High Nutritional Vulnerability and Associated Risk Factors of Bangladeshi Wetland Community People Aged 50 Years and Older

Round 1

Reviewer 1 Report

Dear Authors,

I think the paper has been satisfactorily improved but I would recommend to add as a limitation of the study a comment on the respondents’ age structure. Another issue is the conformity with JAL guidelines for manuscript preparation. There are some adjustments needed as regards citations. In my opinion the final data set should be available as supplementary file.

Author Response

Comment 1: Dear Authors, I think the paper has been satisfactorily improved but I would recommend to add as a limitation of the study a comment on the respondents’ age structure. Another issue is the conformity with JAL guidelines for manuscript preparation. There are some adjustments needed as regards citations. In my opinion the final data set should be available as supplementary file.

Author’s response: The authors express their gratitude towards the reviewer for his or her precious feedback. We corrected the limitation part and added age structurer issue. We also revised the manuscript according to journal guidelines. The dataset used in this study is available on reasonable request to the corresponding authors. Data availability statement has added in the additional information section.

Track-change location: Page#7, Section: Discussion; Line# 224-225. Page#9; section: Data Availability Statement.

Reviewer 2 Report

This is a descriptive study of the prevalence of malnutrition measured with MNA-SF in a population of Bangladeshi wetland community-dwelling older adults.
The first issue is the representativeness of the sample. The total number of individuals Bangladeshi wetland community-dwelling older adults must be presented and from that data, perform a calculation of the sample size. I see that in this version they indicate that they have done it, although it should have been stratified by age (this aspect should be added in limitations of the study).
It seems that this population is highly exposed to risk of malnutrition. I don't know if there will be any population-wide malnutrition prevalence study in Bangladeshi wetland community-dwelling adults.
It draws attention to the Western reader that a person over 50 years of age is considered elderly. It would be important to know the life expectancy. The authors explain very well why a 50-year-old person is considered elderly, but they do not indicate the data on life expectancy.
It would be useful to have a figure in the form of an algorithm showing the number of people captured and how many were surveyed. And the number that did not want to answer the survey and the reason. This can be a very important source of bias.
It is not clear to me how the participants were recruited. If it was for advertisements or they simply went house to house in the town or if a census list of each town was used.
The results are so catastrophic that they should propose in the article a shock plan against malnutrition in that area.

Author Response

Comment 1: This is a descriptive study of the prevalence of malnutrition measured with MNA-SF in a population of Bangladeshi wetland community-dwelling older adults.

The first issue is the representativeness of the sample. The total number of individuals’ Bangladeshi wetland community-dwelling older adults must be presented and from that data, perform a calculation of the sample size. I see that in this version they indicate that they have done it, although it should have been stratified by age (this aspect should be added in limitations of the study).

Author’s response: We appreciate the suggestion given by the reviewer. As already mentioned in the limitation that this study was representative for the wetland communities in north-eastern part of Bangladesh. Please find the highlighted line in page#7. The major wetland area in Bangladesh are situated in this area. Here the used sample size was 400, collected through simple random technique. For your kind information, the total number of wetland community-dwelling older adults is not a known figure. Here, the sample size was estimated by considering 50% (optimum value to get maximum sample size) proportional value, 5% margin of errors and 5% non-response rate. The details computation process was not added in the manuscript due to page limits.

Track-change location: Page#7, Line#224-225. Section: Discussion. Page#3, Section: 2.2. Research design, Settings, sampling and participants

Comment 2: It seems that this population is highly exposed to risk of malnutrition. I don't know if there will be any population-wide malnutrition prevalence study in Bangladeshi wetland community-dwelling adults. It draws attention to the Western reader that a person over 50 years of age is considered elderly. It would be important to know the life expectancy. The authors explain very well why a 50-year-old person is considered elderly, but they do not indicate the data on life expectancy.

Author’s Response: We cordially thank the reviewers for his/her suggestion. As already mentioned that elderly living in wetland community is one of the most disadvantage group of people in Bangladesh. Still now, no nutritional surveillance is conducted in this community. We added the life expectancy issue in justifying age cut-off. Please find the highlighted line in page#3.

Track-change location: Page#3, line#112-114, Section: Research design, Settings, sampling and participants

Comment 3: It would be useful to have a figure in the form of an algorithm showing the number of people captured and how many were surveyed. And the number that did not want to answer the survey and the reason. This can be a very important source of bias. It is not clear to me how the participants were recruited. If it was for advertisements or they simply went house to house in the town or if a census list of each town was used. The results are so catastrophic that they should propose in the article a shock plan against malnutrition in that area.

Author’s response: We cordially appreciate the suggestion given by the reviewer. Sampling techniques and data collection procedures are described and again revised in the manuscript. As the total number of population (size of wetland elderly) is unknown, we estimated the sample size by considering 50% (optimum value to get maximum sample size) proportional value, 5% margin of errors and 5% non-response rate. This estimation resulted 400 as the required sample size. We added the detailed sampling descriptively and did not use algorithm.

Track-change location: Page#3, Section: 2.2. Research design, Settings, sampling and participants

Reviewer 3 Report

This is the revised manuscript of JAL1629972. The authors tried to respond to all reviewers. The reviewer thinks that the authors responded to some issues adequately. However, the reviewer still points out the same issues requiring manuscript revision as described below.

1. The authors mentioned that all the anthropometric measurements were used. BMI must be determined to evaluate the NMA-score. Then, section 2.5 should be before “Outcomes measures” of the Materials and Methods section. Please define the low, normal, and high blood pressure groups here. Again, please define diagnosing diabetes from RBS values in the section.

2. Bar graphs in Figure 1 are not reasonable to show the rate of normal, risk of malnutrition, and malnourished. In addition, why did the columns have error bars? Did the authors show the mean values of the data? The reviewer still recommends changing Figure 1a to the pie chart and Figures 1b-d to the donuts charts.

3. Even after reading the revised version, reviewer 3’s query against JAL1629972 remains. The authors mentioned that the findings could help the proper authority to take a rapid attention. If so, previous findings should have helped pay attention to Bangladesh. Please add further study perspective according to the previous findings and afterward.

Author Response

This is the revised manuscript of JAL1629972. The authors tried to respond to all reviewers. The reviewer thinks that the authors responded to some issues adequately. However, the reviewer still points out the same issues requiring manuscript revision as described below.

Comment 1: The authors mentioned that all the anthropometric measurements were used. BMI must be determined to evaluate the NMA-score. Then, section 2.5 should be before “Outcomes measures” of the Materials and Methods section. Please define the low, normal, and high blood pressure groups here. Again, please define diagnosing diabetes from RBS values in the section.

 Author’s response: We cordially acknowledge the reviewer for this important comment. The section 2.5 has revised accordingly.

Track-change location: Page#4, Section: 2.5. Outcome Measures of related health indicators

Comment 2: Bar graphs in Figure 1 are not reasonable to show the rate of normal, risk of malnutrition, and malnourished. In addition, why did the columns have error bars? Did the authors show the mean values of the data? The reviewer still recommends changing Figure 1a to the pie chart and Figures 1b-d to the donuts charts.

Author’s response: We appreciate suggestion of the reviewer. Although both bar and pie diagram are appropriate here, our statisticians have suggested bar diagram instead of pie and donuts charts. For multiple cases, bar diagram is more visible than donuts. However, we replaced 1.a bar diagram by the pie chart.

Here, the error bar represent error of proportion/percentage generated by Excel-16. It means how far from the reported proportional values the actual values might be.

Comment 3: Even after reading the revised version, reviewer 3’s query against JAL1629972 remains. The authors mentioned that the findings could help the proper authority to take a rapid attention. If so, previous findings should have helped pay attention to Bangladesh. Please add further study perspective according to the previous findings and afterward.

Author’s response: We again appreciate the reviewer for this suggestion. As we mentioned that this is the first study and no previous study assessed malnutrition of wetland elderly. Therefore, this study could be an opening regarding malnutrition of wetland elderly. We also revised this section.

Reviewer 4 Report

The concerns I raised during the first review were addressed. However, the English is still awkward. At times, it is not clear what is being said. Recommend employing a different editor for an additional review.

Author Response

Comment 1: The concerns I raised during the first review were addressed. However, the English is still awkward. At times, it is not clear what is being said. Recommend employing a different editor for an additional review.

Author’s response: We cordially appreciate the suggestion given by the reviewer. We checked and revised our manuscript by a native English speaker.