Higher ratio of plasma omega-6/omega-3 fatty acids is associated with greater risk of all-cause, cancer, and cardiovascular mortality: a population-based cohort study in UK Biobank

Reviewer #1 (Public Review):

Summary: The manuscript offers a commendable exploration into the relationship between plasma omega-6/omega-3 fatty acid ratios and mortality outcomes.

Strengths: The chosen study design and analytical techniques align well with the research objectives, and the results resonate with existing literature.

Weaknesses: Lack of information on the selection criteria for participants; 5. The analysis of individual PUFAs is not appropriate; The definition of comorbidities is vague; The rationale of conducting the mediation analysis of blood biomarkers is not given.

Reviewer #2 (Public Review):

Summary: This study utilized a large sample from the UK Biobank which enhanced statistical robustness, employed a prospective design to establish clear temporal relationships, used objective biomarkers for assessing plasma omega-6/omega-3 ratio, and investigated various mortality causes including CVD and cancer for a holistic health understanding.

Strengths: The authors used a large sample size, employed a prospective design, and investigated various mortality.

Weaknesses: Analyzing n-3 and n-6 PUFAs separately might be less instructive. It might not be methodologically sound to treat TG, HDL, LDL, and apolipoproteins as mediators. It's imperative to exercise caution when drawing causal conclusions from the observed correlations. The manuscript might propose potential research trajectories.

Reviewer #3 (Public Review):

Summary: The authors are trying to find out whether the levels of omega-6 and omega-3 fatty acids in the blood are linked to the likelihood of dying from anything, of dying from cancer and of dying from cardiovascular disease. They use a large dataset called UK Biobank where fatty acid levels were measured in blood at the start of the study and what happened to the participants over the following years (average of 12.7 years) was followed. They find that both omega-6 AND omega-3 fatty acids were linked with less likelihood of dying from anything, from cancer and from cardiovascular disease. The effects of omega-3s were stronger. They then made a ratio of omega-6 to omega-3 fatty acids and found that as that ratio increased risk of dying also increased,. This supports the idea that omega-3s have stronger effects than omega-6s.

Strengths: This is a large study (over 85,000 participants) with a good follow up period (average 12.7 years). Using blood levels of fatty acids is superior to using estimated dietary intakes. The authors take account of many variables that could interfere with the findings (confounding variables) - they do this using statistical methods.

Weaknesses: There are several omega-6 and omega-3 fatty acids - it is not clear which ones were actually measured in this study.