Dear Dr. Montenegro Mendoza,

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Kind regards,

Guoying Wang, MD, PhD

Academic Editor

PLOS One

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When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

3. Thank you for stating the following financial disclosure: [The ENSPA study was funded by the Ministry of Health of Panama via Inter-American Development Bank. HQ and IMV are affiliated with the National Research System (“SNI” in Spanish).].

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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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: The topic is extremely important. With increasing burden of non communicable diseases , research focusing on the risk factors is the need of hour.

The pandemic of obesity is alarming and being obese does not ensure that the individual has no nutritional deficiencies which is supported by evidence in this article.

The article is well written

Reviewer #2: This manuscript examines the double burden of malnutrition among non-pregnant women of reproductive age in Panama using nationally representative data. The topic is very relevant to current public health concerns, and I appreciate the use of a large dataset and appropriate statistical approach. Overall, the manuscript is well organized, and the findings are clearly presented and generally supported by the data.

However, the final analytical sample is smaller than the original survey sample due to exclusions. A short discussion on possible selection bias and whether the final sample remains representative would be useful.

Overall, I found this to be a solid and relevant study that adds to the literature on the double burden of malnutrition. With a few clarifications and minor revisions, it would be suitable for publication.

Reviewer #3: The introduction provides a strong rationale for the study and clearly highlights the public health importance of the double burden of malnutrition. However, the tone at times leans toward a normative or prescriptive perspective. I suggest reframing these sections to use a more analytical and descriptive tone, focusing on the epidemiological transitions and drivers rather than on societal deficits.

For example, on page 1, the manuscript states:

“Malnutrition in all its forms impacts the Human Capital Index and, therefore, the sustainable growth and poverty reductions of nations.”

While this is a valid point of view, it is a normative framing of the problem. To shift toward a more positive or analytical academic style, this could be reframed to focus on the measurable relationship between health variables, such as:

“The co-occurrence of different forms of malnutrition represents a challenge for human capital development, as the physiological impacts of both anemia and obesity have been shown to correlate with economic and productivity indicators at the national level.”

Adopting this descriptive approach throughout the introduction will align the background more closely with the objective, data-driven nature of the results and the rigorous multinomial analysis you have performed.

The authors state that the laboratory subsample (n = 5,212) was designed to be nationally representative and representative by area of residence. However, given the logistical requirements for biosample collection there is a potential risk of selection bias or non-participation bias compared to the full ENSPA-2019 survey sample (n = 17,997).

To strengthen the validity of the findings regarding the double burden of malnutrition, it would be beneficial for the authors to include a comparative analysis of the sociodemographic characteristics (e.g., age, education level, wealth quintile, and geographic region) between the full survey sample and the laboratory subsample of NpWRA.

Specifically:

Table Comparison: Could the authors provide a table (as an appendix or within the results) comparing these key characteristics to demonstrate that no significant systematic differences exist?

Bias Discussion: If differences are found, please discuss how these might impact the prevalence estimates and how the complex sampling weights used in the analysis account for this potential bias.

This comparison would provide greater confidence that the subsample effectively preserves the representativeness of the original survey. If found that there is an important difference in distribution weights might need to be recalcualted.

The data collection section is very comprehensive and provides a clear understanding of the study's execution. However, as the authors note that this methodology has been described in detail elsewhere (e.g., in the primary ENSPA-2019 report or previous publications), the current description in the manuscript is quite lengthy.

To improve the flow and readability of the publication, I suggest the following:

Summarize the Core Methods: Keep only the essential information necessary for the reader to understand the current analysis (e.g., the specific variables used for the double burden of malnutrition and the laboratory subsample flow).

Move Detailed Protocols to an Annex: Transfer the more granular procedural details—such as specific equipment brands, detailed field staff training protocols, and step-by-step biosample handling—to a Supplementary Materials or Annex section.

Cross-Reference: Ensure that the text clearly cites the original methodological publication or the new Annex for readers who require the full technical details.

This adjustment would allow for a more concise manuscript that focuses more directly on the study’s specific findings regarding non-pregnant women of reproductive age.

The Discussion section (pages 31–40) provides a thorough comparison of the study’s findings with similar data from other countries. However, much of the current text is dedicated to repeating the results and noting that they are "consistent with" or "similar to" findings in other regions. To increase the impact of the paper, I suggest the authors reduce the repetitive description of results and instead focus on the underlying reasons for these similarities or differences.

Specifically, the manuscript would benefit from a deeper analysis of the "Panamanian paradox." For example:

Economic Classification vs. Health Outcomes: Panama is classified as a High-Income Country (HIC), yet your results for the double burden of malnutrition and anemia are strikingly similar to those found in Low-Income Countries (LIC) or lower-middle-income regions.

Drivers of Disparity: Rather than just stating that the results match other countries, please expand on why this occurs in Panama. Is it due to the specific nature of the country's high income inequality (as mentioned with the Gini index), the rapid pace of the nutrition transition, or specific gaps in the food system that transcend national wealth?

Shifting the focus from what is happening in other countries to why Panama mirrors certain socioeconomic contexts despite its HIC status would provide a much more robust and insightful discussion.

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

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

Reviewer #2: Yes: Saadia Asiedu

Reviewer #3: No

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Double burden of malnutrition among non-pregnant women of reproductive age: results from the National Health Survey of Panama (ENSPA) 2019.

PONE-D-26-04070R1

Dear Dr. Montenegro Mendoza,

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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Kind regards,

Guoying Wang, MD, PhD

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: The authors have addressed all points in previous review. It addresses a very important topic and is well written and analyzed .It is fit for publication

Reviewer #2: Thank you for the opportunity to review the revised manuscript. I appreciate the authors' careful responses to the reviewers' comments and the revisions made throughout the manuscript.

The authors have addressed the majority of my previous concerns. In particular, the additional clarification of the methodology, discussion of missing data, and improvements to the data availability statement have strengthened the manuscript. The revisions have improved the clarity and transparency of the study.

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

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review?  For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #1: No

Reviewer #2: No

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