PONE-D-25-13648Unveiling the full picture of malnutrition: Extended composite index of anthropometric failure among children under-5 in Sub-Saharan Africa: In the SDG eraPLOS ONE

Dear Dr. Muche,

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.

I suggest you give a careful consideration to all the reviewers' comments, and make effort to address the comments as much as possible, including the typographical errors in the manuscript. The reviews are complementary and they are meant to improve the quality of the manuscript.

Please submit your revised manuscript by Sep 12 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:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

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,

Ayodeji Babatunde Oginni

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

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

2. We note that your Data Availability Statement is currently as follows: All relevant data are within the manuscript and in Supporting Information files.

Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition).

For example, authors should submit the following data:

- The values behind the means, standard deviations and other measures reported;

- The values used to build graphs;

- The points extracted from images for analysis.

Authors do not need to submit their entire data set if only a portion of the data was used in the reported study.

If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories.

If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If data are owned by a third party, please indicate how others may request data access.

3. Please ensure that you refer to Figure 1 and 2 in your text as, if accepted, production will need this reference to link the reader to the figure.

4. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

[Note: HTML markup is below. Please do not edit.]

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

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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

Reviewer #3: 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

Reviewer #3: 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: Thank you for the valuable feedback. Regarding your concern about the organization of the manuscript sections, I acknowledge that the authors may not have fully adhered to the expected academic structure for organizing the sections. Clear and logical organization of manuscript sections is crucial for ensuring that the content is both accessible and comprehensible to readers.

To address this, I suggest the following improvements:

Reorganization of Sections:

The manuscript would benefit from a more structured approach, especially in the Methods and Results sections. These sections should follow a clear progression, with a distinct introduction of the methodology, followed by the results being logically presented.

For instance, the Implications, Applications, and Limitations sections could be more closely tied to the specific findings in the Results and Discussion. A clearer transition between these sections would enhance the manuscript’s readability and make it more cohesive.

Improvement in Consistency:

Consistency in section headings and subheadings should be maintained throughout the manuscript. This includes using clear titles for each subsection (e.g., Statistical Analysis, Data Collection, Prevalence Results), ensuring that the reader can easily follow the content and the logical flow.

Introduction and Conclusion:

The Introduction should provide a clear background and rationale for the study, leading naturally into the Methods. The Conclusion should then succinctly summarize the key findings, their implications, and potential policy recommendations, making the narrative flow from the introduction to the conclusion seamless.

Further, I recommend that the authors review the manuscript and ensure the following:

The Methods section should be more clearly defined, starting with an introduction to the data sources, followed by the study design and statistical approaches.

The Results section should present findings in a systematic manner, beginning with descriptive statistics and followed by the main findings, ideally in subsections for easier reading.

The Discussion should start by revisiting the key results, followed by comparisons with existing literature and, finally, a reflection on the public health implications of these results.

By reorganizing the manuscript with a clearer and more logical structure, the authors can significantly improve the readability and academic rigor of the paper.

Reviewer #2: Title and Abstract

Strengths:

The title is descriptive and informative, clearly reflecting the study’s aim and population of interest.

The abstract concisely presents the background, methods, results, and conclusions.

Areas for improvement:

The abstract could better reflect the novel aspects of the Extended Composite Index of Anthropometric Failure (ECIAF), possibly with a brief explanation of how it surpasses traditional measures.

The use of acronyms like ECIAF could be confusing to non-technical readers in the abstract; consider spelling it out first.

Introduction

Strengths:

The introduction is well-grounded in global health goals (SDGs) and articulates the importance of accurate malnutrition assessment.

It outlines the rationale for using ECIAF and connects it to policy relevance.

Areas for improvement:

The literature review could be more current, with clearer referencing to similar studies post-2020.

The justification for choosing ECIAF over other composite measures could be better articulated with empirical comparisons.

Methods

Strengths:

The use of a large, representative dataset across 26 Sub-Saharan African countries is commendable.

The stratification into individual- and community-level factors and use of multilevel modeling enhance robustness.

Areas for improvement:

The operational definition of ECIAF, while technically accurate, is overly dense. A simplified diagram or table might help.

More detail is needed on ethical considerations, especially since secondary data use still carries responsibility for safeguarding privacy.

The variable selection process (p-value < 0.2 + literature + expert judgment) is common but should be justified more explicitly for transparency.

Results

Strengths:

Clear presentation of descriptive data, subgroup analysis, and multivariate findings.

Use of figures and tables helps to break down complex results.

Areas for improvement:

The writing could be more fluid; it reads as a data dump in parts. Focus on highlighting trends, not just numbers.

Regional variations are well-presented, but the manuscript does not delve deeply into why these differences exist—more interpretive insight is needed.

Discussion

Strengths:

The discussion covers multiple determinants of ECIAF and links findings to prior research.

There’s a commendable effort to draw policy implications from the data.

Areas for improvement:

There’s repetition from the results section; consider condensing and focusing on interpretation.

The discussion lacks a critical reflection on the study's limitations. For example, potential bias from self-reported birth sizes or unmeasured confounders should be acknowledged.

The regional comparison could benefit from linking findings to historical, cultural, or policy-based explanations.

Conclusion

Strengths:

It concisely summarizes key findings and policy relevance.

Emphasizes practical interventions such as improving maternal education and health access.

Areas for improvement:

A clearer statement on the novelty of ECIAF and its potential for replication across other regions would strengthen the final impact.

A recommendation for future research directions (e.g., longitudinal studies or validation of ECIAF) would add value.

Language and Structure

Strengths:

Generally readable and logically structured.

Tables and figures are appropriate and informative.

Areas for improvement:

Grammatical inconsistencies and typos (e.g., “unde-5” instead of “under-5,” “Sothen Africa”) should be corrected for professionalism.

Some paragraphs are too long or overly technical; consider simplifying for broader audiences.

Overall Assessment

This manuscript tackles an important public health issue with methodological rigor and a large dataset. The ECIAF provides an innovative approach to understanding malnutrition beyond standard indices. However, the manuscript would benefit from clearer articulation of novelty, improved interpretation of regional differences, and a more critical engagement with its own limitations. With revisions, it has strong potential to contribute significantly to literature and policy on child nutrition in Sub-Saharan Africa.

Reviewer #3: Dear Author,

Thank you for this timely and large-scale study on the prevalence and determinants of the Extended Composite Index of Anthropometric Failure (ECIAF) among children under five in Sub-Saharan Africa. Your use of DHS data and multilevel modeling is commendable. However, several critical limitations—both methodological and conceptual—need to be addressed more transparently throughout the manuscript. Below are specific areas requiring major revision:

Abstract

The abstract currently lacks any mention of study limitations. Given the use of secondary cross-sectional DHS data, please add a brief note on the inability to infer causality, reliance on maternal recall for child characteristics, and heterogeneity between surveys.

Methods (implied from Results section)

There is insufficient information on how missing data were handled. Were any imputation techniques used? If not, how were incomplete records treated?

More clarity is needed on whether country-level weights were adjusted when pooling multi-country DHS datasets—failure to do so may bias prevalence estimates.

Explain how regional classifications were made and whether they were consistent with WHO or AU regional groupings.

Results

Several prevalence figures are presented without confidence intervals or p-values, limiting interpretability.

The table on ECIAF prevalence by child characteristics omits statistical testing (e.g., chi-square values), making it difficult to judge significance.

The denominators used in ECIAF prevalence estimates for subgroups are unclear. Please clarify if weighted or unweighted counts were reported.

Discussion

While you provide a thorough discussion of significant findings, the section fails to critically reflect on key limitations, including:

Causality: The cross-sectional nature of DHS data precludes inference of directionality or causation.

Measurement error: Many variables (e.g., birth size, comorbidities, feeding practices) are self-reported and subject to recall and social desirability bias.

Survey timing and harmonization: Countries included had DHS surveys in different years, which may affect comparability and trend interpretation.

Residual confounding: Important predictors like dietary intake, maternal nutrition, or food security status were not included, potentially biasing associations.

Model assumptions: There is no assessment of multicollinearity, model diagnostics, or potential cross-level interaction effects in the multilevel model.

Recommendations

Add a dedicated limitations paragraph in the Discussion section. It should clearly articulate data-related constraints, potential biases, and methodological assumptions.

Where possible, conduct robustness checks (e.g., country-specific analyses or sensitivity tests excluding countries with outdated surveys).

Consider reporting intraclass correlation coefficients for key random effects at the country or regional level if applicable.

By incorporating these revisions, your manuscript will better reflect the complexities and constraints inherent in large-scale secondary analyses, while retaining its important policy implications.

**********

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: Yes:  Juliana Aggrey

Reviewer #3: 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.

Attachments

Attachment

Submitted filename: Reviewer Report.docx

Attachment

Submitted filename: Comments 13648.docx

Attachment

Submitted filename: Reviewer comment_Plos One.docx

PONE-D-25-13648R1Unveiling the full picture of malnutrition in Sub-Saharan Africa: The extended composite index of anthropometric failure among children under-5 in the SDG eraPLOS ONE

Dear Dr. Muche,

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.

Line 23-33: The "objective of the study" statement is either missing or not clearly statedLine 34-35: I would like you to revise the sentence to show that you conducted a secondary data analysis research instead of saying that you conducted a community-based cross-sectional survey, since you did not collect the primary data.Line 55: There is a typographical error: "children-5", it should be "children under-5"Line 44-47: I suggest you include all the key factors associated with increased odds for ECIAF: Increasing child age (6-23 months [AOR: 1.56, p<0.001] & 24-59 months [2.03, p<0.001]), multiple birth [2.38, p<0.001], reducing birth size (Average [AOR: 1.20, p<0.001] & Small [1.80, p<0.001]), having comorbidity [AOR: 1.12, p<0.001], reducing level of mother's educational status (Primary [AOR: 1.20, p<0.001] & No formal [1.36, p<0.001]), increasing number of children under-5 in household (2 children [AOR: 1.10, p<0.001] & 3-5 children [1.14, p<0.001]), reducing household wealth status (Rich [AOR: 1.28, p<0.001], Middle [1.31, p<0.001], Poor [1.42, p<0.001], & Poorest [1.45, p<0.001]), living in rural area [AOR:1.15, p<0.001], and having no media exposure [1.15, p<0.001] . Line 51-55: The statement "Child sex, child age, type of birth, preceding birth interval, perceived sizes at birth, comorbidity, educational level of the mother, parity, place of delivery, antenatal care visit, wealth index, family size, number of under-5 children, place of residence, media exposure and Africa region were identified factors associated with ECIAF. " is totally out of place, and irrelevant. It should be expunged. Line 55-59: These statements should be revised to incorporate a set of Nutrition sensitive interventions that will primarily address the risk factors mentioned in the result section and inadvertently reduce the prevalence of ECIAF in the long run . Perhaps these articles may help: https://doi.org/10.1016/S2214-109X(23)00562-4https://doi.org/10.1186/s40795-021-00443-1Line 134: Kindly include the "objective of the study" statement. Line 221-223: To avoid ambiguity and speculation among the readers, I advice you revise these lines to clearly show that you are referring to the primary surveys (DHS) that produced the dataset you used for this secondary data analysis research.  For instance, Line 222-223: "The surveys utilized a two-stage stratified cluster sampling technique to ensure nationally representative estimates across 26 Sub-Saharan African (SSA) countries. "Line 375-377: The statement in these lines needs to be reviewed for correctness. "The odds of having ECIAF was higher among children under-5 having perceived average birth size (AOR: 1.20; 95% CI: 1.14, 1.26) and perceived small birth size (AOR: 1.80; 95% CI: 1.68, 1.93) ascompared with those whose ages were below 6 months."Line 366 & 380: Maintain consistency: "The odds of having ECIAF" instead of "The risk of having ECIAF"Line 383-387: Please revise the last segment of the statement to read as follows: ".....as compared to primiparity were however significantly protective against the odds of having ECIAF in children under-5 years in SSA ".Line 388: You might need to include "Concerning household level factors ," in the opening statement of the paragraph. Line 388-399: The statement needs revision as follows: "Children under-5 from rich households(AOR: 1.28; 95% CI: 1.17, 1.41), middle households(AOR: 1.31; 95% CI: 1.19, 1.44), poor households(AOR: 1.42; 95% CI: 1.28, 1.56)  and poorest households (AOR: 1.45; 95% CI: 1.31, 1.61), respectively had higher odds of ECIAF as compared to those from richest households" .Line 391-396: The statement requires revision: Other household factors such as having 2 (AOR: 1.17; 95% CI: 1.10, 1.23 ) or 3-5  (AOR: 1.14; 95% CI: 1.06, 1.22) children under-5 in the household as compared to 1 under-5 child was associated with odds of having ECIAF; while having 5-9 member (AOR: 0.92; 95% CI: 0.87, 0.98) or greater than 9 family members (AOR: 0.90; 95% CI: 0.83, 0.98) as compared to 1-4 family members, was protective against the odds of having ECIAF . Line 397-404: Statements requires revision: "With regards to the community level factors, children under-5 from Southern African countries (AOR: 2.01; 95% CI: 1.80, 2.24), Western African countries (AOR: 1.37; 95% CI: 1.24, 1.51), Eastern African countries (AOR: 1.44; 95% CI: 1.30, 1.60), and Central African countries (AOR: 1.97; 95% CI: 1.75, 2.22), respectively had significantly higher odds of ECIAF than the Northern African countries. Other factors such as living in rural residence (AOR: 1.15; 95% CI: 1.09, 1.22) versus urban residence, and exposure to media compared no exposure to media (AOR: 1.15; 95% CI: 1.10, 1.20) exposure were significantly associated with higher odds of ECIAF in children under-5 years old in SSA" . Lastly in the discussion section, I would like you to carefully consider realigning or combining the statements in the following lines to ensure consistency and flow before delving into discussing how "Male children were more affected than females": Line 451-452: "The study also highlights several factors associated with higher ECIAF prevalence."Line 459-467: "The current study also examined factors associated with the Extended Composite Index of Anthropometric Failure (ECIAF) among children under five years old in sub-Saharan Africa (SSA) using a multilevel modeling approach. The findings highlight the significant roles of child, maternal, household, and community-level factors in determining ECIAF. In our study child age, child sex, child size at birth, child birth type, child birth order, child birth interval, child having comorbidity, mother’s education, parity, antenatal care visit, place of delivery, household wealth index, family size, number of under-5 children in the household, African region, place of residence and media exposure were significantly associated with ECIAF in children under-5 years old in SSA." Please submit your revised manuscript by Oct 22 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:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

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,

Ayodeji Babatunde Oginni

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

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.

[Note: HTML markup is below. Please do not edit.]

[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.

Unveiling the full picture of malnutrition in Sub-Saharan Africa: The extended composite index of anthropometric failure among children under-5 in the SDG era

PONE-D-25-13648R2

Dear Mr. Muche,

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. For questions related to billing, please contact billing support .

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,

Ayodeji Babatunde Oginni

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: