patients more than 5 years post-surgery be underreporting their actual UPF intake due to social desirability or forgetfulness? Conversely, those who are 0–6 months out (still under clinical supervision) may report their diet more accurately or rigidly. While this limitation cannot be eliminated, a suggestion is to ensure the Methods describe any steps taken to improve accuracy (e.g., pilot testing of the survey or assurance of anonymity to encourage honesty). Emphasize in conclusions that results rely on subjective reports and would benefit from objective corroboration (e.g., dietary records or clinical assessments) in future studies.
• The pattern of food addiction prevalence over time post-surgery needs careful interpretation. The results show a non-monotonic trend – FA prevalence drops significantly in the first 1–4 years after BMS, then partially increases after 4 years. This U-shaped pattern is essential; however, the phrasing in some places could be clearer. The abstract conclusion currently states “decreased FA prevalence” over time since surgery, which might be read as if FA steadily declines over the entire postoperative period. In fact, FA is lowest at 2–4 years, with a resurgence later (though still lower than in the immediate postoperative phase). I suggest that the authors explicitly describe this trend as an initial improvement, followed by a partial relapse. For example: “FA prevalence decreased up to 4 years post-surgery, before rising again in those beyond 4 years (yet remaining below the <6-month level).” This nuance should be reflected in the Abstract, Results, and Discussion for accuracy. Additionally, it may be worth discussing possible reasons for the post-4-year resurgence in FA symptoms – the manuscript touches on weight regain and the return of old habits as one explanation. The authors might expand the discussion there: e.g., does loss of the initial physiological effects of surgery or reduced follow-up support after several years contribute to resurgent addictive eating? A brief speculation or reference to relevant literature (if available) on long-term psychological changes following BMS would strengthen the interpretation.
• The analytical approach is generally appropriate, as it combines categorical comparisons and regression. One concern is whether modeling “time since surgery” as a continuous linear predictor (in the linear regression for NOVA-UPF and FA symptoms) is truly justified given the non-linear patterns observed. The linear model found a significant negative beta for FA symptoms with time; yet, we know the FA symptom count bottoms out and then rises, deviating from a strictly linear decline. The authors wisely supplemented this with categorical Poisson models (Table 3) to capture the non-linear prevalence changes. It may be worth mentioning in the Methods or Results section that time was treated as both continuous and categorical, and clarifying the rationale behind this approach. For example, did the authors test for non-linearity (e.g., adding a quadratic term for time or using a spline) in the continuous model? If not, consider noting that the linear association represents an average trend across the entire range, whereas the categories reveal a more complex shape. This is a minor analytical point overall, since the key results were presented by category; however, addressing it would preempt readers’ questions about the appropriateness of the linear model for FA.
• Patients in the first 0–6 months after surgery are typically under strict dietary modifications (liquid/pureed stages, etc.). This likely contributes to their dramatically lower UPF intake (and higher FA symptoms, possibly due to acute withdrawal from former eating behaviors). The authors allude to physiological drivers of reduced intake (e.g., intolerance and dumping syndrome) in the discussion. This is an important context that could be highlighted even more. As a reviewer, I wonder if the Introduction or Discussion could better frame the expected trajectory post-surgery: initially low intake (due to surgery-induced effects) and gradually liberalizing diet. For instance, mentioning clinical guidelines that advise patients to avoid solid UPFs entirely from 0 to 3 months post-surgery might help readers understand why the 0–to 6 6-month group is an appropriate reference for the “lowest” consumption. The study’s findings essentially confirm that patients tend to relax their diets and possibly revert to old habits over time, a concern that worries clinicians. Emphasizing this clinical insight (with perhaps a citation to post-bariatric diet guidelines or behavior changes) would connect the results to practice. It’s not a flaw in the study per se, but a suggestion to strengthen the Discussion: the authors could note that early post-op dietary restrictions and hormonal changes suppress UPF intake and FA, but that these effects diminish with time, reinforcing the need for long-term dietary monitoring.

 

Minor Concerns

• Overall, the manuscript is well-written; however, a few sentences could be rephrased for greater clarity. For example, in the Discussion, it states, “It was also observed that a lower consumption of fresh fruits occurred in those individuals with a longer time since surgery”. This passive construction could be clearer as: “We observed that individuals longer post-surgery consumed fewer fresh fruits.” Similarly, “with increases observed only in the group of individuals with more than 48 months since surgery” might be reworded to explicitly say FA increased only in the >48 month group. Converting some passive phrases (“It was observed that…”) to active voice (“We observed…”) would improve readability. There are a few long sentences with multiple clauses (often joined by semicolons or commas) – consider splitting these for easier reading. For instance, the sentence in the Introduction starting “Bariatric and metabolic surgery (BMS) is an alternative treatment for obesity, as it is recognized for providing significant and sustained weight loss and for contributing to the control of associated comorbidities…” is quite lengthy.
• Ensure consistent use of terms for surgical procedures. The manuscript sometimes says “gastric sleeve” and elsewhere refers to “sleeve (gastrectomy)”. The formal term “sleeve gastrectomy” is preferable and should be used consistently instead of “gastric sleeve.” In Table 3’s footnote, “sleeve gastric” appears to be a typo – this should read “sleeve gastrectomy.” Similarly, use a consistent format for Roux-en-Y gastric bypass (capitalize “Roux-en-Y” appropriately).
• The tables are generally clear with appropriate details, but a couple of points need attention:
• Table 1: The notation of superscript letters (a, b, c, d) to denote group differences is not explained in the visible text. A footnote should be added (or clarified if already present but not in the excerpt) to explain that different superscript letters indicate statistically significant differences between time groups (Tukey’s post-hoc, p<0.05). This will help readers interpret which groups differ in variables such as BMI or FA symptoms.
• Table 3: There is a likely error in the group sample sizes reported. In the univariable columns, the 6–12 months group is listed as n = 245, whereas in the multivariable analysis (and in Table 1), the 6–12 months group is listed as n = 275. It appears the value 245 is a mistake, since 275 is the actual number of participants in that category. Please double-check and correct the n for the 6–12 month group in Table 3’s univariable analysis. This inconsistency could confuse readers or suggest unintended exclusion of cases. If there was a reason 30 participants from that category were excluded in the univariable analysis (which would be unusual, since univariable analysis should use all data), it should be explained; otherwise, it should be corrected to 275.
• Figure 1: The flow diagram of participant inclusion is mentioned, but the description “Flow diagram of participant inclusion” can be smoothed out. Change to “Flow diagram of participant inclusion” or “Study enrollment flowchart”. Ensure that this figure clearly shows reasons for exclusions of the 399 questionnaires (e.g., incomplete responses, did not meet criteria, duplicates, etc.), as that’s important information. Also, verify that all figure and table captions are self-explanatory (e.g., specifying that BMS = bariatric/metabolic surgery, FA = food addiction, etc., on first mention in a figure/table if those abbreviations appear there).
• There are a few minor typos/phrasing issues:
• In the Abstract results, “without decreasing fresh fruits and vegetables consumption” is a bit awkward. It could be “without a corresponding decrease in fresh fruit and vegetable consumption.” This clarifies that, despite an increase in UPFs, healthy food intake did not decrease (an important point).
• In the Introduction, “which seems to have negative impacts on weight regain” – weight regain itself is negative, so this phrase is confusing. Perhaps “contributing to weight regain” is what is meant. (Weight regain is an outcome, not something you want to impact further negatively.) Please rephrase that sentence for clarity.
• The term “ultra-processed foods (UPF)” should use the plural abbreviation “UPFs” if referring to them in general, to maintain plural agreement (the text sometimes uses “UPF are foods that…” – strictly, that should be “UPFs are foods that…” or simply “UPF products are…”).
• Check for missing articles in a few places. For example, “the habit of eating while watching screens” might read better as “the habit of eating while watching screen media (TV, phone, etc.)”, but this is stylistic. Also, “excluding those with lower access or engagement” – consider specifying “lower internet access or engagement” for clarity.
• Some references to percentages and numbers could use consistent formatting. In the text, a decimal point is sometimes used for percentages (e.g., 24.8%) and sometimes not – but that’s fine as given. More importantly, when giving percentages of a subsample, ensure it’s clear what the denominator is. For instance, “the majority of the sample belonged to economic class B2 (n = 633; 41.5%)” – presumably 41.5% of the 1525 participants. That’s clear. Just make sure all such statements are accurate (one might double-check if 633 out of 1525 is 41.5% – it is).
• In the Methods, the CHERRIES checklist is referenced as Table S2, but later in the References list, the journal name appears truncated (“J Med Internet Res. 2004;6(3):e34” is listed for Eysenbach 2004 ). Make sure to consistently cite full names or standard abbreviations of journals in text if needed. Minor point: ensure the Supplementary material (Tables S1 and S2) is properly labeled and cited; it appears the authors have done so, which is good.
• All acronyms should be defined at first use. The manuscript generally does this (e.g., BMS, UPF, and FA are defined in the Abstract/Introduction). One minor oversight: “FA” (food addiction) is first used in the Abstract without being explicitly defined in that section. It’s later defined in the Introduction. It would be better to spell out “food addiction (FA)” at first mention in the Abstract for completeness. Likewise, ensure “CSI” and “NOVA” are spelled out initially (CSI is defined as Cooking Skills Index in Abstract or Methods, which is good; NOVA is an established term for food processing classification, but the first time “NOVA-UPF” appears, a brief note that NOVA is a classification system could help).
• In the Discussion, when comparing to other studies, make sure the text is precise. For example, the authors mention that “Farias et al. (2020) found that UPF accounted for 52.75%, 49.39%, 51.85% of energy at baseline, 6m, 12m, respectively, indicating intake remains consistently high rather than increasing linearly.” This is a valuable point, but it reads a bit densely due to the inclusion of all the numbers. Consider simplifying: “Farias et al. observed that UPFs made up ~50% of energy intake even at 6 and 12 months post-surgery, essentially unchanged from baseline. This suggests that UPF intake remains high and does not continuously increase during the first year, aligning with our finding that the major increase happens later.” Additionally, when citing multiple studies to support a point, ensure they are presented in a logical order. In one sentence, Pinto et al. (2019) are mentioned alongside Nunes-Neto (2018) (ref [39]) with [19,39], which is fine since both support the statement; however, note the reference ordering by appearance.

 

 

Comments on the Quality of English Language

Language Review

• The authors sometimes use very long sentences. Breaking these into shorter sentences would improve readability. For example, the sentence in the Results starting “In the multivariable analysis, it was observed that individuals at 12–48 months after surgery showed the lowest prevalence of FA diagnosis (…); whereas individuals with more than 48 months since surgery showed a PR similar to those with 6–12 months since surgery (…), yet still significantly lower than those with less than 6 months since surgery.” is quite lengthy and hard to follow. It can be split into two or three sentences for clarity: “In multivariable analysis, the 12–48 month post-op group had the lowest FA prevalence (PR = 0.39 vs the <6 month group). Those >48 months post-op showed an increase in FA (PR = 0.63), similar to the 6–12 month group, but prevalence was still significantly lower than in the immediate post-op (<6m) group.” Such rephrasing would guide the reader through the comparisons step by step. I recommend scanning the text for other instances of multiple clauses that could be separated.
• The manuscript toggles between past tense and present tense. For instance, “Pinto et al. (2019) demonstrated a reduction in UPF consumption 3 months after the procedure…” (past tense – correct for referring to a published study), but then “other studies have reinforced that after 60 months postoperatively, there is a tendency for individuals to revert to preoperative habits” (present tense). It would be slightly more consistent to use the past tense when describing findings of specific studies (e.g., “other studies reinforced that after 60 months… there was a tendency…”).
• A few word choices could be improved for precision:
• The word “submitted” in “individuals submitted to BMS” is understandable, but not the most common phrasing in English. “Individuals undergoing BMS” or “individuals who had BMS” would sound more natural.
• The term “markers” is used to refer to dietary indicators, which is appropriate given the context (the SISVAN “markers of consumption” questionnaire). Just ensure that an international reader understands “markers” means food frequency indicators in this context. The authors might consider briefly explaining in Methods that these markers are essentially yes/no questions about whether certain foods were consumed the previous day .
• There are instances of colloquial phrasing that could be more formal. For example, “snacks, and/or salty cookies” – “salty cookies” is a direct translation of “biscoitos salgados” but English readers might interpret it oddly. Perhaps “savory crackers or snacks” is closer to the intent. Likewise, “hamburgers and/or sausages” is fine, though it essentially means processed meats – maybe just stick with “processed meats (e.g., hamburgers or sausages)” for clarity. These details may already be clear to Brazilian readers, but for an international audience, a bit of clarification is helpful.
• The word “observed” is used very frequently (e.g., “it was observed that…”, “we observed…”). To improve narrative flow, the authors could occasionally vary word choice (e.g., “noted,” “found,” “saw”) or restructure sentences to avoid beginning so often with “It was observed…” or “We observed…”. For instance, instead of “We also observed a significant reduction in both the symptomatology and the prevalence of FA…”, one could write “There was also a significant reduction in both the number of FA symptoms and the prevalence of FA in our sample…”.

 

Reference Formatting

 

The reference list will need some editing to conform to the journal’s style (Obesities follows the typical MDPI reference format). Here are specific issues identified:

• Many references include a DOI or URL, but a few are missing DOIs even when they are available. For consistency and completeness, please add DOIs for references where applicable. For example:
• Ref. 7 (Chu et al., 2018) and Ref. 28 (LaFata & Gearhardt, 2022) list journal information but do not provide a DOI. These articles likely have DOIs (e.g., DOI for Chu 2018 in Diabetes Metab Syndr should be obtainable).
• Ref. 10 (Bordalo et al., 2011) has no DOI given; if none exists (older journal issues sometimes lack DOIs), that’s acceptable, but if one exists, include it.
• Ref. 18 (Louzada et al., 2022) is missing a DOI. The citation has a volume and article eNumber (“37, e00323020”) – often Brazilian journals have DOIs; consider adding it if available.
• Ref. 19 (Pinto et al., 2019, Obesity Surgery) does not list a DOI, whereas Ref. 20 (another Pinto et al. 2019 in Obes Surg) does include a DOI. For consistency, add the DOI for Ref. 19 as well (it should be obtainable via the journal or CrossRef).
• Ref. 21 (Farias et al., 2020, Nutrition) shows “110746” (article number). It would be good to include the DOI for that article (which likely exists, given it’s a journal paper).
• Ref. 30 (Watanabe et al., 2024, Nutrition) – if a DOI is available for this in-press article, include it; otherwise, it’s fine as is with the article number.
• Ref. 33 (Vandenbroucke et al., 2014, STROBE explanation in Int J Surg) lacks a DOI. This paper has a DOI (e.g., 10.1016/j.ijsu.2014.07.014); please add it.
• Ref. 34 (Eysenbach 2004, CHERRIES) – this also has a DOI (10.2196/jmir.6.3.e34); adding it is recommended.
• Ref. 38 (Schulte & Gearhardt 2017, Eur Eat Disord Rev) – no DOI is listed; please add (DOI: 10.1002/erv.2515).
• Ref. 39 (Nunes-Neto et al., 2018, J Psychiatr Res) – no DOI listed; if available (likely 10.1016/j.jpsychires.2017.09.020), include it.
• Ref. 44 (Marconi et al., 2023, Nutrients) – as an MDPI journal article, it definitely has a DOI (should be in the format 10.3390/nu15194143). Include that DOI for completeness.

Including DOIs for all references where possible will meet MDPI’s preference for providing persistent links. Conversely, ensure that web addresses are properly handled. For instance, Ref. 1 (WHO fact sheet) is provided as a URL. MDPI style usually requires an access date for website references. Please add “(accessed on Day Month Year)” for the WHO webpage (and any similar website). The WHO page should also have a title; currently, Ref . 1 is just “World Health Organization (2024). Obesity and overweight. URL…”. It might be better formatted as: World Health Organization. Obesity and overweight Fact Sheet, 17 June 2021. Available online: <URL> (accessed October 10, 2025). – Update the date accordingly if the page has a last updated date. Similarly, Ref. 2 (Brazil Ministry of Health, Vigitel 2023 report) could have an access date or a link if available online. Since Ref . 2 is a formal report, the current format is mostly fine (though if it’s downloadable, a URL or DOI would be useful for readers).

• Ensure the use of et al. is consistent with journal guidelines. Some references list up to 6 authors, then use “et al.,” while others list fewer before truncation. For example, Ref. 8 lists 8 authors without et al., while Ref. 7 lists 7 authors then et al. Check if the journal limits the number of authors before using 'et al.' (typically, if there are more than six authors, then 'et al.' is used). Adjust as needed so all references follow the same rule. Currently, it’s mostly consistent, but double-check edge cases. Also, be aware of initials formatting (there should generally be no period after each initial in MDPI style, just spaces or nothing). E.g., “Chu D-T., Minh Nguyet N.T.” is fine.
• MDPI typically requires the full title of each cited article, and either the full journal name in italics or the NLM-approved abbreviation in normal font, year, volume, and page range. Looking at the list:
• Most references do include the article title (e.g., Ref . 4: “Productivity loss due to overweight and obesity: a systematic review of indirect costs.”). Good. A few, like Ref . 3 “Relationship between overweight and obesity and the development or worsening of chronic diseases in adults.” – ensure this is exactly as the title appears (likely it is).
• Be careful with capitalization in titles: Only proper nouns and the first word should be capitalized, except where the original title has capitalization. E.g., Ref . 24: “Social, clinical, and policy implications of ultra-processed food addiction” – the capitalization is fine as is. Ref . 28: “Ultra-processed food addiction: an epidemic?” – make sure the question mark is included (it is) and that only “Ultra” is capitalized at the start.
• Some journal names are oddly presented. For instance, Ref . 5: “Obes Rev: Official J Int Assoc Study Obes”. It would be cleaner to use the standard abbreviation or full name. Probably just Obes Rev. 2017, 18, 869–879. (No need to include “Official Journal of the International Association for the Study of Obesity” – that’s extra). Similarly, Ref . 7: “Diab Metab Syndr: Clin Res Rev.” could be formatted as Diabetes Metab. Syndr. 2018, 12, 1095–1100, or spelled out fully. Consistency is key – currently, some journals are abbreviated, while others are not. It might be easiest to use the official NLM abbreviations for all journal names (since many are already in that form). For example, Surgery for Obesity and Related Diseases can be abbreviated as Surg. Obes. Relat. Dis., American Journal of Clinical Nutrition as Am. J. Clin. Nutr., etc. Check MDPI’s reference style guide; they usually allow either full name or abbreviation but prefer one style throughout.
• Volume and page formatting: Some references separate year and volume with a semicolon (e.g., “BMJ Open 2017; 7:e014632” ) while others use a comma (“Nutrients 2022, 14, 164” ). MDPI style typically uses a comma after the year of the journal. For example: BMJ Open 2017; 7:e014632. Please update references to a uniform format (either all “Year, Volume, pages” or “Year;Volume:pages”). The MDPI reference examples suggest using commas. So Ref . 4 should be “BMJ Open 2017, 7, e014632,” and Ref . 5 “Obes. Rev. 2017, 18, 869–879.” Likewise, add a comma in Ref . 42 between year and volume: it currently says “Surgery for Obesity and Related Diseases 20.4 (2024): 383-390”; better as “Surg. Obes. Relat. Dis. 2024, 20(4), 383–390.” Ensure page ranges use en-dash and include all digits (869–879, not 869–79, unless the journal abbreviates the range – but MDPI usually prints the full range).
• Journal names should be italicized (in the final typeset, MDPI will likely do this). If not already, in the final document, ensure they are marked appropriately.
• Some references currently include extra information that isn’t standard in reference lists:
• Ref . 24 includes “[published correction appears in BMJ. 2023…]. BMJ. 2023;383:e075354. Published 2023 Oct 9.”. While it’s thorough to note a correction, the reference list usually doesn’t require the publication date to be spelled out or the note about the correction (unless the journal specifically requests it). It might be cleaner to cite the original article and, if needed, mention in the text that a correction exists. Given this is a BMJ article with a correction, you could simplify Ref . 24 to: Gearhardt, A.N.; et al. Social, clinical, and policy implications of ultra-processed food addiction. BMJ 2023, 383, e075354. (Include DOI). The note about the correction could be dropped or moved to a footnote if absolutely desired.
• Ref . 22 (Lobão et al. 2024) includes “Epub 2024 May 18. PMID: 38762612. Generally, MDPI style does not include PubMed IDs or Epub dates in the reference list. That information can be removed to streamline the entry: just keep the standard journal citation and DOI. So Ref.22 could end with “…Obes. Surg. 2024, 34, 2492–2498. DOI:…”. Please remove “Epub [date]” and “PMID: …” from references 22 and any others containing them (Ref.15 also has a PMID listed ; remove that as well).
• Ref . 25 (Gearhardt et al. 2016) is formatted as “Gearhardt A.N., Corbin W.R., Brownell K.D. (2016). Development of the Yale food addiction scale version 2.0. Psychology of Addictive Behaviors. Journal of the Society of Psychologists in Addictive Behaviors, 30(1), 113–121. This is slightly inconsistent with others. The publication year shouldn’t be in parentheses after the authors (it should come after the journal name). And the journal name appears to be given twice (full name plus subtitle). It should be condensed to something like: Gearhardt, A.N.; Corbin, W.R.; Brownell, K.D. Development of the Yale Food Addiction Scale version 2.0. Psychol. Addict. Behav. 2016, 30(1), 113–121. DOI:…. Please revise that reference to match the standard format.
• Check capitalization of proper nouns in titles within references. For example, Ref.40 (Scarpellini et al. 2020) title is in Portuguese (“Consenso internacional sobre o diagnóstico e tratamento da síndrome de dumping.”). That’s fine to leave in the original language, but ensure it’s exactly as it appears in the source. Additionally, if not an English title, some style guides italicize it or provide an English translation in brackets. MDPI typically doesn’t translate titles, so it’s acceptable as is.
• Reference 8 (Carter et al. 2025) looks mostly fine, but be aware of the journal name: “Surgery for Obesity and Related Diseases 2025; 21:199–206” should have a comma after 2025 if following the style, and perhaps include issue number if available (though SoARD might not have issue yet for 2025). Minor detail: ensure consistency in use of issue numbers (some references include issue in parentheses, others don’t; include them where available for consistency).

 

Website/DOI Revision

The manuscript currently contains a placeholder DOI link in the header: “https://doi.org/10.3390/xxxxx”. This is understandable for a submission, but it must be updated to the actual DOI or URL before publication once the paper is assigned a DOI by the journal (likely something like 10.3390/obesities issue **-article number), which should replace the placeholder. The authors should coordinate with the editorial office to get the correct DOI. If, for some reason, the DOI is not immediately available at the proof stage, at least ensure the placeholder is removed or replaced with a valid identifier (the journal will typically handle this during production).

 

Finally, regarding external links in references: ensure none point to “[doi.org/10.3390/xxxxx]” in references. All MDPI articles cited (e.g., reference 11 Medicina 2025, reference 14 IJERPH 2022, reference 26 Nutrients 2022, reference 27 Appetite 2023, etc.) appear to have proper DOIs assigned. Just double-check any “XXXXX” in references. I notice reference 11 (Ghusn et al. Medicina 2025) has “https://doi.org/10.3390/medicina61020350” which looks valid..

Author Response

Reviewer #2

“This study explores how time since bariatric surgery (BMS) relates to patients’ intake of ultra-processed foods (UPFs), food addiction (FA), and cooking skills. Conducted via a cross-sectional online survey in Brazil with 1,525 post-bariatric adults (mean age ~38, 96% women), it assessed dietary intake using food frequency markers and a NOVA-UPF screener, measuring FA with the modified Yale Food Addiction Scale 2.0 and culinary skills with a Cooking Skills Index (CSI). Participants were grouped by time since surgery: 0–6 months, 6–12 months, 12–48 months, and >48 months.”

 

• Commentary 1

Major Concerns

A central limitation is the cross-sectional nature of the study, which the authors acknowledge. Patients at different post-op times were compared, but they were not the same individuals over time. Therefore, it cannot be concluded that increasing time causes higher UPF intake or lower FA; other cohort differences or secular trends might contribute. The manuscript should emphasize even more clearly that associations with “time since surgery” do not establish causality. For example, patients >4 years post-op may differ in unmeasured ways (e.g., received surgery under older guidelines or experienced different follow-up care) compared to recent patients. Strengthening the caution in the Abstract and Conclusions about this point would improve the scientific soundness. The title and text do use the phrase “associated with,” which is appropriate. Still, any language implying a trajectory or causal effect of time (e.g., “each year since surgery increased NOVA-UPF score by 0.67…”) should be interpreted carefully. Consider explicitly stating that these are correlations and that longitudinal studies would be needed to confirm causation.

Authors’ response:

Understanding the importance of such a comment, we have included the following sentence in our limitations:

“Therefore, the findings in this study should be interpreted with caution, and it is suggested that cohorts be conducted to evaluate the same individuals over time for the outcomes of interest at different post-surgery time points.”

• Commentary 2

The recruitment via social media and the sample characteristics raise concerns about the generalizability of the results. The authors note that the sample likely overrepresents individuals who are active on the internet and social networks. This could skew the results toward younger or more health-conscious patients, possibly underestimating problems in less engaged populations. Moreover, the sample was overwhelmingly female (95.6%). While females do constitute a majority of bariatric patients, the extreme gender imbalance limits the applicability of findings to male patients. The authors should discuss whether any gender-specific analyses were attempted or feasible; if not, it’s worth noting that the conclusions primarily apply to female post-bariatric patients. Similarly, over half of the participants resided in the Southeast region of Brazil, and most were from a middle-class background (economic class B2). These demographic skews could influence dietary habits (e.g., regional food availability or cultural differences in cooking). I recommend that the authors temper their conclusions by acknowledging these biases and limited representativeness.

Authors’ response:

                        Thank you for your comment. We have added this to our limitations.

"The generalizability of our findings is limited. Because recruitment occurred through social media platforms, the sample likely overrepresents individuals who are younger, digitally active, and more engaged with postoperative care. Additionally, 95.6% of participants were women, and more than half resided in the Southeast region of Brazil, predominantly within economic class B2. Therefore, the results may primarily reflect the experiences of middle-income women living in more urbanized regions, and dietary behaviors may differ among men or individuals from other geographic or socioeconomic contexts."

• Commentary 3

Additional details on how recruitment was conducted (including which social media platforms and any targeting strategies employed) and the inclusion criteria (e.g., minimum age, specific types of surgery included) would also help assess sampling bias. Currently, the inclusion/exclusion criteria are only briefly implied (adults with BMS, with no personal identifiers collected). Clarifying these in the Methods could help readers understand who was eligible and how the 399 excluded cases failed to qualify (presumably due to incomplete responses or not meeting the criteria).

Authors’ response:

            Thank you for this comment. We reviewed the manuscript and noted that the inclusion, non-inclusion, and exclusion criteria, as well as recruitment details, are reported in the methods in lines 142-152.

 

• Commentary 4

All data (dietary intake, addiction symptoms, cooking skills, and weights) were self-reported via an online questionnaire. This method is prone to recall and reporting biases. The authors acknowledge the possibility of under- or overestimation in self-reported data. It is a major concern because individuals who regained weight or returned to unhealthy eating might under-report problematic foods, and those who are early after surgery might over-report compliance. The Discussion could elaborate on how recall bias might specifically impact the key findings. For instance, could patients more than 5 years post-surgery be underreporting their actual UPF intake due to social desirability or forgetfulness? Conversely, those who are 0–6 months out (still under clinical supervision) may report their diet more accurately or rigidly. While this limitation cannot be eliminated, a suggestion is to ensure the Methods describe any steps taken to improve accuracy (e.g., pilot testing of the survey or assurance of anonymity to encourage honesty). Emphasize in conclusions that results rely on subjective reports and would benefit from objective corroboration (e.g., dietary records or clinical assessments) in future studies.

            Authors’ response:

                        Thank you for this comment. We have added this more clearly to our limitations.

"Another important limitation is that all data—including dietary intake, food addiction symptoms, culinary skills, and anthropometric measures—were self-reported through an online questionnaire. This approach is inherently susceptible to recall and reporting biases. Individuals further from surgery may underreport the consumption of UPFs due to social desirability or difficulty recalling habitual intake, whereas those in the early postoperative period—who are still under structured clinical monitoring—may report their behaviors more rigidly and accurately. Although anonymity and attention-check items were used to improve data quality, these measures cannot fully eliminate the risk. The reliance on subjective information underscores the need for future studies incorporating objective assessments, such as food records, clinical evaluations, or biochemical markers."

• Commentary 5

The pattern of food addiction prevalence over time post-surgery needs careful interpretation. The results show a non-monotonic trend – FA prevalence drops significantly in the first 1–4 years after BMS, then partially increases after 4 years. This U-shaped pattern is essential; however, the phrasing in some places could be clearer. The abstract conclusion currently states “decreased FA prevalence” over time since surgery, which might be read as if FA steadily declines over the entire postoperative period. In fact, FA is lowest at 2–4 years, with a resurgence later (though still lower than in the immediate postoperative phase). I suggest that the authors explicitly describe this trend as an initial improvement, followed by a partial relapse. For example: “FA prevalence decreased up to 4 years post-surgery, before rising again in those beyond 4 years (yet remaining below the <6-month level).” This nuance should be reflected in the Abstract, Results, and Discussion for accuracy. Additionally, it may be worth discussing possible reasons for the post-4-year resurgence in FA symptoms – the manuscript touches on weight regain and the return of old habits as one explanation. The authors might expand the discussion there: e.g., does loss of the initial physiological effects of surgery or reduced follow-up support after several years contribute to resurgent addictive eating? A brief speculation or reference to relevant literature (if available) on long-term psychological changes following BMS would strengthen the interpretation.

Authors’ response:

Thank you for your comment. We reviewed the entire manuscript to avoid any sentences with this tone. We also clarified the prevalence of AF in the abstract, results, discussion, and conclusion. We added a paragraph to the discussion section discussing possible explanations for this finding.

 

“The observed U-shaped pattern in FA prevalence may be explained by a combination of physiological, behavioral, and psychological factors. In the first year post-surgery, metabolic changes, reduced gastric capacity, and structured clinical follow-up likely suppress addictive eating behaviors [43, 44, 45]. Over time, however, di-minished supervision, increased availability of UPFs, and psychological vulnerabilities—such as stress, anxiety, or prior disordered eating tendencies—may contribute to a resurgence of FA symptoms [43, 46]. This pattern suggests that initial protection conferred by surgery may wane, highlighting the need for long-term behavioral and nutritional support.”

• Commentary 6

The analytical approach is generally appropriate, as it combines categorical comparisons and regression. One concern is whether modeling “time since surgery” as a continuous linear predictor (in the linear regression for NOVA-UPF and FA symptoms) is truly justified given the non-linear patterns observed. The linear model found a significant negative beta for FA symptoms with time; yet, we know the FA symptom count bottoms out and then rises, deviating from a strictly linear decline. The authors wisely supplemented this with categorical Poisson models (Table 3) to capture the non-linear prevalence changes. It may be worth mentioning in the Methods or Results section that time was treated as both continuous and categorical, and clarifying the rationale behind this approach. For example, did the authors test for non-linearity (e.g., adding a quadratic term for time or using a spline) in the continuous model? If not, consider noting that the linear association represents an average trend across the entire range, whereas the categories reveal a more complex shape. This is a minor analytical point overall, since the key results were presented by category; however, addressing it would preempt readers’ questions about the appropriateness of the linear model for FA.

Authors’ response:

As stated in the comment, we believe that the analyses performed in this manuscript are adequate and meet the objectives established for the current investigation. Thus, analyses such as nonlinear tests were not performed, which may be of interest in future investigations by the group.

 

• Commentary 7

Patients in the first 0–6 months after surgery are typically under strict dietary modifications (liquid/pureed stages, etc.). This likely contributes to their dramatically lower UPF intake (and higher FA symptoms, possibly due to acute withdrawal from former eating behaviors). The authors allude to physiological drivers of reduced intake (e.g., intolerance and dumping syndrome) in the discussion. This is an important context that could be highlighted even more. As a reviewer, I wonder if the Introduction or Discussion could better frame the expected trajectory post-surgery: initially low intake (due to surgery-induced effects) and gradually liberalizing diet. For instance, mentioning clinical guidelines that advise patients to avoid solid UPFs entirely from 0 to 3 months post-surgery might help readers understand why the 0–to 6 6-month group is an appropriate reference for the “lowest” consumption. The study’s findings essentially confirm that patients tend to relax their diets and possibly revert to old habits over time, a concern that worries clinicians. Emphasizing this clinical insight (with perhaps a citation to post-bariatric diet guidelines or behavior changes) would connect the results to practice. It’s not a flaw in the study per se, but a suggestion to strengthen the Discussion: the authors could note that early post-op dietary restrictions and hormonal changes suppress UPF intake and FA, but that these effects diminish with time, reinforcing the need for long-term dietary monitoring.

 

Authors’ response:

Thank you very much for your comment. We have added a paragraph about this in the discussion.

“The markedly lower UPFs consumption during the first 0–6 months post-surgery likely reflects strict dietary modifications in the immediate postoperative period, including liquid and pureed diets, as well as surgery-induced physiological effects such as intolerance to high-fat and high-sugar foods and dumping syndrome. Clinical guidelines recommend adopting healthy eating patterns, gradually progressing food textures, and ensuring adequate intake of protein, vitamins, and minerals. These factors likely explain why this group represents the lowest consumption in our study. As restrictions are relaxed and tolerance improves over time, UPFs intake tends to rise and FA symptoms may partially return, underscoring the need for ongoing nutritional monitoring and long-term behavioral support.”

 

• Commentary 8

Minor Concerns

Overall, the manuscript is well-written; however, a few sentences could be rephrased for greater clarity. For example, in the Discussion, it states, “It was also observed that a lower consumption of fresh fruits occurred in those individuals with a longer time since surgery”. This passive construction could be clearer as: “We observed that individuals longer post-surgery consumed fewer fresh fruits.” Similarly, “with increases observed only in the group of individuals with more than 48 months since surgery” might be reworded to explicitly say FA increased only in the >48 month group. Converting some passive phrases (“It was observed that…”) to active voice (“We observed…”) would improve readability. There are a few long sentences with multiple clauses (often joined by semicolons or commas) – consider splitting these for easier reading. For instance, the sentence in the Introduction starting “Bariatric and metabolic surgery (BMS) is an alternative treatment for obesity, as it is recognized for providing significant and sustained weight loss and for contributing to the control of associated comorbidities…” is quite lengthy.

 

Authors’ response:

            Thank you for your comment. We appreciate your suggestion to rewrite the sentence in the active voice. We made some changes throughout the text and chose to maintain a combination of active and passive voice. We also reviewed and changed some sentences that were too long.

 

• Commentary 9

Ensure consistent use of terms for surgical procedures. The manuscript sometimes says “gastric sleeve” and elsewhere refers to “sleeve (gastrectomy)”. The formal term “sleeve gastrectomy” is preferable and should be used consistently instead of “gastric sleeve.” In Table 3’s footnote, “sleeve gastric” appears to be a typo – this should read “sleeve gastrectomy.” Similarly, use a consistent format for Roux-en-Y gastric bypass (capitalize “Roux-en-Y” appropriately).

 

Authors’ response:

            Thank you for this. We review this in every manuscript and standardize its use.                        

• Commentary 10

The tables are generally clear with appropriate details, but a couple of points need attention:

Table 1: The notation of superscript letters (a, b, c, d) to denote group differences is not explained in the visible text. A footnote should be added (or clarified if already present but not in the excerpt) to explain that different superscript letters indicate statistically significant differences between time groups (Tukey’s post-hoc, p<0.05). This will help readers interpret which groups differ in variables such as BMI or FA symptoms.

 

Authors’ response:

Thank you. We have added the information in the footnote of Table 1.

• Commentary 11

Table 3: There is a likely error in the group sample sizes reported. In the univariable columns, the 6–12 months group is listed as n = 245, whereas in the multivariable analysis (and in Table 1), the 6–12 months group is listed as n = 275. It appears the value 245 is a mistake, since 275 is the actual number of participants in that category. Please double-check and correct the n for the 6–12 month group in Table 3’s univariable analysis. This inconsistency could confuse readers or suggest unintended exclusion of cases. If there was a reason 30 participants from that category were excluded in the univariable analysis (which would be unusual, since univariable analysis should use all data), it should be explained; otherwise, it should be corrected to 275.

Authors’ response:

            Thank you for pointing this out. It was a typo and has been corrected.

 

• Commentary 12

Figure 1: The flow diagram of participant inclusion is mentioned, but the description “Flow diagram of participant inclusion” can be smoothed out. Change to “Flow diagram of participant inclusion” or “Study enrollment flowchart”. Ensure that this figure clearly shows reasons for exclusions of the 399 questionnaires (e.g., incomplete responses, did not meet criteria, duplicates, etc.), as that’s important information. Also, verify that all figure and table captions are self-explanatory (e.g., specifying that BMS = bariatric/metabolic surgery, FA = food addiction, etc., on first mention in a figure/table if those abbreviations appear there).

Authors’ response:

Thank you for your comment. The suggestion to change the title of Figure 1 seems to be the same as what is already stated in the figure. In addition, Figure 1 shows all the reasons for exclusion for each participant. All tables and figures have been revised to be self-explanatory.

• Commentary 13

There are a few minor typos/phrasing issues:

In the Abstract results, “without decreasing fresh fruits and vegetables consumption” is a bit awkward. It could be “without a corresponding decrease in fresh fruit and vegetable consumption.” This clarifies that, despite an increase in UPFs, healthy food intake did not decrease (an important point).

Authors’ response:

            We changed this.

 

• Commentary 14

In the Introduction, “which seems to have negative impacts on weight regain” – weight regain itself is negative, so this phrase is confusing. Perhaps “contributing to weight regain” is what is meant. (Weight regain is an outcome, not something you want to impact further negatively.) Please rephrase that sentence for clarity.

Authors’ response:

            We changed this sentence.

 

• Commentary 15

The term “ultra-processed foods (UPF)” should use the plural abbreviation “UPFs” if referring to them in general, to maintain plural agreement (the text sometimes uses “UPF are foods that…” – strictly, that should be “UPFs are foods that…” or simply “UPF products are…”).

 

Authors’ response:

            We reviewed the entire manuscript and adjusted the abbreviations.

• Commentary 16

Check for missing articles in a few places. For example, “the habit of eating while watching screens” might read better as “the habit of eating while watching screen media (TV, phone, etc.)”, but this is stylistic. Also, “excluding those with lower access or engagement” – consider specifying “lower internet access or engagement” for clarity.

 

Authors’ response:

            Thank you.

 

• Commentary 17

Some references to percentages and numbers could use consistent formatting. In the text, a decimal point is sometimes used for percentages (e.g., 24.8%) and sometimes not – but that’s fine as given. More importantly, when giving percentages of a subsample, ensure it’s clear what the denominator is. For instance, “the majority of the sample belonged to economic class B2 (n = 633; 41.5%)” – presumably 41.5% of the 1525 participants. That’s clear. Just make sure all such statements are accurate (one might double-check if 633 out of 1525 is 41.5% – it is).

 

Authors’ response:

            We checked and adjusted this throughout the manuscript.

 

• Commentary 18

In the Methods, the CHERRIES checklist is referenced as Table S2, but later in the References list, the journal name appears truncated (“J Med Internet Res. 2004;6(3):e34” is listed for Eysenbach 2004 ). Make sure to consistently cite full names or standard abbreviations of journals in text if needed.

 

Authors’ response:

            We have corrected this.

 

• Commentary 19

Minor point: ensure the Supplementary material (Tables S1 and S2) is properly labeled and cited; it appears the authors have done so, which is good.

 

Authors’ response:                

            Thank you.

 

• Commentary 20

All acronyms should be defined at first use. The manuscript generally does this (e.g., BMS, UPF, and FA are defined in the Abstract/Introduction). One minor oversight: “FA” (food addiction) is first used in the Abstract without being explicitly defined in that section. It’s later defined in the Introduction. It would be better to spell out “food addiction (FA)” at first mention in the Abstract for completeness. Likewise, ensure “CSI” and “NOVA” are spelled out initially (CSI is defined as Cooking Skills Index in Abstract or Methods, which is good; NOVA is an established term for food processing classification, but the first time “NOVA-UPF” appears, a brief note that NOVA is a classification system could help).

Authors’ response:

            We checked the manuscript and the term “food addiction” is defined the first time it appears (this happens on line 15 of the first page). In addition, we decided to keep NOVA-UPF as it is, since this is the name of the tool.

 

• Commentary 21

In the Discussion, when comparing to other studies, make sure the text is precise. For example, the authors mention that “Farias et al. (2020) found that UPF accounted for 52.75%, 49.39%, 51.85% of energy at baseline, 6m, 12m, respectively, indicating intake remains consistently high rather than increasing linearly.” This is a valuable point, but it reads a bit densely due to the inclusion of all the numbers. Consider simplifying: “Farias et al. observed that UPFs made up ~50% of energy intake even at 6 and 12 months post-surgery, essentially unchanged from baseline. This suggests that UPF intake remains high and does not continuously increase during the first year, aligning with our finding that the major increase happens later.”

Authors’ response:

            Thank you. We have made this change.

 

• Commentary 22

Additionally, when citing multiple studies to support a point, ensure they are presented in a logical order. In one sentence, Pinto et al. (2019) are mentioned alongside Nunes-Neto (2018) (ref \[39]) with \[19,39], which is fine since both support the statement; however, note the reference ordering by appearance.

Authors’ response:

Thank you. We checked this throughout the manuscript.

 

• Commentary 23

The authors sometimes use very long sentences. Breaking these into shorter sentences would improve readability. For example, the sentence in the Results starting “In the multivariable analysis, it was observed that individuals at 12–48 months after surgery showed the lowest prevalence of FA diagnosis (…); whereas individuals with more than 48 months since surgery showed a PR similar to those with 6–12 months since surgery (…), yet still significantly lower than those with less than 6 months since surgery.” is quite lengthy and hard to follow. It can be split into two or three sentences for clarity: “In multivariable analysis, the 12–48 month post-op group had the lowest FA prevalence (PR = 0.39 vs the <6 month group). Those >48 months post-op showed an increase in FA (PR = 0.63), similar to the 6–12 month group, but prevalence was still significantly lower than in the immediate post-op (<6m) group.” Such rephrasing would guide the reader through the comparisons step by step. I recommend scanning the text for other instances of multiple clauses that could be separated.

Authors’ response:

Thank you. We have adjusted this in our manuscript.

 

• Commentary 24

The manuscript toggles between past tense and present tense. For instance, “Pinto et al. (2019) demonstrated a reduction in UPF consumption 3 months after the procedure…” (past tense – correct for referring to a published study), but then “other studies have reinforced that after 60 months postoperatively, there is a tendency for individuals to revert to preoperative habits” (present tense). It would be slightly more consistent to use the past tense when describing findings of specific studies (e.g., “other studies reinforced that after 60 months… there was a tendency…”).

Authors’ response:

            Thank you for your comment. The change has been made.

 

• Commentary 25

A few word choices could be improved for precision:

The word “submitted” in “individuals submitted to BMS” is understandable, but not the most common phrasing in English. “Individuals undergoing BMS” or “individuals who had BMS” would sound more natural.

Authors’ response:

            Thank you for your comment. The change has been made.

 

• Commentary 26

The term “markers” is used to refer to dietary indicators, which is appropriate given the context (the SISVAN “markers of consumption” questionnaire). Just ensure that an international reader understands “markers” means food frequency indicators in this context. The authors might consider briefly explaining in Methods that these markers are essentially yes/no questions about whether certain foods were consumed the previous day.

Authors’ response:

            We believe that the suggested format makes the tool easier to understand. Therefore, we have included a sentence explaining the possible answers.

 

• Commentary 27

There are instances of colloquial phrasing that could be more formal. For example, “snacks, and/or salty cookies” – “salty cookies” is a direct translation of “biscoitos salgados” but English readers might interpret it oddly. Perhaps “savory crackers or snacks” is closer to the intent. Likewise, “hamburgers and/or sausages” is fine, though it essentially means processed meats – maybe just stick with “processed meats (e.g., hamburgers or sausages)” for clarity. These details may already be clear to Brazilian readers, but for an international audience, a bit of clarification is helpful.

Authors’ response:

            We chose to maintain the terminology used by the tools, which has already been used in other published studies that utilized this tool.

 

• Commentary 28

The word “observed” is used very frequently (e.g., “it was observed that…”, “we observed…”). To improve narrative flow, the authors could occasionally vary word choice (e.g., “noted,” “found,” “saw”) or restructure sentences to avoid beginning so often with “It was observed…” or “We observed…”. For instance, instead of “We also observed a significant reduction in both the symptomatology and the prevalence of FA…”, one could write “There was also a significant reduction in both the number of FA symptoms and the prevalence of FA in our sample…”.

Authors’ response:

            Thank you for your comment. We have reviewed and revised the entire manuscript.

 

• Commentary 29

Reference Formatting

The reference list will need some editing to conform to the journal’s style (Obesities follows the typical MDPI reference format).

 

Authors’ response:

Thank you for your review. We have revised and adjusted all references in the manuscript.

 

• Commentary 30

The manuscript currently contains a placeholder DOI link in the header: “https://doi.org/10.3390/xxxxx”. This is understandable for a submission, but it must be updated to the actual DOI or URL before publication once the paper is assigned a DOI by the journal (likely something like 10.3390/obesities issue \*\*-article number), which should replace the placeholder. The authors should coordinate with the editorial office to get the correct DOI. If, for some reason, the DOI is not immediately available at the proof stage, at least ensure the placeholder is removed or replaced with a valid identifier (the journal will typically handle this during production).

Authors’ response:

            Thank you for your comment. The link with “xxxxx” is standard practice for the journal. We believe this will be replaced after the manuscript is accepted, when we receive the final version for approval.

 

• Commentary 31

Finally, regarding external links in references: ensure none point to “\[doi.org/10.3390/xxxxx]” in references. All MDPI articles cited (e.g., reference 11 Medicina 2025, reference 14 IJERPH 2022, reference 26 Nutrients 2022, reference 27 Appetite 2023, etc.) appear to have proper DOIs assigned. Just double-check any “XXXXX” in references. I notice reference 11 (Ghusn et al. Medicina 2025) has “https://doi.org/10.3390/medicina61020350” which looks valid..

Authors’ response:

            We check all references.

 

 

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have been diligent in responding to the reviewer’s feedback.

Comments on the Quality of English Language

n/A