Dear Dr. Li,

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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?

Reviewer #1: Yes

Reviewer #2: Yes

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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

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1:  Dear authors

I read your manuscript with interest. The study addresses a relevant topic from a public health perspective, and the chosen methodology appears appropriate. The statistical tools employed are suitable and consistent with those commonly used in studies based on Global Burden of Disease (GBD) data.

While the manuscript is easy to read and conveys the main message clearly, I believe it is essential to explicitly clarify the substantive differences between your study and the recently published article. 'Global trends and burden of age-related hearing loss: A 32-Year Study' (Archives of Gerontology and Geriatrics, 2025, https://doi.org/10.1016/j.archger.2025.105847).

Both studies share similar objectives, data sources and methodological approaches. Your manuscript includes some differentiating elements, such as the use of YLDs instead of DALYs and the analysis of the inequality slope index, but these differences should be elaborated on more and contextualised in order to highlight their added value.

Below, I present a series of specific suggestions for improvement:

• Introduction:

A more detailed description of the Global Burden of Disease (GBD) initiative would be helpful, including its purpose, scope, and the mechanisms by which data are collected, standardised, and modelled.

With regard to age-related hearing loss (ARHL) specifically, I recommend providing a brief explanation of how the estimates are generated, including the sources used (e.g. national health surveys, clinical records, scientific literature) and the operational definitions of hearing loss employed.

• Methods:

While the manuscript adequately describes the methods used, I recommend explicitly stating which statistical software or packages were employed for each type of analysis (e.g. linear regression, Bayesian models and inequality analysis). This would improve transparency and facilitate reproducibility for other researchers.

• Discussion

It would be beneficial to strengthen the connection between your findings and their potential implications for public policy and health planning, especially considering regional disparities according to development levels.

Additionally, I suggest explicitly referencing the findings from the previously cited published study, and elaborating further on how your results complement, nuance, or challenge those findings.

You may wish to briefly discuss the limitations of relying exclusively on modeled secondary data, as is the case with GBD, and the potential implications this has for the precision of regional estimates—particularly in countries with limited availability of primary data.

Reviewer #2:  The manuscript by Li et al. presents well written analysis of the global burden of age-related hearing loss (ARHL) from 1990 to 2021, with projections extending to 2050. Based on data from the GBD study, the authors provide evidence that ARHL and the associated burden are increasing globally, with significant differences among regions and development status. The finding are consistent with the information and projections from the World Health Organization and contribute valuable insights for global hearing health in people > 60 years.

Overall, methodology is clear and could be replicated.

Comments

• Ln 47-48: reference for this line (7) is about employment not about cognitive decline. Also, the idea “…accelerates cognitive decline” could be interpreted as an overstatement.

• The information contained in Table 1 could be divided into two tables for clearer presentation (Prevalence and YLD).

• Ln 83: may be useful for the readers to have de detail of the direction of change in EAPC (eg. greater than 0 = increase).

• Figure 2: It may be helpful to choose an alternative color palette, considering the challenges that red–green combinations pose for individuals with color vision deficiency. A useful reference could be the following work: Guo, Z., Ji, W., Song, P. et al. Global, regional, and national burden of hearing loss in children and adolescents, 1990–2021: a systematic analysis from the Global Burden of Disease Study 2021. BMC Public Health 24, 2521 (2024). https://doi.org/10.1186/s12889-024-20010-0

• Figure 6 shows the frontier analysis of SDI and YLDs of ARHL among individuals aged 60 and older of the 1990-2021 period. The caption of the figure mention “Frontier analysis…. in 2021”. Please check and modify.

A plot B could be added to the figure to show 2021 data, highlighting some countries with greater potential to reduce ARHL. For the dots representing individual countries, it may be useful to use different colors for increase or decrease in the effective difference. This article shows something similar: Chen, X., Zhou, C. W., Fu, Y. Y., Li, Y. Z., Chen, L., Zhang, Q. W., & Chen, Y. F. (2023). Global, regional, and national burden of chronic respiratory diseases and associated risk factors, 1990-2019: Results from the Global Burden of Disease Study 2019. Frontiers in medicine, 10, 1066804. https://doi-org.uchile.idm.oclc.org/10.3389/fmed.2023.1066804

• The focus of this work was people 60 and older, which is described as a limitation of the study by the authors (not including younger population). However, I do not consider this a major limitation, as this age group is relevant for the analysis of ARHL.

However, if this point is important for the authors, it would be helpful to support the choice of age cutoff with data from WHO and other sources to strengthen the rationale. For example, including individuals aged 50 and older.

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what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: PONE-D-25-09817_rev.docx

The global burden of age-related hearing loss among individuals aged 60 years and older: an analysis for the global burden of disease study 2021 and predictions to 2050

PONE-D-25-09817R1

Dear Dr. Li,

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,

Paul H Delano, Ph.D.

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Dear Authors,

I have carefully reviewed the new version of the manuscript and appreciate the effort made to respond to the comments from the first round. In my opinion, you have adequately complied with the recommendations made. The work was already solid from a statistical and methodological point of view, and the modifications introduced reinforce this impression.

The introduction is now better contextualized, with a clearer statement of the problem and a more complete description of the GBD framework and how the estimates used are generated. Likewise, the incorporation of additional technical details improves the transparency and reproducibility of the analyses. Finally, the discussion descends more explicitly into the implications for public policy, which enhances the practical usefulness of the results.

I have recommended the manuscript for publication.

Best regards

Reviewer #2: (No Response)

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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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