PONE-D-25-18984Global Burden of Major Chronic Respiratory Diseases Among Older Adults Aged 55 and Above from 1990 to 2021: Changes, Challenges, and Predictions Amid the PandemicPLOS ONE

Dear Dr. Fang,

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Alireza Sadeghi, M.D., M.P.H.

Academic Editor

PLOS ONE

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Additional Editor Comments :

Dear Authors,

Thank you for submitting your manuscript for consideration. Your work presents a comprehensive analysis of the GBD data, populated with different analyses. The study is well-structured (but too lengthy), and you have done an excellent job in discussing the limitations of your analysis as well as the policy implications of your findings. However, to further improve the clarity, rigor, and impact of your manuscript, I have a some suggestions for revision.

1. Clarity and Readability

The current writing can be challenging to follow in many sections. I recommend revising for conciseness and clarity, ensuring that each sentence conveys its point as directly as possible. Consider breaking down long, complex sentences.

The abstract and results sections are overly detailed and could benefit from restructuring to focus on the key objectives, methods, findings, and implications in a more succinct manner. A standard abstract typically follows the Background, Methods, Results, Conclusions framework in 200-250 words. Remember to use your keywords in your title and abstract strategically to improve indexing and findability.

2. Abbreviations

Several abbreviations (e.g., COVID-19, GBD, ILD&PS) are used without first being defined in the main text. Please ensure that all abbreviations are spelled out in full at first mention, followed by the abbreviated form in parentheses (e.g., Global Burden of Disease (GBD)). This is essential for readability, especially for readers outside your immediate field.

3. Citations and Literature Context

To strengthen the scholarly foundation of your work, please ensure that you cite and discuss the most relevant and recent literature in your field. This includes studies that have used similar methodologies or addressed related research questions, even in other countries and regions (if you don't believe you should cite them, provide them in your response so the reviewers can compare your work with similar works).

4. Figures and Tables

The image quality in the current version is suboptimal. If this is due to PDF rendering issues, please ensure high-resolution figures are submitted elsewhere or hosted on the web with links. If the original figures are of low resolution, consider regenerating them for better clarity. If possible, please provide vectorized images.

Figure formatting: As a general rule, plot titles should be moved to the figure captions rather than embedded in the plots themselves (e.g., Figure 4). This improves consistency with journal formatting standards.

Results section: While detailed, this section could be more concise. Avoid restating exact numerical values and facts that are already clearly presented in tables/figures—instead, focus on trends, key findings, and their significance.

5. Reviewer Comments

Please ensure that all points raised by the reviewers are addressed in your revision. If you disagree with any suggestions, provide a well-justified response explaining your reasoning.

Final Remarks

Your manuscript has strong potential, and with these refinements, it will make an even more valuable contribution to the literature. I appreciate the effort you have put into this work and look forward to reviewing your revised submission.

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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: Partly

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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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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: Thank you for the submission and it was really a pleasure to read such a powerful and informative study. I have very minor suggestions for you to address.

Abstract: We recommend to write abstract not exceeding 300 words. That is why I would suggest you to concise the abstract a little more.

Introduction:

There is one sentence I found is long and dense. Breaking them into shorter sentences will improve readability for non-professionals too:

Rather than writing, "The improvement in global health status over the past three decades has proven fragile, vanishing under the impact of the pandemic, leading to a reversal and increase in the overall disease burden."

I would suggest to write, "Although global health improved over the past three decades, the COVID-19 pandemic reversed much of that progress, increasing the overall disease burden." You do not need to copy and paste, if you can simplify with your own sentence, you are most welcome.

Abbreviations: Define abbreviations upon first appearance in the text, I think that is enough. It is not necessary to put it with a different subheading.

Acknowledgement: Please acknowledge the Research Assistants, Data collectors or other contributors too who did not meet the eligibility criteria of authorship (if any).

Funding/Financial Disclosure: So, I am confused here. In the submission system, you have mentioned that the study was not funded but in the manuscript, you wrote, "This study was supported by Longhua Hospital, affiliated with Shanghai University of Traditional Chinese Medicine, and the Shanghai Municipal Fund." Kindly mention the clear funding statement in the submission system, if the study was really funded or not. If it was funded then which section was funded, study design, fieldwork, data analysis, decision to publish or preparation? Kindly mention and clarify the section.

Kindly address the above mentioned issues. Good Luck.

Reviewer #2: Thank you for the opportunity to review this important manuscript exploring the global burden of chronic respiratory diseases (CRDs) among adults aged 55 and above using GBD 2021 data and multiple modeling approaches. The study addresses a globally significant issue and utilizes large-scale epidemiological data; however, major revisions are necessary to ensure clarity, methodological transparency, interpretive accuracy, and compliance with PLOS ONE's publication standards. Below are my specific concerns and suggestions:

1. Methodological Clarity and Transparency

The manuscript uses several complex models (e.g., Joinpoint regression, Age-Period-Cohort [APC], Bayesian APC [BAPC]) but lacks adequate explanation of how these models were selected, validated, and interpreted. Provide a supplementary file describing model specifications, priors, convergence checks (e.g., trace plots or R-hat values), and reasoning for using multiple models rather than selecting one consistent analytical approach.

2. Overinterpretation of Projections and Trends

The manuscript presents future CRD projections with unwarranted certainty, lacking discussion of key assumptions or potential global disruptions. The authors should temper predictive claims, clearly acknowledge model limitations, and consider uncertainty factors such as post-pandemic health shifts, tobacco trends, or environmental policy changes.

3. Presentation and Structure of Results

While the dataset is extensive, the manuscript presents too much detail without clear prioritization of statistically or clinically meaningful findings. Streamline the results to focus on key patterns (e.g., high-burden regions, divergent trends by SDI quintile). Suppress or summarize non-significant results and consolidate overlapping figures/tables for clarity.

4. Language and Expression

The manuscript has several grammatical errors and inconsistent phrasing, particularly in the Introduction and Discussion, which sometimes obscures the intended meaning, e.g. “This implies that while addressing environmental issues, it is also crucial to consider other epidemiological shifts” is vague and lacks subject clarity. It is unclear what "this" refers to or what the “other shifts” are. Revise for grammatical correctness and precision, and consider a professional language editing.

5. Ethical and Data Transparency

Although the study uses publicly available data, ethical oversight and data/code availability are not adequately addressed. In the Ethics section, “Not applicable” is stated without explanation. Additionally, while GBD is cited, the manuscript does not share processed data tables or scripts used for analysis. Provide a brief justification for the ethical exemption (e.g., use of secondary, de-identified data) and comply with PLOS ONE’s reproducibility standards by depositing analysis scripts (e.g., R code for APC/BAPC models) and processed data tables in a public repository.

This manuscript covers an important global health topic and utilizes reputable data sources, but significant revisions are required to meet publication standards. I encourage the authors to: justify and clarify their modeling approaches adequately, interpret projections with caution, improve visual and textual presentation of results, revise language for clarity, and provide appropriate transparency on data ethics and availability.

With these revisions, the study will be more methodologically sound, interpretable, and useful to the global health and policy community.

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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

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Global Burden of Major Chronic Respiratory Diseases Among Older Adults Aged 55 and Above from 1990 to 2021: Changes, Challenges, and Predictions Amid the Pandemic

PONE-D-25-18984R1

Dear Dr. Fang,

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,

Taiwo Opeyemi Aremu

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 #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: (No Response)

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

Reviewer #1: Yes

Reviewer #2: (No Response)

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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: (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

Reviewer #2: (No Response)

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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: No More Changes Required from My Side. I wish you all the best for your future endeavor. Hopefully we will have happy reading.

Reviewer #2: (No Response)

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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 #1: No

Reviewer #2: Yes:  Tinkhani Mbichila

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