-->PONE-D-25-31196-->-->Predictors of Infant Birth Weights: Role of the Lebanese Mediterranean Diet, Psychosocial Factors and Maternal Health Status-->-->PLOS One

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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.

Additional Editor Comments:

The study investigated an important topic, the impact of Mediterranean Diet (LMeD), psychosocial factors, and maternal health indicators on infant birth weight categories (SGA, AGA, LGA) among Lebanese pregnant women, However, the manuscript requires substantial improvements in clarity, statistical reporting, and narrative focus before it can be considered for publication in PLOS ONE.

Major Issues

Methodological and Reporting Inconsistencies: The manuscript contains multiple inconsistencies in sampling, data collection, and variable measurement. (see my comments below).

Insufficient Statistical Reporting: Non significant regression results are omitted, Model 1 is referenced but not presented. Without full regression outputs, reviewers cannot evaluate the validity of the findings.

Several psychosocial and clinical measurement tools (PSS 10, PSQI, EPDS, BP measurement protocols) are inadequately described or incorrectly referenced (see my comments below).

The manuscript is lengthy, repetitive, lack precision and sometimes misinterprets cited literature.

A major concern relates to the reference list, as a substantial number of the cited sources are not retrievable using the information provided in the manuscript. This issue significantly undermines the credibility of the work.

Abstract

The abstract ends abruptly monitoring MAP, PP and sleep quality and promoting adherence to the LMeD). please add a concluding sentence summarizing implications.

Introduction

The manuscript is overly lengthy, with extensive detail that at times obscures the main findings. Recommendation: Streamline the Introduction and Discussion by eliminating redundancies and emphasizing the most relevant evidence to improve clarity and focus.

Study Design and Sampling

The description of the sampling strategy is insufficient and requires substantial clarification. The manuscript states that “Among 732 obstetric clinics, a total of 20 private and hospital‑based private clinics were selected using simple random sampling.” However, the process by which this random selection occurred is unclear. Please clarify the following points:

o How were the 20 clinics randomly selected? (Was a random number generator used? Or Were clinics stratified by governorate before random selection?)

o How were participants recruited within each clinic? (consecutively or randomly recruited?)

o Explain the apparent inconsistency in regional recruitment (30.7% of participants were recruited from Mount Lebanon, drawn from 3 clinics, while 12.4% were recruited from Beirut, drawn from 5 clinics, and that a minimum of 30 women were recruited from each clinic). These numbers are difficult to reconcile. If each clinic contributed approximately 30 participants, then regions with more clinics should contribute more participants. Instead, the opposite appears to be true.

o Given the unequal distribution of clinics and participants across governorates, weighting may be necessary to avoid over‑ or under‑representation of certain regions. If no weighting was applied, please justify this decision.

At Line 128, there is a clear typo error in the description of clinic locations. The manuscript refers to “South China” and “North China”, These should be corrected to: South Lebanon, North Lebanon.

Study Design

The manuscript states that “the questionnaires were readministered in the 2nd and 3rd trimesters”, yet Table 2 presents data for certain instruments (e.g., Pittsburgh Sleep Quality Index and Perceived Stress Scale) across T1, T2, and T3, implying administration in the first trimester as well. In contrast, PARmed-X for Pregnancy is only reported for T2 and T3. This inconsistency suggests a reporting bias.

Line 155 “abbreviation” SBP, DBP, MAP. PP”, line 489” LMIC”. It require the first mention of an abbreviation to be spelled out.

Line 176-177:” this tool had a good correlation (r=0.56) with the Italian MeD tool.” Saying "good correlation" for r = 0.56 is a bit subjective. In healthcare research, a correlation coefficient of r ≈ 0.5–0.6 is generally interpreted as moderate, not “good.”, you might want to phrase it more precisely: “This tool demonstrated a moderate positive correlation (r=0.56) with the Italian MeD tool”. and consider moving this statement to the first paragraph of the “Dietary assessment and adherence to the Lebanese Mediterranean diet” section to enhance readability and emphasize its importance

Line 171-172: The authors reported “in the LMeD, other main components, such as fish, red meat, poultry, and wine consumption, are missing. While this adaptation reflects cultural dietary practices, the absence of these elements may limit comparability with other Mediterranean populations and should be acknowledged as a methodological limitation.

Line 171 notes wine consumption as missing, while Line 177 explains that alcohol intake (including wine) was excluded due to cultural absence. This overlap creates redundancy and potential confusion regarding whether wine is missing due to cultural adaptation or excluded as part of alcohol intake. Consider merging these into a single, consistent explanation to improve clarity.

The LMeD score is based on tertiles of intake, but the manuscript does not specify Whether tertiles were calculated per trimester or based on baseline distribution.

Line 201-203:

o The text states that FBG values were collected only in trimesters 1 and 3, yet categorization is described as occurring during the second trimester visit. This creates confusion: how can categorization be based on a trimester where no values were collected?

o The unit “mmol/” is incomplete; it should be “mmol/L.”

Line 214: Infant birth outcomes: Clarify whether gestational age was based on LMP or ultrasound.

Line 208-212: The use of trimester-specific MAP cutoffs is appropriate; however, the rationale for applying PP cutoffs derived from a single population study with only 20 women (reference 49) requires justification.

Line 208-212: Given that the study population was drawn from multiple clinics across different geographic areas, the authors should specify whether blood pressure measurements were obtained using standardized protocols and uniform devices. This information is essential to ensure consistency, reliability, and comparability of measurements across sites. If standardized procedures or devices were not used, this should be explicitly acknowledged and discussed as a limitation of the study.

Psychosocial variables (line 220-226)

o In Lines 220–226, the authors claim that the Perceived Stress Scale (PSS-10) has been validated among the Lebanese population, but no supporting reference is provided. The appropriate citation is: Chaaya, M., Osman, H., Naassan, G., et al. (2010). Validation of the Arabic version of the Cohen Perceived Stress Scale (PSS-10) among pregnant and postpartum women. BMC Psychiatry, 10, 111. https://doi.org/10.1186/1471-244X-10-111. In this validation study, Cronbach’s alpha was used to assess internal consistency reliability, while test–retest reliability was evaluated using Spearman’s correlation coefficient. These two values should be reported separately to clearly distinguish between the two scales.

o Line 223-224: The author reported that Lebanese version is Correlated with and with a general health questionnaire (r=0.48) and EPDS (r=0.58), but was not clear from where these value came, the original article in table-2 (Chaaya 2010) reported different values (.59) and .49 respectively.”

o Lines 228–232: The study validating the Arabic version of the Pittsburgh Sleep Quality Index (PSQI) is not cited. The appropriate reference is: Suleiman K., Al-Hadid L., Duhni A. (2012). Psychometric testing of the Arabic version of the Pittsburgh Sleep Quality Index (A‑PSQI) among coronary artery disease patients in Jordan. Journal of Natural Sciences Research, 2(8), 15–20

o Line 236: The term “global sum” is ambiguous. Do you mean the “total score”? Please clarify the terminology.

o Line 237-239: The authors reported that Edinsburgh Perinatal/Postnatal Depression Scale (EPDS) tool was used to assess depression, however, the reference cit the tool Edinsburgh Postnatal Depression Scale (EPDS) 1987 which used only for POST natal. Furthermore, the authors claim that the tool has been validated among the Lebanese population, but no supporting reference is provided. The appropriate citation is “Ghubash, R., Abou-Saleh, M. T., & Daradkeh, T. K. (1997). The validity of the Arabic Edinburgh Postnatal Depression Scale. Social Psychiatry and Psychiatric Epidemiology, 32(8), 474–476. https://doi.org/10.1007/BF00789142”

Results:

The results are reported without interpretation, simply restating data already presented in the tables. The narrative should inform the reader with meaningful statements that emphasize trends and group differences. For example, instead of writing ‘Factors that differed revealed that greater adherence to the LMeD was associated in both trimesters 2 (p<0.033) and 3 (p<0.038), but not in trimester 1,’ the authors could write ‘AGA mothers consistently show better adherence to the LMeD in later trimesters.’ This style of reporting should be applied consistently across the results section to enhance clarity and impact.

There is an inconsistency in participant reporting. The authors state that 42 participants dropped out due to miscarriages or other reasons. However, the analysis (lines 275–286) describes the characteristics of 618 pregnant women, while Table 1 presents characteristics for only 576 women. Furthermore, Table 2 (Comparisons of maternal health factors across the SGA, AGA, and LGA groups) and the supplementary tables report data for 618 women, despite the earlier statement that 42 participants were excluded. This discrepancy suggests a reporting bias and requires clarification regarding the actual sample size used in each analysis.

In Table 1, Infant sex, Birth weight, Birth weight z score should be presented as percentages with appropriate units. Please revise the table to ensure clarity.

Model 1 is referenced in the text, but the corresponding results are not presented in tables or in the supplementary materials.

Table 2 is very long and difficult to interpret. Move some variables to supplementary tables is recommended.

Table 3 presents only the statistically significant adjusted variables from the multiple logistic regression model, while non-significant results are omitted—even from supplementary materials. Without access to the full regression output, including non-significant predictors, the model cannot be adequately reviewed or interpreted. The authors should provide a complete list of variables assessed, ideally in supplementary tables, to ensure methodological transparency and allow for proper peer evaluation.

Line 278: The sample appears to be highly educated, with 76% of participants holding a university degree. This raises concerns about selection bias and limits the generalizability of the findings to populations with more diverse educational and socioeconomic backgrounds. The authors should further discuss how this skewed educational profile may influence health behaviors, access to care, and study outcomes, and explicitly address these socioeconomic factors in the limitations section.

Line 314: Stress and depression were measured but were not included in the analytical models. Given that their prevalence exceeded 50% of mothers across T1, T2, and T3, the authors should discuss why these variables did not demonstrate significant associations with the outcomes. Potential explanations such as measurement timing, confounding with other psychosocial or clinical factors should be explored.

Line 395: The manuscript states that dairy products in the third trimester (T3) were associated with increased BWGA; however, Table 3 indicates that this association was observed in the second trimester.

Discussion:

The Discussion section is overly narrative and includes tangential literature.

The discussion section is relatively long, and several paragraphs repeat or restate results rather than providing interpretation. For example, the paragraph in lines 577–585 (“Pre‑pregnancy BMI, gestational weight gain (GWG) and birth outcomes”) reads more like a results summary than a critical discussion. In addition, multiple sections are overly lengthy and contain redundancies. Streamlining the discussion, removing repeated results, and focusing on interpretation, implications, and comparison is needed.

The authors used sometimes overstates causality, therefore, using cautious language such as “associated with,” “may contribute to” is highly recommended.

Lines 533–537: The Iranian study you cite does not support your findings as stated. The Iranian study reports that as the ratio of MUFA (olive oil) to SFA increases, gestational weight gain decreases—meaning higher olive intake is associated with lower GWG. In contrast, your results indicate that women who delivered LGA infants had higher olive intake in Trimester 2. These two interpretations appear contradictory. Please clarify this discrepancy and explain how the cited study supports your findings. You may need to discuss potential confounding such as total energy intake, cooking methods.

Line 495: The author reported that LMeD adherence did not enter models for SGA or LGA, yet specific LMeD components did. This distinction needs clearer framing in the discussion: why does the overall pattern fail to predict risk while individual components like olive oil in T2 increase LGA risk?

Line 498-499: Is there any explanation why the AGA mothers consistently show better adherence to the LMeD in later trimesters.

Line 555: Eggs show the highest positive coefficient among the listed food groups. It is recommended to explicitly link this finding to its nutritional significance. Eggs are a high‑quality protein source and provide key nutrients such as choline and essential fatty acids, which play critical roles in fetal brain development, cellular growth, and overall pregnancy outcomes. Highlighting these mechanisms would strengthen the interpretation of this result.

Line 696: The authors describe the association between poor sleep in T3 and increased LGA risk as a “novel psychosocial dimension.” I disagree with this characterization, as multiple previous studies have already reported similar associations between maternal sleep disturbances and fetal overgrowth. The authors should revise this statement to accurately reflect the existing body of evidence.

Others

The authors state that the data are available within the manuscript and supporting files. However, PLOS ONE requires that the minimal data set be provided in a form that allows full replication of the analyses. In the current submission, non‑significant results appear to be omitted—even from the supplementary materials. Without access to the complete regression outputs, including non‑significant predictors, it is not possible to adequately review or interpret the models

A major concern relates to the reference list, as a substantial number of the cited sources are not retrievable using the information provided in the manuscript. This issue significantly undermines the credibility of the work. Ensure all references are current and correctly formatted and are complete (some missing journal names or years). Reference 57 appears to be a duplicate of Reference 54.

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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?

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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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Reviewer #1: Yes

Reviewer #2: Yes

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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: Minor Revision

Abstract :

Some editing mistakes (L41 « . ») / review the conclusion (nonverbal phrase).

Introduction :

L108 : abbreviation of Body mass Index (BMI)

Materials and methods :

L114 : how did u define the study being « national » ?, while the recrutment was exclusively conducted in private clinics and not public hospitals and the recrutment from the capital Beirut was just 12.4%.

L119 : If women were recruted in their 1st trimester of gestation, are the structural and chromosomal anomalies diagnosted at this early stage of pregnancy ?

L126 : how did you ended up with the 732 obstetric clinics ? was the data from the ministry of health ? or other organisation ?

L128 : The study is conducted in Lebanon and not in South or North China like mentionned.

L133 : Provide the ethical consent of the affiliated academic institution.

L149 : Provide more information about the physical activity status of participating pregnant women. Why the research team did not rely on a validated tool such as the PPAQ ?

L153 : why anemia was assessed ? and not explored later in regard to neonatal outcomes ? were the participants supplemented ?

L160/161 : Pls note that this FFQ was not validated among pregnant Lebanese women. This should be cited in the limitations.

L168 : dried fruits or nuts ? since oleaginous fruits are more consumed by the Lebanese population.

L171 : fish, red meat and wine are major food components implicated in measuring the adherence in the mediteranean diet. Provide an explanation why they were excluded from the initial tool, since it may affect the results and not considered a reliable tool?

L173 : Provide a detailed measurement analysis of this tool. How was the final adherence to Med Diet among this sample ? Compare and cite with studies assessing dietary patterns among Lebanese pregnant women.

L177 : Reference 35 is Buysse DJ, et al. Pittsburgh Sleep Quality Index (PSQI). Sleep. 1989;12(1):65-72 and not an italian validated Med tool !

L188 : change the word « according » written twice in the same phrase.

L204 : is it 50 g or 75 g or 1g / kg body weight ? (75g is more widely used)

L214 : cite the other birth outcomes, since they were mentionned in the result part.

L250 : how was the physical activity assessed and categorized ?

L280 : pls correct all values ( 63.4% instead of 67.6% , 32.7% instead of 32.4% and change « or » with « and » )

L293 : Add N= … the number of participants in the title / L336 too

Table 1 Some editing mistakes « , » near GWG T3 and remove « . » near 58 (Boy) /

L315 : Delivery mode was not cited in the results. Why this variable was not taken into account during the analyses?

L316 Participants suffering from delivery complications, were they dropped from the study ? Data is not reported in the tables.

L340 : the format of the footer in table 1 is different from table 2, 3… pls review the formatting

Discussion :

- No mention about the smoking status of the participants, especially that it may be linked to negative neonatal outcomes and linked to HBP.

- L503 editing mistake « . » after ref 58.

- L536 : higher olive intake ? or olive oil ? and specifically how much in ml ?

- L559 : fruits or nuts ?

- L571 – 573 : the statement proposed is not clear. Pls rephrase.

- L577 : replace reference 79, by recent published studies conducted among Lebanese pregnant women in regard to neonatal outcomes.

- L707 editing mistake « . » after « findings ».

Limitations :

L713 Mention about the limitations of the tool used to assess the Med-diet adherence and the lack of assessment of not only energy intake but also macro and micronutrient and fiber content of their diet, since neonatal outcomes are highly influenced by caloric intake and the contribution of fat and protein during pregnancy.

References :

Review pls the referencing of some citations too (57, 74..). Provide the names of all authors, unless if the publication is authored by more than 6 authors and not just the first author with al. The name of some contributing authors are lacking in the citations.

Reviewer #2: The authors are commended for conducting such a robust study in a population where the is a

paucity of data related to pregnancy outcomes.

However, there are several concerns about some of the unusual finding from this study such as

associations of healthy fat intake (olive oil) and wheat with poor pregnancy outcomes and (LGA and

SGA respectively), high MAP during pregnancy being associated with LGA and poor sleep being

associated with LGA. The authors are encouraged to robustly explain these findings and how they

contradict current understandings in this field.

Detailed comments Uploaded as an attachment

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Reviewer #1: Yes: Tatiana Papazian

Reviewer #2: Yes: Shrish Budree, MD, PhD

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Attachments

Attachment

Submitted filename: Summary of Comments on PONE-D-25-31196_SB_12.7.pdf

-->PONE-D-25-31196R1-->-->Predictors of Infant Birth Weights: Role of the Lebanese Mediterranean Diet, Psychosocial Factors and Maternal Health Status-->-->PLOS One

Dear Dr. Fares,

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.

The authors have satisfactorily addressed several of the previous comments; however, a number of important issues remain unresolved. Kindly see my comments below.

Please submit your revised manuscript by May 30 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:-->

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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.

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As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only the individual author can complete the verification step; PLOS staff cannot verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Maher Abdelraheim Titi

Academic Editor

PLOS One

Journal Requirements:

1. 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.

2. 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.

Additional Editor Comments:

The authors have satisfactorily addressed several of the previous comments; however, a number of important issues remain unresolved:

• Manuscript length and focus: I still believe that the manuscript is overly lengthy, with extensive detail that at times obscures the main findings. Further streamlining of the Introduction and Discussion is needed, particularly by removing redundancies and focusing on the key messages.

• Line 125 – Clarification of clinic types: “A total of 20 private and hospital-based private clinics were stratified by governorate.” Please clarify the distinction between private clinics and hospital-based private clinics. How do these settings differ operationally or structurally, and why is this distinction relevant to the study?

• Line 128 – Definition of “first prenatal visit” and recruitment strategy

“Participants were then randomly recruited within each clinic at their first prenatal visit.”

Please clarify what is meant by “their first prenatal visit.” Does this refer to women attending their first-ever prenatal visit at that clinic during the study period? If so, this appears closer to consecutive recruitment rather than random recruitment.

• Lines 112–113 – Governorate distribution and percentages: “Governorates of Lebanon that included Mount Lebanon (30.7%), Beirut (12.4%), Bekaa (16.4%), South Lebanon (and Nabatieh) (29.4%), and Akkar (3.7%).”

The percentages sum to 92.6%, not 100%.

o Please provide the total number of participants per governorate in addition to percentages.

o Ensure that these numbers and percentages are consistent with what is reported in lines 126–127 and elsewhere in the manuscript.

• Pulse pressure cutoff and supporting literature

I recommend citing additional studies with larger populations and clearly defined pulse pressure (PP) thresholds to justify the cutoff used in this study. the rationale for the PP cutoff adopted in this study is not sufficiently supported by the literature and should be more clearly justified, For example:

o Mullan et al., 2021: PP cutoff 55 mmHg

o Thadhani et al., 2001: PP cutoff 50 mmHg

o Maykin et al., 2024: furosemide RCT that did not define or analyze a PP threshold.

o Sampson et al., 2024: PP cutoff 50 mmHg

In its current form,

• Lines 158–159: “Initially, 660 participants were recruited; however, 42 dropped out due to miscarriage or unwillingness to participate, making the total sample size N = 618.”

This statement is more appropriate for the Results section rather than the Methods. Please relocate this description of participant flow to the Results

• Table 1 –It would be preferable to display the units in parentheses (e.g., kg, %) and to standardize unit presentation across all variables in Table 1.

• Supplementary tables : Please ensure that the numbering and labeling of all supplementary tables are consistent between the text and the supplementary material.

• Table 3 –dairy products are reported as significantly associated with increased BWGA. Please verify whether this association pertains to T1 or T2 and ensure that the text and table are fully consistent and clearly labeled.

• Reference list: A major concern remains regarding the reference list. The references need to be revised carefully for accuracy, and consistency. Specific issues include, but are not limited to:

o The reference for Martínez-Galiano et al. (“Effect of Adherence to a Mediterranean Diet and Olive Oil Intake during Pregnancy on Risk of Small for Gestational Age Infants”) appears incomplete and/or incorrectly formatted. Please provide full citation details and numbering.

o Line 235: The cited article number “34” appears to be incorrect; please verify and correct.

o Line 470: The reference cited here should be checked for accuracy and consistency with the reference list.

o Lines 485–486: The reference cited to support the authors’ claim in these lines appears inappropriate or not directly supportive of the statement. Please revise the citation or modify the claim to align with the evidence.

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Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

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Reviewer #1: 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

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

Reviewer #1: Yes

**********

-->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

**********

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

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Reviewer #1: 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: All points raised during the peer-review process have been modified and the manuscript in its final version is acceptable for publication.

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Reviewer #1: Yes: Tatiana Wahanian Papazian

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-->PONE-D-25-31196R2-->-->Predictors of Infant Birth Weights: Role of the Lebanese Mediterranean Diet, Psychosocial Factors and Maternal Health Status-->-->PLOS One

Dear Dr. Fares,

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.

The authors have successfully resolved and responded to all reviewer comments. Howevre, the manuscript continues to exhibit substantial issues related to reference accuracy, and citation consistency. Kindly see my comments belows.

Please submit your revised manuscript by Jun 25 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'.

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As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only the individual author can complete the verification step; PLOS staff cannot verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Maher Abdelraheim Titi

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.

Additional Editor Comments:

The authors have successfully resolved and responded to all reviewer comments. However, the manuscript continues to exhibit substantial issues related to reference accuracy, and citation consistency. The following concerns require careful and systematic correction:

• Missing and Incorrect Citations

o Reference 4 is listed in the reference list but not cited anywhere in the manuscript.

o Reference 54 is also not cited in the text.

o Reference 81 appears to contain an error. Please verify the correct numbering, formatting, and citation placement.

• The manuscript frequently supports individual statements with an unnecessarily large number of references. This practice weakens the clarity and precision of the argument.

Examples include:

o Line 489: Claim supported by seven references [87–93].

o Line 469: Claim supported by eight references [66–73].

o Line 459: Claim supported by six references [59–94].

• Please reduce the number of citations per claim. Supporting a statement with ONE - TWO high quality, recent and relevant studies is generally sufficient unless the claim explicitly requires broader evidence synthesis.

• The overall number of references should be reduced. Several citations appear redundant or marginally relevant. Please ensure that each reference directly contributes to the argument and is essential for supporting the manuscript’s claims.

• The crossed out statement at line 168 should be removed entirely.

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To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

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Predictors of Infant Birth Weights: Role of the Lebanese Mediterranean Diet, Psychosocial Factors and Maternal Health Status

PONE-D-25-31196R3

Dear Dr. Fares,

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,

Maher Abdelraheim Titi

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: