PONE-D-25-18917The validity of mid-upper arm circumference as an indicator of underweight, overweight and obesity adults in BangladeshPLOS ONE

Dear Dr. Kamruzzaman,

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ACADEMIC EDITOR: Experts in the field have reviewed your manuscript and you are expected to address their comments as early as possible. Thank you./>==============================

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Academic Editor

PLOS 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: Yes

Reviewer #2: Yes

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

Reviewer #1: I Don't Know

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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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: This manuscript presents a well-conducted analysis using a nationally representative dataset (BDHS 2017–18) to propose sex- and age-specific mid-upper arm circumference (MUAC) cut-offs for identifying underweight, overweight, and obesity among adults in Bangladesh. The methods are statistically sound, and the manuscript is generally well-organized. However, several areas could be improved to strengthen the overall quality and clarity of the paper. As I do not have sufficient expertise in the advanced statistical methods applied in this study, I recommend that a statistician review the analytical components to ensure their appropriateness and robustness.

Introduction:

1.The introduction is well-written, but could be made more concise by removing some repetitive information.

2.While the strengths of MUAC are discussed, its limitations are not adequately addressed. For example, MUAC measurements may be less accurate in individuals with conditions like edema or muscle hypertrophy or variations in measurement technique. In some circumstances, it might be best to complement MUAC with other anthropometric indicators to provide a more complete picture.

Methods:

1.Please justify the selection of age groups (18–40, 40–60, >60). Were these based on previous studies, expert opinion, or data-driven criteria?

2.Line 222: The Youden Index is mentioned as the method for determining cut-off points. Please ensure consistent spelling throughout the text.

3.Lines 227–230: Restricted cubic spline analysis is appropriate, but the number and placement of knots should be explained, e.g., was it based on the AIC criteria?.

4.Line 237: Please use decimal points (.) consistently in accordance with English language conventions, rather than commas (,).

5.Please indicate whether any data were missing and how missing values were handled.

6.Consider moving the ethical approval and data access information into a separate subsection titled “Ethics Approval and Data Availability” to improve clarity and organization.

Results:

1.The Results section is quite dense and could be difficult to follow. Adding subheadings for different analysis components could enhance readability.

2.Please define all abbreviations in tables and figures, including “+PV” and “–PV,” in the footnotes to ensure they are self-explanatory.

Discussion:

1.The discussion does not explain why MUAC cut-offs are lower in older adults or the biological basis of sex-specific differences. Please consider discussing age-related muscle mass loss and fat redistribution as possible explanations.

2.Some odds ratios reported (e.g., OR > 100) appear extremely large. It would be helpful to caution readers about potential overestimation due to stratification or sparse data.

3.Consider elaborating on how these MUAC cut-offs could be used in clinical and community settings and whether further research is needed to validate their use.

4.The discussion could be expanded to include examples of how MUAC could be applied in the field, such as for community health worker (CHW) screening or integration into national nutrition surveillance systems.

5.Several relevant limitations are not mentioned, including: (a) MUAC measurements can be distorted by conditions such as edema or muscle hypertrophy, or (2) No discussion is provided on measurement reliability (e.g., inter- or intra-observer variability), which is important for field-based anthropometric tools like MUAC.

Conclusions:

1.The conclusion notes the use of MUAC but could be expanded by adding some suggestions for how it could be integrated into health systems or programs.

2.Authors could add a sentence about whether there is a need for validation with body composition measures and implementation studies.

Reviewer #2: I suggest to add to abstract that the cut-off point were selected by Younden index.

Statistic

I suggest to summarize it to avoid repetition.

I suggest to add the word adults through out the work

I failed to see if you include or exclude pregnant women

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: Review PLOS ONE_22052025_rev.docx

The validity of mid-upper arm circumference as an indicator of underweight, overweight and obesity adults in Bangladesh

PONE-D-25-18917R1

Dear Dr. Kamruzzaman,

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.

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Kind regards,

Olutosin Ademola Otekunrin

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 #2: 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 #2: Yes

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

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 #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 #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 #2: Authors have responded and replied to all of my comments.

I suggest to accept this work in its current form.

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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 #2: No

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