PONE-D-25-10924Changes in Obesity Indices, Lifestyle Medicine, and Mental Stress with Ramadan Intermittent Fasting among Healthy Students: Competent Cohort StudyPLOS ONE

Dear Dr. AL-Dalaeen,

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.

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Mehran Rahimlou, PhD

Academic Editor

PLOS ONE

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Additional Editor Comments :Please note that I have acted as a reviewer for this manuscript, and you will find my comments below, under Reviewer 2

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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: The subject is interesting. However, many queries need attention.

Title and text: ‘Anthropometric Indices’ seems more appropriate than ‘obesity indices’, as well as ‘Lifestyle pattern/behaviour’ than ‘lifestyle medicine’ and ‘a prospective cohort study’ than ‘a competent cohort study’. Please re-write the title.

Abstract:

-AVI and BAI were not calculated in the present study. They figure in the abstract and the method section.

-Avoid the use of ‘never been studied’

-The number of participants (150; 153) and their age (18-40; 18-45), gender (100/ 95 female; and function (students; students and university employees) are different in the abstract, methods, and results sections.

-Some units are lacking (Kg).

-Line 47: please reformulate the sentence.

-It is unclear if the data collected during the second visit concerned RIF or the week after RIF. Please clarify and correct accordingly in the text and tables.

Keywords: intermittent fasting and anthropometry or waist circumference (rather than obesity) can be added.

Introduction

-Line 74: some repetition

Methods

-Conditions of Ramadan 2024: please indicate the temperature and the exact duration of fasting.

-Please indicate the population’s life conditions: university housing?

-101-102: sentence without a verb.

-105 and 110: repetition

-Figure 1 is lacking

-Inclusion criteria: add ‘patients willing to fast during Ramadan 2024’.

-Please describe the term ‘professional staff’

-Please indicate how many times dietary intake was evaluated (line 118).

-The technique of hip circumference measurement is lacking (lines 136-137).

-The formulas are unclear, please re-write and use ‘x’ instead of ‘*’.

-CI and WHtR indices were not defined.

-please use only one abbreviation: IRF or RF.

Results:

-The number of fasted days in the subjects was not mentioned.

-Please verify the numbering of the paragraphs and the tables.

-Line 165: JD?

-Table 1: Please verify, the age, and sex of the population. The total for each parameter should be 100%. Income (Equivalent in dollars).

-Table 3 (please correct the number): perceived stress level: it should rather be expressed by the number of subjects for each category.

-Table 4: data should be expressed as mean and SD (if normally distributed). Daily calories intake was not calculated. It seems important to discuss weight loss.

-The sentence in lines 182-183 can be displaced to line 176 with table 3 data and ‘however’ should be deleted.

Discussion

-Lines 187-190: please reformulate as no analysis of the changes in anthropometric indices and lifestyle patterns was performed.

-Line 195: Please correct: there was a significant decrease in BMI.

-Lines 200-207: useless here as these data were not studied in the present study.

-Lines 213; and 214: please use the past tense.

-Subjects lost 6 Kg in weight: this important weight loss should be discussed (IRF, living conditions, dehydration…).

-The changes in the different anthropometric indices were not discussed; what does it mean? what is the importance of the calculation of these indices?

-Line 271: the sample size was considered adequate? How?

-Line 273: which variables do the authors mean?

Conclusion:

Improvements in dietary habits? Sleep duration? Please re-write the conclusion.

References: There are too many references (52).

Reviewer #2: Abstract:

There are some minor grammatical and typographical errors in the abstract:

• "The association between Ramadan Intermittent Fasting (RIF) and metabolic profiles has been studies." should be "has been studied."

• The sentence, "RIF fasting positive body weight, obesity indices, and stress levels among health students," is unclear. It seems incomplete and should be rephrased for clarity.

The abstract mentions significant reductions in various indices but does not include full p-values for all reported results, which would enhance the clarity and statistical rigor of the findings.

The results about changes in obesity indices are somewhat disjointed. The abstract lists significant changes in BMI, WHtR, and BRI, but other indices are not clearly presented. A more structured presentation of results would improve readability.

Introduction:

The flow between topics (from obesity to lifestyle medicine to fasting) is somewhat abrupt. For example, the transition from discussing obesity indices to lifestyle medicine could be smoother, providing a clearer link between these areas and RIF.

"Lifestyle medicine is an emerging discipline that emphasizes the prevention and management of diseases linked to unhealthy lifestyle choices." Add reference like this study to this sentence: DOI: 10.1093/nutrit/nuad096 and DOI: 10.2174/1871530321666210316103403

The sentence "Fasting is considered to be a healthy practice, recent studies have shown a positive association between fasting and longevity" could be more precise. It would be beneficial to specify whether the longevity mentioned refers to Ramadan fasting specifically or fasting in general.

Method

While the sample size of 150 participants is mentioned, there is no mention of a power analysis to justify this sample size. A power analysis would help assess whether this sample size is sufficient to detect statistically significant differences and strengthen the study’s statistical reliability.

The description of data collection (questionnaires, interviews) could include more detail on how these tools were administered. Were the interviews standardized? Were they conducted in person or online? Providing more specifics here would increase transparency and replicability.

It would be useful to mention whether any control variables were considered, especially for lifestyle factors like diet, physical activity, or mental health status before the study began. Acknowledging or controlling for such factors is important in determining whether changes in outcomes are truly attributable to Ramadan fasting.

Result

While paired t-tests are used, it would be helpful to also report effect sizes (such as Cohen’s d) to provide a sense of the practical significance of the findings. This would aid readers in understanding the magnitude of the changes, not just their statistical significance.

The text notes that there was "no significant difference in other obesity indices" but doesn’t explain why certain indices like BMI, WHtR, and BRI showed significant changes while others did not. A more thorough analysis of why some measures responded to fasting and others did not would be valuable for interpretation.

Discussion

The discussion implies a causal relationship between Ramadan fasting and changes in health outcomes. However, the study’s design is observational, which means it can only show associations, not causality. The authors should be cautious in their language and clarify that the findings represent associations, not causal effects.

While the manuscript compares its results to previous studies, it would be useful to better reconcile the differences in findings with potential methodological differences between studies. For example, what are the reasons for discrepancies in findings about stress and weight gain/loss? Are these linked to differences in study design, fasting durations, or cultural dietary habits?

Although the authors briefly mention the need for larger sample sizes and more homogeneous groups, the discussion could benefit from more specific suggestions for future studies. For instance, longitudinal studies following participants over a longer period would help assess the long-term effects of Ramadan fasting on health outcomes.

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Reviewer #1: Yes: Melika Chihaoui

Reviewer #2: Yes: Mehran Rahimlou

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PONE-D-25-10924R1Changes in Anthropometric Indices, Lifestyle Patterns, and Mental Stress with Ramadan Intermittent Fasting among Healthy Students: A Prospective Cohort StudyPLOS One

Dear Dr. AL-Dalaeen,

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.

Please submit your revised manuscript by Mar 29 2026 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 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,

Mehran Rahimlou, PhD

Academic Editor

PLOS ONE

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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.

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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 #3: (No Response)

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

Reviewer #6: (No Response)

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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 #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

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

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: 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 #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: No

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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 #3: Yes

Reviewer #4: Yes

Reviewer #5: No

Reviewer #6: 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 #3: Thank you for your thorough revisions. I have no further comments. The manuscript is suitable for publication.

Reviewer #4: After a thorough evaluation of the revised manuscript, I find that the authors have fully and effectively addressed all previous reviewer comments. The revised version shows clear improvement in organization, methodological rigor, and presentation quality.

The authors have corrected inconsistencies in participant demographics, added missing methodological details (e.g., fasting duration, environmental conditions, measurement procedures, power analysis, and control variables), and clarified data collection and statistical analysis. The inclusion of Cohen’s d effect sizes, standardized formulas, and expanded discussion on non-significant anthropometric indices has strengthened both the interpretive depth and statistical transparency of the work.

The writing is now coherent, grammatically sound, and aligns with PLOS ONE’s editorial and reporting standards. The study designs a prospective cohort investigation of Ramadan fasting’s effects on anthropometric indices, lifestyle habits, and mental stress is well executed and ethically conducted. Findings are clearly presented and supported by appropriate analyses. The discussion appropriately acknowledges limitations, avoids causal overstatements, and situates results within the context of relevant literature.

Overall, this revision represents a methodologically sound and ethically compliant study with clear public health and behavioral implications. It contributes useful, reproducible evidence on the physiological and psychological effects of Ramadan fasting in healthy adults. I therefore recommend that the manuscript be accepted for publication

Reviewer #5: I appreciate your manuscript as it explores a relatively unique and less researched area. While I commend the overall structure and content of the manuscript, I have noted several areas where enhancements could be made.

• The document is slightly bulky and has too many references

• Your document needs a through grammatical and editorial revision

Abstract

• On line 24 ‘anthropometric indices related to obesity during RIF…’ since your study population is not defined by the BMI or whether they are obese or not replace the OBESITY with more general term like WEIGHT or other suitable one as all your study participants are not obese

• Also on line 24 you have used ‘these have never been thoroughly investigated’ which is an absolute language please replace with more qualified statement to convey the gap like ‘these have not been extensively investigated’

• On line 36 better to remove (p>0.05)

Introduction

1. You did not pick the main topic of your manuscript, RIF until the third paragraph I would rather recommend you to pick earlier (in the first or 2nd paragraph) after your brief opening so that the reader quickly gets the main point of interest

2. Line 72 ‘…Muslims fast daily from m dawn to sunset’ writing errors are plenty in your document, please revise thoroughly

Methodology

1. Line 89 ‘...during Ramadan from March to April 2024 (Shaban-1445 to Ramadan-1445) these two time frames are conflicting, may you please remove DURING RAMADAN or change to during the months of Shaban and Ramadan

2. Line 90-91 and line 135 ‘... on obesity indices...’ as your study is not confined to only using obesity indices (Conicity Index (CI), Abdominal Volume Index (AVI), Body Adiposity Index (BAI), Weight-Adjusted-Waist Index (WWI), and Body Roundness Index (BRI).) which are often designed for fat distribution estimation, rephrase and add the other anthropometric indices (BMI etc) by saying ( .. Obesity and other anthropometric indices ...’ or you can use the more general term which is Anthropometric indices as all obesity indices are anthropometric indices, but not all anthropometric indices are obesity indices

3. Line 103 regarding study participant ‘..This prospective cohort study was conducted on 150 university students (58 males and 92 females), was taking this male to female ratio a predetermined plan?, otherwise this is not expected here in methodology instead you describe the sociodemographic characteristics of your participants at the beginning of your result part

4. Your methodology part needs the following considerations;

• Add at least one subtitle which addresses variables under which you put your dependent (effect of RIF on anthropometric indices...) and independent variables (socio economic characteristics, dietary, sleep and other factors you have assessed including anthropometric and obesity indices)

• line 88, instead of putting Study design alone, you would make (Study design, area and period)

• the other important missing section is Sampling technique or procedure which tells how you selected your study participants. Is it randomly or...?

• you may also need to add operational terms section which defines your main operational terms like PSS for the readers and instead of defining those terms sparsely in the document, I would rather recommend you to combine them under definition of terms.

• In your analysis, in addition to p-value why don’t you add confidence interval(CI), as the confidence interval gives you a range within which you can be reasonably confident that the true mean difference lies

Result

1. Line 174-175, you said ‘The demographics and 175 clinical information of the study participants are shown in Table 1’ but to avoid bulky document, just put (Table 1 or see Table 1) at the end of your first paragraph (line 174) and remove the long statement.

Discussion

1. Revise the first paragraph of your discussion as it has the following problems:

• You have started with some background and objectives of your study, instead focus on your result not objectives, aim or background information

• The paragraph is fragmented and has poor coherence eg. Line 204-210

2. There are contradicting statement about your study population in which you mentioned your study participants as University students but in discussion line 299-301, you said ‘This study has several limitations that should be acknowledged. Firstly, the heterogeneity of the participants, which included both university students and employees, may have influenced the results.’

Reviewer #6: The abstract should be reorganised into clearly labelled sections such as Background, Methods, Result and Conclusion.

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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 #3: No

Reviewer #4: Yes: Bruce Ayabilla Abugri

Reviewer #5: No

Reviewer #6: No

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Changes in Anthropometric Indices, Lifestyle Patterns, and Mental Stress with Ramadan Intermittent Fasting among Healthy Students: A Prospective Cohort Study

PONE-D-25-10924R2

Dear Dr. Anfal AL-Dalaeen

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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