PONE-D-24-52592Socioeconomic Disparities in Growth and Nutritional Status Among Primary School Children in Central Sudan: A Potential Association with School MealsPLOS ONE

Dear Dr. Alhassan,

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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Dear Dr Mohammed,

This is an important topic that you have discussed in your manuscript.

Please go through the major comments provided by the reviewers and answer them one by one.

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Bilal Ahmad Rahimi, M.D., D.T.M.&H., M.C.T.P., Ph.D

Academic Editor

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: 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: Yes

Reviewer #2: Yes

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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: The authors have not categorically pointed out the inculsion and exclusion crieteria for the subject sample. Sample size (506) does not represent the socioeconomic disparities associated with growth and nutritional status of the children at national level hence a larger study is needed to depict if the same situation prevail in the country. There have been spelling and grammar mistakes in the text which need to be addressed. The verbatin while interpreting data has to be avoided as it creats a bit confusion for the readers implying the article should have more clarity.

Reviewer #2: REVIEWER’S COMMENTS

I commend the authors for the efforts put into this study on socioeconomic disparities in growth and nutritional status among primary school children in Central Sudan: A potential association with school meals. The shows potentials for interventions to promote child growth. The following comments may help to improve the manuscript for publication.

Title: Growth should be expunged in the title as direct growth assessment was not conducted. The growth indices assessed depict nutritional status.

Abstract

The method section of the abstract is not detailed enough to show how the objective was achieved. Was comparison of the Z scores between private and public schools the only assessment conducted? The study design, sample size and sampling techniques used are missing. Which data collection methods were employed? How were the data analysed? The title showed that the authors also assessed growth. How was this conducted?

The results are clear but results on growth is missing. It is either removed in the title or the missing part included. By growth, I expected to see baseline and endline values and mean differences that shows increase or decrease in growth parameters (weight, height, BMI). When these parameters are related to age or any other parameter, it becomes an index of nutritional status.

Growth used in the conclusion is inappropriate because growth was not assessed. The authors assessed nutritional status; the growth indicators are not direct assessment of growth pattern.

The key words should also be reviewed in line with this statement.

Introduction

weight for height or body mass index (BMI) for age: these are indices and should be written as compound words.

Materials and methods

1. We estimated a sample size of 392: This statement is inappropriate. The authors estimated the sample size instead of calculating it based on a prevalence of malnutrition of 15%, a confidence limit of 5%, a cluster effect of 2 and a 95% confidence level. Is there any explanation for this? The authors estimated a sample size of 392 but distributed 1000 consent forms. What was the essence of estimating (uncalculated) the sample size. It appears that selection of the pupils for the study was dependent on return of consent forms. It is also not clear how they arrived at the 1000 pupils given the forms. How many children were selected from each of the areas (public/private) schools and on what basis. Same applies to each of the schools.

2. A random sample of healthy children aged 5 and 10 years was selected from each school: How did the authors establish that the children were healthy? There are different types of random sampling. The authors should describe the ones used. Sampling technique is an important aspect of research. The authors should detail step by step how the sample was selected.

3. The school sector was used as a proxy for socioeconomic class: How could this be? Was it extremely difficult to elicit and classify the socioeconomic status of the parents/guardians? Some middle and low socio-economic class parents who appreciate the benefits of good education strive against all odds to offer their children good education.

4. Prior to data collection, a pen-and-paper questionnaire was sent to the children's parents or guardians, seeking their informed consent for their child's participation: How did the authors handle rejection because it is obvious they did not meet the parents to explain.

Results

1. The authors estimated a sample size of 392 but distributed 1000 consent forms to parents/guardians of the primary school children. Out of which 506 were returned recruited in the study. What was the reason for sending out 1000 consent forms? It implies that selection of the pupils for the study was dependent on return of consent forms. It is also not clear how they arrived at the 1000 pupils given the forms.

2. Table 1: Please change Character to variables.

3. The total after each variable should be expunged since there is total beneath the headings.

4. The m in the table should be written in full or explained as a footnote.

5. Monthly income category: The options under this variable is not clear. Example, Have to debt and saving do not show monthly income.

6. School meal availability/intake: This is not clear. Availability and intake (consumption) are not the same.

7. Chi-squared or Fisher’s exact: Which one did the authors use?

8. Nutritional status and anthropometric measurements by school sector: What is the difference between nutritional status and anthropometric measurements? There are no weight and height measurements values in the table.

9. Figure 3: Pupils from public schools were 320. Out of this, 270 consume school meals and 44 did not giving a total of 314 instead of 320. Is there an explanation for this discrepancy?

10. Table 2 summarizes the stature and nutritional status: Is stature (height) not a parameter for assessing nutrition status? HAZ, WAZ, BMIAZ are all nutritional status indices.

Discussion

1. Growth is measured through nutritional status assessment. Using both the way it is seen in this study is somehow not clear. Increases or decreases in anthropometric parameters (weight, height, BMI) were not studied.

2. Future research should aim to identify and investigate these factors: This better as Future research should aim to investigate and identify these factors.

3. School meals mentioned in this study did not specify if the meals were caregiver provided or government provided. Figure 3 shows that some children in public schools did not consume school meals.

References

1. Ref 18 should be reviewed for journal title and appropriate punctuations.

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Reviewer #1: Yes:  That's Ok

Reviewer #2: Yes:  Professor Rufina N. B. Ayogu

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<div>PONE-D-24-52592R1Socioeconomic Disparities in Growth and Nutritional Status Among Primary School Children in Central Sudan: A Potential Association with School MealsPLOS ONE

Dear Dr. Alhassan,

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.

==============================Dear Alhassan,You have addressed the comments, but there are still minor comments you need to address.Best wishes ==============================

Please submit your revised manuscript by Apr 16 2025 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:

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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,

Bilal Ahmad Rahimi, M.D., D.T.M.&H., M.C.T.P., Ph.D

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.

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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

Reviewer #2: (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

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: 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: Yes

Reviewer #2: 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 #1: Yes

Reviewer #2: 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 paper seems too lengthy and can be cut short if this does not impact the overall structure and findings of this pieace of research

Reviewer #2: Reviewer’s comment: I have read the authors’ response to the comments on growth and nutrition status. According to UNICEF ‘Weight gain is the most important sign that a child is healthy and is growing and developing well’ This is one of the basis for the suggestion to expunge growth.

https://www.unicef.org/uganda/key-practice-monitoring-growth-and-development-child#:~:text=Weight%20gain%20is%20the%20most,if%20the%20child%20is%20overweight.

Based on this reference, I would like to explain a bit further that when data on weight, height and BMI are obtained using a cross-sectional survey design, the single data are related to the child’s age and sex and compared to child growth standards as explained by the authors. This comparison yields anthropometric indices (weight-for-age and others) which are interpreted to showcase anthropometric status (a component of nutrition status) such as stunting, wasting, thinness and underweight. These can be used to identify children who are growing well. For the term growth to be used in a title of a manuscript, I expected to see weight gain calculated and not necessarily growth velocity/growth rate which are extension of growth assessment. Weight gain or weight loss as shown by UNICEF is the most important indicator of growth status. This is lacking in the manuscript. Besides, nutrition status assessment has 4 components (anthropometric, biochemical, clinical and dietary components). In assessment of nutrition status of individuals, at least 2 components should be used otherwise the specific component assessed (in this case anthropometric status) should be named and not the broad heading (nutritional status) despite the fact that some journals have published them. In the study under discourse, the authors used only anthropometry (one out of four) and therefore should use the term (anthropometric status) instead of nutrition status (for specificity). Again, their use of growth and nutrition status sort of separated growth from nutrition status which is correct because through out the study, they did not show weight status (gain or loss) or linear growth but compared the current anthropometric measurements as obtained cross sectionally with age and sex and interpreted them in line with child growth standards. Comparing anthropometric indices (HAZ, WAZ, BMIAZ, WHZ) with child growth standards would not yield data on growth status (gain or loss) but anthropometric status as normal, retarded (stunting, underweight, thinness and wasting) or above normal (overweight, obesity, too tall). Granted that some published articles may have used this same title, it does not seem to be correct. Based on this, I would suggest a rephrase of the title as Socioeconomic Disparities in Anthropometric Status Among Primary School Children in Central Sudan: A Potential Association with School Meals. This makes the title very specific to what the authors studied. Anthropometric assessment alone cannot showcase nutrition status as explained above. This is because nutrition status is much more than anthropometric status.

A study published in PLOS ONE journal showed growth and nutritional status clearly and there is no doubt about its title. Please see Hamid Namaganda L, Andrews C, Wabwire-Mangen F, Peterson S, Forssberg H, Kakooza-Mwesige A (2023) Nutritional status and growth of children and adolescents with and without cerebral palsy in eastern Uganda: A longitudinal comparative analysis. PLOS Glob Public Health 3(6): e0001241. ttps://doi.org/10.1371/journal.pgph.0001241

The authors may also wish to look at this article for growth assessment: Zoleko-Manego R, Mischlinger J, Dejon-Agobé JC, Basra A, Mackanga JR, Akerey Diop D, et al. (2021) Birth weight, growth, nutritional status and mortality of infants from Lambaréné and Fougamou in Gabon in their first year of life. PLoS ONE 16(2): e0246694. https://doi.org/10.1371/journal.pone.0246694.

Response: We sincerely appreciate the reviewer's comment. However, we respectfully disagree with the suggestion to remove 'growth' from the title for the following reasons:

• Our study, certainly, assessed growth using standard anthropometric measures:

We measured height, weight, and BMI and plotted them on established growth charts, which is the standard method for assessing one-point growth status in children.

Reviewer’s response: When this is done, the outcome is anthropometric status, one aspect of nutrition status assessment.

o This is the same approach used in clinical practice and epidemiological studies to assess child growth (https://www.cdc.gov/growthcharts/background.htm).

Reviewer’s response: Actually, it is to assess anthropometric status an aspect of nutrition status assessment as shown in the result section of this study.

• Nutritional status was assessed as a reflection of growth assessment:

Reviewer’s response: Anthropometric status and not nutrition status (one component out of 4 was assessed)

o We could not have assessed nutritional status without first assessing growth through these standard anthropometric indices.

Reviewer’s response: If you assessed growth, what was the outcome of your assessment? No table showed this.

o Both assessments were conducted at a single point in time, aligning with widely accepted methodologies (https://www.ncbi.nlm.nih.gov/books/NBK537315).

• Cross-sectional (one-off) growth assessments are an established method in child health research:

Reviewer’s response: I would rather say that anthropometric assessments are.

o The CDC growth charts, one of the most widely used references, were developed using this exact approach—measuring different children’s growth at different ages rather than tracking growth velocity over time.

Reviewer’s response: The emphasis is far from growth velocity.

o It is common practice in both clinical and public health research to use single-time-point growth assessments to evaluate children's health status (https://pubmed.ncbi.nlm.nih.gov/12043359).

Reviewer’s response: No doubt about this but it requires further assessment beyond what anthropometry reveals.

• We used 'growth charts,' not 'nutritional status charts.'

Reviewer’s response: There is no thing as nutritional status charts but child growth charts which reveal anthropometric status, a component of nutrition status.

o The charts and Z-score standards we used are called 'growth charts,' not 'nutritional status charts.'

o Removing 'growth' would inaccurately reflect the standard terminology used in growth and nutritional research (https://www.who.int/tools/child-growth-standards/standards).

Reviewer’s response: No, studies should report specifically what they revealed. This study was on anthropometric status of children using anthropometric indices (weight-for-age, height-for-age and BMI-for-age Z scores).

• Title relevance and study visibility:

o Keeping 'growth' in the title is essential for clarity, accuracy, and search visibility in scientific literature.

Reviewer’s response: Only if the authors assessed growth. They assessed anthropometric status using anthropometric indices derived from anthropometric measurements specific to age and sex.

o It correctly represents the study’s focus and ensures it is easily identified by relevant readers and researchers.

• Clarification on what we did not assess:

o We did not assess longitudinal growth velocity (growth rate over time), which seems to be the reviewer's concern.

Reviewer’s response: Of course, no data showed this. The issue is growth status and not growth rate. There is no way this study would show growth rate since it is design is cross sectional.

o However, cross-sectional growth assessments remain the primary method for evaluating child growth and nutritional status in epidemiological studies (https://www.cdc.gov/growth-chart-training/hcp/using-growth-charts/who-methodology.html).

Reviewer’s response: Cross-sectional growth assessments: the correct phrase is: cross sectional anthropometric assessment using WHO child growth standards. These standards relate anthropometric measurements/calculations (weight, height, BMI) to the age and sex of healthy children in the populations to identify those with deficits or excesses. It is not enough to assess nutrition status with only one component. It may be allowed but it is not appropriate to use nutrition status when this is done.

Given these points, we respectfully request that the reviewer reconsider this suggestion and allow us to retain 'growth' in the title and relevant sections.

Reviewer’s response: I am not convinced that the authors assessed growth of the children. They assessed anthropometric status by taking weight and height measurements and calculating BMI in a cross sectional study. They used child growth standards specific to age and sex to evaluate these parameters and arrived at the anthropometric status of the children showcasing their Z scores. The result section showed these clearly.

Reviewer comment: Abstract: The method section of the abstract is not detailed enough to show how the objective was achieved. Was comparison of the Z scores between private and public schools the only assessment conducted? The study design, sample size and sampling techniques used are missing. Which data collection methods were employed? How were the data analysed? The title showed that the authors also assessed growth. How was this conducted?

Response: We thank the reviewer for her valuable comments. We have revised the abstract to provide additional methodological details, including the study design, sample size, sampling method, data collection approach, and statistical analyses.

Regarding the reviewer's last point, we have already clarified in our previous response that growth was assessed using standard anthropometric measures (height, weight, and BMI), which were plotted on WHO growth charts. This remains the standard approach for evaluating growth at a single point in time in both clinical and epidemiological settings.

Reviewer’s response: What do the authors have as outcome of using standard anthropometric measures (height, weight, and BMI), plotted on WHO growth charts? If we take it that growth is assessed using anthropometric indices, what do the authors mean by nutrition status then? Would it not be unnecessary repetition? Anthropometry alone cannot stand for nutrition status because it is only one out of 4 components of nutrition status.

We cannot have growth and at the same time nutrition status in the same title where growth was not assessed to show gain or loss but growth parameters were related to age and sex to arrive at anthropometric indices and thus status. I am not satisfied with the explanation because the specific term assessed is missing in the title. Article titles should be direct, accurate and appropriate, precise and should not be misleading.

Reviewer’s response: How the weight and height values were converted into Z-scores is missing in the manuscript. How did the authors obtain BMI data before converting to Z scores? These details are necessary.

As discussed in our previous response, our study followed this standard cross-sectional methodology, making it an appropriate and widely accepted approach. We hope this clarification addresses the reviewer’s concern.

Reviewer’s response: ‘baseline and endline measurements reflects growth velocity assessment (growth rate over time)’. Not always, it depends on what the authors want to achieve. When the weights are plotted, a graph is produced to reveal weight gain, loss or static weight. The authors assessed anthropometric status of the children using growth parameters of weight, height and BMI. These were compared to sex and age and the indices interpreted to yield anthropometric status which is but one component of nutrition status.

Abstract conclusion

Reviewer’s response: Public school children exhibit unfavorable growth and nutritional status: Does this sentence imply that growth and nutrition status are one word or can be used interchangeably? There is no table or graph showing the growth status to be precise.

Revised text: We have reviewed the manuscript to ensure consistent usage of these terms following standard scientific conventions.

Reviewer’s response: All the anthropometric indices are written as compound words using hyphens, please.

Reviewer’s response: The use of the word around in ‘around 90000 primary school children’ showed approximation. Is it that the authors could not assess school registers to arrive at the exact population?

Revised text: A simple random sample of children aged 5–10 years was selected from each school using a list of enrollees in grades matching the eligible age groups. A simple manual selection method was applied, where names of all listed students were drawn randomly by the investigator. Those selected were checked for eligibility, and if found ineligible, replacements were drawn using the same random selection process."

Reviewer’s response: This is fine but it is obvious the authors do not want to disclose the number selected per school. It would have been good to see how the 1000 consent forms were distributed among the 10 schools.

Reviewer’s response: I would want to believe that the entire 10 schools had population that represented them well.

Reviewer’s response: Table 1: Please indicate that the ages are in years.

Reviewer’s response: Table 2: The reason for using Nutritional Status and Growth Z-scores in the same title is not clear.

Reviewer’s response: Title of Table 2 should be adjusted to: Mean Growth Z-scores and anthropometric status of the children.

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Reviewer #1: No

Reviewer #2: Yes:  Rufina Ayogu

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Socioeconomic Disparities in Anthropometric Status Among Primary School Children: A Potential Association with School Meals

PONE-D-24-52592R2

Dear Dr. Alhassan,

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