Factors associated with dietary diversity among pregnant women in the western hill region of Nepal: A community based cross-sectional study

Vintuna Shrestha; Rajan Paudel; Dev Ram Sunuwar; Andrew L. Thorne Lyman; Swetha Manohar; Archana Amatya

doi:10.1371/journal.pone.0247085

Peer Review History

Original SubmissionSeptember 21, 2020
8 Dec 2020 Decision Letter - Abid Hussain, Editor PONE-D-20-29709 Factors associated with dietary diversity among pregnant women in the western hill region of Nepal: a community based cross-sectional study PLOS ONE Dear Dr. Shrestha, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Overall, your manuscript is very interesting. However, it needs some improvements, particularly in introduction, discussions and conclusions sections. Please see reviewers' comments for details. Please submit your revised manuscript by Jan 22 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. 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If your ethics statement is written in any section besides the Methods, please delete it from any other section. Additional Editor Comments: Dear authors, Thank you so much for your submission to PLOS ONE. There is need of further strengthening of introduction, discussions and conclusions sections. For details, please see reviewers' comments. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: No Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No Reviewer #2: No ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This is an interesting paper examining dietary diversity among pregnant women. While the overall paper looks okay, I find nothing new in this paper. Most of the factors associated with dietary diversity are well established. One way, the paper could have benefited by contextualizing the measures which I did not see. This also lacked in the discussion. There is no discussion around policy implications of the study. Therefore, I don't fully understand what is the utility of this study. Perhaps, authors could have also examined the how MNCH outcomes among women are placed in relationship to the DD. Aside from these broad remarks, following are some of the specific comments: 1. The authors says data are available within the manuscript. However, I did not find it. Perhaps, authors idea of data refers to tables. I would encourage authors to include the statement on where the data is available and how it can be accessed. 2. Reference to Figure 1 is missing in the text of the paper. 3. In the study context, provide more details on MNCH situation in Baglung and how it is different from rest of Nepal. It is important for international audience to understand the context better to interpret the findings. 4. Please provide more details on the enrollment process of the individuals into the study. You say that list of women were taken from FCHV? Was it not a violation of privacy of Individuals? How was the consent taken? What was the refusal rate? 5. Table 3: I feel something is not right about this table. Did you check for multi-collinearity. It seems several of the covariates may be correlated with each other. Also, it does not make sense to include a variable with very low cell frequencies. The authors could have combined such categories with another category of the variable. 6. For Table 3, present row percentages of dietary diversity. That would enable effective comparison. Also, check the p-value for food security in the multivariable analysis. It seems incorrect given the range of 95% CI. 7. In the discussion, the authors should interpret the findings more in the study context. I feel that is completely missing. Good luck with the revision Reviewer #2: The present study has explored one of the important issues among pregnant women in one of the urban areas in Nepal. Indeed, it’s an important issue to be discussed. The study is very interesting, I appreciate the efforts made by the authors for completing this project. My suggestions are mentioned below for further improvement. 1. As the study is explanatory in nature, therefore, I may suggest a strong theoretical framework. It will enrich the analysis and discussion. 2. The introduction section should have explanation of the factors that are associated with the dietary diversity from other parts of the world. 3. Study area selection, the sampling is well defined. 4. Why the variable is dichotomous, what is its advantage over the ratio variable and may be regressed as OLS method. 5. How the independent predictors are selected. Are these selected from the literature, expert opinion or by some other statistical techniques, please mention it. 6. Were these socio-economic factors checked for the multi-collinearity problem? 7. How the sample size assumption and linearity of independent variables and log odds are checked first. 8. In the conclusion section, please more focus on the policy implications. These implication should to the point and practically implemented. Moreover, what programs which are already going on in Nepal can help to solve the problems. These kind of problems may also be linked in discussion section with the results. 9. Language editing is needed. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: Yes:** Shahab E. Saqib [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0247085.r001
Revision 1
21 Jan 2021 Author Response Academic editor comments and concern We note that Figure 1 in your submission contains map images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright. AUTHORS: Thank you very much for your concern. We assure you that the provided Fig. 1 contains a study area Map is copyright free. We created this map using Arc GIS software version 10.8 and base files of the administrative provinces and districts of Nepal were obtained from the freely available copyright free resources Government of Nepal, Ministry of Land Management, [1] and Natural Earth.[2]. The map was displayed the location of the study sites in Baglung Municipality, Baglung district, Nepal. Please ensure that you refer to Figure 1 in your text as, if accepted, production will need this reference to link the reader to the figure. AUTHORS: Thank you for the comments. We have mentioned the Fig 1 legend as “Fig.1 Map showing the location of study sites" in the revised manuscript in line number: 96 Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. AUTHORS: Thank you for kind suggestion. We have deleted the ethical statement in declaration section in the revised manuscript. Reviewer 1 This is an interesting paper examining dietary diversity among pregnant women. While the overall paper looks okay, I find nothing new in this paper. Most of the factors associated with dietary diversity are well established. One way, the paper could have benefited by contextualizing the measures which I did not see. This also lacked in the discussion. There is no discussion around policy implications of the study. Therefore, I don't fully understand what the utility of this study is. Perhaps, authors could have also examined the how MNCH outcomes among women are placed in relationship to the DD. AUTHORS: Thank you very much for your comments. We feel it’s important to place the study into context here: indeed, factors associated with dietary diversity among women of reproductive age are fairly well established in the international context. In Nepal, however, only limited studies have been published; the country is very diverse in terms of both its ecology and cultural practices. To date most of the published studies were conducted in the Terai region of the country where two active research sites exist. Comparably little information is available on dietary diversity among pregnant women in the hill region of Nepal. Thus, we feel this study provides an important source of information on dietary practices in this region which may differ from findings from other regions. It is also important to note that we have focused on pregnant women specifically, which is important because cultural practices in pregnancy in Nepal influence the foods that women eat (food taboos, prescriptions and proscriptions are present). We have added the manuscript to better emphasize the context and importance. The authors says data are available within the manuscript. However, I did not find it. Perhaps, authors idea of data refers to tables. I would encourage authors to include the statement on where the data is available and how it can be accessed. AUTHORS: We uploaded the data to accompany the manuscript during the manuscript submission process. The filename is Dataset.dta which is zip/ compressed file. We have again uploaded the file “Dataset.dta” under the item section Supporting Information ZIP files. Reference to Figure 1 is missing in the text of the paper. AUTHORS: Thank you for pointing this out. We have added this. In the study context, provide more details on MNCH situation in Baglung and how it is different from rest of Nepal. It is important for international audience to understand the context better to interpret the findings. AUTHORS: This is important feedback. We have added the information under the subheading study design and setting in lines: 91-95, page number: 5. We have included statistics on low birth weight, ANC visits and iron supplementation. Although we wanted to add more information like maternal underweight, could not collect it even after rigorous data searching in internet and study of annual report of Baglung. Please provide more details on the enrollment process of the individuals into the study. You say that list of women were taken from FCHV? Was it not a violation of privacy of Individuals? How was the consent taken? What was the refusal rate? AUTHORS: Ethical approval was obtained for the study from the Institute of Medicine at Tribhuvan University and written consent was obtained from all participants as described under the ethical consideration subheading, lines: 190-195, page number: 9. An approval letter introducing the researcher and stating the study’s objectives was shared with Baglung Municipality’s Health Section Chief and its Mayor as well as the responsible supervisor of the health posts in each of the selected wards. Formal permission was taken from these concerned authorities. The refusal rate was zero, which is not uncommon in Nepal where research participation is typically high [3]. Table 3: I feel something is not right about this table. Did you check for multi-collinearity. It seems several of the covariates may be correlated with each other. Also, it does not make sense to include a variable with very low cell frequencies. The authors could have combined such categories with another category of the variable. AUTHORS: We have checked multi-collinearity and report of the VIF was included in supplementary file as “S4 Table” in the revised manuscript. Initially, a total of 19 predictor variables were included in our study. We agree with you with regards to some variables not providing a great deal of additional discriminatory information such as religion, first ANC visit, and food security. As such, we have removed these variables from the Table 3 and now a total of 16 variables are included in the revised manuscript. In addition, we have merged the women empowerment variable where we noticed that one cell have low cell frequency. Women empowerment was classified as ‘low’, ‘moderate’, and ‘high’. Now we have merged low/ moderate and present the data in the revised manuscript. For Table 3, present row percentages of dietary diversity. That would enable effective comparison. Also, check the p-value for food security in the multivariable analysis. It seems incorrect given the range of 95% CI. AUTHORS: Thank you for these suggestions. We have revised the Table 3 and presented row percentage of dietary diversity and added the related statistics in the revised manuscript. In the discussion, the authors should interpret the findings more in the study context. I feel that is completely missing. AUTHORS: We have added the more contextual information in the discussion section within the revised manuscript, line: 266-267, page number: 16; line: 281-286, page number: 17; line: 294-298, page number: 17-18 and line: 306, page number: 18. Reviewer #2: The present study has explored one of the important issues among pregnant women in one of the urban areas in Nepal. Indeed, it’s an important issue to be discussed. The study is very interesting, I appreciate the efforts made by the authors for completing this project. AUTHORS: We highly appreciate your thorough review. As the study is explanatory in nature, therefore, I may suggest a strong theoretical framework. It will enrich the analysis and discussion. AUTHORS: Thank you for the suggestion. We have added this to the paper in Fig 2. Legend as “Fig.2 Conceptual framework on factors associated with dietary diversity” in line number: 172. The introduction section should have explanation of the factors that are associated with the dietary diversity from other parts of the world. AUTHORS: We have added to line number: 72-74, page number: 4 to highlight information on factors associated with dietary diversity from other parts of the world in the introduction section. Study area selection, the sampling is well defined. AUTHORS: We thank you for the comment. Why the variable is dichotomous, what is its advantage over the ratio variable and may be regressed as OLS method. AUTHORS: The dependent variable dietary diversity is dichotomous as it was used from Minimum dietary diversity for women of reproductive age (MDD-W) indicator developed by Food and Agriculture Organization of the United Nation (FAO). MDD-W is a population level indicator that can be used as a proxy indicator for higher micronutrient adequacy, one important dimension of diet quality. MDD-W is a dichotomous indicator that classifies women into those with low dietary diversity (who would be highly unlikely to meet their micronutrient requirements) and those with minimum dietary diversity (who would be more likely to meet their micronutrient requirements) so it signifies whether micronutrients are met or not. Thus being a dichotomous variable it’s easier to interpret, communicate and advocate even to individual with no nutrition knowledge rather than continuous variable. How the independent predictors are selected. Are these selected from the literature, expert opinion or by some other statistical techniques, please mention it. AUTHORS: Independent variables were selected after intensive literature review Were these socio-economic factors checked for the multi-collinearity problem? AUTHORS: Yes, the variables were checked for the multi-collinearity problem and reports are presented in supplementary file as S4 Table. How the sample size assumption and linearity of independent variables and log odds are checked first. AUTHORS: To check for linearity of independent variables multicollinearity test was done. None of the variables had Variance Inflation Factors (VIF) more than 10. There was no problem of collinearity among independent variables as the highest VIF was 1.9. In the conclusion section, please more focus on the policy implications. These implication should to the point and practically implemented. Moreover, what programs which are already going on in Nepal can help to solve the problems. These kind of problems may also be linked in discussion section with the results. AUTHORS: Thank you for your comment. We have added the line: 347-349, page number: 20 to focus on practical implications of the finding of the study. Language editing is needed. AUTHORS: We have gone through the manuscript again to try our best and edit the language where needed. References 1. Goverment of Nepal, Survey Department. Ministry of Land Management, Coperatives and Poverty Alleviation. 2020. 2. North American Cartographic Information Society (NACIS) Collaborators. Natural Earth. 3. Karmacharya C, Saleh A, Shrestha B, Bhandari S, Manohar S, Thorne-Lyman A, et al. PoSHAN Community Studies: Panel 2 Survey Report. 2016. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0247085.r002
2 Feb 2021 Decision Letter - Abid Hussain, Editor Factors associated with dietary diversity among pregnant women in the western hill region of Nepal: a community based cross-sectional study PONE-D-20-29709R1 Dear Dr. Shrestha, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Abid Hussain Academic Editor PLOS ONE Additional Editor Comments (optional): Dear Authors, Thank you for adequately addressing the comments from the reviewers. Reviewers' comments: https://doi.org/10.1371/journal.pone.0247085.r003
Formally Accepted
30 Mar 2021 Acceptance Letter - Abid Hussain, Editor PONE-D-20-29709R1 Factors associated with dietary diversity among pregnant women in the western hill region of Nepal: a community based cross-sectional study Dear Dr. Shrestha: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Abid Hussain Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0247085.r004

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