Dear Editor,

We congratulate Dutra et al^{(Reference Dutra, Fragoso and Wanderley1)}. for their comprehensive systematic review and meta-analysis, ‘Diet’s Total Antioxidant Capacity and Women’s Health,’. This synthesis of nineteen observational studies (ranging from 64 to 3209 women) elegantly elucidates the association between dietary total antioxidant capacity (TAC) and diverse women’s health outcomes, including breast cancer, polycystic ovary syndrome, infertility and obstetric conditions. The meta-analysis, particularly the significant finding of lower TAC in breast cancer patients via vitamin C equivalents (VCEs) (MD: –110·53, 95 % CI: –171·53, –49·52), offers valuable insights into antioxidants’ protective potential. We applaud the authors’ global perspective and rigorous methodology and respectfully suggest enhancements.

The authors’ use of JBI’s critical appraisal tool to assess methodological quality is a strength, identifying most studies as adequate, save one of lower quality. We propose a sensitivity analysis based on study quality to explore its impact on pooled estimates. Excluding or stratifying lower-quality studies (e.g., Vahid et al., 2021, flagged for unclear exposure exemption) could clarify whether methodological rigour influences the significant VCE-breast cancer association or the mixed ferric reducing antioxidant power (FRAP)/oxygen radical absorbance capacity results (I² = 0 % v. 68 %). This would enhance robustness, offering readers greater confidence in applying these findings to diverse populations and conditions, from neoplasms to gestational diabetes^{(Reference IntHout, Ioannidis and Rovers2)}.

Additionally, while the review excels in qualitative synthesis, we suggest incorporating the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework to assess evidence certainty. GRADE evaluates the risk of bias, inconsistency, indirectness, imprecision and publication bias, providing a structured lens on confidence levels. For instance, the VCE meta-analysis’s low heterogeneity (I² = 0 %) suggests consistency, yet wide CI in FRAP (–1·56 to −0·05) indicate imprecision^{(Reference Li, Zhang and Luo3,Reference Yin, Kuai and Liu4)} . Applying GRADE could contextualize the moderate-to-high certainty of breast cancer findings against the less certain endometrial cancer or bacterial vaginosis outcomes, guiding clinicians on where evidence is strongest for dietary interventions.

From our clinical perspective, this study resonates deeply. The inverse TAC–breast cancer link aligns with our observations that patients with antioxidant-poor diets report higher disease burdens, supporting dietary counselling for prevention. Similarly, reduced menopausal symptoms and obstetric risks with higher TAC reinforce nutrition’s role in women’s health management^{(Reference Chen, Wen and Li5,Reference Chen and Pan6)} . However, the predominance of Iranian studies (12/19) prompts us to consider cultural dietary variations – our patients’ diverse food patterns may yield different TAC profiles. We gently encourage future research to broaden geographic representation and standardize TAC methods (e.g. FRAP v. VCE) to enhance generalizability, aiding practical application in our settings.

Dutra et al.’s work is a laudable contribution to nutritional science, illuminating dietary TAC’s health benefits for women. We respectfully suggest a quality-based sensitivity analysis and GRADE assessment to refine this robust analysis, complemented by our call for broader clinical applicability. This study poised to inform health strategies, and we eagerly await its final publication.