PONE-D-21-38283Prevalence of undernutrition and its associated factors among elderly people using Mini Nutritional Assessment tools in Womberma District, West Gojjam Zone, Amhara Region, North West Ethiopia, 2020 .PLOS ONE

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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: Partly

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

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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: Yes

Reviewer #2: Yes

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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: No

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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: The study is well justified with a primary objective of estimating the prevalence of undernutrition/malnutrition among the older adults in Ethiopia.

While the strengths of the study include a very limited objective, in vulnerable study population population and use of validated standardized tools, the study needs further improvements before it can be published. The following suggestions may be of help to the authors:

1. While I was able to understand the artionale of the study, a more explicit description in a few lines would definitiely help. Why was this study done in this particular setting/population and why now ? What were the previous gaps in knowledge identified and how thsi study would like to fill those gaps ? Has previous evidence synthesis/reviews identified the need for such a study in this population ?

2. The authors may think of adding secondary objectives to the study (correlates of malnutrition ?)

3. I would like to see more justification on the sample size calculations. Specifically for the design effect of 2 and a non-response of 10%. As I can see, the final sample size is same as the calculated one and that implies ZERO non-response?

4. A graphical representation of the sampling frame/sampilng methods would he useful to the readers as well.'

5. The statistical analysis is to be further justified. The reasoning for the selection of variables (p value <0.25 ?), the actual multivariate model used , the predictor variable selection (possible correlates) and the goodness of fit estimate cut offs need further explanation. Did the authors find multicollinearity ? What was the finding of VIF analyses ?

6. It may be useful to start the results with a Study flow diagram- how many households were approached to how many finally included. Maybe the authors can look at some standard templates for such cross sectional surveys.

7. Did the authors analyse further the association between chronic conditions and nutritional status? Was multimorbidity associated with malnutrition ? What chronic conditions seem to be predictive of malnutrition ? This would be an interesting analyses and add value.

8. The discussion needs to focus more on the uniqueness of the findings of this study. As the authors themseleves quote local studies in similar settings with similar results, what was the added benefit of this study needs to be made more clearer. Boradly speaking, the discussion needs revisions as I felt the readers would have to be provided with a more compact and less verbose dicussion on major findings. Comparisons with all previousl studies seem unncessary at some points. Additionally a more in depth discussion on the role of chronic conditions (not just hemorrhoids) may be of interest.

9. Why was only verbal consent obtained? I feel such studies in vulnerable groups ask for written informed consent as per most national and international guidelines on health research. A justification for the same is warranted.

10. Was anemia assessed and if so a detailed discussion on its association with malnutrition may be added.

11. The recommnedations need to be based on the findings of the study in question and not gerenal observations and dissemination of knowledge. I suggest the authors to narrow down their recommendations and focus on what they found alone.

12. A section on potential strengths and limitations of the study is required in the discussion section and may be added.

13. On some minor issues, I suggest tha authors to stick to the terminology of 'older adults' throughout the manuscript and avoid the term 'elderly' which is being less frequently used in current literature to describe this population group. Further additional references on chronic condition and malnutritions may be added. The utility of figure-2 is questionable and so may be removed as it has been described in the text. The prevalence of depression seems high. Any discussion on this would be useful for a group of readers. The spelling of hypertension, mellitus, arthritis and hemorrhoids may be checked in the figure. Also 'physical problems' may need more explanation on operational definition.

I feel the study holds merit and may be of scienntific interest. However I feel the above observations need to be addressed before it can be taken up for publication.

Reviewer #2: Major comments

1. The article provides important information on nutritional problems in the elderly in North West Ethiopia. However, the conclusions by the authors are too broad and is far reaching that is beyond the objective of the study.

2. The authors may focus why existing surveys such as DHS do not undertake nutrition surveys in this vulnerable population and what are the limitations (if any) and how the DHS can include this vulnerable age groups.

3. This will provide much needed rational for the incorporation of elderly population within the DHS surveys and will be of great help for recommendations for the policy makers across the developing world.

4. The statistical analysis needs to adjust for the cluster design adopted and it is unclear whether this was taken into account for the analysis.

5. BMI is a simple indicator for assessing nutritional deficiencies in older adults but the authors do not mention the same and how it compares with the existing method.

Minor Comments

Abstract

1. In methods section, rephrase the sentence. ” kebeles” may be replaced by a generic word such as “ward or village”.

2. Rephrase the last sentence in methods section and correct the word “statistical”. Use either 95% CI or P value less than 0.05 but not both as they represent the same.

3. Rephrase the last line of conclusions and do not make it general but specific to the study.

Paper

1. In introduction, Para 4, last line may be rephrased from “It is a good way to start the day” and provide context specific information.

2. In methods, the model and make used for anthropometric measurements needed to be mentioned (e.g. SECA 874 flat weighing scale, Hamburg, Germany).

3. In methods, how many had armspan measurements were taken and how many heights were measured need to be reported.

4. In the methods section, for the last para, “The goodness of fit of the model was checked by using the Hosmer and Lemeshow test with a p-value of 0.734.” needs an appropriate reference.

5. In results section, details on weight, arm span, height, weight and BMI may be presented.

6. In discussion, limitations and strengths of the study may be discussed.

7. In conclusions, major comments may be used as the basis for write-up.

8. References need to be formatted properly and should include journal name, issue number as per the journal requirements.

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Reviewer #1: Yes: Jaya Singh Kshatri, MD

Reviewer #2: Yes: Dr. Raja Sriswan Mamidi

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Prevalence of undernutrition and its associated factors among older adults using Mini Nutritional Assessment tools in Womberma District, West Gojjam Zone, Amhara Region, North West Ethiopia, 2020 .

PONE-D-21-38283R1

Dear Dr. Anto,

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.

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Kind regards,

Subhendu Kumar Acharya, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. 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 #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: (No Response)

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4. 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 #2: Yes

Reviewer #3: Yes

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5. 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 #2: Yes

Reviewer #3: Yes

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6. 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 #2: I thank the authors for incorporating all my suggestions and addressing my comments.

Minor comment

Line 72: ofin to be separated as of in.

While, a complex survey analysis could have been performed, the conclusions of the paper are far reaching on the policy makers to include old age groups in DHS surveys and is recommended for publication. This is a seminal paper that needs to be highlighted and flagged in future meetings of DHS.

Reviewer #3: Thanks, the authors for addressing all the comments provided in first round of review. However, the manuscript needs minor English revision.

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7. 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.

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Reviewer #2: Yes: Raja Sriswan Mamidi

Reviewer #3: Yes: Krushna Chandra Sahoo, ICMR-Regional Medical Research Centre, Bhubaneswar, India

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