Association of food environment with diet quality and Body Mass Index (BMI) of school-going adolescents in Nepal

Pragya Sharma; Neha Limaye; Rajeeb Kumar Sah; Archana Shrestha

doi:10.1371/journal.pone.0321524

Peer Review History

Original SubmissionAugust 28, 2024
28 Aug 2024 Author Response https://doi.org/10.1371/journal.pone.0321524.r001
28 Dec 2024 Decision Letter - Larissa Mendes, Editor PONE-D-24-36721Association of Food Environment with Diet Quality and Body Mass Index (BMI) of School-going Adolescents in NepalPLOS ONE Dear Dr. Sharma, 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. Please submit your revised manuscript by Feb 11 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. 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Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: 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: Yes Reviewer #2: Yes ****** 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: No Reviewer #2: 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 aimed to determine how certain features of the home food environment affect the diet quality and Body Mass Index (BMI) of school-going adolescents. The methods are well described, but some parts need more explanation and discussion. I recommend checking all the text for clarity and consistency of information. Sometimes, the writing makes the text difficult to read. Furthermore, the manuscript is not in the journal's template, which has many details of how to present each section of the manuscript. Methods I did not find Table 1, but your work includes many tables and images, more than the journal allows. So, I recommend including Table 1 in the supporting files. Which software did you use to do the statistical analysis? You need to mention this in your manuscript. Results I recommend doing more complete title tables, including the place and year of the study. I did not find Figure 2. And where is Figure 1? You did not mention it in the text? In Tables 3 and 4, did you think to characterize your sample by GDR score (categorized) and BMI (categorized)? It would be interesting to see if there is some kind of difference. Table 4: In the footnote, include all the aspects you included in model 3 of the home food environment. You also need to make clear the outcome variable of your model. You can put the outcome variable in a line above the models. Based on my comments on Table 4, I recommend revising Table 5. You do not put a footnote in Table 5. Discussion I miss citations of studies about the importance of the school environment in adolescents’ food consumption. In the third paragraph, you did not cite one article to discuss this theme; in the next paragraph, when you cited this theme again, you did not mention any previous work. In your discussion, you cite other works that found similar results. However, I miss you discussing possible reasons for the findings you found, reasons that could justify why you see some patterns in your sample. You only mention the conceptual framework in the discussion. It should be mentioned in your methods and explain how you use it. Furthermore, citing the supplementary material in the text is recommended so the readers can go to the site and learn that these files exist and learn more about your work. Reviewer #2: General Considerations The article has a clear line of reasoning consistent with the components of the text. The procedures used are described in a way that allows for the replication of the study. The instruments appear to be appropriate and utilize reliable methods for data treatment. The conclusions address the objective proposed by the authors. The following corrections are suggested to enhance the value of the work for future publication. Specific Comments: Title: Appropriate and conveys the study’s purpose. Abstract: Well-written and consistent. I believe the conclusion could be phrased more effectively. Introduction: Clearly presents and connects the facts related to the topic. However, I felt the need for a deeper exploration of the concepts related to the home food environment, as addressed in Gálvez-Espinoza’s (2017) conceptual model, which explores the food environment in Low- and Middle-Income Countries (LMICs). Additionally, it lacks an overview of the nutritional status of adolescents in Nepal, which would better contextualize the findings in the discussion. Moreover, the second paragraph is somewhat confusing. I suggest using this paragraph to discuss the GDR and its relevance to this type of study or why assessing diet quality is important in this population. Nonetheless, after reading the introduction in its entirety, the motivations for conducting the study are clear. Methods: Comprehensive and explanatory, allowing for easy replication of the study. My suggestion is to clarify exactly which sociodemographic variables were used in each regression model, as there are many. Results: The results are clearly presented and support the subsequent discussions. Regarding the tables, the captions could be more explicit, in line with the earlier suggestion about detailing the sociodemographic variables used in each regression model. Additionally, what is the relevance of the data on the "most popular media source"? It is shown in Table 2 but was not used in any analysis. Was there a hypothesis regarding this variable? Discussion: The discussion addresses all the results and corroborates the findings with prior literature, but I found the text a bit tedious due to its repetitive structure in each paragraph: presenting the finding in one sentence, bringing in one or two studies that support or contradict it, and then offering hypotheses. I suggest rewriting and better connecting the paragraphs for smoother reading. I am uncertain about the conclusion that positive parental modeling is associated with higher BMI being a healthy pattern. What is the predominant nutritional status of adolescents in the same age group in the country? Is there any population-based study that supports this conclusion? I did not find references cited in this paragraph. Conclusion: Clear and addresses the study question while proposing future studies to address questions this study could not answer. Regarding the writing, ensure that all parentheses are properly opened and closed. ****** 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 Reviewer #2: 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. https://doi.org/10.1371/journal.pone.0321524.r002
Revision 1
4 Mar 2025 Author Response Response to Comments: 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 Response: We have checked for templates and inserted line numbers to the document, and we have followed PLOS ONE's style requirements for file naming too. 2. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical. Response: The title of the article has been revised as “Association of food environment with diet quality and Body Mass Index (BMI) of school-going adolescents in Nepal”, in the manuscript as that in online submission form. 3. Please ensure that you refer to Figure 2 in your text as, if accepted, production will need this reference to link the reader to the figure. Response: The text “S2 Figure 2: Body Mass Index (BMI) Chart of the participants ” is in the Results section (Page number 13). 4. Please remove all personal information, ensure that the data shared are in accordance with participant consent, and re-upload a fully anonymized data set. Response: All the personal information, including name, contact number and also the participant ID have been removed in the re-uploaded data set. Response to Reviewers Reviewer 1: Methods Comment: I did not find Table 1, but your work includes many tables and images, more than the journal allows. So, I recommend including Table 1 in the supporting files. Which software did you use to do the statistical analysis? You need to mention this in your manuscript. Response: The table is included in supplementary information and named as “S3 Table: Food groups and the corresponding items”. This way we have renumbered tables and we tables numbered 1-4 in the Result section as compared to 1-5 previously. We have now included the following sentence under the Statistical Analysis section in the Methods to clarify the software used: "All statistical analyses were conducted using STATA version 14." Results Comment: I recommend doing more complete title tables, including the place and year of the study. Response: We have revised the titles by adding place and year of study as follows: “Table 1: Socio-demographic characteristics of the participants (n = 678) - Budanilkantha, Nepal, 2022 Table 2: Characteristics of the Participants' Parents (n=678) - Budanilkantha, Nepal, 2022 Table 3: Associations of Home Food Environment with Diet Quality (GDR Score) - Budanilkantha, Nepal, 2022 Table 4: Association of Home Food Environment with BMI - Budanilkantha, Nepal, 2022” Comment: I did not find Figure 2. And where is Figure 1? You did not mention it in the text? Response: Figure 1 and Figure 2 are included in supplementary information. Figure 1 is named as S1 Figure 1: Conceptual Framework of the Study and S2 Figure 2: Body Mass Index (BMI) Chart of the participants. Figure 1 is mentioned in the text in the second last paragraph of Methods section as follows: “The conceptual model (S1 Figure 1) illustrates the hypothesized relationships among the home food environment, diet quality, BMI and other covariates that include socio-demographic characteristics and lifestyle factors. It also guided the selection of variables for data collection and informed the data analysis by providing a structured approach to examine the interactions among the assessed variables.” Figure 2 is mentioned in the text as “S2 Figure 2: Body Mass Index (BMI) Chart of the participants” in the Result section. Comment: In Tables 3 and 4, did you think to characterize your sample by GDR score (categorized) and BMI (categorized)? It would be interesting to see if there is some kind of difference. Response: The GDR score is a score with a range from 0 to 18 that indicates adherence to global dietary recommendations, which include dietary factors protective against non-communicable diseases. [21] We used GDR score in its continuous variable form during the analyses to capture the level of healthy eating and also avoid arbitrary groupings, as this could introduce potential bias. In addition to this, variables in continuous forms allow greater statistical power in our analyses which is why we kept both of the outcome variables (GDR Score and BMI) in their continuous forms in the analyses. Comment: Table 3: In the footnote, include all the aspects you included in model 3 of the home food environment. Response: In table 3, in the footnote, “other aspects of home food environment” has been replaced with “aspects of home food environment that include home food availability, accessibility to shops, parental modeling and parenting style” and the model 3 has been written as follows: “Model 3: Multivariate Analysis of Features of Home Food Environment with Diet Quality (GDR) Score adjusting for Socio-demographics, Physical Activity, Smoking Status and aspects of home food environment that include home food availability, accessibility to shops, parental modeling and parenting style” Comment: You also need to make clear the outcome variable of your model. You can put the outcome variable in a line above the models. Response: In the footnote of table 3, this text has been added: “Outcome variable: Global Dietary Recommendations (GDR) score indicating the diet quality” In the footnote of table 4, this text has been added: “Outcome variable: Body Mass Index (BMI)” Comment: Based on my comments on Table 3, I recommend revising Table 4. You do not put a footnote in Table 4. Response: Footnotes have been added to table 4 as well just like that in table 3 as follows: “* Model 1: Bivariate Analysis of Features of Home Food Environment with Diet Quality (GDR) Score Model 2: Multivariate Analysis of Features of Home Food Environment with Diet Quality (GDR) Score Adjusting for Socio-demographics, Physical Activity and Smoking Status * Model 3: Multivariate Analysis of Features of Home Food Environment with Diet Quality (GDR) Score adjusting for Socio-demographics, Physical Activity, Smoking Status and aspects of home food environment that include home food availability, accessibility to shops, parental modeling and parenting style” Discussion Comment: I miss citations of studies about the importance of the school environment in adolescents’ food consumption. In the third paragraph, you did not cite one article to discuss this theme; in the next paragraph, when you cited this theme again, you did not mention any previous work. Response: Thank you for notifying us of this. In the third paragraph of the discussion section, the citation has been added to this text: “It did not consider the distance from their schools, which could also play a significant role in their eating habits, as adolescents might spend a significant portion of their day at school [29] and could purchase food from vendors near their school instead of near their home as the accessibility of street food in neighborhoods close to schools may have a big impact on their dietary choices. [32]” In the fourth paragraph of the discussion section, the citation has been added to this text: “These contradicting results may be influenced by other factors, such as the consumption of food outside the home, particularly at school, which can affect diet quality regardless of what is available at home. [32]” Comment: In your discussion, you cite other works that found similar results. However, I miss you discussing possible reasons for the findings you found, reasons that could justify why you see some patterns in your sample. Response: Thank you for the comments. We have addressed it by adding additional texts explaining the reasons for the patterns in our sample. The new texts are pasted below and presented in bold text: “Adolescents had lower diet quality scores when they lived at a walking distance of less than 10 minutes or greater than 20 minutes to a vegetable shop; this association did not exist for accessibility of fruit shops. Studies [26], [27] have documented that increased accessibility was positively associated with fruit and vegetable intake in children, but this was not seen in our findings. A number of contextual factors may explain this discrepancy. One possible explanation for the lower diet quality associated with vegetable shops farther away is that these places may have fewer overall healthy food alternatives or be located in communities with limited access to fresh produce markets. Furthermore, greater distances to vegetable shops could exacerbate the challenges associated with transportation, time constraints, and economic barriers to purchasing fresh produce. This could lead to a general lack of access to a diverse range of fresh and healthy foods, not only vegetables, resulting in a lower quality diet. Adolescents also had lower diet quality scores when they lived within 10 minutes or > 20 minutes from street food vendors. However, it's important to note that the study only measured the accessibility to street food shops from the adolescents' homes. It did not consider the distance from their schools, which could also play a significant role in their eating habits, as adolescents might spend a significant portion of their day at school [29] and could purchase food from vendors near their school instead of near their home as the accessibility of street food in neighborhoods close to schools may have a big impact on their dietary choices. [32] One of the intriguing findings in our study was the negative association between availability of starchy foods, particularly rice, and BMI. Starchy foods, particularly rice, are part of the staple diet in almost every Nepalese household. Everyday availability of certain foods at home is expected to affect the diet pattern and hence the BMI, as seen in a national US study [35]. Starchy food items such as rice contain carbohydrates which are known to contribute to increasing the body weight and would raise the BMI [36] but we found that home availability of a starchy staple in the past day was associated with a lower BMI. This unexpected finding may be attributed to the small number of adolescents (15 out of 678) who reported not having starchy staples available at home, which limits the generalizability of the result. Other dietary factors such as portion sizes and eating frequency that this study did not measure may explain this paradoxical finding. Hence, this finding should be interpreted with caution, as the small sample of respondents without availability of starchy staples at home may not adequately represent broader trends within the population. Positive parental modeling was associated with a higher BMI. Since the majority of our study participants were either underweight (41%) or had a normal weight (47%), a higher BMI might indicate better health status in our study population. Adolescent Nutrition Survey in Nepal, 2014 indicated that 42.2 % of adolescents aged 15-19 years were underweight, 55.9 % had a normal weight and only 1.8 % were overweight. [18] The NDHS 2022 also reported that only 5% of the adolescent girls aged 15-19 years were overweight and less than 1% were obese. [24] These data suggest that higher BMI likely indicates better health status in our population, hence, this finding is in expected direction as better eating practices of parents is suggested by positive parental modeling.” Comment: You only mention the conceptual framework in the discussion. It should be mentioned in your methods and explain how you use it. Furthermore, citing the supplementary material in the text is recommended so the readers can go to the site and learn that these files exist and learn more about your work. Response: Apologies for the confusion. The conceptual framework mentioned in the discussion section is not that of the study but of the food environment. We clarified this further in the second last paragraph of our discussion section and have also provided citation to the supplementary material as follows: “There are several strengths to this study. First, to our knowledge, the food environment has not been studied before in Nepalese adolescents and this study is first of its kind in Nepal. Second, for our characterization of the food environment, assessment of home food availability and diet quality, and measurement of parenting style, we have used validated conceptual frameworks of the food environment [10] and tools along with expert suggestions, and pretested all tools that were used.” and citation of the conceptual framework has been added too. Also, details on conceptual framework has been added in the methods section in the second last paragraph as follows: “A conceptual framework was developed to guide the study, illustrating the relationship between home food environment, diet quality, and BMI among adolescents. The framework allowed identification of the variables and their interaction among each other. The conceptual model (Figure 1) illustrates the hypothesized relationships among the home food environment, diet quality, BMI and other covariates that include socio-demographic characteristics and lifestyle factors. It also guided the selection of variables for data collection and informed the data analysis by providing a structured approach to examine the interactions among the assessed variables.” Reviewer 2: Abstract: Comment: Well-written and consistent. I believe the conclusion could be phrased more effectively. Response: Thank you. We have rephrased the conclusion in abstract as follows: “This study highlights the impact of home food environment on diet quality and BMI among adolescents in urban Nepal. Availability of healthy foods positively affects diet quality, while that of unhealthy items negatively influences it. Future research should explore broader food environmental factors and intervention strategies to improve adolescents’ diet quality.” Introduction: Comment: Clearly presents and connects the facts related to the topic. However, I felt the need for a deeper exploration of the concepts related to the home food environment, as addressed in Gálvez-Espinoza’s (2017) conceptual model, which explores the food environment in Low- and Middle-Income Countries (LMICs). Response: Thank you for the comment. Regarding concepts on food environment, we have accessed info from the paper titled “Concepts and critical perspectives for food environment research: A global framework with implications for action in low- and middle-income countries” and its reference has been provided in our paper. Turner C, Aggarwal A, Walls H, Herforth A, Drewnowski A, Coates J, et al. Concepts and critical perspectives for food environment research: A global framework with implications for action in low- and middle-income countries. Global Food Security. 2018;18: 93–101. doi:10.1016/j.gfs.2018.08.003 We have added the following text in the third paragraph of introduction section to clarify this more: “The food environment influences food acquisition and consumption of the individuals. It includes external factors such as food availability and price as well as individual determinants like accessibility and affordability.[10]” Comment: Additionally, it lacks an overview of the nutritional status of adolescents in Nepal, which would better contextualize the findings in the discussion. Response: Thank you for the comment. We have added the following information on this in the third last paragraph of the introduction section: Regarding overview of the nutritional status of adolescents in Nepal, this info has been added in the third last paragraph of Introduction section: “The Nepal Demographic and Health Survey 2022 reports that among adolescent girls aged 15-19 years, 27% are of short stature (indicating stunting), 26% are thin (indicating undernutrition), 5% are overweight, and less than 1% are obese, while among adolescent boys of the same age group, 7% are of short stature (indicating stu Attachments Attachment Submitted filename: Response to Reviewers .docx https://doi.org/10.1371/journal.pone.0321524.r003
10 Mar 2025 Decision Letter - Larissa Mendes, Editor Association of food environment with diet quality and Body Mass Index (BMI) of school-going adolescents in Nepal PONE-D-24-36721R1 Dear Dr. Sharma, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Larissa Loures Mendes, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): The revision met all the demands and suggestions of the reviewers and I believe that the article in its current format will contribute to the advancement of the theme of food environments. https://doi.org/10.1371/journal.pone.0321524.r004
Formally Accepted
Acceptance Letter - Larissa Mendes, Editor PONE-D-24-36721R1 PLOS ONE Dear Dr. Sharma, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Larissa Loures Mendes Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0321524.r005

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