-->PONE-D-26-16450-->-->Neck Circumference as a Predictor of Overweight among School Age Children in Bharatpur, Nepal: A Community Based Study-->-->PLOS One

Dear Dr. Bajracharya,

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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: No

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: No

Reviewer #2: Yes

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Reviewer #1: No

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: 1. The primary concern relates to the study design and sampling strategy. Participants were selected using a non-probability consecutive sampling technique from a single ward of Bharatpur Metropolitan City. This approach limits representativeness and introduces selection bias. Since the sample was not randomly selected and came from one localized semi-urban area, the derived NC cutoff values may not generalize to broader pediatric populations in Nepal with different ethnic, nutritional, socioeconomic, or rural–urban backgrounds. The authors should discuss this limitation more explicitly and avoid overgeneralization of conclusions.

2. A second major issue concerns the statistical analysis of overweight prediction. Only 31 children (10.3%) were classified as overweight, yet logistic regression produced a very large adjusted odds ratio (AOR = 20.817, 95% CI: 6.34–68.29). With such a relatively small number of outcome events, regression estimates may be unstable and confidence intervals wide. The manuscript should clarify the number of variables entered into the model, assess events-per-variable adequacy, and explain whether assumptions of logistic regression were fully met. In addition, odds ratios for a continuous predictor such as NC should specify the unit increase (per 1 cm increase or categorized threshold).

3. The ROC analysis is interesting, but the manuscript should provide more detail regarding cutoff derivation and validation. The proposed NC thresholds were developed and tested using the same dataset, which may overestimate performance. No internal validation methods (bootstrapping, split-sample validation, cross-validation) or external validation cohort were used. Therefore, the reported sensitivity, specificity, and AUC values should be interpreted cautiously. Independent validation in another Nepali pediatric cohort would substantially strengthen the manuscript.

4. Another concern is the data availability statement. The manuscript states that data are available from the corresponding author upon reasonable request. PLOS ONE generally expects the minimal underlying dataset to be publicly available unless justified restrictions apply. The authors should deposit de-identified data in a suitable repository or provide a stronger rationale for restricted access. Several potentially important confounders were not adequately addressed. Although age and sex were adjusted in one model, other factors such as pubertal stage, dietary habits, physical activity, parental BMI, socioeconomic status, and ethnicity may influence both NC and overweight status. Because children aged 6–11 years may vary in developmental stage, this should be acknowledged more clearly.

5. Use of BMI-for-age as the Only Reference Standard:

The study evaluates neck circumference against BMI-for-age alone. While BMI is widely used, it does not directly measure body fat distribution or adiposity. Since NC is proposed as an alternative screening marker, comparison with additional standards such as skinfold thickness, waist-to-height ratio, or body composition methods would strengthen validity.

6. Very High Underweight Prevalence (41.3%):

The sample had a strikingly high proportion of underweight children, much higher than overweight cases (10.3%). This unusual nutritional distribution may affect ROC-derived cutoffs and may not represent broader school-age populations. Authors should discuss whether the cutoff values are specific to this malnutrition-burdened population.

7. Cross-Sectional Design Limits Predictive Claim:

The title uses “predictor,” but this is a cross-sectional study. It identifies association and classification ability, not prospective prediction of future overweight. Wording should be revised to avoid implying causal or longitudinal predictive power.

8. Older Statistical Software:

Use of SPSS version 16 is not itself fatal, but it is outdated. Authors should confirm methods were properly implemented and report exact procedures used for ROC and regression analyses.

9. Measurement Reliability Not Reported:

Anthropometric measurements were performed by one investigator, but no intra-observer reliability, repeated measurement error, or calibration consistency data were provided. Since NC differences of less than 1 cm affect cutoffs, measurement precision is important.

Reviewer #2: Thank you for your nice work.

-Neck circumference is labeling more children as normal (68.7) vs BMI based normal range (48.3%).

-NC is labeling more children as overweight (31.3%) vs BMI based overweight (10.3 %). Can you please provide explanation

-On Table 6: BMI has three categories while NC has two. Are the underweight children be classified as normal in the NC group? Please provide explanation and if it has resulted in the above discrepance as well

-Please provide explanation for the relatively wide confidence interval (6.34–68.29)

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Reviewer #1: Yes:  Shake Ibna Abir

Reviewer #2: Yes:  Abraham Sisay Abie

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Neck circumference as an anthropometric marker of overweight among school-aged children in Bharatpur, Nepal: a community-based study

PONE-D-26-16450R1

Dear Dr. Bajracharya,

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,

Aleksandra Klisic

Academic Editor

PLOS One

Additional Editor Comments (optional):

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 #2: 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 #2: Yes

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

Reviewer #2: 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 #2: 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 #2: Yes

**********

-->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 #2: (No Response)

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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.

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Reviewer #2: Yes:  Abraham Sisay Abie

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