-->PONE-D-26-07428-->-->Waist-to-height ratio identifies children with lower physical activity and reduced cardiorespiratory fitness: longitudinal evidence from Norwegian primary schools – the Health Oriented Pedagogical Project (HOPP).-->-->PLOS One

Dear Dr.  Fredriksen,

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 May 13 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.

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“The HOPP study is funded by Horten municipality, Kristiania

University College, the Norwegian Order of Odd Fellow Research Fund, the Oslofjord

Regional Research Fund, and the Norwegian Fund for Post-Graduate

Training in Physiotherapy.

Powered”

Please state what role the funders took in the study.  If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

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Additional Editor Comments:

-->This manuscript does not describe a technically sound piece of scientific research with data that supports the conclusions. Several methodological and reporting aspects require clarification, particularly regarding the statistical model structure, measurement procedures, and interpretation of regression results.-->

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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: I Don't Know

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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: No

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Reviewer #1: Yes

Reviewer #2: No

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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: Overall, the manuscript addresses an important public health question by examining the longitudinal relationship between waist-to-height ratio, physical activity, and cardiorespiratory fitness in a large cohort of Norwegian children.

The large sample size and longitudinal design of the HOPP study provide strong potential for meaningful insights into pediatric health risk indicators.

However, several methodological and reporting aspects require clarification, particularly regarding the statistical model structure, measurement procedures, and interpretation of regression results.

Strengthening these areas and moderating causal interpretations would significantly improve the scientific clarity and impact of the manuscript.

Abstract

1. The abstract contains an important methodological inconsistency: it states that WHtR was used as the independent variable, but then lists age, sex, MVPA, VO₂peak, and Andersen intermittent running test as dependent variables, which is conceptually unclear because age and sex are typically covariates or control variables rather than dependent outcomes. This needs clarification.

2. The results section of the abstract focuses on statistical significance but should better explain the practical meaning of the regression coefficients (e.g., how much fitness decreases with higher WHtR).

3. The conclusion should avoid implying a direct causal relationship between WHtR and lower physical activity or fitness, since the design primarily demonstrates associations within a longitudinal cohort.

Introduction

4. The introduction provides strong background on childhood obesity, physical inactivity, and cardiometabolic risk, but it places relatively little emphasis on the specific advantages of waist-to-height ratio compared with other adiposity indicators such as BMI or waist circumference alone. A clearer justification for selecting WHtR as the primary indicator would strengthen the rationale.

5. Several paragraphs broadly discuss physical activity and obesity in children but do not directly connect this information to the specific research objective of examining longitudinal relationships between WHtR, MVPA, and aerobic fitness. The section would benefit from a more focused narrative leading directly to the research question.

6. The final paragraph should more clearly state the specific hypotheses, particularly whether the authors expected WHtR to predict lower MVPA, lower VO₂peak, or both.

Methods

Study Design and Participants

7. The description of the Health Oriented Pedagogical Project (HOPP) cohort is informative, but the manuscript should more clearly explain the sampling framework and school recruitment procedures, including whether schools were randomly selected or volunteered to participate.

8. Because the study spans several years (2015–2020), it is important to clarify participant retention and attrition rates, including how many children were included in repeated measurements and how missing data were handled.

9. Additional detail about socioeconomic background or school characteristics would help contextualize the population and improve the interpretation of generalizability.

Measurements (WHtR, Physical Activity, Fitness)

10. The measurement procedures for waist circumference and height should provide clearer methodological detail (e.g., number of measurements taken, measurement reliability, and standardization procedures).

11. The manuscript should more clearly explain how physical activity (MVPA) was measured and processed, including accelerometer settings, epoch length, wear-time criteria, and cut-points used to classify MVPA.

12. The relationship between VO₂peak and the Andersen intermittent running test should be clarified, particularly whether VO₂peak was directly measured or estimated from the test performance.

Statistical Analysis

13. The manuscript states that linear mixed models (LMM) were used, which is appropriate for longitudinal data, but the description of the model structure requires clarification. Specifically, it should clearly indicate which variables were treated as fixed effects and which were included as random effects (e.g., participant or school level).

14. The analysis section should clarify whether time was included as a repeated factor in the model, given the longitudinal design of the HOPP dataset.

15. The manuscript should also explain how potential confounding variables such as age, sex, and growth-related changes were incorporated into the models.

Results

16. The results section clearly reports associations between WHtR and fitness-related variables, but the presentation would benefit from clearer interpretation of regression coefficients, explaining their practical meaning for child health and performance.

17. Given the large sample size (n ≈ 2297), the manuscript should place greater emphasis on effect size interpretation rather than relying primarily on statistical significance.

18. The relationship between WHtR, MVPA, and VO₂peak could be presented more clearly by emphasizing the direction and magnitude of associations rather than focusing primarily on p-values.

Discussion

19. The discussion appropriately highlights the relationship between central adiposity and reduced physical fitness, but the explanation of mechanisms could be expanded to include physiological and behavioral pathways linking adiposity to reduced physical activity and aerobic capacity.

20. The manuscript should more clearly compare the findings with previous research examining WHtR, BMI, and fitness in children, highlighting whether the current results confirm or extend existing evidence.

21. The limitations section should more explicitly acknowledge several important issues, including measurement limitations of accelerometry, potential residual confounding, and the observational nature of the data, which limits causal interpretation.

Practical Implications

22. The manuscript suggests that WHtR may be a useful screening tool for identifying children with lower physical activity and fitness; however, the practical implications should further explain how schools or health professionals could implement such screening in real-world settings.

23. The discussion could also address how school-based physical activity programs might target children with higher WHtR to improve both fitness and cardiometabolic health.

Conclusions

24. The conclusions should be slightly moderated to avoid implying that WHtR directly determines physical activity or fitness levels.

25. The section should emphasize that WHtR is associated with lower MVPA and lower cardiorespiratory fitness, highlighting its potential value as an early screening indicator for cardiometabolic risk in children.

Reviewer #2: This is an important and useful study examining an emerging measure of excess adiposity in detecting the risk of physical fitness, however, the authors submitted an embarrassing text. This reviewer provided comments with an interest in improving the study; otherwise, this is a straight rejection.

Major comments.

The article has no reference bibliography, the in-text citation has two types of referencing styles… This is unprofessional and sloppy. The authors should provide an explanation for such sloppiness.

Did the authors use ChatGPT to write the original draft of the article?

The authors should include the latest longitudinal evidence and reviews in the introductory rationale. Remove all references >10 years old. The field is rapidly evolving.

For example, rather than cite (Tremblay et al. 2011) in Line #98 on relations between movement behaviour and adiposity, a stronger long-term evidence exists in children, https://doi.org/10.1038/s41467-023-43316-w

A review on sedentary behaviour is also important to this work. https://doi.org/10.1152/physrev.00022.2022

Remove all references for adults from the text and focus on children and adolescents.

This statement has no meaning “Tests like 20 m SRT and Yo-Yo can be problematic from a pedagogical view.”… please delete. https://doi.org/10.1152/ajpheart.00570.2025

Focus on establishing the role of pediatric WHtR in detecting cardiometabolic risk, liver diseases, type 2 diabetes, and hypertension in the introductory rationale and adding these new references to both the introduction and discussion

https://doi.org/10.1038/s41366-025-01949-5

https://doi.org/10.1016/j.tjnut.2026.101426

https://doi.org/10.1093/obendo/wjaf002

https://doi.org/10.1210/jendso/bvaf079

“This study aims to test the WHtR’s ability to predict physical activity and fitness in children” is a weak justification. The authors should link the updated introduction to why this research question is important. One reason is the new approach to defining obesity, as emphasized in the new obesity guideline. Moreover, validating peadiatric WHtR cutoff as highlighted in the discussion is a valid research question.

Results:

Tables should be editable. The authors approach to copy paste photos or screenshots of table is very poor and suggests a lack of diligence.

What does the two repeated column of WHtR represent in Table 1?

Table 1 should present the baseline characteristics of the participants. It is shameful that there is no information.

Prepare a table showing the values of WHtR per quartile in this cohort.

Reanalyse your study using a pediatric validated cutoff which you have cited as reference #50.

What is the prevalence of high and excess fat in this population based on the Waist-to-height ratio cut points are <0.40 (low fat mass), 0.40 to < 0.50 (normal fat mass), 0.50 to < 0.53 (high fat mass), and ≥0.53 (excess fat mass) in males. Waist-to-height ratio cut points for females are <0.40 (low fat mass), 0.40 to < 0.51 (normal fat mass), 0.51 to < 0.54 (high fat mass), and ≥0.54 (excess fat mass)

The discussion should be entirely rewritten, not with chatGPT as it is too long and incoherent. Use the references suggested above to improve this manuscript.

is this a longitudinal study, what was the follow up duration. which measures are undertaken at baseline and follow-up.

Statistical analysis strategy must be well written for clarity and repeatability.

What does this mean? Automatisk oppdatering av henvisninger er deaktivert. For å se bibliografien, klikk Oppdater I Zotero fanen.

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Reviewer #1: Yes:   Júlio Alejandro Henriques Castro da Costa

Reviewer #2: No

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-->PONE-D-26-07428R1-->-->Waist-to-height ratio identifies children with lower physical activity and reduced cardiorespiratory fitness: longitudinal evidence from Norwegian primary schools – the Health Oriented Pedagogical Project (HOPP).-->-->PLOS One

Dear Dr. Fredriksen,-->-->

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.-->--> -->-->There are a few minor and a major comment pointed out by Reviewer 2 that need to be attended to, including spelling errors, same changes, and improving the discussion section! -->--> -->-->Please submit your revised manuscript by Jun 12 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.

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,

Timoteo Salvador Lucas Daca, Ph.D

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.

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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 #1: All comments have been addressed

Reviewer #2: (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 #1: Yes

Reviewer #2: (No Response)

**********

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

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #2: (No Response)

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-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: I am satisfied with the current version of the manuscript.

The authors have done a thorough job in revising the paper and have adequately addressed all the questions that were raised.

Reviewer #2: Thank you for the significant upgrade of the manuscript, which makes for a good read. A few minor and a major comment are listed herewith.

Line 78… spelling error ”therefor”

Line 88… change “closely tied to” two modifiable factors “of” future cardiometabolic health

Line 129… It appears that something is missing in the text “only children born 200 (the youngest)”

Line 182… typo error “HOPP’s primarily objective”… should be “primary”.

Line 228… typo error "from HOPP provid an overview”…. should be “provide”.

In the discussion, the authors should emphasise the significance of WHtR which was confirmed in this study regarding how WHtR overcame a major limitation of BMI variability with age and sex. The authors noted in the result section that “WHtR remains stable over time for both sexes” See the following references… https://doi.org/10.1038/s41366-025-01949-5

https://doi.org/10.1038/s41390-024-03112-8

Table 2 should include a column of mean age and SD of the boys and girls per study year and SES.

Also mean (SD) for MVPA, VO2 peak and Sedentary time must be included in Table 2 per year of follow up.

There are two symbols in the result Line 243-247 that should be defined at first use (β,d)

This point should be included in the abstract “Each 0.1 unit increase in WHtR was linked to a -0.62 min/day reduction in average MVPA”

The title of Table 3 reads more like a footnote, kindly revise.

The major concern is that representing WHtR in quartile is not clinically relevant. The topmost quartile equals 75th percentile. This lumps together normal WHtR fat mass, high fat mass and excess fat mass in the same category. Therefore, creating room for misclassifications. It is also impossible to state the role of excess adiposity on MVPA clearly.

Importantly, the authors response to the previous comment is not satisfactory “What is the prevalence of high and excess fat in this population based on the waist-to-height ratio cutpoints: <0.40 (low fat mass), 0.40 to <0.50 (normal fat mass), 0.50 to <0.53 (high fat mass), and ≥0.53 (excess fat mass) in males? Waist-to-height ratio cut points for females are <0.40 (low fat mass), 0.40 to <0.51 (normal fat mass), 0.51 to <0.54 (high fat mass), and ≥0.54 (excess fat mass).

This is the clinical relevance of this new study. These WHtR cutpoints represent 85th percentile to <95th percentile for high fat mass and 95th percentile and above as excess fat mass.

Rather than use quartile, this validated clinical cutpoints provide detailed information that could make this study a reference in future clinical guideline update. Kindly re-analyse the data based in the provide cutpoint.

This statement was repeated several times in the discussion, kindly delete all redundant repetitions “these results support WHtR as a simple marker that may help identify children at risk”

The nul association between sedentary behaviour and WHtR may be due to the quartile category approach which does not clearly delineate between real excess adiposity. Hence the clinical relevant cutpoints should be used to reexamine the associations of sedentary time and WHtR.

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Reviewer #1: Yes:   Júlio Alejandro Henriques Castro da Costa

Reviewer #2: No

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Waist-to-height ratio identifies children with lower physical activity and reduced cardiorespiratory fitness: longitudinal evidence from Norwegian primary schools – the Health Oriented Pedagogical Project (HOPP).

PONE-D-26-07428R2

Dear Dr. Fredriksen,

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.

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Kind regards,

Timoteo Salvador Lucas Daca, Ph.D

Academic Editor

PLOS One