Dietary Imbalance between Natural and Added Nutrient Sources Is Associated with Higher Fat Mass in Young Non-Obese Individuals

Round 1

Reviewer 1 Report

I found the content presented in the manuscript interesting but would suggest reworking it for further improvement.

Title: In line 3 the authors start with a, from my point of view, problematic or at least confusing wording they keep throughout the manuscript: “adiposity”. What do you mean by the term? Could you say higher waist circumference? Higher abdominal fat mass?

In line 91 you said that you wanted to understand the impact of altered food habits on different anthropometric parameters ….and to link them with nutritional knowledge. For me, this is not the same as saying in line 21 in the abstract “adiposity”. I would better define it what is your interpretation of this term or write it explicitly so that it can’t cause any false interpretations.

Material and Methods:

I imagine that you included students from one site, if it is so please state it more clearly.

Could you describe better how the participants were invited to take part in the study? What was your population?

Please describe how you did the randomization of participants. (see line 101)

Could you describe in more detail the process of data collection in the study at hand? I had the impression that you did first the NKQ, then the FFQ, and then they were measured (anthropometric evaluation)? Had the participants to go to a certain place? Or did you add some questions to a survey? Who did the measurements (trained persons, health professionals…)?

Please report it more clearly.

In the last paragraph of the methods section, you state (in line 142) that nonparametric correlations were used. Please add here a phrase because you did this.

Results section: I think it would enhance the readability of the figures if you would add the descriptions you give under the tables regarding the columns (see lines 225, 273, 299-300) as headings for the columns.

For the two Tables please specify the number of participants (n=)

Could you also add for the two Tables a column before the results in which you add the whole title of “naturally present”, “added sources”/”total”?

In the paragraph after Fig 3 (line 307-311) you use several times the abbreviated word “NK” I would suggest improving the readability to write it at least once.

The paragraph before Table 1 has some flaws. You are describing negative correlations and in line 332 “no correlations”. Do you mean no significant differences?

The last sentence of this paragraph did remain unclear to me (line 335-338) If you have defined earlier (as I suggested)  in the article what you mean by “adiposity measures”, then you can refer to it here

What is increased adiposity? (line 336)

Please try to formulate these lines easier, clearer, and better understandably. I couldn’t follow the several “decreased” and “increased” formulations.

Discussion: In the first sentence in line 389 you use the word “demonstrated”: You have done a cross-sectional study (maybe with skewed) small sample… With limited generalization… Therefore I would say it more modestly.

In line 446 you write about “higher risk of adiposity and obesity”, did you mean overweight and obesity?

Maybe one point could be the better nutritional education programs at universities, as you suggest in line 411, but surely it would not be enough. Also better physical activity facilities, etc.….could help… Please declare your point more clearly as “one” point to improve.

For me, the formulation “in detriment” in line 414 seems an awkward expression. Maybe this is a linguistic flaw?

In line 448 you are referring to the study of Fox: I imagine you wanted to say “by” instead of “be”?

Also in line 454 you use increased “adiposity”: please try to improve this formulation throughout the paper and state clearly what is meant with “adiposity”.

In line 467-468 you write about the waist to height ratio as a weaker discriminant variable. To my knowledge, the WtHR is related to the need for weight loss (Ashwell et al.).

https://pubmed.ncbi.nlm.nih.gov/22106927

https://bmjopen.bmj.com/content/6/3/e010159

I would suggest stating in the last paragraph (lines 469-482) with more detail the limitations of your study: e.g. cross-sectional, skewed sample? Small sample, only at one site……

Author Response

Journal: Diabetology

Manuscript ID: diabetology-1172377

Title: DIETARY IMBALANCE BETWEEN NATURAL AND ADDED NUTRIENT SOURCES IS ASSOCIATED WITH HIGHER ADIPOSITY IN YOUNG NON-OBESE INDIVIDUALS

_____________________________________________________________________________________________________________

 RESPONSE TO REVIEWERS

 We want to thank the editor and the reviewers for their critical assessment of our work. We have acted upon the recommendations of the reviewers, which were pertinent, allowing us to improve the manuscript quality. We added our point-by-point responses (in blue text) to each comment (in black text). In addition, we highlighted revisions in yellow in the updated manuscript.

REVIEWER 1:

I found the content presented in the manuscript interesting but would suggest reworking it for further improvement.

We are grateful to the reviewer for the positive evaluation of our manuscript, as well as for the constructive comments that we used to improve the manuscript quality. Please find below a point-by-point response to all the comments, questions and suggestions raised.

In line 3 the authors start with a, from my point of view, problematic or at least confusing wording they keep throughout the manuscript: “adiposity”. What do you mean by the term? Could you say higher waist circumference? Higher abdominal fat mass?

The term adiposity was chosen because the parameters observed to better correlate with nutrient sources are total fat mass and waist circumference. Adiposity refers to adipose tissue amount.  Nevertheless, we have changed to fat mass throughout the manuscript to avoid misinterpretation

In line 91 you said that you wanted to understand the impact of altered food habits on different anthropometric parameters ….and to link them with nutritional knowledge. For me, this is not the same as saying in line 21 in the abstract “adiposity”. I would better define it what is your interpretation of this term or write it explicitly so that it can’t cause any false interpretations.

The term adiposity was changed to fat mass

I imagine that you included students from one site, if it is so please state it more clearly. Could you describe better how the participants were invited to take part in the study? What was your population? Please describe how you did the randomization of participants. (see line 101). Could you describe in more detail the process of data collection in the study at hand? I had the impression that you did first the NKQ, then the FFQ, and then they were measured (anthropometric evaluation)? Had the participants to go to a certain place? Or did you add some questions to a survey? Who did the measurements (trained persons, health professionals…)? Please report it more clearly.

We have chosen students from our University and that was included in the text. The population was composed of students recruited to the study in a voluntary basis upon invitation to participate to all the academic community. Given the extension and detail of the questionnaire, only a small fraction of the entire academic population was included. The selection was random (first 80 to answer were included). All the evaluations and questionnaires were performed ate the same time and room in the school facilities by Nutritionists and Nutrition students (authors)

Materials and Methods - line 142. In the last paragraph of the methods section, you state (in line 142) that nonparametric correlations were used. Please add here a phrase because you did this.

Non-parametric tests were used because data did not have a normal distribution. This was a flaw in the first version of the manuscript and was now included in the statistics section of the methods

I think it would enhance the readability of the figures if you would add the descriptions you give under the tables regarding the columns (see lines 225, 273, 299-300) as headings for the columns.

The descriptions were added in the top of the figures

For the two Tables please specify the number of participants (n=)

The suggestion was accepted and it was included in table title

Could you also add for the two Tables a column before the results in which you add the whole title of “naturally present”, “added sources”/”total”?

The suggestion was accepted

In the paragraph after Fig 3 (line 307-311) you use several times the abbreviated word “NK” I would suggest improving the readability to write it at least once.

The suggestion was accepted

The paragraph before Table 1 has some flaws. You are describing negative correlations and in line 332 “no correlations”. Do you mean no significant differences?

In this sentence were describe that no correlations were observed between nutrients obtained from added sources and none of the anthropometric parameters. It really refers to correlations, not significant differences because it refers to the table and no to any of the figures, where the population was divided in groups. Here, it mentions the entire studied population.

The last sentence of this paragraph did remain unclear to me (line 335-338) If you have defined earlier (as I suggested)  in the article what you mean by “adiposity measures”, then you can refer to it here. What is increased adiposity? (line 336) Please try to formulate these lines easier, clearer, and better understandably. I couldn’t follow the several “decreased” and “increased” formulations.

The word adiposity was changed and the sentence was improved

Discussion: In the first sentence in line 389 you use the word “demonstrated”: You have done a cross-sectional study (maybe with skewed) small sample… With limited generalization… Therefore I would say it more modestly.

It was changed to “observed”

In line 446 you write about “higher risk of adiposity and obesity”, did you mean overweight and obesity?

Adiposity was changed to fat mass

Maybe one point could be the better nutritional education programs at universities, as you suggest in line 411, but surely it would not be enough. Also better physical activity facilities, etc.….could help… Please declare your point more clearly as “one” point to improve.

We have followed the suggestion of the reviewer

For me, the formulation “in detriment” in line 414 seems an awkward expression. Maybe this is a linguistic flaw?

Sorry, it was a linguistic flaw, and it was corrected

In line 448 you are referring to the study of Fox: I imagine you wanted to say “by” instead of “be”?

It was a mistake, sorry. It was corrected

Also in line 454 you use increased “adiposity”: please try to improve this formulation throughout the paper and state clearly what is meant with “adiposity”.

Adiposity was changed to fat mass

In line 467-468 you write about the waist to height ratio as a weaker discriminant variable. To my knowledge, the WtHR is related to the need for weight loss (Ashwell et al.).

In the text is suggested that it may be weaker in non-obese populations. Our population only included volunteers with normal BMI or overweight, and not anyone with obesity. Indeed, it was our objective to understand the relation between dietary patterns and fat mass before obesity, in order to reinforce the need for prevention programs. Our sentence is only related to non-obese populations.

I would suggest stating in the last paragraph (lines 469-482) with more detail the limitations of your study: e.g. cross-sectional, skewed sample? Small sample, only at one site…

We have included such information in the last paragraph.

Author Response File: Author Response.docx

Reviewer 2 Report

This MS investigates the fact that increased energy intake from carbohydrates and sugars has been associated with being overweight/obese. Thus the researchers aimed to correlate dietary sugars/lipids with adiposity in young individuals.    The means/tools used were limited (but are the ones usually employed): food frequency and nutritional knowledge questionnaires & anthropometric measures.    The main finding , that individuals with higher fat mass percentage had lower nutritional knowledge and lower consumption of lipids and sugars from naturally present sources, is of moderate interest (and is a rather predictable result).    The authors conclude (predictably also) that increased nutritional knowledge could strengthen the prevention of obesity.    My concern with this article is that there is no a priori sample size calculation or a post-hoc power analysis for this study. This is – I suppose – an easy task for the authors to fulfill.

Author Response

Journal: Diabetology

Manuscript ID: diabetology-1172377

Title: DIETARY IMBALANCE BETWEEN NATURAL AND ADDED NUTRIENT SOURCES IS ASSOCIATED WITH HIGHER ADIPOSITY IN YOUNG NON-OBESE INDIVIDUALS

_____________________________________________________________________________________________________________

 RESPONSE TO REVIEWERS

 We want to thank the editor and the reviewers for their critical assessment of our work. We have acted upon the recommendations of the reviewers, which were pertinent, allowing us to improve the manuscript quality. We added our point-by-point responses (in blue text) to each comment (in black text). In addition, we highlighted revisions in yellow in the updated manuscript.

REVIEWER 2:

 This MS investigates the fact that increased energy intake from carbohydrates and sugars has been associated with being overweight/obese. Thus, the researchers aimed to correlate dietary sugars/lipids with adiposity in young individuals.    The means/tools used were limited (but are the ones usually employed): food frequency and nutritional knowledge questionnaires & anthropometric measures.    The main finding, that individuals with higher fat mass percentage had lower nutritional knowledge and lower consumption of lipids and sugars from naturally present sources, is of moderate interest (and is a rather predictable result).    The authors conclude (predictably also) that increased nutritional knowledge could strengthen the prevention of obesity. 

We are grateful to the reviewer for the careful evaluation of our manuscript.

My concern with this article is that there is no a priori sample size calculation or a post-hoc power analysis for this study. This is – I suppose – an easy task for the authors to fulfil.

We acknowledge the comment. Indeed, this study comes in the sequence of other smaller studies made by Nutrition students, which evaluated the relation between macronutrient intake and anthropometric parameters in students. Thus, we have designed a larger and more detailed study to determine the role of nutrient sources in fat mass and overweight. Indeed, we calculated the sample size of 68 volunteers as the number necessary to achieve significant differences in fat mass, when a random population was selected, based on previous data. However, based on the fact that we have never performed before this kind of study, we have included about 80 individuals.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The Authors reworked the manuscript taking into account the suggestions given. Now it is better readable and with a clearer understanding of their methods and findings, including also explicitly some limitations.