PONE-D-24-09213Food insecurity is associated with decreased quality of life in patients with chronic Chagas diseasePLOS ONE

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Additional Editor Comments:

The study makes a significant contribution to the discourse on social inequalities among individuals affected by Chagas disease (CD). It articulates a relevant objective and adheres to the necessary ethical requirements. However, several limitations warrant clarification, particularly regarding methodological issues and the discussion of the study, as highlighted by the reviewers.

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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: No

Reviewer #2: Yes

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

Reviewer #1: No

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: The study makes an important contribution to the debate on social inequalities in individuals with Chagas disease (CD). It also presents a relevant objective and the necessary ethical requirements. However, there are some points that deserve to be highlighted:

- The introduction does not explore the health inequities of patients with CD in Brazil and Latin America. It focuses on health indicators in a broad way, not exposing specificities of the reality and context of the study population.

- As it was a study with a cross-sectional epidemiological design, the data collection time was very long.

- What is the maximum age limit? Elderly people too? From the perspective of FI and quality of life, the elderly would have different debates.

- The magnitude of the INI (Evandro Chagas National Institute of Infectious Diseases) for patients with CD in Brazil is not clear in the methodology. What does this mean, thinking about readers who do not know the reality of INI? Does it allow inferences? Local level? National?

- The authors need to better explain the inclusion, exclusion and sampling criteria, if applicable. How do patients get to the INI?

- Why two months between visits? Was there a minimum period between visits?

- Regarding food insecurity (FI), the article presents important methodological issues:

(a) The recommendation in Brazil for the use of EBIA is the questionnaire with a scale of 14 questions, validated in 2014 (https://www.scielo.br/j/rn/a/X9vkr9sc7WX8tH8dcWP8XPN/?format=pdf&lang=en) and not the one used in the study. In some contexts, the short 8-question questionnaire may be used. All commonly used in IBGE research, for example.

(b) The dimension of the EBIA for measuring FI levels is household and not individual. Individual variables can be related to FI, if it belongs to the head of the household. And there is no mention of this throughout the text.

(c) Considering the FI outcome, I find the associations made by the authors to be delicate, such as total cholesterol (mg/dl) and weight or height in isolation. What is the real objective of relating a possible experience of hunger at home with an individual's cholesterol level? What about the weight or height ratio of adults, without a relationship like BMI? Why would it be associated with FI? These are examples of just some of the variables. But there are others where the association would not make sense.

- Another important point in the methodology concerns statistical analyses: the authors carried out logistic regression models to estimate OR. What binary outcome? FI Yes or no? Because in table 2, there are 3 outcomes (FI, which I understand to be the reference, Mild FI and Moderate/Severe FI). Therefore, you would need a multinomial model.

- Due to methodological limitations, all results are dubious inferences and should be redone. The same applies to the discussion.

Reviewer #2: Parabenizo os autores por abordarem as principais lacunas na temática das pessoas com Doença de Chagas (DC) e por ressaltarem a importância das pesquisas nesse campo. No entanto, recomendo a reformulação de alguns parágrafos para aprimorar a coesão e o refinamento do texto.

Linha 64-65: Sugiro focar na América Latina e, se possível, abordar os desafios do atendimento a pessoas com DC no Brasil.

Linha 65-69: Recomendo a reformulação da frase para melhorar a abordagem da relação entre DC, condições de vida e acesso à alimentação. Indago qual é a relação entre o aumento da expectativa de vida e a migração; alguns estudos apontam que, apesar da baixa renda e escolaridade, existe uma longevidade atrelada às condições de vida na área rural. O aumento da "exposição a estilos de vida pouco saudáveis" seria prejudicial para os pacientes ou para os moradores da área urbana?

Linha 72-75: Na frase “The factors that contribute to the link between CD and poverty are complex, including poor housing conditions and inadequate access to healthcare services, that are more commonly observed in middle and low-income countries.”, sugiro a adição de uma referência.

Linha 78-79: Recomendo inserir uma conexão entre os parágrafos.

Linha 79-90: Sugiro dividir o parágrafo, criando um dedicado à Insegurança Alimentar (IA) e às doenças possivelmente associadas. Sugiro criar outro parágrafo a partir da frase “Considering the low socioeconomic status of individuals with CD,...”

Linha 123-133: As escalas de aferição da IA são distintas entre países, e no Brasil foi validada a EBIA. Desde 2004 foram realizadas algumas alterações na escala, e atualmente a versão indicada para o uso é a de 14 itens (Segall-Corrêa AM, Marin-León L, Melgar-Quiñonez H, Pérez-Escamilla R. Refinement of the Brazilian Household Food Insecurity Measurement Scale: Recommendation for a 14-item EBIA. Rev Nutr. abril de 2014;27:241–51.). Apesar da comparabilidade entre as escalas, autores realizam adaptação das escalas (como nos resultados dos relatório da Pesquisa Nacional de Insegurança Alimentar durante a Pandemia de Covid-19 realizada pela Rede Penssan). Caso não seja possível a reformulação nesta pesquisa, indico que nas próximas pesquisas, seja utilizada a versão mais atual da EBIA completa (14 itens).

Linha 167-186: Recomendo descrever separadamente as variáveis que caracterizam tanto o domicílio quanto o paciente. A raça/cor da pessoa é um dos principais indicadores da IA. No entanto, sugiro evitar a associação de grupos como pretos, pardos, indígenas e amarelos, pois isso pode levar à superestimação dos dados, considerando as diferentes prevalências de IA em cada grupo populacional. Proponho a união de pretos e pardos em uma categoria denominada "negros" (em português; em inglês, utiliza-se "Black/Brown"). Questiono também quantos pacientes indígenas e amarelos foram incluídos no estudo, uma vez que outros trabalhos coletaram esses dados, mas não os utilizaram nas análises devido ao baixo número amostral e ao risco de viés.

Resultados: Sugiro adicionar uma tabela, em anexo, das características dos pacientes sem a estratificação pela IA. Avaliar a possibilidade com os demais autores.

Table 1: Indico inserir o intervalo de confiança. Sugiro que os valores fiquem dispostos desta forma: % (n; IC95%). Avaliar a necessidade de apresentar o número da amostra. Indico elucidar o que seriam “Other countries”, visto que não está disposto na legenda e na metodologia – ainda indico rever a necessidade da sua permanecência na tabela.

Linha 252 – 261: Trago uma reflexão para os autores. A EBIA é uma escala de percepção da IA, não avalia quantitativamente – apesar da utilização das prevalências. Os dados da IA do ano de 2013 (PNAD) e 2018 (POF) são diferentes devido o cenário de crises políticas, econômicas, ambientais e sociais, e pergunto-me como os dados obtidos no estudo foram semelhante as pesquisas, se estas mesmas possuem dados distintos. Além disso, embora os programas de transferência de renda sejam extremamente importantes, os valores estão defasados em relação ao cenário de desigualdades sociais e crises sistêmicas no país, podendo não garantir a segurança alimentar nos domicílios. Com isso, sugiro relacionar a prevalência da IA aos indicadores sociais identificados na amostra, que podem influenciar o acesso a uma alimentação adequada e saudável (como escolaridade, rendimento, macrorregião, dentre outros).

Linha 262-277: Indico diminuir ou dividir o parágrafo – está extenso. Existem poucos estudos no Brasil que correlacionem a IA e estado nutricional, por isso, parabenizo pela discussão. Indico este artigo, por ser um dos mais recentes nacionalmente na temática: Domingos, T. B., Sichieri, R., & Salles-Costa, R. (2022). Sex differences in the relationship between food insecurity and weight status in Brazil. The British journal of nutrition, 1–19. Advance online publication. https://doi.org/10.1017/S0007114522001192

Linha 278-299: Indico diminuir ou dividir o parágrafo – está extenso.

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Reviewer #1: No

Reviewer #2: No

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Food insecurity is associated with decreased quality of life in patients with chronic Chagas disease

PONE-D-24-09213R1

Dear Dr.Mediano,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Karina Cardoso Meira, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Dr Mediano.

Congratulations on the thoughtful revisions you have made to the manuscript. Both reviewers appreciate the quality of your work and its relevance to understanding the clinical and demographic correlates of food insecurity.

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: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

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: I find the responses satisfactory and I think the authors were careful in reviewing the requests made.

Reviewer #2: I congratulate the authors for the changes in the manuscript.

Results:

# Table 1 contains the clinical and demographic characteristics according to Food Insecurity. The results are interesting. However, when analyzing other articles that work with the theme, the values are distributed in the row (and not in the column). This occurs because the covariates are usually analyzed based on the levels of food insecurity or food security.

In fact, the authors point out the distribution in the row in the study population: Food Security = 69.4%; n=249; Mild Food Insecurity = 22.5%; n=81) and Moderate/Severe Food Insecurity = 8.1%; n=29.

I recommend caution when comparing in the discussion with other articles, since the prevalence may have been analyzed in another format.

Possibly, due to the analysis in the column, some results differ from the general population:

- 7% of people with more education in Moderate/Severe Food Insecurity;

- The Northeast has the highest Food Security when compared to the other regions (67.1%);

- 48.3% of eutrophic people in Moderate/Severe Food Insecurity and 45.5% in Food Security.

If possible, I suggest that an analysis be carried out to confirm whether the best approach would not be the analysis in the row, considering the levels of insecurity, rather than the distribution in the column (considering the categories).

# If possible, I suggest that you divide Table 1 into two. One for prevalence and another for averages or divide Table 1 for demographic characteristics and Table 2 for clinical characteristics.

Besides, I have nothing else to add. I hope that the comments will enrich the manuscript.

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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

Reviewer #2: No

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