PONE-D-24-43792Glycemic Fluctuations, Fatigue, and Sleep Disturbances in Type 2 Diabetes During Ramadan Fasting: A Cross-Sectional StudyPLOS ONE

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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: Partly

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

Reviewer #1: Yes

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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: No

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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

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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: Dear Author(s),

As a reviewer, I have carefully read your manuscript, titled "Glycemic Fluctuations, Fatigue, and Sleep Disturbances in Type 2 Diabetes During Ramadan Fasting: A Cross-Sectional Study." I appreciate your effort in conducting this important research, which addresses critical aspects of managing type 2 diabetes during Ramadan fasting. Below, I provide several suggestions that I believe would enhance the clarity, scientific rigor, and practical impact of your study.

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Suggestions for Improvement:

1. Abstract:

Consider including specific recommendations for sleep duration to improve clarity for readers. For example, highlighting 7–8 hours as an optimal “cut-off” could offer a practical guideline.

Briefly mention dietary factors that may benefit glycemic control, such as low glycemic index foods, lean proteins, and healthy fats.

Clarify the use of the Multidimensional Fatigue Inventory-20 (IMFI-20) for assessing fatigue, which would strengthen the scientific credibility of your work.

2. Introduction:

Discuss the importance of adequate sleep for individuals with diabetes and its impact on blood glucose regulation. Including more background on sleep needs could enhance the relevance of your study.

Introduce the potential benefits of a low glycemic index diet, lean proteins, and fiber-rich foods for blood glucose control, especially during fasting periods.

Mention the use of IMFI-20 as a validated tool for assessing fatigue to provide a theoretical basis for including this measurement.

3. Methods:

Expand on your choice of fatigue and sleep assessment tools (IMFI-20 and PSQI) and their validation in the target population.

Clearly define an optimal sleep duration (such as 7–8 hours) as a benchmark to evaluate sleep adequacy in your participants.

Consider adding details about participants’ dietary habits and whether specific dietary recommendations were made, as this could impact blood glucose and fatigue outcomes.

4. Results:

Provide more detailed data on the relationship between sleep quality and blood glucose control, and clarify if specific sleep durations (like 7–8 hours) are associated with better glucose management.

Include information on how dietary habits (e.g., low glycemic index foods) affected blood glucose levels and fatigue to offer a more comprehensive understanding of these variables.

Analyze each dimension of the IMFI-20 separately to show the specific areas of fatigue most affected by blood glucose fluctuations.

5. Discussion:

Offer practical recommendations for optimal sleep, such as encouraging 7–8 hours per night to improve blood glucose stability during Ramadan.

Include dietary suggestions, particularly emphasizing the role of low glycemic index foods, lean proteins, and healthy fats in blood glucose management.

Provide a detailed analysis of fatigue dimensions using IMFI-20 results to better illustrate the physiological and psychological impact of Ramadan fasting on diabetic patients.

6. Conclusion:

Suggest specific recommendations on diet and sleep duration for diabetic patients during Ramadan to make the conclusion actionable.

Emphasize the importance of using tools like IMFI-20 and PSQI in routine diabetes management during fasting periods.

Consider proposing future research that focuses on the effects of various dietary interventions and sleep duration on blood glucose and fatigue during Ramadan.

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Incorporating these suggestions would not only add depth to your findings but also make the results more accessible and applicable to clinical practice. I commend you for this important work and hope that these recommendations are helpful in enhancing your manuscript.

Thank you for the opportunity to review your study.

Best regards,

[Your Name]

[Your Affiliation]

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Reviewer #1: No

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<p>Glycemic Fluctuations, Fatigue, and Sleep Disturbances in Type 2 Diabetes During Ramadan Fasting: A Cross-Sectional Study

PONE-D-24-43792R1

Dear Dr. Romadlon,

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,

Julio Alejandro Henriques Castro da Costa

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: 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 #1: Yes

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

Reviewer #1: (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 #1: (No Response)

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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 #1: 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 #1: Dear Author

I have reviewed the revised version of your manuscript and appreciate the effort you have made to address the reviewers' comment s. The study provides valuable insights into glycemic fluctuations, fatigue, and sleep disturbances in individuals with type 2 diabetes during Ramadan.

However, I believe one critical aspect that could further enhance the comprehensiveness of the study is the evaluation of insulin sensitivity. While the manuscript indirectly addresses this through HbA1c and glycemic fluctuations, a direct measurement of insulin sensitivity (e.g., HOMA-IR or Quicki Index) would have added significant depth to your findings. This would allow a clearer understanding of how factors such as sleep quality, fatigue, and dietary patterns affect insulin resistance and metabolic control.

I strongly recommend that this be included in the limitations section, with a note suggesting future studies to investigate the relationship between insulin sensitivity and the studied variables more comprehensively. For instance:

"One limitation of this study is the lack of direct evaluation of insulin sensitivity, which could provide a more robust understanding of the metabolic mechanisms underlying glycemic fluctuations. Future research should consider including indices such as HOMA-IR or Quicki to analyze the relationship between insulin sensitivity, sleep quality, fatigue, and dietary patterns."

Adding this point would not only acknowledge the scope of the current study but also pave the way for future research to build upon your valuable findings.

Thank you for your contributions to this important field. I look forward to seeing the final version of your work.

Best regards,

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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.

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

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