PONE-D-22-30022Surgical patients’ self-screening for “at risk of malnutrition” in a home setting – a feasibility study (ClinicalTrails.gov: NCTT03105713)PLOS ONE

Dear Dr. Skeie,

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.

==============================

The reviewer has highlighted a critical area of confusion concerning the word “feasibility”. I suggest that the authors carefully examine their manuscript and locate all instances of “feasibility”, then replace it another word that conveys their meaning, such as “practicability”.

The other important point the reviewer makes is that study outcomes are not clear.

Please submit your revised manuscript by May 01 2023 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. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Maret G Traber, PhD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

3. Thank you for stating the following in the Competing Interests section:

"I have read the journal's policy and the authors of this manuscript have the following competing interests: ASH has previously received travel re-imbursement for representing the International Federation of Nurse Anaesthetists in the European Society of Anaesthesiology and Intensive Care’s Patient Quality and Safety Committee. All the other authors have declared that no competing interests exist."

Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to  PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

5. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

Additional Editor Comments:

The reviewer has highlighted a critical area of confusion concerning the word “feasibility”. Authors frequently are asked in clinical trials to state the kind of study design In the title. As noted “Feasibility studies are pieces of research done before a main study to answer the question 'Can this study be done? ' They are used to estimate important parameters that are needed to design the main study.”(see: https://www.nihr.ac.uk/glossary/?letter=F&postcategory=-1). In other words, a feasibility study is one that has not collected data, but has a study design and statistical support for that design. The study the authors have carried out might be better described as a “pilot trial” that shows positive results. To avoid the difficulty with the multiple meanings of feasibility, I suggest that the authors carefully examine their manuscript and locate all instances of “feasibility”, then replace it another word that conveys their meaning, such as “practicability”.

The other important point the reviewer makes is that they have not done a power calculation to estimate how many subjects they need to claim that the results are statistically significant. A power calculation may not be possible without the data they collected, suggesting another reason to call this a pilot trial.

[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: Yes

**********

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

Reviewer #1: Yes

**********

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

**********

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

**********

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 study is presented as a feasibility study, however it doesn't seem to have actually been intended to assess feasibility of an intervention, as the objectives are presented as "investigating whether self-screening for nutritional risk factors prior to surgery in a home setting will increase the amount of patients screened for nutritional risk, and secondly, to compare their screening results with healthcare professionals..." (lines 26 to 29). Going by this, the objective of this study is to assess effectiveness of an intervention. The authors should be clearer about what the study was intending to achieve as the title, objectives in the abstract, and objectives at the end of the methods section are at odds.

If the authors did indeed aim to "investigate whether self screening... will increase the amount of patients screened...", then there are a number of aspects that need to be clearly reported, including the outcomes of the study and how they were measured, and also compared across groups. However, if the study aimed to investigate feasibility as stated in the title and in line 75, then the authors need to clearly describe what the feasibility endpoints are, ie. what outcome would they need to observe to conclude that self-screening was feasible. Additionally, the authors should describe how they determined the appropriate size of the study - a reader cannot tell whether the 215 patients who participated were sufficient to address the objectives of the study.

**********

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

**********

[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.

PONE-D-22-30022R1Practicability of self-screening for “at risk of malnutrition” among surgical patients’ in a home setting (ClinicalTrails.gov: NCT03105713)PLOS ONE

Dear Dr. Skeie,

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.

Your manuscript has been evaluated by four new reviewers, and their comments are appended below and in the attached document.

The reviewers have provided a range of comments regarding your manuscript, particularly regarding the study design and its communication in the text, the statistical methodology, and discussion of the results. Please ensure your address each of the reviewers' comments when revising your manuscript file.

Please also consider further the comments from Reviewer 1 of the previous round of peer review and assess whether the revision of 'feasible' to 'practicable' is a meaningful difference, and whether this study is assessing feasibility/practicability or effectiveness and reliability. Please make any revisions necessary to clarify this matter.

Please submit your revised manuscript by Oct 16 2023 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. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Hugh Cowley

Staff Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

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: (No Response)

Reviewer #4: (No Response)

Reviewer #5: (No Response)

**********

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: Partly

Reviewer #4: Partly

Reviewer #5: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

Reviewer #5: Yes

**********

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

Reviewer #4: Yes

Reviewer #5: Yes

**********

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

Reviewer #4: Yes

Reviewer #5: Yes

**********

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: Generally, the content in the manuscript is well described.

Please make a minor technical amendment to the manuscript before finalised submission. Insert the comment in the attached file.

Reviewer #3: This manuscript aims to investigate the important question how we can improve access to nutrition screening preoperatively to identify patients at risk of malnutrition and therefore at increased risk of postoperative complications. The manuscript contains some interesting data but needs major revisions to enable interpretation of the findings.

Abstract:

Line 28 - amount should be number of patients

Line 45 - how many patients had both an healthcare professional and a self screening completed? This is the most important number and should be reported. What was the time difference between the screening tools being completed?

Line 47 - 48 - the conclusion does not reflect the results section. The agreement is stated as "poor".

Methods:

Line 87 - how was this sample size calculated? Please include further details.

Line 96 - 98 - were patients recruited while an inpatient or at an outpatient clinic appointment? It is not clear. Why did health professionals not complete the nutrition screening at this point in time rather than when patients were admitted for surgery?

Please add further details about the NRS 2002 questions and timing of screening.

Lines 105 to 107 - how did calculate BMI? Was this based on self-reported weight and height? Did they have to use tables on paper to work this out? Please include the exact screening tool questions that were used in this study in a table or figure or supplementary information.

Lines 113- 117. It is unclear if the scoring system for "at risk of malnutrition" was changed given patients did not complete all questions. Please include a comment about whether this is an acceptable use of the screening tool.

Section starting Line 101. When did patients complete the tool? If a patient completes the tool 12 weeks prior to the health professional completing the tool the inter-rater agreement cannot be compared b/c they are not assessing the same state. It is likely that changes in weight and food intake will occur during this period.

Line 119 - 120 - has this question been used in previous studies? Please provide evidence to support it's inclusion or at least justify why is has been included.

Statistical methods:

This section does not detail which kappa measure of agreement was used. Please review accordingly. Assumption 5 of Cohen's kappa was not met - "Assumption #5: The same two raters are used to judge all observations (e.g., patients). This has been referred to as having fixed or unique raters. If different raters were used for each observation (e.g., patient), Cohen's kappa is not the appropriate test to use. However, in this latter case, you could use Fleiss' kappa instead, which allows randomly chosen raters for each observation (e.g., patient)."

Results:

Line 169 - were the patients who believed they were at risk of malnutrition the same patients who were identified as at risk of malnutrition on the NRS2002? This is important to know.

Line 171-172 "All these patients were screened after surgery". The use of the screening tool after surgery is not detailed in the methods section. Please make it clear in the. methods section when HPs and patients completed the screening tool.

Line 192 - be aware over interpreting the statistics. The number of patients identified at risk of malnutrition was only 5% of the population and the agreement statistic is based on a small sample of 9 versus 11 screening tool results.

Discussion

Line 230 - this needs a reference please.

Line 255 - it is not clear what the "high prevelance indices" is referring to.

Line 260 - 262 - these results are not clearly presented in the results section. Please revise accordingly.

Line 264 - please add further details about the time difference to the results section. This is very important as timing of risk of malnutrition prior to surgery dictates the type of intervention that could be provided to reduce risk preoperatively.

Line 278 to 279 - yes very important point!

Line 284 - the time delay here is also important. For example, screening by health professionals at the time of booking surgery date would be a more accurate method to compare with self-screening at time of booking.

Reviewer #4: I reviewed the article "Practicability of self-screening for "at risk of malnutrition" among surgical patients in a home setting.” The study's primary purpose is to investigate and compare the agreement rates between preoperatively measured self-reported malnutrition screening at home by patients and at the hospital by nurses. Although the study has a good design and presentation, some major methodological points make the study lower quality.

1- Missing data when choosing the patients in the study is much more than expected, which may cause a bias in the analyses.

2- The hypothesis and purpose of the study needed to be well documented in the paper. I could not understand what this work would add to this area. Preoperatively self-measured malnutrition rate should be similar to measurements in the hospital. However, kappa analysis results show shallow coefficient scores.

Best regards,

Reviewer #5: ABSTRACT

Results – might be useful to include the numbers screened in hospital prior to surgery, I got the impression that those screened pre surgery was more important than post.

Conclusions – might also be useful to mention here that hospital screening for malnutrition risk doesn’t always occur before surgery, so limiting opportunity to treat and better prepare for surgery.

MAIN TEXT

Introduction (line 65) - font is different

Statistics – state what is an adequate level of agreement for this study. See: https://pubmed.ncbi.nlm.nih.gov/23092060/

Results - I think that there is maybe still a bit of confusion over what the study set out to achieve, more clarity is needed. If main aim is to assess if self-screening increases amount of patients screened for malnutrition risk prior to surgery, then this should be stated as a main outcome. Results should open with and highlight the number(%) out of 215 that self-screened prior to surgery compared to the number(%) out of 215 that were screened in hospital prior to surgery. Currently this information reads more like descriptive stats rather than the main outcome and there is no direct comparison between numbers self-screened and numbers screened in hospital prior to surgery. This would allow you state that ‘self-screening improved malnutrition screening by X% compared to hospital screening prior to surgery’

Limitations – another limitation could be that there was a low number of patients who were identified as at risk of malnutrition.

Discussion – I felt that this started quite negatively by highlighting the main limitation of this study (missing screenings at hospital) – suggest to move this further down in the discussion. You could instead open more positively – this study highlights the importance of self-screening at home and demonstrates that self-screening is possible and increases numbers of patients screened for malnutrition risk prior to surgery. I think this should help to make your primary outcome come across better as currently level of agreement (secondary outcome) overshadows the main outcome.

**********

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.

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 #2: No

Reviewer #3: No

Reviewer #4: No

Reviewer #5: Yes: Debra Jones

**********

[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.

Attachments

Attachment

Submitted filename: PONE-D-22-30022 - MANUSCRIPT.pdf

PONE-D-22-30022R2Is self-screening for 'at risk of malnutrition' feasible in a home setting? (ClinicalTrails.gov: NCT03105713)PLOS ONE

Dear Dr. Tangvik,

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.

The manuscript has been evaluated by three reviewers, and their comments are available below.

The reviewers have raised a number of concerns that need attention, including reference to comments provided at the last round of revision to which no response was provided. They request additional information on methodological aspects of the study and revisions to the wording used to increase clarity

Could you please revise the manuscript to carefully address the concerns raised?

Please submit your revised manuscript by Jan 12 2024 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. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Jennifer Tucker, PhD

Staff Editor

PLOS ONE

Additional Editor Comments (if provided):

Please ensure that you provide a detailed response to reviewers with your revised submission, addressing each reviewer comment point by point to allow for assessment of whether their requests have been completed.

[Note: HTML markup is below. Please do not edit.]

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 #3: All comments have been addressed

Reviewer #4: (No Response)

Reviewer #5: (No Response)

**********

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 #3: Partly

Reviewer #4: Partly

Reviewer #5: Yes

**********

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

Reviewer #3: No

Reviewer #4: (No Response)

Reviewer #5: Yes

**********

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 #3: Yes

Reviewer #4: (No Response)

Reviewer #5: Yes

**********

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 #3: Yes

Reviewer #4: (No Response)

Reviewer #5: No

**********

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 #3: Please see attachment that includes specific comments and recommendations based on the author review.

Reviewer #4: I could not see any responses to my comments in the response documents. Therefore, I still think there is a significant methodological and hypothetical concern with this paper,

Best regards,

Reviewer #5: I have attached my comments - I have suggested quite a few edits to language as I don't feel that it makes sense in places or that its particularly clear.

**********

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.

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 #3: No

Reviewer #4: No

Reviewer #5: Yes: Debra Jones

**********

[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.

Attachments

Attachment

Submitted filename: second feedback for PLOS1 paper.docx

Attachment

Submitted filename: PLOS one second review.docx

Is self-screening for 'at risk of malnutrition' feasible in a home setting? (ClinicalTrails.gov: NCT03105713)

PONE-D-22-30022R3

Dear Randi Tangvik,

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,

Mohammed Hasen Badeso, MPH in Field Epidemiology

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 #1: (No Response)

Reviewer #4: All comments have been addressed

**********

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 #1: Yes

Reviewer #4: Yes

**********

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

Reviewer #1: Yes

Reviewer #4: Yes

**********

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 #1: Yes

Reviewer #4: Yes

**********

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 #1: Yes

Reviewer #4: Yes

**********

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 #1: This is a generally well-described study, I have only a few minor comments.

- In line 93 do you mean 'trial' instead of 'trail'?

- Also in the same part, I think a bit more detail about the sample size of the overarching study might be useful, for example, what size of effect or difference for what outcome with how much power at what level of significance and what ICC for clustering did the study deem 300 participants in six clusters to be sufficient.

- In line 152 you likely mean 'estimated' instead of 'investigated', and in line 149 'used' instead of 'applied'.

Reviewer #4: Thank you for your appropriate revisions. The last version of the study seems to be ready to be accepted for publication.

Best regards,

**********

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.

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 #4: No

**********