PONE-D-24-02702Consumption of protective and risk food groups for non-communicable diseases among women of reproductive age in rural areas of Morogoro, TanzaniaPLOS ONE

Dear Dr. Mwanri,

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.

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PLOS ONE

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This research is part of the Food and Local, Agricultural and Nutritional Diversity (FoodLAND) research project that has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement [GA No 862802]. 

Please state what role the funders took in the study.  If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." 

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Additional Editor Comments:

This is an interesting topic, and use of the MDD-W and the GDR score (NCD-protect and NCD-risk) is good - these (relatively) new measures have potential for assessing diet, and there are as yet relatively few studies using these new measures. Both reviewers have suggested ways to tighten up the analysis. It is important to use consistent terminology throughout (Reviewer 1 notes that the MDD-W isn't always spelled out accurately, and Reviewer 2 notes that NCD-protect and NCD-risk are not always spelled out correctly. The sum of NCD-risk and NCD-protect should add up to the GDR score, which national data for Tanzania suggest is about 10 (see https://www.dietquality.org/indicators/gdr-score/map) and it seems as though the score obtained here would be substantially lower.

Please respond to the careful comments of the two reviews when revising your paper.

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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: Yes

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: No

Reviewer #2: 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

Reviewer #2: 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:  There is a great need for context-specific evidence on diet quality of women (and men) in countries like Tanzania. This study utilizes the Diet Quality Questionnaire, a tool that has been specifically adapted for Tanzania, to assess the quality of diet among 512 women of reproductive age with a child 6-23 months in one district of Morogoro region. They assess the proportion of women who meet the criteria for minimum diet diversity as well as the scores for the two metrics used to assess NCD-risk and NCD-protective dietary intake. The authors use regression models to assess the association of these scores with a range of socioeconomic dependent variables. Their findings show relatively low dietary diversity in this sample of women, as well as relatively low scores for both NCD-risk and NCD-protective measures. The results are largely consistent with the nationally representative survey conducted in 2021 by Gallup Poll of 1000 women and men in both urban and rural areas of Tanzania, although the authors of this study do not seem to be aware of that data.

The submitted manuscript describes the study background, methods and key findings adequately. The manuscript would benefit from more detailed description of the methods used in a couple of ways - what time of year the data were collected (especially with respect to seasonal food availability), how random sampling of the women across the villages was carried out, and who conducted the data collection (number of people, training provided, any assessment of inter-rater reliability). With respect to the results, it would be helpful to have a full description of the MDD-W results by dependent variable (Table 6a) - see my suggestions in the attached PDF file. Furthermore, the results of the logistic regression model used to explore the association of the dependent variables with MDD-W would be easier to interpret if the coefficients were presented as odds ratios with 95% confidence intervals.

I noted that the minimum dietary diversity indicator is frequently incorrectly described as 'medium dietary diversity' throughout the manuscript. Also, there were several instances where the in-text citation of a study was done incorrectly. Please add the name of the study author when referring to an article in the text rather than saying "a study done by [19]" - example from line 247.

In both the results and discussion sections, I found that it would be helpful to consider these women more holistically, looking at patterns or groups within the dataset. For example, rather than looking at independent associations of age and mobile phone ownership, were there patterns across these characteristics? Were the women who owned mobile phones also more likely to be younger women? Similarly for the discussion of NCD-protect and MDD-W, there is a large amount of overlap in these two metrics of diet quality. While they are distinct indicators designed to be interpreted in different ways, there did not seem to be a recognition that the same dietary intake patterns that drive one also drive the other. Rather than discussing them separately, it would be helpful to consider what are the common underlying factors that make it difficult for women to consume more fruits and vegetables, for example.

Finally, I found the discussion of implications of these results a bit sparse, limited to one sentence in the Conclusion section. Rather than placing all the responsibility on these women and their communities for increased production, increased incomes and better food choices, what are the potential implications for agriculture, food and healthy diet policies in the country? Given that households may start to purchase more food as incomes increase, what are the options for ensuring that more diverse and healthy foods are available for purchase in this district, even if it is not possible for the communities to produce all of it themselves? What role can public health actors play in providing nutrition education to all ages, including young people, to enhance awareness of foods that are associated with increased risk of NCDs? And given the challenge in meeting nutrient adequacy with locally available foods, how can the country's food fortification agenda be scaled up to benefit women in these communities? These are some possible questions for the authors to consider as they expand a bit more on what can be done in response to these findings.

Please see the attached file with additional comments and edits.

Reviewer #2:  Abstract:

Line 29: prevalence of overweight or obesity: overweight and obesity are not the same as they have different BMI cut-offs, so I would suggest rephrasing it such that they are complement (i.e. AND , not OR).

Line 30-31 the sentence on limited studies on diet quality: the mention of diet quality here is quite abrupt without any earlier indication on how diet is/might be related to malnutrition/overweight.

Results: the statistics on education and owning mobile phone are not results of the study, rather they are descriptive statistics of the sample. Vegetables and fried food consumption need to be defined, for example, did 70% consumed vegetables everyday? Does that imply that the remaining 30% do not consume vegetables at all?

Line 43: NCD-risk and protect score needs a brief explanation.

Line 44-45 mentions a number of factors that are associated with NCD-protect and risk scores. Given that one is a protection score and the other a risk score, the same household factors cannot be associated with both, without mentioning the direction of the association.

Introduction:

Line 55: remove “a” before “low birth weight”.

Line 62: does it imply that undernutrition does not at all affect those who are not in the mentioned group at all?

Line 66-67: sentence unclear/check grammar.

Line 73-74 needs reference.

Line 78: by [12]- incorrect method of citation. Similarly in line 247, 278, and others.

Line 80: what is the age range for women of reproductive age?

Description of study area: this section can be made concise, e.g. the information on latitude, longitude and rainfall and irrigation schemes are somewhat unnecessary. More importantly, is the district primarily urban or rural?

Line 98: unclear/confusing sentence, consider rephrasing.

Data collection and sampling:

the FoodLAND project is introduced abruptly without description or future mention of it.

This section is 518 mothers while the abstract says 512.

Econometrics model:

Line 147: “a single model with two dependent variables…” is misleading, kindly rephrase.

I would assume that owning a mobile phone is correlated with household income, and if this is true, there is a possibility of collinearity between them. Similarly, income might be correlated to the household head being a male, explaining the results later that both income and having a male household head are associated with higher NCD-protect and risk scores and dietary diversity. I would suggest examining possible correlations between your dependent variables and if there is indeed a strong one, collinearity needs to be accounted for in the regression.

The variable names in equation 1 and 2 need to be defined.

Results: the association between the dependent variables and the sociodemographic variables needs to be unpacked and explained (direction and strength of the relationship and what they actually mean).

Line 250: check grammar.

Line 256-260: these two sentences are difficult to understand.

Line 279-282: I would avoid making a comparison between findings from rural Tanzania and that from the US and UK, as they have a completely different demography, level of development, and food market.

Some areas mention “NCD-protect” and sometimes “NCD-protective” is used.

Line 349: male household heads may also have more resources, not just access? Refer to my earlier comment on possible correlation between male household head and household income. Is there any literature that shows male household heads is associated with better nutrition in the family?

Line 369-370: see earlier comment in abstract.

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Reviewer #1: No

Reviewer #2: Yes:  Daphne C. Wu

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Attachments

Attachment

Submitted filename: PONE-D-24-02702 +reviewer comments.pdf

PONE-D-24-02702R1Consumption of protective and risk food groups for non-communicable diseases among women of reproductive age in rural areas of Morogoro, TanzaniaPLOS ONE

Dear Dr. Mwanri,

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.

 We have made suggestions as to how to bring the manuscript to the required professional level of writing. In the course of revisions you may also find other examples of similar errors (e.g. plural verbs with singular nouns, or singular verbs with plural nouns; inconsistencies in the way a specific term or acronym is written) and if so please also correct ones we may have missed. 

Please submit your revised manuscript by Dec 04 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'.
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• 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,

Susan Horton

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Thank you for responding to the two Reviews' comments. As Associate Editor, I am suggesting a substantial number of edits to make this into a professional-quality publication. It is extremely helpful for readers to be absolutely consistent in use of abbreviations, title, etc. I have gone through in detail and suggested many such changes, but please also do your own checking in case there are other examples I have missed. Using the "edit" and "find" commands in Word and going through the whole document can be helpful.

Here are my detailed suggestions:

All line numbers refer to originally submitted manuscript with “track changes” marked (not the revised clean version or the original clean version).

Line 37: “A structure questionnaire was used to collect demographic data and the Global Diet Quality Questionnaire was used to collect dietary intake dat for women” instead of “A structured questionnaire and the Global Diet Quality Questionnaire for women were used to collect demographic and dietary intake data”

Line 47: “employment or self-employment in agriculture” not “agriculture”

Line 52: suggest you define non-communicable diseases as “NCDs” not “NCD” and then use this consistently throughout

Line 52: Capitalize Agriculture (Ministry of Agriculture)

Line 64: retain word “both”

Line 75: suggest “and of underweight is 10%” not “and underweight of 10%”

Line 84: suggest “fat, salt” not “fat salt”

Line 94: use acronym “NCDs” since you have defined it above (and for any subsequent references)

Line 128: suggest “minimum dietary diversity score for women (MDD-W)” not “minimum dietary diversity score” (since MDD usually refers to the score for children). Then do a search and replace throughout to consistently abbreviate minimum dietary diversity score to MDD-W thereafter.

Line 130 “are free” not “it is free” (tools is plural)

Line 133: suggest you are consistent in the titles of the scores: e.g. “NCD-protect” and “NCD-risk” throughout (or “NCD-Protect” and “NCD-Risk” as in lines 134 and 140) but don’t switch between them. Do a search and replace. Also, keep them in the same order throughout when talking about both scores e.g. NCD-protect and risk, don’t switch to NCD-risk and protect as occurs at subsequent points in the text.

Line 154: “were used” not “was used” (variables, used in line 153, is plural)

Line 156 “Econometric model” not “Econometrics model”

Line 161: “were analyzed” (models is plural)

Line 171: delete “monthly” from food expenditure – if the expenditure is all monthly then define it that way at first usage, and thereafter do not add “monthly”. Need to be consistent

Lines 174 and 186: suggest “Agricultural Employment/Self-employment” – if defined here, then you can use “agricultural” as a short form later

Lines 175 and 187: “Sex of head of household is Male” (if that is correct)

Line 188: suggest you use title Minimum Dietary Diversity for Women; and you don’t need to redefine it in line 189 and 193 as it has been defined above.

Line 191: suggest add “:” before commencing the list

Line 193: suggest end the list with “and other vegetables and fruit”

Line 199: I think you mean “socio-demographic” not “social demographic”

Line 219: if you have redefined 0 monthly income as missing, then you need to give the actual minimum in line 219 and in the table below. Also in line 219, replace “1,550,000” with “1,550,000 TZS” for clarity, and state “mean monthly household income” not “average household income”

Line 213: suggest “26.4, with a standard deviation of 7.3” not “26.4 +/- 7.3” – this isn’t a confidence interval.

Line 229 and Table 3: use term baked/ grain-based sweets consistently (same format as QDQQ), here and elsewhere.

Line 241: Table 4b: add in table header NCD-Protect (mean+/-SD) and NCD-Risk (mean +/- SD). Also integrate table 4a as 2 additional lines in table 4b. You don’t need to retain the data on the ranges, since you don’t have those in table 4b.

Table 5: either state “Agricultural” or “Agricultural employment/self-employment” to be consistent. Also reorganize lines 153 and 154 as 4 additional lines of Table 5 (one row for RMSE, R-square and F. You can add asterisks to indicate significance to the F statistics, and then no row for P is required.

Table 6: make title Minimum Dietary Diversity for Women Score and replace DDS by MDD-W within the table

Renumber Table 6b as Table 7 (and change text references consistently). Consider carefully whether you really need 4 decimal places throughout table. 2 will likely suffice. Also relabel “Agicultural employment” either as “Agricultural” or “Agricultural employment/self-employment”

Line 321: “younger counterparts” not “counterparts”

Line 345: “NCD-risk” not “NCDs-risk”

Line 350: “french fries” not “French fries”

Line 355: “minimum” not “medium”

Line 387: “chores which” not “chores”

Line 390: “MDD-W” not “minimum dietary diversity”; note that this change should be made throughout. MDD refers to children’s diet diversity, and data on this has not been presented in this study. In line 398, do these other studies look at “adequate dietary diversity” or do they look at MDD-W?

Line 407: “MDD-W” not “MDD) – same as previous comment.

Line 411: Ministry of Agriculture” not “Ministry of agriculture”; similar comment re “ministry of education” in following sentence.

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Consumption of protective and risk food groups for non-communicable diseases among women of reproductive age in rural areas of Morogoro, Tanzania

PONE-D-24-02702R2

Dear Dr. Mwanri,

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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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,

Susan Horton

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

You may wish to provide the exact reference for calculating NCD-risk and NCD-protect which is https://drive.google.com/file/d/1eplRm9i5_109-a5Ac1Lqj-lUI3VgVIFx/view It can probably be found somehow from reference [15] in the paper, but would take effort.

Please also consider the following small edits. Line numbers below refer to tracked changes version of revised document. Reviewer 1 has also suggested some small edits.

Line 37 (abstract): “structured” not “structure”

Line 47: “NCD-protect” not “protect”

Line 49 “with NCD-protect” not “NCD protect”

Line 196: “Ten food groups that include” not “includes”

Bottom of table 5: the coefficient on the constant is also significant (add asterisks). Same in table 7.

Lines 288-289. What does “consumption in by 97%” mean? Are there missing words here?

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)

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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: Yes

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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: The majority of concerns have been addressed by the authors. There are still a few minor edits to enhance the quality of the final version, which I have suggested in the attached file.

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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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Submitted filename: PONE-D-24-02702_R2 +reviewer edits.pdf